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Yeo M, Sarkar A, Singh YP, Derman ID, Datta P, Ozbolat IT. Synergistic coupling between 3D bioprinting and vascularization strategies. Biofabrication 2023; 16:012003. [PMID: 37944186 PMCID: PMC10658349 DOI: 10.1088/1758-5090/ad0b3f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 09/27/2023] [Accepted: 11/09/2023] [Indexed: 11/12/2023]
Abstract
Three-dimensional (3D) bioprinting offers promising solutions to the complex challenge of vascularization in biofabrication, thereby enhancing the prospects for clinical translation of engineered tissues and organs. While existing reviews have touched upon 3D bioprinting in vascularized tissue contexts, the current review offers a more holistic perspective, encompassing recent technical advancements and spanning the entire multistage bioprinting process, with a particular emphasis on vascularization. The synergy between 3D bioprinting and vascularization strategies is crucial, as 3D bioprinting can enable the creation of personalized, tissue-specific vascular network while the vascularization enhances tissue viability and function. The review starts by providing a comprehensive overview of the entire bioprinting process, spanning from pre-bioprinting stages to post-printing processing, including perfusion and maturation. Next, recent advancements in vascularization strategies that can be seamlessly integrated with bioprinting are discussed. Further, tissue-specific examples illustrating how these vascularization approaches are customized for diverse anatomical tissues towards enhancing clinical relevance are discussed. Finally, the underexplored intraoperative bioprinting (IOB) was highlighted, which enables the direct reconstruction of tissues within defect sites, stressing on the possible synergy shaped by combining IOB with vascularization strategies for improved regeneration.
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Affiliation(s)
- Miji Yeo
- The Huck Institutes of the Life Sciences, Penn State University, University Park, PA 16802, United States of America
- Engineering Science and Mechanics Department, Penn State University, University Park, PA 16802, United States of America
| | - Anwita Sarkar
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research, Kolkata, West Bengal 700054, India
| | - Yogendra Pratap Singh
- The Huck Institutes of the Life Sciences, Penn State University, University Park, PA 16802, United States of America
- Engineering Science and Mechanics Department, Penn State University, University Park, PA 16802, United States of America
| | - Irem Deniz Derman
- The Huck Institutes of the Life Sciences, Penn State University, University Park, PA 16802, United States of America
- Engineering Science and Mechanics Department, Penn State University, University Park, PA 16802, United States of America
| | - Pallab Datta
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research, Kolkata, West Bengal 700054, India
| | - Ibrahim T Ozbolat
- The Huck Institutes of the Life Sciences, Penn State University, University Park, PA 16802, United States of America
- Engineering Science and Mechanics Department, Penn State University, University Park, PA 16802, United States of America
- Department of Biomedical Engineering, Penn State University, University Park, PA 16802, United States of America
- Materials Research Institute, Penn State University, University Park, PA 16802, United States of America
- Department of Neurosurgery, Penn State College of Medicine, Hershey, PA 17033, United States of America
- Penn State Cancer Institute, Penn State University, Hershey, PA 17033, United States of America
- Biotechnology Research and Application Center, Cukurova University, Adana 01130, Turkey
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Ferreira FV, Souza AG, Ajdary R, de Souza LP, Lopes JH, Correa DS, Siqueira G, Barud HS, Rosa DDS, Mattoso LH, Rojas OJ. Nanocellulose-based porous materials: Regulation and pathway to commercialization in regenerative medicine. Bioact Mater 2023; 29:151-176. [PMID: 37502678 PMCID: PMC10368849 DOI: 10.1016/j.bioactmat.2023.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/16/2023] [Accepted: 06/24/2023] [Indexed: 07/29/2023] Open
Abstract
We review the recent progress that have led to the development of porous materials based on cellulose nanostructures found in plants and other resources. In light of the properties that emerge from the chemistry, shape and structural control, we discuss some of the most promising uses of a plant-based material, nanocellulose, in regenerative medicine. Following a brief discussion about the fundamental aspects of self-assembly of nanocellulose precursors, we review the key strategies needed for material synthesis and to adjust the architecture of the materials (using three-dimensional printing, freeze-casted porous materials, and electrospinning) according to their uses in tissue engineering, artificial organs, controlled drug delivery and wound healing systems, among others. For this purpose, we map the structure-property-function relationships of nanocellulose-based porous materials and examine the course of actions that are required to translate innovation from the laboratory to industry. Such efforts require attention to regulatory aspects and market pull. Finally, the key challenges and opportunities in this nascent field are critically reviewed.
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Affiliation(s)
- Filipe V. Ferreira
- Nanotechnology National Laboratory for Agriculture (LNNA), Embrapa Instrumentation – Rua XV de Novembro, 1452, São Carlos, SP, 13560-979, Brazil
| | - Alana G. Souza
- Center for Engineering, Modeling, and Applied Social Sciences (CECS), Federal University of ABC (UFABC), Santo André, Brazil
| | - Rubina Ajdary
- Department of Bioproducts and Biosystems, School of Chemical Engineering, Aalto University, P. O. Box 16300, Aalto, Espoo, FIN-00076, Finland
| | - Lucas P. de Souza
- College of Engineering and Physical Sciences, Aston Institute of Materials Research, Aston University, Birmingham, UK
| | - João H. Lopes
- Department of Chemistry, Division of Fundamental Sciences (IEF), Technological Institute of Aeronautics (ITA), São Jose dos Campos, SP, Brazil
| | - Daniel S. Correa
- Nanotechnology National Laboratory for Agriculture (LNNA), Embrapa Instrumentation – Rua XV de Novembro, 1452, São Carlos, SP, 13560-979, Brazil
| | - Gilberto Siqueira
- Laboratory for Cellulose & Wood Materials, Empa - Swiss Federal Laboratories for Materials Science and Technology, Überlandstrasse 129, 8600, Dübendorf, Switzerland
| | - Hernane S. Barud
- Biopolymers and Biomaterials Laboratory (BIOPOLMAT), University of Araraquara (UNIARA), Araraquara, 14801-340, São Paulo, Brazil
| | - Derval dos S. Rosa
- Center for Engineering, Modeling, and Applied Social Sciences (CECS), Federal University of ABC (UFABC), Santo André, Brazil
| | - Luiz H.C. Mattoso
- Nanotechnology National Laboratory for Agriculture (LNNA), Embrapa Instrumentation – Rua XV de Novembro, 1452, São Carlos, SP, 13560-979, Brazil
| | - Orlando J. Rojas
- Department of Bioproducts and Biosystems, School of Chemical Engineering, Aalto University, P. O. Box 16300, Aalto, Espoo, FIN-00076, Finland
- Bioproducts Institute, Department of Chemical & Biological Engineering, Department of Chemistry and, Department of Wood Science, The University of British Columbia, 2360 East Mall, Vancouver, BC, V6T 1Z3, Canada
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Sultan MT, Lee OJ, Lee JS, Park CH. Three-Dimensional Digital Light-Processing Bioprinting Using Silk Fibroin-Based Bio-Ink: Recent Advancements in Biomedical Applications. Biomedicines 2022; 10:biomedicines10123224. [PMID: 36551978 PMCID: PMC9775525 DOI: 10.3390/biomedicines10123224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/28/2022] [Accepted: 12/07/2022] [Indexed: 12/15/2022] Open
Abstract
Three-dimensional (3D) bioprinting has been developed as a viable method for fabricating functional tissues and organs by precisely spatially arranging biomaterials, cells, and biochemical components in a layer-by-layer fashion. Among the various bioprinting strategies, digital light-processing (DLP) printing has gained enormous attention due to its applications in tissue engineering and biomedical fields. It allows for high spatial resolution and the rapid printing of complex structures. Although bio-ink is a critical aspect of 3D bioprinting, only a few bio-inks have been used for DLP bioprinting in contrast to the number of bio-inks employed for other bioprinters. Recently, silk fibroin (SF), as a natural bio-ink material used for DLP 3D bioprinting, has gained extensive attention with respect to biomedical applications due to its biocompatibility and mechanical properties. This review introduces DLP-based 3D bioprinting, its related technology, and the fabrication process of silk fibroin-based bio-ink. Then, we summarize the applications of DLP 3D bioprinting based on SF-based bio-ink in the tissue engineering and biomedical fields. We also discuss the current limitations and future perspectives of DLP 3D bioprinting using SF-based bio-ink.
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Affiliation(s)
- Md. Tipu Sultan
- Nano-Bio Regenerative Medical Institute (NBRM), College of Medicine, Hallym University, Chuncheon 24252, Republic of Korea
| | - Ok Joo Lee
- Nano-Bio Regenerative Medical Institute (NBRM), College of Medicine, Hallym University, Chuncheon 24252, Republic of Korea
| | - Joong Seob Lee
- Nano-Bio Regenerative Medical Institute (NBRM), College of Medicine, Hallym University, Chuncheon 24252, Republic of Korea
- Department of Otorhinolaryngology-Head & Neck Surgery, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea
| | - Chan Hum Park
- Nano-Bio Regenerative Medical Institute (NBRM), College of Medicine, Hallym University, Chuncheon 24252, Republic of Korea
- Depratment of Otorhinolaryngology-Head and Neck Surgery, Chuncheon Sacred Heart Hospital, Chuncheon 24253, Republic of Korea
- Correspondence:
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Panda S, Hajra S, Mistewicz K, Nowacki B, In-Na P, Krushynska A, Mishra YK, Kim HJ. A focused review on three-dimensional bioprinting technology for artificial organ fabrication. Biomater Sci 2022; 10:5054-5080. [PMID: 35876134 DOI: 10.1039/d2bm00797e] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Three-dimensional (3D) bioprinting technology has attracted a great deal of interest because it can be easily adapted to many industries and research sectors, such as biomedical, manufacturing, education, and engineering. Specifically, 3D bioprinting has provided significant advances in the medical industry, since such technology has led to significant breakthroughs in the synthesis of biomaterials, cells, and accompanying elements to produce composite living tissues. 3D bioprinting technology could lead to the immense capability of replacing damaged or injured tissues or organs with newly dispensed cell biomaterials and functional tissues. Several types of bioprinting technology and different bio-inks can be used to replicate cells and generate supporting units as complex 3D living tissues. Bioprinting techniques have undergone great advancements in the field of regenerative medicine to provide 3D printed models for numerous artificial organs and transplantable tissues. This review paper aims to provide an overview of 3D-bioprinting technologies by elucidating the current advancements, recent progress, opportunities, and applications in this field. It highlights the most recent advancements in 3D-bioprinting technology, particularly in the area of artificial organ development and cancer research. Additionally, the paper speculates on the future progress in 3D-bioprinting as a versatile foundation for several biomedical applications.
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Affiliation(s)
- Swati Panda
- Department of Robotics and Mechatronics Engineering, Daegu Gyeongbuk Institute of Science and Technology, Daegu-42988, South Korea.
| | - Sugato Hajra
- Department of Robotics and Mechatronics Engineering, Daegu Gyeongbuk Institute of Science and Technology, Daegu-42988, South Korea.
| | - Krystian Mistewicz
- Institute of Physics - Center for Science and Education, Silesian University of Technology, Krasińskiego 8, Katowice, Poland
| | - Bartłomiej Nowacki
- Faculty of Materials Engineering, Silesian University of Technology, Krasińskiego 8, Katowice, Poland
| | - Pichaya In-Na
- Department of Chemical Technology, Faculty of Science, Chulalongkorn University, 254 Phyathai Road, Wangmai, Pathumwan, Bangkok-10330, Thailand
| | - Anastasiia Krushynska
- Engineering and Technology Institute Groningen (ENTEG), Faculty of Science and Engineering, University of Groningen, Nijenborgh 4, Groningen, 9747 AG, Netherlands
| | - Yogendra Kumar Mishra
- Mads Clausen Institute, NanoSYD, University of Southern Denmark, Alsion 2, 6400 Sønderborg, Denmark
| | - Hoe Joon Kim
- Department of Robotics and Mechatronics Engineering, Daegu Gyeongbuk Institute of Science and Technology, Daegu-42988, South Korea. .,Robotics and Mechatronics Research Center, Daegu Gyeongbuk Institute of Science and Technology, Daegu-42988, South Korea
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Three-Dimensional (3D) Printing in Cancer Therapy and Diagnostics: Current Status and Future Perspectives. Pharmaceuticals (Basel) 2022; 15:ph15060678. [PMID: 35745597 PMCID: PMC9229198 DOI: 10.3390/ph15060678] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 12/10/2022] Open
Abstract
Three-dimensional (3D) printing is a technique where the products are printed layer-by-layer via a series of cross-sectional slices with the exact deposition of different cell types and biomaterials based on computer-aided design software. Three-dimensional printing can be divided into several approaches, such as extrusion-based printing, laser-induced forward transfer-based printing systems, and so on. Bio-ink is a crucial tool necessary for the fabrication of the 3D construct of living tissue in order to mimic the native tissue/cells using 3D printing technology. The formation of 3D software helps in the development of novel drug delivery systems with drug screening potential, as well as 3D constructs of tumor models. Additionally, several complex structures of inner tissues like stroma and channels of different sizes are printed through 3D printing techniques. Three-dimensional printing technology could also be used to develop therapy training simulators for educational purposes so that learners can practice complex surgical procedures. The fabrication of implantable medical devices using 3D printing technology with less risk of infections is receiving increased attention recently. A Cancer-on-a-chip is a microfluidic device that recreates tumor physiology and allows for a continuous supply of nutrients or therapeutic compounds. In this review, based on the recent literature, we have discussed various printing methods for 3D printing and types of bio-inks, and provided information on how 3D printing plays a crucial role in cancer management.
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Shinkar K, Rhode K. Could 3D extrusion bioprinting serve to be a real alternative to organ transplantation in the future? ANNALS OF 3D PRINTED MEDICINE 2022. [DOI: 10.1016/j.stlm.2022.100066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Correlating Rheological Properties of a Gellan Gum-Based Bioink: A Study of the Impact of Cell Density. Polymers (Basel) 2022; 14:polym14091844. [PMID: 35567015 PMCID: PMC9102283 DOI: 10.3390/polym14091844] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 11/17/2022] Open
Abstract
Here, for the production of a bioink-based gellan gum, an amino derivative of this polysaccharide was mixed with a mono-functionalized aldehyde polyethyleneglycol in order to improve viscoelastic macroscopic properties and the potential processability by means of bioprinting techniques as confirmed by the printing tests. The dynamic Schiff base linkage between amino and aldehyde groups temporally modulates the rheological properties and allows a reduction of the applied pressure during extrusion followed by the recovery of gellan gum strength. Rheological properties, often related to printing resolution, were extensively investigated confirming pseudoplastic behavior and thermotropic and ionotropic responses. The success of bioprinting is related to different parameters. Among them, cell density must be carefully selected, and in order to quantify their role on printability, murine preostoblastic cells (MC3T3-E1) and human colon tumor cells (HCT-116) were chosen as cell line models. Here, we investigated the effect of their density on the bioink’s rheological properties, showing a more significant difference between cell densities for MC3T3-E1 compared to HCT-116. The results suggest the necessity of not neglecting this aspect and carrying out preliminary studies to choose the best cell densities to have the maximum viability and consequently to set the printing parameters.
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Nelson C, Tuladhar S, Habib A. Physical Modification of Hybrid Hydrogels to Fabricate Full-Scale Construct Using Three-Dimensional Bio-Printing Process. JOURNAL OF MICRO- AND NANO-MANUFACTURING 2022; 10:011005. [PMID: 36439989 PMCID: PMC9680535 DOI: 10.1115/1.4055230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/08/2022] [Indexed: 06/16/2023]
Abstract
Bioprinting for regenerative medicine has been gaining a lot of popularity in today's world. Despite being one of the rigorously studied fields, there are still several challenges yet to be solved. Geometric fidelity and mechanical complexities stand as roadblocks when it comes to the printability of the customized constructs. Exploring the rheological properties of the compositions helps us understand the physical and mechanical properties of the biomaterials which are closely tied to the printability of the filament and eventually, geometric fidelity of the constructs. To ensure the structural integrity of the constructs, viscosity enhancers such as carboxymethyl cellulose (CMC) and crosslinkers like CaCl2 and CaSO4 were used. These crosslinkers can be used before (precrosslinking) and after (postcrosslinking) the extrusion of considered compositions to investigate and compare the outcome. To do this, mixtures of CMC (viscosity enhancer), Alginate, and CaCl2 and CaSO4 (crosslinkers) were prepared at various concentrations maintaining minimum solid content (≤8%). Each composition was subjected to a set of rheological tests like flow curve for shear thinning behavior, three points thixotropic for recovery rate, and amplitude test for gelation point. Various geometric fidelity identification tests were conducted and correlated with their physical properties. Some compositions were used to fabricate large-scale constructs (in cm-scale) to demonstrate their capability. This research is a thorough investigation of compositions when they are introduced to crosslinkers and viscosity enhancers which can be crucial for the 3D printing world.
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Affiliation(s)
- Cartwright Nelson
- Sustainable Product Design and Architecture, Keene State College, 229 Main Street, Keene, NH 03435
| | - Slesha Tuladhar
- Sustainable Product Design and Architecture, Keene State College, 229 Main Street, Keene, NH 03435
| | - Ahasan Habib
- Sustainable Product Design and Architecture, Keene State College, 229 Main Street, Keene, NH 03435
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3D Bio-Printability of Hybrid Pre-Crosslinked Hydrogels. Int J Mol Sci 2021; 22:ijms222413481. [PMID: 34948280 PMCID: PMC8708105 DOI: 10.3390/ijms222413481] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/07/2021] [Accepted: 12/13/2021] [Indexed: 11/19/2022] Open
Abstract
Maintaining shape fidelity of 3D bio-printed scaffolds with soft biomaterials is an ongoing challenge. Here, a rheological investigation focusing on identifying useful physical and mechanical properties directly related to the geometric fidelity of 3D bio-printed scaffolds is presented. To ensure during- and post-printing shape fidelity of the scaffolds, various percentages of Carboxymethyl Cellulose (CMC) (viscosity enhancer) and different calcium salts (CaCl2 and CaSO4, physical cross-linkers) were mixed into alginate before extrusion to realize shape fidelity. The overall solid content of Alginate-Carboxymethyl Cellulose (CMC) was limited to 6%. A set of rheological tests, e.g., flow curves, amplitude tests, and three interval thixotropic tests, were performed to identify and compare the shear-thinning capacity, gelation points, and recovery rate of various compositions. The geometrical fidelity of the fabricated scaffolds was defined by printability and collapse tests. The effect of using multiple cross-linkers simultaneously was assessed. Various large-scale scaffolds were fabricated (up to 5.0 cm) using a pre-crosslinked hybrid. Scaffolds were assessed for the ability to support the growth of Escherichia coli using the Most Probable Number technique to quantify bacteria immediately after inoculation and 24 h later. This pre-crosslinking-based rheological property controlling technique can open a new avenue for 3D bio-fabrication of scaffolds, ensuring proper geometry.
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Hauser PV, Chang HM, Nishikawa M, Kimura H, Yanagawa N, Hamon M. Bioprinting Scaffolds for Vascular Tissues and Tissue Vascularization. Bioengineering (Basel) 2021; 8:178. [PMID: 34821744 PMCID: PMC8615027 DOI: 10.3390/bioengineering8110178] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 10/25/2021] [Accepted: 10/27/2021] [Indexed: 02/07/2023] Open
Abstract
In recent years, tissue engineering has achieved significant advancements towards the repair of damaged tissues. Until this day, the vascularization of engineered tissues remains a challenge to the development of large-scale artificial tissue. Recent breakthroughs in biomaterials and three-dimensional (3D) printing have made it possible to manipulate two or more biomaterials with complementary mechanical and/or biological properties to create hybrid scaffolds that imitate natural tissues. Hydrogels have become essential biomaterials due to their tissue-like physical properties and their ability to include living cells and/or biological molecules. Furthermore, 3D printing, such as dispensing-based bioprinting, has progressed to the point where it can now be utilized to construct hybrid scaffolds with intricate structures. Current bioprinting approaches are still challenged by the need for the necessary biomimetic nano-resolution in combination with bioactive spatiotemporal signals. Moreover, the intricacies of multi-material bioprinting and hydrogel synthesis also pose a challenge to the construction of hybrid scaffolds. This manuscript presents a brief review of scaffold bioprinting to create vascularized tissues, covering the key features of vascular systems, scaffold-based bioprinting methods, and the materials and cell sources used. We will also present examples and discuss current limitations and potential future directions of the technology.
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Affiliation(s)
- Peter Viktor Hauser
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (P.V.H.); (H.-M.C.); (N.Y.)
- Medical and Research Services, Greater Los Angeles Veterans Affairs Healthcare System at Sepulveda, North Hills, CA 91343, USA
| | - Hsiao-Min Chang
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (P.V.H.); (H.-M.C.); (N.Y.)
- Medical and Research Services, Greater Los Angeles Veterans Affairs Healthcare System at Sepulveda, North Hills, CA 91343, USA
| | - Masaki Nishikawa
- Department of Chemical System Engineering, Graduate School of Engineering, University of Tokyo, Tokyo 113-8654, Japan;
| | - Hiroshi Kimura
- Department of Mechanical Engineering, School of Engineering, Tokai University, Isehara 259-1207, Japan;
| | - Norimoto Yanagawa
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (P.V.H.); (H.-M.C.); (N.Y.)
- Medical and Research Services, Greater Los Angeles Veterans Affairs Healthcare System at Sepulveda, North Hills, CA 91343, USA
| | - Morgan Hamon
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (P.V.H.); (H.-M.C.); (N.Y.)
- Medical and Research Services, Greater Los Angeles Veterans Affairs Healthcare System at Sepulveda, North Hills, CA 91343, USA
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