<meta charset="utf8"></head><body>Rat EVLP 모델에서 PolyhHb 기반 관류를 사용한 폐 이식 발전

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
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		<tr>
			<td>10 cc insulin syringe 29 G x 1/2&#34; needle</td>
			<td>B-D</td>
			<td>309301</td>
			<td></td>
		</tr>
		<tr>
			<td>30 L Glass Batch Bioreactor</td>
			<td>Ace Glass</td>
			<td></td>
			<td></td>
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			<td>30g Needle</td>
			<td>Med Needles</td>
			<td>BD-305106</td>
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			<td>Baytril (enrofloxacin) Antibacterial Tablets</td>
			<td>Elanco</td>
			<td>NA</td>
			<td></td>
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		<tr>
			<td>Calcium Chloride dihydrate (CaCl2.2H2O)</td>
			<td>Sigma Aldrich</td>
			<td>10035-04-8</td>
			<td>For modified Ringer&#39;s lactate</td>
		</tr>
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			<td>CFBA carrier frequency bridge amplifier type 672</td>
			<td>Harvard Apparatus</td>
			<td>731747</td>
			<td></td>
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		<tr>
			<td>Connect kit D150</td>
			<td>Cole-Parmer</td>
			<td>&#160;VK 73-3763</td>
			<td></td>
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			<td>Dumont #5 Forceps</td>
			<td>Fine Science tools</td>
			<td>11252-50</td>
			<td></td>
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			<td>Dumont Medical #5/45 Forceps - Angled 45&#176;</td>
			<td>Fine Science tools</td>
			<td>11253-25</td>
			<td></td>
		</tr>
		<tr>
			<td>Ecoline Star Edition 003, E100 Water Heater</td>
			<td>Lauda</td>
			<td>LCK 1879</td>
			<td></td>
		</tr>
		<tr>
			<td>Expired human leukoreduced, packed RBC units</td>
			<td>Wexner Medical Center 
			Canadian Blood Services 
			Zen-Bio Inc</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Fiberoxygenator D150</td>
			<td>Hugo Sachs Elektronik</td>
			<td>PY2 73-3762</td>
			<td></td>
		</tr>
		<tr>
			<td>Forceps</td>
			<td>Fine Science tools</td>
			<td>11027-12</td>
			<td></td>
		</tr>
		<tr>
			<td>Glutaraldehyde (C5H8O2 70 wt%)</td>
			<td>Sigma Aldrich</td>
			<td>111-30-8 (G7776)</td>
			<td></td>
		</tr>
		<tr>
			<td>Halsted-Mosquito Hemostat</td>
			<td>Roboz Surgical</td>
			<td>RS-7112</td>
			<td></td>
		</tr>
		<tr>
			<td>Heparin 30,000 units per 30 ml</td>
			<td>APP Pharmaceuticals</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Human Serum Albumin (HSA)</td>
			<td>OctaPharma Plasma</td>
			<td></td>
			<td>Perfusate additive</td>
		</tr>
		<tr>
			<td>IL2 Tube set for perfusate</td>
			<td>Harvard Apparatus</td>
			<td>733842</td>
			<td></td>
		</tr>
		<tr>
			<td>IPL-2 Basic Lung Perfusion System</td>
			<td>Harvard Apparatus</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Ketamine 500 mg per 5 ml</td>
			<td>JHP Pharmaceuticals</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Left Atrium cannula</td>
			<td>Harvard Apparatus</td>
			<td>730712</td>
			<td></td>
		</tr>
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			<td>Liqui-Cel EXF Series G420 Membrane Contactor</td>
			<td>3M</td>
			<td>G420</td>
			<td>gas contactor</td>
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		<tr>
			<td>low potassium dextran glucose solution (perfadex)</td>
			<td>XVIVO</td>
			<td></td>
			<td>solution flushing the lung</td>
		</tr>
		<tr>
			<td>Masterflex Platinum Coated Tubing(Size: 73,17,16,24)</td>
			<td>Cole-Palmer</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>N-Acetyl-L-cysteine (NALC, C5H9NO3S)</td>
			<td>Sigma Aldrich</td>
			<td>616-91-1 (A7250)</td>
			<td>For modified Ringer&#39;s lactate</td>
		</tr>
		<tr>
			<td>Nalgene Vessels (10L, 20L)</td>
			<td>Nalgene</td>
			<td></td>
			<td>Filtration vessels</td>
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		<tr>
			<td>Peristaltic Pump</td>
			<td>&#160;Ismatec</td>
			<td>&#160;ISM 827B</td>
			<td></td>
		</tr>
		<tr>
			<td>PES, 0.65 &#181;m TFF module</td>
			<td>Repligen</td>
			<td>N02-E65U-07-N</td>
			<td></td>
		</tr>
		<tr>
			<td>PhysioSuite</td>
			<td>Kent Scientific Corporation</td>
			<td>PS-MSTAT-RT</td>
			<td></td>
		</tr>
		<tr>
			<td>polyethersulfone (PES), 0.2 &#181;m TFF module</td>
			<td>Repligen</td>
			<td>N02-S20U-05-N</td>
			<td></td>
		</tr>
		<tr>
			<td>Polysulfone (PS), 500 kDa TFF module</td>
			<td>Repligen</td>
			<td>N02-P500-05-N</td>
			<td></td>
		</tr>
		<tr>
			<td>Potassium Chloride (KCl)</td>
			<td>Fisher Scientific</td>
			<td>7447-40-7</td>
			<td>For PBS</td>
		</tr>
		<tr>
			<td>PowerLab 8/35</td>
			<td>&#160;ADInstruments</td>
			<td>730045</td>
			<td></td>
		</tr>
		<tr>
			<td>Pulmonary Artery cannula</td>
			<td>Harvard Apparatus</td>
			<td>730710</td>
			<td></td>
		</tr>
		<tr>
			<td>Pump Head tubing (Size: 73,17,16,24)</td>
			<td>PharMed BPT</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Puralube&#160;Ophthalmic Ointment</td>
			<td>Dechra</td>
			<td>NA</td>
			<td></td>
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		<tr>
			<td>Scissors</td>
			<td>Fine Science tools</td>
			<td>14090-11</td>
			<td></td>
		</tr>
		<tr>
			<td>SCP Servo controller for perfusion type 704</td>
			<td>Harvard Apparatus</td>
			<td>732806</td>
			<td></td>
		</tr>
		<tr>
			<td>Small Animal Ventilator model 683</td>
			<td>Harvard Apparatus</td>
			<td>55-000</td>
			<td></td>
		</tr>
		<tr>
			<td>Sodium Chloride (NaCl)</td>
			<td>Fisher Scientific</td>
			<td>7647-14-5 (S271-10)</td>
			<td>For PBS and saline</td>
		</tr>
		<tr>
			<td>Sodium cyanoborohydride (NaCNBH3)</td>
			<td>Sigma Aldrich</td>
			<td>25895-60-7</td>
			<td></td>
		</tr>
		<tr>
			<td>Sodium Dithionite (Na2S2O4)</td>
			<td>Sigma Aldrich</td>
			<td>7775-14-6</td>
			<td></td>
		</tr>
		<tr>
			<td>Sodium Hydroxide (NaOH)</td>
			<td>Fisher Scientific</td>
			<td>1310-73-2</td>
			<td>For modified Ringer&#39;s lactate</td>
		</tr>
		<tr>
			<td>Sodium Lactate (NaC3H5O3)</td>
			<td>Sigma Aldrich</td>
			<td>867-56-1</td>
			<td>For modified Ringer&#39;s lactate</td>
		</tr>
		<tr>
			<td>Sodium phosphate dibasic (Na2HPO4)</td>
			<td>Fisher Scientific</td>
			<td>7558-79-4</td>
			<td>For PBS</td>
		</tr>
		<tr>
			<td>Sodium phosphate monobasic (NaH2PO4)</td>
			<td>Fisher Scientific</td>
			<td>7558-80-7</td>
			<td>For PBS</td>
		</tr>
		<tr>
			<td>SomnoSuite Small Animal Anesthesia System</td>
			<td>Kent Scientific Corporation</td>
			<td>SS-MVG-Module</td>
			<td></td>
		</tr>
		<tr>
			<td>Sprague-Dawley rats</td>
			<td>Envigo</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>TAM-A transducer amplifier module type 705/1</td>
			<td>Harvard Apparatus</td>
			<td>73-0065</td>
			<td></td>
		</tr>
		<tr>
			<td>TAM-D transducer amplifier type 705/2</td>
			<td>Harvard Apparatus</td>
			<td>&#160;73-1793</td>
			<td></td>
		</tr>
		<tr>
			<td>TCM time control module type 686</td>
			<td>Harvard Apparatus</td>
			<td>731750</td>
			<td></td>
		</tr>
		<tr>
			<td>Tracheal cannula</td>
			<td>Harvard Apparatus</td>
			<td>733557</td>
			<td></td>
		</tr>
		<tr>
			<td>Tube set for moist chamber</td>
			<td>Harvard Apparatus</td>
			<td>&#160;73V83157</td>
			<td></td>
		</tr>
		<tr>
			<td>Tubing Cassette</td>
			<td>Cole-Parmer</td>
			<td>IS 0649</td>
			<td></td>
		</tr>
		<tr>
			<td>Tweezer #5 Dumostar</td>
			<td>Kent Scientific Corporation</td>
			<td>&#160;INS500085-A</td>
			<td></td>
		</tr>
		<tr>
			<td>Tweezer #5 stainless steel, curved</td>
			<td>Kent Scientific Corporation</td>
			<td>IND500232</td>
			<td></td>
		</tr>
		<tr>
			<td>Tweezer #7 Titanium</td>
			<td>Kent Scientific Corporation</td>
			<td>&#160;INS600187</td>
			<td></td>
		</tr>
		<tr>
			<td>Tygon E-3603 Tubing 2.4 mm ID</td>
			<td>Harvard Apparatus</td>
			<td>721017</td>
			<td>perfusate line entering lung</td>
		</tr>
		<tr>
			<td>Tygon E-3603 Tubing 3.2 mm ID</td>
			<td>Harvard Apparatus</td>
			<td>721019</td>
			<td>perfusate line leaving lung</td>
		</tr>
		<tr>
			<td>Vannas-Tubingen Spring Scissors</td>
			<td>Fine Science Tools</td>
			<td>15008-08</td>
			<td></td>
		</tr>
		<tr>
			<td>VCM ventilator control module type 681</td>
			<td>Harvard Apparatus</td>
			<td>731741</td>
			<td></td>
		</tr>
		<tr>
			<td>William&#39;s E Media</td>
			<td>Gibco, ThermoFisher Scientific</td>
			<td>A12176-01</td>
			<td>Perfusate additive</td>
		</tr>
		<tr>
			<td>Xylazine 100 mg per 1 ml</td>
			<td>Akorn</td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

exploring alternative perfusion solutions using next-generation polymerized hemoglobin-based oxygen carriers in a model of rat ex vivo lung perfusion

Like any field in solid organ transplantation, lung transplantation suffers from a shortage of donor organs. In order to increase the donor pool, significant research has been dedicated to investigating the potential of allografts that were once thought to be unsuitable for transplantation, i.e., extended criteria donors (ECD). These allografts can be considered ECD for a milieu of reasons, including questionable quality, poor function, infection, trauma, prolonged warm or cold ischemic times, and advanced age1,2. In certain cases, where these lungs are suitable for immediate transplant3, it is often advantageous to providers and recipients alike to evaluate these lungs for an additional time to determine their suitability for transplantation. Ex vivo lung perfusion (EVLP) is such a technology that allows for extended assessment of potential lung allografts in a closed circuit outside the donor2,4,5,6,7, affording the transplant provider the ability to determine transplantation suitability. EVLP has shown the ability to adequately assess donor organs8,9,10,11, decrease the effects of ischemic reperfusion injury (IRI)12,13 and increase the donor pool14,15 thus making lung transplantation a more accessible treatment for all.
In general, an EVLP system is a closed system with a ventilatory circuit (achieved by connecting a ventilator to the trachea to introduce air into the system) and a vascular circuit (achieved by connecting the left atrium (LA) to the pulmonary artery (PA) with tubing)7. The vascular circuit has perfusate running through the tubing to give the lung vital nutrients and oxygen while limiting the cold ischemic time (CIT)5,8,16,17. This solution is either blood-based (i.e., via the addition of packed red blood cells (PRBCs))16,17 or acellular-based (i.e., no PRBCs)4,5. However, there are several notable disadvantages to using PRBCs. If using PRBCs from donors who died from trauma or brain-dead donors (BDD), these fluids often contain large amounts of inflammatory cytokines, which may increase cellular damage during EVLP as well as increase levels of cell-free hemoglobin (Hb), heme, iron, and cell fragments which deliver additional damage to cells18,19. Furthermore, as these donors are often multi-organ, the collection of PRBCs prior to procurement could lead to decreasing blood volume in the donor and subsequently increasing ischemia to all organs. If using PRBCs from another source, providers could face blood shortages as this is a scarce material in and of itself20,21. Finally, PRBCs are prone to mechanical lysis on the EVLP circuit regardless of their source, releasing Hb and other components that contribute to cellular damage.
Thus, for many reasons, it could be advantageous to use an artificial red blood cell substitute, i.e., hemoglobin-based oxygen carriers (HBOCs), as a perfusate supplement. One particularly promising HBOC is polymerized human hemoglobin (PolyhHb). PolyhHb is synthesized from Hb purified from expired PRBCs that were deemed unsuitable for immediate transfusion22. They have been shown to be viable blood substitutes in hemorrhagic shock23 and transplantation24 and can be produced in large quantities22. However, large-scale adoption of PolyhHb has been unsuccessful due to unforeseen complications such as vasoconstriction, increasing blood pressure, and cardiac arrest23,25. The reasons behind these findings were likely due to the presence of cell-free Hb or low molecular weight Hb polymers (&#60; 500 kDa) in the PolyhHb solution, as they have a propensity to extravasate into the tissue space, which resulted in decreased nitric oxide availability, subsequent vasoconstriction, systemic hypertension, and ultimately oxidative tissue injury26,27. To improve upon these issues, the Palmer Laboratory has worked to develop a next-generation PolyhHb that contains minimal low MW species and cell-free Hb, which has demonstrated improved biophysical characteristics and in vivo responses22,28,29,30. Several transfusion studies in animals have shown that if low molecular weight Hb polymers are eliminated from the HBOC, vasoconstriction, systemic hypertension, and oxidative damage can be mitigated28,29,31,32,33,34,35. Therefore, making this next-generation PolyhHb a promising perfusate candidate.
Here, we describe the application of a next-generation PolyhHb to be used in a perfusate and the protocol by which this perfusion solution can be tested in a model of rat EVLP. The goal of this study is to provide the lung transplant community with key information in designing and developing novel perfusion solutions, as well as provide protocols to test them in clinically relevant translational transplant models.

<meta charset="utf8"></head><body>저자 스포트라이트: 쥐의 기증자 폐 평가 및 보존 개선을 위한 차세대 중합 인간 헤모글로빈 활용

Rat Ex Vivo 폐 관류 모델에서 차세대 중합 헤모글로빈 기반 산소 운반체를 사용한 대체 관류 솔루션 탐색

Ex vivo lung perfusion or EVLP enables extended evaluation of donor lungs. There are two perfusion solutions, an acellular and cellular. This study details using a polymerized human hemoglobin or a poly HB-based oxygen carrier as a perfusate in the protocol for testing this solution in a rat EVLP model.The recent advances in ex vivo organ perfusion have enabled expanding the donor organ pool with improved function. Working to extend normothermic profusion times with tailored perfusates will allow for further advances in this space. Current perfusion techniques use cellular or acellular perfusates, each with pros and cons.Perfusion composition is crucial for metabolic support, reducing inflammation and maintaining oncotic pressure. However, existing solutions can cause pulmonary edema and damage. Thus, it is necessary to develop novel perfusion solutions that prevent excessive damage while maintaining proper cellular homeostasis.A promising hemoglobin-based oxygen carrier or HBOC is polymerized human hemoglobin synthesized from expired packed red blood cells. Our laboratory developed a next generation poly HB with minimal low molecular weight species and cell-free hemoglobin. This has shown improved biophysical characteristics and has reduced vasoconstriction, hypertension, and oxidative damage in animal studies.These characteristics make it a promising perfusate candidate.

Lung transplantation is hampered by the lack of suitable donors. Previously, donors that were thought to be marginal or inadequate were discarded. ...

exploring-alternative-perfusion-solutions-using-next-generation

Research

JoVE Journal

Medicine

Exploring Alternative Perfusion Solutions Using Next-Generation Polymerized Hemoglobin-Based Oxygen Carriers in a Model of Rat Ex Vivo Lung Perfusion

323 조회수.  The Ohio State University Wexner Medical Center. 체외 폐 관류(EVLP)를 통해 기증자 폐의 확장된 평가를 수행할 수 있습니다. 관류 용액에는 무세포와 세포의 두 가지 용액이 있습니다. 이 연구는 쥐 EVLP 모델에서 이 용액을 테스트하기 위한 프로토콜에서 중합된 인간 헤모글로빈 또는 폴리 HB 기반 산소 운반체를 관류물로 사용하는 것에 대해 자세히 설명합니다.최근 체외 장기 관류의 발전으로 ...

비디오: 저자 스포트라이트: 쥐의 기증자 폐 평가 및 보존 개선을 위한 차세대 중합 인간 헤모글로빈 활용

Lung transplantation is hampered by the lack of suitable donors. Previously, donors that were thought to be marginal or inadequate were discarded. However, new and exciting technology, such as ex vivo lung perfusion (EVLP), offers lung transplant providers extended assessment for marginal donor allografts. This dynamic assessment platform has led to an increase in lung transplantation and has allowed providers to use donors that were previously discarded, thus expanding the donor pool. Current perfusion techniques use cellular or acellular perfusates, and both have distinct advantages and disadvantages. Perfusion composition is critical to maintaining a homeostatic environment, providing adequate metabolic support, decreasing inflammation and cellular death, and ultimately improving organ function. Perfusion solutions must contain sufficient protein concentration to maintain appropriate oncotic pressure. However, current perfusion solutions often lead to fluid extravasation through the pulmonary endothelium, resulting in inadvertent pulmonary edema and damage. Thus, it is necessary to develop novel perfusion solutions that prevent excessive damage while maintaining proper cellular homeostasis. Here, we describe the application of a polymerized human hemoglobin (PolyhHb)-based oxygen carrier as a perfusate and the protocol in which this perfusion solution can be tested in a model of rat EVLP. The goal of this study is to provide the lung transplant community with key information in designing and developing novel perfusion solutions, as well as the proper protocols to test them in clinically relevant translational transplant models.

Here, we describe the application of a polymerized human hemoglobin (PolyhHb)-based oxygen carrier as a perfusate and the protocol in which this perfusion solution can be tested in a model of rat ex vivo lung perfusion.

연구

의학

Setup of an Ex Vivo Lung Perfusion (EVLP) Circuit with PolyhHb for Lung Perfusion in Rats

To begin, take human serum albumin at a final concentration of 3%Into it, add polymerized hemoglobin, or PolyhHb, diluted to a final concentration of 3.7 grams per deciliter with William's E Medium. Then add one milliliter of heparin solution to the resultant diluted PolyhHb solution. Place PolyhHb perfusate into the EVLP circuit reservoir and set the water bath temperature to 37 degrees Celsius.Then turn on the roller pumps and ensure that perfusate is circulating within the circuit. Connect de-oxygenation gas to the hollow fiber oxygenator to de-oxygenate the perfusate. Open data acquisition software on the computer.Verify that pulmonary artery pressure, tracheal differential pressure, respiratory flow differential pressure, lung weight, and pump speed transducers are connected to both the circuit and data converter box. Carefully examine all tube connections to ensure no leaks are present and warm water is circulating throughout. Press Run on the software to check that all pressure transducers are functioning.Once the system is properly functioning, turn off the roller pumps.

쥐의 폐 관류를 위한 PolyhHb를 사용한 EVLP(Ex Vivo Lung Perfusion) 회로 설정

Procurement and Cannulation of Donor Rat Lung Block for Ex Vivo Lung Perfusion

To begin, place the autoclaved surgical instruments on the surgical table. Shave the abdomen of the anesthetized rat and place the rat in the supine position on the surgical board. Clean the abdomen with povidone iodine followed by 70%ethanol.Place ophthalmic ointment under the rat's eyes to prevent dryness. Secure the rat in place on the surgical board. Start the data acquisition software and begin recording.Turn on the ventilator at four milliliters per kilogram and ensure positive end expiratory pressure is around two centimeters of water. Using scissors, perform a midline laparotomy from the xiphoid process to the pubic symphysis. Then with the help of a blunt instrument, perform a medial-lateral visceral rotation and visualize the infrahepatic inferior vena cava.Inject heparin into the inferior vena cava with a 20-gauge needle. Using a pair of scissors, cut the skin from the sternal notch to just below the angle of the mandible and begin to dissect toward the trachea. Then, bluntly dissect away necessary strap muscles to expose the trachea.Make a transverse incision on the anterior trachea between the cartilaginous rings, ensuring not to cut through the posterior portion of the trachea. Place a 5-0 silk suture around the trachea. Insert the endotracheal tube into the cartilaginous rings, and secure it with the 5-0 silk suture.Connect the endotracheal tube to the ventilator and ensure proper chest rising. Using scissors, perform a median sternotomy and enter the thoracic cavity. Place chest wall retractors to expose the heart and lungs, avoiding any inadvertent manipulation of the lungs.With the combination of sharp and blunt dissection, remove the thymus from the anterior mediastinum. Identify the pulmonary artery and place a 5-0 silk suture around it to prepare for cannulation. Make a two to three millimeter incision in the right ventricular outflow tract using scissors to place the arterial cannula within the pulmonary artery and secure it with the 5-0 suture.After euthanizing the rat, quickly connect the de-aired lung preservation fluid to the arterial cannula to gravity flush the lungs. Connect the arterial cannula to the EVLP circuit. Turn on the roller pump and allow a small amount of perfusate to flow through the lung and out of the left ventricle into the thoracic cavity.Once perfusate begins to flow out of the left atrium, turn off the roller pump. Next, place a small forceps in the left ventricle and gently stretch the mitral valve annulus. Place a 5-0 silk tie around the heart and loosely tie.Insert the left atrium cannula into the left ventricle and advance the cannula until it can be seen within the atrium. Secure the left atrium with the pre-tied 5-0 suture. Identify the esophagus and clamp it with a hemostat as close to the diaphragm as possible.Then, cut the esophagus below the hemostat. Using the spine as a guide, cut all ligamentous attachments connecting the heart-lung block to the surrounding structures with scissors. Then dissect the trachea from the neck and cut the trachea above the endotracheal tube to free the heart-lung block.Move the heart-lung block to the thoracic jacket within the EVLP circuit and attach the left atrium cannula to the circuit. Turn the roller pump on and connect the ventilator monitor. Check the bubble trap to ensure no air emboli are being introduced into the system.Slowly change ventilation and perfusion settings to the desired experimental levels during the initial 15 minutes. Additionally, increase the perfusion flow rate to the desired rate and pressure. At designated time points, check perfusate gas levels and pulmonary function tests.All tested perfusates showed a slight decrease in left atrium partial pressure of oxygen with the RBC-based perfusate significantly decreasing at one hour. For the next several hours, both polyhHB and control perfusates had stable left atrium partial pressure of oxygen. The delta partial pressure of oxygen significantly decreased at one hour in the RBC perfusate group while it remained stable in the polyhHB and control perfusates with a non-significant trend.Left atrium partial pressure of carbon dioxide was significantly lower in the RBC and control perfusate compared to polyhHB after the first hour, and this trend continues over the following hours. The delta partial pressure of carbon dioxide was significantly increased in the RBC perfusate after one hour and after that remained stable in both the polyhHB and control perfusate. Real-time lung physiological data demonstrate that the RBC perfusate significantly increased pulmonary vascular resistance within the first hour.While both polyhHB and control perfusates maintained low and stable pulmonary vascular resistance over the period, the change in lung weight was significant in the RBC perfusate initially, with a continued increase in all perfusates, slightly more in polyhHB. Compliance decreased significantly in the RBC perfusate within the first hour, while it decreased non-significantly in other perfusates. PolyhHB had the highest compliance after four hours.