Name: semi-quantitative assessment using [18f]fdg tracer in patients with severe brain injury
Uploaded: 2018-11-09T15:00:00
Description: Watch this Scientific Journal Video about Semi-quantitative Assessment Using [18F]FDG Tracer in Patients with Severe Brain Injury at JoVE.com

The authors wish to thank Dr. Uchino in Sousen hospital for all procedures. The authors also thank Adam Phillips from the Edanz Group (www.edanzediting.com/ac) for editing a draft of this manuscript.

This study was performed in compliance with the institutional review board (approval No. 07-01) and adhered to the tenets of the Declaration of Helsinki. Informed consent for medical record and brain image use was obtained from the patients&#8217; legal representatives. The study was conducted after approval by the institutional ethics committee (2017-14). This protocol was made following the guidelines of the Japanese Society of Nuclear Medicine and European Association of Nuclear Medicine as a reference<sup class="xref...

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This protocol provides the means to conduct a series of brain-glucose metabolic assessments with [18F]FDG-PET/CT using self-produced [18F]FDG tracer at a single institution.
The production of [18F]FDG tracer follows the procedure described in the FDG synthesizer operator manual; however, caution is necessary regarding three points. First, the bombardment time and energy (step 2.5) should be adjusted according to the number of patients. Second, attention should ...

Patients with sTBI are presented with unforeseeable neurological difficulties over the course of rehabilitation that include motor deficits, sensory deficits, and psychiatric instability1. Although clinical assessment is generally performed verbally, patients with sTBI such as unresponsive wakefulness syndrome or minimally conscious state have particular difficulty in knowing whether they are accurately expressing their thoughts and emotions because of disorders of consciousness, disrupted higher brain function, and verbal disturbances2,3. Family members, medical staff, and caregivers are sometimes confounded by unforeseeable neurological changes or the lack of response that can result from insufficient communicatory ability4,5.
Recently, multimodal brain imaging has been used to explore regional brain function6,7,8,9. The brain is the main consumer of glucose-derived energy, with glucose metabolism providing approximately 95% of the adenosine triphosphate (ATP) required for the brain to function10. The uptake of [18F]-fluorodeoxyglucose (FDG) is a marker for the uptake of glucose by brain tissue. [18F]FDG-PET/CT can detect [18F]FDG uptake and is, therefore, a useful tool for examining brain function11. In general, [18F]FDG image analysis is divided into two categories: ROI analysis and voxel-based analysis (VBA)12. Previous reports show that ROI analysis is preferred for studying specific regions of traumatic injury. This is because VBA (such as statistical parametric mapping [SPM]) requires coregistration and normalization to a standard brain, which does not work well in cases of TBI due to brain tissue deformation such as brain atrophy, swelling, enlargement, and shrinking of ventricular space7,12. Although various algorithms and software have been developed for analyzing magnetic resonance imaging (MRI) data, metals used in neurosurgical and orthopedic surgery generate noise artefacts7,12,13. Recently, the use of photomultipliers with PET/CT devices has improved the spatial resolution of PET/CT-derived brain images14. The current protocol focuses on semi-quantitatively measuring glucose uptake via ROI analysis in [18F]FDG-PET/CT using self-produced [18F]FDG tracers in patients with sTBI.

<table>
	<tbody>
		<tr>
			<td>20ml syringe</td>
			<td>Terumo</td>
			<td>SS-20ESZ</td>
			<td></td>
		</tr>
		<tr>
			<td>10ml syringe</td>
			<td>Terumo</td>
			<td>SS-10ESZ</td>
			<td></td>
		</tr>
		<tr>
			<td>1ml syringe</td>
			<td>Terumo</td>
			<td>SS-01T</td>
			<td></td>
		</tr>
		<tr>
			<td>Protective plug</td>
			<td>Top</td>
			<td>ML-KS</td>
			<td></td>
		</tr>
		<tr>
			<td>Three-way cock L type 180&#176;</td>
			<td>Terumo</td>
			<td>TS-TL2K</td>
			<td></td>
		</tr>
		<tr>
			<td>Extension tube</td>
			<td>Top</td>
			<td>X1-50</td>
			<td></td>
		</tr>
		<tr>
			<td>Indwelling needle 22G or 24G</td>
			<td>Terumo</td>
			<td>SR-OT2225C</td>
			<td></td>
		</tr>
		<tr>
			<td>Tegaderm transparent dressing</td>
			<td>3M</td>
			<td>1624W</td>
			<td></td>
		</tr>
		<tr>
			<td>Hepaflash 10U/ml 10ml</td>
			<td>Terumo</td>
			<td>PF-10HF10UA</td>
			<td></td>
		</tr>
		<tr>
			<td>Auto dispensing and injection system</td>
			<td>Universal Giken Co., Ltd.</td>
			<td>UG-01</td>
			<td></td>
		</tr>
		<tr>
			<td>Fluid for auto dispensing and injection system</td>
			<td>Universal Giken Co., Ltd.</td>
			<td>UG-01-001</td>
			<td></td>
		</tr>
		<tr>
			<td>Millex-GS Syringe Filter Unit</td>
			<td>Millipore</td>
			<td>SLGSV255F</td>
			<td></td>
		</tr>
		<tr>
			<td>Air needle</td>
			<td>Terumo</td>
			<td>XX-MFA2038</td>
			<td></td>
		</tr>
		<tr>
			<td>Check valve</td>
			<td>Hakko</td>
			<td>23310100</td>
			<td></td>
		</tr>
		<tr>
			<td>Saline 500ml</td>
			<td>HIKARI pharmaceutical Co., Ltd.</td>
			<td>18610155-3</td>
			<td></td>
		</tr>
		<tr>
			<td>Yukiban 25x7mm</td>
			<td>Nitto</td>
			<td>3252</td>
			<td></td>
		</tr>
		<tr>
			<td>Elascot No.3</td>
			<td>Alcare</td>
			<td>44903221</td>
			<td></td>
		</tr>
		<tr>
			<td>Presnet No.3 27x20mm</td>
			<td>Alcare</td>
			<td>11674</td>
			<td></td>
		</tr>
		<tr>
			<td>Steri Cotto a 4x4cm</td>
			<td>Kawamoto</td>
			<td>023-720220-00</td>
			<td></td>
		</tr>
		<tr>
			<td>StatstripXp3</td>
			<td>Nova Biomedical</td>
			<td>11-110</td>
			<td></td>
		</tr>
		<tr>
			<td>Statstrip Glucose strips</td>
			<td>Nova Biomedical</td>
			<td>11-106</td>
			<td></td>
		</tr>
		<tr>
			<td>JMSsheet</td>
			<td>JMS</td>
			<td>JN-SW3X</td>
			<td></td>
		</tr>
		<tr>
			<td>Injection pad</td>
			<td>Nichiban</td>
			<td>No.30-N</td>
			<td></td>
		</tr>
		<tr>
			<td>Stepty</td>
			<td>Nichiban</td>
			<td>No.80</td>
			<td></td>
		</tr>
		<tr>
			<td>Advantage Workstation</td>
			<td>GE Healthcare</td>
			<td>Volume Share 7. version 4.7</td>
			<td></td>
		</tr>
		<tr>
			<td>Discovery MI PET/CT</td>
			<td>GE Healthcare</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>EV Insite</td>
			<td>PSP</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>GE TRACERlab MXFDG synthesizer reagent kit</td>
			<td>ABX</td>
			<td>K-105TM</td>
			<td></td>
		</tr>
		<tr>
			<td>TRACERlab MXFDG cassette</td>
			<td>GE Healthcare</td>
			<td>P5150ME</td>
			<td></td>
		</tr>
		<tr>
			<td>Extension tube</td>
			<td>Universal Giken Co., Ltd</td>
			<td>AT511-ST-001</td>
			<td></td>
		</tr>
		<tr>
			<td>TSK sterilized injection needle 18x100</td>
			<td>Tochigiseiko</td>
			<td>AT511-ST-004</td>
			<td></td>
		</tr>
		<tr>
			<td>TSK sterilized injection needle 18x60</td>
			<td>Tochigiseiko</td>
			<td>AT511-ST-002</td>
			<td></td>
		</tr>
		<tr>
			<td>TSK sterilized injection needle 21x65</td>
			<td>Tochigiseiko</td>
			<td>AT511-ST-003</td>
			<td></td>
		</tr>
		<tr>
			<td>Seal sterile vial -N 5ml</td>
			<td>Mita Rika Kogyo Co., Ltd.</td>
			<td>SSVN5CBFA</td>
			<td></td>
		</tr>
		<tr>
			<td>k222 TLC plate</td>
			<td>Universal Giken Co., Ltd.</td>
			<td>AT511-01-005</td>
			<td></td>
		</tr>
		<tr>
			<td>Anion-cation test paper</td>
			<td>Toyo Roshi Kaisha</td>
			<td>7030010</td>
			<td></td>
		</tr>
		<tr>
			<td>Endospecy ES-24S set</td>
			<td>Seikagaku corporation</td>
			<td>20170</td>
			<td></td>
		</tr>
		<tr>
			<td>Sterile evacuated vial</td>
			<td>Gi phama</td>
			<td>10214</td>
			<td></td>
		</tr>
		<tr>
			<td>5ml syringe</td>
			<td>Terumo</td>
			<td>SS-05SZ</td>
			<td></td>
		</tr>
		<tr>
			<td>Extension tube</td>
			<td>Top</td>
			<td>X-120</td>
			<td></td>
		</tr>
		<tr>
			<td>Finefilter F</td>
			<td>Forte grow medical Co.Ltd.</td>
			<td>F162</td>
			<td></td>
		</tr>
		<tr>
			<td>Millex FG</td>
			<td>Merck</td>
			<td>SLFG I25 LS</td>
			<td></td>
		</tr>
		<tr>
			<td>Vented Millex GS</td>
			<td>Merck</td>
			<td>SLGS V25 5F</td>
			<td></td>
		</tr>
		<tr>
			<td>Injection needle 18x38</td>
			<td>Terumo</td>
			<td>NN-1838R</td>
			<td></td>
		</tr>
		<tr>
			<td>Injection needle 21x38</td>
			<td>Terumo</td>
			<td>NN-2138R</td>
			<td></td>
		</tr>
		<tr>
			<td>Water-18O</td>
			<td>Taiyo Nippon Sanso</td>
			<td>F03-0027</td>
			<td></td>
		</tr>
		<tr>
			<td>Distilled water</td>
			<td>Otsuka phrmaceutical</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Hydrogen gas G1</td>
			<td>Hosi Iryou Sanki</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Helium gas G1</td>
			<td>Hosi Iryou Sanki</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Nitrogen G1</td>
			<td>Hosi Iryou Sanki</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>TRACERlabMXFDG</td>
			<td>GE Healthcare</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Sep-Pak Light Accell Plus QMA</td>
			<td>WATERS</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Sep-Pak Plus tC18</td>
			<td>WATERS</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Sep-Pak Plus Alumina N</td>
			<td>WATERS</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>HPLC with 3.9 X 300 mm columns</td>
			<td>WATERS</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>US-2000</td>
			<td>Universal Giken CO. Ltd.</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Kryptofix222</td>
			<td>Merck</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>EG Reader SV-12</td>
			<td>Seikagaku Corporation</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>UG-01</td>
			<td>Universal Giken Co., Ltd.</td>
			<td></td>
			<td></td>
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		<tr>
			<td>syngo.via</td>
			<td>Siemens Healthineers</td>
			<td></td>
			<td></td>
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			<td>Advantage Workstation Volume Share 7, version 4.7</td>
			<td>GE Healthcare</td>
			<td></td>
			<td></td>
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			<td>Q clear</td>
			<td>GE Healthcare</td>
			<td></td>
			<td></td>
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			<td>CRC-15PET dose calibrator</td>
			<td>CAPINTEC, INC.</td>
			<td></td>
			<td></td>
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semi-quantitative assessment using [18f]fdg tracer in patients with severe brain injury

Patients with severe traumatic brain injury (sTBI) have difficulty knowing whether they are accurately expressing their thoughts and emotions because of disorders of consciousness, disrupted higher brain function, and verbal disturbances. As a consequence of an insufficient ability to communicate, objective evaluations are needed from family members, medical staff, and caregivers. One such evaluation is the assessment of functioning brain areas. Recently, multimodal brain imaging has been used to explore the function of damaged brain areas. [18F]-fluorodeoxyglucose positron emission tomography-computed tomography ([18F]FDG-PET/CT) is a successful tool for examining brain function. However, the assessment of brain glucose metabolism based on [18F]FDG-PET/CT is not standardized and depends on several varying parameters, as well as the patient&#39;s condition. Here, we describe a series of semiquantitative assessment protocols for a region-of-interest (ROI) image analysis using self-produced [18F]FDG tracers in patients with sTBI. The protocol focuses on screening the participants, preparing the [18F]FDG tracer in the hot lab, scheduling the acquisition of [18F]FDG-PET/CT brain images, and measuring glucose metabolism using the ROI analysis from a targeted brain area.

A 63-year-old man who had been run over by a car while cycling was brought to the emergency room via ambulance. The examination revealed a Glasgow Coma Scale score of 7 (eye opening = 1, best verbal response = 2, best motor response = 4), anisocoria (right: 2 mm, and left: 3 mm), and a negative corneal response17. A CT of the head showed subarachnoid and intracranial hemorrhage and a skull fracture of the left zygoma, temporal bones, and parietal bones. Th...

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Semi-quantitative Assessment Using [18F]FDG Tracer in Patients with Severe Brain Injury

[18F]-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography is useful for studying glucose metabolism related to brain function. Here, we present a protocol for an [18F]FDG tracer set-up and semiquantitative assessment of the region-of-interest analysis for targeted brain areas associated with clinical manifestations in patients with severe traumatic brain injury.

Semi-quantitative Assessment Using [18F]FDG Tracer in Patients with Severe Brain Injury

Patients with severe traumatic brain injury (sTBI) have difficulty knowing whether they are accurately expressing their thoughts and emotions because of ...

This list can help us with key questions in the neuro-rehabilition field. Regarding Unresponsive Wakefulness Syndrome and minimal conscious states following cerebral traumatic brain injury. The main advantage of this technique is that, patients with brain tissue deformation such as, atrophy, swelling, enlargement and shrinking of ventricular spaces can be assisted in the chronic stage.Demonstrating the procedure will be Tomoki Uchida, our pharmacist, Kazuaki Yokoyama, our skilled operator, Mizuho Kamezawa, our nurse, Shinji Onodera and Yoshihiro Ozaki, Radio Technologist from my laboratory. Begin manufacturing reagent kits for the automated production of FDG, tailored to the synthesizer in use. Set the syringes for the manufacturing reagent kits on to the corresponding syringe drivers in the automated FDG Synthesizer.Be sure to use the automatic program to check the mobility of the pumping system. Check the volume of the Oxygen-16 and 18 water, and the volume of helium, hydrogen and nitrogen gases. Also ensure that the tap water is under 25 degrees celsius for primary cooling and under 22 degrees celsius for secondary cooling.After one hour, ensure that air cannot leak from the reagent kit. Set out vials of acetonitrile, mannose triflate, ethanol, and PH buffer solution. Begin preliminary irradiation of Oxygen-16 in the cyclotron.Check that two to three milliliters of water is irradiated in optimal conditions in the target area. Next, begin the irradiation of Oxygen-18 water in the cyclotron 90 minutes after starting. Set the bombardment time for up to 20 minutes, and the energy of the impinging protons to 16.5 mega electron volts.Ensure that the lamp lights up, when the cyclotron is running. After irradiation, use helium gas to transfer two to three milliliters of the Oxygen-18 water from the cyclotron to the polypropylene receiver of the FDG Synthesizer. Hook syringes on to the corresponding syringe drivers and the pressurized reagent vials.Then, dissolve the mannose triflate in one vial of 99.5 percent pure acetonitrile, then rinse the cassette with acetonitrile. Transfer the irradiate Oxygen-18 water to the FDG synthesizer. Then, after transferring the eluent to the containing Fluorine-18 without liquid into the reaction vessels.Allow the solvents to evaporate until dry. During the drying process, add 80 microliters of acetonitrile to the reaction vessel three times. Perform the evaporation at 95 degrees celsius under nitrogen flow and vacuum.Dissolve 25 milligrams of mannose triflate precursor in about 3.5 milliliters of 99.5 percent pure acetonitrile, then add it to the dry residue. A nucleophilic substitution reaction occurs at 85 degrees Celsius in the FDG Synthesizer. As a preliminary purification, mixed the labeled solution with 26 milliliters of distilled water.Then, send about four milliliters of the diluted labeling solution back to the reaction vessel to recover the remaining activity. Next, pass the solution through the reverse phase cartridge. Then, rinse the cartridge containing the trapped labeled precursor four times using distilled water.Now, convert the acetylated compound into FDG within the cartridge via alkaline hydrolysis. Using 750 microliters of 2 N sodium hydroxide for 90 seconds at room temperature. After hydrolysis is complete, collect the alkaline FDG solution in 70 milliliters of water, and mix it with a neutralization solution.Then, purify the resulting neutralized FDG solution. Pass the neutralized FDG solution through a second reverse phase cartridge retaining the partially hydrolyzed compounds and non-bipolar byproducts. Then, pass it through an Alumina-N cartridge retaining the last trace of unreacted F-18 flouride ions, then pass it through a 0.22 micrometer filter.Next, rinse the cassette and cartridges and filter with 3 milliliters of water to recover the residual FDG in the lines. Then, drain the FDG into the final vial which should contain 15 to 17 milliliters of liquid. After two hours and 30 minutes from start of preparation, perform a qualitative analysis by examining the vial to confirm that it is transparent without particles.Also, measure the amount of liquid using a robe revolves balance. And measure the radioactivity and half-life using a radioisotope dose calibrator. Now, measure the PH as well as the residual cryptand-22 using test paper.Also, measure the endotoxins with the appropriate device through the absorbance measuring. Next, dispense 0.5 milliliters from the vial and perform a radiochemical purity test via carbohydrated analysis. Use columns of 3.9 by 300 millimeters for high performance liquid chromatography to detect the peak radioactivity.Finally, fill the vial covered by lead and tungsten with the FDG Tracer, at a dosage of 5 megabecquerel per kilogram of body weight. Then, three hours and 25 minutes after the start time, transfer the Tracer from the Hot Lab to the working room. Begin by preparing the intravenous route for the FDG Tracer administration.Secure a 22 to 24 gauge needle with 5 milliliters of heparin sodium, on one of the lower limbs. The patient should then lie down for 30 minutes before entering the radiation controlled area. Next, recheck the patency of the intravenous route by drawing blood and measure the patient's blood glucose level.Then, transfer the FDG Tracer from the Hot Lab to the working room through the window. Set the tracer up in the Auto Dispensing and Injection System. Check the aspiration of the FDG Tracer from the vial on the monitor.Connect the tube between the patient and the Auto Dispensing Injection System. Push the bottom and inject the FDG Tracer to the patient. At this point, stop to confirm the Tracer amount and lot number, programmed radioactivity, injection time, injection speed, and measured radioactivity level.Now, record the automatic measurement of pre-injected radioactivity that appears on the display of the Auto Display and Injection System. Then, inject the Tracer via the intravenous route at three hours and 30 minutes, after the start. Have the patient wait in the waiting room of the radiation controlled area for 50 minutes.Then, four hours and 30 minutes after the start time, transfer the patient from the waiting room to the PET/CT machine, and record brain images for 10 minutes. After imaging, check the injection area for extravasation. Once all data is acquired, evaluation all image data for a standardized uptake value measurement using imaging software and compare the clinical assessment with the FDG-PET/CT images.This figure shows a representative FDG-PET/CT brain image. Shown here is the measurement of the right thalamic glucose metabolism in a 3-dimensional image browser. Here we see a representative color mapped image after FDG-PET and CT fusion.The blood glucose level at the time of the scan as depicted as red with a 50 percent SUV max threshold. This panel, shows representative 3-dimensional brain surface FDG-PET images. The red regions have a higher glucose metabolism than the green regions.The blood glucose level at the time of scan is shown in red. While attempting this procedure, it's important that bombardment time and energy are adjusted according to the number of patients. Also, attention should be paid to the cryptand-222 tube, because it can be easily become stopped up by crystallization.Also know that the hook of syringes should be handled carefully because it can be easily broken. In addition, be aware that a patient with cerebral traumatic brain injury can sometimes make unforeseen movements during image acquisition. Follow this procedure, add in many ways various radioactive tests can be applied in order to answer additional questions involving amino acid metabolism.Don't forget that working with radioactive materials can be extremely hazardous and precautions such as radiation protection should always be taken while performing this procedure.

semi-quantitative-assessment-using-18ffdg-tracer-patients-with-severe

Research

JoVE Journal

Medicine

Non-invasive Imaging of Acute Allograft Rejection after Rat Renal Transplantation Using 18F-FDG PET

The number of patients with end-stage renal disease, and the number of kidney allograft recipients continuously increases. Episodes of acute cellular allograft rejection (AR) are a negative prognostic factor for long-term allograft survival, and its timely diagnosis is crucial for allograft function 1. At present, AR can only be definitely diagnosed by core-needle biopsy, which, as an invasive method, bares significant risk of graft injury or even loss. Moreover, biopsies are not feasible in patients taking anticoagulant drugs and the limited sampling site of this technique may result in false negative results if the AR is focal or patchy. As a consequence, this gave rise to an ongoing search for new AR detection methods, which often has to be done in animals including the use of various transplantation models.
Since the early 60s rat renal transplantation is a well-established experimental method for the examination and analysis of AR 2. We herein present in addition small animal positron emission tomography (PET) using 18F-fluorodeoxyglucose (FDG) to assess AR in an allogeneic uninephrectomized rat renal transplantation model and propose graft FDG-PET imaging as a new option for a non-invasive, specific and early diagnosis of AR also for the human situation 3. Further, this method can be applied for follow-up to improve monitoring of transplant rejection 4.

Non-invasive Imaging of Acute Allograft Rejection after Rat Renal Transplantation Using 18F-FDG PET

We herein present a rat renal transplantation model to non-invasively assess acute allograft rejection using positron emission tomography with 18F-fluorodeoxyglucose.

The number of patients with end-stage renal  disease, and the number of kidney allograft recipients continuously increases.  Episodes of acute cellular ...

A Contusion Model of Severe Spinal Cord Injury in Rats

The translational potential of novel treatments should be investigated in severe spinal cord injury (SCI) contusion models. A detailed methodology is described to obtain a consistent model of severe SCI. Use of a stereotactic frame and computer controlled impactor allows for creation of reproducible injury. Hypothermia and urinary tract infection pose significant challenges in the post-operative period. Careful monitoring of animals with daily weight recording and bladder expression allows for early detection of post-operative complications. The functional results of this contusion model are equivalent to transection models. The contusion model can be utilized to evaluate the efficacy of both neuroprotective and neuroregenerative approaches.

A contusion model of severe spinal cord injury is described. Detailed pre-operative, operative and post-operative steps are described to obtain a consistent model.

The translational potential of novel treatments should be investigated in severe spinal cord injury (SCI) contusion models. A detailed methodology is ...

Evaluation of Respiratory Muscle Activation Using Respiratory Motor Control Assessment (RMCA) in Individuals with Chronic Spinal Cord Injury

During breathing, activation of respiratory muscles is coordinated by integrated input from the brain, brainstem, and spinal cord. When this coordination is disrupted by spinal cord injury (SCI), control of respiratory muscles innervated below the injury level is compromised1,2 leading to respiratory muscle dysfunction and pulmonary complications. These conditions are among the leading causes of death in patients with SCI3. Standard pulmonary function tests that assess respiratory motor function include spirometrical and maximum airway pressure outcomes: Forced Vital Capacity (FVC), Forced Expiratory Volume in one second (FEV1), Maximal Inspiratory Pressure (PImax) and Maximal Expiratory Pressure (PEmax)4,5. These values provide indirect measurements of respiratory muscle performance6. In clinical practice and research, a surface electromyography (sEMG) recorded from respiratory muscles can be used to assess respiratory motor function and help to diagnose neuromuscular pathology. However, variability in the sEMG amplitude inhibits efforts to develop objective and direct measures of respiratory motor function6. Based on a multi-muscle sEMG approach to characterize motor control of limb muscles7, known as the voluntary response index (VRI)8, we developed an analytical tool to characterize respiratory motor control directly from sEMG data recorded from multiple respiratory muscles during the voluntary respiratory tasks. We have termed this the Respiratory Motor Control Assessment (RMCA)9. This vector analysis method quantifies the amount and distribution of activity across muscles and presents it in the form of an index that relates the degree to which sEMG output within a test-subject resembles that from a group of healthy (non-injured) controls. The resulting index value has been shown to have high face validity, sensitivity and specificity9-11. We showed previously9 that the RMCA outcomes significantly correlate with levels of SCI and pulmonary function measures. We are presenting here the method to quantitatively compare post-spinal cord injury respiratory multi-muscle activation patterns to those of healthy individuals.

Evaluation of Respiratory Muscle Activation Using Respiratory Motor Control Assessment RMCA in Individuals with Chronic Spinal Cord Injury

The purpose of this publication is to present our original work on a multi-muscle surface electromyographic approach to quantitatively characterize respiratory muscle activation patterns in individuals with chronic spinal cord injury using vector-based analysis.

During breathing, activation of respiratory muscles is coordinated by integrated input from the brain, brainstem, and spinal cord. When this coordination ...

Computerized Dynamic Posturography for Postural Control Assessment in Patients with Intermittent Claudication

Computerized dynamic posturography with the EquiTest is an objective technique for measuring postural strategies under challenging static and dynamic conditions. As part of a diagnostic assessment, the early detection of postural deficits is important so that appropriate and targeted interventions can be prescribed. The Sensory Organization Test (SOT) on the EquiTest determines an individual&#39;s use of the sensory systems (somatosensory, visual, and vestibular) that are responsible for postural control. Somatosensory and visual input are altered by the calibrated sway-referenced support surface and visual surround, which move in the anterior-posterior direction in response to the individual&#39;s postural sway. This creates a conflicting sensory experience. The Motor Control Test (MCT) challenges postural control by creating unexpected postural disturbances in the form of backwards and forwards translations. The translations are graded in magnitude and the time to recover from the perturbation is computed.
Intermittent claudication, the most common symptom of peripheral arterial disease, is characterized by a cramping pain in the lower limbs and caused by muscle ischemia secondary to reduced blood flow to working muscles during physical exertion. Claudicants often display poor balance, making them susceptible to falls and activity avoidance. The Ankle Brachial Pressure Index (ABPI) is a noninvasive method for indicating the presence of peripheral arterial disease and intermittent claudication, a common symptom in the lower extremities. ABPI is measured as the highest systolic pressure from either the dorsalis pedis or posterior tibial artery divided by the highest brachial artery systolic pressure from either arm. This paper will focus on the use of computerized dynamic posturography in the assessment of balance in claudicants.

Individuals with intermittent claudication exhibit poor balance compared to healthy controls. Computerized dynamic posturography is an objective method for measuring an individual's postural responses to balance disturbances. This provides an objective reflection of the person&#x2019;s ability to respond to situations under which sensory stimuli are altered and unexpected perturbations occur.

Computerized dynamic posturography with the EquiTest is an objective technique for measuring postural strategies under challenging static and dynamic ...

Assessment of Vascular Function in Patients With Chronic Kidney Disease

Patients with chronic kidney disease (CKD) have significantly increased risk of cardiovascular disease (CVD) compared to the general population, and this is only partially explained by traditional CVD risk factors. Vascular dysfunction is an important non-traditional risk factor, characterized by vascular endothelial dysfunction (most commonly assessed as impaired endothelium-dependent dilation [EDD]) and stiffening of the large elastic arteries. While various techniques exist to assess EDD and large elastic artery stiffness, the most commonly used are brachial artery flow-mediated dilation (FMDBA) and aortic pulse-wave velocity (aPWV), respectively. Both of these noninvasive measures of vascular dysfunction are independent predictors of future cardiovascular events in patients with and without kidney disease. Patients with CKD demonstrate both impaired FMDBA, and increased aPWV. While the exact mechanisms by which vascular dysfunction develops in CKD are incompletely understood, increased oxidative stress and a subsequent reduction in nitric oxide (NO) bioavailability are important contributors. Cellular changes in oxidative stress can be assessed by collecting vascular endothelial cells from the antecubital vein and measuring protein expression of markers of oxidative stress using immunofluorescence. We provide here a discussion of these methods to measure FMDBA, aPWV, and vascular endothelial cell protein expression.

The degree of vascular dysfunction and contributing physiological mechanisms can be assessed in patients with chronic kidney disease by measuring brachial artery flow-mediated dilation, aortic pulse-wave velocity, and vascular endothelial cell protein expression.

Patients with chronic kidney disease (CKD) have significantly increased risk of cardiovascular disease (CVD) compared to the general population, and this ...

Non-invasive Imaging and Analysis of Cerebral Ischemia in Living Rats Using Positron Emission Tomography with 18F-FDG

Stroke is the third leading cause of death among Americans 65 years of age or older1. The quality of life for patients who suffer from a stroke fails to return to normal in a large majority of patients2, which is mainly due to current lack of clinical treatment for acute stroke. This necessitates understanding the physiological effects of cerebral ischemia on brain tissue over time and is a major area of active research. Towards this end, experimental progress has been made using rats as a preclinical model for stroke, particularly, using non-invasive methods such as 18F-fluorodeoxyglucose (FDG) coupled with Positron Emission Tomography (PET) imaging3,10,17. Here we present a strategy for inducing cerebral ischemia in rats by middle cerebral artery occlusion (MCAO) that mimics focal cerebral ischemia in humans, and imaging its effects over 24 hr using FDG-PET coupled with X-ray computed tomography (CT) with an Albira PET-CT instrument. A VOI template atlas was subsequently fused to the cerebral rat data to enable a unbiased analysis of the brain and its sub-regions4. In addition, a method for 3D visualization of the FDG-PET-CT time course is presented. In summary, we present a detailed protocol for initiating, quantifying, and visualizing an induced ischemic stroke event in a living Sprague-Dawley rat in three dimensions using FDG-PET.

Non-invasive Imaging and Analysis of Cerebral Ischemia in Living Rats Using Positron Emission Tomography with 18F-FDG

Brain damage resulting from cerebral ischemia may be non-invasively imaged and studied in rats using pre-clinical positron emission tomography coupled with the injectable radioactive probe, 18F-fluorodeoxyglucose. Further, the use of modern software tools that include volume of interest (VOI) brain templates dramatically increase the quantitative information gleaned from these studies.

Stroke is the third leading cause of death among Americans 65 years of age or older1. The quality of life for patients who suffer from a stroke fails to ...

A Multimodal Imaging- and Stimulation-based Method of Evaluating Connectivity-related Brain Excitability in Patients with Epilepsy

Resting-state functional connectivity MRI (rs-fcMRI) is a technique that identifies connectivity between different brain regions based on correlations over time in the blood-oxygenation level dependent signal. rs-fcMRI has been applied extensively to identify abnormalities in brain connectivity in different neurologic and psychiatric diseases. However, the relationship among rs-fcMRI connectivity abnormalities, brain electrophysiology and disease state is unknown, in part because the causal significance of alterations in functional connectivity in disease pathophysiology has not been established. Transcranial Magnetic Stimulation (TMS) is a technique that uses electromagnetic induction to noninvasively produce focal changes in cortical activity. When combined with electroencephalography (EEG), TMS can be used to assess the brain's response to external perturbations. Here we provide a protocol for combining rs-fcMRI, TMS and EEG to assess the physiologic significance of alterations in functional connectivity in patients with neuropsychiatric disease. We provide representative results from a previously published study in which rs-fcMRI was used to identify regions with abnormal connectivity in patients with epilepsy due to a malformation of cortical development, periventricular nodular heterotopia (PNH). Stimulation in patients with epilepsy resulted in abnormal TMS-evoked EEG activity relative to stimulation of the same sites in matched healthy control patients, with an abnormal increase in the late component of the TMS-evoked potential, consistent with cortical hyperexcitability. This abnormality was specific to regions with abnormal resting-state functional connectivity. Electrical source analysis in a subject with previously recorded seizures demonstrated that the origin of the abnormal TMS-evoked activity co-localized with the seizure-onset zone, suggesting the presence of an epileptogenic circuit. These results demonstrate how rs-fcMRI, TMS and EEG can be utilized together to identify and understand the physiological significance of abnormal brain connectivity in human diseases.

Resting-state functional-connectivity MRI has identified abnormalities in patients with a wide range of neuropsychiatric disorders, including epilepsy due to malformations of cortical development. Transcranial Magnetic Stimulation in combination with EEG can demonstrate that patients with epilepsy have cortical hyperexcitability in regions with abnormal connectivity.

Resting-state functional connectivity MRI (rs-fcMRI) is a technique that identifies connectivity between different brain regions based on correlations ...

Determining Glucose Metabolism Kinetics Using 18F-FDG Micro-PET/CT

This paper describes the use of 18F-FDG and micro-PET/CT imaging to determine in vivo glucose metabolism kinetics in mice (and is transferable to rats). Impaired uptake and metabolism of glucose in multiple organ systems due to insulin resistance is a hallmark of type 2 diabetes. The ability of this technique to extract an image-derived input function from the vena cava using an iterative deconvolution method eliminates the requirement of the collection of arterial blood samples. Fitting of tissue and vena cava time activity curves to a two-tissue, three compartment model permits the estimation of kinetic micro-parameters related to the 18F-FDG uptake from the plasma to the intracellular space, the rate of transport from intracellular space to plasma and the rate of 18F-FDG phosphorylation. This methodology allows for multiple measures of glucose uptake and metabolism kinetics in the context of longitudinal studies and also provides insights into the efficacy of therapeutic interventions.

Determining Glucose Metabolism Kinetics Using 18F-FDG Micro-PET/CT

This study describes a protocol that uses 18F-FDG and positron emission tomography/computed tomography (PET/CT) imaging, together with kinetic modelling, to quantify the in vivo, real-time uptake of 18F-FDG into tissues.

This paper describes the use of 18F-FDG and micro-PET/CT imaging to determine in vivo glucose metabolism kinetics in mice (and is transferable to rats). ...

Severe Burn Injury in a Swine Model for Clinical Dressing Assessment

Wound healing is a dynamic repair process and is the most complex biological process in human life. In response to burn injury, alterations in biological pathways impair the inflammation response, resulting in delayed wound healing. Impaired wound healing frequently occurs in patients with diabetes leading to unfavorable outcomes such as amputation. Hence, dressings having beneficial effect in promoting burn wound repair are needed. However, studies on burn wound treatment are limited due to lack of proper animal models. Our previous study demonstrated wound-healing performance in rat and swine models using a minimally invasive surgical technique. This study aimed to demonstrate a swine model of severe burn injury that eliminates wound contraction and more closely approximates the human processes of re-epithelialization and new tissue formation. This protocol provides a detailed procedure for creating consistent burn wounds and examining the wound-healing performance under the treatment of an experimental dressing in a swine model. Six burn wounds were created symmetrically on the dorsum, which were covered with a clinical dressing composed of four layers: an inner contact layer of experimental materials, an inner intermediate layer of waterproof film, an outer intermediate layer of gauze, and an outer layer of adhesive plaster. Upon the completion of experiments, wound closure, wound area, and Vancouver Scar Scale score were examined. The samples of skin resected from each animal post-sacrifice were histologically prepared and stained using hematoxylin and eosin staining. Antibacterial activity of each dressing in the context of wound healing was also examined. The application of the clinical dressing to the wounds in swine model mimics the biological processes of human wound healing with respect to the processes of epithelialization, cellular proliferation, and angiogenesis. Therefore, this swine model provides an easy-to-learn, cost-effective, and robust method to assess the effect of clinical dressings in severe burn injury.

To closely mimic the mode of burn injuries requires the interplay between clinical observation and studies in animal models. In this study, a swine model of severe burn injury was established to assess an experimental dressing in physiological and pathophysiological settings.

Wound healing is a dynamic repair process and is the most complex biological process in human life. In response to burn injury, alterations in biological ...

Whole Body and Regional Quantification of Active Human Brown Adipose Tissue Using 18F-FDG PET/CT

In endothermic animals, brown adipose tissue (BAT) is activated to produce heat for defending body temperature in response to cold. BAT&#39;s ability to expend energy has made it a potential target for novel therapies to ameliorate obesity and associated metabolic disorders in humans. Though this tissue has been well studied in small animals, BAT&#39;s thermogenic capacity in humans remains largely unknown due to the difficulties of measuring its volume, activity, and distribution. Identifying and quantifying active human BAT is commonly performed using 18F-Fluorodeoxyglucose (18F-FDG) positron emission tomography and computed tomography (PET/CT) scans following cold-exposure or pharmacological activation. Here we describe a detailed image-analysis approach to quantify total-body human BAT from 18F-FDG PET/CT scans using an open-source software. We demonstrate the drawing of user-specified regions of interest to identify metabolically active adipose tissue while avoiding common non-BAT tissues, to measure BAT volume and activity, and to further characterize its anatomical distribution. Although this rigorous approach is time-consuming, we believe it will ultimately provide a foundation to develop future automated BAT quantification algorithms.

Whole Body and Regional Quantification of Active Human Brown Adipose Tissue Using 18F-FDG PET/CT

Using free, open-source software, we have developed an analytical approach to quantify total and regional brown adipose tissue (BAT) volume and metabolic activity of BAT using 18F-FDG PET/CT.

In endothermic animals, brown adipose tissue (BAT) is activated to produce heat for defending body temperature in response to cold. BAT&#39;s ability to ...