Revealing tumor microstructure with oscillating diffusion encoding MRI in pre-surgical and post-treatment glioma patients.

PURPOSE: We hypothesized that the time-dependent diffusivity at short diffusion times, as measured by oscillating gradient spin echo (OGSE) diffusion MRI, can characterize tissue microstructures in glioma patients. THEORY AND METHODS: Five adult patients with known diffuse glioma, including two pre-surgical and three with new enhancing lesions after treatment for high-grade glioma, were scanned in an ultra-high-performance gradient 3.0T MRI system. OGSE diffusion MRI at 30-100 Hz and pulsed gradient spin echo diffusion imaging (approximated as 0 Hz) were obtained. The ADC and trace-diffusion-weighted image at each acquired frequency were calculated, that is, ADC (f) and TraceDWI (f). RESULTS: In pre-surgical patients, biopsy-confirmed solid enhancing tumor in a high-grade glioblastoma showed higher ADC ( f ) ADC ( 0 Hz ) $$ \frac{\mathrm{ADC}\ (f)}{\mathrm{ADC}\ \left(0\ \mathrm{Hz}\right)} $$ and lower TraceDWI ( f ) TraceDWI ( 0 Hz ) $$ \frac{\mathrm{TraceDWI}\ (f)}{\mathrm{TraceDWI}\ \left(0\ \mathrm{Hz}\right)} $$ , compared to that at same OGSE frequency in a low-grade astrocytoma. In post-treatment patients, the enhancing lesions of two patients who were diagnosed with tumor progression contained more voxels with high ADC ( f ) ADC ( 0 Hz ) $$ \frac{\mathrm{ADC}\ (f)}{\mathrm{ADC}\ \left(0\ \mathrm{Hz}\right)} $$ and low TraceDWI ( f ) TraceDWI ( 0 Hz ) $$ \frac{\mathrm{TraceDWI}\left(\mathrm{f}\right)}{\mathrm{TraceDWI}\left(0\ \mathrm{Hz}\right)} $$ , compared to the enhancing lesions of a patient who was diagnosed with treatment effect. Non-enhancing T2 signal abnormality lesions in both the pre-surgical high-grade glioblastoma and post-treatment tumor progressions showed regions with high ADC ( f ) ADC ( 0 Hz ) $$ \frac{\mathrm{ADC}\ (f)}{\mathrm{ADC}\ \left(0\ \mathrm{Hz}\right)} $$ and low TraceDWI ( f ) TraceDWI ( 0 Hz ) $$ \frac{\mathrm{TraceDWI}\ \left(\mathrm{f}\right)}{\mathrm{TraceDWI}\ \left(0\ \mathrm{Hz}\right)} $$ , consistent with infiltrative tumor. The solid tumor of the glioblastoma, the enhancing lesions of post-treatment tumor progressions, and the suspected infiltrative tumors showed high diffusion time-dependency from 30 to 100 Hz, consistent with high intra-tumoral volume fraction (cellular density). CONCLUSION: Different characteristics of OGSE-based time-dependent diffusivity can reveal heterogenous tissue microstructures that indicate cellular density in glioma patients.

Calibration of concomitant field offsets using phase contrast MRI for asymmetric gradient coils.

PURPOSE: Asymmetric gradient coils introduce zeroth- and first-order concomitant field terms, in addition to higher-order terms common to both asymmetric and symmetric gradients. Salient to compensation strategies is the accurate calibration of the concomitant field spatial offset parameters for asymmetric coils. A method that allows for one-time calibration of the offset parameters is described. THEORY AND METHODS: A modified phase contrast pulse sequence with single-sided bipolar flow encoding is proposed to calibrate the offsets for asymmetric, transverse gradient coils. By fitting the measured phase offsets to different gradient amplitudes, the spatial offsets were calculated by fitting the phase variation. This was used for calibrating real-time pre-emphasis compensation of the zeroth- and first-order concomitant fields. RESULTS: Image quality improvement with the proposed corrections was demonstrated in phantom and healthy volunteers with non-Cartesian and Cartesian trajectory acquisitions. Concomitant field compensation using the calibrated offsets resulted in a residual phase error <3% at the highest gradient amplitude and demonstrated substantial reduction of image blur and slice position/selection artifacts. CONCLUSIONS: The proposed implementation provides an accurate method for calibrating spatial offsets that can be used for real-time concomitant field compensation of zeroth and first-order terms, substantially reducing artifacts without retrospective correction or sequence specific waveform modifications.

Peripheral nerve stimulation limits of a high amplitude and slew rate magnetic field gradient coil for neuroimaging.

PURPOSE: To establish peripheral nerve stimulation (PNS) thresholds for an ultra-high performance magnetic field gradient subsystem (simultaneous 200-mT/m gradient amplitude and 500-T/m/s gradient slew rate; 1 MVA per axis [MAGNUS]) designed for neuroimaging with asymmetric transverse gradients and 42-cm inner diameter, and to determine PNS threshold dependencies on gender, age, patient positioning within the gradient subsystem, and anatomical landmarks. METHODS: The MAGNUS head gradient was installed in a whole-body 3T scanner with a custom 16-rung bird-cage transmit/receive RF coil compatible with phased-array receiver brain coils. Twenty adult subjects (10 male, mean ± SD age = 40.4 ± 11.1 years) underwent the imaging and PNS study. The tests were repeated by displacing subject positions by 2-4 cm in the superior-inferior and anterior-posterior directions. RESULTS: The x-axis (left-right) yielded mostly facial stimulation, with mean ΔGmin = 111 ± 6 mT/m, chronaxie = 766 ± 76 µsec. The z-axis (superior-inferior) yielded mostly chest/shoulder stimulation (123 ± 7 mT/m, 620 ± 62 µsec). Y-axis (anterior-posterior) stimulation was negligible. X-axis and z-axis thresholds tended to increase with age, and there was negligible dependency with gender. Translation in the inferior and posterior directions tended to increase the x-axis and z-axis thresholds, respectively. Electric field simulations showed good agreement with the PNS results. Imaging at MAGNUS gradient performance with increased PNS threshold provided a 35% reduction in noise-to-diffusion contrast as compared with whole-body performance (80 mT/m gradient amplitude, 200 T/m/sec gradient slew rate). CONCLUSION: The PNS threshold of MAGNUS is significantly higher than that for whole-body gradients, which allows for diffusion gradients with short rise times (under 1 msec), important for interrogating brain microstructure length scales.

Oscillating diffusion-encoding with a high gradient-amplitude and high slew-rate head-only gradient for human brain imaging.

PURPOSE: We investigate the importance of high gradient-amplitude and high slew-rate on oscillating gradient spin echo (OGSE) diffusion imaging for human brain imaging and evaluate human brain imaging with OGSE on the MAGNUS head-gradient insert (200 mT/m amplitude and 500 T/m/s slew rate). METHODS: Simulations with cosine-modulated and trapezoidal-cosine OGSE at various gradient amplitudes and slew rates were performed. Six healthy subjects were imaged with the MAGNUS gradient at 3T with OGSE at frequencies up to 100 Hz and b = 450 s/mm2 . Comparisons were made against standard pulsed gradient spin echo (PGSE) diffusion in vivo and in an isotropic diffusion phantom. RESULTS: Simulations show that to achieve high frequency and b-value simultaneously for OGSE, high gradient amplitude, high slew rates, and high peripheral nerve stimulation limits are required. A strong linear trend for increased diffusivity (mean: 8-19%, radial: 9-27%, parallel: 8-15%) was observed in normal white matter with OGSE (20 Hz to 100 Hz) as compared to PGSE. Linear fitting to frequency provided excellent correlation, and using a short-range disorder model provided radial long-term diffusivities of D∞,MD = 911 ± 72 µm2 /s, D∞,PD = 1519 ± 164 µm2 /s, and D∞,RD = 640 ± 111 µm2 /s and correlation lengths of lc,MD = 0.802 ± 0.156 µm, lc,PD = 0.837 ± 0.172 µm, and lc,RD = 0.780 ± 0.174 µm. Diffusivity changes with OGSE frequency were negligible in the phantom, as expected. CONCLUSION: The high gradient amplitude, high slew rate, and high peripheral nerve stimulation thresholds of the MAGNUS head-gradient enables OGSE acquisition for in vivo human brain imaging.

Highly efficient head-only magnetic field insert gradient coil for achieving simultaneous high gradient amplitude and slew rate at 3.0T (MAGNUS) for brain microstructure imaging.

PURPOSE: To develop a highly efficient magnetic field gradient coil for head imaging that achieves 200 mT/m and 500 T/m/s on each axis using a standard 1 MVA gradient driver in clinical whole-body 3.0T MR magnet. METHODS: A 42-cm inner diameter head-gradient used the available 89- to 91-cm warm bore space in a whole-body 3.0T magnet by increasing the radial separation between the primary and the shield coil windings to 18.6 cm. This required the removal of the standard whole-body gradient and radiofrequency coils. To achieve a coil efficiency ~4× that of whole-body gradients, a double-layer primary coil design with asymmetric x-y axes, and symmetric z-axis was used. The use of all-hollow conductor with direct fluid cooling of the gradient coil enabled ≥50 kW of total heat dissipation. RESULTS: This design achieved a coil efficiency of 0.32 mT/m/A, allowing 200 mT/m and 500 T/m/s for a 620 A/1500 V driver. The gradient coil yielded substantially reduced echo spacing, and minimum repetition time and echo time. In high b = 10,000 s/mm2 diffusion, echo time (TE) < 50 ms was achieved (>50% reduction compared with whole-body gradients). The gradient coil passed the American College of Radiology tests for gradient linearity and distortion, and met acoustic requirements for nonsignificant risk operation. CONCLUSIONS: Ultra-high gradient coil performance was achieved for head imaging without substantial increases in gradient driver power in a whole-body 3.0T magnet after removing the standard gradient coil. As such, any clinical whole-body 3.0T MR system could be upgraded with 3-4× improvement in gradient performance for brain imaging.

Medical 3D Printing for the Radiologist.

While use of advanced visualization in radiology is instrumental in diagnosis and communication with referring clinicians, there is an unmet need to render Digital Imaging and Communications in Medicine (DICOM) images as three-dimensional (3D) printed models capable of providing both tactile feedback and tangible depth information about anatomic and pathologic states. Three-dimensional printed models, already entrenched in the nonmedical sciences, are rapidly being embraced in medicine as well as in the lay community. Incorporating 3D printing from images generated and interpreted by radiologists presents particular challenges, including training, materials and equipment, and guidelines. The overall costs of a 3D printing laboratory must be balanced by the clinical benefits. It is expected that the number of 3D-printed models generated from DICOM images for planning interventions and fabricating implants will grow exponentially. Radiologists should at a minimum be familiar with 3D printing as it relates to their field, including types of 3D printing technologies and materials used to create 3D-printed anatomic models, published applications of models to date, and clinical benefits in radiology. Online supplemental material is available for this article.

Point-of-Need Additive Manufacturing in Austere Arctic Environments: An Evaluation of Medical Logistics Requirements and Capabilities Demonstration.

Medical response to military conflicts, natural disasters, and humanitarian crises are challenged by operational logistics with unreliable supply chains, delayed medical evacuation, and compatibility of the disparate medical equipment and consumables. In these environments, stocks of supplies will become more quickly depleted and the need for equipment parts increases secondary to their higher likelihood for failure from overuse. Additive Manufacturing (AM), or 3D printing, at or closer to the point-of-need provides potential solutions to mitigate these logistics challenges. AM's ability to tailor the resultant product through computer design enables real-time modification of a product to meet a specific situation. In this study, we deployed two different 3D printers to an arctic locale to demonstrate the utility of 3D printing and bioprinting in austere environments. Deployment of AM solutions in austere environments will likely impact medical care following natural disasters and conflicts with contested logistics. The work presented here furthers the readiness status of AM for use in austere environments to manufacture medical equipment parts and demonstrates its potential use for tissue engineering and advanced medical treatments in remote environments.

An Exosome-Laden Hydrogel Wound Dressing That Can Be Point-of-Need Manufactured in Austere and Operational Environments.

Skin wounds often form scar tissue during healing. Early intervention with tissue-engineered materials and cell therapies may promote scar-free healing. Exosomes and extracellular vesicles (EV) secreted by mesenchymal stromal cells (MSC) are believed to have high regenerative capacity. EV bioactivity is preserved after lyophilization and storage to enable use in remote and typically resource-constrained environments. We developed a bioprinted bandage containing reconstituted EVs that can be fabricated at the point-of-need. An alginate/carboxymethyl cellulose (CMC) biomaterial ink was prepared, and printability and mechanical properties were assessed with rheology and compression testing. Three-dimensional printed constructs were evaluated for Young's modulus relative to infill density and crosslinking to yield material with stiffness suitable for use as a wound dressing. We purified EVs from human MSC-conditioned media and characterized them with nanoparticle tracking analysis and mass spectroscopy, which gave a peak size of 118 nm and identification of known EV proteins. Fluorescently labeled EVs were mixed to form bio-ink and bioprinted to characterize EV release. EV bandages were bioprinted on both a commercial laboratory bioprinter and a custom ruggedized 3D printer with bioprinting capabilities, and lyophilized EVs, biomaterial ink, and thermoplastic filament were deployed to an austere Arctic environment and bioprinted. This work demonstrates that EVs can be bioprinted with an alginate/CMC hydrogel and released over time when in contact with a skin-like substitute. The technology is suitable for operational medical applications, notably in resource-limited locations, including large-scale natural disasters, humanitarian crises, and combat zones.

Multiacquisition T1-mapping MRI during tidal respiration for quantification of myocardial T1 in swine with heart failure.

OBJECTIVE: The purpose of this article is to evaluate a free-breathing pulse sequence to quantify myocardial T1 changes in a swine model of tachycardia-induced heart failure. MATERIALS AND METHODS: Yorkshire swine were implanted with pacemakers and were ventricularly paced at 200 beats/min to induce heart failure. Animals were scanned twice with a 1.5-T MRI scanner, once at baseline and once at heart failure. A T1-mapping sequence was performed during tidal respiration before and 5 minutes after the administration of a gadolinium-chelate contrast agent. T1-mapping values were compared between the baseline and heart failure scans. The percentage of fibrosis of heart failure myocardial tissue was compared with similar left ventricular tissue from control animals using trichrome blue histologic analysis. RESULTS: In the study cohort, differences were found between the baseline and heart failure T1-mapping values before the administration of contrast agent (960 ± 96 and 726 ± 94 ms, respectively; p = 0.02) and after contrast agent administration (546 ± 180 and 300 ± 171 ms, respectively; p = 0.005). The animals with heart failure also had a difference histologically in the percentage of myocardial collagen compared with tissue from healthy control animals (control, 5.4% ± 1.0%; heart failure, 9.4% ± 1.6%; p < 0.001). CONCLUSION: The proposed T1-mapping technique can quantify diffuse myocardial changes associated with heart failure without the use of a contrast agent and without breath-holding. These T1 changes appear to be associated with increases in the percentage of myocardial collagen that in this study were not detected by traditional myocardial delayed enhancement imaging. T1 mapping may be a useful technique for detecting early but clinically significant myocardial fibrosis.

Optimal Agents for Visualizing Collagen Tissue Microarchitecture Using Contrast-Enhanced MicroCT.

Micro-computed tomography (microCT) is a common tool for the visualization of the internal composition of organic tissues. Collagen comprises approximately 25-35% of the whole-body protein content in mammals, and the structure and arrangement of collagen fibers contribute significantly to the integrity of tissues. Collagen type I is also frequently used as a key structural component in tissue-engineered and bioprinted tissues. However, the imaging of collagenous tissues is limited by their inherently low X-ray attenuation, which makes them indistinguishable from most other soft tissues. An imaging contrast agent that selectively alters X-ray attenuation is thus essential to properly visualize collagenous tissue using a standard X-ray tube microCT scanner. This review compares various contrast-enhanced techniques reported in the literature for MicroCT visualization of collagen-based tissues. An ideal microCT contrast agent would meet the following criteria: (1) it diffuses through the tissue quickly; (2) it does not deform or impair the object being imaged; and (3) it provides sufficient image contrast for reliable visualization of the orientation of individual fibers within the collagen network. The relative benefits and disadvantages of each method are discussed. Lugol's solution (I3K), phosphotungstic acid (H3PW12O40), mercury(II) chloride (HgCl2), and Wells-Dawson polyoxometalates came closest to fitting the criteria. While none of the contrast agents discussed in the literature met all criteria, each one has advantages to consider in the context of specific lab capabilities and imaging priorities.

Additive Manufacturing for Fabrication of Point-of-Care Therapies in Austere Environments.

INTRODUCTION: Known as the "golden hour," survival of most critically injured patients is highly dependent on providing the required treatment within the first hour of injury. Recent technological advances in additive manufacturing (also known as three-dimensional [3D] printing) allow for austere deployment and point-of-care rapid fabrication of a variety of medical supplies, including human tissues and bioactive bandages, in prolonged field care scenarios. In this pilot project, our aim was to investigate the ability to 3D print a range of potential biomedical supplies and solutions in an austere field environment. MATERIALS AND METHODS: We specifically designed and fabricated novel surgical tools, bioactive bandages, objects (screw and anatomic models), and human meniscal tissue in an austere African desert environment. A total of seven packages were sent using a commercial carrier directly to the end destination. A multi-tool ruggedized 3D printer was used as the manufacturing platform for all objects fabricated downrange. Human mesenchymal stem cells were shipped for 3D bioprinting of human menisci and bioactive bandages. Design and fabrication for all 3D-printed products utilized computer-aided design (CAD) tools. RESULTS: Initial shipment from a single U.S. site to the sub-Saharan Africa location was relatively prompt, taking an average of 4.7 days to deliver three test packages. However, the actual delivery of the seven packages from Orlando, FL, to the same sub-Saharan Africa site took an average of 16 days (range 7-23 days). The ruggedized printer successfully fabricated relevant medical supplies using biocompatible filament, bioink hydrogels, and stem cell-loaded bioinks. This prototype did not, however, have the capacity to provide a sterile environment. A multi-material complete bandage was 3D printed using polyamide polyolefin and cellulose, live cells, neomycin salve, and adhesive. The bandage, wound covering backing, and adhesive backing print took under 2 min to 3D print. Surgical instrument CAD files were based on commercially available medical-grade stainless-steel instruments. The screw CAD file was downloaded from the NIH 3D Print Exchange website. The prints of the two surgical tools and screw using thermoplastic material were successful. Menisci, relatively complex forms of the cartilage, were 3D bioprinted with a gel that held their form well after printing and were then solidified slightly using a cross-linking solution. After 2 min of solidification, it was possible to remove and handle the menisci. CONCLUSION: The current and future challenges of prolonged field care need to be addressed with new techniques, training, and technology. Ruggedized, deployable 3D printers allow for the direct fabrication of medical tools, supplies, and biological solutions for austere use. Delivery of packages can vary, and attention to routes and location is key, especially for transit of time-sensitive perishable supplies such as live cells. The significance of this study provides the real possibility to 3D print "just-in-time" medical solutions tailored to the need of an individual service member in any environment. This is a potentially exciting opportunity to bring critical products to the war front.

Shiga Toxin (Stx) Type 1a and Stx2a Translocate through a Three-Layer Intestinal Model.

Shiga toxins (Stxs) produced by ingested E. coli can induce hemolytic uremic syndrome after crossing the intact intestinal barrier, entering the bloodstream, and targeting endothelial cells in the kidney. The method(s) by which the toxins reach the bloodstream are not fully defined. Here, we used two polarized cell models to evaluate Stx translocation: (i) a single-layer primary colonic epithelial cell model and (ii) a three-cell-layer model with colonic epithelial cells, myofibroblasts, and colonic endothelial cells. We traced the movement of Stx types 1a and 2a across the barrier models by measuring the toxicity of apical and basolateral media on Vero cells. We found that Stx1a and Stx2a crossed both models in either direction. However, approximately 10-fold more Stx translocated in the three-layer model as compared to the single-layer model. Overall, the percentage of toxin that translocated was about 0.01% in the epithelial-cell-only model but up to 0.09% in the three-cell-layer model. In both models, approximately 3- to 4-fold more Stx2a translocated than Stx1a. Infection of the three-cell-layer model with Stx-producing Escherichia coli (STEC) strains showed that serotype O157:H7 STEC reduced barrier function in the model and that the damage was not dependent on the presence of the eae gene. Infection of the three-layer model with O26:H11 STEC strain TW08571 (Stx1a+ and Stx2a+), however, allowed translocation of modest amounts of Stx without reducing barrier function. Deletion of stx2a from TW08571 or the use of anti-Stx1 antibody prevented translocation of toxin. Our results suggest that single-cell models may underestimate the amount of Stx translocation and that the more biomimetic three-layer model is suited for Stx translocation inhibitor studies.

Military-related mild traumatic brain injury: clinical characteristics, advanced neuroimaging, and molecular mechanisms.

Mild traumatic brain injury (mTBI) is a significant health burden among military service members. Although mTBI was once considered relatively benign compared to more severe TBIs, a growing body of evidence has demonstrated the devastating neurological consequences of mTBI, including chronic post-concussion symptoms and deficits in cognition, memory, sleep, vision, and hearing. The discovery of reliable biomarkers for mTBI has been challenging due to under-reporting and heterogeneity of military-related mTBI, unpredictability of pathological changes, and delay of post-injury clinical evaluations. Moreover, compared to more severe TBI, mTBI is especially difficult to diagnose due to the lack of overt clinical neuroimaging findings. Yet, advanced neuroimaging techniques using magnetic resonance imaging (MRI) hold promise in detecting microstructural aberrations following mTBI. Using different pulse sequences, MRI enables the evaluation of different tissue characteristics without risks associated with ionizing radiation inherent to other imaging modalities, such as X-ray-based studies or computerized tomography (CT). Accordingly, considering the high morbidity of mTBI in military populations, debilitating post-injury symptoms, and lack of robust neuroimaging biomarkers, this review (1) summarizes the nature and mechanisms of mTBI in military settings, (2) describes clinical characteristics of military-related mTBI and associated comorbidities, such as post-traumatic stress disorder (PTSD), (3) highlights advanced neuroimaging techniques used to study mTBI and the molecular mechanisms that can be inferred, and (4) discusses emerging frontiers in advanced neuroimaging for mTBI. We encourage multi-modal approaches combining neuropsychiatric, blood-based, and genetic data as well as the discovery and employment of new imaging techniques with big data analytics that enable accurate detection of post-injury pathologic aberrations related to tissue microstructure, glymphatic function, and neurodegeneration. Ultimately, this review provides a foundational overview of military-related mTBI and advanced neuroimaging techniques that merit further study for mTBI diagnosis, prognosis, and treatment monitoring.

Development of a bioreactor for in-vitro compression cycling of tissue engineered meniscal implants.

Injuries to the meniscus are common and can impair physical activities. Bioprinted meniscal tissue offers an attractive alternative to donor tissue for meniscal repair but achieving the strength of native tissue is a challenge. Here we report the development of a tissue engineering bioreactor designed to apply repetitive force which may lead to an increase in the compressive modulus and durability of bioprinted meniscal tissues. The modular bioreactor system is composed of a sterilizable tissue culture vessel together with a dock that applies and measures mechanical force. The culture vessel allows for simultaneous compression cycling of two anatomically sized menisci. Using a hybrid linear actuator with a stepper motor, the dock can apply up to 300 N of force at speeds up to 20 mm/s, corresponding to the upper limits of anatomical force and motion in the knee. An interchangeable 22 N load cell was mated between the culture vessel and the dock to log changes in force. Both the culture vessel and dock are maintained in a standard cell culture incubator to provide heat and CO2, while the dock is powered and controlled externally using a step motor drive and customized software.

Flexible cardiac T1 mapping using a modified Look-Locker acquisition with saturation recovery.

A modified Look-Locker acquisition using saturation recovery (MLLSR) for breath-held myocardial T(1) mapping is presented. Despite its reduced dynamic range, saturation recovery enables substantially higher imaging efficiency than conventional inversion recovery T(1) mapping because it does not require time for magnetization to relax to equilibrium. Therefore, MLLSR enables segmented readouts, shorter data acquisition windows, and shorter breath holds compared with inversion recovery. T(1) measurements in phantoms using MLLSR showed a high correlation with conventional single-point inversion recovery spin echo. In vivo T(1) measurements from normal and infarcted myocardium in 41 volunteers and patients were consistent with previously reported values. Twenty subjects were also scanned with MLLSR using an accelerated sampling scheme that required half the scan time (eight vs. 16 heartbeats) but yielded equivalent results. The flexibility afforded by the improved imaging efficiency of MLLSR allows the acquisition to be tailored to particular clinical needs and to individual patient's breath-holding abilities.

A review of strategies for development of tissue engineered meniscal implants.

The meniscus is a key stabilizing tissue of the knee that facilitates proper tracking and movement of the knee joint and absorbs stresses related to physical activity. This review article describes the biology, structure, and functions of the human knee meniscus, common tears and repair approaches, and current research and development approaches using modern methods to fabricate a scaffold or tissue engineered meniscal replacement. Meniscal tears are quite common, often resulting from sports or physical training, though injury can result without specific contact during normal physical activity such as bending or squatting. Meniscal injuries often require surgical intervention to repair, restore basic functionality and relieve pain, and severe damage may warrant reconstruction using allograft transplants or commercial implant devices. Ongoing research is attempting to develop alternative scaffold and tissue engineered devices using modern fabrication techniques including three-dimensional (3D) printing which can fabricate a patient-specific meniscus replacement. An ideal meniscal substitute should have mechanical properties that are close to that of natural human meniscus, and also be easily adapted for surgical procedures and fixation. A better understanding of the organization and structure of the meniscus as well as its potential points of failure will lead to improved design approaches to generate a suitable and functional replacement.

Even a little sleepiness influences neural activation and clinical reasoning in novices.

BACKGROUND AND AIMS: Sleepiness influences alertness and cognitive functioning and impacts many aspects of medical care, including clinical reasoning. However, dual processing theory suggests that sleepiness will impact clinical reasoning differently in different individual, depending on their level of experience with the given condition. Our aim, therefore, was to examine the association between clinical reasoning, neuroanatomical activation, and sleepiness in senior medical students. METHODS: Our methodology replicated an earlier study but with novices rather than board-certified physicians. Eighteen final-year medical students answered validated multiple-choice questions (MCQs) during an fMRI scan. Each MCQ was projected in three phases: reading, answering, and reflection (modified think aloud). Echo-planar imaging (EPI) scans gave a time series that reflected blood oxygenation level dependent (BOLD) signal in each location (voxel) within the brain. Sleep data were collected via self-report (Epworth Sleepiness Scale) and actigraphy. These data were correlated with answer accuracy using Pearson correlation. RESULTS: Analysis revealed an increased BOLD signal in the right dorsomedial prefrontal cortex (P < .05) during reflection (Phase 3) associated with increased self-reported sleepiness (ESS) immediately before scanning. Covariate analysis also revealed that increased BOLD signal in the right supramarginal gyrus (P < .05) when reflecting (Phase 3) was associated with increased correct answer response time. Both patterns indicate effortful analytic (System 2) reasoning. CONCLUSION: Our findings that novices use System 2 thinking for clinical reasoning and even a little (perceived) sleepiness influences their clinical reasoning ability to suggest that the parameters for safe working may be different for novices (eg, junior doctors) and experienced physicians.

3D Bioprinting and Its Application to Military Medicine.

INTRODUCTION: Traditionally, tissue engineering techniques have largely focused on 2D cell culture models-monolayers of immortalized or primary cells growing on tissue culture plastic. Although these techniques have proven useful in research, they often lack physiological validity, because of the absence of fundamental tissue properties, such as multicellular organization, specialized extracellular matrix structures, and molecular or force gradients essential to proper physiological function. More recent advances in 3D cell culture methods have facilitated the development of more complex physiological models and tissue constructs; however, these often rely on self-organization of cells (bottom-up design), and the range of tissue construct size and complexity generated by these methods remains relatively limited. By borrowing from advances in the additive manufacturing field, 3D bioprinting techniques are enabling top-down design and fabrication of cellular constructs with controlled sizing, spacing, and chemical functionality. The high degree of control over engineered tissue architecture, previously unavailable to researchers, enables the generation of more complex, physiologically relevant 3D tissue constructs. Three main 3D bioprinting techniques are reviewed-extrusion, droplet-based, and laser-assisted bioprinting techniques are among the more robust 3D bioprinting techniques, each with its own strengths and weaknesses. High complexity tissue constructs created through 3D bioprinting are opening up new avenues in tissue engineering, regenerative medicine, and physiological model systems for researchers in the military medicine community. MATERIALS AND METHODS: Recent primary literature and reviews were selected to provide a broad overview of the field of 3D bioprinting and illustrate techniques and examples of 3D bioprinting relevant to military medicine. References were selected to illustrate specific examples of advances and potential military medicine applications in the 3D bioprinting field, rather than to serve as a comprehensive review. RESULTS: Three classes of 3D bioprinting techniques were reviewed: extrusion, droplet-based, and laser-assisted bioprinting. Advantages, disadvantages, important considerations, and constraints of each technique were discussed. Examples from the primary literature were given to illustrate the techniques. Relevant applications of 3D bioprinting to military medicine, namely tissue engineering/regenerative medicine and new models of physiological systems, are discussed in the context of advancing military medicine. CONCLUSIONS: 3D bioprinting is a rapidly evolving field that provides researchers the ability to build tissue constructs that are more complex and physiologically relevant than traditional 2D culture methods. Advances in bioprinting techniques, bioink formulation, and cell culture methods are being translated into new paradigms in tissue engineering and physiological system modeling, advancing the state of the art, and increasing construct availability to the military medicine research community.

Radiologic evaluation of suspected congenital heart disease in adults.

The population of adults with congenital heart disease is increasing in North America. Radiologic imaging is critical for the initial assessment and for surveillance in this population. Chest radiography and echocardiography are valuable first-line tools for evaluation. However, magnetic resonance imaging and computed tomography are often necessary, particularly for assessment of extracardiac anatomy or specific vascular connections or relationships, which may be complex in postoperative patients. Although magnetic resonance imaging and computed tomography can provide volumetric data for more comprehensive evaluation of cardiac anatomy and function, magnetic resonance imaging does not require patient exposure to ionizing radiation or nephrotoxic iodinated contrast media. Magnetic resonance imaging also can measure blood flow for quantification of left-to-right shunts, regurgitant fractions, and pressure gradients. Although noninvasive imaging techniques have limitations, they can evaluate most lesions and preclude the need for cardiac catheterization. Noninvasive imaging is particularly useful for serial evaluation of patients with surgically corrected congenital heart disease, because nearly one half of these patients will require two or more surgeries.

Aortic dilatation and dissection in Turner syndrome.

BACKGROUND: The risk for aortic dissection is increased among relatively young women with Turner syndrome (TS). It is unknown whether aortic dilatation precedes acute aortic dissection in TS and, if so, what specific diameter predicts impending deterioration. METHODS AND RESULTS: Study subjects included 166 adult volunteers with TS (average age, 36.2 years) who were not selected for cardiovascular disease and 26 healthy female control subjects. Ascending and descending aortic diameters were measured by magnetic resonance imaging at the right pulmonary artery. TS women were on average 20 cm shorter, yet average aortic diameters were identical in the 2 groups. Ascending aortic diameters normalized to body surface area (aortic size index) were significantly greater in TS, and approximately 32% of TS women had values greater than the 95th percentile of 2.0 cm/m2. Ascending diameter/descending diameter ratios also were significantly greater in the TS group. During approximately 3 years of follow-up, aortic dissections occurred in 3 women with TS, for an annualized rate of 618 cases/100,000 woman-years. These 3 subjects had ascending aortic diameters of 3.7 to 4.8 cm and aortic size indices > 2.5 cm/m2. CONCLUSIONS: The risk for aortic dissection is greatly increased in young women with TS. Because of their small stature, ascending aortic diameters of < 5 cm may represent significant dilatation; thus, the use of aortic size index is preferred. Individuals with a dilated ascending aorta defined as aortic size index > 2.0 cm/m2 require close cardiovascular surveillance. Those with aortic size index > or = 2.5 cm/m2 are at highest risk for aortic dissection.