Toxicological, medical and industrial hygiene aspects of glutaraldehyde with particular reference to its biocidal use in cold sterilization procedures

Dear Laparoscopic Surgeons: Caution with the Use of Glutaraldehyde!!!

Background

The occupational hazards of glutaraldehyde are well known; the possibility of harm to the patients has been highlighted in the form of isolated reports only.

Objective

To synthesize evidence for contact mucosal injury or injury due to intraperitoneal instillation of glutaraldehyde following its use during laparoendoscopy.

Materials and Methods

The current review is Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) compliant. PubMed, PubMed Central, and Google Scholar were interrogated for animal and human studies upon the harmful effects of glutaraldehyde during laparoscopy and proctosigmoido-colonoscopy.

Results

Thirty-five studies substratified into animal experiments (n = 2), glutaraldehyde-induced colitis (G-iC) postendoscopy (n = 30), and laparoscopy (n = 3) were included. Rats suffered mucosal injury following colonic injection of glutaraldehyde which was time- and concentration-dependent quantum and developed bloody diarrhoea. Omental and renal injury was observed due to glutaraldehyde instillation during simulation of intra-peritoneal insufflation in rats; the serum leucocytes, CRP and creatinine were also elevated. G-iC following colonoscopy was related to contact mucosal injury due to failure (human or machinery) to rinse the chemical off the instrument surface or as a case of mistaken identity (glutaraldehyde was mistaken for saline or another reagent). The incubation period was <24 h in 90% of patients; clinical presentation was related to the initiation of intense inflammation. Intraperitoneal instillation during laparoscopy also leads to intense inflammation. One patient was asymptomatic, the second required laparotomy and peritoneal irrigation for 48 h, while the third case underwent multiple laparotomies for enteric cutaneous and enteroenteric fistulae, adhesions, and multiple intra-abdominal abscesses. Hydronephrosis consequent to retroperitoneal fibrosis has been reported.

Conclusions

The use of glutaraldehyde in the patient care facilities should be discontinued; when unavoidable, the standard processes of disinfection and rinsing must be stringently followed.

Long-term disinfectant exposure on intestinal immunity and microbiome variation of grass carp

The gut microbiome is crucial in maintaining fish health homeostasis. Disinfectants can kill important pathogens and disinfect fish eggs, yet their effect on the immune pathways and intestinal microbiome in healthy fish remains unknown. In this study, we investigated the effects of two disinfectants on the transcriptome profiles, immunological response, and gut microbiota dynamics of grass carp over a four-week trial. In particular, aquatic water was disinfected with 80 μg/L glutaraldehyde or 50 μg/L povidone-iodine. We found that glutaraldehyde and povidone-iodine induced gut antioxidant system and depressed the function of grass carp digestive enzymes. The results of the 16S rDNA high-throughput sequencing identified a reduction in the diversity of grass carp gut microbiota following the disinfectant treatment. Moreover, transcriptome profiling revealed that disinfectant exposure altered the immune-related pathways of grass carp and inhibited the expression of inflammation and tight junction related genes. Finally, the histopathological observation and apoptosis detection results suggested that the long-term diet of disinfectant destroyed intestinal structural integrity and promoted apoptosis. In conclusion, long-term exposure to disinfectants was observed to reduce oxidation resistance, suppress the immune response, dysbiosis of the intestinal flora, and resulted in increasing the apoptosis in intestinal of grass carp.

Weaponizing chitosan and its derivatives in the battle against lung cancer

Lung cancer (LC) is a crisis of catastrophic proportions. It is a global problem and urgently requires a solution. The classic chemo drugs are lagging behind as they lack selectivity, where their side effects are spilled all over the body, and these adverse effects would be terribly tragic for LC patients. Therefore, they could make a bad situation worse, inflict damage on normal cells, and inflict pain on patients. Since our confidence in classic drugs is eroding, chitosan can offer a major leap forward in LC therapy. It can provide the backbone and the vehicle that enable chemo drugs to penetrate the hard shell of LC. It could be functionalized in a variety of ways to deliver a deadly payload of toxins to kill the bad guys. It is implemented in formulation of polymeric NPs, lipidic NPs, nanocomposites, multiwalled carbon nanotubes, and phototherapeutic agents. This review is a pretty clear proof of chitosan's utility as a weapon in battling LC. Chitosan-based formulations could work effectively to kill LC cells. If a researcher is looking for a vehicle for medication for LC therapy, chitosan can be an appropriate choice.

Mimicking the Physicochemical Properties of the Cornea: A Low-Cost Approximation Using Highly Available Biopolymers

Corneal diseases represent a significant global health challenge, often resulting in blindness, for which penetrating keratoplasty is the clinical gold standard. However, in cases involving compromised ocular surfaces or graft failure, osteo-odonto keratoprosthesis (OOKP) emerges as a vital yet costly and complex alternative. Thus, there is an urgent need to introduce soft biomaterials that mimic the corneal tissue, considering its translation's physicochemical, biological, and economic costs. This study introduces a cross-linked mixture of economically viable biomaterials, including gelatin, chitosan, and poly-D-lysine, that mimic corneal properties. The physicochemical evaluation of certain mixtures, specifically gelatin, chitosan, and poly-D-lysine cross-linked with 0.10% glutaraldehyde, demonstrates that properties such as swelling, optical transmittance, and thermal degradation are comparable to those of native corneas. Additionally, constructs fabricated with poly-D-lysine exhibit good cytocompatibility with fibroblasts at 72 h. These findings suggest that low-cost biopolymers, particularly those incorporating poly-D-lysine, mimic specific corneal characteristics and have the potential to foster fibroblast survival. While further studies are required to reach a final corneal-mimicking solution, this study contributes to positioning low-cost reagents as possible alternatives to develop biomaterials with physicochemical properties like those of the human cornea.

The cross-linking ability of dialdo-galactose in food processing condition

Cross-linking is a popular strategy to tailor the mechanical profile of foods and materials. Dialdo-galactose (DAG) is a hetero-sugar bearing two aldehyde groups that could potentially cross-link amino-group rich systems. In this study, we proved even in undesirable Maillard reaction condition, DAG is a very reactive Maillard substrate that could effectively cross-link all the tested foods, enhance their mechanical strength, and generate brown pigments during cross-linking. In particular, DAG treated sea cucumber exhibited good stability against heat-induced deterioration. In addition, DAG treated collagen sausage casing was more elastic and flexible then glutaraldehyde (GA) treated ones. DAG also outperformed GA in generating stronger chitosan hydrogels with higher G', and the DAG cross-linked chitosan film was more robust against acid-catalyzed decompositions. These results have not only confirmed DAG's cross-linking ability in food processing condition, but also provided useful information for the development of new food cross-linking agents based on oxidized saccharides.

Determination of o-phthalaldehyde for dose verification of the clinical disinfectant by fluorescent sequential injection analysis

A new automated, generic analytical approach for determining the clinical disinfectant o-phthalaldehyde (OPA) is reported in this study. The proposed sequential injection analysis (SIA) is based on the online reaction of the OPA with glycine/N-acetylcysteine (NAC) in a neutral medium (pH = 7.0) to form a highly fluorescent isoindole derivative. All critical flow and reaction variables were investigated, while validation was carried out in the linearity detection range (0.0075-0.02%). As a result, excellent linearity (R2 > 0.99) and precision (1.5-2.4% for repeatability and 0.7-2.2% for reproducibility) were achieved for the reference OPA solutions. Furthermore, reasonable concentration verification of OPA disinfection (0.2-0.6%) in healthcare institutes can be achieved using the developed fluorescent SIA due to its good sensitivity (0.111 V/%) and precision (1.0-2.3% for intermediate precision) around the minimum effective concentration (MEC) of 0.3% for Cidex-OPA disinfectant.

An Electrochemical o-Phthalaldehyde Sensor Using a Modified Disposable Screen-Printed Electrode with Polyacrylate Hydrogel for Concentration Verification of Clinical Disinfectant

The study proposes an o-phthalaldehyde (OPA) sensor for rapid and reliable detection of OPA in healthcare disinfection practices, based on a hydrogel-modified screen-printed carbon electrode strip. The hydrogel film, which contains glycine and N-acetylcysteine, reacts with OPA to produce a reductive isoindole derivative. The derivative is then oxidized for OPA determination using cyclic voltammetry. The proposed sensor achieves an optimal detection time of 20-30 s and requires only a small analyte volume of 5 µL. It exhibits good precision (10%) and sensitivity (3.3 μA/cm² mM) in a phosphate-buffered solution (pH 7.6), with excellent linearity (R² > 0.97) and precision (<3%) in the detection range (0.2-0.6%) required for clinical OPA solutions. Moreover, the sensor demonstrates good concentration verification of Cidex-OPA disinfection in healthcare institutes, with high sensitivity (18.28 μA/cm² mM) and precision around the minimum effective concentration (0.3%). Overall, the proposed sensor offers a promising and practical solution for accurate and reliable OPA detection in clinical disinfection practices.

Transdermal drug delivery system of lidocaine hydrochloride based on dissolving gelatin/sodium carboxymethylcellulose microneedles

In this study, it was aimed to introduce a transdermal drug delivery system with dissolving microneedles (DMNs) based on gelatin (GEL) and sodium carboxymethyl cellulose (NaCMC) for lidocaine hydrochloride (LidoHCl) delivery. Different ratios of GEL and NaCMC were mixed, loaded with an active agent of LidoHCl, and treated with glutaraldehyde (GTA) as a crosslinker agent. Prepared hydrogels were cast into a silicon mold. Hereby, microneedles (MNs) with 500 µm height, 35° needle angle, 40-µm tip radius, and 960-µm tip-to-tip distance were fabricated. Samples containing LidoHCl 40%, GEL/NaCMC 5:1 (wt/wt), and polymer/GTA ratio 3.1 (wt/wt) showed the highest drug release ability (t < 10 min) with proper mechanical properties in comparison with other samples. Due to the drug release in a short time (fewer than 10 min), this drug delivery system can be used for rapid local anesthesia for pain relief as well as before minor skin surgeries.

Graphical Abstract

Inhibitory effect of pre-gelatinized dialdehyde starch on heat-induced deterioration of sea cucumber

BACKGROUND

This study sought to investigate the inhibitory effect of pre-gelatinized dialdehyde starch (P-DAS) on the deterioration of sea cucumber during high-temperature sterilization.

RESULTS

It was found that pre-gelatinization reduced crystallinity and average molecular weight of dialdehyde starch (DAS), exposed free aldehyde groups, improved the solubility, and unified the particle sizes. According to the texture profiles of sea cucumber, the crosslinking power of P-DAS was higher than that of DAS. The results of free amino content, total soluble substance, water retention, water distribution, relaxation time and scanning electron microscopy all showed that the crosslinking effect was dose-dependent on crosslinking agent.

CONCLUSION

These results have proved that large molecules such as P-DAS, when properly handled, could also efficiently enter collagen hydrogels and perform crosslinking, providing reference for the development of new protein food stabilizing agents. © 2022 Society of Chemical Industry.

Magnetic CLEAs of β-Galactosidase from Aspergillus oryzae as a Potential Biocatalyst to Produce Tagatose from Lactose

β-galactosidase is an enzyme capable of hydrolysing lactose, used in various branches of industry, mainly the food industry. As the efficient industrial use of enzymes depends on their reuse, it is necessary to find an effective method for immobilisation, maintaining high activity and stability. The present work proposes cross-linked magnetic cross-linked enzyme aggregates (mCLEAs) to prepare heterogeneous biocatalysts of β-galactosidase. Different concentrations of glutaraldehyde (0.6%, 1.0%, 1.5%), used as a cross-linking agent, were studied. The use of dextran-aldehyde as an alternative cross-linking agent was also evaluated. The mCLEAs presented increased recovered activity directly related to the concentration of glutaraldehyde. Modifications to the protocol to prepare mCLEAs with glutaraldehyde, adding a competitive inhibitor or polymer coating, have not been effective in increasing the recovered activity of the heterogeneous biocatalysts or its thermal stability. The biocatalyst prepared using dextran-aldehyde presented 73.6% recovered activity, aside from substrate affinity equivalent to the free enzyme. The thermal stability at 60 °C was higher for the biocatalyst prepared with glutaraldehyde (mCLEA-GLU-1.5) than the one produced with dextran-aldehyde (mCLEA-DEX), and the opposite happened at 50 °C. Results obtained for lactose hydrolysis, the use of its product to produce a rare sugar (D-tagatose) and operational and storage stability indicate that heterogeneous biocatalysts have adequate characteristics for industrial use.

Antibacterial and degradation properties of dialdehyded and aminohexamethylated nanocelluloses

Dialdehyde cellulose nanofibrils (CNF) and nanocrystals (CNC) were prepared via periodate oxidation (CNF/CNC-ox) and subsequently functionalized with hexamethylenediamine (HMDA) via a Schiff-base reaction, resulting in partially crosslinked micro-sized (0.5-10 μm) particles (CNF/CNC-ox-HMDA) with an aggregation and sedimentation tendency in an aqueous media, as assessed by Dynamic Light Scattering and Scanning Electron Microscopy. The antibacterial efficacy, aquatic in vivo (to Daphnia magna) and human in vitro (to A594 lung cells) toxicities, and degradation profiles in composting soil of all forms of CNF/CNC were assessed to define their safety profile. CNF/CNC-ox-HMDA exhibited higher antibacterial activity than CNF/CNC-ox and higher against Gram-positive S. aureus than Gram-negative E. coli, yielding a bacteria reduction of >90 % after 24 h of exposure at the minimum (≤2 mg/mL), but potentially moderately/aquatic and low/human toxic concentrations (≥50 mg/L). The presence of anionic, un/protonated amino-hydrophobized groups in addition to unconjugated aldehydes of hydrodynamically smaller (<1 μm) CNC-ox-HMDA increased the reduction of both bacteria to log 9 at ≥4 mg/mL and their bactericidal activity. While only CNF/CNC-ox can be considered as biosafe and up to >80 % biodegradable within 24 weeks, this process was inhibited for the CNF/CNC-ox-HMDA. This indicated their different stability, application and disposal after use (composting vs. recycling).

Developmental neurotoxicity induced by glutaraldehyde in neuron/astrocyte co-cultured cells and zebrafish

The genotoxicity, development toxicity, carcinogenicity, and acute or chronic toxic effects of glutaraldehyde (GA), particularly during occupational exposure through its use as a fixative, disinfectant, and preservative, are well-documented but its effects on neurotoxicity have not been investigated. We performed in vitro and in vivo studies to examine the developmental neurotoxicity (DNT) of GA. Neurite outgrowth was examined in an in vitro co-culture model consisting of SH-SY5Y human neuroblastoma cells and human astrocytes. Cell Counting Kit-8, lactate dehydrogenase assay, and high-content screening revealed that GA significantly inhibited neurite outgrowth at non-cytotoxic concentration. Further studies showed that GA upregulated the mRNA expression of the astrocyte markers GFAP and S100β and downregulated the expression of the neurodevelopmental genes Nestin, βIII-tubulin, GAP43, and MAP2. Furthermore, in vivo zebrafish embryo toxicity tests explored the effects of GA on neural morphogenesis. GA adversely affected the early development of zebrafish embryos, resulting in decreased survival, irregular hatching, and reduced heart rate in a time- and concentration-dependent manner. Furthermore, the width of the brain and spinal cord was reduced, and the myelination of Schwann cells and oligodendrocytes was decreased by GA in transgenic zebrafish lines. These data suggest that GAs have potential DNT in vitro and in vivo, highlighting the need for caution regarding the neurotoxicity of GA.

The role of aldehyde-functionalized crosslinkers on the property of chitosan hydrogels

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Bacterial safety study of the production process of hemoglobin-based oxygen carriers

Hemoglobin microparticles (HbMP) produced with a three-step procedure, including coprecipitation of hemoglobin with manganese carbonate, protein cross-linking, and dissolution of the carbonate template were shown to be suitable for application as artificial oxygen carriers. First preclinical safety investigations delivered promising results. Bacterial safety plays a decisive role during the production of HbMP. Therefore, the bioburden and endotoxin content of the starting materials (especially hemoglobin) and the final particle suspension are intensively tested. However, some bacteria may not be detected by standard tests due to low concentration. The aim of this study was to investigate how these bacteria would behave in the fabrication process. Biocidal effects are known for glutaraldehyde and for ethylenediaminetetraacetic acid, chemicals that are used in the fabrication process of HbMP. It was shown that both chemicals prevent bacterial growth at the concentrations used during HbMP fabrication. In addition, the particle production was carried out with hemoglobin solutions spiked with Escherichia coli or Staphylococcus epidermidis. No living bacteria could be detected in the final particle suspensions. Therefore, we conclude that the HbMP fabrication procedure is safe in respect of bacterial contamination.

Eu3+-β-diketone functionalized covalent organic framework hybrid material as a sensitive and rapid response fluorescent sensor for glutaraldehyde

A covalent organic framework (named as TpDq) linked by β-ketoamine was prepared by imine condensation reaction with 1,3,5-triformylphloroglucinol (TFP) and 2,6-diaminoanthraquinone (DAAQ) as building blocks. Via employing a functionalized modification strategy, a new lanthanide complex Eu³⁺-β-diketone functionalized covalent organic framework hybrid material, Eu-TTA@TpDq (TTA = 2-thenoyltrifluoroacetone), has been synthesized. After post-synthetic modification (PSM), the shape and structure of the parent framework is well preserved and the modified material shows remarkable luminescence properties. Based on this, we designed it as a fluorescent probe and tried to use it to sense common aldehydes. The results indicate that Eu-TTA@TpDq exhibits a turn-off response toward glutaraldehyde which can distinguish from other common aldehydes. The fluorescent probe has the advantages of reusability, pH stability (4.50-8.52), fast luminescence response (<1 min) and low detection limit. The linear range of this method was 0-100 μM; the detection limit was 4.55 μM; the relative standard deviation was 2.16%. Furthermore, it has broad application prospect in both practical sensing of glutaraldehyde in water environment and simple detection of glutaraldehyde vapor. In addition, we preliminarily discussed the possible sensing mechanism.

Prevalence and Antimicrobial Resistance of Paeniclostridium sordellii in Hospital Settings

(1) Background: The purpose of this study was to determine the prevalence of clostridia strains in a hospital environment in Algeria and to evaluate their antimicrobial susceptibility to antibiotics and biocides. (2) Methods: Five hundred surface samples were collected from surfaces in the intensive care unit and surgical wards in the University Hospital of Tlemcen, Algeria. Bacterial identification was carried out using MALDI-TOF-MS, and then the minimum inhibitory concentrations (MICs) of various antimicrobial agents were determined by the E-test method. P. sordellii toxins were searched by enzymatic and PCR assays. Seven products intended for daily disinfection in the hospitals were tested against Clostridium spp. spore collections. (3) Results: Among 100 isolates, 90 P. sordellii were identified, and all strains were devoid of lethal and hemorrhagic toxin genes. Beta-lactam, linezolid, vancomycin, tigecycline, rifampicin, and chloramphenicol all proved effective against isolated strains. Among all strains tested, the spores of P. sordellii exhibited remarkable resistance to the tested biocides compared to other Clostridium species. The (chlorine-based 0.6%, 30 min), (glutaraldehyde solution 2.5%, 30 min), and (hydrogen peroxide/peracetic acid 3%, 15 min) products achieved the required reduction in spores. (4) Conclusions: Our hospital’s current cleaning and disinfection methods need to be optimized to effectively remove spores from caregivers’ hands, equipment, and surfaces.

Preparation of gels of chitosan through a hydrothermal reaction in the presence of malonic acid and cinnamaldehyde: characterization and antibacterial activity

The preparation of composite gels through the hydrothermal reaction of a mixture of chitosan (CH), malonic acid (MLA), urea (UR) and cinnamaldehyde (CA), all of which are sustainable materials, is reported.

In vitro genotoxicity evaluation and metabolic study of residual glutaraldehyde in animal-derived biomaterials

Glutaraldehyde (GA) is an important additive that is mainly used in animal-derived biomaterials to improve their mechanical and antimicrobial capacities. However, GA chemical toxicity and the metabolic mechanism remain relatively unknown. Therefore, residual GA has always been a major health risk consideration for animal-derived medical devices. In this study, extracts of three bio-patches were tested via the GA determination test and mouse lymphoma assay (MLA). The results showed that dissolved GA was a potential mutagen, which could induce significant cytotoxic and mutagenic effects in mouse lymphoma cells. These toxic reactions were relieved by the S9 metabolic activation (MA) system. Furthermore, we confirmed that GA concentration decreased and glutaric acid was generated during the catalytic process. We revealed GA could be oxidized via cytochrome P450 which was the main metabolic factor of S9. We found that even though GA was possibly responsible for positive reactions of animal-derived biomaterials' biocompatibility evaluation, it may not represent the real situation occurring in human bodies, owing to the presence of various detoxification mechanisms including the S9 system. Overall, in order to achieve a general balance between risk management and practical application, rational decisions based on comprehensive analyses must be considered.

Poisoning of glutaraldehyde-containing products: clinical characteristics and outcomes

OBJECTIVE

This study describes the clinical characteristics, outcomes, and factors at presentation associated with death of cases poisoned by glutaraldehyde (GA)-containing products.

METHODS

We performed a 5-year retrospective cohort study (July 2013-June 2018) using data from the Ramathibodi Poison Center.

RESULTS

There were 244 cases included in this study. Most were men with a median age of 37 years. The GA-containing products were mainly used as farm disinfectants (99.2%), with a median concentration of 15%. Most products (76.2%) contained co-formulants such as cationic detergents and formaldehyde.Most circumstances were accidental (56.9%). The others were suicide attempts by ingestion, except one patient who intentionally injected GA subcutaneously. The most common route of exposure was ingestion (95.0%). Local symptoms in areas of exposure were common. Ingestion resulted in more severe local effects than other routes, and corrosive effects occurred in 23 cases (9.4%). Systemic signs and symptoms occurred in 149 patients (61.1%). Systemic effects included abnormal vital signs, desaturation, altered mental status, hypo/hypernatremia, hypokalemia, low bicarbonate/metabolic acidosis, acute kidney injury (AKI), hepatitis, and rhabdomyolysis. Systemic effects mostly resulted from ingestion. Most patients had mild severity, received only supportive treatment, and fully recovered. The median length of hospital stay was 2 days. The one case of subcutaneous injection developed both local and systemic effects but survived. The mortality rate was 3.7%. Multivariate analysis indicated that either neurological symptoms or AKI at presentation were associated with death.

CONCLUSIONS

In our study, patients were exposed to GA-containing products that were mainly used as farm disinfectants and were generally co-formulated with other substances. Poisoning with these products commonly resulted in mild local irritative symptoms. However, some cases developed corrosive symptoms, systemic effects, or even died. As neurological symptoms or AKI could prognosticate deaths; physicians should look for these factors in patients with GA exposure at presentation for close monitoring and aggressive treatment.

Evaluation of the disinfectant concentration used on livestock facilities in Korea during dual outbreak of foot and mouth disease and high pathogenic avian influenza

BACKGROUND

A nationwide outbreak of foot-and-mouth disease (FMD) in South Korea caused massive economic losses in 2010. Since then, the Animal and Plant Quarantine Agency (QIA) has enhanced disinfection systems regarding livestock to prevent horizontal transmission of FMD and Avian influenza (AI). Although the amount of disinfectant used continues to increase, cases of FMD and AI have been occurring annually in Korea, except 2012 and 2013.

OBJECTIVES

This study measured the concentration of the disinfectant to determine why it failed to remove the horizontal transmission despite increased disinfectant use.

METHODS

Surveys were conducted from February to May 2017, collecting 348 samples from disinfection systems. The samples were analyzed using the Standards of Animal Health Products analysis methods from QIA.

RESULTS

Twenty-three facilities used inappropriate or non-approved disinfectants. Nearly all sampled livestock farms and facilities-93.9%-did not properly adjust the disinfectant concentration. The percentage using low concentrations, or where no effective substance was detected, was 46.9%. Furthermore, 13 samples from the official disinfection station did not use effective disinfectant, and-among 72 samples from the disinfection station-88.89% were considered inappropriate concentration, according to the foot-and-mouth disease virus guidelines; considering the AIV guideline, 73.61% were inappropriate concentrations. Inappropriate concentration samples on automatic (90.00%) and semi-automatic (90.90%) disinfection systems showed no significant difference from manual methods (88.24%). Despite this study being conducted during the crisis level, most disinfectants were used inappropriately.

CONCLUSIONS

This may partially explain why horizontal transmission of FMD and AI cannot be effectively prevented despite extensive disinfectant use.

Corrosive Esophagitis and Gastritis Induced by Glutaraldehyde Ingestion

Corrosive esophagitis and gastritis are characterized by caustic damage due to ingestion of chemical agents. Caustic agents cause tissue destruction through liquefaction or coagulation reactions. Here, we report a case of corrosive esophagitis and gastritis caused by accidental ingestion of glutaraldehyde in Korea. A 62-year-old man presented to the emergency department 8 hours after ingesting glutaraldehyde, which is widely used for the prevention of foot-and-mouth disease in pigs. Urgent endoscopic examination revealed severely damaged mucosae of the esophagus and stomach. With conservative treatment, the patient’s condition was improved, and he was discharged on the 35th day of admission.

On the Stability of Glutaraldehyde in Biocide Compositions

Glutaraldehyde (GA) is used as biocide in hospitals. Recent public investigations on the chemical composition of biocides used in Romania have in some cases found GA, as a key ingredient, to be apparently diluted. However, these data did not explicitly consider the complex chemical equilibria inherent to GA. An investigation of experimental and theoretical data is reported here, assessing the stability of GA solutions relevant for biocide compositions. GA solutions of various chemical composition and under varying circumstances were analyzed using spectroscopy (UV-VIS, Raman, NMR) coupled with density functional theory (DFT) calculations, as well as chemically, such as via the formation of imines in reaction/titration with glycine monitored at 270 nm; using LC-MS; or using SDS-PAGE analysis with GA as reagent in the polymerization of two test proteins- hemoglobin and myoglobin. The spectral properties of GA changed significantly over time, in a temperature-dependent manner; titration with glycine confirmed the spectral data. SDS-PAGE experiments demonstrated a non-linear and apparently unpredictable change in the reactivity of GA over time. The results may be relevant for the determination of GA concentration in various settings such as biocide analysis, hospital wastewaters, and others.

Preparation of CLEAs and magnetic CLEAs of a recombinant l-arabinose isomerase for d-tagatose synthesis

The insolubilization of a recombinant l-arabinose isomerase (l-AI) from Enterococcus faecium by cross-linked enzyme aggregates (CLEA) was investigated, aiming the biochemical production of d-tagatose from d-galactose. d-tagatose is a functional sweetener that has many health benefits, sweetening properties and lower calorific value. Different precipitants (ammonium sulfate, ethanol, acetone, polyethylene glycol 4000) were used in the first step of the protocol, in order to establish the precipitation conditions, and the best results of yield and activity were achieved with ammonium sulfate. In order to facilitate the recovery of the biocatalyst, a new strategy for immobilization of the multimeric enzyme l-arabinose isomerase was proposed. Magnetic cross-linked enzyme aggregates (m-CLEA) were obtained using ammonium sulfate as precipitant and magnetic nanoparticles (MNP) functionalized with APTES (3- Aminopropyltriethoxysilane). Another immobilization strategy was to immobilize the enzyme onto MNP-APTES, as a control. The best results were achieved when the m-CLEA was produced with 20 mg of MNP, 7.69 U. g^-1 of enzymatic activity, 7.61 % of recovered activity, 99 % of yield of immobilization. On the other hand, the enzyme immobilized onto MNP-APTES, presented only 2.12 U. g^-1 of enzymatic activity, 32.3 % of recovered activity, and 15 % of yield of immobilization.

Anticipating Xenogenic Pollution at the Source: Impact of Sterilizations on DNA Release From Microbial Cultures

The dissemination of DNA and xenogenic elements across waterways is under scientific and public spotlight due to new gene-editing tools, such as do-it-yourself (DIY) CRISPR-Cas kits deployable at kitchen table. Over decades, prevention of spread of genetically modified organisms (GMOs), antimicrobial resistances (AMR), and pathogens from transgenic systems has focused on microbial inactivation. However, sterilization methods have not been assessed for DNA release and integrity. Here, we investigated the fate of intracellular DNA from cultures of model prokaryotic (Escherichia coli) and eukaryotic (Saccharomyces cerevisiae) cells that are traditionally used as microbial chassis for genetic modifications. DNA release was tracked during exposure of these cultures to conventional sterilization methods. Autoclaving, disinfection with glutaraldehyde, and microwaving are used to inactivate broths, healthcare equipment, and GMOs produced at kitchen table. DNA fragmentation and PCR-ability were measured on top of cell viability and morphology. Impact of these methods on DNA integrity was verified on a template of free λ DNA. Intense regular autoclaving (121°C, 20 min) resulted in the most severe DNA degradation and lowest household gene amplification capacity: 1.28 ± 0.11, 2.08 ± 0.03, and 4.96 ± 0.28 logs differences to the non-treated controls were measured from E. coli, S. cerevisiae, and λ DNA, respectively. Microwaving exerted strong DNA fragmentation after 100 s of exposure when free λ DNA was in solution (3.23 ± 0.06 logs difference) but a minor effect was observed when DNA was released from E. coli and S. cerevisiae (0.24 ± 0.14 and 1.32 ± 0.02 logs differences with the control, respectively). Glutaraldehyde prevented DNA leakage by preserving cell structures, while DNA integrity was not altered. The results show that current sterilization methods are effective on microorganism inactivation but do not safeguard an aqueous residue exempt of biologically reusable xenogenic material, being regular autoclaving the most severe DNA-affecting method. Reappraisal of sterilization methods is required along with risk assessment on the emission of DNA fragments in urban systems and nature.

In vitro study of chitosan-based multi-responsive hydrogels as drug release vehicles: a preclinical study

Systematic administration of painkillers and anti-inflammatory drugs is routinely employed to minimize pain and bodily disorders. Controlled drug delivery has the potential to improve the outcomes of disorders by providing sustained exposure to efficacious drug concentrations. Herein, we report the fabrication of multi-responsive hydrogels using reactive and functional polymers such as chitosan and polyvinyl pyrrolidone by varying the concentration of a cleavable crosslinker, tetraethyl orthosilicate. The swelling indices of the hydrogels were evaluated in distilled water, solutions with different pH values and different electrolytes. FTIR, WAXRD and TGA were conducted to investigate the structures, crystallinities and thermal stabilities of the prepared multi-responsive hydrogels, respectively. The ultimate tensile strength and elongations at break of the fabricated hydrogels were investigated to assess their mechanical stability. Optical microscopy, biodegradation, antimicrobial and cytotoxicity analyses were further carried out to verify the magnified crosslinked and porous structures, biodegradabilities, biocompatibilities and toxic behaviour of the as-prepared hydrogels, respectively. Drug release analysis was conducted to evaluate their release behaviour in PBS, SGF, SIF and electrolyte solutions. The overall results indicate the successful development of novel, non-toxic and sustained drug deliverable hydrogels, which can be considered as a paramount success towards the fabrication of controlled drug delivery systems.

Use of ethylene-oxide gas sterilisation to terminate multidrug-resistant bacterial outbreaks linked to duodenoscopes

Background

Cleaning and high-level disinfection have been the standard in the USA and other countries for reprocessing flexible endoscopes, including duodenoscopes and other types of gastrointestinal endoscopes. For decades, this practice has been a cornerstone for infection prevention in the endoscopic setting. However, amid recent reports associating the use of duodenoscopes with infections and outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) and related multidrug-resistant organisms (MDROs), reasonable questions about the adequacy of current practices for reprocessing duodenoscopes have emerged.

Objectives

To review and evaluate the adequacy of current reprocessing practices for preventing duodenoscopes from transmitting CRE and related MDROs.

Methods

The MEDLINE/PubMed database was searched to identify published cases associating confirmed (or suspected) infections of CRE or a related MDRO with exposure to a duodenoscope since 2012, when duodenoscopes became a recognised risk factor for the transmission of CRE. The Internet was also searched to identify news articles and other reports documenting eligible cases occurring during this same timeframe but not identified during the MEDLINE database’s search. The Food and Drug Administration’s (FDA) medical device database was queried to identify regulatory reports describing these same types of cases, also recorded since 2012. The clinical and reprocessing details of each eligible case were reviewed to identify (when possible): (a) the reprocessing method (eg, high-level disinfection) performed at the time of the infections, (b) whether the facility’s compliance with the manufacturer’s reprocessing instructions was confirmed, and (c) the measure(s) or corrective action(s) the facility implemented to prevent additional multidrug-resistant infections.

Results

Seventeen cases in the USA and six in other countries (primarily Europe) associating infections (and colonizations) of CRE or a related MDRO with exposure to a duodenoscope were reviewed. Fourteen of these 23 outbreaks were caused by CRE, and six by a related MDRO. Two of these six latter cases identified Klebsiella pneumoniae carrying the mcr-1 gene as the pathogen. For 12 of these 23 cases, it was reported or implied that the duodenoscope was being high-level disinfected at the time of the infections, consistent with published guidelines. For the remaining 11 cases, the associated report(s) did not clearly identify how the duodenoscope was being reprocessed at the time of the infections (although it may be reasonably concluded that at least some, if not all, of these 11 cases involved high-level disinfection).

Further, eight of the 23 cases reported the duodenoscope was being reprocessed in accordance with the manufacturer’s instructions for use (and professional guidelines) at the time of the infections. Seven of the cases discussed the design of the duodenoscope (eg, the forceps elevator mechanism) in the context of reprocessing and the infections. Three of the cases identified one or more reprocessing lapses, including inadequate cleaning, delayed reprocessing and improper drying and/or storage of the duodenoscope. Most of these 23 cases were associated with exposure to a duodenoscope model featuring a sealed elevator-wire channel. Six of the cases reported adopting (or in one case supplementing high-level disinfection with) ethylene oxide (EO) gas sterilisation of the duodenoscope, with at least three reporting this measure terminated the outbreak. Other measures adopted to prevent additional infections included removing the implicated duodenoscope from use, re-training staff about proper cleaning, microbiological culturing of the duodenoscope and returning the duodenoscope to the manufacturer for evaluation, maintenance and/or repair.

Conclusions

This study's findings suggest current reprocessing practices may not always be sufficiently effective to prevent a duodenoscope from transmitting CRE and related MDROs, at least in some circumstances including an outbreak setting. Factors this review identified that may contribute to the device remaining contaminated after reprocessing include the device’s design; breaches of recommended reprocessing guidelines (eg, inadequate manual cleaning, delayed reprocessing or improper device storage); damage to the device; lacking servicing, maintenance or repair; and/or the presence of biofilms. Measures that can mitigate the impact of these and other reprocessing challenges and reduce, if not eliminate, the risk of transmission of CRE or a related MDRO by a duodenoscope include the use of EO gas sterilization (or another comparably effective process or method). In 2015, the FDA suggested healthcare facilities consider performing at least one of four supplemental measures, which include EO gas sterilisation, to improve the effectiveness of duodenoscope reprocessing. Whether the FDA and Centers for Disease Control and Prevention might reclassify duodenoscopes as critical devices requiring sterilisation is currently unresolved.

Degradability of chitosan micro/nanoparticles for pulmonary drug delivery

Chitosan, a natural carbohydrate polymer, has long been investigated for drug delivery and medical applications due to its biodegradability, biocompatibility and low toxicity. The micro/nanoparticulate forms of chitosan are reported to enhance the efficiency of drug delivery with better physicochemical properties including improved solubility and bioavailability. This polymer is known to be biodegradable and biocompatible; however, crosslinked chitosan particles may not be biodegradable. Crosslinkers (e.g., tripolyphosphate and glutaraldehyde) are needed for efficient micro/nanoparticle formation, but it is not clear whether the resultant particles are biodegradable or able to release the encapsulated drug fully. To date, no studies have conclusively demonstrated the complete biodegradation or elimination of chitosan nanoparticles in vivo. Herein we review the synthesis and degradation mechanisms of chitosan micro/nanoparticles frequently used in drug delivery especially in pulmonary drug delivery to understand whether these nanoparticles are biodegradable.

Fabrication of Quaternized Chitosan Nanoparticles Using Tripolyphosphate/Genipin Dual Cross-Linkers as a Protein Delivery System

Various amounts of 2-((acryloyloxy)ethyl)trimethylammonium chloride were grafted onto chitosan (CS) via redox polymerization method to obtain water-soluble quaternized CS (QCS). The QCS nanoparticles loaded with bovine serum albumin (BSA) were then produced by ionic gelation with tripolyphosphate (TPP) and further covalently cross-linked with genipin. The formation of QCS nanoparticles was optimized as a function of monomer grafting yield, QCS/TPP weight ratio, and QCS/genipin weight ratio by Box-Behnken design and response surface methodology. The results showed that QCS nanoparticles prepared with a grafting yield of 50%, QCS/TPP weight ratio of 7.67, and QCS/genipin weight ratio of 60 had a particle size of 193.68 ± 44.92 nm, polydispersity of 0.232, zeta potential of +23.97 mV and BSA encapsulation efficiency of 46.37 ± 2.89%, which were close to the predicted values from mathematical models. In vitro drug release studies at pH 1.2 and pH 7.4 exhibited that the release rate of BSA was significantly decreased and the release period was significantly prolonged after QCS nanoparticles cross-linking with genipin. Therefore, QCS nanoparticles cross-linked with TPP/genipin dual cross-linkers may be a promising protein drug carrier for a prolonged and sustained delivery.

Acute Glutaraldehyde Mucosal Injury of the Upper Aerodigestive Tract Due to Damage to the Working Channel of an Endoscope

Objectives

Glutaraldehyde (Cidex) is a commonly used agent for cold sterilization of endoscopes despite its known irritative, allergic, and carcinogenic potential. This report details the clinical course of 2 patients who suffered acute glutaraldehyde exposure during office injection procedures.

Methods

Clinical records of 2 outpatients undergoing office injection procedures were reviewed. One patient underwent bilateral injections of hydroxyapatite, and 1 underwent voice gel injection.

Results

Both patients developed acute mucosal injury in the form of supraglottitis and laryngitis. Both patients required inpatient admission with airway monitoring (1 requiring admission to the intensive care unit) and were treated with steroids and antibiotics. The same channel endoscope was used for both procedures and was noted after careful examination to have retained glutaraldehyde inside the scope due to a perforation of the lining of the working channel.

Conclusions

Glutaraldehyde can cause acute mucosal injury to supraglottic and glottic structures, and diligent procedures must be maintained for flushing the channels and monitoring glutaraldehyde retention in the channels. Great care should be taken to avoid damage to the lining of working channels from instrumentation.

The Effect of Sterilization Methods of Endoscopic Instruments on the Body: A Study on Rat Model

PURPOSE

Laparoscopy is widely used in many surgical areas for diagnosis and treatment. The need for sterilization of reusable instruments is an important issue. Ensuring patient safety, preventing infection, and protecting the functionality of the instruments are the most important points to be considered. We aimed to investigate two sterilization methods and their effects generated by their distribution into intra-abdominal tissues during insufflation.

MATERIALS AND METHODS

21 rats were used in the study. The Control Group (Group 1) received anesthesia for 1 hour; Group 2 (Glutaraldehyde (GA)-Pneumoperitoneum Group) received anesthesia for 1 hour; Group 3 (Ethylene Oxide (EO)-Pneumoperitoneum Group) received anesthesia for 1 hour. After 24 hours, the animals were sacrificed, and the kidneys and omentum of the animals were analyzed in a histopathological manner. Blood samples were analyzed at preoperative 24th hour and at postoperative 24th hour.

RESULTS

There was a statistically significant difference in omentum, endothelium, and glomerular scores between the groups (p < 0.001 for all groups). Endothelial and glomerular scores were different at a statistically significant level in the EO and GA groups compared to the Control Group. The total score was higher at a statistically significant level in the EO and GA groups compared to the Control Group (p < 0.001 for both groups).

CONCLUSION

It was determined in our study that sterilization methods such as EO and GA cause damage in intra-abdominal tissues. In the light of these results, we consider that the most ideal laparoscopic surgery set is the single-use laparoscopy set. However, this does not seem possible especially in developing countries in practice.

Optimisation of one-step desolvation and scale-up of gelatine nanoparticle production

Gelatine nanoparticles (GNPs) are biodegradable and biocompatible drug delivery systems with excellent clinical performances. A two-step desolvation is commonly used for their preparation, although this methodology has several shortcomings: lack of reproducibility, small scales and low yields. A straightforward and more consistent GNP preparation approach is presented here focusing on the development of a one-step desolvation with the use of a commercially available gelatine type. Controlled stirring conditions and ultrafiltration are used to achieve large-scale production of nanoparticles of up to 2.6 g per batch. Particle size distributions are conserved and comparable to those determined for two-step desolvation on small scale. Additionally, a range of cross-linking agents is examined for their effectiveness in stabilising GNPs as an alternative to glutaraldehyde. Glyceraldehyde demonstrated outstanding properties, which led to high colloidal stability. This approach optimises the manufacturing process and the scale-up of the production capacity, providing a clear potential for future applications.

Preparation and characterization of genipin-cross-linked silk fibroin/chitosan sustained-release microspheres

We report the effects of distinct concentrations of genipin and silk fibroin (SF):chitosan (CS) ratios on the formation of SF–CS composite microspheres. We selected microspheres featuring an SF:CS ratio of 1:1, encapsulated various concentrations of bovine serum albumin (BSA), and then compared their encapsulation efficiency and sustained-release rate with those of pure CS microspheres. We determined that the following five groups of microspheres were highly spherical and featured particle sizes ranging from 70 μm to 147 μm: mass ratio of CS:SF =1:0.5, 0.1 g or 0.5 g genipin; CS:SF =1:1, 0.05 g or 1 g genipin; and CS:SF =1:2, 0.5 g genipin. The microspheres prepared using 1:1 CS:SF ratio and 0.05 g genipin in the presence of 10 mg, 20 mg, and 50 mg of BSA exhibited encapsulation efficiencies of 50.16%±4.32%, 56.58%±3.58%, and 42.19%±7.47%, respectively. Fourier-transform infrared spectroscopy (FTIR) results showed that SF and CS were cross-linked and that the α-helices and random coils of SF were converted into β-sheets. BSA did not chemically react with CS or SF. Moreover, thermal gravimetric analysis (TGA) results showed that the melting point of BSA did not change, which confirmed the FTIR results, and X-ray diffraction results showed that BSA was entrapped in microspheres in a noncrystalline form, which further verified the TGA and FTIR data. The sustained-release microspheres prepared in the presence of 10 mg, 20 mg, and 50 mg of BSA burst release 30.79%±3.43%, 34.41%±4.46%, and 41.75%±0.96% of the entrapped BSA on the 1st day and cumulatively released 75.20%±2.52%, 79.16%±4.31%, and 89.04%±4.68% in 21 days, respectively. The pure CS microspheres prepared in the presence of 10 mg of BSA burst release 39.53%±1.76% of BSA on the 1st day and cumulatively released 83.57%±2.33% of the total encapsulated BSA in 21 days. The SF–CS composite microspheres exhibited higher sustained release than did the pure CS microspheres, and thus these composite microspheres might function as a superior drug carrier.

Long-term storage of aerobic granules in liquid media: viable but non-culturable status

Long-term storage and successful reactivation after storage are essential for practical applications of aerobic granules on wastewater treatment. This study cultivated aerobic granules (SI) in sequencing batch reactors and then stored the granules at 4 °C in five liquid media (DI water (SW), acetone (SA), acetone/isoamyl acetate mix (SAA), saline water (SS), and formaldehyde (SF)) for over 1 year. The first four granules were then successfully reactivated in 24h cultivation. The specific oxygen uptake rates (SOUR) of the granules followed SI>SS>SA>SAA>SW>SF; and the corresponding granular strengths (10 min ultrasound) followed SI>SA=SS>SAA>SW>>SF. During storage the granular cells secreted excess quantities of cyclic-diguanylate (c-di-GMP) and pentaphosphate (ppGpp) as responses to the stringent challenges. We proposed that to force cells in granules (Alphaproteobacteria, Flavobacteria, Betaproteobacteria, Gammaproteobacteria, Actinobacteria, Sphingobacteria, and Clostridia) entering viable but non-culturable (VBNC) status is the key of success for extended period storage of granules.

Effect of mouse strain in a model of chemical-induced respiratory allergy

The inhalation of many types of chemicals is a leading cause of allergic respiratory diseases, and effective protocols are needed for the detection of environmental chemical–related respiratory allergies. In our previous studies, we developed a method for detecting environmental chemical–related respiratory allergens by using a long-term sensitization–challenge protocol involving BALB/c mice. In the current study, we sought to improve our model by characterizing strain-associated differences in respiratory allergic reactions to the well-known chemical respiratory allergen glutaraldehyde (GA). According to our protocol, BALB/c, NC/Nga, C3H/HeN, C57BL/6N, and CBA/J mice were sensitized dermally with GA for 3 weeks and then challenged with intratracheal or inhaled GA at 2 weeks after the last sensitization. The day after the final challenge, all mice were euthanized, and total serum IgE levels were assayed. In addition, immunocyte counts, cytokine production, and chemokine levels in the hilar lymph nodes (LNs) and bronchoalveolar lavage fluids (BALF) were also assessed. In conclusion, BALB/c and NC/Nga mice demonstrated markedly increased IgE reactions. Inflammatory cell counts in BALF were increased in the treated groups of all strains, especially BALB/c, NC/Nga, and CBA/J strains. Cytokine levels in LNs were increased in all treated groups except for C3H/HeN and were particularly high in BALB/c and NC/Nga mice. According to our results, we suggest that BALB/c and NC/Nga are highly susceptible to respiratory allergic responses and therefore are good candidates for use in our model for detecting environmental chemical respiratory allergens.

2,5-Dimethoxy 2,5-dihydrofuran crosslinked chitosan fibers enhance bone regeneration in rabbit femur defects

Chitosan fibers were fabricated via pH induced neutralization and precipitation in a 5 w/v% NaOH bath.

Gelatin-based nanoparticles as drug and gene delivery systems: reviewing three decades of research

Gelatin is one of the most versatile natural biopolymers widely used in pharmaceutical industries due to its biocompatibility, biodegradability, low cost and numerous available active groups for attaching targeting molecules. These advantages led to its application in the synthesis of nanoparticles for drug and gene delivery during the last thirty years. The current article entails a general review of the different preparation techniques of gelatin nanoparticles (GNPs): desolvation, coacervation-phase separation, emulsification-solvent evaporation, reverse phase microemulsion, nanoprecipitation, self-assembly and layer-by-layer coating, from the point of view of the methodological and mechanistic aspects involved. Various crosslinkers used to improve the physicochemical properties of GNPs includintg aldehydes, genipin, carbodiimide/N-hydroxysuccinimide, and transglutaminase are reported. An analysis is given of the physicochemical behavior of GNPs including drug loading, release, particle size, zeta-potential, cytotoxicity, cellular uptake and stability. This review also attempts to provide an overview of the major applications of GNPs in drug delivery and gene therapy and their in vivo pharmacological performances, as well as site-specific drug targeting using various ligands modifying the surface of GNPs. Finally, nanocomplexes of gelatin with polymers, lipids or inorganic materials are also discussed.

A novel hemostatic sealant composed of gelatin, transglutaminase and thrombin effectively controls liver trauma-induced bleeding in dogs

AIM

novel hemostatic sealant based on the in situ gel formation of gelatin catalyzed by thrombin and crosslinked by transglutaminase was designed. The aim of this study was to investigate the efficacy of the hemostatic sealant in control of bleeding caused by liver trauma in dogs.

METHODS

Hepatic trauma that mimicked the grade III-IV rupture of liver was made in 20 dogs. The traumatic lesion was topically administered the hemostatic sealant (treatment group, n=10), or a thrombin solution (control group, n=10). The time to achieve hemostasis and the blood loss were measured. Contrast-enhanced ultrasound (CEUS) examination was performed in each animal on d 3, d 7, and d 10 d postoperatively to study the healing of the lesions.

RESULTS

The mean time to achieve hemostasis in the treatment group was significantly shorter than that in the control group (1.20±0.33 vs 6.70±0.64 min, P<0.05). The mean blood loss in the treatment group was significantly less than that in the control group (47.22±8.61 vs 79.29±11.97 mL, P<0.05). In CEUS examination, the traumatic lesions in the treatment group became significantly smaller on d 3, and disappeared on d 7, whereas the lesions in the control group still existed on d 10. Ascites were never found during 10 d follow-up in the treatment group but were observed on d 3 and d 7 in the control group.

CONCLUSION

Compared with thrombin, the novel hemostatic sealant shows much better efficacy in hemostasis and may promote wound healing in dog liver trauma.

Glutaraldehyde exposure and its occupational impact in the health care environment

Despite the search for effective and less toxic substitutes, glutaraldehyde (GA) remains one of the few substances capable of high-level instrument disinfection in modern health care. Workers commonly affected include operating room nurses, radiographers, x-ray technicians and cleaners. Widespread hospital usage combined with its well-known irritant properties, has ensured an increase in occupationally-related illnesses during recent years. Operating room nurses, laboratory workers and x-ray technicians frequently contact GA in both the liquid and vapor form. Workplace exposure is usually dependent on job tasks, ventilation levels and the use of protective equipment. GA is a relatively potent irritant and sensitizer, with a well-documented history of symptoms following occupational exposure. Although mechanisms for GA toxicity have been postulated, research on the toxicological, teratogenic, and carcinogenic potential of this chemical has shown inconsistent results. Reducing workplace exposure to its lowest possible level represents the most important hazard reduction strategy. This may be achieved by keeping GA containers tightly sealed when not in use, maintaining adequate ventilation levels and the rigid adherence to appropriate personal protective equipment. Substitution with automated cold sterilization machines may be another appropriate measure, while banning unnecessary practices such as GA fogging and its use as a surface disinfectant may also be helpful in reducing occupational exposure in the health care environment.