Severe propylene glycol toxicity secondary to use of anti-epileptics

Safety and Efficacy of Propylene Glycol-Free Melphalan in Patients with AL Amyloidosis Undergoing Autologous Stem Cell Transplantation: Results of a Phase II Study

Patients with systemic light chain (AL) amyloidosis undergoing treatment with high-dose melphalan and autologous stem cell transplantation (HDM/SCT) may develop renal and cardiac toxicities potentially exacerbated by the co-solvent propylene glycol in conventional melphalan formulations. We investigated the safety and efficacy of propylene glycol-free melphalan (PGF-Mel) during HDM/SCT in patients with AL amyloidosis (ClinicalTrials.gov identifier NCT02994784). The primary objective of this phase II, open-label study was evaluation for renal dysfunction, new cardiac arrhythmias, and postural hypotension related to autonomic dysfunction. Secondary objectives included time to neutrophil and platelet engraftment, treatment-related mortality (TRM), overall hematologic response, organ response, and number of peritransplantation hospitalizations. Twenty-eight patients with AL amyloidosis enrolled, of whom 27 underwent HDM/SCT. PGF-Mel at 140 to 200 mg/m2 was administered i.v. in 2 equally divided doses. Patients were monitored for up to 30 days after the last administration of PGF-Mel to assess for treatment-related toxicity. Patients were followed for 12 months from the time of treatment with HDM/SCT for evaluation of hematologic and organ responses. Kaplan-Meier analysis was used to estimate progression-free survival. Two patients (7%) developed renal dysfunction, 5 (19%) experienced new cardiac arrhythmias, and 3 (11%) developed orthostatic hypotension. All patients achieved neutrophil and platelet engraftment, at a median of 10 days and 17 days post-HDM/SCT, respectively. TRM on day +100 was 0%. Peritransplantation hospitalization was required for 23 patients (85%). The most common nonhematologic adverse events were diarrhea (93%), fatigue (82%), and nausea (74%). At 6 months post-HDM/SCT, hematologic complete response or very good partial response occurred in 66% of the patients. At 12 months post-HDM/SCT, renal response occurred in 12 of 23 (52%) patients with renal involvement, and cardiac response occurred in 3 of 11 (27%) patients with evaluable cardiac involvement. Our data indicate that PGF-Mel is safe and efficacious as a high-dose conditioning regimen for autologous SCT in patients with AL amyloidosis.

Ambient 1,2-propanediol exposure accelerates the degradation of lipids and amino acids in milk via allosteric effects and affects the utilization of nutrients containing amide bond

The scandal of detecting 1, 2-propanediol (PL) in milk brought a crisis to the trust of consumers in the dairy industry, and the potential toxicity of PL has aroused the public concern about dietary exposure. A total of 200 pasteurized milk samples were collected from 15 regions, and the quantity of PL ranged between 0 and 0.31 g kg^-1. Pseudo-targeted quantitative metabolomics integrated with proteomics demonstrated that PL enhanced the reduction of κ-casein, β-casein, and 107 substances (41 amines and 66 amides) containing amide bonds. Pathway enrichment and topological analysis indicated that PL induced the metabolism of lipids, amino acids, oligosaccharide nucleotides, and alkaloids by accelerating the rate of nucleophilic reaction, and acetylcholinesterase, sarcosine oxidase, and prolyl 4-hydroxylase were determined as the vital enzymes related to the degradation of above nutrients. The results of molecular simulation calculation illustrated that the number of hydrogen bonds between acetylcholinesterase, sarcosine oxidase, and substrate increased to 2 and 3, respectively, while the position of hydrogen bonds between prolyl 4-hydroxylase and proline was shifted, indicating the change of conformation and the enhancement of hydrogen bond force were essential factors for the up-regulation of enzyme activity. This study first revealed the mechanism of deposition and transformation of PL in milk, which contributed to the knowledge of the quality control of milk and provided vital indicators to evaluate the adverse risks of PL in dairy products.

UHPLC-Q-Orbitrap-Based Integrated Lipidomics and Proteomics Reveal Propane-1,2-diol Exposure Accelerating Degradation of Lipids via the Allosteric Effect and Reducing the Nutritional Value of Milk

The scandal of detecting the flavoring solvent propane-1,2-diol (PD) in milk has brought a crisis to the trust of consumers in the dairy industry, while its deposition and transformation are still indistinct. Pseudo-targeted lipidomics revealed that PD accelerated the degradation of glycerolipid (33,638.3 ± 28.9 to 104,54.2 ± 28.4 mg kg^-1), phosphoglyceride (467.4 ± 8.2 to 56.6 ± 4.2 mg kg^-1), and sphingolipids (11.4 ± 0.3 to 0.7 ± 0.2 mg kg^-1), which extremely decreased the milk quality. Recoveries and relative standard deviations (RSDs) of the established method were 85.0-109.9 and 0.1-14.9%, respectively, indicating that the approach was credible. Protein-lipid interactions demonstrated that 10 proteins originating from fat globules were upregulated significantly and the activities of 7 enzymes related to lipid degradation were improved. Diacylglycerol cholinephosphotransferase was the only enzyme with decreased activity, and the molecular docking results indicated that PD adjusted its activity through regulating the conformation of the active center and weakening the hydrogen bond force between the enzyme and substrate. This study firstly revealed the mechanism of deposition and transformation of PD in milk, which contributed to the knowledge on the milk quality control and provided key indicators to evaluate the adverse risks of PD in dairy products.

Management of status epilepticus in adults. Position paper of the Italian League against Epilepsy

Since the publication of the Italian League Against Epilepsy guidelines for the treatment of status epilepticus in 2006, advances in the field have ushered in improvements in the therapeutic arsenal. The present position paper provides neurologists, epileptologists, neurointensive care specialists, and emergency physicians with updated recommendations for the treatment of adult patients with status epilepticus. The aim is to standardize treatment recommendations in the care of this patient population.

Potentiation of Sodium Metabisulfite Toxicity by Propylene Glycol in Both in Vitro and in Vivo Systems

Many consumer products used in our daily lives result in inhalation exposure to a variety of chemicals, although the toxicities of the active ingredients are not well known; furthermore, simultaneous exposure to chemical mixtures occurs. Sodium metabisulfite (SM) and propylene glycol (PG) are used in a variety of products. Both the cytotoxicity and the sub-acute inhalation toxicity of each chemical and their mixtures were evaluated. Assays for cell viability, membrane damage, and lysosome damage demonstrated that SM over 100 μg/ml induced significant cytotoxicity; moreover, when PG, which was not cytotoxic, was mixed with SM, the cytotoxicity of the mixture was enhanced. Solutions of 1, 5, and 20% SM, each with 1% PG solution, were prepared, and the whole body of rats was exposed to aerosols of the mixture for 6 h/day, 5 days/week for 2 weeks. The rats were sacrificed 1 (exposure group) or 7 days (recovery group) after termination of the exposure. The actual concentration of SM in the low-, medium-, and high-exposure groups was 3.91 ± 1.26, 35.73 ± 6.01, and 80.98 ± 5.47 mg/m³, respectively, and the actual concentration of PG in each group was 6.47 ± 1.25, 8.68 ± 0.6, and 8.84 ± 1.77 mg/m³. The repeated exposure to SM and PG caused specific clinical signs including nasal sound, sneeze, and eye irritation which were not found in SM single exposure. In addition, the body weight of treatment group rats decreased compared to that of the control group rats in a time-dependent manner. The total protein concentration and lactate dehydrogenase activity in the bronchoalveolar lavage fluid (BALF) increased. Histopathological analysis of the lungs, liver, and nasal cavity was performed. Adverse effects were observed in the nasal cavity, with squamous cell metaplasia identified in the front of the nasal cavity in all high-exposure groups, which completely recovered 7 days after exposure was terminated. Whereas inhalation of SM for 2 weeks only reduced body weight in the high-dose group, inhalation of SM and PG mixtures for 2 weeks significantly decreased body weight and induced metaplasia of the respiratory epithelium into squamous cells in the medium- and high-dose groups. In conclusion, PG potentiated the toxicity of SM in human lung epithelial cells and the inhalation toxicity in rats.

Systemic Complications Following Status Epilepticus

PURPOSE OF REVIEW

Status epilepticus (SE) is a multisystem disorder. Initially, complications of a massive catecholamine release followed by the side effects of medical therapies, impact patients' outcomes. The aim of this article is to provide an updated summary of the systemic complications following SE.

RECENT FINDINGS

In recent years, the importance of the multifaceted nature of SE and its relationship with clinical outcomes has been increasingly recognized. The cumulative systemic effects of prolonged seizures and their treatment contribute to morbidity and mortality in this condition. Most systemic complications after SE are predictable. Anticipating their occurrence and respecting a number of simple guidelines may improve the prognosis of these patients.

Extracorporeal Treatment in Phenytoin Poisoning: Systematic Review and Recommendations from the EXTRIP (Extracorporeal Treatments in Poisoning) Workgroup

The Extracorporeal Treatments in Poisoning (EXTRIP) Workgroup conducted a systematic literature review using a standardized process to develop evidence-based recommendations on the use of extracorporeal treatment (ECTR) in patients with phenytoin poisoning. The authors reviewed all articles, extracted data, summarized findings, and proposed structured voting statements following a predetermined format. A 2-round modified Delphi method was used to reach a consensus on voting statements, and the RAND/UCLA Appropriateness Method was used to quantify disagreement. 51 articles met the inclusion criteria. Only case reports, case series, and pharmacokinetic studies were identified, yielding a very low quality of evidence. Clinical data from 31 patients and toxicokinetic grading from 46 patients were abstracted. The workgroup concluded that phenytoin is moderately dialyzable (level of evidence = C) despite its high protein binding and made the following recommendations. ECTR would be reasonable in select cases of severe phenytoin poisoning (neutral recommendation, 3D). ECTR is suggested if prolonged coma is present or expected (graded 2D) and it would be reasonable if prolonged incapacitating ataxia is present or expected (graded 3D). If ECTR is used, it should be discontinued when clinical improvement is apparent (graded 1D). The preferred ECTR modality in phenytoin poisoning is intermittent hemodialysis (graded 1D), but hemoperfusion is an acceptable alternative if hemodialysis is not available (graded 1D). In summary, phenytoin appears to be amenable to extracorporeal removal. However, because of the low incidence of irreversible tissue injury or death related to phenytoin poisoning and the relatively limited effect of ECTR on phenytoin removal, the workgroup proposed the use of ECTR only in very select patients with severe phenytoin poisoning.

Management of super-refractory status epilepticus with isoflurane and hypothermia

Super-refractory status epilepticus (SRSE) is defined as status epilepticus that continues 24 h or more after the onset of anesthesia, and includes those cases in which epilepsy is recurrent upon treatment reduction. We describe the presentation and successful management of a male patient with SRSE using the inhaled anesthetic isoflurane, and mild hypothermia (HT). The potential utility of combined HT and volatile anesthesia is discussed.