People with epilepsy (PWE) have an increased suicide prevalence. This study aimed to identify the risk factors for suicidal tendency among PWE in West China. A nested case–control study was designed in a cohort of patients with epilepsy (n = 2087). In total, 28 variates were calculated. In the univariate analysis, unemployment, low income, seizure frequency, seizure-free time, infectious or structural etiology, levetiracetam or phenobarbital use, anxiety, depression, and stigma were associated with suicidal tendency. A multivariate analysis indicated that unemployment , levetiracetam use , depression , and stigma  were independently associated with suicidal tendency. Conditional inference tree analysis indicated that SSCI and C-NDDI-E scores could effectively identify patients with suicidal tendency. Thus, this study suggests that unemployment, levetiracetam use, depression, and stigma are independent risk factors for suicidal tendency in PWE in China. It is associated with social distress, vulnerability, and reduced quality of life (QOL)2. In particular, comorbidities are associated with poor outcomes4, such as depression, which is the most common psychiatric comorbidity. Although suicide is more commonly reported among patients with antiepileptic drug (AED)-resistant epilepsy (25–55%)5, it can also occur in those with well-controlled seizures6. Suicide is also a cause of premature mortality in people with epilepsy (PWE)9. The proportion of death from suicide among PWE is 2.06–4.6 times higher than in the general population12.Epilepsy is a major neurological disorder that affects approximately nine million people in China14. The AEDs and psychiatric disorders have a larger influence on suicide than other risk factors. The use of new AEDs, including levetiracetam, topiramate, and vigabatrin, leads to a three-fold increase in the risk of suicide-related behavior when compared with no AED use15. The combination of three or more drugs is also associated with an increased risk of suicide16.The risk factors for suicide include being female, unemployment, low income, high seizure frequency, some AEDs, seizure-preceding auras, temporal epilepsy, psychiatric disorders, and antidepressant drugs17, as well as sleep quality18. Recent studies indicated that epilepsy, psychiatric disorders, and suicide may be pathophysiologically linked20. The risk of suicide was 2.6 times higher among PWE with psychiatric disorders, including major depression, anxiety, and psychosis, compared to those without mental illnesses21. Although many factors are associated with suicide in PWE, psychiatric illnesses and side effects of drugs are regarded as the most significant22.Other studies also found a connection between suicide and stigma23. Considering the heavy burden and the serious consequences suicidality has on society, it is necessary and of interest to identify the clinical correlation of suicidal tendency in this population reveal the associated factors that may eventually lead to better control and prevention of suicide in PWE. Thus, we conducted this study using the database of the West China Hospital epilepsy center26.To our knowledge, only one study has examined the factors associated with suicide among PWE in mainland ChinaOur study was based on a database established in October 2014. The database enrolled adult patients with epilepsy who visited the West China Hospital for consultation between October 2014 and April 2019. Patients in the database were followed-up each year to update their clinical information. Their diagnosis of epilepsy was made by at least two board-certified professional neurologists. The inclusion criteria were as follows: (1) diagnosis of epilepsy according to the International League Against Epilepsy (ILAE) criteria, (2) willingness to provide information regarding the disease and their social situation, and (3) sufficient reading ability to understand the questionnaire.Patients meeting any of the following criteria were excluded from this study: (1) under 18 years and (2) severe coexisting physical or psychiatric illnesses such as cancer, strokes, dementia, schizophrenia, or intellectual disability.During the 2018 and 2019 follow-up, we evaluated all patients in the database using the Chinese version of the Neurological Disorders Depression Inventory for Epilepsy (C-NDDI-E), seven-item anxiety scale (GAD-7), Stigma Scale for Chronic Illnesses 8-item version (SSCI-8), and the Mini International Neuropsychiatric Interview (MINI). Once a moderate or high risk of suicide  was identified in a person with epilepsy, we randomly selected three patients without suicide risk from the study cohort, ensuring matching age (within 2 years) and gender.For patients with a high risk of suicide, mental health support was offered by an experienced specialist. This study was approved by the Ethics Committee of West China Hospital of Sichuan University .All information was collected by experienced neurologists via face-to-face or telephonic interviews. Clinical factors including demographic information, age at disease onset, classification of seizure, surgery history, etiological factors, AED usage, electroencephalography, and imaging (magnetic resonance imaging/computed tomography) results of patients were all recorded in a standardized form by certified staff.27. In this study, the risk of suicide was measured using the Suicidality Module of the MINI, which divides the risk of suicide into low (1–5), moderate (6–9), and high (≥ 10) risk. The validity of this scale (Chinese version 5.0.0) has been established in the Chinese population28. In this study, a high risk of suicide was defined as a MINI score ≥ 6. Notably, the MINI score indicates a low risk if there was no suicidal intention or ideation in the last month even if the patient had attempted suicide previously.The MINI is a short structured diagnostic interview for psychiatric disordered classified using DSM-IV and ICD-1029. It is a six-item self-administered instrument with a total score ranging from 6 to 24. Each item is assigned a score of 1–4 . The optimal cut-off score for the C-NDDI-E was ≥ 1330.The C-NDDI-E is a reliable and valid screening tool for the detection of major depression in Chinese patients with epilepsy31. As each of the seven items is scored from 0 to 3, the GAD-7 score ranges from 0 to 21. Cut-off points of 5, 10, and 15 on the GAD-7 are interpreted as representing mild, moderate, and severe levels of anxiety, respectively31. The validity of this scale has been verified in the Chinese population32.The GAD-7 is used to screen for generalized anxiety disorder and assess its severity in clinical practice and research33. The raw summed score range is 8–40 for this scale. The higher the score of a patient, the higher their level of stigma experienced. The validity of this scale has been established in the Chinese population34.The SSCI-8 is a short form assessing enacted and internalized stigma for patients with neurological disordersDescriptive statistics of the patients and controls were conducted. Quantitative data were expressed as mean ± standard deviation, and qualitative data were summarized as proportions. Demographic and clinical data between the two groups were compared. Student’s t-test was used for continuous variables, and the chi-squared test was used for categorical variables.p-value < 0.2 in the univariate analysis, and (2) clinical factors from a previous study that were associated with suicide . All analyses were conducted using SPSS 15.0 . All tests were two-tailed, and p-values < 0.05 were considered statistically significant.To identify potential correlations between clinical or sociodemographic variables and suicidal tendency, a univariate analysis and conditional multiple logistic regression were performed. Crude odds ratios (ORs) were calculated based on the univariate analysis. The conditional multiple logistic regression model included (1) variables that yielded a www.r-project.org) with the rattle package 35, a conditional inference decision tree was employed to recognize patients with suicidal tendency. To identify the many possible factors associated with suicidal tendency in PWE, the decision tree grows as more and more splits are defined, until it cannot find any predictor that leads to significantly different child nodes. The final sets of trees indicate the most effective associated factors.Using R .A total of 42 people had suicidal tendencies (according to the MINI score), of which 40 had clear suicidal thoughts in the last month, 8 had attempted suicide, and 13 had suicide plans. Among the 8 patients who had attempted suicide, 6 had clear suicidal thoughts in the last month. The baseline demographic findings are shown in Table The demographic and sociological associations are presented in Table The clinical characteristics of the patients are shown in Table The use of antiepileptic drugs for the two groups is compared in Table According to the questionnaire scores, presence of high anxiety , depression , and stigma  were all associated with suicidal tendency in PWE. This is depicted in Table Multivariate logistic regression analysis 36, which is consistent with other studies23.Compared to other areas in China, the southwestern region is a relatively underdeveloped area. To date, many studies have examined the risk factors that are associated with suicidal tendency among PWE in developed areas or countries, but few studies have enrolled populations of underdeveloped areas. Our study focuses on various association factors in this population, which may differ from those in developed regions. We found a 2.3% the incidence of suicide while the rates of suicide differ across other regions. For instance, in Korea, suicidality was present in 208 (30.4%) of the 684 PWE37. To improve patients’ life span and QOL, an optimal interaction between PWE and the social environment is needed. This interaction could be obtained through long-term health-related support. Past research shows that PWE have a higher economic burden compared to healthy people in China38. Considering the risk of suicide in unemployed and low-income patients, we should consider their economic burden during diagnosis and treatment. When necessary, healthcare professionals could also refer these patients to employment counseling. In addition, unemployment is a risk factor in the general population. In a Hong Kong study39, the OR for unemployment was 9.40 (95% CI 4.94–17.88), while in our study, it was 5.11 (95% CI 2.27–11.50). As a result, since there is no statistical difference, we cannot conclude that unemployment is a greater risk for suicide for PWE than it is for healthy people.Our results demonstrate that unemployment and low income play significant roles in the assessment of suicidal tendency in PWE. A previous study suggested a strong relationship between socioeconomic factors or poverty and suicide attempts in patients with chronic disorders40. Both personal and external factors may have a negative impact on interpersonal relationships, including lower rates of schooling, employment, leisure activities, marriage, driving, and other types of social interaction, which may result in social isolation, discrimination, and misconception. These may have adverse effects on QOL41. It is well known that epilepsy is associated with high levels of stigma40. Epilepsy is commonly misunderstood as a disorder that represents a form of “insanity” or “madness,” thus harming the reputation of PWE44. It is necessary to improve public health education and reduce discrimination against these patients. Meanwhile, medical professionals should employ more screenings for stigma during the diagnosis and treatment of suicidal ideation.In our study, depression and anxiety were highly related to suicidal behavior, which is consistent with the findings of previous studies. Meanwhile, our study showed that stigma also plays an important role. A study reported that stigmatization is correlated with low self-esteem and self-competence, a lowered sense of capability, an increased sense of vulnerability, increased rates of both depression and anxiety symptoms, and, ultimately, decreased life satisfaction22. A previous study15 found that the use of newer AEDs , which have a high potential for causing depression12, is associated with a threefold increased risk of self-harm/suicidal behavior when compared to other treatment options. In our study, levetiracetam was associated with a 3.76-fold (95%CI 1.73–8.14) of suicidal tendency, which is similar to the value reported by Andersohn et al.15. Phenobarbital was also associated with a higher suicide risk in the current study. Interestingly, phenobarbital has not previously been reported to be associated with an increased risk of suicide among PWE, whereas in the current study, this risk was 5.54-fold (95%CI 1.26–24.28). This finding is important because phenobarbital is still more widely used in rural China45 than in developed countries. Therefore, healthcare professionals in developing countries should be encouraged to closely assess and monitor the patients using phenobarbital for possible suicidal tendencies.In the present study, using levetiracetam was independently associated with suicidal tendency, which is consistent with the results of published studies46, infectious and structural etiologies were associated with suicidal tendency in PWE, while previous studies were based on the 1989 classification48.In our study, which is based on the 2017 classification of ILAEThe results of the conditional inference tree analysis suggest that SSCI and C-NDDI-E scores are useful for the identification of PWE with suicidal tendency. They indicate that if SSCI and C-NDDI-E scores are relatively high, then healthcare professionals should pay more attention to the suicide risks in such patients; for them, healthcare professionals should avoid prescribing AEDs that may increase the risk of suicide. In a future study, we will combine SSCI and C-NDDI-E scores to assess suicidal tendency because of the result of conditional inference tree analysis.The present study has some limitations: (1) As a single-center study, patients were recruited at a tertiary referral center. Recruitment from such a setting may have introduced some selection bias toward more severe cases of epilepsy. In the future, we intend to collaborate with many epilepsy centers in other areas to avoid this possible bias. (2) The sample of patients with suicidal behavior was too small for further investigation. Although there were more than 1800 participants in the sample pool, less than 50 participants had a high risk of suicide. Owing to the limited sample size, the confidence intervals were wider. The model conditional inference tree analysis might be less effective. For future research, a longitudinal design is needed to identify changes in suicidal behaviors that may occur at different stages of epilepsy.This study suggests that unemployment, levetiracetam use, depression, and stigma are independent risk factors for suicidal tendency in PWE in China.The study was approved by the Ethics Committee of the West China Hospital of Sichuan University as part of a large outpatient registration and follow-up project . All patients provided written informed consent prior to their participation. This study was conducted in accordance with the ethical guidelines of the Declaration of Helsinki.


Sinonasal Undifferentiated carcinoma (SNUC) comprises 3% of the head and neck tumors, including metastatic neoplasms. Herein we report the case of a 60-year-old male who was brought dead to our institute with previous records of a contrast-enhanced CT scan of the brain and MRI with evidence of tumor in the maxillary sinus with intracranial extensions. The histopathological examination of the mass in the maxillary sinus proved to be SNUC with metastases to the brain, lungs, and around the aorta. These tumors are undifferentiated and are distinct from other poorly differentiated tumors in deriving their origin from the Schneiderian epithelium. The aggressive nature of the tumor renders the prognosis quite dismal. SNUCs need to be early recognized and distinguished from other poorly differentiated carcinomas with the help of immunohistochemistry. The patient was seeking treatment for his illness, as documented by accompanying relatives. Further detailed clinical history was not available, as the case was brought for medicolegal autopsy by police personnel due to sudden death.The patient’s available records included a contrast-enhanced CT scan of the head taken 3 months back, showing two hyperdense, and non-enhancing brain parenchymal lesions in the left frontal and occipital lobes, measuring 11×10 mm and 10×10 mm, suggestive of neoplastic origin. The brain MRI showed multiple heterogeneous signal lesions with peripheral enhancement and perilesional edema involving the right capsular region, left frontal lobe, left occipital lobe, and the right cerebellum. The lesions were considered as possible metastasis. The paranasal sinus showed a large heterogeneous signal mass lesion involving the right maxillary sinus with an invasion of the right zygomatic bone, arch, and right sphenoidal vein with intracranial extension, causing compression over the right anterior temporal lobeAn autopsy was performed.The external examination revealed a body of a well-nourished man with a swelling over the zygomatic and maxillary area. The examination of the skull revealed a pinkish-white soft mass over the anterior and middle cranial fossa. The mass involved the right sphenoidal bone and extended into the right maxillary sinus and zygomatic bone. The left lung weighed 672 g, and the right lung weighed 780 g . On cut section, reddish-brown fluid oozed out. There was no evidence of thrombus or consolidation. The thoracic cavity was unremarkable.In the mediastinum, a hard mass was found surrounding the aortic arch. The Pathology Department received a soft mass from the maxillary sinus, the whole brain, the whole dissected heart, a fragment of the abdominal aorta, part of the aorta with the hard mediastinal mass, both lungs, two pieces of the kidneys, pieces of the pancreas, spleen, and liver.The soft mass from the maxillary sinus measured 5.7×3.5×2.5 cm and weighed 27.4 gm. The cut section was grayish-white .The brain weighed 1308 g after autopsy and 1364.5 g post-fixation (reference range:1179-1621 g). The external surface showed normal gyri and sulci. No herniation was seen. On the coronal slicing, a lesion, measuring 1×0.8 cm, was seen in the insular cortex at the junction of the right cerebral hemisphere’s grey and white matters. On the left hemisphere, a lesion measuring 1×0.8×0.8 cm was seen at the grey and white matter junction A. The leThe representative fragment of the aorta with an attached hard mass measured 10.1×6.7×41 cm. The aortic arch measured 4.5 cm in length .The luminal diameter at one end was 2 cm, and at the other end was 1.5 cm. The whole hard mediastinal mass weighed 178.1 g. The cut section of the mass showed a whitish growth with central blackish discoloration abutting the wall of the arch of the aorta, which was thickened and showed atheromatous plaque.Both lungs’ gross examination showed irregular and whitish nodules, which at the cut surface exhibited a central blackish discoloration measuring 2×2.5×4.2 cm and 4×3 cm, respectively.The representative samples of the kidneys, pancreas, spleen, and liver did not show any gross evidence of tumor involvement.Sections from the mass in the maxillary sinus showed a tumor arranged in the acinar and pseudo-alveolar pattern. The individual cells showed conspicuous to inconspicuous nucleoli with mild to moderate nuclear pleomorphism and abundant eosinophilic cytoplasm along with areas of necrosis. Increased mitotic count was observed. Occasional nuclear grooves and bizarre forms were identified. Numerous entrapped nerves were seen 4B. ThereSections from the cerebrum and cerebellum showed metastatic deposits A.Sections from the heart showed atheromatous changes in the main coronary artery and left anterior descending artery with 50% occlusion at a distance of 3 cm from the origin. However, no myocardial infarction was noted, ruling out an ischemic myocardial disease as a possibility of the immediate cause of death. The wall of the abdominal aorta showed atheromatous plaque.Sections from both lungs’ lesions B and theThe sections from the soft mass subjected to immunohistochemistry (IHC) reacted positively for CK 8/18 A and higThe post mortem diagnosis was of Sinonasal Undifferentiated Carcinoma arising from maxillary sinus with metastasis to brain, soft tissue around the aorta, and bilateral lungs.Sinonasal Undifferentiated carcinoma (SNUC) is a rare and highly aggressive tumor with an uncertain histogenesis and etiology.SNUCs are more commonly seen in males and are more prevalent in the elderly with the mean age ranging between55-60 years of age.The most common symptoms are nasal obstruction, periorbital pain and swelling, proptosis, diplopia, and cranial nerve palsies.On light microscopy, the tumor is generally arranged in sheets, nests, and trabecular patterns with small to medium polygonal cells with moderate amphophilic cytoplasm, vesicular to hyperchromatic nucleus and inconspicuous to prominent nucleoli. Brisk mitotic activity is noted along with prominent areas of necrosis and angiolymphatic invasion, which were observed in our case.1SNUCs are immunoreactive for CK7, CK8/18, CK19, and epithelial membrane antigen (EMA) and negative for synaptophysin, chromogranin, vimentin, and CD45, these reactions are necessary to rule out all the other poorly differentiated malignancies of the head and neck region.,The differential diagnosis of SNUCs includes (i) nasopharyngeal carcinoma; (ii) esthesioneuroblastoma; (iii) neuroendocrine carcinoma; (iv) rhabdomyosarcoma; (v) lymphoepithelioma; (vi) lymphoma; (vii) melanoma; and (viii) poorly differentiated adenoid cystic carcinoma. Therefore, immunohistochemistry is fundamental for the precise diagnosis.Our case was immunoreactive for CK 8/18, high molecular weight cytokeratin and focally for p16and negative for vimentin, desmin, p40, synaptophysin, Human Papilloma Virus (HPV), Leucocyte Common Antigen, and HMB45, thus ruling out the possibility of a sarcoma, squamous cell carcinoma, and melanocytic tumour.Moreover, to rule out SNUC-like neoplasms, immunohistochemistry for INI-1 and IDH-2 was also performed. INI-1 was found retained ruling out the possibility of SMARCB1 deficient tumors, and IDH-2 mutant was positive reinforcing the diagnosis of SNUC. Hence, a diagnosis of SNUC was rendered. The differential diagnosis of SNUC-like tumors has been enumerated in the ,The treatment protocol advised in the available literature is radical curative resection followed by adjuvant chemo-radiation.Unfortunately, in our case, the patient succumbed to the disease with widespread metastases due to a probable diagnosis delay. As we could not elicit a detailed clinical history, we cannot comment upon the disease’s course.The purpose of this case report is to emphasize the highly infiltrating nature of this tumor and the various implications it may have due to widespread metastasis if left untreated. Ignored cases might lead to the infiltration and failure of multiple organ systems to such an extent that the tumor itself may not remain the only cause of the patient’s suffering or death.


To identify overload and associated factors among caregivers of adult patients receiving palliative care.Descriptive, quantitative, and cross-sectional study addressing 40 adults under palliative care and their respective caregivers enrolled in the Home Care System in Ribeirão Preto, Brazil. Data concerning the patients included demographic profile and Mini-Mental State Examination. A form was used to collect the caregivers’ demographic data along with the Zarit Burden Interview Scale, Self-Reporting Questionnaire, Beck Depression Inventory, and Coping Strategies Inventory.p=0.002), number of days spent with care (p=0.004), and depression (p<0.001) with overload.Regarding the patients, 84.2% were women, 52.6% were over 80, 65.8% had no partner, and 76.3% presented cognitive impairment. The caregivers were mostly women (84.5%), aged 56.67 years old on average, were the patients’ children (42.5%); had no partner (55%), and lived with the patient (77.5%). The mean score obtained in the burden scale was 28.78 points, 32.5% had stress, and 42.5% depression. Regarding coping strategies, the ones most frequently used were positive reappraisal (12.8), withdrawal (10.2), and problem solution (9.7). A positive and statistically significant correlation was found between time spent with care (days and hours) and escape/avoidance with overload. Linear regression analysis revealed an association between being a woman (Being a woman, spending more days providing care, and depressive symptoms were associated with caregiver overload. An estimated 40 million people require palliative care (PC) every year; 78% of these individuals live in developing countries. With epidemiological and demographic changes, Non-communicable Chronic Diseases (NCDs) are the leading cause of a condition in which PC is required that exposes the finitude of life while promoting autonomy during the dying process. PC is deAn informal caregiver is generally an individual who provides unpaid care and possibly experiences restrictions arising from the responsibility of providing care, which may lead to a condition called caregiver overload. CaregiveA patient receiving PC demands time from caregivers, who need to adapt their lives to the patient’s routine and needs, which may cause physical changes (back pain and loss of sleep), compromise domestic chores, lead to psychological (depression and stress) and social changes  causing caregivers to experience health problems. The incrDescriptive, quantitative, and cross-sectional study conducted in the Home Care Service of the City Health Department in Ribeirão Preto, Brazil. The study’s population was recruited from the Home Care Service database, which included 150 patients, 96 of whom were receiving palliative care. Fifteen of these patients refused to participate, 12 had moved to another city, 15 had died, eight changed their phone numbers, and six were hospitalized at the time of data collection, so that 40 patients and their respective caregivers, enrolled in the Home Care Service from January to April 2019 composed the final sample. Inclusion criteria used for adult/elderly patients were: being enrolled in the Home Care Service, 18 years old or older, capable of answering the instruments or being accompanied by an informal caregiver, and receiving PC. Inclusion criteria for caregivers were: being the primary caregiver and aged 18 years old or older.A meeting was scheduled at the patient’s home, and undergraduate and graduate students previously trained by the study’s coordinator held a 30-minute interview to collect data from both participants, using the following instruments:- Sociodemographic profile: information regarding the patients’ sex , age (complete years), marital status (with or without a partner), education (years of schooling), number of children, number of people living with the adult-elderly patient, and the patient’s and family’s monthly income.- Mini-Mental State Examination (MMSE): instrument addressing cognitive function. It was translated and validated to Portuguese, and its - Sociodemographic profile: addressing information such as sex , age (full years), marital status (with or without a partner), kinship, how long the caregiver has provided care to the patient, how many hours and days are spent in the care provided to the patient, and knowledge regarding the patient’s disease.- Zarit Burden Interview Scale: translated and validated for the Brazilian culture, this sca- Self-Reporting Questionnaire (SRQ): developed and validated in Brazil, the obj- Beck Depression Inventory: developed by the American Psychiatric Association to detect depressive symptoms and later validated to Portuguese. It cons- Coping Strategies Inventory (CSI): validated to Portuguese it encom® was used to tabulate data, which were later imported to the IBM SPSS, version 25. Descriptive statistics were used along with central tendency (mean and median) and dispersion measures (standard deviation) for quantitative variables, and frequency and percentages were used for categorical variables. Additionally, the Spearman’s correlation was used to compare the means between Coping strategies and caregiver overload. The Mann-Whitney test was used to identify associations between the different factors with overload. Linear regression was used in the final analysis, with caregiver overload being the outcome variable. The significance level was established at p<0.05 with a 95% confidence interval for all the statistical tests.Microsoft ExcelThe study was approved by the City Health Department at Ribeirão Preto and the Institutional Review Board at the University of São Paulo at Ribeirão Preto, College of Nursing (No. CAE 90111018.8.0000.5393). All the participants (patients and caregivers) signed two copies of free and informed consent forms and kept one copy.Most of the 40 patients participating in the study were women (84.2%), aged over 80 (52.6%) with a mean of 76.5±13.8, had no partners (65.8%), lived with other family members (68.4%), and presented cognitive deficit (76.3%). The patients lived with 3.11 people on average, had 5.5 children, and a monthly income of R$1,850.63 (1 U$=R$ 4.06), while the family’s income was 3.75 times the minimum wage. Regarding the caregivers, most were women (84.5%), aged 56.7 years old on average. The caregivers were the patients’ children (42.5%), did not have a partner (55%), lived with the patient (77.5%), and had a monthly income of R$1,299.02 on average. The caregivers had provided care for an average of 82.66 months and spent 6.73 days and 20.62 hours/day providing care to patients.Regarding caregiver overload, a mean of 28.78 points was found. Additionally, 32.5% of the caregivers experienced stress, and 42.5% presented some depressive symptoms. Regarding coping strategies, the caregivers most frequently used positive reappraisal (mean=12.88), withdrawal (10.25), and problem-solving (9.78) .Analysis of the correlation between the patients’ and caregivers’ variables, relationship with care, and coping strategies with overload scale, revealed that the time spent providing care and the number of days and hours providing care presented a low positive correlation. The escape/avoidance strategy presented a statistically significant moderate positive correlation .Some variables were associated with the score obtained in caregiver overload, such as the patient’s marital status (patients without a partner lead to more significant overload), caregiver’s sex (women experience more overload than men), and caregivers experiencing stress or depressive symptoms .The model’s goodness of fit revealed that the variables being a woman, number of days providing care to patients, and depressive symptoms are factors related with caregiver overload .The progression of the illness of a patient under PC, even with long-term treatment for chronic disease, requires health care for life. Thus, the family of a patient receiving PC needs to adapt its daily routine to meet this patient's health needs, especially the primary caregivers who provide care for most of the time. This study shows that most caregivers were women, had children, had no partner, lived with the elderly individual, and obtained a mean overload score of 28.78 points. Additionally, caregiver overload was associated with being a female caregiver, the number of days providing care, and depressive symptoms.,3,The demographic profile of caregivers is similar to that presented by other studies addressing this topic,,15 in whThe mean score obtained in the Zarit Burden Interview Scale was 28.7Caregiver overload cause changes in the relationship established with the family, at work, income, leisure, and in the caregiver’s mental and physical health. This oveOverload was correlated with the escape/avoidance strategy. In one study conducted with 225 caregivers, the authors identified that the three most frequently used strategies were self-control, positive reappraisal, and planned problem-solving, which alleviated caregiver overload and improved the care plan of patients undergoing hemodialysis, while confrontation and escape/avoidance were the least used strategies. The escaData analysis showed an association between caregiver stress and overload. The long-term disease of a patient receiving care at home is a situation that leads to stress, threatening an individual’s personal, familiar, and social balance. Lack of balance leads caregivers to experience problems, as they no longer have a problem-solving mechanism, experiencing disorganization and negative feelings such as fear, guilt, and anxiety.Women also experienced more intense overload compared to male caregivers. The hypothesis is that family care dynamics changed after women entered the job market. In addition to working outside the home, women assume the role of mothers, wives, and homemakers; that is, women assume an excess of responsibilities, which, combined with the caregiver role, can lead to overload.et al.(,An association was found between the number of days providing care and caregiver overload. Delalibera et al. report tet al.,8 Additiet al.,The relationship between depression and caregiver overload may be influenced by various sociocultural factors such as sex, age, race, lack of social support, which may influence how caregivers respond to overload, harming This study has two limitations: 1. The participants were recruited from a database provided by a Home Care Service, which presented inconsistent data, hindering the identification and retrieval of information; 2. The sample's small size may be related to the population's particular characteristics so that inferences concerning this study's results cannot be generalized to other populations. Data analysis revealed that the factors associated with caregiver overload were being a woman, number of days providing care to patients, and depressive symptoms.This study contributes to scientific knowledge concerning overload among the caregivers of patients receiving palliative care and monitored by a Home Care Service at home. Attention should be paid to the cultural, historical context in which this responsibility is assigned to female caregivers, to the fact that the mental health of caregivers is often neglected, and on how nurses have aided these caregivers to manage their health. Therefore, future studies are recommended to address a larger sample of caregivers of patients under palliative care and implement follow-up to devise strategies, care plans, and interventions intended to decrease caregiver overload and later become part of palliative care protocols. It is crucial that nursing workers are attentive to the health needs of patients and caregivers, heeding the needs of caregivers and enabling them to provide quality and effective care to patients receiving PC.


Background: The diagnosis of lymphoma requires surgical specimens to perform morphological evaluation, immunohistochemical and molecular analyses. Ultrasound-guided fine needle aspiration may represent an appropriate first approach to obtain cytological samples in impalpable lesions and/or in patients unsuitable for surgical procedures. Although cytology has intrinsic limitations, the cell block method may increase the possibility of achieving an accurate diagnosis. Methods: We retrospectively selected a total of 47 ultrasound-guided fine needle aspiration and drainage samples taken from patients with effusion and deep-seated lesions which are clinically suspicious in terms of malignancy. Results: In 27 cases, both cell block and conventional cytology were performed: 21/27 cell blocks were adequate for the diagnosis of lymphoma and suitable for immunocytochemistry and molecular analyses vs. 12/20 samples to which only conventional cytology was applied. Moreover, in five patients we were able to make a diagnosis of Hodgkin lymphoma with the cell block (CB) technique. Conclusions: Contrary to conventional cytology, the cell block method may allow immunocytochemistry and molecular studies providing useful information for the diagnosis and subtypization of lymphoma in patients unsuitable for surgical procedure or with deep-seated lesions or extra-nodal diseases; additionally, it is a daily, simple and helpful approach. Moreover, we describe the usefulness of cell blocks in the diagnosis of Hodgkin lymphoma. Lymphoma is a malignant neoplasm of the hematopoietic tissue. It includes different non-Hodgkin lymphoma (NHL) and Hodgkin lymphoma (HL) subtypes. According to the current World Health Organization (WHO) classification, an integrated diagnostic system based on morphological pattern recognition, immunophenotyping and molecular analyses is recommended in clinical practice to establish a correct diagnosis, provide prognostic information and choose the most appropriate and effective therapy ,2. SurgiWe compared the final diagnoses in a retrospective series of 47 samples obtained from 36 US-FNAs, 3 EBUS-FNAs and 8 drainages in patients with effusion, deep-seated lesions or extra-nodal diseases with a clinical suspicion of lymphoma or carcinoma. We evaluated the possibility to achieve a conclusive diagnosis of NHL by CB, with the aid of immunophenotyping and FISH, and a first diagnosis of HL.We searched in our electronic data system all consecutive FNAs  and drainages performed on patients with deep-seated lesions or extra-nodal lesions with clinical suspicion of lymphoma (first diagnosis and/or relapsing disease) and with a final diagnosis of lymphoma from October 2013 to November 2019. Patient demographics, radiological findings, procedure details as well as follow-up data were collected from our Electronic Hospital Database (SISWEB). A total of 36 US-FNAs, 3 EBUS-FNAs and 8 drainages procedures were selected, and 22 patients were men and 25 women. The mean age of patients was 61 (range 18–93) .http://www.wma.net/en/30publications/10policies/b3/). This was a retrospective study and no extra tests were conducted on the patients’ material.All information regarding human material was managed using anonymous numerical codes, and all samples were handled in compliance with the Helsinki Declaration  scan, EBUS-FNA was performed using an ultrasound bronchoscope  in combination with an ultrasound processor  under local anesthesia and conscious sedation. The ultrasound bronchoscope was passed through the mouth to the trachea A; then tThoracentesis and paracentesis were performed with the introduction of a needle into the thoracic or abdominal cavity to extract the liquid content; the needle was connected to a small tube through which it was possible to collect the fluid.There were no complications after EBUS-FNA, US-FNA and drainage procedures.The CC procedure consisted of cytological samples processed by smear and cytocentrifuge, according to the agreed international procedure.Specifically, smears were prepared directly by the clinician immediately after US-FNA and placed in an 95° alcohol fixative solution. Finally, they were stained with the Papanicolau method inside the laboratory.For drainage, the cytocentrifuge method was used. In detail, drainage samples were received in a 50% alcoholic solution and precentrifugated in falcons at 2500 rpm for 5 min; after the elimination of the supernatant, the cell button was resuspended, vortexed and put in four 0.5 mL/cuvettes for each sample for a second cytocentrifugation at 800 rpm for 4 min. Finally, re-fixation with cytofix for 60 min was performed, and the four cellular spots were stained with May–Grünwald–Giemsa, Papanicolau and hematoxylin and eosin (H&E) (2 sections) stains, respectively.Samples obtained from EBUS-FNA and fixed in a 10% neutral buffered formalin solution A were auSamples obtained from drainages were centrifuged at 2500 rpm for 5 min. If the residual cellularity was scant, samples were placed in a calcium chloride/plasma solution; if the residual cellularity was in a greater amount, samples were fixated in 10% buffered formalin.To avoid preanalytic artifacts that could affect morphological interpretation, immunocytochemistry and FISH analyses, an internal agreement among pathologists, technicians and interventional operators has been made on the timing of sample collections and sample deliveries to the pathology laboratory. In particular, all the FNAs were conducted in the morning and taken to the laboratory in the early afternoon; the samples were processed in the same evening when they were obtained, in a time-fixation range of 6–12 h. This caution avoids the hyperfixation of the sample.Our internal protocol of CB preparation was improved in March 2014 with the help of an expert cytopreparatory technician (GB).Immunocytochemical analysis was possible only on CBs, on three micron-thick unstained sections. An initial panel of antibodies was used in malignant cases to differentiate lymphoma from carcinoma and sarcoma, namely pan-cytokeratin , CD45/LCA , CD20 , CD79α , CD3 , EMA , CD30 , CD15  and PAX5 . In case a diagnosis of B-lineage NHL had been advanced, a second lineage of immunocytochemical markers was performed, including BCL2 , BCL6 , CD10 , CD5 , CyclinD1 , MUM1/IRF4  and Mib1 . All staining procedures were carried out on Autostainer Link48 , according to the manufacturer’s instructions and in the presence of appropriate controls. Neither morphology nor first- nor second-line immunocytochemical analyses aroused suspicion of T-lineage NHL.nuclei. In normal intact cells, two separate red and two separate green individual signals were visible, whereas a reciprocal translocation t generated two fused red/green signals accompanied by one red and one green signal . To investigate a possible diagnosis of high-grade lymphoma with double or triple translocations (HG lymphoma Double Hit/Triple Hit according to 2017 WHO) in two cases (cases 21 and 33), FISH analysis using MYC , BCL2 , and BCL6 , were performed according to the manufacturer’s instructions. Each assay is a pool of probes hybridizing upstream (green probes) and downstream (red) of the breakpoint of the gene. The MYC, BCL2, and BCL6 normal signals are a yellow signal from fused red and green fluorescence. FISH pattern hybridization was analyzed according to the manufacturer’s instructions.FISH was needed to subclassify 4 cases of NHL according to the WHO 2017 classification. In two cases, to establish an unequivocal diagnosis of Mantle Cell lymphoma (MCL) (cases 20 and 47), FISH was performed, according to the manufacturer’s instructions , using Vysis LSI IGH/CCND1 XT Dual Color Dual Fusion Probes, a pool of probes hybridizing to chromosome 14q32 (IGH Spectrum Green) and chromosome 11q13 (CCND1 Spectrum Orange) , which is able to detect the translocation t. The hybridized slides were viewed on an Olympus IX-50 epifluorescence microscope (Olympus) equipped with a cooled CCD camera (Princeton Instruments) at 100× magnification with oil immersion. The GenASIs software  was used to generate multicolor images. t translocation was assessed by scoring all evaluable Forty-seven patients were identified as follows: for 20 patients, only CC (smears or cytocentrifugate) was performed; for 15 patients, only the CB procedure was carried out; in 12 patients, the specimens were treated to obtain both CCs and CBs. In these 12 patients, a definitive diagnosis of lymphoma could be performed on CBs. Targeted lesions were distributed as follows: mediastinum (10), pleural/peritoneal effusions, (8), deep soft tissues (10), deep lymph-nodes (11), liver (2), lung (2) and spleen (4) .Of 47 specimens, 33 (70%) were adequate for a diagnosis of lymphoma, in particular 12 (60%) of the 20 CCs and 21 (78%) of the 27 CBs .For samples analyzed only by CC, only the diagnosis of lymphoma could be suggested, and the need for integration with clinical data and CF was underlined in the cytological report. Eight out of 47 cases were inadequate for a definitive diagnosis because of scant cellularity: in particular, 5 (25%) of the 20 CCs and 3 (11%) of the 27 CBs. Six cases were diagnosed as suspicious for lymphoma, specifically 3 (15%) of the 20 CCs and 3 (10%) of the 27 CBs. Within CB samples, 5 were morphologically compatible with HL, classical type; therefore, immunocytochemistry was performed. In three cases, immunocytochemistry confirmed the diagnosis: large mononucleated cells and Reed–Sternberg cells were strongly positive for CD30 and CD15, faintly positive for PAX5 and negative for CD45, CD3 and CD20  and, in one case, the diagnosis was confirmed from a subsequent biopsy (case 30). No conclusive diagnosis of HL was made on CC samples. In 16/21 CBs, we were able to perform immunocytochemistry to subclassify NHL according to the 2017 WHO classification; in four cases, FISH was also performed and allowed to confirm MCL  which were tuberculosis-suspicious, but the final diagnosis was HL, classical type, as previously reported . FifteenTherefore, in nine cases, surgery for carcinoma was ruled out and further hematological investigations were scheduled.Of five patients with a final diagnosis of HL, classical type, on CBs, three cases received a diagnosis of lymphoma that was not clinically advanced, and two of these patients were suspected to have carcinoma and one patient suspected to have tuberculosis on the basis of the radiological findings. In the remaining two cases presenting with mediastinic mass, an epithelial neoplasm arising in the follow-up for HL and a differential diagnosis between lymphoma and thymoma were advanced, respectively.p-values < 0.05 were considered statistically significant.The two different methods (CCs and CBs) were compared using the Pearson Chi-square test or Fisher’s exact test, when indicated, and p = 0.187) when we compared the “compatible” with “inadequate” and “suspicious” results (The percentage of “compatible” results observed in CBs method (78%) was higher than in CCs method (60%) but not statistically significant  and in extra-nodal visceral localization of lymphoma, FNA is the only feasible procedure .The aim of CB is to better preserve tissue architecture and morphological details to distinguish malignant from non-malignant cells as well as to obtain adequate material for immunocytochemical and molecular analyses . The advIn our retrospective series, we were able to make a definitive diagnosis of lymphoma in 21/27 CB cases (78%) compared to 12/20 CC cases (60%). In CB samples, we were able to perform a definitive diagnosis of HL, classical type, in three cases; a strongly suspected diagnosis of HL, classical type, in two cases, and, in 16 NHL cases, to carry out ancillary studies to subclassify them according to the WHO classification. Conversely, in CC samples, the diagnosis of NHL needed integration with CF and no diagnosis of HL was possible. In about half of CB cases, lymphoma was not clinically suspected and CB allowed us to perform ancillary studies and guide clinical management.Regarding the diagnosis of HL on cytological samples, very few studies have been described in the literature.The diagnostic efficacy of CC in HL diagnosis was described in a series of patients with a proven histopathological diagnosis of classical HL  and clasRecently, the limited sensitivity of CB in a retrospective series of patients with superficial nodal localization of NLPHL variant has been described . DespiteNevertheless, it is imperative to look for alternative methods to surgical biopsies in “selected clinical practice” and improve our diagnostic ability, trying to better deal with available cytological samples.In our series, CB was very useful in establishing the first diagnosis of HL, especially in patients whose clinical presentation and radiological findings were not predictive of a diagnosis of lymphoma.In detail, case number 19 was a 69-year-old woman presenting with asthenia and fever. A CT scan showed multiple, confluent mediastinal lymphoadenopathies, up to 9 cm in maximum diameter, which is suspicious in terms of carcinoma. CB was obtained from EBUS-FNA and a HL diagnosis was possible with the aid of immunocytochemistry. Because of the strong clinical suspicion of carcinoma, a mediastinal biopsy was immediately performed, and a diagnosis of classic HL was confirmed.Case number 24, previously described , was an Case number 25 is a 41-year-old man diagnosed with carcinosarcoma of the glands. Synchronously, the CT scan documented an intraosseous pelvic mass and confluent lymphoadenopathies with a diameter greater than 11 cm located in the mediastinum, extending to pulmonary hilum and supraclavear region and involving large caliber vessels. The clinical-radiological hypothesis was metastases from the penile carcinosarcoma. CB was obtained from EBUS-FNA on mediastinal mass, and a diagnosis of HL was made. After appropriate therapy for HL and penile carcinosarcoma, the patient is alive and in a good health condition.Case number 30 is a 30-year-old man, previously affected by adult-onset Still’s disease, presenting with asthenia and fever. The CT scan showed an antero-superior mediastinal mass of 9 cm in maximum diameter, clinically suspicious for thymoma/lymphoma. US-FNA was performed and CC and CBs were obtained. Based on morphology (immunocytochemistry was not useful because of low cellularity), the findings were strongly suspicious for HL. Surgery for thymoma was not performed, and a mediastinal biopsy was required, confirming the diagnosis of HL.As can be guessed, these four patients were not suitable for surgical procedure, and FNA provided cytological samples which CB made adequate for the diagnosis of HL. These unexpected diagnoses allowed the clinicians to choose the best medical management for the patients and, in case 30, to switch the therapy from surgical to medical.Finally, case number 2 was a 19-year-old woman with a diagnosis of nodal classic HL from 2014. After disease progression, with evidence of mediastinal and abdominal lymphadenopathies and multiple nodularities in the pulmonary parenchyma, US-FNA of the mediastinal lymph nodes was performed. A diagnosis of strong suspicion of HL on CBs was made, although immunocytochemistry was not informative and our diagnosis was sufficient to schedule an adequate therapy.We are aware that the retrospective nature of this study is a major limitation and that the small number of cases does not allow an adequate statistical analysis. However, we would suggest that in selected patients, CB represents a valuable diagnostic tool to choose the most appropriate clinical management and therapeutic approach, also in the diagnosis of HL.Moreover, CB obtains an adequate cellularity for the diagnosis of lymphoma also from drainage, which is well known to provide samples with a poor cellularity.A correct diagnosis and subtyping of lymphoma is imperative for adequate therapy and clinical management. For deep-seated and extra-nodal lesions, mostly in patients with comorbidities or unfitness, an easy and less invasive method, such as US-FNA and EBUS-FNA, is needed for the collection of samples. CB is a very useful method to perform a morphological analysis, as well as immunocytochemical and molecular studies. In our study, we confirm that CB is more useful than CC in achieving a diagnosis of NHL and its subclassifications, and we demonstrate CB utility in the first diagnosis of HL, classical type, in patients with deep-seated lesions or unusual presentation.


Escherichia coli metabolism. Cells were briefly exposed to four times the minimum inhibitory concentration and spectra were quickly acquired in the high-throughput mode. After preprocessing optimization, a partial least squares discriminant analysis and principal component analysis were conducted. The metabolic fingerprints obtained with FTIR spectroscopy were sufficiently specific to allow a clear distinction between different antibiotics, across three independent cultures, with either analysis algorithm. These fingerprints were coherent with the known MOA of all the antibiotics tested, which include examples that target the protein, DNA, RNA, and cell wall biosynthesis. Because FTIR spectroscopy acquires a holistic fingerprint of the effect of antibiotics on the cellular metabolism, it holds great potential to be used for high-throughput screening in antibiotic discovery and possibly towards a better understanding of the MOA of current antibiotics.The discovery of antibiotics has been slowing to a halt. Phenotypic screening is once again at the forefront of antibiotic discovery, yet Mechanism-Of-Action (MOA) identification is still a major bottleneck. As such, methods capable of MOA elucidation coupled with the high-throughput screening of whole cells are required now more than ever, for which Fourier-Transform Infrared (FTIR) spectroscopy is a promising metabolic fingerprinting technique. A high-throughput whole-cell FTIR spectroscopy-based bioassay was developed to reveal the metabolic fingerprint induced by 15 antibiotics on the  The discovery of antibiotics has been considered a miracle of modern medicine, but since the golden age of antibiotic discovery, when most classes were introduced, innovation has been slowing to a halt . The genStaphylococcus aureus has emphasized the metabolic alterations that are specific to the MOA of three antibiotics acting on the major biosynthetic pathways, i.e., cell wall, DNA, and protein biosynthesis . The bacteria were grown in1 L erlenmeyers, with 400 mL of MHB, in an orbital incubator  at 37 °C and 250 rpm. The cells were incubated until ODlsewhere .590 was taken and bacterial inactivation was determined. The cells were, again, pelleted and resuspended in cold 0.9% NaCl to obtain an OD590 of 1, from which 2 mL of aliquots were further centrifuged for three minutes at 13,000 rpm   and resuspended in 100 µL of cold 0.9% NaCl to obtain an OD590 of 20 for FTIR readings. The samples were then plated on an infrared-transparent ZnSe 96 well plate  in quintuplicates. ZnSe plates were dehydrated for 3 h in a vacuum desiccator with silica, and inserted in a HTS-XT module coupled to a Vertex-70 spectrometer . Spectra were acquired in transmission mode and consisted of 40 coadded scans at a 4-cm−1 resolution. These were then exported as data point table files, which were imported into Matlab  for subsequent analysis. To reduce spectra heterogeneity originating from operator handling and other undesirable sources of variability, the spectra of mechanical replicates (quintuplicates) were averaged. Subsequently, the averaged spectra were preprocessed with the SG filter and then with LMSC. A range of parameters were used for either algorithm, and the parameters that produced the highest successful classification of an LOO-CV PLS-DA model were used to build the final PLS-DA predictive model as well as for PCA. After incubation with the antibiotics, samples were quickly centrifuged at 3000 Relative Centrifugal Force (RCF) for 10 min at 4 °C , the supernatant was discarded, and the cell pellet was resuspended in 25 mL of cold 0.9% NaCl  to quench the metabolism. Subsequently, the OD


Hemangioblastomas in the kidney are rare. Although a few cases of renal hemangioblastoma (RH) have been reported, the content of these articles mainly focused on clinical and pathological research, with minimal descriptions of radiologic findings. Moreover, there are no descriptions of magnetic resonance imaging (MRI) with enhancement of this condition. Herein, we report 2 cases of RH with computed tomography (CT) and MRI findings.Two patients presented to our institution because of dull pain in the left abdomen, and a mass in the left kidney was found by ultrasound examination in each case. The patient had no special family history. Physical examination revealed no obvious tenderness or percussion pain in the renal and ureteral walking areas, and there was no obvious mass. Routine blood and urine tests were normal, and the serum tumor markers were negative. No obvious lesions were found on imaging of the other body parts.Similar radiologic findings were observed in both cases and mimicked those of cavernous hemangiomas of the liver, including peripheral nodular enhancement in the corticomedullary phase, progressive centripetal enhancement in the nephrographic and delayed phases, and occasional complete “filling in” in the delayed phase. We made a radiologic diagnosis of renal clear cell carcinoma for patient 1 and suspected renal clear cell carcinoma for patient 2, but the pathological results showed RH.Given the suspicion of renal cell carcinoma, both patients underwent partial nephrectomy.The recovery of the two patients was uneventful, and there was no evidence of local recurrence or metastasis many years after surgery.RH is a rare benign tumor that can be easily misdiagnosed as clear cell carcinoma. Characteristic CT and MRI manifestations may improve preoperative diagnostic accuracy to avoid surgery or indicate nephron-sparing surgery. Loss, mutation, or methylation inactivation of the VHL gene disturbs PVHL synthesis, which is an important molecular basis for VHL disease. VHL-related tumors include hemangioblastomas that are usually located in the CNS, fewer renal and pancreatic cystic tumors, neuroendocrine tumors of the pancreas, renal clear cell carcinoma, endolymphatic sac tumors, pheochromocytomas, and paragangliomas.,6Hemangioblastomas are vascular tumors that often occur in the central nervous system (CNS), especially in the cerebellum. Most cases are sporadic, and about 20% to 38% of patients also have Von-Hippel-Lindau (VHL) disease, which is an autosomal dominant genetic condition with an incidence of 1/27,300 to 1/45,000.,8 retroperitoneum,,10 pelvic cavity, soft tissue, bone, adrenal glands, lungs, and liver. The PubMed database was searched for literature using the keywords “hemangioblastoma” and “kidney or renal.” After screening all articles in the database, the first case report of renal hemangioblastoma (RH) was reported by Nonaka et al in 2007. RH is rare, and no more than 30 cases have been reported, but the content of these articles mainly focused on clinical and pathological research with limited descriptions of radiologic findings.–27 Moreover, there are no descriptions of enhanced MRI findings of RHs. To the best of our knowledge, this is the first report of enhanced MRI findings.Beyond the CNS, hemangioblastomas can also occur in the peripheral nervous system,We report 2 cases of patients with RH confirmed by surgery and pathology with complete clinical, pathological, and imaging data collected in our hospital. Neither patient had VHL disease, and was diagnosed with sporadic RH.22.1A 64-slice spiral contrast-enhanced (CE) abdominal CT  was used for both patients. The CT scanning parameters were as follows: reconstruction thickness of 2 mm, reconstruction of increment, pitch of 1.25, tube voltage of 120 kV, and tube current of 170 to 360 mAs using automatic tube current modulation technology. CE abdominal CT scans were performed with the patient in a supine position and scanned from the xiphoid process to the anterior superior iliac level. After the plain scan, the patient received intravenous nonionic iodinated contrast agent iohexol (320 mgI/mL) as a 75-mL bolus at a rate of 3.0 mL/s, followed by 50 mL of normal saline. Corticomedullary and nephrographic phase images were obtained 30 and 60 seconds after contrast agent injection, respectively.2.2MRI examinations were performed using a Signa HDxt 3.0T magnetic resonance (MR) system , with the use of the body coil as a transmitter and an 8-channel phased-array coil as the receiver. The detailed examination protocols are summarized in Table 33.1In November 2015, a 45-year-old male patient presented to our institution with a dull pain in the left abdomen that had been present for 2 weeks. The patient had never undergone surgery and had an unremarkable family history. The respiratory frequency of the patient was 18 times per minute, with a body temperature of 36.7°, pulse rate of 76 beats per minute, and blood pressure of 110/76 mm Hg. Physical examination revealed no obvious tenderness or percussion pain in the renal or ureteral walking area, and there was no palpable mass. Routine blood and urine tests were normal, and serum carbohydrate antigen 199, carbohydrate antigen 125, alpha-fetoprotein, carcinoembryonic antigen, and prostate-specific antigen were negative. No obvious lesions were found on chest X-ray, head CT, or ultrasonography of the liver, gallbladder, pancreas, and spleen.Ultrasonography Fig. A revealeGiven the suspicion of renal cell carcinoma (RCC), the patient underwent laparoscopic right partial nephrectomy. The pathological results revealed an RH Fig. H. Immuno3.2In December 2017, a 42-year-old female patient presented to our institution with a mass in the left kidney found during an ultrasound examination in a local hospital. The patient had a history of cesarean section 16 years earlier and had no special family history. Her respiratory frequency was 21 beats per minute, with a body temperature of 36.5°C, pulse rate of 78 beats per minute, and blood pressure of 100/58 mm Hg. Physical examination revealed no obvious tenderness or percussion pain in the renal or ureteral walking area, and there was no obvious mass. Routine blood and urine tests were normal, and serum carbohydrate antigen 199, carbohydrate antigen 125, alpha-fetoprotein, carcinoembryonic antigen, and prostate-specific antigen were negative. No obvious lesions were found on chest radiography or ultrasonography of the liver, gallbladder, pancreas, or spleen.The MRI findings are shown in Figure Given the suspicion of RCC, the patient underwent da Vinci robot-assisted left partial nephrectomy. The pathological results showed RH, and the tumor was surrounded by a fibrous capsule Fig. H. Immuno4 However, a correlation between VHL syndrome and VHL gene mutation has not been reported, and the biological behavior of the tumor is benign. RH is a rare, slow-growing, benign renal tumor. It usually affects middle-aged and elderly patients, but can also occur in younger patients.,20 Compared with women, men are 1.5 to 2 times more likely to develop RH. In sporadic cases such as those described here, there is no VHL-related disease and no associated family history of VHL disease in the patient .The latest 2016 World Health Organization classification of tumors of the urinary system and male genital organs now includes RH as a mesenchymal tumor, which is similar to CNS hemangioblastoma.,20,29 On the basis of the stromal cell components, they could be divided into 3 types: capillary-dominated, interstitial cell-dominated, and classic type (intermediate between the other 2 types). Unfortunately, although the stromal cells of RH appear normal, they may show obvious nuclear pleomorphism, similar to malignant tumors. Therefore, RH can be easily misdiagnosed as RCC or other malignant tumors.The gross features of RH include a predominantly solid tumor rich in capillaries with a well-demarcated border from the surrounding renal parenchyma, which is consistent with what we observed in the surgical specimens. Microscopically, RH is a morphologically distinctive vascular neoplasm with rich capillary networks and lipid-rich stromal cells.–33 Our results are consistent with the results of the above studies.Because it is difficult to distinguish RH from renal clear cell carcinoma by routine hematoxylin and eosin (HE) staining alone, immunohistochemical examination is helpful for differential diagnosis. Studies have shown that labeling with inhibin alpha, S-100, and CD10 helps distinguish RH from renal clear cell carcinoma. Inhibin alpha and S-100 are usually positive in RH and negative in renal clear cell carcinoma and contrast; CD10 is usually positive in renal clear cell carcinoma and negative in RH.–37CT and MRI are very useful examination methods that have been widely used in the diagnosis and differential diagnosis of diseases in various systems. Both have gained increased acceptance for the accurate diagnosis and differential diagnosis of renal tumors.,39 The most common and typical radiologic findings correspond to the last type and show a markedly enhanced small mural nodule attached to a large unenhanced cyst wall.,41 There is limited literature describing the imaging findings of RH, but they report RH as a solid, heterogeneously enhanced mass, which is consistent with our cases.,22,23 However, they do not correspond with the most common and typical radiological findings of hemangioblastoma in the cerebellum. This discrepancy may be related to the different tumor growth environments.Most hemangioblastomas are in the cerebellum and can be divided into 3 types: solid, solid-cystic, or predominantly cystic with small mural nodules.,43 Other renal tumors do not exhibit these enhancement patterns, which may be unique to RH. At present, these findings have not been reported in the literature. It may be that others have not noticed this feature, or they may not have performed CE multiphase scanning with CT and MRI. T2WI also helps in the differential diagnosis. The high signal intensity on T2WI indicated slow blood flow in the neoplastic vascular channel, which is of great significance to angiogenic tumors. The first case was less typical due to bleeding, but the second case was similar to cavernous hemangioma of the liver, showing a significantly high signal intensity known as the “light bulb sign.”In addition to solid tumors, the CT and MRI findings of our 2 patients were similar to those of cavernous hemangiomas of the liver, including peripheral nodular enhancement in the corticomedullary phase, progressive centripetal enhancement in the nephrographic and delayed phases, and sometimes complete “filling in” in the delayed phase. If a correct preoperative diagnosis was made, these 2 patients may have received different treatments. Unfortunately, RH can easily be misdiagnosed as renal clear cell carcinoma, the most common malignant tumor of the kidney, which can lead to overtreatment. Characteristic CT and MRI manifestations may help guide the preoperative diagnosis. At the same time, once RH is surgically confirmed, a comprehensive examination should be performed to determine if the tumor is associated with VHL disease.Because RHs are indolent neoplasms, asymptomatic tumors may be managed with observation. Gross total resection is the most suitable treatment if an intervention is required.In conclusion, RH is a rare benign tumor that can be easily misdiagnosed as clear cell carcinoma. Characteristic manifestations on CT and MRI may help us make a preoperative diagnosis to avoid surgery or indicate nephron-sparing surgery. This highlights the importance of accurate preoperative radiologic diagnoses.Data curation: Jie He, Wangwang Liu.Funding acquisition: Qiangfeng Wang.Methodology: Wenli Zhou, Hongjie Hu.Writing – original draft: Jie He, Nan Liu, Hongjie Hu.Writing – review & editing: Hongjie Hu.


One of the biggest challenges in tissue engineering is the manufacturing of porous structures that are customized in size and shape and that mimic natural bone structure. Additive manufacturing is known as a sufficient method to produce 3D porous structures used as bone substitutes in large segmental bone defects. The literature indicates that the mechanical and biological properties of scaffolds highly depend on geometrical features of structure , surface morphology, and chemistry. The objective of this review is to present the latest advances and trends in the development of titanium scaffolds concerning the relationships between applied materials, manufacturing methods, and interior architecture determined by porosity, pore shape, and size, and the mechanical, biological, chemical, and physical properties. Such a review is assumed to show the real achievements and, on the other side, shortages in so far research. Scaffolds, in terms of a three-dimensional porous structure that provides support and allows cells to adhere, proliferate, and differentiate, are used as bone substitutes for large segmental bone defects to restore the functionality of bone . ScaffolOne of the biggest challenges in tissue engineering is the manufacturing of porous structures that are customized in size and shape and that mimic natural bone structure . ScaffolThe titanium alloys are characterized by excellent biocompatibility, corrosion resistance, high strength-to-weight ratio, and good fatigue resistance. However, the significant mismatch of moduli between titanium and bones may contribute to stress shielding, leading to implant loosening . AccordiDifferent methods have been proposed to develop a titanium porous structure. Conventional manufacturing approaches, mostly based on powder metallurgy, such as metal injection molding or the space-holder method, are subtractive methods where parts of the material are removed from an initial block to achieve the desired shape. Although those fabrication technologies have shown great promise in fabricating scaffolds, certain limitations, such as the impossibility to manufacture highly complex parts with controllable geometry , precious dimensions (pore and strut size), and predictable mechanical properties, remain. Additionally, due to the extensive production line involving tooling and manufacturing sequences, the traditional methods become cost- and time-consuming ,13,14.The most promising rapid prototyping techniques, introduced to overcome conventional manufacturing limitations, are called additive manufacturing (AM) processes that deliver the final three-dimensional object via deposition of overlying layers. An important improvement is the possibility to create custom-made products using computer-assisted technologies (CAD), starting from the patient’s body medical images. AM methods allow production of complex geometry with internal and external macro- and microarchitecture, dimensional accuracies, significantly lower defect rates, and enhanced mechanical properties, all within a shorter time and with lower materials wastes .According to Maroulakos , AM techThe issue of parts and scaffolds made through additive manufacturing (AM) has been often characterized in the literature. Some reviews collected and analyzed data about different metallic and nonmetallic materials, and various AM techniques ,19,20,21All recent reviews have been either devoted to some specific subjects or process optimization or overall presentation of AM methods. The objective of this review is to present the latest advances and trends in the development of titanium scaffolds concerning the relationships between applied materials, manufacturing methods, and interior architecture determined by porosity, pore shape, and size and the mechanical, biological, chemical, and physical properties. Such a review is assumed to show the real achievements and, on the other side, shortages in research so far. Even more importantly, it fills to some extent a gap in this specific science field, showing not only the main requirements of the titanium implants, different fabrication AM technologies, and titanium and its alloys proposed for scaffolds, but also a relatively new approach in design and manufacturing of porous Ti and its alloys, i.e., relationships between all microstructural factors, regardless of their materials, by which method they are manufactured, and their mechanical, biological, and chemical properties.The methodology to prepare this review was based on several inclusion factors. The main factors included the subject of the study , publication data , addressed readers , peer review , reported outcomes , and searched databases . The originality of this review is in its limitation for all titanium-made scaffolds (not only Ti-6Al-4V), their additive manufacturing approaches, surface treatment, and properties, with an emphasis put on relationships between manufacturing technique, material microstructure, and mechanical, biological, and chemical properties.The present understanding of the biomechanical processes that affect healing is based on the natural bone formation process, which can be divided into two stages: primary and secondary bone healing. Primary bone healing occurs when the fracture is rigidly stabilized and the gap is less than 0.1 mm. The bone formation is provided directly by osteoclasts and osteoblasts. Secondary bone healing occurs when only a small movement at the fracture appears . In geneKnowledge about the biological structure of bone and the natural healing process is important in terms of improving therapeutic approaches to tissue engineering. The structure of bone contains bone tissue , osteons (100 µm) with Haversian canals, fiber patterns (50 µm), fibers (5 µm), mineralized collagen fibrils (500 nm), collagen, and hydroxyapatite (HAp) . The orgScaffolds for bone regeneration should meet certain material, structural, and mechanical criteria to provide cell interaction and structural support . The misPorous structures exist in many forms, both stochastic (irregular), such as expanded or reticular (regular) foams, or as grid structures or meshes with continuously repeating elementary cells  11,52,5,552,53.Stochastic  open-cell foams are characterized by randomly shaped and sized pores with irregularly repeated unit cells, stochastically connected and orientated struts. The structure of stochastic foams is often heterogeneous, which means that foams are strong in some regions but weak in others ,54. WeakPorosity is defined as the percentage of overall voids’ volume in solid material, and its value depends on pore and struts size as well as porous structures . PorositResearch has shown that the minimal pore size for promoting bone ingrowth is in the range of 100–150 µm ,66,67,68z-axis. Another basic structure is marked by diagonally oriented struts and checked pores [There have been several studies focusing on the influence of unit cell shape ,72. As sed pores . The stred pores ,77 stateed pores  also reped pores  showed tThe main requirements of the bone scaffold are shown in 2 powder as the Ti source. In [1.924, the scaffolds possessing pores in the range of 300–600 μm were fabricated. Titanium hydride resulted in higher surface roughness and higher microporosity than in pure titanium. The effect of the space holder fraction was also analyzed. Xu et al. [4HCO3 volume content was increased from 63% to 79%, and the average pore size enlarged from 230 µm to 430 µm. For the titanium scaffolds sintered at 1200 °C for 3 h, the carbamide space holder showed a maximum specific surface area at its addition in 60–65 vol % [The porosity and pore size are dependent on the kind of space holder and the ratio of the titanium biomaterial to a space holder. As the space holders, NaCl ,81,82, surce. In , using Tu et al.  observed65 vol % . An incr65 vol % ,85. For 65 vol % . The obt65 vol % , for por65 vol % , the 1:165 vol % ,98,99.In , porous 2 contents ranged between 20% and 30%. The porosity achieved was 39–53%, pore size 54–113 µm, Young’s modulus 1.4–4.1 GPa, and compressive strength 250–450 MPa. In other research [In ,103, theresearch , titaniuresearch . The sizresearch , for the2 powder. Macropores were sized in the range of 100–600 µm and had rounded shapes, appropriate for the ingrowths of the new-bone tissues and the transport of the body fluids. The compression strength was 24 MPa for 75% porosity [In , the porporosity .4 K/s in the fabrication of Ti-6Al-4V were applied. EBM generates a similar peak temperature range, but the high build temperature of 600–750 °C decreases the cooling rate locally. The thermal behavior during SLM processes resulted in an acicular α′ martensite microstructure and high tensile stresses, whereas the high build temperature involved in the EBM process led to an α + β lamellar microstructure free from residual stresses. Despite a huge number of attempts, the questions of whether the SLM can produce scaffolds at high geometric accuracy of struts in each part of the scaffold and how the size of the scaffold affects this accuracy still remain. Such a problem is crucial for securing the free flow of body fluids, transport of nutrients and oxygen into the scaffold interior, and bone ingrowths.An additive manufacturing, such as the SLM technique, becomes a promising opportunity for obtaining structures with controlled architecture, with porosity, pore shape, and size improving implant stability and implant–cell interaction ,111. TheSLS, known as one of the powder bed fusion fabrication methods in which powder materials are heated to fusion instead of completely melted, results in a net-shaped implant with high ductility and porosity ,117. ForEBM, as another powder bed fusion fabrication method, also gives similar opportunities as the SLM and it can  process LENS belong to the group of direct laser deposition techniques, where the powder is fed through argon pressurized nozzles . Some auIn , a simplDIW, which is also known as robocasting belongs to the material extrusion method, where the colloidal inks are directly extruded from a nozzle . The Ti-The MIM is another method to produce the titanium scaffolds  when com3DF deposition is based on forcing Ti slurry through the syringe nozzle using a 3D bioplotter machine. The slurry is plotted on a stage as a fiber, which rapidly solidifies by drying, and the scaffold is fabricated by layering a pattern of fibers. After deposition, the obtained Ti-6Al-4V scaffolds were dried for 24 h at RT and sintered under a high vacuum at 1200 °C for 2 h. By varying spacing and fiber laydown patterns, different Ti alloy scaffolds of the low, middle, and high porosity, double-layered, and with gradient porosity were produced .The comparison of the different additive manufacturing technologies available for the fabrication of titanium scaffolds is shown in All AM techniques, which use significant heat amounts, can produce serious discrepancies between perfect design and real geometry . Such daThe main imperfections can be divided into exterior and interior ones ,145. TheAnother imperfection is an excessive roughness of the surface. Sometimes, at smooth parts , the roughness is not allowed and must be removed by polishing. In other cases, when using titanium scaffolds as bone implants, rough surfaces enhance the fixation between an implant and bone. Loose powder on the surface is undesirable and should be removed, e.g., by chemical etching .The imperfections may result from both material and process determinants ,25. The The optimization of the initial process parameters may minimize the number of inherent defects, and further thermomechanical treatment may decrease residual stresses, adjust the microstructure , and resIn the case of Ti alloys, the processing parameters decide whether equiaxed or elongated columnar grains or both, may appear, even if they might possess a perfect microstructure. However, the grains formed during the AM process are smaller near the interface with the substrate as compared to the subsurface layers. The mechanical performance of the scaffolds is determined rather by the microporosity than microstructure . The lacThe mechanical properties are influenced by the microstructure of the titanium scaffold and its imperfections. The manufacturing errors may decrease strength, ductility, hardness, toughness, fatigue limit, and wear resistance . The optThe desired biological properties need a proper design of a titanium scaffold that requires an appropriate pore shape, pore size, and porosity. All these variables can affect biological performance, such as cell adhesion and proliferation, nutrient transportation, and bone ingrowth. The grain size also seems important . The strThe effect of geometric mismatch and inherent defects on the corrosion behavior of Ti materials is relatively moderate and depends on the AM technique. The potentiodynamic polarization tests showed that the corrosion resistance of the SLM specimen was the best under the low electric potential and that of the EBM specimen was the best under the high electric potential. The crevice corrosion resistance of the EBM specimen was the best, and the corrosion resistance of the SLM specimen was the lowest in the immersion test. On the other side, both scaffolds, fabricated with either EBM or SLM, had good corrosion resistance and were suitable for implantation in vivo . On the In general, Ti and titanium-based alloys show better biocompatibility and mechanical properties compared to stainless steel. Among titanium alloys, the Ti-6Al-4V alloy has been widely used as an orthopedic biomaterial due to its good corrosion behavior and mechanical properties. However, to lower elastic modulus and minimal contents of toxic elements such as aluminum and vanadium, new biocompatible β-Ti alloys with β stabilizing alloying elements  were recently developed. According to the literature, β-type Ti alloys demonstrate better mechanical properties, due to the moduli closer to those of human bone in comparison to α-type Ti alloys and α + β-type Ti alloys, as well as better biocompatibility due to the non-toxic nature of β-stabilizers . For exa3, respectively) and melting point  between Ti and Ta could lead to strong inhomogeneity during the alloy formation [2 nanotubes on the surface through two-step anodization and loading mesoporous bioactive glass into TiO2 nanotubes. Another research group [Most researchers have obtained a highly porous structure with a reasonably high compressive strength that mimics the morphology of the replaced bone. According to the literature, commercially pure titanium (CP-Ti) and Ti-6Al-4V alloy are the most used titanium materials in biomedical implants . Some auormation . Neverthormation , the efformation , when faormation . For exaormation  obtainedormation  used SLSormation , the SLMormation  showed tormation , the bioch group  successfch group  used Ti-ch group ,177 presch group . Other rch group  proposedch group ,165. Thech group  used Ti ch group , with vach group  obtainedch group . In a dich group  used Ti-Van Bael et al.  presenteThe triply periodic minimal surfaces (TMPS), especially gyroid structures, are characterized by better compressive fatigue resistance correlated with lower stress concentrations . For as-In 2 scaffolds were functionalized on the surface of the scaffolds using alkaline phosphatase (ALP), which was chosen in this study due to its important role in the bone mineralization process. After 28 days in simulated body fluid (SBF), ALP coated titania scaffolds exhibited increased hydroxyapatite formation. Another surface treatment helpful in an enhancement of biomineralization was the deposition of three-layer bioglass within the titanium scaffolds [2 layer and HAp coating. The apatite-forming ability test and in vitro cell culture assay resulted in the highest apatite formation and significantly greater adhesion and differentiation of mesenchymal stem cells (MSCs) on the HT/AH-porous Ti6Al4V compared to the scaffolds without HAp-coating [3)3 as a new therapeutic agent to promote bone formation. The results of the apatite-forming ability in SBF solution showed the continuous and homogeneous apatite layer with a Ca/P ratio of 1.7 after five days of incubation. The longer the incubation time was, the greater thickness of apatite coating appeared, while with a higher concentration of gallium nitrate (100 mM) the apatite layer was formed faster and could be already noticed on the 3rd day.Biocompatibility is understood as the capability of a material to perform with an appropriate host response in a specific application , and biocaffolds . In [216caffolds . SLM man-coating . In [217-coating  group usAs can be observed, titanium scaffolds are often subjected to different surface treatments. However, small specimens are applied and no research results on apatite deposition inside the scaffolds have been given what could be of capital importance for an assessment of total mineralization and the efficiency of different methods. The investigations of mineralization are made on the surface, and exceptions are rare.2 surface allowed greater adsorption of serum proteins and further enhancement of the ALP activity of MC3T3-E1 osteoblasts. In another research study [2+ or Ca2+ ion-substitution process [2 nanostructures obtained by hydrothermal treatment on three-dimensional porous titanium scaffolds surface facilitated the cell culture medium to penetrate the inner pores of the scaffold. In [2 nanotube arrays (Ti-NTs) and mesoporous bioactive glass (Ti-NTs-MBG). After the 7th day of in vitro assay, the cells cultured on the 3D-Ti-NTs-MBG scaffolds presented no significantly different proliferation rates, when compared with those on the 3D-Ti-NTs scaffolds. In [There has been a great amount of research in vitro on titanium scaffolds, without or with surface modification. When the selective laser melting was employed to fabricate the trabecularlike porous scaffolds with porosities 49–74%, the surface of the SLM-fabricated Ti-6Al-4V scaffolds was favorable for osteoblasts’ adhesion and migration because of microscale pores and ravines . In 219219, the ch study , the ele process  affected process , TiO2 nafold. In , the behfold. In , the higfold. In , where tfold. In , the prefold. In , Ti scaffold. In , severalfold. In , the Ti-fold. In , the autfold. In . Li et afold. In  showed tfold. In , ALP actfold. In  filled tfold. In  used gelfold. In  the obtafold. In  with fibfold. In  developeolds. In , cell be3), with or without low-intensity pulsed ultrasound (LIPUS) as a mechanical wave promoting bone regeneration, was used to modify the surface of a porous Ti-6Al-4V scaffold. In vitro results of bone marrow mesenchymal stem cells, namely adhesion, proliferation, and gene expression were significantly higher for BaTiO3/Ti, Ti + LIPUS, and BaTiO3/Ti + LIPUS groups compared to the Ti. The ALP activity was also higher in the BaTiO3/Ti + LIPUS group than in the BaTiO3/Ti and Ti + LIPUS groups. The results were in line with the in vivo experiments of implantation in large segmental bone defects in the radius of rabbits, where osteogenesis and osseointegration at 6 and 12 weeks after implantation were significantly better for these implants compared to porous Ti condition [A novel biomimetic porous titanium implant with good osseointegration was prepared by freeze-casting and thermal oxidation  as measuondition . Other rondition  studied ondition , the aut2 hindered bacterial growth. Finally, in [Escherichia coli (E. coli) and Staphylococcus aureus (S. aureus), was demonstrated. In [3 (Ch+Ag) via the EPD method, or biofunctionalized with vancomycin (Ch+Vanco). The implants demonstrated antibacterial behavior of 99.9%, while 100% was observed in Ch+Vanco implants. However, in vivo implantation in the rat tibia indicated that all implants were colonized with bacteria after 28 days, among them the Ch+Vanco group significantly reduced bone infection as compared to other implants  [Staphylococcus aureus and 70% for Escherichia coli. Results showed that CHX was more effective against Gram-positive bacteria than Gram-negative ones, thus the minimal required concentration of CHX should be 1.5 mM for inhibition of both bacteria growth. Additionally, the authors determined a significantly higher total amount of CHX loaded to the coating (136.8 μg/mL) compared to the previous research presented by that research group  [Pseudomonas aeruginosa and E. coli, and only in the first hours. Both were characterized by a quick release of Ga ion and after 48 h no bacteria growth inhibition was noticed. Additionally, the minimal concentration of Ga required for inhibition effect against E.coli bacteria was 100 mM.Antibacterial scaffolds have not been often proposed. In , a poroually, in , silver ated. In  Ti-6Al-4, Ch+Ag) . In [217coating) . Moreovecoating)  successfIn The most studied chemical property of titanium scaffolds is their corrosion resistance in a biological environment. Generally, the corrosion resistance is high, but at inflammations states, the pH value drastically decreases, and the corrosion rate increases. In scaffold, the important problem is the presence of long and narrow holes, which may provoke the localized corrosion . In 248248, poroThis review briefly summarizes recent progress in additive manufacturing techniques of porous Ti and its alloys dedicated for biomedical applications, focusing especially on structural and material determinants influencing the mechanical and biological properties. First, a brief introduction to the biological background comprising the formation and regeneration process of bone is presented. Afterward, the main requirements for bone scaffolds are discussed. Next, fabrication methods of the titanium scaffolds focus mostly on additive manufacturing techniques with their advantages and disadvantages based on the latest research are comparatively studied. Afterward, titanium materials and their alloys are described. Finally, the scaffold’s structural factors influencing the mechanical, biological, and chemical properties are discussed.Porous titanium structures with different pore shapes and biomedical properties that are similar to those of the human bones, minimizing the stress shielding and improving the longevity of implants, can be successfully fabricated by additive manufacturing techniques. Many aspects affect the mechanical and biological responses of porous structures, such as the manufacturing methods and their process parameters, design , material selection, post-treatment. Highly porous scaffolds are found to have lower mechanical properties, higher permeability, and better cell ingrowth, especially when the larger pores are situated on outer surfaces. The increasing strut diameter leads to a higher load-bearing capacity. The obtuse angles of struts improve mechanical properties, while a larger number of them improve cells’ bridging effects. A compromise between bone ingrowth, vascularization, mechanical strength, and permeability, shows that the optimum pore size is supposed to range between 300 and 600 μm. Titanium and its alloys are widely used for manufacturing porous scaffolds. However, the latest research is mostly focused on investigating porous structures with new β-type titanium alloys , which are characterized by better mechanical properties and lower amounts of toxic elements. Among manufacturing methods, SLM-made scaffolds present superior properties compared to those produced by conventional methods, especially casting, with only a minor reduction in maximum deformation strain. The SLS process is characterized by the high temperature of the process, while the EBM, due to the vacuum condition of the process, leads to the lower number of defects of manufactured parts, compared to SLM-made structures. Besides many advantages of 3D printing, the microstructural defects in the builds are still a challenge. Thus, several surface modification methods are used to improve mechanical and biological properties. Heat and acid-treatment, anodizing, coatings contained CaP, HA, chitosan, or antibiotics are commonly used to enhance surface roughness, corrosion, and wear resistance, as well as improve the osseointegration process.Despite indisputable advantages of AM as a technology for titanium scaffold fabrication, some considerable challenges and disadvantages in this area exist. Future research should consider the following direction: Research standardization, Hybrid 3D printing, a combination of 3D and 2D printing.The mechanical and biological properties of scaffolds cited in the literature are quite different even for similar materials. The large variations in experimental procedures may be correlated with different AM process conditions, different sizes of titanium powder particles used in the fabrication process as well as the difference in research methodology. The completed database contains categorization of existing results, supported by medical examination should be evaluated.Although titanium alloys can meet the mechanical requirements, their bioactivity should be improved. The surface treatment which usually enhances the bioactivity of titanium materials, in the case of scaffolds is a big challenge due to the difficulties correlated with homogenous incorporation of bioactive elements into the porous structure. Thus, a hybrid printing, contains 3D printing  and parallel 3D printing allows the incorporation of biochemical molecules  directly into a 3D printed scaffold should be evaluated.Another approach to minimize the disadvantages of 3D printing is a combination of 2D and 3D printing methods. Similarly to the issues mentioned above. The surface treatment is difficult inside the scaffolds, especially the removal of loose powders after AM leads to a decreasing of the interconnectivity of scaffolds, thus using 3D printing combined with 2D nanostructuring of each of the layers during the formation of the 3D structure should be evaluated.Finally, due to the complexity of factors influencing the behavior of scaffolds, the computer-enhanced design with patient-specific finite element models of bones should be evaluated.