Outpatient multimodal intravenous analgesia in patients undergoing day-case surgery: description of a three year experience.

BACKGROUND: The use of elastomeric devices for ambulatory intravenous pain treatment in Major Ambulatory Surgery (MAS) has been described to improve postoperative pain management. The objective of the study was to describe the first 3 years experience of the use of elastomeric devices for ambulatory intravenous pain treatment in MAS implemented at our site since 2010. METHODS: Data were retrieved from the medical records for all patients who, between January 2010 and March 2014, underwent surgical procedures at the ambulatory surgical centre at our hospital and were prescribed a home-based continuous intravenous analgesia. RESULTS: Data were retrieved from the medical records of 1128 patients. The most frequent surgical interventions included orthopedic and proctology surgeries. 80 % of patients were discharged home without pain; during the first 48 h after discharge roughly 40 % of subjects were completely free of pain, 50 % reported mild pain (VAS 1 to 3) and 9 % reported higher pain scores (4 and above). Peripheral nerve block was associated to better pain control in the immediate postoperative period. Vomiting in the first 24 h was 4.6 % before introducing haloperidol into the drug schemes, and 2.6 % thereafter. Complications related with the intravenous route required treatment withdrawal in 1.1 % cases. Only 3.5 % of patients returned to the hospital in the first 72 h, mainly for non-pain related reasons. Overall, 99.5 % of patients were satisfied with the treatment received at home. CONCLUSION: Our initial experience suggest that outpatient multimodal intravenous analgesia in patients undergoing day-case surgery is a feasible alternative in our setting, that allows an effective management of postoperative pain with a small rate of adverse events and complications requiring readmission.

Effect of structure, topography and chemistry on fibroblast adhesion and morphology.

Surface biofunctionalisation of many biodegradable polymers is one of the used strategies to improve the biological activity of such materials. In this work, the introduction of collagen type I over the surface of a biodegradable polymer (poly lactic acid) processed in the forms of films and fibers leads to an enhancing of the cellular adhesion of human dermal fibroblast when compared to unmodified polymer and biomolecule-physisorbed polymer surface. The change of topography of the material does not affect the cellular adhesion but results in a higher proliferation of the fibroblast cultured over the fibers. Moreover, the difference of topography governs the cellular morphology, i.e. cells adopt a more stretched conformation where cultured over the films while a more elongated with lower area morphology are obtained for the cells grown over the fibers. This study is relevant for designing and modifying different biodegradable polymers for their use as scaffolds for different applications in the field of Tissue Engineering and Regenerative Medicine.

Enhanced cell-material interactions through the biofunctionalization of polymeric surfaces with engineered peptides.

Research on surface modification of polymeric materials to guide the cellular activity in biomaterials designed for tissue engineering applications has mostly focused on the use of natural extracellular matrix (ECM) proteins and short peptides, such as RGD. However, the use of engineered proteins can gather the advantages of these strategies and avoid the main drawbacks. In this study, recombinant engineered proteins called elastin-like recombinamers (ELRs) have been used to functionalize poly(lactic) acid (PLA) model surfaces. The structure of the ELRs has been designed to include the integrin ligand RGDS and the cross-linking module VPGKG. Surface functionalization has been characterized and optimized by means of ELISA and atomic force microscopy (AFM). The results suggest that ELR functionalization creates a nonfouling canvas able to restrict unspecific adsorption of proteins. Moreover, AFM analysis reveals the conformation and disposition of ELRs on the surface. Biological performance of PLA surfaces functionalized with ELRs has been studied and compared with the use of short peptides. Cell response has been assessed for different functionalization conditions in the presence and absence of the bovine serum albumin (BSA) protein, which could interfere with the surface-cell interaction by adsorbing on the interface. Studies have shown that ELRs are able to elicit higher rates of cell attachment, stronger cell anchorages and faster levels of proliferation than peptides. This work has demonstrated that the use of engineered proteins is a more efficient strategy to guide the cellular activity than the use of short peptides, because they not only allow for better cell attachment and proliferation, but also can provide more complex properties such as the creation of nonfouling surfaces.

Control of microenvironmental cues with a smart biomaterial composite promotes endothelial progenitor cell angiogenesis.

Smart biomaterials play a key role when aiming at successful tissue repair by means of regenerative medicine approaches, and are expected to contain chemical as well as mechanical cues that will guide the regenerative process. Recent advances in the understanding of stem cell biology and mechanosensing have shed new light onto the importance of the local microenvironment in determining cell fate. Herein we report the biological properties of a bioactive, biodegradable calcium phosphate glass/polylactic acid composite biomaterial that promotes bone marrow-derived endothelial progenitor cell (EPC) mobilisation, differentiation and angiogenesis through the creation of a controlled bone healing-like microenvironment. The angiogenic response is triggered by biochemical and mechanical cues provided by the composite, which activate two synergistic cell signalling pathways: a biochemical one mediated by the calcium-sensing receptor and a mechanosensitive one regulated by non-muscle myosin II contraction. Together, these signals promote a synergistic response by activating EPCs-mediated VEGF and VEGFR-2 synthesis, which in turn promote progenitor cell homing, differentiation and tubulogenesis. These findings highlight the importance of controlling microenvironmental cues for stem/progenitor cell tissue engineering and offer exciting new therapeutical opportunities for biomaterial-based vascularisation approaches and clinical applications.

In silico evaluation of a new composite disc substitute with a L3-L5 lumbar spine finite element model.

When the intervertebral disc is removed to relieve chronic pain, subsequent segment stabilization should restore the functional mechanics of the native disc. Because of partially constrained motions and the lack of intrinsic rotational stiffness ball-on-socket implants present many disadvantages. Composite disc substitutes mimicking healthy disc structures should be able to assume the role expected for a disc substitute with fewer restrictions than ball-on-socket implants. A biomimetic composite disc prototype including artificial nucleus fibre-reinforced annulus and endplates was modelled as an L4-L5 disc substitute within a L3-L5 lumbar spine finite element model. Different device updates, i.e. changes of material properties fibre distributions and volume fractions and nucleus placements were proposed. Load- and displacement-controlled rotations were simulated with and without body weight applied. The original prototype reduced greatly the flexibility of the treated segment with significant adjacent level effects under displacement-controlled or hybrid rotations. Device updates allowed restoring large part of the global axial and sagittal rotational flexibility predicted with the intact model. Material properties played a major role, but some other updates were identified to potentially tune the device behaviour against specific motions. All device versions altered the coupled intersegmental shear deformations affecting facet joint contact through contact area displacements. Loads in the bony endplates adjacent to the implants increased as the implant stiffness decreased but did not appear to be a strong limitation for the implant biomechanical and mechanobiological functionality. In conclusion, numerical results given by biomimetic composite disc substitutes were encouraging with greater potential than that offered by ball-on-socket implants.

Hydroxyapatite nanorod-reinforced biodegradable poly(L-lactic acid) composites for bone plate applications.

Novel PLLA composite fibers containing hydroxyapatite (HAp) nanorods with or without surface lactic acid grafting were produced by extrusion for use as reinforcements in PLLA-based bone plates. Fibers containing 0-50% (w/w) HAp nanorods, aligned parallel to fiber axis, were extruded. Lactic acid surface grafting of HAp nanorods (lacHAp) improved the tensile properties of composites fibers better than the non-grafted ones (nHAp). Best tensile modulus values of 2.59, 2.49, and 4.12 GPa were obtained for loadings (w/w) with 30% lacHAp, 10% nHAp, and 50% amorphous HAp nanoparticles, respectively. Bone plates reinforced with parallel rows of these composite fibers were molded by melt pressing. The best compressive properties for plates were obtained with nHAp reinforcement (1.31 GPa Young's Modulus, 110.3 MPa compressive strength). In vitro testing with osteoblasts showed good cellular attachment and spreading on composite fibers. In situ degradation tests revealed faster degradation rates with increasing HAp content. To our knowledge, this is the first study containing calcium phosphate-polymer nanocomposite fibers for reinforcement of a biodegradable bone plate or other such implants and this biomimetic design was concluded to have potential for production of polymer-based biodegradable bone plates even for load bearing applications.

Self-hardening calcium deficient hydroxyapatite/gelatine foams for bone regeneration.

In this work gelatine was used as multifunctional additive to obtain injectable self-setting hydroxyapatite/gelatine composite foams for bone regeneration. The foaming and colloidal stabilization properties of gelatine are well known in food and pharmaceutical applications. Solid foams were obtained by foaming liquid gelatine solutions at 50 degrees C, followed by mixing them with a cement powder consisting of alpha tricalcium phosphate. Gelatine addition improved the cohesion and injectability of the cement paste. After setting the foamed paste transformed into a calcium deficient hydroxyapatite. The final porosity, pore interconnectivity and pore size were modulated by modifying the gelatine content in the liquid phase.

Poly-l/dl-lactic acid films functionalized with collagen IV as carrier substrata for corneal epithelial stem cells.

Limbal epithelial stem cells (LESCs) are responsible for the renewal of corneal epithelium. Cultivated limbal epithelial transplantation is the current treatment of choice for restoring the loss or dysfunction of LESCs. To perform this procedure, a substratum is necessary for in vitro culturing of limbal epithelial cells and their subsequent transplantation onto the ocular surface. In this work, we evaluated poly-L/DL-lactic acid 70:30 (PLA) films functionalized with type IV collagen (col IV) as potential in vitro carrier substrata for LESCs. We first demonstrated that PLA-col IV films were biocompatible and suitable for the proliferation of human corneal epithelial cells. Subsequently, limbal epithelial cell suspensions, isolated from human limbal rings, were cultivated using culture medium that did not contain animal components. The cells adhered significantly faster to PLA-col IV films than to tissue culture plastic (TCP). The mRNA expression levels for the LESC specific markers, K15, P63α and ABCG2 were similar or greater (significantly in the case of K15) in limbal epithelial cells cultured on PLA-col IV films than limbal epithelial cells cultured on TCP. The percentage of cells expressing the corneal (K3, K12) and the LESC (P63α, ABCG2) specific markers was similar for both substrata. These results suggest that the PLA-col IV films promoted LESC attachment and helped to maintain their undifferentiated stem cell phenotype. Consequently, these substrata offer an alternative for the transplantation of limbal cells onto the ocular surface.

Nanotechnology in regenerative medicine: the materials side.

Regenerative medicine is an emerging multidisciplinary field that aims to restore, maintain or enhance tissues and hence organ functions. Regeneration of tissues can be achieved by the combination of living cells, which will provide biological functionality, and materials, which act as scaffolds to support cell proliferation. Mammalian cells behave in vivo in response to the biological signals they receive from the surrounding environment, which is structured by nanometre-scaled components. Therefore, materials used in repairing the human body have to reproduce the correct signals that guide the cells towards a desirable behaviour. Nanotechnology is not only an excellent tool to produce material structures that mimic the biological ones but also holds the promise of providing efficient delivery systems. The application of nanotechnology to regenerative medicine is a wide issue and this short review will only focus on aspects of nanotechnology relevant to biomaterials science. Specifically, the fabrication of materials, such as nanoparticles and scaffolds for tissue engineering, and the nanopatterning of surfaces aimed at eliciting specific biological responses from the host tissue will be addressed.

Directional alignment of MG63 cells on polymer surfaces containing point microstructures.

MG63 cells cultured on regular arrays of point microstructures (posts and holes) are shown to preferentially align at certain angles to the pattern of the structures, at 0 degrees, 30 degrees, and 45 degrees in particular. The effect is found to be more pronounced for post rather than hole structures (although no significant difference is found for the angles the cells make to the holes or posts) and is thought to be due to the fact that the cells use the posts as anchorage points to hold themselves to the surface. It is also shown that cells preferentially align with the structures depending on the dimensions of the structures and the distance between neighboring structures. This is important when designing structured surfaces for cell-surface interaction studies for materials to be used in, for example, drug delivery or tissue engineering.

Mechanical and structural characterisation of completely degradable polylactic acid/calcium phosphate glass scaffolds.

This study involves the mechanical and structural characterisation of completely degradable scaffolds for tissue engineering applications. The scaffolds are a composite of polylactic acid (PLA) and a soluble calcium phosphate glass, and are thus completely degradable. A factorial experimental design was applied to optimise scaffold composition prior to simultaneous microtomography and micromechanical testing. Synchrotron X-ray microtomography combined with in situ micromechanical testing was performed to obtain three-dimensional (3D) images of the scaffolds under compression. The 3D reconstruction was converted into a finite element mesh which was validated by simulating a compression test and comparing it with experimental results. The experimental design reveals that larger glass particle and pore sizes reduce the stiffness of the scaffolds, and that the porosity is largely unaffected by changes in pore sizes or glass weight content. The porosity ranges between 93% and 96.5%, and the stiffness ranges between 50 and 200 kPa. X-ray projections show a homogeneous distribution of the glass particles within the PLA matrix, and illustrate pore-wall breakage under strain. The 3D reconstructions are used qualitatively to visualise the distribution of the phases of the composite material, and to follow pore deformation under compression. Quantitatively, scaffold porosity, pore interconnectivity and surface/volume ratios have been calculated. Finite element analysis revealed the stress and strain distribution in the scaffold under compression, and could be used in the future to characterise the mechanical properties of the scaffolds.

Factors affecting the structure and properties of an injectable self-setting calcium phosphate foam.

One of the main challenges in the investigation on calcium phosphate cements (CPC) lies in the introduction of macroporosity, without loosing the self-setting ability and injectability, characteristic of the cement-type materials. The benefits of macroporosity are related to the enhancement of bone regeneration mechanisms, such as angiogenesis and tissue ingrowth. In this work, the feasibility to obtain self-setting injectable macroporous hydroxyapatite foams by the incorporation of a protein-based foaming agent to a CPC is demonstrated. Albumen is combined with an alpha-tricalcium phosphate [Ca3(PO4)2, alpha-TCP] paste, which hydrolyzes to a calcium deficient hydroxyapatite during the setting reaction. A systematic study is presented, where the effect of different processing parameters is analyzed in terms of porosity, setting properties, injectability, and compressive strength. Self-setting foams with porosities up to 70%, which maintain their porous structure after injection, are obtained. These injectable foams can be used both for direct in vivo applications and for the fabrication of low temperature tissue engineering scaffolds.

Nanoembossed polymer substrates for biomedical surface interaction studies.

Biomedical devices are moving towards the incorporation of nanostructures to investigate the interactions of biological species with such topological surfaces found in nature. Good optical transparency and sealing properties, low fabrication cost, fast design realization times, and biocompatibility make polymers excellent candidates for the production of surfaces containing such nanometric structures. In this work, a method for the production of nanostructures in free-standing sheets of different thermoplastic polymers is presented, with a view to using these substrates in biomedical cell-surface applications where optical microscopy techniques are required. The process conditions for the production of these structures in poly(methyl methacrylate), poly(ethylene naphthalate), poly(lactic acid), poly(styrene), and poly(ethyl ether ketone) are given. The fabrication method used is based on a modified nanoimprint lithography (NIL) technique using silicon based moulds, fabricated via reactive ion etching or focused ion beam lithography, to emboss nanostructures into the surface of the biologically compatible thermoplastic polymers. The method presented here is designed to faithfully replicate the nanostructures in the mould while maximising the mould lifetime. Examples of polymer replicas with nanostructures of different topographies are presented in poly(methyl methacrylate), including nanostructures for use in cell-surface interactions and nanostructure-containing microfluidic devices.

The effect of shot blasting and heat treatment on the fatigue behavior of titanium for dental implant applications.

OBJECTIVES: The effect of shot blasting treatment on the cyclic deformation and fracture behavior of a commercial pure titanium with two different microstructures; equiaxed (alpha-phase) and acicular (martensitic alpha'-phase) was investigated. METHODS: Fatigue tests were carried out in artificial saliva at 37 degrees C. Cyclic deformation tests were carried out up to fracture and fatigue crack nucleation and propagation were analysed. Residual stresses were determined by means of X-ray diffraction. RESULTS: The results show that shot blasting treatment improves fatigue life in the different microstructures studied. The equiaxed phase has improved mechanical properties compared to the acicular one. Despite the fact that control of the variables of shot blasting is not precise because of the nature of the treatment, it improves the fatigue life by the fact that the initiation site of the fatigue crack changes from the surface of the specimen to the interior of the shot blasted specimen. This is a consequence of the layer of compressive residual stresses that the treatment generates on titanium surfaces. The acicular morphology of the martensite favors crack propagation along the interface of the alpha' plates. SIGNIFICANCE: Shot blasting, which is widely used on titanium dental implants in order to favour their osseointegration, can also improve their fatigue resistance.

Fast-degrading PLA/ORMOGLASS fibrous composite scaffold leads to a calcium-rich angiogenic environment.

The success of scaffold implantation in acellular tissue engineering approaches relies on the ability of the material to interact properly with the biological environment. This behavior mainly depends on the design of the graft surface and, more precisely, on its capacity to biodegrade in a well-defined manner (nature of ions released, surface-to-volume ratio, dissolution profile of this release, rate of material resorption, and preservation of mechanical properties). The assessment of the biological behavior of temporary templates is therefore very important in tissue engineering, especially for composites, which usually exhibit complicated degradation behavior. Here, blended polylactic acid (PLA) calcium phosphate ORMOGLASS (organically modified glass) nanofibrous mats have been incubated up to 4 weeks in physiological simulated conditions, and their morphological, topographical, and chemical changes have been investigated. The results showed that a significant loss of inorganic phase occurred at the beginning of the immersion and the ORMOGLASS maintained a stable composition afterward throughout the degradation period. As a whole, the nanostructured scaffolds underwent fast and heterogeneous degradation. This study reveals that an angiogenic calcium-rich environment can be achieved through fast-degrading ORMOGLASS/PLA blended fibers, which seems to be an excellent alternative for guided bone regeneration.

The proangiogenic potential of a novel calcium releasing composite biomaterial: Orthotopic in vivo evaluation.

Insufficient angiogenesis remains a major hurdle in current bone tissue engineering strategies. An extensive body of work has focused on the use of angiogenic factors or endothelial progenitor cells. However, these approaches are inherently complex, in terms of regulatory and methodologic implementation, and present a high cost. We have recently demonstrate the potential of electrospun poly(lactic acid) (PLA) fiber-based membranes, containing calcium phosphate (CaP) ormoglass particles, to elicit angiogenesis in vivo, in a subcutaneous model in mice. Here we have devised an injectable composite, containing CaP glass-ceramic particles, dispersed within a (Hydroxypropyl)methyl cellulose (HPMC) matrix, with the capacity to release calcium in a more sustained fashion. We show that by tuning the release of calcium in vivo, in a rat bone defect model, we could improve both bone formation and increase angiogenesis. The bone regeneration kinetics was dependent on the Ca2+ release rate, with the faster Ca2+ release composite gel showing improved bone repair at 3weeks, in relation to control. In the same line, improved angiogenesis could be observed for the same gel formulation at 6weeks post implantation. This methodology allows to integrate two fundamental processes for bone tissue regeneration while using a simple, cost effective, and safe approach. STATEMENT OF SIGNIFICANCE: In current bone tissue engineering approaches the achievement of sufficient angiogenesis, during tissue regeneration, is a major limitation in order to attain full tissue functionality. Recently, we have shown that calcium ions, released by the degradation of calcium phosphate ormoglasses (CaP), are effective angiogenic promoters, in both in vitro and in a subcutaneous implantation model. Here, we devised an injectable composite, containing CaP glass-ceramic particles, dispersed within a HPMC matrix, enabling the release of calcium in a more sustained fashion. We show that by tuning the release of calcium in vivo, in a rat bone defect model, we could improve both bone formation and increase angiogenesis. This simple and cost effective approach holds great promise to translate to the clinics.

Calcium phosphate cements: competitive drug carriers for the musculoskeletal system?

This paper attempts to provide an insight in the application of calcium phosphate cements (CPC) in the field of drug delivery devices for the musculoskeletal system. Their ability to set once implanted within the body, giving a highly microporous material, allows incorporation of many types of drugs and biologically active molecules, without losing activity and denaturalization. Additionally, by being injectable these materials can be used in the growing market for new technologies of minimally invasive surgery, and in the treatment of difficult accessible sites. All these characteristics, together with the excellent biological behaviour of CPC, make them good candidates for drug delivery devices to be used in the pharmacological treatment of a great number of diseases of the bone tissue.

Micro-finite element models of bone tissue-engineering scaffolds.

Tissue engineering is an emerging area in bioengineering at the frontiers between biomaterials, biology and biomechanics. The basic knowledge of the interactions between mechanical stimuli, cells and biomaterials is growing but the quantitative effect of mechanical stimuli on cells attached to biomaterials is still unknown. The objective of this study was to develop finite element models of various bone scaffolds based on calcium phosphate in order to calculate the load transfer from the biomaterial structure to the biological entities. Samples of porous calcium phosphate bone cement and biodegradable glass were scanned using micro-CT to determine the overall macroporosity, architecture and to develop finite element models of such materials. Compressive loads were applied on the models to simulate the in vitro environment of a bioreactor and stress and strain distributions were calculated. It was found that the effective Young's modulus was linearly related to the sample macroporosity. Results suggest that a 0.5% overall compressive strain can produce internal strain of the same order of magnitude as found in previous in vitro mechanically cell-strained studies or in mechanoregulation studies. Stress and strain concentrations due to the porous structures are possible candidate for favouring cell differentiation. Although strain distributions were similar between bone cement and porous glass, the stress distribution is clearly different. Future in vitro results could correlate the results obtained with such finite element study to explain the influence of mechanical stimuli on cell behaviour.

Transparent micro- and nanopatterned poly(lactic acid) for biomedical applications.

The formation of structures in poly(lactic acid) has been investigated with respect to producing areas of regular, superficial features with dimensions comparable to those of cells or biological macromolecules. Nanoembossing, a novel method of pattern replication in polymers, has been used for the production of features ranging from tens of micrometers, covering areas up to 1 cm(2), down to hundreds of nanometers. Both micro- and nanostructures are faithfully replicated. Contact-angle measurements suggest that positive microstructuring of the polymer (where features protrude from the polymer surface) produces a more hydrophilic surface than negative microstructuring. The ability to structure the surface of the poly(lactic acid), allied to the polymer's postprocessing transparency and proven biocompatibility, means that thin films produced in this way will be useful for bioengineers studying the interaction of micro- and nanodimensioned features with biological specimen, with regard to tissue engineering, for example.

The proangiogenic potential of a novel calcium releasing biomaterial: Impact on cell recruitment.

In current bone tissue engineering strategies the achievement of sufficient angiogenesis during tissue regeneration is still a major limitation in order to attain full functionality. Several strategies have been described to tackle this problem, mainly by the use of angiogenic factors or endothelial progenitor cells. However, when facing a clinical scenario these approaches are inherently complex and present a high cost. As such, more cost effective alternatives are awaited. Here, we demonstrate the potential of electrospun poly(lactic acid) (PLA) fiber-based membranes, containing calcium phosphate ormoglass (CaP) particles, to elicit angiogenesis in vivo, in a subcutaneous model in mice. We show that the current approach elicited the local expression of angiogenic factors, associated to a chemotactic effect on macrophages, and sustained angiogenesis into the biomaterial. As both PLA and CaP are currently accepted for clinical application these off-the-shelf novel membranes have great potential for guided bone regeneration applications. STATEMENT OF SIGNIFICANCE: In current bone tissue engineering approaches the achievement of sufficient angiogenesis, during tissue regeneration, is a major limitation in order to attain full tissue functionality. Recently, our group has found that calcium ions released by the degradation of calcium phosphate ormoglasses (CaP) are effective angiogenic promoters. Based on this, in this work we successfully produced hybrid fibrous mats with different contents of CaP nanoparticles and thus with different calcium ion release rates, using an ormoglass - poly(lactic acid) blend approach. We show that these matrices, upon implantation in a subcutaneous site, could elicit the local expression of angiogenic factors, associated to a chemotactic effect on macrophages, and sustained angiogenesis into the biomaterial, in a CaP dose dependent manner. This off-the-shelf cost effective approach presents great potential to translate to the clinics.