The sensitivity of biological tissue to ultrasound

The lack of international and national health policies to protect persons with self-declared electromagnetic hypersensitivity

Electromagnetic hypersensitivity (EHS), known also as an idiopathic environmental intolerance attributed to electromagnetic fields (IEI-EMF) or a microwave sickness, is not considered by the World Health Organization (WHO) as being caused by the exposures to electromagnetic fields (EMF). EHS is not recognized as a disease anywhere in the world. Some studies have roughly estimated that 1-10% of the population might experience some form of EHS. However, because of the lack of diagnostic criteria for EHS, these estimates might be either under- or over-estimates. Because the vast majority of human population is exposed to EMF, the possibility of developing EHS from the EMF is a substantial public health issue that should be dealt with globally, even if the individual risk of developing EHS might be small. The WHO recognizes that the symptoms experienced by the EHS persons might be severe and might significantly hamper everyday life. However, after a broad analysis of international and national documents, there seems to be currently no effort to develop health policies for the dealing with EHS, no matter what causes it. National governments, follow the opinions of the WHO and the EMF safety standards setting organizations, the International Commission on Non-Ionizing Radiation Protection (ICNIRP) and the Institute of Electrical and Electronics Engineers - International Committee on Electromagnetic Safety (IEEE-ICES), are not developing any practical health policy advisories for self-declared EHS sufferers. However, symptoms experienced by the self-declared EHS persons affect their well-being and, according to the Constitution of the WHO, are a health problem. Hence, independently of what causes EHS symptoms, this admitted well-being-impairment should be dealt with globally by developing an uniform health policy. Furthermore, WHO, ICNIRP and IEEE-ICES should be advocating and supporting research that would generate a reliable scientific evidence on what are the possible cause(s) of EHS. Without such research there is not possible to develop diagnostic methods as well as any possible mitigation approaches. There is an urgent need for the WHO to advocate for the national governments to urgently develop a comprehensive and common EHS health policy.

Force-Based Neuromodulation

Technologies for neuromodulation have rapidly developed in the past decade with a particular emphasis on creating noninvasive tools with high spatial and temporal precision. The existence of such tools is critical in the advancement of our understanding of neural circuitry and its influence on behavior and neurological disease. Existing technologies have employed various modalities, such as light, electrical, and magnetic fields, to interface with neural activity. While each method offers unique advantages, many struggle with modulating activity with high spatiotemporal precision without the need for invasive tools. One modality of interest for neuromodulation has been the use of mechanical force. Mechanical force encapsulates a broad range of techniques, ranging from mechanical waves delivered via focused ultrasound (FUS) to torque applied to the cell membrane.Mechanical force can be delivered to the tissue in two forms. The first form is the delivery of a mechanical force through focused ultrasound. Energy delivery facilitated by FUS has been the foundation for many neuromodulation techniques, owing to its precision and penetration depth. FUS possesses the potential to penetrate deeply (∼centimeters) into tissue while maintaining relatively precise spatial resolution, although there exists a trade-off between the penetration depth and spatial resolution. FUS may work synergistically with ultrasound-responsive nanotransducers or devices to produce a secondary energy, such as light, heat, or an electric field, in the target region. This layered technology, first enabled by noninvasive FUS, overcomes the need for bulky invasive implants and also often improves the spatiotemporal precision of light, heat, electrical fields, or other techniques alone. Conversely, the second form of mechanical force modulation is the generation of mechanical force from other modalities, such as light or magnetic fields, for neuromodulation via mechanosensitive proteins. This approach localizes the mechanical force at the cellular level, enhancing the precision of the original energy delivery. Direct interaction of mechanical force with tissue presents translational potential in its ability to interface with endogenous mechanosensitive proteins without the need for transgenes.In this Account, we categorize force-mediated neuromodulation into two categories: 1) methods where mechanical force is the primary stimulus and 2) methods where mechanical force is generated as a secondary stimulus in response to other modalities. We summarize the general design principles and current progress of each respective approach. We identify the key advantages of the limitations of each technology, particularly noting features in spatiotemporal precision, the need for transgene delivery, and the potential outlook. Finally, we highlight recent technologies that leverage mechanical force for enhanced spatiotemporal precision and advanced applications.

Recent advances of ultrasound-responsive nanosystems in tumor immunotherapy

Immunotherapy has revolutionized cancer treatment by boosting the immune system and preventing disease escape mechanisms. Despite its potential, challenges like limited response rates and adverse immune effects impede its widespread clinical adoption. Ultrasound (US), known for its safety and effectiveness in tumor diagnosis and therapy, has been shown to significantly enhance immunotherapy when used with nanosystems. High-intensity focused ultrasound (HIFU) can obliterate tumor cells and elicit immune reactions through the creation of immunogenic debris. Low-intensity focused ultrasound (LIFU) bolsters tumor immunosuppression and mitigates metastasis risk by concentrating dendritic cells. Ultrasonic cavitation (UC) produces microbubbles that can transport immune enhancers directly, thus strengthening the immune response and therapeutic impact. Sonodynamic therapy (SDT) merges nanotechnology with immunotherapy, using specialized sonosensitizers to kill cancer cells and stimulate immune responses, increasing treatment success. This review discusses the integration of ultrasound-responsive nanosystems in tumor immunotherapy, exploring future opportunities and current hurdles.

Ultrasound-Mediated Ocular Drug Delivery: From Physics and Instrumentation to Future Directions

Drug delivery to the anterior and posterior segments of the eye is impeded by anatomical and physiological barriers. Increasingly, the bioeffects produced by ultrasound are being proven effective for mitigating the impact of these barriers on ocular drug delivery, though there does not appear to be a consensus on the most appropriate system configuration and operating parameters for this application. In this review, the fundamental aspects of ultrasound physics most pertinent to drug delivery are presented; the primary phenomena responsible for increased drug delivery efficacy under ultrasound sonication are discussed; an overview of common ocular drug administration routes and the associated ocular barriers is also given before reviewing the current state of the art of ultrasound-mediated ocular drug delivery and its potential future directions.

Polysaccharide-based nanocarriers for efficient transvascular drug delivery

Polysaccharide-based nanocarriers (PBNs) are the focus of extensive investigation because of their biocompatibility, low cost, wide availability, and chemical versatility, which allow a wide range of anticancer agents to be loaded within the nanocarriers. Similar to other nanocarriers, most PBNs are designed to extravasate out of tumor vessels, depending on the enhanced permeability and retention (EPR) effect. However, the EPR effect is compromised in some tumors due to the heterogeneity of tumor structures. Transvascular transport efficacy is decreased by complex blood vessels and condensed tumor stroma. The limited extravasation impedes efficient drug delivery into tumor parenchyma, and thus affects the subsequent tumor accumulation, which hinders the therapeutic effect of PBNs. Therefore, overcoming the biological barriers that restrict extravasation from tumor vessels is of great importance in PBN design. Many strategies have been developed to enhance the EPR effect that involve nanocarrier property regulation and tumor structure remodeling. Moreover, some researchers have proposed active transcytosis pathways that are complementary to the paracellular EPR effect to increase the transvascular extravasation efficiency of PBNs. In this review, we summarize the recent advances in the design of PBNs with enhanced transvascular transport to enable optimization of PBNs in the extravasation of the drug delivery process. We also discuss the obstacles and challenges that need to be addressed to clarify the transendothemial mechanism of PBNs and the potential interactions between extravasation and other drug delivery steps.

Review of the scientific evidence on the individual sensitivity to electromagnetic fields (EHS)

Part of the population considers themselves as sensitive to the man-made electromagnetic radiation (EMF) emitted by powerlines, electric wiring, electric home appliance and the wireless communication devices and networks. Sensitivity is characterized by a broad variety of non-specific symptoms that the sensitive people claim to experience when exposed to EMF. While the experienced symptoms are currently considered as a real life impairment, the factor causing these symptoms remains unclear. So far, scientists were unable to find causality link between symptoms experienced by sensitive persons and the exposures to EMF. However, as presented in this review, the executed to-date scientific studies, examining sensitivity to EMF, are of poor quality to find the link between EMF exposures and sensitivity symptoms of some people. It is logical to consider that the sensitivity to EMF exists but the scientific methodology used to find it is of insufficient quality. It is time to drop out psychology driven provocation studies that ask about feelings-based non-specific symptoms experienced by volunteers under EMF exposure. Such research approach produces only subjective and therefore highly unreliable data that is insufficient to prove, or to disprove, causality link between EHS and EMF. There is a need for a new direction in studying sensitivity to EMF. The basis for it is the notion of a commonly known phenomenon of individual sensitivity, where individuals' responses to EMF depend on the genetic and epigenetic properties of the individual. It is proposed here that new studies, combining provocation approach, where volunteers are exposed to EMF, and high-throughput technologies of transcriptomics and proteomics are used to generate objective data, detecting molecular level biochemical responses of human body to EMF.

Therapeutic Ultrasound-Enhanced Transcorneal PHMB Delivery In Vitro

OBJECTIVE

Delivery of therapeutic agents to the cornea is a difficult task in the treatment of parasitic keratitis. In this study, we looked at using different combinations of ultrasound parameters to enhance corneal permeability to polyhexamethylene biguanide (PHMB), a clinically available ophthalmic antiparasitic formulation.

METHODS

Permeability of PHMB was investigated in vitro using a standard diffusion cell setup. Continuous or 25% duty-cycle ultrasound was used at frequencies of 400 or 600 kHz, intensities of 0.5 or 0.8 W/cm² , and exposure times ranging from 1 to 5 minutes. Structural changes in the cornea were examined using light microscopy.

RESULTS

Ultrasound exposure produced increases in transcorneal delivery in every treatment parameter combination when compared to the sham treatment. The highest increase was 2.36 times for 5 minutes of continuous ultrasound at a frequency of 600 kHz and an intensity of 0.5 W/cm² with statistical significance (p <.001). Histological analysis showed that ultrasound application only caused structural changes in the corneal epithelium, with most damage being at the surface layers.

CONCLUSIONS

This study suggests the possibility of therapeutic ultrasound as a novel drug delivery technique for the treatment of parasitic keratitis. Further studies are needed to examine the thermal effects of these proposed ultrasound applications and the long-term viability of this treatment.

Nanoparticle-Assisted Sonosensitizers and Their Biomedical Applications

As a non-invasive strategy, sonodynamic therapy (SDT) which utilizes sonosensitizers to generate reactive oxygen species (ROS) has received significant interest over recent years due to its ability to break depth barrier. However, intrinsic limitations of traditional sonosensitizers hinder the widespread application of SDT. With the development of nanotechnology, various nanoparticles (NPs) have been designed and used to assist sonosensitizers for SDT. This review first summarizes the possible mechanisms of SDT, then classifies the NPs-assisted sonosensitizers and discusses their biomedical applications in ultrasonography, drug delivery, high intensity focused ultrasound and SDT-based combination treatment. Finally, some challenges and future perspectives of NPs-assisted SDT has also been discussed.

Multi-Frequency Ultrasonic Extraction of Anthocyanins from Blueberry Pomace and Evaluation of Its Antioxidant Activity

Background

A large amount of blueberry pomace is discarded and wasted.

Objective

To make full use of blueberry pomace and extract anthocyanins.

Method

Multi-frequency ultrasound was used to extract anthocyanins from blueberry pomace. The effects of different extraction conditions on the anthocyanin yields were studied. The antioxidant activity of anthocyanins was evaluated, and the main anthocyanin components were identified by HPLC-electrospray ionization (ESI)-MS/MS.

Results

The optimal anthocyanin extraction conditions were as follows: dual-frequency ultrasound of 40 + 80 kHz, ultrasonic power of 350 W, extraction temperature of 50°C, and extraction time of 40 min. Compared with single frequency (25 kHz) and tri-frequency ultrasound (25 + 40 + 80 kHz), the anthocyanin yield with dual-frequency ultrasound increased by 15.26% and 5.45% respectively. Furthermore, the antioxidant activities (DPPH, hydroxyl radical scavenging ability, and reducing power) of anthocyanins extracted with dual-frequency ultrasound were all higher than those without ultrasound. Seven kinds of anthocyanins were identified by HPLC-ESI-MS/MS.

Conclusions

Dual-frequency ultrasound had a higher extraction yield than single frequency ultrasound, tri-frequency ultrasound, and no ultrasound.

Highlights

Dual-frequency ultrasonic technology provides an effective approach for improving the extraction yield of anthocyanins from blueberry pomace.

A Review of Acoustic Impedance Matching Techniques for Piezoelectric Sensors and Transducers

The coupling of waves between the piezoelectric generators, detectors, and propagating media is challenging due to mismatch in the acoustic properties. The mismatch leads to the reverberation of waves within the transducer, heating, low signal-to-noise ratio, and signal distortion. Acoustic impedance matching increases the coupling largely. This article presents standard methods to match the acoustic impedance of the piezoelectric sensors, actuators, and transducers with the surrounding wave propagation media. Acoustic matching methods utilizing active and passive materials have been discussed. Special materials such as nanocomposites, metamaterials, and metasurfaces as emerging materials have been presented. Emphasis is placed throughout the article to differentiate the difference between electric and acoustic impedance matching and the relation between the two. Comparison of various techniques is made with the discussion on capabilities, advantages, and disadvantages. Acoustic impedance matching for specific and uncommon applications has also been covered.

Alleviation Effects and Mechanisms of Low-intensity Focused Ultrasound on Pain Triggered by Soft Tissue Injury

OBJECTIVES

Pain caused by soft tissue injury (STI) is always intractable and will eventually result in physical and psychological problems. This experiment aimed to assess the efficacy and mechanisms of low-intensity focused ultrasound (LIFU) for pain-related STI.

METHODS

Rabbits (n = 30) with STI were given fixed treatment for 20 seconds and then mobile treatment for 60 seconds daily for 10 consecutive days by an LIFU device with a power output of 5 to 6 W and a frequency of 0.8 MHz. To evaluate the degree of pain, the levels of β-endorphin in serum were measured by an enzyme-linked immunosorbent assay before and 5 to 10 minutes after the 1st, 3rd, 7th, and 10th treatments. The pain threshold was measured by an electronic analgesy meter on the 1st, 3rd, 7th, 10th, 17th, and 24th days after the start of the treatment. To investigate inflammation, prostaglandin E₂ , interleukin-1β, and 5-hydroxytryptamine levels were detected by an enzyme-linked immunosorbent assay, and nuclear factor κB messenger RNA levels were determined by a real-time quantitative polymerase chain reaction at the same time as the pain threshold was tested.

RESULTS

Compared with non-LIFU groups, β-endorphin levels and pain thresholds were significantly increased (P < .05), whereas nuclear factor- κB messenger RNA, prostaglandin E₂ , interleukin- 1β, and 5-hydroxytryptamine levels were significantly reduced (P < .05) after LIFU treatment in rabbits with STI.

CONCLUSIONS

Low-intensity focused ultrasound can alleviate pain induced by STI and could have further clinical applications.

Micro/nano-bubble-assisted ultrasound to enhance the EPR effect and potential theranostic applications

Drug delivery for tumor theranostics involves the extensive use of the enhanced permeability and retention (EPR) effect. Previously, various types of nanomedicines have been demonstrated to accumulate in solid tumors via the EPR effect. However, EPR is a highly variable phenomenon because of tumor heterogeneity, resulting in low drug delivery efficacy in clinical trials. Because ultrasonication using micro/nanobubbles as contrast agents can disrupt blood vessels and enhance the specific delivery of drugs, it is an effective approach to improve the EPR effect for the passive targeting of tumors. In this review, the basic thermal effect, acoustic streaming, and cavitation mechanisms of ultrasound, which are characteristics that can be utilized to enhance the EPR effect, are briefly introduced. Second, micro/nanobubble-enhanced ultrasound imaging is discussed to understand the validity and variability of the EPR effect. Third, because the tumor microenvironment is complicated owing to elevated interstitial fluid pressure and the deregulated extracellular matrix components, which may be unfavorable for the EPR effect, few new trends in smart bubble drug delivery systems, which may improve the accuracy of EPR-mediated passive drug targeting, are summarized. Finally, the challenging and major concerns that should be considered in the next generation of micro/nanobubble-contrast-enhanced ultrasound theranostics for EPR-mediated passive drug targeting are also discussed.

Ultrasound-Enhanced Ciclopirox Delivery for Treatment of Onychomycosis

The study aim was to determine ultrasound's efficacy in increasing the permeability of the nail in order to improve treatment outcomes in onychomycosis. Three sets of ultrasound experiments were performed - the luminosity experiment and two sets of diffusion cell experiments. The luminosity experiments assessed dye levels inside the nail after ultrasound application as compared to sham treatments, and the diffusion cell experiments compared changes in nail permeability due to the application of ultrasound. All in vitro experiments used planar ultrasound transducers, frequencies of 400 kHz, 600 kHz, 800 kHz, and 1 MHz, an intensity of 1 W/$cm^{2}$ and a duration of 5 min in a continuous mode. The safety of applying ultrasound to the toe was assessed by performing modeling studies. It was found that application of ultrasound at higher frequencies (800 kHz and 1 MHz) resulted in more (and statistically significant) permeation of the nail, as compared to the control trials.

Methods for powering bioelectronic microdevices

Bioelectronic microdevices are an emerging class of biomedical devices miniaturized at the scale of a millimeter or less, which promise new capabilities for monitoring and treating human disease. Although rapid progress has been made in the sensing and actuation capabilities of microdevices, a major technological challenge remains in the way that these devices are powered within the body. In this review, we revisit the power requirements of microdevices, describe current methods for storing, transferring or harvesting energy in microdevices, provide an overview of emerging powering approaches and discuss the promise of microdevices in biomedicine.

Ultrasound-Enhanced Drug Delivery for Treatment of Onychomycosis

OBJECTIVES

The aim of our study was to determine the effectiveness of using ultrasound (US) to increase the permeability of the nail, with the goal of improving outcomes in the treatment of onychomycosis.

METHODS

Porcine nails were used because of their similarity to human nails. A hydrophilic blue dye was used as a drug-mimicking compound. Two sets of experiments were performed: luminosity experiments to assess the dye levels inside the nail after US and sham treatments and diffusion cell experiments for determination of changes in nail permeability due to US application. In both sets of experiments, planar US transducers were used to sonicate the nails at frequencies of 400, 600, and 800 kHz and 1 MHz, an intensity of 1 W/cm² , and a duration of 5 min in a continuous mode. Modeling studies were also performed to assess the safety of US application to the human toe for later clinical studies.

RESULTS

In the luminosity experiments, application of US at frequencies of 600 and 800 kHz led to statistically significant results (P < .05), with an increase in dye delivery into the nail of up to 95% compared to control values. The diffusion cell results found statistical significance (P < .05) at all applied frequencies, with up to a 70% increase in the nail permeability compared to the control. Safety modeling studies found a maximal temperature increase of 4.4 °C in the bone.

CONCLUSIONS

Our proposed US method may offer an alternative for improved treatment of onychomycosis. The current maximal temperature increase was found to be at the safety limit, and so pulsing and other alternatives will be investigated to minimize this temperature increase.

Low-intensity pulsed ultrasound stimulation facilitates in vitro osteogenic differentiation of human adipose-derived stem cells via up-regulation of heat shock protein (HSP)70, HSP90, and bone morphogenetic protein (BMP) signaling pathway

Low-intensity pulsed ultrasound (LIPUS) has positive effects on osteogenic differentiation. However, the effect of LIPUS on osteogenic differentiation of human adipose-derived stem cells (hASCs) is unclear. In the present study, we investigated whether LIPUS could promote the proliferation and osteogenic differentiation of hASCs. hASCs were isolated and osteogenically induced with LIPUS stimulation at 20 and 30 mW cm^-2 for 30 min day^-1 Cell proliferation and osteogenic differentiation potential of hASCs were respectively analyzed by cell counting kit-8 assay, Alizarin Red S staining, real-time polymerase chain reaction, and Western blotting. The results indicated that LIPUS stimulation did not significantly affect the proliferation of hASCs, but significantly increased their alkaline phosphatase activity on day 6 of culture and markedly promoted the formation of mineralized nodules on day 21 of culture. The mRNA expression levels of runt-related transcription factor, osteopontin, and osteocalcin were significantly up-regulated by LIPUS stimulation. LIPUS stimulation did not affect the expression of heat shock protein (HSP) 27, HSP40, bone morphogenetic protein (BMP)-6 and BMP-9, but significantly up-regulated the protein levels of HSP70, HSP90, BMP-2, and BMP-7 in the hASCs. Further studies found that LIPUS increased the mRNA levels of Smad 1 and Smad 5, elevated the phosphorylation of Smad 1/5, and suppressed the expression of BMP antagonist Noggin. These findings indicated that LIPUS stimulation enhanced osteogenic differentiation of hASCs possibly through the up-regulation of HSP70 and HSP90 expression and activation of BMP signaling pathway. Therefore, LIPUS might have the potential to promote the repair of bone defect.

Ultrastructural and histopathologic findings after pars plana vitrectomy with a new hypersonic vitrector system. Qualitative preliminary assessment

Purpose

Preliminary assessment of a new prototype ultrasound-based hypersonic vitrector (HV) by qualitatively examining the histopathological changes in the retina and vitreous body after pars plana vitrectomy (PPV) and its ability to fragment vitreous collagen.

Methods

Fourteen porcine cadaveric eyes, 20 eyes in live swine and six human cadaveric eyes underwent PPV using the HV or a pneumatic guillotine vitrector (GV). An additional 4 porcine crystalline lenses were touched with either the HV or GV for 1 minute. Following PPV, human vitreous was removed and processed for electron microscopy (EM). Eyes and lenses were fixed and sectioned for light microscopy (LM).

Results

There were no macroscopic retinal or optic nerve defects associated with either HV or GV PPVs. Cadaveric retinal specimens showed separation of the inner limiting membrane (ILM) and vacuolization and fragmentation at the nerve fiber layer (NFL) and the ganglion cell layer (GCL). ILM fragmentation and separation were found after PPV in live swine with both vitrectors. Small disruptions of the posterior capsule or structural lens defects were found after HV touch. The EM analysis revealed more fragmentation of human vitreous collagen fibrils after HV compared to GV PPV.

Conclusions

LM and EM analysis of retina, vitreous, and crystalline lens after PPV showed similar morphological changes using the HV or the GV. Vitreous fragmentation appeared more effective with the HV. Overall this study suggests that the HV may be a promising new technology. More work is needed to quantitatively assess its safety and efficacy.

Wireless Power Transfer Strategies for Implantable Bioelectronics

Neural implants have emerged over the last decade as highly effective solutions for the treatment of dysfunctions and disorders of the nervous system. These implants establish a direct, often bidirectional, interface to the nervous system, both sensing neural signals and providing therapeutic treatments. As a result of the technological progress and successful clinical demonstrations, completely implantable solutions have become a reality and are now commercially available for the treatment of various functional disorders. Central to this development is the wireless power transfer (WPT) that has enabled implantable medical devices (IMDs) to function for extended durations in mobile subjects. In this review, we present the theory, link design, and challenges, along with their probable solutions for the traditional near-field resonant inductively coupled WPT, capacitively coupled short-ranged WPT, and more recently developed ultrasonic, mid-field, and far-field coupled WPT technologies for implantable applications. A comparison of various power transfer methods based on their power budgets and WPT range follows. Power requirements of specific implants like cochlear, retinal, cortical, and peripheral are also considered and currently available IMD solutions are discussed. Patient's safety concerns with respect to electrical, biological, physical, electromagnetic interference, and cyber security from an implanted neurotech device are also explored in this review. Finally, we discuss and anticipate future developments that will enhance the capabilities of current-day wirelessly powered implants and make them more efficient and integrable with other electronic components in IMDs.

Influence of peptide dendrimers and sonophoresis on the transdermal delivery of ketoprofen

The aim of this study was to determine the individual and combined effects of peptide dendrimers and low frequency ultrasound on the transdermal permeation of ketoprofen. Arginine terminated peptide dendrimers of varying charges (4⁺, 8⁺ and 16⁺, named as A4. A8 and A16 respectively) were synthesized and characterized. Ketoprofen was subjected to passive, peptide dendrimer-assisted and sonophoretic permeation studies (with and without dendrimer application) across Swiss albino mouse skin, both in vitro and in vivo. The studies revealed that the synthesized peptide dendrimers considerably increased the transdermal permeation of ketoprofen and displayed enhancement ratios of up to 3.25 (with A16 dendrimer), compared to passive diffusion of drug alone in vitro. Moreover, the combination of peptide dendrimer treatment and ultrasound application worked in synergy and gave enhancement ratios of up to 1369.15 (with ketoprofen-A16 dendrimer complex). In vivo studies demonstrated that dendrimer and ultrasound-assisted permeation of drug achieved much higher plasma concentration of drug, compared to passive diffusion. Comparison of transdermal and oral absorption studies revealed that transdermal administration of ketoprofen with A8 dendrimer showed comparable absorption and plasma drug levels with oral route. The excised mouse skin after in vivo permeation study with dendrimers and ultrasound did not show major toxic reactions. This study demonstrates that arginine terminated peptide dendrimers combined with sonophoresis can effectively improve the transdermal permeation of ketoprofen.

Thermal safety of ultrasound-enhanced ocular drug delivery: A modeling study

PURPOSE

Delivery of sufficient amounts of therapeutic drugs into the eye for treatment of various ocular diseases is often a challenging task. Ultrasound was shown to be effective in enhancing ocular drug delivery in the authors' previous in vitro and in vivo studies.

METHODS

The study reported here was designed to investigate the safety of ultrasound application and its potential thermal effects in the eye using PZFlex modeling software. The safety limit in this study was set as a temperature increase of no more than 1.5 °C based on regulatory recommendations and previous experimental safety studies. Acoustic and thermal specifications of different human eye tissues were obtained from the published literature. The tissues of particular interest in this modeling safety study were cornea, lens, and the location of optic nerve in the posterior eye. Ultrasound application was modeled at frequencies of 400 kHz-1 MHz, intensities of 0.3-1 W/cm(2), and exposure duration of 5 min, which were the parameters used in the authors' previous drug delivery experiments. The baseline eye temperature was 37 °C.

RESULTS

The authors' results showed that the maximal tissue temperatures after 5 min of ultrasound application were 38, 39, 39.5, and 40 °C in the cornea, 39.5, 40, 42, and 43 °C in the center of the lens, and 37.5, 38.5, and 39 °C in the back of the eye (at the optic nerve location) at frequencies of 400, 600, 800 kHz, and 1 MHz, respectively.

CONCLUSIONS

The ocular temperatures reached at higher frequencies were considered unsafe based on current recommendations. At a frequency of 400 kHz and intensity of 0.8 W/cm(2) (parameters shown in the authors' previous in vivo studies to be optimal for ocular drug delivery), the temperature increase was small enough to be considered safe inside different ocular tissues. However, the impact of orbital bone and tissue perfusion should be included in future modeling efforts to determine the safety of this method in the whole orbit especially regarding potential adverse optic nerve heating at the location of the bone.

Design of a Subtarsal Ultrasonic Transducer for Mild Hyperthermia Treatment of Dry Eye Disease

Dry eye disease is a disorder of the ocular surface that causes pain and low vision in a significant portion of the adult population. A common cause is obstructive Meibomian gland dysfunction, whereby the Meibomian glands secrete abnormal meibum with a melting point elevated by 3°C-4°C; hence, hyperthermia is the typical treatment. A design is proposed for an ultrasound hyperthermia device made of a transducer contained inside a contact lens with an internal air gap. The transducer heats the posterior of the tarsus, and the air gap provides an air backing to the transducer, preventing direct heating of the cornea. A prototype device was built, and hyperthermia experiments were performed on a porcine subject in vivo. A therapeutic temperature rise of 5°C-7°C was achievable in 10-15 min. The temperature of the cornea did not rise more than 2°C during any of the experiments.

Omnidirectional Ultrasonic Powering for Millimeter-Scale Implantable Devices

In addition to superior energy-conversion efficiency at millimeter-scale dimensions, ultrasonic wireless powering offers deeper penetration depth and omnidirectionality as compared to the traditional inductive powering method. This makes ultrasound an attractive candidate for powering deep-seated implantable medical devices. In this paper, we investigate ultrasonic powering of millimeter-scale devices with specific emphasize on the output power levels, efficiency, range, and omnidirectionality. Piezoelectric receivers 1 ×5 ×1 mm(3), 2 ×2 ×2 mm(3), and 2 ×4 ×2 mm(3) in size are able to generate 2.48, 8.7, and 12.0 mW of electrical power, while irradiated at 1.15 and 2.3 MHz within FDA limits for medical imaging (peak acoustic intensity of 720 mW/cm(2)). The receivers have corresponding efficiencies of 0.4%, 1.7%, and 2.7%, respectively, at 20-cm powering distance. Due to the form factor and reflections from tissue-air boundaries, the output power stays constant to within 92% when the angular positions of the transmitter and receiver are varied around a cylindrical shell.

Prenatal exposure to ultrasound affects learning and memory in young rats

Prenatal exposure to ultrasound may cause cognitive impairments in experimental animals; however, the exact mechanisms remain unknown. In this study, we exposed pregnant rats (or sham-exposed controls) to different intensities of ultrasound repeatedly on days 6, 12 and 18 of pregnancy for 4 min (3.5 MHz, spatial peak time average intensity = 7.6 mW/cm(2), mechanical index = 0.1, thermal index bone = 0.1: 4-min group) or 20 min (3.5 MHz, spatial peak time average intensity = 106 mW/cm(2), mechanical index = 1.4, thermal index bone = 1.0: 20-min group). The Morris water maze was used to assess learning and memory function in pups at 2 mo of age. Noticeable deficits in behavior occurred in the group exposed to ultrasound for 20 min. Using real-time polymerase chain reaction and Western blot, we also determined that both the mRNA and protein expression levels of hippocampal N-methyl-D-aspartate (NMDA) receptor units 1 (NR1) and 2B (NR2B) and brain-derived neurotrophic factor (BDNF) were significantly lower in pups exposed to ultrasound for 20 min than in controls. Furthermore, the morphology of the synapses in the hippocampus was partially damaged. Compared with the control group, the 4-min group had better spatial learning and memory abilities, as well as higher mRNA and protein levels of NR1, NR2B and BDNF. Our study suggests that high-intensity ultrasound irradiation can decrease learning and memory abilities by reducing the expression of NR1, NR2B and BDNF in the hippocampal regions and damaging the structure of synapses. In contrast, low-intensity ultrasound irradiation can enhance the learning and memory abilities of the offspring rats by increasing the expression of NR1, NR2B and BDNF receptor in the hippocampal regions.

Ultrasonically triggered drug delivery: breaking the barrier

The adverse side-effects of chemotherapy can be minimized by delivering the therapeutics in time and space to only the desired target site. Ultrasound offers one fairly non-invasive method of accomplishing such precise delivery because its energy can disrupt nanosized containers that are designed to sequester the drug until the ultrasonic event. Such containers include micelles, liposomes and solid nanoparticles. Conventional micelles and liposomes are less acoustically sensitive to ultrasound because the strongest forces associated with ultrasound are generated by gas-liquid interfaces, which both of these conventional constructs lack. Acoustically activated carriers often incorporate a gas phase, either actively as preformed bubbles, or passively such as taking advantage of dissolved gasses that form bubbles upon insonation. Newer concepts include using liquids that form gas when insonated. This review focuses on the ultrasonically activated delivery of therapeutics from micelles, liposomes and solid particles. In vitro and in vivo results are summarized and discussed. Novel structural concepts from micelles and liposomes are presented. Mechanisms of ultrasonically activated release are discussed. The future of ultrasound in drug delivery is envisioned.

Ultrasound induced cancer immunotherapy

Recently, the use of ultrasound (US) has been shown to have potential in cancer immunotherapy. High intensity focused US destruction of tumors may lead to immunity forming in situ in the body by immune cells being exposed to the tumor debris and immune stimulatory substances that are present in the tumor remains. Another way of achieving anti-cancer immune responses is by using US in combination with microbubbles and nanobubbles to deliver genes and antigens into cells. US leads to bubble destruction and the forces released to direct delivery of the substances into the cytoplasm of the cells thus circumventing the natural barriers. In this way tumor antigens and antigen-encoding genes can be delivered to immune cells and immune response stimulating genes can be delivered to cancer cells thus enhancing immune responses. Combination of bubbles with cell-targeting ligands and US provides an even more sophisticated delivery system whereby the therapy is not only site specific but also cell specific. In this review we describe how US has been used to achieve immunity and discuss the potential and possible obstacles in future development.

Physical energy for drug delivery; poration, concentration and activation

Techniques for controlling the rate and duration of drug delivery, while targeting specific locations of the body for treatment, to deliver the cargo (drugs or DNA) to particular parts of the body by what are becoming called "smart drug carriers" have gained increased attention during recent years. Using such smart carriers, researchers have also been investigating a number of physical energy forces including: magnetic fields, ultrasound, electric fields, temperature gradients, photoactivation or photorelease mechanisms, and mechanical forces to enhance drug delivery within the targeted cells or tissues and also to activate the drugs using a similar or a different type of external trigger. This review aims to cover a number of such physical energy modalities. Various advanced techniques such as magnetoporation, electroporation, iontophoresis, sonoporation/mechnoporation, phonophoresis, optoporation and thermoporation will be covered in the review. Special emphasis will be placed on photodynamic therapy owing to the experience of the authors' laboratory in this area, but other types of drug cargo and DNA vectors will also be covered. Photothermal therapy and theranostics will also be discussed.

Effects of low-frequency ultrasound and microbubbles on angiogenesis-associated proteins in subcutaneous tumors of nude mice

It has been shown that 1 and 3 MHz low-intensity ultrasound was able to affect the fragile and leaky angiogenic blood vessels in a tumor. However, the biological effects of 21 kHz low-intensity ultrasound on tumors remain unclear. The aim of the present study was to explore the effects of 21 kHz ultrasound with microbubbles on the regulation of vascular endothelial growth factor (VEGF), cyclooxygenase-2 (COX-2) and apoptosis in subcutaneous prostate tumors in nude mice. The study included three parts, each with 20 tumor-bearing nude mice. Twenty nude mice were divided into four groups: control (sham treatment), microbubble ultrasound contrast agent (UCA), low-frequency ultrasound (US) and US+UCA groups. The UCA used was a microbubble contrast agent (SonoVue). The parameter of ultrasound: 21 kHz, an intensity of 26 mW/cm2, 40% duty cycle (on 2 sec, off 3 sec), 3 min, once every other day for 2 weeks. In the first study, all subcutaneous tumors were examined by contrast-enhanced ultrasonography (CEUS) at the initiation and completion of the experiments. Peak intensity (PI), time to peak intensity (TTP) and area under the curve (AUC) on the time intensity curve (TIC) were analyzed. In the second study, the intensity of VEGF and COX-2 protein expression in the vascular endothelium and cytoplasm was evaluated using immunohistochemistry and laser confocal microscopy. In the third study, terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick end labeling (TUNEL) assay was used for the evaluation of cell apoptosis in tumor tissues. The tumor cells and vasculature were examined by transmission electron microscopy (TEM). Only in the US+UCA group, PI and AUC decreased. The intensity of COX-2 and VEGF in the US+UCA group in immunohistochemical staining and laser confocal microscopy was lower compared to that of the other three groups. More cell apoptosis was found in the US+UCA group compared to the other 3 groups. In the control, UCA and US groups, the tumors had intact vascular endothelium and vessel lumens in TEM. However, lumen occlusion of vessels was observed in the US+UCA group. Twenty-one kHz low-intensity ultrasound with microbubbles may have anti-angiogenic effects on subcutaneous tumors in nude mice.

Ultrasound-triggered Release from Micelles

Ultrasound is an ideal trigger for site-actuated drug delivery because it can be focused through the skin to internal targets without surgery. Thermal or mechanical energy can be delivered via tissue heating or bubble cavitation, respectively. Bubble cavitation, which concentrates energy that can trigger drug release from carriers, occurs more readily at low frequencies and at bubble resonant frequencies. Other mechanical and physical consequences of cavitation are reviewed. Micelles are nanosized molecular assemblies of amphiphilic molecules that spontaneously form in aqueous solution and possess a hydrophobic core capable of sequestering hydrophobic drugs. Micelles have traditionally been used to increase the solubility of hydrophobic therapeutics for oral and intravenous administration. For ultrasonic drug delivery, polymeric micelles containing polyethylene oxide blocks are preferred because they have longer circulation time in vivo. Passive delivery occurs when micelles accumulate in tumor tissues that have malformed capillaries with porous walls. In active delivery targeting ligands are attached to the micelles, which directs their binding to specific cells. Actuated delivery occurs when ultrasound causes drug release from micelles and is attributed to bubble cavitation since the amount released correlates with acoustic signatures of cavitation. The mechanisms of ultrasonic drug release are discussed, including the prevalent theory that gas bubble cavitation events create high shear stress and shock waves that transiently perturb the structure of the micelles and allow drug to escape from the hydrophobic core. Ultrasound also perturbs cell membranes, rendering them more permeable to drug uptake. Tumors in rats and mice have been successfully treated using low-frequency ultrasound and chemotherapeutics in polymeric micelles. Ultrasonically activated drug delivery has great clinical potential.

Insonation of targeted microbubbles produces regions of reduced blood flow within tumor vasculature

OBJECTIVES

In ultrasound molecular imaging, a sequence of high-pressure ultrasound pulses is frequently applied to destroy bound targeted microbubbles, to quantify accumulated microbubbles or to prepare for successive microbubble injections; however, the potential for biological effects from such a strategy has not been fully investigated. Here, we investigate the effect of high-pressure insonation of bound microbubbles and the potential for thrombogenic effects.

MATERIALS AND METHODS

A total of 114 mice carrying either Met-1 or neu deletion mutant (NDL) tumors was insonified (Siemens Sequoia system, 15L8 transducer, 5-MHz color-Doppler pulses, 4 or 2 MPa peak-negative pressure, 8.1-millisecond pulse repetition period, 6-cycle pulse length, and 900-millisecond insonation). Microbubbles conjugated with cyclic-arginine-glycine-aspartic acid (cRGD) or cyclic-aspartic-acid-glycine-tyrosine (3-NO)-glycine-hydroxyproline-asparagine (LXY-3) peptides or control (no peptide) microbubbles were injected, and contrast pulse sequencing was used to visualize the flowing and bound microbubbles. An anti-CD41 antibody was injected in a subset of animals to block potential thrombogenic effects.

RESULTS

After the accumulation of targeted microbubbles and high-pressure (4 MPa) insonation, reduced blood flow, as demonstrated by a reduction in echoes from flowing microbubbles, was observed in 20 Met-1 mice (71%) and 4 NDL mice (40%). The area of low image intensity increased from 22 ± 13% to 63 ± 17% of the observed plane in the Met-1 model (P < 0.01) and from 16 ± 3% to 45 ± 24% in the NDL model (P < 0.05). Repeated microbubble destruction at 4 MPa increased the area of low image intensity to 76.7 ± 13.4% (P < 0.05). The fragmentation of bound microbubbles with a lower peak-negative pressure (2 MPa) reduced the occurrence of the blood flow alteration to 28% (5/18 Met-1 tumor mice). The persistence of the observed blood flow change was approximately 30 minutes after the microbubble destruction event. Dilated vessels and enhanced extravasation of 150 kDa fluorescein-isothiocyanate (FITC)-dextran were observed by histology and confocal microscopy. Preinjection of an anti-CD41 antibody blocked the reduction of tumor blood flow, where a reduction in blood flow was observed in only 1 of 26 animals.

CONCLUSION

High-pressure fragmentation of microbubbles bound to tumor endothelial receptors reduced blood flow within 2 syngeneic mouse tumor models for ∼30 minutes. Platelet activation, likely resulting from the injury of small numbers of endothelial cells, was the apparent mechanism for the flow reduction.

Are ultrasound-guided ophthalmic blocks injurious to the eye? A comparative rabbit model study of two ultrasound devices evaluating intraorbital thermal and structural changes

BACKGROUND

Since Atkinson's original description of retrobulbar block in 1936, needle-based anesthetic techniques have become integral to ophthalmic anesthesia. These techniques are unfortunately associated with rare, grave complications such as globe perforation. Ultrasound has gained widespread acceptance for peripheral nerve blockade, but its translation to ocular anesthesia has been hampered because sonic energy, in the guise of thermal or biomechanical insult, is potentially injurious to vulnerable eye tissue. The US Food and Drug Administration (FDA) has defined guidelines for safe use of ultrasound for ophthalmic examination, but most ultrasound devices used by anesthesiologists are not FDA-approved for ocular application because they generate excessive energy. Regulating agencies state that ultrasound examinations can be safely undertaken as long as tissue temperatures do not increase >1.5°C above physiological levels.

METHODS

Using a rabbit model, we investigated the thermal and mechanical ocular effects after prolonged ultrasonic exposure to single orbital- and nonorbital-rated devices. In a dual-phase study, aimed at detecting ocular injury, the eyes of 8 rabbits were exposed to continuous 10-minute ultrasound examinations from 2 devices: (1) the Sonosite Micromaxx (nonorbital rated) and (2) the Sonomed VuMax (orbital rated) machines. In phase I, temperatures were continuously monitored via thermocouples implanted within specific eye structures (n = 4). In phase II the eyes were subjected to ultrasonic exposure without surgical intervention (n = 4). All eyes underwent light microscopy examinations, followed at different intervals by histology evaluations conducted by an ophthalmic pathologist.

RESULTS

Temperature changes were monitored in the eyes of 4 rabbits. The nonorbital-rated transducer produced increases in ocular tissue temperature that surpassed the safe limit (increases >1.5°C) in the lens of 3 rabbits (at 5.0, 5.5, and 1.5 minutes) and cornea of 2 rabbits (both at 1.5 minutes). A secondary analysis of temporal temperature differences between the orbital-rated and nonorbital transducers revealed statistically significant differences (Bonferroni-adjusted P < 0.05) in the cornea at 3.5 minutes, the lens at 2.5 minutes, and the vitreous at 4.0 minutes. Light microscopy and histology failed to elicit ocular injury in either group.

CONCLUSIONS

The nonorbital-rated ultrasound machine (Sonosite Micromaxx) increases the ocular tissue temperature. A larger study is needed to establish safety. Until then, ophthalmic ultrasound-guided blocks should only be performed with ocular-rated devices.

Mechanobiological modulation of cytoskeleton and calcium influx in osteoblastic cells by short-term focused acoustic radiation force

Mechanotransduction has demonstrated potential for regulating tissue adaptation in vivo and cellular activities in vitro. It is well documented that ultrasound can produce a wide variety of biological effects in biological systems. For example, pulsed ultrasound can be used to noninvasively accelerate the rate of bone fracture healing. Although a wide range of studies has been performed, mechanism for this therapeutic effect on bone healing is currently unknown. To elucidate the mechanism of cellular response to mechanical stimuli induced by pulsed ultrasound radiation, we developed a method to apply focused acoustic radiation force (ARF) (duration, one minute) on osteoblastic MC3T3-E1 cells and observed cellular responses to ARF using a spinning disk confocal microscope. This study demonstrates that the focused ARF induced F-actin cytoskeletal rearrangement in MC3T3-E1 cells. In addition, these cells showed an increase in intracellular calcium concentration following the application of focused ARF. Furthermore, passive bending movement was noted in primary cilium that were treated with focused ARF. Cell viability was not affected. Application of pulsed ultrasound radiation generated only a minimal temperature rise of 0.1°C, and induced a streaming resulting fluid shear stress of 0.186 dyne/cm(2), suggesting that hyperthermia and acoustic streaming might not be the main causes of the observed cell responses. In conclusion, these data provide more insight in the interactions between acoustic mechanical stress and osteoblastic cells. This experimental system could serve as basis for further exploration of the mechanosensing mechanism of osteoblasts triggered by ultrasound.

A MECHANISM OF ULTRASONIC IRRADIATION TO ASSIST OR INHIBIT THE PARAMECIUM CELLS

This paper investigates the biological reactions of unicellular creature irradiated to a low intensity of ultrasonic field. The current study attempts to anticipate the value of the ultrasonic driving frequency which will induce the most significant biological reactions by using the theoretical model. The theoretical model of the cells in response to the ultrasonic irradiation is simulated using Rayleigh–Plesset's bubble activation theory. The simulation results indicate that the resonant frequency of the Paramecium vacuoles considered in the present study lies in the range 0.54–1.24 MHz. Ultrasonic irradiation experiments are performed at various power level intensities at driving frequencies corresponding to resonant (0.5 and 1 MHz) and nonresonant (0.25 and 5 MHz) frequencies. It is found that samples irradiated under different ultrasonic conditions exhibit clear differences in their cell proliferation tendencies. For example, in samples irradiated with lower power intensities and driving frequencies of 0.5 and 1 MHz, the number of cells in the treated samples is found to be approximately 30% higher than that in the original unexposed samples. However, when resonant frequencies and higher intensities are applied, the ultrasonic irradiation causes a shape change of the cell organelles and a corresponding reduction in the total number of cells in the treated sample. For the samples exposed to nonresonant frequency ultrasonic irradiation, it is found that the cell proliferation is limited and appears to vary independently of the applied irradiation intensity.

On the efficiency of water soluble antioxidants

The wide use of high intensity ultrasound (HIU) in modern medicine raises the question of bio-safety. It has been shown that the effect of HIU in biological media may have similarity to the effects of ionizing radiation. Exposure of biological media to HIU field may lead to cavitation phenomenon followed by formation of free radicals such as hydroxyl radical (OH(·)) and the super-oxide ion (O(2)(·-)). These are highly reactive species that may cause harmful effects and induce oxidative stress. In the present study we employed electron spin resonance (ESR) spectroscopy together with spin traps to quantify the dynamics of hydroxyl radical formation during exposure to HIU field in the presence of different amounts of six antioxidants. Thus, the efficiency of water-soluble antioxidants, namely Allicin, Melatonin, Deoxyribose, Trolox, Nuphlutine and Hermidin, to suppress accumulation of OH radicals was examined. The results show that among the six, Trolox and Allicin reduce hydroxyl concentration with the highest efficiency.

Ultrasound increases nanoparticle delivery by reducing intratumoral pressure and increasing transport in epithelial and epithelial-mesenchymal transition tumors

Acquisition of the epithelial-mesenchymal transition (EMT) tumor phenotype is associated with impaired chemotherapeutic delivery and a poor prognosis. In this study, we investigated the application of therapeutic ultrasound methods available in the clinic to increase nanotherapeutic particle accumulation in epithelial and EMT tumors by labeling particles with a positron emission tomography tracer. Epithelial tumors were highly vascularized with tight cell-cell junctions, compared with EMT tumors where cells displayed an irregular, elongated shape with loosened cell-cell adhesions and a reduction in E-cadherin and cytokeratins 8/18 and 19. Without ultrasound, the accumulation of liposomal nanoparticles administered to tumors in vivo was approximately 1.5 times greater in epithelial tumors than EMT tumors. When ultrasound was applied, both nanoaccumulation and apparent tumor permeability were increased in both settings. Notably, ultrasound effects differed with thermal and mechanical indices, such that increasing the thermal ultrasound dose increased nanoaccumulation in EMT tumors. Taken together, our results illustrate how ultrasound can be used to enhance nanoparticle accumulation in tumors by reducing their intratumoral pressure and increasing their vascular permeability.

The Safe Use of Diagnostic Ultrasound in Obstetrics and Gynecology

The diagnostic ultrasound was considered safe after the intensity threshold was known and the output intensity (Ispta) was regulated to be less than 10 mW/cm2 in diagnostic devices in Japan, and diagnostic ultrasound was thought safe in USA when both thermal index (TI) and mechanical index were less than 1.0 in the obstetrical setting. Simple B-mode machine was not concerned from the thermal reason due to its extremely low ultrasound intensity, while the exposure was recommended within 30 minutes. Diagnostic ultrasound should be used after obstetrical setting in fetal study. The TI will be higher in febrile cases than nonfebrile, and the surface temperature of transvaginal scan (TVS) probe should be lower than 41°C. Simple three-dimensional or four-dimensional ultrasound imaging without pulsed Doppler studies will be as safe as Bmode when the study is within 30 minutes, because they are composed of simple B-mode images. The spectral Doppler study was not routinely used and its exposure should be short in 11 to 13 weeks of pregnancy in the statements of WFUMB and ISUOG, because experimentally early fetal animal tissue was sensitive to the studies. The use of diagnostic ultrasound should be limited for medical purposes, but not for the entertainment or keepsake of pregnancy.

How to cite this article

Maeda K, Kurjak A. The Safe Use of Diagnostic Ultrasound in Obstetrics and Gynecology. Donald School J Ultrasound Obstet Gynecol 2012;6(3):313-317.

Forced wave motion with internal and boundary damping

A d'Alembert-based solution of forced wave motion with internal and boundary damping is presented with the specific intention of investigating the transient response. The dynamic boundary condition is a convenient method to model the absorption and reflection effects of an interface without considering coupled PDE's. Problems with boundary condition of the form [Formula: see text] are not self-adjoint which greatly complicates solution by spectral analysis. However, exact solutions are found with d'Alembert's method. Solutions are also derived for a time-harmonically forced problem with internal damping and are used to investigate the effect of ultrasound in a bioreactor, particularly the amount of energy delivered to cultured cells. The concise form of the solution simplifies the analysis of acoustic field problems.

Improving image quality of diagnostic ultrasound by using the safe use time model with the dynamic safety factor and the effect of the exposure time on the image quality

Resolution and penetration are primary criteria for image quality of diagnostic ultrasound. In theory (and usually in practice), the maximum depth of imaging in a tissue increases as power (pressure) is increased. Alternatively, at a particular effective penetration, an increased power may be used to allow a higher ultrasound frequency for higher resolution and tissue contrast. Recently, Karagoz and Kartal proposed a safety parameter for thermal bioeffects of diagnostic ultrasound; that is, SUT (safe use time). The SUT model is constructed to determine how long one piece of tissue can be insonated safely according to a threshold exposure. Also, Karagoz and Kartal suggested that an increase in acoustic intensity beyond the current US Food and Drug Administration (FDA) limit of intensity can be theoretically possible by using SUT model while staying within the safe limit. The present study was motivated particularly by the goals of higher resolution and/or deeper penetration by using SUT model. The results presented here suggest that the safe use of higher exposure levels than currently allowed by the FDA may be possible for obtaining substantial improvements in penetration depth and/or resolution. Also, the study reveals that image quality can be functionally related to exposure time in addition to acoustic energy and frequency.

Osteogenic differentiation of rat bone marrow stromal cells by various intensities of low-intensity pulsed ultrasound

Bone growth and repair are under the control of biochemical and mechanical signals. Low-intensity pulsed ultrasound (LIPUS) stimulation at 30mW/cm(2) is an established, widely used and FDA approved intervention for accelerating bone healing in fractures and non-unions. Although this LIPUS signal accelerates mineralization and bone regeneration, the actual intensity experienced by the cells at the target site might be lower, due to the possible attenuation caused by the overlying soft tissue. The aim of this study was to investigate whether LIPUS intensities below 30mW/cm(2) are able to provoke phenotypic responses in bone cells. Rat bone marrow stromal cells were cultured under defined conditions and the effect of 2, 15, 30mW/cm(2) and sham treatments were studied at early (cell activation), middle (differentiation into osteogenic cells) and late (biological mineralization) stages of osteogenic differentiation. We observed that not only 30mW/cm(2) but also 2 and 15mW/cm(2), modulated ERK1/2 and p38 intracellular signaling pathways as compared to the sham treatment. After 5 days with daily treatments of 2, 15 and 30mW/cm(2), alkaline phosphatase activity, an early indicator of osteoblast differentiation, increased by 79%, 147% and 209%, respectively, compared to sham, indicating that various intensities of LIPUS were able to initiate osteogenic differentiation. While all LIPUS treatments showed higher mineralization, interestingly, the highest increase of 225% was observed in cells treated with 2mW/cm(2). As the intensity increased to 15 and 30mW/cm(2), the increase in the level of mineralization dropped to 120% and 82%. Our data show that LIPUS intensities lower than the current clinical standard have a positive effect on osteogenic differentiation of rat bone marrow stromal cells. Although Exogen™ at 30mW/cm(2) continues to be effective and should be used as a clinical therapy for fracture healing, if confirmed in vivo, the increased mineralization at lower intensities might be the first step towards redefining the most effective LIPUS intensity for clinical use.

Tissue harvest by means of suction-assisted or third-generation ultrasound-assisted lipoaspiration has no effect on osteogenic potential of human adipose-derived stromal cells

BACKGROUND

Human adipose-derived stromal cells readily undergo osteogenic differentiation in vitro and in vivo. Thus, interest in their potential role in skeletal tissue engineering continues to escalate. Very little is known regarding the effects that energy delivered by means of third-generation ultrasound-assisted lipoaspiration may have on the osteogenic potential of these cells. The authors investigated whether differences in adipose-derived stromal cell yield, and the in vitro proliferation and osteogenic potential of these cells obtained by suction-assisted lipoaspiration or third-generation ultrasound-assisted lipoaspiration, exist.

METHODS

Adipose-derived stromal cells were harvested from lipoaspiration specimens of patients undergoing elective suction-assisted lipoaspiration and third-generation ultrasound-assisted lipoaspiration. Harvested cells were seeded to evaluate proliferative capacity and in vitro osteogenic potential. Alkaline phosphatase and alizarin red staining were performed to evaluate early and terminal osteogenic differentiation, respectively. Quantitative real-time polymerase chain reaction analysis was used to examine osteogenic gene expression patterns of RUNX2/CFBA1 (early differentiation) and osteocalcin (late differentiation).

RESULTS

No significant differences in the proliferative capacity (n = 3), alkaline phosphatase staining (n = 3), or extracellular matrix mineralization (n = 3) of suction-assisted lipoaspiration- or third-generation ultrasound-assisted lipoaspiration-derived cells were appreciated. Transcript levels of markers of early and terminal osteogenic differentiation were not significantly different (n = 3).

CONCLUSIONS

These findings suggest that exposure of adipose-derived stromal cells to ultrasound energy during tissue harvest by means of third-generation ultrasound-assisted lipoaspiration does not impart a negative consequence toward their proliferative capacity or osteogenic potential. Thus, the cells harvested using third-generation ultrasound-assisted lipoaspiration are comparable to those obtained by means of suction-assisted lipoaspiration for use in the study of osteogenic differentiation and skeletal tissue engineering.

Advanced techniques for detecting lesions in bone

Imaging is an important clinical aid for the diagnosis of endodontic bone lesions. Traditional radiology performs more accurately than any other diagnostic tool. Computed tomography has been used for the last 20 years with important implications in the management of lesions in bone. Among the newest systems, digital volume tomography is becoming a new standard and real-time echotomography is gaining an interesting space in the diagnostic field of endodontics. These techniques offer some advantages for the increased safety and the amount of detailed information they can provide.

Ultrasound and microbubble-induced intra- and intercellular bioeffects in primary endothelial cells

Recent developments in the field of ultrasound (US) contrast agents have demonstrated that these encapsulated microbubbles can not only be used for diagnostic imaging but may also be employed as therapeutic carriers for localized, targeted drug or gene delivery. The exact mechanisms behind increased uptake of therapeutic compounds by US-exposed microbubbles are still not fully understood. Therefore, we studied the effects of stably oscillating SonoVue microbubbles on relevant parameters of cellular and intercellular permeability, i.e., reactive oxygen species (ROS) homeostasis, calcium permeability, F-actin cytoskeleton, monolayer integrity and cell viability using live-cell fluorescence microscopy. US was applied at 1-MHz, 0.1MPa peak-negative pressure, 0.2% duty cycle and 20Hz pulse repetition frequency to primary endothelial cells. We demonstrated increased membrane permeability for calcium ions, with an important role for H(2)O(2). Catalase, an extracellular H(2)O(2) scavenger, significantly blocked the influx of calcium ions. Further changes in ROS homeostasis involved an increase in intracellular H(2)O(2) levels, protein nitrosylation and a decrease in total endogenous glutathione levels. In addition, an increase in the number of F-actin stress fibers and F-actin cytoskeletal rearrangement were observed. Furthermore, US-exposed microbubbles significantly affected endothelial monolayer integrity, but importantly, disrupted cell-cell interactions were restored within 30min. Finally, cell viability was not affected. In conclusion, these data provide more insight in the interactions between US, microbubbles and endothelial cells, which is important for understanding the mechanisms behind US and microbubble-enhanced uptake of drugs or genes.

Ultrasound imaging and contrast agents: A safe alternative to MRI?

Microbubble contrast media are used to enhance ultrasound images. Because ultrasound is a real-time investigation, contrast-enhanced ultrasound offers possibilities for perfusion imaging. This review is conducted to evaluate the safety of contrast-enhanced ultrasound and its possible role in medical imaging. The safety of diagnostic ultrasound is still an important field of research. The wanted and unwanted effects of ultrasound and microbubble contrast media as well as the effects of ultrasound on these microbubbles are described. Furthermore, some of the possible applications and indications of contrast-enhanced ultrasound will be discussed. The shared advantages of MRI and ultrasound are the use of non-ionizing radiation and non-nephrotoxic contrast media. From this review it can be concluded that, for certain indications, contrast enhanced ultrasound could be a safe alternative to MRI and a valuable addition to medical imaging.