Sensory prediction error drives subconscious motor learning outside of the laboratory.

Sensorimotor adaptation is supported by at least two parallel learning systems: an intentionally controlled explicit strategy and an involuntary implicit learning system. Past work focused on constrained reaches or finger movements in laboratory environments has shown subconscious learning systems to be driven in part by sensory prediction error (SPE), i.e., the mismatch between the realized and expected outcome of an action. We designed a ball rolling task to explore whether SPEs can drive implicit motor adaptation during complex whole body movements that impart physical motion on external objects. After applying a visual shift, participants rapidly adapted their rolling angles to reduce the error between the ball and the target. We removed all visual feedback and told participants to aim their throw directly toward the primary target, revealing an unintentional 5.06° implicit adjustment to reach angles that decayed over time. To determine whether this implicit adaptation was driven by SPE, we gave participants a second aiming target that would "solve" the visual shift, as in the study by Mazzoni and Krakauer (Mazzoni P, Krakauer JW. J Neurosci 26: 3642-3645, 2006). Remarkably, after rapidly reducing ball-rolling error to zero (due to enhancements in strategic aiming), the additional aiming target caused rolling angles to deviate beyond the primary target by 3.15°. This involuntary overcompensation, which worsened task performance, is a hallmark of SPE-driven implicit learning. These results show that SPE-driven implicit processes, previously observed within simplified finger or planar reaching movements, actively contribute to motor adaptation in more complex naturalistic skill-based tasks.NEW & NOTEWORTHY Implicit and explicit learning systems have been detected using simple, constrained movements inside the laboratory. How these systems impact movements during complex whole body, skill-based tasks has not been established. Here, we demonstrate that sensory prediction errors significantly impact how a person updates their movements, replicating findings from the laboratory in an unconstrained ball-rolling task. This real-world validation is an important step toward explaining how subconscious learning helps humans execute common motor skills in dynamic environments.

A software tool for at-home measurement of sensorimotor adaptation.

Sensorimotor adaptation is traditionally studied in well-controlled laboratory settings with specialized equipment. However, recent public health concerns such as the COVID-19 pandemic, as well as a desire to recruit a more diverse study population, have led the motor control community to consider at-home study designs. At-home motor control experiments are still rare because of the requirement to write software that can be easily used by anyone on any platform. To this end, we developed software that runs locally on a personal computer. The software provides audiovisual instructions and measures the ability of the subject to control the cursor in the context of visuomotor perturbations. We tested the software on a group of at-home participants and asked whether the adaptation principles inferred from in-lab measurements were reproducible in the at-home setting. For example, we manipulated the perturbations to test whether there were changes in adaptation rates (savings and interference), whether adaptation was associated with multiple timescales of memory (spontaneous recovery), and whether we could selectively suppress subconscious learning (delayed feedback, perturbation variability) or explicit strategies (limited reaction time). We found remarkable similarity between in-lab and at-home behaviors across these experimental conditions. Thus, we developed a software tool that can be used by research teams with little or no programming experience to study mechanisms of adaptation in an at-home setting.

Competition between parallel sensorimotor learning systems.

Sensorimotor learning is supported by at least two parallel systems: a strategic process that benefits from explicit knowledge and an implicit process that adapts subconsciously. How do these systems interact? Does one system's contributions suppress the other, or do they operate independently? Here, we illustrate that during reaching, implicit and explicit systems both learn from visual target errors. This shared error leads to competition such that an increase in the explicit system's response siphons away resources that are needed for implicit adaptation, thus reducing its learning. As a result, steady-state implicit learning can vary across experimental conditions, due to changes in strategy. Furthermore, strategies can mask changes in implicit learning properties, such as its error sensitivity. These ideas, however, become more complex in conditions where subjects adapt using multiple visual landmarks, a situation which introduces learning from sensory prediction errors in addition to target errors. These two types of implicit errors can oppose each other, leading to another type of competition. Thus, during sensorimotor adaptation, implicit and explicit learning systems compete for a common resource: error.

Adaptive control of movement deceleration during saccades.

As you read this text, your eyes make saccades that guide your fovea from one word to the next. Accuracy of these movements require the brain to monitor and learn from visual errors. A current model suggests that learning is supported by two different adaptive processes, one fast (high error sensitivity, low retention), and the other slow (low error sensitivity, high retention). Here, we searched for signatures of these hypothesized processes and found that following experience of a visual error, there was an adaptive change in the motor commands of the subsequent saccade. Surprisingly, this adaptation was not uniformly expressed throughout the movement. Rather, after experience of a single error, the adaptive response in the subsequent trial was limited to the deceleration period. After repeated exposure to the same error, the acceleration period commands also adapted, and exhibited resistance to forgetting during set-breaks. In contrast, the deceleration period commands adapted more rapidly, but suffered from poor retention during these same breaks. State-space models suggested that acceleration and deceleration periods were supported by a shared adaptive state which re-aimed the saccade, as well as two separate processes which resembled a two-state model: one that learned slowly and contributed primarily via acceleration period commands, and another that learned rapidly but contributed primarily via deceleration period commands.

An implicit memory of errors limits human sensorimotor adaptation.

During extended motor adaptation, learning appears to saturate despite persistence of residual errors. This adaptation limit is not fixed but varies with perturbation variance; when variance is high, residual errors become larger. These changes in total adaptation could relate to either implicit or explicit learning systems. Here, we found that when adaptation relied solely on the explicit system, residual errors disappeared and learning was unaltered by perturbation variability. In contrast, when learning depended entirely, or in part, on implicit learning, residual errors reappeared. Total implicit adaptation decreased in the high-variance environment due to changes in error sensitivity, not in forgetting. These observations suggest a model in which the implicit system becomes more sensitive to errors when they occur in a consistent direction. Thus, residual errors in motor adaptation are at least in part caused by an implicit learning system that modulates its error sensitivity in response to the consistency of past errors.

The Origins of Anterograde Interference in Visuomotor Adaptation.

Anterograde interference refers to the negative impact of prior learning on the propensity for future learning. There is currently no consensus on whether this phenomenon is transient or long lasting, with studies pointing to an effect in the time scale of hours to days. These inconsistencies might be caused by the method employed to quantify performance, which often confounds changes in learning rate and retention. Here, we aimed to unveil the time course of anterograde interference by tracking its impact on visuomotor adaptation at different intervals throughout a 24-h period. Our empirical and model-based approaches allowed us to measure the capacity for new learning separately from the influence of a previous memory. In agreement with previous reports, we found that prior learning persistently impaired the initial level of performance upon revisiting the task. However, despite this strong initial bias, learning capacity was impaired only when conflicting information was learned up to 1 h apart, recovering thereafter with passage of time. These findings suggest that when adapting to conflicting perturbations, impairments in performance are driven by two distinct mechanisms: a long-lasting bias that acts as a prior and hinders initial performance and a short-lasting anterograde interference that originates from a reduction in error sensitivity.

Postural control of arm and fingers through integration of movement commands.

Every movement ends in a period of stillness. Current models assume that commands that hold the limb at a target location do not depend on the commands that moved the limb to that location. Here, we report a surprising relationship between movement and posture in primates: on a within-trial basis, the commands that hold the arm and finger at a target location depend on the mathematical integration of the commands that moved the limb to that location. Following damage to the corticospinal tract, both the move and hold period commands become more variable. However, the hold period commands retain their dependence on the integral of the move period commands. Thus, our data suggest that the postural controller possesses a feedforward module that uses move commands to calculate a component of hold commands. This computation may arise within an unknown subcortical system that integrates cortical commands to stabilize limb posture.

Moving an arm requires the brain to send electrical signals to the arm's muscles, causing them to contract. Neuroscientists call these types of brain signals "move signals". The brain also sends so-called hold signals, which hold the arm still in a desired position. Part of the brain known as the primary motor cortex helps to calculate the move signals for the arm, but it was unclear how the brain produces the corresponding hold signals. Fortunately, the fact that the brain moves other things besides arms may help answer this question. Previous research has shown, for example, that a brain area called the "neural integrator" calculates the hold signals needed to hold the eye in a specific position. The neural integrator does this by using basic principles of physics, and details of the speed and duration of the eye's movements. Now, Albert et al. show a similar mechanism appears to control hold signals for arm movements. In one set of experiments, muscle activity was measured as monkeys moved their arms or fingers to different target positions. In other experiments, human volunteers held a robot arm, and Albert et al. measured the forces they produced while reaching and holding still. Both the human and monkey experiments revealed a relationship between move signals and hold signals. Like for eye movements, hold signals for the arm could be calculated from the move signals. In further experiments with stroke patients where the brain had been damaged, the move signals were found to be deteriorated, but the way hold signals were calculated stayed the same. This suggests that there is an unknown structure within the brain that calculates hold signals based on move signals. Investigating how the brain holds the arm still may help scientists understand why some neurological conditions like stroke or dystonia cause unwanted movements or unusual postures. This might also lead scientists to develop new ways to treat these conditions.

Estimating properties of the fast and slow adaptive processes during sensorimotor adaptation.

Experience of a prediction error recruits multiple motor learning processes, some that learn strongly from error but have weak retention and some that learn weakly from error but exhibit strong retention. These processes are not generally observable but are inferred from their collective influence on behavior. Is there a robust way to uncover the hidden processes? A standard approach is to consider a state space model where the hidden states change following experience of error and then fit the model to the measured data by minimizing the squared error between measurement and model prediction. We found that this least-squares algorithm (LMSE) often yielded unrealistic predictions about the hidden states, possibly because of its neglect of the stochastic nature of error-based learning. We found that behavioral data during adaptation was better explained by a system in which both error-based learning and movement production were stochastic processes. To uncover the hidden states of learning, we developed a generalized expectation maximization (EM) algorithm. In simulation, we found that although LMSE tracked the measured data marginally better than EM, EM was far more accurate in unmasking the time courses and properties of the hidden states of learning. In a power analysis designed to measure the effect of an intervention on sensorimotor learning, EM significantly reduced the number of subjects that were required for effective hypothesis testing. In summary, we developed a new approach for analysis of data in sensorimotor experiments. The new algorithm improved the ability to uncover the multiple processes that contribute to learning from error. NEW & NOTEWORTHY Motor learning is supported by multiple adaptive processes, each with distinct error sensitivity and forgetting rates. We developed a generalized expectation maximization algorithm that uncovers these hidden processes in the context of modern sensorimotor learning experiments that include error-clamp trials and set breaks. The resulting toolbox may improve the ability to identify the properties of these hidden processes and reduce the number of subjects needed to test the effectiveness of interventions on sensorimotor learning.

Classification of Indeterminate Melanocytic Lesions by MicroRNA Profiling.

PURPOSE: Identification of indeterminate melanocytic skin lesions capable of neoplastic progression is suboptimal and may potentially result in unnecessary morbidity from surgery. MicroRNAs (miRs) may be useful in classifying indeterminate Spitz tumors as having high or low risk for malignant behavior. METHODS: RNA was extracted from paraffin-embedded tissues of benign nevi, benign Spitz tumors, indeterminate Spitz tumors, and Spitzoid melanomas in adults (n = 62) and children (n = 28). The expression profile of 12 miRs in adults (6 miRs in children) was analyzed by real-time polymerase chain reaction. RESULTS: Benign Spitz lesions were characterized by decreased expression of miR-125b and miR-211, and upregulation of miR-22, compared with benign nevi (p < 0.05). A comparison of Spitzoid melanomas to benign nevi revealed overexpression of miR-21, miR-150, and miR-155 in the malignant primaries (p < 0.05). In adults, Spitzoid melanomas exhibited upregulation of miR-21, miR-150, and miR-155 compared with indeterminate Spitz lesions. Indeterminate Spitz lesions with low-risk pathologic features had lower miR-21 and miR-155 expression compared with Spitzoid melanoma tumors in adults (p < 0.05), while pathologic high-risk indeterminate Spitz lesions had increased levels of miR-200c expression compared with low-risk indeterminate lesions (p < 0.05). Pediatric Spitzoid melanomas exhibited increased miR-21 expression compared with indeterminate Spitz lesions (p < 0.05). Moreover, miR-155 expression was increased in indeterminate lesions with mitotic counts >1 and depth of invasion >1 mm, suggesting miR-155 expression is associated with histological characteristics. CONCLUSIONS: miR expression profiles can be measured in indeterminate Spitz tumors and correlate with markers of malignant potential.

Hair removal-related injuries in the United States, 1991-2014.

BACKGROUND: Hair removal practices have changed in frequency and location on the body. Previous research on hair removal injuries has focused on a specific body region, age, or gender. OBJECTIVE: This study sought to take a broader perspective of hair removal-associated injuries in the United States which sought treatment at emergency departments. METHODS: Data from the National Electronic Injury Surveillance System (NEISS) from 1991 to 2014 were used to identify hair removal-related injuries. Incidence rates were determined for the overall population and stratified by gender and age category using US Census Bureau population estimates. RESULTS: From 1991 to 2014, there were an estimated 292 053 hair removal-associated injuries in the United States. The overall incidence rate was highest in 2013 (9/100 000). Those aged 65+ had the highest incidence from 1991 to 2010 with those aged 19-34 having the highest rate starting in 2011. When stratified by body region injured, males had highest injury rates to the face and females had highest rates to the lower limbs. Starting in 2010, those aged 19-34 had higher incidence particularly for pubic and trunk regions. CONCLUSION: The incidence of hair removal-associated injuries seen by emergency departments increased nearly ninefold between 1991 and 2013. Due to the increased incidence among 19- to 34-year-olds, caution should be taken particularly for this age group when undergoing depilatory practices. Overall, individuals should practice safe and acceptable usage of hair removal products to reduce the risk of injury.

The Neural Feedback Response to Error As a Teaching Signal for the Motor Learning System.

UNLABELLED: When we experience an error during a movement, we update our motor commands to partially correct for this error on the next trial. How does experience of error produce the improvement in the subsequent motor commands? During the course of an erroneous reaching movement, proprioceptive and visual sensory pathways not only sense the error, but also engage feedback mechanisms, resulting in corrective motor responses that continue until the hand arrives at its goal. One possibility is that this feedback response is co-opted by the learning system and used as a template to improve performance on the next attempt. Here we used electromyography (EMG) to compare neural correlates of learning and feedback to test the hypothesis that the feedback response to error acts as a template for learning. We designed a task in which mixtures of error-clamp and force-field perturbation trials were used to deconstruct EMG time courses into error-feedback and learning components. We observed that the error-feedback response was composed of excitation of some muscles, and inhibition of others, producing a complex activation/deactivation pattern during the reach. Despite this complexity, across muscles the learning response was consistently a scaled version of the error-feedback response, but shifted 125 ms earlier in time. Across people, individuals who produced a greater feedback response to error, also learned more from error. This suggests that the feedback response to error serves as a teaching signal for the brain. Individuals who learn faster have a better teacher in their feedback control system. SIGNIFICANCE STATEMENT: Our sensory organs transduce errors in behavior. To improve performance, we must generate better motor commands. How does the nervous system transform an error in sensory coordinates into better motor commands in muscle coordinates? Here we show that when an error occurs during a movement, the reflexes transform the sensory representation of error into motor commands. To learn from error, the nervous system scales this feedback response and then shifts it earlier in time, adding it to the previously generated motor commands. This addition serves as an update to the motor commands, constituting the learning signal. Therefore, by providing a coordinate transformation, the feedback system generates a template for learning from error.

Outcomes in patients with obstructive jaundice from metastatic colorectal cancer and implications for management.

INTRODUCTION: Patients with metastatic colorectal cancer can develop jaundice from intrahepatic or extrahepatic causes. Currently, there is little data on the underlying causes and overall survival after onset of jaundice. The purpose of this study was to characterize the causes of jaundice and determine outcomes. METHODS: Six hundred twenty-nine patients treated for metastatic colorectal cancer between 2004 and 2010 were retrospectively reviewed. Those developing jaundice were grouped as having intrahepatic or extrahepatic obstruction. Demographics, clinicopathologic, and outcome data were analyzed. RESULTS: Sixty-two patients with metastatic colorectal cancer developed jaundice. Intrahepatic biliary obstruction was most common, occurring in younger patients. Time from metastatic diagnosis to presentation of jaundice was similar between groups, as was the mean number of prior lines of chemotherapy. Biliary decompression was successful 41.7 % of the time and was attempted more commonly for extrahepatic causes. Median overall survival after onset of jaundice was 1.5 months and it was similar between groups, but improved to 9.6 months in patients who were able to receive further chemotherapy. CONCLUSIONS: Jaundice due to metastatic colorectal cancer is an ominous finding, representing aggressive tumor biology or exhaustion of therapies. Biliary decompression is often difficult and should only be pursued when additional treatment options are available.

An indeterminate nodule in the cirrhotic liver discovered by surveillance imaging is a prelude to malignancy.

BACKGROUND: Surveillance imaging often shows indeterminate lesions in the cirrhotic liver, which may represent early hepatocellular carcinoma (HCC), dysplastic or regenerative nodules, or vascular shunts. The risk of HCC after identification of an indeterminate nodule is not well described. METHODS: We identified 252 patients with cirrhosis and at least one indeterminate nodule discovered on surveillance imaging over a 4-year period. The incidence of HCC development within 2 years of nodule identification was measured along with baseline risk factors associated with developing HCC. RESULTS: The incidence of HCC in this population was 21% (53 of 252), and risk factors associated with HCC included chronic viral hepatitis, male gender, and low platelet count. The median time from identification of an indeterminate nodule to diagnosis of HCC was 2.7 months. Patients with indeterminate nodules who developed HCC were more likely have to have an indeterminate nodule with arterial enhancement. CONCLUSIONS: The 2-year incidence of HCC in the setting of cirrhosis and an indeterminate nodule discovered by surveillance imaging may be as high as one in five persons. Early follow-up imaging, biopsy, or empiric treatment should be considered for those at higher risk. Further, this population is well suited for early detection biomarker and chemoprevention studies.

Influence of the renal artery ostium flow diverter on hemodynamics and atherogenesis.

The structure and function of the renal artery ostium flow diverter on the caudal side of the renal branch point were previously reported; in this study, we further evaluate the diverter׳s possible functions. The protrusion of this structure into the abdominal aorta suggests that the diverter may preferentially direct blood flow to the renal arteries, and that it may also influence flow patterns and recirculation known to be involved in atherogenesis. Three-dimensional computational fluid dynamics (CFD) simulations of steady and pulsatile blood flow are performed to investigate the influence of diverter size and position, and vascular geometry, on the flow patterns and fluid mechanical forces in the neighborhood of the diverter. CFD results show that the flow diverter does affect the blood distribution; depending on the diverter׳s position, the flow to the renal arteries may be increased or reduced. Calculated results also demonstrate the diverter׳s effect on the wall shear stress (WSS) distribution, and suggest that the diverter contributes to an atherogenic environment in the abdominal aorta, while being atheroprotective in the renal arteries themselves. These results support previous clinical findings, and suggest directions for further clinical study. The results of this work have direct implications in understanding the physiological significance of the diverter, and its potential role in the pathophysiological development of atherosclerosis.

Chemically modified tetracycline 3 prevents acute respiratory distress syndrome in a porcine model of sepsis + ischemia/reperfusion-induced lung injury.

Experimental pharmacotherapies for the acute respiratory distress syndrome (ARDS) have not met with success in the clinical realm. We hypothesized that chemically modified tetracycline 3 (CMT-3), an anti-inflammatory agent that blocks multiple proteases and cytokines, would prevent ARDS and injury in other organs in a clinically applicable, porcine model of inflammation-induced lung injury. Pigs (n = 15) were anesthetized and instrumented for monitoring. A "2-hit" injury was induced: (a) peritoneal sepsis-by placement of a fecal clot in the peritoneum, and (b) ischemia/reperfusion-by clamping the superior mesenteric artery for 30 min. Animals were randomized into two groups: CMT-3 group (n = 7) received CMT-3 (200 mg/kg); placebo group (n = 9) received the same dose of a CMT-3 vehicle (carboxymethylcellulose). Experiment duration was 48 h or until early mortality. Animals in both groups developed polymicrobial bacteremia. Chemically modified tetracycline 3 treatment prevented ARDS as indicated by PaO(2)/FIO(2) ratio, static compliance, and plateau airway pressure (P < 0.05 vs. placebo). It improved all histological lesions of ARDS (P < 0.05 vs. placebo). The placebo group developed severe ARDS, coagulopathy, and histological injury to the bowel. Chemically modified tetracycline 3 treatment prevented coagulopathy and protected against bowel injury. It significantly lowered plasma concentrations of interleukin 1ß (IL-1ß), tumor necrosis factor α, IL-6, IL-8, and IL-10. This study presents a clinically relevant model of lung injury in which CMT-3 treatment prevented the development of ARDS due in part to reduction of multiple plasma cytokines. Treatment of sepsis patients with CMT-3 could significantly reduce progression from sepsis into ARDS.

Transverse sinus thrombosis after internal jugular vein ligation.

BACKGROUND: Cerebral vein and dural sinus thrombosis is a rare condition with a wide range of causes and a highly variable presentation. It can lead to significant morbidity, but scant literature is available describing diagnosis and treatment when this occurs after ligation of the internal jugular vein. OBJECTIVES: To discuss potential risk factors for cerebral vein and dural sinus thrombosis after ligation of the internal jugular vein, and present current options for diagnosis and treatment. CASE REPORT: A 23-year-old male construction worker was brought to the Emergency Department by Emergency Medical Services after sustaining a severe neck laceration from a hand-held grinder. He was treated with ligation of the left internal jugular vein, but subsequently developed severe headaches and symptoms of increased intracranial pressure. A magnetic resonance venogram of the head revealed a left transverse sinus thrombosis requiring treatment with anticoagulation. The placement of a lumboperitoneal shunt was ultimately needed for relief of his symptoms. CONCLUSIONS: Early diagnosis and aggressive therapeutic interventions are critical to prevent further morbidity in patients who develop cerebral vein and dural sinus thrombosis after ligation of the internal jugular vein.

Comparison of "open lung" modes with low tidal volumes in a porcine lung injury model.

BACKGROUND: Ventilator strategies that maintain an "open lung" have shown promise in treating hypoxemic patients. We compared three "open lung" strategies with standard of care low tidal volume ventilation and hypothesized that each would diminish physiologic and histopathologic evidence of ventilator induced lung injury (VILI). MATERIALS AND METHODS: Acute lung injury (ALI) was induced in 22 pigs via 5% Tween and 30-min of injurious ventilation. Animals were separated into four groups: (1) low tidal volume ventilation (LowVt -6 mL/kg); (2) high-frequency oscillatory ventilation (HFOV); (3) airway pressure release ventilation (APRV); or (4) recruitment and decremental positive-end expiratory pressure (PEEP) titration (RM+OP) and followed for 6 h. Lung and hemodynamic function was assessed on the half-hour. Bronchoalveolar lavage fluid (BALF) was analyzed for cytokines. Lung tissue was harvested for histologic analysis. RESULTS: APRV and HFOV increased PaO(2)/FiO(2) ratio and improved ventilation. APRV reduced BALF TNF-α and IL-8. HFOV caused an increase in airway hemorrhage. RM+OP decreased SvO(2), increased PaCO(2), with increased inflammation of lung tissue. CONCLUSION: None of the "open lung" techniques were definitively superior to LowVt with respect to VILI; however, APRV oxygenated and ventilated more effectively and reduced cytokine concentration compared with LowVt with nearly indistinguishable histopathology. These data suggest that APRV may be of potential benefit to critically ill patients but other "open lung" strategies may exacerbate injury.

A clinically applicable porcine model of septic and ischemia/reperfusion-induced shock and multiple organ injury.

BACKGROUND: Although many sepsis treatments have shown efficacy in acute animal models, at present only activated protein C is effective in humans. The likely reason for this discrepancy is that most of the animal models used for preclinical testing do not accurately replicate the complex pathogenesis of human sepsis. Our objective in this study was to develop a clinically applicable model of severe sepsis and gut ischemia/reperfusion (I/R) that would cause multiple organ injury over a period of 48 h. MATERIALS AND METHODS: Anesthetized, instrumented, and ventilated pigs were subjected to a "two-hit" injury by placement of a fecal clot through a laparotomy and by clamping the superior mesenteric artery (SMA) for 30 min. The animals were monitored for 48 h. Wide spectrum antibiotics and intravenous fluids were given to maintain hemodynamic status. FiO(2) was increased in response to oxygen desaturation. Twelve hours following injury, a drain was placed in the laparotomy wound. Extensive hemodynamic, lung, kidney, liver, and renal function measurements and serial measurements of arterial and mixed venous blood gases were made. Bladder pressure was measured as a surrogate for intra-peritoneal pressure to identify the development of the abdominal compartment syndrome (ACS). Plasma and peritoneal ascites cytokine concentration were measured at regular intervals. Tissues were harvested and fixed at necropsy for detailed morphometric analysis. RESULTS: Polymicrobial sepsis developed in all animals. There was a progressive deterioration of organ function over the 48 h. The lung, kidney, liver, and intestine all demonstrated clinical and histopathologic injury. Acute lung injury (ALI) and ACS developed by consensus definitions. Increases in multiple cytokines in serum and peritoneal fluid paralleled the dysfunction found in major organs. CONCLUSION: This animal model of Sepsis+I/R replicates the systemic inflammation and dysfunction of the major organ systems that is typically seen in human sepsis and trauma patients. The model should be useful in deciphering the complex pathophysiology of septic shock as it transitions to end-organ injury thus allowing sophisticated preclinical studies on potential treatments.

Titration of mean airway pressure and FiO2 during high frequency oscillatory ventilation in a porcine model of acute lung injury.

BACKGROUND: High frequency oscillatory ventilation (HFOV) is frequently utilized for patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). However, precise criteria to titrate mean airway pressure (mPaw) and FiO(2) as the patient's condition improves are lacking. We hypothesized that reducing mPaw and FiO(2) too quickly after reaching target arterial oxygen saturation levels would promote ventilator induced lung injury (VILI). MATERIALS AND METHODS: ALI was induced by instilling 3% Tween 20. Pigs were placed supine and received 30 min of nonprotective ventilation. Pigs were separated into two groups: HFOV constant (HFOVC, n = 3) = constant mPaw and FiO(2) for the duration; HFOV titrated (HFOVT, n = 4) = FiO(2) and/or mPaw were reduced every 30 min if the oxygen saturation remained between 88%-95%. Hemodynamic and pulmonary measurements were made at baseline, after lung injury, and every 30 min during the 6-h study. Lung histopathology was determined by quantifying alveolar hyperdistension, fibrin, congestion, atelectasis, and polymorphonuclear leukocyte (PMN) infiltration. RESULTS: Oxygenation was significantly lower in the HFOVT group compared to the HFOVC group after 6 h. Lung histopathology was significantly increased in the HFOVT group in the following categories: PMN infiltration, alveolar hyperdistension, congestion, and fibrin deposition. CONCLUSIONS: Rapid reduction of mPaw and FiO(2) in our ALI model significantly reduced oxygenation, but, more importantly, caused VILI as evidenced by increased lung inflammation and alveolar hyperdistension. Specific criteria for titration of mPaw and inspired oxygen are needed to maximize the lung protective effects of HFOV while maintaining adequate gas exchange.