3D bioprinting of liver models: A systematic scoping review of methods, bioinks, and reporting quality

Background

Effective communication is crucial for broad acceptance and applicability of alternative methods in 3R biomedical research and preclinical testing. 3D bioprinting is used to construct intricate biological structures towards functional liver models, specifically engineered for deployment as alternative models in drug screening, toxicological investigations, and tissue engineering. Despite a growing number of reviews in this emerging field, a comprehensive study, systematically assessing practices and reporting quality for bioprinted liver models is missing.

Methods

In this systematic scoping review we systematically searched MEDLINE (Ovid), EMBASE (Ovid) and BioRxiv for studies published prior to June 2nd, 2022. We extracted data on methodological conduct, applied bioinks, the composition of the printed model, performed experiments and model applications. Records were screened for eligibility and data were extracted from included articles by two independent reviewers from a panel of seven domain experts specializing in bioprinting and liver biology. We used RAYYAN for the screening process and SyRF for data extraction. We used R for data analysis, and R and Graphpad PRISM for visualization.

Results

Through our systematic database search we identified 1042 records, from which 63 met the eligibility criteria for inclusion in this systematic scoping review. Our findings revealed that extrusion-based printing, in conjunction with bioinks composed of natural components, emerged as the predominant printing technique in the bioprinting of liver models. Notably, the HepG2 hepatoma cell line was the most frequently employed liver cell type, despite acknowledged limitations. Furthermore, 51% of the printed models featured co-cultures with non-parenchymal cells to enhance their complexity. The included studies offered a variety of techniques for characterizing these liver models, with their primary application predominantly focused on toxicity testing. Among the frequently analyzed liver markers, albumin and urea stood out. Additionally, Cytochrome P450 (CYP) isoforms, primarily CYP3A and CYP1A, were assessed, and select studies employed nuclear receptor agonists to induce CYP activity.

Conclusion

Our systematic scoping review offers an evidence-based overview and evaluation of the current state of research on bioprinted liver models, representing a promising and innovative technology for creating alternative organ models. We conducted a thorough examination of both the methodological and technical facets of model development and scrutinized the reporting quality within the realm of bioprinted liver models. This systematic scoping review can serve as a valuable template for systematically evaluating the progress of organ model development in various other domains. The transparently derived evidence presented here can provide essential support to the research community, facilitating the adaptation of technological advancements, the establishment of standards, and the enhancement of model robustness. This is particularly crucial as we work toward the long-term objective of establishing new approach methods as reliable alternatives to animal testing, with extensive and versatile applications.

Development of a highly stable, active small interfering RNA with broad activity against SARS-CoV viruses

Treatment options for COVID-19 remain limited. Here, we report the optimization of an siRNA targeting the highly conserved leader region of SARS-CoV-2. The siRNA was rendered nuclease resistant by the introduction of modified nucleotides without loss of activity. Importantly, the siRNA also retained its inhibitory activity against the emerged omicron sublineage variant BA.2, which occurred after the siRNA was designed and is resistant to other antiviral agents such as antibodies. In addition, we show that a second highly active siRNA designed against the viral 5'-UTR can be applied as a rescue molecule, to minimize the spread of escape mutations. We therefore consider our siRNA-based molecules to be promising broadly active candidates for the treatment of current and future SARS-CoV-2 variants.

Xeno-Free 3D Bioprinted Liver Model for Hepatotoxicity Assessment

Three-dimensional (3D) bioprinting is one of the most promising methodologies that are currently in development for the replacement of animal experiments. Bioprinting and most alternative technologies rely on animal-derived materials, which compromises the intent of animal welfare and results in the generation of chimeric systems of limited value. The current study therefore presents the first bioprinted liver model that is entirely void of animal-derived constituents. Initially, HuH-7 cells underwent adaptation to a chemically defined medium (CDM). The adapted cells exhibited high survival rates (85-92%) after cryopreservation in chemically defined freezing media, comparable to those preserved in standard medium (86-92%). Xeno-free bioink for 3D bioprinting yielded liver models with high relative cell viability (97-101%), akin to a Matrigel-based liver model (83-102%) after 15 days of culture. The established xeno-free model was used for toxicity testing of a marine biotoxin, okadaic acid (OA). In 2D culture, OA toxicity was virtually identical for cells cultured under standard conditions and in CDM. In the xeno-free bioprinted liver model, 3-fold higher concentrations of OA than in the respective monolayer culture were needed to induce cytotoxicity. In conclusion, this study describes for the first time the development of a xeno-free 3D bioprinted liver model and its applicability for research purposes.

Predation risk drives long-term shifts in migratory behaviour and demography in a large herbivore population

Migration is an adaptive life-history strategy across taxa that helps individuals maximise fitness by obtaining forage and avoiding predation risk. The mechanisms driving migratory changes are poorly understood, and links between migratory behaviour, space use, and demographic consequences are rare. Here, we use a nearly 20-year record of individual-based monitoring of a large herbivore, elk (Cervus canadensis) to test hypotheses for changing patterns of migration in and adjacent to a large protected area in Banff National Park (BNP), Canada. We test whether bottom-up (forage quality) or top-down (predation risk) factors explained trends in (i) the proportion of individuals using 5 different migratory tactics, (ii) differences in survival rates of migratory tactics during migration and whilst on summer ranges, (iii) cause-specific mortality by wolves and grizzly bears, and (iv) population abundance. We found dramatic shifts in migration consistent with behavioural plasticity in individual choice of annual migratory routes. Shifts were inconsistent with exposure to the bottom-up benefits of migration. Instead, exposure to landscape gradients in predation risk caused by exploitation outside the protected area drove migratory shifts. Carnivore exploitation outside the protected area led to higher survival rates for female elk remaining resident or migrating outside the protected area. Cause-specific mortality aligned with exposure to predation risk along migratory routes and summer ranges. Wolf predation risk was higher on migratory routes than summer ranges of montane-migrant tactics, but wolf predation risk traded-off with heightened risk from grizzly bears on summer ranges. A novel eastern migrant tactic emerged following a large forest fire that enhanced forage in an area with lower predation risk outside of the protected area. The changes in migratory behaviour translated to population abundance, where abundance of the montane-migratory tactics declined over time. The presence of diverse migratory life histories maintained a higher total population abundance than would have been the case with only one migratory tactic in the population. Our study demonstrates the complex ways in which migratory populations change over time through behavioural plasticity and associated demographic consequences because of individuals balancing predation risk and forage trade-offs.

Urodrill - a novel MRI-guided endoscopic biopsy technique to sample and molecularly classify muscle-invasive bladder cancer without fractionating the specimen during transurethral resection

The current diagnostic pathway for patients with muscle-invasive bladder cancer (MIBC), which involves with computed tomography urography, cystoscopy, and transurethral resection of the bladder (TURB) to histologically confirm MIBC, delays definitive treatment. The Vesical Imaging-Reporting and Data System (VI-RADS) has been suggested for MIBC identification using magnetic resonance imaging (MRI), but a recent randomized trial reported misclassification in one-third of patients. We investigated a new endoscopic biopsy device (Urodrill) for histological confirmation of MIBC and assessment of molecular subtype by gene expression in patients with VI-RADS 4 and 5 lesions on MRI. In ten patients, Urodrill biopsies were guided by MR images to the muscle-invasive portion of the tumor via a flexible cystoscope under general anesthesia. During the same session, conventional TURB was subsequently performed. A Urodrill sample was successfully obtained in nine of ten patients. MIBC was verified in six of nine patients, and seven of nine samples contained detrusor muscle. In seven of eight patients for whom a Urodrill biopsy sample was subjected to RNA sequencing, single-sample molecular classification according to the Lund taxonomy was feasible. No complications related to the biopsy device occurred. A randomized trial comparing this new diagnostic pathway for patients with VI-RADS 4 and 5 lesions and the current standard (TURB) is warranted.

Patient summary

We report on a novel biopsy device for patients with muscle-invasive bladder cancer that facilitates histology analysis and molecular characterization of tumor samples.

Integrating EM and Patch-seq data: Synaptic connectivity and target specificity of predicted Sst transcriptomic types

Neural circuit function is shaped both by the cell types that comprise the circuit and the connections between those cell types ¹ . Neural cell types have previously been defined by morphology ^{2, 3} , electrophysiology ^{4, 5} , transcriptomic expression ^6-8 , connectivity ^9-13 , or even a combination of such modalities ^14-16 . More recently, the Patch-seq technique has enabled the characterization of morphology (M), electrophysiology (E), and transcriptomic (T) properties from individual cells ^17-20 . Using this technique, these properties were integrated to define 28, inhibitory multimodal, MET-types in mouse primary visual cortex ²¹ . It is unknown how these MET-types connect within the broader cortical circuitry however. Here we show that we can predict the MET-type identity of inhibitory cells within a large-scale electron microscopy (EM) dataset and these MET-types have distinct ultrastructural features and synapse connectivity patterns. We found that EM Martinotti cells, a well defined morphological cell type ^{22, 23} known to be Somatostatin positive (Sst+) ^{24, 25} , were successfully predicted to belong to Sst+ MET-types. Each identified MET-type had distinct axon myelination patterns and synapsed onto specific excitatory targets. Our results demonstrate that morphological features can be used to link cell type identities across imaging modalities, which enables further comparison of connectivity in relation to transcriptomic or electrophysiological properties. Furthermore, our results show that MET-types have distinct connectivity patterns, supporting the use of MET-types and connectivity to meaningfully define cell types.

Generation of a Perfusable 3D Lung Cancer Model by Digital Light Processing

Lung cancer still has one of the highest morbidity and mortality rates among all types of cancer. Its incidence continues to increase, especially in developing countries. Although the medical field has witnessed the development of targeted therapies, new treatment options need to be developed urgently. For the discovery of new drugs, human cancer models are required to study drug efficiency in a relevant setting. Here, we report the generation of a non-small cell lung cancer model with a perfusion system. The bioprinted model was produced by digital light processing (DLP). This technique has the advantage of including simulated human blood vessels, and its simple assembly and maintenance allow for easy testing of drug candidates. In a proof-of-concept study, we applied gemcitabine and determined the IC₅₀ values in the 3D models and 2D monolayer cultures and compared the response of the model under static and dynamic cultivation by perfusion. As the drug must penetrate the hydrogel to reach the cells, the IC₅₀ value was three orders of magnitude higher for bioprinted constructs than for 2D cell cultures. Compared to static cultivation, the viability of cells in the bioprinted 3D model was significantly increased by approximately 60% in the perfusion system. Dynamic cultivation also enhanced the cytotoxicity of the tested drug, and the drug-mediated apoptosis was increased with a fourfold higher fraction of cells with a signal for the apoptosis marker caspase-3 and a sixfold higher fraction of cells positive for PARP-1. Altogether, this easily reproducible cancer model can be used for initial testing of the cytotoxicity of new anticancer substances. For subsequent in-depth characterization of candidate drugs, further improvements will be necessary, such as the generation of a multi-cell type lung cancer model and the lining of vascular structures with endothelial cells.

Facilitators and barriers impacting in-hospital Trauma Quality Improvement Program (TQIP) implementation across country income levels: a scoping review

OBJECTIVE

Trauma is a leading cause of mortality and morbidity globally, disproportionately affecting low/middle-income countries (LMICs). Understanding the factors determining implementation success for in-hospital Trauma Quality Improvement Programs (TQIPs) is critical to reducing the global trauma burden. We synthesised topical literature to identify key facilitators and barriers to in-hospital TQIP implementation across country income levels.

DESIGN

Scoping review.

DATA SOURCES

PubMed, Web of Science and Global Index Medicus databases were searched from June 2009 to January 2022.

ELIGIBILITY CRITERIA

Published literature involving any study design, written in English and evaluating any implemented in-hospital quality improvement programme in trauma populations worldwide. Literature that was non-English, unpublished and involved non-hospital TQIPs was excluded.

DATA EXTRACTION AND SYNTHESIS

Two reviewers completed a three-stage screening process using Covidence, with any discrepancies resolved through a third reviewer. Content analysis using the Consolidated Framework for Implementation Research identified facilitator and barrier themes for in-hospital TQIP implementation.

RESULTS

Twenty-eight studies met the eligibility criteria from 3923 studies identified. The most discussed in-hospital TQIPs in included literature were trauma registries. Facilitators and barriers were similar across all country income levels. The main facilitator themes identified were the prioritisation of staff education and training, strengthening stakeholder dialogue and providing standardised best-practice guidelines. The key barrier theme identified in LMICs was poor data quality, while high-income countries (HICs) had reduced communication across professional hierarchies.

CONCLUSIONS

Stakeholder prioritisation of in-hospital TQIPs, along with increased knowledge and consensus of trauma care best practices, are essential efforts to reduce the global trauma burden. The primary focus of future studies on in-hospital TQIPs in LMICs should target improving registry data quality, while interventions in HICs should target strengthening communication channels between healthcare professionals.

Nurses' perceptions of nurse-patient communication in seclusion rooms in psychiatric inpatient care: A focus group study

INTRODUCTION

Communication between nurses and patients is essential in mental health nursing. In coercive situations (e.g. seclusion), the importance of nurse-patient communication is highlighted. However, research related to nurses' perceptions of nurse-patient communication during seclusion is scant.

AIM

The aim of this study was to describe nurses' perceptions of nurse-patient communication during patient seclusion and the ways nurse-patient communication can be improved.

METHOD

A qualitative study design using focus group interviews was adopted. Thirty-two nurses working in psychiatric wards were recruited to participate. The data were analysed using inductive qualitative content analysis.

RESULTS

Nurses aimed to communicate in a patient-centred way in seclusion events, and various issues affected the quality of communication. Nurses recognized several ways to improve communication during seclusion.

DISCUSSION

Treating patients in seclusion rooms presents highly demanding care situations for nurses. Seclusion events require nurses to have good communication skills to provide ethically sound care.

CONCLUSION

Improved nurse-patient communication may contribute to shorter seclusion times and a higher quality of care. Improving nurses' communication skills may help support the dignity of the secluded patients. Safewards practices, such as respectful communication and recognizing the effect of non-verbal behaviour, could be considered when developing nurse-patient communication in seclusion events.

RELEVANCE STATEMENT

This study deepens the understanding of nurse-patient communication during seclusion events from the perspective of nurses. Caring for patients in seclusion presents challenging situations for nurses and demands that they have good communication skills. To enhance their communication skills in seclusion events, nurses require opportunities to take part in further training after education related to communication skills for demanding care situations. Knowing the appropriate ways to interact with individual patients during seclusion can help nurses create and maintain communication with patients. For mental health nursing, nurses' enhanced communication may promote increased use of noncoercive practices in psychiatric settings. For patients, improving nurses' communication skills may help support dignity and autonomy during seclusion and shorten the time spent in seclusion, resulting in a better quality of care and more positive patient experiences related to care offered in seclusion. In this, the perspectives of people with lived experience of mental health problems should be acknowledged. Components of Safewards practices, such as using respectful and individual communication and paying attention to one's non-verbal communication (Soft Words), could be useful when developing nurse-patient communication in seclusion events.

Longitudinal assessment of myocardial edema following experimental acute myocardial infarction using a comprehensive CMR protocol

Background

Preclinical and clinical data following acute myocardial infarction (MI) and reperfusion have shown a bimodal pattern of edematous myocardium at risk (MaR) on cardiovascular magnetic resonance (CMR) imaging during the first week [1,2]. In contrary, there have also been data demonstrating that MaR is stable during the first week in patients using contrast-enhanced steady-state free precession (CE-SSFP) imaging [3].

Purpose

To use a comprehensive CMR protocol to assess the dynamics of edematous MaR during the first week following acute experimental MI.

Methods

Acute myocardial ischemia was induced in seven pigs by endovascular balloon occlusion in the left anterior descending artery with reperfusion after 40 minutes. CMR was performed at baseline, at 120 minutes, 24 hours and seven days post-reperfusion on a 1.5T scanner. The CMR protocol comprised of a prototype T2-SSFP sequence where two experiments with 16 echo times (T2 mapping16) and with 10 echo times (T2 mapping10) [1] were performed. After contrast administration, a short-axis CE-SSFP stack and late gadolinium enhancement (LGE) images were acquired. T2-maps were acquired in a mid-apical ventricular short-axis slice corresponding to the same anatomical level at all time points. All image analysis was performed using designated software. Severity of MaR was measured by placing a region of interest in the ischemic area on T2 maps and extent of MaR was assessed by delineating hyperintense areas in CE-SSFP short-axis stacks. Data is presented as mean ± SD and one-way ANOVA was used followed by Tukey's multiple comparison test.

Results

An example of all acquired CMR sequences is shown in Figure 1, with red arrows depicting the extent of edematous MaR. Figure 2 shows the severity of MaR by T2 values from T2 mapping16 where T2 values were significantly lower at 24 hours compared to 120 minutes post-reperfusion (P<0.05). However, no significant difference was seen at 120 minutes or at 24 hours compared to T2 values at seven days (P=0.46 and P=0.35). No difference at baseline (47±3 ms vs 49±3 ms, P=0.10) was observed when comparing T2 mapping16 against T2 mapping10 but a significant difference between the time points 120 min (80±8 ms vs 69±7 ms, P=0.02), 24 h, (69±9 ms vs 54±4 ms, P=0.03), and seven days (76±10 ms vs 67±5 ms, P=0.04) post-reperfusion. There was no statistically significant difference between T2 values post-reperfusion using T2 mapping10 (P=ns). The extent of myocardium at risk assessed by CE-SSFP did not show a bimodal pattern of edema, but rather a significantly lower extent at seven days compared to the extent at 120 minutes and 24 hours (P<0.05).

Conclusion

The severity and extent of edematous myocardium at risk does not follow a bimodal pattern over the course of one week. However, absolute T2 values differ between T2 mapping sequences and therefore a standardization of a CMR protocol for the assessment of MaR is of importance.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Swedish Heart-Lung Foundation and The Medical Faculty of Lund University (ALF)

Diagnostic value of electroanatomical mapping in patients with suspected arrhythmogenic cardiomyopathy

Background

Case series suggested that low voltage areas (LVA) on invasive electroanatomical mapping (EAM) could identify arrhythmogenic cardiomyopathy (ACM) at an earlier stage as compared to late gadolinium enhancement (LGE) and fatty infiltration on cardiac magnetic resonance (CMR). Data comparing LVA with structural abnormalities on CMR are lacking.

Purpose

To report the prevalence of substrate abnormalities identified by EAM vs. CMR in a cohort of patients with suspected ACM.

Methods

We retrospectively identified 66 consecutive patients with suspected ACM, who underwent EAM following clinical onset with ventricular arrhythmias. The cutoff value for EAM-defined LVA was <0.5 mV bipolar, <8 mV unipolar. Data from a prior CMR, performed no more than 12 months before, were used for comparison.

Results

The study cohort (mean age 47 years, range 21–76; 83% males; mean left ventricular ejection fraction 53%, range 28–70%) was composed of patients with suspected ACM involving either the right (n=62) or the left ventricle (n=4) following presentation with sustained monomorphic ventricular tachycardia. EAM was obtained by isolated endocardial, epicardial, or combined approach, respectively, in 11 (17%), 15 (23%) and 40 (61%) patients. Overall, 61 patients (92%) had documented LVA, of whom 89% showed an epicardial localization. In the same population, CMR identified a lower prevalence of substrate abnormalities (LGE 65%; fatty infiltration 50%). In particular, there were 27 patients (41%) with EAM-defined LVA and absent substrate abnormalities on CMR. Based on the 2010 Task Force Criteria and the 2021 Padua Criteria, a definite diagnosis of ACM was missing for a total of 19 patients (29%): due to the uniform identification of LVA in the absence of CMR abnormalities, EAM helped to establish the most likely diagnosis of ACM in all of them (19/19).

Conclusions

Our data suggest that EAM is capable of identifying substrate abnormalities in a consistent proportion of patients with suspected ACM and absent abnormalities on CMR. In this setting, the implementation of LVA to the current diagnostic criteria could improve the diagnostic yield for ACM.

Funding Acknowledgement

Type of funding sources: None.

High prevalence of malignant ventricular arrhythmias in patients with early-stage left ventricular noncompaction

Background

Early-stage left ventricular non compaction (LVNC) is a nonischemic cardiomyopathy characterized with nondilated phenotype and unpredictable risk of malignant ventricular arrhythmias (MVA).

Purpose

To report the occurrence of MVA in patients with early-stage LVNC.

Methods

Consecutive patients (n=63) diagnosed with LVNC according to recognized criteria either on transthoracic echocardiogram or cardiac magnetic resonance were retrospectively enrolled. Patients with late-stage LVNC, defined by a coexistent dilated cardiomyopathy phenotype, were excluded (n=49). Patient-tailored medical treatment, as well as ICD implantation strategies, were based on the updated ESC guidelines integrated by the experience of a referral center for arrhythmia management. The study endpoint was the occurrence of MVA (defined as sustained VT, VF, or appropriate ICD therapy) by 5-year follow-up.

Results

The study cohort consisted of 14 patients (mean age 37±17 y, 64% males), presenting with palpitation (n=4), syncope (n=4), or dyspnea on effort (n=6). LVNC was diagnosed by echocardiogram and cardiac magnetic resonance in 13 and 1 patients, respectively. Because of nonmalignant VA, seven patients (50%) underwent ICD implant before discharge. By 5-year follow-up, 5 patients (36%) experienced MVA, including VF or appropriate ICD shocks for fast VT. Left ventricular ejection fraction (LVEF) ≥45% was the only factor associated with the occurrence of MVA (5/11 event in cases with LVEF ≥45% vs. 0/3 events in controls with LVEF <45%; p=0.145). Baseline features, including age, gender, NC/C ratio, and clinical presentation were comparable between cases with LVEF ≥45% and controls, all p>0.05. Drug treatment, including RAAS inhibitors, betablockers and antiarrhythmics was also comparable.

Conclusions

Our preliminary data show that in early-stage LVNC the occurrence of MVA is higher for patients with LVEF ≥45%. Efforts are needed to identify earlier predictors of arrhythmic risk, to improve patient selection for ICD implant.

Funding Acknowledgement

Type of funding sources: None.

Hypothermia yields favourable cardiac energetics in experimental ischemia/reperfusion – insights from non-invasive pressure-volume loops by CMR

Background/Introduction

In experimental studies, mild hypothermia (<35°C) has reduced infarct size [1], potentially through reduced reperfusion injury [2], but human trials have been ambiguous [3]. Furthermore, a pressure-volume (PV) loop framework is the gold standard for assessing cardiac performance, but the invasive approach limits its clinical use. Therefore, we used a porcine model of ischemia/reperfusion with cardiovascular magnetic resonance (CMR) imaging throughout one week to acquire non-invasive PV loops.

Purpose

To quantify the cardioprotective effects of hypothermia at reperfusion by serial CMR imaging in a perspective of cardiac energy and mechanics.

Methods

Normothermia and Hypothermia groups (n=7+7 pigs) were imaged with CMR at baseline and subjected to 40 minutes of normothermic ischemia by catheter intervention. Thereafter, the Hypothermia group was rapidly cooled (<35°C) for 5 minutes before reperfusion. Additional imaging at two hours, 24 hours, and seven days were used to assess ventricular volumes and ischemic injuries. Infarct size was determined by high-resolution ex-vivo T1-weighted images.

Results

Figure 1 shows that stroke volume (SV: p=0.029; Friedmans test) and ejection fraction (EF: p=0.068) were notably reduced post-reperfusion in the Normothermia group. In contrast, the decreases were ameliorated in the Hypothermia group (SV: p=0.77; EF: p=0.13). Mean arterial pressure (MAP) was stable in the Normothermia group (p=0.77) but dropped two hours post-reperfusion in hypothermic animals (p=0.007). Over one week, both groups experienced the same decrease and partial recovery pattern for stroke work, external power, and ventricular-arterial coupling. Still, the adverse effects from ischemia were generally attenuated in the Hypothermia group. Although not significant, ischemia/reperfusion caused smaller infarcts in the Hypothermia group (10±8% vs 15±8%; p=0.32). The change in PV loop variables from baseline to 24 hours was compared with infarct size for each group. Though statistical power was limited, the general trend in analyses of covariance indicated that hypothermia has cardioprotective properties incremental to reducing infarct sizes (Figure 2), such as higher external power (p=0.061) and lower arterial elastance (p=0.015).

Conclusion

Using non-invasive PV loops by CMR, we observed that mild hypothermia before reperfusion results in favourable cardiac energetics that alleviates the heart's work after an ischemia/reperfusion injury during the first week. This study suggests that hypothermia has cardioprotective properties, incremental to reducing infarct size. The primary cardioprotective mechanism was likely an afterload reduction unloading the injured left ventricle.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Swedish Heart-Lung FoundationThe Medical Faculty of Lund University (ALF)

Non-European immigrants' self-described strategies for mental health promotion and perceptions of Finnish mental health services: A qualitative descriptive analysis

PURPOSE

This study aims to describe non-European immigrants' perceptions toward mental health care in Finland and the factors that support their mental health.

DESIGN AND METHODS

Participants (N = 17) were interviewed through semistructured interviews, after which interview transcripts were analyzed using a six-phase thematic analysis process.

FINDINGS

The participants reported that developing self-help strategies benefitted their mental health. The participants primarily preferred unprofessional help over professional mental health care. Several structural and cultural barriers to help-seeking were identified.

PRACTICAL IMPLICATION

Health care staff working with immigrants need proper education and knowledge to provide sufficient, holistic care; for this reason, information about the cultural differences among immigrants and cultural sensitivity should be included in basic as well as post-graduate nursing education.

Analysis of rare disruptive germline mutations in 2,135 enriched BRCA-negative breast cancers excludes additional high-impact susceptibility genes

BACKGROUND

Breast cancer has a significant heritable basis, of which approximately 60% remains unexplained. Testing for BRCA1/BRCA2 offers useful discrimination of breast cancer risk within families, and identification of additional breast cancer susceptibility genes could offer clinical utility.

PATIENTS AND METHODS

We included 2,135 invasive breast cancer cases recruited via the BOCS study, a retrospective UK study of familial breast cancer.

ELIGIBILITY CRITERIA

female, BRCA-negative, white European ethnicity, and one of: i) breast cancer family history, ii) bilateral disease, iii) young age of onset (<30 years), iv) concomitant ovarian cancer. We undertook exome sequencing of cases and performed gene-level burden testing of rare damaging variants against those from 51,377 ethnicity-matched population controls from gnomAD.

RESULTS

159/2135 (7.4%) cases had a qualifying variant in an established breast cancer susceptibility gene, with minimal evidence of signal in other cancer susceptibility genes. Known breast cancer susceptibility genes PALB2, CHEK2 and ATM were the only genes to retain statistical significance after correcting for multiple testing. Due to the enrichment of hereditary cases in the series, we had good power (>80%) to detect a gene of BRCA1-like risk (odds ratio = 10.6) down to a population minor allele frequency of 4.6 x 10^-5 (1 in 10,799, less than one tenth that of BRCA1)and of PALB2-like risk (odds ratio = 5.0) down to a population minor allele frequency of 2.8 x 10^-4 (1 in 1,779, less than half that of PALB2). Power was lower for identification of novel moderate penetrance genes (odds ratio = 2-3) like CHEK2 and ATM.

CONCLUSIONS

This is the largest case-control whole-exome analysis of enriched breast cancer published to date. Whilst additional breast cancer susceptibility genes likely exist, those of high penetrance are likely to be of very low mutational frequency. Contention exists regarding the clinical utility of such genes.

Evaluating the Suitability of 3D Bioprinted Samples for Experimental Radiotherapy: A Pilot Study

Radiotherapy is an important component in the treatment of lung cancer, one of the most common cancers worldwide, frequently resulting in death within only a few years of diagnosis. In order to evaluate new therapeutic approaches and compare their efficiency with regard to tumour control at a pre-clinical stage, it is important to develop standardized samples which can serve as inter-institutional outcome controls, independent of differences in local technical parameters or specific techniques. Recent developments in 3D bioprinting techniques could provide a sophisticated solution to this challenge. We have conducted a pilot project to evaluate the suitability of standardized samples generated from 3D printed human lung cancer cells in radiotherapy studies. The samples were irradiated at high dose rates using both broad beam and microbeam techniques. We found the 3D printed constructs to be sufficiently mechanically stable for use in microbeam studies with peak doses up to 400 Gy to test for cytotoxicity, DNA damage, and cancer cell death in vitro. The results of this study show how 3D structures generated from human lung cancer cells in an additive printing process can be used to study the effects of radiotherapy in a standardized manner.

Perceived usefulness of trauma audit filters in urban India: a mixed-methods multicentre Delphi study comparing filters from the WHO and low and middle-income countries

OBJECTIVE

To compare experts' perceived usefulness of audit filters from Ghana, Cameroon, WHO and those locally developed; generate context-appropriate audit filters for trauma care in selected hospitals in urban India; and explore characteristics of audit filters that correlate to perceived usefulness.

DESIGN

A mixed-methods approach using a multicentre online Delphi technique.

SETTING

Two large tertiary hospitals in urban India.

METHODS

Filters were rated on a scale from 1 to 10 in terms of perceived usefulness, with the option to add new filters and comments. The filters were categorised into three groups depending on their origin: low and middle-income countries (LMIC), WHO and New (locally developed), and their scores compared. Significance was determined using Kruskal-Wallis test followed by Wilcoxon rank-sum test. We performed a content analysis of the comments.

RESULTS

26 predefined and 15 new filter suggestions were evaluated. The filters had high usefulness scores (mean overall score 9.01 of 10), with the LMIC filters having significantly higher scores compared with those from WHO and those newly added. Three themes were identified in the content analysis relating to medical relevance, feasibility and specificity.

CONCLUSIONS

Audit filters from other LMICs were deemed highly useful in the urban India context. This may indicate that the transferability of defined trauma audit filters between similar contexts is high and that these can provide a starting point when implemented as part of trauma quality improvement programmes in low-resource settings.

Safety hazards in clinical practice of seclusion in psychiatric care

Introduction

Seclusion is part of the clinical practice in European psychiatric hospital care with the aim to maintain the safety of patients and staff. Adverse events and harm have been reported for patients and staff resulting from seclusion. Safety hazards, which are the prerequisite of adverse events, can be identified using video observation methods. Identifying safety hazards can be used to prevent adverse events and improve the quality of psychiatric care.

Objectives

To identify safety hazards during seclusion in psychiatric hospital care.

Methods

Descriptive design with non-participant video-observation of seclusion care practice. Data consisted of video recordings (n = 36) from six wards of one psychiatric hospital in Finland. The data were analysed with inductive thematic analysis.

Results

Clinical practice of seclusion included safety hazards stemming from the actions of patients and staff. Patients’ actions were as follows: aggressive behaviour, attempting to escape, precarious movements, preventing the visibility of staff, exposing themselves to contamination, and falls during seclusion. Staff actions included: leaving dangerous items to seclusion, issues in the administration of medication, performing physical and mechanical restraints in unsecure way, and precarious movements and postures.

Conclusions

According to our results, the use of seclusion has safety hazards that can result in harm for patients and staff. To improve the quality and safety of seclusion in clinical practice, the guidelines, practices, and staff training need to consider the various safety hazards. While the work in Europe to abolish the use of seclusion is still in progress, this topic requires attention in clinical practice, education, and policymaking.

Disclosure

No significant relationships.

A pilot multicentre cluster randomised trial to compare the effect of trauma life support training programmes on patient and provider outcomes

INTRODUCTION

Trauma accounts for nearly 10% of the global burden of disease. Several trauma life support programmes aim to improve trauma outcomes. There is no evidence from controlled trials to show the effect of these programmes on patient outcomes. We describe the protocol of a pilot study that aims to assess the feasibility of conducting a cluster randomised controlled trial comparing advanced trauma life support (ATLS) and primary trauma care (PTC) with standard care.

METHODS AND ANALYSIS

We will pilot a pragmatic three-armed parallel, cluster randomised controlled trial in India, where neither of these programmes are routinely taught. We will recruit tertiary hospitals and include trauma patients and residents managing these patients. Two hospitals will be randomised to ATLS, two to PTC and two to standard care. The primary outcome will be all-cause mortality at 30 days from the time of arrival to the emergency department. Our secondary outcomes will include patient, provider and process measures. All outcomes except time-to-event outcomes will be measured both as final values as well as change from baseline. We will compare outcomes in three combinations of trial arms: ATLS versus PTC, ATLS versus standard care and PTC versus standard care using absolute and relative differences along with associated CIs. We will conduct subgroup analyses across the clinical subgroups men, women, blunt multisystem trauma, penetrating trauma, shock, severe traumatic brain injury and elderly. In parallel to the pilot study, we will conduct community consultations to inform the planning of the full-scale trial.

ETHICS AND DISSEMINATION

We will apply for ethics approvals to the local institutional review board in each hospital. The protocol will be published to Clinical Trials Registry-India and ClinicalTrials.gov. The results will be published and the anonymised data and code for analysis will be released publicly.

Safety hazards in patient seclusion events in psychiatric care: A video observation study

WHAT IS KNOWN ON THE SUBJECT?: Coercive measures such as seclusion are used to maintain the safety of patients and others in psychiatric care. The use of coercive measures can lead to harm among patients and staff. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study is the first of its kind to rely on video observation to expose safety hazards in seclusion events that have not been reported previously in the literature. The actions that both patients and staff take during seclusion events can result in various safety hazards. IMPLICATIONS FOR PRACTICE?: Constant monitoring of patients during seclusion is important for identifying safety hazards and intervening to prevent harm. Nursing staff who use seclusion need to be aware of how their actions can contribute to safety hazards and how they can minimize their potential for harm ABSTRACT: Introduction Seclusion is used to maintain safety in psychiatric care. There is still a lack of knowledge on potential safety hazards related to seclusion practices. Aim To identify safety hazards that might jeopardize the safety of patients and staff in seclusion events in psychiatric hospital care. Method A descriptive design with non-participant video observation was used. The data consisted of 36 video recordings, analysed with inductive thematic analysis. Results Safety hazards were related to patient and staff actions. Patient actions included aggressive behaviour, precarious movements, escaping, falling, contamination and preventing visibility. Staff actions included leaving hazardous items in a seclusion room, unsafe administration of medication, unsecured use of restraints and precarious movements and postures. Discussion This is the first observational study to identify safety hazards in seclusion, which may jeopardize the safety of patients and staff. These hazards were related to the actions of patients and staff. Implications for Practice Being better aware of possible safety hazards could help prevent adverse events during patient seclusion events. It is therefore necessary that nursing staff are aware of how their actions might impact their safety and the safety of the patients. Video observation is a useful method for identifying safety hazards. However, its use requires effort to safeguard the privacy and confidentiality of those included in the videos.

Spontaneous Formation of 3D Breast Cancer Tissues on Electrospun Chitosan/Poly(ethylene oxide) Nanofibrous Scaffolds

Three-dimensional (3D) tissue culture has attracted a great deal of attention as a result of the need to replace the conventional two-dimensional cell cultures with more meaningful methods, especially for understanding the sophisticated nature of native tumor microenvironments. However, most techniques for 3D tissue culture are laborious, expensive, and limited to spheroid formation. In this study, a low-cost and highly effective nanofibrous scaffold is presented for spontaneous formation of reproducible 3D breast cancer microtissues. Experimentally, aligned and non-aligned chitosan/poly(ethylene oxide) nanofibrous scaffolds were prepared at one of two chitosan concentrations (2 and 4 wt %) and various electrospinning parameters. The resulting fabricated scaffolds (C2P1 and C4P1) were structurally and morphologically characterized, as well as analyzed in silico. The obtained data suggest that the fiber diameter, surface roughness, and scaffold wettability are tunable and can be influenced based on the chitosan concentration, electrospinning conditions, and alignment mode. To test the usefulness of the fabricated scaffolds for 3D cell culture, a breast cancer cell line (MCF-7) was cultured on their surfaces and evaluated morphologically and biochemically. The obtained data showed a higher proliferation rate for cells grown on scaffolds compared to cells grown on two-dimensional adherent plates (tissue culture plate). The MTT assay revealed that the rate of cell proliferation on nanofibrous scaffolds is statistically significantly higher compared to tissue culture plate (P ≤ 0.001) after 14 days of culture. The formation of spheroids within the first few days of culture shows that the scaffolds effectively support 3D tissue culture from the outset of the experiment. Furthermore, 3D breast cancer tissues were spontaneously formed within 10 days of culture on aligned and non-aligned nanofibrous scaffolds, which suggests that the scaffolds imitate the in vivo extracellular matrix in the tumor microenvironment. Detailed mechanisms for the spontaneous formation of the 3D microtissues have been proposed. Our results suggest that scaffold surface topography significantly influences tissue formation and behavior of the cells.

Bioprinted Cancer Model of Neuroblastoma in a Renal Microenvironment as an Efficiently Applicable Drug Testing Platform

Development of new anticancer drugs with currently available animal models is hampered by the fact that human cancer cells are embedded in an animal-derived environment. Neuroblastoma is the most common extracranial solid malignancy of childhood. Major obstacles include managing chemotherapy-resistant relapses and resistance to induction therapy, leading to early death in very-high-risk patients. Here, we present a three-dimensional (3D) model for neuroblastoma composed of IMR-32 cells with amplified genes of the myelocytomatosis viral related oncogene&nbsp;MYCN and the anaplastic lymphoma kinase (ALK) in a renal environment of exclusively human origin, made of human embryonic kidney 293 cells and primary human kidney fibroblasts. The model was produced with two pneumatic extrusion printheads using a commercially available bioprinter. Two drugs were exemplarily tested in this model: While the histone deacetylase inhibitor panobinostat selectively killed the cancer cells by apoptosis induction but did not affect renal cells in the therapeutically effective concentration range, the peptidyl nucleoside antibiotic blasticidin induced cell death in both cell types. Importantly, differences in sensitivity between two-dimensional (2D) and 3D cultures were cell-type specific, making the therapeutic window broader in the bioprinted model and demonstrating the value of studying anticancer drugs in human 3D models. Altogether, this cancer model allows testing cytotoxicity and tumor selectivity of new anticancer drugs, and the open scaffold design enables the free exchange of tumor and microenvironment by any cell type.

Ventricular longitudinal shortening is an independent predictor of death in heart failure patients with reduced ejection fraction

Reduced ventricular longitudinal shortening measured by atrioventricular plane displacement (AVPD) and global longitudinal strain (GLS) are prognostic markers in heart disease. This study aims to determine if AVPD and GLS with cardiovascular magnetic resonance (CMR) are independent predictors of cardiovascular (CV) and all-cause death also in heart failure with reduced ejection fraction (HFrEF). Patients (n = 287) were examined with CMR and AVPD, GLS, ventricular volumes, myocardial fibrosis/scar were measured. Follow-up was 5 years with cause of death retrieved from a national registry. Forty CV and 60 all-cause deaths occurred and CV non-survivors had a lower AVPD (6.4 ± 2.0 vs 8.0 ± 2.4 mm, p < 0.001) and worse GLS (− 6.1 ± 2.2 vs − 7.7 ± 3.1%, p = 0.001). Kaplan–Meier analyses displayed increased survival for patients in the highest AVPD- and GLS-tertiles vs. the lowest tertiles (AVPD: p = 0.001, GLS: p = 0.013). AVPD and GLS showed in univariate analysis a hazard ratio (HR) of 1.30 (per-mm-decrease) and 1.19 (per-%-decrease) for CV death. Mean AVPD and GLS were independent predictors of all-cause death (HR = 1.24 per-mm-decrease and 1.15 per-%-decrease), but only AVPD showed incremental value over age, sex, body-mass-index, EF, etiology and fibrosis/scar for CV death (HR = 1.33 per-mm-decrease, p < 0.001). Ventricular longitudinal shortening remains independently prognostic for death in HFrEF even after adjusting for well-known clinical risk factors.

Inhibition of SARS-CoV-2 Replication by a Small Interfering RNA Targeting the Leader Sequence

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected almost 200 million people worldwide and led to approximately 4 million deaths as of August 2021. Despite successful vaccine development, treatment options are limited. A promising strategy to specifically target viral infections is to suppress viral replication through RNA interference (RNAi). Hence, we designed eight small interfering RNAs (siRNAs) targeting the highly conserved 5′-untranslated region (5′-UTR) of SARS-CoV-2. The most promising candidate identified in initial reporter assays, termed siCoV6, targets the leader sequence of the virus, which is present in the genomic as well as in all subgenomic RNAs. In assays with infectious SARS-CoV-2, it reduced replication by two orders of magnitude and prevented the development of a cytopathic effect. Moreover, it retained its activity against the SARS-CoV-2 alpha variant and has perfect homology against all sequences of the delta variant that were analyzed by bioinformatic means. Interestingly, the siRNA was even highly active in virus replication assays with the SARS-CoV-1 family member. This work thus identified a very potent siRNA with a broad activity against various SARS-CoV viruses that represents a promising candidate for the development of new treatment options.