Pressure-flow Relationship Research Articles

Tidal expiratory flow limitation induces expiratory looping of the alveolar pressure-flow relation in COPD patients.

During spontaneous breathing at rest, the alveolar pressure (Palv)-flow (V̇) relation exhibits a prominent expiratory loop in many chronic obstructive pulmonary disease (COPD) patients. Among the possible determinants of the loop, tidal expiratory flow limitation (tEFL) may be the main responsible. To compare the characteristics of the expiratory loop in COPD patients with flow limitation (FL) and without flow limitation (NFL), tEFL was assessed with the negative expiratory pressure technique in stable mild to very severe COPD patients undergoing body plethysmography before and after bronchodilation (BD), an intervention that is able to reduce mechanical heterogeneity, recruitment/derecruitment, and gas trapping but rarely abolishes tEFL. The magnitude of the expiratory loop was indexed by the integral of Palv on V̇ during expiration (Aexp). Before BD, Aexp was 360% greater in FL (n = 35) than in NFL (n = 25) patients (P < 0.001). After BD, Aexp was unchanged in NFL patients (ΔAexp 0%, P = 0.882) and slightly decreased in FL patients who remained FL (n = 32, ΔAexp -17%, P = 0.064). Three FL patients became NFL after BD, and their Aexp decreased markedly (ΔAexp -61%), reaching values similar to those observed in NFL patients at baseline. In conclusion, the greater Aexp measured in FL relative to NFL COPD patients, its relative invariance after BD when flow limitation persists, and its fall when flow limitation is abolished indicate that tEFL is a major determinant of the magnitude of the expiratory loop. Furthermore, Aexp can be used as a predictor of the presence of tEFL.NEW & NOTEWORTHY In stable chronic obstructive pulmonary disease (COPD) patients spontaneously breathing at rest, tidal expiratory flow limitation is the major determinant of the occurrence of expiratory looping in the plethysmographic flow-alveolar pressure diagram. In these patients the magnitude and the characteristics of the loop can be used as predictors of the presence of tidal expiratory flow limitation.

Long-term changes of exercise hemodynamics and physical capacity in chronic thromboembolic pulmonary hypertension after pulmonary thromboendarterectomy

BackgroundA substantial number of chronic thromboembolic pulmonary hypertension (CTEPH) patients experience dyspnea on exertion and limited exercise capacity despite surgically successful pulmonary endarterectomy (PEA). We sought to prospectively evaluate resting and peak exercise hemodynamics before, 3 and 12 months after PEA in consecutive CTEPH-patients and correlate it to physical functional capacity. Methods and resultsTwenty consecutive CTEPH-patients were examined. Twelve months after PEA, 75% of patients with severely increased pre-PEA mean pulmonary arterial pressure (mPAP) at rest had normal or mildly increased mPAP. However, mPAP reduction was less pronounced during exercise where only 45% had normal or mildly increased mPAP at 12 months. Hemodynamic changes during exercise were tested using the pressure-flow relationship (i.e. mPAP/cardiac output (CO) slope). The average mPAP/CO slope was 7.5 ± 4.2 mm Hg/L/min preoperatively and 3.9 ± 3.0 mm Hg/L/min at 12 months (p < .005). CO reserve (CO increase from rest to peak exercise) was increased (5.7 ± 2.9 L/min) 12 months after PEA compared with pre-PEA (2.5 ± 1.8 L/min), p < .0001. However, 12 months after PEA, the CO reserve was only 49% of that of healthy controls, p < .0001. Changes in cardiac output (∆CO), calculated as the difference between CO before PEA and 12 months later, were significantly correlated with six-minute-walk-test and peak oxygen uptake (VO2), both at rest and peak exercise. ConclusionInvasive exercise hemodynamic examination in CTEPH-patients demonstrates that after otherwise successful PEA surgery, >50% of patients have a significant increase in exercise mPAP, and the CO reserve remains compromised 12 months after PEA. Improvement in physical capacity is correlated with ∆CO.

Comparison of automated irrigation systems using an in vitro ureteroscopy model.

ABSTRACTIntroduction:Two automated irrigation systems have been released for use during endoscopic procedures such as ureteroscopy: the Cogentix RocaFlow® (CRF) and Thermedx FluidSmart® (TFS). Accurate pressure control using automated systems may help providers maintain irrigation pressures within a safe range while also providing clear visualization. Our objective was to directly compare these systems based on their pressure accuracy, pressure-flow relationships, and fluid heating capabilities in order to help providers better utilize the temperature and pressure settings of each system.Materials and Methods:An in vitro ureteroscopy model was used for testing, consisting of a short semirigid ureteroscope (6/7, 5F, 31cm Wolf 425612) connected to a continuous digital pressure transducer (Meriam m1550). Each system pressure output and flow-rate, via 100mL beaker filling time, was measured using multiple trials at pressure settings between 30 and 300mmHg. Output fluid temperature was monitored using a digital thermometer (Omega DP25-TH).Results:The pressure output of both systems exceeded the desired setting across the entire tested range, a difference of 15.7±2.4mmHg for the TFS compared to 5.2±1.5mmHg for the CRF (p <0.0001). Related to this finding, the TFS also had slightly higher flow rates across all trials (7±2mL/min). Temperature testing revealed a similar maximum temperature of 34.0°C with both systems, however, the TFS peaked after only 8 minutes and started to plateau as early as 4-5 minutes into the test, while the CRF took over 18 minutes to reach a similar peak.Conclusions:Our in vitro ureteroscopy testing found that the CRF system had better pressure accuracy than the TFS system but with noticeably slower fluid heating capabilities. Each system provided steady irrigation at safe pressures within their expected operating parameters with small differences in performance that should not limit their ability to provide steady irrigation at safe pressures.

Exercise stress echocardiography of the pulmonary circulation and right ventricular-arterial coupling in healthy adolescents.

To explore the effects of age and sex in adolescents vs. young or middle-aged adults on pulmonary vascular function and right ventricular-arterial (RV-PA) coupling as assessed by exercise stress echocardiography. Forty healthy adolescents aged 12-15 years were compared with 40 young adults aged 17-22 years and 40 middle-aged adults aged 30-50 years. Sex distribution was equal in the three groups. All the subjects underwent an exercise stress echocardiography. A pulmonary vascular distensibility coefficient α was determined from multipoint pulmonary vascular pressure-flow relationships. RV-PA coupling was assessed by the tricuspid annular plane systolic excursion (TAPSE) to systolic pulmonary artery pressure (PASP) ratio, who has been previously validated by invasive study. While cardiac index and mean PAP were not different, adolescents compared to young and middle-aged adults, respectively had higher pulmonary vascular distensibility coefficients α (1.60 ± 0.31%/mmHg vs. 1.39 ± 0.29%/mmHg vs. 1.20 ± 0.35%/mmHg, P < 0.00001). Adolescents and young adults compared to middle-aged adults, respectively had higher TAPSE/PASP ratios at rest (1.24 ± 0.18 mm/mmHg and 1.22 ± 0.17 mm/mmHg vs. 1.07 ± 0.18 mm/mmHg, P < 0.008) and during exercise (0.86 ± 0.24, 0.80 ± 0.15 and 0.72 ± 0.15 mm/mmHg, P < 0.04). The TAPSE/PASP ratio decreased with exercise. There were no sex differences in α or TAPSE/PASP. Compared to adults, adolescents present with a sex-independent more distensible pulmonary circulation. Resting and exercise RV-PA coupling is decreased in middle-aged adults.

Post‐Exercise Central Hypotension is Associated with Changes in Forward Pulse Wave Amplitude and Reflected Pulse Wave Timing in Young, Healthy Individuals

In the hours following moderate intensity aerobic exercise (AE), persistent dilation of the arterial circulation supplying previously exercised muscle decreases total peripheral resistance (TPR) and contributes to post‐exercise hypotension. In addition to the effect of vasodilation on TPR, the diameter and tone of arterial vessels also influences central blood pressures via changes in the amplitude of forward (Pf) and backward (Pb) pulse waves, as well as the apparent wave reflection return timing (i.e. reflected wave transit time, RWTT). Prior research has assessed these parameters over a limited timeframe (e.g. 15 min) and relied on synthesized aortic flow waves rather than measured left ventricular outflow. As such, the prolonged post exercise effects of AE on pulse wave characteristics and central blood pressure are unclear.PurposeThis study aimed to characterize changes in pulsatile hemodynamics in the two hours following AE. We hypothesized that Pf and Pb would be reduced, and RWTT would be increased post‐AE relative to baseline (BL).MethodsTwelve young, recreationally active participants (8M/4F, 26±3 years, VO2max: 50.8±14.3 ml·kg−1·min−1) were studied at BL and then every 20 min after completing 60 min of upright cycling at 60% VO2max. At each timepoint, central pressure waveforms were derived from radial artery applanation tonometry and aortic inflow waves were acquired via echocardiographic pulsed‐Doppler assessment of blood velocity in the left ventricular outflow tract. Pressure and flow waves were averaged over 10 cardiac cycles and pressure‐flow relations were determined offline via wave separation analysis.ResultsAs expected, brachial systolic blood pressure (SBP) was decreased across the 120 min period post‐AE relative to BL (time effect P&lt;0.001) while TPR was only reduced at 20 min (Δ−15±5%, P&lt;0.05 vs BL) and cardiac output (CO) was maintained at all timepoints (time effect P=0.12). The nadir in central SBP occurred at 60 min post‐AE (Δ−11±2%, P&lt;0.001 vs BL). At 60 min post‐AE, Pf and Pb were reduced by Δ−14.3±2.5% and Δ−24.2±3.3%, respectively (each P&lt;0.001 vs BL) and RWTT was increased (Δ19.5±5.3% P&lt;0.02 vs BL). The percent change in central SBP from BL to 60 min was related to changes in RWTT (r=−0.79, P=0.02) and Pf (r=0.65, P=0.02) but not Pb (r=0.38, P=0.22), CO (r=0.27, P=0.40) or TPR (r=0.14, P=0.66).ConclusionsThese data highlight the contribution of changes in pulsatile hemodynamic parameters, in contrast to changes in non‐pulsatile parameters (CO and TPR), to reductions in central BP following moderate intensity AE.Support or Funding InformationSupported by NIH grants R01‐HL104106 and P20‐GM113125

Comparing the Accuracy of Physiologic and Triangular Pseudoflow Waveforms for Estimating Wave Reflection Indices in Adults

Central aortic pressure waveforms contain valuable prognostic information in addition to central systolic pressure. Using wave separation analysis, aortic pressure‐flow relations can be used to decompose aortic pressure waveforms into forward (Pf) and backward‐travelling (Pb) components. Pf and Pb are used to calculate reflection magnitude (RM=Pb/Pf) which is predictive of heart failure and all‐cause mortality. Aortic blood flow can be measured non‐invasively via ultrasonography or estimated using a triangular pseudoflow waveform; however, the latter can underestimate true flow and thus overestimate Pb and RM. Recently, a physiologic pseudoflow waveform has been developed that improves on the assumptions of triangulation and so may provide a more accurate estimation of wave reflection.PURPOSEThe purpose of this study was to compare estimates of Pf, Pb, and RM derived from physiologic and triangular pseudoflow waveforms relative to measured flow. We hypothesized that the physiologic waveform would provide a more accurate estimate of wave reflection indices compared to the triangular waveform.METHODSIn 75 adults (age 18–75 yrs), radial artery pressure waveforms were acquired with applanation tonometry and a generalized transfer function was used to synthesize central pressure waveforms. Aortic blood flow velocities were measured via echocardiography and estimated using physiologic (in‐house software) and triangular (SphygmoCor CvMS) pseudoflow waveforms. Pressure‐flow relations were established offline and wave separation analysis was performed. Accuracy of the physiologic and triangular‐derived estimates of Pf, Pb, and RM were assessed using 95% equivalence testing, paired t‐tests comparing the mean absolute biases, and Bland‐Altman plots.RESULTSUsing a 10% equivalence zone as the maximum acceptable difference, the physiologic and triangular pseudoflow waveforms were both comparable to the measured flow waveform in deriving Pf. However, only the physiologic waveform yielded similar estimates of Pb and RM compared to the measured waveform. Further, the physiologic waveform yielded lower mean absolute biases compared to the triangular waveform for Pf (1.7 ± 2.1 vs. 2.8 ± 2.6 mmHg, p&lt;0.001), Pb (1.0 ± 1.1 vs. 3.3 ± 2.7 mmHg, p&lt;0.001), and RM (3 ± 3 vs. 14 ± 13%, p&lt;0.001). Lastly, Bland‐Altman biases were smaller, and 95% limits of agreement were narrower, for all wave reflection indices derived from the physiologic waveform than from the triangular waveform.CONCLUSIONThese data suggest that the physiologic pseudoflow waveform provides a more accurate estimate of wave reflection indices compared to the triangular waveform, and thus may offer a superior alternative when true flow cannot be measured.

Modeling the upper airway: A precursor to personalized surgical interventions for the treatment of sleep apnea.

An accurate benchtop model was developed to mimic the different forms of human upper airway collapse in adult sleep apnea patients. This was done via modeling the airway through digital imaging. Airway representative models were then produced in two steps via a customized pneumatic extrusion 3D printing system. This allowed the pressure of collapse and planes of collapse to be manipulated to accurately represent those seen in sleep apnea patients. The pressure flow relationships of the collapsible airways were then studied by inserting the collapsible airways into a module that allowed the chamber pressure (Pc ) around the airways to be increased in order to cause collapse. Airways collapsed at physiologically relevant pressures (5.32-9.58 cmH2 O). Nickel and iron magnetic polymers were then printed into the airway in order to investigate the altering of the airway collapse. The introduction of the nickel and iron magnetic polymers increased the pressure of collapse substantially (7.38-17.51 cmH2 O). Finally, the force produced by the interaction of the magnetic polymer and the magnetic module was studied by measuring a sample of the magnetic airways. The peak force in (48.59-163.34 cN) and the distance over which the forces initially registered (6.8-9.7 mm) were measured using a force transducer. This data set may be used to inform future treatment of sleep apnea, specifically the production of an implantable polymer for surgical intervention.

The effect of hemodynamic parameters in patient-based coronary artery models with serial stenoses: normal and hypertension cases

The purpose of this study is to investigate the hemodynamic significance of various degrees of coronary area of stenosis (AS) and multiple sequential stenoses (MSS) in normal and hypertension pressure conditions. MSS in a single branch coronary artery pose challenges to determine the physiological assessment in the prevalent invasive intervention. The hemodynamic parameters of each stenosis are influenced by other stenoses in the single branch of MSS coronary artery. In this study, we entirely use open source tools and techniques for coronary computed tomography angiography (CCTA) image segmentation, 3D reconstruction, grid generation and hemodynamic simulations. The results yield different hemodynamic parameters such as velocity magnitude, mean arterial pressure difference, flow-pressure linear relation, wall shear stress (WSS) and eventually virtual fractional flow reserve (vFFR) allowing for the prediction and the assessment of lumen area severity conditions in MSS coronaries.

Biologically Inspired, Open, Helicoid Impeller Design for Mechanical Circulatory Assist.

Rotating impeller actuated by electromagnet has been a key technological innovation which surpassed earlier limitations of pulsatile pumps. Current impeller design, however, is alien to the functional unit of the human circulatory system and remains a potential cause of adverse prothrombotic events such as hemolysis or pump thrombosis by forcing blood cells to pass over a narrow space available within the rapidly alternating blades attached along its central hub, creating fundamentally a nonphysiologic flow, especially for miniaturized percutaneous blood pumps. Here, we present a biologically inspired, open, helicoid (BiO-H) impeller design for a circulatory assist device that has a fundamentally different footprint from the conventional Archimedean screw-based impeller designs by implementing new design features inspired by an avian right atrioventricular valve. Design parameters including an inner diameter, helix height, overall height, helix revolutions/pitch, blade length, blade thickness, introductory blade angle, number of blades, and blade shape were optimized for maximum output volumetric flow rate through the parametric analysis in computational fluid dynamics simulation. BiO-H shows an improved flow path with 2.25-fold less cross-sectional area loss than the conventional impeller designs. BiO-H with a diameter of 15 mm resulted in a maximum flow rate of 25 L/min at 15,000 revolutions per minute in simulation and showed further improved pressure-flow relationship in benchtop experiments. The design shows promise in increasing flow and could serve as a new impeller design for future blood pumps.

Dynamic cerebral autoregulation across the cardiac cycle during 8 hr of recovery from acute exercise.

Current protocols examining cerebral autoregulation (CA) parameters require participants to refrain from exercise for 12–24 hr, however there is sparse objective evidence examining the recovery trajectory of these measures following exercise across the cardiac cycle (diastole, mean, and systole). Therefore, this study sought to determine the duration acute exercise impacts CA and the within‐day reproducibility of these measures. Nine participants performed squat–stand maneuvers at 0.05 and 0.10 Hz at baseline before three interventions: 45‐min moderate‐continuous exercise (at 50% heart‐rate reserve), 30‐min high‐intensity intervals (ten, 1‐min at 85% heart‐rate reserve), and a control day (30‐min quiet rest). Squat–stands were repeated at hours zero, one, two, four, six, and eight after each condition. Transcranial doppler ultrasound of the middle cerebral artery (MCA) and the posterior cerebral artery (PCA) was used to characterize CA parameters across the cardiac cycle. At baseline, the systolic CA parameters were different than mean and diastolic components (ps < 0.015), however following both exercise protocols in both frequencies this disappeared until hour four within the MCA (ps > 0.079). In the PCA, phase values were affected only following high‐intensity intervals until hour four (ps > 0.055). Normalized gain in all cardiac cycle domains remained different following both exercise protocols (ps < 0.005) and across the control day (p < .050). All systolic differences returned by hour six across all measures (ps < 0.034). Future CA studies may use squat–stand maneuvers to assess the cerebral pressure–flow relationship 6 hr after exercise. Finally, CA measures under this paradigm appear to have negligible within‐day variation, allowing for reproducible interpretations to be drawn.

Effective Arterial Elastance in the Pulmonary Arterial Circulation: Derivation, Assumptions, and Clinical Applications.

Effective Arterial Elastance in the Pulmonary Arterial Circulation: Derivation, Assumptions, and Clinical Applications.

Posture related in-vitro characterization of a flow regulated MEMS CSF valve.

Overdrainage in upright position is one of the most prevalent issues in treating hydrocephalus with a cerebrospinal fluid (CSF) shunt. Anti-siphon devices (ASDs) are employed to reduce this problem. A novel microelectromechanical system (MEMS)-based valve, termed Chronoflow device, aims to regulate CSF drainage indifferently of the body posture. With this study, the suitability of this MEMS-based valve is evaluated regarding its use for the treatment of hydrocephalus, particularly for the prevention of overdrainage and blockage. In total, four Chronoflow devices were tested. An established in-vitro hardware-in-the-loop (HIL) test bed was used to investigate the valves regarding their pressure-flow characteristics, their behaviors towards CSF dynamics, and their capabilities to prevent CSF overdrainage in upright position. Additionally, a contamination test was conducted to evaluate the susceptibility of the device to blockage due to particles. All valves tested regulated the drainage rate at similar nominal flows and independently of posture. The pressure-flow relation measured, however, was notably higher than numerically calculated. Regarding the CSF dynamics, the first three valves tested led to a decreased steady-state intracranial pressure in supine position and showed stable drainage rate in upright position. During the transitional phase from supine to upright and vice versa, the valves continuously adjusted the outflow resistance, which resulted in a stable transitional phase preventing overdrainage. Yet, the fourth valve showed continuous overdrainage in upright position due to an increased nominal flow. However, after several test iterations the nominal flow decreased and stabilized at a level similar to that of the first three valves tested. The contamination test showed that most particles initially adhere to the pillars and spread throughout the cavity of the valve as the concentration of particles increases, thereby affecting the displacement of the membrane. The devices generally provide a stable flow regulation and prevent overdrainage in upright position. Specifically, their drainage behaviors during the posture changes are very effective. However, they also showed high hysteresis and sensitivity towards particle contamination, which resulted in initial increased and altering nominal flows after many test iterations. This result suggests that the MEMS design presented lacks robustness. Yet, an upstream filter and specific coatings on the fluid pathway may increase significantly its reliability.

Changes in Retinal Blood Flow in Response to an Experimental Increase in IOP in Healthy Participants as Assessed With Doppler Optical Coherence Tomography.

PurposeBlood flow autoregulation is an intrinsic mechanism of the healthy retinal vasculature to keep blood flow constant when ocular perfusion pressure (OPP) is changed. In the present study, we set out to investigate retinal blood flow in response to an experimental decrease in OPP in healthy participants using Doppler optical coherence tomography.MethodsFifteen healthy participants aged between 22 and 31 years (mean, 27 ± 3 years) were included in the present open study. IOP was increased stepwise via the suction cup method to induce a decrease in OPP. Retinal blood flow in arteries and veins was assessed using a custom-built Doppler optical coherence tomography system and pressure–flow relationships were calculated to assess autoregulation.ResultsSuction cup application induced a pronounced increase in IOP with a maximum value of 50.5 ± 8.0 mm Hg at the highest level of suction. Pressure–flow relationships revealed that blood flow was autoregulated until the OPP was decreased by approximately 21 mm Hg and started to decrease significantly when the OPP was reduced by 30 mm Hg. Retinal blood flow at the last suction period decreased at a maximum of –57.0 ± 22.3% and 65.2 ± 15.4% in retinal arteries and retinal veins, respectively. These changes in retinal blood flow were less pronounced than the decrease in OPP (–75.2 ± 19.2%), indicating retinal autoregulation.ConclusionsThe results of the present study confirm that retinal blood flow is autoregulated in response to changes in the OPP. Doppler optical coherence tomography has the potential to become a clinical tool for the investigation of retinal blood flow autoregulation in the future, because of its ability to assess the blood velocities and diameter of the retinal vessels parallel and therefore also their blood flow in absolute values. (Clinicaltrials.gov number NCT03398616)

A magnetic screw pump for magnetorheological clutch durability enhancement

Magnetorheological clutches have great potential for demanding applications such as powertrains and aircraft primary flight controls. However, in such high-power applications (&gt;1 kW), durability is a challenge because of the continuous slippage at the clutch shear interface. To improve durability, this research studies the potential of using a magnetic screw pump to promote fluid mixing within a magnetorheological clutch. The screw flights are made of magnetorheological fluid formed by the concentration of the magnetic field lines around helical grooves machined into the shear interface (drum) of the clutch. While the magnetic pump does not display a typical screw pump behavior, a semi-empirical yield screw pump model is proposed to better understand the macroscopic behavior. Experimental flow characterization results show that the pressure–flow relation is significantly affected by the number of grooves, magnetic field intensity, and rotational speed. For a clutch containing 50 mL of magnetorheological fluid, maximum flow rates of up to 25 mL/min and a maximum pressure of 150 kPa are achieved. Finally, durability test results show that the magnetic screw pump can increase durability by up to 42% when compared to a standard magnetorheological clutch, confirming that such a device is a viable solution for promoting durability.

Numerical investigation of the separated and reattaching flow over a 5:1 rectangular cylinder in streamwise sinusoidal flow

Three-dimensional Large-Eddy Simulations (3D LES) are performed to study the separated and reattaching flow over a 5:1 rectangular cylinder in streamwise sinusoidal flow. The ratio of inflow frequency to natural vortex-shedding frequency is varied from 0 to 6 ​at five amplitudes up to 60% of the time-mean velocity. The effect on the two-dimensional (2D) and three-dimensional (3D) characteristics of the separation bubble and surface pressures are reported. The relationship between the time-averaged flow field and the statistics of the chordwise pressure distribution are obtained firstly. The flow-pressure relationships are qualitatively similar in uniform and sinusoidal flows. Then, the amplitude-frequency domain of the sinusoidal flow is divided into three regimes to describe the effects on the mean reattachment length. The simulations capture the interferences between leading-edge vortices and trailing edge vortices for longer separation bubbles. However, the interactions are not observed in shorter separation bubbles due to the diffusions of leading-edge vortices. Finally, the flow three-dimensionality is studied by performing proper orthogonal decomposition (POD) and spanwise correlation analysis on the surface pressures. The oncoming flow oscillations correspond to the most energetic structures dominating the pressure field, which are constant in the spanwise direction. While the local vortical structures mainly influence the 3D features of the flow dynamics.

Abstract TP417: An Autoregulation-Derived Prediction Model for Midline Shift After Ischemic Stroke

Introduction: Identification of patients likely to develop midline shift (MLS) after large-vessel occlusion (LVO) stroke is essential for appropriate triage and patient disposition. Studies have identified clinical and radiographic predictors of MLS, but with limited accuracy. Using an innovative assessment of cerebral autoregulation, we sought to develop an accurate predictive model for MLS. Methods: We prospectively enrolled 73 patients with LVO stroke. Beat-by-beat cerebral blood flow (transcranial Doppler) and arterial pressure (arterial catheter or finger photoplethysmography) were recorded within 24 hours of the stroke, and a 24-hour brain MRI was obtained to determine infarct volume and MLS. Autoregulatory function was quantified from pressure-flow relation via projection pursuit regression (PPR), allowing for characterization of 5 hemodynamic markers (Figure 1A). We assessed the predictive relation of autoregulatory capacity and radiological and clinical variables to MLS using recursive classification tree models. Results: PPR successfully quantified autoregulatory function in 50/73 (68.5%) patients within 24 hours of LVO ischemic stroke (age 63.9±13.6, 66% F, NIHSS 15.8±6.7). Of these 50 patients, most (78%) underwent endovascular therapy. Thirteen (26%) experienced 24-h MLS; in these patients, infarct volumes were larger (140.2 vs. 48.6 mL, P&lt;0.001 ), and ipsilateral (but not contralateral) falling slopes were steeper (1.1 vs. 0.7 cm·s -1 ·mmHg -1 , P=0.001 ). Among all clinical, demographic, and hemodynamic variables, only two (infarct volume, ipsilateral falling slope) significantly contributed to prediction of MLS (accuracy 94%; Figure 1B). Conclusions: This predictive model of MLS wields translatable potential for triaging level of care in patients suffering from LVO ischemic stroke, but further research, including optimization of the PPR algorithm as well as prospective use of the predictive model, is needed.

Development of An Integrated Surface and Sub-Surface Simulation Model in A Single Simulation Platform

An integrated model between surface and sub-surface is typically done by interconnecting many process modelling platforms. PROSPER and GAP are the common steady state modelling platforms for sub-surface while VMGSim and HYSYS are typical steady state surface modelling platforms. A major issue of using multiple simulation platforms is the compatibility of thermodynamic physical properties calculations among the platforms. This situation makes the simulations difficult to converge to a consistent thermo physical properties values. This is due to different interaction parameters applied in each platform that impact flashing and the physical property values even though the same property package such as Peng Robinson is used. To overcome this convergence problem, a single simulation platform within iCON (PETRONAS’s standard process simulation software, co-developed with VMG-Schlumberger) has been developed. This allows the use of one thermodynamic package across the integrated model. PROSPER sub-surface pressure-flow relationship results were automatically correlated and connected to surface models within the iCON environment. This integrated model was validated with data from operations and yielded about 1.23% average error tolerance. Based on this validated model, an optimization envelope can be developed with all possible well lineup configurations. This envelope covers set points for the operations where CAPEX free optimization can readily be applied.

Pulmonary vascular function at exercise in systemic sclerosis: A case-control study

Systemic sclerosis (SSc) is a severe form of associated pulmonary arterial hypertension (PAH), for which annual screening is recommended based on resting echocardiography. While the latter may be normal in the early stages of PAH, exercise echocardiography (Ex-Echo) may provide additional insights on pulmonary vascular function. However, the clinical use of Ex-Echo is limited by methodological concerns. Although it is currently admitted that pulmonary arterial pressure (PAP) at exercise should be interpreted relative to flow change, few studies investigated the relationship between PAP and cardiac output (CO) during exercise in SSc patients. We sought to explore exercise-induced changes in the pulmonary circulation by pressure-flow relationship in SSc patients compared with healthy subjects. SSc patients without overt lung or heart involvement, and healthy subjects underwent symptom-limited Ex-Echo to generate multipoint relationship between meanPAP (PAPm) and CO. Conventional markers of RV function were also recorded during exercise. Forty-two patients and 47 controls were included. At peak exercise, patients had lower PAP, lower CO, but higher PAPm to CO ratio (TPR) than controls ( Table 1 ). The slope of PAPm to CO relationship (P/Q slope) was higher in patients ( Fig. 1 ), but this was not significant after correction for age. Age was an independent determinant for the P/Q slope, but did not affect the difference in peak-exercise TPR. Markers of RV function (TAPSE, S wave velocity, and IVA) were lower in patients at exercise. SSc patients presented with different pulmonary vascular and myocardial adaptation to exercise compared with healthy individuals. In contrast with P/Q slope, changes in peak TPR were not influenced by age. This pattern may be observed in patients without evidence of cardiac or pulmonary involvement and explain, at least in part, lower exercise capacity in these patients.

Effects of thyroplasty implant stiffness on glottal shape and voice acoustics.

ObjectivesVocal fold (VF) stiffness and geometry are determinant variables in voice production. Type 1 medialization thyroplasty (MT), the primary surgical treatment for glottic insufficiency, changes both of these variables. Understanding the cause and effect relationship between these variables and acoustic output might improve voice outcomes after MT. In this study, the effects of thyroplasty implants with variable stiffness on glottal shape and acoustics were investigated.MethodsIn an ex vivo human larynx phonation model, bilateral MT with implants of four stiffness levels (1386, 21.6, 9.3, and 5.5 kPa) were performed. Resulting acoustics and aerodynamics were measured across multiple airflow levels. A vertical partial hemilaryngectomy was performed and stereoscopic images of the VF medial surface taken to reconstruct its three‐dimensional (3D) surface contour. The results were compared across implants.ResultsThe effects of implant stiffness on acoustics varied by airflow. Softer implants resulted in improved acoustics, as measured by cepstral peak prominence (CPP), at lower airflow levels compared to stiffer implants but this relationship reversed at high airflow levels. Stiffer implants generally required less airflow to generate a given subglottal pressure. Stiffer implants resulted in greater medialized surface area and maximal medialization, but all implants had similar effects on overall VF medial surface contour.ConclusionSofter implants result in less medialization but better acoustics at low airflow rates. Stiffer implants provide better acoustics and more stable pressure‐flow relationships at higher airflow rates. This highlights a potential role for patient‐specific customized thyroplasty implants of various stiffness levels.Level of EvidenceNA.

Fritz Rohrer (1888-1926), a pioneer in pulmonary mechanics whose work was inexplicably ignored for about 30 years.

Fritz Rohrer (1888-1926) has a special place in the history of respiratory physiology for two reasons. The first is that he laid the foundations of modern pulmonary mechanics in the early 1900s. For example, his seminal paper on pulmonary dynamics, that is, the pressure-flow relationships in the airways, was published in 1915 in one of the top journals in the field. It included extensive measurements of airway dimensions in postmortem human lungs and a sophisticated analysis of the modes of airflow. This was closely followed by a very original analysis of lung statics, which included studies of airway pressures at normal, maximal, and minimal lung volumes in relaxed normal volunteers, and was published in 1916. Remarkably, both papers were essentially ignored at the time. Fortunately, in 1925 he was able to summarize his major findings in a chapter in an important handbook of physiology. However, he tragically died from pulmonary tuberculosis in the following year at the early age of 37. The second reason for his importance in the history of pulmonary mechanics is that inexplicably his very innovative research was essentially ignored for about 30 years. It was not until the 1940s that his work was rediscovered, although not in time to save investigators from duplicating his very original studies. Possible reasons why his work was ignored for so long are discussed. Even today it is not easy to recover some important features of his career, and some aspects of his very original research are still almost unknown.