From the Vascular Integrated Physiology and Experimental Therapeutics (VIPERx) Laboratory, this work was supported by funds from the Department of Surgery, University of California, San Francisco and the Northern California Institute for Research and Education. The project described was supported by Award Number KL2RR024130 from the National Center for Research Resources. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.

The following procedure, developed as part of an investigator-initiated study, was reviewed and approved by the University of California, San Francisco (UCSF) Committee on Human Research (CHR) and all participants gave informed consent.
1. Equipment
<ol>
	<li>Use an EKG gated image capture system to record and analyze the FMD. Connect a Philips HD11 ultrasound to a desktop PC.</li>
	<li>Connect a video signal from the ultrasound with a special frame-grabber card on the PC.</li>
	<li>Relay an...

Endothelial dysfunction is an imbalance in the chemical mediators affecting vessel tone and an early step in the development of atherosclerosis. Measuring the reactivity of an artery is a way to assess the state of these chemical pathways. Both direct and indirect methods of assessing reactivity exist for the different vascular beds, ranging from direct infusion of an endothelium agonist in the coronary circulation to non-invasive, pulse waveform analysis in the index finger38.
Brac...

The human vascular endothelium provides structural and functional roles within the body. In histological sections, the endothelium appears small, comprising a thin layer of cells 1-2 microns thick sitting atop a layer of smooth muscle cells (the media) and a thick layer of connective tissue (the adventitia). Taken as a whole, the endothelium provides a wide area for the exchange of information between the blood and vascular smooth muscle tissue. By one estimate, a cross sectional area of 700 m2 and a mass of 1,000-1,500 grams in a 70 kg man, is comparable in mass to the liver1. A healthy endothelium allows for mechanical to chemical signal transduction to maintain homeostasis of the blood vessel. Endothelial dysfunction is an imbalance of these mediators and the first step in vascular disease, present prior to histological evidence of atherosclerosis. A non-invasive, in vivo method for quantifying the vasodilatory function of human artery exists. This method, endothelium-dependent, flow-mediated vasodilation (FMD) is widely used in clinical trials.
The endothelium acts as a structural component of the vasculature and manufactures components of the extracellular matrix such as glycosaminoglycans and fibronectin2. Long term changes in blood flow and acute injury to the artery may lead to structural changes. Functionally, the vascular endothelial cells participate in regulation of vessel tone, inflammatory processes, antithrombosis, and anticoagulation. Endothelial cells affect vasoconstriction through endothelin while vasodilation is mediated by nitric oxide (NO), prostacyclin, and endothelial derived hyperpolarizing factor (EDHF)3-6.
Endothelial dysfunction is an impairment of any of these mediators and the first step in atherosclerosis. Not surprisingly, as a mechanism of disease, it is associated with a number of clinically important conditions such as coronary artery disease, hypertension and diabetes mellitus7-11. Importantly, endothelial dysfunction can be observed in individuals without diagnosed cardiovascular disease and is predictive of future cardiovascular events7,12,13. One measure of endothelial dysfunction, in combination with the Framingham score, can provide additional prognostic information above either measure alone14.
Measures of endothelial dysfunction may involve the direct infusion of a pharmacological agent. Intercoronary infusion of acetylcholine, for example, combined with quantitative angiography demonstrates vasodilation in subjects with an intact endothelium. However, individuals with endothelial damage experience paradoxical vasoconstriction.15 In peripheral arteries, infusion of a pharmacological agent with measurement of flow by gauge-strain plethysmography is possible16.
Agents that directly affect the endothelium and elicit a chemical signal are termed endothelium-dependent vasodilators. Acetylcholine, for example, acts on muscarinic receptors on endothelial cells, leading to increased intra-cellular calcium concentration, activation of nitric oxide synthase and vasodilation. Agents that affect vasodilation without involvement of the endothelium are called endothelium-independent agents. Nitroglycerin, for example, activates soluble guanyl cyclase and cyclic guanosine-3&#8217;,-5&#8217;-monophasphate (cGMP) which mediates vasodilation in the vessel wall through protein kinases regulating intracellular calcium concentrations17.
There is a non-invasive, in vivo method for quantifying endothelial dysfunction introduced by Celermajer and associates called &#8220;flow-mediated, endothelium-dependent vasodilation&#8221; (FMD)18. Briefly, changes to arterial blood flow open shear stress sensitive ion channels in the endothelium. The signal is tranduced via a second-messenger cascade and activates endothelial nitric oxide synthase (eNOS), generating NO. This species diffuses across the cell membrane to neighboring smooth muscle cells (SMC). Within the SMC, the signal is transduced, lowering intracellular calcium concentration and affecting vasorelaxation19. The diameter of the artery lumen increases, leading to an increase in blood flow consistent with the Hagen-Poiseullie equation. The effect of FMD may be abolished with administration of an NO synthase inhibitor such as mono-methylarginine (L-NMMA)20.
Celermajer et al.&#8217;s innovative work has allowed the use of high resolution B-mode ultrasound to assess the change in artery diameter during the reactive hyperemia that follows ischemia. In this technique, a human subject rests supine and the diameter of the brachial artery is measured in a longitudinal plane. A blood-pressure cuff is used to produce ischemia in the limb. Following release of the blood pressure cuff the diameter of the artery is measured again. The rapid change in shear stress is the stimulus for NO mediated vasodilation. A simple equation describes the change in the diameter relative to the baseline diameter (Equation 1). A full discussion of the parameters of this equation, hyperemia and baseline diameter, can be found in the Protocol and Results sections.

In multiple studies, percent FMD has been found to predict cardiovascular events in patient with established cardiovascular disease21-24. A correlation between brachial artery percent FMD and coronary artery FMD was established by Anderson et al., demonstrating a link between peripheral measurements and the more clinically-relevant ischemic changes to the heart25. FMD does not demonstrate the maximum vasodilation of the vessel. To evaluate this, FMD can be followed by endothelium-dependent, nitroglycerin-mediated vasodilation of the same vessel.
There are technical issues affecting the measurement of percent FMD. Since the introduction of the technique, several studies showed a high degree of within-subject and inter-operator variability26. It has been shown that physiological factors such as cigarette smoking, antihypertensive medications, time of day, and fasting state affect percent FMD. Likewise, technical choices such as the position of the cuff relative to the site of measurement and duration of occlusion have been shown to affect the measurement27,28. Guidelines have been published that describe the current consensus and allow for standardization of technique between laboratories19,29.
Despite the evolving consensus on technique, flow-mediated vasodilation remains heavily operator dependent with a long learning curve. Corretti, for example, recommends the sonographer complete 100 scans under the supervision of an experienced investigator before operating independently. To maintain a level of adequate expertise, it is recommended the technician complete 100 scans annually. For investigators with a small sample population and limited resources, the learning curve presents a barrier to entry. This article will demonstrate a method for flow-mediated vasodilation of the brachial artery in the upper arm and offer technical suggestions to reduce intra-operator variability.

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	<tbody>
		<tr height="42">
			<td height="42" style="height:42px;width:216px;">Name of Material/ Equipment</td>
			<td style="width:71px;">Company</td>
			<td style="width:119px;">Catalog Number</td>
			<td style="width:167px;">Comments/Description</td>
		</tr>
		<tr height="63">
			<td height="63" style="height:63px;width:216px;">Philips HD 11XE ultrasound</td>
			<td style="width:71px;">Philips Healthcare</td>
			<td style="width:119px;"></td>
			<td></td>
		</tr>
		<tr height="63">
			<td height="63" style="height:63px;width:216px;">5-12 MHz linear array transducer</td>
			<td style="width:71px;">Philips Healthcare</td>
			<td style="width:119px;">L12-5</td>
			<td></td>
		</tr>
		<tr height="63">
			<td height="63" style="height:63px;width:216px;">Ultrasound gel</td>
			<td style="width:71px;">Parker Laboratories</td>
			<td style="width:119px;"></td>
			<td></td>
		</tr>
		<tr height="84">
			<td height="84" style="height:84px;width:216px;">Vascular Research Tools v.5.0</td>
			<td style="width:71px;">Medical Imaging Applications, LLC</td>
			<td style="width:119px;"></td>
			<td></td>
		</tr>
		<tr height="84">
			<td height="84" style="height:84px;width:216px;">MIA Gating module</td>
			<td style="width:71px;">Medical Imaging Applications, LLC</td>
			<td style="width:119px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:216px;">Desktop PC</td>
			<td style="width:71px;">Dell, Inc</td>
			<td style="width:119px;"></td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:216px;">Windows XP</td>
			<td style="width:71px;">Microsoft, Inc</td>
			<td style="width:119px;"></td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:216px;">5 cm tourniquet blood pressure cuff</td>
			<td style="width:71px;">Hokanson</td>
			<td style="width:119px;">SC 5</td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:216px;">Hand-held aneroid manometer</td>
			<td style="width:71px;">Welch Allyn</td>
			<td style="width:119px;">DS66</td>
			<td></td>
		</tr>
	</tbody>
</table>

ultrasound assessment of endothelial-dependent flow-mediated vasodilation of the brachial artery in clinical research

The vascular endothelium is a monolayer of cells that cover the interior of blood vessels and provide both structural and functional roles. The endothelium acts as a barrier, preventing leukocyte adhesion and aggregation, as well as controlling permeability to plasma components. Functionally, the endothelium affects vessel tone.
Endothelial dysfunction is an imbalance between the chemical species which regulate vessel tone, thombroresistance, cellular proliferation and mitosis. It is the first step in atherosclerosis and is associated with coronary artery disease, peripheral artery disease, heart failure, hypertension, and hyperlipidemia.
The first demonstration of endothelial dysfunction involved direct infusion of acetylcholine and quantitative coronary angiography. Acetylcholine binds to muscarinic receptors on the endothelial cell surface, leading to an increase of intracellular calcium and increased nitric oxide (NO) production. In subjects with an intact endothelium, vasodilation was observed while subjects with endothelial damage experienced paradoxical vasoconstriction.
There exists a non-invasive, in vivo method for measuring endothelial function in peripheral arteries using high-resolution B-mode ultrasound. The endothelial function of peripheral arteries is closely related to coronary artery function. This technique measures the percent diameter change in the brachial artery during a period of reactive hyperemia following limb ischemia.
This technique, known as endothelium-dependent, flow-mediated vasodilation (FMD) has value in clinical research settings. However, a number of physiological and technical issues can affect the accuracy of the results and appropriate guidelines for the technique have been published. Despite the guidelines, FMD remains heavily operator dependent and presents a steep learning curve. This article presents a standardized method for measuring FMD in the brachial artery on the upper arm and offers suggestions to reduce intra-operator variability.

The key variables of flow-mediated vasodilation are shown in Table 1.
<table border="0" cellpadding="0" cellspacing="0" fo:keep-together.within-page="always">
	<tbody>
		<tr>
			<td>Variable</td>
			<td>Description</td>
		</tr>
		<tr>
			<td>Mean Velocity (cm/sec)</td>
			<td>The mean arterial velocity of blood in the middle 50% of the lumen during one cardiac cycle estimated from Doppler spectral waveforms, proportional to blood flow and inversely proportional to cross-sectional area (see Fi...

Watch this Scientific Journal Video about Ultrasound Assessment of Endothelial-Dependent Flow-Mediated Vasodilation of the Brachial Artery in Clinical Research at JoVE.com

Ultrasound Assessment of Endothelial-Dependent Flow-Mediated Vasodilation of the Brachial Artery in Clinical Research

Endothelial dysfunction is associated with numerous disease states and is predictive of adverse cardiovascular events in humans. Flow-mediated vasodilation (FMD) is a non-invasive ultrasound method of evaluating endothelial function. Methodological choices and operator experience may affect results. A systematic approach to FMD in human studies is discussed here.

The vascular endothelium is a monolayer of cells that cover the interior of blood vessels and provide both structural and functional roles. The ...

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27.1K ビュー.  University of California, San Francisco. 内皮機能不全は、多くの疾患状態に関連した、ヒトでの有害心血管イベントの予測です。血流依存性血管拡張（FMD）は、内皮機能を評価する非侵襲的な超音波法である。方法論的な選択とオペレータの経験が結果に影響を与える場合があります。ヒト試験における口蹄疫への体系的なアプローチは、ここで議論されている。 

ビデオ: Ultrasound Assessment of Endothelial-Dependent Flow-Mediated Vasodilation of the Brachial Artery in Clinical Research

Endothelial dysfunction is associated with numerous disease states and is predictive of adverse cardiovascular events in humans. Flow-mediated vasodilation (FMD) is a non-invasive ultrasound method of evaluating endothelial function. Methodological choices and operator experience may affect results. A systematic approach to FMD in human studies is discussed...

ultrasound assessment of flow-mediated dilation of the brachial and superficial femoral arteries in rats

Ultrasound Assessment of Flow-Mediated Dilation of the Brachial and Superficial Femoral Arteries in Rats

Non-invasive assessment of endothelial function in humans can be determined by the flow-mediated dilation technique. Although thousands of studies have used this technique, no study has performed this technique non-invasively in rats. The following article describes non-invasive measurement of flow-mediated dilation in the brachial and superficial femoral arteries of...

ultrasound assessment of endothelial function: a technical guideline of the flow-mediated dilation test

Ultrasound Assessment of Endothelial Function: A Technical Guideline of the Flow-mediated Dilation Test

The flow mediated dilation (FMD) test is the most commonly utilized, non-invasive, ultrasound assessment of endothelial function in humans. Although the FMD test has been related with the prediction of future cardiovascular disease and events, it is a physiological assessment with many inherent confounding factors that need to be considered.

ultrasound based assessment of coronary artery flow and coronary flow reserve using the pressure overload model in mice

Ultrasound Based Assessment of Coronary Artery Flow and Coronary Flow Reserve Using the Pressure Overload Model in Mice

Coronary flow reserve (CFR) is useful for assessment of myocardial oxygen demand and evaluation of cardiovascular risk. This study establishes a step-by-step transthoracic Doppler echocardiographic (TTDE) method for longitudinal monitoring of the changes in CFR, as measured from coronary artery in mice, under the experimental pressure overload of aortic...

brachial artery catheterization in swine

Brachial Artery Catheterization in Swine

The video describes in detail the catheterization of the distal brachial artery in swine. This procedure accurately measures arterial blood pressure and is a simple and fast method to collect samples for arterial blood gas...

doppler ultrasound-based leg blood flow assessment during single-leg knee-extensor exercise in an uncontrolled setting

Author Spotlight: Assessing the Reliability of Doppler Ultrasound in Measuring Leg Blood Flow 

This test-retest study evaluated leg blood flow measured by the Doppler ultrasound technique during single-leg knee-extensor exercise. The within-day, between-day, and inter-rater reliability of the method was investigated. The approach demonstrated high within-day and acceptable between-day reliability. However, the inter-rater reliability was unacceptably low during rest and at low...

Assessing Leg Blood Flow in Training Workloads

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ultrasound assessment of aortic and carotid artery intima-media thickness in children and adolescents

The present article describes the methodological considerations for the noninvasive assessment of abdominal aortic and carotid intima-media thickness using B-mode ultrasonography. This technique is commonly used in the developmental origins of health and disease research as a surrogate for early arterial...

Ultrasound Assessment of Aortic and Carotid Artery Intima-media Thickness in Children and Adolescents

flow cytometric assessment of oxygen-dependent car expression in car-t cells

Flow Cytometric Assessment of Oxygen-Dependent CAR Expression in CAR-T Cells

non-invasive assessment of microvascular and endothelial function

Non-invasive Assessment of Microvascular and Endothelial Function

Capillaroscopy is a non-invasive, relatively inexpensive methodology for directly visualizing the microcirculation. The forearm blood flow technique provides accepted non-invasive measures of endothelial...

assessing antibody-dependent, cell-mediated cytotoxicity in cancer cells using antibody-dependent cell-mediated cytotoxicity reporter bioassay

Author Spotlight: Optimizing Antibody-Based Cancer Treatments via Antibody-Dependent, Cell-Mediated Cytotoxicity Assay

Here, we present a protocol for an antibody-dependent, cell-mediated cytotoxicity (ADCC) assay using an ADCC bioassay kit. This method offers a valuable tool for elucidating the ADCC mechanism and evaluating the therapeutic potential of antibodies in cancer immunotherapy.

Assessing Antibody-dependent, Cell-mediated Cytotoxicity in Cancer Cells using Antibody-Dependent Cell-Mediated Cytotoxicity Reporter Bioassay

pulse-wave velocity, flow-mediated dilation, and carotid intima-media thickness to assess cardiovascular risk in population with metabolic syndrome

Author Spotlight: Assessing the Cardiovascular Profile of Patients with Metabolic Syndrome

Endothelial/vascular aging and atherogenesis are key mechanisms that promote the development of cardiovascular diseases. The present protocol describes methods to evaluate arterial stiffness, endothelial dysfunction, and atherogenesis in patients with related risk factors, which are highly valuable in the cardiovascular research...

Using Arterial Stiffness and Endothelial Function for Cardiovascular Assessment

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ultrasound scanning protocol in the assessment of ulnar neuropathy at the elbow

Ultrasound Scanning Protocol in the Assessment of Ulnar Neuropathy at the Elbow

This is a standardized protocol for evaluating the ulnar nerve at the elbow using ultrasound.

Doppler Ultrasound-Based Leg Blood Flow Assessment During Single-Leg Knee-Extensor Exercise in an Uncontrolled Setting

contrast enhanced ultrasound imaging for assessment of spinal cord blood flow in experimental spinal cord injury

Contrast Enhanced Ultrasound Imaging for Assessment of Spinal Cord Blood Flow in Experimental Spinal Cord Injury

Contrast Enhanced Ultrasound imaging is a reliable in-vivo tool for quantifying spinal cord blood flow in an experimental rat spinal cord injury model. This paper contains a comprehensive protocol for application of this technique in association with a contusion model of thoracic spinal cord...

pneumococcus infection of primary human endothelial cells in constant flow

Pneumococcus Infection of Primary Human Endothelial Cells in Constant Flow

This study describes the microscopic monitoring of pneumococcus adherence to von Willebrand factor strings produced on the surface of differentiated human primary endothelial cells under shear stress in defined flow conditions. This protocol can be extended to detailed visualization of specific cell structures and quantification of bacteria by applying differential immunostaining...

induction of adhesion-dependent signals using low-intensity ultrasound

Induction of Adhesion-dependent Signals Using Low-intensity Ultrasound

This protocol describes the stimulation of cultured fibroblasts with low-intensity pulsed ultrasound, which drives focal adhesion formation and Rac1 activation by mimicking engagement of the transmembrane matrix receptor, syndecan-4.  This approach allows investigation of a successful clinical technique at the cellular level, thereby providing opportunities for refinement of the...

evaluating endothelial dysfunction using flow-mediated dilation and subclinical atherogenesis using carotid intima-media thickness for cardiovascular risk assessment

Evaluating Endothelial Dysfunction Using Flow-Mediated Dilation and Subclinical Atherogenesis Using Carotid Intima-Media Thickness for Cardiovascular Risk Assessment

point of care transcranial color-coded duplex ultrasound of the middle cerebral artery

Author Spotlight: Advancing Neuromonitoring &#8212; Robotic Transcranial Ultrasound and POCUS for Acute Neurological Dysfunction

Transcranial ultrasound is an essential tool for monitoring patients with various neurological conditions. Although it is commonly used in a protocolized fashion in consultative studies, the brain has been overlooked in many protocols utilizing point-of-care ultrasound (PoCUS). This study proposes a PoCUS image acquisition...

Point of Care Transcranial Color-Coded Duplex Ultrasound of the Middle Cerebral Artery

clinical effects of ultrasound-guided acupotomy in knee osteoarthritis treatment

Author Spotlight: Minimally Invasive Ultrasound-Guided Acupotomy in Knee Osteoarthritis Treatment

This paper introduces the operation method of ultrasound-guided acupotomy for knee osteoarthritis, which can reduce synovial thickness and improve knee joint function. It has the advantages of precise target, low treatment risk, few complications, and high...

Clinical Effects of Ultrasound-Guided Acupotomy in Knee Osteoarthritis Treatment

the use of pharmacological-challenge fmri in pre-clinical research: application to the 5-ht system

The Use of Pharmacological-challenge fMRI in Pre-clinical Research: Application to the 5-HT System

The goal of this technique is to assess serotonin (5-HT) neurotransmitter function in the live and free-breathing animal with pharmacological magnetic resonance imaging (phMRI) and an intravenous challenge with a selective serotonin reuptake inhibitor (SSRI),...

Pharmacological MRI (phMRI) is a new and promising method to study the effects of substances on brain function that can ultimately be used to unravel underlying neurobiological mechanisms behind drug action and neurotransmitter-related disorders, such as depression and ADHD. Like most of the imaging methods (PET, SPECT, CT) it represents a progress in the investigation of brain disorders and the related function of neurotransmitter pathways in a non-invasive way with respect of the overall neuronal connectivity. Moreover it also provides the ideal tool for translation to clinical investigations. MRI, while still behind in molecular imaging strategies compared to PET and SPECT, has the great advantage to have a high spatial resolution and no need for the injection of a contrast-agent or radio-labeled molecules, thereby avoiding the repetitive exposure to ionizing radiations. Functional MRI (fMRI) is extensively used in research and clinical setting, where it is generally combined with a psycho-motor task. phMRI is an adaptation of fMRI enabling the investigation of a specific neurotransmitter system, such as serotonin (5-HT), under physiological or pathological conditions following activation via administration of a specific challenging drug.
The aim of the method described here is to assess brain 5-HT function in free-breathing animals. By challenging the 5-HT system while simultaneously acquiring functional MR images over time, the response of the brain to this challenge can be visualized. Several studies in animals have already demonstrated that drug-induced increases in extracellular levels of e.g. 5-HT (releasing agents, selective re-uptake blockers, etc) evoke region-specific changes in blood oxygenation level dependent (BOLD) MRI signals (signal due to a change of the oxygenated/deoxygenated hemoglobin levels occurring during brain activation through an increase of the blood supply to supply the oxygen and glucose to the demanding neurons) providing an index of neurotransmitter function. It has also been shown that these effects can be reversed by treatments that decrease 5-HT availability16,13,18,7. In adult rats, BOLD signal changes following acute SSRI administration have been described in several 5-HT related brain regions, i.e. cortical areas, hippocampus, hypothalamus and thalamus9,16,15. Stimulation of the 5-HT system and its response to this challenge can be thus used as a measure of its function in both animals and humans2,11.

The goal of this technique is to assess serotonin (5-HT) neurotransmitter function in the live and free-breathing animal with pharmacological magnetic resonance imaging (phMRI) and an intravenous challenge with a selective serotonin reuptake inhibitor (SSRI), fluoxetine.

Pharmacological MRI (phMRI) is a new and promising method to study the effects of substances on brain function that can ultimately be used to unravel ...

A Novel Application of Musculoskeletal Ultrasound Imaging

Ultrasound is an attractive modality for imaging muscle and tendon motion during dynamic tasks and can provide a complementary methodological approach for biomechanical studies in a clinical or laboratory setting. Towards this goal, methods for quantification of muscle kinematics from ultrasound imagery are being developed based on image processing. The temporal resolution of these methods is typically not sufficient for highly dynamic tasks, such as drop-landing. We propose a new approach that utilizes a Doppler method for quantifying muscle kinematics. We have developed a novel vector tissue Doppler imaging (vTDI) technique that can be used to measure musculoskeletal contraction velocity, strain and strain rate with sub-millisecond temporal resolution during dynamic activities using ultrasound. The goal of this preliminary study was to investigate the repeatability and potential applicability of the vTDI technique in measuring musculoskeletal velocities during a drop-landing task, in healthy subjects. The vTDI measurements can be performed concurrently with other biomechanical techniques, such as 3D motion capture for joint kinematics and kinetics, electromyography for timing of muscle activation and force plates for ground reaction force. Integration of these complementary techniques could lead to a better understanding of dynamic muscle function and dysfunction underlying the pathogenesis and pathophysiology of musculoskeletal disorders.

We describe a new ultrasound-based vector tissue Doppler imaging technique to measure muscle contraction velocity, strain and strain rate with sub-millisecond temporal resolution during dynamic activities. This approach provides complementary measurements of dynamic muscle function and could lead to a better understanding of mechanisms underlying musculoskeletal disorders.

Ultrasound is an attractive modality for imaging muscle and tendon  motion during dynamic tasks and can provide a complementary methodological  approach ...

Clinical Assessment of Spatiotemporal Gait Parameters in Patients and Older Adults

Spatial and temporal characteristics of human walking are frequently evaluated to identify possible gait impairments, mainly in orthopedic and neurological patients1-4, but also in healthy older adults5,6. The quantitative gait analysis described in this protocol is performed with a recently-introduced photoelectric system (see&#160;Materials table) which has the potential to be used in the clinic because it is portable, easy to set up (no subject preparation is required before a test), and does not require maintenance and sensor calibration. The photoelectric system consists of series of high-density floor-based photoelectric cells with light-emitting and light-receiving diodes that are placed parallel to each other to create a corridor, and are oriented perpendicular to the line of progression7. The system simply detects interruptions in light signal, for instance due to the presence of feet within the recording area. Temporal gait parameters and 1D spatial coordinates of consecutive steps are subsequently calculated to provide common gait parameters such as step length, single limb support and walking velocity8, whose validity against a criterion instrument has recently been demonstrated7,9. The measurement procedures are very straightforward; a single patient can be tested in less than 5 min&#160;and a comprehensive report can be generated in less than 1&#160;min.

This protocol is used to evaluate spatial and temporal gait variables of neurological/orthopedic patients and older persons by means of a recently-introduced floor-based photocell system.

Spatial and temporal characteristics of human walking are frequently evaluated to identify possible gait impairments, mainly in orthopedic and ...

Transthoracic Doppler echocardiography (TTDE) is a clinically useful, noninvasive tool for studying coronary artery flow velocity and coronary flow reserve (CFR) in humans. Reduced CFR is accompanied by marked intramyocardial and pericoronary fibrosis and is used as an indication of the severity of dysfunction. This study explores, step-by-step, the real-time changes measured in the coronary flow velocity, CFR and systolic to diastolic peak velocity (S/D) ratio in the setting of an aortic banding model in mice. By using a Doppler transthoracic imaging technique that yields reproducible and reliable data, the method assesses changes in flow in the septal coronary artery (SCA), for a period of over two weeks in mice, that previously either underwent aortic banding or thoracotomy. 
During imaging, hyperemia in all mice was induced by isoflurane, an anesthetic that increased coronary flow velocity when compared with resting flow. All images were acquired by a single imager. Two ratios, (1) CFR, the ratio between hyperemic and baseline flow velocities, and (2) systolic (S) to diastolic (D) flow were determined, using a proprietary software and by two independent observers. Importantly, the observed changes in coronary flow preceded LV dysfunction as evidenced by normal LV mass and fractional shortening (FS). 
The method was benchmarked against the current gold standard of coronary assessment, histopathology. The latter technique showed clear pathologic changes in the coronary artery in the form of peri-coronary fibrosis that correlated to the flow changes as assessed by echocardiography. 
The study underscores the value of using a non-invasive technique to monitor coronary circulation in mouse hearts. The method minimizes redundant use of research animals and demonstrates that advanced ultrasound-based indices, such as CFR and S/D ratios, can serve as viable diagnostic tools in a variety of investigational protocols including drug studies and the study of genetically modified strains.

Coronary flow reserve (CFR) is useful for assessment of myocardial oxygen demand and evaluation of cardiovascular risk. This study establishes a step-by-step transthoracic Doppler echocardiographic (TTDE) method for longitudinal monitoring of the changes in CFR, as measured from coronary artery in mice, under the experimental pressure overload of aortic banding.

Transthoracic Doppler echocardiography (TTDE) is a clinically useful, noninvasive tool for studying coronary artery flow velocity and coronary flow ...

Cardiovascular disease is the primary cause of mortality and a major cause of disability worldwide. The dysfunction of the vascular endothelium is a pathological condition characterized mainly by a disruption in the balance between vasodilator and vasoconstrictor substances and is proposed to play an important role in the development of atherosclerotic cardiovascular disease. Therefore, a precise evaluation of endothelial function in humans represents an important tool that could help better understand the etiology of multiple cardio-centric pathologies.
Over the past twenty-five years, many methodological approaches have been developed to provide an assessment of endothelial function in humans. Introduced in 1989, the FMD test incorporates a forearm occlusion and subsequent reactive hyperemia that promotes nitric oxide production and vasodilation of the brachial artery. The FMD test is now the most widely utilized, non-invasive, ultrasonic assessment of endothelial function in humans and has been associated with future cardiovascular events.
Although the FMD test could have clinical utility, it is a physiological assessment that has inherited several confounding factors that need to be considered. This article describes a standardized protocol for determining FMD including the recommended methodology to help minimize the physiological and technical issues and improve the precision and reproducibility of the assessment.

The flow mediated dilation (FMD) test is the most commonly utilized, non-invasive, ultrasound assessment of endothelial function in humans. Although the FMD test has been related with the prediction of future cardiovascular disease and events, it is a physiological assessment with many inherent confounding factors that need to be considered.

Cardiovascular disease is the primary cause of mortality and a major cause of disability worldwide. The dysfunction of the vascular endothelium is a ...

Ultrasound-based Pulse Wave Velocity Evaluation in Mice

Arterial stiffness can be evaluated by calculating pulse wave velocity (PWV), i.e., the speed with which the pulse wave travels in a conduit vessel. This parameter is being increasingly investigated in small rodent models in which it is used for assessing alterations in vascular function related to particular genotypes/treatments or for characterizing cardiovascular disease progression. This protocol describes an image processing algorithm which leads to non-invasive arterial PWV measurement in mice using ultrasound (US) images only. The proposed technique has been used to assess abdominal aorta PWV in mice and evaluate its age-associated changes.
Abdominal aorta US scans are obtained from mice under gaseous anesthesia using a specific US device equipped with high-frequency US probes. B-mode and Pulse-Wave Doppler (PW-Doppler) images are analyzed in order to obtain diameter and mean velocity instantaneous values, respectively. For this purpose, edge detection and contour tracking techniques are employed. The single-beat mean diameter and velocity waveforms are time aligned and combined in order to achieve the diameter-velocity (lnD-V) loop. PWV values are obtained from the slope of the linear part of the loop, which corresponds to the early systolic phase.
With the present approach, anatomical and functional information about the mouse abdominal aorta can be non-invasively achieved. Requiring the processing of US images only, it may represent a useful tool for the non-invasive characterization of different arterial sites in the mouse in terms of elastic properties. The application of the present technique can be easily extended to other vascular districts, such as the carotid artery, thus providing the possibility to obtain a multi-site arterial stiffness assessment.

Arterial stiffness represents a key factor in cardiovascular disease and pulse wave velocity (PWV) can be considered as a surrogate index for arterial stiffness. This protocol describes an image processing algorithm for calculating PWV in mice based on ultrasound image processing that is applicable at different arterial sites.

Arterial stiffness can be evaluated by calculating pulse wave velocity (PWV), i.e., the speed with which the pulse wave travels in a conduit vessel. This ...

Arterial vasodilation to increases in wall shear rate is indicative of vascular endothelial function. In humans, the non-invasive measurement of endothelial function can be achieved by employing the flow-mediated dilation technique, typically performed in the brachial or superficial femoral artery. Briefly, a blood pressure cuff placed distal to an ultrasound probe is inflated to a suprasystolic pressure, which results in limb ischemia. After 5 min of occlusion the cuff is deflated, resulting in reactive hyperemia and increases in wall shear rate that signal vasodilatory molecules to be released from the endothelium eliciting vasodilation. Despite the thousands of studies performing flow-mediated dilation in humans, surprisingly, no studies have performed this technique non-invasively in living rats. Considering the recent shift in focus to translational research, the establishment of guidelines for non-invasive measurement of flow-mediated dilation in rats and other rodents would be extremely valuable. In the following article, a protocol is presented for the non-invasive measurement of flow-mediated dilation in brachial and superficial femoral arteries of rats, as those sites are most commonly measured in humans.

Non-invasive assessment of endothelial function in humans can be determined by the flow-mediated dilation technique. Although thousands of studies have used this technique, no study has performed this technique non-invasively in rats. The following article describes non-invasive measurement of flow-mediated dilation in the brachial and superficial femoral arteries of rats.

Arterial vasodilation to increases in wall shear rate is indicative of vascular endothelial function. In humans, the non-invasive measurement of ...

The video describes in detail the catheterization of the distal brachial artery in swine. This technique enables researchers to measure arterial blood pressure continuously and collect arterial blood samples to assess arterial blood gas measurements. Arterial blood pressures and arterial blood gases are important physiological parameters to monitor during experimental procedures. In swine, four common methods of arterial catheterization have been described, including catheterization of the carotid, femoral, auricular, and medial saphenous arteries. Each of these techniques have advantages, such as ease of access for the auricular artery, and disadvantages that include deep tissue dissection for carotid artery catheterization. The described alternative method of arterial catheterization in swine, the catheterization of the distal aspect of the brachial artery, is a rapid procedure that requires relatively minimal tissue dissection and provides information that is in line with data collected from other arterial catheterization sites. The procedure uses a medial approach along an oblique plane of the lower brachium, positioned between the olecranon and the flexor aspect of the elbow joint, and this approach allows researchers the major advantage of unimpeded freedom for procedures that involve the caudoventral, caudodorsal back, or hind limbs of the pig. Due to the location of the upper forelimb of the catheterized vessel and potential challenges of effective homeostasis following catheter removal from the artery, this technique may be limited to non-recovery procedures.

The video describes in detail the catheterization of the distal brachial artery in swine. This procedure accurately measures arterial blood pressure and is a simple and fast method to collect samples for arterial blood gas measurements.

The video describes in detail the catheterization of the distal brachial artery in swine. This technique enables researchers to measure arterial blood ...

Assessment of Static Graviceptive Perception in the Roll-Plane using the Subjective Visual Vertical Paradigm

Vestibular disorders are among the most common syndromes in medicine. In recent years, new vestibular diagnostic systems have been introduced that allow the examination of all semicircular canals in the clinical setting. Assessment methods of the otolithic system, which is responsible for the perception of linear acceleration and perception of gravity, are far less in clinical use. There are several experimental approaches for measuring the perception of gravity. The most frequently used method is the determination of the subjective visual vertical. This is usually measured with the head in an upright position. We present here an assessment method for testing otolith function in the roll plane. The subjective visual vertical is measured in the head upright position as well as with head inclination of &#177; 15&#176; and &#177; 30&#176; in the roll plane. This extended functional paradigm is an easy-to-perform clinical test of otolith function and ensures increased information content for the detection of impaired graviceptive perception.

The perception of gravity is commonly determined by the subjective visual vertical in the head upright position. The additional assessment at head tilts of &#177; 15&#176; and &#177; 30&#176; in the roll plane ensures increased information content for the detection of impaired graviceptive perception.

Vestibular disorders are among the most common syndromes in medicine. In recent years, new vestibular diagnostic systems have been introduced that allow ...

Providing Visual Biofeedback Using Brightness Mode Ultrasound During a Golf Swing

Using ultrasound biofeedback in conjunction with verbal cueing can increase muscle thickness more than verbal cueing alone and may augment traditional rehabilitation techniques in an athletic, physically active population. Brightness mode (B-mode) ultrasound can be applied using frame-by-frame analysis synchronized with video to understand muscle thickness changes during these dynamic tasks. Visual biofeedback with ultrasound has been established in static positions for the muscles of the lateral abdominal wall. However, by securing the transducer to the abdomen using an elastic belt and foam block, biofeedback can be applied during more specific tasks prevalent in lifetime sports, such as golf. To analyze muscle activity during a golf swing, muscle thickness changes can be compared. The thickness must increase throughout the task, indicating that the muscle is more active. This methodology allows clinicians to immediately replay ultrasound videos for patients as a visual tool to instruct proper activity of the muscles of interest. For example, ultrasound can be used to target the external and internal obliques, which play an important role in swinging a golf club or any other rotational sport or activity. This methodology aims to increase oblique muscle thickness during the golf swing. Additionally, the timing of muscle contraction can be targeted by instructing the patient to contract the abdominal muscles at specific time points, such as the beginning of the downswing, with the goal of improving muscle firing patterns during tasks.

Brightness mode ultrasound can be used to provide visual biofeedback of the muscles of the lateral abdominal wall during a golf swing. Post-swing visual and verbal instruction can increase the muscle activation and timing of the external and internal obliques.

Using ultrasound biofeedback in conjunction with verbal cueing can increase muscle thickness more than verbal cueing alone and may augment traditional ...