Lung Cancer Survival Trends in the Veterans Health Administration

INTRODUCTION

Lung cancer survival is improving in the United States. We investigated whether there was a similar trend within the Veterans Health Administration (VHA), the largest integrated healthcare system in the United States.

MATERIALS AND METHODS

Data from the Veterans Affairs Central Cancer Registry were analyzed for temporal survival trends using Kaplan-Meier estimates and linear regression.

RESULTS

A total number of 54,922 Veterans were identified with lung cancer diagnosed from 2010 to 2017. Histologies were classified as non-small-cell lung cancer (NSCLC) (64.2%), small cell lung cancer (SCLC) (12.9%), and 'other' (22.9%). The proportion with stage I increased from 18.1% to 30.4%, while stage IV decreased from 38.9% to 34.6% (both P < .001). The 3-year overall survival (OS) improved for stage I (58.6% to 68.4%, P < .001), stage II (35.5% to 48.4%, P < .001), stage III (18.7% to 29.4%, P < .001), and stage IV (3.4% to 7.8%, P < .001). For NSCLC, the median OS increased from 12 to 21 months (P < .001), and the 3-year OS increased from 24.1% to 38.3% (P < .001). For SCLC, the median OS remained unchanged (8 to 9 months, P = .10), while the 3-year OS increased from 9.1% to 12.3% (P = .014). Compared to White Veterans, Black Veterans with NSCLC had similar OS (P = .81), and those with SCLC had higher OS (P = .003).

CONCLUSION

Lung cancer survival is improving within the VHA. Compared to White Veterans, Black Veterans had similar or higher survival rates. The observed racial equity in outcomes within a geographically and socioeconomically diverse population warrants further investigation to better understand and replicate this achievement in other healthcare systems.

Liquid Crystal Elastomer Lattices with Thermally Programmable Deformation via Multi-Material 3D Printing

An integrated design, modeling, and multi-material 3D printing platform for fabricating liquid crystal elastomer (LCE) lattices in both homogeneous and heterogeneous layouts with spatially programmable nematic director order and local composition is reported. Depending on their compositional topology, these lattices exhibit different reversible shape-morphing transformations upon cycling above and below their respective nematic-to-isotropic transition temperatures. Further, it is shown that there is good agreement between their experimentally observed deformation response and model predictions for all LCE lattice designs evaluated. Lastly, an inverse design model is established and the ability to print LCE lattices with the predicted deformation behavior is demonstrated. This work opens new avenues for creating architected LCE lattices that may find potential application in energy-dissipating structures, microfluidic pumping, mechanical logic, and soft robotics.

Social vulnerability and lung malignancy mortality

INTRODUCTION

Lung cancer is a major cause of death in the United States. Social determinants of health (SDOH) are important factors that impact the treatment and prognosis of lung cancer. The social vulnerability index (SVI) is a validated measure of SDOH. This cross-sectional study aimed to investigate the impact of the SVI on lung cancer mortality using descriptive epidemiology.

METHODS

Mortality data for lung malignancies from 2014 to 2018 was obtained from the CDC database and was age-adjusted and standardized to the population in the year 2000. The SVI for the same years was obtained from the CDC Agency for Toxic Substances and Disease Registry database. Age-adjusted mortality rates (AAMR) were estimated for each SVI quartile (SVI-Q) and demographic subgroup.

RESULTS

We found that counties in SVI-Q4 (most vulnerable) had a higher cumulative AAMR compared to counties in SVI-Q1 (least vulnerable), accounting for a 4.48 excess death rate per 100,000 person-years. AAMR among males in SVI-Q4 was higher compared to SVI-Q1, accounting for a 9.96 excess death rate per 100,000 person-years, whereas no mortality differences were observed for female populations between SVI-Q4 and SVI-Q1. AAMR in SVI-Q4 was higher for both Hispanic and non-Hispanic populations, except for American Indian/Alaska Native populations. Similar trends were observed in both metropolitan and non-metropolitan counties.

CONCLUSION

Our study suggests that the SVI may play a significant role in lung cancer mortality and highlights the need for interventions targeting vulnerable populations to improve outcomes.

The Association of Organizational Readiness With Lung Cancer Screening Utilization

INTRODUCTION

Lung cancer screening is widely underutilized. Organizational factors, such as readiness for change and belief in the value of change (change valence), may contribute to underutilization. The aim of this study was to evaluate the association between healthcare organizations' preparedness and lung cancer screening utilization.

METHODS

Investigators cross-sectionally surveyed clinicians, staff, and leaders at10 Veterans Affairs from November 2018 to February 2021 to assess organizational readiness to implement change. In 2022, investigators used simple and multivariable linear regression to evaluate the associations between facility-level organizational readiness to implement change and change valence with lung cancer screening utilization. Organizational readiness to implement change and change valence were calculated from individual surveys. The primary outcome was the proportion of eligible Veterans screened using low-dose computed tomography. Secondary analyses assessed scores by healthcare role.

RESULTS

The overall response rate was 27.4% (n=1,049), with 956 complete surveys analyzed: median age of 49 years, 70.3% female, 67.6% White, 34.6% clinicians, 61.1% staff, and 4.3% leaders. For each 1-point increase in median organizational readiness to implement change and change valence, there was an associated 8.4-percentage point (95% CI=0.2, 16.6) and a 6.3-percentage point increase in utilization (95% CI= -3.9, 16.5), respectively. Higher clinician and staff median scores were associated with increased utilization, whereas leader scores were associated with decreased utilization after adjusting for other roles.

CONCLUSIONS

Healthcare organizations with higher readiness and change valence utilized more lung cancer screening. These results are hypothesis generating. Future interventions to increase organizations' preparedness, especially among clinicians and staff, may increase lung cancer screening utilization.

National Survey of Lung Cancer Screening Practices in Veterans Health Administration Facilities

INTRODUCTION

Lung cancer screening can save lives through the early detection of lung cancer, and professional societies recommend key lung cancer screening program components to ensure high-quality screening. Yet, little is known about the key components that comprise the various screening program models in routine clinical settings. The objective was to compare the utilization of these key components across centralized, hybrid, and decentralized lung cancer screening programs.

METHODS

The survey was designed to identify current structures and processes of lung cancer screening programs. It was administered electronically to Veterans Health Administration facilities nationally (N=122) between August and December 2021. Results were analyzed between March and August 2022 and stratified by self-identified lung cancer screening program type, and we tested the hypothesis that centralized screening programs would be more likely to have implemented practices that support lung cancer screening, followed by hybrid and decentralized programs, using the Cochran-Armitage trend test.

RESULTS

Overall, 69 (56.6%) facilities completed the survey, and respondents were lung cancer screening coordinators (39.1%), pulmonologists (33.3%), and oncologists (10.1%). Facilities most frequently self-identified as having a centralized (37.7%) program model, followed by identifying as having hybrid (30.4%) and decentralized (20.3%) programs. There was varying implementation of practices to support lung cancer screening, with hybrid and decentralized programs less likely to have lung cancer screening registries, lung cancer screening steering committees, or dedicated lung cancer screening coordinators.

CONCLUSIONS

Although there is overlap between the components of various lung cancer screening program types, centralized programs more frequently implemented practices before the initial screening to support lung cancer screening. This work provides a path for future investigations to identify which lung cancer screening practices are effective to improve lung cancer screening outcomes, which could help inform implementation in settings with limited resources.

Biomimetic human skin model patterned with rete ridges

Rete ridges consist of undulations between the epidermis and dermis that enhance the mechanical properties and biological function of human skin. However, most human skin models are fabricated with a flat interface between the epidermal and dermal layers. Here, we report a micro-stamping method for producing human skin models patterned with rete ridges of controlled geometry. To mitigate keratinocyte-induced matrix degradation, telocollagen-fibrin matrices with and without crosslinks enable these micropatterned features to persist during longitudinal culture. Our human skin model exhibits an epidermis that includes the following markers: cytokeratin 14, p63, and Ki67 in the basal layer, cytokeratin 10 in the suprabasal layer, and laminin and collagen IV in the basement membrane. We demonstrated that two keratinocyte cell lines, one from a neonatal donor and another from an adult diabetic donor, are compatible with this model. We tested this model using an irritation test and showed that the epidermis prevents rapid penetration of sodium dodecyl sulfate. Gene expression analysis revealed differences in keratinocytes obtained from the two donors as well as between 2D (control) and 3D culture conditions. Our human skin model may find potential application for drug and cosmetic testing, disease and wound healing modeling, and aging studies.

Identification and Characterization of Avoidable Hospital Admissions in Patients With Lung Cancer

BACKGROUND

More than 50% of patients with lung cancer are admitted to the hospital while receiving treatment, which is a burden to patients and the healthcare system. This study characterizes the risk factors and outcomes of patients with lung cancer who were admitted to the hospital.

METHODS

A multidisciplinary oncology care team conducted a retrospective medical record review of patients with lung cancer admitted in 2018. Demographics, disease and admission characteristics, and end-of-life care utilization were recorded. Following a multidisciplinary consensus review process, admissions were determined to be either "avoidable" or "unavoidable." Generalized estimating equation logistic regression models assessed risks and outcomes associated with avoidable admissions.

RESULTS

In all, 319 admissions for 188 patients with a median age of 66 years (IQR, 59-74 years) were included. Cancer-related symptoms accounted for 65% of hospitalizations. Common causes of unavoidable hospitalizations were unexpected disease progression causing symptoms, chronic obstructive pulmonary disease exacerbation, and infection. Of the 47 hospitalizations identified as avoidable (15%), the median overall survival was 1.6 months compared with 9.7 months (hazard ratio, 2.07; 95% CI, 1.34-3.19; P<.001) for unavoidable hospitalizations. Significant reasons for avoidable admissions included cancer-related pain (P=.02), hypervolemia (P=.03), patient desire to initiate hospice services (P=.01), and errors in medication reconciliation or distribution (P<.001). Errors in medication management caused 26% of the avoidable hospitalizations. Of admissions in patients receiving immunotherapy (n=102) or targeted therapy (n=44), 9% were due to adverse effects of treatment. Patients receiving immunotherapy and targeted therapy were at similar risk of avoidable hospitalizations compared with patients not receiving treatment (P=.3 and P=.1, respectively).

CONCLUSIONS

We found that 15% of hospitalizations among patients with lung cancer were potentially avoidable. Uncontrolled symptoms, delayed implementation of end-of-life care, and errors in medication reconciliation were associated with avoidable inpatient admissions. Symptom management tools, palliative care integration, and medication reconciliations may mitigate hospitalization risk.

Immune-infiltrated kidney organoid-on-chip model for assessing T cell bispecific antibodies

T cell bispecific antibodies (TCBs) are the focus of intense development for cancer immunotherapy. Recently, peptide-MHC (major histocompatibility complex)-targeted TCBs have emerged as a new class of biotherapeutics with improved specificity. These TCBs simultaneously bind to target peptides presented by the polymorphic, species-specific MHC encoded by the human leukocyte antigen (HLA) allele present on target cells and to the CD3 coreceptor expressed by human T lymphocytes. Unfortunately, traditional models for assessing their effects on human tissues often lack predictive capability, particularly for "on-target, off-tumor" interactions. Here, we report an immune-infiltrated, kidney organoid-on-chip model in which peripheral blood mononuclear cells (PBMCs) along with nontargeting (control) or targeting TCB-based tool compounds are circulated under flow. The target consists of the RMF peptide derived from the intracellular tumor antigen Wilms' tumor 1 (WT1) presented on HLA-A2 via a bivalent T cell receptor-like binding domain. Using our model, we measured TCB-mediated CD8+ T cell activation and killing of RMF-HLA-A2-presenting cells in the presence of PBMCs and multiple tool compounds. DP47, a non-pMHC-targeting TCB that only binds to CD3 (negative control), does not promote T cell activation and killing. Conversely, the nonspecific ESK1-like TCB (positive control) promotes CD8+ T cell expansion accompanied by dose-dependent T cell-mediated killing of multiple cell types, while WT1-TCB* recognizing the RMF-HLA-A2 complex with high specificity, leads solely to selective killing of WT1-expressing cells within kidney organoids under flow. Our 3D kidney organoid model offers a platform for preclinical testing of cancer immunotherapies and investigating tissue-immune system interactions.

Rural barriers and facilitators of lung cancer screening program implementation in the veterans health administration: a qualitative study

Introduction

To assess healthcare professionals' perceptions of rural barriers and facilitators of lung cancer screening program implementation in a Veterans Health Administration (VHA) setting through a series of one-on-one interviews with healthcare team members.

Methods

Based on measures developed using Reach Effectiveness Adoption Implementation Maintenance (RE-AIM), we conducted a cross-sectional qualitative study consisting of one-on-one semi-structured telephone interviews with VHA healthcare team members at 10 Veterans Affairs medical centers (VAMCs) between December 2020 and September 2021. An iterative inductive and deductive approach was used for qualitative analysis of interview data, resulting in the development of a conceptual model to depict rural barriers and facilitators of lung cancer screening program implementation.

Results

A total of 30 interviews were completed among staff, providers, and lung cancer screening program directors and a conceptual model of rural barriers and facilitators of lung cancer screening program implementation was developed. Major themes were categorized within institutional and patient environments. Within the institutional environment, participants identified systems-level (patient communication, resource availability, workload), provider-level (attitudes and beliefs, knowledge, skills and capabilities), and external (regional and national networks, incentives) barriers to and facilitators of lung cancer screening program implementation. Within the patient environment, participants revealed patient-level (modifiable vulnerabilities) barriers and facilitators as well as ecological modifiers (community) that influence screening behavior.

Discussion

Understanding rural barriers to and facilitators of lung cancer screening program implementation as perceived by healthcare team members points to opportunities and approaches for improving lung cancer screening reach, implementation and effectiveness in VHA rural settings.

Microporogen-Structured Collagen Matrices for Embedded Bioprinting of Tumor Models for Immuno-Oncology

Embedded bioprinting enables the rapid design and fabrication of complex tissues that recapitulate in vivo microenvironments. However, few biological matrices enable good print fidelity, while simultaneously facilitate cell viability, proliferation, and migration. Here, a new microporogen-structured (µPOROS) matrix for embedded bioprinting is introduced, in which matrix rheology, printing behavior, and porosity are tailored by adding sacrificial microparticles composed of a gelatin-chitosan complex to a prepolymer collagen solution. To demonstrate its utility, a 3D tumor model is created via embedded printing of a murine melanoma cell ink within the µPOROS collagen matrix at 4 °C. The collagen matrix is subsequently crosslinked around the microparticles upon warming to 21 °C, followed by their melting and removal at 37 °C. This process results in a µPOROS matrix with a fibrillar collagen type-I network akin to that observed in vivo. Printed tumor cells remain viable and proliferate, while antigen-specific cytotoxic T cells incorporated in the matrix migrate to the tumor site, where they induce cell death. The integration of the µPOROS matrix with embedded bioprinting opens new avenues for creating complex tissue microenvironments in vitro that may find widespread use in drug discovery, disease modeling, and tissue engineering for therapeutic use.

3D vascularised proximal tubules-on-a-multiplexed chip model for enhanced cell phenotypes

Modelling proximal tubule physiology and pharmacology is essential to understand tubular biology and guide drug discovery. To date, multiple models have been developed; however, their relevance to human disease has yet to be evaluated. Here, we report a 3D vascularized proximal tubule-on-a-multiplexed chip (3DvasPT-MC) device composed of co-localized cylindrical conduits lined with confluent epithelium and endothelium, embedded within a permeable matrix, and independently addressed by a closed-loop perfusion system. Each multiplexed chip contains six 3DvasPT models. We performed RNA-seq and compared the transcriptomic profile of proximal tubule epithelial cells (PTECs) and human glomerular endothelial cells (HGECs) seeded in our 3D vasPT-MCs and on 2D transwell controls with and without a gelatin-fibrin coating. Our results reveal that the transcriptional profile of PTECs is highly dependent on both the matrix and flow, while HGECs exhibit greater phenotypic plasticity and are affected by the matrix, PTECs, and flow. PTECs grown on non-coated Transwells display an enrichment of inflammatory markers, including TNF-a, IL-6, and CXCL6, resembling damaged tubules. However, this inflammatory response is not observed for 3D proximal tubules, which exhibit expression of kidney signature genes, including drug and solute transporters, akin to native tubular tissue. Likewise, the transcriptome of HGEC vessels resembled that of sc-RNAseq from glomerular endothelium when seeded on this matrix and subjected to flow. Our 3D vascularized tubule on chip model has utility for both renal physiology and pharmacology.

Design of medical tympanostomy conduits with selective fluid transport properties

Implantable tubes, shunts, and other medical conduits are crucial for treating a wide range of conditions from ears and eyes to brain and liver but often impose serious risks of device infection, obstruction, migration, unreliable function, and tissue damage. Efforts to alleviate these complications remain at an impasse because of fundamentally conflicting design requirements: Millimeter-scale size is required to minimize invasiveness but exacerbates occlusion and malfunction. Here, we present a rational design strategy that reconciles these trade-offs in an implantable tube that is even smaller than the current standard of care. Using tympanostomy tubes (ear tubes) as an exemplary case, we developed an iterative screening algorithm and show how unique curved lumen geometries of the liquid-infused conduit can be designed to co-optimize drug delivery, effusion drainage, water resistance, and biocontamination/ingrowth prevention in a single subcapillary-length-scale device. Through extensive in vitro studies, we demonstrate that the engineered tubes enabled selective uni- and bidirectional fluid transport; nearly eliminated adhesion and growth of common pathogenic bacteria, blood, and cells; and prevented tissue ingrowth. The engineered tubes also enabled complete eardrum healing and hearing preservation and exhibited more efficient and rapid antibiotic delivery to the middle ear in healthy chinchillas compared with current tympanostomy tubes, without resulting in ototoxicity at up to 24 weeks. The design principle and optimization algorithm presented here may enable tubes to be customized for a wide range of patient needs.

Embedded 3D Printing of Architected Ceramics via Microwave-Activated Polymerization

Light- and ink-based 3D printing methods have vastly expanded the design space and geometric complexity of architected ceramics. However, light-based methods are typically confined to a relatively narrow range of preceramic and particle-laden resins, while ink-based methods are limited in geometric complexity due to layerwise assembly. Here, embedded 3D printing is combined with microwave-activated curing to generate architected ceramics with spatially controlled composition in freeform shapes. Aqueous colloidal inks are printed within a support matrix, rapidly cured via microwave-activated polymerization, and subsequently dried and sintered into dense architectures composed of one or more oxide materials. This integrated manufacturing method opens new avenues for the design and fabrication of complex ceramic architectures with programmed composition, density, and form for myriad applications.

Functional maturation of kidney organoid tubules: PIEZO1-mediated Ca2+ signaling

Kidney organoids cultured on adherent matrices in the presence of superfusate flow generate vascular networks and exhibit more mature podocyte and tubular compartments compared with static controls (Homan KA, Gupta N, Kroll KT, Kolesky DB, Skylar-Scott M, Miyoshi T, Mau D, Valerius MT, Ferrante T, Bonventre JV, Lewis JA, Morizane R. Nat Methods 16: 255-262, 2019; Takasato M, Er PX, Chiu HS, Maier B, Baillie GJ, Ferguson C, Parton RG, Wolvetang EJ, Roost MS, Chuva de Sousa Lopes SM, Little MH. Nature 526: 564-568, 2015.). However, their physiological function has yet to be systematically investigated. Here, we measured mechano-induced changes in intracellular Ca2+ concentration ([Ca2+]i) in tubules isolated from organoids cultured for 21-64 days, microperfused in vitro or affixed to the base of a specimen chamber, and loaded with fura-2 to measure [Ca2+]i. A rapid >2.5-fold increase in [Ca2+]i from a baseline of 195.0 ± 22.1 nM (n = 9; P ≤ 0.001) was observed when microperfused tubules from organoids >40 days in culture were subjected to luminal flow. In contrast, no response was detected in tubules isolated from organoids <30 days in culture. Nonperfused tubules (41 days) subjected to a 10-fold increase in bath flow rate also exhibited a threefold increase in [Ca2+]i from baseline (P < 0.001). Mechanosensitive PIEZO1 channels contribute to the flow-induced [Ca2+]i response in mouse distal tubule (Carrisoza-Gaytan R, Dalghi MG, Apodaca GL, Kleyman TR, Satlin LM. The FASEB J 33: 824.25, 2019.). Immunodetectable apical and basolateral PIEZO1 was identified in tubular structures by 21 days in culture. Basolateral PIEZO1 appeared to be functional as basolateral exposure of nonperfused tubules to the PIEZO1 activator Yoda 1 increased [Ca2+]i (P ≤ 0.001) in segments from organoids cultured for >30 days, with peak [Ca2+]i increasing with advancing days in culture. These results are consistent with a maturational increase in number and/or activity of flow/stretch-sensitive Ca2+ channels, including PIEZO1, in tubules of static organoids in culture.

Barriers to Implementation of Breast Cancer Risk Assessment: The Health Care Team Perspective

PURPOSE

To assess health care professionals' perceptions of barriers to the utilization of breast cancer risk assessment tools in the public health setting through a series of one-on-one interviews with health care team members.

METHODS

We conducted a cross-sectional qualitative study consisting of one-on-one semistructured telephone interviews with health care team members in the public health setting in the state of Tennessee between May 2020 and October 2020. An iterative inductive-deductive approach was used for qualitative analysis of interview data, resulting in the development of a conceptual framework to depict influences of provider behavior in the utilization of breast cancer risk assessment.

RESULTS

A total of 24 interviews were completed, and a framework of influences of provider behavior in the utilization of breast cancer risk assessment was developed. Participants identified barriers to the utilization of breast cancer risk assessment (knowledge and understanding of risk assessment tools, workflow challenges, and availability of personnel); patient-level barriers as perceived by health care team members (psychological, economic, educational, and environmental); and strategies to increase the utilization of breast cancer risk assessment at the provider level (leadership buy-in, training, supportive policies, and incentives) and patient level (improved communication and better understanding of patients' perceived cancer risk and severity of cancer).

CONCLUSIONS

Understanding barriers to implementation of breast cancer risk assessment and strategies to overcome these barriers as perceived by health care team members offers an opportunity to improve implementation of risk assessment and to identify a racially, geographically, and socioeconomically diverse population of young women at high risk for breast cancer.

Black Women's Perspectives on Breast Cancer Risk Assessment

PURPOSE

The aim of this study was to gather the perspectives of Black women on breast cancer risk assessment through a series of one-on-one interviews.

METHODS

The authors conducted a cross-sectional qualitative study consisting of one-on-one semistructured telephone interviews with Black women in Tennessee between September 2020 and November 2020. Guided by the Health Belief Model, qualitative analysis of interview data was performed in an iterative inductive and deductive approach and resulted in the development of a conceptual framework to depict influences on a woman's decision to engage with breast cancer risk assessment.

RESULTS

A total of 37 interviews were completed, and a framework of influences on a woman's decision to engage in breast cancer risk assessment was developed. Study participants identified several emerging themes regarding women's perspectives on breast cancer risk assessment and potential influences on women's decisions to engage with risk assessment. Much of women's decision context was based on risk appraisal (perceived severity of cancer and susceptibility of cancer), emotions (fear and trust), and perceived risks and benefits of having risk assessment. The decision was further influenced by modifiers such as communication, the risk assessment protocol, access to health care, knowledge, and health status. Perceived challenges to follow-up if identified as high risk also influenced women's decisions to pursue risk assessment.

CONCLUSIONS

Black women in this study identified several barriers to engagement with breast cancer risk assessment. Efforts to overcome these barriers and increase the use of breast cancer risk assessment can potentially serve as a catalyst to address existing breast cancer disparities. Continued work is needed to develop patient-centric strategies to overcome identified barriers.

Embedded 3D Printing of Multimaterial Polymer Lattices via Graph-Based Print Path Planning

Recent advances in computational design and 3D printing enable the fabrication of polymer lattices with high strength-to-weight ratio and tailored mechanics. To date, 3D lattices composed of monolithic materials have primarily been constructed due to limitations associated with most commercial 3D printing platforms. Here, freeform fabrication of multi-material polymer lattices via embedded three-dimensional (EMB3D) printing is demonstrated. An algorithm is developed first that generates print paths for each target lattice based on graph theory. The effects of ink rheology on filamentary printing and the effects of the print path on resultant mechanical properties are then investigated. By co-printing multiple materials with different mechanical properties, a broad range of periodic and stochastic lattices with tailored mechanical responses can be realized opening new avenues for constructing architected matter.

Using the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to study adaptations in lung cancer screening delivery in the Veterans Health Administration: a cohort study

BACKGROUND

Lung cancer screening is a complex clinical process that includes identification of eligible individuals, shared decision-making, tobacco cessation, and management of screening results. Adaptations to the delivery process for lung cancer screening in situ are understudied and underreported, with the potential loss of important considerations for improved implementation. The Framework for Reporting Adaptations and Modifications-Expanded (FRAME) allows for a systematic enumeration of adaptations to implementation of evidence-based practices. We applied FRAME to study adaptations in lung cancer screening delivery processes implemented by lung cancer screening programs in a Veterans Health Administration (VHA) Enterprise-Wide Initiative.

METHODS

We prospectively conducted semi-structured interviews at baseline and 1-year intervals with lung cancer screening program navigators at 10 Veterans Affairs Medical Centers (VAMCs) between 2019 and 2021. Using this data, we developed baseline (1st) process maps for each program. In subsequent years (year 1 and year 2), each program navigator reviewed the process maps. Adaptations in screening processes were identified, documented, and mapped to FRAME categories.

RESULTS

We conducted a total of 16 interviews across 10 VHA lung cancer screening programs (n=6 in year 1, n=10 in year 2) to collect adaptations. In year 1 (2020), six programs were operational and eligible. Of these, three reported adaptations to their screening process that were planned or in response to COVID-19. In year 2 (2021), all 10 programs were operational and eligible. Programs reported 14 adaptations in year 2. These adaptations were planned and unplanned and often triggered by increased workload; 57% of year 2 adaptations were related to the identification and eligibility of Veterans and 43% were related to follow-up with Veterans for screening results. Throughout the 2 years, adaptations related to data management and patient tracking occurred in 60% of programs to improve the data collection and tracking of Veterans in the screening process.

CONCLUSIONS

Using FRAME, we found that adaptations occurred primarily in the areas of patient identification and communication of results due to increased workload. These findings highlight navigator time and resource considerations for sustainability and scalability of existing and future lung cancer screening programs as well as potential areas for future intervention.

Goal setting, goal attainment and quality of life of children following selective dorsal rhizotomy

AIM

The aim of this study is to describe the individualized occupational performance issues identified by parents/carers and children prior to selective dorsal rhizotomy (SDR) surgery and analyse change up to 2 years post surgery in goal attainment and quality of life (QoL).

METHOD

The Australian SDR Research Registry (trial registration: ACTRN12618000985280) was used to extract data for individualized goals, goal attainment and QoL based on the Canadian Occupational Performance Measure (COPM) and the Cerebral Palsy Quality of Life Questionnaire for Children (CP QOL-Child parent-proxy) at baseline and 1 and 2 years following SDR. Change in mean scores was analysed using linear mixed models.

RESULTS

Fifty-two children had COPM scores at baseline and 1 and/or 2 years post, of which 28 had two QoL scores. COPM problem areas included leisure (n = 39), productivity (n = 37) and self-care (n = 173). The most common goals were walking (26.1%), participation in physical activities (17.7%) and transitions (14.1%). Mean COPM scores improved significantly between baseline to 1 year and baseline to 2 years (P < 0.001). Mean QoL scores improved between baseline to 1 year for functional QoL domains: participation and physical health (P = 0.003) and pain and impact of disability (P = 0.011).

CONCLUSIONS

Collaborative goal setting is an integral part of family-centred rehabilitation practice. The COPM was an appropriate individualized outcome measure in identifying meaningful goals for our SDR cohort. Results demonstrate improved scores in goal attainment and improvement in functional QoL domains. This paper highlights the need to include outcomes that measure daily life experiences.

Kidney organoids: a pioneering model for kidney diseases

The kidney is a vital organ that regulates the bodily fluid and electrolyte homeostasis via tailored urinary excretion. Kidney injuries that cause severe or progressive chronic kidney disease have driven the growing population of patients with end-stage kidney disease, leading to substantial patient morbidity and mortality. This irreversible kidney damage has also created a huge socioeconomical burden on the healthcare system, highlighting the need for novel translational research models for progressive kidney diseases. Conventional research methods such as in vitro 2D cell culture or animal models do not fully recapitulate complex human kidney diseases. By contrast, directed differentiation of human induced pluripotent stem cells enables in vitro generation of patient-specific 3D kidney organoids, which can be used to model acute or chronic forms of hereditary, developmental, and metabolic kidney diseases. Furthermore, when combined with biofabrication techniques, organoids can be used as building blocks to construct vascularized kidney tissues mimicking their in vivo counterpart. By applying gene editing technology, organoid building blocks may be modified to minimize the process of immune rejection in kidney transplant recipients. In the foreseeable future, the universal kidney organoids derived from HLA-edited/deleted induced pluripotent stem cell (iPSC) lines may enable the supply of bioengineered organotypic kidney structures that are immune-compatible for the majority of the world population. Here, we summarize recent advances in kidney organoid research coupled with novel technologies such as organoids-on-chip and biofabrication of 3D kidney tissues providing convenient platforms for high-throughput drug screening, disease modelling, and therapeutic applications.

Organoid-on-a-chip model of human ARPKD reveals mechanosensing pathomechanisms for drug discovery

Organoids serve as a novel tool for disease modeling in three-dimensional multicellular contexts. Static organoids, however, lack the requisite biophysical microenvironment such as fluid flow, limiting their ability to faithfully recapitulate disease pathology. Here, we unite organoids with organ-on-a-chip technology to unravel disease pathology and develop therapies for autosomal recessive polycystic kidney disease. PKHD1-mutant organoids-on-a-chip are subjected to flow that induces clinically relevant phenotypes of distal nephron dilatation. Transcriptomics discover 229 signal pathways that are not identified by static models. Mechanosensing molecules, RAC1 and FOS, are identified as potential therapeutic targets and validated by patient kidney samples. On the basis of this insight, we tested two U.S. Food and Drug Administration-approved and one investigational new drugs that target RAC1 and FOS in our organoid-on-a-chip model, which suppressed cyst formation. Our observations highlight the vast potential of organoid-on-a-chip models to elucidate complex disease mechanisms for therapeutic testing and discovery.

3D proximal tubule-on-chip model derived from kidney organoids with improved drug uptake

Three-dimensional, organ-on-chip models that recapitulate kidney tissue are needed for drug screening and disease modeling. Here, we report a method for creating a perfusable 3D proximal tubule model composed of epithelial cells isolated from kidney organoids matured under static conditions. These organoid-derived proximal tubule epithelial cells (OPTECs) are seeded in cylindrical channels fully embedded within an extracellular matrix, where they form a confluent monolayer. A second perfusable channel is placed adjacent to each proximal tubule within these reusable multiplexed chips to mimic basolateral drug transport and uptake. Our 3D OPTEC-on-chip model exhibits significant upregulation of organic cation (OCT2) and organic anion (OAT1/3) transporters, which leads to improved drug uptake, compared to control chips based on immortalized proximal tubule epithelial cells. Hence, OPTEC tubules exhibit a higher normalized lactate dehydrogenase (LDH) release, when exposed to known nephrotoxins, cisplatin and aristolochic acid, which are diminished upon adding OCT2 and OAT1/3 transport inhibitors. Our integrated multifluidic platform paves the way for personalized kidney-on-chip models for drug screening and disease modeling.

The Association of Health Care System Resources With Lung Cancer Screening Implementation

Background

The Veterans Health Administration issued policy for lung cancer screening resources at eight Veterans Affairs Medical Centers (VAMCs) in a demonstration project (DP) from 2013 through 2015.

Research Question

Do policies that provide resources increase lung cancer screening rates?

Study Design and Methods

Data from eight DP VAMCs (DP group) and 20 comparable VAMCs (comparison group) were divided into before DP (January 2011-June 2013), DP (July 2013-June 2015), and after DP (July 2015-December 2018) periods. Coprimary outcomes were unique veterans screened per 1,000 eligible per month and those with 1-year (9-15 months) follow-up screening. Eligible veterans were estimated using yearly counts and the percentage of those with eligible smoking histories. Controlled interrupted time series and difference-in-differences analyses were performed.

Results

Of 27,746 veterans screened, the median age was 66.5 years and most were White (77.7%), male (95.6%), and urban dwelling (67.3%). During the DP, the average rate of unique veterans screened at DP VAMCs was 17.7 per 1,000 eligible per month, compared with 0.3 at comparison VAMCs. Adjusted analyses found a higher rate increase at DP VAMCs by 0.93 screening per 1,000 eligible per month (95% CI, 0.25-1.61) during this time, with an average facility-level difference of 17.4 screenings per 1,000 eligible per month (95% CI, 12.6-22.3). Veterans with 1-year follow-up screening also increased more rapidly at DP VAMCs during the DP, by 0.39 screening per 1,000 eligible per month (95% CI, 0.18-0.60), for an average facility-level difference of 7.2 more screenings per 1,000 eligible per month (95% CI, 5.2-9.2). Gains were not maintained after the DP.

Interpretation

In this cohort, provision of resources for lung cancer screening implementation was associated with an increase in veterans screened and those with 1-year follow-up screening. Screening gains associated with the DP were not maintained.

Using the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to study lung cancer screening adaptations in the Veterans Health Administration

Background: Lung cancer screening includes identification of eligible individuals, shared decision-making inclusive of tobacco cessation, and management of screening results. Adaptations to the implemented processes for lung cancer screening in situ are understudied and underreported, with potential loss of important considerations for improved implementation. The Framework for Reporting Adaptations and Modifications-Expanded (FRAME) allows for systematic enumeration of adaptations to implementations of evidence-based practices. We used FRAME to study adaptations in lung cancer screening processes that were implemented as part of a Veterans Health Administration (VHA) Enterprise-Wide Initiative. Methods: We conducted semi-structured interviews at baseline and 1-year intervals with lung cancer screening program navigators at 10 Veterans Affairs Medical Centers (VAMC) between 2019-2021. Using this data, we developed baseline (1st) process maps for each program. In subsequent years (year 1 and year 2), each program navigator reviewed the process maps. Adaptations in screening processes were identified, recorded and mapped to FRAME categories. Results: A total of 14 program navigators across 10 VHA lung cancer screening programs participated in 20 interviews. In year 1 (2019-2020), seven programs were operational and of these, three reported adaptations to their screening process that were either planned and in response to COVID-19. In year 2 (2020-2021), all 10 programs were operational. Programs reported 14 adaptations in year 2. These adaptations were both planned and unplanned and often triggered by increased workload; 57% of year 2 adaptations were related to identification and eligibility of Veterans and 43% were related to follow-up with Veterans for screening results. Throughout the 2 years, adaptations related to data management and patient tracking occurred in 6 of 10 programs to improve the data collection and tracking of Veterans in the screening process. Conclusions: Using FRAME, we found that adaptations occurred throughout the lung cancer screening process but primarily in the areas of patient identification and communication of results. These findings highlight considerations for lung cancer screening implementation and potential areas for future intervention.

Programmed shape-morphing into complex target shapes using architected dielectric elastomer actuators

Dielectric elastomer actuators (DEAs) are among the fastest and most energy-efficient, shape-morphing materials. To date, their shapes have been controlled using patterned electrodes or stiffening elements. While their actuated shapes can be analyzed for prescribed configurations of electrodes or stiffening elements (the forward problem), the design of DEAs that morph into target shapes (the inverse problem) has not been fully addressed. Here, we report a simple analytical solution for the inverse design and fabrication of programmable shape-morphing DEAs. To realize the target shape, two mechanisms are combined to locally control the actuation magnitude and direction by patterning the number of local active layers and stiff rings of varying shapes, respectively. Our combined design and fabrication strategy enables the creation of complex DEA architectures that shape-morph into simple target shapes, for instance, those with zero, positive, and negative Gaussian curvatures as well as complex shapes, such as a face.

Programming Cellular Alignment in Engineered Cardiac Tissue via Bioprinting Anisotropic Organ Building Blocks

The ability to replicate the 3D myocardial architecture found in human hearts is a grand challenge. Here, the fabrication of aligned cardiac tissues via bioprinting anisotropic organ building blocks (aOBBs) composed of human induced pluripotent stem cell derived cardiomyocytes (hiPSC-CMs) is reported. A bioink composed of contractile cardiac aOBBs is first generated and aligned cardiac tissue sheets with linear, spiral, and chevron features are printed. Next, aligned cardiac macrofilaments are printed, whose contractile force and conduction velocity increase over time and exceed the performance of spheroid-based cardiac tissues. Finally, the ability to spatially control the magnitude and direction of contractile force by printing cardiac sheets with different aOBB alignment is highlighted. This research opens new avenues to generating functional cardiac tissue with high cell density and complex cellular alignment.

Characterization of avoidable hospital admissions in patients with lung cancer in the immunotherapy and targeted therapy era

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Background: Hospitalization is the second largest contributor of cancer care spending, and over 50% of lung cancer patients are admitted to the hospital while receiving treatment. Patients who avoid hospital admission have reduced health care costs with a higher quality of life. This is the first study that characterizes the risk factors and outcomes for avoidable hospital admissions of lung cancer patients. It is the first to examine the extent to which hospitalizations from immunotherapy and targeted therapy could be avoided. Methods: A retrospective chart review of lung cancer patients admitted January 2018 through December 2018 was conducted. Demographics, disease and treatment history, admission characteristics, outcomes, and end-of-life care utilization were recorded. Following a multidisciplinary consensus review, hospitalizations were determined “avoidable” or “unavoidable.” Generalized estimating equation logistic regression models analyzed risks and outcomes associated with avoidable admissions. Kaplan-Meier estimators examined the median overall survival (mOS) between patients with and without avoidable admissions. Results: We evaluated 319 admissions from 188 patients with a median age of 66 and 16%/84% SCLC/NSCLC. Cancer-related symptoms accounted for 66% of hospitalizations; pneumonia and other infections comprised 34%, and 32% were due to cancer-related pain, vomiting, or failure to thrive (FTT). Common causes of unavoidable hospitalizations were unexpected disease progression causing symptoms, COPD exacerbation, and infection. Of the 47 hospitalizations identified as avoidable (15%), the mOS was 1.6 months; the mOS of unavoidable hospitalizations was 9.7 months (HR 2.07; 95% CI 1.34-3.19; p < 0.001). Significant reasons for avoidable admissions included cancer-related pain (p = 0.021), hypervolemia (p = 0.033), patient desire to initiate hospice services (p = 0.011), and errors in medication reconciliation or distribution (p < 0.001). Errors in medication management caused 26% of the avoidable hospitalizations. Of admissions in patients on immunotherapy (n = 102) or targeted therapy (n = 44), 9% were due to adverse effects of treatment. Patients on immunotherapy and targeted therapy were not more likely to have avoidable hospitalizations compared to patients not on the treatments (p = 0.323 and 0.133, respectively). Patients with avoidable admissions were 3.02 times more likely to enroll in hospice within 30 days of hospitalization compared to unavoidable admissions (95% CI 1.54-5.92; p = 0.001). Conclusions: Patients on immunotherapy or targeted therapy were only rarely admitted due to side effects of treatment. Hospitalizations may be avoided with more aggressive outpatient symptom management, earlier hospice discussion with at-risk patients, and outpatient pharmacist review of medications following hospital discharge.

Biomanufacturing human tissues via organ building blocks

The construction of human organs on demand remains a tantalizing vision to solve the organ donor shortage. Yet, engineering tissues that recapitulate the cellular and architectural complexity of native organs is a grand challenge. The use of organ building blocks (OBBs) composed of multicellular spheroids, organoids, and assembloids offers an important pathway for creating organ-specific tissues with the desired cellular-to-tissue-level organization. Here, we review the differentiation, maturation, and 3D assembly of OBBs into functional human tissues and, ultimately, organs for therapeutic repair and replacement. We also highlight future challenges and areas of opportunity for this nascent field.

Biomimetic and Biologically Compliant Soft Architectures via 3D and 4D Assembly Methods: A Perspective

Recent progress in soft material chemistry and enabling methods of 3D and 4D fabrication-emerging programmable material designs and associated assembly methods for the construction of complex functional structures-is highlighted. The underlying advances in this science allow the creation of soft material architectures with properties and shapes that programmably vary with time. The ability to control composition from the molecular to the macroscale is highlighted-most notably through examples that focus on biomimetic and biologically compliant soft materials. Such advances, when coupled with the ability to program material structure and properties across multiple scales via microfabrication, 3D printing, or other assembly techniques, give rise to responsive (4D) architectures. The challenges and prospects for progress in this emerging field in terms of its capacities for integrating chemistry, form, and function are described in the context of exemplary soft material systems demonstrating important but heretofore difficult-to-realize biomimetic and biologically compliant behaviors.

Orthogonally induced differentiation of stem cells for the programmatic patterning of vascularized organoids and bioprinted tissues

The generation of organoids and tissues with programmable cellular complexity, architecture and function would benefit from the simultaneous differentiation of human induced pluripotent stem cells (hiPSCs) into divergent cell types. Yet differentiation protocols for the overexpression of specific transcription factors typically produce a single cell type. Here we show that patterned organoids and bioprinted tissues with controlled composition and organization can be generated by simultaneously co-differentiating hiPSCs into distinct cell types via the forced overexpression of transcription factors, independently of culture-media composition. Specifically, we used such orthogonally induced differentiation to generate endothelial cells and neurons from hiPSCs in a one-pot system containing either neural or endothelial stem-cell-specifying media, and to produce vascularized and patterned cortical organoids within days by aggregating inducible-transcription-factor and wild-type hiPSCs into randomly pooled or multicore-shell embryoid bodies. Moreover, by leveraging multimaterial bioprinting of hiPSC inks without extracellular matrix, we generated patterned neural tissues with layered regions composed of neural stem cells, endothelium and neurons. Orthogonally induced differentiation of stem cells may facilitate the fabrication of engineered tissues for biomedical applications.

Photoswitchable Covalent Adaptive Networks Based on Thiol-Ene Elastomers

Covalent adaptive networks combine the advantages of cross-linked elastomers and dynamic bonding in a single system. In this work, we demonstrate a simple one-pot method to prepare thiol-ene elastomers that exhibit reversible photoinduced switching from an elastomeric gel to fluid state. This behavior can be generalized to thiol-ene cross-linked elastomers composed of different backbone chemistries (e.g., polydimethylsiloxane, polyethylene glycol, and polyurethane) and vinyl groups (e.g., allyl, vinyl ether, and acrylate). Photoswitching from the gel to fluid state occurs in seconds upon exposure to UV light and can be repeated over at least 180 cycles. These thiol-ene elastomers also exhibit the ability to heal, remold, and serve as reversible adhesives.

Association of Rurality With Annual Repeat Lung Cancer Screening in the Veterans Health Administration

PURPOSE

Lung cancer causes the largest number of cancer-related deaths in the United States. Lung cancer incidence rates, mortality rates, and rates of advanced stage disease are higher among those who live in rural areas. Known disparities in lung cancer outcomes between rural and nonrural populations may be in part because of barriers faced by rural populations. The authors tested the hypothesis that among Veterans who receive initial lung cancer screening, rural Veterans would be less likely to complete annual repeat screening than nonrural Veterans.

METHODS

A retrospective cohort study was conducted of 10 Veterans Affairs medical centers from 2015 to 2019. Rural and nonrural Veterans undergoing lung cancer screening were identified. Rural status was defined using the rural-urban commuting area codes. The primary outcome was annual repeat lung cancer screening in the 9- to 15-month window (primary analysis) and 31-day to 18-month window (sensitivity analysis) after the first documented lung cancer screening. To examine rurality as a predictor of annual repeat lung cancer screening, multivariable logistic regression models were used.

RESULTS

In the final analytic sample of 11,402 Veterans, annual repeat lung cancer screening occurred in 27.7% of rural Veterans (641 of 2,316) and 31.8% of nonrural Veterans (2,891 of 9,086) (adjusted odds ratio: 0.86; 95% confidence interval: 0.73-1.03). Similar results were seen in the sensitivity analysis, with 41.6% of rural Veterans (963 of 2,316) versus 45.2% of nonrural Veterans (4,110 of 9,086) (adjusted odds ratio: 0.88; 95% confidence interval: 0.73-1.04) having annual repeat screening in the expanded 31-day to 18-month window.

CONCLUSIONS

Among a national cohort of Veterans, rural residence was associated with numerically lower odds of annual repeat lung cancer screening than nonrural residence. Continued, intentional outreach efforts to increase annual repeat lung cancer screening among rural Veterans may offer an opportunity to decrease deaths from lung cancer.

Innervated, Self-Sensing Liquid Crystal Elastomer Actuators with Closed Loop Control

The programmable assembly of innervated LCE actuators (iLCEs) with prescribed contractile actuation, self-sensing, and closed loop control via core-shell 3D printing is reported. This extrusion-based direct ink writing method enables coaxial filamentary features composed of pure LM core surrounded by an LCE shell, whose director is aligned along the print path. Specifically, the thermal response of the iLCE fiber-type actuators is programmed, measured, and modeled during Joule heating, including quantifying the concomitant changes in fiber length and resistance that arise during simultaneous heating and self-sensing. Due to their reversible, high-energy actuation and their resistive feedback, it is also demonstrated that iLCEs can be regulated with closed loop control even when perturbed with large bias loads. Finally, iLCE architectures capable of programmed, self-sensing 3D shape change with closed loop control are fabricated.

Organizational Readiness for Lung Cancer Screening: A Cross-Sectional Evaluation at a Veterans Affairs Medical Center

OBJECTIVES

Lung cancer has the highest cancer-related mortality in the United States and among Veterans. Screening of high-risk individuals with low-dose CT (LDCT) can improve survival through detection of early-stage lung cancer. Organizational factors that aid or impede implementation of this evidence-based practice in diverse populations are not well described. We evaluated organizational readiness for change and change valence (belief that change is beneficial and valuable) for implementation of LDCT screening.

METHODS

We performed a cross-sectional survey of providers, staff, and administrators in radiology and primary care at a single Veterans Affairs Medical Center. Survey measures included Shea's validated Organizational Readiness for Implementing Change (ORIC) scale and Shea's 10 items to assess change valence. ORIC and change valence were scored on a scale from 1 to 7 (higher scores representing higher readiness for change or valence). Multivariable linear regressions were conducted to determine predictors of ORIC and change valence.

RESULTS

Of 523 employees contacted, 282 completed survey items (53.9% overall response rate). Higher ORIC scores were associated with radiology versus primary care (mean 5.48, SD 1.42 versus 5.07, SD 1.22, β = 0.37, P = .039). Self-identified leaders in lung cancer screening had both higher ORIC (5.56, SD 1.39 versus 5.11, SD 1.26, β = 0.43, P = .050) and change valence scores (5.89, SD 1.21 versus 5.36, SD 1.19, β = 0.51, P = .012).

DISCUSSION

Radiology health professionals have higher levels of readiness for change for implementation of LDCT screening than those in primary care. Understanding health professionals' behavioral determinants for change can inform future lung cancer screening implementation strategies.

Protocol to evaluate an enterprise-wide initiative to increase access to lung cancer screening in the Veterans Health Administration

INTRODUCTION

The Veterans Affairs Partnership to increase Access to Lung Screening (VA-PALS) is an enterprise-wide initiative to implement lung cancer screening programs at VA medical centers (VAMCs). VA-PALS will be using implementation strategies that include program navigators to coordinate screening activities, trainings for navigators and radiologists, an open-source software management system, tools to standardize low-dose computed tomography image quality, and access to a support network. VAMCs can utilize strategies according to their local needs. In this protocol, we describe the planned program evaluation for the initial 10 VAMCs participating in VA-PALS.

MATERIALS AND METHODS

The implementation of programs will be evaluated using the Consolidated Framework for Implementation Research to ensure broad contextual guidance. Program evaluation measures have been developed using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework. Adaptations of screening processes will be assessed using the Framework for Reporting Adaptations and Modifications to Evidence Based Interventions. Measures collected will reflect the inner settings, estimate and describe the population reached, adoption by providers, implementation of the programs, report clinical outcomes and maintenance of programs. Analyses will include descriptive statistics and regression to evaluate predictors and assess implementation over time.

DISCUSSION

This theory-based protocol will evaluate the implementation of lung cancer screening programs across the Veterans Health Administration using scientific frameworks. The findings will inform plans to expand the VA-PALS initiative beyond the original sites and can guide implementation of lung cancer screening programs more broadly.

Hierarchically Porous Ceramics via Direct Writing of Binary Colloidal Gel Foams

Hierarchically porous ceramics with a high specific surface area and interconnected porosity may find potential application as particulate filters, catalyst supports, and battery electrodes. We report the design and programmable assembly of cellular ceramic architectures with controlled pore size, volume, and interconnectivity across multiple length scales via direct foam writing. Specifically, binary colloidal gel foams are created that contain entrained bubbles stabilized by the irreversible adsorption of attractive alumina and carbon (porogen) particles at their air-water interfaces. Composition effects on foam ink rheology and printing behavior are investigated. Sintered ceramic foams exhibited specific permeabilities that increased from 2 × 10^-13 to 1 × 10^-12 m² and compressive strengths that decreased from 40 to 1 MPa, respectively, with increasing specific interfacial area. Using direct foam writing, 3D ceramic lattices composed of open-cell foam struts were fabricated with tailored mechanical properties and interconnected porosity across multiple length scales.

Evidence-based smoking cessation treatment: a comparison by healthcare system

BACKGROUND

A systems-level approach to smoking cessation treatment may optimize healthcare provider adherence to guidelines. Institutions such as the Veterans Health Administration (VHA) are unique in their systematic approach, but comparisons of provider behavior in different healthcare systems are limited.

METHODS

We surveyed general medicine providers and specialists in a large academic health center (AHC) and its affiliated VHA in the Mid-South in 2017 to determine the cross-sectional association of healthcare system in which the provider practiced (exposure: AHC versus VHA) with self-reported provision of evidence-based smoking cessation treatment (delivery of counseling plus smoking cessation medication or referral) at least once in the past 12 months (composite outcome). Multivariable logistic regression with adjustment for specialty was performed in 2017-2019.

RESULTS

Of 625 healthcare providers surveyed, 407 (65%) responded, and 366 (59%) were analyzed. Most respondents practiced at the AHC (273[75%] vs VHA 93[25%]) and were general internists (215[59%]); pulmonologists (39[11%]); hematologists/oncologists (69[19%]); and gynecologists (43[12%]). Most respondents (328[90%]) reported the primary outcome. The adjusted odds of evidence-based smoking cessation treatment were higher among VHA vs. AHC healthcare providers (aOR = 4.3; 95% CI 1.3-14.4; p = .02). Health systems differed by provision of individual treatment components, including smoking cessation medication use (98% VHA vs. 90% AHC, p = 0.02) and referral to smoking cessation services (91% VHA vs. 65% AHC p = 0.001).

CONCLUSIONS

VHA healthcare providers were significantly more likely to provide evidence-based smoking cessation treatment compared to AHC healthcare providers. Healthcare systems' prioritization of and investment in smoking cessation treatment is critical to improving providers' adherence to guidelines.

Low Provider Knowledge Is Associated With Less Evidence-Based Lung Cancer Screening

BACKGROUND

Despite widespread recommendation and supportive policies, screening with low-dose CT (LDCT) is incompletely implemented in the US healthcare system. Low provider knowledge of the lung cancer screening (LCS) guidelines represents a potential barrier to implementation. Therefore, we tested the hypothesis that low provider knowledge of guidelines is associated with less provider-reported screening with LDCT.

PATIENTS AND METHODS

A cross-sectional survey was performed in a large academic medical center and affiliated Veterans Health Administration in the Mid-South United States that comprises hospital and community-based practices. Participants included general medicine providers and specialists who treat patients aged >50 years. The primary exposure was LCS guideline knowledge (US Preventive Services Task Force/Centers for Medicare & Medicaid Services). High knowledge was defined as identifying 3 major screening eligibility criteria (55 years as initial age of screening eligibility, smoking status as current or former smoker, and smoking history of ≥30 pack-years), and low knowledge was defined as not identifying these 3 criteria. The primary outcome was self-reported LDCT order/referral within the past year, and the secondary outcome was screening chest radiograph. Multivariable logistic regression evaluated the adjusted odds ratio (aOR) of screening by knowledge.

RESULTS

Of 625 providers recruited, 407 (65%) responded, and 378 (60.5%) were analyzed. Overall, 233 providers (62%) demonstrated low LCS knowledge, and 224 (59%) reported ordering/referring for LDCT. The aOR of ordering/referring LDCT was less among providers with low knowledge (0.41; 95% CI, 0.24-0.71) than among those with high knowledge. More providers with low knowledge reported ordering screening chest radiographs (aOR, 2.7; 95% CI, 1.4-5.0) within the past year.

CONCLUSIONS

Referring provider knowledge of LCS guidelines is low and directly proportional to the ordering rate for LDCT in an at-risk US population. Strategies to advance evidence-based LCS should incorporate provider education and system-level interventions to address gaps in provider knowledge.

National Lung Cancer Screening Utilization Trends in the Veterans Health Administration

Background

Many Veterans are high risk for lung cancer. Low-dose computed tomography (LDCT) is an effective strategy for lung cancer early detection in a high-risk population. Our objective was to describe and compare annual and geographic utilization trends for LDCT screening in the Veteran's Health Administration (VHA).

Methods

A national retrospective cohort of screened Veterans from January 1, 2011 to May 31, 2018 was used to calculate annual and regional rates of initial LDCT utilization per 1000 eligible Veterans. We identified Veterans with a first LDCT exam using common procedure terminology codes G0297 or 71250 and described as "lung cancer screening," "screening," or "LCS." The number of screen-eligible Veterans per year was calculated as unique Veterans aged 55 to 80 years seen at a Veterans Affairs medical center (VAMC) in that year, multiplied by 32% (estimated proportion with eligible smoking history). We present 95% confidence intervals (CI) for rates.

Results

Screened Veterans had a mean age of 66.1 years (standard deviation [SD] = 5.6); 95.5% male; 77.4% Caucasian. There were 119 300 LDCT exams, of which 80 819 (67.7%) were initial. Nationally, initial screens increased from 0 (95% CI = 0.00 to 0.00) in 2011 to 29.6 (95% CI = 29.26 to 29.88) scans per 1000 eligible Veterans in 2018 (P_trend < .001). Initial screens increased over time within all geographic regions, most prominently in northeastern and Florida VAMCs.

Conclusion

VHA LDCT utilization increased from 2011 to 2018. However, overall utilization remained low. Future interventions are needed to increase lung cancer screening utilization among eligible Veterans.

Effect of luminal flow on doming of mpkCCD cells in a 3D perfusable kidney cortical collecting duct model

The cortical collecting duct (CCD) of the mammalian kidney plays a major role in the maintenance of total body electrolyte, acid/base, and fluid homeostasis by tubular reabsorption and excretion. The mammalian CCD is heterogeneous, composed of Na⁺-absorbing principal cells (PCs) and acid-base-transporting intercalated cells (ICs). Perturbations in luminal flow rate alter hydrodynamic forces to which these cells in the cylindrical tubules are exposed. However, most studies of tubular ion transport have been performed in cell monolayers grown on or epithelial sheets affixed to a flat support, since analysis of transepithelial transport in native tubules by in vitro microperfusion requires considerable expertise. Here, we report on the generation and characterization of an in vitro, perfusable three-dimensional kidney CCD model (3D CCD), in which immortalized mouse PC-like mpkCCD cells are seeded within a cylindrical channel embedded within an engineered extracellular matrix and subjected to luminal fluid flow. We find that a tight epithelial barrier composed of differentiated and polarized PCs forms within 1 wk. Immunofluorescence microscopy reveals the apical epithelial Na⁺ channel ENaC and basolateral Na⁺/K⁺-ATPase. On cessation of luminal flow, benzamil-inhibitable cell doming is observed within these 3D CCDs consistent with the presence of ENaC-mediated Na⁺ absorption. Our 3D CCD provides a geometrically and microphysiologically relevant platform for studying the development and physiology of renal tubule segments.

3D Printable and Reconfigurable Liquid Crystal Elastomers with Light-Induced Shape Memory via Dynamic Bond Exchange

3D printable and reconfigurable liquid crystal elastomers (LCEs) that reversibly shape-morph when cycled above and below their nematic-to-isotropic transition temperature (T_NI ) are created, whose actuated shape can be locked-in via high-temperature UV exposure. By synthesizing LCE-based inks with light-triggerable dynamic bonds, printing can be harnessed to locally program their director alignment and UV light can be used to enable controlled network reconfiguration without requiring an imposed mechanical field. Using this integrated approach, 3D LCEs are constructed in both monolithic and heterogenous layouts that exhibit complex shape changes, and whose transformed shapes could be locked-in on demand.

Voxelated soft matter via multimaterial multinozzle 3D printing

There is growing interest in voxelated matter that is designed and fabricated voxel by voxel^1-4. Currently, inkjet-based three-dimensional (3D) printing is the only widely adopted method that is capable of creating 3D voxelated materials with high precision^1-4, but the physics of droplet formation requires the use of low-viscosity inks to ensure successful printing⁵. By contrast, direct ink writing, an extrusion-based 3D printing method, is capable of patterning a much broader range of materials^6-13. However, it is difficult to generate multimaterial voxelated matter by extruding monolithic cylindrical filaments in a layer-by-layer manner. Here we report the design and fabrication of voxelated soft matter using multimaterial multinozzle 3D (MM3D) printing, in which the composition, function and structure of the materials are programmed at the voxel scale. Our MM3D printheads exploit the diode-like behaviour that arises when multiple viscoelastic materials converge at a junction to enable seamless, high-frequency switching between up to eight different materials to create voxels with a volume approaching that of the nozzle diameter cubed. As exemplars, we fabricate a Miura origami pattern¹⁴ and a millipede-like soft robot that locomotes by co-printing multiple epoxy and silicone elastomer inks of stiffness varying by several orders of magnitude. Our method substantially broadens the palette of voxelated materials that can be designed and manufactured in complex motifs.

Architected Polymer Foams via Direct Bubble Writing

Polymer foams are cellular solids composed of solid and gas phases, whose mechanical, thermal, and acoustic properties are determined by the composition, volume fraction, and connectivity of both phases. A new high-throughput additive manufacturing method, referred to as direct bubble writing, for creating polymer foams with locally programmed bubble size, volume fraction, and connectivity is reported. Direct bubble writing relies on rapid generation and patterning of liquid shell-gas core droplets produced using a core-shell nozzle. The printed polymer foams are able to retain their overall shape, since the outer shell of these bubble droplets consist of a low-viscosity monomer that is rapidly polymerized during the printing process. The transition between open- and closed-cell foams is independently controlled by the gas used, while the foam can be tailored on-the-fly by adjusting the gas pressure used to produce the bubble droplets. As exemplars, homogeneous and graded polymer foams in several motifs, including 3D lattices, shells, and out-of-plane pillars are fabricated. Conductive composite foams with controlled stiffness for use as soft pressure sensors are also produced.

Association of a Lung Screening Program Coordinator With Adherence to Annual CT Lung Screening at a Large Academic Institution

BACKGROUND

Detection of early-stage lung cancer improves during subsequent rounds of screening with low-dose CT and potentially leads to saving lives with curative treatment. Therefore, adherence to annual lung screening is important. We hypothesized that adherence to annual screening would increase after hiring of a dedicated program coordinator.

METHODS

We performed a mixed-methods study in a retrospective cohort of patients who underwent lung screening at our academic institution between January 1, 2014, and March 31, 2018. Patients with baseline lung screening examinations performed between January 1, 2014, and September 30, 2016, with Lung CT Screening Reporting & Data System 1 or 2 scores and a 12-month follow-up recommendation were included. We tracked patient adherence to annual follow-up lung screening over time (before and after hiring of a program coordinator) and conducted a cross-sectional survey of patients nonadherent to annual follow-up to elicit quantitative and qualitative feedback.

RESULTS

Of the 319 patients who completed baseline lung screening with normal results, 189 (59%) were adherent to annual follow-up recommendations and 130 (41%) were nonadherent. Patient adherence varied over time: 21.7% adherence (10 of 46) before hiring a program coordinator and 65.6% adherence (179 of 273) after the program coordinator's hire date. Patients reported the following reasons for nonadherence to annual lung screening: lack of transportation, financial cost, lack of communication by physicians, and lack of current symptoms.

CONCLUSIONS

Adherence to annual lung screening after normal baseline studies increased significantly over time. Hiring a full-time program coordinator was likely associated with this increased in adherence.

Biomanufacturing of organ-specific tissues with high cellular density and embedded vascular channels

Engineering organ-specific tissues for therapeutic applications is a grand challenge, requiring the fabrication and maintenance of densely cellular constructs composed of ~10⁸ cells/ml. Organ building blocks (OBBs) composed of patient-specific-induced pluripotent stem cell-derived organoids offer a pathway to achieving tissues with the requisite cellular density, microarchitecture, and function. However, to date, scant attention has been devoted to their assembly into 3D tissue constructs. Here, we report a biomanufacturing method for assembling hundreds of thousands of these OBBs into living matrices with high cellular density into which perfusable vascular channels are introduced via embedded three-dimensional bioprinting. The OBB matrices exhibit the desired self-healing, viscoplastic behavior required for sacrificial writing into functional tissue (SWIFT). As an exemplar, we created a perfusable cardiac tissue that fuses and beats synchronously over a 7-day period. Our SWIFT biomanufacturing method enables the rapid assembly of perfusable patient- and organ-specific tissues at therapeutic scales.

Untethered soft robotic matter with passive control of shape morphing and propulsion

There is growing interest in creating untethered soft robotic matter that can repeatedly shape-morph and self-propel in response to external stimuli. Toward this goal, we printed soft robotic matter composed of liquid crystal elastomer (LCE) bilayers with orthogonal director alignment and different nematic-to-isotropic transition temperatures (T _NI) to form active hinges that interconnect polymeric tiles. When heated above their respective actuation temperatures, the printed LCE hinges exhibit a large, reversible bending response. Their actuation response is programmed by varying their chemistry and printed architecture. Through an integrated design and additive manufacturing approach, we created passively controlled, untethered soft robotic matter that adopts task-specific configurations on demand, including a self-twisting origami polyhedron that exhibits three stable configurations and a "rollbot" that assembles into a pentagonal prism and self-rolls in programmed responses to thermal stimuli.

National lung cancer screening utilization trends in the Veterans Health Administration

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Background: Low-dose CT (LDCT) is an effective means for early lung cancer detection, but is often underutilized. An estimated 900,000 Veterans are eligible for lung cancer screening. We are the first to describe national lung cancer screening utilization trends in the Veterans Health Administration (VHA). Methods: We assembled a retrospective cohort of patients within the VHA’s Observational Medical Outcomes Partnership (OMOP) Common Data Model who underwent lung cancer screening. LDCT scans with Common Procedure Terminology (CPT) codes G0297 or 71250 from January 1, 2011 to May 31, 2018 were eligible for inclusion. We further selected exams described as “lung cancer screening,” “screening,” or “LCS.” We used descriptive statistics with frequencies and medians to calculate the total exams per Veteran and evaluate utilization trends over time and by region. Results: At initial screening, Veterans had a median age of 66 (IQR 61, 70), 95% were male, 76% Caucasian. From January 1, 2011 to May 31, 2018, 75 VHA facilities performed 129,363 LDCT exams for lung cancer screening; 87,950 (68%) initial and 41,413 (32%) subsequent exams. Screening has increased over time (226 in 2011-2012; 7848 in 2013-2014; 41,225 in 2015-2016; 80,064 in 2017 until May 31, 2018) in all regions. Providers in primary care/internal medicine (56%), family medicine (16%), pulmonology (6%), oncology (0.3%), other specialties (21%) ordered screening exams. Conclusions: Lung cancer screening with low-dose CT within the VHA increased over time within all geographic regions. Future strategies aimed at the Veteran, provider, and healthcare system levels are needed to increase lung cancer screening utilization among eligible Veterans. [Table: see text]

Perovskite nanowire-block copolymer composites with digitally programmable polarization anisotropy

One-dimensional (1D) nanomaterials with highly anisotropic optoelectronic properties are key components in energy harvesting, flexible electronics, and biomedical imaging devices. 3D patterning methods that precisely assemble nanowires with locally controlled composition and orientation would enable new optoelectronic device designs. As an exemplar, we have created and 3D-printed nanocomposite inks composed of brightly emitting colloidal cesium lead halide perovskite (CsPbX₃, X = Cl, Br, and I) nanowires suspended in a polystyrene-polyisoprene-polystyrene block copolymer matrix. The nanowire alignment is defined by the programmed print path, resulting in optical nanocomposites that exhibit highly polarized absorption and emission properties. Several devices have been produced to highlight the versatility of this method, including optical storage, encryption, sensing, and full-color displays.