Bacterial endotoxin detection in hyaluronic acid-based medical devices

Late-Onset Reactions after Hyaluronic Acid Dermal Fillers: A Consensus Recommendation on Etiology, Prevention and Management

Hyaluronic acid (HA) dermal fillers, generally considered low-risk, can lead to rare late-onset reactions (LORs) manifesting between 3 and 4 months postinjection, occasionally even as early as 24 h postinjection. The Complication Assessment and Risk Evaluation (CARE) board was established to review these reactions. In this publication, the authors aims to explore the etiological hypotheses underlying LORs, associated risk factors, prevention, and management approaches suggested by the CARE board. The CARE board identified three etiological hypotheses contributing to LORs. Firstly, the physicochemical structure of the filler, particularly low molecular weight HA, which may trigger an immune response. Secondly, infection, potentially introduced during injection or by dormant biofilm activation. Lastly, an imbalance in the host immune system, caused by factors like autoimmune diseases or viral infections, may lead to extended foreign body reactions, delayed type IV hypersensitivity, or adjuvant-based reactions. Based on these hypotheses, the board categorized various risk factors as patient-related (e.g., recent dental treatment, current medical status, active autoimmune disease), product-related (e.g., molecular weight), and procedure-related (e.g., aseptic technique and trauma). To reduce the risk of LORs, the CARE board recommends diligent patient selection, including comprehensive medical history assessment and informed consent. Practitioners should maintain an effective aseptic technique, and choose an appropriate product and injection depth for the anatomical location. Post-procedure, patients should receive education on proper filler care. Management of LORs depends on the suspected etiology, and the CARE board has proposed an algorithm to determine the most appropriate treatment. Hyaluronidase is recommended for noninflammatory reactions in the absence of active infection, while watchful waiting and/or steroid treatment may be preferred for inflammatory reactions. Hyaluronidase is not recommended as a first-line treatment for infections, which require drainage, bacterial culture, and antibiotic treatment. However, the board emphasizes the need for individualized evaluation and treatment in all cases.

Diversity, Complexity, and Specificity of Bacterial Lipopolysaccharide (LPS) Structures Impacting Their Detection and Quantification

Endotoxins are toxic lipopolysaccharides (LPSs), extending from the outer membrane of Gram-negative bacteria and notorious for their toxicity and deleterious effects. The comparison of different LPSs, isolated from various Gram-negative bacteria, shows a global similar architecture corresponding to a glycolipid lipid A moiety, a core oligosaccharide, and outermost long O-chain polysaccharides with molecular weights from 2 to 20 kDa. LPSs display high diversity and specificity among genera and species, and each bacterium contains a unique set of LPS structures, constituting its protective external barrier. Some LPSs are not toxic due to their particular structures. Different, well-characterized, and highly purified LPSs were used in this work to determine endotoxin detection rules and identify their impact on the host. Endotoxin detection is a major task to ensure the safety of human health, especially in the pharma and food sectors. Here, we describe the impact of different LPS structures obtained under different bacterial growth conditions on selective LPS detection methods such as LAL, HEK-blue TLR-4, LC-MS2, and MALDI-MS. In these various assays, LPSs were shown to respond differently, mainly attributable to their lipid A structures, their fatty acid numbers and chain lengths, the presence of phosphate groups, and their possible substitutions.

Evaluation for endotoxin in intraocular materials used during phacoemulsification surgery using a recombinant factor C assay

OBJECTIVE

Cataract surgery remains the sole method to resolve blindness secondary to cataract formation. One complication includes fibrin web formation post-operatively. This study aimed to investigate the presence of endotoxin within materials used during cataract surgery as a possible cause of fibrin web phenomenon.

METHODS

Preservative-free epinephrine, heparin, viscoelastic devices, and intraocular lenses were collected for evaluation. Various manufacturers and manufacturing lot numbers were used when available. Viscosity of viscoelastics was reduced by incubating samples with human recombinant hyaluronidase. Intraocular product (IOL) packaging fluid was collected and stored for testing. The IOLs were then washed with a sterile balanced salt solution, incubated at 37°C for 48 h, and then fluid was collected for testing to mimic intraocular placement. Samples were tested using a commercially available rFC kit. Fluorescence was measured at time zero and after 1 h using a fluorescence microplate reader. The change in fluorescence was corrected for blank fluorescence and plotted to a standard curve.

RESULTS

Endotoxin levels were below the limit of detection (0.05 EU/mL) in all samples. Incubation of IOLs at intraocular temperature did not increase extraction of endotoxin.

CONCLUSION

Endotoxin was not identified in any tested sample, including those used in cases of fibrin web formation post-phacoemulsification. As fibrin webs are often observed episodically, it is possible that endotoxin levels may vary between batches, or that endotoxin is not related to fibrin formation.

Ophthalmic viscoelastics commonly used in cataract surgery: A microbiota investigation

PURPOSE

To survey commonly used, sterile ophthalmic viscoelastic materials used during routine cataract surgery for the presence of bacterial DNA and/or viable bacteria and endotoxin quantification.

METHODS

Samples from three different ophthalmic viscoelastic manufacturers and three different production lots per manufacturer were collected for 16 S ribosomal ribonucleic acid (rRNA) sequencing and conventional aerobic and capnophilic bacterial culture. Other samples of viscoelastic material from the same three manufacturers were collected for endotoxin quantification using a commercially available Limulus amebocyte lysate (LAL) assay. Statistical analysis was performed using Sigma Plot 14.0, and R v4.0.2.0. Differences (p ≤ .05) between sample collection sites in total DNA concentration, microbial richness, mean intra-group distances, and endotoxin quantification alongside reagent controls were evaluated.

RESULTS

Culture yielded two isolates, identified as Staphylococcus epidermidis and Bacillus megaterium. 16 S rRNA sequencing revealed no differences between brands in richness or overall composition. The most common bacterial DNA detected across all brands was Staphylococcus sp., Cutibacterium sp., Flavobacterium sp., and Lactobacillus sp. A significant difference was found between the median endotoxin concentration between Anvision and Hyvisc® viscoelastic (Anvision: 0.171 EU/mL, Hyvisc®: 0.03 EU/mL; p < .001).

CONCLUSIONS

No brand-specific differences in bacterial DNA were detected in the viscoelastic materials. Staphylococcus, Cutibacterium, Flavobacterium, and Lactobacillus were the dominant contributors to the bacterial DNA detected. Although Anvision viscoelastic samples contained significantly more endotoxin than Hyvisc® viscoelastic samples, endotoxin concentrations were below the FDA limit of 0.2 EU/mL for both manufacturers. These data further the understanding of inflammatory outcomes following cataract surgery.

Hyaluronic acid hydrolysis using vacuum ultraviolet TiO2 photocatalysis combined with an oxygen nanobubble system

Advanced technologies for producing high-quality low molecular weight hyaluronic acid (LMW-HA) are required from the perspective of cost-efficiency and biosafety. Here, we report a new LMW-HA production system from high molecular weight HA (HMW-HA) using vacuum ultraviolet TiO₂ photocatalysis with an oxygen nanobubble system (VUV-TP-NB). The VUV-TP-NB treatment for 3 h resulted in a satisfactory LMW-HA (approximately 50 kDa measured by GPC) yield with a low endotoxin level. Further, there were no inherent structural changes in the LMW-HA during the oxidative degradation process. Compared with conventional acid and enzyme hydrolysis methods, VUV-TP-NB showed similar degradation degree with viscosity though reduced process time by at least 8-fold. In terms of endotoxin and antioxidant effects, degradation using VUV-TP-NB demonstrated the lowest endotoxin level (0.21 EU/mL) and highest radical scavenging activity. This nanobubble-based photocatalysis system can thus be used to produce biosafe LMW-HA cost-effectively for food, medical, and cosmetics applications.

High value applications and current commercial market for eggshell membranes and derived bioactives

Chicken eggshell membrane (ESM) is a highly insoluble structure that is greatly stabilized by extensive desmosine, isodesmosine, and disulfide cross-linkages. The ESM possesses numerous biological functions including anti-microbial, anti-inflammatory, anti-wrinkle, and antioxidant activities. The ESM is mainly proteinaceous; proteomics and bioinformatics analysis of ESM has identified > 500 proteins, such as collagens, glycoproteins, avian beta-defensins, and lysozyme. ESM also contains significant amounts of carbohydrate, including hyaluronic acid (HA). In general, HA plays an important role in tissue hydration and cellular mechanisms such as growth, differentiation, and transport, and has diverse health and medical applications. Despite ESM being rich in important bioactive compounds, it is often considered as a waste product of the egg-breaking industry and is under-utilized. A major challenge for the successful commercial exploitation of ESM and bioactive constituents is its limited solubility and bioavailability due to cross-linkages of ESM fibers. Various processing and extraction methods are employed to overcome these limitations and improve the production of HA and collagen-based ESM formats. Moreover, we believe that there is a wide scope to exploit ESM for novel applications, leading to new intellectual property (IP) and patenting opportunities. This review presents an overview of scientific background, IP landscape and current commercial market for ESM and derived bioactives including collagens and HA. A detailed literature survey is provided for each area of interest. We analyze regulatory guidelines for ESM, contrasting quality control / microbial safety assessment in cosmetics and personal care products (hazard based) with that of the food industry (risk-based). New perspectives for upcycling of ESM waste to commercially viable high-value biomaterials as nutraceutical supplements and as cosmetics ingredients are discussed. This overview of ESM separation techniques and applications could form the basis for directed research and product development in order to exploit the unique bioactivities of ESM.

Cost-Effective Cosmetic-Grade Hyaluronan Hydrogels for ReNcell VM Human Neural Stem Cell Culture

Hyaluronic acid (HA) is a polysaccharide polymer frequently used as a starting material to fabricate hydrogels, especially for recapitulating the brain's extracellular matrix (ECM) for in vitro neural stem cell (NSC) cultures. Here, we report the successful synthesis of a methacrylated HA (MeHA) polymer from an inexpensive cosmetic-grade hyaluronan starting material. The MeHA polymers synthesized from cosmetic-grade HA yielded similar chemical purity to those from pharmaceutical/research-grade HA reported in the literature. Crosslinked MeHA (x-MeHA) hydrogels were formed using radical polymerization which resulted in mechanical properties matching previously reported mechanical property ranges for enhanced neuronal differentiation of NSCs. We assessed cellular adhesion, spreading, proliferation, and stiffness-dependent neuronal differentiation properties of ReNcell VM human neural stem cells (hNSCs) and compared our results to studies reported in the literature (that utilized non-human and human pluripotent cell-derived NSCs).

An Effective Translation: The Development of Hyaluronan-Based Medical Products From the Physicochemical, and Preclinical Aspects

This review shows the steps toward material selection focalized on the design and development of medical devices based on hyaluronan (HA). The selection is based on chemical and mechanical properties, biocompatibility, sterilization, safety, and scale-up costs. These facts play a vital role in the industrialization process. Approved medical devices containing-HA are illustrated to identify key parameters. The first part of this work involves the steps toward a complete characterization of chemical and mechanical aspects, reproducibility of the processes and scale up. In a second stage, we aimed to describe the preclinical in vitro and in vivo assays and selected examples of clinical trials. Furthermore, it is important to keep in mind the regulatory affairs during the research and development (R&D) using standardization (ISO standards) to achieve the main goal, which is the functionality and safety of the final device. To keep reproducible experimental data to prepare an efficient master file for the device, based on quality and recorded manufacturing data, and a rigorous R&D process may help toward clinical translation. A strong debate is still going on because the denominated basic research in HA field does not pay attention to the purity and quality of the raw materials used during the development. So that, to achieve the next generation of devices is needed to overcome the limitations of state of art in terms of efficacy, biodegradability, and non-toxicity.

Sequential one-pot multienzyme synthesis of hyaluronan and its derivative

Hyaluronan (HA) is a linear polysaccharide composed of repeating disaccharide units. It has been well documented to play an array of biological functions in cancer events. Here, we reported a sequential one-pot multienzyme (OPME) strategy for in vitro synthesis of HA and its derivatives. The strategy, which combined in situ sugar nucleotides generation with HA chain polymerization, could convert cheap monosaccharides into HA polymers without consuming exogenous sugar nucleotide donors. HA polymers (number-average molecular weight ranged from 1.5×10⁴ to 5.5×10⁵Da) with over 70% yields were efficiently synthesized and purified from this one-pot system. More importantly, partial labeled HA derivative was further synthesized by metabolic incorporation of unnatural monosaccharide analogues into the sequential OPME system. Cross-linked HA hydrogel was achieved via copper (I)-catalyzed azide-alkyne cycloaddition and exhibited novel networks consisting of both inter- and intra-connected HA chains, which could facilitate the potential applications of this unique polysaccharide.