A comparative review on methods of detection and quantification of mycotoxins in solid food and feed: a focus on cereals and nuts

Many emerging factors and circumstances urge the need to develop and optimize the detection and quantification techniques of mycotoxins in solid food and feed. The diversity of mycotoxins, which have different properties and affinities, makes the standardization of the analytical procedures and the adoption of a single protocol that covers the attributes of all mycotoxins a tedious or even an impossible mission. Several modifications and improvements have been undergone in order to optimize the performance of these methods including the extraction solvents, the extraction methods, the clean-up procedures, and the analytical techniques. The techniques range from the rapid screening methods, which lack sensitivity and specificity such as TLC, to a spectrum of more advanced protocols, namely, ELISA, HPLC, and GC-MS and LC-MS/MS. This review aims at assessing the current studies related to these analytical techniques of mycotoxins in solid food and feed. It discusses and evaluates, through a critical approach, various sample treatment techniques, and provides an in-depth examination of different mycotoxin detection methods. Furthermore, it includes a comparison of their actual accuracy and a thorough analysis of the observed benefits and drawbacks.

Staphylococcus epidermidis biofilm assembly and self-dispersion: bacteria and matrix dynamics

Staphylococcus epidermidis, despite being a commensal of human skin and mucosa, is a major nosocomial pathogen implicated in device-associated infections. The dissemination of infection to other body sites is related to biofilm dispersal. This study focused on the dispersion stage of S. epidermidis CIP 444 biofilm, with the assessment of biofilm matrix composition in a time-dependent experiment (7 days extended) with 3 independent repetitions, using confocal laser scanning microcopy (CLSM) in association with ZEN 3.4 blue edition, COMSTAT, and ImageJ software. SYTO-9, propidium iodide (PI), DID'OIL, FITC, and calcofluor white M2R (CFW) were used to stain biofilm components. The results indicated that the biomass of dead cells increased from 15.18 ± 1.81 µm3/µm2 (day 3) to 23.15 ± 6.075 µm3/µm2 (day 4), along with a decrease in alive cells' biomass from 22.75 ± 2.968 µm3/µm2 (day 3) to 18.95 ± 5.713 µm3/µm2 (day 4). When the intensities were measured after marking the biofilm components, in a 24-h-old biofilm, polysaccharide made up the majority of the investigated components (52%), followed by protein (18.9%). Lipids make up just 11.6% of the mature biofilm. Protein makes up the largest portion (48%) of a 4-day-old biofilm, followed by polysaccharides (37.8%) and lipids (7.27%). According to our findings, S. epidermidis CIP 444 dispersion occurred on day 4 of incubation, and new establishment of the biofilm occurred on day 7. Remarkable changes in biofilm composition will pave the way for a new approach to understanding bacterial strategies inside biofilms and finding solutions to their impacts in the medical field.

Aflatoxins and Ochratoxin A in Tea Sold in Lebanon: Effects of Type, Packaging, and Origin

Tea is among the oldest and most-known beverages around the world, and it has many flavors and types. Tea can be easily contaminated in any of its production steps, especially with mycotoxins that are produced particularly in humid and warm environments. This study aims to examine the level of ochratoxin A (OTA) and total aflatoxin (AF) contamination in black and green tea sold in Lebanon, evaluate its safety compared to international standards, and assess the effect of different variables on the levels of OTA and AFs. For this, the Lebanese market was screened and all tea brands (n = 37; 24 black and 13 green) were collected twice. The Enzyme-Linked Immunoassay (ELISA) method was used to determine OTA and AFs in the samples. AFs and OTA were detected in 28 (75.7%) and 31 (88.6%) samples, respectively. The average of AFs in the positive (above detection limit: 1.75 μg/kg) samples was 2.66 ± 0.15 μg/kg, while the average of OTA in the positive (above detection limit: 1.6 μg/kg) samples was 3.74 ± 0.72 μg/kg. The mean AFs in black and green tea were 2.65 ± 0.55 and 2.54 ± 0.40 μg/kg, respectively, while for OTA, the mean levels were 3.67 ± 0.96 and 3.46 ± 1.09 μg/kg in black and green tea samples, respectively. Four brands (10.8%) contained total aflatoxin levels above the EU limit (4 μg/kg). As for OTA, all samples had OTA levels below the Chinese limit (5 μg/kg). No significant association (p > 0.05) was found between OTA and tea type, level of packaging, country of origin, country of packing, and country of distribution. However, AF contamination was significantly (p < 0.05) higher in unpacked tea, and in brands where the country of origin, packing, and distributor was in Asia. The results showed that the tea brands in Lebanon are relatively safe in terms of AFs and OTA.

Phenolic Compounds Recovery from Blood Orange Peels Using a Novel Green Infrared Technology Ired-Irrad®, and Their Effect on the Inhibition of Aspergillus flavus Proliferation and Aflatoxin B1 Production

The intensification of total phenolic compound (TPC) extraction from blood orange peels was optimized using a novel green infrared-assisted extraction technique (IRAE, Ired-Irrad^®) and compared to the conventional extraction using a water bath (WB). Response surface methodology (RSM) allowed for the optimization of ethanol concentration (E), time (t), and temperature (T) in terms of extracted TPC and their antiradical activity, for both WB extraction and IRAE. Using WB extraction, the multiple response optimums as obtained after 4 h at 73 °C and using 79% ethanol/water were 1.67 g GAE/100 g for TPC and 59% as DPPH inhibition percentage. IRAE increased the extraction of TPC by 18% using 52% ethanol/water after less than 1 h at 79 °C. This novel technology has the advantage of being easily scalable for industrial usage. HPLC analysis showed that IRAE enhanced the recovery of gallic acid, resveratrol, quercetin, caffeic acid, and hesperidin. IR extracts exhibited high bioactivity by inhibiting the production of Aflatoxin B1 by 98.9%.

Single, Subsequent, or Simultaneous Treatments to Mitigate Mycotoxins in Solid Foods and Feeds: A Critical Review

Mycotoxins in solid foods and feeds jeopardize the public health of humans and animals and cause food security issues. The inefficacy of most preventive measures to control the production of fungi in foods and feeds during the pre-harvest and post-harvest stages incited interest in the mitigation of these mycotoxins that can be conducted by the application of various chemical, physical, and/or biological treatments. These treatments are implemented separately or through a combination of two or more treatments simultaneously or subsequently. The reduction rates of the methods differ greatly, as do their effect on the organoleptic attributes, nutritional quality, and the environment. This critical review aims at summarizing the latest studies related to the mitigation of mycotoxins in solid foods and feeds. It discusses and evaluates the single and combined mycotoxin reduction treatments, compares their efficiency, elaborates on their advantages and disadvantages, and sheds light on the treated foods or feeds, as well as on their environmental impact.

Lactobacillus rhamnosus and Staphylococcus epidermidis in gut microbiota: in vitro antimicrobial resistance

The gastrointestinal tract is one of the most complex microbiological niches containing beneficial and non-pathogenic bacterial strains of which some may evolve into virulent under specific conditions. Lactobacillus rhamnosus GG is of the most known beneficial species with an ability to protect the intestine as opposed to Staphylococcus epidermidis 444 which causes serious health risks due to its high antimicrobial resistance. This study investigates first the survival and coexistence ability of L. rhamnosus GG, and S. epidermidis 444 at different pH levels. Subsequently, lysozyme's antimicrobial and antibiofilm effect on these two strains was elucidated before adding different concentrations of oxytetracycline hydrochloride antibiotic. Results showed that 50% inhibition of L. rhamnosus GG, S. epidermidis 444, and a co-culture of these planktonic strains were obtained respectively at a lysozyme concentration of 30, 18, and 26 mg/mL after the addition of ethylenediamine tetra-acetic acid (EDTA). At a pH of 7.5, mixing lysozyme (at IC₅₀) and EDTA with oxytetracycline hydrochloride (700 μg/mL) showed an additional bactericidal effect as compared to its known bacteriostatic effect. Similarly, the addition of lysozyme to the antibiotic further increased the biofilm eradication of S. epidermidis 444 and L. rhamnosus GG where a maximal eradication of 70% was reached. Therefore, the potential development of new drugs based on adding a lysozyme-EDTA mixture to different types of antibiotics may be highly promising.

Dietary Exposure and Risk Assessment of Mycotoxins in Thyme and Thyme-Based Products Marketed in Lebanon

This study aimed at evaluating the incidence of aflatoxin B1 (AFB1) and ochratoxin A (OTA) in thyme and thyme-based products, related dietary exposure, and cancer risk for regular and high consumption. A total of 160 samples were collected, and 32 composite samples were analyzed. AFB1 and OTA were respectively found in 84% (27/32) and 38% (12/32) of the samples. AFB1 exceeded the limits in 41% (13/32) and 25% (8/32) of the samples according to the Lebanese and European standards, respectively. OTA was unacceptable in only 6% (2/32) and 3% (1/32) of the samples according to the Lebanese and European standards, respectively. AFB1 and OTA daily exposure was shown to be 4.270 and 1.345 ng/kg bw/day, respectively. AFB1 was shown to be associated with 0.41 and 0.35 additional cancer cases per 100,000 persons per year for regular consumption, respectively; while for high consumption, an increase of 0.911 and 0.639 cancer cases per 100,000 person per year was noted, respectively. The margin of exposure (MOE) for OTA was >10,000 for the non-neoplastic effect and >200 for the neoplastic effect, representing no toxicological concerns for consumers.

Detoxification approaches of mycotoxins: by microorganisms, biofilms and enzymes

Mycotoxins are generally found in food, feed, dairy products, and beverages, subsequently presenting serious human and animal health problems. Not surprisingly, mycotoxin contamination has been a worldwide concern for many research studies. In this regard, many biological, chemical, and physical approaches were investigated to reduce and/or remove contamination from food and feed products. Biological detoxification processes seem to be the most promising approaches for mycotoxins removal from food. The current review details the newest progress in biological detoxification (adsorption and metabolization) through microorganisms, their biofilms, and enzymatic degradation, finally describing the detoxification mechanism of many mycotoxins by some microorganisms. This review also reports the possible usage of microorganisms as mycotoxins’ binders in various food commodities, which may help produce mycotoxins-free food and feed.

Antifungal and anti-aflatoxigenic properties of organs of Cannabis sativa L.: relation to phenolic content and antioxidant capacities

Aflatoxin B1 is a carcinogenic mycotoxin that frequently contaminates crops worldwide. Current research indicates that the use of natural extracts to combat mycotoxin contamination may represent an eco-friendly, sustainable strategy to ensure food safety. Although Cannabis sativa L. has long been known for its psychoactive cannabinoids, it is also rich in many other bioactive molecules. This study examines extracts from various organs of Cannabis sativa L. to determine their ability to limit aflatoxin production and growth of Aspergillus flavus. The results indicate that flower extract is most effective for limiting the synthesis of aflatoxin B1, leading to an almost-complete inhibition of toxin production at a concentration of 0.225 mg dry matter per gram of culture medium. Since flower extract is rich in phenolic compounds, its total antioxidant ability and radical-scavenging capacity are determined. Compared with other anti-aflatoxigenic extracts, the anti-oxidative potential of Cannabis sativa L. flower extract appears moderate, suggesting that its anti-mycotoxin effect may be related to other bioactive compounds.

Aflatoxin B1 and ochratoxin A in imported and Lebanese wheat and -products

AFB₁ and OTA are produced in food products due to climatic conditions like temperature and humidity. In Lebanon, few studies address AFB₁ and OTA contamination in wheat and wheat products. In this study, a total of 312 samples of wheat and wheat products were collected from different sites, including port, silos, mills, and supermarkets were analysed. Wheat and wheat products consumption in Lebanon was quantified using a food frequency questionnaire. Exposure to AFB₁ and OTA was calculated and liver and kidney cancer risk were evaluated. Results showed that AFB₁ and OTA were, respectively, found in 65.7% and 100% of the samples, with 0.6% and 17.6% exceeding the maximum limit set by the European Commission. AFB₁ was shown to be associated with 0.076 additional cancer cases per 100,000 persons per year and OTA weekly exposure was shown to be 53.2 ng/kg bw, which is less than the Provisional Tolerable Weekly Intake of 100 ng/kg bw.

Regulation of Secondary Metabolism in the Penicillium Genus

Penicillium, one of the most common fungi occurring in a diverse range of habitats, has a worldwide distribution and a large economic impact on human health. Hundreds of the species belonging to this genus cause disastrous decay in food crops and are able to produce a varied range of secondary metabolites, from which we can distinguish harmful mycotoxins. Some Penicillium species are considered to be important producers of patulin and ochratoxin A, two well-known mycotoxins. The production of these mycotoxins and other secondary metabolites is controlled and regulated by different mechanisms. The aim of this review is to highlight the different levels of regulation of secondary metabolites in the Penicillium genus.

Prediction of Salmonella serovars isolated from clinical and food matrices in Lebanon and genomic-based investigation focusing on Enteritidis serovar

Salmonella enterica subsp. enterica serovars are considered major causes of food poisoning and we performed this study because Salmonella is a burden in Lebanon. The present study investigated the ability of genomic information to predict serovar using a collection of Salmonella isolates from infected humans (n = 24) and contaminated food (n = 63) in Lebanon. Further, the phylogenomic relationships of the serovar the predominated in Lebanon (i.e., S. Enteritidis; n = 25) were investigated in comparison with isolates from other countries (n = 130) based on coregenome single nucleotide polymorphisms (SNPs). Genetic elements, specifically Salmonella pathogenicity islands (SPIs), plasmid replicons, and antibiotic-resistance genes were screened in S. Enteritidis genomes (n = 155). Our results revealed that the Salmonella serovars identification by seroagglutination from the samples isolated in Lebanon (n = 87) was highly correlated with the genomic-based prediction of serovars (80.4-85.0% with SeqSero1 and 93.1-94.2% with SeqSero2). The Salmonella serovars isolated from human and food samples in Lebanon were mainly Enteritidis (28.7%) and Infantis (26%). To a rare extent, other serovars included Amager, Anatum, Bredeney, Chincol, Heidelberg, Hofit, Kentucky, Montevideo, Muenster, Newport, Schwarzengrund, Senftenberg and Typhimurium. In comparison with other countries, S. Enteritidis samples isolated in Lebanon (56 ± 27 intra-group pairwise SNP differences) presented a strong phylogenomic relativeness at the coregenome level with samples, as for example with samples isolated from Syria (65 ± 31 inter-group pairwise SNP differences). Most of the studied S. Enteritidis genomes encoded 10 SPIs involved in survival in immune cells (i.e. SPIs 1, 2, 3, 4, 5, 12, 13, 14, 16 and 17). The plasmid replicons IncFIB (S)_1 and IncFII (S)_1 encoding elements involved in virulence were identified in the majority of the S. Enteritidis genomes (94% and 96%, respectively), the majority exhibiting aminoglycosides (gene aac(6')-Iaa_1). The IncI_1_Alpha replicon responsible for ampicillin-resistance was only detected in 2 of 25 S. Enteritidis Lebanese strains. Genomic-based risk assessment of Salmonella serovars in Lebanon showed that food imported from Syria might be an origin of the S. Enteritidis human cases in Lebanon. The detection of several SPIs involved in the survival, plasmid replicons involved in virulence, and aminoglycoside-resistance genes, emphasizes that S. Enteritidis is of paramount importance for public health in Lebanon and other countries.

Ipsilateral ureteroureterostomy for ureteral duplication anomalies: predictors of adverse outcomes

INTRODUCTION AND OBJECTIVE

Ipsilateral ureteroureterostomy (UU) has gained popularity for treating ureteral duplication (UD) associated with obstruction or vesicoureteral reflux (VUR). Several studies have demonstrated its high success rate and low morbidity. This study aimed to identify the predictors of adverse outcomes associated with UU.

STUDY DESIGN

A retrospective chart review was conducted for patients with UD treated with UU at the study institution. Patients with less than 6 months of follow-up were excluded. Charts were reviewed for demographics, pre-operative imaging, surgical indications, operative notes, and follow-up data. Pre-operative and intra-operative variables were tested for association with adverse outcomes including unplanned surgery, worsening hydronephrosis, and febrile UTI recurrence.

RESULTS

A total of 35 patients underwent UU for UD between 2009 and 2017 at the study institution. The majority (33/35) had a distal anastomosis. A concomitant re-implantation of the recipient ureter was performed in 9 (25.7%) patients. After a median follow-up of 36.7 months, adverse outcomes developed in 9 patients (25.7%). No further surgery was required in 88.6% of the subjects. Adverse outcomes were associated with female gender (p = 0.048) and hydronephrosis of both upper and lower moieties (p = 0.015) and were more likely associated with ectopic ureteroceles (50%, p = 0.074) and having a concomitant re-implant performed (44.4%, p = 0.19) (table).

DISCUSSION

In this study, the low re-operation rates of UU for treating UD in patients with ectopic ureters or intravesical ureteroceles was demonstrated. The majority of patients with ectopic ureteroceles treated with UU and concomitant ureteral re-implantation had worsening hydronephrosis of both moieties and recurrent febrile UTI in the absence of mechanical obstruction. Interestingly, some of them had progression of hydronephrosis after excision of the upper pole. While worsening of hydronephrosis of the recipient moiety after UU was historically attributed to yo-yo reflux, most of the study patients did not have worsening hydronephrosis despite having distal anastomosis. Therefore, mechanical obstruction should be ruled out, and any underlying bladder dysfunction should be aggressively managed in patients with worsening hydronephrosis or recurrent UTI after UU before considering additional surgery.

CONCLUSION

Ureteroureterostomy is a successful option for UD with a low risk of adverse events in patients with ectopic ureters or intravesical ureteroceles. However, it should be cautiously considered in patients with hydronephrosis of both moieties, with ectopic ureteroceles, or if a concomitant re-implant is needed.

Assorted Methods for Decontamination of Aflatoxin M1 in Milk Using Microbial Adsorbents

Aflatoxins (AF) are carcinogenic metabolites produced by different species of Aspergillus which readily colonize crops. AFM1 is secreted in the milk of lactating mammals through the ingestion of feedstuffs contaminated by aflatoxin B1 (AFB1). Therefore, its presence in milk, even in small amounts, presents a real concern for dairy industries and consumers of dairy products. Different strategies can lead to the reduction of AFM1 contamination levels in milk. They include adopting good agricultural practices, decreasing the AFB1 contamination of animal feeds, or using diverse types of adsorbent materials. One of the most effective types of adsorbents used for AFM1 decontamination are those of microbial origin. This review discusses current issues about AFM1 decontamination methods. These methods are based on the use of different bio-adsorbent agents such as bacteria and yeasts to complex AFM1 in milk. Moreover, this review answers some of the raised concerns about the binding stability of the formed AFM1-microbial complex. Thus, the efficiency of the decontamination methods was addressed, and plausible experimental variants were discussed.

A comparative study of procedures for binding of aflatoxin M1 to Lactobacillus rhamnosus GG

Several strains of lactic acid bacteria (LAB), frequently used in food fermentation and preservation, have been reported to bind different types of toxins in liquid media. This study was carried out to investigate the effect of different concentrations of Lactobacillus rhamnosus GG (ATCC 53103) to bind aflatoxin M1 (AFM1) in liquid media. AFM1 binding was tested following repetitive washes or filtration procedures in combination with additional treatments such as heating, pipetting, and centrifugation. The mixture of L. rhamnosus GG and AFM1 was incubated for 18h at 37°C and the binding efficiency was determined by quantifying the unbound AFM1 using HPLC. The stability of the complexes viable bacteria-AFM1 and heat treated bacteria-AFM1 was tested. Depending on the bacterial concentration and procedure used, the percentages of bound AFM1 by L. rhamnosus GG varied from as low as undetectable to as high as 63%. The highest reduction in the level of unbound AFM1 was recorded for the five washes procedure that involved heating and pipetting. Results also showed that binding was partially reversible and AFM1 was released after repeated washes. These findings highlight the effect of different treatments on the binding of AFM1 to L. rhamnosus GG in liquid matrix.

Ability of Soil Isolated Actinobacterial Strains to Prevent, Bind and Biodegrade Ochratoxin A

Ochratoxin A (OTA) is one of the most important mycotoxins, and contaminates several agricultural products, particularly cereals, grapes, maize, barley, spices and coffee. The aim of this project was to reduce the levels of OTA by supplementing the artificially contaminated solutions with seven strains of actinobacteria (AT10, AT8, SN7, MS1, ML5, G10 and PT1) in order to evaluate their capacity for binding and metabolizing the OTA, as well as their ability to reduce the expression of the genes responsible for its production in A. carbonarius. In the first part of this study, we evaluated the capacity of Streptomyces strains for binding OTA on their surfaces after 0, 30 and 60 min of incubation with PBS solution supplemented with OTA. In the second part, we tested the ability of these strains, as well as their supernatants, to detoxify the ISP2 medium. Finally, we studied the effect of the Streptomyces cocultured with Aspergillus carbonarius on the expression of OTA biosynthesis genes. Results showed that, among the strains co-cultured with A. carbonarius, the strain G10 was able to reduce the expression of acpks, acOTApks, acOTAnrps and vea genes, thus reducing OTA from solid PDA medium to 13.50% of reduction. This strain was remarkably able to detoxify and bind OTA up to 47.07%. Strain AT8 was stronger in detoxifying OTA (52.61%), but had no significant effect on the studied gene expression.

Identification of the Anti-Aflatoxinogenic Activity of Micromeria graeca and Elucidation of Its Molecular Mechanism in Aspergillus flavus

Of all the food-contaminating mycotoxins, aflatoxins, and most notably aflatoxin B₁ (AFB₁), are found to be the most toxic and economically costly. Green farming is striving to replace fungicides and develop natural preventive strategies to minimize crop contamination by these toxic fungal metabolites. In this study, we demonstrated that an aqueous extract of the medicinal plant Micromeria graeca—known as hyssop—completely inhibits aflatoxin production by Aspergillus flavus without reducing fungal growth. The molecular inhibitory mechanism was explored by analyzing the expression of 61 genes, including 27 aflatoxin biosynthesis cluster genes and 34 secondary metabolism regulatory genes. This analysis revealed a three-fold down-regulation of aflR and aflS encoding the two internal cluster co-activators, resulting in a drastic repression of all aflatoxin biosynthesis genes. Hyssop also targeted fifteen regulatory genes, including veA and mtfA, two major global-regulating transcription factors. The effect of this extract is also linked to a transcriptomic variation of several genes required for the response to oxidative stress such as msnA, srrA, catA, cat2, sod1, mnsod, and stuA. In conclusion, hyssop inhibits AFB₁ synthesis at the transcriptomic level. This aqueous extract is a promising natural-based solution to control AFB₁ contamination.

A study on the physicochemical parameters for Penicillium expansum growth and patulin production: effect of temperature, pH, and water activity

Penicillium expansum is among the most ubiquitous fungi disseminated worldwide, that could threaten the fruit sector by secreting patulin, a toxic secondary metabolite. Nevertheless, we lack sufficient data regarding the growth and the toxigenesis conditions of this species. This work enables a clear differentiation between the favorable conditions to the P. expansum growth and those promising for patulin production. A mathematical model allowing the estimation of the P. expansum growth rate according to temperature, a W, and pH, was also developed. An optimal growth rate of 0.92 cm/day was predicted at 24°C with pH level of 5.1 and high a W level of 0.99. The model's predictive capability was tested successfully on artificial contaminated apples. This model could be exploited by apple growers and the industrialists of fruit juices in order to predict the development of P. expansum during storage and apple processing.

Development of a real-time PCR assay for Penicillium expansum quantification and patulin estimation in apples

Due to the occurrence and spread of the fungal contaminants in food and the difficulties to remove their resulting mycotoxins, rapid and accurate methods are needed for early detection of these mycotoxigenic fungi. The polymerase chain reaction and the real time PCR have been widely used for this purpose. Apples are suitable substrates for fungal colonization mostly caused by Penicillium expansum, which produces the mycotoxin patulin during fruit infection. This study describes the development of a real-time PCR assay incorporating an internal amplification control (IAC) to specifically detect and quantify P. expansum. A specific primer pair was designed from the patF gene, involved in patulin biosynthesis. The selected primer set showed a high specificity for P. expansum and was successfully employed in a standardized real-time PCR for the direct quantification of this fungus in apples. Using the developed system, twenty eight apples were analyzed for their DNA content. Apples were also analyzed for patulin content by HPLC. Interestingly, a positive correlation (R(2) = 0.701) was found between P. expansum DNA content and patulin concentration. This work offers an alternative to conventional methods of patulin quantification and mycological detection of P. expansum and could be very useful for the screening of patulin in fruits through the application of industrial quality control.

Quantification of Fusarium graminearum and Fusarium culmorum by real-time PCR system and zearalenone assessment in maize

Zearalenone (ZEA) is a mycotoxin produced by some species of Fusarium, especially by Fusarium graminearum and F. culmorum. ZEA induces hyperoestrogenic responses in mammals and can result in reproductive disorders in farm animals. In the present study, a real-time PCR (qPCR) assay has been successfully developed for the detection and quantification of Fusarium graminearum based on primers targeting the gene PKS13 involved in ZEA biosynthesis. A standard curve was developed by plotting the logarithm of known concentrations of F. graminearum DNA against the cycle threshold (Ct) value. The developed real time PCR system was also used to analyze the occurrence of zearalenone producing F. graminearum strains on maize. In this context, DNA extractions were performed from thirty-two maize samples, and subjected to real time PCR. Maize samples also were analyzed for zearalenone content by HPLC. F. graminearum DNA content (pg DNA/ mg of maize) was then plotted against ZEA content (ppb) in maize samples. The regression curve showed a positive and good correlation (R²=0.760) allowing for the estimation of the potential risk from ZEA contamination. Consequently, this work offers a quick alternative to conventional methods of ZEA quantification and mycological detection and quantification of F. graminearum in maize.

Differentiation between Aspergillus flavus and Aspergillus parasiticus from pure culture and aflatoxin-contaminated grapes using PCR-RFLP analysis of aflR-aflJ intergenic spacer

Aflatoxins (AFs) represent the most important single mycotoxin-related food safety problem in developed and developing countries as they have adverse effects on human and animal health. They are produced mainly by Aspergillus flavus and A. parasiticus. Both species have different aflatoxinogenic profile. In order to distinguish between A. flavus and A. parasiticus, gene-specific primers were designed to target the intergenic spacer (IGS) for the AF biosynthesis genes, aflJ and aflR. Polymerase chain reaction (PCR) products were subjected to restriction endonuclease analysis using BglII to look for restriction fragment length polymorphisms (RFLPs). Our result showed that both species displayed different PCR-based RFLP (PCR-RFLP) profile. PCR products from A. flavus cleaved into 3 fragments of 362, 210, and 102 bp. However, there is only one restriction site for this enzyme in the sequence of A. parasiticus that produced only 2 fragments of 363 and 311 bp. The method was successfully applied to contaminated grapes samples. This approach of differentiating these 2 species would be simpler, less costly, and quicker than conventional sequencing of PCR products and/or morphological identification.

Effect of donor pneumoperitoneum on early allograft perfusion following renal transplantation in pediatric patients: an intraoperative Doppler ultrasound study

Decreased perfusion and trauma during laparoscopic harvesting are proposed causative factors for DGF and rejection in children following renal transplantation with laparoscopic donor nephrectomy (LDN) allograft. We performed a retrospective review of 11 children who underwent LDN transplant and 11 preceding patients who underwent ODN transplant. Intraoperative DUS findings, creatinine values and clearance, time to nadir creatinine and AR episodes were compared. There were no significant differences in the BMI, vascular anatomy, side of nephrectomy, or warm ischemia time in the two groups. Mean follow-up duration was 11.4 and 30.4 months in LDN and ODN groups. DUS showed initial turbulent flow in five of the LDN and four of the ODN group with an average RI of 0.59 and 0.66 in the ODN and LDN groups, respectively (NS). Three patients in the ODN group had an abnormal RI compared to none in the LDN group (p = 0.034). The creatinine values, creatinine clearances (at 24 h, one, four wk and last follow-up) and AR episodes were similar in both groups. Pneumoperitoneum during LDN does not appear to have an adverse impact on early graft reperfusion.

Occurrence of ochratoxin A- and aflatoxin B1-producing fungi in Lebanese grapes and ochratoxin a content in musts and finished wines during 2004

This paper reports the results of an extensive survey on the occurrence of filamentous fungi isolated from wine-grapes in Lebanon and to test their ability to produce ochratoxin A (OTA) and aflatoxin B1 (AFB1) on CYA culture medium, in order to assess their potential for producing these mycotoxins on grapes. From the 470 grapes samples taken during season 2004, 550 fungi strains were isolated with 490 belonging to Aspergillus spp. and 60 belonging to Penicillium spp. All these isolated fungi starins were tested for their ability to produce OTA and AFB1. Aspergillus carbonarius shows that it is the only species able to produce OTA with a production percentage reaching 100% and a maximum concentration of 52.8 microg/g of Czapek yeast extract agar (CYA). In its turn, Aspergillus flavus was considered as the only AFB1-producing species with production percentage of 45.3% and a maximum concentration reaching 40 microg/g CYA. A total of 47 handmade musts produced from the collected grapes were also analyzed in order to correlate the presence of OTA in must and the occurrence of filamentous fungi on grapes; 57.4% were contaminated with OTA at low level with concentrations ranging between 0.011 and 0.221 microg OTA L(-1). The analysis of these must samples was not performed with regard to AFB1. Seventy samples of finish red wine were also assayed for OTA content. The results showed that 42 of the tested samples (60%) were found to be positive for OTA with low levels (0.012-0.126 microg OTA L(-1)).

Should the presence of congenital para-ureteral diverticulum affect the management of vesicoureteral reflux?

PURPOSE

The presence of congenital para-ureteral diverticulum (PUD) has been presumed to lower the resolution rate of vesicoureteral reflux (VUR). PUD is considered an important cause of distortion of the vesicoureteral junction and persistence of VUR. Early surgery has been recommended based on this assumption. However, the scientific evidence supporting this approach is weak. We have been managing this group of patients more conservatively in the last 7 to 8 years on the premise that the presence of PUD is not per se an indication for surgery. To test this hypothesis, we performed a retrospective cohort study to compare the outcome of VUR in children with and without PUD.

MATERIALS AND METHODS

We identified 141 consecutive patients with VUR associated with PUD between 1990 and 2004. Of the patients 57 with duplication, ureterocele, neurogenic bladder or outlet obstruction were excluded from study. Median age of the remaining 84 patients at diagnosis was 2.9 years and 56 (69%) were males. Reflux was bilateral in 4 patients, and low (I to II), intermediate (III) and high (IV to V) grade in 39%, 35% and 26%, respectively. Followup was 3 to 168 months (median 47). The outcome was compared to a control group of 95 patients (150 units) with primary VUR and no PUD. The baseline parameters and followup were comparable in both groups.

RESULTS

Overall, VUR resolved in 43%, persisted in 27% and was surgically corrected in 30% of the units with PUD. In the 25 patients (26 units) who underwent surgical intervention breakthrough urinary tract infection or new renal scars were the indication in only 5. The remainder were operated on because of persistent VUR and the presence of PUD, mainly before 1997. The incidence of breakthrough urinary tract infection or new renal scar was similar in the controls (6% in PUD group vs 10% in controls, p = 0.7). The resolution rate was 60% for low grade, 39% for intermediate grade and 22% for high grade VUR. These figures were not significantly different from those of the control group in which the resolution rates were 52%, 28% and 33% for comparable grades (p = 0.9). Kaplan-Meier analysis and log rank test did not show any difference in resolution of VUR in the 2 groups (p = 0.84). Multivariate analysis identified grade as the only variable affecting resolution (p = 0.028). The size of PUD did not affect the likelihood of resolution.

CONCLUSIONS

The outcome of VUR is similar in children with or without PUD. Therefore, treatment of these patients should not differ. Surgery should be reserved for patients with breakthrough infection or renal scar progression.

The predictive value of diagnostic imaging for histological lesions of the upper poles in duplex systems with ureteroceles

OBJECTIVE

To compare the diagnostic imaging findings with the histological lesions in upper pole nephrectomy (UPN) specimens of duplex system ureteroceles, using renal ultrasonography (US) and nuclear renal scintigraphy.

PATIENTS AND METHODS

Between 1992 and 2000, 86 patients with a ureterocele in a duplex system underwent surgery. The results from US were reviewed in 84 patients by a radiologist, for echogenicity, parenchymal thinning and hydronephrosis; 77 nuclear renal scans describing the differential function of the upper poles were also reviewed. Fifty-five patients underwent UPN (25 antenatal, 30 postnatal; 18 intravesical, 37 extravesical) and the specimens were available for independent review by a pathologist, describing five histological categories, i.e. chronic interstitial inflammation, fibrosis, tubular atrophy, glomerulosclerosis and dysplasia. Histological lesions were categorized as severe (> 25%) or minimal (<or= 25%). Radiological features and the histology of UPN were then analysed, and correlated using Fisher's exact test and multivariate analysis.

RESULTS

Severe histological lesions were reported in 38 specimens (69%) and minimal lesions in 17 UPN specimens (31%). Severe parenchymal thinning was associated with a severe pathological lesion (P < 0.02). There was no correlation with the echogenicity or degree of hydronephrosis. Dysplasia, found in 64% of specimens, did not correlate with increased echogenicity. Minimally functioning upper poles on nuclear renal scan (<or= 4% overall function) were significantly associated with severe histological lesions (P = 0.01). There was no correlation between diagnostic imaging features and the mode of presentation or type of ureterocele.

CONCLUSIONS

Multivariate analysis, severe parenchymal thinning on renal US and minimal function on nuclear renal scan can be used to predict the severity of histological lesions of the upper pole. These results may be helpful in the making therapeutic decisions for patients with ureteroceles in duplex systems.

The use of tolterodine in children after oxybutynin failure

OBJECTIVE

To assess the safety and efficacy of tolterodine tartrate prescribed to children who previously failed to tolerate oxybutynin chloride.

PATIENTS AND METHODS

We reviewed 34 children, followed for>1 year, who were prospectively crossed-over from oxybutynin to tolterodine because of side-effects. The initial diagnosis was dysfunctional voiding in 31 patients. All patients were placed on a behavioural modification protocol. When their symptoms did not improve after 6 months, treatment with an anticholinergic agent was considered. Urodynamic studies were conducted in 20 patients, confirming uninhibited contractions in 19. The remaining 14 patients were empirically started on antimuscarinic or anticholinergic agents. The 34 patients were treated with oxybutynin for a median (range) of 6 (2-84) months. When significant side-effects were reported, they were crossed over to tolterodine. The efficacy of tolterodine was assessed as defined by the International Children's Continence Society, with tolerability assessed and side-effects documented using a questionnaire.

RESULTS

The mean age at the first dose of tolterodine was 8.9 years; the dose was 1 mg twice daily for 12 patients and 2 mg twice daily for 22. The median treatment with tolterodine was 11.5 months, with 20 (59%) patients reporting no side-effects; six described the same but tolerable side-effects as with oxybutynin. Eight patients discontinued tolterodine because of side-effects after a median (range) of 5 (1-11) months. The efficacy of tolterodine was comparable with that of oxybutynin, as reported by the questionnaire and voiding diaries. The reduction in wetting episodes at 1 year was> 90% in 23 (68%), more than half in five and less than half (or failure) in six patients.

CONCLUSION

Tolterodine is tolerated well in children. In this subgroup of patients who could not tolerate oxybutynin, 77% were able to continue tolterodine treatment with no significant side-effects.

Renal pseudoaneurysm after blunt renal trauma in a pediatric patient: management by angiographic embolization

Renal pseudoaneurysm is a rare complication after blunt renal trauma. Only 18 cases have been reported in English-language published reports. We present a case of blunt renal trauma in an 11-year-old boy, complicated by delayed bleeding from a renal artery pseudoaneurysm. The patient was initially treated with conservative measures and was later treated with selective embolization of the pseudoaneurysm. The clinical presentation, management options, and clinical decisions are discussed.

Healing of unstented tubularized incised plate urethroplasty: an experimental study in a rabbit model

OBJECTIVE

To develop a rabbit model to study the temporal healing taking place after an unstented tubularized incised plate urethroplasty (TIPU).

MATERIALS AND METHODS

The study comprised 13 New Zealand white rabbits (3-4 kg); the ventral wall of the penile urethra was excised to create a hypospadias-like defect. A vertical incision was made in the dorsal urethral plate and the incised urethra tubularized. Two animals were killed at 2 days and two at 5 days after surgery, and the remainder killed at 2, 6 and 12 weeks (three each). A retrograde urethrogram was taken at autopsy. Serial sections of the penis were stained with haematoxylin and eosin, and Masson trichrome for microscopy.

RESULTS

There were no deaths related to the procedure and all animals voided spontaneously. Retrograde urethrograms showed no fistulae or stricture. Microscopic examination at 2 and 5 days showed partial coverage of the incision with regenerating urothelium. At 2 weeks there was full-thickness urothelium with a mild inflammatory reaction. At 6 and 12 weeks, remodelling of the peri-urethral connective tissue with minimal fibrosis completed the healing.

CONCLUSION

The mechanism of healing of the incised urethral plate involves normal urothelial regeneration into the depth of the incised defect, which explains the gain in urethral diameter after TIPU. Urine flow, during normal voiding, might be responsible for keeping the incised plate open during urothelial regeneration. A urethral stent was not necessary for normal healing in this model.

22 week assessment of bladder acellular matrix as a bladder augmentation material in a porcine model

Previous studies on the reconstruction of porcine bladder using bladder acellular matrix allograft (BAMA) have indicated positive preliminary results with respect to graft shrinkage and cellular repopulation. The current study was conducted to investigate the feasibility of using BAMA in a similar model of bladder reconstruction out to longer time frames (22 weeks). At predetermined time points, the macroscopic, histological and mechanical properties of explanted native and BAMA tissues were evaluated and compared. Macroscopically, contracture of the BAMA was observed. The peripheral regions of the grafts experienced extensive cellular repopulation. Towards the centre however, all grafts were consistently devoid of organized smooth muscle bundles and a well-developed urothelium. An alteration in both the amount and organization of collagen was also observed within this region. Significant differences (p < 0.05) in the rupture strain and the elastic modulus of the BAMA compared to native bladder tissue appear to correlate with macroscopic graft contracture as well as the fibroproliferative tissue response of the matrix.

High resolution ultrasound characterization of early allograft hemodynamics in pediatric living related renal transplantation

PURPOSE

Allograft vascular thrombosis occurs in 5% to 10% of pediatric renal transplants. The hemodynamics of renal allograft immediately after implantation is unclear. High resolution Doppler ultrasound of the renal allograft performed in the operating room after incision closure is an effective and objective method to advance our understanding of baseline renal allograft hemodynamics, and identify unsuspected vascular complications early enough to ensure prompt surgical repair.

MATERIALS AND METHODS

Between September 1998 and July 2000 high resolution, color power Doppler ultrasound was prospectively performed on 21 living related renal transplants in the operating room immediately after incision closure. Each ultrasound described allograft anastomotic blood flow, direction of diastolic flow, parenchymal perfusion and resistive indexes.

RESULTS

There were 20 (95%) allografts with good power Doppler perfusion that had satisfactory immediate function with no vascular complications at 9 to 26-month followup. Initially, anastomotic turbulence was described in 15 (71%) allografts, and resistive indexes were abnormal in 8 (38%). Turbulence and abnormal resistive index normalized in all allografts by 1-month followup. Ultrasound of 1 allograft identified unsuspected poor perfusion and reversal of diastolic flow in the operating room after incision closure. In another allograft in which a 4-hour post-transplant ultrasound was compared with the baseline study in the operating room an unsuspected thrombosis of the right common iliac vein was confirmed.

CONCLUSIONS

Good parenchymal perfusion and forward diastolic flow after renal reperfusion correlated well with immediate graft function. Initial turbulence and abnormal resistive index in the presence of favorable perfusion are misleading and not independent predictors of graft function. Ultrasound performed in the operating room identified 2 unsuspected major vascular complications facilitating prompt surgical correction.

Tunica vaginalis for correcting penile chordee in a rabbit model: is there a difference in flap versus graft?

PURPOSE

We compared tunica vaginalis applied as a flap versus a graft for covering defects in the ventral tunica albuginea in a rabbit model.

MATERIALS AND METHODS

We used 18 New Zealand White rabbits in the study. The urethra was mobilized off of the corpus cavernosum. A defect was created in the ventral aspect of the tunica albuginea by excising a 1 x 0.5 cm. rectangular area. The defect was covered by the testicular surface of tunica vaginalis as a vascularized flap in 9 animals and as a graft in 9. At 2, 6 and 12-week intervals 3 animals per group were sacrificed. Transverse sections of the penis at the repair site were stained with hematoxylin and eosin, and Masson's trichrome for microscopy.

RESULTS

Autopsy revealed no contracture in any of the tunica vaginalis flaps. In contrast, the tunica vaginalis grafts had contracted by a mean of 22% (range 20% to 25%) at 2, 38% (range 30% to 44%) at 6 and 42% (range 38% to 48%) at 12 weeks. Microscopic examination of the tunica vaginalis flaps showed evidence of an intact blood supply and viable cremasteric muscle layer but no evidence of necrosis. Collagen remodeling and maturation was noted at 12 weeks. In tunica vaginalis grafts there was evidence of necrosis of all tunica vaginalis layers at 2 weeks with granulation tissue and active fibrosis at the periphery. At 6 and 12 weeks most necrotic tissue was replaced by fibrosis. Osseous metaplasia was identified in 1 graft at 12 weeks.

CONCLUSIONS

The optimal use of tunica vaginalis for correction of chordee is as a flap rather than as a free graft. Grafts were associated with significant necrosis and contracture, of which neither was associated with flaps.

A population based analysis of continence outcomes and bladder exstrophy

PURPOSE

Whereas the literature on bladder exstrophy is replete with outcomes of specific continence surgical procedures in highly select patients, there are no data on the outcomes related to continence for a complete exstrophy population, which is more comprehensive with respect to a variety of surgical procedures performed to achieve continence. To provide urologists and patients with an overview of potential continence outcomes devoid of any selection bias, we report on a comprehensive exstrophy population, focusing on the various procedures required for urinary continence.

MATERIALS AND METHODS

We reviewed the charts of all patients with bladder and cloacal exstrophy who underwent a staged repair to achieve urinary continence at a single institution between 1988 and 1998. Urinary continence was then correlated to the types of surgical procedures, and subgroup analysis for predictors of urinary continence was performed. The type of bladder neck reconstruction allowed subgrouping cases into group 1-bladder neck reconstruction only, group 2-bladder neck reconstruction with augmentation and/or appendicovesicostomy and group 3-bladder neck closure.

RESULTS

Of the 43 patients identified 26 were male, 4 had cloacal exstrophy and 3 had complex exstrophy variants with ectopic hindgut and spina bifida. Groups 1 to 3 comprised 9, 15 and 19 patients with urinary continence rates of 56%, 67% and 100%, respectively. The age at which patients became continent was delayed in groups 2 and 3 (8.2 and 8.7 years, respectively) compared to group 1 (4.8). Of all the potential variants measured gender was the strongest predictor of continence with 94% of females versus 69% of males achieving it. Of the males those with (57%) compared to those without (83%) a history of bladder neck stenosis or paraexstrophy flaps had worse continence. Repeat bladder neck reconstruction was only successful in 23% of patients.

CONCLUSIONS

All patients can be rendered continent but many may achieve this successful outcome by other procedures following initial bladder neck reconstruction. When managing failed bladder neck reconstruction, the type of surgical repair chosen may need to address the need for enhanced bladder storage and the issue of potential bladder augmentation. The advances made in the treatment of the epispadiac urethra may now facilitate clean intermittent catheterization. Earlier recognition of the need for adjunctive storage procedures in addition to bladder neck reconstruction may facilitate the timing of providing enhanced continence, independence and self-esteem, and do so with fewer operative procedures. We speculate that the current complete urethral and bladder repair in newborns will add further to the storage functions of the native bladder tissues and improve the potential of achieving more effective bladder outlet control.

A population based analysis of continence outcomes and bladder exstrophy

PURPOSE

Whereas the literature on bladder exstrophy is replete with outcomes of specific continence surgical procedures in highly select patients, there are no data on the outcomes related to continence for a complete exstrophy population, which is more comprehensive with respect to a variety of surgical procedures performed to achieve continence. To provide urologists and patients with an overview of potential continence outcomes devoid of any selection bias, we report on a comprehensive exstrophy population, focusing on the various procedures required for urinary continence.

MATERIALS AND METHODS

We reviewed the charts of all patients with bladder and cloacal exstrophy who underwent a staged repair to achieve urinary continence at a single institution between 1988 and 1998. Urinary continence was then correlated to the types of surgical procedures, and subgroup analysis for predictors of urinary continence was performed. The type of bladder neck reconstruction allowed subgrouping cases into group 1-bladder neck reconstruction only, group 2-bladder neck reconstruction with augmentation and/or appendicovesicostomy and group 3-bladder neck closure.

RESULTS

Of the 43 patients identified 26 were male, 4 had cloacal exstrophy and 3 had complex exstrophy variants with ectopic hindgut and spina bifida. Groups 1 to 3 comprised 9, 15 and 19 patients with urinary continence rates of 56%, 67% and 100%, respectively. The age at which patients became continent was delayed in groups 2 and 3 (8.2 and 8.7 years, respectively) compared to group 1 (4.8). Of all the potential variants measured gender was the strongest predictor of continence with 94% of females versus 69% of males achieving it. Of the males those with (57%) compared to those without (83%) a history of bladder neck stenosis or paraexstrophy flaps had worse continence. Repeat bladder neck reconstruction was only successful in 23% of patients.

CONCLUSIONS

All patients can be rendered continent but many may achieve this successful outcome by other procedures following initial bladder neck reconstruction. When managing failed bladder neck reconstruction, the type of surgical repair chosen may need to address the need for enhanced bladder storage and the issue of potential bladder augmentation. The advances made in the treatment of the epispadiac urethra may now facilitate clean intermittent catheterization. Earlier recognition of the need for adjunctive storage procedures in addition to bladder neck reconstruction may facilitate the timing of providing enhanced continence, independence and self-esteem, and do so with fewer operative procedures. We speculate that the current complete urethral and bladder repair in newborns will add further to the storage functions of the native bladder tissues and improve the potential of achieving more effective bladder outlet control.

Serotonergic function in major depression and effect of sertraline and paroxetine treatment

We investigated platelet [14C]serotonin (5-HT) uptake and lysergic acid diethylamide [N-methyl-3H] ([3H]LSD)- and phenyl-6'-paroxetine ([3H]paroxetine) binding in 30 patients with major depression at baseline and after 6 months of treatment with either paroxetine or sertraline. The study was of a double-blind design. Baseline data was compared with an age- and gender-matched group of healthy volunteers. Baseline Vmax was significantly lower in patients than in controls. Bmax for [3H]paroxetine binding were similar in patients and controls, but patients who suffered their first depression had significantly lower Bmax for [3H]paroxetine binding than patients who had suffered multiple depressions. Twenty-three patients (76%) (13 in the paroxetine group and 10 in the sertraline group) responded to treatment as judged by a 50% or more reduction in Montgomery-Asberg Depression Rating Scale (MADRS) scores after 6 months of treatment. There were no significant differences between the paroxetine and sertraline treated groups. Both paroxetine and sertraline caused a significant reduction in Vmax and a significant increase in Km. There was a strong correlation between Km and plasma drug concentration in patients who experienced their first depression but not in patients who had suffered multiple episodes. Bmax for [3H]paroxetine binding increased after paroxetine treatment while the opposite occurred after sertraline treatment. There was a significant interaction between the impact of drug and earlier depressions. All patients included in the study had been drug free for at least 2 months. Earlier antidepressant treatment may have long withstanding effects on the serotonin uptake machinery but it cannot be excluded that the sensitivity of the uptake mechanism may become more resistant to change in patients with recurrent depressive episodes.

Are postoperative studies justified after extravescial ureteral reimplantation?

PURPOSE

We evaluated the usefulness of postoperative imaging studies after extravesical ureteroneocystostomy and identified patient subsets in which these studies are necessary.

MATERIALS AND METHODS

Records of 438 patients who had undergone extravesical ureteroneocystostomy from 1991 to 1997 were reviewed retrospectively. Study inclusion criterion was primary reflux with at least 1 year of postoperative followup. Grades I to III reflux were defined as low, and grades IV and V were defined as high. All patients were on prophylactic antibiotics. Evaluation included ultrasound and a voiding cystourethrogram 3 months postoperatively, and if reflux persisted the studies were repeated at 12 months.

RESULTS

A total of 438 patients (723 renal units) underwent extravesical ureteral reimplantation. At 3 months the procedure was successful in 93.2% of ureters (91.3% patients), and at 12 months the success rate increased to 97.9% of ureters (95.4% patients). There were 49 renal units in 38 cases that were refluxing at 3 months, 11 of which were contralateral. At 12 months reflux resolved spontaneously in 20 of 38 ipsilateral and 8 of 11 contralateral ureters. Of the remaining 18 ipsilateral units reflux was high grade preoperatively in 12 and persisted postoperatively in 4. There was a statistically significant difference in the success rate at 1 year between high (94%) versus low (99%) grade reflux (p = 0.007). Age and preoperative bladder function did not significantly affect the success rates but males had a lower success rate. Hydronephrosis was noted in 7.2% of ureters at 6 weeks and in only 0.005% at 12 months.

CONCLUSIONS

Extravesical reimplantation is successful in treating vesicoureteral reflux. Postoperative voiding cystourethrogram should be reserved for high grade reflux. Limiting these studies will help reduce patient discomfort and the cost of treatment.

Regeneration of functional bladder substitutes using large segment acellular matrix allografts in a porcine model

PURPOSE

We previously reported on the short-term (4 weeks) morphometric analysis of a large bladder acellular matrix allograft used as a bladder bioprosthesis (average size 24 cm.2). We demonstrated cellular repopulation through the entire thickness of the graft. We now present the long-term (12 weeks) morphometric results of graft regenerated porcine bladders using segments measuring an average of 40 cm.2.

MATERIALS AND METHODS

Bladders harvested from pigs were subjected to detergent and enzymatic extractions to render them acellular. Partial cystectomy was performed in 21 pigs and the defect was repaired with a bladder acellular matrix allograft (average size 40.52 cm.2). Of the animals 8 were sacrificed at 1, 2 and 4 weeks and 13 were sacrificed at 8 and 12 weeks. To evaluate cellular repopulation and matrix reorganization the native bladder and graft were analyzed using standard histological and immunofluorescent techniques. To evaluate for calcium deposits in the grafts a radiological evaluation of the graft was performed after explantation.

RESULTS

All animals survived the surgical procedure and there were no significant urinary leaks. No stones were noted in any of the bladders. At 1 week there was a diffuse infiltration with acute inflammatory cells. At 2 weeks the luminal surface of the graft was lined with a single layer of urothelium, and there was stromal infiltration with unorganized smooth muscle cells and angiogenesis. At 4 weeks the urothelium was multilayered with organizing groups of smooth muscle cells and angiogenesis. At 8 and 12 weeks there was repopulation throughout the bladder acellular matrix allograft implant with all native cellular components participating.

CONCLUSIONS

We present evidence that large patch bladder acellular matrix allograft implantation is technically feasible and may prove to be a viable surgical alternative to bladder augmentation with intestinal segments. Its advantages may include the potential for complete and functional regeneration of a bladder substitute.

Lessons learned from laser tissue soldering and fibrin glue pyeloplasty in an in vivo porcine model

PURPOSE

We compared sutured pyeloplasty to 2 newer techniques of tissue anastomosis, including laser soldered pyeloplasty using a diode laser with 50% albumin solder mixed with indocyanine green and fibrin glue.

MATERIALS AND METHODS

We performed 53 pyeloplasties in 50 pigs using suture, laser or fibrin glue. In the immediate group anastomotic leak pressure was measured immediately postoperatively, and then animals were euthanized. At 1, 3 and 4 weeks postoperatively a pressure flow study at 10 cc per minute in cm. H2O was performed, and tissue was sent for histological and collagen content analysis.

RESULTS

In the immediate studies laser soldering achieved a significantly higher mean anastomotic leak pressure (50.5 +/- 15.1 cm. H2O) than sutured (17.3 +/- 5.4) or fibrin glued (3.5 +/- 1.5) repairs. In the 1, 2 and 4-week studies animals in the sutured pyeloplasty group had no complications, and all pressure flow studies except 1 were normal. However, in the laser soldered groups we observed 8 urinomas in 19 animals, and most occurred during the first part of our study. This complication was prevented by stopping urine flow at the anastomotic site at laser irradiation and by improving application of the solder. Of the 11 animals in which pressure flow studies were performed only 2 were obstructed. Of the 7 chronic fibrin glue group 4 animals had urinomas and 2 had unobstructed pressure flow studies. Histological studies and immunohistochemical staining for collagen showed no differences in collagen distribution among the 3 procedures.

CONCLUSIONS

Laser soldering and fibrin glue pyeloplasties are not superior in the long-term compared to sutured pyeloplasty. Fibrin glue in our animal model had the highest failure rate. Further improvements in the technical aspect of laser tissue welding need to be made to benefit from its theoretical advantages in minimally invasive surgery.

Localized drug delivery using crosslinked gelatin gels containing liposomes: factors influencing liposome stability and drug release

We describe a drug-delivery vehicle that combines the sustained release properties of liposomes with the structural advantages of crosslinked gelatin gels that can be implanted directly or coated onto medical devices. Liposome inclusion in gelatin gels does not compromise thermal stability nor does it interfere with the resiliency of gels to tensile force. However, electron spin resonance analysis of sequestered DPPC liposomes revealed a slight depression (ca. 1.0 degrees C) of the gel-to-fluid phase transition relative to liposomes in suspension. The level of liposome release from gels was determined by liposome concentration, liposome size, and the presence of poly(ethylene oxide) chains in the gel matrix or in the liposome membrane. Both neutral and charged liposomes displayed relatively high affinities for poly(ethylene glycol)gelatin gels, with only 10-15% release of initially sequestered liposomes while liposomes in which poly(ethylene glycol) was included within the membrane were not as well retained (approximately 65% release). The in vitro efflux of ciprofloxacin from liposomal gels immersed in serum was nearly complete after 24 h compared to 38% release of liposomal chlorhexidine after 6 days. The serum-induced destabilization of liposomal ciprofloxacin depended on the accessibility of serum components to gels as partly immersed gels retained approximately 50% of their load of drug after 24 h. In vivo experiments using a catheterized rabbit model of urinary tract infection revealed the absence of viable Escherichia coli on coated catheter surfaces in seven out of nine cases while all untreated catheter surfaces examined (n = 7) were contaminated.

The use of magnetic resonance imaging in the diagnosis and followup of pediatric pelvic rhabdomyosarcoma

PURPOSE

Previous radiological descriptions of pelvic rhabdomyosarcoma emphasized ultrasonography and computerized tomography (CT). Few reports are available on the use of magnetic resonance imaging (MRI) for diagnosing and following pelvic rhabdomyosarcoma. We retrospectively compared MRI to CT for diagnosing and following children with pelvic rhabdomyosarcoma.

MATERIALS AND METHODS

We treated 4 boys and 3 girls for pelvic rhabdomyosarcoma. Initial and followup evaluations included pelvic CT and MRI at intervals determined by treatment and disease status. We retrospectively reviewed the clinical charts and imaging studies of these patients. The initial radiological report was evaluated and then 1 radiologist reviewed all studies. Attention was directed toward identifying lesions revealed by CT or MRI but not by the other modality.

RESULTS

MRI detected all lesions shown by CT. On the other hand, MRI detected residual disease in 1 case that was not demonstrated by CT. In 2 other patients MRI was superior to CT for delineating the local extent of disease, especially urethral involvement.

CONCLUSIONS

Compared with CT, MRI improves the detection of residual pelvic rhabdomyosarcoma. Tissue planes are well delineated, allowing more accurate assessment of tumor invasion into adjacent structures. MRI is the imaging modality of choice for following pediatric patients with pelvic rhabdomyosarcoma.

Acellular bladder matrix allografts in the regeneration of functional bladders: evaluation of large-segment (> 24 cm) substitution in a porcine model

OBJECTIVES

To evaluate the use of a large-segment (> 24 cm2) bladder substitution with porcine bladder acellular matrix allograft (BAMA) in a large animal model. Materials and methods Bladders were harvested from pigs at the time of necropsy and subjected to detergent and enzymatic extractions to render them acellular. The BAMA produced had the surgical handling and suture-retaining properties of normal bladder tissue. Six pigs had BAMA segments implanted under general anaesthesia, through a low midline abdominal incision and after partial cystectomy. The defect was repaired with a BAMA patch (mean size 43.88 cm2, range 12-72), with no urinary diversion. Two animals each were then killed at 9, 16 and 30 days and the bladders explanted. The native bladder and BAMA patch were analysed morphometrically to evaluate cellular re-population and matrix re-organization.

RESULTS

All animals survived surgery; there were no urinary leaks and no stones detected in any of the bladders. At 9 days there was a diffuse infiltration with acute inflammatory cells, but no areas of necrosis. There were isolated areas of smooth muscle cell (SMC) infiltration of the BAMA. At 16 days the luminal surface was lined with a single layer of urothelium, there was stromal infiltration with disorganized SMC and angiogenesis, with mature vessels in the BAMA patch. At 30 days the urothelium was multilayered with organizing groups of SMCs and angiogenesis. The highest cell density was at the periphery of the repopulated BAMA patch, decreasing towards the centre.

CONCLUSIONS

The implantation of large patches of BAMA is technically feasible and may prove to be a viable surgical alternative to bladder augmentation with intestinal segments. The advantages of BAMA include the potential for complete and functional regeneration of a bladder substitute. This model provides a tool with which to obtain a better understanding of the cellular and molecular aspects of matrix re-population.

Issues surrounding the prevention and management of device-related infections

The use of biomaterial devices in all aspects of modern medicine has increased exponentially in the past three decades. Device-related infections constitute one of the main impediments to their long-term use. We discuss the pathogenesis, prevention, and management of catheter-associated urinary tract infection (CAUTI). The recent innovations in biomaterial design and surface coatings intended to prevent colonization of the device surface are presented. Despite these significant advances, the ability to protect these surfaces beyond the short term presents a continued challenge to investigators.

Concomitant modified bladder neck closure and Mitrofanoff urinary diversion

PURPOSE

We describe a modification of bladder neck closure for managing urinary incontinence in children.

MATERIALS AND METHODS

In 11 patients with intractable urinary incontinence that persisted after multiple failed surgical procedures we performed modified bladder neck closure with construction of a catheterizable continent conduit.

RESULTS

Mean followup is 3 years. All patients were continent after the procedure and none had a fistula or urinary leakage. One patient required stomal and conduit revision, and bladder stones in 3 necessitated endoscopic removal.

CONCLUSIONS

We recommend this modified technique of bladder neck closure as an option for managing urinary incontinence in a complex group of children because it allows the achievement of continence with minimal morbidity.

Initial experience with endoscopic holmium laser lithotripsy for pediatric urolithiasis

PURPOSE

Due to the unavailability of suitable pediatric instruments children have not benefited from advances in endoscopic lithotripsy. This limitation may be overcome by the holmium: YAG laser. We evaluated the indications for, and efficacy and complications of holmium:YAG laser lithotripsy.

MATERIALS AND METHODS

We retrospectively reviewed all cases of laser lithotripsy. Access to the calculus was antegrade or retrograde. A solid state holmium:YAG laser was used.

RESULTS

Eight patients 4 to 14 years old underwent laser lithotripsy during the study period. Average calculous surface area was 357.13 mm.2 (range 14 to 1,645). Five patients required 1 procedure to render them stone-free, while the remaining 3 required multiple procedures. No complications were associated with laser lithotripsy.

CONCLUSIONS

The ability of the holmium:YAG laser to pulverize urinary calculi makes it an alternative choice for lithotripsy. In our series all patients are stone-free with stable renal function. The advantages of the holmium:YAG laser are that it may be precisely applied via small fibers, and it pulverizes calculi with minimal scattering of energy and retropulsion of the calculus, decreasing trauma to tissues at the perioperative site. There is also a lower risk of residual fragments, which is associated with a lower incidence of calculous regrowth. Holmium: YAG laser is safe and effective for treating pediatric urolithiasis.