Potential of computational models in personalized treatment of obstructive sleep apnea: a patient-specific partial 3D finite element study

The upper airway experiences mechanical loads during breathing. Obstructive sleep apnea is a very common sleep disorder, in which the normal function of the airway is compromised, enabling its collapse. Its treatment remains unsatisfactory with variable efficacy in the case of many surgeries. Finite element models of the upper airway to simulate the effects of various anatomic and physiologic manipulations on its mechanics could be helpful in predicting surgical success. Partial 3D finite element models based on patient-specific CT-scans were undertaken in a pilot study of 5 OSA patients. Upper airway soft tissues including the soft palate, hard palate, tongue, and pharyngeal wall were segmented around the midsagittal plane up to a width of 2.5 cm in the lateral direction. Simulations of surgical interventions such as Uvulopalatopharyngoplasty (UPPP), maxillo-mandibular advancement (MMA), palatal implants, and tongue implants have been performed. Our results showed that maxillo-mandibular advancement (MMA) surgery of 1 cm improved the critical closing pressure by at least 212.2%. Following MMA, the best improvement was seen via uvulopalatopharyngoplasty (UPPP), with an improvement of at least 19.12%. Palatal and tongue implants also offered a certain degree of improvement. Further, we observed possible interacting mechanisms that suggested simultaneous implementation of UPPP and tongue stiffening; and palatal and tongue stiffening could be beneficial. Our results suggest that computational modeling is a useful tool for analyzing the influence of anatomic and physiological manipulations on upper airway mechanics. The goal of personalized treatment in the case of OSA could be achieved with the use of computational modeling.

Macro-indentation testing of soft biological materials and assessment of hyper-elastic material models from inverse finite element analysis

Mechanical characterization of hydrogels and ultra-soft tissues is a challenging task both from an experimental and material parameter estimation perspective because they are much softer than many biological materials, ceramics, or polymers. The elastic modulus of such materials is within the 1 - 100 kPa range, behaving as a hyperelastic solid with strain hardening capability at large strains. In the current study, indentation experiments have been performed on agarose hydrogels, bovine liver, and bovine lymph node specimens. This work reports on the reliable determination of the elastic modulus by indentation experiments carried out at the macro-scale (mm) using a spherical indenter. However, parameter identification of the hyperelastic material properties usually requires an inverse finite element analysis due to the lack of an analytical contact model of the indentation test. Hence a comprehensive study on the spherical indentation of hyperelastic soft materials is carried out through robust computational analysis. Neo-Hookean and first-order Ogden hyperelastic material models were found to be most suitable. A case study on known anisotropic hyperelastic material showed the inability of the inverse finite element method to uniquely identify the whole material parameter set.

An Experiential Learning Opportunity in Norway: Computation for Bioengineering and Mechanical Engineering Students

The global learning initiative at Northeastern University is focused on fostering intercultural communication skills. The Dialogue of Civilization (DOC) program serves as a mechanism to achieve such a goal by offering faculty-led international experiences. In this paper, we have presented a detailed account of a DOC program that took place in Norway. The primary objective of the program was to teach mechanical engineering and bio-engineering students computational skills while stimulating critical thinking about the cultural and social aspects of technology and engineering in Norway. The program focused on two courses: a technical course and a special topics course. The technical course introduced students to finite element analysis, with practical applications and site visits in Norway to enhance experiential learning. In the special topics course, the interplay between modern technologies, like green energy, state policies, and the rights and traditions of the indigenous Sámi people was explored. The course highlighted both the progressive social policies in Norway and the historical discrimination against the Sámi. Student feedback was positive and experiential learning components such as guest lectures and site visits were particularly appreciated. Additional surveys showed that students' self-confidence was higher following the DOC program. In addition, female-identifying students had higher confidence in their future success after completion of this program as compared to their male-identifying counterparts. Our paper is expected to serve as a resource for educators seeking to integrate technical education with intercultural experiences and discussions on social and cultural impacts in engineering.

Fourier transform-based method for quantifying the three-dimensional orientation distribution of fibrous units

Several materials and tissues are characterized by a microstructure composed of fibrous units embedded in a ground matrix. In this paper, a novel three-dimensional (3D) Fourier transform-based method for quantifying the distribution of fiber orientations is presented. The method allows for an accurate identification of individual fiber families, their in-plane and out-of-plane dispersion, and showed fast computation times. We validated the method using artificially generated 3D images, in terms of fiber dispersion by considering the error between the standard deviation of the reconstructed and the prescribed distributions of the artificial fibers. In addition, we considered the measured mean orientation angles of the fibers and validated the robustness using a measure of fiber density. Finally, the method is employed to reconstruct a full 3D view of the distribution of collagen fiber orientations based on in vitro second harmonic generation microscopy of collagen fibers in human and mouse skin. The dispersion parameters of the reconstructed fiber network can be used to inform mechanical models of soft fiber-reinforced materials and biological tissues that account for non-symmetrical fiber dispersion.

Mechanical Behavior and Collagen Structure of Degenerative Mitral Valve Leaflets and a Finite Element Model of Primary Mitral Regurgitation

Degenerative mitral valve disease is the main cause of primary mitral regurgitation with two phenotypes: fibroelastic deficiency (FED) often with localized myxomatous degeneration and diffuse myxomatous degeneration or Barlow's disease. Myxomatous degeneration disrupts the microstructure of the mitral valve leaflets, particularly the collagen fibers, which affects the mechanical behavior of the leaflets. The present study uses biaxial mechanical tests and second harmonic generation microscopy to examine the mechanical behavior of Barlow and FED tissue. Three tissue samples were harvested from a FED patient and one sample is from a Barlow patient. Then we use an appropriate constitutive model by excluding the collagen fibers under compression. Finally, we built an FE model based on the echocardiography of patients diagnosed with FED and Barlow and the characterized material model and collagen fiber orientation. The Barlow sample and the FED sample from the most affected segment showed different mechanical behavior and collagen structure compared to the other two FED samples. The FE model showed very good agreement with echocardiography with 2.02±1.8 mm and 1.05±0.79 mm point-to-mesh distance errors for Barlow and FED patients, respectively. It has also been shown that the exclusion of collagen fibers under compression provides versatility for the material model; it behaves stiff in the belly region, preventing excessive bulging, while it behaves very softly in the commissures to facilitate folding. STATEMENT OF SIGNIFICANCE: None.

In Silico Analysis Provides Insights for Patient-Specific Annuloplasty in Barlow´s Disease

Objective

To predict the required mitral annular area reduction in patients with Barlow's disease to obtain a predefined leaflet area index by a novel in silico modeling method.

Methods

Three-dimensional echocardiography was used to create patient-specific mitral valve models of 8 patients diagnosed with Barlow's disease and bileaflet prolapse preoperatively. Six patients were also studied postoperatively in a finite element framework, to quantify the optimal coaptation area index. For the patient-specific finite element analyses, realistic papillary muscle and annular motion are incorporated, also for the in silico annuloplasty analyses. The annuloplasty ring size is reduced moderately until the optimal coaptation area index is achieved for each patient.

Results

The mean mitral annular area at end-diastole was reduced by 58 ± 7% postoperatively (P < .001), resulting in a postoperative coaptation area index of 20 ± 5%. To achieve the same coaptation area index with moderate annular reductions and no leaflet resection the annular reduction was 31 ± 6% (P < .001).

Conclusions

In silico analysis in selected patients diagnosed with Barlow's disease demonstrates that annuloplasty with only moderate annular reduction may be sufficient to achieve optimal coaptation as compared to conventional surgical procedures.

Mitral annulus strain by 3D echo reveals regional annular dysfunction in Barlow's disease

Background

Barlow's disease (BD) provides both diagnostic and therapeutic challenges. Annular dilation is typically seen in BD, however, data on regional deformation is lacking.

Purpose

We hypothesized that mitral annulus dilates non-homogenously during ventricular systole in BD. A method to calculate annular regional strain was developed and applied in a subset of BD patients and healthy controls.

Methods

Ten patients with BD and late systolic mitral regurgitation and nine healthy controls were studied. For each subject, the mitral annulus was segmented throughout the cardiac cycle using 3D echocardiography. Twelve evenly distributed geometrical points were annotated along the annular perimeter, enabling the creation of periodic degree-3 spline curves parameterized by arc length at each discrete time-frame. The motion of the mitral annulus was then acquired by assuming that heterogeneity in annular strain is small and finding the point-wise map that minimized the total displacement between the consecutive curves. Then, the end-diastolic annular curve was divided into 200 evenly distributed points around the annular perimeter, and the point-wise mapping was implemented to create a continuous movement of the discretized annulus throughout the cycle. Annular strain was then calculated for each individual line segment. The method presented herein is validated by comparing the strain between sonomicrometric crystals in pigs and the method described above. The timescale was normalized from ED (end-diastole) to mitral valve opening for each individual. The regional strains of the annulus were calculated with the ED configuration as reference.

Results

Hemodynamic data are presented in Table 1. In BD annulus area increased from 16.6±3.2 to 21.7±4.2 cm2 at end-diastole and peak systole, respectively (p&lt;0.001). In controls, annulus area at end-diastole and end-systole was 9.6±2.2 cm2 and 9.2±1.8 cm2, respectively (NS). Figure 1 demonstrates non-homogenous regional strain at peak systole, with the most severe deformation in the posteromedial region. In healthy controls, peak systolic strain was similar in all segments.

Conclusions

In the present study, we have applied a novel non-invasive method to demonstrate non-homogenous deformation of the mitral annulus in Barlow patients. On average, the most severe deformation was seen in the posteromedial region. This finding may reveal further insight into the mechanisms of late systolic mitral regurgitation in BD as well as the design of annuloplasty in the future.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Trond Mohn Foundation

Adiponectin Reduces Bone Stiffness: Verified in a Three-Dimensional Artificial Human Bone Model In Vitro

Primary human osteoblasts and osteoclasts incubated in a rotating coculture system without any scaffolding material, form bone-like tissue that may be used to evaluate effects of various compounds on mechanical strength. Circulating adiponectin has been found to be negatively associated with BMD and strength and was therefore assessed in this system. Osteospheres of human osteoblasts and osteoclasts were generated with and without adiponectin. The osteospheres were scanned using micro-computed tomography, the mechanical properties were tested by flat punch compression using nanoindentation equipment, and the cellular morphology characterized by microscopy. The association between autologously produced adiponectin and biomechanical properties was further evaluated by quantitation of adiponectin levels using quantitative polymerase chain reaction (qPCR) and immunoassays, and identification of stiffness by bending test of rat femurs. The molecular mechanisms were examined in vitro using human bone cells. Mechanical testing revealed that adiponectin induced a more compliant osteosphere compared with control. The osteospheres had a round, lobulated appearance with morphologically different areas; inner regions containing few cells embedded in a bone-like material surrounded by an external area with a higher cell quantity. The expression of adiponectin was found to correlate positively to ultimate bending moment and ultimate energy absorption and deflection, on the other hand, it correlated negatively to bending stiffness, indicating autocrine and/or paracrine effects of adiponectin in bone. Adiponectin enhanced proliferation and expression of collagen, leptin, and tumor necrosis factor-alpha in osteoblasts and stimulated proliferation, but not the functional activity of osteoclasts. Our results indicate that both administration of adiponectin during osteosphere production and in situ elevated levels of adiponectin in rat femurs, reduced stiffness of the bone tissues. An increase in undifferentiated cells and extracellular matrix proteins, such as collagen, may explain the reduced bone stiffness seen in the osteospheres treated with adiponectin.

Nanoindentation and finite element modelling of chitosan-alginate multilayer coated hydrogels

Composite soft materials are used as compounds for determining the effects of mechanical cues on cell behavior and cell encapsulation and for controlling drug release. The appropriate composite soft materials are conventionally prepared by selective deposition of polymers at the surface of an ionic hydrogel. In the present study we address the impact of a mechanically stratified two-layer structure of these materials on their overall mechanical characterization by applying a combination of nanoindentation, confocal microscopy and finite element modelling. We prepare covalent cross-linked hydrogels based on acrylamide (AAM) and including an anionic group, and impregnate them using a multilayer deposition strategy of alternating exposure to cationic chitosan and anionic alginate. The thickness of the chitosan-alginate layer on the hydrogels was determined to be 0.4 ± 0.05 μm for 4 bilayers, and 0.7 ± 0.1 μm for the 8 bilayer deposition procedure employing a fluorescently labelled chitosan and confocal microscopy. The force-indentation data for the AAM gels were highly reproducible, whereas 77% and 50% of the force-indentation data were reproducible following the 4 and 8 bilayer deposition. The main trends in the reproducible force-distance data were found to yield an apparent increased Young's modulus after the deposition. Finite element modelling showed that adaption of a homogeneous Young's modulus for the specimens with deposited layers yields approximately three times too low stiffness compared to the estimate of the mechanical properties of the outer part in the two-layered mechanical model. The thickness of the multilayer region determined by confocal microscopy was used in the model. This study shows that the mechanical layered property needs to be included in the interpretation of the nanoindentation data when there is a significant mechanical contrast.

Velocity profiles in the human ductus venosus: a numerical fluid structure interaction study

The veins distributing oxygenated blood from the placenta to the fetal body have been given much attention in clinical Doppler velocimetry studies, in particular the ductus venosus. The ductus venosus is embedded in the left liver lobe and connects the intra-abdominal portion of the umbilical vein (IUV) directly to the inferior vena cava, such that oxygenated blood can bypass the liver and flow directly to the fetal heart. In the current work, we have developed a mathematical model to assist the clinical assessment of volumetric flow rate at the inlet of the ductus venosus. With a robust estimate of the velocity profile shape coefficient (VC), the volumetric flow rate may be estimated as the product of the time-averaged cross-sectional area, the time-averaged cross-sectional maximum velocity and the VC. The time average quantities may be obtained from Doppler ultrasound measurements, whereas the VC may be estimated from numerical simulations. The mathematical model employs a 3D fluid structure interaction model of the bifurcation formed by the IUV, the ductus venosus and the left portal vein. Furthermore, the amniotic portion of the umbilical vein, the right liver lobe and the inferior vena cava were incorporated as lumped model boundary conditions for the fluid structure interaction model. A hyperelastic material is used to model the structural response of the vessel walls, based on recently available experimental data for the human IUV and ductus venous. A parametric study was constructed to investigate the VC at the ductus venosus inlet, based on a reference case for a human fetus at 36 weeks of gestation. The VC was found to be [Formula: see text] (Mean [Formula: see text] SD of parametric case study), which confirms previous studies in the literature on the VC at the ductus venosus inlet. Additionally, CFD simulations with rigid walls were performed on a subsection of the parametric case study, and only minor changes in the predicted VCs were observed compared to the FSI cases. In conclusion, the presented mathematical model is a promising tool for the assessment of ductus venosus Doppler velocimetry.

Smooth muscle in the human mitral valve: extent and implications for dynamic modelling

The mitral valve is increasingly been regarded as having dynamic and contractile capabilities, but the presence of muscle in the valve has been investigated to a limited extent. The aim of this study was to investigate the presence, architecture and phenotype of muscle in the human mitral valve. Twelve mitral valves were cut into strips, sectioned for histology, and the cut edges examined by microscope after staining included immunophenotyping. Smooth muscle bundles were present at the atrial side of the leaflets, and distinctly more in the anterior leaflet than in the posterior leaflet. The smooth muscle bundles extended up to two-thirds the distance from the annulus to the rim of the leaflets, and they ran in various directions, but seemingly mainly perpendicular to the annulus. The thickness and density of the bundles seemed to decrease with the distance from the annulus, and also in a radial direction from the centre portion of each leaflets attachment at the annulus towards the rim. Cross striation was not detected. Cardiac muscle in the left atrial wall extended into the annular base of the leaflets in close proximity to the annular border of the smooth muscle bundles in the leaflets. In conclusion, especially the anterior leaflet of the mitral valve seems to have a separate smooth muscle formed as a meshwork of bundles close to the atrial surface.

FSI simulation of asymmetric mitral valve dynamics during diastolic filling

In this article, we present a fluid-structure interaction algorithm accounting for the mutual interaction between two rigid bodies. The algorithm was used to perform a numerical simulation of mitral valve (MV) dynamics during diastolic filling. In numerical simulations of intraventricular flow and MV motion, the asymmetry of the leaflets is often neglected. In this study the MV was rendered as two rigid, asymmetric leaflets. The 2D simulations incorporated the dynamic interaction of blood flow and leaflet motion and an imposed subject-specific, transient left ventricular wall movement obtained from ultrasound recordings. By including the full Jacobian matrix in the algorithm, the speed of the simulation was enhanced by more than 20% compared to using a diagonal Jacobian matrix. Furthermore, our results indicate that important features of the flow field may not be predicted by the use of symmetric leaflets or in the absence of an adequate model for the left atrium.

Reduction in Wire Tension Caused by Wire Clamping and Wire Tensioner Removal: An Experimental Ilizarov Frame Study

The stability of an external ring fixator mainly depends on wire tension. Wire fixators should maintain the tension during both wire clamping to the ring and removal of the tensioner device. In the present study the loss in wire tension related to fixator clamping and wire tensioner removal using three different wire fixator designs was studied. The fixators were based on two different cannulated bolts and a washer. Effects from two different pretension levels in combination with three different bolt torque levels upon loss in wire tension were described. Emitted wire vibration frequency was used to assess the corresponding wire tension. Wire tension was determined after each wire fixator tightening and after the removal of the wire tensioner. Increased bolt torque led to a small decrease in tension for both pretension levels. A considerable higher tension loss was measured when removing the wire tensioner. In all cases, the combination of a new cannulated bolt and a washer maintained the highest tension.

Subject specific finite element analysis of implant stability for a cementless femoral stem

BACKGROUND

The primary stability of a cementless implant is crucial to ensure long term stability through osseointegration. In the present study we have examined how subject specific finite element models can be used to evaluate the stability of a cementless femoral stem.

METHODS

Micromotion on the bone-implant interface of a cementless stem was measured experimentally in six human cadaver femurs. Subject specific finite element models were built from computed tomography of the same femurs, and used to simulate the same load scenario used experimentally.

FINDINGS

Both experimental measurements and numerical analyses showed a tendency of increased rotational stability for bigger implants. Good correlation was found between measurements and calculated values of axial rotation (R(2)=0.74, P<0.001). The finite element models produced interface micromotion of the same magnitude as measured experimentally, with micromotion generally below 40 microm. Bigger femoral stems were found to decrease the micromotion in the experimental measurements. This tendency could not be recognised in the interface micromotion from the finite element models.

INTERPRETATION

The finite element models showed limited success in predicting interfacial micromotion, but reproduced a similar pattern of rotational stability for the implants as seen experimentally. Since rotation in retroversion is often the main concern when studying implant stability, subject specific finite element models could be employed for pre-clinical evaluation of implants.

Constitutive models for constrained compression of unimpacted and impacted human morselized bone grafts

Morselized corticocancellous bone (MCB) is widely used in revision surgery with and without impaction. In the current study material parameters for the nonlinear viscoelastic and plastic responses of impacted and unimpacted human MCBs were determined during constrained compression. These models may be useful in finite element analyses of surgical constructs involving impacted and unimpacted MCBs. MCB is impacted layer by layer in the femoral canal during revision surgery. The influence of different layers on the mechanical properties was therefore also examined by comparing the relaxation strength and elastic and plastic strains for bone pellets impacted in one and two layers during constrained compression of human MCB. The relaxation strength was found to increase significantly by 14% for two layer pellets compared to one layer pellets, and the plastic strains decreased significantly by 15%, while the elastic strains were similar.

Skin changes following minor trauma

BACKGROUND AND OBJECTIVE

Bruises are currently evaluated by visual inspection, and little is known about the first phase after injury. The temporal development of fresh injuries must be accurately described to be able to age bruises in a reliable manner. Color changes in a bruise caused by hemoglobin breakdown products will depend on the severity of the trauma, and thus on the local immune response in the skin. It is therefore important to relate the nature of the impact to the temporal tissue responses.

MATERIALS AND METHODS

Controlled injuries were inflicted on anesthetized domestic pigs. Trauma was induced either by a pendulum device, or by paintballs released using pressurized air. The speed of the projectiles was recorded using a high speed camera. Biopsies and reflection spectra (400-850 nm) were collected from normal and bruised skin. The experiments were approved by the national animal research authority.

RESULTS

The temporal development of the injury was found to depend strongly on the weight and speed of the object. Low speed, blunt objects did not cause persistent skin changes. However, deep muscular bleeding could be found in most cases. High speed, light weight objects caused a rapidly developing bruise. These bruises were fully developed within 15-20 minutes. No deep muscular hemorrhages were observed in those cases. White blood cells (neutrophilic granulocytes) could be found in biopsies from high speed injuries. The amount of white blood cells depended on the time between injury and collection of the biopsies.

CONCLUSION

Further investigations utilizing a larger range of object weight and velocities are required to be able to fully classify minor traumatic injuries. Preliminary results indicate that this can be achieved by controlled experiments using a porcine model. Reflectance spectroscopy was found to be a useful tool to study immediate skin reactions to the trauma.