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Clarke DO, Datta K, French K, Leach MW, Olaharski D, Mohr S, Strein D, Bussiere J, Feyen B, Gauthier BE, Graziano M, Harding J, Hershman K, Jacob B, Ji S, Lange R, Salian-Mehta S, Sayers B, Thomas N, Flandre T. Opportunities and challenges for use of minipigs in nonclinical pharmaceutical development: Results of a follow-up IQ DruSafe survey. Regul Toxicol Pharmacol 2024; 154:105729. [PMID: 39481797 DOI: 10.1016/j.yrtph.2024.105729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2024] [Revised: 10/07/2024] [Accepted: 10/19/2024] [Indexed: 11/02/2024]
Abstract
Minipigs are valid nonrodent species infrequently utilized for pharmaceutical research and development (R&D) compared with dogs or nonhuman primates (NHPs). A 2022 IQ DruSafe survey revealed a modest increase in minipig use by pharmaceutical companies compared with a prior 2014 survey, primarily in the development of oral small molecules and parenteral protein molecules. Some companies considered using minipigs more often due to NHP shortages and regional ethical concerns with using NHPs and dogs. However, for most pharmaceutical companies, minipigs still represent ≤5% of their nonrodent animal use. Key challenges noted by companies to wider adoption of minipigs were high test article requirement, limited historical control data, and lack of relevant reagents or assays. Additionally, some companies expressed uncertainties about contract research organization (CRO) capabilities and experience, a perception not shared by respondent CROs. These latest survey results indicate persistence of many concerns previously identified in 2014. Several case studies are included to illustrate areas of expanded minipig use as well as the challenges that hinder broader adoption. Ongoing, focused, and industry-wide initiatives to address the identified or perceived challenges may lead to more frequent or routine consideration of minipigs as a test species in pharmaceutical R&D.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Bianca Feyen
- Johnson & Johnson Innovative Medicine, Beerse, Belgium
| | | | | | - Joanna Harding
- Exscientia (formerly represented Astra Zeneca), Oxford, UK
| | | | | | - Shaofei Ji
- Johnson & Johnson Innovative Medicine, Springhouse, PA, USA
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2
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Jhelum H, Grand N, Jacobsen KR, Halecker S, Salerno M, Prate R, Krüger L, Kristiansen Y, Krabben L, Möller L, Laue M, Kaufer B, Kaaber K, Denner J. First virological and pathological study of Göttingen Minipigs with Dippity Pig Syndrome (DPS). PLoS One 2023; 18:e0281521. [PMID: 37319233 PMCID: PMC10270609 DOI: 10.1371/journal.pone.0281521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/24/2023] [Indexed: 06/17/2023] Open
Abstract
Dippity Pig Syndrome (DPS) is a well-known but rare complex of clinical signs affecting minipigs, which has not been thoroughly investigated yet. Clinically affected animals show acute appearance of red, exudating lesions across the spine. The lesions are painful, evidenced by arching of the back (dipping), and the onset of clinical signs is generally sudden. In order to understand the pathogenesis, histological and virological investigations were performed in affected and unaffected Göttingen Minipigs (GöMPs). The following DNA viruses were screened for using PCR-based methods: Porcine cytomegalovirus (PCMV), which is a porcine roseolovirus (PCMV/PRV), porcine lymphotropic herpesviruses (PLHV-1, PLHV-2, PLHV-3), porcine circoviruses (PCV1, PCV2, PCV3, PCV4), porcine parvovirus 1 (PPV1), and Torque Teno sus viruses (TTSuV1, TTSuV2). Screening was also performed for integrated porcine endogenous retroviruses (PERV-A, PERV-B, PERV-C) and recombinant PERV-A/C and their expression as well as for the RNA viruses hepatitis E virus (HEV) and SARS-CoV-2. Eight clinically affected and one unaffected GöMPs were analyzed. Additional unaffected minipigs had been analyzed in the past. The analyzed GöMPs contained PERV-A and PERV-B integrated in the genome, which are present in all pigs and PERV-C, which is present in most, but not all pigs. In one affected GöMPs recombinant PERV-A/C was detected in blood. In this animal a very high expression of PERV mRNA was observed. PCMV/PRV was found in three affected animals, PCV1 was found in three animals with DPS and in the unaffected minipig, and PCV3 was detected in two animals with DPS and in the unaffected minipig. Most importantly, in one animal only PLHV-3 was detected. It was found in the affected and unaffected skin, and in other organs. Unfortunately, PLHV-3 could not be studied in all other affected minipigs. None of the other viruses were detected and using electron microscopy, no virus particles were found in the affected skin. No porcine virus RNA with exception of PERV and astrovirus RNA were detected in the affected skin by next generation sequencing. This data identified some virus infections in GöMPs with DPS and assign a special role to PLHV-3. Since PCMV/PRV, PCV1, PCV3 and PLHV-3 were also found in unaffected animals, a multifactorial cause of DPS is suggested. However, elimination of the viruses from GöMPs may prevent DPS.
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Affiliation(s)
- Hina Jhelum
- Institute of Virology, Free University, Berlin, Germany
| | | | | | | | - Michelle Salerno
- Marshall BioResources, North Rose, New York, NY, United States of America
| | - Robert Prate
- Institute of Virology, Free University, Berlin, Germany
| | | | | | | | - Lars Möller
- Robert Koch Institute, Centre for Biological Threats and Special Pathogens ZBS 4: Advanced Light and Electron Microscopy, Berlin, Germany
| | - Michael Laue
- Robert Koch Institute, Centre for Biological Threats and Special Pathogens ZBS 4: Advanced Light and Electron Microscopy, Berlin, Germany
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3
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Feller LE, Sargeant A, Ehrhart EJ, Balmer B, Nelson K, Lamoureux J. Cardiac Rhabdomyoma in Four Göttingen Minipigs. Toxicol Pathol 2023; 51:61-66. [PMID: 36726336 DOI: 10.1177/01926233221148393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Göttingen minipigs are increasingly used as an alternative large animal model in nonclinical toxicology studies, and proliferative lesions in this species are rare. Here, we report four cases of cardiac rhabdomyoma in Göttingen minipigs, an incidental and benign mass in the heart. Three cases lacked gross observations and had a microscopic nodule in either the left ventricle or interventricular septum. The last case had a large, firm, raised nodule on a left ventricular papillary muscle noted at necropsy, with additional microscopic intramural masses in the left ventricular wall. In all cases, microscopic evaluation revealed well-circumscribed, expansile nodules composed of bundles of large, highly vacuolated, ovoid to polygonal cells with variable cytoplasmic processes radiating from a centrally located nucleus. Cells displayed patchy accumulation of intracytoplasmic, PAS-positive material and haphazardly arranged cytoplasmic cross-striations. There was no evidence of cardiac insufficiency or other data to suggest the masses were clinically meaningful. Cardiac rhabdomyomas have been reported in meat-hybrid swine, with a breed predisposition in red wattle. This lesion is well established in guinea pigs, but documentation in other laboratory species used in toxicologic studies is limited to two beagle dogs. To our knowledge, this is the first report of spontaneous cardiac rhabdomyoma in Göttingen minipigs.
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Affiliation(s)
- Laine E Feller
- Cornell University, Ithaca, New York, USA
- Johns Hopkins University, Baltimore, Maryland, USA
| | | | - E J Ehrhart
- Charles River Laboratories, Spencerville, Ohio, USA
| | | | - Keith Nelson
- Charles River Laboratories, Mattawan, Michigan, USA
- Inotiv, St. Louis, Missouri, USA
| | - Jennifer Lamoureux
- Charles River Laboratories, Mattawan, Michigan, USA
- Inotiv, St. Louis, Missouri, USA
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Weyrich A, Becker S, Vienenkötter J, Reiner G, Herden C. A rare case of multicentric eosinophilic granulocytic sarcoma as cause of hindlimb weakness and non‐regenerative anaemia in a minipig. VETERINARY RECORD CASE REPORTS 2021. [DOI: 10.1002/vrc2.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Angelika Weyrich
- Institute of Veterinary Pathology Justus‐Liebig‐University Giessen Germany
| | - Sabrina Becker
- Department of Veterinary Clinical Sciences, Swine Diseases Justus‐Liebig‐University Giessen Germany
| | - Julia Vienenkötter
- Institute of Veterinary Pathology Justus‐Liebig‐University Giessen Germany
| | - Gerald Reiner
- Department of Veterinary Clinical Sciences, Swine Diseases Justus‐Liebig‐University Giessen Germany
| | - Christiane Herden
- Institute of Veterinary Pathology Justus‐Liebig‐University Giessen Germany
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Skydsgaard M, Dincer Z, Haschek WM, Helke K, Jacob B, Jacobsen B, Jeppesen G, Kato A, Kawaguchi H, McKeag S, Nelson K, Rittinghausen S, Schaudien D, Vemireddi V, Wojcinski ZW. International Harmonization of Nomenclature and Diagnostic Criteria (INHAND): Nonproliferative and Proliferative Lesions of the Minipig. Toxicol Pathol 2021; 49:110-228. [PMID: 33393872 DOI: 10.1177/0192623320975373] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The INHAND (International Harmonization of Nomenclature and Diagnostic Criteria for Lesions) Project (www.toxpath.org/inhand.asp) is a joint initiative of the Societies of Toxicologic Pathology from Europe (ESTP), Great Britain (BSTP), Japan (JSTP), and North America (STP) to develop an internationally accepted nomenclature for proliferative and nonproliferative lesions in laboratory animals. The purpose of this publication is to provide a standardized nomenclature for classifying microscopic lesions observed in most tissues and organs from the minipig used in nonclinical safety studies. Some of the lesions are illustrated by color photomicrographs. The standardized nomenclature presented in this document is also available electronically on the internet (http://www.goreni.org/). Sources of material included histopathology databases from government, academia, and industrial laboratories throughout the world. Content includes spontaneous lesions as well as lesions induced by exposure to test materials. Relevant infectious and parasitic lesions are included as well. A widely accepted and utilized international harmonization of nomenclature for lesions in laboratory animals will provide a common language among regulatory and scientific research organizations in different countries and increase and enrich international exchanges of information among toxicologists and pathologists.
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Affiliation(s)
| | - Zuhal Dincer
- Pathology Department, Covance Laboratories Limited, Harrogate, United Kingdom
| | - Wanda M Haschek
- Department of Pathobiology, University of Illinois, Urbana, IL, USA
| | - Kris Helke
- Medical University of South Carolina, Charleston, SC, USA
| | | | - Bjoern Jacobsen
- Roche Pharmaceutical Research and Early Development, Pharmaceutical Sciences, Roche Innovation Center, Basel, Switzerland
| | - Gitte Jeppesen
- Charles River Laboratories Copenhagen, Lille Skensved, Denmark
| | - Atsuhiko Kato
- Chugai Pharmaceutical Co, Ltd Research Division, Shizuoka, Japan
| | | | - Sean McKeag
- Pathology Department, Covance Laboratories Limited, Harrogate, United Kingdom
| | | | - Susanne Rittinghausen
- Fraunhofer Institute for Toxicology and Experimental Medicine ITEM, Hannover, Germany
| | - Dirk Schaudien
- Fraunhofer Institute for Toxicology and Experimental Medicine ITEM, Hannover, Germany
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Abstract
Pigs represent a potentially attractive model for medical research. Similar body size and physiological patterns of kidney injury that more closely mimic those described in humans make larger animals attractive for experimentation. Using larger animals, including pigs, to investigate the pathogenesis of acute kidney injury (AKI) also serves as an experimental bridge, narrowing the gap between clinical disease and preclinical discoveries. This article compares the advantages and disadvantages of large versus small AKI animal models and provides a comprehensive overview of the development and application of porcine models of AKI induced by clinically relevant insults, including ischemia-reperfusion, sepsis, and nephrotoxin exposure. The primary focus of this review is to evaluate the use of pigs for AKI studies by current investigators, including areas where more information is needed.
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Affiliation(s)
- Jianni Huang
- Department of Nephrology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - George Bayliss
- Department of Medicine, Rhode Island Hospital and Alpert Medical School, Brown University, Providence, Rhode Island
| | - Shougang Zhuang
- Department of Nephrology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Medicine, Rhode Island Hospital and Alpert Medical School, Brown University, Providence, Rhode Island
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7
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Vrolyk V, Desmarais MJ, Lambert D, Haruna J, Benoit-Biancamano MO. Neonatal and Juvenile Ocular Development in Göttingen Minipigs and Domestic Pigs: A Histomorphological and Immunohistochemical Study. Vet Pathol 2020; 57:889-914. [PMID: 33021158 DOI: 10.1177/0300985820954551] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pigs are considered one of the relevant animal models for ocular research as they share several histological and anatomical similarities with the human eye. With the increasing interest in juvenile animal models, this study aimed to describe the postnatal development of ocular structures in 16 Göttingen minipigs and 25 F2 domestic pigs, between birth and 6 months of age, using histopathology and immunohistochemistry against Ki-67, caspase-3, calbindin, glial fibrillary acidic protein, rhodopsin, and synaptophysin. All ocular structures in both pig breeds were incompletely developed at birth and for variable periods postnatally. Noteworthy histological features of immaturity included vascularization in the corneal stroma in neonatal Göttingen minipigs, increased cellularity in different substructures, remnants of the hyaloid vasculature, short and poorly ramified ciliary body processes, and a poorly developed cone inner segment. Increased cellular proliferation, highlighted by abundant Ki-67 immunolabeling, was observed in almost all developing structures of the pig eye for variable periods postnatally. Apoptosis, highlighted with caspase-3 immunolabeling, was observed in the retinal inner nuclear layer at birth and in the regressing hyaloid vasculature remnants. Immunohistochemistry against rhodopsin, synaptophysin, and calbindin demonstrated the short size of the developing photoreceptors and the immature cone inner segment morphology. Calbindin labeling revealed significant differences in the amount of positively labeled cone nuclei between the retinal area centralis and the non-area centralis regions. The elongation of Müller cell processes in the developing retina was shown with glial fibrillary acidic protein. In both pig breeds, the eyes reached histomorphological and immunohistochemical maturity at 6 months of age.
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Affiliation(s)
- Vanessa Vrolyk
- Research Group on Infectious Diseases in Production Animals (GREMIP) and Swine and Poultry Infectious Disease Research Center (CRIPA), Faculty of Veterinary Medicine, 70354Université de Montréal, Saint-Hyacinthe, Quebec, Canada
- 67115Charles River Laboratories Montreal ULC, Laval, Quebec, Canada
| | | | - Daniel Lambert
- 67115Charles River Laboratories Montreal ULC, Laval, Quebec, Canada
| | - Julius Haruna
- 67115Charles River Laboratories Montreal ULC, Laval, Quebec, Canada
| | - Marie-Odile Benoit-Biancamano
- Research Group on Infectious Diseases in Production Animals (GREMIP) and Swine and Poultry Infectious Disease Research Center (CRIPA), Faculty of Veterinary Medicine, 70354Université de Montréal, Saint-Hyacinthe, Quebec, Canada
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Seely JC, Francke S, Mog SR, Frazier KS, Hard GC. Renal Papillary Rarefaction: An Artifact Mimicking Papillary Necrosis. Toxicol Pathol 2019; 47:645-648. [PMID: 31117926 DOI: 10.1177/0192623319852291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In histopathology, the presence of a tissue change that does not represent the tissue's normal appearance can often lead to an incorrect diagnosis and interpretation. These changes are collectively known as "artifacts" resulting from postmortem autolysis, improper fixation, problems with tissue handling or slide preparation procedures. Most tissue artifacts are obvious, yet some artifacts may be subtle, occur in relatively well-fixed tissue, and demand careful observation to avoid confusion with real biological lesions. The kidney often contains artifacts that may be observed throughout all regions of the renal parenchyma. Cortical tubule artifacts present the greatest challenge when discerning an artifact versus an induced lesion following exposure to a xenobiotic. However, confounding artifacts observed at the tip of the renal papilla may also be problematic for the pathologist. An uncommon artifact involving tinctorial alteration and rarefaction affecting the papillary tip of the rat kidney is described here and differentiated from treatment induced lesions of renal papillary necrosis.
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Affiliation(s)
- John Curtis Seely
- 1 Experimental Pathology Laboratories, Inc, Research Triangle Park, North Carolina, USA
| | - Sabine Francke
- 2 Food and Drug Administration, Office of Food Additive Safety, Center for Food Safety and Applied Nutrition, College Park, Maryland, USA
| | - Steven R Mog
- 2 Food and Drug Administration, Office of Food Additive Safety, Center for Food Safety and Applied Nutrition, College Park, Maryland, USA
| | | | - Gordon C Hard
- 4 Consultant in Toxicology, Pathology, Carcinogenesis, Tairua, New Zealand
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Abstract
Lymph nodes and associated lymphatics filter extracellular fluid and lymph to maintain tissue-fluid balance and detect distant tissue injury. Examination of regional draining lymph nodes (RDLs; lymph nodes that drain the route of article dosing) is an important step in detecting immunotoxicity and other associated changes during general toxicology studies. Similarly, evaluation of RDLs is often a key component of evaluating medical devices. Nonclinical medical device studies can present challenges for RDL evaluation, due to the wide variety of tissues and organs that are implanted with devices, the potential for wear debris/degradation products, and the likely disruption of normal lymphatic drainage by surgical procedures. This article discusses concepts for consideration when designing a nonclinical medical device study that includes the macroscopic evaluation, collection, histologic processing, microscopic assessment, and documentation of findings within RDLs. References describing RDLs for common implantation sites are reported, as are considerations for specific tissues and species commonly used in medical device biocompatibility and functional testing.
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10
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Foditsch EE, Miclaus G, Patras I, Hutu I, Roider K, Bauer S, Janetschek G, Aigner L, Zimmermann R. A new technique for minimal invasive complete spinal cord injury in minipigs. Acta Neurochir (Wien) 2018; 160:459-465. [PMID: 29330575 PMCID: PMC5807451 DOI: 10.1007/s00701-017-3442-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/21/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND The aim of this study was to develop a minimal invasive complete spinal cord injury (SCI) minipig model for future research applications. The minipig is considered a translationally relevant model for SCI research. However, a standardized minimal invasive complete SCI model for pigs has not yet been established. METHODS Adult Göttingen minipigs were anesthetized and placed in extended prone position. After initial computed tomography (CT) scan, the skin was incised, a needle placed in the epidural fatty tissue. Using the Seldinger technique, a guidewire and dilators were introduced to insert the balloon catheter to Th12. After confirmation of the level Th11/Th12, the balloon was inflated to 2 atm for 30 min. The severity of the lesion was followed by CT and by MRI, and by immunohistochemistry. Function was assessed at the motor and sensory level. RESULTS Duration of procedure was about 60 min including the 30-min compression time. The balloon pressure of 2 atm was maintained without losses. The lesion site was clearly discernible and no intradural bleeding was observed by CT. Neurological assessments during the 4-month follow-up time showed consistent, predictable, and stable neurological deficits. Magnetic resonance imaging analyses at 6 h and 4 weeks post SCI with final immunohistochemical analyses of spinal cord tissue underlined the neurological outcomes and proved SCI completeness. CONCLUSIONS We have established a new, minimal invasive, highly standardized, CT-guided spinal cord injury procedure for minipigs. All risks of the open surgery can be excluded using this technique. This CT-guided SC compression is an excellent technique as it avoids long surgery and extensive trauma and allows a feasible inter-animal comparison.
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Affiliation(s)
- Elena E Foditsch
- Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria.
- University Clinics of Urology and Andrology, General Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria.
- Institute of Molecular Regenerative Medicine, Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University, Salzburg, Austria.
| | | | - Irina Patras
- Banat University of Agricultural Sciences and Veterinary Medicine, Timisoara, Romania
| | - Ioan Hutu
- Banat University of Agricultural Sciences and Veterinary Medicine, Timisoara, Romania
| | - Karin Roider
- Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria
- University Clinics of Urology and Andrology, General Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
- Institute of Molecular Regenerative Medicine, Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Sophina Bauer
- University Clinics of Urology and Andrology, General Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Günter Janetschek
- Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria
| | - Ludwig Aigner
- Institute of Molecular Regenerative Medicine, Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University, Salzburg, Austria
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Ramot Y, Weber K, Moreno Lobato B, Sánchez-Margallo FM, Guillén Caro JF, Dávila Gómez L, Shabat R, Nyska A. Trauma as a Cause for Hepatopathy in Newborn Göttingen Minipigs. Toxicol Pathol 2016; 44:1123-1127. [DOI: 10.1177/0192623316667570] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Routine husbandry procedures during animal toxicity studies can result in incidental pathological changes. We report on trauma-induced hepatopathy in newborn Göttingen minipigs. Sixty-four neonatal minipigs were allocated to 13- and 26-week treatment arms. There was a 4-week recovery period for both arms. The animals were divided into 2 treatment groups and a vehicle group and were dosed 3 times daily by direct oral administration using a syringe. During the feeding procedure in the first weeks, the animals had to be handled firmly. After 13 weeks, randomly distributed foci of degeneration/necrosis and focal congestion and/or hemorrhage were found in the livers of several animals from all groups. Reduced incidence and severity were evident in the recovery phase, and the lesions were absent after 26 weeks. These changes were considered as related to the manual handling of the animals. Knowledge of these findings is crucial for interpretation of studies utilizing newborn minipigs.
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Affiliation(s)
- Yuval Ramot
- Hadassah—Hebrew University Medical Center, Jerusalem, Israel
| | | | | | | | | | | | - Roni Shabat
- Roni Shabat CCMI Israel Ltd., Nazareth, Israel
| | - Abraham Nyska
- Sackler School of Medicine, Tel Aviv University, Timrat, Israel
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