The protocol follows the guidelines of the Buenos Aires British Hospital&#39;s human research ethics committee.
1. Patient evaluation
<ol>
	<li>Clinical evaluation
	<ol>
		<li>Evaluate patients clinically to rule out symptoms propagating from other anatomical regions or other associated pathology in the shoulder that may be the source of symptoms.</li>
		<li>Include shoulder inspection and palpation, evaluate the active and passive range of motion, and perform pain provocative maneuvers and integrity tests. In addition, evaluate the cervical spine and the elbow joint.</li>
	</ol>
	</li>
	<li>Radiological evaluation
	<ol>
		<li>Use radiographic anteroposterior (AP) projections, a lateral scapular view, and an axillary view of the shoulder.</li>
		<li>Classify the calcifications by their evolutionary stage according to G&#228;rtner6. Request an MRI to rule out any associated pathology in the shoulder.</li>
	</ol>
	</li>
	<li>Inclusion criteria
	<ol>
		<li>Include patients classified as having G&#228;rtner type I and II calcifications who have undergone at least 3 months of previous conservative treatment without result.</li>
		<li>Never inject corticosteroids into the subacromial space when treating rotator cuff tendinopathy, as they have a deleterious effect on the elastic fibers of the tendons40,41.</li>
	</ol>
	</li>
	<li>Exclusion criteria: Do not include patients with G&#228;rtner type III calcifications or other associated pathology in the affected shoulder.</li>
</ol>
2. Application technique
<ol>
	<li>Patient positioning: Position the patient comfortably and in a way that allows exposure to the area to be treated.
	<ol>
		<li>Supraspinatus or infraspinatus tendon location: Treat by placing the patient in the supine or sitting position.</li>
		<li>Subscapularis: Treat by placing the patient in the supine position.</li>
		<li>Teres minor: Treat by placing the patient in the sitting, lateral decubitus, or oblique decubitus position for better access to the posterior aspect of the shoulder.</li>
	</ol>
	</li>
	<li>Coupling pads 
	NOTE: Three pad sizes are available, each determining a specific depth of treatment focus (Figure 1).
	<ol>
		<li>Select a coupling pad size depending on the required penetration depth of the focused point (Table 1). The selection of the coupling pad varies in shoulder calcification cases according to patient&#39;s build and location. The most frequently used sizes are large and medium.</li>
	</ol>
	</li>
	<li>Location of the area to be treated: Locate the area to be treated, considering anatomical landmarks and, if necessary, with the help of ultrasound images (Figure 2). 
	NOTE: It is very important to locate the exact area of the calcification and to focus the treatment on it4,42. The use of anatomical references and the help of ultrasound localization allows identifying the correct location. The need for a diagnostic ultrasound to locate the area is disputed, as there are studies that have not found significant differences with its use43. The application of focused waves is risky if done on large vessels and nerves or in areas close to the pleura44. Anatomical approaches that avoid these structures should be used.</li>
	<li>Operator positioning: The use of this type of device implies the support of an applicator by the operator. Work in an ergonomic position. 
	NOTE: The operator must always be aware of the condition of the patient, as exceptional cases of fainting during treatment have been reported44.</li>
	<li>Anesthesia: Do not use anesthesia. The use of local anesthesia is contraindicated because the presence of fluids alters the acoustic impedance of the tissue. In general, tolerance to treatment with this type of device is good, even when working with high energy levels.</li>
	<li>Contact gel: Apply adequate contact gel to the skin in the area to be treated.</li>
	<li>Navigation controls: Turn on the computer and access the touch screen. Select the Manual option at the top of the screen. The controls of the various treatment parameters are displayed. Use the rotary selection knob to set the parameters, including the intensity, frequency, and number of shocks.</li>
	<li>Intensity: Set the initial intensity of the treatment. The energy flux density (EFD) is graduated in the device used in millijoules per square millimeter of tissue (mJ/mm2).
	<ol>
		<li>Increase the intensity progressively as tolerated by the patient. Start with low intensity. Reach at least an energy level above 0.40 mJ/mm2 to obtain reproducible results19,20,21,22,23,24,25,26. The mean maximum intensity used is 0.50 mJ/mm2.</li>
	</ol>
	</li>
	<li>Frequency: Select the frequency to be used. The equipment has a frequency between 1-25 Hz. Use 4-6 Hz.</li>
	<li>Number of shocks: Select the number of shocks to be applied using the rotary selection knob. Apply at least 4,000 shocks per session.</li>
	<li>Modification of parameters during treatment: Modify the frequency and especially the intensity during the application. Use the display located on the applicator head to easily modify the application parameters during the treatment without having to interrupt it.</li>
	<li>The interval between sessions: Carry out three sessions at weekly intervals.</li>
</ol>
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/64426/64426fig01.jpg" /> 
Figure 1: Applicator and coupling pad variations. Three different sizes of coupling pads are available. Each one allows the focus to be taken to a different depth in the tissues. <a href="https://www.jove.com/files/ftp_upload/64426/64426fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/64426/64426fig02.jpg" /> 
Figure 2: Applicator positioning. Focused wave application in the supraspinatus tendon. <a href="https://www.jove.com/files/ftp_upload/64426/64426fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
3. Post-treatment protocol
<ol>
	<li>After the first session, alert the patients that in approximately 5% of cases, they may suffer an acute resorption process with intense pain. If discomfort occurs, recommend the patient to apply ice to the areas of pain in short sessions of no more than 10 min. 
	NOTE: Paracetamol is preferred over non-steroidal anti-inflammatory drugs. Shock waves modulate the inflammatory process, and it is better not to alter it by other means while the treatment lasts.</li>
	<li>Immobilization: It is not necessary to immobilize the treated limb. Advise the patient to avoid extreme efforts and range of motions that may cause pain.</li>
	<li>Rehabilitation program
	<ol>
		<li>As the sessions progress, if tolerance is good, increase the range of movement and incorporate exercises to strengthen the depressors of the humeral head.</li>
		<li>If symptomatic relapses do not occur, include recovery exercises for the extreme ranges of movement. The strengthening of the three portions of the deltoid and the scapular stabilizers are also indicated.</li>
	</ol>
	</li>
	<li>Radiological follow-up:
	<ol>
		<li>Perform the first radiographic examination at 6 weeks after the sessions and the second one at 12 weeks. In the case of observing a partial resorption process that has not been completed after 12 weeks, continue the radiological follow-up.</li>
		<li>If there have been no changes, opt for a new treatment module or move on to invasive procedures. 
		NOTE: In many patients, very important changes can be seen in the first control x-ray. In other cases, variable changes can be seen from baseline studies, and there may be no change even on long-term radiographs in other cases.</li>
	</ol>
	</li>
</ol>

This study shows encouraging results with the application of focused shock waves generated by a single-crystal piezoelectric device in a series of retrospectively evaluated patients with calcific tendinitis of the shoulder. According to the bibliographic search we carried out, this is the first study that reports results with a single-crystal piezoelectric device. Recently, Louwerens39 published a study using a piezoelectric shock wave device for the treatment of rotator cuff calcifications. Howev...

Calcium crystal deposits can appear in different regions of the musculoskeletal system, but their most frequent location is in the shoulder region. Gondos1 reported that 69% of calcification cases occur in the shoulder location. Calcific shoulder tendinopathies are characterized by the presence of hydroxyapatite deposits in the rotator cuff tendons. It is estimated that the prevalence in the general population ranges from 2.7% to 20%2.
Calcific tendinitis of the shoulder typically affects patients between 30 to 60 years old2. It is also more frequent in women (57%-76.7%) with respect to men3. The location of the calcium deposit is much more frequent in the distal tendon of the supraspinatus muscle4, while localizations in the infraspinatus, teres minor, subscapularis, and long head of the biceps have also been reported4.
Women between 30 and 60 years old, with a calcification over 1.5 cm in length, have the highest chance of being symptomatic5. Although it tends to spontaneously resolve itself, the cycle can often be halted. In these cases, symptoms of pain and disability appear, and it is necessary to take active therapeutic action.
G&#228;rtner&#39;s radiological classification6 differentiates three types of images. In type I, the image is dense, with well-defined borders corresponding to the formative phase. In the type II image, the appearance is mixed, with a deposit that can be dense but with diffuse borders, or transparent with well-defined borders. Finally, type III, characteristic of the resorptive phase, presents a transparent deposit with diffuse borders. Active therapeutic action, including shock wave applications, ultrasound-guided interventions, or surgery, must be taken in G&#228;rtner type I and II, since in type III cases, the chance of short-term spontaneous resorption is very high6.
Conservative treatment is initially preferred. This classically includes rest, analgesics, non-steroidal and steroidal anti-inflammatory drugs, rehabilitation, and local injections. Good results of conservative treatment have been shown, especially in the resorptive stage, but a failure of conservative treatment has been reported in 27% to 39% of cases7,8,9. Several prognostic factors have been recognized as having a significant influence on the results of conservative treatment7,8. The location on both shoulders, the presence of a large-volume deposit, the location of the calcification in the anterior region of the acromion, and the spread of the deposit medially beyond the level of the acromioclavicular joint, are factors of poor prognosis7,8. A G&#228;rtner stage III calcification and lack of sonographic extinction of the calcific deposit are considered predictors of good prognosis for conservative treatment7.
When conservative treatment fails, many patients end up becoming chronic carriers of shoulder pain with similar clinical characteristics to chronic rotator cuff non-calcific tendinopathies. The usual alternative to conservative treatment failure was surgery. Gschwend10 formulated three precise surgical indications for rotator cuff calcifications: symptom progression, constant and unmanageable pain, and failure of conservative treatment. Surgical treatment can be performed open or arthroscopically. Although open treatment was historically performed with good results11, arthroscopic techniques have gained popularity12,13. Musculoskeletal ultrasound and ultrasound-guided interventions (UGI) have significantly developed and been used in clinical practice in recent years14,15,16.
Extracorporeal shock wave treatment (ESWT) has emerged as an effective option prior to invasive procedures when conservative treatment has failed. Its therapeutic effect is not just mechanical, but based on mechanotransduction, a phenomenon by which cells can recognize a mechanical stimulus and react biologically17. However, shock wave treatment has limitations. Unlike lithotripsy, in which we only depend on the mechanical effect of the waves, there must also be a biological response by the patient. This response does not always occur.
The generic term &#34;extracorporeal shock waves&#34; includes two different technologies: focused shock waves and radial pressure waves17,18,19. The two technologies have therapeutic efficacy but differ in their physical characteristics and indications. Focused shock waves have a wide frequency range (from approximately 150 kHz up to 100 MHz), large pressure amplitude (up to 150 MPa) with a short rise time and small pulse width, followed by a low-stress wave (up to -25 MPa)18,19. Focused shock waves are generated by electrohydraulic, electromagnetic, and piezoelectric sources17,18,19.
Radial pressure waves are sound waves with pressure peaks of up to 30 MPa and much higher rise times than focused shock waves (about 3 &#181;s)18,19. Radial pressure waves are generated by accelerating a projectile inside a cylindrical guiding tube by compressed air. The projectile hits an applicator at the end of the tube and produces a radial pressure wave that expands into the target tissue17,18,19.
Focused shock waves have a grade &#34;A&#34; recommendation for the treatment of rotator cuff calcifications17. This means that there is high-quality scientific evidence supported by level I studies with consistent findings. In the case of radial waves, the level of recommendation for rotator cuff calcifications is &#34;I&#34;. This means that the evidence is insufficient to make a recommendation17.
Therapeutical efficacy of focused shock waves in calcific tendinopathies of the shoulder has been compared with open20 and arthroscopic21 surgery, with comparable results. However, shock waves have less frequent and less severe complications20,21, and the method is also cost-effective. Haake22 reported a significant difference between surgical costs (&#8364;13,400-23,450) and those of focused shock waves (&#8364;2,700-4,300). His results match with other studies that have shown a five- to sevenfold decrease in the cost of shock wave treatment compared to arthroscopic surgery23,24. There are also studies in which shock waves have been compared with ultrasound-guided interventions with controversial results15,25. Several publications4,17,26,27,28,29,30,31,32,33 have reported that a high level of energy is more effective when treating calcific tendinitis of the shoulder. Verstraelen27 reported that the use of high energy determines a higher rate of calcific resorption in a level I evidence study. This is a clear advantage for focused devices over radial ones because they can generate higher levels of energy. Numerous studies have reported good results with electrohydraulic4,17,34,35 and electromagnetic4,17,36,37,38 focused devices. A report has also been published using a multi-crystal piezoelectric device to treat rotator cuff calcifications39. We are not aware of any reports publishing the technique and results of single-crystal piezoelectric devices as of yet.
This report aims to describe the treatment protocol using a single-crystal piezoelectric device and to report the preliminary results.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>BTL 6000 FSWT&#160;</td>
			<td>BTL</td>
			<td>09400B001107</td>
			<td>Focused Shock Wave Piezoelectric Source</td>
		</tr>
		<tr>
			<td>Ultrasound &#38; SWT Gel 300 mL</td>
			<td>BTL</td>
			<td>237-GEL102</td>
			<td>Alcohol free hypoallergic gel</td>
		</tr>
	</tbody>
</table>

treatment protocol for rotator cuff calcific tendinitis using a single-crystal piezoelectric focused shock wave source

Focused shock waves have emerged as a highly effective noninvasive therapeutic option for the treatment of calcific tendinitis of the shoulder. There are three types of focused shock wave generators: electrohydraulic, electromagnetic, and piezoelectric. According to our literature search, there are no reports of results with the use of single-crystal piezoelectric generators in calcific tendinitis of the shoulder. In a consecutive retrospective series of 23 patients with G&#228;rtner type I and II calcifications of the rotator cuff, we performed three applications of high-energy piezoelectric focused waves (4,000 pulses per session with a frequency of 6 Hz). At the final follow-up (average of 14 months), 82.6% of the cases showed complete resorption of the calcification in radiographic controls. In 8.7% of the cases, partial disappearance of the calcification was achieved, and in the remaining 8.7% there were no significant changes. Single-crystal piezoelectric generators have a success rate comparable to those already reported with electrohydraulic and electromagnetic devices.

A retrospective study of a series of patients with shoulder pain due to calcium deposits in the rotator cuff tendons was carried out in our institution. The inclusion criteria were G&#228;rtner stage I and II calcifications and at least 3 months of previous conservative treatment without satisfactory results. Patients with G&#228;rtner III calcifications, other associated pathology in the affected shoulder, previous local cortisone injection, and a history of surgery in the affected shoulder were excluded.
<p class="...

Watch this Scientific Journal Video about Treatment Protocol for Rotator Cuff Calcific Tendinitis Using a Single-Crystal Piezoelectric Focused Shock Wave Source at JoVE.com

Treatment Protocol for Rotator Cuff Calcific Tendinitis Using a Single-Crystal Piezoelectric Focused Shock Wave Source

Calcific tendinitis of the shoulder is a relatively common condition with numerous treatment options. Here, we discuss the indications of focused shock waves generated by a single-crystal piezoelectric device, describe a treatment protocol, and present the preliminary results.

Focused shock waves have emerged as a highly effective noninvasive therapeutic option for the treatment of calcific tendinitis of the shoulder. There are ...

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2.5K Views.  Buenos Aires British Hospital. Calcific tendinitis of the shoulder is a relatively common condition with numerous treatment options. Here, we discuss the indications of focused shock waves generated by a single-crystal piezoelectric device, describe a treatment protocol, and present the preliminary results.

Video: Treatment Protocol for Rotator Cuff Calcific Tendinitis Using a Single-Crystal Piezoelectric Focused Shock Wave Source

The Trier Social Stress Test Protocol for Inducing Psychological Stress

This article demonstrates a psychological stress protocol for use in a laboratory setting. Protocols that allow researchers to study the biological pathways of the stress response in health and disease are fundamental to the progress of research in stress and anxiety.1 Although numerous protocols exist for inducing stress response in the laboratory, many neglect to provide a naturalistic context or to incorporate aspects of social and psychological stress. Of psychological stress protocols, meta-analysis suggests that the Trier Social Stress Test (TSST) is the most useful and appropriate standardized protocol for studies of stress hormone reactivity.2 In the original description of the TSST, researchers sought to design and evaluate a procedure capable of inducing a reliable stress response in the majority of healthy volunteers.3 These researchers found elevations in heart rate, blood pressure and several endocrine stress markers in response to the TSST (a psychological stressor) compared to a saline injection (a physical stressor).3 Although the TSST has been modified to meet the needs of various research groups, it generally consists of a waiting period upon arrival, anticipatory speech preparation, speech performance, and verbal arithmetic performance periods, followed by one or more recovery periods. The TSST requires participants to prepare and deliver a speech, and verbally respond to a challenging arithmetic problem in the presence of a socially evaluative audience.3 Social evaluation and uncontrollability have been identified as key components of stress induction by the TSST.4 In use for over a decade, the goal of the TSST is to systematically induce a stress response in order to measure differences in reactivity, anxiety and activation of the hypothalamic-pituitary-adrenal (HPA) or sympathetic-adrenal-medullary (SAM) axis during the task.1 Researchers generally assess changes in self-reported anxiety, physiological measures (e.g. heart rate), and/or neuroendocrine indices (e.g. the stress hormone cortisol) in response to the TSST. Many investigators have adopted salivary sampling for stress markers such as cortisol and alpha-amylase (a marker of autonomic nervous system activation) as an alternative to blood sampling to reduce the confounding stress of blood-collection techniques. In addition to changes experienced by an individual completing the TSST, researchers can compare changes between different treatment groups (e.g. clinical versus healthy control samples) or the effectiveness of stress-reducing interventions.1

This article describes a protocol for inducing psychological stress in participants, which enables researchers to measure psychological, physiological and neuroendocrine responses to stress within single participants or between groups.

This article demonstrates a psychological stress protocol for use in a laboratory setting.  Protocols that allow researchers to study the biological ...

Implantation of a Carotid Cuff for Triggering Shear-stress Induced Atherosclerosis in Mice

It is widely accepted that alterations in vascular shear stress trigger the expression of inflammatory genes in endothelial cells and thereby induce atherosclerosis (reviewed in 1 and 2). The role of shear stress has been extensively studied in vitro investigating the influence of flow dynamics on cultured endothelial cells 1,3,4 and in vivo in larger animals and humans 1,5,6,7,8. However, highly reproducible small animal models allowing systematic investigation of the influence of shear stress on plaque development are rare. Recently, Nam et al. 9 introduced a mouse model in which the ligation of branches of the carotid artery creates a region of low and oscillatory flow. Although this model causes endothelial dysfunction and rapid formation of atherosclerotic lesions in hyperlipidemic mice, it cannot be excluded that the observed inflammatory response is, at least in part, a consequence of endothelial and/or vessel damage due to ligation.
In order to avoid such limitations, a shear stress modifying cuff has been developed based upon calculated fluid dynamics, whose cone shaped inner lumen was selected to create defined regions of low, high and oscillatory shear stress within the common carotid artery 10. By applying this model in Apolipoprotein E (ApoE) knockout mice fed a high cholesterol western type diet, vascular lesions develop upstream and downstream from the cuff. Their phenotype is correlated with the regional flow dynamics 11 as confirmed by in vivo Magnetic Resonance Imaging (MRI) 12: Low and laminar shear stress upstream of the cuff causes the formation of extensive plaques of a more vulnerable phenotype, whereas oscillatory shear stress downstream of the cuff induces stable atherosclerotic lesions 11. In those regions of high shear stress and high laminar flow within the cuff, typically no atherosclerotic plaques are observed.
 
In conclusion, the shear stress-modifying cuff procedure is a reliable surgical approach to produce phenotypically different atherosclerotic lesions in ApoE-deficient mice.

The constricting cuff presented in this article is designed to induce atherosclerosis in the murine common carotid artery. Due to the conical shape of its inner lumen the implanted cuff generates well-defined regions of low, high and oscillatory shear stress triggering the development of atherosclerotic lesions of different inflammatory phenotypes.

It is widely accepted that alterations in vascular shear stress trigger the expression of inflammatory genes in endothelial cells and thereby induce ...

MRI-guided Disruption of the Blood-brain Barrier using Transcranial Focused Ultrasound in a Rat Model

Focused ultrasound (FUS) disruption of the blood-brain barrier (BBB) is an increasingly investigated technique for circumventing the BBB1-5. The BBB is a significant obstacle to pharmaceutical treatments of brain disorders as it limits the passage of molecules from the vasculature into the brain tissue to molecules less than approximately 500 Da in size6. FUS induced BBB disruption (BBBD) is temporary and reversible4 and has an advantage over chemical means of inducing BBBD by being highly localized. FUS induced BBBD provides a means for investigating the effects of a wide range of therapeutic agents on the brain, which would not otherwise be deliverable to the tissue in sufficient concentration. While a wide range of ultrasound parameters have proven successful at disrupting the BBB2,5,7, there are several critical steps in the experimental procedure to ensure successful disruption with accurate targeting. This protocol outlines how to achieve MRI-guided FUS induced BBBD in a rat model, with a focus on the critical animal preparation and microbubble handling steps of the experiment.

Microbubble-mediated focused ultrasound disruption of the blood-brain barrier (BBB) is a promising technique for non-invasive targeted drug delivery in the brain1-3. This protocol outlines the experimental procedure for MRI-guided transcranial BBB disruption in a rat model.

Focused ultrasound (FUS) disruption of the blood-brain barrier (BBB) is an increasingly investigated technique for circumventing the BBB1-5. The BBB is a ...

Collection Protocol for Human Pancreas

This dissection and sampling procedure was developed for the Network for Pancreatic Organ Donors with Diabetes (nPOD) program to standardize preparation of pancreas recovered from cadaveric organ donors. The pancreas is divided into 3 main regions (head, body, tail) followed by serial transverse sections throughout the medial to lateral axis. Alternating sections are used for fixed paraffin and fresh frozen blocks and remnant samples are minced for snap frozen sample preparations, either with or without RNAse inhibitors, for DNA, RNA, or protein isolation. The overall goal of the pancreas dissection procedure is to sample the entire pancreas while maintaining anatomical orientation.
Endocrine cell heterogeneity in terms of islet composition, size, and numbers is reported for human islets compared to rodent islets 1. The majority of human islets from the pancreas head, body and tail regions are composed of insulin-containing &beta;-cells followed by lower proportions of glucagon-containing &alpha;-cells and somatostatin-containing &delta;-cells. Pancreatic polypeptide-containing PP cells and ghrelin-containing epsilon cells are also present but in small numbers. In contrast, the uncinate region contains islets that are primarily composed of pancreatic polypeptide-containing PP cells 2. These regional islet variations arise from developmental differences. The pancreas develops from the ventral and dorsal pancreatic buds in the foregut and after rotation of the stomach and duodenum, the ventral lobe moves and fuses with the dorsal 3. The ventral lobe forms the posterior portion of the head including the uncinate process while the dorsal lobe gives rise to the rest of the organ. Regional pancreatic variation is also reported with the tail region having higher islet density compared to other regions and the dorsal lobe-derived components undergoing selective atrophy in type 1 diabetes4,5.
Additional organs and tissues are often recovered from the organ donors and include pancreatic lymph nodes, spleen and non-pancreatic lymph nodes. These samples are recovered with similar formats as for the pancreas with the addition of isolation of cryopreserved cells. When the proximal duodenum is included with the pancreas, duodenal mucosa may be collected for paraffin and frozen blocks and minced snap frozen preparations.

This video demonstrates a dissection procedure for processing human pancreas into multiple storage formats. Anatomical orientation is maintained throughout the pancreatic regions to allow definition of regional islet composition and density.

This dissection and sampling procedure was developed for the Network for Pancreatic Organ Donors with Diabetes (nPOD) program to standardize preparation ...

Murine Cervical Heart Transplantation Model Using a Modified Cuff Technique

Mouse models are of special interest in research since a wide variety of monoclonal antibodies and commercially defined inbred and knockout strains are available to perform mechanistic in vivo studies. While heart transplantation models using a suture technique were first successfully developed in rats, the translation into an equally widespread used murine equivalent was never achieved due the technical complexity of the microsurgical procedure. In contrast, non-suture cuff techniques, also developed initially in rats, were successfully adapted for use in mice1-3. This technique for revascularization involves two major steps I) everting the recipient vessel over a polyethylene cuff; II) pulling the donor vessel over the formerly everted recipient vessel and holding it in place with a circumferential tie. This ensures a continuity of the endothelial layer, short operating time and very high patency rates4.
Using this technique for vascular anastomosis we performed more than 1,000 cervical heart transplants with an overall success rate of 95%. For arterial inflow the common carotid artery and the proximal aortic arch were anastomosed resulting in a retrograde perfusion of the transplanted heart. For venous drainage the pulmonary artery of the graft was anastomosed with the external jugular vein of the recipient5.
Herein, we provide additional details of this technique to supplement the video.

The murine cervical heart transplantation model is well suited for immunological as well as ischemia reperfusion injury studies. We modified the procedure using a non-suture cuff technique and performed more than 1,000 successful transplants with this approach.
Herein, we provide additional details of this technique to supplement the video.

Mouse models are of special interest in research since a wide variety of monoclonal antibodies and commercially defined inbred and knockout strains are ...

MRI-guided dmPFC-rTMS as a Treatment for Treatment-resistant Major Depressive Disorder

Here we outline the protocol for magnetic resonance imaging (MRI) guided repetitive transcranial magnetic stimulation (rTMS) to the dorsal medial prefrontal cortex (dmPFC) in patients with major depressive disorder (MDD). Technicians used a neuronavigation system to process patient MRIs to generate a 3-dimensional head model. The head model was subsequently used to identify patient-specific stimulatory targets. The dmPFC was stimulated daily for 20 sessions. Stimulation intensity was titrated to address scalp pain associated with rTMS. Weekly assessments were conducted on the patients using the Hamilton Rating Scale for Depression (HamD17) and Beck Depression Index II (BDI-II). Treatment-resistant MDD patients achieved significant improvements on both HAMD and BDI-II. Of note, angled, double-cone coil rTMS at 120% resting motor threshold allows for optimal stimulation of deeper midline prefrontal regions, which results in a possible therapeutic application for MDD. One major limitation of the rTMS field is the heterogeneity of treatment parameters across studies, including duty cycle, number of pulses per session and intensity. Further work should be done to clarify the effect of stimulation parameters on outcome. Future dmPFC-rTMS work should include sham-controlled studies to confirm its clinical efficacy in MDD.

Here we outline the procedure for MRI-guided repetitive transcranial magnetic stimulation to the dorsomedial prefrontal cortex as an experimental treatment for major depressive disorder.

Here we outline the protocol for magnetic resonance imaging (MRI) guided repetitive transcranial magnetic stimulation (rTMS) to the dorsal medial ...

Network Analysis of Foramen Ovale Electrode Recordings in Drug-resistant Temporal Lobe Epilepsy Patients

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control seizures. However, a significant minority of patients continues to exhibit post-operative seizures, even in those cases in which the suspected source of seizures has been correctly localized and resected. The protocol presented here combines a clinical procedure routinely employed during the pre-operative evaluation of temporal lobe epilepsy (TLE) patients with a novel technique for network analysis. The method allows for the evaluation of the temporal evolution of mesial network parameters. The bilateral insertion of foramen ovale electrodes (FOE) into the ambient cistern simultaneously records electrocortical activity at several mesial areas in the temporal lobe. Furthermore, network methodology applied to the recorded time series tracks the temporal evolution of the mesial networks both interictally and during the seizures. In this way, the presented protocol offers a unique way to visualize and quantify measures that considers the relationships between several mesial areas instead of a single area.

This protocol describes a procedure to track the evolution of mesial network measures in temporal lobe epilepsy (TLE) patients. It is based on the combination of intracranial recordings with a novel numerical technique for data analysis. Specifically, we present a protocol for network analyses of foramen ovale recordings.

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control ...

A Detailed Protocol for Perspiration Monitoring Using a Novel, Small, Wireless Device

Perspiration monitoring can be utilized for the detection of certain diseases, such as thermoregulation and mental disorders, particularly when the patients are unaware of such disorders or are having difficulty expressing their symptoms. Until now, several devices for perspiration monitoring have been developed; however, such devices tend to have a relatively large exterior, considerable power consumption, and/or less sensitivity.
Recently, we developed a small, wireless device for perspiration monitoring. The device consists of a temperature/relative humidity (T/RH) sensor, battery-driven small data logger, and silica gel as a desiccant in a small cylindrical exterior. The T/RH sensor is placed between the detection windows (through which the water vapor from the skin enters) and the silica gel. The underlying principle of the perspiration monitoring device is based on Fick&#39;s law of diffusion, which means that water vapor flux from the skin to the silica gel (i.e.&#160;transepidermal water loss and perspiration) can be captured by change in humidity at the T/RH sensor. In addition, a baseline subtraction method was adopted to distinguish perspiration and transepidermal water loss.
As shown in the previous report, the developed device can monitor the perspiration at any sites of the body in an easy, wireless manner. However, detailed methods of how to use the device have not been disclosed yet. In this article, therefore, we would like to show the point-by-point tutorials of how to use the device for perspiration monitoring, by showing the sympathetic activity test with the sympathetic skin response monitoring as an example.

Recently, we developed a small wireless device for perspiration monitoring. In this article, we present detailed protocols on how to use the device for perspiration monitoring with an example of the sympathetic activity test.

Perspiration monitoring can be utilized for the detection of certain diseases, such as thermoregulation and mental disorders, particularly when the ...

Mouse Model for Pancreas Transplantation Using a Modified Cuff Technique

Mouse models have several advantages in transplantation research, including easy handling, a variety of genetically well-defined strains, and the availability of the widest range of molecular probes and reagents to perform in vivo as well as in vitro studies. Based on our experience with various murine transplantation models, we developed a heterotopic pancreas transplantation model in mice with the intent to analyze mechanisms underlying severe ischemia reperfusion injury-associated early graft damage. In contrast to previously described techniques using suture techniques, herein we describe a new procedure using a non-suture cuff technique. 
In recent years, we have performed more than 300 pancreas transplantations in mice with an overall success rate of &gt;90%, a success rate never described before in mouse pancreas transplantation. The backbone of this non-suture cuff technique for graft revascularization consists of two major steps: (I) pulling the recipient vessel over a polyethylene/polyamide cuff and fixing it with a circumferential ligature, and (II) placing the donor vessel over the everted recipient vessel and fixing it with a second circumferential ligature. The resultant continuity of the endothelial layer results in less thrombogenic lesions with high patency rates and, finally, high success rates.
In this model, arterial anastomosis is achieved by pulling the abdominal aorta of the donor graft over the everted common carotid artery of the recipient animal. Venous drainage of the graft is achieved by pulling the portal vein of the graft over the everted external jugular vein of the recipient. This manuscript provides details and crucial steps of the organ recovery and organ implantation procedures, which will allow researchers with microsurgical skills to perform the transplantation successfully in their laboratories.

Among abdominal solid organ transplantation, pancreatic grafts are prone to develop severe ischemia reperfusion injury-associated graft damage, leading eventually to early graft loss. This protocol describes a model of murine pancreas transplantation using a non-suture cuff technique, ideally suited for analyzing these early, deleterious damages.

Mouse models have several advantages in transplantation research, including easy handling, a variety of genetically well-defined strains, and the ...

Complete and Partial Aortic Occlusion for the Treatment of Hemorrhagic Shock in Swine

Hemorrhage remains the leading cause of preventable deaths in trauma. Endovascular management of non-compressible torso hemorrhage has been at the forefront of trauma care in recent years. Since complete aortic occlusion presents serious concerns, the concept of partial aortic occlusion has gained a growing attention. Here, we present a large animal model of hemorrhagic shock to investigate the effects of a novel partial aortic balloon occlusion catheter and compare it with a catheter that works on the principles of complete aortic occlusion. Swine are anesthetized and instrumented in order to conduct controlled fixed-volume hemorrhage, and hemodynamic and physiological parameters are monitored. Following hemorrhage, aortic balloon occlusion catheters are inserted and inflated in the supraceliac aorta for 60 min, during which the animals receive whole-blood resuscitation as 20% of the total blood volume (TBV). Following balloon deflation, the animals are monitored in a critical care setting for 4 h, during which they receive fluid resuscitation and vasopressors as needed. The partial aortic balloon occlusion demonstrated improved distal mean arterial pressures (MAPs) during the balloon inflation, decreased markers of ischemia, and decreased fluid resuscitation and vasopressor use. As swine physiology and homeostatic responses following hemorrhage have been well-documented and are like those in humans, a swine hemorrhagic shock model can be used to test various treatment strategies. In addition to treating hemorrhage, aortic balloon occlusion catheters have become popular for their role in cardiac arrest, cardiac and vascular surgery, and other high-risk elective surgical procedures.

Here, we present a protocol demonstrating a hemorrhagic shock model in swine that uses aortic occlusion as a bridge to definitive care in trauma. This model has application in testing a wide range of surgical and pharmacological therapeutic strategies.