1
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Veiga A, Foster O, Kaplan DL, Oliveira AL. Expanding the boundaries of silk sericin biomaterials in biomedical applications. J Mater Chem B 2024; 12:7020-7040. [PMID: 38935038 DOI: 10.1039/d4tb00386a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
Silk sericin (SS) has a long history as a by-product of the textile industry. SS has emerged as a sustainable material for biomedical engineering due to its material properties including water solubility, diverse impact on biological activities including antibacterial and antioxidant properties, and ability to promote cell adhesion and proliferation. This review addresses the origin, structure, properties, extraction, and underlying functions of this protein. An overview of the growing research studies and market evolution is presented, along with highlights of the most common fabrication matrices (hydrogels, bioinks, porous and fibrous scaffolds) and tissue engineering applications. Finally, the future trends with this protein as a multifaceted toolbox for bioengineering are explored, along with the challenges with SS. Overall, the present review can serve as a foundation for the creation of innovative biomaterials utilizing SS as a fundamental building block that hold market potential.
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Affiliation(s)
- Anabela Veiga
- CBQF-Centro de Biotecnologia e Química Fina-Laboratório Associado, Universidade Católica Portuguesa, Escola Superior de Biotecnologia, Rua Diogo Botelho 1327, 4169-005 Porto, Portugal
- LEPABE-Laboratory for Process Engineering, Environment, Biotechnology & Energy, Department of Chemical Engineering, Faculty of Engineering of the University of Porto, R. Dr. Roberto Frias, 4200-465 Porto, Portugal
- ALiCE-Associate Laboratory in Chemical Engineering, Faculty of Engineering, University of Porto, Rua Dr. Roberto Frias, 4200-465 Porto, Portugal.
- Department of Biomedical Engineering, Tufts University, 4 Colby St., Medford, MA 02155, USA
| | - Olivia Foster
- Department of Biomedical Engineering, Tufts University, 4 Colby St., Medford, MA 02155, USA
| | - David L Kaplan
- Department of Biomedical Engineering, Tufts University, 4 Colby St., Medford, MA 02155, USA
| | - Ana Leite Oliveira
- ALiCE-Associate Laboratory in Chemical Engineering, Faculty of Engineering, University of Porto, Rua Dr. Roberto Frias, 4200-465 Porto, Portugal.
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2
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Chen X, Zhou Z, Yang M, Zhu S, Zhu W, Sun J, Yu M, He J, Zuo Y, Wang W, He N, Han X, Liu H. A biocompatible pea protein isolate-derived bioink for 3D bioprinting and tissue engineering. J Mater Chem B 2024; 12:6716-6723. [PMID: 38899871 DOI: 10.1039/d4tb00781f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Three-dimensional bioprinting is a potent biofabrication technique in tissue engineering but is limited by inadequate bioink availability. Plant-derived proteins are increasingly recognized as highly promising yet underutilized materials for biomedical product development and hold potential for use in bioink formulations. Herein, we report the development of a biocompatible plant protein bioink from pea protein isolate. Through pH shifting, ethanol precipitation, and lyophilization, the pea protein isolate (PPI) transformed from an insoluble to a soluble form. Next, it was modified with glycidyl methacrylate to obtain methacrylate-modified PPI (PPIGMA), which is photocurable and was used as the precursor of bioink. The mechanical and microstructural studies of the hydrogel containing 16% PPIGMA revealed a suitable compress modulus and a porous network with a pore size over 100 μm, which can facilitate nutrient and waste transportation. The PPIGMA bioink exhibited good 3D bioprinting performance in creating complex patterns and good biocompatibility as plenty of viable cells were observed in the printed samples after 3 days of incubation in the cell culture medium. No immunogenicity of the PPIGMA bioink was identified as no inflammation was observed for 4 weeks after implantation in Sprague Dawley rats. Compared with methacrylate-modified gelatin, the PPIGMA bioink significantly enhanced cartilage regeneration in vitro and in vivo, suggesting that it can be used in tissue engineering applications. In summary, the PPIGMA bioink can be potentially used for tissue engineering applications.
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Affiliation(s)
- Xin Chen
- College of Material Science and Engineering, Hunan University, Changsha 410082, China.
| | - Zheng Zhou
- College of Biology, Hunan University, Changsha 410082, China.
| | - Mengni Yang
- College of Material Science and Engineering, Hunan University, Changsha 410082, China.
| | - Shuai Zhu
- College of Material Science and Engineering, Hunan University, Changsha 410082, China.
| | - Wenxiang Zhu
- College of Material Science and Engineering, Hunan University, Changsha 410082, China.
| | - Jingjing Sun
- College of Biology, Hunan University, Changsha 410082, China.
| | - Mengyi Yu
- College of Material Science and Engineering, Hunan University, Changsha 410082, China.
| | - Jiaqian He
- College of Biology, Hunan University, Changsha 410082, China.
| | - You Zuo
- College of Biology, Hunan University, Changsha 410082, China.
| | - Wenxin Wang
- College of Mechanical and Vehicle Engineering, Hunan University, Changsha 410082, China
| | - Ning He
- College of Mechanical and Vehicle Engineering, Hunan University, Changsha 410082, China
| | - Xiaoxiao Han
- College of Mechanical and Vehicle Engineering, Hunan University, Changsha 410082, China
| | - Hairong Liu
- College of Material Science and Engineering, Hunan University, Changsha 410082, China.
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3
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Cecuda-Adamczewska V, Romanik-Chruścielewska A, Kosowska K, Sokołowska I, Łukasiewicz N, Korycka P, Florys-Jankowska K, Zakrzewska A, Wszoła M, Klak M. Elasticity Modification of Biomaterials Used in 3D Printing with an Elastin-Silk-like Recombinant Protein. J Funct Biomater 2024; 15:141. [PMID: 38921515 PMCID: PMC11204424 DOI: 10.3390/jfb15060141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/10/2024] [Accepted: 05/22/2024] [Indexed: 06/27/2024] Open
Abstract
The recombinant structural protein described in this study was designed based on sequences derived from elastin and silk. Silk-elastin hybrid copolymers are characterized by high solubility while maintaining high product flexibility. The phase transition temperature from aqueous solution to hydrogel, as well as other physicochemical and mechanical properties of such particles, can differ significantly depending on the number of sequence repeats. We present a preliminary characterization of the EJ17zipR protein obtained in high yield in a prokaryotic expression system and efficiently purified via a multistep process. Its addition significantly improves biomaterial's rheological and mechanical properties, especially elasticity. As a result, EJ17zipR appears to be a promising component for bioinks designed to print spatially complex structures that positively influence both shape retention and the internal transport of body fluids. The results of biological studies indicate that the addition of the studied protein creates a favorable microenvironment for cell adhesion, growth, and migration.
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Affiliation(s)
- Violetta Cecuda-Adamczewska
- Foundation of Research and Science Development, 01-424 Warsaw, Poland; (A.R.-C.); (K.K.); (I.S.); (N.Ł.); (P.K.); (K.F.-J.)
| | | | - Katarzyna Kosowska
- Foundation of Research and Science Development, 01-424 Warsaw, Poland; (A.R.-C.); (K.K.); (I.S.); (N.Ł.); (P.K.); (K.F.-J.)
| | - Iwona Sokołowska
- Foundation of Research and Science Development, 01-424 Warsaw, Poland; (A.R.-C.); (K.K.); (I.S.); (N.Ł.); (P.K.); (K.F.-J.)
| | - Natalia Łukasiewicz
- Foundation of Research and Science Development, 01-424 Warsaw, Poland; (A.R.-C.); (K.K.); (I.S.); (N.Ł.); (P.K.); (K.F.-J.)
| | - Paulina Korycka
- Foundation of Research and Science Development, 01-424 Warsaw, Poland; (A.R.-C.); (K.K.); (I.S.); (N.Ł.); (P.K.); (K.F.-J.)
| | - Katarzyna Florys-Jankowska
- Foundation of Research and Science Development, 01-424 Warsaw, Poland; (A.R.-C.); (K.K.); (I.S.); (N.Ł.); (P.K.); (K.F.-J.)
| | | | - Michał Wszoła
- Polbionica Ltd., 01-424 Warsaw, Poland; (A.Z.); (M.W.)
| | - Marta Klak
- Polbionica Ltd., 01-424 Warsaw, Poland; (A.Z.); (M.W.)
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4
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Tian H, Wu J, Hu Y, Chen X, Cai X, Wen Y, Chen H, Huang J, Wang S. Recent advances on enhancing 3D printing quality of protein-based inks: A review. Compr Rev Food Sci Food Saf 2024; 23:e13349. [PMID: 38638060 DOI: 10.1111/1541-4337.13349] [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: 11/28/2023] [Revised: 02/26/2024] [Accepted: 03/27/2024] [Indexed: 04/20/2024]
Abstract
3D printing is an additive manufacturing technology that locates constructed models with computer-controlled printing equipment. To achieve high-quality printing, the requirements on rheological properties of raw materials are extremely restrictive. Given the special structure and high modifiability under external physicochemical factors, the rheological properties of proteins can be easily adjusted to suitable properties for 3D printing. Although protein has great potential as a printing material, there are many challenges in the actual printing process. This review summarizes the technical considerations for protein-based ink 3D printing. The physicochemical factors used to enhance the printing adaptability of protein inks are discussed. The post-processing methods for improving the quality of 3D structures are described, and the application and problems of fourth dimension (4D) printing are illustrated. The prospects of 3D printing in protein manufacturing are presented to support its application in food and cultured meat. The native structure and physicochemical factors of proteins are closely related to their rheological properties, which directly link with their adaptability for 3D printing. Printing parameters include extrusion pressure, printing speed, printing temperature, nozzle diameter, filling mode, and density, which significantly affect the precision and stability of the 3D structure. Post-processing can improve the stability and quality of 3D structures. 4D design can enrich the sensory quality of the structure. 3D-printed protein products can meet consumer needs for nutritional or cultured meat alternatives.
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Affiliation(s)
- Han Tian
- College of Chemical Engineering, College of Biological Science and Engineering, Fuzhou University, Fuzhou, China
| | - Jiajie Wu
- College of Chemical Engineering, College of Biological Science and Engineering, Fuzhou University, Fuzhou, China
| | - Yanyu Hu
- College of Chemical Engineering, College of Biological Science and Engineering, Fuzhou University, Fuzhou, China
| | - Xu Chen
- Qingyuan Innovation Laboratory, Quanzhou, China
- School of Mechanical Science & Engineering, Huazhong University of Science and Technology, Wuhan, China
| | - Xixi Cai
- College of Chemical Engineering, College of Biological Science and Engineering, Fuzhou University, Fuzhou, China
- Qingyuan Innovation Laboratory, Quanzhou, China
- Marine Green Processing Research Center, Fuzhou Institute of Oceanography, Fuzhou, China
| | - Yaxin Wen
- College of Chemical Engineering, College of Biological Science and Engineering, Fuzhou University, Fuzhou, China
| | - Huimin Chen
- College of Chemical Engineering, College of Biological Science and Engineering, Fuzhou University, Fuzhou, China
| | - Jianlian Huang
- Fujian Provincial Key Laboratory of Frozen Processed Aquatic Products, Xiamen, China
- Anjoy Food Group Co. Ltd., Xiamen, China
| | - Shaoyun Wang
- College of Chemical Engineering, College of Biological Science and Engineering, Fuzhou University, Fuzhou, China
- Qingyuan Innovation Laboratory, Quanzhou, China
- Marine Green Processing Research Center, Fuzhou Institute of Oceanography, Fuzhou, China
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5
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Jain P, Kathuria H, Ramakrishna S, Parab S, Pandey MM, Dubey N. In Situ Bioprinting: Process, Bioinks, and Applications. ACS APPLIED BIO MATERIALS 2024. [PMID: 38598256 DOI: 10.1021/acsabm.3c01303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
Traditional tissue engineering methods face challenges, such as fabrication, implantation of irregularly shaped scaffolds, and limited accessibility for immediate healthcare providers. In situ bioprinting, an alternate strategy, involves direct deposition of biomaterials, cells, and bioactive factors at the site, facilitating on-site fabrication of intricate tissue, which can offer a patient-specific personalized approach and align with the principles of precision medicine. It can be applied using a handled device and robotic arms to various tissues, including skin, bone, cartilage, muscle, and composite tissues. Bioinks, the critical components of bioprinting that support cell viability and tissue development, play a crucial role in the success of in situ bioprinting. This review discusses in situ bioprinting techniques, the materials used for bioinks, and their critical properties for successful applications. Finally, we discuss the challenges and future trends in accelerating in situ printing to translate this technology in a clinical settings for personalized regenerative medicine.
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Affiliation(s)
- Pooja Jain
- Faculty of Dentistry, National University of Singapore, Singapore 119805, Singapore
| | - Himanshu Kathuria
- Nusmetics Pte Ltd, E-Centre@Redhill, 3791 Jalan Bukit Merah, Singapore 159471, Singapore
| | - Seeram Ramakrishna
- Department of Mechanical Engineering, Center for Nanotechnology and Sustainability, National University of Singapore, Singapore 117581, Singapore
| | - Shraddha Parab
- Department of Pharmacy, Birla Institute of Technology and Science, Pilani, Pilani Campus, Rajasthan India, 333031
| | - Murali M Pandey
- Department of Pharmacy, Birla Institute of Technology and Science, Pilani, Pilani Campus, Rajasthan India, 333031
| | - Nileshkumar Dubey
- Faculty of Dentistry, National University of Singapore, Singapore 119805, Singapore
- ORCHIDS: Oral Care Health Innovations and Designs Singapore, National University of Singapore, Singapore 119805, Singapore
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6
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Bebiano LB, Presa R, Vieira F, Lourenço BN, Pereira RF. Bioinspired and Photo-Clickable Thiol-Ene Bioinks for the Extrusion Bioprinting of Mechanically Tunable 3D Skin Models. Biomimetics (Basel) 2024; 9:228. [PMID: 38667239 PMCID: PMC11048463 DOI: 10.3390/biomimetics9040228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/07/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
Bioinks play a fundamental role in skin bioprinting, dictating the printing fidelity, cell response, and function of bioprinted 3D constructs. However, the range of bioinks that support skin cells' function and aid in the bioprinting of 3D skin equivalents with tailorable properties and customized shapes is still limited. In this study, we describe a bioinspired design strategy for bioengineering double crosslinked pectin-based bioinks that recapitulate the mechanical properties and the presentation of cell-adhesive ligands and protease-sensitive domains of the dermal extracellular matrix, supporting the bioprinting of bilayer 3D skin models. Methacrylate-modified pectin was used as a base biomaterial enabling hydrogel formation via either chain-growth or step-growth photopolymerization and providing independent control over bioink rheology, as well as the mechanical and biochemical cues of cell environment. By tuning the concentrations of crosslinker and polymer in bioink formulation, dermal constructs were bioprinted with a physiologically relevant range of stiffnesses that resulted in strikingly site-specific differences in the morphology and spreading of dermal fibroblasts. We also demonstrated that the developed thiol-ene photo-clickable bioinks allow for the bioprinting of skin models of varying shapes that support dermis and epidermis reconstruction. Overall, the engineered bioinks expand the range of printable biomaterials for the extrusion bioprinting of 3D cell-laden hydrogels and provide a versatile platform to study the impact of material cues on cell fate, offering potential for in vitro skin modeling.
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Affiliation(s)
- Luís B. Bebiano
- i3S—Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Rua Alfredo Allen, 208, 4200-135 Porto, Portugal
- INEB—Instituto de Engenharia Biomédica, Universidade do Porto, Rua Alfredo Allen, 208, 4200-135 Porto, Portugal
| | - Rafaela Presa
- i3S—Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Rua Alfredo Allen, 208, 4200-135 Porto, Portugal
- INEB—Instituto de Engenharia Biomédica, Universidade do Porto, Rua Alfredo Allen, 208, 4200-135 Porto, Portugal
- ICBAS—Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira, 228, 4050-313 Porto, Portugal
| | - Francisca Vieira
- i3S—Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Rua Alfredo Allen, 208, 4200-135 Porto, Portugal
- INEB—Instituto de Engenharia Biomédica, Universidade do Porto, Rua Alfredo Allen, 208, 4200-135 Porto, Portugal
| | - Bianca N. Lourenço
- i3S—Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Rua Alfredo Allen, 208, 4200-135 Porto, Portugal
- INEB—Instituto de Engenharia Biomédica, Universidade do Porto, Rua Alfredo Allen, 208, 4200-135 Porto, Portugal
| | - Rúben F. Pereira
- i3S—Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Rua Alfredo Allen, 208, 4200-135 Porto, Portugal
- INEB—Instituto de Engenharia Biomédica, Universidade do Porto, Rua Alfredo Allen, 208, 4200-135 Porto, Portugal
- ICBAS—Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira, 228, 4050-313 Porto, Portugal
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7
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Jeyaraman M, Jeyaraman N, Nallakumarasamy A, Iyengar KP, Jain VK, Potty AG, Gupta A. Silver nanoparticle technology in orthopaedic infections. World J Orthop 2023; 14:662-668. [PMID: 37744720 PMCID: PMC10514710 DOI: 10.5312/wjo.v14.i9.662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/24/2023] [Accepted: 09/04/2023] [Indexed: 09/14/2023] Open
Abstract
The irrational and prolonged use of antibiotics in orthopaedic infections poses a major threat to the development of antimicrobial resistance. To combat antimicrobial resistance, researchers have implemented various novel and innovative modalities to curb infections. Nanotechnology involves doping ions/metals onto the scaffolds to reach the target site to eradicate the infective foci. In this connotation, we reviewed silver nanoparticle technology in terms of mechanism of action, clinical applications, toxicity, and regulatory guidelines to treat orthopaedic infections.
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Affiliation(s)
- Madhan Jeyaraman
- Department of Orthopaedics, ACS Medical College and Hospital, Dr MGR Educational and Research Institute, Chennai 600077, Tamil Nadu, India
- Department of Orthopaedics, South Texas Orthopaedic Research Institute, Laredo, TX 78045, United States
| | - Naveen Jeyaraman
- Department of Orthopaedics, ACS Medical College and Hospital, Dr MGR Educational and Research Institute, Chennai 600077, Tamil Nadu, India
| | - Arulkumar Nallakumarasamy
- Department of Orthopaedics, ACS Medical College and Hospital, Dr MGR Educational and Research Institute, Chennai 600077, Tamil Nadu, India
| | - Karthikeyan P Iyengar
- Department of Trauma and Orthopaedics, Southport & Ormskirk Hosp NHS Trust Southport, Richmond PR8 6PN, Southport, United Kingdom
| | - Vijay Kumar Jain
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, Delhi 110001, New Delhi, India
| | - Anish G Potty
- Department of Orthopaedics, South Texas Orthopaedic Research Institute, Laredo, TX 78045, United States
| | - Ashim Gupta
- Department of Orthopaedics, South Texas Orthopaedic Research Institute, Laredo, TX 78045, United States
- Department of Regenerative Medicine, Regenerative Orthopaedics, Noida 201301, Uttar Pradesh, India
- Department of Regenerative Medicine, Future Biologics, Lawrenceville, GA 30043, United States
- Department of Regenerative Medicine, BioIntegarte, Lawrenceville, GA 30043, United States
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8
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Rijal G. Bioinks of Natural Biomaterials for Printing Tissues. Bioengineering (Basel) 2023; 10:705. [PMID: 37370636 DOI: 10.3390/bioengineering10060705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
Bioinks are inks-in other words, hydrogels-prepared from biomaterials with certain physiochemical properties together with cells to establish hierarchically complex biological 3D scaffolds through various 3D bioprinting technologies [...].
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Affiliation(s)
- Girdhari Rijal
- Department of Medical Laboratory Sciences, Public Health and Nutrition Science, Tarleton State University, a Member of Texas A & M University System, Fort Worth, TX 76104, USA
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9
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Samadi A, Moammeri A, Pourmadadi M, Abbasi P, Hosseinpour Z, Farokh A, Shamsabadipour A, Heydari M, Mohammadi MR. Cell Encapsulation and 3D Bioprinting for Therapeutic Cell Transplantation. ACS Biomater Sci Eng 2023; 9:1862-1890. [PMID: 36877212 DOI: 10.1021/acsbiomaterials.2c01183] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
The promise of cell therapy has been augmented by introducing biomaterials, where intricate scaffold shapes are fabricated to accommodate the cells within. In this review, we first discuss cell encapsulation and the promising potential of biomaterials to overcome challenges associated with cell therapy, particularly cellular function and longevity. More specifically, cell therapies in the context of autoimmune disorders, neurodegenerative diseases, and cancer are reviewed from the perspectives of preclinical findings as well as available clinical data. Next, techniques to fabricate cell-biomaterials constructs, focusing on emerging 3D bioprinting technologies, will be reviewed. 3D bioprinting is an advancing field that enables fabricating complex, interconnected, and consistent cell-based constructs capable of scaling up highly reproducible cell-biomaterials platforms with high precision. It is expected that 3D bioprinting devices will expand and become more precise, scalable, and appropriate for clinical manufacturing. Rather than one printer fits all, seeing more application-specific printer types, such as a bioprinter for bone tissue fabrication, which would be different from a bioprinter for skin tissue fabrication, is anticipated in the future.
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Affiliation(s)
- Amirmasoud Samadi
- Department of Chemical and Biomolecular Engineering, 6000 Interdisciplinary Science & Engineering Building (ISEB), Irvine, California 92617, United States
| | - Ali Moammeri
- School of Chemical Engineering, College of Engineering, University of Tehran, Enghelab Square, 16 Azar Street, Tehran 1417935840, Iran
| | - Mehrab Pourmadadi
- School of Chemical Engineering, College of Engineering, University of Tehran, Enghelab Square, 16 Azar Street, Tehran 1417935840, Iran
| | - Parisa Abbasi
- Department of Chemical and Petroleum Engineering, Sharif University of Technology, Azadi Avenue, Tehran 1458889694, Iran
| | - Zeinab Hosseinpour
- Biotechnology Research Laboratory, Faculty of Chemical Engineering, Babol Noshirvani University of Technology, Babol 4714871167, Mazandaran Province, Iran
| | - Arian Farokh
- School of Chemical Engineering, College of Engineering, University of Tehran, Enghelab Square, 16 Azar Street, Tehran 1417935840, Iran
| | - Amin Shamsabadipour
- School of Chemical Engineering, College of Engineering, University of Tehran, Enghelab Square, 16 Azar Street, Tehran 1417935840, Iran
| | - Maryam Heydari
- Department of Cell and Molecular Biology, Faculty of Biological Science, University of Kharazmi, Tehran 199389373, Iran
| | - M Rezaa Mohammadi
- Dale E. and Sarah Ann Fowler School of Engineering, Chapman University, Orange, California 92866, United States
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10
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Silva ACQ, Silvestre AJD, Vilela C, Freire CSR. Cellulose and protein nanofibrils: Singular biobased nanostructures for the design of sustainable advanced materials. Front Bioeng Biotechnol 2022; 10:1059097. [PMID: 36582838 PMCID: PMC9793328 DOI: 10.3389/fbioe.2022.1059097] [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: 09/30/2022] [Accepted: 11/25/2022] [Indexed: 12/15/2022] Open
Abstract
Polysaccharides and proteins are extensively used for the design of advanced sustainable materials. Owing to the high aspect ratio and specific surface area, ease of modification, high mechanical strength and thermal stability, renewability, and biodegradability, biopolymeric nanofibrils are gaining growing popularity amongst the catalog of nanostructures exploited in a panoply of fields. These include the nanocomposites, paper and packaging, environmental remediation, electronics, energy, and biomedical applications. In this review, recent trends on the use of cellulose and protein nanofibrils as versatile substrates for the design of high-performance nanomaterials are assessed. A concise description of the preparation methodologies and characteristics of cellulosic nanofibrils, namely nanofibrillated cellulose (NFC), bacterial nanocellulose (BNC), and protein nanofibrils is presented. Furthermore, the use of these nanofibrils in the production of sustainable materials, such as membranes, films, and patches, amongst others, as well as their major domains of application, are briefly described, with focus on the works carried out at the BioPol4Fun Research Group (Innovation in BioPolymer based Functional Materials and Bioactive Compounds) from the Portuguese associate laboratory CICECO-Aveiro Institute of Materials (University of Aveiro). The potential for partnership between both types of nanofibrils in advanced material development is also reviewed. Finally, the critical challenges and opportunities for these biobased nanostructures for the development of functional materials are addressed.
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11
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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.
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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
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12
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Brodin E, Boehmer M, Prentice A, Neff E, McCoy K, Mueller J, Saul J, Sparks JL. Extrusion 3D printing of keratin protein hydrogels free of exogenous chemical agents. Biomed Mater 2022; 17. [PMID: 35793683 DOI: 10.1088/1748-605x/ac7f15] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 07/06/2022] [Indexed: 11/11/2022]
Abstract
Keratins are a class of intermediate filament proteins that can be obtained from numerous sources including human hair. Materials fabricated from keratins offer desirable characteristics as scaffolds for tissue engineering, including intrinsic cell adhesion sequences and tunable degradation kinetics. The capacity to create 3D printed constructs from keratin-based bio-inks generates unique opportunities for spatial control of scaffold physicochemical properties to direct scaffold functions in ways not readily achieved through other means. The aim of this study was to leverage the controllable rheological properties of keratin hydrogels to create a strategy for extrusion 3D printing of keratin bio-inks without the use of exogenous rheological modifiers, crosslinking agents, or photocurable resins. The rheological properties of keratin hydrogels were tuned by varying two parameters: (a) the ratio of keratose (obtained by oxidative extraction of keratin) to kerateine (obtained by reductive extraction of keratin); and (b) the weight percentage of total keratin protein in the gel. A computational model of the dispensing nozzle for a commercially available extrusion 3D printer was developed to calculate the needed pneumatic printing pressures based on the known rheological properties of the gels. Keratin hydrogel constructs, of varying keratose/kerateine ratios and total keratin weight percentages, were 3D printed in cylindrical geometries via extrusion 3D printing. Rheology and degradation studies showed that gels with greater relative kerateine content exhibited greater flow resistance and slower degradation kinetics when submerged in phosphate buffered saline solution at 37 °C, owing to the presence of cysteine residues in kerateine and the capability of forming disulfide bonds. Total keratin weight percentage was found to influence gel yield stress, with possible implications for tuning filament fidelity. Findings from this work support the use of keratose/kerateine ratio and total keratin weight percentage as handles for modulating rheological characteristics of keratin hydrogels to enhance printability and control scaffold properties.
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Affiliation(s)
- Erik Brodin
- Department of Chemical, Paper and Biomedical Engineering, Miami University, Oxford, OH, United States of America
| | - Melanie Boehmer
- Department of Chemical, Paper and Biomedical Engineering, Miami University, Oxford, OH, United States of America
| | - Alexandra Prentice
- Department of Chemical, Paper and Biomedical Engineering, Miami University, Oxford, OH, United States of America
| | - Emily Neff
- Department of Chemical, Paper and Biomedical Engineering, Miami University, Oxford, OH, United States of America
| | - Kathleen McCoy
- Department of Chemical, Paper and Biomedical Engineering, Miami University, Oxford, OH, United States of America
| | - Jens Mueller
- High Performance Computing Services, Miami University, Oxford, OH, United States of America
| | - Justin Saul
- Department of Chemical, Paper and Biomedical Engineering, Miami University, Oxford, OH, United States of America
| | - Jessica L Sparks
- Department of Chemical, Paper and Biomedical Engineering, Miami University, Oxford, OH, United States of America
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13
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Zhang CY, Fu CP, Li XY, Lu XC, Hu LG, Kankala RK, Wang SB, Chen AZ. Three-Dimensional Bioprinting of Decellularized Extracellular Matrix-Based Bioinks for Tissue Engineering. MOLECULES (BASEL, SWITZERLAND) 2022; 27:molecules27113442. [PMID: 35684380 PMCID: PMC9182049 DOI: 10.3390/molecules27113442] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 05/19/2022] [Accepted: 05/24/2022] [Indexed: 01/01/2023]
Abstract
Three-dimensional (3D) bioprinting is one of the most promising additive manufacturing technologies for fabricating various biomimetic architectures of tissues and organs. In this context, the bioink, a critical element for biofabrication, is a mixture of biomaterials and living cells used in 3D printing to create cell-laden structures. Recently, decellularized extracellular matrix (dECM)-based bioinks derived from natural tissues have garnered enormous attention from researchers due to their unique and complex biochemical properties. This review initially presents the details of the natural ECM and its role in cell growth and metabolism. Further, we briefly emphasize the commonly used decellularization treatment procedures and subsequent evaluations for the quality control of the dECM. In addition, we summarize some of the common bioink preparation strategies, the 3D bioprinting approaches, and the applicability of 3D-printed dECM bioinks to tissue engineering. Finally, we present some of the challenges in this field and the prospects for future development.
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Affiliation(s)
- Chun-Yang Zhang
- Institute of Biomaterials and Tissue Engineering, Huaqiao University, Xiamen 361021, China; (C.-Y.Z.); (X.-Y.L.); (X.-C.L.); (L.-G.H.); (R.K.K.); (S.-B.W.)
- Fujian Provincial Key Laboratory of Biochemical Technology, Huaqiao University, Xiamen 361021, China
| | - Chao-Ping Fu
- Institute of Biomaterials and Tissue Engineering, Huaqiao University, Xiamen 361021, China; (C.-Y.Z.); (X.-Y.L.); (X.-C.L.); (L.-G.H.); (R.K.K.); (S.-B.W.)
- Fujian Provincial Key Laboratory of Biochemical Technology, Huaqiao University, Xiamen 361021, China
- Correspondence: (C.-P.F.); (A.-Z.C.)
| | - Xiong-Ya Li
- Institute of Biomaterials and Tissue Engineering, Huaqiao University, Xiamen 361021, China; (C.-Y.Z.); (X.-Y.L.); (X.-C.L.); (L.-G.H.); (R.K.K.); (S.-B.W.)
- Fujian Provincial Key Laboratory of Biochemical Technology, Huaqiao University, Xiamen 361021, China
| | - Xiao-Chang Lu
- Institute of Biomaterials and Tissue Engineering, Huaqiao University, Xiamen 361021, China; (C.-Y.Z.); (X.-Y.L.); (X.-C.L.); (L.-G.H.); (R.K.K.); (S.-B.W.)
- Fujian Provincial Key Laboratory of Biochemical Technology, Huaqiao University, Xiamen 361021, China
| | - Long-Ge Hu
- Institute of Biomaterials and Tissue Engineering, Huaqiao University, Xiamen 361021, China; (C.-Y.Z.); (X.-Y.L.); (X.-C.L.); (L.-G.H.); (R.K.K.); (S.-B.W.)
- Fujian Provincial Key Laboratory of Biochemical Technology, Huaqiao University, Xiamen 361021, China
| | - Ranjith Kumar Kankala
- Institute of Biomaterials and Tissue Engineering, Huaqiao University, Xiamen 361021, China; (C.-Y.Z.); (X.-Y.L.); (X.-C.L.); (L.-G.H.); (R.K.K.); (S.-B.W.)
- Fujian Provincial Key Laboratory of Biochemical Technology, Huaqiao University, Xiamen 361021, China
| | - Shi-Bin Wang
- Institute of Biomaterials and Tissue Engineering, Huaqiao University, Xiamen 361021, China; (C.-Y.Z.); (X.-Y.L.); (X.-C.L.); (L.-G.H.); (R.K.K.); (S.-B.W.)
- Fujian Provincial Key Laboratory of Biochemical Technology, Huaqiao University, Xiamen 361021, China
| | - Ai-Zheng Chen
- Institute of Biomaterials and Tissue Engineering, Huaqiao University, Xiamen 361021, China; (C.-Y.Z.); (X.-Y.L.); (X.-C.L.); (L.-G.H.); (R.K.K.); (S.-B.W.)
- Fujian Provincial Key Laboratory of Biochemical Technology, Huaqiao University, Xiamen 361021, China
- Correspondence: (C.-P.F.); (A.-Z.C.)
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14
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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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15
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Stocco E, Porzionato A, De Rose E, Barbon S, Caro RD, Macchi V. Meniscus regeneration by 3D printing technologies: Current advances and future perspectives. J Tissue Eng 2022; 13:20417314211065860. [PMID: 35096363 PMCID: PMC8793124 DOI: 10.1177/20417314211065860] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/24/2021] [Indexed: 01/10/2023] Open
Abstract
Meniscal tears are a frequent orthopedic injury commonly managed by conservative
strategies to avoid osteoarthritis development descending from altered
biomechanics. Among cutting-edge approaches in tissue engineering, 3D printing
technologies are extremely promising guaranteeing for complex biomimetic
architectures mimicking native tissues. Considering the anisotropic
characteristics of the menisci, and the ability of printing over structural
control, it descends the intriguing potential of such vanguard techniques to
meet individual joints’ requirements within personalized medicine. This
literature review provides a state-of-the-art on 3D printing for meniscus
reconstruction. Experiences in printing materials/technologies, scaffold types,
augmentation strategies, cellular conditioning have been compared/discussed;
outcomes of pre-clinical studies allowed for further considerations. To date,
translation to clinic of 3D printed meniscal devices is still a challenge:
meniscus reconstruction is once again clear expression of how the integration of
different expertise (e.g., anatomy, engineering, biomaterials science, cell
biology, and medicine) is required to successfully address native tissues
complexities.
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Affiliation(s)
- Elena Stocco
- Department of Neuroscience, Section of Human Anatomy, University of Padova, Padova, Italy
- L.i.f.e.L.a.b. Program, Consorzio per la Ricerca Sanitaria, Padova, Italy
| | - Andrea Porzionato
- Department of Neuroscience, Section of Human Anatomy, University of Padova, Padova, Italy
- L.i.f.e.L.a.b. Program, Consorzio per la Ricerca Sanitaria, Padova, Italy
| | - Enrico De Rose
- Department of Neuroscience, Section of Human Anatomy, University of Padova, Padova, Italy
| | - Silvia Barbon
- Department of Neuroscience, Section of Human Anatomy, University of Padova, Padova, Italy
- L.i.f.e.L.a.b. Program, Consorzio per la Ricerca Sanitaria, Padova, Italy
| | - Raffaele De Caro
- Department of Neuroscience, Section of Human Anatomy, University of Padova, Padova, Italy
- L.i.f.e.L.a.b. Program, Consorzio per la Ricerca Sanitaria, Padova, Italy
| | - Veronica Macchi
- Department of Neuroscience, Section of Human Anatomy, University of Padova, Padova, Italy
- L.i.f.e.L.a.b. Program, Consorzio per la Ricerca Sanitaria, Padova, Italy
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Masri S, Zawani M, Zulkiflee I, Salleh A, Fadilah NIM, Maarof M, Wen APY, Duman F, Tabata Y, Aziz IA, Bt Hj Idrus R, Fauzi MB. Cellular Interaction of Human Skin Cells towards Natural Bioink via 3D-Bioprinting Technologies for Chronic Wound: A Comprehensive Review. Int J Mol Sci 2022; 23:476. [PMID: 35008902 PMCID: PMC8745539 DOI: 10.3390/ijms23010476] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/20/2021] [Accepted: 12/24/2021] [Indexed: 12/22/2022] Open
Abstract
Skin substitutes can provide a temporary or permanent treatment option for chronic wounds. The selection of skin substitutes depends on several factors, including the type of wound and its severity. Full-thickness skin grafts (SGs) require a well-vascularised bed and sometimes will lead to contraction and scarring formation. Besides, donor sites for full-thickness skin grafts are very limited if the wound area is big, and it has been proven to have the lowest survival rate compared to thick- and thin-split thickness. Tissue engineering technology has introduced new advanced strategies since the last decades to fabricate the composite scaffold via the 3D-bioprinting approach as a tissue replacement strategy. Considering the current global donor shortage for autologous split-thickness skin graft (ASSG), skin 3D-bioprinting has emerged as a potential alternative to replace the ASSG treatment. The three-dimensional (3D)-bioprinting technique yields scaffold fabrication with the combination of biomaterials and cells to form bioinks. Thus, the essential key factor for success in 3D-bioprinting is selecting and developing suitable bioinks to maintain the mechanisms of cellular activity. This crucial stage is vital to mimic the native extracellular matrix (ECM) for the sustainability of cell viability before tissue regeneration. This comprehensive review outlined the application of the 3D-bioprinting technique to develop skin tissue regeneration. The cell viability of human skin cells, dermal fibroblasts (DFs), and keratinocytes (KCs) during in vitro testing has been further discussed prior to in vivo application. It is essential to ensure the printed tissue/organ constantly allows cellular activities, including cell proliferation rate and migration capacity. Therefore, 3D-bioprinting plays a vital role in developing a complex skin tissue structure for tissue replacement approach in future precision medicine.
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Affiliation(s)
- Syafira Masri
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
| | - Mazlan Zawani
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
| | - Izzat Zulkiflee
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
| | - Atiqah Salleh
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
| | - Nur Izzah Md Fadilah
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
| | - Manira Maarof
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
| | - Adzim Poh Yuen Wen
- Department of Surgery, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
| | - Fatih Duman
- Department of Biology, Faculty of Science, University of Erciyes, 38039 Kayseri, Turkey
| | - Yasuhiko Tabata
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
- Department of Biomaterials, Institute of Frontier Medical Science, Kyoto University, 53 Kawara-cho Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - Izhar Abd Aziz
- 3D Gens Sdn Bhd, 18, Jalan Kerawang U8/108, Bukit Jelutong, Shah Alam 40150, Malaysia
| | - Ruszymah Bt Hj Idrus
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
| | - Mh Busra Fauzi
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
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