Tissue Engineering

Tissue Engineering, Third Edition provides a completely revised release with sections focusing on Fundamentals of Tissue Engineering and Tissue Engineering of Selected Organs and Tissues. Key chapters are updated with the latest discoveries, including coverage of new areas (skeletal TE, ophthalmology TE, immunomodulatory biomaterials and immune systems engineering). The book is written in a scientific language that is easily understood by undergraduate and graduate students in basic biological sciences, bioengineering and basic medical sciences, and researchers interested in learning about this fast-growing field. Presents a clear structure of chapters that is aimed at those new to the field Includes new chapters on immune systems engineering, skeletal tissue engineering (skeletal muscle, tendon, and ligament) eye, cornea and ophthalmology tissue engineering Includes applied clinical cases studies that illustrate basic science applications Front Cover Tissue Engineering Tissue EngineeringThird EditionEditorsJan de BoerClemens A. van BlitterswijkAssistant EditorsJorge Alfredo UquillasNusrat Malik Contents Contributors Preface 1 - An introduction to tissue engineering; the topic and the book 1.1 Learning objectives 1.2 What inspired you to pick up this book? 1.3 What is tissue engineering about? 1.4 Tissue engineering's origin and progression over time 1.5 Tissue engineering's limitations and promises 1.6 The future of tissue engineering 1.7 Tissue engineering and you 1.8 How to use this book? A guide for students and teachers 1.9 How to use the chapters? 1.10 References 2 - Stem cells 2.1 Learning objectives 2.2 Introduction 2.3 What defines a stem cell? Self-renewal, proliferation, and differentiation 2.4 Self-renewal 2.5 Stem cell proliferation 2.6 Stem cell differentiation 2.7 Stem cell quiescence and activation 2.8 Cell death is normal—apoptosis, autophagy, necrosis, and necroptosis 2.9 Characterization of stem cells—protein expression 2.10 Characterization of stem cells—RNA analysis by RT-PCR, microarray, and RNA-sequencing 2.11 Characterization of stem cells—cell differentiation 2.12 Stem cell signaling—the Wnt and β-catenin pathway 2.13 Hematopoietic stem cells 2.14 Mesenchymal stem cells 2.14.1 MSC modulation of the immune system 2.14.2 Epithelial stem cells—skin and intestine 2.15 Skin stem cells 2.16 Lgr5+ stem cells of the intestine 2.17 Central nervous system stem cells 2.18 Induced pluripotent stem cells—iPS cells 2.18.1 Deextinction of the northern white rhino by iPS cells 2.19 Natural pluripotent and embryonic stem cells 2.19.1 Differentiation of pluripotent stem cells 2.19.2 Application of pluripotent stem cells 2.20 Organoids, exosomes, and extracts from stem cells 2.21 Stem cell mechanobiology: stretch and strain 2.22 Future perspective 2.23 The dark side: cancer stem cells 2.24 Recommended literature 2.25 Assessment of your knowledge 2.26 Glossary 2.27 Further reading 3 - Tissue formation during embryogenesis 3.1 Learning objectives 3.2 Introduction 3.2.1 Organ formation during embryogenesis 3.2.2 The formation of the three germ layers during gastrulation 3.2.3 Establishment of the body plan by morphogen signaling 3.2.4 Neural crest cells 3.3 Cardiac development 3.3.1 Geometrical changes transform a single beating heart tube into a four-chambered heart 3.3.2 Cardiomyocytes 3.3.3 Future perspective 3.4 Blood vessel development 3.4.1 Vasculogenesis and angiogenesis 3.4.2 Blood pressure drives specification of vessels in arteria or veins 3.4.3 Vessel wall stabilization by smooth muscle cells and pericytes 3.4.4 Recruitment of mural cells is mediated by PDGF signaling 3.4.5 Future perspective 3.5 Development of peripheral nerve tissue 3.5.1 Development of the schwann cell lineage 3.5.2 Myelinating and nonmyelinating nerve fibers 3.5.3 Structure of the peripheral nerve sheath 3.5.4 Future perspective 3.6 Embryonic skin development 3.6.1 Interfollicular epidermis 3.6.2 Follicular epidermis 3.6.3 Dermis 3.6.4 Tissue engineering of embryonic and newborn skin 3.6.5 Cell–cell interactions and growth factors 3.6.6 Future perspective 3.7 Bone development 3.7.1 Skeletal precursor cells 3.7.2 Endochondral ossification 3.7.3 Intramembranous ossification and osteoblast differentiation 3.7.4 Osteoclast differentiation 3.7.5 Tissue engineering of bone 3.7.6 Tissue engineering of articular cartilage 3.7.7 Future perspective 3.8 Recommended literature 3.9 Assessment of your knowledge 3.10 Glossary 4 - Cellular signaling 4.1 Learning objectives 4.2 Paradigm of cellular signaling 4.3 Signal initiation 4.4 Signal transduction 4.4.1 G-protein–coupled receptor–mediated signaling 4.4.2 Receptor tyrosine kinase signaling 4.4.3 TGF-β superfamily signaling 4.4.4 Wnt signaling 4.4.5 Rho kinase signaling 4.4.6 NF-κB signaling 4.4.7 Vitamin D signaling 4.5 Gene activation 4.6 Variations on a theme 4.7 Future perspective 4.8 Recommended literature 4.9 Assessment of your knowledge 4.10 Glossary 4.11 References 5 - Extracellular matrix as a bioscaffold for tissue engineering 5.1 Learning objectives 5.2 Introduction 5.3 Native extracellular matrix 5.3.1 ECM composition Collagen Fibronectin Laminin Glycosaminoglycans Growth factors 5.4 ECM scaffold preparation 5.5 Constructive tissue remodeling 5.5.1 Default mammalian wound healing versus constructive remodeling 5.5.2 Mechanisms behind ECM-mediated constructive tissue remodeling Scaffold degradation Endogenous cell therapy by ECM bioscaffolds Modulation of the host immune response by ECM bioscaffolds Macrophage heterogeneity ECM bioscaffolds promote a constructive macrophage phenotype Antimicrobial properties of ECM bioscaffolds 5.6 Clinical translation of ECM bioscaffolds 5.6.1 Skeletal muscle reconstruction 5.6.2 Esophageal mucosa reconstruction 5.7 Commercially available scaffolds composed of ECM 5.8 Future perspective 5.9 Recommended literature 5.10 Assessment of your knowledge 5.11 Glossary 5.12 References 6 - Synthetic biomaterials 6.1 Learning objectives 6.2 Introduction 6.2.1 Why are biomaterials important? 6.2.2 Synthetic biomaterials and their features 6.3 Biomaterials and synthetic chemistry: a molecular view 6.3.1 Atoms, molecules, and interactions 6.3.2 Classes of materials Polymers: naturals, synthetics, and hybrids Inorganics: ceramics and glasses Composites 6.3.3 Synthetic transformations 6.4 The extracellular matrix: a chemical view 6.4.1 What are we trying to mimic? 6.4.2 The ECM is nothing but polymers and composites 6.5 Rational design 6.5.1 Degradation 6.5.2 Mechanical properties 6.5.3 Stimuli response 6.5.4 Bioactivity 6.5.5 Biomimicry 6.6 Future developments 6.6.1 Spatiotemporal complexity 6.6.2 Biohybrid approaches 6.6.3 Rational design 6.6.4 Precision 6.7 Case study: vascularization 6.7.1 How to create a synthetic system for vascularization 6.7.2 Designing a material system Clinical/industrial solution Academic solution Testing 6.8 Recommended literature 6.8 Recommended literature 6.9 Assessment of your knowledge 6.10 Glossary 6.11 References 7 - Degradation of biomaterials 7.1 Learning objectives 7.2 Introduction 7.3 Bioceramics and glasses 7.3.1 Properties of bioceramics and glasses that influence degradation 7.3.2 Degradation mechanisms of bioceramics Physicochemical degradation of bioceramics Cellular degradation of bioceramics 7.4 Biodegradable polymers 7.4.1 Introduction 7.4.2 Mechanisms of polymer degradation and erosion 7.4.3 Bulk erosion Overview Surface erosion Degradation kinetics 7.4.4 Factors that influence degradation 7.4.5 Material composition 7.4.6 Bulk eroding polymers 7.4.7 Surface-eroding polymers 7.4.8 Molecular weight 7.4.9 Crystallinity 7.4.10 Glass transition temperature 7.4.11 Architecture 7.4.12 Processing 7.4.13 In vivo degradation Conditions at implantation site Inflammatory response Size and shape 7.4.14 In vitro testing and characterization 7.4.15 In vivo testing and characterization 7.5 Biodegradable metals 7.5.1 Principles of metal corrosion Corrosion in the in vivo environment Localized corrosion effects 7.5.2 Magnesium-based implants Magnesium corrosion Controlling magnesium degradation rates Mg-based tissue scaffolds: designing for function and enhanced properties 7.6 Future perspective 7.7 Recommended literature 7.8 Assessment of your knowledge 7.9 Glossary 7.10 References 8 - Cell–material interactions 8.1 Learning objectives 8.2 Introduction 8.2.1 Cell–material/cell–extracellular matrix interactions 8.2.2 Integrins 8.2.3 Integrin-mediated adhesion structures 8.2.4 Mechanotransduction 8.2.5 Cell adherence to synthetic materials 8.3 Surface chemistry 8.3.1 Hydrophobicity and hydrophilicity 8.3.2 Presentation of chemical groups 8.3.3 Patterning using surface chemistry 8.3.4 Ligand spacing 8.3.5 Dynamic chemistry 8.4 Material mechanics (stiffness) 8.4.1 Cell behaviors and matrix mechanics 8.4.2 Mimicking tissue stiffness in vitro 8.4.3 Stem cell differentiation and substrate mechanics 8.5 Topography 8.5.1 Cell guidance by micro- and nanostructures 8.5.2 Nanotopography and stem cell differentiation 8.6 Future perspective 8.7 Recommended literature 8.8 Assessment of your knowledge 8.9 Glossary 8.10 References 9 - Biomaterials discovery: experimental and computational approaches 9.1 Learning objectives 9.2 Introduction 9.3 The challenges of biomaterials discovery 9.4 Approaches to materials discovery 9.5 Experimental high throughput materials discovery 9.5.1 The supporting substrate and coating 9.5.2 Materials libraries 9.5.2.1 High throughput screening systems 9.5.2.2 Combinatorial polymer libraries 9.5.2.3 Genetic methods for materials design 9.5.2.4 design of experiments 9.5.2.5 Synergistic effects 9.5.3 Biological assays 9.6 Computational materials discovery 9.6.1 Problems and opportunities raised by the size of chemical space 9.6.2 Introduction to computational modeling 9.6.3 Ontologies 9.6.4 Computational modeling of structure–property relationships 9.6.4.1 Descriptors 9.6.4.2 Feature selection 9.6.4.3 Statistical and machine learning models 9.6.4.4 Model validation and assessment of predictivity 9.6.5 Illustrative example: correlating measured material properties with cellular attachment 9.6.6 Evolving materials computationally 9.6.7 White box modeling 9.7 Future perspective 9.8 Recommended literature 9.9 Assessment of your knowledge 9.10 Glossary 10 - Microfabrication technology in tissue engineering 10.1 Learning objectives 10.2 Introduction 10.2.1 Background 10.2.2 Microfabrication meets tissue engineering 10.3 Microfabrication techniques in tissue engineering 10.3.1 Photolithography 10.3.2 Soft lithography 10.3.3 Microfluidic fabrication of microtissues Microfluidic fabrication of point-shaped microtissues Microfluidic fabrication of line-shaped microtissues Microfluidic fabrication of plane-shaped microtissues 10.3.4 Microtissue assembly and application perspectives Self-assembly of microtissues Textile techniques for the assembly of line-shaped microtissues Templated molding of microtissues 10.4 Future perspective 10.5 Recommended literature 10.6 Assessment of your knowledge 10.7 Glossary 10.8 References 11 - Scaffold design and fabrication 11.1 Learning objectives 11.2 Introduction 11.3 Scaffold design 11.3.1 Morphology 11.3.2 Porosity 11.3.3 Interconnectivity 11.3.4 Pore characterization 11.3.5 General scholium to scaffold design 11.4 Classical scaffold fabrication techniques 11.4.1 Porogen leaching 11.4.2 Phase separation 11.4.3 Ice templating 11.4.4 Micromolding 11.4.5 Gas foaming 11.4.6 Classical nonwoven textiles 11.4.7 Knitted and braided textiles 11.5 Electrospinning 11.5.1 Electrospinning principles 11.5.1.1 Collection systems 11.5.1.2 Electric field variations 11.5.1.3 Spinneret configurations 11.5.2 Cell/electrospun scaffold interactions 11.5.3 Melt electrospinning 11.6 Additive manufacturing 11.6.1 Direct writing and extrusion of polymers 11.6.2 Inkjet/powder systems (3D printing) 11.6.3 Stereolithography 11.6.4 Digital light processing 11.6.5 Digital light synthesis 11.6.6 Two-photon polymerization 11.6.7 Selective laser sintering 11.6.8 Melt electrowriting 11.7 Hybrid fabrication 11.8 Clinical translation of scaffold guided tissue engineering 11.9 Future perspective 11.10 Recommended literature 11.11 Assessment of your knowledge 11.12 Glossary 11.13 References 12 - Controlled release strategies in tissue engineering 12.1 Learning objectives 12.2 Introduction 12.2.1 Bioactive molecules of interest in tissue engineering 12.2.2 Modes of controlled release 12.3 Physical mixtures of bioactive factors within matrices 12.4 Bioactive factors entrapped within gel matrices 12.5 Bioactive factors entrapped within hydrophobic scaffolds or microparticles 12.6 Bioactive factors bound to affinity sites within matrices 12.7 Bioactive factors covalently bound to matrices 12.8 Matrices used for immunomodulation 12.9 Recommended literature 12.10 Assessment of your knowledge 12.11 Glossary 12.12 References 13 - Bioreactors: enabling technologies for research and manufacturing 13.1 Learning objectives 13.2 Introduction 13.3 Basic requirements 13.4 Mimicking physiological culture conditions 13.4.1 Mass transport 13.4.2 Physical stimuli 13.5 Bioreactors for cell expansion and cell-based products 13.5.1 Cell-based products 13.5.2 Bioreactor types 13.5.2.1 Mixing bioreactors 13.5.2.2 Perfusion bioreactors 13.5.3 Scale-up versus scale-out 13.6 Bioreactors for tissue engineering 13.6.1 Cell seeding 13.6.2 Differentiation 13.7 Future perspective 13.8 Recommended literature 13.9 Assessment of your knowledge 13.10 Glossary 13.11 References 14 - Strategies to promote vascularization, survival, and functionality of engineered tissues 14.1 Learning objectives 14.2 Introduction 14.3 Strategies to improve vascular ingrowth into TE constructs 14.3.1 Modification of scaffolds Chemical composition Physical properties Biological properties—decellularized matrices 14.3.2 Fabrication of predefined hollow channel networks—new technologies 3D printing Microfluidics Sound wave technology 14.4 Strategies to improve vascular ingrowth into TE constructs—biological features 14.4.1 Incorporation of growth factors 14.4.2 Incorporation of vascular or proangiogenic cells 14.4.3 Incorporation of microvascular fragments 14.5 Strategies to promote neo-vascularization 14.5.1 In vitro prematuration 14.5.2 Strategies to improve cell survival 14.5.3 Strategies to promote inosculation 14.5.4 In situ prevascularization 14.6 In vivo models 14.6.1 Assessments of the vascularity within constructs—in vivo models 14.6.2 Assessment of graft vascularization and functionality of engineered tissues—in vivo imaging 14.6.3 Assessment of graft vascularization and functionality of engineered tissues—ex vivo analysis 14.7 Translation into clinics 14.8 Recommended literature 14.9 Assessment of your knowledge 14.10 Glossary 15 - Skin tissue engineering and keratinocyte stem cell therapy 15.1 Learning objectives 15.2 Introduction 15.2.1 Burn wounds 15.2.2 Chronic wounds 15.3 Structure and function of the epidermis 15.3.1 Keratins 15.4 Structure and function of the dermis 15.5 Epidermal and hair follicle stem cells of the skin 15.5.1 Keratinocyte stem cells 15.6 In vitro keratinocyte culture 15.6.1 Cultured keratinocyte sheet grafts for the treatment of burns 15.7 Cultured three-dimensional skin models 15.8 Immunogenicity with allogeneic and biosynthetic materials 15.9 Development of in vivo somatic keratinocyte stem cell grafting 15.9.1 Evolution of epidermal replacement 15.9.2 Evolution of dermal replacement 15.10 Poor keratinocyte “take” 15.11 Skin tissue engineering 15.11.1 Acellular dermal matrix Integra dermal regeneration template AlloDerm Matriderm Matriderm Matriderm Matriderm Biobrane Spincare 15.11.2 Dermal matrix with fibroblasts Dermagraft 15.11.3 Skin cell suspensions (applied as sprays or injections) Recell and Keraheal 15.11.4 Dermal matrix with keratinocytes Kaloderm and Holoderm Full-thickness skin equivalents Apligraf DenovoSkin 15.12 The use of adult stem cells in tissue-engineered skin 15.12.1 Induced pluripotent stem cells 15.12.2 Mesenchymal stem cells and adipose-derived stromal cells 15.13 Future perspective 15.14 Recommended literature 15.14 Recommended literature 15.15 Assessment of your knowledge 15.16 Glossary 15.17 References 16 - Cartilage and bone regeneration 16.1 Learning objectives 16.2 Introduction: cartilage 16.3 Cellular structures and matrix composition of hyaline cartilage 16.4 Collagen 16.5 Proteoglycans 16.6 The chondrocyte 16.7 Stem cells in cartilage and proliferation of chondrocytes 16.8 Pathophysiology of cartilage lesion development 16.9 Artificial induction of cartilage repair 16.10 Rationale for cell implantation 16.11 Cartilage specimens for implantation 16.12 Cell seeding density 16.13 What type of chondrogenic cells is ideal for cartilage engineering? 16.14 Allogeneic versus autologous cells 16.15 Articular chondrocytes versus other cells 16.16 Embryonic stem cells andinduced pluripotent stem cells 16.17 Xenograft cells 16.18 Direct isolation of tissue 16.19 Scaffolds in cartilage tissue engineering 16.20 Bioreactors in cartilage tissue engineering 16.21 Growth factors that stimulate chondrogenesis 16.22 Future developments in cartilage biology 16.23 Introduction: bone—basic bone biology: structure, function, and cells 16.24 Intramembranous and endochondral bone formation 16.25 Fracture repair 16.26 Critical size defect 16.27 Skeletal stem cells 16.27.1 Immunomodulatory properties 16.28 Expansion and differentiation 16.29 Growth factors for bone repair 16.29.1 Scaffolds for bone regeneration 16.30 Scaffold biocompatibility 16.31 The function of the vasculature in skeletal regeneration 16.32 Animal models in bone tissue engineering 16.33 Clinical experience in bone tissue engineering 16.34 Future perspectives for bone regeneration 16.35 Assessment of your knowledge 16.36 Glossary 16.37 References 16.38 Further reading 17 - Tissue engineering of the nervous system 17.1 Learning objectives 17.2 Introduction 17.3 Peripheral nerve 17.3.1 Peripheral nerve anatomy 17.3.2 Peripheral nerve injury 17.3.3 Autologous nerve grafts (autograft) 17.3.4 Use of nerve guides (tubes) in the lesioned PNS 17.3.5 Critical gap length 17.3.6 Nerve guides as supports for regeneration strategies Matrices Oriented matrices Scaffolds Acellular allografts Schwann cell grafts Neurotrophic factors 17.3.7 Biofabricated nerve guides 17.3.8 Bioprinting for the PNS 17.3.9 PNS summary 17.4 CNS: spinal cord 17.4.1 Summary of anatomy and injury response The tissue engineering challenge to overcome spinal cord scarring 17.4.2 SCI models Contusion animal model Hemisection model Full transection models Intrathecal delivery Gender and age Species selection for SCI models 17.4.3 Cell transplantation Schwann cells Olfactory ensheathing glia Stem cells Genetically modified cells 17.4.4 Nanomedicine to treat SCI 17.4.5 Matrices and scaffolds Relevant peptide sequences Matrices Scaffolds 17.4.6 Nerve guides in the CNS 17.4.7 Summary 17.5 CNS: brain 17.5.1 Trauma and stroke 17.5.2 Neurodegenerative diseases 17.5.3 Drug delivery to the brain Brain targeted therapies 17.5.4 Bioprinting for the brain 17.6 CNS: optic nerve 17.6.1 Regenerative therapies 17.7 CNS: retina 17.7.1 Diseases of the retina 17.7.2 Cell transplantation 17.8 Future perspective 17.9 Recommended literature 17.10 Assessment of your knowledge 17.11 Glossary 17.12 References 18 - Principles of cardiovascular tissue engineering 18.1 Learning objectives 18.2 Introduction 18.3 Heart structure, disease, and regeneration 18.3.1 The myocardium 18.3.2 Myocardial infarction and heart failure 18.3.3 Cardiac ECM—function and pathological changes after MI 18.3.4 Endogenous myocardial regeneration 18.3.5 Potential therapeutic targets and strategies to induce myocardial regeneration 18.4 Cell sources for cardiovascular tissue engineering and regeneration 18.5 Biomaterials—polymers, scaffolds, and basic design criteria 18.6 Biomaterials as vehicles for stem cells or bioactive molecule delivery after MI 18.6.1 Stem cell delivery 18.6.2 Delivery of bioactive molecules 18.7 Bioengineering of cardiac patches, in vitro 18.7.1 Strategies for in vitro cardiac patch engineering 18.7.2 Biomimetic scaffolds and integration of cell–matrix interactions 18.7.3 Perfusion bioreactors and stimulation patterns 18.8 Vascularization of cardiac patches 18.8.1 Prevascularization in vitro 18.8.2 Prevascularization in vivo 18.9 Three-dimensional bioprinting of vascularized tissues and components of heart 18.9.1 3D bioprinting strategies for generation of a vascular network Direct printing of cellular microfluidic channels Channel networks fabrication methods based on sacrificial technology 18.9.2 3D bioprinting of heart-like structure 18.10 Challenges for clinical application 18.11 Future perspective 18.12 Recommended literature 18.13 Assessment of your knowledge 18.14 Glossary 18.15 References 19 - Tissue engineering of organ systems 19.1 Learning objectives 19.2 Introduction 19.3 Urogenital tissue engineering 19.3.1 Bladder 19.3.2 Urethra 19.3.3 Kidney 19.4 Reproductive organs 19.4.1 Uterus 19.4.2 Vagina 19.4.3 Ovaries 19.5 Liver tissue engineering 19.6 Gastrointestinal tissue engineering 19.6.1 Natural biomaterials for intestinal repair 19.6.2 Combining biomaterials with cells for intestinal repair 19.7 Pancreas tissue engineering 19.7.1 Creating new β cells for cell therapy in type I diabetes 19.8 Lung tissue engineering 19.9 Future perspective 19.10 Recommend literature 19.11 Assessment of your knowledge 19.12 Glossary 19.13 References 20 - Product and process design: scalable and sustainable tissue-engineered product manufacturing 20.1 Learning objectives 20.2 Introduction 20.2.1 ATMPs—definitions and current manufacturing status 20.2.2 Current challenges of TEP manufacturing 20.3 Regulatory aspects of TEP manufacturing 20.3.1 Legal framework for TEPs 20.3.2 TEP product quality 20.3.3 Regulation of TEP manufacturing 20.4 The TEP manufacturing process 20.4.1 Unit operations 20.4.2 Process monitoring 20.4.3 Process scalability and cost 20.5 Manufacturing process development: quality by design 20.5.1 Design-of-experiments 20.6 Smart manufacturing driven by digital twins 20.6.1 In silico models in digital twins 20.7 Future perspective 20.8 Recommended literature 20.9 Assessment of your knowledge 20.10 Glossary 20.11 References 21 - Clinical translation 21.1 Learning objectives 21.2 Introduction 21.2.1 Historical perspective 21.2.2 Framework for clinical development of conventional medicinal products 21.3 Clinical translation of tissue-engineered products 21.3.1 Medical device regulation 21.3.2 Advanced therapy medicinal products 21.3.3 ATMP preclinical phase 21.3.4 ATMP clinical phase 21.4 Typical challenges for tissue engineering encountered in the clinical phase 21.4.1 Exploratory trial 21.4.2 Dosing 21.4.3 Defining the comparator 21.4.4 Randomization 21.4.5 Blinding a trial 21.4.6 Standardization of patient care and follow-up 21.4.7 Outcome measures 21.5 Implementation of a clinical trial 21.5.1 Protocol 21.5.2 Investigator brochure 21.5.3 Investigational medicinal product dossier and investigational new drug application 21.5.4 Informed consent 21.5.5 Case report form and database 21.5.6 Institutional Review Board/Independent Ethics Committee and Competent Authority 21.5.7 Monitoring, audits, and inspections 21.5.8 Sponsor 21.6 Special points to consider 21.6.1 Define the patient 21.6.2 Manufacturing challenges and up-scaling 21.6.3 Exploratory trials in the academic environment 21.6.4 Hospital exemption (EU only) 21.6.5 Voluntary harmonization procedure (EU only) 21.6.6 Combination products 21.7 Future perspective 21.8 Recommended literature 21.8.1 Recommended websites 21.9 Assessment of your knowledge 21.10 Glossary 21.11 References Index A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Back Cover