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Swift LM, Roberts A, Pressman J, Guerrelli D, Allen S, Haq KT, Reisz JA, D’Alessandro A, Posnack NG. Evidence for the cardiodepressive effects of the plasticizer di-2-ethylhexyl phthalate. Toxicol Sci 2023; 197:79-94. [PMID: 37812252 PMCID: PMC10734602 DOI: 10.1093/toxsci/kfad105] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
Di-2-ethylhexyl phthalate (DEHP) is commonly used in the manufacturing of plastic materials, including intravenous bags, blood storage bags, and medical-grade tubing. DEHP can leach from plastic medical products, which can result in inadvertent patient exposure. DEHP concentrations were measured in red blood cell units stored between 7 and 42 days (17-119 μg/ml). Using these concentrations as a guide, Langendorff-perfused rat heart preparations were acutely exposed to DEHP. Sinus activity remained stable with lower doses of DEHP (25-50 μg/ml), but sinus rate declined by 43% and sinus node recovery time (SNRT) prolonged by 56.5% following 30-min exposure to 100 μg/ml DEHP. DEHP exposure also exerted a negative dromotropic response, as indicated by a 69.4% longer PR interval, 108.5% longer Wenckebach cycle length (WBCL), and increased incidence of atrioventricular (AV) uncoupling (60-min exposure). Pretreatment with doxycycline partially rescued the effects of DEHP on sinus activity, but did not ameliorate the effects on AV conduction. DEHP exposure also prolonged the ventricular action potential and effective refractory period, but had no measurable effect on intracellular calcium transient duration. Follow-up studies using human-induced pluripotent stem cell-derived cardiomyocytes confirmed that DEHP slows electrical conduction in a time (15 min-3 h) and dose-dependent manner (10-100 μg/ml). Previous studies have suggested that phthalate toxicity is specifically attributed to metabolites of DEHP, including mono-2-ethylhexylphthalate. This study demonstrates that DEHP exposure also contributes to cardiac dysfunction in a dose- and time-dependent manner. Future work is warranted to investigate the impact of DEHP (and its metabolites) on human health, with special consideration for clinical procedures that employ plastic materials.
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Affiliation(s)
- Luther M Swift
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, District of Columbia 20010, USA
- Children’s National Heart Institute, Children’s National Hospital, Washington, District of Columbia 20010, USA
| | - Anysja Roberts
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, District of Columbia 20010, USA
- Children’s National Heart Institute, Children’s National Hospital, Washington, District of Columbia 20010, USA
| | - Jenna Pressman
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, District of Columbia 20010, USA
- Children’s National Heart Institute, Children’s National Hospital, Washington, District of Columbia 20010, USA
- Department of Biomedical Engineering, School of Engineering and Applied Sciences, The George Washington University, Washington, District of Columbia 20037, USA
| | - Devon Guerrelli
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, District of Columbia 20010, USA
- Children’s National Heart Institute, Children’s National Hospital, Washington, District of Columbia 20010, USA
- Department of Biomedical Engineering, School of Engineering and Applied Sciences, The George Washington University, Washington, District of Columbia 20037, USA
| | - Samuel Allen
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, District of Columbia 20010, USA
- Children’s National Heart Institute, Children’s National Hospital, Washington, District of Columbia 20010, USA
| | - Kazi T Haq
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, District of Columbia 20010, USA
- Children’s National Heart Institute, Children’s National Hospital, Washington, District of Columbia 20010, USA
| | - Julie A Reisz
- Department of Biochemistry and Molecular Genetics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado 80045, USA
| | - Angelo D’Alessandro
- Department of Biochemistry and Molecular Genetics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado 80045, USA
| | - Nikki Gillum Posnack
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, District of Columbia 20010, USA
- Children’s National Heart Institute, Children’s National Hospital, Washington, District of Columbia 20010, USA
- Department of Pediatrics, School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia 20037, USA
- Department of Pharmacology & Physiology, School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia 20037, USA
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Swift LM, Roberts A, Pressman J, Guerrelli D, Allen S, Haq KT, Reisz JA, D'Alessandro A, Posnack NG. Evidence for the cardiodepressive effects of the plasticizer di-2-ethylhexylphthalate (DEHP). BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.05.22.541729. [PMID: 37293060 PMCID: PMC10245927 DOI: 10.1101/2023.05.22.541729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Di-2-ethylhexylphthalate (DEHP) is commonly used in the manufacturing of plastic materials, including intravenous bags, blood storage bags, and medical-grade tubing. DEHP can leach from plastic medical products, which can result in inadvertent patient exposure. DEHP concentrations were measured in red blood cell (RBC) units stored between 7-42 days (23-119 μg/mL). Using these concentrations as a guide, Langendorff-perfused rat heart preparations were acutely exposed to DEHP. Sinus activity remained stable with lower doses of DEHP (25-50 μg/mL), but sinus rate declined by 43% and sinus node recovery time prolonged by 56.5% following 30-minute exposure to 100 μg/ml DEHP. DEHP exposure also exerted a negative dromotropic response, as indicated by a 69.4% longer PR interval, 108.5% longer Wenckebach cycle length, and increased incidence of atrioventricular uncoupling. Pretreatment with doxycycline partially rescued the effects of DEHP on sinus activity, but did not ameliorate the effects on atrioventricular conduction. DEHP exposure also prolonged the ventricular action potential and effective refractory period, but had no measurable effect on intracellular calcium transient duration. Follow-up studies using hiPSC-CM confirmed that DEHP slows electrical conduction in a time (15 min - 3 hours) and dose-dependent manner (10-100 μg/mL). Previous studies have suggested that phthalate toxicity is specifically attributed to metabolites of DEHP, including mono-2-ethylhexyl phthalate (MEHP). This study demonstrates that DEHP exposure also contributes to cardiac dysfunction in a dose- and time-dependent manner. Future work is warranted to investigate the impact of DEHP (and its metabolites) on human health, with special consideration for clinical procedures that employ plastic materials.
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Guerrelli D, Desai M, Semaan Y, Essa Y, Zurakowski D, Cendali FI, Reisz JA, D'Alessandro A, Luban NC, Posnack NG. Prevalence and Clinical Implications of Heightened Plastic Chemical Exposure in Pediatric Patients Undergoing Cardiopulmonary Bypass. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.02.23289379. [PMID: 37205364 PMCID: PMC10187441 DOI: 10.1101/2023.05.02.23289379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Importance Phthalate chemicals are used to manufacture disposable plastic medical products, including blood storage bags and components of cardiopulmonary bypass (CPB) circuits. During cardiac surgery, patients can be inadvertently exposed to phthalate chemicals that are released from these plastic products. Objective To quantify iatrogenic phthalate chemical exposure in pediatric patients undergoing cardiac surgery, and examine the link between phthalate exposure and post-operative outcomes. Design Setting and Participants The study cohort included 122 pediatric patients undergoing cardiac surgery at Children's National Hospital. For each patient, a single plasma sample was collected pre-operatively and two additional samples were collected post-operatively upon return from the operating room (post-operative day 0) and the morning after surgery (post-operative day 1). Exposures Concentrations of di(2-ethylhexyl)phthalate (DEHP) and its metabolites were quantified using ultra high-pressure liquid chromatography coupled to mass spectrometry. Main Outcomes and Measures Plasma concentrations of phthalates, post-operative blood gas measurements, and post-operative complications. Results Study subjects were subdivided into three groups, according to surgical procedure: 1) cardiac surgery not requiring CPB support, 2) cardiac surgery requiring CPB with crystalloid prime, and 3) cardiac surgery requiring CPB with red blood cells (RBCs) to prime the circuit. Phthalate metabolites were detected in all patients, and postoperative phthalate levels were highest in patients undergoing CPB with RBC-based prime. Age-matched (<1 year) CPB patients with elevated phthalate exposure were more likely to experience post-operative complications, including arrhythmias, low cardiac output syndrome, and additional post-operative interventions. RBC washing was an effective strategy to reduce DEHP levels in CPB prime. Conclusions and Relevance Pediatric cardiac surgery patients are exposed to phthalate chemicals from plastic medical products, and the degree of exposure increases in the context of CPB with RBC-based prime. Additional studies are warranted to measure the direct effect of phthalates on patient health outcomes and investigate mitigation strategies to reduce exposure. Key Points Question: Is cardiac surgery with cardiopulmonary bypass a significant source of phthalate chemical exposure in pediatric patients?Findings: In this study of 122 pediatric cardiac surgery patients, phthalate metabolites were quantified from blood samples before and after surgery. Phthalate concentrations were highest in patients undergoing cardiopulmonary bypass with red blood cell-based prime. Heightened phthalate exposure was associated with post-operative complications.Meaning: Cardiopulmonary bypass is a significant source of phthalate chemical exposure, and patients with heightened exposure may be at greater risk for postoperative cardiovascular complications.
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Neonatal exposure to phthalate and alternative plasticizers via parenteral nutrition. Int J Pharm 2023; 631:122472. [PMID: 36526146 DOI: 10.1016/j.ijpharm.2022.122472] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/03/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022]
Abstract
Di-(2-ethylhexyl) phthalate (DEHP), a plasticizer used to soften plastic medical devices (PMDs), was restricted in PMDs due to adverse health effects, being gradually replaced by alternative plasticizers (APs). Parenteral nutrition (PN), essential in the care for premature neonates in the neonatal intensive care unit, is stored in plastic storage bags and administered intravenously through plastic infusion circuits. We investigated to which extent PN contributes to current phthalate and AP exposure in premature neonates. First, we showed that DEHP and several APs are present in relevant amounts in PMDs used for neonatal PN administration. Secondly, ex vivo experiments mimicking clinical PN administration showed that lipid emulsions contained significant concentrations of DEHP and several APs (ATBC, TOTM, DEHT & DEHA), while hardly any plasticizers were detected in non-lipid solutions. ATBC leached from infusion circuits, while lipid emulsions were the major source for DEHP, TOTM, DEHT, and DEHA. PN administration resulted in estimated daily exposures of 13.9 µg/kg/d DEHP and 95.7 µg/kg/d ATBC in premature neonates, below their respective reference doses. Our data indicate that premature neonates requiring PN are still exposed to DEHP, as well as to a range of APs, making it a target for reduction of harmful plasticizer exposure.
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Jenkins RD. Phthalates cause a low-renin phenotype commonly found in premature infants with idiopathic neonatal hypertension. Pediatr Nephrol 2022; 38:1717-1724. [PMID: 36322257 DOI: 10.1007/s00467-022-05773-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/24/2022] [Accepted: 09/24/2022] [Indexed: 03/01/2023]
Abstract
Since the 1970s, when the initial reports of neonatal hypertension related to renal artery thromboembolism were published, other secondary causes of neonatal hypertension have been reported. Those infants with no identifiable cause of hypertension were labeled with a variety of terms. Herein, we describe such infants as having idiopathic neonatal hypertension (INH). Most, but not all, of these hypertensive infants were noted to have bronchopulmonary dysplasia (BPD). More recently, reports described common clinical characteristics seen in INH patients, whether or not they had BPD. This phenotype includes low plasma renin activity, presentation near 40 weeks postmenstrual age, and a favorable response to treatment with spironolactone. A small prospective study in INH patents showed evidence of mineralocorticoid receptor activation due to inhibition of 11β-HSD2, the enzyme that converts cortisol to the less potent mineralocorticoid-cortisone. Meanwhile, phthalate metabolites have been shown to inhibit 11β-HSD2 in human microsomes. Premature infants can come in contact with exceptionally large phthalate exposures, especially those infants with BPD. This work describes a common low-renin phenotype, commonly seen in patients categorized as having INH. Further, we review the evidence that hypertension in INH patients with the low-renin phenotype may be mediated by phthalate-associated inhibition of 11β-HSD2. Lastly, we review the implications of these findings regarding identification, treatment, and prevention of the low-renin hypertension phenotype seen in premature infants categorized as having INH.
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Affiliation(s)
- Randall D Jenkins
- Oregon Health & Science University, 707 SW Gaines Rd., Mail Code CDRC-P, Portland, OR, 97239, USA.
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Phthalate Exposures in the Neonatal Intensive Care Unit. TOXICS 2021; 9:toxics9050090. [PMID: 33919093 PMCID: PMC8143182 DOI: 10.3390/toxics9050090] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/31/2021] [Accepted: 04/16/2021] [Indexed: 11/30/2022]
Abstract
Background: Di-2-ethylhexyl phthalate (DEHP), a phthalate compound found in medical devices, may cause toxic effects in premature infants. In this study, the objective is to quantify DEHP exposures from various intravenous and respiratory therapy devices, and to use these values to predict typical exposure for an infant in a neonatal unit. Methods: Common IV products used on infants are directed through various types of IV tubing (IVT) and analyzed for DEHP content. DEHP exposure for infants receiving respiratory therapy was determined indirectly through analysis of urine DEHP metabolites. By deriving these values for DEHP we calculated the daily exposure to DEHP from common IV fluids (IVF) and respiratory devices during hospitalization in a neonatal unit. Results: IVF labeled DEHP-positive showed very high concentrations of DEHP, but when passed through IVT, substantial amounts were adsorbed. DEHP was undetectable with all DEHP-negative IVF tests, except when passed through DEHP-positive IVT. The DEHP leached from most respiratory devices was relatively modest, except that detected from bubble CPAP. In 14 very low birthweight infants, the mean DEHP exposure was 182,369 mcg/kg over 81.2 days of the initial hospitalization. Ninety-eight percent of the exposure was from respiratory devices, with bubble CPAP accounting for 95% of the total DEHP exposure in these infants. Conclusions: The DEHP exposure in our neonatal unit can be reduced markedly by avoiding or modifying bubble CPAP equipment and avoiding IV tubing containing DEHP.
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Elimination of Intravenous Di-2-Ethylhexyl Phthalate Exposure Abrogates Most Neonatal Hypertension in Premature Infants with Bronchopulmonary Dysplasia. TOXICS 2021; 9:toxics9040075. [PMID: 33918157 PMCID: PMC8067010 DOI: 10.3390/toxics9040075] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/24/2021] [Accepted: 03/30/2021] [Indexed: 11/24/2022]
Abstract
(1) Background: The incidence of hypertension in very low birthweight (VLBW) infants in a single neonatal intensive care unit (NICU) dropped markedly during a 2-year period when the IV fluid (IVF) in both the antenatal unit and the NICU temporarily changed to a di-2-ethylhexyl phthalate (DEHP)-free formulation. The objective of the current report is to document this observation and demonstrate the changes in incidence of hypertension were not associated with the variation in risk factors for hypertension; (2) Methods: The charts of all VLBW infants born in a single NICU during a 7-year span were reviewed. This time includes 32 months of baseline, 20 months of DEHP-free IVF, 20 months of IVF DEHP re-exposure, and two 4-month washout intervals. The group of interest was limited to VLBW infants with bronchopulmonary dysplasia (BPD). Chi-square analysis was used to compare incidence of hypertension among periods. Vermont Oxford NICU Registry data were examined for variation in maternal and neonatal risk factors for hypertension; Results: Incidence of hypertension in VLBW infants with BPD decreased from 7.7% (baseline) to 1.4% when IVF was DEHP-free, rising back to 10.1% when DEHP-containing IVF returned to use. Risk factors for neonatal hypertension were stable across the 3 study periods in the NICU’s group of VLBW infants; (3) Conclusions: Serendipitous removal of IVF containing DEHP resulted in near elimination of hypertension in one NICU—an effect entirely reversed after the same brand of DEHP-containing IVF returned to clinical use. These results suggest that DEHP exposure from IVF plays a major role in neonatal hypertension.
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Interactions of amphiphiles with plasticisers used in polymers: Understanding the basis of health and environmental challenges. Adv Colloid Interface Sci 2020; 277:102109. [PMID: 32028074 DOI: 10.1016/j.cis.2020.102109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 01/18/2020] [Accepted: 01/20/2020] [Indexed: 11/21/2022]
Abstract
Plasticisers are widely used to provide desirable mechanical properties of many polymeric materials. These small molecule additives are also known to leach from the finished products, and this not only may modify the physical properties but the distribution of these materials in the environment and in the human body can cause long-term health concerns and environmental challenges. Many of these plasticisers are esters of polyvalent acids and phthalic acid has previously been predominant but various alternatives are now being more widely explored. The eventual distribution of these compounds depends not just on solubility in aqueous media and on vapour pressure but also on their interaction with other materials, particularly lipids and amphiphiles. This review provides an overview of both the basic physical data (solubility, partition coefficients, surface tension, vapour pressure) that is available in the literature and summarises what has been learnt about the molecular interactions of various plasticisers with surfactants and lipids.
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The changing spectrum of hypertension in premature infants. J Perinatol 2019; 39:1528-1534. [PMID: 31388120 DOI: 10.1038/s41372-019-0457-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 06/24/2019] [Accepted: 06/28/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The objective is to document changes in the etiologic spectrum of hypertension in premature infants. STUDY DESIGN We reviewed all cases of systemic hypertension (HTN) in premature infants at two centers over 8 years. Infants were sorted into categorical groups as described in 2012 by Flynn. Analyses included frequency of diagnosis, timecourse of HTN, and diagnostics. Phthalate exposure via intravenous fluid and respiratory equipment was compared among groups and centers. RESULTS One hundred and twenty-nine infants having 130 episodes of HTN met the inclusion criteria. Sixty-five percent of cases were classified as pulmonary and 16% as miscellaneous. Plasma renin activity (PRA) was undetectable or <11 ng/mL/h in almost all hypertensive infants. Cases categorized as Pulmonary, medications/intoxications, and miscellaneous presented near 40 weeks postmenstrual age, with low PRA and large phthalate exposures. CONCLUSIONS High PRA HTN has been replaced by low PRA in most cases, and may be due to phthalate exposure.
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Jenkins R, Tackitt S, Gievers L, Iragorri S, Sage K, Cornwall T, O'Riordan D, Merchant J, Rozansky D. Phthalate-associated hypertension in premature infants: a prospective mechanistic cohort study. Pediatr Nephrol 2019; 34:1413-1424. [PMID: 31028470 PMCID: PMC6579777 DOI: 10.1007/s00467-019-04244-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/05/2019] [Accepted: 03/18/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Phthalates are associated with increased blood pressure in children. Large exposures to di-(2-ethylhexyl) phthalate (DEHP) among premature infants have been a cause for concern. METHODS We conducted a prospective observational cohort study to determine if DEHP exposures are related to systolic blood pressure (SBP) in premature infants, and if this exposure is associated with activation of the mineralocorticoid receptor (MR). Infants were monitored longitudinally for 8 months from birth. Those who developed idiopathic hypertension were compared with normotensive infants for DEHP exposures. Appearance of urinary metabolites after exposure was documented. Linear regression evaluated the relationship between DEHP exposures and SBP index and whether urinary cortisol/cortisone ratio (a surrogate marker for 11β-HSD2 activity) mediated those relationships. Urinary exosomes were quantified for sodium transporter/channel expression and interrogated against SBP index. RESULTS Eighteen patients met the study criteria, nine developed transient idiopathic hypertension at a postmenstrual age of 40.6 ± 3.4 weeks. The presence of urinary DEHP metabolites was associated with prior IV and respiratory tubing DEHP exposures (p < 0.05). Both IV and respiratory DEHP exposures were greater in hypertensive infants (p < 0.05). SBP index was related to DEHP exposure from IV fluid (p = 0.018), but not respiratory DEHP. Urinary cortisol/cortisone ratio was related to IV DEHP and SBP index (p < 0.05). Sodium transporter/channel expression was also related to SBP index (p < 0.05). CONCLUSIONS Increased blood pressure and hypertension in premature infants are associated with postnatal DEHP exposure. The mechanism of action appears to be activation of the MR through inhibition of 11β-HSD2.
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MESH Headings
- 11-beta-Hydroxysteroid Dehydrogenases/metabolism
- Administration, Intravenous/adverse effects
- Administration, Intravenous/instrumentation
- Airway Management/adverse effects
- Airway Management/instrumentation
- Blood Pressure/drug effects
- Diethylhexyl Phthalate/toxicity
- Female
- Humans
- Hypertension/chemically induced
- Hypertension/diagnosis
- Hypertension/epidemiology
- Hypertension/metabolism
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/chemically induced
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/epidemiology
- Male
- Plasticizers/toxicity
- Prospective Studies
- Receptors, Mineralocorticoid/metabolism
- Signal Transduction/drug effects
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Affiliation(s)
- Randall Jenkins
- Department of Pediatrics, Oregon Health & Science University, 707 SW Gaines Road, Mail Code CDRC-P, Portland, OR, 97239, USA.
| | | | - Ladawna Gievers
- Department of Pediatrics, Oregon Health & Science University, 707 SW Gaines Road, Mail Code CDRC-P, Portland, OR, 97239, USA
| | - Sandra Iragorri
- Department of Pediatrics, Oregon Health & Science University, 707 SW Gaines Road, Mail Code CDRC-P, Portland, OR, 97239, USA
| | - Kylie Sage
- Biostatistics and Design Program, School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - Tonya Cornwall
- Department of Pediatrics, Oregon Health & Science University, 707 SW Gaines Road, Mail Code CDRC-P, Portland, OR, 97239, USA
| | | | | | - David Rozansky
- Department of Pediatrics, Oregon Health & Science University, 707 SW Gaines Road, Mail Code CDRC-P, Portland, OR, 97239, USA
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Malarvannan G, Onghena M, Verstraete S, van Puffelen E, Jacobs A, Vanhorebeek I, Verbruggen SCAT, Joosten KFM, Van den Berghe G, Jorens PG, Covaci A. Phthalate and alternative plasticizers in indwelling medical devices in pediatric intensive care units. JOURNAL OF HAZARDOUS MATERIALS 2019; 363:64-72. [PMID: 30308366 DOI: 10.1016/j.jhazmat.2018.09.087] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/23/2018] [Accepted: 09/29/2018] [Indexed: 05/07/2023]
Abstract
The present study aimed to identify plasticizers present in indwelling plastic medical devices commonly used in the pediatric intensive care unit (PICU). We have analyzed a wide range of medical devices (n = 97) daily used in the PICUs of two academic hospitals in Belgium and the Netherlands. Identified compounds varied between the samples. Most of the indwelling medical devices and essential accessories were found to actively leach phthalates and alternative plasticizers. Results indicated that DEHP was predominantly present as plasticizer (60 of 97 samples), followed by bis(2-ethylhexyl) adipate (DEHA, 32 of 97), bis(2-ethylhexyl) terephthalate (DEHT, 24 of 97), tris(2-ethylhexyl) trimellitate (TOTM, 20 of 97), and tributyl-O-acetyl citrate (ATBC, 10 of 97). Other plasticizers, such as di-isononyl-cyclohexane-1,2-dicarboxylate (DINCH, 2 of 97), di-isononyl phthalate (DiNP, 4 of 97), di(2-propylheptyl) phthalate (DPHP, 4 of 97) and di-isodecyl phthalate (DiDP, 2 of 97) were detected in < 5% of the investigated samples. Several devices contained multiple plasticizers, e.g. devices containing TOTM contained also DEHP and DEHT. Our data indicate that PICU patients are exposed to a wide range of plasticizers, including the controversial DEHP. Future studies should investigate the exposure to APs in children staying in the PICU and the possible health effects thereof.
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Affiliation(s)
| | | | - Sören Verstraete
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Esther van Puffelen
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - An Jacobs
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Ilse Vanhorebeek
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Sascha C A T Verbruggen
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Koen F M Joosten
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Philippe G Jorens
- Department of Intensive Care Medicine and Clinical Pharmacology, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Adrian Covaci
- Toxicological Centre, University of Antwerp, Wilrijk, Belgium.
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Fauchere C, Berger-Gryllaki M, Sadeghipour F. Investigation of Drug-Packaging Interactions with Mass Spectroscopy Detectors: A Meta-Synthesis of the Literature. PHARMACEUTICAL TECHNOLOGY IN HOSPITAL PHARMACY 2019. [DOI: 10.1515/pthp-2018-0027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Abstract
Background
The production of hospital-compounded medicines with a longer shelf life raises questions about drug-packaging interactions, especially desorption events involving extractables and leachables (E/L). A meta-synthesis of the literature was performed to describe which mass spectrometer is suitable for identifying and quantifying E/L.
Methods
A meta-synthesis of studies focused on the identification or quantification of E/L published between January 1997 and December 2017 was performed. Inclusion criteria were E/L studies dealing with pharmaceutical products, in which mass spectrometry (MS) coupled to liquid chromatography (LC) or gas chromatography (GC) was used. The full-text articles had to be available and written in English. Articles about food packaging, environmental contamination, counterfeit compounds, pharmacokinetics, or process-related impurity studies were excluded. Two researchers independently assessed the papers according to a score based on a seven-item questionnaire.
Results
In total, 32 papers matched our criteria and were included in the meta-synthesis. For qualitative analysis with LC, quadrupole time-of-flight (QTOF; n=4) and ion trap (n=4) mass detectors were used the most; and with GC, single quadrupole (n=8). For quantification studies with LC, QTOF (n=3) and triple quadrupole (n=2) were used the most; and with GC, single quadrupole (n=7).
Conclusions
For simultaneous qualitative and quantitative analysis of E/L with LC, QTOF or Orbitrap is a suitable detector. For quantitative analysis with LC only, triple quadrupole is suitable. For qualitative and quantitative analysis with GC, single quadrupole can be used.
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Affiliation(s)
- Camille Fauchere
- Pharmacy , Centre Hospitalier Universitaire Vaudois , Lausanne , Switzerland
- Ecole de Pharmacie Geneve-Lausanne , Geneve , GE , Switzerland
| | | | - Farshid Sadeghipour
- Pharmacy , Centre Hospitalier Universitaire Vaudois , Lausanne , Switzerland
- Ecole de Pharmacie Geneve-Lausanne , Geneve , GE , Switzerland
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Haned Z, Moulay S, Lacorte S. Migration of plasticizers from poly(vinyl chloride) and multilayer infusion bags using selective extraction and GC–MS. J Pharm Biomed Anal 2018; 156:80-87. [DOI: 10.1016/j.jpba.2018.04.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 04/02/2018] [Accepted: 04/09/2018] [Indexed: 11/25/2022]
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Tortolano L, Matmati H, Bourhis M, Manerlax K, Lemare F, Saunier J, Yagoubi N. DinCH and ESBO actual migration from PVC infusion tubings used in an oncopediatric unit. J Appl Polym Sci 2018. [DOI: 10.1002/app.46649] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Lionel Tortolano
- EA 401: Matériaux et santé; Université Paris-Saclay, UFR Pharmacie; Châtenay-Malabry F-92290 France
- Groupe hospitalier Henri Mondor, Department of Pharmacy; Assistance Publique-Hôpitaux de Paris; Créteil F-94010 France
| | - Houssem Matmati
- EA 401: Matériaux et santé; Université Paris-Saclay, UFR Pharmacie; Châtenay-Malabry F-92290 France
| | - Matthieu Bourhis
- Département de Pharmacie Clinique; Gustave Roussy, Université Paris-Saclay; Villejuif F-94805 France
| | - Katia Manerlax
- EA 401: Matériaux et santé; Université Paris-Saclay, UFR Pharmacie; Châtenay-Malabry F-92290 France
| | - François Lemare
- Département de Pharmacie Clinique; Gustave Roussy, Université Paris-Saclay; Villejuif F-94805 France
- Chair of Clinical Pharmacy, Faculty of Pharmacy of Paris; Sorbonne-Paris University; Paris F-75006 France
- EA 7348 (MOS) de l'Ecole des Hautes Etudes de Santé Publique; Rennes F-35000 France
| | - Johanna Saunier
- EA 401: Matériaux et santé; Université Paris-Saclay, UFR Pharmacie; Châtenay-Malabry F-92290 France
| | - Najet Yagoubi
- EA 401: Matériaux et santé; Université Paris-Saclay, UFR Pharmacie; Châtenay-Malabry F-92290 France
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Di (2-Ethylhexyl) Phthalate and Its Role in Developing Cholestasis: An In Vitro Study on Different Liver Cell Types. J Pediatr Gastroenterol Nutr 2018; 66:e28-e35. [PMID: 29095348 DOI: 10.1097/mpg.0000000000001813] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Di(2-ethylhexyl) phthalate (DEHP) is a plasticizer used in many polyvinylchloride medical devices and is washed out easily. Thereby critically ill infants can become exposed to DEHP concentrations significantly exceeding the recommended threshold. We suspect DEHP to play an important role in the development of intestinal failure-associated liver disease. The aim of this study was therefore to determine the direct influence of DEHP on different liver cell types. METHODS HepG2, human upcyte hepatocytes, primary murine hepatocytes, LX-2, human upcyte hepatic stellate cells, and liver organoids were cultured with DEHP (0.5-500 μmol/L) and parameters including cytotoxicity, cell-cell interactions, and expression of metabolizing enzymes were investigated. RESULTS DEHP modulated the expression of xenobiotic metabolizing enzymes, reduced the formation of bile canaliculi and cell polarity, and inhibited Cyp-activity in hepatocytes. DEHP had a toxic effect on LX-2 and induced the fibrogenic activation of hepatic stellate cells. The mode of action of DEHP was different in monolayer cultures compared to 3D-liver organoids, which were more sensitive to DEHP. CONCLUSIONS This study suggests that DEHP modulates expression and activity of drug-detoxifying liver enzymes in humans at a clinically relevant concentration. Furthermore, it may contribute to the development of cholestasis and fibrosis. These findings strongly support the opinion, that there is a significant potential for serious adverse effects of DEHP derived from medical devices on human health, especially in very young infants with immature livers.
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Nouman M, Saunier J, Jubeli E, Yagoubi N. Additive blooming in polymer materials: Consequences in the pharmaceutical and medical field. Polym Degrad Stab 2017. [DOI: 10.1016/j.polymdegradstab.2017.07.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Faessler D, McCombie G, Biedermann M, Felder F, Subotic U. Leaching of plasticizers from polyvinylchloride perfusion lines by different lipid emulsions for premature infants under clinical conditions. Int J Pharm 2017; 520:119-125. [PMID: 28126549 DOI: 10.1016/j.ijpharm.2017.01.046] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 01/22/2017] [Accepted: 01/23/2017] [Indexed: 11/28/2022]
Abstract
Plasticizers migrate from polyvinylchloride (PVC) infusion systems into lipid emulsions. The aim of this study was to investigate the leaching of different plasticizers from PVC perfusion lines by a selection of lipid emulsions under clinical conditions. Seven PVC perfusion lines with an equal length of 150cm and three internal diameters were perfused with three lipid emulsions: Intralipid® 20%, ClinOleic® 20% and SMOFlipid® 20%, mimicking clinical conditions. The concentrations of the plasticizers were measured directly in the emulsions by gas chromatography - mass spectrometry. Of the four plasticizers examined in this study, di (2-ethylhexyl) phthalate (DEHP) leached the most and was found, on average, at 46.5μg/ml in the emulsions - around one order of magnitude higher than the other plasticizers. This study demonstrates that the leaching of DEHP by lipid emulsions in conditions of total parenteral nutrition is many times higher than should be accepted and higher when compared to the other plasticizers. There was no significant difference in leaching of plasticizers in relation to the type of lipid emulsion. The influence of tube diameter on the leaching rate of plasticizers should be taken into account especially in particular exposed patients.
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Affiliation(s)
- David Faessler
- Division of Visceral, Neonatal, and Fetal Surgery, Department of Pediatric Surgery, University Children's Hospital Zurich, Switzerland
| | - Gregor McCombie
- :Official Food Control Laboratory of the Canton of Zurich, Zurich, Switzerland
| | - Maurus Biedermann
- :Official Food Control Laboratory of the Canton of Zurich, Zurich, Switzerland
| | - Florian Felder
- :Official Food Control Laboratory of the Canton of Zurich, Zurich, Switzerland
| | - Ulrike Subotic
- Division of Visceral, Neonatal, and Fetal Surgery, Department of Pediatric Surgery, University Children's Hospital Zurich, Switzerland.
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Abstract
Exposure to environmental chemicals has adverse effects on the health and survival of humans. Emerging evidence supports the idea that exposure to endocrine-disrupting compounds (EDCs) can perturb an individual’s physiological set point and as a result increase his/her propensity toward several diseases. The purpose of this review is to provide an update on di-(2-ethylhexyl) phthalate, the primary plasticizer found in plastic medical devices used in neonatal intensive care units, its effects on the fetus and newborn, epidemiological studies, pharmacokinetics, toxicity and epigenetic implications. We searched the PubMed databases to identify relevant studies. Phthalates are known EDCs that primarily are used to improve the flexibility of polyvinyl chloride plastic products and are called plasticizers in lay terms. Neonates and infants are particularly vulnerable to the effects of phthalates, beginning with maternal exposure and placental transfer during gestation and during infancy following birth. In line with the developmental origins of adult disease, a focus on the effects of environmental chemicals in utero or early childhood on the genesis of adult diseases through epigenome modulation is timely and important. The epigenetic effects of phthalates have not been fully elucidated, but accumulating evidence suggests that they may be associated with adverse health effects, some of which may be heritable. Phthalate exposure during pregnancy and the perinatal period is particularly worrisome in health-care settings. Although the clinical significance of phthalate exposure has been difficult to assess with epidemiologic studies, the evidence that physiological changes occur due to exposure to phthalates is growing and points toward the need for more investigation at a molecular, specifically epigenetic level.
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Al Salloum H, Saunier J, Tfayli A, Yagoubi N. Studying DEHP migration in plasticized PVC used for blood bags by coupling Raman confocal microscopy to UV spectroscopy. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2015; 61:56-62. [PMID: 26838824 DOI: 10.1016/j.msec.2015.12.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 10/06/2015] [Accepted: 12/04/2015] [Indexed: 11/28/2022]
Abstract
Plasticized PVC is widely used to make medical devices such as tubing, perfusion bags and blood bags. By using confocal Raman microscopy on a PVC sheet plasticized with around 40% of di-(2-ethylhexyl)phthalate (DEHP), we propose a simple and sensitive approach to studying and understanding the diffusion of plasticizers from polymers into the surrounding media. Moreover, we sought to correlate our findings to standard measurements conducted by UV spectroscopy. This study showed differences in the concentration gradient observed due to the diffusion of the plasticizer inside a PVC sheet. We can thus follow the critical DEHP ratios that can impact the diffusion process. Water and ethanol were chosen as storage media: in ethanol, the lowest concentration of DEHP was observed at the surface resulting in the formation of a less plasticized layer near the interface; unlike ethanol, PVC sheets stored in water showed a greater concentration of DEHP on the film surface as an exudation of DEHP onto the surface.
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Affiliation(s)
- H Al Salloum
- IFR 141, EA 401, UFR de Pharmacie - Université Paris Sud, 92290 Chatenay Malabry, France
| | - J Saunier
- IFR 141, EA 401, UFR de Pharmacie - Université Paris Sud, 92290 Chatenay Malabry, France.
| | - A Tfayli
- Lip(Sys)(2), UFR de Pharmacie - Université Paris Sud, 92290 Chatenay Malabry, France
| | - N Yagoubi
- IFR 141, EA 401, UFR de Pharmacie - Université Paris Sud, 92290 Chatenay Malabry, France
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Bernard L, Cueff R, Chagnon MC, Abdoulouhab F, Décaudin B, Breysse C, Kauffmann S, Cosserant B, Souweine B, Sautou V. Migration of plasticizers from PVC medical devices: Development of an infusion model. Int J Pharm 2015; 494:136-45. [DOI: 10.1016/j.ijpharm.2015.08.033] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 08/10/2015] [Accepted: 08/11/2015] [Indexed: 10/23/2022]
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Luo H, Sun G, shi Y, Shen Y, Xu K. Evaluation of the Di(2-ethylhexyl)phthalate released from polyvinyl chloride medical devices that contact blood. SPRINGERPLUS 2014; 3:58. [PMID: 24516786 PMCID: PMC3916584 DOI: 10.1186/2193-1801-3-58] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 01/27/2014] [Indexed: 11/10/2022]
Abstract
Extraction methods that simulate those used in the clinic are recommended for obtaining extraction solutions. For polyvinyl chloride (PVC) medical devices that have contact with human blood, an alternative medium (ethanol/water mixture) is suggested as an extraction screening vehicle to evaluate the di(2-ethylhexyl)phthalate (DEHP) released. A test comparing the extraction ability between the alternative medium and whole blood from three healthy volunteers has been conducted. An experimental method is provided outlining the chemical analysis of the DEHP released from medical devices made with polyvinyl chloride (PVC). Gas chromatography-mass spectrometry (GC-MS) in the selective ion monitoring (SIM) mode was used to analyze and quantify the extracted DEHP. The linear range of the SIM method was 0.1-200 μg/mL, and the recoveries were 89.6-101.5% and 91.0-98.9% when using the ethanol/water mixture and whole blood as the extraction media, respectively. The validated method demonstrates that it is suitable for the determination of the DEHP released from PVC medical devices that have contact with blood. The results from the determination of the DEHP released will be compared with the limits derived from toxicological data for the parenteral exposure route and certain population groups, and the results will be used in the risk assessment of medical devices.
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Affiliation(s)
- Hongyu Luo
- />CFDA Jinan Quality Inspection Center for Medical Devices, 99 Tianluo Road H-T Industrial Development Zone, Jinan, 250000 China
- />Shandong Provincial Key Laboratory of Biological Evaluation of Medical Device, 99 Tianluo Road H-T Industrial Development Zone, Jinan, 250000 China
| | - Guangyu Sun
- />CFDA Jinan Quality Inspection Center for Medical Devices, 99 Tianluo Road H-T Industrial Development Zone, Jinan, 250000 China
- />Shandong Provincial Key Laboratory of Biological Evaluation of Medical Device, 99 Tianluo Road H-T Industrial Development Zone, Jinan, 250000 China
| | - Yanping shi
- />CFDA Jinan Quality Inspection Center for Medical Devices, 99 Tianluo Road H-T Industrial Development Zone, Jinan, 250000 China
- />Shandong Provincial Key Laboratory of Biological Evaluation of Medical Device, 99 Tianluo Road H-T Industrial Development Zone, Jinan, 250000 China
| | - Yong Shen
- />Shandong Hengxin Inspection Technology Development Center, 99 Tianluo Road H-T Industrial Development Zone, Jinan, 250000 China
| | - Kai Xu
- />Shandong Hengxin Inspection Technology Development Center, 99 Tianluo Road H-T Industrial Development Zone, Jinan, 250000 China
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22
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Perspectives on alternatives to phthalate plasticized poly(vinyl chloride) in medical devices applications. Prog Polym Sci 2013. [DOI: 10.1016/j.progpolymsci.2013.03.001] [Citation(s) in RCA: 192] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Rose RJ, Priston MJ, Rigby‐Jones AE, Sneyd JR. The effect of temperature on di(2‐ethylhexyl) phthalate leaching from PVC infusion sets exposed to lipid emulsions. Anaesthesia 2012; 67:514-520. [DOI: 10.1111/j.1365-2044.2011.07006.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - M. J. Priston
- Principle Healthcare Scientist, Department of Pharmacy, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - A. E. Rigby‐Jones
- Research Fellow, Anaesthesia Research Group, Peninsula College of Medicine & Dentistry, University of Plymouth, Plymouth, UK
| | - J. R. Sneyd
- Vice Dean and Professor of Anaesthesia, Peninsula College of Medicine & Dentistry, University of Plymouth, Plymouth, UK
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Bagel S, Dessaigne B, Bourdeaux D, Boyer A, Bouteloup C, Bazin JE, Chopineau J, Sautou V. Influence of Lipid Type on Bis (2-ethylhexyl)phthalate (DEHP) Leaching From Infusion Line Sets in Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2011; 35:770-5. [PMID: 21868720 DOI: 10.1177/0148607111414021] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sandrine Bagel
- CHU Clermont-Ferrand, Department of Pharmacy, G Montpied Hospital, Clermont-Ferrand, France
| | - Bérangère Dessaigne
- CHU Clermont-Ferrand, Department of Pharmacy, G Montpied Hospital, Clermont-Ferrand, France
| | - Daniel Bourdeaux
- CHU Clermont-Ferrand, Department of Pharmacy, G Montpied Hospital, Clermont-Ferrand, France
- Faculty of Pharmacy, Laboratory of Clinical Pharmacy and Biotechnics, University Clermont 1, Clermont-Ferrand, France
| | - Anne Boyer
- CHU Clermont-Ferrand, Department of Pharmacy, G Montpied Hospital, Clermont-Ferrand, France
- Faculty of Pharmacy, Laboratory of Clinical Pharmacy and Biotechnics, University Clermont 1, Clermont-Ferrand, France
| | - Corinne Bouteloup
- CHU Clermont-Ferrand, Department of Hepato-gastroenterology, Estaing Hospital, Clermont-Ferrand, France
| | - Jean-Etienne Bazin
- CHU Clermont-Ferrand, Surgical Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine, Estaing Hospital, Clermont-Ferrand, France
| | - Jean Chopineau
- CHU Clermont-Ferrand, Department of Pharmacy, G Montpied Hospital, Clermont-Ferrand, France
- Faculty of Pharmacy, Laboratory of Clinical Pharmacy and Biotechnics, University Clermont 1, Clermont-Ferrand, France
| | - Valérie Sautou
- CHU Clermont-Ferrand, Department of Pharmacy, G Montpied Hospital, Clermont-Ferrand, France
- Faculty of Pharmacy, Laboratory of Clinical Pharmacy and Biotechnics, University Clermont 1, Clermont-Ferrand, France
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Van Vliet EDS, Reitano EM, Chhabra JS, Bergen GP, Whyatt RM. A review of alternatives to di (2-ethylhexyl) phthalate-containing medical devices in the neonatal intensive care unit. J Perinatol 2011; 31:551-60. [PMID: 21311501 PMCID: PMC3377474 DOI: 10.1038/jp.2010.208] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Revised: 11/28/2010] [Accepted: 12/03/2010] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To conduct an extensive literature and toxicological database review on substitute compounds and available alternative medical products to replace polyvinyl chloride (PVC) and/or di(2-ethylhexyl) phthalate (DEHP), and conduct a DEHP-medical inventory analysis at a large metropolitan neonatal intensive care unit (NICU). STUDY DESIGN A systematic search for DEHP-free alternative products was performed using online databases. An informal audit of a large metropolitan NICU was undertaken in 2005 and 2006; 21 products were identified that could potentially contain DEHP. Availability of DEHP-free alternatives was determined through company websites and phone interviews. RESULT Two alternative approaches are available for replacing DEHP in NICU medical products: (1) replacement by DEHP-free plasticizers; and (2) replacement of PVC entirely through the use of other polymers. Both approaches seem to provide less harmful substitutes to DEHP, but support PVC-free polymers as the preferred alternative. However, significant data gaps exist, particularly for the alternative polymers. In all, 10 out of 21 (48%) products in the NICU audit were DEHP-free; six consisted of alternative polymers and four of alternative plasticizers. Of the remaining 11 products, only three were available without DEHP at the time of the audit. CONCLUSION Because of significant data gaps, systematic toxicological testing of DEHP-free alternatives is imperative. Continued development of alternative products is also needed.
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Affiliation(s)
- E D S Van Vliet
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY 10032, USA.
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26
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Genay S, Luciani C, Décaudin B, Kambia N, Dine T, Azaroual N, Di Martino P, Barthélémy C, Odou P. Experimental study on infusion devices containing polyvinyl chloride: to what extent are they di(2-ethylhexyl)phthalate-free? Int J Pharm 2011; 412:47-51. [PMID: 21497186 DOI: 10.1016/j.ijpharm.2011.03.060] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 03/31/2011] [Indexed: 11/17/2022]
Abstract
The use of medical devices containing highly criticized phthalates including di(2-ethylhexyl) phthalate (DEHP) has been challenged by European directive 2007/47/CE, put into effect in March 2010. New plasticizers are now being used to soften PVC in medical devices: trioctyltrimellitate (TOTM), di-isononyl-cyclohexan-1,2-dicarboxilate (DINCH) and di(2-ethylhexyl) terephthalate (DEHT). To quantify DEHP in nine DEHP-free medical devices made of PVC softened by alternative plasticizers, high performance liquid chromatography analysis with ultraviolet detection at 220 nm wavelength was achieved. An NMR spectroscopy was performed to confirm DEHP presence. Only two medical devices out of the nine tested were truly without DEHP. One of them showed traces of DEHP exceeding the threshold contamination of 0.1% in plastic mass set by REACH regulations. TOTM plasticizer is still incriminated when polyvinyl-chloride (PVC) is contaminated with DEHP. Manufacturers must verify the purity of their raw material, not only on PVC, but also on other soft plastics entering into the composition of medical infusion devices. The clinical consequences of exposure to certain levels of DEHP have not been evaluated. A solution could be to use alternative PVC-free materials.
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Affiliation(s)
- Stéphanie Genay
- Department of Biopharmacy, Galenic and Hospital Pharmacy (EA 4481, IFR114), Université Lille Nord de France, F-59000 Lille, France
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Bagel S, Décaudin B, Neuville S, Chopineau J, Odou P, Sautou V. Les phtalates dans les dispositifs médicaux destinés à la nutrition artificielle. NUTR CLIN METAB 2011. [DOI: 10.1016/j.nupar.2010.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Vetrano AM, Laskin DL, Archer F, Syed K, Gray JP, Laskin JD, Nwebube N, Weinberger B. Inflammatory effects of phthalates in neonatal neutrophils. Pediatr Res 2010; 68:134-9. [PMID: 20453712 PMCID: PMC2908957 DOI: 10.1203/pdr.0b013e3181e5c1f7] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Hospitalized infants are exposed to numerous devices containing the plasticizer di-(2-ethylhexyl) phthalate. Urinary levels of the phthalate metabolite, mono-(2-ethylhexyl) phthalate (MEHP), are markedly elevated in premature infants. Phthalates inactivate peroxisome proliferator-activated receptor-gamma (PPAR-gamma), a nuclear transcription factor that mediates the resolution of inflammation, a process impaired in neonates. We speculate that this increases their susceptibility to MEHP, and this was analyzed. MEHP inhibited neutrophil apoptosis; neonatal cells were more sensitive than adult cells. In neonatal, but not in adult neutrophils, MEHP also inhibited chemotaxis, stimulated oxidative metabolism, and up-regulated expression of NADPH oxidase-1. In both adult and neonatal neutrophils, MEHP stimulated IL-1beta and VEGF production, whereas IL-8 production was stimulated only in adult cells. In contrast, MEHP-inhibited production of MIP-1beta by adult cells, and Regulated on Activation Normal T Cell Expressed and Secreted (RANTES) by neonatal neutrophils. The effects of MEHP on apoptosis and oxidative metabolism in neonatal cells were reversed by the PPAR-gamma agonist, troglitazone. Whereas troglitazone had no effect on MEHP-induced alterations in inflammatory protein or chemokine production, constitutive IL-8 and MIP-1beta production was reduced in adult neutrophils, and RANTES and MIP-1beta in neonatal cells. These findings suggest that neonatal neutrophils are more sensitive to phthalate-mediated inhibition of PPAR-gamma, which may be related to decreased anti-inflammatory signaling.
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Affiliation(s)
- Anna M Vetrano
- Department of Pediatrics, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, New Jersey 08901, USA
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Pérez-Feás C, Barciela-Alonso MC, Sedes-Díaz A, Bermejo-Barrera P. Phthalates determination in pharmaceutical formulae used in parenteral nutrition by LC-ES-MS: importance in public health. Anal Bioanal Chem 2009; 397:529-35. [DOI: 10.1007/s00216-009-3337-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Revised: 11/13/2009] [Accepted: 11/21/2009] [Indexed: 11/28/2022]
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von Rettberg H, Hannman T, Subotic U, Brade J, Schaible T, Waag KL, Loff S. Use of di(2-ethylhexyl)phthalate-containing infusion systems increases the risk for cholestasis. Pediatrics 2009; 124:710-6. [PMID: 19651587 DOI: 10.1542/peds.2008-1765] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Most polyvinylchloride infusion systems are plasticized with up to 60% of di(2-ethylhexyl)phthalate (DEHP). DEHP is easily extracted from the tubing by total parenteral nutrition (TPN) solutions and has been shown to have toxic effects on various organ systems including the liver in animals and humans. A role was postulated for DEHP in the development of hepatobiliary dysfunction in premature and newborn infants receiving parenteral nutrition, and the incidence of cholestasis was investigated after changing from polyvinylchloride infusion systems to polyvinylchloride-free infusion systems. MATERIALS AND METHODS Two 3-year periods from 1998 to 2004 were investigated retrospectively before and after changing from polyvinylchloride to polyvinylchloride-free infusion systems in our department. This resulted in 1 group of 30 patients treated with polyvinylchloride lines and a second group of 46 patients treated with polyvinylchloride-free lines. The 2 groups were examined for the incidence of cholestasis and other possible contributing factors. Statistics were performed by using SAS software (SAS Institute, Cary, NC). RESULTS After changing infusion systems, the incidence of cholestasis dropped from 50% to 13%. Using DEHP-plasticized polyvinylchloride infusion systems for TPN increased the risk for cholestasis by a factor of 5.6. The use of polyvinylchloride lines correlated strongly with the development of TPN-associated cholestasis (P = .0004). CONCLUSIONS Using DEHP-containing polyvinylchloride infusions systems contributes to the development of cholestasis. Therefore, the use of DEHP-free infusion systems for TPN is recommended, especially in premature and newborn infants.
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Affiliation(s)
- Heike von Rettberg
- Department of Pediatric Surgery, University Hospital Mannheim, Mannheim, Germany.
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Loff S, Hannmann T, Subotic U, Reinecke FM, Wischmann H, Brade J. Extraction of diethylhexylphthalate by home total parenteral nutrition from polyvinyl chloride infusion lines commonly used in the home. J Pediatr Gastroenterol Nutr 2008; 47:81-6. [PMID: 18607273 DOI: 10.1097/mpg.0b013e318164d933] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Recently, our group detected that polyvinyl chloride (PVC) perfusion lines leach large amounts of the toxic plasticizer diethylhexylphthalate (DEHP) under conditions typical of intensive care units. In the present study, we investigated the extraction of DEHP from PVC connecting tubes that are commonly used for total parenteral nutrition (TPN) solutions. The aim of the study was to estimate the amount of DEHP to which children receiving home TPN are exposed for months and years. MATERIALS AND METHODS 1000 mL of TPN, identical in constitution and amount to the home TPN of 1 of our patients, were perfused through 5 different connecting tube systems and collected in hexane-rinsed glass bottles. The concentration of DEHP in the TPN was analyzed before and after perfusion. RESULTS Before perfusion of the lines, the solution had a DEHP concentration of 0.05 to 0.69 microg/mL (baseline value). After perfusion of the lines, the load of DEHP in the solution varied between 1.41 and 2.07 microg/mL. This TPN was established for children weighing 20 kg. The daily dosage is between 71 and 104 microg x kg(-1) x day(-1). TPN is administered at home for many months and years. The monthly charge of DEHP is between 42.3 and 62.1 mg. Children weighing 20 kg therefore receive a dosage between 2.1 and 3.1 mg x kg(-1) x month(-1). CONCLUSIONS Diethylhexylphthalate and its metabolite monoethylhexylphthalate have been demonstrated to be carcinogenic, embryotoxic, hepatotoxic, pneumotoxic, and cardiotoxic and are known to disrupt endocrine pathways and liver detoxifying capacity in animals. They are suspected of having multiple effects in humans as well. The doses presented above should therefore be avoided in children receiving home TPN by the use of tubing systems that are completely free of DEHP. Such systems are available.
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Affiliation(s)
- Steffan Loff
- University Clinic of Pediatric Surgery, University of Marburg, Marburg, Germany.
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Burkhart HM, Joyner N, Niles S, Ploessl J, Everett J, Iannettoni M, Richenbacher W. Presence of Plasticizer Di-2(ethylhexyl)phthalate in Primed Extracorporeal Circulation Circuits. ASAIO J 2007; 53:365-7. [PMID: 17515730 DOI: 10.1097/mat.0b013e3180317395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Many centers advocate the use of a standby wet-primed extracorporeal membrane oxygenation (ECMO) circuit for rapid deployment during cardiopulmonary resuscitation. However, concerns with regard to the potential health hazards associated with the release of the plasticizer di-2(ethylhexyl)phthalate (DEHP) from the polyvinyl chloride (PVC) tubing exist. The purpose of this study was to determine the time course of DEHP release from a preprimed ECMO circuit and to evaluate the effect of PVC tubing coatings on DEHP release. Seven circuits including three uncoated (Medtronic, Medtronic with albumin, and Medtronic Super Tygon) and four attenuated surfaces (Carmeda, COBE Smart, Medtronic Trillium, and Terumo x-coated) were primed with Plasmalyte A. Samples of the circuit prime were collected over a period of 2 weeks and were analyzed for DEHP, using gas chromatography. Results were compared by using a two-tailed t test. One coated (Carmeda) and all three uncoated circuits leached DEHP. The greatest amount of leaching occurred in the uncoated Medtronic tubing with albumin. The COBE Smart, Medtronic Trillium, and Terumo x-coated circuits had undetectable amounts of DEHP (p = 0.006 vs Medtronic uncoated). Prepriming an ECMO circuit composed of uncoated PVC tubing is associated with DEHP release. Using coated PVC tubing appears to eliminate DEHP release over a 2-week period.
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Affiliation(s)
- Harold M Burkhart
- Department of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, Children's Hospital of Iowa, Iowa City, Iowa, USA
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Kim JH, Yun J, Sohng JK, Cha JM, Choi BC, Jeon HJ, Kim SH, Choi CH. Di(2-ethylhexyl)phthalate leached from medical PVC devices serves as a substrate and inhibitor for the P-glycoprotein. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2007; 23:272-278. [PMID: 21783769 DOI: 10.1016/j.etap.2006.11.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2006] [Revised: 10/28/2006] [Accepted: 11/07/2006] [Indexed: 05/31/2023]
Abstract
A di(2-ethylhexyl)phthalate (DEHP) was accidentally extracted from plastics in the process of purification of chemosensitizers reversing P-glycoprotein (Pgp)-mediated multidrug resistance (MDR). The purpose of this study was to investigate the Pgp-reversal activities of phthalates, which are endocrine-disrupting chemicals, by utilizing the Pgp-overexpressing leukemic cell line AML-2/D100. The phthalates includes DEHP, diethyl phthalate (DEP) and dibutyl phthalate (DBP). Of the tested phthalates, DEHP showed the highest Pgp-reversal activity and DEP the most potent drug-accumulating activity. On the other hand, they did not show any chemosensitizing activity against multidrug resistance associated protein-mediated MDR. The complete inhibition of Pgp by verapamil increased the cytotoxicity of DEHP, but neither DEP nor DBP had this effect, suggesting that DEHP alone may be a possible substrate for the Pgp. DEHP showed higher hydrophobicity than the other phthalates when determined by reverse phase-HPLC. In addition, DEHP, but not the others increased the ATPase activity in a concentration-dependent manner. This is the first report that phthalates can reverse Pgp-mediated MDR by increasing drug accumulation, as well as serving as substrates for the Pgp. It is thought that the hydrophobic characteristics of phthalates could play an important role in Pgp-inhibitory activity. Therefore, pharmaco- and toxicokinetic interactions between phthalates leached from medical PVC devices and substrates for the Pgp should be kept in mind.
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Affiliation(s)
- Joon-Ho Kim
- Research Center for Resistant Cells, Chosun University, Gwangju 501-759, Republic of Korea; Department of Pharmacology, Chosun University Medical School, Gwangju 501-759, Republic of Korea
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Sunny MC, Ramesh P, George KE. Effect of partial replacement of di(2-ethyl hexyl)phthalate, by a polymeric plasticizer, on the permeability and leaching properties of poly(vinyl chloride). J Appl Polym Sci 2006. [DOI: 10.1002/app.24821] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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