287. Procalcitonin and D-dimer levels at baseline, but not CRP, were informative of COVID-19 hospitalization outcomes

Background

The WHO estimates 512 million cases of COVID-19 and 6.2 million deaths globally as of May 4^th, 2022. In Michigan (MI), the first case was diagnosed March 10^th, 2020. We describe here outcomes of COVID-19 patients cared for in a large tertiary hospital in 2020 spanning two surges based on baseline lab values for C-reactive protein (CRP), Procalcitonin (PC), and D-Dimer (DD).

Methods

After IRB approval, adult patients diagnosed via PCR with COVID-19 during the two surges in 2020 and admitted to Beaumont Hospital, Royal Oak, an 1,131 beds tertiary care referral center in MI, were reviewed. Demographic, clinical and laboratory characteristics were obtained from the EMR. ICD-10 classification diagnoses were utilized to identify comorbidities, and patient BMIs were based on the admission values in the EMR. Outcomes were defined as death during current admission, transfer to nursing home or other facility, or discharge home. Using a tree-based model and the combined levels of the three labs we defined a hierarchy of four lab levels, each progressively having increased risk of death. We then analyzed the outcome for the four levels, adjusting for time period (surge), age, sex, race, BMI and comorbidities. Data was analyzed using SAS statistical software version 9.4 (SAS Institute).

Results

A total of 2197 patients were identified from March through December 2020, of whom 1118 had CRP, PC and DD available at baseline. The mean age was 66.7 years (SD 16.1) for the cohort in first surge (March-June), and 66.4 (15.6) in the latter surge (July-December, Table1). More patients had a PC of >0.5 in the first surge (25.7%) than the second (13.2%). After adjusting for all other factors, the hierarchical lab levels are significantly associated with outcomes. Of note, baseline CRP value was not informative. Compared to the 2nd level (Table 2), the lowest level (PC < 0.1) has significantly lower odds of death [OR=0.37, 95% CI (0.19, 0.73)], while the highest level, (DD >1000 and PC ≥ 0.26) has significantly higher odds of death [OR=3.01, 95% CI (1.59, 5.72)].

Conclusion

Baseline PC and DD, but not CRP, were informative in determining risk of death and can assist clinicians determine possible outcomes during COVID-19 hospitalization.

Disclosures

Christopher F. Carpenter, MD, MHSA, Atox Bio: Advisor/Consultant|GSK: Advisor/Consultant|Iterum Therapeutics: Advisor/Consultant|Takeda: Advisor/Consultant.

Development and Validation of a Controlled Pressure Method Test Protocol for Vapor Intrusion Pathway Assessment

Controlled pressure method (CPM) testing is a building-specific diagnostic tool for vapor intrusion (VI) pathway assessment which offers advantages over traditional pathway assessment approaches. By manipulating the building pressure conditions, the CPM creates the worst-case VI impact and provides rapid insight into the type of vapor source(s). The primary barrier to general acceptance and use of this tool is the need for definitive guidance on test design parameters, such as the indoor-outdoor pressure difference (or exhaust fan flow rate), CPM test duration, exhaust fan location, and air sampling location(s) and conditions. This study focused on a systematic evaluation of each of these factors, which then led to the formulation of proposed CPM testing guidelines. The results suggest that CPM tests should be conducted with both negative and positive pressure indoor-outdoor differentials of about 10-15 Pa, and the tests should last for at least nine indoor air exchanges for negative pressure difference testing and four indoor air exchanges for positive pressure difference testing. Although exhaust fan intake sampling is sufficient to provide critical information to assess impacts during negative pressure testing, adding room-specific indoor air sampling to both negative and positive pressure difference testing can provide insight into vapor entry locations and indoor source contributions.

Creation of a Sub-slab Soil Gas Cloud by an Indoor Air Source and Its Dissipation Following Source Removal

It is accepted that indoor sources of volatile organic compounds can confound vapor intrusion (VI) pathway assessment. When they are discovered during pre-sampling inspection, indoor sources are removed and air sampling is delayed, with the assumption that a few hours to a few days are sufficient for indoor source impacts to dissipate. This assumption was tested through the controlled release of SF₆ and its monitoring in indoor air and soil gas at a study house over 2 years. Results show that indoor sources generate subsurface soil gas clouds as a result of fluctuating direction in the exchange between soil gas and indoor air and that it may take days to weeks under natural conditions for a soil gas cloud beneath a building to dissipate following indoor source removal. The data also reveal temporal variability in indoor air and soil gas concentrations, long-term seasonal patterns, and dissipation of soil gas clouds over days to weeks following source removal. Preliminary modeling results for similar conditions are consistent field observations. If representative of other sites, these results suggest that a typical 1-3 day waiting period following indoor source removal may not be sufficient to avoid confounding data and erroneous conclusions regarding VI occurrence.

Implications Enzymatic Degradation of the Endothelial Glycocalyx on the Microvascular Hemodynamics and the Arteriolar Red Cell Free Layer of the Rat Cremaster Muscle

The endothelial glycocalyx is a complex network of glycoproteins, proteoglycans, and glycosaminoglycans; it lines the vascular endothelial cells facing the lumen of blood vessels forming the endothelial glycocalyx layer (EGL). This study aims to investigate the microvascular hemodynamics implications of the EGL by quantifying changes in blood flow hydrodynamics post-enzymatic degradation of the glycocalyx layer. High-speed intravital microscopy videos of small arteries (around 35 μm) of the rat cremaster muscle were recorded at various time points after enzymatic degradation of the EGL. The thickness of the cell free layer (CFL), blood flow velocity profiles, and volumetric flow rates were quantified. Hydrodynamic effects of the presence of the EGL were observed in the differences between the thickness of CFL in microvessels with an intact EGL and glass tubes of similar diameters. Maximal changes in the thickness of CFL were observed 40 min post-enzymatic degradation of the EGL. Analysis of the frequency distribution of the thickness of CFL allows for estimation of the thickness of the endothelial surface layer (ESL), the plasma layer, and the glycocalyx. Peak flow, maximum velocity, and mean velocity were found to statistically increase by 24, 27, and 25%, respectively, after enzymatic degradation of the glycocalyx. The change in peak-to-peak maximum velocity and mean velocity were found to statistically increase by 39 and 32%, respectively, after 40 min post-enzymatic degradation of the EGL. The bluntness of blood flow velocity profiles was found to be reduced post-degradation of the EGL, as the exclusion volume occupied by the EGL increased the effective volume impermeable to RBCs in microvessels. This study presents the effects of the EGL on microvascular hemodynamics. Enzymatic degradation of the EGL resulted in a decrease in the thickness of CFL, an increase in blood velocity, blood flow, and decrease of the bluntness of the blood flow velocity profile in small arterioles. In summary, the EGL functions as a molecular sieve to solute transport and as a lubrication layer to protect the endothelium from red blood cell (RBC) motion near the vessel wall, determining wall shear stress.

Identification of Alternative Vapor Intrusion Pathways Using Controlled Pressure Testing, Soil Gas Monitoring, and Screening Model Calculations

Vapor intrusion (VI) pathway assessment and data interpretation have been guided by an historical conceptual model in which vapors originating from contaminated soil or groundwater diffuse upward through soil and are swept into a building by soil gas flow induced by building underpressurization. Recent studies reveal that alternative VI pathways involving neighborhood sewers, land drains, and other major underground piping can also be significant VI contributors, even to buildings beyond the delineated footprint of soil and groundwater contamination. This work illustrates how controlled-pressure-method testing (CPM), soil gas sampling, and screening-level emissions calculations can be used to identify significant alternative VI pathways that might go undetected by conventional sampling under natural conditions at some sites. The combined utility of these tools is shown through data collected at a long-term study house, where a significant alternative VI pathway was discovered and altered so that it could be manipulated to be on or off. Data collected during periods of natural and CPM conditions show that the alternative pathway was significant, but its presence was not identifiable under natural conditions; it was identified under CPM conditions when measured emission rates were 2 orders of magnitude greater than screening-model estimates and subfoundation vertical soil gas profiles changed and were no longer consistent with the conventional VI conceptual model.

Risk factors for bloodstream infection caused by extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae: A focus on antimicrobials including cefepime

BACKGROUND

Extended-spectrum β-lactamase (ESBL)-producing pathogens represent increasing challenges to physicians because of rising prevalence, high mortality, and challenging treatment. Identifying high risks and early appropriate therapy is critical to favorable outcomes.

METHODS

This is a 5-year retrospective case-case-control study performed at the Detroit Medical Center on adult patients with bloodstream infection (BSI) caused by ESBL-producing and non-ESBL-producing Escherichia coli or Klebsiella pneumoniae, each compared with uninfected controls. Data were collected from December 2004-August 2009. Multivariate analysis was performed using logistic regression.

RESULTS

Participants included 103 patients with BSI caused by ESBL-producing pathogens and 79 patients with BSI caused by pathogens that did not produce ESBLs. The mean age of patients in the ESBL group was 67 years; of the patients, 51% were men, 77% were black, and 38% (n = 39) died in hospital. The mean age of patients in the non-ESBL group was 58 years; of the patients, 51% were men, 92% were black, and 22% (n = 17) died in hospital. On multivariate analysis, predictors of BSI caused by ESBL-producing pathogens included central venous catheter (odds ratio [OR], 29.4; 95% confidence interval [CI], 3.0-288.3), prior β-lactam-/β-lactamase-inhibitor therapy (OR, 28.1; 95% CI, 1.99-396.5), and prior cefepime therapy (OR, 22.7; 95% CI, 2.7-192.4). The only risk factor for BSI caused by non-ESBL-producing pathogens was urinary catheter insertion (OR, 18.2; 95% CI, 3.3-100.3).

CONCLUSION

Prior antimicrobial therapy, particularly with β-lactam, was the strongest unique risk factor for BSI caused by ESBL-producing E coli or K pneumoniae.

Perfusion pressure and blood flow determine microvascular apparent viscosity

NEW FINDINGS

What is the central question of this study? The aim was to evaluate the effect of perfusion pressure on blood flow in small arterioles. The hypothesis was that blood flow regulates the thickness of the red-cell-free layer and, therefore, blood flow determines blood apparent viscosity and local vascular resistance in vascular networks with limited myogenic or metabolic regulation of blood flow. What is the main finding and its importance? Reduced perfusion pressures lowered volumetric flow rates and increased local vascular resistance, due to increased blood apparent viscosity. Thus, the local vascular resistance of small arterioles with limited myogenic or metabolic regulation of blood flow, appeared to be determined by changes in blood rheology rather than blood vessel diameter. The study of blood flow regulation is important to understand and resolve pathological conditions. As blood is a complex non-Newtonian multiphase system, the foundations of blood rheological properties have been obtained mostly in viscometers. However, blood rheological behaviour in vivo depends on the concentration of red blood cells (RBCs), their mechanical properties and the RBC hydrodynamics, including RBC migration away from the vessel wall in shear flow. This migration promotes the formation of a RBC-depleted zone, or cell-free layer (CFL), which reduces the apparent viscosity of blood. We hypothesize that perfusion pressure determines blood apparent viscosity in microvessels, as shear rate affects axial migration of RBCs by influencing the CFL thickness. In this study, we analysed the effects of perfusion pressure on blood flow in individual arterioles within the rat cremaster muscle preparation. Perfusion pressures to this microvascular bed were controlled by occlusions of the iliac artery using a pressure cuff. Blood flow measurements were obtained from direct measurements of blood flow velocity profile, as well as determination of CFL thickness using intravital microscopy. Our results indicate that perfusion pressure determines shear rates and the CFL thickness and its variations. In addition, blood flow reduction increased local vascular resistance by augmenting blood apparent viscosity rather than vascular hindrance. In conclusion, blood rheology could act as an intrinsic mechanism to further limit blood flow to tissue with limited myogenic and metabolic responses at low perfusion pressures.

Long-term evaluation of the controlled pressure method for assessment of the vapor intrusion pathway

Vapor intrusion (VI) investigations often require sampling of indoor air for evaluating occupant risks, but can be confounded by temporal variability and the presence of indoor sources. Controlled pressure methods (CPM) have been proposed as an alternative, but temporal variability of CPM results and whether they are indicative of impacts under natural conditions have not been rigorously investigated. This study is the first involving a long-term CPM test at a house having a multiyear high temporal resolution indoor air data set under natural conditions. Key observations include (a) CPM results exhibited low temporal variability, (b) false-negative results were not obtained, (c) the indoor air concentrations were similar to the maximum concentrations under natural conditions, and (d) results exceeded long-term average concentrations and emission rates under natural conditions by 1-2 orders of magnitude. Thus, the CPM results were a reliable indicator of VI occurrence and worst-case exposure regardless of day or time of year of the CPM test.

Reduction of diffusive contaminant emissions from a dissolved source in a lower permeability layer by sodium persulfate treatment

Residual contamination contained in lower permeability zones is difficult to remediate and can, through diffusive emissions to adjacent higher permeability zones, result in long-term impacts to groundwater. This work investigated the effectiveness of oxidant delivery for reducing diffusive emissions from lower permeability zones. The experiment was conducted in a 1.2 m tall × 1.2 m wide × 6 cm thick tank containing two soil layers having 3 orders of magnitude contrast in hydraulic conductivity. The lower permeability layer initially contained dissolved methyl tert-butyl ether (MTBE) and benzene, toluene, ethylbenzene, and p-xylenes (BTEX). The treatment involved delivery of 10% w/w nonactivated sodium persulfate (Na2S2O8) solution to the high permeability layer for 14 days. The subsequent diffusion into the lower permeability layer and contaminant emission response were monitored for about 240 days. The S2O8(2-) diffused about 14 cm at 1% w/w into the lower permeability layer during the 14 day delivery and continued diffusing deeper into the layer as well as back toward the higher-lower permeability interface after delivery ceased. Over 209 days, the S2O8(2-) diffused 60 cm into the lower permeability layer, the BTEX mass and emission rate were reduced by 95-99%, and the MTBE emission rate was reduced by 63%. The overall treatment efficiency was about 60-110 g-S2O8(2-)delivered/g-hydrocarbon oxidized, with a significant fraction of the oxidant delivered likely lost by back-diffusion and not involved in hydrocarbon destruction.

Vestibulo-ocular Reflex (VOR) Impact on USAF Undergraduate Pilot Training Proficiency

Objectives:

The US Air Force (USAF) enrolls 1400 Specialized Undergraduate Pilot Trainees (SUPT) at 3 locations within the United States each year. SUPT training has an estimated accumulated cost of $1M to $1.5M per trainee. Attrition rates from training have ranged from 7.8% to 36.9%. The cost associated with trainee disqualification is estimated at $1M per percentage point of annual attrition. One percent of UPT disqualifications are due to medical factors and another 1.5% are due to failure to adapt to flying.

Methods:

In 1994 the USAF conducted rotary chair vestibulo-ocular (VOR) test on 150 SUPT candidates at the USAF Research Laboratory, Brooks Air Force Base as part of the second phase of the Enhanced Flight Screening- Medical Study (EFS-M). Retrospective review of SUPT scores was correlated with pre-training VOR test results of the original 150 pilots who participated in the EFS-M VOR data collection. Twenty-year prospective survey data collected from EFS-M study pilots was correlated to initial EFS-M VOR test results to identify trends in their subsequent pilot career progression and incidence of in-flight physiologic events deemed linked to vestibular illusions.

Results:

VOR performance trends exist between USAF pilot trainee cohorts. VOR performance can predict initial flight training proficiency in SUPT candidates. Long term follow-up survey responses indicate that VOR performance can predict flight career proficiency in SUPT training candidates.

Conclusions:

A validated correlation between VOR results and flight performance can help establish VOR test parameters associated with successful flight training ability.

Effect of dissolved oxygen manipulation on diffusive emissions from NAPL-impacted low permeability soil layers

Aquifer physical model experiments were performed to investigate if diffusive emissions from nonaqueous phase liquid (NAPL)-impacted low-permeability layers into groundwater moving through adjacent NAPL-free high-permeability layers can be reduced by creating an aerobic biotreatment zone at the interface between the two, and if over time that leads to reduced emissions after treatment ceases. Experiments were performed in two 1.2-m long × 1.2-m high × 5.4 cm wide stainless steel tanks; each with a high-permeability sand layer overlying a low-permeability crushed granite layer containing a NAPL mixture of indane and benzene. Each tank was water-saturated with horizontal flow primarily through the sand layer. The influent water was initially deoxygenated and the emissions and concentration distributions were allowed to reach near-steady conditions. The influent dissolved oxygen (DO) level was increased stepwise to 6.5-8.5 mg/L and 17-20 mg/L, and then decreased back to deoxygenated conditions. Each condition was maintained for at least 45 days. Relative to the near-steady benzene emission at the initial deoxygenated condition, the emission was reduced by about 70% when the DO was 6.5-8.5 mg/L, 90% when the DO was 17-20 mg/L, and ultimately 60% when returning to low DO conditions. While the reductions were substantial during treatment, longer-term reductions after 120 d of elevated DO treatment, relative to an untreated condition predicted by theory, were low: 29% and 6% in Tank 1 and Tank 2, respectively. Results show a 1-2 month lag between the end of DO delivery and rebound to the final near-steady emissions level. This observation has implications for post-treatment performance monitoring sampling at field sites.

Microhemodynamic aberrations created by transfusion of stored blood

BACKGROUND

Human red blood cells (RBCs) can be stored for up to 42 days under controlled conditions. Physical and chemical changes occur during RBC storage, altering their function. This study links stored cell mechanical changes with hemodynamic functional alterations upon transfusion.

STUDY DESIGN AND METHODS

Mechanical properties of fresh and stored RBCs were evaluated in vitro. Their transfusion effects were evaluated in vivo using intravital microscopy of the rat's cremaster muscle preparation. Rats were hemodiluted to 30% hematocrit, to mimic an anemic state before transfusion, and then exchange-transfused with fresh or stored cells.

RESULTS

In vitro studies on rheology and oxygen affinity of stored cells confirmed previously published results. Storage was found to modify static and dynamic RBC mechanic behavior. After transfusion, systemic hemodynamics were similar for fresh and stored cells; however, microvascular hemodynamics were drastically affected by stored cells. Stored cells reduced blood flow and oxygen delivery. Additionally, the presence of stored cells in circulation affected cell-to-cell and cell-to-wall interactions and affected cell hydrodynamics. Stored cells disrupted the RBC cell-free layer and wall shear stress signals.

CONCLUSION

The reduced cell deformability due to RBC "storage lesions" caused pathologic changes in microvascular hemodynamics, endothelial cell mechanotransduction, and RBC dynamics. Thus, the mechanical changes of blood-banked cells can limit transfusion ability to achieve its intended goal.

Proof-of-concept study of an aerobic vapor migration barrier beneath a building at a petroleum hydrocarbon-impacted site

A proof-of-concept study was conducted to evaluate an alternative to traditional extraction-based subslab vapor mitigation systems at sites with petroleum hydrocarbon and/or methane vapor impact concerns. The system utilizes the slow delivery of air beneath a foundation to attenuate vapor migration to the building via aerobic biodegradation. The study was conducted at a site having elevated hydrocarbon plus methane and depleted O(2) vapor concentrations (160 mg/L and <1% v/v, respectively) beneath a building having a 195 m(2) footprint and a basement extending 1.5 m below ground surface (BGS). Nonaqueous phase liquid (NAPL)-impacted soils, first encountered at about 7.6 to 9.1 m BGS, were the source of hydrocarbon and methane vapors, with the latter being generated by anaerobic methanagenesis of the former. O(2) concentrations beneath and around the building were monitored prior to and during air injection through a horizontal well installed about 1.5 m beneath the foundation. The air injection rate was increased from 1 to 5 to 10 L/min, with each held steady until the O(2) distribution stabilized (46-60 d). The 10 L/min flow rate achieved >5% v/v soil gas O(2) concentrations beneath the foundation and spanning a 1.5 m vertical interval. It was within 3× of the pretest stoichiometric requirement estimate of 3.8 L/min. This resulted in reductions in subslab hydrocarbon plus methane concentrations from 80 to <0.01 mg/L and benzene, toluene, ethylbenzene, and xylenes (BTEX) reductions to below detection limits (0.5-0.74 ppb(v)). This air injection rate is <1% of flows for typical extraction-based mitigation systems.

Temporal variability of indoor air concentrations under natural conditions in a house overlying a dilute chlorinated solvent groundwater plume

Current vapor intrusion (VI) pathway assessment heavily weights concentrations from infrequent (monthly-seasonal) 24 h indoor air samples. This study collected a long-term and high-frequency data set that can be used to assess indoor air sampling strategies for answering key pathway assessment questions like: "Is VI occurring?", and "Will VI impacts exceed thresholds of concern?". Indoor air sampling was conducted for 2.5 years at 2-4 h intervals in a house overlying a dilute chlorinated solvent plume (10-50 μg/L TCE). Indoor air concentrations varied by 3 orders of magnitude (<0.01-10 ppbv TCE) with two recurring behaviors. The VI-active behavior, which was prevalent in fall, winter, and spring involved time-varying impacts intermixed with sporadic periods of inactivity; the VI-dormant behavior, which was prevalent in the summer, involved long periods of inactivity with sporadic VI impacts. These data were used to study outcomes of three simple sparse data sampling plans; the probabilities of false-negative and false-positive decisions were dependent on the ratio of the (action level/true mean of the data), the number of exceedances needed, and the sampling strategy. The analysis also suggested a significant potential for poor characterization of long-term mean concentrations with sparse sampling plans. The results point to a need for additional dense data sets and further investigation into the robustness of possible VI assessment paradigms. As this is the first data set of its kind, it is unknown if the results are representative of other VI-sites.

Plasma expander viscosity effects on red cell-free layer thickness after moderate hemodilution

The objective of the study was to investigate the effects of plasma viscosity after hemodilution on the thickness of the erythrocyte cell free layer (CFL) and on the interface between the flowing column of erythrocytes and the vascular endothelium. The erythrocyte CFL thickness was measured in the rat cremaster muscle preparation. Plasma viscosity was modified in an isovolemic hemodilution, in which the systemic hematocrit (Hctsys) was lowered to 30%. The plasma expanders (PE) of similar nature and different viscosities were generated by glutaraldehyde polymerization of human serum albumin (HSA) at various molar ratios glutaraldehyde to HSA: (i) unpolymerized HSA; (ii) PolyHSA24:1, molar ratio = 24 and (iii) PolyHSA60:1, molar ratio = 60. The HSA viscosities determined at 200 s(-1) were 1.1, 4.2 and 6.0 dyn x cm(-2), respectively. CFL thickness, vessel diameter and blood flow velocity were measured, while volumetric flow, shear rate and stress were calculated. Hemodilution with PolyHSA60:1 increased plasma viscosity and the blood showed marked shear thinning behavior. CFL thickness decreased as plasma viscosity increased after hemodilution; thus the CFL thickness with HSA and PolyHSA24:1 increased compared to baseline. Conversely, the CFL thickness of PolyHSA60:1 was not different from baseline. Blood flow increased with both PolyHSA's compared to baseline. Wall shear rate and shear stress increased for PolyHSA60:1 compared to HSA and PolyHSA24:1, respectively. In conclusion, PE viscosity determined plasma viscosity after hemodilution and affected erythrocyte column hydrodynamics, changing the velocity profile, CFL thickness, and wall shear stress. This study relates the perfusion caused by PolyHSA60:1 to hemodynamic changes induced by the rheological properties of blood diluted with PolyHSA60:1.

Chlorinated ethene source remediation: lessons learned

Chlorinated solvents such as trichloroethene (TCE) and tetrachloroethene (PCE) are widespread groundwater contaminants often released as dense nonaqueous phase liquids (DNAPLs). These contaminants are difficult to remediate, particularly their source zones. This review summarizes the progress made in improving DNAPL source zone remediation over the past decade, and is structured to highlight the important practical lessons learned for improving DNAPL source zone remediation. Experience has shown that complete restoration is rare, and alternative metrics such as mass discharge are often useful for assessing the performance of partial restoration efforts. Experience also has shown that different technologies are needed for different times and locations, and that deliberately combining technologies may improve overall remedy performance. Several injection-based technologies are capable of removing a large fraction of the total contaminant mass, and reducing groundwater concentrations and mass discharge by 1 to 2 orders of magnitude. Thermal treatment can remove even more mass, but even these technologies generally leave some contamination in place. Research on better delivery techniques and characterization technologies will likely improve treatment, but managers should anticipate that source treatment will leave some contamination in place that will require future management.

Effect of plasma expander viscosity on the cell free layer

The effect of low and high viscosity hemodilution with plasma expanders on the extent of the cell free layer (CFL) width was analyzed in the microcirculation of the exteriorized cremaster muscle preparation of Sprague-Dawley male rats. Anesthetized animals were subjected to 40% hemodilution by blood volume, using 5% human serum albumin (HSA) or 6% Hetastarch (hydroxyethyl starch 670 kDa). Arterioles (n=5 for each treatment) were investigated. Mean arterial pressure, heart rate, vessel flow velocity and CFL width were measured at baseline and 5, 20 and 40 min post-exchange transfusion. Blood and plasma viscosity was determined from terminal blood collections. CFL width and pseudoshear rate, diameter and flow, normalized to baseline, were significantly elevated at all post-exchange assessments. Peripheral vascular resistance decreased. The increase of the CFL width was greater with HSA by comparison with Hetastarch hemodilution (p<0.05). Hetastarch blood and plasma viscosities increased significantly compared to those of HSA (p<0.05). This study shows that CFL widths are influenced by plasma expander viscosity, a phenomenon proportional to the increase in molecular weight of the colloids in solution.

Integration of cardiovascular regulation by the blood/endothelium cell-free layer

The cell-free layer (CFL) width separating red blood cells in flowing blood from the endothelial cell membrane is shown to be a regulator of the balance between nitric oxide (NO) production by the endothelium and NO scavenging by blood hemoglobin. The CFL width is determined by hematocrit (Hct) and the vessel wall flow velocity gradient. These factors and blood and plasma viscosity determine vessel wall shear stress which regulates the production of NO in the vascular wall. Mathematical modeling and experimental findings show that vessel wall NO concentration is a strong nonlinear function of Hct and that small Hct variations have comparatively large effects on blood pressure regulation. Furthermore, NO concentration is a regulator of inflammation and oxygen metabolism. Therefore, small, sustained perturbations of Hct may have long-term effects that can promote pro-hypertensive and pro-inflammatory conditions. In this context, Hct and its variability are directly related to vascular tone, peripheral vascular resistance, oxygen transport and delivery, and inflammation. These effects are relevant to the analysis and understanding of blood pressure regulation, as NO bioavailability regulates the contractile state of blood vessels. Furthermore, regulation of the CFL is a direct function of blood composition therefore understanding of its physiology relates to the design and management of fluid resuscitation fluids. From a medical perspective, these studies propose that it should be of clinical interest to note small variations in patient's Hct levels given their importance in modulating the CFL width and therefore NO bioavailability. WIREs Syst Biol Med 2011 3 458-470 DOI: 10.1002/wsbm.150

Shear stress activation of nitric oxide synthase and increased nitric oxide levels in human red blood cells

Red blood cells (RBC) play an important role in the balance between generation and scavenging of nitric oxide (NO) and hence its local bioavailability and influence on vasomotor control. Previous studies have reported increased NO levels in RBC suspensions subsequent to exposure to shear forces; the present study was designed to further investigate changes in intracellular NO concentration and possible mechanisms involved for RBC exposed to well-controlled shear forces. Attached human RBC were subjected to shear stresses up to 0.1Pa in a parallel-plate flow channel; fluorescent methods were used to monitor changes in intracellular NO and calcium concentrations. Intracellular NO concentration, estimated by the fluorescence level of 4-amino-5-methylamino-2',7'-difluorofluorescein diacetate (DAF-FM), increased sharply within 30s following the application of shear stress between 0.013 and 0.1Pa. This increase was only partially prevented by the absence of l-arginine and by the presence of l-N-acetyl-methyl-arginine (L-NAME), strongly suggesting that this response was in part related to the activation of NO-synthase (NOS) enzyme. The increase in intracellular NO concentration under shear stress was also inhibited by calcium chelation in the suspending medium, indicating the role of calcium entry for NOS activation. Increases of intracellular calcium concentrations under the same shearing conditions were demonstrated by monitoring Fluo-3/AM fluorescence in RBC exposed to shear stress. Serine 1177 phosphorylated NOS protein, the activated form of the enzyme determined by immunohistochemistry, was found to be significantly increased following the exposure of RBC to 0.1Pa shear stress for 1min. These data confirm that RBC possess a NOS enzyme that is actively synthesizing NO and activated by effective shear forces. The data also suggest that there may be additional (e.g., non-enzymatic) NO generating mechanisms in RBC that are also enhanced under shear stress.

The effect of small changes in hematocrit on nitric oxide transport in arterioles

We report the development of a mathematical model that quantifies the effects of small changes in systemic hematocrit (Hct) on the transport of nitric oxide (NO) in the microcirculation. The model consists of coupled transport equations for NO and oxygen (O2) and accounts for both shear-induced NO production by the endothelium and the effect of changing systemic Hct on the rate of NO production and the rate of NO scavenging by red blood cells. To incorporate the dependence of the plasma layer width on changes in Hct, the model couples the hemodynamics of blood in arterioles with NO and O2 transport in the plasma layer. A sensitivity analysis was conducted to determine the effects of uncertain model parameters (the thicknesses of endothelial surface layers and diffusion coefficients of NO and O2 in muscle tissues and vascular walls) on the model's predictions. Our analysis reveals that small increases in Hct may raise NO availability in the vascular wall. This finding sheds new light on the experimental data that show that the blood circulation responds to systematic increases of Hct in a manner that is consistent with increasing NO production followed by a plateau.

The variability of blood pressure due to small changes of hematocrit

The hematocrit (Hct) of awake hamsters was lowered to 90% of baseline by isovolemic hemodilution using hamster plasma to determine the acute effect of small changes in Hct and blood viscosity on systemic hemodynamics. Mean arterial blood pressure increased, reaching a maximum of about 10% above baseline (8.6 +/- 5.5 mmHg) when Hct decreased 8.4 +/- 1.9% (P < 0.005). Cardiac output increased continuously with hemodilution. These conditions were reached at approximately 60 min after exchange transfusion and remained stationary for 1 h. Peripheral vascular resistance was approximately constant up to a decrease of Hct of about 10% and then fell continuously with lowering Hct. Vascular hindrance or vascular resistance independent of blood viscosity increased by about 20% and remained at this level up to an Hct decrease of 20%, indicating that the vasculature constricted with the lowered Hct. The results for the initial 2-h period are opposite but continuous with previous findings with small increases in Hct. In conclusion, limited acute anemic conditions increase mean arterial blood pressure during the initial period of 2 h, an effect that is quantitatively similar but opposite to the acute increase of Hct during the same period.

Cardiovascular benefits in moderate increases of blood and plasma viscosity surpass those associated with lowering viscosity: Experimental and clinical evidence

Decreasing blood viscosity has been proposed since the advent of hemodilution as a means for increasing perfusion in many pathological conditions, and increased plasma viscosity is associated with the presence of pathological conditions. However, experimental studies show that microvascular functions as represented by functional capillary density in conditions of significantly decreased viscosity is impaired, a problem corrected by increasing plasma and blood viscosity. Blood viscosity, primarily dependent on hematocrit (Hct) is a determinant of peripheral vascular resistance, and therefore blood pressure. In the healthy population Hct presents a variability, which is not reflected by the variability of blood pressure. This is due to a regulatory process at the level of the endothelium, whereby the increase of Hct (and therefore blood viscosity) leads to increased shear stress and the production of the vasodilator nitric oxide (NO), a finding supported by experimental studies showing that the acute increase of Hct lowers blood pressure. Studies that in the healthy population show that blood pressure and Hct have a weak positive correlation. However, when the effect of blood viscosity is factored out, blood pressure and Hct are negatively and significantly correlated, indicating that as blood viscosity increases, the circulation dilates. Conversely, lower Hct and blood viscosity conditions lead to a constricted circulation, associated with a condition of decreased NO bioavailability, and therefore a pro-inflammatory condition.

Effect of erythrocyte aggregation and flow rate on cell-free layer formation in arterioles

Formation of a cell-free layer is an important dynamic feature of microcirculatory blood flow, which can be influenced by rheological parameters, such as red blood cell aggregation and flow rate. In this study, we investigate the effect of these two rheological parameters on cell-free layer characteristics in the arterioles (20-60 mum inner diameter). For the first time, we provide here the detailed temporal information of the arteriolar cell-free layer in various rheological conditions to better describe the characteristics of the layer variation. The rat cremaster muscle was used to visualize arteriolar flows, and the extent of aggregation was raised by dextran 500 infusion to levels seen in normal human blood. Our results show that cell-free layer formation in the arterioles is enhanced by a combination of flow reduction and red blood cell aggregation. A positive relation (P < 0.005) was found between mean cell-free layer widths and their corresponding SDs for all conditions. An analysis of the frequency and magnitudes of cell-free layer variation from their mean value revealed that the layer deviated with significantly larger magnitudes into the red blood cell core after flow reduction and dextran infusion (P < 0.05). In accordance, the disparity of cell-free layer width distribution found in opposite radial directions from its mean became greater with aggregation in reduced flow conditions. This study shows that the cell-free layer width in arterioles is dependent on both flow rate and red blood cell aggregability, and that the temporal variations in width are asymmetric with a greater excursion into the red blood cell core than toward the vessel wall.

Computational fluid dynamics of aggregating red blood cells in postcapillary venules

Aggregate formation of red blood cells (RBCs) in a postcapillary venular bifurcation is investigated with three-dimensional computer simulations using the Chimera grid method. Interaction energy between the RBCs is modelled by a depletion interaction theory; RBCs are modelled as rigid oblate ellipsoids. The cell-cell interactions of RBCs are strongly dependent on vessel geometry and shear rates. The experimental data on vessel geometry, pseudoshear rates, and Dextran concentration obtained in our previous in vivo RBC aggregation study in postcapillary venules of the rat spinotrapezius muscle were used to simulate RBC aggregation. The computational results were compared to the experimental results from the in vivo study. The results show that cells have a larger tendency to form an aggregate under reduced flows. Aggregate formation also depends on the angle and location of the cells before they enter the bifurcation region. Comparisons with experimental data are discussed.

Effect of dextran 500 on radial migration of erythrocytes in postcapillary venules at low flow rates

Recently, we reported that collision efficiency (fraction of total collisions that result in the formation of aggregates) between red blood cells was an important factor in the formation of aggregates in postcapillary venules. In the present study, we focus on how high molecular weight dextran influences the overall radial migration trend of red blood cells in the postcapillary venule along a longitudinal distance of 50 microm from the bifurcation which would in turn affect collision behavior of these cells. A radial migration index, which defines the extent of radial migration of individual cells relative to the vessel center, was found to have a larger magnitude after infusion of dextran (1.9 +/- 2.73) compared to that before dextran infusion (1.48 +/- 3.89). This implied that dextran-induced aggregation might provide an external force to actively move cells towards the centerline of the vessel, which could contribute to the greater number of red blood cells participating in collision (16% increase) and aggregate formation. Further analysis of the collision behavior of individual red blood cells revealed that collision frequencies of individual cells decreased from a wide range (1 to 14) to a narrow range (1 to 5) after dextran treatment, indicating the alteration of collision behavior of red blood cells by the presence of aggregates along the flow stream.

Effects of erythrocyte deformability and aggregation on the cell free layer and apparent viscosity of microscopic blood flows

Concentrated erythrocyte (i.e., red blood cell) suspensions flowing in microchannels have been simulated with an immersed-boundary lattice Boltzmann algorithm, to examine the cell layer development process and the effects of cell deformability and aggregation on hemodynamic and hemorheological behaviors. The cells are modeled as two-dimensional deformable biconcave capsules and experimentally measured cell properties have been utilized. The aggregation among cells is modeled by a Morse potential. The flow development process demonstrates how red blood cells migrate away from the boundary toward the channel center, while the suspending plasma fluid is displaced to the cell free layer regions left by the migrating cells. Several important characteristics of microscopic blood flows observed experimentally have been well reproduced in our model, including the cell free layer, blunt velocity profile, changes in apparent viscosity, and the Fahraeus effect. We found that the cell free layer thickness increases with both cell deformability and aggregation strength. Due to the opposing effects of the cell free layer lubrication and the high viscosity of cell-concentrated core, the influence of aggregation is complex but the lubrication effect appears to dominate, causing the relative apparent viscosity to decrease with aggregation. It appears therefore that the immersed-boundary lattice Boltzmann numerical model may be useful in providing valuable information on microscopic blood flows in various microcirculation situations.

An evaluation of compound-specific isotope analyses for assessing the biodegradation of MTBE at Port Hueneme, CA

The use of compound-specific isotope analysis (CSIA) as a diagnostic tool for MTBE biodegradation in aquifers was tested at the Port Hueneme, CA site. There, a 1500-m long dissolved MTBE plume and associated engineered aerobic flow-through biobarrier have been well-studied, leading to delineation of regions of known significant and limited bioattenuation. This allowed comparison of field-scale CSIA results with a priori knowledge of aerobic MTBE biodegradation, leading to conclusions concerning the utility of CSIA as a diagnostic tool for other aerobic biodegradation sites. Groundwater samples were collected and analyzed for both 13C and 2H (D) in MTBE through the bioactive treatment zone and within the larger MTBE plume. For reference, the 13C enrichment factor for MTBE biodegradation in laboratory-scale microcosms using site groundwater and sediments was also quantified. Aerobic microcosms showed a 13C enrichment of 5.5 to 6.4 +/- 0.2 per thousand over a two-order of magnitude concentration decrease, with an average isotope enrichment factor (epsilon(c)) of -1.4 per thousand, in agreement with other aerobic microcosm studies. Less 13C enrichment (about 25%) was observed for similar MTBE concentration reductions in groundwater samples collected within the aerobic biotreatment zone, and this enrichment was comparable to the scatter in delta13C values within the source zone. Increasing enrichment with decreasing MTBE concentration seen in microcosm data was not evident in either the 13C or D field data. The discrepancy between field and laboratory data may reflect small-scale (<1 m) spatial heterogeneity in MTBE biodegradation activity and the mixing of water from adjacent strata during groundwater sampling; for example, relatively nonattenuated MTBE-impacted water from one stratum could be mixed with highly attenuated/low-MTBE concentration from another, and this could produce a sample with both reduced MTBE concentration and low enrichment. Overall, the results suggest that 13C data alone may produce inconclusive results at sites where MTBE undergoes aerobic biodegradation, and that even with two-dimensional CSIA (13C and D), an increase in the confidence of data interpretation may only be possible with data sets larger than those typically collected in practice.

Oxygen transport from the atmosphere to soil gas beneath a slab-on-grade foundation overlying petroleum-impacted soil

Modeling and field study results suggest that, in the case of a building overlying an aerobically biodegradable vapor source (i.e., petroleum-impacted soil), the significance of vapor intrusion into the building depends on the source vapor concentration, the relative position of the vapor source and building, and the rate of O2 transport from the atmosphere to the soil gas beneath the building. This work quantified the latter at a house having about a 250 m2 slab-on-grade foundation footprint. It was constructed on 1.5 m of clean fill overlying a petroleum hydrocarbon-impacted soil layer undergoing methanogenesis. Soil gas O2 and CH4 profiles adjacent to and beneath the foundation were measured and then the soil gas beneath the slab was rapidly displaced with N2. The natural replenishment of O2 was monitored for 90 days using in situ O2 sensors, and the responses with time were similar, independent of location. The O2 replenishment rate was about 2500 g-O2/d immediately after the N2 flood and then it declined to 200-500 g-O2/d over 30 days. Weather events affected the O2 replenishment rate; an increase occurred during a strong wind period (> 3 m/s), and a decrease occurred during a heavy rainfall event. The spatial and temporal patterns in the O2 sensor responses and quantified O2 replenishment rates could not be accounted for by simple mechanistic hypotheses involving lateral diffusion or advection through the bulk soil, and instead the data suggest rapid replenishment immediately below the foundation followed by downward diffusion.

Red blood cell aggregation and dissociation in shear flows simulated by lattice Boltzmann method

In this paper we develop a lattice Boltzmann algorithm to simulate red blood cell (RBC) behavior in shear flows. The immersed boundary method is employed to incorporate the fluid-membrane interaction between the flow field and deformable cells. The cell membrane is treated as a neo-Hookean viscoelastic material and a Morse potential is adopted to model the intercellular interaction. Utilizing the available mechanical properties of RBCs, multiple cells have been studied in shear flows using a two-dimensional approximation. These cells aggregate and form a rouleau under the action of intercellular interaction. The equilibrium configuration is related to the interaction strength. The end cells exhibit concave shapes under weak interaction and convex shapes under strong interaction. In shear flows, such a rouleau-like aggregate will rotate or be separated, depending on the relative strengths of the intercellular interaction and hydrodynamic viscous forces. These behaviors are qualitatively similar to experimental observations and show the potential of this numerical scheme for future studies of blood flow in microvessels.

Temporal and spatial variations of cell-free layer width in arterioles

Separation of red blood cells and plasma in microcirculatory vessels produces a cell-free layer at the wall. This layer may be an important determinant of blood viscosity and wall shear stress in arterioles, where most of the hydraulic pressure loss in the circulatory system occurs and flow regulatory mechanisms are prominent. With the use of a newly developed method, the width of the cell-free layer was rapidly and repeatedly determined in arterioles (10- to 50-μm inner diameter) in the rat cremaster muscle at normal arterial pressure. The temporal variation of the cell-free layer width was non-Gaussian, but calculated mean and median values differed by <0.2 μm. The correlation length of the temporal variations downstream (an indication of mixing) was ∼30 μm and was independent of pseudoshear rate (ratio of mean velocity to vessel diameter) and of vessel diameter. The cell-free layer width was significantly different on opposite sides of the vessel and inversely related. Increasing red blood cell aggregability reduced this inverse relation but had no effect on correlation length. In the diameter range studied, the mean width of the cell-free layer increased from 0.8 to 3.1 μm and temporal variations increased from 30% to 70% of the mean width. Increased aggregability did not alter either relationship. In summary, the cell-free layer width in arterioles is diameter dependent and shows substantial non-Gaussian temporal variations. The temporal variations increase as diameter increases and are inversely related on opposite sides of the vessel.

Lowering of blood pressure by increasing hematocrit with non nitric oxide scavenging red blood cells

Isovolemic exchange transfusion of 40% of the blood volume in awake hamsters was used to replace native red blood cells (RBCs) with RBCs whose hemoglobin (Hb) was oxidized to methemoglobin (MetHb), MetRBCs. The exchange maintained constant blood volume and produced different final hematocrits (Hcts), varying from 48 to 62% Hct. Mean arterial pressure (MAP) did not change after exchange transfusion, in which 40% of the native RBCs were replaced with MetRBCs, without increasing Hct. Increasing Hct with MetRBCs lowered MAP by 12 mm Hg when Hct was increased 12% above baseline. Further increases of Hct with MetRBCs progressively returned MAP to baseline, which occurred at 62% Hct, a 30% increase in Hct from baseline. These observations show a parabolic "U" shaped distribution of MAP against the change in Hct. Cardiac index, cardiac output divided by body weight, increased between 2 and 17% above baseline for the range of Hcts tested. Peripheral vascular resistance (VR) was decreased 18% from baseline when Hct was increased 12% from baseline. VR and MAP were above baseline for increases in Hct higher than 30%. However, vascular hindrance, VR normalized by blood viscosity (which reflects the contribution of vascular geometry), was lower than baseline for all the increases in Hct tested with MetRBC, indicating prevalence of vasodilation. These suggest that acute increases in Hct with MetRBCs increase endothelium shear stress and stimulate the production of vasoactive factors (e.g., nitric oxide [NO]). When MetRBCs were compared with functional RBCs, vasodilation was augmented for MetRBCs probably due to the lower NO scavenging of MetHb. Consequently, MetRBCs increased the viscosity related hypotension range compared with functional RBCs as NO shear stress vasodilation mediated responses are greater.

Contributions of collision rate and collision efficiency to erythrocyte aggregation in postcapillary venules at low flow rates

Red blood cell aggregation at low flow rates increases venous vascular resistance, but the process of aggregate formation in these vessels is not well understood. We previously reported that aggregate formation in postcapillary venules of the rat spinotrapezius muscle mainly occurs in a middle region between 15 and 30 microm downstream from the entrance. In light of the findings in that study, the main purpose of this study was to test two hypotheses by measuring collision frequency along the length of the venules during low flow. We tested the hypothesis that aggregation rarely occurs in the initial 15-microm region of the venule because collision frequency is very low. We found that collision frequency was lower than in other regions, but collision efficiency (the ratio of aggregate formation to collisions) was almost nil in this region, most likely because of entrance effects and time required for aggregation. Radial migration of red blood cells and Dextran 500 had no effect on collision frequency. We also tested the hypothesis that aggregation was reduced in the distal venule region because of the low aggregability of remaining nonaggregated cells. Our findings support this hypothesis, since a simple model based on the ratio of aggregatable to nonaggregatable red blood cells predicts the time course of collision efficiency in this region. Collision efficiency averaged 18% overall but varied from 0 to 52% and was highest in the middle region. We conclude that while collision frequency influences red blood cell aggregate formation in postcapillary venules, collision efficiency is more important.

Is the distribution of tissue pO(2) homogeneous?

Oxygen transport from blood to the mitochondria is dependent on oxygen gradients. The interstitial or extracellular pO(2), measured by the phosphorescence-decay method, is indicative of these driving forces and the amount of oxygen available to the mitochondria. Diverse protocols for sampling tissue pO(2) show that measurements sampling only interstitial pO(2) levels provide a reliable measurement of the tissue pO(2) level. Present findings lead to the hypothesis that tissue has a fairly uniform interstitial fluid pO(2) level and that local inhomogeneity due to the presence arteriolar and venular vessels is smoothed out by the steep gradients at the microvascular walls.

Contribution of anaerobic metabolism to reactive hyperemia in skeletal muscle

Elevated blood flow (reactive hyperemia) is seen in many organs after a period of blood flow stoppage. This hyperemia is often considered to be due in part to a shift to anaerobic metabolism during tissue hypoxia. The aim of our study was to test this hypothesis in skeletal muscle. For this purpose we measured NADH fluorescence at localized tissue areas in cat sartorius muscle during and after arterial occlusions of 5-300 s. In parallel studies, red blood cell (RBC) velocity was measured in venules. Tissue NADH fluorescence rose significantly with occlusions of 45 s or greater, reaching a maximum of 44% above control at 180 s. Peak RBC velocity rose to four times control as occlusion duration was increased from 5 to 45 s, but hyperemia duration was stable at approximately 70 s. With occlusions of 45-240 s, hyperemia duration increased progressively to 210 s while peak flow was unchanged. However, after 300-s occlusions, peak flow rose to six times above control and hyperemia duration fell to 140 s. With occlusions of 45-300 s the time integral both of increased NADH fluorescence and of reduced fluorescence following occlusion release showed a high degree of correlation with the additional hyperemia. We conclude that in this muscle anaerobic vasodilator metabolites are responsible for the increase in reactive hyperemia with arterial occlusions longer than 45 s. Since the durations of reactive hyperemia and reduced fluorescence are substantially different, vasodilator metabolite removal may be due to washout by the bloodstream rather than metabolic uptake.

Application of Chimera grid to modelling cell motion and aggregation in a narrow tube

A computational scheme using the Chimera grid method is presented for simulation of three-dimensional motion and aggregation of two red blood cells (RBCs) in a narrow tube. The cells are modelled as rigid ellipsoidal particles; the computational scheme is applicable to deformable fluid-filled particles. Attractive energy between two RBCs is modelled by a depletion interaction theory and used for simulating aggregation of two cells. Through the simulation, we show that the Chimera grid method is applicable to the simulation of three-dimensional motion and aggregation of multiple RBCs in a microvessel and microvascular network.

Red blood cell velocity profiles in skeletal muscle venules at low flow rates are described by the Casson model

Knowledge of the effects of red blood cell aggregation on blood flow in small vessels is crucial to a better understanding of resistance changes in the venous microcirculation. Recent studies on rat spinotrapezius muscle indicate that enhanced red blood cell aggregation, induced by dextran 500, significantly affects velocity profiles at pseudoshear rates (the ratio of mean velocity to diameter) less than 40 s(-1). Since the use of a power-law model to describe these profiles does not provide a consistent rheological description, we have evaluated using the Casson model that has been widely used to characterize in vitro blood rheology. In the present study, we report experimental values of rat blood viscosity in the presence of dextran 500 and combine these in vitro measurements with previously obtained in vivo venular velocity profiles to determine whether the Casson model can provide a valid description of in vivo velocity profiles. Our analysis shows that the two-phase Casson model with a peripheral plasma layer is in quantitative agreement with experimentally obtained velocity profiles obtained in venules of rat spinotrapezius muscle under low flow rate. These results have implications for pathological low-flow conditions, such as hemorrhage and sepsis, and they quantitatively describe blunted velocity profiles and elevated flow resistance in postcapillary venules.