1
|
Song W, Guo Y, Liu W, Yao Y, Zhang X, Cai Z, Yuan C, Wang X, Wang Y, Jiang X, Wang H, Yu W, Li H, Zhu Y, Kong L, He Y. Circadian Rhythm-Regulated ADSC-Derived sEVs and a Triphasic Microneedle Delivery System to Enhance Tendon-to-Bone Healing. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2024; 36:e2408255. [PMID: 39120049 DOI: 10.1002/adma.202408255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/23/2024] [Indexed: 08/10/2024]
Abstract
Modulating the inflammatory microenvironment to reconstruct the fibrocartilaginous layer while promoting tendon repair is crucial for enhancing tendon-to-bone healing in rotator cuff repair (RCR), a persistent challenge in orthopedics. Small extracellular vesicles (sEVs) hold significant potential to modulate inflammation, yet the efficient production of highly bioactive sEVs remains a substantial barrier to their clinical application. Moreover, achieving minimally invasive local delivery of sEVs to the tendon-to-bone interface presents significant technical difficulties. Herein, the circadian rhythm of adipose-derived stem cells is modulated to increase the yield and enhance the inflammatory regulatory capacity of sEVs. Circadian rhythm-regulated sEVs (CR-sEVs) enhance the cyclic adenosine monophosphate signaling pathway in macrophage (Mφ) via platelet factor 4 delivery, thereby inhibiting Mφ M1 polarization. Subsequently, a triphasic microneedle (MN) scaffold with a tip, stem, and base is designed for the local delivery of CR-sEVs (CR-sEVs/MN) at the tendon-to-bone junction, incorporating tendon-derived decellularized extracellular matrix in the base to facilitate tendon repair. CR-sEVs/MN mitigates inflammation, promotes fibrocartilage regeneration, and enhances tendon healing, thereby improving biomechanical strength and shoulder joint function in a rat RCR model. Combining CR-sEVs with this triphasic microneedle delivery system presents a promising strategy for enhancing tendon-to-bone healing in clinical settings.
Collapse
Affiliation(s)
- Wei Song
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, P. R. China
| | - Ying Guo
- Department of Cardiology, Heart Center, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, P. R. China
| | - Wencai Liu
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, P. R. China
| | - Yijing Yao
- Department of Ultrasound, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, P. R. China
| | - Xuancheng Zhang
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, P. R. China
| | - Zhuochang Cai
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, P. R. China
| | - Chenrui Yuan
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, P. R. China
| | - Xin Wang
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, P. R. China
| | - Yifei Wang
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, P. R. China
| | - Xiping Jiang
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, P. R. China
| | - Haoyuan Wang
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, P. R. China
| | - Weilin Yu
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, P. R. China
| | - Haiyan Li
- Chemical and Environmental Engineering Department, School of Engineering, STEM College, RMIT University, 124 La Trobe St., Melbourne, Victoria, 3000, Australia
| | - Yanlun Zhu
- State Key Laboratory of High Performance Ceramics and Superfine Microstructure, Shanghai Institute of Ceramics, Chinese Academy of Sciences, Shanghai, 200050, P. R. China
| | - Lingzhi Kong
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, P. R. China
| | - Yaohua He
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, P. R. China
- Department of Orthopedic Surgery, Jinshan District Central Hospital affiliated to Shanghai University of Medicine & Health Sciences, Jinshan Branch of Shanghai Sixth People's Hospital, Shanghai, 201500, P. R. China
| |
Collapse
|
2
|
Salinas-Fernandez S, Garcia O, Kelly DJ, Buckley CT. The influence of pH and salt concentration on the microstructure and mechanical properties of meniscus extracellular matrix-derived implants. J Biomed Mater Res A 2024; 112:359-372. [PMID: 37921203 DOI: 10.1002/jbm.a.37634] [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: 06/13/2023] [Revised: 10/05/2023] [Accepted: 10/16/2023] [Indexed: 11/04/2023]
Abstract
Meniscus-related injuries are a common orthopedic challenge with an increasing incidence in the population. While the preservation of viable meniscal tissue is the preferred approach in repair strategies, complex or total traumatic lesions may require alternative therapeutic approaches such as meniscal reconstruction using allografts or engineered equivalents. Although clinical studies suggest promising outcomes with the use of acellular implants, further development is needed to improve their biological and mechanical requirements. Decellularized extracellular matrix (dECM) derived from menisci is a promising biomaterial for meniscus tissue engineering due to its recapitulation of the native tissue environment and the maintenance of tissue-specific cues. However, the associated mechanical limitations of dECM-derived scaffolds frequently impedes their adoption, requiring additional reinforcement or combining with stiffer biomaterials to increase their load-bearing properties. In this study, decellularized extracellular matrix was extracted and its fibrillation was controlled by adjusting both pH and salt concentrations to fabricate mechanically functional meniscal tissue equivalents. The effect of collagen fibrillation on the mechanical properties of the dECM constructs was assessed, and porcine-derived fibrochondrocytes were used to evaluate in vitro biocompatibility. It was also possible to fabricate meniscus-shaped implants by casting of the dECM and to render the implants suitable for off-the-shelf use by adopting a freeze-drying preservation method. Suture pull-out tests were also performed to assess the feasibility of using existing surgical methods to fix such implants within a damaged meniscus. This study highlights the potential of utilizing ECM-derived materials for meniscal tissue substitutes that closely mimic the mechanical and biological properties of native tissue.
Collapse
Affiliation(s)
- Soraya Salinas-Fernandez
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Discipline of Mechanical, Manufacturing and Biomedical Engineering, School of Engineering, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Advanced Materials and Bioengineering Research (AMBER) Centre, Royal College of Surgeons in Ireland & Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Orquidea Garcia
- Johnson & Johnson 3D Printing Innovation & Customer Solutions, Johnson & Johnson Services, Inc., Irvine, California, USA
| | - Daniel J Kelly
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Discipline of Mechanical, Manufacturing and Biomedical Engineering, School of Engineering, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Advanced Materials and Bioengineering Research (AMBER) Centre, Royal College of Surgeons in Ireland & Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Tissue Engineering Research Group, Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Conor T Buckley
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Discipline of Mechanical, Manufacturing and Biomedical Engineering, School of Engineering, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Advanced Materials and Bioengineering Research (AMBER) Centre, Royal College of Surgeons in Ireland & Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Tissue Engineering Research Group, Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| |
Collapse
|
3
|
Golebiowska AA, Intravaia JT, Sathe VM, Kumbar SG, Nukavarapu SP. Decellularized extracellular matrix biomaterials for regenerative therapies: Advances, challenges and clinical prospects. Bioact Mater 2024; 32:98-123. [PMID: 37927899 PMCID: PMC10622743 DOI: 10.1016/j.bioactmat.2023.09.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/21/2023] [Accepted: 09/25/2023] [Indexed: 11/07/2023] Open
Abstract
Tissue engineering and regenerative medicine have shown potential in the repair and regeneration of tissues and organs via the use of engineered biomaterials and scaffolds. However, current constructs face limitations in replicating the intricate native microenvironment and achieving optimal regenerative capacity and functional recovery. To address these challenges, the utilization of decellularized tissues and cell-derived extracellular matrix (ECM) has emerged as a promising approach. These biocompatible and bioactive biomaterials can be engineered into porous scaffolds and grafts that mimic the structural and compositional aspects of the native tissue or organ microenvironment, both in vitro and in vivo. Bioactive dECM materials provide a unique tissue-specific microenvironment that can regulate and guide cellular processes, thereby enhancing regenerative therapies. In this review, we explore the emerging frontiers of decellularized tissue-derived and cell-derived biomaterials and bio-inks in the field of tissue engineering and regenerative medicine. We discuss the need for further improvements in decellularization methods and techniques to retain structural, biological, and physicochemical characteristics of the dECM products in a way to mimic native tissues and organs. This article underscores the potential of dECM biomaterials to stimulate in situ tissue repair through chemotactic effects for the development of growth factor and cell-free tissue engineering strategies. The article also identifies the challenges and opportunities in developing sterilization and preservation methods applicable for decellularized biomaterials and grafts and their translation into clinical products.
Collapse
Affiliation(s)
| | - Jonathon T. Intravaia
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT, 06269, USA
| | - Vinayak M. Sathe
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT, 06032, USA
| | - Sangamesh G. Kumbar
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT, 06269, USA
- Department of Materials Science & Engineering, University of Connecticut, Storrs, CT, 06269, USA
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT, 06032, USA
| | - Syam P. Nukavarapu
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT, 06269, USA
- Department of Materials Science & Engineering, University of Connecticut, Storrs, CT, 06269, USA
- Department of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT, 06032, USA
| |
Collapse
|
4
|
Anjum S, Li T, Saeed M, Ao Q. Exploring polysaccharide and protein-enriched decellularized matrix scaffolds for tendon and ligament repair: A review. Int J Biol Macromol 2024; 254:127891. [PMID: 37931866 DOI: 10.1016/j.ijbiomac.2023.127891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/07/2023] [Accepted: 11/02/2023] [Indexed: 11/08/2023]
Abstract
Tissue engineering (TE) has become a primary research topic for the treatment of diseased or damaged tendon/ligament (T/L) tissue. T/L injuries pose a severe clinical burden worldwide, necessitating the development of effective strategies for T/L repair and tissue regeneration. TE has emerged as a promising strategy for restoring T/L function using decellularized extracellular matrix (dECM)-based scaffolds. dECM scaffolds have gained significant prominence because of their native structure, relatively high bioactivity, low immunogenicity, and ability to function as scaffolds for cell attachment, proliferation, and differentiation, which are difficult to imitate using synthetic materials. Here, we review the recent advances and possible future prospects for the advancement of dECM scaffolds for T/L tissue regeneration. We focus on crucial scaffold properties and functions, as well as various engineering strategies employed for biomaterial design in T/L regeneration. dECM provides both the physical and mechanical microenvironments required by cells to survive and proliferate. Various decellularization methods and sources of allogeneic and xenogeneic dECM in T/L repair and regeneration are critically discussed. Additionally, dECM hydrogels, bio-inks in 3D bioprinting, and nanofibers are briefly explored. Understanding the opportunities and challenges associated with dECM-based scaffold development is crucial for advancing T/L repairs in tissue engineering and regenerative medicine.
Collapse
Affiliation(s)
- Shabnam Anjum
- Department of Tissue Engineering, School of Intelligent Medicine, China Medical University, Shenyang 110122, China; NMPA Key Laboratory for Quality Research and Control of Tissue Regenerative Biomaterial, Institute of Regulatory Science for Medical Device, National Engineering Research Center for Biomaterials, Sichuan University, Chengdu 610064, China
| | - Ting Li
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, Liaoning 110004, China
| | - Mohammad Saeed
- Dr. A.P.J Abdul Kalam Technical University, Lucknow 226031, India
| | - Qiang Ao
- Department of Tissue Engineering, School of Intelligent Medicine, China Medical University, Shenyang 110122, China; NMPA Key Laboratory for Quality Research and Control of Tissue Regenerative Biomaterial, Institute of Regulatory Science for Medical Device, National Engineering Research Center for Biomaterials, Sichuan University, Chengdu 610064, China.
| |
Collapse
|
5
|
Data K, Kulus M, Ziemak H, Chwarzyński M, Piotrowska-Kempisty H, Bukowska D, Antosik P, Mozdziak P, Kempisty B. Decellularization of Dense Regular Connective Tissue-Cellular and Molecular Modification with Applications in Regenerative Medicine. Cells 2023; 12:2293. [PMID: 37759515 PMCID: PMC10528602 DOI: 10.3390/cells12182293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/31/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
Healing of dense regular connective tissue, due to a high fiber-to-cell ratio and low metabolic activity and regeneration potential, frequently requires surgical implantation or reconstruction with high risk of reinjury. An alternative to synthetic implants is using bioscaffolds obtained through decellularization, a process where the aim is to extract cells from the tissue while preserving the tissue-specific native molecular structure of the ECM. Proteins, lipids, nucleic acids and other various extracellular molecules are largely involved in differentiation, proliferation, vascularization and collagen fibers deposit, making them the crucial processes in tissue regeneration. Because of the multiple possible forms of cell extraction, there is no standardized protocol in dense regular connective tissue (DRCT). Many modifications of the structure, shape and composition of the bioscaffold have also been described to improve the therapeutic result following the implantation of decellularized connective tissue. The available data provide a valuable source of crucial information. However, the wide spectrum of decellularization makes it important to understand the key aspects of bioscaffolds relative to their potential use in tissue regeneration.
Collapse
Affiliation(s)
- Krzysztof Data
- Division of Anatomy, Department of Human Morphology and Embryology, Wroclaw Medical University, 50-368 Wroclaw, Poland
| | - Magdalena Kulus
- Department of Veterinary Surgery, Institute of Veterinary Medicine, Nicolaus Copernicus University in Torun, 87-100 Torun, Poland
| | - Hanna Ziemak
- Department of Veterinary Surgery, Institute of Veterinary Medicine, Nicolaus Copernicus University in Torun, 87-100 Torun, Poland
| | - Mikołaj Chwarzyński
- Department of Veterinary Surgery, Institute of Veterinary Medicine, Nicolaus Copernicus University in Torun, 87-100 Torun, Poland
| | - Hanna Piotrowska-Kempisty
- Department of Toxicology, Poznan University of Medical Sciences, 60-631 Poznan, Poland
- Department of Basic and Preclinical Sciences, Institute of Veterinary Medicine, Nicolaus Copernicus University in Torun, 87-100 Torun, Poland
| | - Dorota Bukowska
- Department of Diagnostics and Clinical Sciences, Institute of Veterinary Medicine, Nicolaus Copernicus University in Torun, 87-100 Torun, Poland
| | - Paweł Antosik
- Department of Veterinary Surgery, Institute of Veterinary Medicine, Nicolaus Copernicus University in Torun, 87-100 Torun, Poland
| | - Paul Mozdziak
- Physiolgy Graduate Faculty, North Carolina State University, Raleigh, NC 27695, USA
- Prestage Department of Poultry Sciences, North Carolina State University, Raleigh, NC 27695, USA
| | - Bartosz Kempisty
- Division of Anatomy, Department of Human Morphology and Embryology, Wroclaw Medical University, 50-368 Wroclaw, Poland
- Department of Veterinary Surgery, Institute of Veterinary Medicine, Nicolaus Copernicus University in Torun, 87-100 Torun, Poland
- Physiolgy Graduate Faculty, North Carolina State University, Raleigh, NC 27695, USA
- Department of Obstetrics and Gynecology, University Hospital and Masaryk University, 601 77 Brno, Czech Republic
| |
Collapse
|
6
|
Hanai H, Hart DA, Jacob G, Shimomura K, Ando W, Yoshioka Y, Ochiya T, Nakagawa S, Nakamura M, Okada S, Nakamura N. Small extracellular vesicles derived from human adipose-derived mesenchymal stromal cells cultured in a new chemically-defined contaminate-free media exhibit enhanced biological and therapeutic effects on human chondrocytes in vitro and in a mouse osteoarthritis model. J Extracell Vesicles 2023; 12:e12337. [PMID: 37367299 PMCID: PMC10295161 DOI: 10.1002/jev2.12337] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 06/13/2023] [Indexed: 06/28/2023] Open
Abstract
Human small extracellular vesicles (sEVs) derived from adipose-derived mesenchymal stromal cells (ASC) have been reported to suppress the progression of osteoarthritis (OA) in animal studies and subsequently, translation of this potential to assess their clinical efficacy is anticipated. However, fabrication protocols for sEVs to eliminate potential contamination by culture medium-derived components need to be established prior to their clinical use. The purpose of the present studies was to elucidate the influence of medium-derived contaminants on the biological effects of sEVs, and to establish isolation methods for sEVs using a new clinical grade chemically-defined media (CDM). The quantity and purity of ASC-derived sEVs cultured in four different CDMs (CDM1, 2, 3 and 4) were evaluated. The concentrates of the four media incubated without cells were used as the background (BG) control for each set of sEVs. The biological effect of sEVs fabricated in the four different CDMs on normal human articular chondrocytes (hACs) were evaluated in vitro using a variety of methodological assessments. Finally, the sEVs with the highest purity were tested for their ability to suppress the progression of knee OA mouse model. Analysis of the BG controls revealed that CDM1-3 contained detectable particles, while there was no visible contamination of culture media-derived components detected with CDM4. Accordingly, the sEVs fabricated with CDM4 (CDM4-sEVs) exhibited the highest purity and yield. Notably, the CDM4-sEVs were the most efficient in promoting the cellular proliferation, migration, chondrogenic differentiation, and anti-apoptotic activity of hACs. Furthermore, CDM4-sEVs significantly suppressed the osteochondral degeneration in vivo model. Small EVs derived from ASCs cultured in a CDM without detectable contaminants demonstrated enhanced biological effects on hACs and the progression of OA. Thus, sEVs isolated with CDM4 most optimally meet the requirements of efficacy and safety for assessment in their future clinical applications.
Collapse
Affiliation(s)
- Hiroto Hanai
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - David A Hart
- Department of Surgery and the McCaig Institute for Bone & Joint Health, University of Calgary, Calgary, Canada
| | - George Jacob
- Department of Orthopaedics, VPS Lakeshore Hospital, Kerala, India
| | - Kazunori Shimomura
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Wataru Ando
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
- Department of Orthopaedic Surgery, Kansai Rosai Hospital, Hyogo, Japan
| | - Yusuke Yoshioka
- Department of Molecular and Cellular Medicine, Institute of Medical Science, Tokyo Medical University, Tokyo, Japan
| | - Takahiro Ochiya
- Department of Molecular and Cellular Medicine, Institute of Medical Science, Tokyo Medical University, Tokyo, Japan
| | - Shinicihi Nakagawa
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masato Nakamura
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Seiji Okada
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Norimasa Nakamura
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
- Institute for Medical Science in Sports, Osaka Health Science University, Osaka, Japan
- Global Center for Medical Engineering and Informatics, Osaka University, Osaka, Japan
| |
Collapse
|
7
|
Noh KM, Park SJ, Moon SH, Jung SY. Extracellular matrix cues regulate the differentiation of pluripotent stem cell-derived endothelial cells. Front Cardiovasc Med 2023; 10:1169331. [PMID: 37435057 PMCID: PMC10330705 DOI: 10.3389/fcvm.2023.1169331] [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: 02/19/2023] [Accepted: 05/23/2023] [Indexed: 07/13/2023] Open
Abstract
The generation of endothelial cells (ECs) from human pluripotent stem cells (PSCs) has been a promising approach for treating cardiovascular diseases for several years. Human PSCs, particularly induced pluripotent stem cells (iPSCs), are an attractive source of ECs for cell therapy. Although there is a diversity of methods for endothelial cell differentiation using biochemical factors, such as small molecules and cytokines, the efficiency of EC production varies depending on the type and dose of biochemical factors. Moreover, the protocols in which most EC differentiation studies have been performed were in very unphysiological conditions that do not reflect the microenvironment of native tissue. The microenvironment surrounding stem cells exerts variable biochemical and biomechanical stimuli that can affect stem cell differentiation and behavior. The stiffness and components of the extracellular microenvironment are critical inducers of stem cell behavior and fate specification by sensing the extracellular matrix (ECM) cues, adjusting the cytoskeleton tension, and delivering external signals to the nucleus. Differentiation of stem cells into ECs using a cocktail of biochemical factors has been performed for decades. However, the effects of mechanical stimuli on endothelial cell differentiation remain poorly understood. This review provides an overview of the methods used to differentiate ECs from stem cells by chemical and mechanical stimuli. We also propose the possibility of a novel EC differentiation strategy using a synthetic and natural extracellular matrix.
Collapse
Affiliation(s)
- Kyung Mu Noh
- Stem Cell Research Institute, T&R Biofab Co. Ltd., Seongnam-si, Republic of Korea
| | - Soon-Jung Park
- Stem Cell Research Institute, T&R Biofab Co. Ltd., Seongnam-si, Republic of Korea
| | - Sung-Hwan Moon
- Department of Animal Science and Technology, College of Biotechnology and Natural Resources, Chung-Ang University, Anseong-si, Republic of Korea
| | - Seok Yun Jung
- Stem Cell Research Institute, T&R Biofab Co. Ltd., Seongnam-si, Republic of Korea
| |
Collapse
|
8
|
Jones CL, Penney BT, Theodossiou SK. Engineering Cell-ECM-Material Interactions for Musculoskeletal Regeneration. Bioengineering (Basel) 2023; 10:bioengineering10040453. [PMID: 37106640 PMCID: PMC10135874 DOI: 10.3390/bioengineering10040453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/23/2023] [Accepted: 03/28/2023] [Indexed: 04/29/2023] Open
Abstract
The extracellular microenvironment regulates many of the mechanical and biochemical cues that direct musculoskeletal development and are involved in musculoskeletal disease. The extracellular matrix (ECM) is a main component of this microenvironment. Tissue engineered approaches towards regenerating muscle, cartilage, tendon, and bone target the ECM because it supplies critical signals for regenerating musculoskeletal tissues. Engineered ECM-material scaffolds that mimic key mechanical and biochemical components of the ECM are of particular interest in musculoskeletal tissue engineering. Such materials are biocompatible, can be fabricated to have desirable mechanical and biochemical properties, and can be further chemically or genetically modified to support cell differentiation or halt degenerative disease progression. In this review, we survey how engineered approaches using natural and ECM-derived materials and scaffold systems can harness the unique characteristics of the ECM to support musculoskeletal tissue regeneration, with a focus on skeletal muscle, cartilage, tendon, and bone. We summarize the strengths of current approaches and look towards a future of materials and culture systems with engineered and highly tailored cell-ECM-material interactions to drive musculoskeletal tissue restoration. The works highlighted in this review strongly support the continued exploration of ECM and other engineered materials as tools to control cell fate and make large-scale musculoskeletal regeneration a reality.
Collapse
Affiliation(s)
- Calvin L Jones
- Department of Mechanical and Biomedical Engineering, Boise State University, 1910 University Dr MS2085, Boise, ID 83725, USA
| | - Brian T Penney
- Department of Mechanical and Biomedical Engineering, Boise State University, 1910 University Dr MS2085, Boise, ID 83725, USA
| | - Sophia K Theodossiou
- Department of Mechanical and Biomedical Engineering, Boise State University, 1910 University Dr MS2085, Boise, ID 83725, USA
| |
Collapse
|
9
|
Biehl A, Gracioso Martins AM, Davis ZG, Sze D, Collins L, Mora-Navarro C, Fisher MB, Freytes DO. Towards a standardized multi-tissue decellularization protocol for the derivation of extracellular matrix materials. Biomater Sci 2023; 11:641-654. [PMID: 36504129 PMCID: PMC9844390 DOI: 10.1039/d2bm01012g] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/21/2022] [Indexed: 12/14/2022]
Abstract
The goal of tissue decellularization is to efficiently remove unwanted cellular components, such as DNA and cellular debris, while retaining the complex structural and molecular milieu within the extracellular matrix (ECM). Decellularization protocols to date are centered on customized tissue-specific and lab-specific protocols that involve consecutive manual steps which results in variable and protocol-specific ECM material. The differences that result from the inconsistent protocols between decellularized ECMs affect consistency across batches, limit comparisons between results obtained from different laboratories, and could limit the transferability of the material for consistent laboratory or clinical use. The present study is the first proof-of-concept towards the development of a standardized protocol that can be used to derive multiple ECM biomaterials (powders and hydrogels) via a previously established automated system. The automated decellularization method developed by our group was used due to its short decellularization time (4 hours) and its ability to reduce batch-to-batch variability. The ECM obtained using this first iteration of a unified protocol was able to produce ECM hydrogels from skin, lung, muscle, tendons, cartilage, and laryngeal tissues. All hydrogels formed in this study were cytocompatible and showed gelation and rheological properties consistent with previous ECM hydrogels. The ECMs also showed unique proteomic composition. The present study represents the first step towards developing standardized protocols that can be used on multiple tissues in a fast, scalable, and reproducible manner.
Collapse
Affiliation(s)
- Andreea Biehl
- Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina-Chapel Hill, 4130 Engineering Building III, Campus Box 7115, Raleigh, NC 27695, USA.
- Comparative Medicine Institute, North Carolina State University, 1060 William Moore Drive, Raleigh, NC 27606, USA
| | - Ana M Gracioso Martins
- Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina-Chapel Hill, 4130 Engineering Building III, Campus Box 7115, Raleigh, NC 27695, USA.
- Comparative Medicine Institute, North Carolina State University, 1060 William Moore Drive, Raleigh, NC 27606, USA
| | - Zachary G Davis
- Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina-Chapel Hill, 4130 Engineering Building III, Campus Box 7115, Raleigh, NC 27695, USA.
- Comparative Medicine Institute, North Carolina State University, 1060 William Moore Drive, Raleigh, NC 27606, USA
| | - Daphne Sze
- Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina-Chapel Hill, 4130 Engineering Building III, Campus Box 7115, Raleigh, NC 27695, USA.
- Comparative Medicine Institute, North Carolina State University, 1060 William Moore Drive, Raleigh, NC 27606, USA
| | - Leonard Collins
- Molecular Education, Technology and Research Innovation Center (METRIC), North Carolina State University, Dabney Hall, 2620 Yarbrough Drive, Raleigh, NC 27607, USA
| | - Camilo Mora-Navarro
- Department of Chemical Engineering, University of Puerto Rico-Mayaguez, Route 108, Mayaguez, Puerto Rico, USA
| | - Matthew B Fisher
- Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina-Chapel Hill, 4130 Engineering Building III, Campus Box 7115, Raleigh, NC 27695, USA.
- Comparative Medicine Institute, North Carolina State University, 1060 William Moore Drive, Raleigh, NC 27606, USA
- Department of Orthopaedics, University of North Carolina School of Medicine, 102 Mason Farm Road Second Floor, Chapel Hill, NC 27514, USA
| | - Donald O Freytes
- Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina-Chapel Hill, 4130 Engineering Building III, Campus Box 7115, Raleigh, NC 27695, USA.
- Comparative Medicine Institute, North Carolina State University, 1060 William Moore Drive, Raleigh, NC 27606, USA
| |
Collapse
|
10
|
Lu H, Ying K, Shi Y, Liu D, Chen Q. Bioprocessing by Decellularized Scaffold Biomaterials in Cultured Meat: A Review. BIOENGINEERING (BASEL, SWITZERLAND) 2022; 9:bioengineering9120787. [PMID: 36550993 PMCID: PMC9774511 DOI: 10.3390/bioengineering9120787] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/24/2022] [Accepted: 11/04/2022] [Indexed: 12/14/2022]
Abstract
As novel carrier biomaterials, decellularized scaffolds have promising potential in the development of cellular agriculture and edible cell-cultured meat applications. Decellularized scaffold biomaterials have characteristics of high biocompatibility, bio-degradation, biological safety and various bioactivities, which could potentially compensate for the shortcomings of synthetic bio-scaffold materials. They can provide suitable microstructure and mechanical support for cell adhesion, differentiation and proliferation. To our best knowledge, the preparation and application of plant and animal decellularized scaffolds have not been summarized. Herein, a comprehensive presentation of the principles, preparation methods and application progress of animal-derived and plant-derived decellularized scaffolds has been reported in detail. Additionally, their application in the culture of skeletal muscle, fat and connective tissue, which constitute the main components of edible cultured meat, have also been generally discussed. We also illustrate the potential applications and prospects of decellularized scaffold materials in future foods. This review of cultured meat and decellularized scaffold biomaterials provides new insight and great potential research prospects in food application and cellular agriculture.
Collapse
Affiliation(s)
- Hongyun Lu
- Department of Food Science and Nutrition, Zhejiang University, Hangzhou 310058, China
| | - Keqin Ying
- College of Food Science and Technology, Nanjing University, Nanjing 210095, China
| | - Ying Shi
- Department of Food Science and Nutrition, Zhejiang University, Hangzhou 310058, China
- Correspondence: (Y.S.); (D.L.); (Q.C.)
| | - Donghong Liu
- Department of Food Science and Nutrition, Zhejiang University, Hangzhou 310058, China
- Innovation Center of Yangtze River Delta, Zhejiang University, Jiashan 310000, China
- Correspondence: (Y.S.); (D.L.); (Q.C.)
| | - Qihe Chen
- Department of Food Science and Nutrition, Zhejiang University, Hangzhou 310058, China
- Innovation Center of Yangtze River Delta, Zhejiang University, Jiashan 310000, China
- Correspondence: (Y.S.); (D.L.); (Q.C.)
| |
Collapse
|
11
|
Al-Hakim Khalak F, García-Villén F, Ruiz-Alonso S, Pedraz JL, Saenz-del-Burgo L. Decellularized Extracellular Matrix-Based Bioinks for Tendon Regeneration in Three-Dimensional Bioprinting. Int J Mol Sci 2022; 23:12930. [PMID: 36361719 PMCID: PMC9657326 DOI: 10.3390/ijms232112930] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/23/2022] [Accepted: 10/24/2022] [Indexed: 11/08/2023] Open
Abstract
In the last few years, attempts to improve the regeneration of damaged tendons have been rising due to the growing demand. However, current treatments to restore the original performance of the tissue focus on the usage of grafts; although, actual grafts are deficient because they often cannot provide enough support for tissue regeneration, leading to additional complications. The beneficial effect of combining 3D bioprinting and dECM as a novel bioink biomaterial has recently been described. Tendon dECMs have been obtained by using either chemical, biological, or/and physical treatments. Although decellularization protocols are not yet standardized, recently, different protocols have been published. New therapeutic approaches embrace the use of dECM in bioinks for 3D bioprinting, as it has shown promising results in mimicking the composition and the structure of the tissue. However, major obstacles include the poor structural integrity and slow gelation properties of dECM bioinks. Moreover, printing parameters such as speed and temperature have to be optimized for each dECM bioink. Here, we show that dECM bioink for 3D bioprinting provides a promising approach for tendon regeneration for future clinical applications.
Collapse
Affiliation(s)
- Fouad Al-Hakim Khalak
- NanoBioCel Group, Laboratory of Pharmaceutics, School of Pharmacy, University of the Basque Country (UPV/EHU), 01006 Vitoria-Gasteiz, Spain
- Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Health Institute Carlos III, Monforte de Lemos 3-5, 28029 Madrid, Spain
- Bioaraba Health Research Institute, Jose Atxotegi, s/n, 01009 Vitoria-Gasteiz, Spain
| | - Fátima García-Villén
- NanoBioCel Group, Laboratory of Pharmaceutics, School of Pharmacy, University of the Basque Country (UPV/EHU), 01006 Vitoria-Gasteiz, Spain
- Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Health Institute Carlos III, Monforte de Lemos 3-5, 28029 Madrid, Spain
- Bioaraba Health Research Institute, Jose Atxotegi, s/n, 01009 Vitoria-Gasteiz, Spain
| | - Sandra Ruiz-Alonso
- NanoBioCel Group, Laboratory of Pharmaceutics, School of Pharmacy, University of the Basque Country (UPV/EHU), 01006 Vitoria-Gasteiz, Spain
- Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Health Institute Carlos III, Monforte de Lemos 3-5, 28029 Madrid, Spain
- Bioaraba Health Research Institute, Jose Atxotegi, s/n, 01009 Vitoria-Gasteiz, Spain
| | - José Luis Pedraz
- NanoBioCel Group, Laboratory of Pharmaceutics, School of Pharmacy, University of the Basque Country (UPV/EHU), 01006 Vitoria-Gasteiz, Spain
- Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Health Institute Carlos III, Monforte de Lemos 3-5, 28029 Madrid, Spain
- Bioaraba Health Research Institute, Jose Atxotegi, s/n, 01009 Vitoria-Gasteiz, Spain
| | - Laura Saenz-del-Burgo
- NanoBioCel Group, Laboratory of Pharmaceutics, School of Pharmacy, University of the Basque Country (UPV/EHU), 01006 Vitoria-Gasteiz, Spain
- Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Health Institute Carlos III, Monforte de Lemos 3-5, 28029 Madrid, Spain
- Bioaraba Health Research Institute, Jose Atxotegi, s/n, 01009 Vitoria-Gasteiz, Spain
| |
Collapse
|
12
|
Herrera Quijano MA, Sharma N, Morissette Martin P, Séguin CA, Flynn LE. Development of 2-D and 3-D culture platforms derived from decellularized nucleus pulposus. Front Bioeng Biotechnol 2022; 10:937239. [PMID: 36237211 PMCID: PMC9551564 DOI: 10.3389/fbioe.2022.937239] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022] Open
Abstract
Bioscaffolds derived from the extracellular matrix (ECM) have shown the capacity to promote regeneration by providing tissue-specific biological instructive cues that can enhance cell survival and direct lineage-specific differentiation. This study focused on the development and characterization of two-dimensional (2-D) and three-dimensional (3-D) cell culture platforms incorporating decellularized nucleus pulposus (DNP). First, a detergent-free protocol was developed for decellularizing bovine nucleus pulposus (NP) tissues that was effective at removing cellular content while preserving key ECM constituents including collagens, glycosaminoglycans, and the cell-adhesive glycoproteins laminin and fibronectin. Next, novel 2-D coatings were generated using the DNP or commercially-sourced bovine collagen type I (COL) as a non-tissue-specific control. In addition, cryo-milled DNP or COL particles were incorporated within methacrylated chondroitin sulphate (MCS) hydrogels as a 3-D cell culture platform for exploring the effects of ECM particle composition. Culture studies showed that the 2-D coatings derived from the DNP could support cell attachment and growth, but did not maintain or rescue the phenotype of primary bovine NP cells, which de-differentiated when serially passaged in monolayer culture. Similarly, while bovine NP cells remained highly viable following encapsulation and 14 days of culture within the hydrogel composites, the incorporation of DNP particles within the MCS hydrogels was insufficient to maintain or rescue changes in NP phenotype associated with extended in vitro culture based on gene expression patterns. Overall, DNP produced with our new decellularization protocol was successfully applied to generate both 2-D and 3-D bioscaffolds; however, further studies are required to assess if these platforms can be combined with additional components of the endogenous NP microenvironment to stimulate regeneration or lineage-specific cell differentiation.
Collapse
Affiliation(s)
- Marco A. Herrera Quijano
- Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON, Canada
- Bone and Joint Institute, The University of Western Ontario, London, ON, Canada
| | - Nadia Sharma
- Bone and Joint Institute, The University of Western Ontario, London, ON, Canada
- School of Biomedical Engineering, The University of Western Ontario, London, ON, Canada
| | - Pascal Morissette Martin
- Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON, Canada
| | - Cheryle A. Séguin
- Bone and Joint Institute, The University of Western Ontario, London, ON, Canada
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON, Canada
- *Correspondence: Lauren E. Flynn, ; Cheryle A. Séguin,
| | - Lauren E. Flynn
- Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON, Canada
- Bone and Joint Institute, The University of Western Ontario, London, ON, Canada
- School of Biomedical Engineering, The University of Western Ontario, London, ON, Canada
- Department of Chemical and Biochemical Engineering, Faculty of Engineering, The University of Western Ontario, London, ON, Canada
- *Correspondence: Lauren E. Flynn, ; Cheryle A. Séguin,
| |
Collapse
|
13
|
Wang X, Chan V, Corridon PR. Decellularized blood vessel development: Current state-of-the-art and future directions. Front Bioeng Biotechnol 2022; 10:951644. [PMID: 36003539 PMCID: PMC9394443 DOI: 10.3389/fbioe.2022.951644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/14/2022] [Indexed: 12/31/2022] Open
Abstract
Vascular diseases contribute to intensive and irreversible damage, and current treatments include medications, rehabilitation, and surgical interventions. Often, these diseases require some form of vascular replacement therapy (VRT) to help patients overcome life-threatening conditions and traumatic injuries annually. Current VRTs rely on harvesting blood vessels from various regions of the body like the arms, legs, chest, and abdomen. However, these procedures also produce further complications like donor site morbidity. Such common comorbidities may lead to substantial pain, infections, decreased function, and additional reconstructive or cosmetic surgeries. Vascular tissue engineering technology promises to reduce or eliminate these issues, and the existing state-of-the-art approach is based on synthetic or natural polymer tubes aiming to mimic various types of blood vessel. Burgeoning decellularization techniques are considered as the most viable tissue engineering strategy to fill these gaps. This review discusses various approaches and the mechanisms behind decellularization techniques and outlines a simplified model for a replacement vascular unit. The current state-of-the-art method used to create decellularized vessel segments is identified. Also, perspectives on future directions to engineer small- (inner diameter >1 mm and <6 mm) to large-caliber (inner diameter >6 mm) vessel substitutes are presented.
Collapse
Affiliation(s)
- Xinyu Wang
- Biomedical Engineering and Healthcare Engineering Innovation Center, Khalifa University, Abu Dhabi, United Arab Emirates
- Department of Immunology and Physiology, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Vincent Chan
- Biomedical Engineering and Healthcare Engineering Innovation Center, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Peter R Corridon
- Department of Immunology and Physiology, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates
- Center for Biotechnology, Khalifa University, Abu Dhabi, United Arab Emirates
| |
Collapse
|
14
|
Qian C, Zhang Z, Zhao R, Wang D, Li H. Effect of acellular nerve scaffold containing human umbilical cord-derived mesenchymal stem cells on nerve repair and regeneration in rats with sciatic nerve defect. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:483. [PMID: 35571424 PMCID: PMC9096419 DOI: 10.21037/atm-22-1578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/20/2022] [Indexed: 11/11/2022]
Abstract
Background The aim of the present study was to investigate the effect of acellular nerve scaffold (ANS) containing human umbilical cord-derived mesenchymal stem cells (hUC-MSCs) on nerve repair and regeneration in rats with sciatic nerve defect. Methods Sciatic nerve trunks were removed from 6 female Sprague-Dawley (SD) rats, and ANS was prepared by lyophilization + enzymatic method and divided into A, B, C, D and E groups according to different treatment times. hUC-MSCs were isolated from the collected umbilical cords and cultured, and then ANS-hUC-MSCs complexes were made. The other 24 adult female SD rats were randomly divided into the control, autograft, ANS, and ANS-hUC-MSCs groups, and a rat model of sciatic nerve defect was established. Hematoxylin-eosin (HE) staining, Luxol fast blue (LFB) staining, Masson staining, and scanning electron microscopy were used to observe the morphology and tissue structure of ANS. The performance of ANS was evaluated by mechanical detection, and hydroxyproline (HYP) content was evaluated using a biochemical kit. Flow cytometry was adopted to detect the levels of hUC-MSCs surface antigens CD29, CD44, and CD34, as well as electrophysiological detection and muscle wet weight recovery rate for measuring rat muscle performance. Results ANS was prepared according to group A method and had good mechanical properties, with less residues of cells and myelin, and higher HYP content, indicating that this scaffold had the best performance. ANS-hUC-MSCs significantly reduced myelin injury in the sciatic nerve, and increased axonal regeneration, effectively improving sciatic nerve injury in rats. In addition, ANS-hUC-MSCs significantly increased compound muscle action potential (CMAP), nerve conduction velocity (NCV), and muscle wet weight, and reduced muscle atrophy. Conclusions ANS containing hUC-MSCs can promote nerve repair and regeneration in rats with sciatic nerve defects.
Collapse
Affiliation(s)
- Chuang Qian
- Department of Orthopaedics, Children's Hospital of Fudan University and National Children's Medical Center, Shanghai, China
| | - Zhiqiang Zhang
- Department of Orthopaedics, Children's Hospital of Fudan University and National Children's Medical Center, Shanghai, China
| | - Rui Zhao
- Department of Neurosurgery, Children's Hospital of Fudan University and National Children's Medical Center, Shanghai, China
| | - Dahui Wang
- Department of Orthopaedics, Children's Hospital of Fudan University and National Children's Medical Center, Shanghai, China
| | - Hao Li
- Department of Neurosurgery, Children's Hospital of Fudan University and National Children's Medical Center, Shanghai, China
| |
Collapse
|