Joseph E. Hayward

Optimal Time Delay between Epinephrine Injection and Incision to Minimize Bleeding

Background: The time until maximal cutaneous vasoconstriction after injection of lidocaine with epinephrine is often given in textbooks and multiple choice examinations as 7 to 10 minutes. However, in our experience, there is significantly less cutaneous bleeding if one waits considerably longer than 7 to 10 minutes after injection of local anesthesia with epinephrine for most procedures on human skin. Methods: This was a prospective, randomized, triple-blind study where 12 volunteers were injected simultaneously in each arm with either 1% lidocaine with epinephrine (study group) or 1% plain lidocaine (control group), after which the relative hemoglobin concentration of the underlying skin and soft tissues was measured over time using spectroscopy. Results: In the epinephrine group, the mean time at which the lowest cutaneous hemoglobin level was obtained was 25.9 minutes (95 percent CI, 25.9 ± 5.1 minutes). This was significantly longer than the historical literature values of 7 to 10 minutes for maximum vasoconstriction after injection. Mean hemoglobin index values at every time measurement after postinjection minute 1 were significantly different between the study group and the control group, with use of a two-tailed paired t test (p < 0.01). Conclusions: If optimal visualization is desired, the ideal time for the surgeon to begin the incision should be 25 minutes after injection of local anesthetic with epinephrine. It takes considerably longer than 7 to 10 minutes for a new local equilibrium to be obtained in relation to hemoglobin quantity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Haemoglobin oxygenation of a two-layer tissue-simulating phantom from time-resolved reflectance: effect of top layer thickness

A dual wavelength time-resolved reflectance system was developed for monitoring haemoglobin saturation noninvasively. At each wavelength, the time-resolved reflectance data were fitted to a diffusion model of light propagation in a homogeneous, semi-infinite medium to yield the absolute scattering and absorption coefficients. The absorption coefficients were then used to calculate haemoglobin saturation. A two-layer phantom containing human erythrocytes in a scattering solution in the bottom layer was used to study system performance under more realistic conditions. The top layer was chosen to simulate either skin or fat and the oxygenation of the bottom layer, which corresponded to muscle, was controlled. The thickness of the fat layer was varied from 1.5 to 10 mm to investigate the effects of increasing the top layer thickness. These results, obtained with the simple diffusion model, were compared with simultaneous measurements of oxygenation made directly in the bottom layer. Errors in estimating haemoglobin saturation with this method ranged from 5-11% depending on the thickness of the top layer and its optical properties.

Hyperspectral fluorescence lifetime imaging for optical biopsy

Abstract. A hyperspectral fluorescence lifetime imaging (FLIM) instrument is developed to study endogenous fluorophores in biological tissue as an optical biopsy tool. This instrument is able to spectrally, temporally, and spatially resolve fluorescence signal, thus providing multidimensional information to assist clinical tissue diagnosis. An acousto-optic tunable filter (AOTF) is used to realize rapid wavelength switch, and a photomultiplier tube and a high-speed digitizer are used to collect the time-resolved fluorescence decay at each wavelength in real time. The performance of this instrument has been characterized and validated on fluorescence tissue phantoms and fresh porcine skin specimens. This dual-arm AOTF design achieves high spectral throughput while allowing microsecond nonsequential, random wavelength switching, which is highly desirable for time-critical applications. In the results reported here, a motorized scanning stage is used to realize spatial scanning for two-dimensional images, while a rapid beam steering technique is feasible and being developed in an ongoing project.

Composite depth dose measurement for total skin electron (TSE) treatments using radiochromic film

Total skin electron (TSE) radiotherapy is routinely used to treat cutaneous T-cell lymphomas and can be implemented using a modified Stanford technique. In our centre, the composite depth dose for this technique is achieved by a combination of two patient positions per day over a three-day cycle, and two gantry angles per patient position. Due to patient morphology, underdosed regions typically occur and have historically been measured using multiple thermoluminescent dosimeters (TLDs). We show that radiochromic film can be used as a two-dimensional relative dosimeter to measure the percent depth dose in TSE radiotherapy. Composite depth dose curves were measured in a cylindrical, polystyrene phantom and compared with TLD data. Both multiple films (1 film per day) and a single film were used in order to reproduce a realistic clinical scenario. First, three individual films were used to measure the depth dose, one per treatment day, and then compared with TLD data; this comparison showed a reasonable agreement. Secondly, a single film was used to measure the dose delivered over three daily treatments and then compared with TLD data; this comparison showed good agreement throughout the depth dose, which includes doses well below 1 Gy. It will be shown that one piece of radiochromic film is sufficient to measure the composite percent depth dose for a TSE beam, hence making radiochromic film a suitable candidate for monitoring underdosed patient regions.

Characterization of Fluorescence Lifetime of Photofrin and Delta-Aminolevulinic Acid Induced Protoporphyrin IX in Living Cells Using Single- and Two-Photon Excitation

Photodynamic therapy (PDT) is an effective treatment option for various types of invasive tumors. The efficacy of PDT treatment depends strongly on selective cell uptake and selective excitation of the tumor. The characterization of fluorescence lifetimes of photosensitizers localized inside living cells may provide the basis for further investigation of in vivo PDT dosage measurements using time-domain spectroscopy and imaging. In this communication, we investigated the fluorescence lifetime of localized Photofrin and delta-aminolevulinic acid (ALA) induced protoporphyrin IX (PpIX) in living MAT-LyLu (MLL) rat prostate adenocarcinoma cells. The MLL cells were incubated with the photosensitizers, and then treated with light under well-oxygenated conditions using a two-photon fluorescence lifetime imaging microscope (FLIM). Fluorescence lifetime images of these cells were recorded with average lifetimes of 5.5 plusmn 1.2 ns for Photofrin and 6.3 plusmn 1.2 ns for ALA-induced PpIX. When localized in cells, the lifetimes of both photosensitizers were found to be significantly shorter than those measured in organic solutions. The result for PpIX is consistent with literature values, while the lifetime of Photofrin is shorter than what has been reported. These results suggest that time-domain methods measuring photosensitizer lifetime changes may be good candidates for in vivo PDT dosage monitoring.

Monitoring photosensitizer uptake using two photon fluorescence lifetime imaging microscopy.

Photodynamic Therapy (PDT) provides an opportunity for treatment of various invasive tumors by the use of a cancer targeting photosensitizing agent and light of specific wavelengths. However, real-time monitoring of drug localization is desirable because the induction of the phototoxic effect relies on interplay between the dosage of localized drug and light. Fluorescence emission in PDT may be used to monitor the uptake process but fluorescence intensity is subject to variability due to scattering and absorption; the addition of fluorescence lifetime may be beneficial to probe site-specific drug-molecular interactions and cell damage. We investigated the fluorescence lifetime changes of Photofrin® at various intracellular components in the Mat-LyLu (MLL) cell line. The fluorescence decays were analyzed using a bi-exponential model, followed by segmentation analysis of lifetime parameters. When Photofrin® was localized at the cell membrane, the slow lifetime component was found to be significantly shorter (4.3 ± 0.5 ns) compared to those at other locations (cytoplasm: 7.3 ± 0.3 ns; mitochondria: 7.0 ± 0.2 ns, p < 0.05).

Fiber-optic probe design and optical property recovery algorithm for optical biopsy of brain tissue

Abstract. Optical biopsy techniques offer a minimally invasive, real-time alternative to traditional biopsy and pathology during tumor resection surgery. Diffuse reflectance spectroscopy (DRS) is a commonly used technique in optical biopsy. Optical property recovery from spatially resolved DRS data allows quantification of the scattering and absorption properties of tissue. Monte Carlo simulation methods were used to evaluate a unique fiber-optic probe design for a DRS instrument to be used specifically for optical biopsy of the brain. The probe diameter was kept to a minimum to allow usage in small surgical cavities at least 1 cm in diameter. Simulations showed that the close proximity of fibers to the edge of the probe resulted in boundary effects due to reflection of photons from the surrounding air–tissue interface. A new algorithm for rapid optical property recovery was developed that accounts for this reflection and therefore overcomes these effects. The parameters of the algorithm were adjusted for use over the wide range of optical properties encountered in brain tissue, and its precision was evaluated by subjecting it to random noise. This algorithm can be adapted to work with any probe geometry to allow optical property recovery in small surgical cavities.

Porcine cortical bone ablation by ultrashort pulsed laser irradiation.

Ultrashort pulsed lasers in bone ablation show promise for many orthopedic applications. To minimize collateral tissue damage and control the ablation process, the ablation threshold fluence must be well characterized. Using an amplified femtosecond laser (170 fs, 800 nm, 1 kHz), the ablation threshold on unaltered porcine cortical bone was measured using the D(2) method at multiple incident pulse numbers ranging from 25 to 1000 pulses per spot. The lowered threshold at greater pulse numbers indicated an incubation effect. Using a power law model, the incubation coefficient of unaltered porcine cortical bone was found to be 0.89 ± 0.03. Through extrapolation, the single-pulse ablation threshold was found to be 3.29 ± 0.14 J/cm(2).

High-sensitivity transient spectroscopy using tunable diode lasers

Experimental techniques have been developed to monitor transient infrared absorptions using lead-salt tunable diode lasers. The techniques are easily implemented, yield sensitivities which are limited by detector noise at 10−5 level of absorbance, and have a response time on the order of one microsecond. The transient absorption detection techniques are high frequency versions of the sweep integration technique pioneered by Jennings [Appl. Opt.19, 2695 (1980)]. TDL modulation rates of 100 kHz and 500 kHz allow for absorption sampling rates of 200 kHz and 1 MHz, respectively. In order to reproducibly achieve near-detector-noise-limited sensitivities for 100 kHz TDL modulation rates, an automated analog subtraction circuit has been developed which removes the effects of minor TDL power variations. At the 500 kHz modulation rate, digital filtering techniques are used to remove the effects of this power variation.

Measurements of extrinsic fluorescence in Intralipid and polystyrene microspheres

The fluorescence of Intralipid and polystyrene microspheres with sphere diameter of 1 µm at a representative lipid and microsphere concentration for simulation of mucosal tissue scattering has not been a subject of extensive experimental study. In order to elucidate the quantitative relationship between lipid and microsphere concentration and the respective fluorescent intensity, the extrinsic fluorescence spectra between 360 nm and 650 nm (step size of 5 nm) were measured at different lipid concentrations (from 0.25% to 5%) and different microsphere concentrations (0.00364, 0.0073, 0.0131 spheres per cubic micrometer) using laser excitation at 355 nm with pulse energy of 2.8 µJ. Current findings indicated that Intralipid has a broadband emission between 360 and 650 nm with a primary peak at 500 nm and a secondary peak at 450 nm while polystyrene microspheres have a single peak at 500 nm. In addition, for similar scattering properties the fluorescence of Intralipid solutions is approximately three-fold stronger than that of the microsphere solutions. Furthermore, Intralipid phantoms with lipid concentrations ~2% (simulating the bottom layer of mucosa) produce up to seven times stronger fluorescent emission than phantoms with lipid concentration ~0.25% (simulating the top layer of mucosa). The fluoresence decays of Intralipid and microsphere solutions were also recorded for estimation of fluorescence lifetime.