Hemolysis of 40% hematocrit, Albunex-supplemented human erythrocytes by pulsed ultrasound: frequency, acoustic pressure and pulse length dependence

Microbubbles, Nanodroplets and Gas-Stabilizing Solid Particles for Ultrasound-Mediated Extravasation of Unencapsulated Drugs: An Exposure Parameter Optimization Study

Ultrasound-induced cavitation has been proposed as a strategy to tackle the challenge of inadequate extravasation, penetration and distribution of therapeutics into tumours. Here, the ability of microbubbles, droplets and solid gas-trapping particles to facilitate mass transport and extravasation of a model therapeutic agent following ultrasound-induced cavitation is investigated. Significant extravasation and penetration depths on the order of millimetres are achieved with all three agents, including the range of pressures and frequencies achievable with existing clinical ultrasound systems. Deeper but highly directional extravasation was achieved with frequencies of 1.6 and 3.3 MHz compared with 0.5 MHz. Increased extravasation was observed with increasing pulse length and exposure time, while an inverse relationship is observed with pulse repetition frequency. No significant cell death or any haemolytic activity in human blood was observed at clinically relevant concentrations for any of the agents. Overall, solid gas-trapping nanoparticles were found to enable the most extensive extravasation for the lowest input acoustic energy, followed by microbubbles and then droplets. The ability of these agents to produce sustained inertial cavitation activity whilst being small enough to follow the drug out of the circulation and into diseased tissue, combined with a good safety profile and the possibility of real-time monitoring, offers considerable potential for enhanced drug delivery of unmodified drugs in oncological and other biomedical applications.

Mechanical and Biological Effects of Ultrasound: A Review of Present Knowledge

Ultrasound is widely used for medical diagnosis and increasingly for therapeutic purposes. An understanding of the bio-effects of sonography is important for clinicians and scientists working in the field because permanent damage to biological tissues can occur at high levels of exposure. Here the underlying principles of thermal mechanisms and the physical interactions of ultrasound with biological tissues are reviewed. Adverse health effects derived from cellular studies, animal studies and clinical reports are reviewed to provide insight into the in vitro and in vivo bio-effects of ultrasound.

Frequency-dependent evaluation of the role of definity in producing sonoporation of Chinese hamster ovary cells

OBJECTIVES

Sonoporation uses ultrasound (US) and ultrasound contrast agents (UCAs) to enhance cell permeabilization, thereby allowing delivery of therapeutic compounds non-invasively into specific target cells. The objective of this study was to elucidate the biophysical mechanism of sonoporation, specifically the role of UCAs as well as exposure frequency. The inertial cavitation (IC) thresholds of the lipid-shelled octafluoropropane UCA were directly compared to the levels of generated sonoporation to determine the involvement of UCAs in producing sonoporation.

METHODS

Chinese hamster ovary cells were exposed as a monolayer in a solution of the UCA, 500,000-Da fluorescein isothiocyanate-dextran, and phosphate-buffered saline to 30 seconds of pulsed US (pulse duration, 5 cycles; pulse repetition frequency, 10 Hz) at 3 frequencies (0.92, 3.2, and 5.6 MHz). The peak rarefactional pressure (P(r)) was varied over a range from 4 kPa to 4.1 MPa, and 5 to 7 independent replicates were performed at each pressure.

RESULTS

The experimental observations demonstrated that IC was likely not the physical mechanism for sonoporation. Sonoporation activity was observed at pressure levels below the threshold for IC of the UCA (1.27 ± 0.32 MPa at 0.92 MHz, 0.84 ± 0.19 MPa at 3.2 MHz, and 2.57 ± 0.26 MPa at 5.6 MHz) for all 3 frequencies examined. The P(r) values at which the peak sonoporation activity occurred were 1.4 MPa at 0.92 MHz, 0.25 MPa at 3.2 MHz, and 2.3 MPa at 5.6 MHz. The UCA collapse thresholds followed a similar trend. A 1-way analysis of variance test confirmed that sonoporation activity differed among the 3 frequencies examined (P = 10(-8)).

CONCLUSIONS

These results thus suggest that sonoporation is related to linear and/or nonlinear oscillation of the UCA occurring at pressure levels below the IC threshold.

Ultrasound bioeffects and safety

The main mechanisms by which ultrasound can induce biological effects as it passes through the body are thermal and mechanical in nature. The mechanical effects are primarily related to the presence of gas, whether drawn out of solution by the negative going ultrasound pressure wave (acoustic cavitation), a naturally occurring gas body (such as lung alveoli), or deliberately introduced into the blood stream to increase imaging contrast (microbubble contrast agents). Observed biological effects are discussed in the context of these mechanisms and their relevance to ultrasound safety is discussed.

Bioeffects considerations for diagnostic ultrasound contrast agents

Diagnostic ultrasound contrast agents have been developed for enhancing the echogenicity of blood and for delineating other structures of the body. Approved agents are suspensions of gas bodies (stabilized microbubbles), which have been designed for persistence in the circulation and strong echo return for imaging. The interaction of ultrasound pulses with these gas bodies is a form of acoustic cavitation, and they also may act as inertial cavitation nuclei. This interaction produces mechanical perturbation and a potential for bioeffects on nearby cells or tissues. In vitro, sonoporation and cell death occur at mechanical index (MI) values less than the inertial cavitation threshold. In vivo, bioeffects reported for MI values greater than 0.4 include microvascular leakage, petechiae, cardiomyocyte death, inflammatory cell infiltration, and premature ventricular contractions and are accompanied by gas body destruction within the capillary bed. Bioeffects for MIs of 1.9 or less have been reported in skeletal muscle, fat, myocardium, kidney, liver, and intestine. Therapeutic applications that rely on these bioeffects include targeted drug delivery to the interstitium and DNA transfer into cells for gene therapy. Bioeffects of contrast-aided diagnostic ultrasound happen on a microscopic scale, and their importance in the clinical setting remains uncertain.

Overview of experimental studies of biological effects of medical ultrasound caused by gas body activation and inertial cavitation

Ultrasound exposure can induce bioeffects in mammalian tissue by the nonthermal mechanism of gas body activation. Pre-existing bodies of gas may be activated even at low-pressure amplitudes. At higher-pressure amplitudes, violent cavitation activity with inertial collapse of microbubbles can be generated from latent nucleation sites or from the destabilization of gas bodies. Mechanical perturbation at the activation sites leads to biological effects on nearby cells and structures. Shockwave lithotripsy was the first medical ultrasound application for which significant cavitational bioeffects were demonstrated in mammalian tissues, including hemorrhage and injury in the kidney. Lithotripter shockwaves can also cause hemorrhage in lung and intestine by activation of pre-existing gas bodies in these tissues. Modern diagnostic ultrasound equipment develops pressure amplitudes sufficient for inertial cavitation, but the living body normally lacks suitable cavitation nuclei. Ultrasound contrast agents (UCAs) are suspensions of microscopic gas bodies created to enhance the echogenicity of blood. Ultrasound contrast agent gas bodies also provide nuclei for inertial cavitation. Bioeffects from contrast-aided diagnostic ultrasound depend on pressure amplitude, UCA dose, dosage delivery method and image timing parameters. Microvascular leakage, capillary rupture, cardiomyocyte killing, inflammatory cell infiltration, and premature ventricular contractions have been reported for myocardial contrast echocardiography with clinical ultrasound machines and clinically relevant agent doses in laboratory animals. Similar bioeffects have been reported in intestine, skeletal muscle, fat, lymph nodes and kidney. These microscale bioeffects could be induced unknowingly in diagnostic examinations; however, the medical significance of bioeffects of diagnostic ultrasound with contrast agents is not yet fully understood in relation to the clinical setting.

Biological and environmental factors affecting ultrasound-induced hemolysis in vitro: 5. Temperature

This research project tested the hypothesis that cold-equilibrated (approximately 0 degrees C) human erythrocytes in vitro in the presence of an ultrasound contrast agent (Albunex) will undergo greater ultrasound-induced hemolysis than physiologically equilibrated (37 degrees C) human erythrocytes in vitro because of a temperature-related transition in membrane fluidity leading to increased fragility. First, it was shown that cold-equilibrated erythrocytes are more susceptible to mechanically induced hemolysis than physiologically equilibrated erythrocytes. Second, when adjustments were made for (1) temperature-dependent efficiencies of a 1-MHz transducer (200 micros pulse length, 20 ms interpulse interval, 30 s exposure duration) such that when cold or physiological temperatures were employed, there were equivalent acoustic outputs in terms of peak negative pressure (MPa P-) and (2) comparable viscosities of the 0 and 37 degrees C blood plasmas, the cold (approximately 0 degrees C) erythrocytes displayed substantially greater amounts of ultrasound-induced hemolysis than the physiological (37 degrees C) erythrocytes. The data supported the hypothesis.

Vascular effects induced by combined 1-MHz ultrasound and microbubble contrast agent treatments in vivo

Previous in vivo studies have demonstrated that microvessel hemorrhages and alterations of endothelial permeability can be produced in tissues containing microbubble-based ultrasound contrast agents when those tissues are exposed to MHz-frequency pulsed ultrasound of sufficient pressure amplitudes. The general hypothesis guiding this research was that acoustic (viz., inertial) cavitation, rather than thermal insult, is the dominant mechanism by which such effects arise. We report the results of testing five specific hypotheses in an in vivo rabbit auricular blood vessel model: (1) acoustic cavitation nucleated by microbubble contrast agent can damage the endothelia of veins at relatively low spatial-peak temporal-average intensities, (2) such damage will be proportional to the peak negative pressure amplitude of the insonifying pulses, (3) damage will be confined largely to the intimal surface, with sparing of perivascular tissues, (4) greater damage will occur to the endothelial cells on the side of the vessel distal to the source transducer than on the proximal side and (5) ultrasound/contrast agent-induced endothelial damage can be inherently thrombogenic, or can aid sclerotherapeutic thrombogenesis through the application of otherwise subtherapeutic doses of thrombogenic drugs. Auricular vessels were exposed to 1-MHz focused ultrasound of variable peak pressure amplitude using low duty factor, fixed pulse parameters, with or without infusion of a shelled microbubble contrast agent. Extravasation of Evans blue dye and erythrocytes was assessed at the macroscopic level. Endothelial damage was assessed via scanning electron microscopy (SEM) image analysis. The hypotheses were supported by the data. We discuss potential therapeutic applications of vessel occlusion, e.g., occlusion of at-risk gastric varices.

Ultrasonic excitation of a bubble near a rigid or deformable sphere: implications for ultrasonically induced hemolysis

A number of independent studies have reported increased ultrasound bioeffects, such as hemolysis and hemorrhage, when ultrasound contrast agents are present. To better understand the role of cavitation in these bioeffects, one- and two-dimensional models have been developed to investigate the interactions between ultrasonically excited bubbles and model "cells." First, a simple one-dimensional model based on the Rayleigh-Plesset equation was developed to estimate upper bounds for strain, strain rate, and areal expansion of a simulated red blood cell. Then, two-dimensional boundary element models were developed (with DynaFlow Inc.) to obtain simulations of asymmetric bubble dynamics in the presence of rigid and deformable spheres. The deformable spherical "cell" was modeled using Tait's equation of state for water, with a membrane approximated by surface tension that increases linearly with areal expansion. The presence of a rigid or deformable sphere had little effect on the bubble expansion, but caused an asymmetric collapse and jetting for the conditions considered. Predicted membrane areal expansions were found to be below critical values for hemolysis reported in the literature for the cases considered near the inertial cavitation threshold.

Cell size relations for sonolysis

The occurrence of cell lysis following exposure to ultrasound (US) has been well documented; the specifics of the mechanistic process(es) involved have proven to be difficult to characterize. There appear to be two major mechanisms of US-induced cell lysis in vitro, acoustic cavitation and bubble transport. Both involve shear forces. Earlier research showed that the size of oil droplets was a crucial factor in their rupture by shear forces; the greater the size the greater the rupture per unit shear force. Here we find further support (Miller et al. 2000, 2001a, 2003a; Miller and Battaglia 2003; Abramwocz et al. 2003) that, under a number of experimental US conditions causing hemolysis in vitro, cell volume (i.e., size) is an apparently critical factor.

The Effect of Time and of Vasoactive Drugs on Capillary Leakage Induced During Myocardial Contrast Echocardiography

BACKGROUND

Premature ventricular contractions (PVC), capillary leakage, and petechial hemorrhage can occur during myocardial contrast echocardiography (MCE). The effects occur as a result of the interaction of contrast agent microbubbles and the ultrasound, but the detailed etiology of the effects is not yet clear. This study tested the hypothesis that the capillary leakage results from a physiological response to injury, which might be protracted and modulated by vasoactive drugs.

METHODS

Hairless rats were anesthetized and transthoracically scanned with a diagnostic ultrasound system (GE Vingmed System V) at 1.7 MHz with 1:4 triggered frames at end systole. The scan head and rats were mounted in a 37 degrees C water bath to assure free-field conditions and placement of the heart at a similar focal distance as humans. A tail vein was cannulated for injections of Optison contrast agent, vasoactive medications, and Evans Blue dye (EB). EB was injected as a marker of capillary leakage before or after scanning.

RESULTS

PVCs, petechia, and capillary leakage occurred during ultrasound exposure of microbubbles in myocardium, with no effects detected in shams. The influence of the vasoactive medications propranolol and isoproterenol on the effects did not support the hypothesis. Capillary leakage occurred during and postexposure, but diminished for EB injection 20 minutes after scanning with or without isoproterenol pretreatment.

CONCLUSION

MCE induced PVCs, petechia, and capillary leakage, all of which ended immediately or within 20 minutes after the examination. Contrary to the hypothesis of a physiological mechanism, the capillary leakage appears to be primarily a mechanical effect rather than a physiological response.

Contrast agent bubble and erythrocyte behavior in a 1.5-MHz standing ultrasound wave

Human erythrocytes and Optison contrast agent have been exposed to ultrasound, both alone and in combination, in a single-half-wavelength chamber driven at its resonance frequency (fo) of 1.5 MHz. Cell movements were recorded by video microscopy at speeds up to 500 frames/s. The hypothesis that cells near a standing wave pressure node might be stressed by the microbubble products of sonicated contrast agent was examined. In the absence of contrast agent, cells moved rapidly to form an aggregate in the standing wave pressure node plane. First subharmonic and second harmonic emissions were detected from cell-contrast agent suspensions immediately on exposure to a threshold peak pressure amplitude of 0.98 MPa. Emissions at 3fo/2 occurred at 1.47 MPa, whereas white noise and lower-order subharmonic emissions coincided with the appearance of visible bubbles at a threshold of approximately 1.96 MPa. Cells exposed together with contrast agent at a pressure of 0.98 MPa precessed very rapidly about the pressure node plane. This behavior was discussed in the context of a recent analysis predicting that, in contrast to the situation for lower-pressure amplitudes, subresonant size bubbles translate about pressure node plane if the driving pressure amplitude is sufficiently high. Many precessing erythrocytes were clearly spiculated and this morphology persisted after the cells had left the area of precession. Hemoglobin release was significant under conditions inducing precession with first subharmonic and first harmonic emissions. Protein release increased discontinuously near the pressure thresholds, where more complex categories of frequency emission were detected. The potential of this system, which induces erythrocyte morphology changes and some protein release at the first emission threshold, to provide some control on the membrane-permeabilizing stress experienced by cells in a cavitation field is discussed.

The relevance of cell size on ultrasound-induced hemolysis in mouse and human blood in vitro

This paper describes a further test of the hypothesis that cell size is an important physical parameter in ultrasound (US)-induced hemolysis, that is, the larger the cell the greater the potential for sonolysis by a cavitational mechanism. Mouse (M) and human (Hu) erythrocytes in vitro were used; their mean corpuscular volumes were 49.0 and 89.5 fL, respectively. At a US exposure in vitro in the presence of Albunex that yielded an average of 36.8% hemolysis for M blood, the Hu blood yielded an average of 54.0% hemolysis. The data supported the hypothesis. This paper also briefly discusses the difficulty of extrapolating sonolytic in vitro results to those derived in vivo.

Comparative hemolytic effectiveness of 1 MHz ultrasound on human and rabbit blood in vitro

This project continued testing of the general working hypothesis that cell size is a physical determinant in extent of ultrasound (US)-induced hemolysis, the larger the cell the greater the lysis. For this project, the specific hypothesis tested was that human erythrocytes, being larger than rabbit erythrocytes, would be the more sensitive to sonolysis induced by inertial cavitation in the presence of Albunex, a US contrast agent. The rationale behind this hypothesis was 1. an earlier-published analytic construct indicating an inverse relation between particle size and the shear force required for deformation, and 2. a number of independent demonstrations that, among sized populations of erythrocytes, an inverse relation exists between erythrocyte volume and mechanically-induced shear forces in the cell-bathing medium; namely, the larger the cell, the less shear force required to rupture the cell's membrane. The present data support the hypothesis; over six independent trials, the mean corpuscular volumes of human (H) and rabbit (R) erythrocytes were 89.5 and 64.1 microm(3), respectively, H > R (p << 0.001), and the ratio of US-induced hemolysis in H to R blood in vitro was 1.12:1.0 (p < 0.004).

Inertial cavitation dose and hemolysis produced in vitro with or without Optison

Gas-based contrast agents (CAs) increase ultrasound (US)-induced bioeffects, presumably via an inertial cavitation (IC) mechanism. The relationship between IC dose (ICD) (cumulated root mean squared [RMS] broadband noise amplitude; frequency domain) and 1.1-MHz US-induced hemolysis in whole human blood was explored with Optison; the hypothesis was that hemolysis would correlate with ICD. Four experimental series were conducted, with variable: 1. peak negative acoustic pressure (P-), 2. Optison concentration, 3. pulse duration and 4. total exposure duration and Optison concentration. P- thresholds for hemolysis and ICD were approximately 0.5 MPa. ICD and hemolysis were detected at Optison concentrations >/= 0.01 V%, and with pulse durations as low as four or two cycles, respectively. Hemolysis and ICD evolved as functions of time and Optison concentration; final hemolysis and ICD values depended on initial Optison concentration, but initial rates of change did not. Within series, hemolysis was significantly correlated with ICD; across series, the correlation was significant at p < 0.001.

The pulse length-dependence of inertial cavitation dose and hemolysis

Gas-based ultrasound (US) contrast agents increase erythrocyte sonolysis, presumably via enhancing inertial cavitation (IC) activity. The amount of IC activity (IC "dose") and hemolysis generated by exposure to 1.15 MHz US were examined with different US pulse lengths, but with the same delivered acoustic energy, for Optison and Albunex. The hypotheses were that 1. at longer pulse lengths, IC would generate more bubbles that could nucleate additional IC activity; 2. if the interval between pulse pairs were short enough for the next pulse to hit derivative bubbles before their dissolution, more IC could be induced; and 3. hemolysis would be proportional to IC activity. Two types of studies were performed. In the first, bubble generation after each burst of IC activity was quantified using an active cavitation detector (ACD), for different pulse lengths (5, 10, 20, 30, 50, 100 or 200 cycles), but the same pressure level (3 MPa) and total "on" time (173.16 ms). Low concentrations of either Optison or Albunex were added into the tank with high-intensity and interrogating transducers orthogonal to each other. For pulse lengths > 100 cycles, and pulse repetition intervals < 5 ms, a "cascade" effect (explosive bubble generation) was observed. In the second, IC was measured by passive detection methods. IC dose and hemolysis were determined in whole blood samples at a pressure level (3 MPa) and interpulse interval (5 ms) that induced the "cascade" effect. Each blood sample was mixed with the same number of contrast microbubbles (Optison approximately 0.3 v/v % and Albunex approximately 0.5 v/v %), but exposed to different pulse lengths (5, 10, 20, 30, 50, 100 or 200 cycles). With Optison, up to 60% hemolysis was produced with long pulses (100 and 200 cycles), compared with < 10% with short pulses (5 and 10 cycles). Albunex generated considerably less IC activity and hemolysis. The r(2) value was 0.99 for the correlation between hemolysis and IC dose. High pulse-repetition frequency (PRF) (500 Hz) generated more hemolysis than the low PRF (200 Hz) at 3 MPa. All experimental results could be explained by the dissolution times of IC-generated bubbles.

Biological and environmental factors affecting ultrasound-induced hemolysis in vitro: medium tonicity

Whole human anticoagulated blood in vitro underwent controlled plasma replacement with either isotonic (0.9%) or hypotonic (0.5%) saline to 1. restore the blood to its original volume (which resulted in different hematocrits) or 2. bring the blood to a singular hematocrit (40%). The hypotonic cell MCVs were, on average, considerably larger than their isotonic counterpart by a ratio of 1.4:1. The blood samples were then subjected to two tests, one of mechanical fragility, the other to ultrasound (US)-induced hemolysis. The US exposure metrics were: 1.0-MHz center frequency, 200-micros pulse duration, 20-ms interpulse interval, exposure durations of 10 to 30 s in the presence of Albunex, as a control on blood gas nucleation, and exposure vessel rotation at 200 rpm. In all instances, the hypotonic blood displayed higher levels of hemolysis than the corresponding isotonic treatment. The highest ratio of US-induced hemolysis for the hypotonic:isotonic regimens was 2.2. In some instances, the ratio was somewhat less but appeared to be related to differences in whole blood viscosities among the regimens or other factors. The data supported the a priori hypothesis that hypotonicity will result in an increased tension on the cell membrane and render it more susceptible to shear-induced hemolysis, including exposure to US under conditions known to foster the occurrence of inertial cavitation. There was no temperature increase during the insonations of the blood.

Biological and environmental factors affecting ultrasound-induced hemolysis in vitro: 3. Antioxidant (Trolox) inclusion

This project tested the hypothesis that human erythrocytes pretreated with Trolox (a water-soluble analog of vitamin E) would be more susceptible to ultrasound (US)-induced hemolysis by a cavitational mechanism because of an increased fragility of the erythrocyte membrane over that without Trolox supplementation. Samples of whole human blood from apparently healthy donors (hematocrit approximately 40%) in vitro were supplemented or not supplemented with Trolox at various concentrations, ranging from 1.8 to 0.0018 mg/mL plasma. Mechanical fragility tests indicated the Trolox-treated blood in vitro exhibited greater hemolysis than untreated blood in vitro (p < 0.001). US exposures at comparable acoustic amplitude, pulse length and duty factor in the presence of the US contrast agent Albunex yielded differing results; at 1 MHz, the Trolox-supplemented blood had significantly greater hemolysis in vitro than non-Trolox-supplemented blood; at 3 MHz, there was a substantial reduction in hemolysis relative to that obtained at 1 MHz, and no statistically significant difference between the Trolox-supplemented and -unsupplemented blood. There was also essentially no support for an alternative hypothesis that the Trolox was functioning primarily as a pro-oxidant. These collective experimental results support the hypothesis and suggest duality in the functionality of membranous antioxidant inclusions or associations; they may foster protection against oxidative damage, yet render the cell less capable of withstanding mechanical stress.

Biological and environmental factors affecting ultrasound-induced hemolysis in vitro: 2. Medium dissolved gas (pO2) content

The data collected in this project supported the a priori hypothesis that the concentration of dissolved oxygen in whole human blood in vitro affected the extent of ultrasound (US)-induced hemolysis under conditions conducive to the occurrence of inertial cavitation. Aliquots of whole human blood in vitro with a relatively high O(2) level had statistically significantly more 1-MHz US-induced hemolysis than aliquots with a relatively low O(2) level in the presence of controlled gas nucleation (Albunex or ALX, supplementation), with US-induced hemolytic yields being substantially less at 2.2- and 3.5-MHz exposures or in the absence of ALX-supplementation at otherwise comparable acoustic pressures, pulse lengths and duty factors. Passive cavitation detection (pcd) measures indicated a linear relationship for hemolysis up to about 70% and pcd values (R(2) = 0.99).

Biological and environmental factors affecting ultrasound-induced hemolysis in vitro: 1. HIV macrocytosis (cell size)

This paper reports the results of a further test of the hypothesis that the extent of ultrasound (US)-induced cell lysis in the presence of a US contrast agent to enhance cavitational effects is a function of cell size. The present data support the hypothesis. Human adult erythrocytes in vitro derived from patients with HIV (n = 15) and apparently healthy individuals (n = 15) were compared for US-induced hemolysis in vitro. The anticoagulated whole blood from patients with HIV and macrocytic erythrocytes had significantly greater (p <0.0001) mean corpuscular volume (MCV) and a significantly greater (p <0.03) extent of US-induced hemolysis in vitro relative to blood from apparently normal, healthy individuals. As a control to determine if disease state (i.e., HIV infection per se) might be a contributing factor in US-induced hemolysis in vitro, the blood from patients with HIV and apparently normal MCVs (n = 15) was also tested against an additional population of apparently normal, healthy individuals (n = 15); there were no statistically significant differences in MCVs or US-induced hemolysis between the two groups (p >> 0.05). There were also no statistically significant differences in viscosities or hematocrits of the whole blood or plasma in vitro from HIV-macrocytic or apparently healthy individuals but, for all blood types, a pooled correlation existed between hematocrit and whole blood viscosity.

Microbubbles induce renal hemorrhage when exposed to diagnostic ultrasound in anesthetized rats

The generation of ultrasound (US) bioeffects using a clinical imaging system is controversial. We tested the hypothesis that the presence of microbubbles in the US field of a medical imager induces biologic effects. Both kidneys of anesthetized rats were insonified for 5 min using a medical imaging system after the administration of microbubbles. One kidney was insonified using a continuous mode (30 Hz) and the opposite kidney was insonified using an intermittent (1 Hz) technique. The microbubbles were exposed to three different transducer frequencies and four transducer output powers. After insonification, the animals were euthanized, the kidneys were removed and their gross appearance scored under "blinded" conditions using a defined scale. After the administration of microbubbles, US imaging of the kidney caused hemorrhage in the renal tissue. The severity and area of hemorrhage increased with an increase in the transducer power and a decrease in the transducer frequency. Intermittent insonification in the presence of microbubbles produced a greater degree of renal hemorrhage than continuous imaging techniques.

A comparison of the hemolytic potential of Optison and Albunex in whole human blood in vitro: acoustic pressure, ultrasound frequency, donor and passive cavitation detection considerations

This project tested the hypothesis that a "second-generation" ultrasound (US) contrast agent (Optison), offering extended echogenicity over that of its "first-generation" predecessor (Albunex), would have the greater potential for sonolysis of human erythrocytes in vitro. Whole human blood, obtained from apparently healthy donors, was anticoagulated and subsequently exposed in vitro to US in the presence of one of each or neither of the two US contrast agents. The US exposures were for 30 s and involved frequency (1.0, 2.2 and 3.4 MHz) and amplitude (approximately 2.8 to 0.38 MPa P(-)) regimens; pulse duration (200 micros) and interpulse interval (20 ms) were held constant. The data supported the hypothesis, with an overall ratio of approximately 2.5 for relative extent of background-corrected US-induced hemolysis of the Optison/Albunex regimens. Passive cavitation detection analyses corroborated the results obtained with hemolysis.

Comparative sensitivity of human fetal and adult erythrocytes to hemolysis by pulsed 1 MHz ultrasound

Human fetal and adult erythrocytes differ significantly in mean corpuscular volume (MCV), the fetal cells being larger than adult cells and diminishing in MCV as gestational age (GA) increases. Previous studies have shown that the sensitivity of erythrocytes from different species to lysis by mechanically applied shear stress increases as MCV increases. The tested hypotheses in the present project were: 1. fetal erythrocytes would be more sensitive to sonolysis than adult erythrocytes because of the former's larger size, and 2. erythrocyte sonolytic sensitivity would scale with MCV. Fetal and adult erythrocytes were resuspended to 40% hematocrit in oxygenated isotonic saline solution and 500 microL aliquots were exposed for 60 s to 200 micros bursts of 1-MHz ultrasound (US) (peak pressures: approximately 4.8 MPa positive, approximately 2.7 MPa negative; duty factor = 0.01), either with or without 3.6 volume % Albunex (ALX) present. Background-corrected hemolysis was indistinguishable from zero in sham-exposed fetal or adult erythrocyte suspensions. Without ALX, mean background-corrected US-induced hemolysis was significantly greater than zero for fetal and adult cells (0.42 +/- 0.15% vs. 0.62 +/- 0.15), but fetal cell lysis was not significantly greater than adult cell lysis. With ALX, US-induced hemolytic yields increased approximately 80-fold (fetal: 50.53 +/- 2.14; adult: 46.40 +/- 1.85%), and were significantly higher for fetal than for adult cells. There was also a statistically significant correlation between MCV and US-induced background-corrected hemolysis. Thus, the two hypotheses were supported.

Biological effects of ultrasound: development of safety guidelines. Part II: general review

In the 1920s, the availability of piezoelectric materials and electronic devices made it possible to produce ultrasound (US) in water at high amplitudes, so that it could be detected after propagation through large distances. Laboratory experiments with this new mechanical form of radiation showed that it was capable of producing an astonishing variety of physical, chemical and biologic effects. In this review, the early findings on bioeffects are discussed, especially those from experiments done in the first few decades, as well as the concepts employed in explaining them. Some recent findings are discussed also, noting how the old and the new are related. In the first few decades, bioeffects research was motivated partly by curiosity, and partly by the wish to increase the effectiveness and ensure the safety of therapeutic US. Beginning in the 1970s, the motivation has come also from the need for safety guidelines relevant to diagnostic US. Instrumentation was developed for measuring acoustic pressure in the fields of pulsed and focused US employed, and standards were established for specifying the fields of commercial equipment. Critical levels of US quantities were determined from laboratory experiments, together with biophysical analysis, for bioeffects produced by thermal and nonthermal mechanisms. These are the basis for safety advice and guidelines recommended or being considered by national, international, professional and governmental organizations.

The search for cavitation in vivo

Until the mid 1970s, it was generally assumed that, with the short pulses of ultrasound (US) used in medical diagnosis, there was little need for concern about the possibility of inertial cavitation in vivo. This assumption came into question when experimental evidence indicated that killing of fruit fly larvae by diagnostically relevant US was associated with the presence of gas in the respiratory apparatus of the organisms. Independent theoretical contributions by Flynn and Apfel in the early 1980s made it clear that complacency in regard to cavitation was not warranted. Later, the mammalian lung, as with larva, was shown to be particularly vulnerable when it contained air. Yet, overall evidence suggests that lung hemorrhage is not consistent with the classical picture of inertial cavitation. Most recently, however, hemolysis and hemorrhage associated with the use of contrast agents have provided nearly incontrovertible evidence of the occurrence of cavitation in vivo.

Comparative sensitivity of human and bovine erythrocytes to sonolysis by 1-MHz ultrasound

This project tested the hypothesis that human erythrocytes, being larger than bovine erythrocytes, would be the more sensitive to sonolysis induced by inertial cavitation. The rationale behind this hypothesis was an earlier demonstration that, among sized populations of erythrocytes, an inverse relation existed between erythrocyte volume and mechanically-induced shear forces in the surrounding medium; viz, the larger the cell, the less shear force required to rupture the cell's membrane. At low erythrocyte densities (i.e., approximately 5% hematocrit) the hypothesis was supported; at high cell densities (i.e., approximately 35% hematocrit) it was not supported. The data are consistent with an ultrasound (US)-induced symmetric implosion of affected gas nuclei as causing the effect at low cell densities; under such conditions there is ample spacing among cells for US-induced symmetric growth and collapse of gas nuclei and the concomitant production of radially-expanding shock waves (which lyse the cells); at high cell densities there is not sufficient spacing among cells for US-induced symmetric growth and collapse of bubbles and an alternative mechanism, possibly asymmetric bubble collapse, becomes operational.

Sonoporation of monolayer cells by diagnostic ultrasound activation of contrast-agent gas bodies

Human (A431 epidermoid carcinoma) cells were grown as monolayers on 5 microm thick Mylar sheets, which formed the upper window for a 1-mm thick, 23-mm diameter disc-shaped exposure chamber. A 3.5-MHz curved linear-array transducer was aimed upward at the chamber, 7 cm away, in a 37 degrees C water bath. The chamber contained phosphate-buffered saline (PBS) with 10 mg/mL fluorescent dextran and 1% Optison ultrasound (US) contrast agent. Significant fluorescent cell counts, indicative of membrane damage (i.e., sonoporation), up to about 10% of cells within a 1-mm diameter field of view, were noted for spectral Doppler and two-dimensional (2-D) scan mode with or without a tissue-mimicking phantom. The effect was only weakly dependent on pulse-repetition frequency or exposure duration, but was strongly dependent on contrast agent concentration below 2%. Thus, diagnostic US activation of contrast-agent gas bodies can produce cell membrane damage.

Erosion of artificial endothelia in vitro by pulsed ultrasound: acoustic pressure, frequency, membrane orientation and microbubble contrast agent dependence

The erosion of cells from fibroblast monolayers simulating the vascular endothelium by 20 micros pulses of ultrasound at 500 Hz PRF was studied in relation to the peak negative acoustic pressure (P-; 0.0-2.5 MPa), ultrasound (US) frequency (1.0, 2.1 or 3.5 MHz), orientation of the monolayer (i.e., simulating the sites of ultrasound entry/exit from a blood vessel) and the presence or absence of a microbubble contrast agent (3 Vol% Albunex). The a priori hypotheses were that erosion of the monolayers would: 1. arise due to insonation treatment, 2. arise as a consequence of cavitation activity and, thus, increase with increasing P- at constant frequency, and decrease with increasing frequency at constant P-, 3. be significantly increased by the presence of a microbubble contrast agent, and 4. have a weak dependence on monolayer orientation. The data support these hypotheses. Under the most severe exposure conditions used, most of the affected cells appeared to have been lysed; however, a substantial number of viable cells were dislodged from the monolayer surface.

Transient poration and cell surface receptor removal from human lymphocytes in vitro by 1 MHz ultrasound

The study objective was to gain insight into ultrasound-induced, sub-lytic cell surface modifications. Two primary hypotheses were tested by flow cytometric methods; viz., sonication will: 1. remove all or part of a specific cell surface marker in lymphocytes surviving insonation, and 2. induce transient pores in the cell membranes of some surviving cells. RPMI 1788 human lymphocytes were exposed in vitro to 1-MHz, continuous-wave ultrasound (approximately 8 W/cm2 ISP) for 30 s, which lysed approximately 50% of the cells. Insonation: 1. altered cell morphology, increasing the population of cells of reduced size but high structure (designated as population R2), many of which were nonviable, and diminishing the population of cells of large size and high structure (designated as population R1), most of which were viable, 2. diminished the fluorescence signal from the pan B lymphocyte marker CD19 in populations R1 and R2 to equivalent extents, and 3. increased by approximately 7-fold the number of transiently permeabilized cells in R1, as evidenced by simultaneous uptake of propidium iodide and fluorescein diacetate. The results indicate that ultrasound-induced CD19 removal from R1 cells can occur without accompanying gross membrane loss. The cell morphology/mortality shifts indicate that the ultrasound-induced morphological change is associated with lethal membrane poration, suggesting that the diminished CD19 fluorescence signal from insonated R2 cells arises partly by simultaneous loss of membrane fragments, CD19 and cytoplasm.

Ultrasound-induced cell lysis and sonoporation enhanced by contrast agents

The enhancement of ultrasound-induced cell destruction, lysis, and sonoporation in low cell concentration suspensions (2 x 10(5)/mL) by the presence of contrast agents (gas bubble to cell ratio = 230) was demonstrated using cervical cancer cells (HeLa S3) suspensions containing micron-size denatured albumin microspheres filled with air (Albunex) or octafluoropropane (Optison). The suspensions were insonificated by 2-MHz continuous or tone burst ultrasound in near field. The spatial peak-pressure amplitude was 0.2 MPa. The enhancement of cell destruction due to Optison was shown to be much higher than that due to Albunex for similar bubble concentration and ultrasound conditions. For tone burst exposures, significant lysis and sonoporation only occurred in the presence of a contrast agent. The majority of the bioeffects observed occurred in the first 5 min of exposure. The relationship between the enhancement of bioeffects and duty cycle of tone burst ultrasound appears to indicate that both stable gas spheres of contrast agents and cavitation nuclei created by the disruption of the gas spheres play a significant role in causing the bioeffects.

Sonolysis of Albunex-supplemented, 40% hematocrit human erythrocytes by pulsed 1-MHz ultrasound: pulse number, pulse duration and exposure vessel rotation dependence

The hypotheses tested were that sonolysis of erythrocytes in the presence of a gas-based ultrasound contrast agent in vitro will be related quantitatively to the duration and number of ultrasound pulses applied using a constant pulse repetition period and, at least qualitatively, to the total exposure duration (i.e., the product of pulse number x pulse duration). An objective was to determine the influence of sample rotation during insonation on the amount of hemolysis produced under these conditions. Human erythrocytes, suspended to 40% hematocrit in autologous plasma containing 3.6% (V:V) Albunex, were exposed/sham-exposed to 1-100 pulses of 1-MHz ultrasound (6.2 MPa peak positive, 3.6 MPa peak negative acoustic pressures; I(SPTP) approximately 800 W/cm2) using a 1-s pulse repetition period. Pulse durations ranged from 20-20,000 micros; samples were either stationary or rotated (200 rpm) during insonation. Hemolysis was independent of vessel rotation treatment at all tested pulse durations and pulse numbers. Levels of hemolysis statistically greater than in sham-exposed samples were obtained with > or = 50 pulses of 20 micros duration, and > or = 1 pulse of 200, 2000 or 20,000 micros duration. Hemolysis increased with increasing pulse number and pulse duration. Approximately equivalent levels of hemolysis were produced by different pulse number x pulse duration combinations, yielding the same total exposure duration.

Gas-body-based contrast agent enhances vascular bioeffects of 1.09 MHz ultrasound on mouse intestine

Anesthetized hairless mice were exposed to continuous or pulsed 1.09-MHz ultrasound with or without prior injection of a gas-body-based ultrasound contrast agent. Albunex at a dose of 10 mL/kg increased the production of intestinal hyperemia, petechia and hemorrhages by continuous ultrasound. For pulsed ultrasound, with 10 micros pulses and 0.01 duty cycle, petechiae were produced for exposures as low as 1 MPa spatial peak pressure amplitude with added gas bodies. The enhancement of petechiae production was robust for pulsed exposure; for example, at 2.8 MPa, an average of 227 petechiae was obtained with added gas bodies, which was 30 times more than without the agent. The production of petechia was roughly proportional to the dosage of Albunex for pulsed exposure. Results did not appear to be strongly dependent on pulsing parameters, but long bursts (0.1 s) were somewhat more effective than pulses (10 micros). The observed vascular bioeffects appeared to involve both thermal and nonthermal mechanisms for continuous exposure, but to result primarily from gas-body activation for pulsed exposure.

Frequency relationships for ultrasonic activation of free microbubbles, encapsulated microbubbles, and gas-filled micropores

The ultrasonic activation of free microbubbles, encapsulated microbubbles, and gas-filled micropores was explored using available linear theory. Encapsulated microbubbles, used in contrast agents for diagnostic ultrasound, have relatively high resonance frequencies and damping. At 2 MHz the resonance radii are 1.75 microns for free microbubbles, 4.0 microns for encapsulated microbubbles, and 1.84 microns for gas-filled micropores. Higher-pressure amplitudes are needed to elicit equivalent subharmonic, fundamental, or second-harmonic responses from the encapsulated microbubbles, and this behavior increases for higher frequencies. If an encapsulated microbubble becomes destabilized during exposure,the resulting liberated microbubble would be about twice the linear resonance size, which would be likely to produce subharmonic signals. Scattered signals used for medical imaging purposes may be indicative of bioeffects potential: The second harmonic signal is proportional to local shear stress for a microbubble on a boundary, and a strong subharmonic signal may imply destabilization and nucleation of free-microbubble cavitation activity. The potential for bioeffects from contrast agent gas bodies decreases rapidly with increasing frequency. This information should be valuable for understanding of the etiology of bioeffects related to contrast agents and for developing exposure indices and risk management strategies for their use in diagnostic ultrasound.

Sonochemicals increase the mutation frequency of V79 cells in vitro

Phosphate buffered saline (PBS) was insonated or sham-insonated (1 MHz, 35 W/cm2, continuous wave, 30 min) in rotating (200 rpm) sterile polystyrene culture tubes. After treatment, the PBS was used immediately to suspend washed Chinese hamster V79 cells in vitro. Cells were incubated in the PBS at 37 degrees C for 15 min and then transferred to complete growth medium. Some insonation regimens also involved the inclusion of Albunex (ALX; an ultrasound microbubble contrast agent) to enhance ultrasound-induced inertial cavitation. Following exposure to the pretreated PBS and 6 d of subculture in complete medium, the cells were assayed for plating efficiencies and mutation frequencies (resistance to 6-thioguanine). X-rays (3 Gy) served as a positive control. Cells exposed to insonated PBS with or without ALX or x-rays had statistically significantly elevated mean mutation frequencies (4.37+/-0.97, 4.54+/-1.00, and 24.28+/-3.83 mutant colonies/10(6) viable cells, respectively) relative to corresponding control regimens (ultrasound sham, 2.44+/-0.56; x-ray sham, 2.96+/-0.88 mutant colonies/10(6) viable cells. The data supported the hypothesis that sonochemicals resulting from inertial cavitation have mutagenic potential.

Biological Effects of Ultrasound. The Perceived Safety of Diagnostic Ultrasound Within the Context of Ultrasound Biophysics: A Personal Perspective

This brief review addresses the issue of health and safety from exposure to diagnostic ultrasound. The exemplary historical record of diagnostic ultrasound exposures is coupled with great patient benefit. However, the power outputs of clinical devices have been increasing over the past decade such that inertial cavitation seems reasonably likely to occur if appropriate gas nuclei are present. The use of microbubble contrast agents for certain diagnostic procedures ensures a well nucleated system. Under such conditions, the use of low signal output levels and short exam times will decrease the chance of cavitation related bioeffects.