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

Background

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

Methods

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

Results

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

Conclusion

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

Corrigendum: Development of new approach methods for the identification and characterization of endocrine metabolic disruptors-a PARC project

[This corrects the article DOI: 10.3389/ftox.2023.1212509.].

Unnatural Endotype B PPAPs as Novel Compounds with Activity against Mycobacterium tuberculosis

Pre-SARS-CoV-2, tuberculosis was the leading cause of death by a single pathogen. Repetitive exposure of Mycobacterium tuberculosis(Mtb) supported the development of multidrug- and extensively drug-resistant strains, demanding novel drugs. Hyperforin, a natural type A polyprenylated polycyclic acylphloroglucinol from St. John's wort, exhibits antidepressant and antibacterial effects also against Mtb. Yet, Hyperforin's instability limits the utility in clinical practice. Here, we present photo- and bench-stable type B PPAPs with enhanced antimycobacterial efficacy. PPAP22 emerged as a lead compound, further improved as the sodium salt PPAP53, drastically enhancing solubility. PPAP53 inhibits the growth of virulent extracellular and intracellular Mtb without harming primary human macrophages. Importantly, PPAP53 is active against drug-resistant strains of Mtb. Furthermore, we analyzed the in vitro properties of PPAP53 in terms of CYP induction and the PXR interaction. Taken together, we introduce type PPAPs as a new class of antimycobacterial compounds, with remarkable antibacterial activity and favorable biophysical properties.

Adverse outcome pathway-based analysis of liver steatosis in vitro using human liver cell lines

Here, we present an in vitro test battery to analyze chemicals for their potential to induce liver triglyceride accumulation, a hallmark of liver steatosis. We describe steps for using HepG2 and HepaRG human hepatoma cells in conjunction with a combination of several in vitro assays covering the different molecular initiating events and key events of the respective adverse outcome pathway. This protocol is suitable for assessing single substance effects as well as mixtures allowing their classification as steatotic or non-steatotic. For complete details on the use and execution of this protocol, please refer to Luckert et al. (2018),1 Lichtenstein et al. (2020),2 and Knebel et al. (2019).3.

Development of new approach methods for the identification and characterization of endocrine metabolic disruptors-a PARC project

In past times, the analysis of endocrine disrupting properties of chemicals has mainly been focused on (anti-)estrogenic or (anti-)androgenic properties, as well as on aspects of steroidogenesis and the modulation of thyroid signaling. More recently, disruption of energy metabolism and related signaling pathways by exogenous substances, so-called metabolism-disrupting chemicals (MDCs) have come into focus. While general effects such as body and organ weight changes are routinely monitored in animal studies, there is a clear lack of mechanistic test systems to determine and characterize the metabolism-disrupting potential of chemicals. In order to contribute to filling this gap, one of the project within EU-funded Partnership for the Assessment of Risks of Chemicals (PARC) aims at developing novel in vitro methods for the detection of endocrine metabolic disruptors. Efforts will comprise projects related to specific signaling pathways, for example, involving mTOR or xenobiotic-sensing nuclear receptors, studies on hepatocytes, adipocytes and pancreatic beta cells covering metabolic and morphological endpoints, as well as metabolism-related zebrafish-based tests as an alternative to classic rodent bioassays. This paper provides an overview of the approaches and methods of these PARC projects and how this will contribute to the improvement of the toxicological toolbox to identify substances with endocrine disrupting properties and to decipher their mechanisms of action.

Analysis of hyperforin (St. John's wort) action at TRPC6 channel leads to the development of a new class of antidepressant drugs

St. John's wort is an herb, long used in folk medicine for the treatment of mild depression. Its antidepressant constituent, hyperforin, has properties such as chemical instability and induction of drug-drug interactions that preclude its use for individual pharmacotherapies. Here we identify the transient receptor potential canonical 6 channel (TRPC6) as a druggable target to control anxious and depressive behavior and as a requirement for hyperforin antidepressant action. We demonstrate that TRPC6 deficiency in mice not only results in anxious and depressive behavior, but also reduces excitability of hippocampal CA1 pyramidal neurons and dentate gyrus granule cells. Using electrophysiology and targeted mutagenesis, we show that hyperforin activates the channel via a specific binding motif at TRPC6. We performed an analysis of hyperforin action to develop a new antidepressant drug that uses the same TRPC6 target mechanism for its antidepressant action. We synthesized the hyperforin analog Hyp13, which shows similar binding to TRPC6 and recapitulates TRPC6-dependent anxiolytic and antidepressant effects in mice. Hyp13 does not activate pregnan-X-receptor (PXR) and thereby loses the potential to induce drug-drug interactions. This may provide a new approach to develop better treatments for depression, since depression remains one of the most treatment-resistant mental disorders, warranting the development of effective drugs based on naturally occurring compounds.

Investigating the in vitro steatotic mixture effects of similarly and dissimilarly acting test compounds using an adverse outcome pathway-based approach

Within the EuroMix project, we have previously developed an adverse outcome pathway (AOP)-based in vitro assay toolbox to investigate the combined effects of liver steatosis-inducing compounds in human HepaRG hepatocarcinoma cells. In this study, we applied the toolbox to further investigate mixture effects of combinations, featuring either similarly acting or dissimilarly acting substances. The valproic acid structural analogs 2-propylheptanoic acid (PHP) and 2-propylhexanoic acid (PHX) were chosen for establishing mixtures of similarly acting substances, while a combination with the pesticidal active substance clothianidin (CTD) was chosen for establishing mixtures of dissimilarly acting compounds. We first determined relative potency factors (RPFs) for each compound based on triglyceride accumulation results. Thereafter, equipotent mixtures were tested for nuclear receptor activation in transfected HepG2 cells, while gene expression and triglyceride accumulation were investigated in HepaRG cells, following the proposed AOP for liver steatosis. Dose addition was observed for all combinations and endpoints tested, indicating the validity of the additivity assumption also in the case of the tested mixtures of dissimilarly acting substances. Gene expression results indicate that the existing steatosis AOP can still be refined with respect to the early key event (KE) of gene expression, in order to reflect the diversity of molecular mechanisms underlying the adverse outcome.

A targeted transcriptomics approach for the determination of mixture effects of pesticides

While real-life exposure occurs to complex chemical mixtures, toxicological risk assessment mostly focuses on individual compounds. There is an increasing demand for in vitro tools and strategies for mixture toxicity analysis. Based on a previously established set of hepatotoxicity marker genes, we analyzed mixture effects of non-cytotoxic concentrations of different pesticides in exposure-relevant binary mixtures in human HepaRG hepatocarcinoma cells using targeted transcriptomics. An approach for mixture analysis at the level of a complex endpoint such as a transcript pattern is presented, including mixture design based on relative transcriptomic potencies and similarities. From a mechanistic point of view, goal of the study was to evaluate combinations of chemicals with varying degrees of similarity in order to determine whether differences in mechanisms of action lead to different mixtures effects. Using a model deviation ratio-based approach for assessing mixture effects, it was revealed that most data points are consistent with the assumption of dose addition. A tendency for synergistic effects was only observed at high concentrations of some combinations of the test compounds azoxystrobin, cyproconazole, difenoconazole, propiconazole and thiacloprid, which may not be representative of human real-life exposure. In summary, the findings of our study suggest that, for the pesticide mixtures investigated, risk assessment based on the general assumption of dose addition can be considered sufficiently protective for consumers. The way of data analysis presented in this paper can pave the way for a more comprehensive use of multi-gene expression data in experimental studies related to mixture toxicity.

An eight-compound mixture but not corresponding concentrations of individual chemicals induces triglyceride accumulation in human liver cells

In real life, organisms are exposed to complex mixtures of chemicals at low concentration levels, whereas research on toxicological effects is mostly focused on single compounds at comparably high doses. Mixture effects deviating from the assumption of additivity, especially synergistic effects, are of concern. In an adverse outcome pathway (AOP)-guided manner, we analyzed the accumulation of triglycerides in human HepaRG liver cells by a mixture of eight steatotic chemicals (amiodarone, benzoic acid, cyproconazole, flusilazole, imazalil, prochloraz, propiconazole and tebuconazole), each present below its individual effect concentration at 1-3 μM. Pronounced and significantly enhanced triglyceride accumulation was observed with the mixture, and similar effects were seen at the level of pregnane-X-receptor activation, a molecular initiating event leading to hepatic steatosis. Transcript pattern analysis indicated subtle pro-steatotic changes at low compound concentrations, which did not exert measurable effects on cellular triglycerides. Mathematical modeling of mixture effects indicated potentially more than additive behavior using a model for compounds with similar modes of action. The present data underline the usefulness of AOP-guided in vitro testing for the identification of mixture effects and highlight the need for further research on chemical mixtures and harmonization of data interpretation of mixture effects.

Pesticide mixture effects on liver protein abundance in HepaRG cells

Toxicological effects of chemicals are mostly tested individually. However, consumers encounter exposure to complex mixtures, for example multiple pesticide residues, by consuming food such as crops, fruits or vegetables. Currently, more than 450 active substances are approved in the European Union, and there is little data on effects after combined exposure to several pesticides. Toxicological animal studies would increase enormously, if pesticide combinations had to be analyzed in vivo. Therefore, in vitro methods addressing this issue are needed. We have developed 32 immunoaffinity-based mass spectrometry assays to investigate the impact of hepatotoxic active substances on liver proteins in human HepaRG cells. Five compounds were selected based on their (dis)similar capability to modulate protein levels, and on their combined use in commercially available formulations. Four binary mixtures were prepared from these five substances and tested in different concentrations over three time points. We applied a novel statistical method to describe deviations from additivity and to detect antagonistic and synergistic effects. The results regarding the abundance of hepatotoxicity-related proteins showed additive behavior for 1323 out of 1427 endpoints tested, while 104 combinatorial effects deviating from additivity, such as antagonism or synergism were observed.

More than additive effects on liver triglyceride accumulation by combinations of steatotic and non-steatotic pesticides in HepaRG cells

The liver is constantly exposed to mixtures of hepatotoxic compounds, such as food contaminants and pesticides. Dose addition is regularly assumed for mixtures in risk assessment, which however might not be sufficiently protective in case of synergistic effects. Especially the prediction of combination effects of substances which do not share a common adverse outcome (AO) might be problematic. In this study, the focus was on the endpoint liver triglyceride accumulation in vitro, an indicator of hepatic fatty acid changes. The hepatotoxic compounds difenoconazole, propiconazole and tebuconazole were chosen which cause hepatic fatty acid changes in vivo, whereas fludioxonil was chosen as a hepatotoxic substance not causing fatty acid changes. Triglyceride accumulation was analyzed for combinations of steatotic and non-steatotic pesticides in human HepaRG hepatocarcinoma cells. Investigations revealed a potentiation of triglyceride accumulation by mixtures of the steatotic compounds with the non-steatotic fludioxonil, as compared to the single compounds. Mathematical modeling of combination effects indicated more than additive effects for the tested combinations if the method by Chou was applied, and a decrease in EC₅₀ values of the steatotic compounds when applied in mixtures. Use of an adverse outcome pathway (AOP)-driven testing strategy for liver steatosis showed interactions of the test compounds with the nuclear receptors AHR, CAR and PXR, as well as a downregulation of ACOX2. An ACOX2-dependent mechanism underlying the observed mixture effect could not be verified using a siRNA approach. By contrast, a toxicokinetic interaction was identified including an inhibition of the metabolic enzyme CYP3A4 by fludioxonil and a decreased metabolic conversion of the CYP3A4 substrate difenoconazole when used in mixture experiments. In conclusion, an interaction by a steatotic and a non-steatotic compound at the toxicokinetic level on the endpoint triglyceride accumulation in vitro was described.

Mixture effects of chemicals: The difficulty to choose appropriate mathematical models for appropriate conclusions

Many different approaches have been proposed to evaluate and predict mixture effects. From a regulatory perspective, several guidance documents have been recently published and provide a strategy for mixture risk assessment based on valuable frameworks to investigate potential synergistic effects. However, some methodological aspects, e.g. for considering mathematical models, are not sufficiently defined. Therefore, the aim of this study was to examine the usefulness of five main mathematical models for mixture effect interpretation: theoretical additivity (TA), concentration addition (CA), independent action (IA), Chou-Talalay (CT), and a benchmark dose approach (BMD) were tested using a fictional data set depicting scenarios of additivity, synergism and antagonism. The synergism and antagonism scenarios were split in x-axis and y-axis synergism/antagonism, meaning a shift of the curve on x-axis or y-axis. The BMD approach was the only model which showed a perfect correspondence for dose addition. Regarding synergism and antagonism, all approaches correspond well for the x-axis synergism and antagonism with only few exceptions. In contrast, some limitations were observed in the particular scenarios of y-axis synergism and antagonism. Therefore our results show that each model has advantages and disadvantages, and that therefore no single model appears the best one for all kinds of application. We would recommend instead the parallel use of different models to increase confidence in the result of mixture effect evaluation.

RNA-protein correlation of liver toxicity markers in HepaRG cells

The liver is a main target organ for the toxicity of many different compounds. While in general, in vivo testing is still routinely used for assessing the hepatotoxic potential of test chemicals, the use of in vitro models offers advantages with regard to throughput, consumption of resources, and animal welfare aspects. Using the human hepatoma cell line HepaRG, we performed a comparative evaluation of a panel of hepatotoxicity marker mRNAs and proteins after exposure of the cells to 30 different pesticidal active compounds comprising herbizides, fungicides, insecticides, and others. The panel of hepatotoxicity markers included nuclear receptor target genes, key players of fatty acid and bile acid metabolism-related pathways, as well as recently identified biomarkers of drug-induced liver injury. Moreover, marker genes and proteins were identified, for example, S100P, ANXA10, CYP1A1, and CYP7A1. These markers respond with high sensitivity to stimulation with chemically diverse test compounds already at non-cytotoxic concentrations. The potency of the test compounds, determined as an overall parameter of their ability to deregulate marker expression in vitro, was very similar between the mRNA and protein levels. Thus, this study does not only characterize the response of human liver cells to 30 different pesticides but also demonstrates that hepatotoxicity testing in human HepaRG cells yields well comparable results at the mRNA and protein levels. Furthermore, robust hepatotoxicity marker genes and proteins were identified in HepaRG cells.

In vitro nanoparticle dosimetry for adherent growing cell monolayers covering bottom and lateral walls

Background

Even though a continuously high number of in vitro studies on nanoparticles are being published, the issue of correct dose matter is often not sufficiently taken into account. Due to their size, the diffusion of nanoparticles is slower, as compared to soluble chemicals, and they sediment slowly. Therefore, the administered dose of particles in in vitro experiments is not necessarily the same (effective) dose that comes into contact with the cellular system. This can lead to misinterpretations of experimental toxic effects and disturbs the meaningfulness of in vitro studies. In silico calculations of the effective nanoparticle dose can help circumventing this problem.

Results

This study addresses more complex in vitro models like the human intestinal cell line Caco-2 or the human liver cell line HepaRG, which need to be differentiated over a few weeks to reach their full complexity. During the differentiation time the cells grow up the wall of the cell culture dishes and therefore a three-dimensional-based in silico model of the nanoparticle dose was developed to calculate the administered dose received by different cell populations at the bottom and the walls of the culture dish. Moreover, the model can perform calculations based on the hydrodynamic diameter which is measured by light scattering methods, or based on the diffusion coefficient measured by nanoparticle tracking analysis (NTA). This 3DSDD (3D-sedimentation-diffusion-dosimetry) model was experimentally verified against existing dosimetry models and was applied to differentiated Caco-2 cells incubated with silver nanoparticles.

Conclusions

The 3DSDD accounts for the 3D distribution of cells in in vitro cell culture dishes and is therefore suitable for differentiated cells. To encourage the use of dosimetry calculating software, our model can be downloaded from the supporting information.

Electronic supplementary material

The online version of this article (10.1186/s12989-018-0278-9) contains supplementary material, which is available to authorized users.

Uptake and molecular impact of aluminum-containing nanomaterials on human intestinal caco-2 cells

Aluminum (Al) is one of the most common elements in the earth crust and increasingly used in food, consumer products and packaging. Its hazard potential for humans is still not completely understood. Besides the metallic form, Al also exists as mineral, including the insoluble oxide, and in soluble ionic forms. Representatives of these three species, namely a metallic and an oxidic species of Al-containing nanoparticles and soluble aluminum chloride, were applied to human intestinal cell lines as models for the intestinal barrier. We characterized physicochemical particle parameters, protein corona composition, ion release and cellular uptake. Different in vitro assays were performed to determine potential effects and molecular modes of action related to the individual chemical species. For a deeper insight into signaling processes, microarray transcriptome analyses followed by bioinformatic data analysis were employed. The particulate Al species showed different solubility in biological media. Metallic Al nanoparticles released more ions than Al₂O₃ nanoparticles, while AlCl₃ showed a mixture of dissolved and agglomerated particulate entities in biological media. The protein corona composition differed between both nanoparticle species. Cellular uptake, investigated in transwell experiments, occurred predominantly in particulate form, whereas ionic Al was not taken up by intestinal cell lines. Transcellular transport was not observed. None of the Al species showed cytotoxic effects up to 200 µg Al/mL. The transcriptome analysis indicated mainly effects on oxidative stress pathways, xenobiotic metabolism and metal homeostasis. We have shown for the first time that intestinal cellular uptake of Al occurs preferably in the particle form, while toxicological effects appear to be ion-related.

Perfluoroalkylated substances (PFAS) affect neither estrogen and androgen receptor activity nor steroidogenesis in human cells in vitro

The perfluoroalkylated substances (PFAS) perfluorooctanesulfonic acid (PFOS) and perfluorooctanoic acid (PFOA) are used for the fabrication of water- and dirt-repellent surfaces. The use of PFOS and PFOA was restricted due to their reprotoxic properties and their environmental persistence. Therefore, industry switches to alternative PFAS, however, in contrast to PFOA and PFOS only few toxicological data are available for their substitutes. The molecular mechanism(s) underlying reproductive toxicity of PFOA and PFOS are largely unknown. Here, the endocrine properties of PFOA, PFOS, and of six substitutes including perfluorohexanesulfonic acid (PFHxS), perfluorobutanesulfonic acid (PFBS), perfluorohexanoic acid (PFHxA), perfluorobutanoic acid (PFBA), ammonium perfluoro(2-methyl-3-oxahexanoate) (PMOH), and 3H-perfluoro-3-[(3-methoxypropoxy) propanoic acid] (PMPP) were examined in vitro by using human cell lines such as MCF-7, H295R, LNCaP and MDA-kb2. PFOA, PFOS and PMOH enhanced 17β-estradiol-stimulated estrogen receptor β activity, and PFOS, PMOH, PFHxA and PFBA enhanced dihydrotestosterone-stimulated androgen receptor activity. In the H295R steroidogenesis assay, PFOA and PFOS slightly enhanced estrone secretion, and progesterone secretion was marginally increased by PFOA. All these effects were only observed at concentrations above 10 μM, and none of the PFAS displayed any effect on any of the molecular endocrine endpoints at concentrations of 10 μM or below. Thus, as the blood serum concentrations of the different PFAS in the general Western population are in the range of 10 nM or below, the results suggest that PFAS might not exert endocrine effects in humans at exposure-relevant concentrations according to the molecular endpoints examined in this study.

Comparative proteomic analysis of hepatic effects induced by nanosilver, silver ions and nanoparticle coating in rats

The presence of nano-scaled particles in food and food-related products has drawn attention to the oral uptake of nanoparticles and their interactions with biological systems. In the present study, we used a toxicoproteomics approach to allow for the untargeted experimental identification and comparative analysis of cellular responses in rat liver after repeated-dose treatment with silver nanoparticles, ions, and the coating matrix used for particle stabilization. The proteomic analysis revealed treatment-related effects caused by exposure to silver in particulate and ionic form. Both silver species induced similar patterns of signaling and metabolic alterations. Silver-induced cellular alterations comprised, amongst others, proteins involved in metal homeostasis, oxidative stress response, and energy metabolism. However, we discovered that secondary nano-scaled structures were formed from ionic silver. Furthermore, also the coating matrix alone gave rise to the formation of nano-scaled particles. The present data confirm, complement, and extend previous knowledge on silver toxicity in rodent liver by providing a comprehensive proteomic data set. The observation of secondary particle formation from non-particle controls underlines the difficulties in separating particle-, ion-, and matrix coating-related effects in biological systems. Awareness of this issue will support proper evaluation of nanotoxicology-related data in the future.

Dosimetric Quantification of Coating-Related Uptake of Silver Nanoparticles

The elucidation of mechanisms underlying the cellular uptake of nanoparticles (NPs) is an important topic in nanotoxicological research. Most studies dealing with silver NP uptake provide only qualitative data about internalization efficiency and do not consider NP-specific dosimetry. Therefore, we performed a comprehensive comparison of the cellular uptake of differently coated silver NPs of comparable size in different human intestinal Caco-2 cell-derived models to cover also the influence of the intestinal mucus barrier and uptake-specialized M-cells. We used a combination of the Transwell system, transmission electron microscopy, atomic absorption spectroscopy, and ion beam microscopy techniques. The computational in vitro sedimentation, diffusion, and dosimetry (ISDD) model was used to determine the effective dose of the particles in vitro based on their individual physicochemical characteristics. Data indicate that silver NPs with a similar size and shape show coating-dependent differences in their uptake into Caco-2 cells. The internalization of silver NPs was enhanced in uptake-specialized M-cells while the mucus did not provide a substantial barrier for NP internalization. ISDD modeling revealed a fivefold underestimation of dose-response relationships of NPs in in vitro assays. In summary, the present study provides dosimetry-adjusted quantitative data about the influence of NP coating materials in cellular uptake into human intestinal cells. Underestimation of particle effects in vitro might be prevented by using dosimetry models and by considering cell models with greater proximity to the in vivo situation, such as the M-cell model.

Impact of an Artificial Digestion Procedure on Aluminum-Containing Nanomaterials

Aluminum has gathered toxicological attention based on relevant human exposure and its suspected hazardous potential. Nanoparticles from food supplements or food contact materials may reach the human gastrointestinal tract. Here, we monitored the physicochemical fate of aluminum-containing nanoparticles and aluminum ions when passaging an in vitro model of the human gastrointestinal tract. Small-angle X-ray scattering (SAXS), transmission electron microscopy (TEM), ion beam microscopy (IBM), secondary ion beam mass spectrometry (TOF-SIMS), and inductively coupled plasma mass spectrometry (ICP-MS) in the single-particle mode were employed to characterize two aluminum-containing nanomaterials with different particle core materials (Al⁰, γAl₂O₃) and soluble AlCl₃. Particle size and shape remained unchanged in saliva, whereas strong agglomeration of both aluminum nanoparticle species was observed at low pH in gastric fluid together with an increased ion release. The levels of free aluminum ions decreased in intestinal fluid and the particles deagglomerated, thus liberating primary particles again. Dissolution of nanoparticles was limited and substantial changes of their shape and size were not detected. The amounts of particle-associated phosphorus, chlorine, potassium, and calcium increased in intestinal fluid, as compared to nanoparticles in standard dispersion. Interestingly, nanoparticles were found in the intestinal fluid after addition of ionic aluminum. We provide a comprehensive characterization of the fate of aluminum nanoparticles in simulated gastrointestinal fluids, demonstrating that orally ingested nanoparticles probably reach the intestinal epithelium. The balance between dissolution and de novo complex formation should be considered when evaluating nanotoxicological experiments.

Protein Corona Analysis of Silver Nanoparticles Links to Their Cellular Effects

The breadth of applications of nanoparticles and the access to food-associated consumer products containing nanosized materials lead to oral human exposure to such particles. In biological fluids nanoparticles dynamically interact with biomolecules and form a protein corona. Knowledge about the protein corona is of great interest for understanding the molecular effects of particles as well as their fate inside the human body. We used a mass spectrometry-based toxicoproteomics approach to elucidate mechanisms of toxicity of silver nanoparticles and to comprehensively characterize the protein corona formed around silver nanoparticles in Caco-2 human intestinal epithelial cells. Results were compared with respect to the cellular function of proteins either affected by exposure to nanoparticles or present in the protein corona. A transcriptomic data set was included in the analyses in order to obtain a combined multiomics view of nanoparticle-affected cellular processes. A relationship between corona proteins and the proteomic or transcriptomic responses was revealed, showing that differentially regulated proteins or transcripts were engaged in the same cellular signaling pathways. Protein corona analyses of nanoparticles in cells might therefore help in obtaining information about the molecular consequences of nanoparticle treatment.

The role of women's leadership and gender equity in leadership and health system strengthening

Gender equity is imperative to the attainment of healthy lives and wellbeing of all, and promoting gender equity in leadership in the health sector is an important part of this endeavour. This empirical research examines gender and leadership in the health sector, pooling learning from three complementary data sources: literature review, quantitative analysis of gender and leadership positions in global health organisations and qualitative life histories with health workers in Cambodia, Kenya and Zimbabwe. The findings highlight gender biases in leadership in global health, with women underrepresented. Gender roles, relations, norms and expectations shape progression and leadership at multiple levels. Increasing women's leadership within global health is an opportunity to further health system resilience and system responsiveness. We conclude with an agenda and tangible next steps of action for promoting women's leadership in health as a means to promote the global goals of achieving gender equity.

It takes more than a coating to get nanoparticles through the intestinal barrier in vitro

Size and shape are crucial parameters which have impact on the potential of nanoparticles to penetrate cell membranes and epithelial barriers. Current research in nanotoxicology additionally focuses on particle coating. To distinguish between core- and coating-related effects in nanoparticle uptake and translocation, two nanoparticles equal in size, coating and charge but different in core material were investigated. Silver and iron oxide nanoparticles coated with poly (acrylic acid) were chosen and extensively characterized by small-angle x-ray scattering, nanoparticle tracing analysis and transmission electron microscopy (TEM). Uptake and transport were studied in the intestinal Caco-2 model in a Transwell system with subsequent elemental analysis. TEM and ion beam microscopy were conducted for particle visualization. Although equal in size, charge and coating, the behavior of the two particles in Caco-2 cells was different: while the internalized amount was comparable, only iron oxide nanoparticles additionally passed the epithelium. Our findings suggest that the coating material influenced only the uptake of the nanoparticles whereas the translocation was determined by the core material. Knowledge about the different roles of the particle coating and core materials in crossing biological barriers will facilitate toxicological risk assessment of nanoparticles and contribute to the optimization of pharmacokinetic properties of nano-scaled pharmaceuticals.

Impact of food components during in vitro digestion of silver nanoparticles on cellular uptake and cytotoxicity in intestinal cells

Because of the rising application of nanoparticles in food and food-related products, we investigated the influence of the digestion process on the toxicity and cellular uptake of silver nanoparticles for intestinal cells. The main food components--carbohydrates, proteins and fatty acids--were implemented in an in vitro digestion process to simulate realistic conditions. Digested and undigested silver nanoparticle suspensions were used for uptake studies in the well-established Caco-2 model. Small-angle X-ray scattering was used to estimate particle core size, size distribution and stability in cell culture medium. Particles proved to be stable and showed radii from 3.6 to 16.0 nm. Undigested particles and particles digested in the presence of food components were comparably taken up by Caco-2 cells, whereas the uptake of particles digested without food components was decreased by 60%. Overall, these findings suggest that in vivo ingested poly (acrylic acid)-coated silver nanoparticles may reach the intestine in a nanoscaled form even if enclosed in a food matrix. While appropriate for studies on the uptake into intestinal cells, the Caco-2 model might be less suited for translocation studies. Moreover, we show that nanoparticle digestion protocols lacking food components may lead to misinterpretation of uptake studies and inconclusive results.

Molecular mechanism of silver nanoparticles in human intestinal cells

Silver nanoparticles are used in consumer products like food contact materials, drinking water technologies and supplements, due to their antimicrobial properties. This leads to an oral uptake and exposure of intestinal cells. In contrast to other studies we found no apoptosis induction by surfactant-coated silver nanoparticles in the intestinal cell model Caco-2 in a previous study, although the particles induced oxidative stress, morphological changes and cell death. Therefore, this study aimed to analyze the molecular mechanism of silver nanoparticles in Caco-2 cells. We used global gene expression profiling in differentiated Caco-2 cells, supported by verification of the microarray data by quantitative real-time RT-PCR and microscopic analysis, impedance measurements and assays for apoptosis and oxidative stress. Our results revealed that surfactant-coated silver nanoparticles probably affect the cells by outside-in signaling. They induce oxidative stress and have an influence on canonical pathways related to FAK, ILK, ERK, MAPK, integrins and adherence and tight junctions, thereby inducing transcription factors like AP1, NFkB and NRF2, which mediate cellular reactions in response to oxidative stress and metal ions and induce changes in the cytoskeleton and cell-cell and cell-matrix contacts. The present data confirm the absence of apoptotic cell death. Non-apoptotic, necrotic cell death, especially in the intestine, can cause inflammation and influence the mucosal immune response.

FALLS-protocol: lung ultrasound in hemodynamic assessment of shock

The assessment of acute circulatory failure is a challenge in absence of solid gold standard. It is suggested that artifacts generated by lung ultrasound can be of help. The FALLS-protocol (Fluid Administration Limited by Lung Sonography) follows Weil's classification of shocks. Firstly, it searches for pericardial fluid, then right heart enlargment, lastly abolished lung sliding. In this setting, the diagnoses of pericardial tamponade, pulmonary embolism and tension pneumothorax, i.e. obstructive shock, can be schematically ruled out. Moreover, the search of diffuse lung rockets (i.e. multiple B-lines, a comet-tail artifact) is performed. Its absence excludes pulmonary edema, that in clinical practice is left cardiogenic shock (most cases). At this step, the patient (defined FALLS-responder) receives fluid therapy. He/she has usually a normal sonographic lung surface, an A-profile. Any clinical improvement suggests hypovolemic shock. The absence of improvement generates continuation of fluid therapy, eventually yielding fluid overload. This condition results in the change from A-profile to B-profile. Lung ultrasound has the advantage to demonstrate this interstitial syndrome at an early and infraclinical stage (FALLS-endpoint). The change from horizontal A-lines to vertical B-lines can be considered as a direct marker of volemia in this use. By elimination, this change indicates schematically distributive shock, while in current practice septic shock. The major limitation is the B-profile on admission generated by an initial lung disorder. FALLS-protocol, which can be associated with no drawback with traditional hemodynamic tools, uses a simple machine (without Doppler) and a suitable microconvex probe allowing for heart, lung and vein assessment.

Lung ultrasound in acute respiratory failure an introduction to the BLUE-protocol

Critical ultrasound, apparently a recent field, is in fact the outcome of a slow process, initiated since 1946. The lung was traditionally not considered as part of ultrasound, yet we considered its inclusion as a priority in our definition of critical ultrasound. Acute respiratory failure is one of the most distressing situations for the patient. An ultrasound approach of this disorder - the BLUE-protocol allows rapid diagnosis. Its main features will be described. Each kind of respiratory failure provides a particular ultrasound profile. In this difficult setting, initial mistakes are frequent. The BLUE-protocol proposes a step-by-step approach for making accurate diagnosis. By combining three signs with binary answer (anterior lung sliding, anterior lung-rockets), with venous analysis when required, seven profiles are generated, yielding a 90.5% accuracy. This rate is highly enhanced when simple clinical and laboratory data are considered. The BLUE-protocol can be achieved in three minutes, because the use of an intelligent machine, a universal probe, and standardized points allow major time-saving. Lung ultrasound in the critically ill was long available. In a domain where everything must be fast and accurate, the BLUE-protocol can play a major role in the diagnosis of an acute respiratory failure, usually answering immediately to questions where only sophisticated techniques were hitherto used.

The Internal jugular veins are asymmetric. Usefulness of ultrasound before catheterization

OBJECTIVE

To demonstrate an asymmetry of the internal jugular veins, a finding which will have consequences for catheterization.

DESIGN

Prospective study.

SETTING

The medical ICU of a university-affiliated teaching hospital.

PATIENTS

Eighty critically ill consecutive patients.

INTERVENTION

Measurement of the cross-sectional area of the internal jugular veins. Search for an asymmetry, defined as an area at least twice that of the contralateral vein.

RESULTS

An asymmetry was noted in 62.5% of the patients. The dominant vein was the right in only 68 % of these cases. In addition, 23% of the 160 jugular internal veins had an area of 0.4 cm2 or less.

CONCLUSIONS

Using a simple technique, ultrasound identifies the dominant internal jugular vein, thus indicating the safer side before blind catheterization.

The "lung point": an ultrasound sign specific to pneumothorax

OBJECTIVE

We studied an ultrasound sign, the fleeting appearance of a lung pattern (lung sliding or pathologic comet-tail artifacts) replacing a pneumothorax pattern (absent lung sliding plus exclusive horizontal lines) in a particular location of the chest wall. This sign was called the "lung point".

DESIGN

Prospective study.

SETTING

The medical ICU of a university-affiliated teaching hospital.

PATIENTS

The "lung point" was sought in 66 consecutive cases of proven pneumothorax analyzable using ultrasound--including 8 radio-occult cases diagnosed by means of CT and in 233 consecutive hemithoraces studied by CT and free of pneumothorax-- including 17 cases where pneumothorax was suspected.

RESULTS

The "lung point" was observed in 44 of 66 cases of pneumothorax (including 6 of 8 radio-occult cases) and in no case in the control group. The location of this sign roughly correlated with the radiological size of the pneumothorax. The "lung point" therefore had an overall sensitivity of 66 % (75 % in the case of radio-occult pneumothorax alone) and a specificity of 100%.

CONCLUSION

The presence of a "lung point" allows positive diagnosis of pneumothorax at the bedside using ultrasound.

Feasibility and safety of ultrasound-aided thoracentesis in mechanically ventilated patients

OBJECTIVE

Thoracentesis in a ventilated patient is rarely performed because of the risk of pneumothorax. We have evaluated the safety of this procedure when aided by ultrasound.

DESIGN

Prospective study.

SETTING

Medical intensive care unit, university-affiliated hospital.

PATIENTS

45 procedures were performed in 40 consecutive patients with ultrasound signs of pleural effusion, all mechanically ventilated.

INTERVENTIONS

Pleural effusion was defined on ultrasound as a collection of fluid between parietal and visceral pleura leading to variations in interpleural distance during breathing. When the interpleural distance was >/= 15 mm and visible over three intercostal spaces, a needle (16 or 21 G) was inserted after ultrasound localization in a patient in either dorsal or lateral decubitus.

RESULTS

No complication occurred in the 45 thoracenteses. Fluid was obtained in 44 of 45 procedures, thus confirming the diagnosis of pleural effusion. The procedure was immediate (less than 10 s) in 40 of 45 cases. It was easy (i. e., keeping the patient supine) in 22 of 45 procedures. In 44 cases where fluid was obtained, only 27 bedside radiographs revealed signs of effusion, whereas 17 showed absence of a visible effusion. Ultrasound thus appeared more efficient than bedside X-ray in detecting pleural effusion.

CONCLUSIONS

If basic rules are followed, ultrasound localization makes thoracentesis a safe, easy and simple procedure in patients on mechanical ventilation.

The comet-tail artifact: an ultrasound sign ruling out pneumothorax

OBJECTIVE

Ultrasound artifacts arising from the lung-wall interface are either vertical (comet-tail artifacts) or horizontal. The significance of these artifacts for the diagnosis of pneumothorax was assessed.

DESIGN

Prospective clinical study.

SETTING

The medical ICU of a university-affiliated teaching hospital.

PATIENTS

We compared 41 complete pneumothoraces with 146 hemithoraces in 73 critically ill patients in which computed tomography showed absence of pneumothorax.

MEASUREMENTS

The anterior chest wall was investigated in supine patients using a portable device. The test was defined as positive for complete pneumothorax when only horizontal artifacts were visible, and negative when artifacts arising from the pleural line and spreading up to the edge of the screen (referred to as "comet-tail artifacts") were present.

RESULTS

The feasibility was 98%. Ultrasound showed exclusive horizontal artifacts in all 41 analyzable cases of complete pneumothorax. In the pneumothorax-free group, "comet-tail artifacts" were present in 87 cases and exclusive horizontal artifacts in 56. Ultrasound as well as computed tomography showed anterior consolidation or anterior pleural effusion in three cases. Horizontal artifacts had a sensitivity and a negative predictive value of 100% and a specificity of 60% for the diagnosis of pneumothorax. Horizontal artifacts and absent lung sliding, when combined, had a sensitivity and a negative predictive value of 100% and a specificity of 96.5%.

CONCLUSIONS

Ultrasound detection of the "comet-tail artifact" at the anterior chest wall allows complete pneumothorax to be discounted.

A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact

OBJECTIVE

Acute cardiogenic pulmonary edema and exacerbation of chronic obstructive pulmonary disease (COPD) can have a similar clinical presentation, and X-ray examination does not always solve the problem of differential diagnosis. The potential of lung ultrasound to distinguish these two disorders was assessed.

DESIGN

Prospective clinical study.

SETTING

The medical ICU of a university-affiliated teaching hospital.

PATIENTS

We investigated 66 consecutive dyspneic patients: 40 with pulmonary edema and 26 with COPD. In addition, 80 patients without clinical and radiologic respiratory disorders were studied.

MEASUREMENTS

The sign studied was the comet-tail artifact arising from the lung wall interface, multiple and bilaterally disseminated to the anterolateral chest wall.

RESULTS

The feasibility was 100%. The length of the examination was always under 1 min. The described pattern was present in all 40 patients with pulmonary edema. It was absent in 24 of 26 cases of COPD as well as in 79 of 80 patients without respiratory disorders. The sign studied had a sensitivity of 100% and a specificity of 92% in the diagnosis of pulmonary edema when compared with COPD.

CONCLUSIONS

With a described pattern present in 100% of the cases of pulmonary edema and absent in 92% of the cases of COPD and in 98.75% of the normal lungs, ultrasound detection of the comet-tail artifact arising from the lung-wall interface may help distinguish pulmonary edema from COPD.

The "sinusogram", a real-time ultrasound sign of maxillary sinusitis

OBJECTIVE

To describe a real-time ultrasound sign, the visualization of the cavity and the walls of the maxillary sinus ("sinusogram"), and to assess its correlation with total opacity of the sinus.

DESIGN

Prospective clinical study.

SETTING

The medical ICU of a university-affiliated hospital.

PATIENTS

The significance of this sign was assessed in 50 critically ill supine patients (100 maxillary sinuses) who underwent paranasal CT.

MEASUREMENTS AND RESULTS

The "sinusogram" was defined as complete when the internal, external and posterior walls were frankly visible, and incomplete in the case of partial visualization of the walls. The "sinusogram" was present in all 21 cases of total opacity, in 2 of 12 cases of air-fluid level, in 8 of 14 cases of mucosal thickening, in one giant polyp, and in none of 52 normal sinuses. The "sinusogram" was complete in 10 of 21 cases of total opacity. It was incomplete in 11 of 21 cases of total opacity and in all 8 cases of mucosal thickening with positive ultrasound. For the diagnosis of radiologic maxillary sinusitis (total opacity or air-fluid level within the maxillary cavity), the sensitivity was 67 % and the specificity 87 %. For the diagnosis of total opacity (versus absence of total opacity, which includes fluid level), the sensitivity was 100% and the specificity 86%. When the "sinusogram" was complete, the specificity was 100% for the diagnosis of total opacity.

CONCLUSIONS

Ultrasound may be proposed in first-line diagnosis of radiologic maxillary sinusitis.

The comet-tail artifact. An ultrasound sign of alveolar-interstitial syndrome

Can ultrasound be of any help in the diagnosis of alveolar-interstitial syndrome? In a prospective study, we examined 250 consecutive patients in a medical intensive care unit: 121 patients with radiologic alveolar-interstitial syndrome (disseminated to the whole lung, n = 92; localized, n = 29) and 129 patients without radiologic evidence of alveolar-interstitial syndrome. The antero-lateral chest wall was examined using ultrasound. The ultrasonic feature of multiple comet-tail artifacts fanning out from the lung surface was investigated. This pattern was present all over the lung surface in 86 of 92 patients with diffuse alveolar-interstitial syndrome (sensitivity of 93.4%). It was absent or confined to the last lateral intercostal space in 120 of 129 patients with normal chest X-ray (specificity of 93.0%). Tomodensitometric correlations showed that the thickened sub-pleural interlobular septa, as well as ground-glass areas, two lesions present in acute pulmonary edema, were associated with the presence of the comet-tail artifact. In conclusion, presence of the comet-tail artifact allowed diagnosis of alveolar-interstitial syndrome.