Hematological changes in human lymphotropic-T virus type 1 carriers.

The human T-lymphotropic virus type 1 (HTLV-1), isolated in 1980, causes T-cell leukemia/lymphoma in adulthood, a type of lymphoproliferative disease, and chronic HTLV-1-associated myelopathy, a disease that causes paralysis of the lower limbs, which occur in about 5% of cases in this viral infection. This study aimed to establish the hematological profile of patients with HTLV-1 infection in Belém do Pará, describing the hematological parameters under study, estimating the frequency of lymphocytic atypical, and associating the hematological profile with diseases and symptoms. Hematologic data from 202 individuals were analyzed, including 87 HTLV-1 infected individuals and 115 non-HTLV-1 infected individuals as a control group, composed, at a great part, of relatives of the infected. The seroprevalence of HTLV-1 infection was observed in 71.3% of female individuals, with predominance in the group older than 50 years (44.8%). The analysis of hematological parameters showed a significant difference in the counts of the segmented cells (p = 0.0303) and eosinophils (p = 0.0092) in HTLV-1 carriers. Lymphocytic atypical was a finding present only in HTLV-1 carriers (p = 0.0001). There was no high frequency in the leukocyte counts of those infected by HTLV-1 not among them concerning a significant increase or decrease. It is concluded that HTLV-1 infection is prominent in women over 50 years old. The hematological profile of those infected shows a reduction of segmented cells, an increase of eosinophils, and the presence of atypical lymphocytes. The hematological profile of the HTLV-1 carrier should always be evaluated to identify early some diseases associated with the infection.

Hematological changes in SARS-COV-2 positive patients

Abstract Introduction The novel SARS-CoV-2 infection has been spreading around the world since January 2020 causing the Corona Virus Disease 2019. Leukopenia, lymphopenia and hypercoagulability with elevated D- Dimers have been described in COVID-19 patients to date. This study aimed to clarify if some blood parameters can be used as biomarkers to facilitate diagnosis and establish prognosis. Methods: We selected patients who had tested positive for SARS-CoV-2 and had had a hemogram performed between the March 15 and April 15, 2020. Socio-demographic and analytical data were obtained from 274 patients at admission in two Portuguese public hospitals. We then analyzed the hemogram parameters at admission in the intensive care and collected data on patient survival during the SARS-CoV-2 disease follow-up. The data were analyzed using appropriate statistical tests. Results: Patients requiring the intensive care unit (ICU) present an increase in leukocytes and neutrophils (+3.1 × 109/L and +6.4 × 109/L, respectively), a lymphocyte decrease and a platelet rise (-1.6 × 109/L and +60.8 × 109/L, respectively). The erythrocytes, hemoglobin and median globular volume tend to decrease (-0.5 × 1012, - 1.2 g/dL; -3 fL, respectively). The lactic acid dehydrogenase (LDH) at admission was significantly higher (+58.1 U/L). The age, sex, platelets, lymphocyte count neutrophil counts, neutrophil/lymphocyte ratio, erythrocytes and cell hemoglobin concentration mean (CHCM) are independently associated with mortality (odds ratio (OR) = 0.046, p < 0.001; OR = 0.2364, p= 0.045; OR = 9.106, p= 0.001; OR = 0.194, p= 0.033; OR = 0.062, p= 0.003; OR = 0.098, p= 0.002; OR = 9.021, p < 0.001; OR = 7.016, p= 0.007, respectively). Conclusion The hematological data at admission in the health care system can predict the mortality of the SARS-CoV-2 infection and we recommend its use in the clinical decisions and patient prognosis evaluation.

Hematological changes in SARS-COV-2 positive patients.

Introduction: The novel SARS-CoV-2 infection has been spreading around the world since January 2020 causing the Corona Virus Disease 2019. Leukopenia, lymphopenia and hypercoagulability with elevated D- Dimers have been described in COVID-19 patients to date. This study aimed to clarify if some blood parameters can be used as biomarkers to facilitate diagnosis and establish prognosis. Methods: We selected patients who had tested positive for SARS-CoV-2 and had had a hemogram performed between the March 15 and April 15, 2020. Socio-demographic and analytical data were obtained from 274 patients at admission in two Portuguese public hospitals. We then analyzed the hemogram parameters at admission in the intensive care and collected data on patient survival during the SARS-CoV-2 disease follow-up. The data were analyzed using appropriate statistical tests. Results: Patients requiring the intensive care unit (ICU) present an increase in leukocytes and neutrophils (+3.1 × 109/L and +6.4 × 109/L, respectively), a lymphocyte decrease and a platelet rise (-1.6 × 109/L and +60.8 × 109/L, respectively). The erythrocytes, hemoglobin and median globular volume tend to decrease (-0.5 × 1012, - 1.2 g/dL; -3 fL, respectively). The lactic acid dehydrogenase (LDH) at admission was significantly higher (+58.1 U/L). The age, sex, platelets, lymphocyte count neutrophil counts, neutrophil/lymphocyte ratio, erythrocytes and cell hemoglobin concentration mean (CHCM) are independently associated with mortality (odds ratio (OR) = 0.046, p < 0.001; OR = 0.2364, p = 0.045; OR = 9.106, p = 0.001; OR = 0.194, p = 0.033; OR = 0.062, p = 0.003; OR = 0.098, p = 0.002; OR = 9.021, p < 0.001; OR = 7.016, p = 0.007, respectively). Conclusion: The hematological data at admission in the health care system can predict the mortality of the SARS-CoV-2 infection and we recommend its use in the clinical decisions and patient prognosis evaluation.

Anemia hemolítica imunomediada associada à micoplasmose em um cão / Associated immunomediated hemolytic anemia mycoplasmosis in a dog

A anemia hemolítica imunomediada (AHIM) é uma reação de hipersensibilidade tipo II onde ocorre o aumento da destruição das hemácias. Ela pode ser dividida em primaria, caracterizada por não ter uma causa subjacente, e em secundária, pode ser causada por agentes infecciosos, como a micoplasmose, neoplasias, medicamentos e transfusões. O objetivo desse trabalho foi realizar uma análise clínica e laboratorial de um cão com anemia hemolítica imunomediada decorrente da Mycoplasma spp. Uma cadela da raça Pit Bull, com 05 meses de idade, foi levada ao hospital apresentando vômitos, diarreia e anorexia. No exame físico, foi possível observar a presença de carrapatos e mucosas ictéricas. Nos exames hematológicos foi possível evidenciaras alterações morfológicas de hemácias que caracterizavam anemia hemolítica imunomediada e a presença do parasita Mycoplasma spp. Nas análises bioquímicas se observou níveis séricos aumentados de creatinina e ureia. Pode-se concluir que, a observação de Mycoplasma spp. em esfregaços sanguíneos associada às alterações morfológicas eritrocitárias são de relevante importância para o diagnóstico de AHIM, auxiliando assim na instituição da melhor conduta terapêutica, contribuindo para o prognóstico do paciente.(AU)

Immune-mediated hemolytic anemia (AHIM) is a type II hypersensitivity reaction, where red blood cell destruction occurs or increases. It can be divided into primary, characterized by not having an underlying cause, and secondary, which can be caused by infectious agents, such as mycoplasmosis, neoplasms, drugs and transfusions. The objective of this work was to perform a clinical and laboratory analysis of a dog with immune-mediated hemolytic anemia due to Mycoplasma spp. A five-months-old female Pit Bull dog was taken to the hospital presenting vomiting, diarrhea and anorexia. On physical examination, it was possible to observe the presence of ticks and icteric mucous membranes. In hematological exams, it was possible to show morphological changes in red blood cells that characterize immune-mediated hemolytic anemia and the presence of the parasite Mycoplasma spp. In the biochemical analyzes it was observed increased serum levels of creatinine and urea. It can be concluded that the observation of Mycoplasma spp. in blood vessels associated with erythrocyte morphological changes are of relevant importance for the diagnosis of AHIM, thus assisting in the practice of a better method of therapy, contributing to the patient's prognosis.(AU)

Hematological, clinical and epidemiological aspects of Hepatozoon canis infection by parasitological detection in dogs from the rural area of Sousa, Paraíba, Brazil / Aspectos hematológicos, clínicos e epidemiológicos da infecção por Hepatozoon canis por detecção parasitológica em cães da zona rural de Sousa, Paraíba, Brasil

Hepatozoonosis is caused by protozoa of the genus Hepatozoon. In dogs, the infection is caused mainly by Hepatozoon canis, and there are a few descriptions of the prevalence of this infection in the Northeast region of Brazil, especially in the semi-arid region. Therefore, we aimed to determine the prevalence of Hepatozoon canis infection in dogs in the rural area of Sousa, Paraíba, Brazil, as well as to determine the possible clinical and epidemiological aspects of this infection. Ninety-eight dogs in the rural zone of the municipality of Sousa that were at least 4 months old were evaluated, regardless of their breed or gender. Clinical examinations were carried out, and samples of systemic and peripheral blood were collected to determine the presence of the parasite in blood smears and carry out hemograms. In addition, epidemiological questionnaires about animal health and food management were completed. The prevalence of H. canis infections in dogs was 8.1% (8/98). There were three main changes in the hematological status: thrombocytopenia, anemia and hyperproteinemia, mainly related to percentage of leukocyte infection 5%, and also to the presence of clinical signs such as mucopurulent secretion, lymphadenomegaly, dry skin, pale mucous membranes, and lean or cachectic body score.(AU)

A hepatozoonose é causada por protozoários do gênero Hepatozoon. Em cães, a infecção ocorre principalmente por Hepatozoon canis, sendo escassas as descrições de prevalências desta infecção na região Nordeste do Brasil, sobretudo no Semiárido. Com isso, o trabalho objetivou determinar a prevalência da infecção por Hepatozoon canis em cães da zona rural do município de Sousa, Paraíba, Brasil, como também determinar possíveis sinais clínicos e aspectos epidemiológicos relacionados à esta infecção. Foram avaliados 98 cães da zona rural do município de Sousa, independentemente da raça ou sexo, com idade superior a quatro meses. Foram realizados exames clínicos e colhidas amostras de sangue sistêmico e periférico para a pesquisa do parasito em esfregaços sanguíneos e hemogramas. Além disso, foram preenchidos questionários epidemiológicos acerca do manejo sanitário e alimentar dos animais. A prevalência de cães positivos para H. canis foi de 8,1% (8/98). Foram observados três principais alterações no quadro hematológico, sendo trombocitopenia, anemia e hiperproteinemia, principalmente relacionadas ao percentual de leucócitos infectados 5%, e também à presença de sinais clínicos, como secreção mucopurulenta, linfadenomegalia, pelos ressecados, mucosas hipocoradas e escore corporal magro ou caquético.(AU)

Anemia hemolítica imunomediada associada à micoplasmose em um cão / Associated immunomediated hemolytic anemia mycoplasmosis in a dog

A anemia hemolítica imunomediada (AHIM) é uma reação de hipersensibilidade tipo II onde ocorre o aumento da destruição das hemácias. Ela pode ser dividida em primaria, caracterizada por não ter uma causa subjacente, e em secundária, pode ser causada por agentes infecciosos, como a micoplasmose, neoplasias, medicamentos e transfusões. O objetivo desse trabalho foi realizar uma análise clínica e laboratorial de um cão com anemia hemolítica imunomediada decorrente da Mycoplasma spp. Uma cadela da raça Pit Bull, com 05 meses de idade, foi levada ao hospital apresentando vômitos, diarreia e anorexia. No exame físico, foi possível observar a presença de carrapatos e mucosas ictéricas. Nos exames hematológicos foi possível evidenciaras alterações morfológicas de hemácias que caracterizavam anemia hemolítica imunomediada e a presença do parasita Mycoplasma spp. Nas análises bioquímicas se observou níveis séricos aumentados de creatinina e ureia. Pode-se concluir que, a observação de Mycoplasma spp. em esfregaços sanguíneos associada às alterações morfológicas eritrocitárias são de relevante importância para o diagnóstico de AHIM, auxiliando assim na instituição da melhor conduta terapêutica, contribuindo para o prognóstico do paciente.

Immune-mediated hemolytic anemia (AHIM) is a type II hypersensitivity reaction, where red blood cell destruction occurs or increases. It can be divided into primary, characterized by not having an underlying cause, and secondary, which can be caused by infectious agents, such as mycoplasmosis, neoplasms, drugs and transfusions. The objective of this work was to perform a clinical and laboratory analysis of a dog with immune-mediated hemolytic anemia due to Mycoplasma spp. A five-months-old female Pit Bull dog was taken to the hospital presenting vomiting, diarrhea and anorexia. On physical examination, it was possible to observe the presence of ticks and icteric mucous membranes. In hematological exams, it was possible to show morphological changes in red blood cells that characterize immune-mediated hemolytic anemia and the presence of the parasite Mycoplasma spp. In the biochemical analyzes it was observed increased serum levels of creatinine and urea. It can be concluded that the observation of Mycoplasma spp. in blood vessels associated with erythrocyte morphological changes are of relevant importance for the diagnosis of AHIM, thus assisting in the practice of a better method of therapy, contributing to the patient's prognosis.

Hematological, clinical and epidemiological aspects of Hepatozoon canis infection by parasitological detection in dogs from the rural area of Sousa, Paraíba, Brazil / Aspectos hematológicos, clínicos e epidemiológicos da infecção por Hepatozoon canis por detecção parasitológica em cães da zona rural de Sousa, Paraíba, Brasil

ABSTRACT: Hepatozoonosis is caused by protozoa of the genus Hepatozoon. In dogs, the infection is caused mainly by Hepatozoon canis, and there are a few descriptions of the prevalence of this infection in the Northeast region of Brazil, especially in the semi-arid region. Therefore, we aimed to determine the prevalence of Hepatozoon canis infection in dogs in the rural area of ​​Sousa, Paraíba, Brazil, as well as to determine the possible clinical and epidemiological aspects of this infection. Ninety-eight dogs in the rural zone of the municipality of Sousa that were at least 4 months old were evaluated, regardless of their breed or gender. Clinical examinations were carried out, and samples of systemic and peripheral blood were collected to determine the presence of the parasite in blood smears and carry out hemograms. In addition, epidemiological questionnaires about animal health and food management were completed. The prevalence of H. canis infections in dogs was 8.1% (8/98). There were three main changes in the hematological status: thrombocytopenia, anemia and hyperproteinemia, mainly related to percentage of leukocyte infection ≥5%, and also to the presence of clinical signs such as mucopurulent secretion, lymphadenomegaly, dry skin, pale mucous membranes, and lean or cachectic body score.

RESUMO: A hepatozoonose é causada por protozoários do gênero Hepatozoon. Em cães, a infecção ocorre principalmente por Hepatozoon canis, sendo escassas as descrições de prevalências desta infecção na região Nordeste do Brasil, sobretudo no Semiárido. Com isso, o trabalho objetivou determinar a prevalência da infecção por Hepatozoon canis em cães da zona rural do município de Sousa, Paraíba, Brasil, como também determinar possíveis sinais clínicos e aspectos epidemiológicos relacionados à esta infecção. Foram avaliados 98 cães da zona rural do município de Sousa, independentemente da raça ou sexo, com idade superior a quatro meses. Foram realizados exames clínicos e colhidas amostras de sangue sistêmico e periférico para a pesquisa do parasito em esfregaços sanguíneos e hemogramas. Além disso, foram preenchidos questionários epidemiológicos acerca do manejo sanitário e alimentar dos animais. A prevalência de cães positivos para H. canis foi de 8,1% (8/98). Foram observados três principais alterações no quadro hematológico, sendo trombocitopenia, anemia e hiperproteinemia, principalmente relacionadas ao percentual de leucócitos infectados ≥ 5%, e também à presença de sinais clínicos, como secreção mucopurulenta, linfadenomegalia, pelos ressecados, mucosas hipocoradas e escore corporal magro ou caquético.

Molecular detection, characterization of Anaplasma spp. in domestic cats from Rio de Janeiro state.

Species of the genus Anaplasma, in the family Anaplasmatacae, are responsible to vector-borne diseases that affecting animals and humans. Feline anaplasmosis is poorly reported in Brazil. This study aimed at investigating the occurrence of Anaplasma spp. in domestic cats from Greater Rio de Janeiro, and evaluating hematological changes associated with this rickettsial infection. Were sampled 216 cats, we performed nested PCR (nPCR) and real-time PCR (qPCR) assays targeting A. platys-16S-rDNA, A. platys-gltA and A. phagocytophilum-msp2 sequences. As evaluated with gltA-qPCR the frequency of cats positive for A. platys was 3.7% (n = 8/216) and by 16S-rDNA nested-PCR it was 0.9% (n = 2/216). No cats were positive to msp2-qPCR to A. phagocytophilum. The sequences of A. platys presented 100% similarity with previously described isolates around the world and Brazil. Two cats that were positive in the gltA-qPCR reactions have platelet inclusions in the microscopic examination. However, no significant (p > 0.05) hematological changes were observed, probably due to low parasite load. This study showed that A. platys occur in domestic cats from Greater Rio de Janeiro. Further studies are needed to more precisely characterize these organisms.

Erliquiose canina - relato de caso / Ehrlichiosis canine - case report

Canine ehrlichiosis is a disease caused by species of genus Ehrlichia with great importance in veterinary. The clinical signs as well as haematological changes are variable and it is necessary to use other more specific diagnostic methods. The present work reports the case of a female dog, SRD, presenting hyperthermia, convulsion, uveitis, nystagmus, myoclonus, ataxia, prostration and lymphadenitis. The necropsy report was suggestive of ehrlichiosis.(AU)

Erliquiose canina - relato de caso / Ehrlichiosis canine - case report

Canine ehrlichiosis is a disease caused by species of genus Ehrlichia with great importance in veterinary. The clinical signs as well as haematological changes are variable and it is necessary to use other more specific diagnostic methods. The present work reports the case of a female dog, SRD, presenting hyperthermia, convulsion, uveitis, nystagmus, myoclonus, ataxia, prostration and lymphadenitis. The necropsy report was suggestive of ehrlichiosis.

Alterações hematológicas, hemostáticas e bioquímicas induzidas pela clofazimina e claritromicina, em doses única e múltiplas, em ratos / Hematological, hemostatic and biochemical alterations induced by clofazimine and clarithromycin, in single and multiple doses, in rats

Claritromicina e clofazimina têm sido utilizadas no tratamento da hanseníase, tuberculose e infecções causadas pelo complexo Mycobacterium avium. Como os dados sobre a toxicidade de esquemas terapêuticos que incluem estes fármacos são escassos, este estudo teve como objetivo determinar os efeitos adversos destas terapias, por meio da avaliação dos parâmetros hematológicos, hemostáticos e bioquímicos. Os fármacos foram administrados em ratos machos Wistar, em monoterapia, em regime de doses única e múltipla. Claritromicina provocou aumento de leucócitos mono e polimorfonucleares. Ambos os fármacos inverteram a proporção entre células mono e polimorfonucleares e provocaram aumento do número de células polimorfonucleares e células em degeneração. Clofazimina e claritromicina prolongaram o tempo de protrombina e claritromicina também prolongou o tempo de tromboplastina parcial ativa. Claritromicina causou aumento de bilirrubinas total e direta e, ambos os fármacos, elevaram os níveis plasmáticos de gama-glutamiltransferase. Portanto, clofazimina e claritromicina induzem alterações hematológicas, hemostáticas e hepáticas.

Clarithromycin and clofazimine have been used to treat leprosy, tuberculosis and infections caused by the Mycobacterium avium complex. Since there is a scarcity of data on the toxicity of therapeutic regimens that include these drugs, this study had the aim of determining the adverse effects of these therapies, through evaluation of hematological, hemostatic and biochemical parameters. The drugs were administered to male Wistar rats, as monotherapy, in regimens of single and multiple doses. Clarithromycin caused increases in the numbers of mononuclear and polymorphonuclear leukocytes. Both of the drugs inverted the proportions between mononuclear and polymorphonuclear cells and increased the numbers of polymorphonuclear cells and degenerating cells. Clofazimine and clarithromycin prolonged the prothrombin time and clarithromycin also prolonged the activated partial thromboplastin time. Clarithromycin caused increases in total and direct bilirubin. Both of the drugs increased the plasma levels of gamma-glutamyltransferase. Therefore, clofazimine and clarithromycin induce hematological, hemostatic and hepatic changes.

Investigations on the role of insulin and scorpion antivenom in scorpion envenoming syndrome

Acute myocardiopathy in alloxan treated experimental dogs and rabbits was induced by subcutaneous (SQ) injection of scorpion venom from Mesobuthus tamulus concanesis, Pocock. Envenoming resulted in an initial transient hypertension (180-320 mm Hg.) followed by hypotension. Simultaneous administration of venom and species-specific scorpion antivenom (SAV) prevented hypertension and hypotension. Hypotension did not occur when SAV was given 60 min after envenoming. Blood glucose, triglycerides, cholesterol, amylase, insulin, glucagon, cortisol, hematocrit, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), platelet count, red blood cell (RBC) count, hemoglobin (Hb), 2,3-diphosphoglycerate (2,3-DPG), and glutathione levels were increased 60 and 90 min after envenoming. Total white blood cell (WBC) count was reduced 60 min and increased 90 min after envenoming. Simultaneous administration of venom and SAV did not alter Hb, MCHC, and packed cell volume (PCV) levels, or ECG, and cardiovascular, biochemical, metabolic, and hormonal changes. Hematological parameters were reversed when SAV was given 30 and 60 min after envenoming. PCV, Hb, and MCHC values returned to normal 120 min after SAV. Alloxan-treated dogs showed increased blood glucose, cholesterol, glucagon, cortisol levels; reduced glycogen content of liver, cardiac and skeletal muscles; and reduced insulin levels and insulin/ glucagon ratio (I/G ratio). Envenoming in the alloxan pre-treated dogs further increased these levels and reduced tissue glycogen content, insulin levels, and I/G ratio. Administration of 4 U of insulin to alloxan pre-treated envenomed rabbits caused a biochemical and clinical improvement and increased glycogen content of all tissues in comparison with the values from those administered with SAV to alloxan pre-treated envenomed animals. SAV administration to envenomed alloxan pre-treated rabbits did not cause clinical or biochemical improvement. Severe scorpion envenoming causes an autonomic storm with a massive release of catecholamines and other counter-regulatory hormones; changes in insulin secretion resulting in fuel energy deficits producing multi-system-organ-failure (MSOF); and death. Administration of either insulin or SAV (through the release of insulin) appears to be the physiological basis for the control of the metabolic support to control the adverse effects triggered by counter-regulatory hormones.

Investigations on the role of insulin and scorpion antivenom in scorpion envenoming syndrome

Acute myocardiopathy in alloxan treated experimental dogs and rabbits was induced by subcutaneous (SQ) injection of scorpion venom from Mesobuthus tamulus concanesis, Pocock. Envenoming resulted in an initial transient hypertension (180-320 mm Hg.) followed by hypotension. Simultaneous administration of venom and species-specific scorpion antivenom (SAV) prevented hypertension and hypotension. Hypotension did not occur when SAV was given 60 min after envenoming. Blood glucose, triglycerides, cholesterol, amylase, insulin, glucagon, cortisol, hematocrit, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), platelet count, red blood cell (RBC) count, hemoglobin (Hb), 2,3-diphosphoglycerate (2,3-DPG), and glutathione levels were increased 60 and 90 min after envenoming. Total white blood cell (WBC) count was reduced 60 min and increased 90 min after envenoming. Simultaneous administration of venom and SAV did not alter Hb, MCHC, and packed cell volume (PCV) levels, or ECG, and cardiovascular, biochemical, metabolic, and hormonal changes. Hematological parameters were reversed when SAV was given 30 and 60 min after envenoming. PCV, Hb, and MCHC values returned to normal 120 min after SAV. Alloxan-treated dogs showed increased blood glucose, cholesterol, glucagon, cortisol levels; reduced glycogen content of liver, cardiac and skeletal muscles; and reduced insulin levels and insulin/ glucagon ratio (I/G ratio). Envenoming in the alloxan pre-treated dogs further increased these levels and reduced tissue glycogen content, insulin levels, and I/G ratio. Administration of 4 U of insulin to alloxan pre-treated envenomed rabbits caused a biochemical and clinical improvement and increased glycogen content of all tissues in comparison with the values from those administered with SAV to alloxan pre-treated envenomed animals. SAV administration to envenomed alloxan pre-treated rabbits did not cause clinical or biochemical improvement. Severe scorpion envenoming causes an autonomic storm with a massive release of catecholamines and other counter-regulatory hormones; changes in insulin secretion resulting in fuel energy deficits producing multi-system-organ-failure (MSOF); and death. Administration of either insulin or SAV (through the release of insulin) appears to be the physiological basis for the control of the metabolic support to control the adverse effects triggered by counter-regulatory hormones.