Intensive Care and Department of Surgery, Erasmus MC-Sophia
Children's Hospital, Rotterdam, The Netherlands and Department of
Development and Regeneration, KU Leuven, Leuven, Belgium
Karel.allegaert@uzleuven.be
We have read with great interest the review article on the
pharmacology, prescribing and controversies of codeine in paediatrics and
we agree to a very large extent to the position t...
Intensive Care and Department of Surgery, Erasmus MC-Sophia
Children's Hospital, Rotterdam, The Netherlands and Department of
Development and Regeneration, KU Leuven, Leuven, Belgium
Karel.allegaert@uzleuven.be
We have read with great interest the review article on the
pharmacology, prescribing and controversies of codeine in paediatrics and
we agree to a very large extent to the position taken by the authors: the
use of codeine is becoming more and more obsolete. Replacing codeine by
its metabolite, i.c. morphine is a rational decision since this results in
better predictability of the between individual exposure and subsequent
(side)effects [Andrzejowski et al, Arch Dis Child Ed Practice 2016]. In
adults, this variability in exposure is mainly driven by pharmacogenetics
(PG, i.c. cytochrome P450 (CYP)2D6). In infants and children, this is
driven by both maturation and PG of CYP2D6. On this point, we disagree
with the author's suggestion that CYP2D6 maturation is slow. Although one
can debate on how to classify the rate of maturation, the review suggests
that CYP2D6 maturation is slow. To the very best of our knowledge, its
maturation is quite fast, and this matters for both codeine as well as for
other compounds, like e.g. tramadol.
The pattern of CYP2D6 maturation has been described based on in vivo
observations for tramadol [Allegaert et al, Clin Pharmacokinet 2015] as
well as for dextromethorphan [Blake et al, Clin Pharm Ther 2007] and have
been linked with in vitro observations [Tjollyn et al, AAPS J 2015]. All
observations documented extensive variability in part explained by
pharmacogenetics (CYP2D6, but more recently also OCT1) and fast maturation
[Matic et al, Ther Drug Monit 2016], with already relevant activity in
early infancy.
This goes beyond academic relevance, since this means that the CYP26
driven metabolism of codeine as well as tramadol, already in part depends
on PG polymorphisms and that clinicians should be aware of this when
prescribing or evaluating the dose/effect response in every individual
child, including neonates or young infants. Although tramadol has also non
-opioid related analgesic mechanisms, the major 'opioid' metabolite (M1, O
-desmethyl tramadol) is generated through CYP2D6 metabolism. Consequently,
the PG polymorphisms very likely already affect the PK/PD response of
tramadol and its variability in early infancy. Even more, the subsequent
renal elimination capacity makes M1 accumulation more likely.
In conclusion, we agree to a very large extent to the position taken by
the authors that the use of codeine is becoming more and more obsolete,
and replacing codeine by its metabolite, i.c. morphine is a rational
decision. However, because CYP2D6 maturation is fast, these conclusions
also already apply to neonates and young infants.
Dear Editor, we would like to congratulate Dr Bate et al for so
eloquently highlighting the importance of public and patient involvement
specifically in paediatric research [1]. We would like to further the
discussion by highlighting the involvement of adolescents and young adults
who by virtue of age may be in either paediatric and/or adult-focussed
research. Mattila et al reported that young people in this age group who...
Dear Editor, we would like to congratulate Dr Bate et al for so
eloquently highlighting the importance of public and patient involvement
specifically in paediatric research [1]. We would like to further the
discussion by highlighting the involvement of adolescents and young adults
who by virtue of age may be in either paediatric and/or adult-focussed
research. Mattila et al reported that young people in this age group who
were not involved in research were at risk of poor health outcomes
compared to those who had been [2]. It is also widely reported that young
people are at risk of lapses in care at this time of transition from child
to adult centred services [3] and therefore also at risk of being lost to
research follow-up. The involvement of people of all ages (including young
people) in research is now widely advocated but research priorities are
still largely driven by professional agendas. Evidence from adult
literature has reported a mismatch between researcher and patient
generated lists of research topics. To date, there have been no studies
exploring the priorities of young people with long term conditions
including rheumatic disease other than a few in which a minority of young
people were involved in a larger group of carers and professionals [4,5].
Therefore, there is a need to determine the priorities of young people
across the wide adolescent and young adult age range to inform future
research programmes and funding in this area. In rheumatology, the YOURR
project (Young People's Opinions Underpinning Rheumatology Research) was
therefore established as an early initiative of the Barbara Ansell
National Network for Adolescent Rheumatology (BANNAR) funded by Arthritis
Research UK. Interim guidance regarding involvement of young people in
rheumatology research was developed at the outset supported by a mapping
document of models of good practice in the UK [6, 7]. This was necessary
ground work to inform a study, data collection for which has almost
completed, and the protocol paper just published [8], which explores young
people's beliefs about research priorities in the adolescent rheumatology
field, to inform BANNAR. BANNAR aims to provide a platform to ensure that
young people in the UK have the best chance to benefit from developments
in the field of adolescent rheumatology. Integral to BANNAR is equitable
representation from young people with rheumatic conditions. This project
will help ensure full representation from young people with rheumatic
diseases in the development of a research strategy for BANNAR and will
ultimately inform a young person's led involvement strategy, ensuring
meaningful involvement in future research programmes.
[1]. Bate J, Ranasinghe N, Ling R, Preston J, Nightingale R, Denegri
S. Public and patient involvement in paediatric research. Arch Dis Child
Educ Pract Ed. 2016 Jun;101(3):158-61
[2]. Mattila VM, Parkkari J, Rimpela A. Adolescent survey non-response and
later risk of death. A prospective cohort study of 78609 persons with 11
year follow-up. BMC Public Health 2007;7:87.
[3]. Clinton-McHarg T, Paul C, Sanson-Fisher R, D'Este C, Williamson A.
Determining research priorities for young people with haematological
cancer: a value-weighting approach. Eur J Cancer. 2010 Dec;46 (18):3263-70
[4]. Morris C, Simkiss D, Busk M, Morris M, Allard A, Denness J, Janssens
A, Stimson A, Coghill J, Robinson K, Fenton M, Cowan K. Setting research
priorities to improve the health of children and young people with
neurodisability: a British Academy of Childhood Disability-James Lind
Alliance Research Priority Setting Partnership.BMJ Open. 2015 Jan
28;5(1):e006233.
[5]. Hazel E, Zhang X, Duffy CM, Campillo S. High rates of unsuccessful
transfer to adult care among young adults with juvenile idiopathic
arthritis. Pediatric Rheumatology 2010;8:2
[6]. Dack K, Williams H, Parsons S, Thomson W, McDonagh JE on behalf of
the Barbara Ansell National Network for Adolescent Rheumatology. Summary
of good practice when involving young people in health-related research.
2015 http://bannar.org.uk
[7]. McDonagh JE, Parsons S. BANNAR Guidance for Involvement of Young
People in Rheumatology Research. Interim Statement. 2015
http://bannar.org.uk
[8]. Parsons S, Dack K, Starling B, Thomson W, McDonagh JE. Study
Protocol: Determining what young people with rheumatic disease consider
important to research (the Young People's Opinions Underpinning
Rheumatology Research YOURR project) Research Involvement and Engagement
2016, 11 June [Epub ahead of print]
The author makes an interesting point about the current legislation and automatic inclusion of data in trials where prior informed consent is not possible.
EU legislation focuses on when research without prior consent (RWPC) can occur and the need to obtain consent for continued participation, but does not cover the options for use of data collected prior to consent. The exception to this is where consent is not pr...
The author makes an interesting point about the current legislation and automatic inclusion of data in trials where prior informed consent is not possible.
EU legislation focuses on when research without prior consent (RWPC) can occur and the need to obtain consent for continued participation, but does not cover the options for use of data collected prior to consent. The exception to this is where consent is not provided: ???he or she should be informed of their right to object to the use of data obtained from the clinical trial???. Therefore, this situation is open to interpretation.
We acknowledge the concerns of the letter author regarding not automatically including data. If data are not automatically included there is the potential for bias in the study results if the decision to provide consent for use the data is associated with patient outcome. This could potentially lead to erroneous conclusions with far reaching implications. However, the research community needs to consider the timeframes around stabilisation of the patient with respect to the potential need for continued delivery of the intervention, additional tests and timing of data to be collected after this point. It would be difficult to argue against the current legislation that consent should not be requested here.
CONNECT and studies conducted in neonatal intensive care indicate that children and parents not only want to be informed, but also want to make the decision about the inclusion of their information in research. One question to reflect on is who ???owns??? the data? If it???s the patient, then they (and their parents) surely have the right to be asked for it to be used.
We believe that the automatic inclusion of data with an ???opt out??? approach should be limited to circumstances where a face to face discussion with the family has not been possible before they leave hospital, or is not deemed appropriate at that point in time (e.g. when a child had died) and there has been no response to attempts to contact the family. This approach is currently used in a NIHR HTA funded EcLiPSE Study: Emergency treatment with Levetiracetam or Phenytoin in Status Epilepticus: http://www.nets.nihr.ac.uk/projects/hta/12127134
In developing the CONNECT guidance we had to work within UK and EU legislation ??? otherwise our guidance would have been of no practical use. Article 35 of the 2014 EU legislation stipulates that research in emergency situations should only pose ???a minimal risk to, and impose a minimal burden on the subject in comparison with the standard treatment of the subject???s condition???. Our interpretation is that if a trial intervention posed more than a minimal risk, then a REC should not approve the trial. The CONNECT study findings were in keeping with this, showing that parents supported doing RWPC in trials of interventions already used in clinical care, although they were concerned about doing RWPC in trials involving new interventions, or significant changes in clinical practice.
Dyer et al. wrote an instructive review on how to interpret malaria
tests (1). However there are two important caveats in the interpretation
of these tests which they did not mention. First, a positive test does not
necessarily confirm a diagnosis of malaria. Second, a positive test does
not necessarily mean that malaria is the only diagnosis.
Strictly speaking, the tests described by Dyer et al. are parasite
de...
Dyer et al. wrote an instructive review on how to interpret malaria
tests (1). However there are two important caveats in the interpretation
of these tests which they did not mention. First, a positive test does not
necessarily confirm a diagnosis of malaria. Second, a positive test does
not necessarily mean that malaria is the only diagnosis.
Strictly speaking, the tests described by Dyer et al. are parasite
detection tests rather than malaria tests, since the diagnosis of malaria
requires that there is symptomatic infection with a Plasmodium species.
This is not just a semantic point. Children who live in a malaria endemic
country may develop naturally acquired immunity with repeated infections
(2, 3). This immunity decreases the likelihood of developing symptoms
during infection and permits the asymptomatic carriage of blood stage
parasites. Children from high transmission countries who are visiting or
migrating to the UK and develop a febrile illness may be found to have a
positive parasitological test, but their illness may have a totally
different cause. In these cases it is always sensible to treat for
malaria, but a high index of suspicion of another cause should be
maintained, particularly if the child is seriously ill.
Related to this, there is a well-recognised association between
malaria and risk of invasive bacterial infection (4). Children with
malaria are more likely to develop Gram-negative bacteraemia, particularly
infection with non-Typhoidal Salmonella. For this reason, it should not be
assumed that a positive parasite detection test in an unwell febrile child
makes a diagnosis of malaria and excludes another infection. Recent
guidelines recommend the prudent approach that any child with features of
severe malaria should be treated with broad spectrum antibiotics until it
is clear that there is no co-infection (5).
1. Dyer E, Waterfield T, Eisenhut M. How to interpret malaria tests.
Arch Dis Child Educ Pract Ed 2016;101(2):96-101.
2. Crompton PD, Moebius J, Portugal S, et al. Malaria immunity in man and
mosquito: insights into unsolved mysteries of a deadly infectious disease.
Annual review of immunology 2014;32:157-87.
3. White NJ, Pukrittayakamee S, Hien TT, et al. Malaria. Lancet
2014;383(9918):723-35.
4. Takem EN, Roca A, Cunnington A. The association between malaria and non
-typhoid Salmonella bacteraemia in children in sub-Saharan Africa: a
literature review. Malar J 2014;13:400.
5. Lalloo DG, Shingadia D, Bell DJ, et al. UK malaria treatment guidelines
2016. J Infect 2016.
The recognition of endocrine-related hypernatraemia would be enhanced
if account were taken, not only of biochemically overt hypernatraemia(1),
but also of the possibility that this biochemical derangement might be
masked by co-existing inability to excrete salt-free water. The clinical
counterpart of this phenomenon is encapsulated in the statement "the
symptoms of cranial diabetes insipidus may be ma...
The recognition of endocrine-related hypernatraemia would be enhanced
if account were taken, not only of biochemically overt hypernatraemia(1),
but also of the possibility that this biochemical derangement might be
masked by co-existing inability to excrete salt-free water. The clinical
counterpart of this phenomenon is encapsulated in the statement "the
symptoms of cranial diabetes insipidus may be masked by concomitant ACTH
deficiency...(since) glucocorticoids are necessary for the kidneys to
excrete salt-free water"(2). This scenario has no adverse iatrogenic
sequelae if the recognition and treatment of cranial diabetes insipidus
antedates replacement therapy for co-existing ACTH deficiency. The danger
arises where glucocorticoid replacement therapy is instituted in the face
of unsuspected cranial diabetes insipidus because this might be
accompanied by a rapid rise in plasma sodium which, in one instance, was a
rise from pre-treatment hyponatraemia to post treatment hypernatraemia,
with consequent myelinosis(3). Even the use of ACTH for dynamic testing of
the hypothalamo/pituitary/adrenal axis may have an unmasking effect, this
time by precipitating profound polyuria as was the case in a patient with
suspected anterior pituitary failure in whom co-existing cranial diabetes
insipidus had not been identified(4). Where the investigators deliberately
set out to identify both anterior and posterior pituitary failure in 12
patients with suspected panhypopituitarism. 4 patients in whom unequivocal
carnial diabetes insipidus(charcterised by a negligible increase in plasma
vasopressin following hypertonic saline infusion) co-existed with ACTH
deficiency nevertheless had normal plasma sodium levels(range 140-143
mmol/l)(5). Patients in whom this constellation of parameters is
associated with blunted diuresis are the ones most likely to be missed if,
as in one study, the co-existence of hypernatraemia and polyuria is relied
upon as one of the screening tests for cranial diabetes insipidus(6).
References:
(1) Haycock GB
Hypernatraemia:diagnosis and treatment
Arch Dis Child 2006:91:ep8-ep13
(2) Bayliss PH and Cheetham T
Diabetes insipidus
Arch Dis Child 1998:79:84-89
(3)Lasheen I., Doi SAR., Al-Shoumer KAS
Glucocorticoid replacement in panyhpopituitarism complicated by myelinosis
Medical principles and Practice 2005:14:115-117
(4) Schwartz AR and Leddy AL
Recognition of diabetes insipidus in postpartum hypopituitarism
Obstetrics and Gynecology 1982:59:394-8
(5) Iwasaki Y., Oiso Y., Yamauchi K., et al
Neurohypophyseal function in postpartum hypopituitarism: impaired plasma
vasopressin respnse to osmotic stimuli
Journal of Clinical Endocrinology and Metabolism 1989:68:560-5
(6) Agha A., Rogers B., Mylotte D., et al
Neuroendocrine dysfunction in the acute phase of traumatic brain injury
Clinical Endocrinology 2004:60:584-91
In addition to the documentation of the radiographic stigmata of
paediatric mycobacterium tuberculosis(1), mention also needs to be made
that the differential diagnosis of mediatinal and hilar lymphadenopathy
should include infection with mycobacterium avium complex(MAC) organisms,
especially in patients with HIV/AIDS(2). In the latter context the
prevalence of MAC infection in children has been variou...
In addition to the documentation of the radiographic stigmata of
paediatric mycobacterium tuberculosis(1), mention also needs to be made
that the differential diagnosis of mediatinal and hilar lymphadenopathy
should include infection with mycobacterium avium complex(MAC) organisms,
especially in patients with HIV/AIDS(2). In the latter context the
prevalence of MAC infection in children has been variously documented as
5.7%(3) and 12%(4), increasing to 24% in those with CD4 counts of < 100
cell/cubic millimetre(5). The risk of haematogenous dissemination is high,
with a baseline prevalence of 18% in one adult cohort, the subsequent
prevalence being 41% on 24 months follow up(6). Amongst children, a fall
in CD4 count to < 100 cell/cubic millilitre more than doubles the risk
of haematogenous dissemination(5). A high index of suspicion is required
for the recognition of disseminated MAC infection, given the fact that its
manifestation are much more likely to be systemic than pulmonary, and also
given the fact that the cardinal radiographic abnormality, namely,
mediastinal and hilar lymphadenopathy(2) is itself, not specific for MAC
infection. Th redeeming feature is that, notwithstanding the forecast that
the frequency of disseminated disease would rise(due to a predicted
increase in the percentage of children with very low CD4 cell counts(4),
what has, in fact happened is that, as a result of combination
antiretroviral treatment, the incidence of MAC has declined in all age
groups(7). The propensity for haematogenous dissemination makes it
possible to confirm the diagnosis of MAC by blood culture, obtaining two
blood cultures at different times being generally sufficient to detect
almost all MAC bacteremic episodes(8). The most compelling reason for identifying MAC infection is that its treatment regime is different from that of mycobacterium tuberculosis infection(9)
References:
(1) Marais BJ
Intrathoracic tuberculosis in children
Arch Did Child Educ Pract Ed 2006:91:ep1-ep7
(2)Miller WT
Spectrum of pulmonary nontuberculous mycobacterial infection
Radiology 1994:191:343-50
(3)Horsburgh CB., Caldwell MB., Simons RJ
Epidemiology of disseminated nontuberculous mycobacterial disease in
children with acquired immunodeficiency syndrome
Pediatr Infect Dis J 1993:12:219-22
(4) Hoyt L., Oleske J., Holland B., Connor E
Nontuberculous mycobacteria in children with acquired immunodeficiency
syndtome
Pediatr Infect Dis J 1992:11:354-60
(5)Lewis LL., Butler KM., Husson RN., et al
Defining the population of human immunodeficiency virus-infected children
at risk for mycobacterium avium-intracellulare infection
J Pediatr 1992:121:677-83
(6)Nightingale SD., Byrd LT., Southern PM., et al
Incidence of mycobacterium avium-intracellulare complex bacteremia in
human immunodeficiency virus positive patients
J Infect Dis 1992:165:1082-5
(7)Palella FJ., Delaney KM., Moorman AC
Declining morbidity and mortality among patients with advanced human
immunodeficiency virus infection
N Engl J Med 1998:338:853-60
(8) Yagupsky P., Menegus MA
Cumulative positivity rates of multiple blood cultures for mycobacterium
avium-intracellulare and cryptococcus neoformans in patients with the
acquired immunodeficiency syndrome
Arch Pathol Lab Med 1990:114:923-5
(9) Abrams E
Opportunistic infections and other clinical manifestations of HIV disease in children
Pediatric Clinics of North America 2000:47:79-108
Richard Bowker and the Paediatric Accident and Emergency Research
Group are to be congratulated on their excellent guideline [1]. It
appears comprehensive enough to detect all possible diagnoses while being
concise enough to be workable. It does appear vulnerable in the area of
poisoning, however.
Carbon monoxide remains the most common cause of fatal poisoning in
the UK [2], and should be...
Richard Bowker and the Paediatric Accident and Emergency Research
Group are to be congratulated on their excellent guideline [1]. It
appears comprehensive enough to detect all possible diagnoses while being
concise enough to be workable. It does appear vulnerable in the area of
poisoning, however.
Carbon monoxide remains the most common cause of fatal poisoning in
the UK [2], and should be considered in children presenting to the
Emergency Department with a decreased conscious level. Symptoms progress
from lethargy, headache and vomiting, to convulsions, coma and
cardiovascular collapse [3]. Moreover for every case that comes to the
attention of a clinician several may be missed, either because the patient
or their carer does not report their vague symptoms or because the
physician does not consider the diagnosis [4]. Although not completely
sensitive or specific, a carboxyhaemoglobin (COHb) level may provide
useful information in the search for a cause of reduced conscious level.
COHb may be measured accurately on a venous sample [5] using an automated
blood gas analyser.
I therefore recommend the following alteration to the algorithm: In
Part III (Identify all problems) “Cause unknown” box, change “consider
drug ingestion” to “consider poisoning (including drug ingestion and
carbon monoxide exposure)”.
References:
1. Bowker RP, Stephenson TJ, Baumer JH. Evidence-based guideline for the
management of decreased conscious level. Arch Dis Child Educ Pract
2006;91:ep115-ep122
2. Parfitt A, Henry JA. Troublesome toxins. Emerg Med J 2002;
19:192-193
3. Skinner D, Swain A, Peyton R, Robertson C (Eds). Cambridge
textbook of accident and emergency medicine. Cambridge University Press,
Cambridge, UK (1997) page 216
4. Wright J. Chronic and occult carbon monoxide poisoning: we don’t
know what we’re missing. Emerg Med J 2002;19:386-390
5. Touger M, Gallagher EJ, Tyrell J. Relationship between venous and
arterial carboxyhemoglobin levels in patients with suspected carbon
monoxide poisoning. Annals Emergency Med 1995; 25: 481–3
I have developed a poster that summarises the evidence-based
guideline for the management of decreased conscious level developed by
Richard Bowker and the Paediatric Accident and Emergency Research Group
(PAERG). It was peer-reviewed and presented at the Inaugural Scientific
Conference of the College of Emergency Medicine at Stamford Bridge, London
in December 2006, and will probably be published in a...
I have developed a poster that summarises the evidence-based
guideline for the management of decreased conscious level developed by
Richard Bowker and the Paediatric Accident and Emergency Research Group
(PAERG). It was peer-reviewed and presented at the Inaugural Scientific
Conference of the College of Emergency Medicine at Stamford Bridge, London
in December 2006, and will probably be published in a supplement to the
Emergency Medicine Journal. Meanwhile it may be downloaded free from
www.paediatricguideline.com which also contains a link to the PAERG
guideline. I would envisage displaying the poster for immediate use by
junior medical and nursing staff, while the twelve-page guideline can be
printed off and filled in for each individual patient once the dust has
settled and appropriate specialists have arrived. The poster may be
modified for local use and reproduced freely in print or on health trust
intranets if required.
Drugs that cause acne include those that can impair oxidative
phosphorylation such as antidepressants, anti-seizure medications, and
cyclosporin which closes the permeability transition pore on mitochondrial
membranes. Impairment of oxidative phosphorylation should be accompanied
by a fall in cutaneous tissue pH and energy charge. Drugs that aggravate
acne include testosterone, corticosteroids, and an...
Drugs that cause acne include those that can impair oxidative
phosphorylation such as antidepressants, anti-seizure medications, and
cyclosporin which closes the permeability transition pore on mitochondrial
membranes. Impairment of oxidative phosphorylation should be accompanied
by a fall in cutaneous tissue pH and energy charge. Drugs that aggravate
acne include testosterone, corticosteroids, and anabolic steroids. Might
they do so by causing a fall in cutaneous tissue pH and/or energy charge?
The superficial layers of skin must be alkalotic because they exist
in an hypocarbic hyperoxic environment (1). In decreasing the magnitude of
the protonmotive force this should down-regulate ATP resynthesis by
oxidative phosphorylation and up-regulate that by glycolysis alone. As the
temperature of skin is also lower than core temperature and ATP yield
increases as the temperature increases skin is at a metabolic
disadvantage. Fetal skin, which does not scar, is much better off. It is
exposed to a much higher pCO2, 40 mmHg, the core temperature and a much
lower pO2, one less likely to generate free radicals. Fetal skin has,
therefore, a metabolic advantage over normal skin. Increasing the pCO2 to
which skin is exposed, decreasing the pO2 and increasing its temperature
might all be of benefit in acne sufferers because of an improvement in
tissue energetics. This is not a practical solution.
In myocytes testosterone induces cytoprotection by activation
[opening] of mitoKATP channel (2). It appears to do so by decreasing
myocardial contractility and hence workload. Myocardial dysfunction,
commonly achieved at surgery with potassium cardioplegia, is
cytoprotective to myocytes. Indeed the electrochemical effects of opening
the mitoKATP channel would seem to be very similar to that of potassium
cardioplegia. This is of interest for the primary determinants of ATP
resynthesis appear to be the primary determinants of the degree of
H+(atp) channel openess. In other words the cytoprotection, or
therapeutic dysfunction, induced in the heart by opening the mitoKATP
channel with testosterone might be due to a fall in tissue pH and
accompanying decline in energy charge and its inhibition of ATP-dependent
enzyme activity in accordance with the Daniel Atkinson hypothesis (3).
Might this be how testosterone increases the risk of developing acne?
If so glibenclamide, a mitoKATP closer, and even pinacidil, a
mitoKATP opener, might improve cutaneous tissue energetics and be
effective treatments in patients with acne . Glibenclamide might
increase the energy charge by increasing the rate of ATP resynthesis and
pinacidil by decreasing the rate of ATP utilization. Pinacidil, the
opener, might also make matters worse by increasing the dysfunction to a
degree that precipitates harmful effects including apoptosis and even
necrosis with its accompany inflammatory response. Glibenclamide would
seem, therefore, the safer option. In opposing the action of testosterone
glibenclamide might even be an ideal choice of drug to treat acne if
indeed it is the product of a decline in pH and energy charge induced
partially or wholly by testosterone and other androgens.
Diabetics are at added risk of developing infections and
glibenclamide is used to increase insulin release in insulin-dependent
diabetics. It does so by closing the mitoKATP channel which induces an
influx of Ca++ in beta cells which causes stored insulin to be released
from its vesicles. Insulin release is normally triggered by a rise in
ATP/ADP and, therefore, rise in pH and energy charge. In so doing it
inhibits ATP resynthesis both be decreasing the availability of glucose
and by inhibiting lipolysis and promoting the storage of fat in
adipocytes. A rise in glucose also stimulates insulin secretion by causing
an influx of Ca++ into beta cells. Thus a rise in fasting glucose, which
is associated with adverse outcomes, might indeed be an indication of
impaired tissue energetics (4). Diabetes is a disease characterised by
impaired tissue energetics (5). That, rather than the elevated
concetration of glucose in tissue fluids per se, is the most likely cause
for the increased risk of infections in these patients.
The easiest way to test the hypothesis that glibenclamide might be
effective treatment for patients with acne would be to look at patients
with acne who have been given the drug for insulin-dependent diabetes.
References:
1. Product of a tissue alkalosis induced by hypocarbia? Richard G
Fiddian-Green CJA Online, 21 Dec 2004 re: T Tsubo, T Kudo, A Matsuki and T
Oyama Decreased glucose utilization during prolonged anaesthesia and
surgery Canadian Journal of Anesthesia, Vol 37, 645-649
2. Fikret Er, MD*; Guido Michels, MD*; Natig Gassanov, MD; Francisco
Rivero, MD; Uta C. Hoppe, MD Testosterone Induces Cytoprotection by
Activating ATP-Sensitive K+ Channels in the Cardiac Mitochondrial Inner
Membrane. Circulation. 2004;110:3100-3107
3. Hardie DG, Hawley SA. AMP-activated protein kinase: the energy
charge hypothesis revisited.
Bioessays. 2001 Dec;23(12):1112-9.
4. Richard G Fiddian-Green
Hyperglycaemia = anaerobic threshold has been reached?
http://www.heartjnl.com/cgi/eletters/89/5/512#634, 3 Mar 2005
5. Richard G Fiddian-Green
Grounds for abandoning "diabetes" as a diagnosis?
http://www.postgradmedj.com/cgi/eletters/81/952/103#246, 3 Mar 2005
In a study of patients undergoing moderate and tepid hypothermic
hemodiluted cardiopulmonary bypass cerebral oxygen saturation (RsO(2)) and
mixed venous oxygen saturation (SvO(2)) were continuously monitored with
a cerebral oximeter via a surface electrode placed on the patient's
forehead and with the mixed venous oximeter integrated in the CPB machine,
respectively. There was a poor correlation between...
In a study of patients undergoing moderate and tepid hypothermic
hemodiluted cardiopulmonary bypass cerebral oxygen saturation (RsO(2)) and
mixed venous oxygen saturation (SvO(2)) were continuously monitored with
a cerebral oximeter via a surface electrode placed on the patient's
forehead and with the mixed venous oximeter integrated in the CPB machine,
respectively. There was a poor correlation between the two measurements.
Indeed during moderate hypothermic bypass they changed in opposite
directions, RsO(2) decreasing significantly from 76.0% +/- 9.6% to 58.9%
+/- 6.4% and SvO(2) increasing significantly from 78.6% +/- 3.3% to 84.9%
+/- 3.6% (1). "The temperature-uncorrected PaCO(2) was maintained at the
normocapnic level throughout the study, whereas the temperature-corrected
PaCO(2) was significantly lower during the moderate hypothermic phase
(26.8 +/- 3.1 mmHg) compared with the tepid hypothermic phase (38.9 +/-
3.7 mmHg) of CPB. There was a significant and positive correlation between
RsO(2) and temperature-corrected PaCO(2) during hypothermia"(1). The
inference is that the RsO(2) rises as the pH falls and the magnitude of
the protonmotive force driving ATP resynthesis increases.
In a study in which 18 patients regional oxygen saturation catheters
(Baxter Healthcare Corporation, Edward Critical Care) were placed (2),
however, longitudinal data regression showed that the overall slope of
the regression between the catheter and blood values was 0.997 (p =
0.001).
In the alpha-stat protocol used in hypothermic cardiopulmonary bypass
the PaCO2 is maintained at about 40 mm Hg using the measurement made at
37°C without temperature correction. In the pH-stat protocol, CO2 is added
to the oxygenator inspired gas flow to maintain temperature-corrected pH
at approximately 7.40 and PaCO2 at approximately 40 mm Hg. Thus
"temperature correction" is an adjustment for the hypocarbic alkalosis
that occurs in any aqueous solution that is cooled.
In an experimental hypothermic circulatory arrest model in
piglets"the pH-stat protocol was associated with an increase in cerebral
mixed vascular saturation measured by near-infrared spectroscopy" [i.e.
RsO(2)] raising the possibility of an improvement in cerebral tissue
energetics. (3). In a prospective randomized comparison of pH-stat and
alpha-stat protocols in patients undergoing hypothermic bypass the pH-
stat protocol promoted, relative to alpha stat protocol, "an increase in
SJVO2 [jugular venous] and a decrease in arteriovenous oxygen and
arteriovenous glucose differences. The authors concluded that, "These
findings indicate an increased cerebral supply with pH-stat"(4). As a fall
in pH inhibits glycolysis by inhibiting phosphofructokinase and thereby
shifts substrate utilization from glycogen and glucose to fatty acids, a
alternative explanation for the findings is that the pH-stat protocol
improves the efficiency of ATP resynthesis by increasing the protonmotive
force and thereby up-regulating oxidative phosphorylation. Indeed this
might be interpreted as a corollary of the Bohr effect.
When the rate of blood flow increases in sepsis the SvO(2)
increases. When instead SvO(2)s reduced by, for example, decreasing
FiO(2), flow increases. The opposing changes in SvO(2) are, therefore,
both functions of the rate of blood flow. ) the former the change in
SvO(2) is a circulatory response to an impairment of oxygen uptake and
utilization. The inference is that for RsO(2) to be of any value in
assessing the adequacy of tissue energetics it would first have to be
standardized for blood flow. It would also have to be standardized for
intracerebral tissue pH.
We have reported that the intramucosal PO(2) was a stand-alone
predictor from bleeding from stress ulceration but did not improve the
predictive model derived from the intramucosal pH and number of risk
factors, of dysfunctional organs, present (5). The PaO(2) in those who
bled from stress ulcers was also higher, and thus the difference between
PaO(2) and intramucosal PO(2), greater than that of the healthy controls.
Our interpretation at the time was that the low intramucosal PO(2) was
indicative of the presence of mucosal ischaemia. As the mucosa was
bleeding actively this conclusion was, in retrospect, wrong. Might,
rather, the low intramucosal PO(2) have been a reflection of the up-
regulation of oxidative phosphorylation induced by the fall in pHi an
increased extraction of oxygen from haemoglobin? In other words might a
low RsO(2) in the brain which is accompanied by a low intracerebral pH be
a refelction of the same?
It has been known for 17 years that a fall in intramucosal pH on the
day of surgery is predictive of the development organ dysfunctions and
death after cardiovascular operations(6) and indeed all critical
illnesses. Although I had formerly attributed to unreversed ATP hydrolysis
(7,8) I am now of the opinion that it is initially the product of proton
retention from increased glycolytic turnover, and accompanying rise in
NADH/NAD, and/or an active transport of protons from mitochondria into the
cytosol associated with a reverse of the direction of action of the ATP
synthase rotary pump. The fall in pH may be viewed as a cytoprotective
effect one, aided by an inhibition of ATP-dependent cellular acitivities
in accordance with the Daniel Atkinson energy charge hypothesis, designed
to preserve enough ATP syntheis to maintain viablility (9). Thus a fall in
intramucosal pH may be a sign both of reductive stress and the
cytoprotective response to it.
Dantzker raised the possibility that the gastrointestinal tract might
be the canary of the body, analogous to the canaries once used by coal
miners to obtain early warning of potentially lethal concentrations of
carbon monoxide (10). Maynard et al provided stronfg support for the
hypothesis (11). But the canaries became unconscious and did not develop
gastrointestinal problems! Indeed it has been proposed that the brain may
be a better canary in ambulatory patients, mood and behavioural disorders
preceding unconsciousness. Gologorsky et al have provided objectigve
evidence in support of this hypothesis from a prospectiver randomized
study of 200 pateints having elective coronary artery surgery (12). The
patients were, "randomized to either intraoperative cerebral regional
oxygen saturation (rSO2) monitoring with active display and treatment
intervention protocol, or underwent blinded rSO2 monitoring. Predefined
clinical outcomes were assessed by a blinded observer.
"Significantly more patients in the control group demonstrated
prolonged cerebral desaturation (P = 0.014) and longer duration in the
intensive care unit (P = 0.029) versus intervention patients. There was no
difference in overall incidence of adverse complications, but
significantly more control patients had major organ morbidity or mortality
(death, ventilation >48 h, stroke, myocardial infarction, return for re
-exploration) versus intervention group patients (P = 0.048). Patients
experiencing major organ morbidity or mortality had lower baseline and
mean rSO2, more cerebral desaturations and longer lengths of stay in the
intensive care unit and postoperative hospitalization, than patients
without such complications. There was a significant (r2 = 0.29) inverse
correlation between intraoperative rSO2 and duration of postoperative
hospitalization in patients requiring 10 days postoperative length of
stay". That is the greater the degree of cerebral desaturation the longer
the postoperative length of stay.
The design of the study and the findings are very simuilar to those
of Gutierrez et al (13) who used the intramucosal pH as a supplementary
endpopint in resuscitation. No other forms of monitoring have, to the best
of my knowledge, ever been subjected to this kind of testing. For patients
admitted with low pHi in the Gutierrez study, "survival was similar in the
protocol and control groups (37% vs 36%), whereas for those admitted with
normal pHi, survival was significantly greater in the protocol than in the
control group (58% vs 42%; p less than 0.01)". There was no survival
benefit in the Gologorsky study which included 30 fewer patients than the
Gutierrez study, but statistical significiance in the Gutierrez study was
found only after patients had been divided into two groups. Both studies
might have been limited by current practices which, in some instances,
oppose the logic of the interventions needed to achieve the best outcomes
from these forms of monitoring.
These findings in the Gologorsky study raise the possibility that
rSO2 might be a proxy for monitoring the intramucosal pH or visa versa
placing NICE into the position of approving the one and not the other or
even mandating a comparison before declaring one or the other cost-
effective. What then of other candidates such as continuous monitoring of
tissue and blood pH, PCO(2) and PO(2) with optodes, NMR spectroscopy and
microdialysis to monitor tissue metabolites? Is NICE going to demand that
each be shown to be effective in their own right and comparisons to be
completed before approving any one of them? If that were their decision
how long would it take for patients to benefit from any of the new
technologies and the refinements that willl undoubtedly follow? Until we
know how to use the information derived from any one form of monitoring to
the best advantage can the possibility that any one of them should be
excluded be justified despite the findings of any study? At the end of the
day the information derived from different forms of monitoring is likely
to be complemetary. Consider cerebral oxygen saturation.
What is the potential for cytokines misleading clinicans by
interfering with oxygen uptake and utilization? I am reminded of the pigs
in which we were monitoring intramucosal PO(2) and pH. Both fell with
acute vascular occlusion and in all but one case rose with reperfusion one
hour later. In the one case the intramucosal pH remainded low whilst the
PO(2) rebounded to supranormal levels. The same kind of phenomenon might
occur in sepsis and endotoxaemia. I suspect, therefore, that there will be
cases in which cerebral oxygen saturation diverges from intracerebral pH
and provides clinicans potentially misleading information. At the end of
the day the availability of oxygen does not seem to be a rate limiting
factor in ATP resynthesis in patient (14) except in extremis. That does
not exclude the possiblity that the measurement might be very helpful
especially in evaluating mood and behavioural disorders in subjects in
whom invasive monitoring is undesirable or likely to be refused.
Clinicians need to gain experience with these newer forms of
monitoring and, more importantly, gain some insight to the metabolic
issues involved. If the brain is to be used as a canary it would seem
that the intracerebral pH needs to be monitored for monitoring the rSO2
alone could miss the presence of metabolic stress especially in sepsis and
some forms of poisoniong such as CO poisoning. Having identified a low
intracerebral pH and/or low rSO2 and/or intramucosal pH and being made
aware of the probability of impending complications information about
individual enzyme activity, notably the regulatory enzymes which include
the pyruvate dehydrogenase complex, pyruvate decarboxylase and
phosphofructokinase, may be needed to make and implement rational
decisions in patient management.
References:
1. Baraka A, Naufal M, El-Khatib M. Correlation between cerebral and
mixed venous oxygen saturation during moderate versus tepid hypothermic
hemodiluted cardiopulmonary bypass. J Cardiothorac Vasc Anesth. 2006
Dec;20(6):819-25.
2. Ann M. Ritter1, Shankar P. Gopinath1, Charles Contant1 Raj K.
Narayan1 and Claudia S. Robertson1 Evaluation of a regional oxygen
saturation catheter for monitoring SJVO2 in head injured patients
Journal of Clinical Monitoring and Computing Volume 12, Number 4 / July,
1996 285-291
3. Kurth CD, O’Rourke MM, O’Hara IB. Comparison of pH-stat and alpha-
stat cardiopulmonary bypass on cerebral oxygenation and blood flow in
relation to hypothermic circulatory arrest in piglets. Anesthesiology
1998; 89: 110–8.
4. H. Tarik Kiziltan, Mehmet Baltal, Ahmet Bilen, Gülah Seydaoglu,
Muzaffer Incesoz, Atlay Tasdelen, and Sait Aslamaci. Comparison of Alpha-
Stat and pH-Stat Cardiopulmonary Bypass in Relation to Jugular Venous
Oxygen Saturation and Cerebral Glucose-Oxygen Utilization Anesth Analg
2003;96:644-650
5. Fiddian-Green RG, McGough E, Pittenger G, Rothman E. Predictive
value of intramural pH and other risk factors for massive bleeding from
stress ulceration. Gastroenterology. 1983 Sep;85(3):613-20
6. Fiddian-Green RG. 6. Gut mucosal ischemia during cardiac surgery.
Semin Thorac Cardiovasc Surg. 1990 Oct;2(4):389-99.
8. Fiddian-Green RG. Monitoring of tissue pH: the critical
measurement.
Chest. 1999 Dec;116(6):1839-41.
9. Richard G Fiddian-Green
Monitoring tissue pH vs lactate and ATP degradation products in sepsis
http://adc.bmj.com/cgi/eletters/78/2/155#2830, 14 Dec 2006
10. Dantzker DR. The gastrointestinal tract. The canary of the body?
1: JAMA. 1993 Sep 8;270(10):1247-8
11. Maynard N, Bihari D, Beale R, Smithies M, Baldock G, Mason R,
McColl I. Assessment of splanchnic oxygenation by gastric tonometry in
patients with acute circulatory failure. 1: JAMA. 1993 Sep 8;270(10):1203
-10
12. Gologorsky E, Gologorsky A, Akins C, Murtha S. Regional
cerebral oxyhemoglobin saturation-guided resuscitation. Anesth Analg.
2006 Dec;103(6):1608-9.
13. Gutierrez G, Palizas F, Doglio G, Wainsztein N, Gallesio A, Pacin
J, Dubin A, Schiavi E, Jorge M, Pusajo J, et al. Gastric intramucosal pH
as a therapeutic index of tissue oxygenation in critically ill patients.
Lancet. 1992 Jan 25;339(8787):195-9.
14. Fiddian-Green RG. Oxygen administration can reverse neurological
deficit following carotid cross-clamping. Br J Anaesth. 2005 Aug;95(2):274
-5
K Allegaert
Intensive Care and Department of Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands and Department of Development and Regeneration, KU Leuven, Leuven, Belgium Karel.allegaert@uzleuven.be
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