- Email: [email protected]
CHLORPROPAMIDE ALCOHOL FLUSHING
336
overnight. The whole procedure is done in a laminar-flow cabinet.
DISSOLUTION OF BILEDUCT STONES
SiR,-With great interest I read the paper by Mr Jarrett and his colleagues (Jan. 10, p. 68) on the intraductal infusion of monooctanoin in 24 patients with retained common-duct stones. The discovery of bileduct stones after cholecystectomy is annoying to the patient and to the surgeon and physician. A second operation, will be more risky than simple cholecystectomy, hence the interest in endoscopic stone extraction and conservative treatment with bilesalt perfusions. Favourable results in cholesterol stones have been reported for perfusion with glycero-mono-octanoin (‘Capmul 8210’).11 Using the glyceryl caprylic ester2and alternating treatment with a bile salt EDTA solution (BA- EDT A)3,4 we achieved better solubilising capacity and fewer side effects of mono-octanoin. Unfortunately capmul 8210 will dissolve only cholesterol stones and the monooctanoin ester we used will tackle cholesterol concrements with only minor amounts of calcium carbonate, phosphate, or bilirubinate. Pigment matrix stones resist these perfusion media. We find pigment matrix stones 30-40% of all bileduct stones. These concrements are soft and chalky and consist mainly of calcium bilirubinate with a high proportion of an organic matrix (mucopolysaccharides, proteins, and varying amounts of water). These stones differ from the bilirubinate gallbladder stones where the proportion of organic matrix and water seems to be much lower. With the BA-EDTA solution, however, we have a perfusion medium that dissolves pigment matrix stones in vitro. After stone analysis we did experiments to compare our BAEDTA solution with capmul 8210 and found that pigment matrix stones remain unchanged in capmul 8210 whereas in BA-EDTA molecular dissolution of the pigment components and a disaggregation of the glycoproteid matrix take place. A stone about 1 cm in diameter was dissolved in about 36 h in BA-EDTA, leaving a yellowbrown mud of disaggregated organic matrix. Important features of our perfusion medium seem to be its calcium binding capacity and its pH, buffering capacity, surface tension, and osmolarity. Clinically these BA-EDTA solutions are well tolerated.4 We were surprised that Jarrett et al. found monooctanoin to be well tolerated by their patients. This was not the experience of Schenk et al.5 or Uribe et aI.,6 and we have had to discontinue treatment in some patients because of diarrhoea. Solubilising capacity and tolerance are important factors for the conservative managements of bileduct stones, but it is stone architecture and topographical conditions that will turn out to be responsible for therapeutic failures, especially in big stones. Centre of Internal
Medicine,
University of Frankfurt, 6000 Frankfurt, West Germany
ULRICH LEUSCHNER H. BAUMGARTEL
SiR,—Mr Jarrett and his colleagues state that the solvent must be kept warm to prevent solidification. In our experience sterilisation of mono-octanoin by filtration produces a liquid that does not solidify again at room temperature. Mono-octanoin ("capmul 8210’; Stokely-vanCamp Co, Indiana) is liquefied at 35-40°C to prevent too much colour change and then filtered under pressure through a ’Millipak 50’ filter (0-2 m) (Millipore) and collected in glass infusion bottles sterilised by dry heat with rubber stoppers sterilised by immersion in 70% ethanol 1. Thistle JL, Carlson GL, Hofmann AF, et al. Monooctanoin, a dissolution agent for retained cholesterol bile duct stones- Physical properties and clinical application.
Gastroenterology 1980; 78: 1016-22 U, Wurbs D, Landgraf H. Dissolution of biliary duct
2. Leuschner
octanom.
3. Leuschner
stones
with
mono-
Lancet 1979; i: 103-04
U, Baumgärtel H, Wurbs D. Auflösung von CholesterinGallengangssteinen mit einer modifizierten Capmul 8210-Emulsion und einer EDTA-Gallensalzlösung. Leber Magen Darm 1980; 10: 284-87 4. Leuschner U, Wurbs D, Baumgärtel H, et al. Alternating treatment of common bile duct stones with a modified glyceril-1-monooctanoate preparation (GMOC) and a bile acid-EDTA solution (BA-EDTA) by naso-biliary tube Scand J Gastroenterol (in press). 5. Schenk J, Schmack B, Rosch W, et al Spulbehandlung von Choledochusstemen mit Octanoat (Capmul 8210) Dtsch Med Wschr 1980, 105: 917-21 6. Uribe M, Uscanga L, Sanjurgo JL, et al Medium chain glycerides for the dissolution of retained gallstones: Success and side effects. Gastroenterology 1980; 78: 1281 (abstr).
Since the millipak filter is not delivered as a sterile device it is sterilised with ethanol 70% overnight. The filtration speed is I litre/h. Thin-layer chromatography confirms that this filtration procedure does not affect the constituents of capmul 8210. The validity of the bubble-point test was not affected by this whole procedure. Upon storage the solution slowly darkens but we do not know whether this change is associated with any therapeutic consequences.
Pharmacy, Municipal Hospital,
J. C. KUTSCH LOJENGA
6800 EE Arnhem, Netherlands
A. A.
VAN
SORGE
CHLORPROPAMIDE ALCOHOL FLUSHING
SIR,-As Dr Barrett and Dr Pyke state (Jan. 24, p. 222) those who have used chlorpropamide in treatment of diabetics are aware that the chlorpropamide alcohol flush (CPAF) exists. However, few ever believed that SlOW of such patients were affected by alcohol, nor have’ any other studies confirmed the King’s College Hospital findipgs. 2-4 Such discrepancies cannot encourage clinicians to apply the CPAF reaction as a genetic marker or screening test for retinopathy or other diabetic complications. Even if the prescribed doses of chlorpropamide or alcohol have been too low to give adequate blood levels,we doubt the wisdom of encouraging diabetic patients to take drugs which might induce dangerous hypoglycaemia or impair mental function without having very sound reasons for doing so. COLIN M. KESSON Southern General Hospital, Glasgow G51 4TF JOHN T. IRELAND
SIR,-Chlorpropamide-alcohol flush (CPAF) has some interesting similarities to the dimethylformamide (DMF)-alcohol flush that has been reported sporadically among workmen drinking after exposure to the solvent. It was reported by about 20% in my series though all had been exposed to DMF and most had taken alcohol within 24 h thereafter.6 Like chlorpropamide DMF raises blood acetaldehyde on ethanol challenge, but probably only (or mainly) by the agency of its metabolite N-methylformamide.7 Ethanol reduces the rate of DMF demethylation.8Ifthe flush is triggered by acetaldehyde, and acetaldehyde flush is a recognised entity,9 then there is clearly scope for much individual variation in’ the DMF-alcohol response.
Chlorpropamide similarly is metabolised to a varying extent to p-chlorobenzenesulphonylurea, and its formamide-like side chain might also be expected to block aldehyde dehydrogenase-yet another factor to add to those’mentioned by Dr Jerntorp and his colleagues (Jan. 17, p. 165). Central Medical Department, Couitaulds Ltd, Coventry CV6 5AE.
W.H.LYLE
1. Leslie RG, Pyke DA. Chlorpropamide alcohol flushing: a dominantly inherited trait associated with diabetes Br Med J 1978; ii: 1519-21. 2. K&oacgr;bberling J, Bengsh N, Bruggeboes B et al. The Chlorpropamide alcohol flush. Diabetologia 1980; 19: 359-63. 3. De Silva NE, Tunbridge WMG, Alberti KGMM. Low incidence alcohol flushing in diet-treated, non-insulin-dependent diabetes Lancet 1980; r 128-31. 4. Radder JK, Box MCJG, Lemkes HHPJ. Facial skin temperature and Chlorpropamide-alcohol flush in diabetics. Lancet 1980; ii: 1037. 5. Jerntorp P, Almér L-O, Melander A. Is the blood chlorpropamide concentration critical in chlorpropamide alcohol flush. Lancet 1980; i: 165-6 6. Lyle WH, Spence TWM, McKinneley WM & Duckers K. Dimethylformamide and alcohol intolerance. Br J Ind Med 1979; 36: 61-66. 7. Hanasono GK, Fuller RW, Broddle WD, Gibson WR. Studies on the effects of N, N-dimethylformamide on ethanol disposition & monoamine oxidase activityin rats. Toxicol Appli Pharmacol 1977; 39: 461-72. 8. Eban A, Kimmerle G. Metabolism studies of N, N dimethyl-formamide: III Studies of the influence of ethanol in persons and laboratory animals. Int Arch Occup Envir Health 1976; 36: 243-65. 9. Sauter AM, Boss D, von Warburg JP. Revaluation of the disulfiram-alcohol reaction in man. J Studies Alcohol 1977; 38: 1680-95.
of chlorpropamide-
337
SIR,-Iread with great interest the suggestion of both Dr Jerntorp and his colleagues (Jan. 17, p. 165) and Dr Barnett and Dr Pyke (Jan. 24, p. 222) that chlorpropamide-alcohol flush (CPAF) is associated with an abnormally large rise in plasma acetaldehyde. Summers and II have shown that acetaldehyde combines rapidly with both enkephalins and endorphins to form stable adducts. These adducts show2 marked alterations in their biological activities. Since Leslie et al. have also demonstrated that the opiate antagonist naloxone blocks CPAF, it is possible that it is the alteration of some unknown property of the endogenous opioids by acetaldehyde that causes CPAF. M.R.C. Neurochemical Pharmacology Unit, Medical Research Council Centre, Medical School,
Cambridge CB2 2QH
STAFFORD LIGHTMAN
ENDOTOXINAEMIA PER SE AS CAUSE OF NEONATAL MORBIDITY
SIR,-We have seen an infant with a sepsis-like syndrome which have resulted from endotoxin absorption from the
seems to
gastrointestinal tract. Endotoxinaemia per se has not previously been recorded as a cause of neonatal morbidity. The patient had required prolonged intensive care, including lifelong ventilation and intravenous alimentation, as a result of prematurity, tracheo-oesophageal fistula (repaired), duodenal atresia (bypassed), necrotising enterocolitis, and bronchopulmonary dysplasia. Between 80-90 days of age she acquired marked leucocytosis (44 900/1) with 2507o immature neutrophils, thrombocytopenia (30 000 platelets/1), increasingly severe jaun dice (bilirubin 30 mg/dl direct component) with hepatitis (SGOT 150 IU/1), and multifocal seizures. Urinalysis was abnormal with >50 red blood cells per high power field, 3 + proteinuria, and 2 + granular and hyaline casts. On days 95-97, she became diffusely oedematous, with progressive oliguria. Extensive cultures of blood, spinal fluid, and urine, including cultures for anaerobes, fungi, and viruses, were negative. Ultrasound studies revealed no focal collections in the chest or abdomen. No response was evident to treatment with cloxacillin and tobramycin. Plasma obtained aseptically from a peripheral vein was tested for endotoxin after heat inactivation (60°C for 15 min), using a Limulus lysate assay (’Pyrotell’; Assoc. of Cape Cod). Serial dilution of the sample in pyrogen-free water to the end-point of the test’s sensitivity (0-125 ng/ml reference Escherichia coli endotoxin, Assoc. of Cape Cod) revealed an approximate concentration of endotoxin-like activity (ELA) of 2500 ng/ml. Another sample taken the following day contained 5000 ng/ml ELA. Cultures of gastric fluid indicated the presence of 16x 109 coliform bacteria per ml, prompting instillation of polymyxin B, 5000 units every 4 h, into the stomach. During 10 days of polymyxin therapy the concentration of ELA fell progressively to 0 -25 ng/ml, urinary output returned to normal, the oedema resolved, the urinary sediment improved, and white blood cell and platelet counts returned to normal. Liver function remained abnormal. 2 weeks later, renal failure and oedema recurred causing death. There were no indications of infection, bacterial overgrowth, or endotoxinaemia before death or at necropsy. The damage observed in this infant is compatible with the pathological effects of high-grade endotoxinaemia.3Since a bioassay was used, we cannot be certain that the Limulus activator in plasma was endotoxin. In support of true endotoxinaemia were the reproducible initial titres (making contamination unlikely), the use of heat inactivation of the plasma to obviate non-specific protease activation of the Limulus coagulogen, and the marked fall in ELA associated only with intragastric polymyxin B treatment. No other changes were made in antibiotic or supportive therapy during the period in question. The source of endotoxinaemia is usually bloodstream or focal infection with gram-negative bacteria: neither was revealed here 1. Lightman SL, Summers MC. Alterations in the activities of endogenous opiates by a metabolite of alcohol. J Endocrinol 1980; 87: 38-39P. 2. Leslie RDG, Pyke DA, Stubbs WA. Sensitivity to enkephalin as a cause of non-insulin dependent diabetes. Lancet 1979; i: 341-43. 3. Elm RJ, Wolff SM. Biology of endotoxin. Am Rev Med 1976; 127-41.
extensive investigation. While we have observed endotoxinaemia in association with necrotising enterocolitis, this infant had long recovered when ELA was detected. The overgrowth of coliform bacteria in the stomach suggests an associated overgrowth in small bowel, perhaps as a consequence of the duodenal blind loop. Increased intraluminal concentrations of endotoxin may foster endotoxin absorption. Severe hepatic fibrosis was found at necropsy and this probably impaired removal of endotoxin from portala venous blood, predisposing to systemic endotoxinaemia.2 The postulated "autointoxication" is supported by the prompt decline in ELA following polymyxin B administration since this drug is both broad-spectrum antibiotic and neutraliser of endotoxin ac-
despite
tivity.a
This case is presented to stimulate interest in neonatal endotoxinaemia. New methods of sample preparationsand improved Limulus lysateshave greatly simplified the test, which now requires only micro-samples (<0’ 5ml). These recent advances permit investigation of neonatal endotoxinaemia as a component of gramnegative sepsis and as an independent event in compromised infants. Department of Pediatrics, University of British Columbia, Vancouver General Hospital, Vancouver, Canada V5X 1X2
DAVID W. SCHEIFELE PATRICK W. MELTON VOLKER EBELT
MATERNAL SMOKING AND APGAR SCORE
SIR,-The effects of smoking during pregnancy on intrauterine growth are well establishedbut little is known of the effects of maternal smoking on birth asphyxia, as measured by the Apgar score. Garn et al. presented results on this subject for American Whites and Blacks. We have analysed corresponding information from the Cardiff Birth Survey. Most of the subjects are Whites. The analysis is based on nine years’ deliveries (1970-78) with uniform methods of coding. For this study, entry was restricted to liveborn singleton infants delivered vaginally to Cardiff resident women. The birth condition of the infants was assessed by the 1 min Apgar score.8 26 576 deliveries were analysed. The results do not suggest a clear trend. The numerically largest smoking group consists of mothers smoking 10 -19 cigarettes daily. The excess of low Apgar scores in this group reached significance at the 5% level only when the criterion of Apgar scores less than 6 was used (Chi-squared with Yates’ correction). When the data are examined in terms of amount smoked, differences between the six groups are not significant Which smoking group has the poorest outcome 0’05
1265-69. 6. Davies DP, Gray OP, Elwood PC, et al. Cigarette smoking in pregnancy: Associations with maternal weight gain and foetal growth. Lancet 1976, i: 385. 7. Garn SM, Petzold AS, Ridella SA, et al. Effect of maternal smoking on Apgar and Bayley scores. Lancet 1980; ii: 912. 8. Apgar V., Holaday DA, James LS, et al. Evaluation of the newborn infant-second report. JAMA 1958, 168: 1985. 9. Andrews J, McGarry JM. A community study of smoking in pregnancy. J Obstet Gynaecol Br Common 1972; 79: 1057.
overnight. The whole procedure is done in a laminar-flow cabinet.
DISSOLUTION OF BILEDUCT STONES
SiR,-With great interest I read the paper by Mr Jarrett and his colleagues (Jan. 10, p. 68) on the intraductal infusion of monooctanoin in 24 patients with retained common-duct stones. The discovery of bileduct stones after cholecystectomy is annoying to the patient and to the surgeon and physician. A second operation, will be more risky than simple cholecystectomy, hence the interest in endoscopic stone extraction and conservative treatment with bilesalt perfusions. Favourable results in cholesterol stones have been reported for perfusion with glycero-mono-octanoin (‘Capmul 8210’).11 Using the glyceryl caprylic ester2and alternating treatment with a bile salt EDTA solution (BA- EDT A)3,4 we achieved better solubilising capacity and fewer side effects of mono-octanoin. Unfortunately capmul 8210 will dissolve only cholesterol stones and the monooctanoin ester we used will tackle cholesterol concrements with only minor amounts of calcium carbonate, phosphate, or bilirubinate. Pigment matrix stones resist these perfusion media. We find pigment matrix stones 30-40% of all bileduct stones. These concrements are soft and chalky and consist mainly of calcium bilirubinate with a high proportion of an organic matrix (mucopolysaccharides, proteins, and varying amounts of water). These stones differ from the bilirubinate gallbladder stones where the proportion of organic matrix and water seems to be much lower. With the BA-EDTA solution, however, we have a perfusion medium that dissolves pigment matrix stones in vitro. After stone analysis we did experiments to compare our BAEDTA solution with capmul 8210 and found that pigment matrix stones remain unchanged in capmul 8210 whereas in BA-EDTA molecular dissolution of the pigment components and a disaggregation of the glycoproteid matrix take place. A stone about 1 cm in diameter was dissolved in about 36 h in BA-EDTA, leaving a yellowbrown mud of disaggregated organic matrix. Important features of our perfusion medium seem to be its calcium binding capacity and its pH, buffering capacity, surface tension, and osmolarity. Clinically these BA-EDTA solutions are well tolerated.4 We were surprised that Jarrett et al. found monooctanoin to be well tolerated by their patients. This was not the experience of Schenk et al.5 or Uribe et aI.,6 and we have had to discontinue treatment in some patients because of diarrhoea. Solubilising capacity and tolerance are important factors for the conservative managements of bileduct stones, but it is stone architecture and topographical conditions that will turn out to be responsible for therapeutic failures, especially in big stones. Centre of Internal
Medicine,
University of Frankfurt, 6000 Frankfurt, West Germany
ULRICH LEUSCHNER H. BAUMGARTEL
SiR,—Mr Jarrett and his colleagues state that the solvent must be kept warm to prevent solidification. In our experience sterilisation of mono-octanoin by filtration produces a liquid that does not solidify again at room temperature. Mono-octanoin ("capmul 8210’; Stokely-vanCamp Co, Indiana) is liquefied at 35-40°C to prevent too much colour change and then filtered under pressure through a ’Millipak 50’ filter (0-2 m) (Millipore) and collected in glass infusion bottles sterilised by dry heat with rubber stoppers sterilised by immersion in 70% ethanol 1. Thistle JL, Carlson GL, Hofmann AF, et al. Monooctanoin, a dissolution agent for retained cholesterol bile duct stones- Physical properties and clinical application.
Gastroenterology 1980; 78: 1016-22 U, Wurbs D, Landgraf H. Dissolution of biliary duct
2. Leuschner
octanom.
3. Leuschner
stones
with
mono-
Lancet 1979; i: 103-04
U, Baumgärtel H, Wurbs D. Auflösung von CholesterinGallengangssteinen mit einer modifizierten Capmul 8210-Emulsion und einer EDTA-Gallensalzlösung. Leber Magen Darm 1980; 10: 284-87 4. Leuschner U, Wurbs D, Baumgärtel H, et al. Alternating treatment of common bile duct stones with a modified glyceril-1-monooctanoate preparation (GMOC) and a bile acid-EDTA solution (BA-EDTA) by naso-biliary tube Scand J Gastroenterol (in press). 5. Schenk J, Schmack B, Rosch W, et al Spulbehandlung von Choledochusstemen mit Octanoat (Capmul 8210) Dtsch Med Wschr 1980, 105: 917-21 6. Uribe M, Uscanga L, Sanjurgo JL, et al Medium chain glycerides for the dissolution of retained gallstones: Success and side effects. Gastroenterology 1980; 78: 1281 (abstr).
Since the millipak filter is not delivered as a sterile device it is sterilised with ethanol 70% overnight. The filtration speed is I litre/h. Thin-layer chromatography confirms that this filtration procedure does not affect the constituents of capmul 8210. The validity of the bubble-point test was not affected by this whole procedure. Upon storage the solution slowly darkens but we do not know whether this change is associated with any therapeutic consequences.
Pharmacy, Municipal Hospital,
J. C. KUTSCH LOJENGA
6800 EE Arnhem, Netherlands
A. A.
VAN
SORGE
CHLORPROPAMIDE ALCOHOL FLUSHING
SIR,-As Dr Barrett and Dr Pyke state (Jan. 24, p. 222) those who have used chlorpropamide in treatment of diabetics are aware that the chlorpropamide alcohol flush (CPAF) exists. However, few ever believed that SlOW of such patients were affected by alcohol, nor have’ any other studies confirmed the King’s College Hospital findipgs. 2-4 Such discrepancies cannot encourage clinicians to apply the CPAF reaction as a genetic marker or screening test for retinopathy or other diabetic complications. Even if the prescribed doses of chlorpropamide or alcohol have been too low to give adequate blood levels,we doubt the wisdom of encouraging diabetic patients to take drugs which might induce dangerous hypoglycaemia or impair mental function without having very sound reasons for doing so. COLIN M. KESSON Southern General Hospital, Glasgow G51 4TF JOHN T. IRELAND
SIR,-Chlorpropamide-alcohol flush (CPAF) has some interesting similarities to the dimethylformamide (DMF)-alcohol flush that has been reported sporadically among workmen drinking after exposure to the solvent. It was reported by about 20% in my series though all had been exposed to DMF and most had taken alcohol within 24 h thereafter.6 Like chlorpropamide DMF raises blood acetaldehyde on ethanol challenge, but probably only (or mainly) by the agency of its metabolite N-methylformamide.7 Ethanol reduces the rate of DMF demethylation.8Ifthe flush is triggered by acetaldehyde, and acetaldehyde flush is a recognised entity,9 then there is clearly scope for much individual variation in’ the DMF-alcohol response.
Chlorpropamide similarly is metabolised to a varying extent to p-chlorobenzenesulphonylurea, and its formamide-like side chain might also be expected to block aldehyde dehydrogenase-yet another factor to add to those’mentioned by Dr Jerntorp and his colleagues (Jan. 17, p. 165). Central Medical Department, Couitaulds Ltd, Coventry CV6 5AE.
W.H.LYLE
1. Leslie RG, Pyke DA. Chlorpropamide alcohol flushing: a dominantly inherited trait associated with diabetes Br Med J 1978; ii: 1519-21. 2. K&oacgr;bberling J, Bengsh N, Bruggeboes B et al. The Chlorpropamide alcohol flush. Diabetologia 1980; 19: 359-63. 3. De Silva NE, Tunbridge WMG, Alberti KGMM. Low incidence alcohol flushing in diet-treated, non-insulin-dependent diabetes Lancet 1980; r 128-31. 4. Radder JK, Box MCJG, Lemkes HHPJ. Facial skin temperature and Chlorpropamide-alcohol flush in diabetics. Lancet 1980; ii: 1037. 5. Jerntorp P, Almér L-O, Melander A. Is the blood chlorpropamide concentration critical in chlorpropamide alcohol flush. Lancet 1980; i: 165-6 6. Lyle WH, Spence TWM, McKinneley WM & Duckers K. Dimethylformamide and alcohol intolerance. Br J Ind Med 1979; 36: 61-66. 7. Hanasono GK, Fuller RW, Broddle WD, Gibson WR. Studies on the effects of N, N-dimethylformamide on ethanol disposition & monoamine oxidase activityin rats. Toxicol Appli Pharmacol 1977; 39: 461-72. 8. Eban A, Kimmerle G. Metabolism studies of N, N dimethyl-formamide: III Studies of the influence of ethanol in persons and laboratory animals. Int Arch Occup Envir Health 1976; 36: 243-65. 9. Sauter AM, Boss D, von Warburg JP. Revaluation of the disulfiram-alcohol reaction in man. J Studies Alcohol 1977; 38: 1680-95.
of chlorpropamide-
337
SIR,-Iread with great interest the suggestion of both Dr Jerntorp and his colleagues (Jan. 17, p. 165) and Dr Barnett and Dr Pyke (Jan. 24, p. 222) that chlorpropamide-alcohol flush (CPAF) is associated with an abnormally large rise in plasma acetaldehyde. Summers and II have shown that acetaldehyde combines rapidly with both enkephalins and endorphins to form stable adducts. These adducts show2 marked alterations in their biological activities. Since Leslie et al. have also demonstrated that the opiate antagonist naloxone blocks CPAF, it is possible that it is the alteration of some unknown property of the endogenous opioids by acetaldehyde that causes CPAF. M.R.C. Neurochemical Pharmacology Unit, Medical Research Council Centre, Medical School,
Cambridge CB2 2QH
STAFFORD LIGHTMAN
ENDOTOXINAEMIA PER SE AS CAUSE OF NEONATAL MORBIDITY
SIR,-We have seen an infant with a sepsis-like syndrome which have resulted from endotoxin absorption from the
seems to
gastrointestinal tract. Endotoxinaemia per se has not previously been recorded as a cause of neonatal morbidity. The patient had required prolonged intensive care, including lifelong ventilation and intravenous alimentation, as a result of prematurity, tracheo-oesophageal fistula (repaired), duodenal atresia (bypassed), necrotising enterocolitis, and bronchopulmonary dysplasia. Between 80-90 days of age she acquired marked leucocytosis (44 900/1) with 2507o immature neutrophils, thrombocytopenia (30 000 platelets/1), increasingly severe jaun dice (bilirubin 30 mg/dl direct component) with hepatitis (SGOT 150 IU/1), and multifocal seizures. Urinalysis was abnormal with >50 red blood cells per high power field, 3 + proteinuria, and 2 + granular and hyaline casts. On days 95-97, she became diffusely oedematous, with progressive oliguria. Extensive cultures of blood, spinal fluid, and urine, including cultures for anaerobes, fungi, and viruses, were negative. Ultrasound studies revealed no focal collections in the chest or abdomen. No response was evident to treatment with cloxacillin and tobramycin. Plasma obtained aseptically from a peripheral vein was tested for endotoxin after heat inactivation (60°C for 15 min), using a Limulus lysate assay (’Pyrotell’; Assoc. of Cape Cod). Serial dilution of the sample in pyrogen-free water to the end-point of the test’s sensitivity (0-125 ng/ml reference Escherichia coli endotoxin, Assoc. of Cape Cod) revealed an approximate concentration of endotoxin-like activity (ELA) of 2500 ng/ml. Another sample taken the following day contained 5000 ng/ml ELA. Cultures of gastric fluid indicated the presence of 16x 109 coliform bacteria per ml, prompting instillation of polymyxin B, 5000 units every 4 h, into the stomach. During 10 days of polymyxin therapy the concentration of ELA fell progressively to 0 -25 ng/ml, urinary output returned to normal, the oedema resolved, the urinary sediment improved, and white blood cell and platelet counts returned to normal. Liver function remained abnormal. 2 weeks later, renal failure and oedema recurred causing death. There were no indications of infection, bacterial overgrowth, or endotoxinaemia before death or at necropsy. The damage observed in this infant is compatible with the pathological effects of high-grade endotoxinaemia.3Since a bioassay was used, we cannot be certain that the Limulus activator in plasma was endotoxin. In support of true endotoxinaemia were the reproducible initial titres (making contamination unlikely), the use of heat inactivation of the plasma to obviate non-specific protease activation of the Limulus coagulogen, and the marked fall in ELA associated only with intragastric polymyxin B treatment. No other changes were made in antibiotic or supportive therapy during the period in question. The source of endotoxinaemia is usually bloodstream or focal infection with gram-negative bacteria: neither was revealed here 1. Lightman SL, Summers MC. Alterations in the activities of endogenous opiates by a metabolite of alcohol. J Endocrinol 1980; 87: 38-39P. 2. Leslie RDG, Pyke DA, Stubbs WA. Sensitivity to enkephalin as a cause of non-insulin dependent diabetes. Lancet 1979; i: 341-43. 3. Elm RJ, Wolff SM. Biology of endotoxin. Am Rev Med 1976; 127-41.
extensive investigation. While we have observed endotoxinaemia in association with necrotising enterocolitis, this infant had long recovered when ELA was detected. The overgrowth of coliform bacteria in the stomach suggests an associated overgrowth in small bowel, perhaps as a consequence of the duodenal blind loop. Increased intraluminal concentrations of endotoxin may foster endotoxin absorption. Severe hepatic fibrosis was found at necropsy and this probably impaired removal of endotoxin from portala venous blood, predisposing to systemic endotoxinaemia.2 The postulated "autointoxication" is supported by the prompt decline in ELA following polymyxin B administration since this drug is both broad-spectrum antibiotic and neutraliser of endotoxin ac-
despite
tivity.a
This case is presented to stimulate interest in neonatal endotoxinaemia. New methods of sample preparationsand improved Limulus lysateshave greatly simplified the test, which now requires only micro-samples (<0’ 5ml). These recent advances permit investigation of neonatal endotoxinaemia as a component of gramnegative sepsis and as an independent event in compromised infants. Department of Pediatrics, University of British Columbia, Vancouver General Hospital, Vancouver, Canada V5X 1X2
DAVID W. SCHEIFELE PATRICK W. MELTON VOLKER EBELT
MATERNAL SMOKING AND APGAR SCORE
SIR,-The effects of smoking during pregnancy on intrauterine growth are well establishedbut little is known of the effects of maternal smoking on birth asphyxia, as measured by the Apgar score. Garn et al. presented results on this subject for American Whites and Blacks. We have analysed corresponding information from the Cardiff Birth Survey. Most of the subjects are Whites. The analysis is based on nine years’ deliveries (1970-78) with uniform methods of coding. For this study, entry was restricted to liveborn singleton infants delivered vaginally to Cardiff resident women. The birth condition of the infants was assessed by the 1 min Apgar score.8 26 576 deliveries were analysed. The results do not suggest a clear trend. The numerically largest smoking group consists of mothers smoking 10 -19 cigarettes daily. The excess of low Apgar scores in this group reached significance at the 5% level only when the criterion of Apgar scores less than 6 was used (Chi-squared with Yates’ correction). When the data are examined in terms of amount smoked, differences between the six groups are not significant Which smoking group has the poorest outcome 0’05
1265-69. 6. Davies DP, Gray OP, Elwood PC, et al. Cigarette smoking in pregnancy: Associations with maternal weight gain and foetal growth. Lancet 1976, i: 385. 7. Garn SM, Petzold AS, Ridella SA, et al. Effect of maternal smoking on Apgar and Bayley scores. Lancet 1980; ii: 912. 8. Apgar V., Holaday DA, James LS, et al. Evaluation of the newborn infant-second report. JAMA 1958, 168: 1985. 9. Andrews J, McGarry JM. A community study of smoking in pregnancy. J Obstet Gynaecol Br Common 1972; 79: 1057.