Microcirculation in Cardiovascular Diseases.

Microcirculation is a system composed of interconnected microvessels, which is responsible for the distribution of oxygenated blood among and within organs according to regional metabolic demand. Critical medical conditions, e. g., sepsis, and heart failure are known triggers of microcirculatory disturbance, which usually develops early in such clinical pictures and represents an independent risk factor for mortality. Therefore, hemodynamic resuscitation aiming at restoring microcirculatory perfusion is of paramount importance. Until recently, however, resuscitation protocols were based on macrohemodynamic variables, which increases the risk of under or over resuscitation. The introduction of hand-held video-microscopy (HVM) into clinical practice has allowed real-time analysis of microcirculatory variables at the bedside and, hence, favored a more individualized approach. In the cardiac intensive care unit scenario, HVM provides essential information on patients' hemodynamic status, e. g., to classify the type of shock, to adequate the dosage of vasopressors or inotropes according to demand and define safer limits, to guide fluid therapy and red blood cell transfusion, to evaluate response to treatment, among others. Nevertheless, several drawbacks have to be addressed before HVM becomes a standard of care.

Cells on film - the past and future of cinemicroscopy.

Movie making is now a ubiquitous experimental tool that biologists use alongside more traditional techniques such as molecular biology and biochemistry. It is no longer just cell biologists, but scientists from many other disciplines, such as immunology and neuroscience, that utilise movies to dissect their processes of interest. When did filming become such a standard laboratory technique? Who developed the use of the movie as an experimental tool? The Wellcome Library has recently restored and digitized a number of original 16-mm films from two pioneering cinemicroscopists, Ronald Canti and Michael Abercrombie, which are now freely available to the scientific community. In light of these films, this Essay will give a brief history of the early cinemicroscopists and discuss what is driving the use of movies in the laboratory today.

In vivo imaging using bioluminescence: a tool for probing graft-versus-host disease.

Immunological reactions have a key role in health and disease and are complex events characterized by coordinated cell trafficking to specific locations throughout the body. Clarification of these cell-trafficking events is crucial for improving our understanding of how immune reactions are initiated, controlled and recalled. As we discuss here, an emerging modality for revealing cell trafficking is bioluminescence imaging, which harnesses the light-emitting properties of enzymes such as luciferase for quantification of cells and uses low-light imaging systems. This strategy could be useful for the study of a wide range of biological processes, such as the pathophysiology of graft-versus-host and graft-versus-leukaemia reactions.

A tribute to Shinya Inoue and innovation in light microscopy.

The 2003 International Prize for Biology was awarded to Shinya Inoue for his pioneering work in visualizing dynamic processes within living cells using the light microscope. He and his scientific descendants are now pushing light microscopy even further by developing new techniques such as imaging single molecules, visualizing processes in living animals, and correlating results from light and electron microscopy.

The neuronal naturalist: watching neurons in their native habitat.

Dynamic processes of neural development, such as migrations of precursor cells, growth of axons and dendrites, and formation and modification of synapses, can be fully analyzed only with techniques that monitor changes over time. Although there has been long-standing motivation for following cellular and synaptic events in vivo (intravital microscopy), until recently few preparations have been studied, and then often only with great effort. Innovations in low-light and laser-scanning microscopies, coupled with developments of new dyes and of genetically encoded indicators, have increased both the breadth and depth of in situ imaging approaches. Here we present the motivations and challenges for dynamic imaging methods, offer some illustrative examples and point to future opportunities with emerging technologies.

DIY: "Do Imaging Yourself" - Conventional microscopes as powerful tools for in vivo investigation.

Intravital imaging has been increasingly employed in cell biology studies and it is becoming one of the most powerful tools for in vivo investigation. Although some protocols can be extremely complex, most intravital imaging procedures can be performed using basic surgery and animal maintenance techniques. More importantly, regular confocal microscopes - the same that are used for imaging immunofluorescence slides - can also acquire high quality intravital images and movies after minor adaptations. Here we propose minimal adaptations in stock microscopes that allow major improvements in different fields of scientific investigation.

Advancement of Surgical Visualization Methods: Comparison Study Between Traditional Microscopic Surgery and a Novel Robotic Optoelectronic Visualization Tool for Spinal Surgery.

INTRODUCTION: The operating microscope (OM) has become instrumental in aiding surgeons during key microdissection with greater safety and detail. An exoscope offers similar detail with improved functionality and greater implications for live teaching and improved operating room flow. METHODS: Eleven senior neurosurgery residents and fellows performed unilateral, single-level laminotomies on fresh cadavers using an OM and exoscope. Three attending spine surgeons blinded for the visualization technique used then reviewed and graded each decompression. Data points gathered included time of procedure, grading of decompression (1-5), and complications, including dural tear, nerve root injury, and pars fracture. RESULTS: Operative times between the 2 systems were not significantly different (14.9 minutes OM vs. 15.6 minutes exoscope, P = 0.766). Despite high variability between evaluators in assessing complications and adequacy of decompression, there was no significant difference between either system. Postprocedural surveys indicated greater comfort with the exoscope, greater ease of use, and superior teaching potential for the exoscope over the standard OM. CONCLUSION: In our simulated operating room model, an exoscope is a valid alternative to the standard OM that affords the surgeon greater comfort with greater teaching potential while maintaining many of the microscope's benefits.

Monitoring microcirculation.

The clinical relevance of microcirculation and its bedside observation started gaining importance in the 1990s since the introduction of hand-held video microscopes. From then, this technology has been continuously developed, and its clinical relevance has been established in more than 400 studies. In this paper, we review the different types of video microscopes, their application techniques, the microcirculation of different organ systems, the analysis methods, and the software and scoring systems. The main focus of this review will be on the state-of-art technique, CytoCam-incident dark-field imaging, and the most recent technological and technical updates concerning microcirculation monitoring.

Microcirculation in sepsis: new perspectives.

Microcirculatory dysfunction has been recently recognized as a key pathophysiologic process in the evolution of sepsis. In the present review, we discuss fundamental aspects of microcirculatory abnormalities during septic shock, including pathogenic mechanisms, technological assessment, clinical correlates and potential therapies. The most important function of the microcirculation is the regulation and distribution of flow within the different organs. In septic shock, microcirculatory dysfunction may arise as a result of several factors such as endothelial dysfunction, leukocyte-endothelium interactions, coagulation and inflammatory disorders, hemorheologic abnormalities, and functional shunting. Severity and persistence of these microcirculatory abnormalities are associated with bad prognosis and are not necessarily predicted by systemic variables. The introduction of bedside techniques that allow evaluation of the microcirculation into clinical practice has opened up a new field of functional hemodynamic monitoring. Recent data suggest that microcirculatory abnormalities can be staged in severity. Some microcirculatory indices are more accurately related to morbidity and mortality, and thus a definition of clinically relevant microcirculatory abnormalities is feasible. On the other hand, although several systemic variables do not predict microcirculatory status, high norepinephrine (NE) requirements and hyperlactatemia are associated with a much higher prevalence of relevant microcirculatory derangements. Therefore, severe septic shock patients could represent a more precise target for interventions, particularly in microcirculation-oriented clinical trials. Clinical research has identified various therapeutic approaches that are successful in modifying the microcirculation. Future research must determine whether some of these approaches are successful in improving outcome of critically ill patients by recruiting the microcirculation.

Human microvascular imaging: a review of skin and tongue videomicroscopy techniques and analysing variables.

Imaging techniques are increasingly important in clinical diagnostic work. Microcirculation is essential for function and survival of all tissues, but imaging techniques for microvascular monitoring of patients have only been used to a limited extent in clinical practice. The microcirculation is complex with its static and dynamic feature, and only skin and oral mucosa are readily accessible for microscopic examination. In addition, there is a no general agreement on which microvascular parameters and analysing techniques that could be useful. The aim of this article is to give an overview of techniques for human intra-vital microscopy and to describe software and variables used to analyse pictures and film sequences of human microcirculation. We also present clinical examples where microvascular examinations have been shown to be of diagnostic value. Improved techniques for assessing microvascular morphology and physiology will probably become important tools in clinical work in many disciplines in the near future.

An extended vision for dynamic high-resolution intravital immune imaging.

The past few years have seen the application of confocal and especially two-photon microscopy to the dynamic high-resolution imaging of lymphocytes and antigen presenting cells within organs such as lymph nodes and thymus. After summarizing some of the published results obtained to date using these methods, we describe our view of how this technology will develop and be applied in the near future. This includes its extension to a wide variety of non-lymphoid tissues, to the tracking of functional responses in addition to migratory behavior, to the analysis of molecular events previously studied only in vitro, to dissection of the interplay between hematopoietic and stromal elements, to visualization of a wider array of cell types including neutrophils, macrophages, NK cells, NKT cells and others, and to the interaction of the host with infectious agents. Reaching these goals will depend on a combination of new tools for genetic manipulations, novel fluorescent reporters, enhanced instrumentation, and better surgical techniques for the extended imaging of live animals. The end result will be a new level of understanding of how orchestrated cell movement and interaction contribute to the physiological and pathological activities of the immune system.

Evaluación del tratamiento logopédico en la rehabilitación de la disfonía en adultos: seguimiento de los efectos grupales y de las variaciones individuales / Evaluation of voice therapy for dysphonia in adults: follow-up of group effects and individual variability

Este estudio analiza las diferencias grupales e individuales en los resultados obtenidos tras la reeducación vocal de un grupo de pacientes disfónicos con diferentes diagnósticos, utilizando un protocolo multidimensional breve de evaluación. Las voces de 21 participantes con disfonía y 21 controles se evalúan y comparan en pretratamiento vs. postratamiento logopédico. El funcionamiento de la voz fue valorado antes y después del tratamiento mediante un conjunto de pruebas que incluían la videolaringostroboscopia, la valoración aerodinámica y tests de autoevaluación mediante cuestionarios de autoinforme. El grupo de tratamiento logopédico (TL) recibió 2 sesiones de terapia de la voz a la semana durante 3 meses. Tres reevaluaciones de seguimiento se llevaron también a cabo después de terminado el tratamiento para valorar la eficacia y la latencia del mismo. Un MANOVA con la prueba de la traza de Pillai mostró un efecto significativo de grupo del tratamiento logopédico en todas las variables evaluadas. Un T-test pretratamiento vs. postratamiento de los cambios individuales resultó también significativo en la mayoría de los participantes con disfonía, a pesar del amplio rango de puntuaciones mostrado (alta varianza) por las diferentes medidas utilizadas para valorar el programa de tratamiento logopédico aplicado. Los resultados corroboran la eficacia de la reeducación vocal con logopedia tanto en los análisis grupales como individuales en al menos algunos tipos de patologías de la voz. Sin embargo, ciertas características y antecedentes de los participantes se destacan como las más favorables para beneficiarse del tratamiento logopédico de la voz (AU)

This study analyzed group and individual differences in the results of vocal rehabilitation in a group of dysphonic patients with different diagnoses, using a brief multidimensional assessment protocol. The voices of 21 participants with dysphonia and 21 controls were evaluated and compared in a pre- vs. post-speech therapy treatment. Voice performance was assessed before and after treatment by a set of tests that included videolaryngostroboscopy, aerodynamic tasks, and self-rating questionnaires. The speech-therapy treatment group received two sessions of speech therapy a week for 3 months. Three follow-up reevaluations of group effects and individual variability were also carried out to assess the latency period after the end of treatment. MANOVA with Pillai's trace test showed a significant group effect of the vocal treatment on all of the variables assessed. A pre- vs. post- treatment T-test of individual changes was also significant in most of the dysphonic participants, despite the wide range of scores (high variance) in the different measures used after the voice therapy program. The results of both group and individual analyses support the effectiveness of vocal rehabilitation with speech therapy in at least some types of voice disorders. However, voice therapy was more effective in participants with certain characteristics and antecedents (AU)

Thoracoscopic procedures for intrathoracic and pulmonary diseases.

Since Jacobaeus performed the first thoracoscopy to explore pleural space and mechanically broke pleural adhesions to facilitate the collapse therapy for pulmonary tuberculosis in 1910, numerous thoracic surgeons have been attempting this technique as a means of accomplishing many intrathoracic procedures previously done through open thoracotomy. As the refinement of video technology has advanced, thoracoscopic surgery has played a very important role in thoracic surgery especially since the early 1990s. Because the advantages of video-assisted thoracoscopic surgery for patients include low post-thoracotomy-related morbidity, cosmetic considerations, low pain, earlier post-operative mobilization, and a shorter operation time in some indications, surgeons have been demonstrating its increasing utility in the diagnosis and treatment of the pleura, lung, mediastinum, great vessels, pericardium, and oesophagus. The most common application of the thoracoscopic approach still remains in the management of pleuropulmonary disease. The indications for the thoracoscopic technique are very broad, but its role in the management of primary lung and oesophageal cancer has yet to be confirmed. Thus, the surgeon who uses the technique in these cancerous diseases should be prudent. In conclusion, these thoracoscopic procedures will play more important roles in the practice of thoracic surgery in the future.

Spinning-disk confocal microscopy -- a cutting-edge tool for imaging of membrane traffic.

Confocal laser scanning microscopy is experiencing a revolution in speed from the world of seconds to that of milliseconds. The spinning Nipkow disk method with microlenses has made this remarkable innovation possible. In combination with the ultrahigh-sensitivity, high-speed and high-resolution camera system based on avalanche multiplication of photoconduction, we are now able to observe the extremely dynamic movement of small vesicles in living cells in real time.