Medical Microrobots.

Scientists around the world have long aimed to produce miniature robots that can be controlled inside the human body to aid doctors in identifying and treating diseases. Such microrobots hold the potential to access hard-to-reach areas of the body through the natural lumina. Wireless access has the potential to overcome drawbacks of systemic therapy, as well as to enable completely new minimally invasive procedures. The aim of this review is fourfold: first, to provide a collection of valuable anatomical and physiological information on the target working environments together with engineering tools for the design of medical microrobots; second, to provide a comprehensive updated survey of the technological state of the art in relevant classes of medical microrobots; third, to analyze currently available tracking and closed loop control strategies compatible with the in-body environment; and fourth, to explore the challenges still in place, to steer and inspire future research.

A vibrating capillary for ultrasound rotation manipulation of zebrafish larvae.

Multifunctional micromanipulation systems have garnered significant attention due to the growing interest in biological and medical research involving model organisms like zebrafish (Danio rerio). Here, we report a novel acoustofluidic rotational micromanipulation system that offers rapid trapping, high-speed rotation, multi-angle imaging, and 3D model reconstruction of zebrafish larvae. An ultrasound-activated oscillatory glass capillary is used to trap and rotate a zebrafish larva. Simulation and experimental results demonstrate that both the vibrating mode and geometric placement of the capillary contribute to the developed polarized vortices along the long axis of the capillary. Given its capacities for easy-to-operate, stable rotation, avoiding overheating, and high-throughput manipulation, our system poses the potential to accelerate zebrafish-directed biomedical research.

SonoTransformers: Transformable acoustically activated wireless microscale machines.

Shape transformation, a key mechanism for organismal survival and adaptation, has gained importance in developing synthetic shape-shifting systems with diverse applications ranging from robotics to bioengineering. However, designing and controlling microscale shape-shifting materials remains a fundamental challenge in various actuation modalities. As materials and structures are scaled down to the microscale, they often exhibit size-dependent characteristics, and the underlying physical mechanisms can be significantly affected or rendered ineffective. Additionally, surface forces such as van der Waals forces and electrostatic forces become dominant at the microscale, resulting in stiction and adhesion between small structures, making them fracture and more difficult to deform. Furthermore, despite various actuation approaches, acoustics have received limited attention despite their potential advantages. Here, we introduce "SonoTransformer," the acoustically activated micromachine that delivers shape transformability using preprogrammed soft hinges with different stiffnesses. When exposed to an acoustic field, these hinges concentrate sound energy through intensified oscillation and provide the necessary force and torque for the transformation of the entire micromachine within milliseconds. We have created machine designs to predetermine the folding state, enabling precise programming and customization of the acoustic transformation. Additionally, we have shown selective shape transformable microrobots by adjusting acoustic power, realizing high degrees of control and functional versatility. Our findings open new research avenues in acoustics, physics, and soft matter, offering new design paradigms and development opportunities in robotics, metamaterials, adaptive optics, flexible electronics, and microtechnology.

Steerable acoustically powered starfish-inspired microrobot.

Soft polymeric microrobots that can be loaded with nanocargoes and driven via external field stimuli can provide innovative solutions in various fields, including precise microscale assembly, targeted therapeutics, microsurgery, and the capture and degradation of unwanted wastewater fragments. However, in aquatic environments, it remains challenging to operate with microrobotic devices due to the predominant viscous resistances and the robots' limited actuation and sensing capabilities attributed to their miniaturization. The miniature size prevents the incorporation of onboard batteries that can provide sufficient power for propulsion and navigation, necessitating a wireless power supply. Current research examines untethered microrobot manipulation using external magnetic, electric, thermodynamic, or acoustic field-guided technologies: all strategies capable of wireless energy transmission towards sensitive and hard-to-reach locations. Nonetheless, developing a manipulation strategy that harnesses simple-to-induce strong propulsive forces in a stable manner over extended periods of time remains a significant endeavor. This study presents the fabrication and manipulation of a microrobot consisting of a magnetized soft polymeric composite material that enables a combination of stable acoustic propulsion through starfish-inspired artificial cilia and magnetic field-guided navigation. The acousto-magnetic manipulation strategy leverages the unique benefits of each applied field in the viscous-dominated microscale, namely precise magnetic orientation and strong acoustic thrust.

Ultrasound robotics for precision therapy.

In recent years, the application of microrobots in precision therapy has gained significant attention. The small size and maneuverability of these micromachines enable them to potentially access regions that are difficult to reach using traditional methods; thus, reducing off-target toxicities and maximizing treatment effectiveness. Specifically, acoustic actuation has emerged as a promising method to exert control. By harnessing the power of acoustic energy, these small machines potentially navigate the body, assemble at the desired sites, and deliver therapies with enhanced precision and effectiveness. Amidst the enthusiasm surrounding these miniature agents, their translation to clinical environments has proven difficult. The primary objectives of this review are threefold: firstly, to offer an overview of the fundamental acoustic principles employed in the field of microrobots; secondly, to assess their current applications in medical therapies, encompassing tissue targeting, drug delivery or even cell infiltration; and lastly, to delve into the continuous efforts aimed at integrating acoustic microrobots into in vivo applications.

Ultrasound trapping and navigation of microrobots in the mouse brain vasculature.

The intricate and delicate anatomy of the brain poses significant challenges for the treatment of cerebrovascular and neurodegenerative diseases. Thus, precise local drug delivery in hard-to-reach brain regions remains an urgent medical need. Microrobots offer potential solutions; however, their functionality in the brain remains restricted by limited imaging capabilities and complications within blood vessels, such as high blood flows, osmotic pressures, and cellular responses. Here, we introduce ultrasound-activated microrobots for in vivo navigation in brain vasculature. Our microrobots consist of lipid-shelled microbubbles that autonomously aggregate and propel under ultrasound irradiation. We investigate their capacities in vitro within microfluidic-based vasculatures and in vivo within vessels of a living mouse brain. These microrobots self-assemble and execute upstream motion in brain vasculature, achieving velocities up to 1.5 µm/s and moving against blood flows of ~10 mm/s. This work represents a substantial advance towards the therapeutic application of microrobots within the complex brain vasculature.

An acoustically controlled helical microrobot.

As a next-generation toolkit, microrobots can transform a wide range of fields, including micromanufacturing, electronics, microfluidics, tissue engineering, and medicine. While still in their infancy, acoustically actuated microrobots are becoming increasingly attractive. However, the interaction of acoustics with microstructure geometry is poorly understood, and its study is necessary for developing next-generation acoustically powered microrobots. We present an acoustically driven helical microrobot with a length of 350 µm and a diameter of 100 µm that is capable of locomotion using a fin-like double-helix microstructure. This microrobot responds to sound stimuli at ~12 to 19 kHz and mimics the spiral motion of natural microswimmers such as spirochetes. The asymmetric double helix interacts with the incident acoustic field, inducing a propulsion torque that causes the microrobot to rotate around its long axis. Moreover, our microrobot has the unique feature of its directionality being switchable by simply tuning the acoustic frequency. We demonstrate this locomotion in 2D and 3D artificial vasculatures using a single sound source.

Acoustic microbubble propulsion, train-like assembly and cargo transport.

Achieving controlled mobility of microparticles in viscous fluids can become pivotal in biologics, biotechniques, and biomedical applications. The self-assembly, trapping, and transport of microparticles are being explored in active matter, micro and nanorobotics, and microfluidics; however, little work has been done in acoustics, particularly in active matter and robotics. This study reports the discovery and characterization of microbubble behaviors in a viscous gel that is confined to a slight opening between glass boundaries in an acoustic field. Where incident waves encounter a narrow slit, acoustic pressure is amplified, causing the microbubbles to nucleate and cavitate within it. Intermittent activation transforms microbubbles from spherical to ellipsoidal, allowing them to be trapped within the interstice. Continuous activation propels ellipsoidal microbubbles through shape and volume modes that is developed at their surfaces. Ensembles of microbubbles self-assemble into a train-like arrangement, which in turn capture, transport, and release microparticles.

'This is hardcore': a qualitative study exploring service users' experiences of Heroin-Assisted Treatment (HAT) in Middlesbrough, England.

BACKGROUND: Heroin-Assisted Treatment (HAT) is well evidenced internationally to improve health and social outcomes for people dependent on opioids who have not been helped by traditional treatment options. Despite this evidence base, England has been slow to implement HAT. The first service outside of a trial setting opened in 2019, providing twice-daily supervised injections of medical-grade heroin (diamorphine) to a select sample of high-risk heroin users in Middlesbrough. This paper explores their experiences, including the negotiation of the strict regularly controls required of a novel intervention in the UK context. METHODS: We conducted in-depth interviews with service providers and users of the Middlesbrough HAT service between September and November 2021. Data from each group were thematically analysed and reported separately. This paper details the experiences of the twelve heroin dependent men and women accessing HAT. RESULTS: Participants' accounts of HAT treatment evidenced a tension between the regulatory constraints and uncertainty of treatment provision, and the positive outcomes experienced through supportive service provision and an injectable treatment option. Limited confidence was held in treatment efficacy, longevity of funding, and personal capacity for treatment success. This was counteracted by a strong motivation to cease engagement with the illicit drug market. While attendance requirements placed restrictions on daily activities, participants also experienced benefits from strong, supportive bonds built with the service providers through their continued engagement. CONCLUSIONS: The Middlesbrough HAT programme provided benefits to a high-risk population of opioid dependent people who were unable or disinclined to participate in conventional opioid substitution treatments. The findings in this paper highlight the potential for service modifications to further enhance engagement. The closure of this programme in 2022 prohibits this opportunity for the Middlesbrough community, but holds potential to inform advocacy and innovation for future HAT interventions in England.

OPTICAL COHERENCE TOMOGRAPHY AND OCT ANGIOGRAPHY CHARACTERISTICS OF INDOCYANINE GREEN ANGIOGRAPHIC PLAQUES IN NONEXUDATIVE AGE-RELATED MACULAR DEGENERATION.

PURPOSE: To describe characteristics of indocyanine green (ICG) angiographic plaques in the nonexudative fellow eye of White patients with unilateral treatment-naïve exudative neovascular age-related macular degeneration through optical coherence tomography (OCT) and OCT angiography (OCTA). METHODS: In this retrospective cross-sectional study, nonexudative eyes with ICG angiographic plaques were analyzed by OCT B-scans for the sensitivity of a double-layer sign, a pigment epithelium detachment, outer retinal atrophy, hyperreflective dots, and subretinal hyperreflective material (SRHM). The ICG angiographic plaque was matched with a macular neovascularization in OCTA en face scans and color-coded B scans. RESULTS: In total, 35 ICG angiographic plaques in 33 of 291 (11%) nonexudative eyes were diagnosed. OCT revealed 27 double-layer sign (78%), eight pigment epithelium detachment (23%), 8 outer retinal atrophy (23%), eight hyperreflective dots (23%), and one subretinal hyperreflective material (3%). OCTA confirmed a macular neovascularization in 28 plaques (80%): 7 (20%) in en face scans, 3 (9%) in color-coded B scans, and 18 (51%) in both. The area size in OCTA was significantly smaller than that of ICG angiography ( P = 0.002). CONCLUSION: The diagnosis of an ICG angiographic plaque in nonexudative fellow eyes of Whites with unilateral treatment-naïve exudative neovascular age-related macular degeneration was highly suggestive of a typical macular neovascularization type 1 as characterized by OCT and OCTA.

Rolling microswarms along acoustic virtual walls.

Rolling is a ubiquitous transport mode utilized by living organisms and engineered systems. However, rolling at the microscale has been constrained by the requirement of a physical boundary to break the spatial homogeneity of surrounding mediums, which limits its prospects for navigation to locations with no boundaries. Here, in the absence of real boundaries, we show that microswarms can execute rolling along virtual walls in liquids, impelled by a combination of magnetic and acoustic fields. A rotational magnetic field causes individual particles to self-assemble and rotate, while the pressure nodes of an acoustic standing wave field serve as virtual walls. The acoustic radiation force pushes the microswarms towards a virtual wall and provides the reaction force needed to break their fore-aft motion symmetry and induce rolling along arbitrary trajectories. The concept of reconfigurable virtual walls overcomes the fundamental limitation of a physical boundary being required for universal rolling movements.

A robot-assisted acoustofluidic end effector.

Liquid manipulation is the foundation of most laboratory processes. For macroscale liquid handling, both do-it-yourself and commercial robotic systems are available; however, for microscale, reagents are expensive and sample preparation is difficult. Over the last decade, lab-on-a-chip (LOC) systems have come to serve for microscale liquid manipulation; however, lacking automation and multi-functionality. Despite their potential synergies, each has grown separately and no suitable interface yet exists to link macro-level robotics with micro-level LOC or microfluidic devices. Here, we present a robot-assisted acoustofluidic end effector (RAEE) system, comprising a robotic arm and an acoustofluidic end effector, that combines robotics and microfluidic functionalities. We further carried out fluid pumping, particle and zebrafish embryo trapping, and mobile mixing of complex viscous liquids. Finally, we pre-programmed the RAEE to perform automated mixing of viscous liquids in well plates, illustrating its versatility for the automatic execution of chemical processes.

Light-driven high-precision cell adhesion kinetics.

Existing single-cell adhesion kinetics methods are performed under conditions highly unlike the physiological cell adhesion conditions. Now, researchers have developed a new optical technique for high-precision measurement of cell lateral adhesion kinetics in complex clinical samples.

In vivo acoustic manipulation of microparticles in zebrafish embryos.

In vivo micromanipulation using ultrasound is an exciting technology with promises for cancer research, brain research, vasculature biology, diseases, and treatment development. In the present work, we demonstrate in vivo manipulation of gas-filled microparticles using zebrafish embryos as a vertebrate model system. Micromanipulation methods often are conducted in vitro, and they do not fully reflect the complex environment associated in vivo. Four piezoelectric actuators were positioned orthogonally to each other around an off-centered fluidic channel that allowed for two-dimensional manipulation of intravenously injected microbubbles. Selective manipulation of microbubbles inside a blood vessel with micrometer precision was achieved without interfering with circulating blood cells. Last, we studied the viability of zebrafish embryos subjected to the acoustic field. This successful high-precision, in vivo acoustic manipulation of intravenously injected microbubbles offers potentially promising therapeutic options.

Evaluation of a calculation model to estimate the impact of the COVID-19 pandemic lockdown on visual acuity in neovascular AMD.

PURPOSE: A model was calculated during the first Austrian coronavirus disease-2019 (COVID-19) pandemic lockdown to estimate the effect of a short-term treatment interruption due to healthcare restrictions on visual acuity (VA) in neovascular age-related macular degeneration (nAMD). The model was compared to the real-life outcomes before treatment re-started. METHODS: Retrospective data-collection of 142 eyes in 142 patients receiving repeated intravitreal injections with anti-VEGF at a retina unit in Vienna in a personalized pro-re-nata regimen prior to the COVID-19 associated lockdown, when treatment was deferred between March 16 and May 4, 2020. During the lockdown, the preliminary data was integrated into pre-existing formulae based on the natural course of the disease in untreated eyes in the long term. Patients were re-scheduled and treated after gradually opening operating rooms. The calculation model was compared to the effective VA change. RESULTS: The model calculated an overall VA loss of 3.5 ± 0.8 letters early treatment diabetes retinopathy study (ETDRS) (p < 0.001 [95% CI:3.3;3.6]) on average compared to 2.5 ± 6 letters ETDRS (p < 0.001 [95% CI:1.5;3.5]) as measured with a mean treatment delay of 61 ± 14 days after previously scheduled appointments. The total difference between the model exercise and the real-life outcomes accounted for 1 ± 5.9 letters ETDRS (p = 0.051 [95% CI: 0.1;1.9]). CONCLUSION: The herein presented calculation model might not be suitable to estimate the effective VA loss correctly over time, although untreated eyes and eyes under therapy show similarities after short-term treatment interruption. However, this study demonstrated the potentially negative impact of the COVID-19 pandemic lockdown on patients compromised by nAMD.

Ultrasound-activated ciliary bands for microrobotic systems inspired by starfish.

Cilia are short, hair-like appendages ubiquitous in various biological systems, which have evolved to manipulate and gather food in liquids at regimes where viscosity dominates inertia. Inspired by these natural systems, synthetic cilia have been developed and utilized in microfluidics and microrobotics to achieve functionalities such as propulsion, liquid pumping and mixing, and particle manipulation. Here, we demonstrate ultrasound-activated synthetic ciliary bands that mimic the natural arrangements of ciliary bands on the surface of starfish larva. Our system leverages nonlinear acoustics at microscales to drive bulk fluid motion via acoustically actuated small-amplitude oscillations of synthetic cilia. By arranging the planar ciliary bands angled towards (+) or away (-) from each other, we achieve bulk fluid motion akin to a flow source or sink. We further combine these flow characteristics with a physical principle to circumvent the scallop theorem and realize acoustic-based propulsion at microscales. Finally, inspired by the feeding mechanism of a starfish larva, we demonstrate an analogous microparticle trap by arranging + and - ciliary bands adjacent to each other.

The Diagnostic Capability of Swept Source OCT Angiography in Treatment-Naive Exudative Neovascular Age-Related Macular Degeneration.

PURPOSE: To evaluate the capability of swept source-optical coherence tomography angiography (SS-OCTA) in the detection and localization of treatment-naive macular neovascularization (MNV) secondary to exudative neovascular age-related macular degeneration (nAMD). METHODS: In this prospective, observational case series, 158 eyes of 142 patients were diagnosed with exudative nAMD using fluorescein (FA) and indocyanine green angiography (ICGA) and evaluated by SS-OCTA in a tertiary retina center (Rudolf Foundation Hospital Vienna, Austria). The main outcome measure was the sensitivity of SS-OCTA compared to the standard multimodal imaging approach. Secondary outcome measure was the anatomic analysis of MNV in relation to the retinal pigment epithelium. RESULTS: En-face SS-OCTA confirmed a MNV in 126 eyes (sensitivity: 79.8%), leaving 32 eyes (20.2%) undetected. In 23 of these 32 eyes (71.9%), abnormal flow in cross-sectional SS-OCTA B-scans was identified, giving an overall SS-OCTA sensitivity of 94.3%. Eyes with a pigment epithelium detachment (PED) ≥ 300 µm had a smaller probability for correct MNV detection (p=0.015). Type 1 MNV showed a trend (p=0.051) towards smaller probability for the correct detection compared to all other subtypes. Other relevant factors for the nondetection of MNV in SS-OCTA were image artifacts present in 3 of 32 eyes (9.4%). SS-OCTA confirmed the anatomic localization of 93 in 126 MNVs as compared to FA (sensitivity: 73.8%). There was no influence of age, gender, pseudophakia, visual acuity, central foveal thickness, or subfoveal choroidal thickness on the detection rate of MNV. CONCLUSIONS: SS-OCTA remains inferior to dye-based angiography in the detection rate of exudative nAMD consistent with type 1 MNV and a PED ≥300 µm. The capability to combine imaging modalities and distinguish the respective MNV subtype improves its diagnostic value.

The Effect of Treatment Discontinuation During the COVID-19 Pandemic on Visual Acuity in Exudative Neovascular Age-Related Macular Degeneration: 1-Year Results.

INTRODUCTION: To evaluate the effect of a 9-week treatment deferral due to healthcare restrictions caused by Austria's first governmental lockdown associated with the coronavirus disease 2019 (COVID-19) pandemic on visual acuity (VA) in eyes compromised by exudative neovascular age-related macular degeneration (nAMD) after 1 year. METHODS: Retrospective data collection of 98 eyes (98 patients) with a treatment discontinuation at a tertiary eye care center (Clinic Landstraße, Vienna Healthcare Group, Austria) between March 16 and May 4, 2020. Prior to the lockdown, patients received multiple intravitreal injections (IVI) of anti-vascular endothelial growth factor with a personalized treatment interval for 3 years on average and at least three IVI after the lockdown. RESULTS: When the treatment interval doubled to 117.6 ± 31.4 days in spring 2020, patients lost 2.2 ± 4.6 ETDRS letters (p = 0.002) on average before reinitiating therapy. In total, 4.1 ± 8.1 letters (p < 0.0001) were lost despite continuous individual re-treatment over the course of the next year. In a univariate analysis, the extended interval time remained statistically significant (p < 0.0001), indicating a larger VA reduction within intervals with increasing interval time in days. CONCLUSION: The short-term treatment interruption had a persistent negative impact on the VA course of eyes under therapy after 1 year. Continuous therapy independent of the underlying treatment regimen remains of utmost importance in exudative nAMD. Our data should create awareness to regulators regarding future decisions despite the global pandemic.

Age-related macular degeneration (AMD) is the leading cause of legal blindness in developed countries. Wet AMD refers to the existence of new vessel growth in the macular, the part of the retina with the highest concentration of photoreceptors and hence the best visual acuity. The gold standard therapy of wet AMD consists of repeated injections of an antibody against new vessel formation into the eye to stabilize the disease. The sudden break of a treatment regimen for an individual person has never been investigated as it is ethically not acceptable. The coronavirus disease 2019 (COVID-19) pandemic and its associated lockdown led to an emerging situation in spring, 2020. We were forced by governmental restrictions to minimize contact with the most vulnerable patient cohort­the elderly. As an initial consequence, the Medical Retina Unit of Department of Ophthalmology (Clinic Landstraße, Vienna Healthcare Group, Austria) postponed appointments of patients with only one eye afflicted by wet AMD. This study examined the effect of a short-term treatment deferral caused by the first national COVID-19 lockdown in eyes of patients with ongoing therapy of wet AMD in Austria. The break led to a persistent visual loss despite re-treatment, which was still evident after 1 year. Our findings provide further support for an adequate and permanent therapy of wet AMD and regard intravitreal injections as urgent standard of care. It should be taken into consideration by authorities in future pandemic planning.

Bio-inspired Acousto-magnetic Microswarm Robots with Upstream Motility.

The ability to propel against flows, i.e., to perform positive rheotaxis, can provide exciting opportunities for applications in targeted therapeutics and non-invasive surgery. To date, no biocompatible technologies exist for navigating microparticles upstream when they are in a background fluid flow. Inspired by many naturally- occurring microswimmers such as bacteria, spermatozoa, and plankton that utilize the non-slip boundary conditions of the wall to exhibit upstream propulsion, here, we report on the design and characterization of self-assembled microswarms that can execute upstream motility in a combination of external acoustic and magnetic fields. Both acoustic and magnetic fields are safe to humans, non-invasive, can penetrate deeply into the human body, and are well-developed in clinical settings. The combination of both fields can overcome the limitations encountered by single actuation methods. The design criteria of the acoustically-induced reaction force of the microswarms, which is needed to perform rolling-type motion, are discussed. We show quantitative agreement between experimental data and our model that captures the rolling behaviour. The upstream capability provides a design strategy for delivering small drug molecules to hard-to-reach sites and represents a fundamental step toward the realization of micro- and nanosystem-navigation against the blood flow.

Embedded Microbubbles for Acoustic Manipulation of Single Cells and Microfluidic Applications.

Acoustically excited microstructures have demonstrated significant potential for small-scale biomedical applications by overcoming major microfluidic limitations. Recently, the application of oscillating microbubbles has demonstrated their superiority over acoustically excited solid structures due to their enhanced acoustic streaming at low input power. However, their limited temporal stability hinders their direct applicability for industrial or clinical purposes. Here, we introduce the embedded microbubble, a novel acoustofluidic design based on the combination of solid structures (poly(dimethylsiloxane)) and microbubbles (air-filled cavity) to combine the benefits of both approaches while minimizing their drawbacks. We investigate the influence of various design parameters and geometrical features through numerical simulations and experimentally evaluate their manipulation capabilities. Finally, we demonstrate the capabilities of our design for microfluidic applications by investigating its mixing performance as well as through the controlled rotational manipulation of individual HeLa cells.