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Onishi R, Ueda J, Ide S, Koseki M, Sakata Y, Saito S. Application of Magnetic Resonance Strain Analysis Using Feature Tracking in a Myocardial Infarction Model. Tomography 2023; 9:871-882. [PMID: 37104142 PMCID: PMC10141923 DOI: 10.3390/tomography9020071] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/04/2023] [Accepted: 04/13/2023] [Indexed: 04/28/2023] Open
Abstract
This study validates the usefulness of myocardial strain analysis with cardiac cine magnetic resonance imaging (MRI) by evaluating the changes in the cardiac function and myocardial strain values longitudinally in a myocardial disease model. Six eight-week-old male Wistar rats were used as a model of myocardial infarction (MI). Cine images were taken in the short axis, two-chamber view longitudinal axis, and four-chamber view longitudinal axis directions in rats 3 and 9 days after MI and in control rats, with preclinical 7-T MRI. The control images and the images on days 3 and 9 were evaluated by measuring the ventricular ejection fraction (EF) and the strain values in the circumferential (CS), radial (RS), and longitudinal directions (LS). The CS decreased significantly 3 days after MI, but there was no difference between the images on days 3 and 9. The two-chamber view LS was -9.7 ± 2.1% at 3 days and -13.9 ± 1.4% at 9 days after MI. The four-chamber view LS was -9.9 ± 1.5% at 3 days and -11.9 ± 1.3% at 9 days after MI. Both the two- and four-chamber LS values were significantly decreased 3 days after MI. Myocardial strain analysis is, therefore, useful for assessing the pathophysiology of MI.
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Affiliation(s)
- Ryutaro Onishi
- Department of Medical Physics and Engineering, Area of Medical Imaging Technology and Science, Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
- Division of Clinical Radiology Service, Kyoto University Hospital, Kyoto 606-8507, Japan
| | - Junpei Ueda
- Department of Medical Physics and Engineering, Area of Medical Imaging Technology and Science, Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Seiko Ide
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Masahiro Koseki
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Shigeyoshi Saito
- Department of Medical Physics and Engineering, Area of Medical Imaging Technology and Science, Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
- Department of Advanced Medical Technologies, National Cerebral and Cardiovascular Center Research Institute, Osaka 564-8565, Japan
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Mella H, Mura J, Sotelo J, Uribe S. A comprehensive comparison between shortest-path HARP refinement, SinMod, and DENSEanalysis processing tools applied to CSPAMM and DENSE images. Magn Reson Imaging 2021; 83:14-26. [PMID: 34242693 DOI: 10.1016/j.mri.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/26/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
We addressed comprehensively the performance of Shortest-Path HARP Refinement (SP-HR), SinMod, and DENSEanalysis using 2D slices of synthetic CSPAMM and DENSE images with realistic contrasts obtained from 3D phantoms. The three motion estimation techniques were interrogated under ideal and no-ideal conditions (with MR induced artifacts, noise, and through-plane motion), considering several resolutions and noise levels. Under noisy conditions, and for isotropic pixel sizes of 1.5 mm and 3.0 mm in CSPAMM and DENSE images respectively, the nRMSE obtained for the circumferential and radial strain components were 10.7 ± 10.8% and 25.5 ± 14.8% using SP-HR, 11.9 ± 2.5% and 29.3 ± 6.5% using SinMod, and 6.4 ± 2.0% and 18.2 ± 4.6% using DENSEanalysis. Overall, the results showed that SP-HR tends to fail for large tissue motions, whereas SinMod and DENSEanalysis gave accurate displacement and strain field estimations, being the last which performed the best.
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Affiliation(s)
- Hernán Mella
- Department of Electrical Engineering, Pontificia Universidad Católica de Chile, Santiago, Chile; Biomedical Imaging Centre, Pontificia Universidad Católica de Chile, Santiago, Chile; Millennium Nucleus for Cardiovascular Magnetic Resonance, Santiago, Chile.
| | - Joaquín Mura
- Department of Mechanical Engineering, Universidad Técnica Federico Santa María, Santiago, Chile; Millennium Nucleus for Cardiovascular Magnetic Resonance, Santiago, Chile.
| | - Julio Sotelo
- School of Biomedical Engineering, Universidad de Valparaíso, Valparaíso, Chile; Biomedical Imaging Centre, Pontificia Universidad Católica de Chile, Santiago, Chile; Millennium Nucleus for Cardiovascular Magnetic Resonance, Santiago, Chile.
| | - Sergio Uribe
- Department of Radiology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; Biomedical Imaging Centre, Pontificia Universidad Católica de Chile, Santiago, Chile; Millennium Nucleus for Cardiovascular Magnetic Resonance, Santiago, Chile.
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Lindsey ML, Kassiri Z, Virag JAI, de Castro Brás LE, Scherrer-Crosbie M. Guidelines for measuring cardiac physiology in mice. Am J Physiol Heart Circ Physiol 2018; 314:H733-H752. [PMID: 29351456 PMCID: PMC5966769 DOI: 10.1152/ajpheart.00339.2017] [Citation(s) in RCA: 230] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Cardiovascular disease is a leading cause of death, and translational research is needed to understand better mechanisms whereby the left ventricle responds to injury. Mouse models of heart disease have provided valuable insights into mechanisms that occur during cardiac aging and in response to a variety of pathologies. The assessment of cardiovascular physiological responses to injury or insult is an important and necessary component of this research. With increasing consideration for rigor and reproducibility, the goal of this guidelines review is to provide best-practice information regarding how to measure accurately cardiac physiology in animal models. In this article, we define guidelines for the measurement of cardiac physiology in mice, as the most commonly used animal model in cardiovascular research. Listen to this article’s corresponding podcast at http://ajpheart.podbean.com/e/guidelines-for-measuring-cardiac-physiology-in-mice/.
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Affiliation(s)
- Merry L Lindsey
- Department of Physiology and Biophysics, Mississippi Center for Heart Research, University of Mississippi Medical Center , Jackson, Mississippi.,Research Service, G.V. (Sonny) Montgomery Veterans Affairs Medical Center , Jackson, Mississippi
| | - Zamaneh Kassiri
- Department of Physiology, Cardiovascular Research Centre, Mazankowski Alberta Heart Institute, University of Alberta , Edmonton, Alberta , Canada
| | - Jitka A I Virag
- Department of Physiology, Brody School of Medicine, East Carolina University , Greenville, North Carolina
| | - Lisandra E de Castro Brás
- Department of Physiology, Brody School of Medicine, East Carolina University , Greenville, North Carolina
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Vanhoutte L, Gerber BL, Gallez B, Po C, Magat J, Balligand JL, Feron O, Moniotte S. High field magnetic resonance imaging of rodents in cardiovascular research. Basic Res Cardiol 2016; 111:46. [PMID: 27287250 DOI: 10.1007/s00395-016-0565-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 06/01/2016] [Indexed: 02/07/2023]
Abstract
Transgenic and gene knockout rodent models are primordial to study pathophysiological processes in cardiovascular research. Over time, cardiac MRI has become a gold standard for in vivo evaluation of such models. Technical advances have led to the development of magnets with increasingly high field strength, allowing specific investigation of cardiac anatomy, global and regional function, viability, perfusion or vascular parameters. The aim of this report is to provide a review of the various sequences and techniques available to image mice on 7-11.7 T magnets and relevant to the clinical setting in humans. Specific technical aspects due to the rise of the magnetic field are also discussed.
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Affiliation(s)
- Laetitia Vanhoutte
- Department of Paediatric Cardiology, Cliniques universitaires Saint Luc, Université Catholique de Louvain (UCL), Brussels, Belgium. .,Pole of Pharmacology and Therapeutics (FATH), Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain (UCL), Brussels, Belgium.
| | - Bernhard L Gerber
- Division of Cardiology, Cliniques universitaires Saint Luc, Université Catholique de Louvain (UCL), Brussels, Belgium.,Pole of Cardiovascular Research (CARD), Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Bernard Gallez
- Biomedical Magnetic Resonance Unit (REMA), Louvain Drug Research Institute (LDRI), Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Chrystelle Po
- CNRS, ICube, FMTS, Institut de Physique Biologique, Faculté de Médecine, Université de Strasbourg, Strasbourg, France
| | - Julie Magat
- L'Institut de RYthmologie et de Modélisation Cardiaque (LIRYC), Inserm U1045, Bordeaux, France
| | - Jean-Luc Balligand
- Pole of Pharmacology and Therapeutics (FATH), Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Olivier Feron
- Pole of Pharmacology and Therapeutics (FATH), Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Stéphane Moniotte
- Department of Paediatric Cardiology, Cliniques universitaires Saint Luc, Université Catholique de Louvain (UCL), Brussels, Belgium
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Improving full-cardiac cycle strain estimation from tagged CMR by accurate modeling of 3D image appearance characteristics. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2016. [DOI: 10.1016/j.ejrnm.2015.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Wehner GJ, Suever JD, Haggerty CM, Jing L, Powell DK, Hamlet SM, Grabau JD, Mojsejenko WD, Zhong X, Epstein FH, Fornwalt BK. Validation of in vivo 2D displacements from spiral cine DENSE at 3T. J Cardiovasc Magn Reson 2015; 17:5. [PMID: 25634468 PMCID: PMC4311418 DOI: 10.1186/s12968-015-0119-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 01/13/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Displacement Encoding with Stimulated Echoes (DENSE) encodes displacement into the phase of the magnetic resonance signal. Due to the stimulated echo, the signal is inherently low and fades through the cardiac cycle. To compensate, a spiral acquisition has been used at 1.5T. This spiral sequence has not been validated at 3T, where the increased signal would be valuable, but field inhomogeneities may result in measurement errors. We hypothesized that spiral cine DENSE is valid at 3T and tested this hypothesis by measuring displacement errors at both 1.5T and 3T in vivo. METHODS Two-dimensional spiral cine DENSE and tagged imaging of the left ventricle were performed on ten healthy subjects at 3T and six healthy subjects at 1.5T. Intersection points were identified on tagged images near end-systole. Displacements from the DENSE images were used to project those points back to their origins. The deviation from a perfect grid was used as a measure of accuracy and quantified as root-mean-squared error. This measure was compared between 3T and 1.5T with the Wilcoxon rank sum test. Inter-observer variability of strains and torsion quantified by DENSE and agreement between DENSE and harmonic phase (HARP) were assessed by Bland-Altman analyses. The signal to noise ratio (SNR) at each cardiac phase was compared between 3T and 1.5T with the Wilcoxon rank sum test. RESULTS The displacement accuracy of spiral cine DENSE was not different between 3T and 1.5T (1.2 ± 0.3 mm and 1.2 ± 0.4 mm, respectively). Both values were lower than the DENSE pixel spacing of 2.8 mm. There were no substantial differences in inter-observer variability of DENSE or agreement of DENSE and HARP between 3T and 1.5T. Relative to 1.5T, the SNR at 3T was greater by a factor of 1.4 ± 0.3. CONCLUSIONS The spiral cine DENSE acquisition that has been used at 1.5T to measure cardiac displacements can be applied at 3T with equivalent accuracy. The inter-observer variability and agreement of DENSE-derived peak strains and torsion with HARP is also comparable at both field strengths. Future studies with spiral cine DENSE may take advantage of the additional SNR at 3T.
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Affiliation(s)
- Gregory J Wehner
- />Department of Biomedical Engineering, University of Kentucky, 741 S Limestone, BBSRB B353, Lexington, KY 40509 USA
| | | | | | - Linyuan Jing
- />Department of Pediatrics, University of Kentucky, Lexington, USA
| | - David K Powell
- />Department of Biomedical Engineering, University of Kentucky, 741 S Limestone, BBSRB B353, Lexington, KY 40509 USA
| | - Sean M Hamlet
- />Department of Electrical Engineering, University of Kentucky, Lexington, USA
| | | | | | - Xiaodong Zhong
- />MR R&D Collaborations, Siemens Healthcare, Atlanta, GA USA
| | - Frederick H Epstein
- />Department of Biomedical Engineering, University of Virginia, Charlottesville, VA USA
| | - Brandon K Fornwalt
- />Department of Biomedical Engineering, University of Kentucky, 741 S Limestone, BBSRB B353, Lexington, KY 40509 USA
- />Department of Pediatrics, University of Kentucky, Lexington, USA
- />Departments of Physiology and Medicine, University of Kentucky, Lexington, USA
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Jung B, Odening KE, Dall’Armellina E, Föll D, Menza M, Markl M, Schneider JE. A quantitative comparison of regional myocardial motion in mice, rabbits and humans using in-vivo phase contrast CMR. J Cardiovasc Magn Reson 2012; 14:87. [PMID: 23270566 PMCID: PMC3579745 DOI: 10.1186/1532-429x-14-87] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 12/06/2012] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Genetically manipulated animals like mice or rabbits play an important role in the exploration of human cardiovascular diseases. It is therefore important to identify animal models that closely mimic physiological and pathological human cardiac function. METHODS In-vivo phase contrast cardiovascular magnetic resonance (CMR) was used to measure regional three-directional left ventricular myocardial motion with high temporal resolution in mice (N=18), rabbits (N=8), and humans (N=20). Radial, long-axis, and rotational myocardial velocities were acquired in left ventricular basal, mid-ventricular, and apical short-axis locations. RESULTS Regional analysis revealed different patterns of motion: 1) In humans and rabbits, the apex showed slower radial velocities compared to the base. 2) Significant differences within species were seen in the pattern of long-axis motion. Long-axis velocities during systole were fairly homogeneously distributed in mice, whereas humans showed a dominant component in the lateral wall and rabbits in the base. 3) Rotational velocities and twist showed the most distinct patterns in both temporal evolution and relative contribution of base, mid-ventricle and apex, respectively. Interestingly, a marked difference in rotational behavior during early-systole was found in mice, which exhibited clockwise rotation in all slice locations compared to counter-clockwise rotation in rabbits and humans. CONCLUSIONS Phase contrast CMR revealed subtle, but significantly different regional myocardial motion patterns in mice, rabbits and humans. This finding has to be considered when investigating myocardial motion pattern in small animal models of heart disease.
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Affiliation(s)
- Bernd Jung
- Department of Radiology, Medical Physics, University Medical Center, Freiburg, Germany
| | - Katja E Odening
- Department of Cardiology, University Medical Center, Freiburg, Germany
| | | | - Daniela Föll
- Department of Cardiology, University Medical Center, Freiburg, Germany
| | - Marius Menza
- Department of Radiology, Medical Physics, University Medical Center, Freiburg, Germany
| | - Michael Markl
- Department of Radiology, Northwestern University, Chicago, IL, USA
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Ibrahim ESH. Myocardial tagging by cardiovascular magnetic resonance: evolution of techniques--pulse sequences, analysis algorithms, and applications. J Cardiovasc Magn Reson 2011; 13:36. [PMID: 21798021 PMCID: PMC3166900 DOI: 10.1186/1532-429x-13-36] [Citation(s) in RCA: 203] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 07/28/2011] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular magnetic resonance (CMR) tagging has been established as an essential technique for measuring regional myocardial function. It allows quantification of local intramyocardial motion measures, e.g. strain and strain rate. The invention of CMR tagging came in the late eighties, where the technique allowed for the first time for visualizing transmural myocardial movement without having to implant physical markers. This new idea opened the door for a series of developments and improvements that continue up to the present time. Different tagging techniques are currently available that are more extensive, improved, and sophisticated than they were twenty years ago. Each of these techniques has different versions for improved resolution, signal-to-noise ratio (SNR), scan time, anatomical coverage, three-dimensional capability, and image quality. The tagging techniques covered in this article can be broadly divided into two main categories: 1) Basic techniques, which include magnetization saturation, spatial modulation of magnetization (SPAMM), delay alternating with nutations for tailored excitation (DANTE), and complementary SPAMM (CSPAMM); and 2) Advanced techniques, which include harmonic phase (HARP), displacement encoding with stimulated echoes (DENSE), and strain encoding (SENC). Although most of these techniques were developed by separate groups and evolved from different backgrounds, they are in fact closely related to each other, and they can be interpreted from more than one perspective. Some of these techniques even followed parallel paths of developments, as illustrated in the article. As each technique has its own advantages, some efforts have been made to combine different techniques together for improved image quality or composite information acquisition. In this review, different developments in pulse sequences and related image processing techniques are described along with the necessities that led to their invention, which makes this article easy to read and the covered techniques easy to follow. Major studies that applied CMR tagging for studying myocardial mechanics are also summarized. Finally, the current article includes a plethora of ideas and techniques with over 300 references that motivate the reader to think about the future of CMR tagging.
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Bauer M, Cheng S, Jain M, Ngoy S, Theodoropoulos C, Trujillo A, Lin FC, Liao R. Echocardiographic speckle-tracking based strain imaging for rapid cardiovascular phenotyping in mice. Circ Res 2011; 108:908-16. [PMID: 21372284 DOI: 10.1161/circresaha.110.239574] [Citation(s) in RCA: 192] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
RATIONALE High-sensitivity in vivo phenotyping of cardiac function is essential for evaluating genes of interest and novel therapies in small animal models of cardiovascular disease. Transthoracic echocardiography is the principal method currently used for assessing cardiac structure and function; however, standard echocardiographic techniques are relatively insensitive to early or subtle changes in cardiac performance, particularly in mice. OBJECTIVE To develop and validate an echocardiographic strain imaging methodology for sensitive and rapid cardiac phenotyping in small animal models. METHODS AND RESULTS Herein, we describe a modified echocardiographic technique that uses speckle-tracking based strain analysis for the noninvasive evaluation of cardiac performance in adult mice. This method is found to be rapid, reproducible, and highly sensitive in assessing both regional and global left ventricular (LV) function. Compared with conventional echocardiographic measures of LV structure and function, peak longitudinal strain and strain rate were able to detect changes in adult mouse hearts at an earlier time point following myocardial infarction and predicted the later development of adverse LV remodeling. Moreover, speckle-tracking based strain analysis was able to clearly identify subtle improvement in LV function that occurred early in response to standard post-myocardial infarction cardiac therapy. CONCLUSIONS Our results highlight the utility of speckle-tracking based strain imaging for detecting discrete functional alterations in mouse models of cardiovascular disease in an efficient and comprehensive manner. Echocardiography speckle-tracking based strain analysis represents a method for relatively high-throughput and sensitive cardiac phenotyping, particularly in evaluating emerging cardiac agents and therapies in mice.
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Affiliation(s)
- Michael Bauer
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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Jameel MN, Li Q, Mansoor A, Xiong Q, Swingen C, Zhang J. Long-term preservation of myocardial energetic in chronic hibernating myocardium. Am J Physiol Heart Circ Physiol 2010; 300:H836-44. [PMID: 21131472 DOI: 10.1152/ajpheart.00540.2010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
We previously reported that the myocardial energetic state, as defined by the ratio of phosphocreatine to ATP (PCr/ATP), was preserved at baseline (BL) in a swine model of chronic myocardial ischemia with mild reduction of myocardial blood flow (MBF) 10 wk after the placement of an external constrictor on the left anterior descending coronary artery. It remains to be seen whether this stable energetic state is maintained at a longer-term follow-up. Hibernating myocardium (HB) was created in minipigs (n = 7) by the placement of an external constrictor (1.25 mm internal diameter) on the left anterior descending coronary artery. Function was assessed with MRI at regular intervals until 6 mo. At 6 mo, myocardial energetic in the HB was assessed by (31)P-magnetic resonance spectrometry and myocardial oxygenation was examined from the deoxymyoglobin signal using (1)H-magnetic resonance spectrometry during BL, coronary vasodilation with adenosine, and high cardiac workload with dopamine and dobutamine (DpDb). MBF was measured with radiolabeled microspheres. At BL, systolic thickening fraction was significantly lower in the HB compared with remote region (34.4 ± 9.4 vs. 50.1 ± 10.7, P = 0.006). This was associated with a decreased MBF in the HB compared with the remote region (0.73 ± 0.08 vs. 0.97 ± 0.07 ml · min(-1) · g, P = 0.03). The HB PCr/ATP at BL was normal. DpDb resulted in a significant increase in rate pressure product, which caused a twofold increase in MBF in the HB and a threefold increase in the remote region. The systolic thickening fraction increased with DpDb, which was significantly higher in the remote region than HB (P < 0.05). The high cardiac workload was associated with a significant reduction in the HB PCr/ATP (P < 0.02), but this response was similar to normal myocardium. Thus HB has stable BL myocardial energetic despite the reduction MBF and regional left ventricular function. More importantly, HB has a reduced contractile reserve but has a similar energetic response to high cardiac workload like normal myocardium.
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Affiliation(s)
- Mohammad Nurulqadr Jameel
- Department of Medicine, University of Minnesota Medical School, University of Minnesota Medical School, Minneapolis, Minnesota 55455, USA
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