Revolutionising immune research with organoid-based co-culture and chip systems

The intertwined interactions various immune cells have with epithelial cells in our body require sophisticated experimental approaches to be studied. Due to the limitations of immortalised cell lines and animal models, there is an increasing demand for human in vitro model systems to investigate the microenvironment of immune cells in normal and in pathological conditions. Organoids, which are self-renewing, 3D cellular structures that are derived from stem cells, have started to provide gap-filling tissue modelling solutions. In this review, we first demonstrate with some of the available examples how organoid-based immune cell co-culture experiments can advance disease modelling of cancer, inflammatory bowel disease and tissue regeneration. Then, we argue that to achieve both complexity and scale, organ-on-chip models combined with cutting-edge microfluidics-based technologies can provide more precise manipulation and readouts. Finally, we discuss how genome editing techniques and the use of patient-derived organoids and immune cells can improve disease modelling and facilitate precision medicine. To achieve maximum impact and efficiency, these efforts should be supported by novel infrastructures such as organoid biobanks, organoid facilities, as well as drug screening and host-microbe interaction testing platforms. All these together or in combination can allow researchers to shed more detailed, and often patient-specific, light on the crosstalk between immune cells and epithelial cells in health and disease.

An 8-channel Tx dipole and 20-channel Rx loop coil array for MRI of the cervical spinal cord at 7 Tesla

The quality of cervical spinal cord images can be improved by the use of tailored radiofrequency (RF) coil solutions for ultrahigh field imaging; however, very few commercial and research 7-T RF coils currently exist for the spinal cord, and in particular, those with parallel transmission (pTx) capabilities. This work presents the design, testing, and validation of a pTx/Rx coil for the human neck and cervical/upper thoracic spinal cord. The pTx portion is composed of eight dipoles to ensure high homogeneity over this large region of the spinal cord. The Rx portion is made up of twenty semiadaptable overlapping loops to produce high signal-to-noise ratio (SNR) across the patient population. The coil housing is designed to facilitate patient positioning and comfort, while also being tight fitting to ensure high sensitivity. We demonstrate RF shimming capabilities to optimize B1 + uniformity, power efficiency, and/or specific absorption rate efficiency. B1 + homogeneity, SNR, and g-factor were evaluated in adult volunteers and demonstrated excellent performance from the occipital lobe down to the T4-T5 level. We compared the proposed coil with two state-of-the-art head and head/neck coils, confirming its superiority in the cervical and upper thoracic regions of the spinal cord. This coil solution therefore provides a convincing platform for producing the high image quality necessary for clinical and research scanning of the upper spinal cord.

Shimming toolbox: An open-source software toolbox for B0 and B1 shimming in MRI

PURPOSE

Introduce Shimming Toolbox ( https://shimming-toolbox.org), an open-source software package for prototyping new methods and performing static, dynamic, and real-time B0 shimming as well as B1 shimming experiments.

METHODS

Shimming Toolbox features various field mapping techniques, manual and automatic masking for the brain and spinal cord, B0 and B1 shimming capabilities accessible through a user-friendly graphical user interface. Validation of Shimming Toolbox was demonstrated in three scenarios: (i) B0 dynamic shimming in the brain at 7T using custom AC/DC coils, (ii) B0 real-time shimming in the spinal cord at 3T, and (iii) B1 static shimming in the spinal cord at 7T.

RESULTS

The B0 dynamic shimming of the brain at 7T took about 10 min to perform. It showed a 47% reduction in the standard deviation of the B0 field, associated with noticeable improvements in geometric distortions in EPI images. Real-time dynamic xyz-shimming in the spinal cord took about 5 min and showed a 30% reduction in the standard deviation of the signal distribution. B1 static shimming experiments in the spinal cord took about 10 min to perform and showed a 40% reduction in the coefficient of variation of the B1 field.

CONCLUSION

Shimming Toolbox provides an open-source platform where researchers can collaborate, prototype and conveniently test B0 and B1 shimming experiments. Future versions will include additional field map preprocessing techniques, optimization algorithms, and compatibility across multiple MRI manufacturers.

Lung parenchyma and structure visualisation in paediatric chest MRI: a comparison of different short and ultra-short echo time protocols

AIM

To evaluate image quality acquired at lung imaging using magnetic resonance imaging (MRI) sequences using short and ultra-short (UTE) echo times (TEs) with different acquisition strategies (breath-hold, prospective, and retrospective gating) in paediatric patients and in healthy volunteers.

MATERIALS AND METHODS

End-inspiratory and end-expiratory three-dimensional (3D) spoiled gradient (SPGR3D) and 3D zero echo-time (ZTE3D), and 3D UTE free-breathing (UTE3D), prospective projection navigated radial ZTE3D (ZTE3D vnav), and four-dimensional ZTE (ZTE4D) were performed using a 1.5 T MRI system. For quantitative assessment, the contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) values were calculated. To evaluate image quality, qualitative scoring was undertaken on all sequences to evaluate depiction of intrapulmonary vessels, fissures, bronchi, imaging noise, artefacts, and overall acceptability.

RESULTS

Eight cystic fibrosis (CF) patients (median age 14 years, range 13-17 years), seven children with history of prematurity with or without bronchopulmonary dysplasia (BPD; median 10 years, range 10-11 years), and 10 healthy volunteers (median 32 years, range 20-52 years) were included in the study. ZTE3D vnav provided the most reliable output in terms of image quality, although scan time was highly dependent on navigator triggering efficiency and respiratory pattern.

CONCLUSIONS

Best image quality was achieved with prospective ZTE3D and UTE3D readouts both in children and volunteers. The current implementation of retrospective ZTE3D readout (ZTE4D) did not provide diagnostic image quality but rather introduced artefacts over the entire imaging volume mimicking lung pathology.

8-channel Tx dipole and 20-channel Rx loop coil array for MRI of the cervical spinal cord at 7 Tesla

The quality of cervical spinal cord images can be improved by the use of tailored radiofrequency coil solutions for ultra-high field imaging; however, very few commercial and research 7 Tesla radiofrequency coils currently exist for the spinal cord, and in particular those with parallel transmit capabilities. This work presents the design, testing and validation of a pTx/Rx coil for the human neck and cervical/upper-thoracic spinal cord. The pTx portion is composed of 8 dipoles to ensure high homogeneity over this large region of the spinal cord. The Rx portion is made of 20 semi-adaptable overlapping loops to produce high Signal-to-noise ratio (SNR) across the patient population. The coil housing is designed to facilitate patient positioning and comfort, while being tight fitting to ensure high sensitivity. We demonstrate RF shimming capabilities to optimize B ₁ ⁺ uniformity, power efficiency and/or specific absorption rate (SAR) efficiency. B ₁ ⁺ homogeneity, SNR and g-factor was evaluated in adult volunteers and demonstrated excellent performance from the occipital lobe down to the T4-T5 level. We compared the proposed coil with two state-of-the-art head and head/neck coils, confirming its superiority in the cervical and upper-thoracic regions of the spinal cord. This coil solution therefore provides a convincing platform for producing the high image quality necessary for clinical and research scanning of the upper spinal cord.

Single-Standard Quantification Strategy for Lignin Dimers by Supercritical Fluid Chromatography with Charged Aerosol Detection

The increased interest in utilizing lignin as a feedstock to produce various aromatic compounds requires advanced chemical analysis methods to provide qualitative and quantitative characterization of lignin samples along different technology streamlines. However, due to the lack of commercially available chemical standards, routine quantification of industrially relevant lignin oligomers in complex lignin samples remains a challenge. This study presents a novel method for universal quantification of lignin dimers based on supercritical fluid chromatography with charged aerosol detection (CAD). A series of lignin-derived dimeric compounds that have been reported from reductive catalytic fractionation (RCF) were synthesized and used as standards. The applicability of using linear regression instead of quadratic calibration curves was evaluated over a concentration range of 15-125 mg/L, demonstrating that the former calibration method is as appropriate as the latter. The response factors of lignin dimeric compounds were compared to assess the uniformity of the CAD signal, revealing that the CAD response for the tested lignin dimers did not differ substantially. It was also found that the response factors were not dependent on the number of methoxy groups or linkage motifs, ultimately enabling the use of only one calibrant for these compounds. The importance of chromatographic peak resolution in CAD was stressed, and the use of a digital peak sharpening technique was adopted and applied to address this challenge. The developed method was verified and used for the quantification of lignin dimers in an oil obtained by a RCF of birch sawdust.

Quantitative MRI reveals differences in striatal myelin in children with DLD

Developmental language disorder (DLD) is a common neurodevelopmental disorder characterised by receptive or expressive language difficulties or both. While theoretical frameworks and empirical studies support the idea that there may be neural correlates of DLD in frontostriatal loops, findings are inconsistent across studies. Here, we use a novel semiquantitative imaging protocol - multi-parameter mapping (MPM) - to investigate microstructural neural differences in children with DLD. The MPM protocol allows us to reproducibly map specific indices of tissue microstructure. In 56 typically developing children and 33 children with DLD, we derived maps of (1) longitudinal relaxation rate R1 (1/T1), (2) transverse relaxation rate R2* (1/T2*), and (3) Magnetization Transfer saturation (MTsat). R1 and MTsat predominantly index myelin, while R2* is sensitive to iron content. Children with DLD showed reductions in MTsat values in the caudate nucleus bilaterally, as well as in the left ventral sensorimotor cortex and Heschl's gyrus. They also had globally lower R1 values. No group differences were noted in R2* maps. Differences in MTsat and R1 were coincident in the caudate nucleus bilaterally. These findings support our hypothesis of corticostriatal abnormalities in DLD and indicate abnormal levels of myelin in the dorsal striatum in children with DLD.

Hebbian activity-dependent plasticity in white matter

Synaptic plasticity is required for learning and follows Hebb's rule, the computational principle underpinning associative learning. In recent years, a complementary type of brain plasticity has been identified in myelinated axons, which make up the majority of brain's white matter. Like synaptic plasticity, myelin plasticity is required for learning, but it is unclear whether it is Hebbian or whether it follows different rules. Here, we provide evidence that white matter plasticity operates following Hebb's rule in humans. Across two experiments, we find that co-stimulating cortical areas to induce Hebbian plasticity leads to relative increases in cortical excitability and associated increases in a myelin marker within the stimulated fiber bundle. We conclude that Hebbian plasticity extends beyond synaptic changes and can be observed in human white matter fibers.

Model-based dynamic off-resonance correction for improved accelerated fMRI in awake behaving nonhuman primates

Purpose

To estimate dynamic off‐resonance due to vigorous body motion in accelerated fMRI of awake behaving nonhuman primates (NHPs) using the echo‐planar imaging reference navigator, in order to attenuate the effects of time‐varying off‐resonance on the reconstruction.

Methods

In NHP fMRI, the animal’s head is usually head‐posted, and the dynamic off‐resonance is mainly caused by motion in body parts that are distant from the brain and have low spatial frequency. Hence, off‐resonance at each frame can be approximated as a spatially linear perturbation of the off‐resonance at a reference frame, and is manifested as a relative linear shift in k‐space. Using GRAPPA operators, we estimated these shifts by comparing the navigator at each time frame with that at the reference frame. Estimated shifts were then used to correct the data at each frame. The proposed method was evaluated in phantom scans, simulations, and in vivo data.

Results

The proposed method is shown to successfully estimate spatially low‐order dynamic off‐resonance perturbations, including induced linear off‐resonance perturbations in phantoms, and is able to correct retrospectively corrupted data in simulations. Finally, it is shown to reduce ghosting artifacts and geometric distortions by up to 20% in simultaneous multislice in vivo acquisitions in awake‐behaving NHPs.

Conclusion

A method is proposed that does not need sequence modification or extra acquisitions and makes accelerated awake behaving NHP imaging more robust and reliable, reducing the gap between what is possible with NHP protocols and state‐of‐the‐art human imaging.

Elevated iron concentration in putamen and cortical speech motor network in developmental stuttering

Theoretical accounts of developmental stuttering implicate dysfunctional cortico-striatal-thalamo-cortical motor loops through the putamen. However, the analysis of conventional MRI brain scans in individuals who stutter has failed to yield strong support for this theory in terms of reliable differences in the structure or function of the basal ganglia. Here, we performed quantitative mapping of brain tissue, which can be used to measure iron content alongside markers sensitive to myelin and thereby offers particular sensitivity to the measurement of iron-rich structures such as the basal ganglia. Analysis of these quantitative maps in 41 men and women who stutter and 32 individuals who are typically fluent revealed significant group differences in maps of R2*, indicative of higher iron content in individuals who stutter in the left putamen and in left hemisphere cortical regions important for speech motor control. Higher iron levels in brain tissue in individuals who stutter could reflect elevated dopamine levels or lysosomal dysfunction, both of which are implicated in stuttering. This study represents the first use of these quantitative measures in developmental stuttering and provides new evidence of microstructural differences in the basal ganglia and connected frontal cortical regions.

Reassessing associations between white matter and behaviour with multimodal microstructural imaging

Several studies have established specific relationships between White Matter (WM) and behaviour. However, these studies have typically focussed on fractional anisotropy (FA), a neuroimaging metric that is sensitive to multiple tissue properties, making it difficult to identify what biological aspects of WM may drive such relationships. Here, we carry out a pre-registered assessment of WM-behaviour relationships in 50 healthy individuals across multiple behavioural and anatomical domains, and complementing FA with myelin-sensitive quantitative MR modalities (MT, R1, R2∗).

Surprisingly, we only find support for predicted relationships between FA and behaviour in one of three pre-registered tests. For one behavioural domain, where we failed to detect an FA-behaviour correlation, we instead find evidence for a correlation between behaviour and R1. This hints that multimodal approaches are able to identify a wider range of WM-behaviour relationships than focusing on FA alone.

To test whether a common biological substrate such as myelin underlies WM-behaviour relationships, we then ran joint multimodal analyses, combining across all MRI parameters considered. No significant multimodal signatures were found and power analyses suggested that sample sizes of 40–200 may be required to detect such joint multimodal effects, depending on the task being considered.

These results demonstrate that FA-behaviour relationships from the literature can be replicated, but may not be easily generalisable across domains. Instead, multimodal microstructural imaging may be best placed to detect a wider range of WM-behaviour relationships, as different MRI modalities provide distinct biological sensitivities. Our findings highlight a broad heterogeneity in WM's relationship with behaviour, suggesting that variable biological effects may be shaping their interaction.

Open-access quantitative MRI data of the spinal cord and reproducibility across participants, sites and manufacturers

In a companion paper by Cohen-Adad et al. we introduce the spine generic quantitative MRI protocol that provides valuable metrics for assessing spinal cord macrostructural and microstructural integrity. This protocol was used to acquire a single subject dataset across 19 centers and a multi-subject dataset across 42 centers (for a total of 260 participants), spanning the three main MRI manufacturers: GE, Philips and Siemens. Both datasets are publicly available via git-annex. Data were analysed using the Spinal Cord Toolbox to produce normative values as well as inter/intra-site and inter/intra-manufacturer statistics. Reproducibility for the spine generic protocol was high across sites and manufacturers, with an average inter-site coefficient of variation of less than 5% for all the metrics. Full documentation and results can be found at https://spine-generic.rtfd.io/ . The datasets and analysis pipeline will help pave the way towards accessible and reproducible quantitative MRI in the spinal cord.

Multimodal Imaging Brain Markers in Early Adolescence Are Linked with a Physically Active Lifestyle

The World Health Organization promotes physical exercise and a healthy lifestyle as means to improve youth development. However, relationships between physical lifestyle and human brain development are not fully understood. Here, we asked whether a human brain-physical latent mode of covariation underpins the relationship between physical activity, fitness, and physical health measures with multimodal neuroimaging markers. In 50 12-year old school pupils (26 females), we acquired multimodal whole-brain MRI, characterizing brain structure, microstructure, function, myelin content, and blood perfusion. We also acquired physical variables measuring objective fitness levels, 7 d physical activity, body mass index, heart rate, and blood pressure. Using canonical correlation analysis, we unravel a latent mode of brain-physical covariation, independent of demographics, school, or socioeconomic status. We show that MRI metrics with greater involvement in this mode also showed spatially extended patterns across the brain. Specifically, global patterns of greater gray matter perfusion, volume, cortical surface area, greater white matter extra-neurite density, and resting state networks activity covaried positively with measures reflecting a physically active phenotype (high fit, low sedentary individuals). Showing that a physically active lifestyle is linked with systems-level brain MRI metrics, these results suggest widespread associations relating to several biological processes. These results support the notion of close brain-body relationships and underline the importance of investigating modifiable lifestyle factors not only for physical health but also for brain health early in adolescence.SIGNIFICANCE STATEMENT An active lifestyle is key for healthy development. In this work, we answer the following question: How do brain neuroimaging markers relate with young adolescents' level of physical activity, fitness, and physical health? Combining advanced whole-brain multimodal MRI metrics with computational approaches, we show a robust relationship between physically active lifestyles and spatially extended, multimodal brain imaging-derived phenotypes. Suggesting a wider effect on brain neuroimaging metrics than previously thought, this work underlies the importance of studying physical lifestyle, as well as other brain-body relationships in an effort to foster brain health at this crucial stage in development.

Mapping Human Laryngeal Motor Cortex during Vocalization

The representations of the articulators involved in human speech production are organized somatotopically in primary motor cortex. The neural representation of the larynx, however, remains debated. Both a dorsal and a ventral larynx representation have been previously described. It is unknown, however, whether both representations are located in primary motor cortex. Here, we mapped the motor representations of the human larynx using functional magnetic resonance imaging and characterized the cortical microstructure underlying the activated regions. We isolated brain activity related to laryngeal activity during vocalization while controlling for breathing. We also mapped the articulators (the lips and tongue) and the hand area. We found two separate activations during vocalization-a dorsal and a ventral larynx representation. Structural and quantitative neuroimaging revealed that myelin content and cortical thickness underlying the dorsal, but not the ventral larynx representation, are similar to those of other primary motor representations. This finding confirms that the dorsal larynx representation is located in primary motor cortex and that the ventral one is not. We further speculate that the location of the ventral larynx representation is in premotor cortex, as seen in other primates. It remains unclear, however, whether and how these two representations differentially contribute to laryngeal motor control.

Liquid-cooled Ti:Sapphire thin disk amplifiers for high average power 100-TW systems

In this work, numerical heat transfer simulations of direct water-cooled gain modules for thin disk (TD) Ti:Sapphire (Ti:Sa) power amplifiers are presented. By using the TD technique in combination with the extraction during pumping (EDP) method 100-TW class amplifiers operating around 300 W average power could be reached in the future. Single and double-sided cooling arrangements were investigated for several coolant flow velocities. Simulations which upscale the gain module for multiple kilowatts of average power were also performed for large aperture Ti:Sa disks and for multiple disks with several coolant channels.

Correction of inter-scan motion artifacts in quantitative R1 mapping by accounting for receive coil sensitivity effects

Purpose

Inter‐scan motion causes differential receive field modulation between scans, leading to errors when they are combined to quantify MRI parameters. We present a robust and efficient method that accounts for inter‐scan motion by removing this modulation before parameter quantification.

Theory and Methods

Five participants moved between two high‐resolution structural scans acquired with different flip angles. Before each high‐resolution scan, the effective relative sensitivity of the receive head coil was estimated by combining two rapid low‐resolution scans acquired receiving on each of the body and head coils. All data were co‐registered and sensitivity variations were removed from the high‐resolution scans by division with the effective relative sensitivity. R1 maps with and without this correction were calculated and compared against reference maps unaffected by inter‐scan motion.

Results

Even after coregistration, inter‐scan motion significantly biased the R1 maps, leading to spurious variation in R1 in brain tissue and deviations with respect to a no‐motion reference. The proposed correction scheme reduced the error to within the typical scan–rescan error observed in datasets unaffected by motion.

Conclusion

Inter‐scan motion negatively impacts the accuracy and precision of R1 mapping. We present a validated correction method that accounts for position‐specific receive field modulation. Magn Reson Med 76:1478–1485, 2016. © 2015 The Authors. Magnetic Resonance in Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Magnetic Resonance in Medicine. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Autophagy is required for zebrafish caudal fin regeneration

Regeneration is the ability of multicellular organisms to replace damaged tissues and regrow lost body parts. This process relies on cell fate transformation that involves changes in gene expression as well as in the composition of the cytoplasmic compartment, and exhibits a characteristic age-related decline. Here, we present evidence that genetic and pharmacological inhibition of autophagy - a lysosome-mediated self-degradation process of eukaryotic cells, which has been implicated in extensive cellular remodelling and aging - impairs the regeneration of amputated caudal fins in the zebrafish (Danio rerio). Thus, autophagy is required for injury-induced tissue renewal. We further show that upregulation of autophagy in the regeneration zone occurs downstream of mitogen-activated protein kinase/extracellular signal-regulated kinase signalling to protect cells from undergoing apoptosis and enable cytosolic restructuring underlying terminal cell fate determination. This novel cellular function of the autophagic process in regeneration implies that the role of cellular self-digestion in differentiation and tissue patterning is more fundamental than previously thought.

Current redistribution and generation of kinetic energy in the stagnated Z pinch

The structure of magnetic fields was investigated in stagnated wire-array Z pinches using a Faraday rotation diagnostic at the wavelength of 266 nm. The distribution of current in the pinch and trailing material was reconstructed. A significant part of current can switch from the main pinch to the trailing plasma preheated by x-ray radiation of the pinch. Secondary implosions of trailing plasma generate kinetic energy and provide enhanced heating and radiation of plasma at stagnation. Hot spots in wire-array Z pinches also provide enhanced radiation of the Z pinch. A collapse of a single hot spot radiates 1%-3% of x-ray energy of the Z pinch with a total contribution of hot spots of 10%-30%.

Investigation of plasma instabilities in the stagnated Z pinch

High-resolution laser probing diagnostics at a wavelength of 266 nm allow observation of the internal structure and instabilities in dense stagnated Z pinches, typically hidden by trailing material. The internal structure of the 1-MA Z pinch includes strong kink and sausage instabilities, loops, flares, and disruptions. Mid- and small-scale density perturbations develop in the precursor and main pinch. The three-dimensional shape and dynamics of the wire-array Z pinch are predetermined by the initial configuration of the wire array. Cylindrical, linear, and star wire-array Z pinches present different sets of instabilities seeded to the pinch at the implosion stage. Prolonged implosion of trailing mass can enhance x-ray production in wire arrays. Fast plasma motion with a velocity >100 km/s was observed in the Z pinch at stagnation with two-frame shadowgraphy. Development of instabilities in wire arrays is in agreement with three-dimensional magnetohydrodynamic simulations.

Study of the internal structure and small-scale instabilities in the dense Z pinch

High-resolution laser diagnostics at the wavelength of 266 nm were applied for the investigation of Z pinches at the 1-MA generator. The internal structure of the stagnated Z pinches was observed in unprecedented detail. A dense pinch with strong instabilities was seen inside the column of the trailing plasma. Kink instability, disruptions, and micropinches were seen at the peak of the x-ray pulse and later in time. The three-dimensional structure of the stagnated Z pinch depends on the initial wire-array configuration and implosion scenario. Small-scale density perturbations were found in the precursor plasma and in the stagnated Z pinch. Development of instabilities is in agreement with three-dimensional magnetohydrodynamic simulations.

Measurement of the ionization state and electron temperature of plasma during the ablation stage of a wire-array Z pinch using absorption spectroscopy

Wire-array plasmas were investigated in the nonradiative ablation stage via x-ray absorption spectroscopy. A laser-produced Sm plasma was used to backlight Al wire arrays. The Sm spectrum was simultaneously observed by two spectrometers: one recorded the unattenuated spectrum and the other the transmission spectrum with 1.45-1.55 keV K-shell absorption lines. Analysis of absorption spectra revealed electron temperature in the range of 10-30 eV and the presence of F-, O-, N- and C-like Al ions in the absorbing plasma. A comparison of this electron temperature with the postprocessed absorption spectra of a 2D MHD simulation yields results in general agreement with the data analysis.

Dose response to nitric oxide in adult cardiac surgery patients

STUDY OBJECTIVE

To determine the dose responsiveness to nitric oxide in adult cardiac surgery patients, especially in those patients with pulmonary hypertension.

DESIGN

Prospective, randomized, nonblinded study.

SETTING

University teaching hospital.

PATIENTS

62 consecutive cardiac surgery patients demonstrating pulmonary hypertension immediately before induction of anesthesia.

INTERVENTIONS

Subjects were assigned by random number allocation to receive one of five doses of inhaled nitric oxide on termination of cardiopulmonary bypass (CBP; i.e., restitution of pulmonary artery flow). Subjects in Group 1 (n = 11) received 10 ppm of inhaled nitric oxide, Group 2 subjects (n = 12) received 20 ppm, Group 3 subjects (n = 12) received 30 ppm, and Group 4 subjects (n = 12) received 40 ppm. The fifth group (n = 15) received no nitric oxide. This fifth group served as a control and was treated with milrinone only. Those patients who were randomized to the milrinone group, had milrinone initiated by bolus administration (50 microg/kg) 15 min before separation from CPB. Milrinone was maintained at 0.5 microg/kg/min in the operating room thereafter. The conduct of anesthesia, surgery, and CBP were controlled. A therapeutic algorithm dictated the use of vasoactive substances for all patients.

MEASUREMENTS

Heart rate, mean arterial pressure, pulmonary vascular resistance (PVR), peripheral vascular resistance, cardiac index, and right ventricular ejection fraction were monitored throughout the operative experience.

MAIN RESULTS

There were no significant differences found in demographic data, baseline hemodynamic data, surgical treatment, conduct of CBP, or the use of inotropic or vasoactive drugs among the five treatment groups. The percentage decrease in PVR on treatment with nitric oxide as compared to baseline values was not significantly different among the groups (10 ppm = 38%, 20 ppm = 50%, 30 ppm = 44%, 40 ppm = 36%, milrinone = 58%, p = 0.86).

CONCLUSIONS

Treatment with nitric oxide was associated with significant reductions in PVR in all groups. Dosages higher than 10 ppm were not associated with greater reductions in pulmonary vascular tone. In view of the fact that nitric oxide-related toxicity is dose-related, doses greater than 10 ppm do not appear to be justified in this patient population.

A prospective comparison of three heat preservation methods for patients undergoing hypothermic cardiopulmonary bypass

OBJECTIVE

To prospectively compare 3 methods of body heat preservation in patients undergoing surgery requiring the use of hypothermic cardiopulmonary bypass (CPB).

DESIGN

Prospective, randomized, and nonblinded.

SETTING

University teaching hospital.

PARTICIPANTS

Adult cardiac surgery patients (n = 101).

INTERVENTIONS

Subjects were randomly assigned to 1 of 3 treatment groups: Group 1 (n = 33) used a fluid-filled warming blanket, group 2 (n = 31) used a heated and humidified breathing circuit, and group 3 (n = 37) used intravenous fluid warmers for the administration of all fluids. Treatments started on separation from CPB and concluded at the end of the intraoperative experience. Anesthetic technique, minute ventilation, conduct of CPB, and room temperature in the operating room were standardized.

MEASUREMENTS AND MAIN RESULTS

Blood temperature was measured at its nadir on CPB, on separation from CPB, and just before departure from the operating room. No differences were found among groups for CPB duration, coldest venous temperature on CPB, rewarming time, rate of rewarming, room temperature, or blood temperature on separation from CPB. There were no significant differences found in post-CPB temperature afterdrop among groups.

CONCLUSIONS

This study suggests that there is no statistically significant disparity in the effectiveness of these 3 intraoperative heat preservation methods. Ease of use and cost-effectiveness should guide the choice of warming method post-CPB.

A comparison of inhaled nitric oxide and milrinone for the treatment of pulmonary hypertension in adult cardiac surgery patients

OBJECTIVE

To investigate the relative effects of milrinone and nitric oxide on pulmonary and systemic hemodynamic responses in cardiac surgery patients with a history of pulmonary hypertension.

DESIGN

Prospective and randomized.

SETTING

University hospital.

PARTICIPANTS

Forty-five adult cardiac surgery patients.

INTERVENTIONS

Cardiac surgery patients with pulmonary hypertension were randomly assigned to one of three study groups: Group 1 patients (n = 15) were treated with intravenous milrinone on separation from cardiopulmonary bypass, group 2 patients (n = 15) with 20 ppm of inhaled nitric oxide, and group 3 patients (n = 15) with 40 ppm of inhaled nitric oxide. Heart rate, right ventricular ejection fraction, and pulmonary vascular resistance were measured throughout the perioperative period at specific data points.

MEASUREMENTS AND MAIN RESULTS

There were no significant differences in demographics, anesthesia, surgery, or baseline hemodynamics among the groups. The group receiving 40 ppm nitric oxide had a significantly higher (p<0.05) right ventricular ejection fraction on arrival in the intensive care unit (40% v. 30% for the milrinone group and 33% for the nitric oxide 20 ppm group). The milrinone group required significantly more phenylephrine in the intensive care unit (p<0.05).

CONCLUSIONS

Treatment of pulmonary hypertension in adult cardiac surgery patients with inhaled nitric oxide compared with milrinone is associated with lower heart rates, higher right ventricular ejection fraction, and a lower requirement for treatment with vasopressor agents.