Developing an innovative national ACP-OSCE program in Taiwan: a mixed method study.

OBJECTIVES: To evaluate the process and the comprehensiveness of advance care planning (ACP), we designed a national ACP-OSCE (Objective Structured Clinical Examination) program. METHODS: The program was designed as a 40-minute OSCE test. Participants were categorized as different ACP team members to illustrate realistic scenarios. Preceptors were asked to observe ACP professionals' actions, responses, and communication skills during ACP with standardized patients (SP) through a one-way mirror. Participants' communication skills, medical expertise, legal knowledge, empathetic response and problem-solving skills of ACP were also self-evaluated before and after OSCE. Thematic analysis was used for qualitative analysis. RESULTS: In Nov 2019, a total of 18 ACP teams with 38 ACP professionals completed the ACP-OSCE program, including 15 physicians, 15 nurses, 5 social workers, and 3 psychologists. After the ACP-OSCE program, the average score of communication skills, medical expertise, legal knowledge, empathetic response, ACP problem-solving all increased. Nurses felt improved in medical expertise, legal knowledge, and problem-solving skills, psychologists and social workers felt improved in legal knowledge, while physicians felt no improved in all domain, statistically. Thematic analysis showed professional skills, doctoral-patient communication, benefit and difficulties of ACP were the topics which participants care about. Meanwhile, most participants agreed that ACP-OSCE program is an appropriate educational tool. CONCLUSION: This is the first national ACP-OSCE program in Asia. We believe that this ACP-OSCE program could be applied in other countries to improve the ACP process and quality.

Novel light delivery method for performing transbronchial photodynamic therapy ablation to treat peripheral lung cancer: A pilot study.

BACKGROUND: Photodynamic therapy involves using a photosensitizer with l illumination and is recommended for treating early, centrally located lung cancers, but it is not a standard treatment for peripheral lung tumor.. We previously proposed a novel light delivery method, in which lipiodol is perfused into the bronchial tree to increase the scope of illumination via the fiber effect. Herein, we attempted this novel technique under electromagnetic bronchoscope guidance in a hybrid operation room where lipiodol facilitated light diffusion, and evaluated the effectiveness and feasibility of this technique for peripheral lung cancers. METHODS: This phase 0 pilot study included three patients with peripheral lung cancers (primary tumors ≤20-mm diameter). The photodynamic therapy was administered using Porfimer sodium as the photosensitizer, and an electromagnetic navigation bronchoscope in a hybrid operating room to guide the catheter to the tumor. This facilitated lipiodol infusion to encase the tumor and permit the transbronchial photodynamic therapy ablation. RESULTS: Administering 630 nm 200 J/cm (400mW/500sec) energy through a 3-cm cylindrical diffusing laser fiber was safe; no significant acute complications were observed. Although the treatment outcome was unsatisfactory due to the low light dose, tumor pathology in one case revealed tumor necrosis, with no significant damage to the surrounding lung tissue. CONCLUSIONS: Novel light delivery transbronchial photodynamic therapy ablation for peripheral lung tumors is feasible and safe. Additional clinical trials may help determine the best illumination plan and light dose through multiple deliveries from multiple angles.

Electrospun Tissue-Engineered Arterial Graft Thickness Affects Long-Term Composition and Mechanics.

Wall stress is often lower in tissue-engineered constructs than in comparable native tissues due to the use of stiff polymeric materials having thicker walls. In this work, we sought to design a murine arterial graft having a more favorable local mechanical environment for the infiltrating cells; we used electrospinning to enclose a compliant inner core of poly(glycerol sebacate) with a stiffer sheath of poly(caprolactone) to reduce the potential for rupture. Two scaffolds were designed that differed in the thickness of the core as previous computational simulations found that circumferential wall stresses could be increased in the core toward native values by increasing the ratio of the core:sheath. Our modified electrospinning protocols reduced swelling of the core upon implantation and eliminated residual stresses in the sheath, both of which had contributed to the occlusion of implanted grafts during pilot studies. For both designs, a subset of implanted grafts occluded due to thrombosis or ruptured due to suspected point defects in the sheath. However, there were design-based differences in collagen content and mechanical behavior during early remodeling of the patent samples, with the thinner-core scaffolds having more collagen and a stiffer behavior after 12 weeks of implantation than the thicker-core scaffolds. By 24 weeks, the thicker-core scaffolds also became stiff, with similar amounts of collagen but increased smooth muscle cell and elastin content. These data suggest that increasing wall stress toward native values may provide a more favorable environment for normal arterial constituents to form despite the overall stiffness of the construct remaining elevated due to the absolute increase in load-bearing constituents.

Development of Tissue Engineered Heart Valves for Percutaneous Transcatheter Delivery in a Fetal Ovine Model.

This multidisciplinary work shows the feasibility of replacing the fetal pulmonary valve with a percutaneous, transcatheter, fully biodegradable tissue-engineered heart valve (TEHV), which was studied in vitro through accelerated degradation, mechanical, and hemodynamic testing and in vivo by implantation into a fetal lamb. The TEHV exhibited only trivial stenosis and regurgitation in vitro and no stenosis in vivo by echocardiogram. Following implantation, the fetus matured and was delivered at term. Replacing a stenotic fetal valve with a functional TEHV has the potential to interrupt the development of single-ventricle heart disease by restoring proper flow through the heart.

Slow degrading poly(glycerol sebacate) derivatives improve vascular graft remodeling in a rat carotid artery interposition model.

Porous synthetic grafts made of poly (glycerol sebacate) (PGS) can transform into autologous vascular conduits in vivo upon degradation of PGS. A long-held doctrine in tissue engineering is the necessity to match degradation of the scaffolds to tissue regeneration. Here, we tested the impact of degradation of PGS and its derivative in an interposition model of rat common carotid artery (CCA). Previous work indicates a complete degradation of PGS within approximately 2 weeks, likely at the fast end of the spectrum. Thus, the derivation of PGS focuses on delay degradation by conjugating the free hydroxy groups in PGS with a long chain carboxylic acid: palmitic acid, one of the most common lipid components. We evaluated two of the resultant palmitate-PGS (PPGS) in this study: one containing 9% palmitate (9-PPGS) and the other16% palmitate (16-PPGS). 16-PPGS grafts had the highest patency. Ultrasound imaging showed that the lumens of 16-PPGS grafts were similar to CCA and smaller than 9-PPGS and PGS grafts 12 weeks post-operation. Immunohistological and histological examination showed an endothelialized lumens in all three types of grafts within 4 weeks. Inflammatory responses to 16-PPGS grafts were limited to the adventitial space in contrast to a more diffusive infiltration in 9-PPGS and PGS grafts in week 4. Examination of calponin+ and αSMA+ cells revealed that 16-PPGS grafts remodeled into a distinctive bi-layered wall, while the walls of 9-PPGS grafts and PGS grafts only had one thick layer of smooth muscle-like cells. Correspondingly, the expression of collagen III and elastin displayed an identical layered structure in the remodeled 16-PPGS grafts, in contrast to a more spread distribution in 9-PPGS and PGS grafts. All the three types of grafts exhibited the same collagen content and burst pressure after 12 weeks of host remodeling. However, the compliance and elastin content of 16-PPGS grafts in week 12 were closest to those of CCA. Overall, placing the degradation of PGS derived elastomer to a window of 4-12 weeks results in vascular conduits closer to arteries in a rat carotid artery interposition model over a 12-week observation period.

Fetal Transcatheter Trileaflet Heart Valve Hemodynamics: Implications of Scaling on Valve Mechanics and Turbulence.

The scarcity of data available on the best approach for pulmonary fetal valve replacement or implantation necessitate an investigation on whether practices using adult transcatheter valves could be translated to fetal applications. The objective of this study is to evaluate the hemodynamic characteristics and the turbulent properties of a fetal sized trileaflet transcatheter pulmonary valve in comparison with an adult balloon-expandable valve in order to assess the possibility of designing valves for fetal applications using dynamic similarity. A 6 mm fetal trileaflet valve and a 26 mm SAPIEN 3 valve were assessed in a pulse duplicator. Particle image velocimetry was performed. Pressure gradient (ΔP), effective orifice area (EOA), regurgitant fractions (RF), pinwheeling indices (PI) and turbulent stresses were evaluated. ΔP was 8.56 ± 0.139 and 7.76 ± 0.083 mmHg with fetal valve and SAPIEN respectively (p < 0.0001); EOA was 0.10 ± 0.0007 and 2.1 ± 0.025 cm2 with fetal valve and SAPIEN respectively (p < 0.0001); RF with the fetal valve was 2.35 ± 1.99% and with SAPIEN 10.92 ± 0.11% (p < 0.0001); PI with fetal valve was 0.404 ± 0.01 and with SAPIEN 0.37 ± 0.07; The flow regime with the fetal valve was turbulent and Reynolds numbers reached about 7000 while those with the SAPIEN reached about 20,000 at peak velocity. Turbulent stresses were significantly higher with fetal valve compared with SAPIEN. Instantaneous viscous shear stresses with fetal valve were 5.8 times higher than those obtained with SAPIEN and Reynolds shear stresses were 2.5 times higher during peak systole. The fetal valve implantation leads to a turbulent flow (specific to this particular type and design of valve) regime unlike what is expected of a small valve with different flow properties compared to adult valves.

Control the Mechanical Properties and Degradation of Poly(Glycerol Sebacate) by Substitution of the Hydroxyl Groups with Palmitates.

Mechanical properties and degradation profile are important parameters for the applications of biodegradable polyester such as poly(glycerol sebacate) in biomedical engineering. Here, a strategy is reported to make palmitate functionalized poly(glycerol sebacate) (PPGS) to alter the polymer hydrophobicity, crystallinity, microstructures and thermal properties. The changes of these intrinsic properties impart tunable degradation profiles and mechanical properties to the resultant elastomers depending on the palmitate contents. When the palmitates reach up to 16 mol%, the elastic modulus is tuned from initially 838 ± 55 kPa for the PGS to 333 ± 21 kPa for the PPGS under the same crosslinking conditions. The elastomer undergoes reversible elastic deformations for at least 1000 cycles within 20% strain without failure and shows enhanced elasticity. The polymer degradation is simultaneously inhibited because of the increased hydrophobicity. This strategy is different with other PGS modifications which could form a softer elastomer with less crosslinks but typically lead to a quicker degradation. Because the materials are made from endogenous molecules, they possess good cytocompatibility similar to the PGS control. Although these materials are designed specifically for small arteries, it is expected that they will be useful for other soft tissues too.

Azido-Functionalized Polyurethane Designed for Making Tunable Elastomers by Click Chemistry.

Polyurethane is an important biomaterial with wide applications in biomedical engineering. Here, we report a new method to make an azido-functionalized polyurethane prepolymer with no need of postmodification. This prepolymer can easily form stable porous elastomers through click chemistry for cross-linking, instead of using a toxic polyisocyanate. The mechanical properties can be modulated by simply adjusting either the prepolymer concentrations or azido/alkyne ratios for cross-linking. Young's modulus therefore varies from 0.52 to 2.02 MPa for the porous elastomers. When the azido-functionalized polyurethane elastomer is made with a compact structure, Young's modulus increases up to 28.8 MPa at 0-15% strain. The strain at break reaches 150% that is comparable to the commercially resourced Nylon-12. Both the porous and compact elastomers could undergo reversible elastic deformations for at least 200 and 1000 cycles, respectively, within 20% strain without failure. The material showed a considerable stability against erosion in a basic solution. In vivo biocompatibility study demonstrated no degradation by subcutaneous implantation in mice over 2 months. The implant induced only a mild inflammatory response and fibrotic capsule. This material might be useful to make elastomeric components of biomedical devices.

Three-Dimensional Printing of Poly(glycerol sebacate) Acrylate Scaffolds via Digital Light Processing.

Digital light processing (DLP)-based three-dimensional (3D) printing offers large improvements in fabrication throughput and spatial resolution when compared to various other additive manufacturing techniques. Both properties are highly desirable when fabricating biomaterial scaffolds that require design precision. Poly(glycerol sebacate) acrylate (PGSA) is a degradable, biocompatible, and photocurable elastomer. In this work, PGSA ink was developed for DLP 3D printing of porous tubular structures. Ink formulations with varying prepolymer concentrations (10-60 wt %), diluent (dimethyl sulfoxide (DMSO), 2-butoxyethyl acetate (EGBEA), and 1:1 DMSO/EGBEA), and degree of PGSA acrylation (17-75%) were studied to optimize printing efficiency and bulk properties of the printed scaffolds. Prepolymer inks with viscosity (<5 Pa·s) and photopolymerization kinetics (exposure time <10 s) appropriate for DLP were developed. Photocrosslinked PGSA scaffolds were further exposed to postfabrication treatments including additional UV exposure or thermal curing (150 °C) to demonstrate tunability in scaffold degradation kinetics and mechanical properties. Complementary to this effort, a 3D model-generation tool was developed to enable user-friendly customization of tubular scaffold design by controlling the pore and strut size of the volumetric mesh. The resulting DLP-printed PGSA scaffolds present high mimicry to complex 3D models with a minimum feature thickness of 80 µm. The tunable properties of PGSA coupled with enhanced precision in microstructure geometry provide a fabrication platform for a variety of tissue regeneration applications.

Tyramine functionalization of poly(glycerol sebacate) increases the elasticity of the polymer.

Poly(glycerol sebacate) (PGS) is an elastomer used widely in tissue engineering studies due to good biocompatibility. Hereby we report a tyramine functionalized PGS called PGS-TA. Tyramine adds a stronger physical bonding capability to PGS-TA. Tensile tests showed that the softness and toughness of the material were similar to PGS. However, PGS-TA demonstrated 16-folds increase of elastic deformations compared to PGS processed under identical conditions. The in vitro studies demonstrated that the viability, and metabolic activity of baboon smooth muscle cells were the same as those on tissue culture polystyrene. Porous subcutaneous implants of PGS-TA substantially degraded in vivo over two weeks, showing good biodegradability and biocompatibility. We expect PGS-TA to be useful for applications in tissues and organs that are subjected to large reversible mechanical deformations.

Modulation of keratin in adhesion, proliferation, adipogenic, and osteogenic differentiation of porcine adipose-derived stem cells.

Recently, keratin attracts tremendous interest because of its intrinsic ability to interact with different cells. It has the potential to serve as a controllable extracellular matrix protein that can be used to demonstrate cell mechanism and cell-matrix interaction. However, there have been relatively few studies on the effects of keratin on stem cells. In the present work, we study the effects of human keratin on porcine adipose-derived stem cells (pASCs) and a series of selective cell lines: 3T3 fibroblasts, Madin-Darby canine kidney (MDCK) cells, and MG63 osteoblasts. Relative to un-treated culture plate, our results showed that keratin coating substrates promote cell adhesion and proliferation to above cell lines. Keratin also improved pASCs adhesion, proliferation, and enhanced cell viability. Evaluation of genetic markers showed that adipogenic and osteogenic differentiations of pASCs can be successfully induced, thus demonstrating that keratin did not influence the stemness of pASCs. Furthermore, keratin improved adipogenic differentiations of pASCs in terms of up-regulations in lipoprotein lipase, peroxisome proliferator-activated receptor gamma, and CCAAT-enhancer-binding protein alpha. The osteogenic markers type I collagen, runt-related transcription factor 2, and vitamin D receptor were also upregulated when pASCs cultured on keratin substrates. Therefore, keratin can serve as a biological derived material for surface modification and scaffold fabrication for biomedical purpose. The combination of keratin with stem cells may be a potential candidate for tissue repair in the field of regenerative medicine. © 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 180-192, 2017.

Stage-Dependent Axon Transport of Proteasomes Contributes to Axon Development.

Axon extension at the growing tip requires elevated local protein supply, with a capability sustainable over long axons in varying environments. The exact mechanisms, however, remain elusive. Here we report that axon-promoting factors elicited a retrograde transport-dependent removal of proteasomes from nascent axon terminals, thereby increasing protein stability at axon tips. Such an effect occurred through phosphorylation of a dynein-interacting proteasome adaptor protein Ecm29. During the transition from immature neurites to nascent axons in cultured hippocampal neurons, live-cell imaging revealed a significant increase of the retrograde axonal transport of fluorescently labeled 20S proteasomes. This retrograde proteasome transport depended on neuron stage and increased with axon lengths. Blockade of retrograde transport caused accumulation of proteasomes, reduction of axon growth, and attenuation of growth-associated Par6 at the axon tip of newly polarized neurons. Our results delineate a regulatory mechanism that controls proteasome abundance via preferential transport required for axon development in newborn neurons.

The vascularized periosteum flap as novel tissue engineering model for repair of cartilage defects.

Periosteum is a promising tissue engineering scaffold in research of cartilage repair; so far however, periosteum transfers have not been realized successfully because of insufficient nourishment of the graft. In a translational approach we, for the first time, designed a vascularized periosteum flap as 'independent' biomaterial with its own blood supply to address this problem and to reconstruct circumscript cartilage defects. In six 3-month-old New Zealand rabbits, a critical size cartilage defect of the medial femur condyle was created and covered by a vascularized periosteum flap pedicled on the saphenous vessels. After 28 days, formation of newly built cartilage was assessed macroscopically, histologically and qualitatively via biomechanical compression testing, as well as on molecular biological level via immunohistochemistry. All wounds healed completely, all joints were stable and had full range of motion. All flaps survived and were perfused through their pulsating pedicles. They showed a stable attachment to the bone, although partially incomplete adherence. Hyaline cartilage with typical columnar cell distribution and positive Collagen II staining was formed in the transferred flaps. Biomechanical testing revealed a significantly higher maximum load than the positive control, but a low elasticity. This study proved that vascularization of the periosteum flap is the essential step for flap survival and enables the flap to transform into cartilage. Reconstruction of circumscript cartilage defects seems to be possible. Although these are the first results out of a pilot project, this technique, we believe, can have a wide range of potential applications and high relevance in the clinical field.

Nephrocalcinosis and hypokalemia in a patient with primary Sjögren's syndrome.

Clinically significant renal involvement is uncommon in primary Sjögren's syndrome, amid which tubulointerstitial disorders, distal renal tubular acidosis (dRTA) particularly, account for the majority. Conversely, Sjögren's syndrome comprises at least half the patients presenting with renal tubular acidosis. While underlying dRTA itself is an important cause of nephrocalcinosis and urolithiasis, nephrocalcinosis is rarely a presenting feature of primary Sjögren's syndrome. I report a 41-year-old female contracting nephrocalcinosis and hypokalemia as complications of primary Sjögren's syndrome with dRTA, hereby to emphasize the importance of alkali therapy.

Reactive polymer coatings: a general route to thiol-ene and thiol-yne click reactions.

Reactive polymer coatings were synthesized via chemical vapor deposition (CVD) polymerization process. These coatings decouple surface design from bulk properties of underlying materials and provide a facile and general route to support thiol-ene and thiol-yne reactions on a variety of substrate materials. Through the reported technique, surface functions can be activated through a simple design of thiol-terminated molecules such as polyethylene glycols (PEGs) or peptides (GRGDYC), and the according biological functions were demonstrated in controlled and low-fouling protein adsorptions as well as accurately manipulated cell attachments.

Erythema nodosum and hepatitis B: a case report and literature review.

Erythema nodosum (EN) is the most common of the panniculitides, and is associated with many underlying etiological conditions. Herein, we report a case of EN with probable association with hepatitis B virus (HBV) and review previous reports in the English literature. Since hepatitis B is still an endemic infection in Taiwan, EN related to HBV may not be as uncommon as in developed countries. The incidence and pathogenesis of EN associated with HBV demand further investigation.