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Cordoza M, Chan LN, Bridges E, Thompson H. Methods for Estimating Energy Expenditure in Critically Ill Adults. AACN Adv Crit Care 2021; 31:254-264. [PMID: 32866253 DOI: 10.4037/aacnacc2020110] [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] [Indexed: 11/01/2022]
Abstract
Energy expenditure (EE) is the sum of metabolic activity within the body at a given time and comprises basal EE, diet-induced thermogenesis, and physical activity. In the intensive care unit, EE is most often assessed to determine a patient's caloric requirements. Energy expenditure also may be useful to understand disease states and the metabolic impact of interventions. Several methods for estimating EE are relevant for clinical use, including indirect calorimetry, predictive equations, exhaled carbon dioxide volume, and the Fick method. Indirect calorimetry is the preferred method for evaluating EE and is considered the gold standard for estimating EE in hospitalized patients. However, use of indirect calorimetry is not always practical or possible. Therefore, other methods of estimating EE must be considered. In this review, methods of evaluating EE in critically ill adults are examined and the benefits and limitations of each method are discussed, with practical considerations for use.
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Affiliation(s)
- Makayla Cordoza
- Makayla Cordoza is Postdoctoral Fellow, Division of Sleep and Chronobiology, Perelman School of Medicine, University of Pennsylvania, 1013 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104
| | - Lingtak-Neander Chan
- Lingtak-Neander Chan is Professor, Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington
| | - Elizabeth Bridges
- Elizabeth Bridges is Professor, University of Washington, Seattle, Washington
| | - Hilaire Thompson
- Hilaire Thompson is Professor, Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, Washington
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Moonen HPFX, Beckers KJH, van Zanten ARH. Energy expenditure and indirect calorimetry in critical illness and convalescence: current evidence and practical considerations. J Intensive Care 2021; 9:8. [PMID: 33436084 PMCID: PMC7801790 DOI: 10.1186/s40560-021-00524-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 01/02/2021] [Indexed: 12/11/2022] Open
Abstract
The use of indirect calorimetry is strongly recommended to guide nutrition therapy in critically ill patients, preventing the detrimental effects of under- and overfeeding. However, the course of energy expenditure is complex, and clinical studies on indirect calorimetry during critical illness and convalescence are scarce. Energy expenditure is influenced by many individual and iatrogenic factors and different metabolic phases of critical illness and convalescence. In the first days, energy production from endogenous sources appears to be increased due to a catabolic state and is likely near-sufficient to meet energy requirements. Full nutrition support in this phase may lead to overfeeding as exogenous nutrition cannot abolish this endogenous energy production, and mitochondria are unable to process the excess substrate. However, energy expenditure is reported to increase hereafter and is still shown to be elevated 3 weeks after ICU admission, when endogenous energy production is reduced, and exogenous nutrition support is indispensable. Indirect calorimetry is the gold standard for bedside calculation of energy expenditure. However, the superiority of IC-guided nutritional therapy has not yet been unequivocally proven in clinical trials and many practical aspects and pitfalls should be taken into account when measuring energy expenditure in critically ill patients. Furthermore, the contribution of endogenously produced energy cannot be measured. Nevertheless, routine use of indirect calorimetry to aid personalized nutrition has strong potential to improve nutritional status and consequently, the long-term outcome of critically ill patients.
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Affiliation(s)
| | | | - Arthur Raymond Hubert van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716, RP, Ede, The Netherlands.
- Division of Human Nutrition and Health, Wageningen University & Research, HELIX (Building 124), Stippeneng 4, 6708, WE, Wageningen, The Netherlands.
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Measurement of Oxygen Consumption Variations in Critically Ill Burns Patients: Are the Fick Method and Indirect Calorimetry Interchangeable? Shock 2018; 48:532-538. [PMID: 28452908 DOI: 10.1097/shk.0000000000000885] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To evaluate the interchangeability of oxygen consumption variations measured with the Fick equation (ΔVO2Fick) and indirect calorimetry (ΔVO2Haldane) in critically ill burns patients. METHODS Prospective observational single-center study conducted in a university hospital. Twenty-two consecutive burns patients with circulatory insufficiency and hyperlactatemia (>2 mmol/L) who required a fluid challenge (FC) were included. All patients had cardiac output monitoring (transpulmonary thermodilution technique) and were ventilated and sedated. Simultaneous measurements of VO2Fick and VO2Haldane were performed before and immediately after the FC, at rest, and in hemodynamic conditions stabilized for at least 1 h. VO2Fick and VO2Haldane were measured, respectively, with the standard formulae (using arterial and central venous saturation measured with a blood gas analyzer) and with a metabolic monitor. RESULTS Forty-four paired measurements of VO2 were obtained. At each timepoint, the median (interquartile range, 25-75) VO2Haldane values were significantly higher than the median VO2Fick values (126 (103-192) vs. 90 (66-149) mL O2/min/m (P = 0.004) before FC and 129 (105-189) vs. 80 (54-119) mL O2/min/m (P = 0.001) after FC). Correlation between the ΔVO2Fick and the ΔVO2Haldane (%) measurements was poor, with an r = 0.06, (P = 0.77). The mean bias was 8.6% [limits of agreement (LOA): -75.7%, 92.9%]. CONCLUSIONS Analysis of agreement showed poor concordance for the ΔVO2Haldane and the ΔVO2Fick (%) with a low mean bias but large and clinically unacceptable LOA. ΔVO2Haldane and ΔVO2Fick (%) are not interchangeable in these conditions.
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Holdy KE. Monitoring Energy Metabolism with Indirect Calorimetry: Instruments, Interpretation, and Clinical Application. Nutr Clin Pract 2017; 19:447-54. [PMID: 16215138 DOI: 10.1177/0115426504019005447] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Indirect calorimetry is the best measure to guide calorie administration during nutrition support. This article presents an update of the types of currently available indirect calorimeters and reviews the recent advances that guide the clinical application of indirect calorimetry. The emphasis of this report is placed on issues that the practicing clinician can use to evaluate, interpret, and apply measurements of energy expenditure.
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Affiliation(s)
- Kalman E Holdy
- Nutrition and Metabolic Support Service, Sharp Memorial Hospital, San Diego, California, USA.
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Determination of Patient Energy Requirements by Registered Dietitian Nutritionists in Inpatient and Outpatient Settings. TOP CLIN NUTR 2017. [DOI: 10.1097/tin.0000000000000093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gender-specific differences in energy metabolism during the initial phase of critical illness. Eur J Clin Nutr 2014; 68:707-11. [PMID: 24424078 DOI: 10.1038/ejcn.2013.287] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 12/05/2013] [Accepted: 12/10/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND/OBJECTIVES Women and men differ in substrate and energy metabolism. Such differences may affect energy requirements during the acute phase of critical illness. SUBJECTS/METHODS Data of 155 critically ill medical patients were reviewed for this study. Indirect calorimetry in each patient was performed within the first 72 h following admission to the medical intensive care unit after an overnight fast. RESULTS In overweight (body mass index (BMI) ≥25 kg/m(2)) but not in normal-weight patients, resting energy expenditure (REE) adjusted for body weight (REEaBW) differed significantly between women and men (17.2 (interquartile range (IQR) 15.2-20.7) vs 20.9 (IQR 17.9-23.4) kcal/kg/day, P<0.01). Similarly, REE adjusted for ideal body weight (REEaIBW) was significantly lower in women compared with men (25.5 (IQR 22.6-28.1) vs 28.0 (IQR 25.2-30.0) kcal/kg/day, P<0.05). In overweight patients, gender was identified as an independent predictor of REEaBW in the multivariate regression model (r=-2.57 (95% CI -4.57 to -0.57); P<0.05), even after adjustment for age, simplified acute physiology score (SAPS II), body temperature, body weight and height. CONCLUSIONS REEaBW decreases with increasing body mass in both sexes. This relationship differs between women and men. Overweight critically ill women show significantly lower REEaBW and REEaIBW, respectively, compared with men. These findings could affect the current practice of nutritional support during the early phase of critical illness.
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Dokken M, Rustøen T, Stubhaug A. Indirect calorimetry reveals that better monitoring of nutrition therapy in pediatric intensive care is needed. JPEN J Parenter Enteral Nutr 2013; 39:344-52. [PMID: 24255088 DOI: 10.1177/0148607113511990] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Monitoring nutrition therapy is essential in the care of critically ill children, but the risk of nutrition failure seems to remain. The aims of the present study were to examine the prevalence of underfeeding, adequate feeding, and overfeeding in mechanically ventilated children and to identify barriers to the delivery of nutrition support. MATERIALS AND METHODS Children aged 0-14 years who fulfilled the criteria for indirect calorimetry were enrolled in this prospective, observational study and were studied for up to 5 consecutive days. Actual energy intake was recorded and compared with the required energy intake (measured energy expenditure plus 10%); energy intake was classified as underfeeding (<90% of required energy intake), adequate feeding (90%-110%), or overfeeding (>110%). The reasons for interruptions to enteral and parenteral nutrition were recorded. RESULTS In total, 104 calorimetric measurements for 140 total days were recorded for 30 mechanically ventilated children. Underfeeding, adequate feeding, and overfeeding occurred on 21.2%, 18.3%, and 60.5% of the 104 measurement days, respectively. There was considerable variability in the measured energy expenditure between children (median, 37.2 kcal/kg/d; range, 16.81-66.38 kcal/kg/d), but the variation within each child was small. Respiratory quotient had low sensitivity of 21% and 27% for detecting underfeeding and overfeeding, respectively. Fasting for procedures was the most frequent barrier that led to interrupted nutrition support. CONCLUSION The high percentage of children (~61%) who were overfed emphasizes the need to measure energy needs by using indirect calorimetry.
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Affiliation(s)
- Mette Dokken
- Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Tone Rustøen
- Division of Emergencies and Critical Care, Department of Research and Development, Ullevål, Oslo University Hospital, Oslo, Norway Unit of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Audun Stubhaug
- Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway Faculty of Medicine, University of Oslo, Oslo, Norway
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dos Santos LJ, Hoff FC, Condessa RL, Kaufmann ML, Vieira SRR. Energy expenditure during weaning from mechanical ventilation: is there any difference between pressure support and T-tube? J Crit Care 2010; 26:34-41. [PMID: 20619600 DOI: 10.1016/j.jcrc.2010.05.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2009] [Revised: 03/20/2010] [Accepted: 05/24/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND The objectives of this study were to compare patients' energy expenditure (EE) during pressure support (PS) and T-tube (TT) weaning from mechanical ventilation (MV) through indirect calorimetry (IC) and to crosscheck these findings with the results calculated using Harris-Benedict (HB) equation. METHODS This study is a randomized crossover controlled trial. Patients with clinical criteria for weaning from MV were randomized to PS-TT or TT-PS, with EE measurement for 20 minutes in PS and TT through IC. Energy expenditure was estimated through HB equation with and without activity factor. Statistical analysis used the Student t test for paired samples and Pearson correlation coefficient, as well as Bland-Altman method. RESULTS Forty patients were included. The mean age and Acute Physiology and Chronic Health Evaluation II score were 56 ± 16 years and 23 ± 8, respectively, with predominance of male patients (70%). Mean EE of patients in TT (1782 ± 375 kcal/d) was 14.4% higher than in PS (1558 ± 304 kcal/d; P < .001). In relation to the EE obtained with the HB equation, the mean (SD) value calculated was 1455 (210) kcal/d, and when considering the activity factor, it was 1609 (236) kcal/d, all of them presenting correlation with the values from IC in PS (r = 0.647) and TT (r = 0.539). However, the limits of agreement between the measured EE and the estimated EE suggest that the HB equation tends to underestimate the EE. CONCLUSION Comparison of EE in PS and in TT through IC demonstrated that there is increased EE in the TT mode. The results suggest that the HB equation underestimates the EE of patients in weaning from MV.
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Affiliation(s)
- Laura Jurema dos Santos
- Postgraduate Program in Health Sciences: Cardiology and Cardiovascular Sciences, Medical School, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400-2° andar, 90035-003 Porto Alegre, RS, Brazil
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Alves VGF, da Rocha EEM, Gonzalez MC, da Fonseca RBV, Silva MHDN, Chiesa CA. Assessement of resting energy expenditure of obese patients: Comparison of indirect calorimetry with formulae. Clin Nutr 2009; 28:299-304. [DOI: 10.1016/j.clnu.2009.03.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2008] [Revised: 03/18/2009] [Accepted: 03/23/2009] [Indexed: 10/20/2022]
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Badjatia N, Kowalski RG, Schmidt JM, Voorhees ME, Claassen J, Ostapkovich ND, Presciutti M, Connolly ES, Palestrant D, Parra A, Mayer SA. Predictors and clinical implications of shivering during therapeutic normothermia. Neurocrit Care 2007; 6:186-91. [PMID: 17534584 DOI: 10.1007/s12028-007-0011-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Shivering during induced normothermia (IN) remains a therapeutic limitation. We investigated potential risk factors and clinical implications of shivering during IN. METHODS Post hoc analysis was performed on 24 patients enrolled in a clinical trial of an automated surface cooling system to achieve IN. Hyponatremia was defined as serum levels <136 mmol/L and hypomagnesaemia as levels <1.5 mg/dL. Continuous heat energy transfer (kcal/h) was averaged hourly. Glasgow Coma Scale (GCS) scores were recorded every 2 h. Shivering status was documented hourly. Mixed effects modeling was used to determine clinical measures associated with shivering. Generalized estimating equation (GEE) models were used to compare baseline-adjusted repeated-measures GCS scores. RESULTS About of 24 (39%) patients demonstrated shivering. Shivering was associated with men (67% vs. 21%, P = 0.03), hyponatremia (44% vs. 7%, P = 0.03), and hypomagnesaemia (56% vs. 7%, P = 0.02). The average kcal/h (158 +/- 645 kcal/h vs. 493 +/- 645 kcal/h, P = 0.03) was greater in shivering patients. Shivering was positively associated with increases in heart rate (P < 0.001), respiratory rate (P < 0.001), and kcal/h (P < 0.001). Non-shivering patients showed a greater increase from baseline GCS (GEE, P = 0.02) at 24 h. No differences in sedative doses or fever burden were noted between shiverers and non-shiverers. CONCLUSIONS Men, hyponatremia, and hypomagnesaemia may predispose febrile patients treated with IN to shivering. Shivering dramatically increases the amount of heat transfer required to maintain normothermia, and may be associated with adverse effects on level of consciousness.
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Affiliation(s)
- Neeraj Badjatia
- Department of Neurology, Columbia University College of Physicians & Surgeons, 710 W 168th Street, New York, NY 10032, USA.
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Zauner A, Nimmerrichter P, Anderwald C, Bischof M, Schiefermeier M, Ratheiser K, Schneeweiss B, Zauner C. Severity of insulin resistance in critically ill medical patients. Metabolism 2007; 56:1-5. [PMID: 17161218 DOI: 10.1016/j.metabol.2006.08.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2006] [Accepted: 08/29/2006] [Indexed: 12/19/2022]
Abstract
Critical illness is characterized by a hypermetabolic state associated with increased mortality, which is partly ascribed to the occurrence of hyperglycemia caused by enhanced endogenous glucose production and insulin resistance (IR). Insulin resistance is well described in patients after surgery and trauma. However, it is less clearly quantified in critically ill medical patients. In this clinical cohort study, IR (M value) was quantified in 40 critically ill medical patients and 25 matched, healthy controls by isoglycemic hyperinsulinemic clamps after an overnight fast on the day after admission to a medical intensive care unit. Energy and substrate metabolism were measured by using indirect calorimetry in the patients before and during the clamp. The severity of illness was assessed by the acute physiology and chronic health evaluation (APACHE) III score. M values of critically ill medical patients were significantly lower compared with healthy controls (2.29 +/- 1.0 and 7.6 +/- 2.9 mg/kg per minute, respectively; P < .001) and were closely related to APACHE III scores (r = -0.43, P < .01), body mass index (r = -0.41, P < .01), and resting energy expenditure (r = 0.40, P < .05). The M value was not associated with age, basal glucose concentrations, and respiratory quotient, and it did not differ among patients with various admission diagnoses. In conclusion, insulin sensitivity was found to be reduced by 70% in critically ill medical patients. The severity of IR was associated with the severity of illness, body mass index, and resting energy expenditure, but not with substrate oxidation rates. In addition, the severity of IR did not vary among patients with different admission diagnoses.
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Affiliation(s)
- Alexandra Zauner
- Intensive Care Unit, Department of Internal Medicine IV, Medical University of Vienna, Vienna, Austria
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da Rocha EEM, Alves VGF, da Fonseca RBV. Indirect calorimetry: methodology, instruments and clinical application. Curr Opin Clin Nutr Metab Care 2006; 9:247-56. [PMID: 16607124 DOI: 10.1097/01.mco.0000222107.15548.f5] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review aims to identify the basic methods for accurately measuring a patient's energy expenditure in clinical nutrition practice by indirect calorimetry, and the impact upon a disease state of applying the results obtained. RECENT FINDINGS The open-circuit method is the most widely used in the majority of classical instruments for measuring energy consumption. Advances in gas exchange measurement have made this technique readily and precisely available at the bedside. Nevertheless, it is important to understand its intricate primary methodology for safe and correct application. The stress and activity factors should be carefully and specifically applied, and the respiratory quotient abandoned, for tailoring a patient's daily nutrition regimens. Caloric expenditure measured by indirect calorimetry coupled with the doubly labeled water technique introduced the concept of physical activity energy expenditure, which added to resting energy expenditure results in total daily energy expenditure. Compact modular and handheld devices have been introduced into the market, together with similar technology for evaluating exercise energy expenditure, making utilization easier, safer and precise. In the critically ill population, which is exposed to medical and surgical interventions, indirect calorimetry has greatly changed the practice of caloric administration, significantly reducing the total daily amount. SUMMARY In conclusion, one has to be careful when choosing devices, and understanding and clinically applying the results obtained by indirect calorimetry, bearing in mind that measured resting energy expenditure should be the daily caloric goal in order to diminish clinical morbidity.
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Koca U. What is the meaning of standard venous admixture formula results in septic patients? Physiol Meas 2005; 27:N1-6. [PMID: 16365504 DOI: 10.1088/0967-3334/27/1/n01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The standard venous admixture formula is widely used in the bedside assessment of intrapulmonary shunt in intensive care units. The intrapulmonary shunt fraction calculated by the standard venous admixture formula is affected by the systemic oxygen extraction ratio and thus reflects both systemic and intrapulmonary shunts, especially in septic patients with decreased oxygen extraction ratios. The standard venous admixture formula may cause misestimation of the intrapulmonary shunt fraction, especially in septic patients. Inert gas rebreathing techniques and simultaneous measurement of cardiac output by thermodilution and oxygen consumption by indirect calorimetry may be useful in septic patients.
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Affiliation(s)
- Uğur Koca
- Department of Anesthesiology and Reanimation, Dokuz Eylül University School of Medicine, Izmir, Turkey.
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Stathatos MA. Relativistic parameters of senescence. Med Hypotheses 2005; 64:1039-45. [PMID: 15780508 DOI: 10.1016/j.mehy.2004.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2004] [Accepted: 11/07/2004] [Indexed: 11/26/2022]
Abstract
The laws of biochemistry and biology are governed by parameters whose description in mathematical formulas is based on the three-dimensional space. It is a fact, however, that the life span of a cell and its specific functions, though limited, can be extended or diminished depending on the genetic code but also, on the natural pressure of the environment. The plasticity exhibited by a cellular system has been attributed to the change of the three-dimensional structure of the cell, with time being a simple measure of this change. The model of biological relativity proposed here, considers time as a flexible fourth dimension that corresponds directly to the inertial status of the cells. Two types of clocks are defined: the relativistic biological clock (RBC) and the mechanical clock (MC). In contrast to the MCs that show the astrological reference time, the time shown by the RBCs delay because it depends on cellular activity. The maximum and the expected life span of the cells and/or the organisms can be therefore relied on time transformation. One of the most important factors that can affect time flow is the energy that is produced during metabolic work. Based on this observation, RBCs can be constructed following series of theoretical experiments in order to assess biological time and life span changes.
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Affiliation(s)
- Marios A Stathatos
- Diagnostic and Therapeutic Center of Athens Hygeia SA, Kifissias Avenue and Erythrou Stavrou Street, 15123 Marousi, Athens, Greece.
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