Tissue perfusion pressure enables continuous hemodynamic evaluation and risk prediction in the intensive care unit.

Treatment of circulatory shock in critically ill patients requires management of blood pressure using invasive monitoring, but uncertainty remains as to optimal individual blood pressure targets. Critical closing pressure, which refers to the arterial pressure when blood flow stops, can provide a fundamental measure of vascular tone in response to disease and therapy, but it has not previously been possible to measure this parameter routinely in clinical care. Here we describe a method to continuously measure critical closing pressure in the systemic circulation using readily available blood pressure monitors and then show that tissue perfusion pressure (TPP), defined as the difference between mean arterial pressure and critical closing pressure, provides unique information compared to other hemodynamic parameters. Using analyses of 5,988 admissions to a modern cardiac intensive care unit, and externally validated with 864 admissions to another institution, we show that TPP can predict the risk of mortality, length of hospital stay and peak blood lactate levels. These results indicate that TPP may provide an additional target for blood pressure optimization in patients with circulatory shock.

Smartphone-Based Blood Pressure Monitoring via the Oscillometric Finger Pressing Method: Analysis of Oscillation Width Variations Can Improve Diastolic Pressure Computation.

OBJECTIVE: Oscillometric finger pressing is a potential method for absolute blood pressure (BP) monitoring via a smartphone. The user presses their fingertip against a photoplethysmography-force sensor unit on a smartphone to steadily increase the external pressure on the underlying artery. Meanwhile, the phone guides the finger pressing and computes systolic BP (SP) and diastolic BP (DP) from the measured blood volume oscillations and finger pressure. The objective was to develop and evaluate reliable finger oscillometric BP computation algorithms. METHODS: The collapsibility of thin finger arteries was exploited in an oscillometric model to develop simple algorithms for computing BP from the finger pressing measurements. These algorithms extract features from "width" oscillograms (oscillation width versus finger pressure functions) and the conventional "height" oscillogram for markers of DP and SP. Finger pressing measurements were obtained using a custom system along with reference arm cuff BP measurements from 22 subjects. Measurements were also obtained during BP interventions in some subjects for 34 total measurements. RESULTS: An algorithm employing the average of width and height oscillogram features predicted DP with correlation of 0.86 and precision error of 8.6 mmHg with respect to the reference measurements. Analysis of arm oscillometric cuff pressure waveforms from an existing patient database provided evidence that the width oscillogram features are better suited to finger oscillometry. CONCLUSION: Analysis of oscillation width variations during finger pressing can improve DP computation. SIGNIFICANCE: The study findings may help in converting widely available devices into truly cuffless BP monitors for improving hypertension awareness and control.

Mathematical Modeling of Oscillometric Blood Pressure Measurement: A Complete, Reduced Oscillogram Model.

OBJECTIVE: Oscillogram modeling is a powerful tool for understanding and advancing popular oscillometric blood pressure (BP) measurement. A reduced oscillogram model relating cuff pressure oscillation amplitude ( ∆O) to external cuff pressure of the artery ( Pe) is: [Formula: see text], where g(P) is the arterial compliance versus transmural pressure ( P) curve, Ps and Pd are systolic and diastolic BP, and k is the reciprocal of the cuff compliance. The objective was to determine an optimal functional form for the arterial compliance curve. METHODS: Eight prospective, three-parameter functions of the brachial artery compliance curve were compared. The study data included oscillometric arm cuff pressure waveforms and invasive brachial BP from 122 patients covering a 20-120 mmHg pulse pressure range. The oscillogram measurements were constructed from the cuff pressure waveforms. Reduced oscillogram models, inputted with measured systolic and diastolic BP and each parametric brachial artery compliance curve function, were optimally fitted to the oscillogram measurements in the least squares sense. RESULTS: An exponential-linear function yielded as good or better model fits compared to the other functions, with errors of 7.9±0.3 and 5.1±0.2% for tail-trimmed and lower half-trimmed oscillogram measurements. Importantly, this function was also the most tractable mathematically. CONCLUSION: A three-parameter exponential-linear function is an optimal form for the arterial compliance curve in the reduced oscillogram model and may thus serve as the standard function for this model henceforth. SIGNIFICANCE: The complete, reduced oscillogram model determined herein can potentially improve oscillometric BP measurement accuracy while advancing foundational knowledge.

Celsr1 suppresses Wnt5a-mediated chemoattraction to prevent incorrect rostral migration of facial branchiomotor neurons.

In the developing hindbrain, facial branchiomotor (FBM) neurons migrate caudally from rhombomere 4 (r4) to r6 to establish the circuit that drives jaw movements. Although the mechanisms regulating initiation of FBM neuron migration are well defined, those regulating directionality are not. In mutants lacking the Wnt/planar cell polarity (PCP) component Celsr1, many FBM neurons inappropriately migrate rostrally into r3. We hypothesized that Celsr1 normally blocks inappropriate rostral migration of FBM neurons by suppressing chemoattraction towards Wnt5a in r3 and successfully tested this model. First, FBM neurons in Celsr1; Wnt5a double mutant embryos never migrated rostrally, indicating that inappropriate rostral migration in Celsr1 mutants results from Wnt5a-mediated chemoattraction, which is suppressed in wild-type embryos. Second, FBM neurons migrated rostrally toward Wnt5a-coated beads placed in r3 of wild-type hindbrain explants, suggesting that excess Wnt5a chemoattractant can overcome endogenous Celsr1-mediated suppression. Third, rostral migration of FBM neurons was greatly enhanced in Celsr1 mutants overexpressing Wnt5a in r3. These results reveal a novel role for a Wnt/PCP component in regulating neuronal migration through suppression of chemoattraction.

Photoplethysmography Fast Upstroke Time Intervals Can Be Useful Features for Cuff-Less Measurement of Blood Pressure Changes in Humans.

OBJECTIVE: Photoplethysmography (PPG) waveform analysis is being increasingly investigated for continuous, non-invasive, and cuff-less blood pressure (BP) measurement. However, the efficacy of this approach and the useful features and models remain largely unclear. The objectives were to develop easy-to-understand models relating PPG waveform features to BP changes (after a cuff calibration) and to determine their value in BP measurement accuracy. METHODS: The study data comprised finger, toe, and ear PPG waveforms, an ECG waveform, and reference manual cuff BP measurements from 32 human subjects (25% hypertensive) before and after slow breathing, mental arithmetic, cold pressor, and nitroglycerin administration. Stepwise linear regression was employed to create parsimonious models for predicting the intervention-induced BP changes from popular PPG waveform features, pulse arrival time (PAT, time delay between ECG R-wave and PPG foot), and subject demographics. Leave-one-subject-out cross validation was applied to compare the BP change prediction root-mean-squared-errors (RMSEs) of the resulting models to reference models in which PPG waveform features were excluded. RESULTS: Finger b-time (PPG foot to minimum second derivative time interval) and ear "STT" (PPG amplitude divided by maximum derivative), when combined with PAT, reduced the systolic BP change prediction RMSE of reference models by 6-7% (p 0.022). Ear STT together with pulse width reduced the diastolic BP change prediction RMSE of the reference model by 13% (p = 0.003). CONCLUSION: The two PPG fast upstroke time intervals can offer some added value in cuff-less BP trending. SIGNIFICANCE: This study offers important information towards achieving non-invasive and passive BP monitoring without a cuff.

Defective Neuronal Positioning Correlates With Aberrant Motor Circuit Function in Zebrafish.

Precise positioning of neurons resulting from cell division and migration during development is critical for normal brain function. Disruption of neuronal migration can cause a myriad of neurological disorders. To investigate the functional consequences of defective neuronal positioning on circuit function, we studied a zebrafish frizzled3a (fzd3a) loss-of-function mutant off-limits (olt) where the facial branchiomotor (FBM) neurons fail to migrate out of their birthplace. A jaw movement assay, which measures the opening of the zebrafish jaw (gape), showed that the frequency of gape events, but not their amplitude, was decreased in olt mutants. Consistent with this, a larval feeding assay revealed decreased food intake in olt mutants, indicating that the FBM circuit in mutants generates defective functional outputs. We tested various mechanisms that could generate defective functional outputs in mutants. While fzd3a is ubiquitously expressed in neural and non-neural tissues, jaw cartilage and muscle developed normally in olt mutants, and muscle function also appeared to be unaffected. Although FBM neurons were mispositioned in olt mutants, axon pathfinding to jaw muscles was unaffected. Moreover, neuromuscular junctions established by FBM neurons on jaw muscles were similar between wildtype siblings and olt mutants. Interestingly, motor axons innervating the interhyoideus jaw muscle were frequently defasciculated in olt mutants. Furthermore, GCaMP imaging revealed that mutant FBM neurons were less active than their wildtype counterparts. These data show that aberrant positioning of FBM neurons in olt mutants is correlated with subtle defects in fasciculation and neuronal activity, potentially generating defective functional outputs.

Conventional pulse transit times as markers of blood pressure changes in humans.

Pulse transit time (PTT) represents a potential approach for cuff-less blood pressure (BP) monitoring. Conventionally, PTT is determined by (1) measuring (a) ECG and ear, finger, or toe PPG waveforms or (b) two of these PPG waveforms and (2) detecting the time delay between the waveforms. The conventional PTTs (cPTTs) were compared in terms of correlation with BP in humans. Thirty-two volunteers [50% female; 52 (17) (mean (SD)) years; 25% hypertensive] were studied. The four waveforms and manual cuff BP were recorded before and after slow breathing, mental arithmetic, cold pressor, and sublingual nitroglycerin. Six cPTTs were detected as the time delays between the ECG R-wave and ear PPG foot, R-wave and finger PPG foot [finger pulse arrival time (PAT)], R-wave and toe PPG foot (toe PAT), ear and finger PPG feet, ear and toe PPG feet, and finger and toe PPG feet. These time delays were also detected via PPG peaks. The best correlation by a substantial extent was between toe PAT via the PPG foot and systolic BP [- 0.63 ± 0.05 (mean ± SE); p < 0.001 via one-way ANOVA]. Toe PAT is superior to other cPTTs including the popular finger PAT as a marker of changes in BP and systolic BP in particular.

PPG Sensor Contact Pressure Should Be Taken Into Account for Cuff-Less Blood Pressure Measurement.

OBJECTIVE: Photo-plethysmography (PPG) sensors are often used to detect pulse transit time (PTT) for potential cuff-less blood pressure (BP) measurement. It is known that the contact pressure (CP) of the PPG sensor markedly alters the PPG waveform amplitude. The objective was to test the hypothesis that PTT detected via PPG sensors is likewise impacted by CP. METHODS: A device was built to measure the time delay between ECG and finger PPG waveforms (i.e., pulse arrival time (PAT) - a popular surrogate of PTT) and the PPG sensor CP at different CP levels. These measurements and finger cuff BP were recorded while the CP was slowly varied in 17 healthy subjects. RESULTS: Over a physiologic range of CP, the maximum deviations of PAT detected at the PPG foot and peak were 22±2 and 40±7 ms (p<0.05), which translate to ∼11 and ∼20 mmHg BP error based on the literature. The curve relating PAT detected at the PPG foot to CP was U-shaped with minimum near finger diastolic BP. A conceptual model accounting for finger artery viscoelasticity and nonlinearity explained this curve. CONCLUSION: Since the regulatory bias error for BP measurement is limited to 5 mmHg, PPG sensor CP should be taken into account for cuff-less BP measurement via PTT. SIGNIFICANCE: This study suggests that widely pursued PPG-based BP measurement devices including those that detect PTT should maintain the CP or include a CP measurement in the calibration equation for deriving BP.

Formulas to Explain Popular Oscillometric Blood Pressure Estimation Algorithms.

Oscillometry is the blood pressure (BP) measurement principle of most automatic cuff devices. The oscillogram (which is approximately the blood volume oscillation amplitude-external pressure function) is measured, and BP is then estimated via an empirical algorithm. The objective was to establish formulas to explain three popular empirical algorithms in the literature-the maximum amplitude, derivative, and fixed ratio algorithms. A mathematical model of the oscillogram was developed and analyzed to derive parametric formulas for explaining each algorithm. Exemplary parameter values were obtained by fitting the model to measured oscillograms. The model and formulas were validated by showing that their predictions correspond to measurements. The formula for the maximum amplitude algorithm indicates that it yields a weighted average of systolic and diastolic BP (0.45 and 0.55 weighting) instead of commonly assumed mean BP. The formulas for the derivative algorithm indicate that it can accurately estimate systolic and diastolic BP (<1.5 mmHg error), if oscillogram measurement noise can be obviated. The formulas for the fixed ratio algorithm indicate that it can yield inaccurate BP estimates, because the ratios change substantially (over a 0.5-0.6 range) with arterial compliance and pulse pressure and error in the assumed ratio translates to BP error via large amplification (>40). The established formulas allow for easy and complete interpretation of perhaps the three most popular oscillometric BP estimation algorithms in the literature while providing new insights. The model and formulas may also be of some value toward improving the accuracy of automatic cuff BP measurement devices.

Versatile cell ablation tools and their applications to study loss of cell functions.

Targeted cell ablation is a powerful approach for studying the role of specific cell populations in a variety of organotypic functions, including cell differentiation, and organ generation and regeneration. Emerging tools for permanently or conditionally ablating targeted cell populations and transiently inhibiting neuronal activities exhibit a diversity of application and utility. Each tool has distinct features, and none can be universally applied to study different cell types in various tissue compartments. Although these tools have been developed for over 30 years, they require additional improvement. Currently, there is no consensus on how to select the tools to answer the specific scientific questions of interest. Selecting the appropriate cell ablation technique to study the function of a targeted cell population is less straightforward than selecting the method to study a gene's functions. In this review, we discuss the features of the various tools for targeted cell ablation and provide recommendations for optimal application of specific approaches.

The catalytic activity and secretion of zebrafish RNases are essential for their in vivo function in motor neurons and vasculature.

Angiogenin (hANG), a member of the Ribonuclease A superfamily has angiogenic, neurotrophic and neuroprotective activities. Mutations in hANG have been found in patients with Amyotrophic lateral sclerosis (ALS). The zebrafish (Danio rerio) rnasel-1, 2 and 3 are orthologues of hANG and of these only Rnasel-1 and Rnasel-2 have been shown to be angiogenic. Herein we show that NCI-65828, a potent and specific small molecule inhibitor of hANG inhibits Rnasel-1 to a similar extent. Treatment of early zebrafish embryos with NCI-65828, or with terrein, a fungal metabolite which prevents the secretion of hANG, resulted in spinal neuron aberrations as well defects in trunk vasculature. Our detailed expression analysis and inhibitor studies suggest that Rnasel-1 plays important roles in neuronal migration and pathfinding as well as in angiogenesis in zebrafish. Our studies suggest the usefulness of the zebrafish as a model to dissect the molecular consequences of the ANG ALS variants.

An iPhone Application for Blood Pressure Monitoring via the Oscillometric Finger Pressing Method.

We developed an iPhone X application to measure blood pressure (BP) via the "oscillometric finger pressing method". The user presses her fingertip on both the front camera and screen to increase the external pressure of the underlying artery, while the application measures the resulting variable-amplitude blood volume oscillations via the camera and applied pressure via the strain gauge array under the screen. The application also visually guides the fingertip placement and actuation and then computes BP from the measurements just like many automatic cuff devices. We tested the application, along with a finger cuff device, against a standard cuff device. The application yielded bias and precision errors of -4.0 and 11.4 mmHg for systolic BP and -9.4 and 9.7 mmHg for diastolic BP (n = 18). These errors were near the finger cuff device errors. This proof-of-concept study surprisingly indicates that cuff-less and calibration-free BP monitoring may be feasible with many existing and forthcoming smartphones.

Distinct roles for the cell adhesion molecule Contactin2 in the development and function of neural circuits in zebrafish.

Contactin2 (Cntn2)/Transient Axonal Glycoprotein 1 (Tag1), a neural cell adhesion molecule, has established roles in neuronal migration and axon fasciculation in chick and mouse. In zebrafish, antisense morpholino-based studies have indicated roles for cntn2 in the migration of facial branchiomotor (FBM) neurons, the guidance of the axons of the nucleus of the medial longitudinal fascicle (nucMLF), and the outgrowth of Rohon-Beard (RB) central axons. To study functions of Cntn2 in later stages of neuronal development, we generated cntn2 mutant zebrafish using CRISPR-Cas9. Using a null mutant allele, we detected genetic interactions between cntn2 and the planar cell polarity gene vangl2, as shown previously with cntn2 morphants, demonstrating a function for cntn2 during FBM neuron migration in a sensitized background of reduced planar cell polarity signaling. In addition, maternal-zygotic (MZ) cntn2 mutant larvae exhibited aberrant touch responses and swimming, suggestive of defects in sensorimotor circuits, consistent with studies in mice. However, the nucMLF axon convergence, FBM neuron migration, and RB outgrowth defects seen in morphants were not seen in the mutants, and we show here that they are likely off-target effects of morpholinos. However, MLF axons exhibited local defasciculation in MZcntn2 mutants, consistent with a role for Cntn2 in axon fasciculation. These data demonstrate distinct roles for zebrafish cntn2 in neuronal migration and axon fasciculation, and in the function of sensorimotor circuits.

Smartphone-based blood pressure monitoring via the oscillometric finger-pressing method.

High blood pressure (BP) is a major cardiovascular risk factor that is treatable, yet hypertension awareness and control rates are low. Ubiquitous BP monitoring technology could improve hypertension management, but existing devices require an inflatable cuff and are not compatible with such anytime, anywhere measurement of BP. We extended the oscillometric principle, which is used by most automatic cuff devices, to develop a cuff-less BP monitoring device using a smartphone. As the user presses her/his finger against the smartphone, the external pressure of the underlying artery is steadily increased while the phone measures the applied pressure and resulting variable-amplitude blood volume oscillations. A smartphone application provides visual feedback to guide the amount of pressure applied over time via the finger pressing and computes systolic and diastolic BP from the measurements. We prospectively tested the smartphone-based device for real-time BP monitoring in human subjects to evaluate usability (n = 30) and accuracy against a standard automatic cuff-based device (n = 32). We likewise tested a finger cuff device, which uses the volume-clamp method of BP detection. About 90% of the users learned the finger actuation required by the smartphone-based device after one or two practice trials. The device yielded bias and precision errors of 3.3 and 8.8 mmHg for systolic BP and -5.6 and 7.7 mmHg for diastolic BP over a 40 to 50 mmHg range of BP. These errors were comparable to the finger cuff device. Cuff-less and calibration-free monitoring of systolic and diastolic BP may be feasible via a smartphone.

Role of branchiomotor neurons in controlling food intake of zebrafish larvae.

The physical act of eating or feeding involves the coordinated action of several organs like eyes and jaws, and associated neural networks. Moreover, the activity of the neural networks controlling jaw movements (branchiomotor circuits) is regulated by the visual, olfactory, gustatory and hypothalamic systems, which are largely well characterized at the physiological level. By contrast, the behavioral output of the branchiomotor circuits and the functional consequences of disruption of these circuits by abnormal neural development are poorly understood. To begin to address these questions, we sought to evaluate the feeding ability of zebrafish larvae, a direct output of the branchiomotor circuits, and developed a qualitative assay for measuring food intake in zebrafish larvae at 7 days post-fertilization. We validated the assay by examining the effects of ablating the branchiomotor neurons. Metronidazole-mediated ablation of nitroreductase-expressing branchiomotor neurons resulted in a predictable reduction in food intake without significantly affecting swimming ability, indicating that the assay is robust. Laser-mediated ablation of trigeminal motor neurons resulted in a significant decrease in food intake, indicating that the assay is sensitive. Importantly, in larvae of a genetic mutant with severe loss of branchiomotor neurons, food intake was abolished. These studies establish a foundation for dissecting the neural circuits driving a motor behavior essential for survival.

The atypical cadherin Celsr1 functions non-cell autonomously to block rostral migration of facial branchiomotor neurons in mice.

The caudal migration of facial branchiomotor (FBM) neurons from rhombomere (r) 4 to r6 in the hindbrain is an excellent model to study neuronal migration mechanisms. Although several Wnt/Planar Cell Polarity (PCP) components are required for FBM neuron migration, only Celsr1, an atypical cadherin, regulates the direction of migration in mice. In Celsr1 mutants, a subset of FBM neurons migrates rostrally instead of caudally. Interestingly, Celsr1 is not expressed in the migrating FBM neurons, but rather in the adjacent floor plate and adjoining ventricular zone. To evaluate the contribution of different expression domains to neuronal migration, we conditionally inactivated Celsr1 in specific cell types. Intriguingly, inactivation of Celsr1 in the ventricular zone of r3-r5, but not in the floor plate, leads to rostral migration of FBM neurons, greatly resembling the migration defect of Celsr1 mutants. Dye fill experiments indicate that the rostrally-migrated FBM neurons in Celsr1 mutants originate from the anterior margin of r4. These data suggest strongly that Celsr1 ensures that FBM neurons migrate caudally by suppressing molecular cues in the rostral hindbrain that can attract FBM neurons.

A dynamic intracellular distribution of Vangl2 accompanies cell polarization during zebrafish gastrulation.

During vertebrate gastrulation, convergence and extension movements elongate embryonic tissues anteroposteriorly and narrow them mediolaterally. Planar cell polarity (PCP) signaling is essential for mediolateral cell elongation underlying these movements, but how this polarity arises is poorly understood. We analyzed the elongation, orientation and migration behaviors of lateral mesodermal cells undergoing convergence and extension movements in wild-type zebrafish embryos and mutants for the Wnt/PCP core component Vangl2 (Trilobite). We demonstrate that Vangl2 function is required at the time when cells transition to a highly elongated and mediolaterally aligned body. vangl2 mutant cells fail to undergo this transition and to migrate along a straight path with high net speed towards the dorsal midline. Instead, vangl2 mutant cells exhibit an anterior/animal pole bias in cell body alignment and movement direction, suggesting that PCP signaling promotes effective dorsal migration in part by suppressing anterior/animalward cell polarity and movement. Endogenous Vangl2 protein accumulates at the plasma membrane of mesenchymal converging cells at the time its function is required for mediolaterally polarized cell behavior. Heterochronic cell transplantations demonstrated that Vangl2 cell membrane accumulation is stage dependent and regulated by both intrinsic factors and an extracellular signal, which is distinct from PCP signaling or other gastrulation regulators, including BMP and Nodals. Moreover, mosaic expression of fusion proteins revealed enrichment of Vangl2 at the anterior cell edges of highly mediolaterally elongated cells. These results demonstrate that the dynamic Vangl2 intracellular distribution is coordinated with and necessary for the changes in convergence and extension cell behaviors during gastrulation.

Quantitative photoacoustics to measure single cell melanin production and nanoparticle attachment.

Photoacoustics can be used as a label-free spectroscopic method of identifying pigmented proteins and characterizing their intracellular concentration over time in a single living cell. The authors use a microscopic laser irradiation system with a 5 ns, Q-switched laser focused onto single cells in order to collect photoacoustic responses of melanoma cells from the HS936 cell line and gold nanoparticle labeled breast cancer cells from the T47D cell line. The volume averaged intracellular concentration of melanin is found to range from 29-270 mM for single melanoma cells and the number of gold nanoparticles (AuNP) is shown to range from 850-5900 AuNPs/cell. Additionally, the melanin production response to UV-A light stimulus is measured in four melanoma cells to find a mass production rate of 5.7 pg of melanin every 15 min.