Adhesion-Lubrication Paradox of Articular Cartilage.

The friction of solids is primarily understood through the adhesive interactions between the surfaces. As a result, slick materials tend to be nonstick (e.g., Teflon), and sticky materials tend to produce high friction (e.g., tires and tape). Paradoxically, cartilage, the slippery bearing material of human joints, is also among the stickiest of known materials. This study aims to elucidate this apparent paradox. Cartilage is a biphasic material, and the most cited explanation is that both friction and adhesion increase as load transfers from the pressurized interstitial fluid to the solid matrix over time. In other words, cartilage is slippery and sticky under different times and conditions. This study challenges this explanation, demonstrating the strong adhesion of cartilage under high and low interstitial hydration conditions. Additionally, we find that cartilage clings to itself (a porous material) and Teflon (a nonstick material), as well as other surfaces. We conclude that the unusually strong interfacial tension produced by cartilage reflects suction (like a clingfish) rather than adhesion (like a gecko). This finding is surprising given its unusually large roughness, which typically allows for easy interfacial flow and defeats suction. The results provide compelling evidence that cartilage, like a clingfish, conforms to opposing surfaces and effectively seals submerged contacts. Further, we argue that interfacial sealing is itself a critical function, enabling cartilage to retain hydration, load support, and lubrication across long periods of inactivity.

Effects of arginine vasopressin on human anxiety and associations with sex, dose, and V1a-receptor genotype.

RATIONALE: Arginine vasopressin (AVP) has dose- and sex-specific effects on social behavior, and variation in social responses is related to variation in the V1a receptor gene in animals. Whether such complexity also characterizes AVP effects on anxiety in humans, or whether V1a genotype is related to anxiety and/or AVP's ability to affect it, remains to be determined. OBJECTIVE: To test if AVP has dose-dependent effects on anxiety in men and/or women and if a particular allele within the RS3 promoter region of the V1a receptor gene is associated with anxiety and/or AVP effects on anxiety. METHOD: Men and women self-administered 20 IU or 40 IU intranasal arginine vasopressin (AVP) and placebo in a double-blind, within-subjects design, and State (SA) and Trait (TA) anxiety were measured 60 min later. PCR was used to identify allelic variation within the RS3 region of the V1a receptor gene. RESULTS: AVP decreased SA in men across both doses, whereas only the lower dose had the same effect, across sexes, in individuals who carry at least one copy of a previously identified "risk" allele in the RS3 promoter of the V1a receptor gene. Additionally, after placebo, women who carried a copy of the allele displayed lower TA than women who did not, and AVP acutely increased TA scores in those women. CONCLUSIONS: Exogenous AVP has modest sex- and dose-dependent effects on anxiety/affect in humans. Further, allelic variation in the V1a promoter appears associated with responsiveness to AVP's effects and, at least in women, to stable levels of anxiety/affect.

The modes and competing rates of cartilage fluid loss and recovery.

Cartilage loses, recovers, and maintains its thickness, hydration, and biomechanical functions based on competing rates of fluid loss and recovery under varying joint-use conditions. While the mechanics and implications of load-induced fluid loss have been studied extensively, those of fluid recovery have not. This study isolates, quantifies, and compares rates of cartilage recovery from three known modes: (1) passive swelling - fluid recovery within a static unloaded contact area; (2) free swelling - unrestricted fluid recovery by an exposed surface; (3) tribological rehydration - fluid recovery within a loaded contact area during sliding. Following static loading of adult bovine articular cartilage to between 100 and 500 µm of compression, passive swelling, free swelling, and tribological rehydration exhibited average rates of 0.11 ± 0.04, 0.71 ± 0.15, and 0.63 ± 0.22 µm/s, respectively, over the first 100 s of recovery; for comparison, the mean exudation rate just prior to sliding was 0.06 ± 0.04 µm/s. For this range of compressions, we detected no significant difference between free swelling and tribological rehydration rates. However, free swelling and tribological rehydration rates, those associated with joint articulation, were ∼7-fold faster than passive swelling rates. While previous studies show how joint articulation prevents fluid loss indefinitely, this study shows that joint articulation reverses fluid loss following static loading at >10-fold the preceding exudation rate. These competitive recovery rates suggest that joint space and function may be best maintained throughout an otherwise sedentary day using brief but regular physical activity. STATEMENT OF SIGNIFICANCE: Cartilage loses, recovers, and maintains its thickness, hydration, and biomechanical functions based on competing rates of fluid loss and recovery under varying joint-use conditions. While load-induced fluid loss is extremely well studied, this is the first to define the competing modes of fluid recovery and to quantify their rates. The results show that the fluid recovery modes associated with joint articulation are 10-fold faster than exudation during static loading and passive swelling during static unloading. The results suggest that joint space and function are best maintained throughout an otherwise sedentary day using brief but regular physical activities.

Range-of-motion affects cartilage fluid load support: functional implications for prolonged inactivity.

OBJECTIVE: Joint movements sustain cartilage fluid load support (FLS) through a combination of contact migration and periodic bath exposure. Although there have been suggestions that small involuntary movements may disrupt load-induced exudation during prolonged inactivity, theoretical studies have shown otherwise. This work used well-controlled explant measurements to experimentally test an existing hypothesis that the range-of-motion must exceed the contact length to sustain non-zero FLS. METHOD: Smooth glass spheres (1.2-3.2 mm radius) were slid at 1.5 mm/s (Péclet number >100) against bovine osteochondral explants under varying normal loads (0.05-0.1 N) and migration lengths (0.05-7 mm) using a custom instrument. In situ deformation measurements were used to quantify FLS. RESULTS: Non-zero FLS was maintained at migration lengths as small as 0.05 mm or <10% the typical contact diameter. FLS peaked when track lengths exceeded 10 times the contact diameter. For migration lengths below this threshold, FLS decreased with increased contact stress. CONCLUSIONS: Migration lengths far smaller than the contact diameter can sustain non-zero FLS, which, from a clinical perspective, indicates that fidgeting and drifting can mitigate exudation and loss of FLS during prolonged sitting and standing. Nonetheless, FLS decreased monotonically with decreased migration length when migration lengths were less than 10 times the contact diameter. The results demonstrate: (1) potential biomechanical benefits from small movement (e.g., drifting and fidgeting); (2) the quantitative limits of those benefits; (3) and how loads, movement patterns, and mobility likely impact long term FLS.

Integrated QCM-Microtribometry: Friction of Single-Crystal MoS2 and Gold from µm/s to m/s.

Two opposing microtribometry approaches have been developed over the past decade to help connect the dots between fundamental and practical tribology measurements: spring-based (e.g., AFM) approaches use low speed, low stiffness, and long relative slip length to quantify friction, while quartz crystal microbalance (QCM)-based approaches use high speed, high stiffness, and short relative slip length. Because the friction forces generated in these experiments are attributed to entirely different phenomena, it is unclear if or how the resulting friction forces are related. This study aims to resolve this uncertainty by integrating these distinct techniques into a single apparatus that allows two independent measurements of friction at a single interface. Alumina microspheres were tested against single-crystal MoS2, a model nominally wear-free solid lubricant, and gold, a model metal control, at loads between 0.01 and 1 mN. The combined results from both measurement approaches gave friction coefficients (mean ± standard error) of 0.087 ± 0.007 and 0.27 ± 0.02 for alumina-MoS2 and alumina-gold, respectively. The observed agreement between these methods for two different material systems suggests that friction in microscale contacts can be far less sensitive to external effects from compliance and slip speed than currently thought. Perhaps more importantly, this Article describes and validates a novel approach to closing the "tribology gap" while demonstrating how integration creates new opportunities for fundamental studies of practical friction.

Core-shell patterning of synthetic hydrogels via interfacial bioorthogonal chemistry for spatial control of stem cell behavior.

A new technique is described for the patterning of cell-guidance cues in synthetic extracellular matrices (ECM) for tissue engineering applications. Using s-tetrazine modified hyaluronic acid (HA), bis-trans-cyclooctene (TCO) crosslinkers and monofunctional TCO conjugates, interfacial bioorthogonal crosslinking was used to covalently functionalize hydrogels as they were synthesized at the liquid-gel interface. Through temporally controlled introduction of TCO conjugates during the crosslinking process, the enzymatic degradability, cell adhesivity, and mechanical properties of the synthetic microenvironment can be tuned with spatial precision. Using human mesenchymal stem cells (hMSCs) and hydrogels with a core-shell structure, we demonstrated the ability of the synthetic ECM with spatially defined guidance cues to modulate cell morphology in a biomimetic fashion. This new method for the spatially resolved introduction of cell-guidance cues for the establishment of functional tissue constructs complements existing methods that require UV-light or specialized equipment.

Sliding enhances fluid and solute transport into buried articular cartilage contacts.

OBJECTIVE: Solutes and interstitial water are naturally transported from cartilage by load-induced interstitial fluid pressures. Fluid and solute recovery during joint articulation have been primarily attributed to passive diffusion and mechanical 'pumping' from dynamic loading. This paper tests if the sliding action of articulation is a significant and independent driver of fluid and solute transport in cartilage. DESIGN: The large osteochondral samples utilized in the present study preserve the convergent wedges necessary for physiological hydrodynamics. Following static load-induced fluid exudation and prior to sliding, a fluorescent solute (AlexaFluor 633) was added to the lubricant bath. In situ confocal microscopy was used to quantify the transport of solute from the bath into the buried stationary contact area (SCA) during sliding. RESULTS: Following static exudation, significant reductions in friction and strain during sliding at 60 mm/s were accompanied by significant solute transport into the inaccessible center of the buried contact; no such transport was detected for the 0- or 1 mm/s sliding conditions. The results suggest that external hydrodynamic pressures from sliding induced advective flows that carried solutes from the bath toward the center of contact. CONCLUSIONS: These results provide the first direct evidence that the action of sliding is a significant contributor to fluid and solute recovery by cartilage. Furthermore, they indicate that the sliding-induced transport of solutes into the buried interface was orders of magnitude greater than that attributable to diffusion alone, a result with critical implications for disease prevention and tissue engineering.

Tribological rehydration of cartilage and its potential role in preserving joint health.

OBJECTIVE: During exercise, cartilage recovers interstitial fluid lost during inactivity, which explains how tissue thickness and joint space are maintained over time. This recovery phenomenon is currently explained by a combination of osmotic swelling during intermittent bath exposure and sub-ambient pressurization during unloading. This paper tests an alternate hypothesis that cartilage can retain and recover interstitial fluid in the absence of bath exposure and unloading when physiological hydrodynamics are present. METHOD: Stationary cartilage-on-flat experiments were conducted to eliminate intermittent bath exposure as a potential contributor to fluid uptake. In situ compression measurements were used to monitor the loss, retention, and recovery of interstitial fluid during testing in saline. Samples were left larger than the contact area to preserve a convergence zone for hydrodynamic pressurization. RESULTS: Interstitial fluid lost during static loading was recovered during sliding in the absence of unloading and contact migration; fluid recovery in a stationary contact cannot be explained by biphasic theory and suggests a fundamentally new contributor to the recovery process. We call the phenomenon 'tribological rehydration' because recovery was induced by sliding rather than by unloading or migration. Sensitivities to sliding speed, surface permeability, and nature of the convergence wedge are consistent with the hypothesis that hydrodynamic effects underlie the tribological rehydration phenomenon. CONCLUSIONS: This study demonstrates that cartilage can retain and recover interstitial fluid without migration or unloading. The results suggest that hydrodynamic effects in the joint are not only important contributors to lubrication, they are likely equally important to the preservation of joint space.

Quantifying Cartilage Contact Modulus, Tension Modulus, and Permeability With Hertzian Biphasic Creep.

This paper describes a new method, based on a recent analytical model (Hertzian biphasic theory (HBT)), to simultaneously quantify cartilage contact modulus, tension modulus, and permeability. Standard Hertzian creep measurements were performed on 13 osteochondral samples from three mature bovine stifles. Each creep dataset was fit for material properties using HBT. A subset of the dataset (N = 4) was also fit using Oyen's method and FEBio, an open-source finite element package designed for soft tissue mechanics. The HBT method demonstrated statistically significant sensitivity to differences between cartilage from the tibial plateau and cartilage from the femoral condyle. Based on the four samples used for comparison, no statistically significant differences were detected between properties from the HBT and FEBio methods. While the finite element method is considered the gold standard for analyzing this type of contact, the expertise and time required to setup and solve can be prohibitive, especially for large datasets. The HBT method agreed quantitatively with FEBio but also offers ease of use by nonexperts, rapid solutions, and exceptional fit quality (R2 = 0.999 ± 0.001, N = 13).

Experimental characterization of biphasic materials using rate-controlled Hertzian indentation.

This paper describes a new method, based on Hertzian biphasic theory (HBT), to characterize properties of biphasic materials with reduced time demands, increased surface sensitivity, and reduced computational demands compared to the current gold standards. Indentation experiments were conducted at a single location on a representative osteochondral plug to demonstrate and validate the HBT method against two gold standards, linear biphasic theory (LBT) and tension-compression nonlinear biphasic theory (TCN). The 1) aggregate moduli, 2) permeability and 3) tensile moduli from HBT, LBT, and TCN were 1) HA =0.47, 0.47, and 0.40 MPa, 2) k=0.0026, 0.0014 and 0.0016mm4/Ns, and 3) Et =8.7, 0.46, and 10.3MPa, respectively. The results support the HBT method and encourage its use, especially in light of its practical advantages.

Tribological and material properties for cartilage of and throughout the bovine stifle: support for the altered joint kinematics hypothesis of osteoarthritis.

OBJECTIVE: Prior studies suggest that ligament and meniscus tears cause osteoarthritis (OA) when changes in joint kinematics bring underused and underprepared regions of cartilage into contact. This study aims to test the hypothesis that material and tribological properties vary throughout the joint according to the local mechanical environment. METHOD: The local tribological and material properties of bovine stifle cartilage (N = 10 joints with 20 samples per joint) were characterized under physiologically consistent contact stress and fluid pressure conditions. RESULTS: Overall, cartilage from the bovine stifle had an equilibrium contact modulus of Ec0 = 0.62 ± 0.10 MPa, a tensile modulus of Et = 4.3 ± 0.7 MPa, and a permeability of k = 2.8 ± 0.9 × 10(-3) mm(4)/Ns. During sliding, the cartilage had an effective friction coefficient of µeff = 0.024 ± 0.004, an effective contact modulus of Ec = 3.9 ± 0.7 MPa and a fluid load fraction of F' = 0.81 ± 0.03. Tibial cartilage exhibited significantly poorer material and tribological properties than femoral cartilage. Statistically significant differences were also detected across the femoral condyle and tibial plateau. The central femoral condyle exhibited the most favorable properties while the uncovered tibial plateau exhibited the least favorable properties. CONCLUSIONS: Our findings support a previous hypothesis that altered loading patterns can cause OA by overloading underprepared regions. They also help explain why damage to the tibial plateau often precedes damage to the mating femoral condyle following joint injury in animal models. Because the variations are driven by fundamental biological processes, we anticipate similar variations in the human knee, which could explain the OA risk associated with ligament and meniscus tears.

Role of interstitial fluid pressurization in TMJ lubrication.

In temporomandibular joints (TMJs), the disc and condylar cartilage function as load-bearing, shock-absorbing, and friction-reducing materials. The ultrastructure of the TMJ disc and cartilage is different from that of hyaline cartilage in other diarthrodial joints, and little is known about their lubrication mechanisms. In this study, we performed micro-tribometry testing on the TMJ disc and condylar cartilage to obtain their region- and direction-dependent friction properties. Frictional tests with a migrating contact area were performed on 8 adult porcine TMJs at 5 different regions (anterior, posterior, central, medial, and lateral) in 2 orthogonal directions (anterior-posterior and medial-lateral). Some significant regional differences were detected, and the lateral-medial direction showed higher friction than the anterior-posterior direction on both tissues. The mean friction coefficient of condylar cartilage against steel was 0.027, but the disc, at 0.074, displayed a significantly higher friction coefficient. The 2 tissues also exhibited different frictional dependencies on sliding speed and normal loading force. Whereas the friction of condylar cartilage decreased with increased sliding speed and was independent of the magnitude of normal force, friction of the disc showed no dependence on sliding speed but decreased as normal force increased. Further analysis of the Péclet number and frictional coefficients suggested that condylar cartilage relies on interstitial fluid pressurization to a greater extent than the corresponding contact area of the TMJ disc.

An analytical model to predict interstitial lubrication of cartilage in migrating contact areas.

For nearly a century, articular cartilage has been known for its exceptional tribological properties. For nearly as long, there have been research efforts to elucidate the responsible mechanisms for application toward biomimetic bearing applications. It is now widely accepted that interstitial fluid pressurization is the primary mechanism responsible for the unusual lubrication and load bearing properties of cartilage. Although the biomechanics community has developed elegant mathematical theories describing the coupling of solid and fluid (biphasic) mechanics and its role in interstitial lubrication, quantitative gaps in our understanding of cartilage tribology have inhibited our ability to predict how tribological conditions and material properties impact tissue function. This paper presents an analytical model of the interstitial lubrication of biphasic materials under migrating contact conditions. Although finite element and other numerical models of cartilage mechanics exist, they typically neglect the important role of the collagen network and are limited to a specific set of input conditions, which limits general applicability. The simplified approach taken in this work aims to capture the broader underlying physics as a starting point for further model development. In agreement with existing literature, the model indicates that a large Peclet number, Pe, is necessary for effective interstitial lubrication. It also predicts that the tensile modulus must be large relative to the compressive modulus. This explains why hydrogels and other biphasic materials do not provide significant interstitial pressure under high Pe conditions. The model quantitatively agrees with in-situ measurements of interstitial load support and the results have interesting implications for tissue engineering and osteoarthritis problems. This paper suggests that a low tensile modulus (from chondromalacia or local collagen rupture after impact, for example) may disrupt interstitial pressurization, increase shear stresses, and activate a condition of progressive surface damage as a potential precursor of osteoarthritis.

The extended wedge method: atomic force microscope friction calibration for improved tolerance to instrument misalignments, tip offset, and blunt probes.

One of the major challenges in understanding and controlling friction is the difficulty in bridging the length and time scales of macroscale contacts and those of the single asperity interactions they comprise. While the atomic force microscope (AFM) offers a unique ability to probe tribological surfaces in a wear-free single-asperity contact, instrument calibration challenges have limited the usefulness of this technique for quantitative nanotribological studies. A number of lateral force calibration techniques have been proposed and used, but none has gained universal acceptance due to practical considerations, configuration limitations, or sensitivities to unknowable error sources. This paper describes a simple extension of the classic wedge method of AFM lateral force calibration which: (1) allows simultaneous calibration and measurement on any substrate, thus eliminating prior tip damage and confounding effects of instrument setup adjustments; (2) is insensitive to adhesion, PSD cross-talk, transducer/piezo-tube axis misalignment, and shear-center offset; (3) is applicable to integrated tips and colloidal probes; and (4) is generally applicable to any reciprocating friction coefficient measurement. The method was applied to AFM measurements of polished carbon (99.999% graphite) and single crystal MoS2 to demonstrate the technique. Carbon and single crystal MoS2 had friction coefficients of µ = 0.20 ± 0.04 and µ = 0.006 ± 0.001, respectively, against an integrated Si probe. Against a glass colloidal sphere, MoS2 had a friction coefficient of µ = 0.005 ± 0.001. Generally, the measurement uncertainties ranged from 10%-20% and were driven by the effect of actual frictional variation on the calibration rather than calibration error itself (i.e., due to misalignment, tip-offset, or probe radius).

Fluid load support during localized indentation of cartilage with a spherical probe.

Interstitial fluid pressurization, a consequence of a biphasic tissue structure, is essential to the load bearing and lubrication properties of articular cartilage. Focal tissue degradation may interfere with this protective mechanism, eventually leading to gross degeneration and osteoarthritis. Our long-term goal is to determine whether local contacts can be used as a means to probe local tissue integrity and functionality. In the present work, Hertzian rate-controlled microindentation was used as a model of the more complicated sliding system to directly determine the effects of contact radius and deformation rate on interstitial load support. During localized contact between a steel spherical probe and bovine articular cartilage, the equilibrium and non-equilibrium responses were well-fit by the Hertz model (R(2)>0.998) with a mean equilibrium contact modulus of 0.93 MPa. The effective contact modulus and fluid load fraction were independent of indentation depth, contact radius, and normal force; both increased monotonically with indentation rate. At 21 µm/s indentation rate, the cartilage was effectively stiffened by 6-fold with the fluid pressure supporting 85% of the contact force. The results motivated a simple analytical model that directly links the tribomechanical response (including fluid load support) and the Peclet number to measurable material properties and controllable experimental variables. This paper demonstrates that tribological contacts can be used to probe local functional properties. Such measurements can add important insights into the roles of focal tissue damage and impaired local functionality in the pathogenesis of osteoarthritis.

Cell friction.

Cells sense and respond to their environment. Mechanotransduction is the process by which mechanical forces, stress, and strains are converted into biochemical signals that control cell behavior. In recent decades it has been shown that appropriate mechanical signals are essential to tissue health, but the role of friction and direct contact shearing across cell surfaces has been essentially unexplored. This, despite the obvious existence of numerous biological tissues whose express function depends on sliding contacts. In our studies on frictional interactions of corneal cells we find that the friction coefficients are on the order of mu = 0.03-0.06 for in vitro and in vivo experiments. Additionally, we observe cell death after single cycles of sliding at contact pressures estimated to be approximately 12 kPa. These experimental results suggest that frictional contact forces produce mechanical stresses and strains that are in the cellular mechanosensing ranges.

In-situ studies of cartilage microtribology: roles of speed and contact area.

The progression of local cartilage surface damage toward early stage osteoarthritis (OA) likely depends on the severity of the damage and its impact on the local lubrication and stress distribution in the surrounding tissue. It is difficult to study the local responses using traditional methods; in-situ microtribological methods are being pursued here as a means to elucidate the mechanical aspects of OA progression. While decades of research have been dedicated to the macrotribological properties of articular cartilage, the microscale response is unclear. An experimental study of healthy cartilage microtribology was undertaken to assess the physiological relevance of a microscale friction probe. Normal forces were on the orderof50 mN. Sliding speed varied from 0 to 5 mm/s, and two probes radii, 0.8 mm and 3.2 mm, were used in the study. In-situ measurements of the indentation depth into the cartilage enabled calculations of contact area, effective elastic modulus, elastic and fluid normal force contributions, and the interfacial friction coefficient. This work resulted in the following findings: 1) at high sliding speed (V=1-5 mm/s), the friction coefficient was low (µ = 0.025) and insensitive to probe radius (0.8 mm 3.2 mm) despite the 4-folddifference in the resulting contact areas; 2) The contact area was a strong function of the probe radius and sliding speed; 3) the friction coefficient was proportional to contact area when sliding speed varied from 0.05mm/s-5mm/s; 4) the fluid load support was greater than 85% for all sliding conditions (0% fluid support when V=0) and was insensitive to both probe radius and sliding speed. The findings were consistent with the adhesive theory of friction; as speed increased, increased effective hardness reduced the area of solid-solid contact which subsequently reduced the friction force. Where the severity of the sliding conditions dominates the wear and degradation of typical engineering tribomaterials, the results suggest that joint motion is actually beneficial for maintaining low matrix stresses, low contact areas, and effective lubrication for the fluid-saturated porous cartilage tissue. Further, the results demonstrated effective pressurization and lubrication beneath single asperity microscale contacts. With carefully designed experimental conditions, local friction probes can facilitate more fundamental studies of cartilage lubrication, friction and wear, and potentially add important insights into the mechanical mechanisms of OA.

Vein patch angioplasty with non-penetrating titanium clips. Comparison to standard suture technique.

Our purpose was to compare the Vascular Closure Staples (VCS) clips to a standard suture technique for vein patch angioplasty in a porcine model. Six female pigs underwent vein patch angioplasty of the common iliac arteries with either VCS clips or continuous suturing. The reconstructed vessels were evaluated macroscopically, angiographically and histologically after two months by re-operation. There was a non significant trend towards shorter reconstruction (6.5 +/- 1.8 min. for clips vs. 8.5 +/- 1.7 min. for sutures, p = 0.15) and clamp times when clips were used (8.4 +/- 1.5 min. vs. 10.1 +/- 1.3 min., p = 0.15). At re-operation all vessels were found patent without significant histological differences regarding the intimal reaction. VCS clips are a reliable alternative to sutures for vein patch angioplasty.

Blood substitutes in surgery.

BACKGROUND: Despite increasing safety of blood supplies, and blood conservation strategies, the need for blood transfusion is increasing. Due to storage characteristics, blood is not always available when it is needed. AIMS: Review the necessity for an oxygen carrying blood substitute. Review the history of the compounds that may become blood substitutes, and briefly describe those in clinical trials. MATERIAL AND METHODS: Review of literature in the area of blood substitutes. RESULTS AND CONCLUSIONS: There is a need for oxygen carrying blood substitutes. Despite disappointments in recent clinical trials leading to withdraw of some compounds, there are several promising products nearing clinical approval.