Dosage Related Efficacy and Tolerability of Cannabidiol in Children With Treatment-Resistant Epileptic Encephalopathy: Preliminary Results of the CARE-E Study.

Purpose: There is uncertainty regarding the appropriate dose of Cannabidiol (CBD) for childhood epilepsy. We present the preliminary data of seven participants from the Cannabidiol in Children with Refractory Epileptic Encephalopathy (CARE-E) study. Methods: The study is an open-label, prospective, dose-escalation trial. Participants received escalating doses of a Cannabis Herbal Extract (CHE) preparation of 1:20 Δ9-tetrahydrocannabinol (THC): CBD up to 10-12 mg CBD/kg/day. Seizure frequency was monitored in daily logs, participants underwent regular electroencephalograms, and parents filled out modified Quality of Life in Childhood Epilepsy (QOLCE) and Side Effect rating scale questionnaires. Steady-state trough levels (Css, Min) of selected cannabinoids were quantified. Results: All seven participants tolerated the CHE up to 10-12 mg CBD/kg/day and had improvements in seizure frequency and QOLCE scores. CSS, Min plasma levels for CBD, THC, and cannabichromene (CBC) showed dose-independent pharmacokinetics in all but one participant. CSS, Min CBD levels associated with a >50% reduction in seizures and seizure freedom were lower than those reported previously with purified CBD. In most patients, CSS, Min levels of THC remained lower than what would be expected to cause intoxication. Conclusion: The preliminary data suggest an initial CBD target dose of 5-6 mg/kg/day when a 1:20 THC:CBD CHE is used. Possible non-linear pharmacokinetics of CBD and CBC needs investigation. The reduction in seizure frequency seen suggests improved seizure control when a whole plant CHE is used. Plasma THC levels suggest a low risk of THC intoxication when a 1:20 THC:CBD CHE is used in doses up to 12 mg/kg CBD/kg/day.

The protocol for the Cannabidiol in children with refractory epileptic encephalopathy (CARE-E) study: a phase 1 dosage escalation study.

BACKGROUND: Initial studies suggest pharmaceutical grade cannabidiol (CBD) can reduce the frequency of convulsive seizures and lead to improvements in quality of life in children affected by epileptic encephalopathies. With limited access to pharmaceutical CBD, Cannabis extracts in oil are becoming increasingly available. Physicians show reluctance to recommend Cannabis extracts given the lack of high quality safety data especially regarding the potential for harm caused by other cannabinoids, such as Δ9-tetrahydrocannabinol (Δ9-THC). The primary aims of the study presented in this protocol are (i) To determine whether CBD enriched Cannabis extract is safe and well-tolerated for pediatric patients with refractory epilepsy, (ii) To monitor the effects of CBD-enriched Cannabis extract on the frequency and duration of seizure types and on quality of life. METHODS: Twenty-eight children with treatment resistant epileptic encephalopathy ranging in age from 1 to 10 years will be recruited in four Canadian cities into an open-label, dose-escalation phase 1 trial. The primary objectives for the study are (i) To determine if the CBD-enriched Cannabis herbal extract is safe and well-tolerated for pediatric patients with treatment resistant epileptic encephalopathy and (ii) To determine the effect of CBD-enriched Cannabis herbal extract on the frequency and duration of seizures. Secondary objectives include (i) To determine if CBD-enriched Cannabis herbal extracts alter steady-state levels of co-administered anticonvulsant medications. (ii) To assess the relation between dose escalation and quality of life measures, (iii) To determine the relation between dose escalation and steady state trough levels of bioactive cannabinoids. (iv) To determine the relation between dose escalation and incidence of adverse effects. DISCUSSION: This paper describes the study design of a phase 1 trial of CBD-enriched Cannabis herbal extract in children with treatment-resistant epileptic encephalopathy. This study will provide the first high quality analysis of safety of CBD-enriched Cannabis herbal extract in pediatric patients in relation to dosage and pharmacokinetics of the active cannabinoids. TRIAL REGISTRATION: http://clinicaltrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2016 Dec 16. Identifier NCT03024827, Cannabidiol in Children with Refractory Epileptic Encephalopathy: CARE-E; 2017 Jan 19 [cited 2017 Oct]; Available from: http://clinicaltrials.gov/ct2/show/NCT03024827.

Immunoglobulin A and Protein Content of Low-Fat Human Milk Prepared for the Treatment of Chylothorax.

BACKGROUND: Several case studies report successful recovery from chylothorax while infants were fed low-fat human milk. The reported growth rates were inadequate despite milk supplementation with added medium-chain triglycerides (MCTs). The objective was to determine the effect that various human milk fat separating methods, refrigerated centrifuge, room temperature centrifuge, and refrigeration have on the loss of immunoglobulin A (IgA) and protein in the preparation of low-fat human milk. METHODS: Protein and IgA were measured in 31 samples of reduced-fat human milk. Reduced-fat breastmilk samples were prepared by separating the fat using 3 methods (refrigerated centrifuge, room temperature centrifuge, and a refrigeration method), followed by lower fat milk extraction by syringe. RESULTS: The refrigeration method decreased IgA concentration by 17% (P = .035) while centrifugation and fat removal from the human milk samples led to a 38% decline in IgA concentration in both the nonrefrigerated and refrigerated centrifuge samples (P < .0001 for both). Protein declined by 11% with refrigeration and fat removal (P < .0001) while centrifugation and fat removal decreased protein concentration by 31% (P < .0001) in both nonrefrigerated centrifuge and refrigerated centrifuge samples. CONCLUSIONS: Preparing low-fat human milk for patients with chylothorax decreased the IgA and protein contents. As well as fat (in the form of MCTs), protein likely needs to be supplemented for infants fed low-fat human milk to support adequate growth.

The clinical impact of implementing the Roche® bilirubin total Gen.3 method on neonate phototherapy.

OBJECTIVE: To predict the impact of implementing the Roche® Gen.3 bilirubin total method on the number of bilirubin results that would trigger phototherapy using the phototherapy nomogram published in the Canadian Paediatric Society (CPS) Guidelines for Treatment of Hyperbilirubinemia. DESIGN AND METHODS: BILTS method results (N=563) were obtained on the Roche® C501 analyzer and the corresponding Bilirubin Total Gen.3 assay results were derived by linear regression. Total bilirubin results, gestational age and postnatal age were plotted with the CPS phototherapy nomogram to determine if phototherapy was indicated with both the BILTS and Gen.3 methods. Clinical thresholds for phototherapy using the BILTS and new Gen.3 methods were compared by Pearson's chi square test. RESULTS: 284 bilirubin results obtained from infants 35-37 weeks gestation (n=157 neonates) and 279 results from term infants >38 weeks gestation (n=224 neonates) were interpreted with the CPS phototherapy nomogram as either with or without risk factors. Use of the Gen.3 assay reduced the number of bilirubin results that would meet the high-risk threshold line to initiate phototherapy by 7% (p≤0.05) for 35-37 week gestation infants and would reduce phototherapy by 6% (p≤0.05) for >38 week gestation infants with the medium-risk threshold line compared to when the BILTS method was used. CONCLUSIONS: Replacement of the BILTS method by the Gen.3 bilirubin method is anticipated to be associated with a 7% decrease in the number of neonate results that would meet phototherapy thresholds. It cannot be determined if the BILTS assay was associated with a 7% over-treatment or the Gen.3 assay will be associated with 7% under-treatment. While standardization of bilirubin assays remains elusive, nomograms based on bilirubin methods will remain susceptible to method-biases and patient care decisions will remain subject to this uncertainty.

Causal assessment of dietary acid load and bone disease: a systematic review & meta-analysis applying Hill's epidemiologic criteria for causality.

BACKGROUND: Modern diets have been suggested to increase systemic acid load and net acid excretion. In response, alkaline diets and products are marketed to avoid or counteract this acid, help the body regulate its pH to prevent and cure disease. The objective of this systematic review was to evaluate causal relationships between dietary acid load and osteoporosis using Hill's criteria. METHODS: Systematic review and meta-analysis. We systematically searched published literature for randomized intervention trials, prospective cohort studies, and meta-analyses of the acid-ash or acid-base diet hypothesis with bone-related outcomes, in which the diet acid load was altered, or an alkaline diet or alkaline salts were provided, to healthy human adults. Cellular mechanism studies were also systematically examined. RESULTS: Fifty-five of 238 studies met the inclusion criteria: 22 randomized interventions, 2 meta-analyses, and 11 prospective observational studies of bone health outcomes including: urine calcium excretion, calcium balance or retention, changes of bone mineral density, or fractures, among healthy adults in which acid and/or alkaline intakes were manipulated or observed through foods or supplements; and 19 in vitro cell studies which examined the hypothesized mechanism. Urine calcium excretion rates were consistent with osteoporosis development; however calcium balance studies did not demonstrate loss of whole body calcium with higher net acid excretion. Several weaknesses regarding the acid-ash hypothesis were uncovered: No intervention studies provided direct evidence of osteoporosis progression (fragility fractures, or bone strength as measured using biopsy). The supporting prospective cohort studies were not controlled regarding important osteoporosis risk factors including: weight loss during follow-up, family history of osteoporosis, baseline bone mineral density, and estrogen status. No study revealed a biologic mechanism functioning at physiological pH. Finally, randomized studies did not provide evidence for an adverse role of phosphate, milk, and grain foods in osteoporosis. CONCLUSIONS: A causal association between dietary acid load and osteoporotic bone disease is not supported by evidence and there is no evidence that an alkaline diet is protective of bone health.

Phosphate decreases urine calcium and increases calcium balance: a meta-analysis of the osteoporosis acid-ash diet hypothesis.

BACKGROUND: The acid-ash hypothesis posits that increased excretion of "acidic" ions derived from the diet, such as phosphate, contributes to net acidic ion excretion, urine calcium excretion, demineralization of bone, and osteoporosis. The public is advised by various media to follow an alkaline diet to lower their acidic ion intakes. The objectives of this meta-analysis were to quantify the contribution of phosphate to bone loss in healthy adult subjects; specifically, a) to assess the effect of supplemental dietary phosphate on urine calcium, calcium balance, and markers of bone metabolism; and to assess whether these affects are altered by the b) level of calcium intake, c) the degree of protonation of the phosphate. METHODS: Literature was identified through computerized searches regarding phosphate with surrogate and/or direct markers of bone health, and was assessed for methodological quality. Multiple linear regression analyses, weighted for sample size, were used to combine the study results. Tests of interaction included stratification by calcium intake and degree of protonation of the phosphate supplement. RESULTS: Twelve studies including 30 intervention arms manipulated 269 subjects' phosphate intakes. Three studies reported net acid excretion. All of the meta-analyses demonstrated significant decreases in urine calcium excretion in response to phosphate supplements whether the calcium intake was high or low, regardless of the degree of protonation of the phosphate supplement. None of the meta-analyses revealed lower calcium balance in response to increased phosphate intakes, whether the calcium intake was high or low, or the composition of the phosphate supplement. CONCLUSION: All of the findings from this meta-analysis were contrary to the acid ash hypothesis. Higher phosphate intakes were associated with decreased urine calcium and increased calcium retention. This meta-analysis did not find evidence that phosphate intake contributes to demineralization of bone or to bone calcium excretion in the urine. Dietary advice that dairy products, meats, and grains are detrimental to bone health due to "acidic" phosphate content needs reassessment. There is no evidence that higher phosphate intakes are detrimental to bone health.

Cesium toxicity: a case of self-treatment by alternate therapy gone awry.

Cesium salts have been used in animal models to induce cardiac arrhythmias for several decades, but the sequelae of human cesium toxicity have seldom been described. The authors describe a case of cesium toxicity manifested by syncope, polymorphic ventricular tachycardia, hypokalemia, and a QT interval prolonged to 650 milliseconds that resolved over 4 days following withdrawal of cesium. The patient had a 2-year history of colon cancer and had self-treated with cesium chloride, 3 g/d, for several weeks, using cesium as a form of alternate therapy for cancer. The authors describe the pathophysiologic correlates and risks of cesium consumption and conclude that cesium toxicity should be considered among the differential diagnoses of prolonged QT interval.