Breathing new life into tissue engineering: exploring cutting-edge vascularization strategies for skin substitutes.

Tissue-engineered skin substitutes (TESS) emerged as a new therapeutic option to improve skin transplantation. However, establishing an adequate and rapid vascularization in TESS is a critical factor for their clinical application and successful engraftment in patients. Therefore, several methods have been applied to improve the vascularization of skin substitutes including (i) modifying the structural and physicochemical properties of dermal scaffolds; (ii) activating biological scaffolds with growth factor-releasing systems or gene vectors; and (iii) developing prevascularized skin substitutes by loading scaffolds with capillary-forming cells. This review provides a detailed overview of the most recent and important developments in the vascularization strategies for skin substitutes. On the one hand, we present cell-based approaches using stem cells, microvascular fragments, adipose tissue derived stromal vascular fraction, endothelial cells derived from blood and skin as well as other pro-angiogenic stimulation methods. On the other hand, we discuss how distinct 3D bioprinting techniques and microfluidics, miRNA manipulation, cell sheet engineering and photosynthetic scaffolds like GelMA, can enhance skin vascularization for clinical applications. Finally, we summarize and discuss the challenges and prospects of the currently available vascularization techniques that may serve as a steppingstone to a mainstream application of skin tissue engineering.

A Randomized Controlled Trial of TELEmedicine for Patients with Inflammatory Bowel Disease (TELE-IBD).

INTRODUCTION: Telemedicine has shown promise in inflammatory bowel disease (IBD). The objective of this study was to compare disease activity and quality of life (QoL) in a 1-year randomized trial of IBD patients receiving telemedicine vs. standard care. METHODS: Patients with worsening symptoms in the prior 2 years were eligible for randomization to telemedicine (monitoring via texts EOW or weekly) or standard care. The primary outcomes were the differences in change in disease activity and QoL between the groups; change in healthcare utilization among groups was a secondary aim. RESULTS: 348 participants were enrolled (117 control group, 115 TELE-IBD EOW, and 116 TELE-IBD weekly). 259 (74.4%) completed the study. Age was 38.9 ± 12.3 years, 56.6% were women, 91.9% were Caucasian, 67.9% had Crohn's disease (CD) and 42.5% had active disease at baseline. In CD, all groups experienced a decrease in disease activity (control -5.2 ± 5.0 to 3.7 ± 3.6, TELE-IBD EOW 4.7 ± 4.1 to 4.2 ± 3.9, and TELE-IBD weekly 4.2 ± 4.2 to 3.2 ± 3.4, p < 0.0001 for each of the groups) In UC, only controls had a significant decrease in disease activity (control 2.9 ± 3.1 to 1.4 ± 1.4, p = 0.01, TELE-IBD EOW 2.7 ± 3.1 to 1.7 ± 1.9, p = 0.35, and TELE-IBD Weekly 2.5 ± 2.5 to 2.0 ± 1.8, p = 0.31). QoL increased in all groups; the increase was significant only in TELE-IBD EOW (control 168.1 ± 34.0 to 179.3 ± 28.2, p = 0.06, TELE-IBD EOW 172.3 ± 33.1 to 181.5 ± 28.2, p = 0.03, and TELE-IBD Weekly 172.3 ± 34.5 to 179.2 ± 32.8, p = 0.10). Unadjusted and adjusted changes in disease activity and QoL were not significantly different among groups. Healthcare utilization increased in all groups. TELE-IBD weekly were less likely to have IBD-related hospitalizations and more likely to have non-invasive diagnostic tests and electronic encounters compared to controls; both TELE-IBD groups had decreased non-IBD related hospitalizations and increased telephone calls compared to controls. DISCUSSION: Disease activity and QoL, although improved in all participants, were not improved further through use of the TELE-IBD system. TELE-IBD participants experienced a decrease in hospitalizations with an associated increase in non-invasive diagnostic tests, telephone calls and electronic encounters. Research is needed to determine if TELE-IBD can be improved through patient engagement and whether it can decrease healthcare utilization by replacing standard care.

Legalization of Medicinal Marijuana Has Minimal Impact on Use Patterns in Patients With Inflammatory Bowel Disease.

Background: Patients with inflammatory bowel disease (IBD) have reported use of marijuana to treat symptoms of the disease, yet its classification as a Schedule 1 substance by the federal government has restricted its use. In 2012, Massachusetts legalized medicinal marijuana. We aimed to assess the impact of legalization on use in IBD. Methods: Consecutive patients with IBD, cared for at a tertiary care center in Boston, were surveyed regarding use of marijuana, including its perceived benefits and attitudes. Data were then compared with results of a similar survey study conducted at our center in 2012, before marijuana's legalization. Results: The survey was completed by 302 patients. There was a significant increase in marijuana use overall from 12.3% in 2012 to 22.8% in 2017 (P < 0.001). However, there was no significant increase in medicinal use from 2012 to 2017. On bivariate analysis, severe disease, as assessed by SIBDQ score, prior hospitalization, biologic therapy use, prior surgery, and chronic abdominal pain, was found to be more predictive of medicinal use now than in 2012. Among patients surveyed who have never used marijuana, 39.4% reported being interested in using medicinal marijuana, and 54.3% indicated that legalization did not affect their likelihood of using medicinal marijuana. Conclusions: In an IBD tertiary care center, we identified an overall upward trend in marijuana use but no significant change in medicinal use since its legalization in 2012. Our data suggests that the legalization of medical marijuana has resulted in an insignificant change in medicinal marijuana use in this population. 10.1093/ibd/izy141_video1izy141.video15786500236001.

The Projected Responses of Residency-Sponsoring Institutions to a Reduction in Medicare Support for Graduate Medical Education: A National Survey.

PURPOSE: To assess the projected responses of residency-sponsoring institutions to the proposed reduction in Medicare's indirect medical education (IME) payments. METHOD: In 2012, the authors surveyed directors of graduate medical education (GME) programs, examining (1) overall responses to a reduction in IME reimbursement and (2) the value of individual residencies to the institution from the economic/operational and educational/public service points of view, to determine which programs may be at risk for downsizing. RESULTS: Responses from 192 of 555 institutions (35% response rate) varied by the size of the institution's GME program. Of large programs (six or more residencies), 33 (33%) would downsize at a 10% reduction in IME reimbursement, focusing cuts on specific programs. Small programs (five or fewer residencies) were more likely to retain their existing residencies with modest IME payment reductions and to make across-the-board cuts. The economic/operational value of specialties varied widely, with hospital-intensive residencies valued highest. Family medicine was valued highly from an economic/operational point of view only by small programs. Educational/public service value scores varied less and were higher for all specialties. Preventive medicine was not highly valued in either category. CONCLUSIONS: Even a modest decrease in IME reimbursement could trigger institutions to downsize their GME programs. Programs at the greatest risk for cuts may be those with modest economic/operational value but high societal value, like family medicine. The retention or expansion of training in family medicine may be most easily accomplished then at smaller institutions.

Asymptomatic presentation of giant bulla of the left apical and anterior segment of the left upper lobe of the lung with near complete atelectasis of the remaining left lung.

Giant bullae may be found in association with emphysema. They present as pockets of entrapped air which grow as the surrounding lung retracts away. As they do not take part in gas exchange and merely occupy space, their presence leads to severe impediment of mechanical ventilation in the adjacent lung parenchyma. Patients may present with dyspnoea, exercise intolerance and a feeling of pressure in the chest. The case of a 54 year old gentleman is presented, who was found to have a giant bulla occupying his left hemithorax on a routine chest X-ray. The patient remained asymptomatic despite the large size of the bulla and was treated with surgical resection via thoracotomy i.e. Bullectomy which is the treatment of choice. If left untreated the condition can be complicated by pneumothorax, infection and a slow progression to malignant changes.