Healthcare Innovations to Address the Challenges of the COVID-19 Pandemic.

We have been faced with an unprecedented challenge in combating the COVID-19/SARS-CoV2 outbreak that is threatening the fabric of our civilization, causing catastrophic human losses and a tremendous economic burden globally. During this difficult time, there has been an urgent need for biomedical engineers, clinicians, and healthcare industry leaders to work together to develop novel diagnostics and treatments to fight the pandemic including the development of portable, rapidly deployable, and affordable diagnostic testing kits, personal protective equipment, mechanical ventilators, vaccines, and data analysis and modeling tools. In this position paper, we address the urgent need to bring these inventions into clinical practices. This paper highlights and summarizes the discussions and new technologies in COVID-19 healthcare, screening, tracing, and treatment-related presentations made at the IEEE EMBS Public Forum on COVID-19. The paper also provides recent studies, statistics and data and new perspectives on ongoing and future challenges pertaining to the COVID-19 pandemic.

In vitro microelectrode array technology and neural recordings.

In vitro microelectrode array (MEA) technology has evolved into a widely used and effective methodology to study cultured neural networks. An MEA forms a unique electrical interface with the cultured neurons in that neurons are directly grown on top of the electrode (neuron-on-electrode configuration). Theoretical models and experimental results suggest that physical configuration and biological environments of the cell-electrode interface play a key role in the outcome of neural recordings, such as yield of recordings, signal shape, and signal-to-noise ratio. Recent interdisciplinary approaches have shown that MEA performance can be enhanced through novel nanomaterials, structures, surface chemistry, and biotechnology. In vitro and in vivo neural interfaces share some common factors, and in vitro neural interface issues can be extended to solve in vivo neural interface problems of brain-machine interface or neuromodulation techniques.

The Flow of Axonal Information Among Hippocampal Subregions: 1. Feed-Forward and Feedback Network Spatial Dynamics Underpinning Emergent Information Processing.

The tri-synaptic pathway in the mammalian hippocampus enables cognitive learning and memory. Despite decades of reports on anatomy and physiology, the functional architecture of the hippocampal network remains poorly understood in terms of the dynamics of axonal information transfer between subregions. Information inputs largely flow from the entorhinal cortex (EC) to the dentate gyrus (DG), and then are processed further in the CA3 and CA1 before returning to the EC. Here, we reconstructed elements of the rat hippocampus in a novel device over an electrode array that allowed for monitoring the directionality of individual axons between the subregions. The direction of spike propagation was determined by the transmission delay of the axons recorded between two electrodes in microfluidic tunnels. The majority of axons from the EC to the DG operated in the feed-forward direction, with other regions developing unexpectedly large proportions of feedback axons to balance excitation. Spike timing in axons between each region followed single exponential log-log distributions over two orders of magnitude from 0.01 to 1 s, indicating that conventional descriptors of mean firing rates are misleading assumptions. Most of the spiking occurred in bursts that required two exponentials to fit the distribution of inter-burst intervals. This suggested the presence of up-states and down-states in every region, with the least up-states in the DG to CA3 feed-forward axons and the CA3 subregion. The peaks of the log-normal distributions of intra-burst spike rates were similar in axons between regions with modes around 95 Hz distributed over an order of magnitude. Burst durations were also log-normally distributed around a peak of 88 ms over two orders of magnitude. Despite the diversity of these spike distributions, spike rates from individual axons were often linearly correlated to subregions. These linear relationships enabled the generation of structural connectivity graphs, not possible previously without the directional flow of axonal information. The rich axonal spike dynamics between subregions of the hippocampus reveal both constraints and broad emergent dynamics of hippocampal architecture. Knowledge of this network architecture may enable more efficient computational artificial intelligence (AI) networks, neuromorphic hardware, and stimulation and decoding from cognitive implants.

Designing Neural Networks in Culture: Experiments are described for controlled growth, of nerve cells taken from rats, in predesigned geometrical patterns on laboratory culture dishes.

Technology has advanced to where it is possible to design and grow-with predefined geometry and surprisingly good fidelity-living networks of neurons in culture dishes. Here we overview the elements of design, emphasizing the lithographic techniques that alter the cell culture surface which in turn influences the attachment and growth of the neural networks. Advanced capability in this area makes it possible to design networks of desired complexity. Other issues addressed include the influence of glial cells and media on activity and the potential for extending the designs into three dimensions. Investigators are advancing the art and science of analyzing and controlling through stimulation the function of the neural networks, including the ability to take advantage of their geometric form in order to influence functional properties.

Novel MEA platform with PDMS microtunnels enables the detection of action potential propagation from isolated axons in culture.

This study investigated a novel multi-electrode-array (MEA) design capable of long-term and highly selective recordings of axonal signals using PDMS microtunnels. We successfully grew neurons in culture so that only axons extended through narrow (10 microm wide by 3 microm high) and long (750 microm) microtunnels under which multiple electrodes were integrated. This permitted the recording of relatively large (up to 200 microV) electrical signals, including the propagation speed and direction of these travelling action potentials. To further demonstrate the operation of the device as a diagnostic tool for drug screening assays, the drug mepivacaine was applied in washout experiments. Here, we identified significant changes in mean spiking rate and conduction velocity.

Three-dimensional micro-electrode array for recording dissociated neuronal cultures.

This work demonstrates the design, fabrication, packaging, characterization, and functionality of an electrically and fluidically active three-dimensional micro-electrode array (3D MEA) for use with neuronal cell cultures. The successful function of the device implies that this basic concept-construction of a 3D array with a layered approach-can be utilized as the basis for a new family of neural electrode arrays. The 3D MEA prototype consists of a stack of individually patterned thin films that form a cell chamber conducive to maintaining and recording the electrical activity of a long-term three-dimensional network of rat cortical neurons. Silicon electrode layers contain a polymer grid for neural branching, growth, and network formation. Along the walls of these electrode layers lie exposed gold electrodes which permit recording and stimulation of the neuronal electrical activity. Silicone elastomer micro-fluidic layers provide a means for loading dissociated neurons into the structure and serve as the artificial vasculature for nutrient supply and aeration. The fluidic layers also serve as insulation for the micro-electrodes. Cells have been shown to survive in the 3D MEA for up to 28 days, with spontaneous and evoked electrical recordings performed in that time. The micro-fluidic capability was demonstrated by flowing in the drug tetrotodoxin to influence the activity of the culture.

A retrofitted neural recording system with a novel stimulation IC to monitor early neural responses from a stimulating electrode.

Extracellular electrical stimulation is increasingly used for in vitro neural experimentation, including brain slices and cultured cells. Although it is desirable to record directly from the stimulating electrode, relatively high stimulation levels make it extremely difficult to record immediately after the stimulation. We have shown that this is feasible by a stimulation system (analog IC) that includes the feature of active electrode discharge. Here, we piggybacked the new IC onto an existing recording amplifier system, making it possible to record neural responses directly from the stimulating channel as early as 3 ms after the stimulation. We used the retrofitted recording system to stimulate and record from dissociated hippocampal neurons in culture. This new strategy of retrofitting an existing system is a simple but attractive approach for instrumentation designers interested in adding a new feature for extracellular recording without replacing already existing recording systems.

Association Between Patient and Physician Sex and Physician-Estimated Stroke and Bleeding Risks in Atrial Fibrillation.

BACKGROUND: Physicians treating nonvalvular atrial fibrillation (AF) assess stroke and bleeding risks when deciding on anticoagulation. The agreement between empirical and physician-estimated risks is unclear. Furthermore, the association between patient and physician sex and anticoagulation decision-making is uncertain. METHODS: We pooled data from 2 national primary care physician chart audit databases of patients with AF (Facilitating Review and Education to Optimize Stroke Prevention in Atrial Fibrillation and Coordinated National Network to Engage Physicians in the Care and Treatment of Patients with Atrial Fibrillation Chart Audit) with a combined 1035 physicians (133 female, 902 male) and 10,927 patients (4567 female and 6360 male). RESULTS: Male physicians underestimated stroke risk in female patients and overestimated risk in male patients. Female physicians estimated stroke risk well in female patients but underestimated the risk in male patients. Risk of bleeding was underestimated in all. Despite differences in risk assessment by physician and patient sex, > 90% of patients received anticoagulation across all subgroups. There was modest agreement between physician estimated and calculated (ie, CHADS2 score) stroke risk: Kappa scores were 0.41 (0.35-0.47) for female physicians and 0.34 (0.32-0.36) for male physicians. CONCLUSIONS: Our study is the first to examine the association between patient and physician sex influences and stroke and bleeding risk estimation in AF. Although there were differences in agreement between physician estimated stroke risk and calculated CHADS2 scores, these differences were small and unlikely to affect clinical practice; further, despite any perceived differences in the accuracy of risk assessment by sex, most patients received anticoagulation.

NbActiv4 medium improvement to Neurobasal/B27 increases neuron synapse densities and network spike rates on multielectrode arrays.

The most interesting property of neurons is their long-distance propagation of signals as spiking action potentials. Since 1993, Neurobasal/B27 has been used as a serum-free medium optimized for hippocampal neuron survival. Neurons on microelectrode arrays (MEA) were used as an assay system to increase spontaneous spike rates in media of different compositions. We find spike rates of 0.5 s(-1) (Hz) for rat embryonic hippocampal neurons cultured in Neurobasal/B27, lower than cultures in serum-based media and offering an opportunity for improvement. NbActiv4 was formulated by addition of creatine, cholesterol and estrogen to Neurobasal/B27 that synergistically produced an eightfold increase in spontaneous spike activity. The increased activity with NbActiv4 correlated with a twofold increase in immunoreactive synaptophysin bright puncta and GluR1 total puncta. Characteristic of synaptic scaling, immunoreactive GABAAbeta puncta also increased 1.5-fold and NMDA-R1 puncta increased 1.8-fold. Neuron survival in NbActiv4 equaled that in Neurobasal/B27, but with slightly higher astroglia. Resting respiratory demand was decreased and demand capacity was increased in NbActiv4, indicating less stress and higher efficiency. These results show that NbActiv4 is an improvement to Neurobasal/B27 for cultured networks with an increased density of synapses and transmitter receptors which produces higher spontaneous spike rates in neuron networks.

Pattern separation and completion of distinct axonal inputs transmitted via micro-tunnels between co-cultured hippocampal dentate, CA3, CA1 and entorhinal cortex networks.

OBJECTIVE: Functions ascribed to the hippocampal sub-regions for encoding episodic memories include the separation of activity patterns propagated from the entorhinal cortex (EC) into the dentate gyrus (DG) and pattern completion in CA3 region. Since a direct assessment of these functions is lacking at the level of specific axonal inputs, our goal is to directly measure the separation and completion of distinct axonal inputs in engineered pairs of hippocampal sub-regional circuits. APPROACH: We co-cultured EC-DG, DG-CA3, CA3-CA1 or CA1-EC neurons in a two-chamber PDMS device over a micro-electrode array (MEA60), inter-connected via distinct axons that grow through the micro-tunnels between the compartments. Taking advantage of the axonal accessibility, we quantified pattern separation and completion of the evoked activity transmitted through the tunnels from source into target well. Since pattern separation can be inferred when inputs are more correlated than outputs, we first compared the correlations among axonal inputs with those of target somata outputs. We then compared, in an analog approach, the distributions of correlation distances between rate patterns of the axonal inputs inside the tunnels with those of the somata outputs evoked in the target well. Finally, in a digital approach, we measured the spatial population distances between binary patterns of the same axonal inputs and somata outputs. MAIN RESULTS: We found the strongest separation of the propagated axonal inputs when EC was axonally connected to DG, with a decline in separation to CA3 and to CA1 for both rate and digital approaches. Furthermore, the digital approach showed stronger pattern completion in CA3, then CA1 and EC. SIGNIFICANCE: To the best of our knowledge, these are the first direct measures of pattern separation and completion for axonal transmission to the somata target outputs at the rate and digital population levels in each of four stages of the EC-DG-CA3-CA1 circuit.

Active 3-D microscaffold system with fluid perfusion for culturing in vitro neuronal networks.

This work demonstrated the design, fabrication, packaging, and characterization of an active microscaffold system with fluid perfusion/nutrient delivery functionalities for culturing in vitro neuronal networks from dissociated hippocampal rat pup neurons. The active microscaffold consisted of an 8 x 8 array of hollow, microfabricated, SU-8 towers (1.0 mm or 1.5 mm in height), with integrated, horizontal, SU-8 cross-members that connect adjacent towers, thus forming a 3-D grid that is conducive to branching, growth, and increased network formation of dissociated hippocampal neurons. Each microtower in the microscaffold system contained a hollow channel and multiple fluid ports for media delivery and perfusion of nutrients to the in vitro neuronal network growing within the microscaffold system. Additionally, there were two exposed Au electrodes on the outer wall of each microtower at varying heights (with insulated leads running within the microtower walls), which will later allow for integration of electrical stimulation/recording functionalities into the active microscaffold system. However, characterization of the stimulation/recording electrodes was not included in the scope of this paper. Design, fabrication, fluid packaging, and characterization of the active microscaffold system were performed. Furthermore, use of the active microscaffold system was demonstrated by culturing primary hippocampal embryonic rat pup neurons, and characterizing cell viability within the microscaffold system.

Survival and stimulation of neurite outgrowth in a serum-free culture of spiral ganglion neurons from adult mice.

We have developed a reliable protocol for the serum-free dissociation and culture of spiral ganglion neurons from adult mice, an important animal model for patients with post-lingual hearing loss. Pilot experiments indicated that the viability of spiral ganglion cells in vitro depended critically on the use of Hibernate medium with B27 supplement. With an optimized protocol, we obtained 2 x 10(3) neurons immediately after dissociation, or about one-fifth of those present in the intact spiral ganglion. After four days in culture, 4% of the seeded neurons survived without any exogenous growth factors other than insulin. This yield was highly reproducible in five independent experiments and enabled us to measure systematically the numbers and lengths of the regenerating neurites. Furthermore, the survival rate compared well to the few published protocols for culturing adult spiral ganglion neurons from other species. Enhanced survival and neurite outgrowth upon the addition of brain-derived neurotrophic factor and leukemia inhibitory factor demonstrated that both are potent stimulants for damaged spiral ganglion neurons in adults. This responsiveness to exogenous growth factors suggested that our culture protocol will facilitate the screening of molecular compounds as potential treatments for sensorineural hearing loss.

Specific CA3 neurons decode neural information of dentate granule cells evoked by paired-pulse stimulation in co-cultured networks.

CA3 and dentate gyrus (DG) neurons are cultured in two-chamber devices on multi-electrode arrays (MEAs) and connected via micro-tunnels. In order to evoke time-locked activity, paired-pulse stimulation is applied to 22 different sites and repeated 25 times in each well in 5 MEA co-cultures and results compared to CA3-CA3 and DG-DG networks homologous controls. In these hippocampal sub-regions, we focus on the mechanisms underpinning a network's ability to decode the identity of site specific stimulation from analysis of evoked network responses using a support vector machine classifier. Our results indicate that a pool of CA3 neurons is able to reliably decode the identity of DG stimulation site information.

Narrow microtunnel technology for the isolation and precise identification of axonal communication among distinct hippocampal subregion networks.

Communication between different sub regions of the hippocampus is fundamental to learning and memory. However accurate knowledge about information transfer between sub regions from access to the activity in individual axons is lacking. MEMS devices with microtunnels connecting two sub networks have begun to approach this problem but the commonly used 10 µm wide tunnels frequently measure signals from multiple axons. To reduce this complexity, we compared polydimethylsiloxane (PDMS) microtunnel devices each with a separate tunnel width of 2.5, 5 or 10 µm bridging two wells aligned over a multi electrode array (MEA). Primary rat neurons were grown in the chambers with neurons from the dentate gyrus on one side and hippocampal CA3 on the other. After 2-3 weeks of culture, spontaneous activity in the axons inside the tunnels was recorded. We report electrophysiological, exploratory data analysis for feature clustering and visual evidence to support the expectation that 2.5 µm wide tunnels have fewer axons per tunnel and therefore more clearly delineated signals than 10 or 5 µm wide tunnels. Several measures indicated that fewer axons per electrode enabled more accurate detection of spikes. A clustering analysis comparing the variations of spike height and width for different tunnel widths revealed tighter clusters representing unique spikes with less height and width variation when measured in narrow tunnels. Wider tunnels tended toward more diffuse clusters from a continuum of spike heights and widths. Standard deviations for multiple cluster measures, such as Average Dissimilarity, Silhouette Value (S) and Separation Factor (average dissimilarity/S value), support a conclusion that 2.5 µm wide tunnels containing fewer axons enable more precise determination of individual action potential peaks, their propagation direction, timing, and information transfer between sub networks.

Sparse and Specific Coding during Information Transmission between Co-cultured Dentate Gyrus and CA3 Hippocampal Networks.

To better understand encoding and decoding of stimulus information in two specific hippocampal sub-regions, we isolated and co-cultured rat primary dentate gyrus (DG) and CA3 neurons within a two-chamber device with axonal connectivity via micro-tunnels. We tested the hypothesis that, in these engineered networks, decoding performance of stimulus site information would be more accurate when stimuli and information flow occur in anatomically correct feed-forward DG to CA3 vs. CA3 back to DG. In particular, we characterized the neural code of these sub-regions by measuring sparseness and uniqueness of the responses evoked by specific paired-pulse stimuli. We used the evoked responses in CA3 to decode the stimulation sites in DG (and vice-versa) by means of learning algorithms for classification (support vector machine, SVM). The device was placed over an 8 × 8 grid of extracellular electrodes (micro-electrode array, MEA) in order to provide a platform for monitoring development, self-organization, and improved access to stimulation and recording at multiple sites. The micro-tunnels were designed with dimensions 3 × 10 × 400 µm allowing axonal growth but not migration of cell bodies and long enough to exclude traversal by dendrites. Paired-pulse stimulation (inter-pulse interval 50 ms) was applied at 22 different sites and repeated 25 times in each chamber for each sub-region to evoke time-locked activity. DG-DG and CA3-CA3 networks were used as controls. Stimulation in DG drove signals through the axons in the tunnels to activate a relatively small set of specific electrodes in CA3 (sparse code). CA3-CA3 and DG-DG controls were less sparse in coding than CA3 in DG-CA3 networks. Using all target electrodes with the three highest spike rates (14%), the evoked responses in CA3 specified each stimulation site in DG with optimum uniqueness of 64%. Finally, by SVM learning, these evoked responses in CA3 correctly decoded the stimulation sites in DG for 43% of the trials, significantly higher than the reverse, i.e., how well-recording in DG could predict the stimulation site in CA3. In conclusion, our co-cultured model for the in vivo DG-CA3 hippocampal network showed sparse and specific responses in CA3, selectively evoked by each stimulation site in DG.

Use of Evidence-Based Therapy for Cardiovascular Risk Factors in Canadian Outpatients With Atrial Fibrillation: From the Facilitating Review and Education to Optimize Stroke Prevention in Atrial Fibrillation (FREEDOM AF) and Co-ordinated National Network to Engage Physicians in the Care and Treatment of Patients With Atrial Fibrillation (CONNECT AF).

Using data collected from 2 national atrial fibrillation (AF) primary care physician chart audits (Facilitating Review and Education to Optimize Stroke Prevention in Atrial Fibrillation [FREEDOM AF] and Co-ordinated National Network to Engage Physicians in the Care and Treatment of Patients With Atrial Fibrillation [CONNECT AF]), we evaluated the frequency of, and factors associated with, the use of cardiovascular (CV) evidence-based therapies in Canadian AF outpatients with at least 1 CV risk factor or co-morbidity. Of the 11,264 patients enrolled, 9,495 (84.3%) were eligible for one or more CV evidence-based therapies. The proportions of patients with AF receiving all eligible guideline-recommended therapies were 40.8% of patients with coronary artery disease, 48.9% of patients with diabetes mellitus, 40.2% of patients with heart failure, 96.7% of patients with hypertension, and 55.1% of patients with peripheral arterial disease. Factors that were independently associated with nonreceipt of all indicated evidence-based therapies included sinus rhythm rather than AF at baseline and liver disease. In conclusion, although most Canadian outpatients with AF have CV risk factors or co-morbidities, a substantial portion of these patients did not receive all guideline-recommended therapies. These findings suggest that there is an opportunity to improve the quality of care for patients with AF in Canada.

Neural recording and stimulation of dissociated hippocampal cultures using microfabricated three-dimensional tip electrode array.

There is increasing interest in interfacing dissociated neuronal cultures with planar multielectrode arrays (MEAs) for the study of the dynamics of neuronal networks. Here we report on the successful use of three-dimensional tip electrode arrays (3D MEAs), originally developed for use with brain slices, for recording and stimulation of cultured neurons. We observed that many neurons grew directly on protruding electrode surface, appearing to make excellent contact. A larger than usual portion of extracellular spikes had large positive peaks, while most of the spikes from conventional two-dimensional electrode arrays had large negative spikes. This may be due to the direct capacitive coupling situation provided by relatively large electrode surface area.

Epoxy-silane linking of biomolecules is simple and effective for patterning neuronal cultures.

Surface chemistry is one of the main factors that contributes to the longevity and compliance of cell patterning. Two to three weeks are required for dissociated, embryonic rat neuronal cultures to mature to the point that they regularly produce spontaneous and evoked responses. Though proper surface chemistry can be achieved through the use of covalent protein attachment, often it is not maintainable for the time periods necessary to study neuronal growth. Here we report a new and effective covalent linking approach using (3-glycidoxypropyl) trimethoxysilane (3-GPS) for creating long term neuronal patterns. Micrometer scale patterns of cell adhesive proteins were formed using microstamping; hippocampal neurons, cultured up to 1 month, followed those patterns. Cells did not grow on unmodified 3-GPS surfaces, producing non-permissive regions for the long-term cell patterning. Patterned neuronal networks were formed on two different types of MEA (polyimide or silicon nitride insulation) and maintained for 3 weeks. Even though the 3-GPS layer increased the impedance of metal electrodes by a factor of 2-3, final impedance levels were low enough that low noise extracellular recordings were achievable. Spontaneous neural activity was recorded as early as 10 days in vitro. Neural recording and stimulation were readily achieved from these networks. Our results showed that 3-GPS could be used on surfaces to immobilize biomolecules for a variety of neural engineering applications.

Neuronal network structuring induces greater neuronal activity through enhanced astroglial development.

The confluence of micropatterning, microfabricated multielectrode arrays, and low-density neuronal culture techniques make possible the growth of patterned neuronal circuits overlying multielectrode arrays. Previous studies have shown synaptic interaction within patterned cultures which was more active on average than random cultures. In our present study, we found patterned cultures to have up to five times more astrocytes and three times more neurons than random cultures. In addition, faster development of synapses is also seen in patterned cultures. Together, this yielded greater overall neuronal activity as evaluated by the number of active electrodes. Our finding of astrocytic proliferation within serum-free culture is also novel.