Fournier's gangrene (necrotising fasciitis) complicated by renal and respiratory insufficiency: a case report.

A case report of a 68-year-old male obese diabetic patient with an abscess of left femoral region, and diffuse inflammation of abdominal wall and genital region developing sepsis, respiratory and renal failure. At admission in the regional hospital a diagnosis of polymicrobial necrotising fasciitis with suspected sepsis was declared. The patient was transferred to the special intensive care unit (SICU) of Burns and reconstructive surgery at the Kosice-Saca. The patient was treated surgically, with hyperbaric oxygen and pharmacologically to control his diabetes. The main aetiological agent of the condition was identified as Stenotrophomonas maltophilia. In addition to respiratory and metabolic acidosis and gastric bleeding occurred. Due to acute renal failure (day 38) the patient was transferred to clinic of anaesthesiology and the intensive care medicine at the University Hospital in Kosice. The patient was treated by continuous veno-venous haemodialysis, mechanical ventilation and nasogastric nutritional support. On day 48 the conscious sub-febrile patient with healed wounds was transferred back to the regional hospital with ventilation support and continuous renal replacement therapy. His diabetes was uncontrolled, and only kidney parameters remained pathological. The survival of this patient with an extremely poor prognosis was achieved through prompt transfer to a specialised centre, early identification of the aetiological agent and immediate appropriate antibiotic treatment as a result of good cooperation between surgeons and laboratory specialists.

Brain glucose sensing and counterregulatory response to hypoglycaemia.

An important obstacle to achieve optimal glycaemic control in diabetics on intensive insulin therapy is the frequent occurrence of insulin induced hypoglycaemic events. In healthy subjects and in diabetics without autonomic neuropathy hypoglycaemia activates the sympathetic nervous system, resulting in epinephrine and glucagon release. Both hormones increase hepatic glucose production and this counterregulatory response is of key importance of glucose homeostasis. Recent research shed light on the fact that antecedent hypoglycaemic episodes play pivotal role in hypoglycaemia associated autonomic failure (HAAF). In this condition the sympatho-adrenal response to decreased blood glucose level is blunted. The existence of HAAF clearly indicates that the nervous system contributes to glucose homeostasis in a substantial manner. This review outlines the mechanisms of both peripheral and central neuronal glucose sensing and of neural pathways involved in the counterregulatory response.

Serum S100B protein in early management of patients after mild traumatic brain injury.

BACKGROUND AND PURPOSE: Neuronal protein S100B assays are available now with a perspective of being an early screening tool for serious intracranial injury. The aim of the study was to correlate early S100B measurements and initial CCT findings in the patients sustaining mild traumatic brain injury (MTBI). METHODS: The prospective study included patients of all ages with a history of MTBI. CCT scans and venous blood sampling for S100B analysis were performed within 6 h after injury. Levels of S100B above 0.1 ng/ml (S100B+) and any CCT detectable trauma-relevant intracranial lesions were considered positive (CCT+). RESULTS: A series of 102 patients were involved in the study. CCT+ scans were present in eighteen (17.6%) and CCT- scans in 84 (82.4%) patients. There were 74 (72.5%) patients in S100B+ and 28 (27.5%) in S100B- group. Sensitivity of S100B assay attained 83.3% with a negative predictive value of 89.3%. Three patients from CCT+ group had negative plasma level of S100B. Two of them required surgical treatment. DISCUSSION: S100B serum protein marker seems to be an unrealiable screening tool for determination of an intracranial injury risk group due to low sensitivity and negative predictive value seen from samples taken greater than 3 h after an MTBI.

Monitoring antioxidant enzymes in red cells during allergen immunotherapy.

The aim of this report was to answer the question how specific immunotherapy influences the antioxidant enzyme system in patients with respiratory allergy and in longer perspective to find markers suitable to assess the efficacy of treatment. In open prospective randomised study 28 patients (18 females and 10 males, age 14-48 years) with seasonal respiratory allergy were treated with allergen immunotherapy. Subjects received subcutaneous therapy with allergens absorbed on calcium phoshate or aluminium hydroxide and were analyzed by the established protocol at the beginning, after three and 12 month of the treatment. In all treatment group red cell superoxide dismutase and glutathione peroxidase activities were in the normal range in allergic patients both before and during the treatment. Catalase activity in the allergic patients was lower as compared with controls and a significant increase of the enzyme activity occurred during and at the end of the treatment. In patients treated with calcium phosphate adsorbed allergen there was a continous increase of catalase activity from beginning up to the end of observation. In the case of the aluminium hydroxide treatment there was an increase from the baseline values up in the third month of the treatment and a decrease on the 12th month. In summary, the present results open the question that allergen immunotherapy may cause imbalance of oxidants and antioxidants. To support our findings larger controlled field studies are needed.

Monitoring antioxidant enzymes in red cells during allergen immunotherapy

The aim of this report was to answer the question how specific immunotherapyinfluences the antioxidant enzyme system in patients with respiratory allergy and inlonger perspective to find markers suitable to assess the efficacy of treatment. In openprospective randomised study 28 patients (18 females and 10 males, age 14 – 48 years)with seasonal respiratory allergy were treated with allergen immunotherapy. Subjectsreceived subcutaneous therapy with allergens absorbed on calcium phoshate or aluminiumhydroxide and were analyzed by the established protocol at the beginning,after three and 12 month of the treatment. In all treatment group red cell superoxidedismutase and glutathione peroxidase activities were in the normal range in allergicpatients both before and during the treatment. Catalase activity in the allergicpatients was lower as compared with controls and a significant increase of theenzyme activity occurred during and at the end of the treatment. In patients treatedwith calcium phosphate adsorbed allergen there was a continous increase of catalaseactivity from beginning up to the end of observation. In the case of the aluminiumhydroxide treatment there was an increase from the baseline values up in the thirdmonth of the treatment and a decrease on the 12th month. In summary, the presentresults open the question that allergen immunotherapy may cause imbalance of oxidantsand antioxidants. To support our findings larger controlled field studies areneeded (AU)

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An intravenous immunoglobulin therapy of serious autoimmune rheumatic diseases.

Intravenous immunoglobulins (IVIg) have been widely used in clinical practice for more than 35 years. Their efficacy has been established in many clinical trials for the treatment of autoimmune rheumatic diseases including systemic lupus erythematosus, ANCA positive vasculitis and dermatomyositis, but these indications are classified as the "off label" treatment. For the diseases mentioned above there are no generally accepted therapeutic guidelines. The case reports (one patient with lupus erythematosus chorea, two patients with dermatomyositis and one with the Wegener's granulomatosis) present a treatment of systemic connective tissue diseases with IVIg following the failure of standard therapeutic regimens. A successful therapy has been realized using different doses of IVIg, which raises a question on an appropriate dose. Based on our experience, we conclude that intravenous immunoglobulins are effective in the treatment of many "off label" indications in rheumatology, particularly in cases when standard immunosuppressive therapy could be harmful. Despite the evidence of efficacy, the dosage and timing of IVIg therapy, and questions of costs/benefits ratio still remain insufficiently documented and multicentric controlled clinical trials with consecutive development of guidelines are necessary (Ref. 27).

Antioxidant therapy by oral vitamin E and vitamin E-coated dialyzer in CAPD and haemodialysis patients.

Oxidative stress, increased lipid peroxidation, and impaired function of antioxidant system may contribute to the accelerated development of atherosclerosis in chronic renal failure patients during renal replacement therapy. The aim of the study was to investigate the influence of oral vitamin E (400 mg/day) in 14 patients who underwent continuous ambulatory peritoneal dialysis (CAPD) and effects of the vitamin E-coated dialyzer in 14 haemodialysis patients on several antioxidant biochemical parameters. Six-week treatment with oral vitamin E in CAPD patients and three-month treatment using vitamin E-coated dialyzer in haemodialysis patients led to the significant decrease of plasma malondialdehyde, to the increase of plasma vitamin E and to the increase of erythrocyte vitamin E in haemodialysis patients. No significant changes of erythrocyte antioxidant enzyme--superoxide dismutase, glutathione peroxidase and catalase were found during the both types of antioxidant therapy. At the end of the third month of haemodialysis study the significant increase of erythrocyte glutathione in haemodialysis patients was found, but that value was significantly lower as normal range. Six-week interruption of the administration of oral vitamin E in CAPD patients led to the significant decrease of erythrocyte superoxide dismutase and plasma vitamin E. Ten-week interruption of the use of vitamin E-coated dialyzer led to the significant increase of plasma malondialdehyde and to the decrease of plasma and erythrocyte vitamin E in haemodialysis patients, near to the values at the beginning of the study. Our study confirmed the beneficial effect of oral administration of vitamin E and the use of vitamin E-coated dialyzer against oxidative stress in CAPD and haemodialysis patients.

Total antioxidant capacity of serum and prognostic indices in patients with burn trauma.

Burn trauma leads to increased production of reactive oxygen species and compromises the antioxidant systems. The aim of present study was to assess the total antioxidant capacity of plasma (TAC) in burn patients and evaluate its usefulness in clinical practice through analysis of association between TAC and indices of patient prognosis. We investigated TAC in 48 adults and 27 children with severe burn trauma and in 26 healthy controls. TAC was measured on the admission and every week thereafter until discharge or death of patients. The prognosis of the patients was evaluated by the Baux Index and the Abbreviated Burn Severity Index (ABSI). TAC was significantly decreased in both groups with burn trauma as compared with the controls and the decrease was a long lasting event. Significant indirect negative correlation was found between BSAB and TAC values measured in the later phase of injury. In adults an indirect correlation was found between ABSI and the lowest TAC measured on the 7th day or later. Correlations between TAC values and Baux Index were absent both in adults and in children.

Vitamin E as an antioxidant agent in CAPD patients.

Oxidative stress, increased lipid peroxidation and decreased activity of antioxidant systems may contribute to the accelerated development of atherosclerosis in chronic renal failure patients during renal replacement therapy. The aim of the study was to investigate the influence of vitamin E (400 mg/day) on some antioxidant defense parameters in CAPD patients. In fourteen CAPD patients, erythrocyte antioxidant enzymes, superoxide dismutase (SOD), glutathione peroxidase (GPX) and catalase (CAT), the concentration of plasma malondialdehyde (MDA), vitamin A, vitamin C and vitamin E were investigated. The study was divided into two periods. Each period lasted six weeks. In the first period patients received orally vitamin E 400 mg/day, in the second period they did not receive vitamin E or other antioxidant drugs. Each parameter was determined at the beginning of the study and at the end of each period. Six CAPD patients were treated by erythropoietin (EPO) and received orally pyridoxine 20 mg/day and the others without EPO treatment received pyridoxine 5 mg/day. Six-week treatment by vitamin E (400 mg/day) led to the significant increase of serum vitamin E (from 33.6+/-9.0 to 49.3+/-15.5 micromol/L) and to the significant decrease of MDA (from 2.62+/-0.5 to 2.36+/-0.4 micromol/L). The mean values of erythrocyte enzymes were in or under the lower margin of normal range and were not influenced by vitamin E in CAPD patients. The results of our study showed that orally administered vitamin E is a very important antioxidant agent for CAPD patients.

Development of Myxobolus macrocapsularis (Myxosporea: Myxobolidae) in an oligochaete alternate host, Tubifex tubifex.

The development of Myxobolus macrocapsularis Reuss, 1906, a myxosporean parasite of the gills of common bream Abramis brama L., was studied in experimentally infected oligochaetes. In 3 experiments uninfected Tubifex tubifex Muller and Limnodrilus hoffmeisteri (Claparéde) were exposed to mature myxospores of M. macrocapsularis. In all experiments, typical triactinospores developed in T. tubifex specimens but no infection was found in L. hoffmeisteri. Triactinospores were released from oligochaetes 66 to 99 d after initial exposure. At that time pansporocysts containing 8 triactinospores were located in the gut epithelium of experimental oligochaetes, but free actinosporean stages were also found in the gut lumen of the oligochaetes. Each triactinospore had 3 pyriform polar capsules and a barrel-shaped sporoplasm with 32 secondary cells. The spore body joined the 3 caudal projections with a stout style.

A modified dialyzer with vitamin E and antioxidant defense parameters.

BACKGROUND: Oxidative stress, increased lipid peroxidation, and decreased activity of antioxidant systems may contribute to the accelerated development of atherosclerosis in patients receiving hemodialysis therapy for chronic renal failure. We investigated the influence of vitamin E on antioxidant defense parameters in hemodialysis patients who were using a modified dialyzer. METHODS: In eight hemodialyzed patients, erythrocyte antioxidant enzymes, superoxide dismutase (SOD) and glutathione peroxidase (GPX), plasma total antioxidant capacity (TAC), the concentration of plasma malondialdehyde (MDA), and vitamins A, E, and C were investigated. Each parameter was measured before and after hemodialysis. The study was divided into three periods. Each period lasted three weeks, and during this time, 10 hemodialyses were performed. The first and second periods were carried out using the conventional dialyzer, Terumo CL-S15, but during the second period, patients received vitamin E 400 mg perorally after each hemodialysis. The third period was carried out using a modified dialyzer with vitamin E, Terumo CL-E15. All hemodialyzed patients were treated by erythropoietin and received vitamin C 50 mg/day and pyridoxine 20 mg/day during the entire study. RESULTS: The peroral administration of vitamin E led to a significant increase of serum vitamin E (22%), and no influence on other antioxidant defense parameters was found. The modified dialyzer with vitamin E led to a significant increase of serum vitamin E (33%) and TAC and to the significant decrease of plasma MDA. CONCLUSION: The results of our study suggest that the modified dialyzer with vitamin E provided more effective antioxidant defense than peroral administration of vitamin E in our hemodialysis patients.

Influence of intoxication with organophosphates on rumen bacteria and rumen protozoa and protective effect of clinoptilolite-rich zeolite on bacterial and protozoan concentration in rumen.

The effect of O-ethyl-S-(2-diisopropylaminoethyl) methylthiophosphonate on rumen bacteria and rumen protozoa was investigated in sheep (after premedication with clinoptilolite-rich zeolite and without that premedication). In control animals a decrease in the total concentration of rumen protozoa was observed 3-7 d after intoxication (particularly in small and large ones). In clinoptilolite-rich-zeolite-treated animals only a slight decrease in protozoan numbers occurred during the first hours after the intoxication. Similarly, in every category of rumen bacteria marked differences between the groups were recorded, particularly in concentration of lipolytic bacteria. The results suggest some protective effect of clinoptilolite-rich zeolite for rumen microbiota against the organophosphate poison.

[Relation between metabolism of trace elements and the antioxidant defense system in chronic nephropathies]. / Vztah medzi metabolizmom stopových prvkov a obranným antioxidacným systémom pri chronických nefropatiách.

BACKGROUND: Trace elements--zinc, copper and selenium are part of antioxidant enzymes, superoxide dismutase (SOD) and glutathione peroxidase (GHPx). In renal diseases changes in the trace element metabolism may influence the equilibrium in the antioxidant defence system and enhance the toxic effect of reactive oxygen molecules. METHODS AND RESULTS: The authors examined in 53 children with chronic neprophathies (34 with chronic glomerulonephritis, 11 with chronic renal failure and 8 children included in a chronic dialyzation programme) zinc and selenium in blood and urine and antioxidant enzymes SOD and GHPx in red blood cells. The lowest SOD activity (737 +/- 219 U/g Hb, p < 0.01) and serum zinc concentration (12.9 +/- 3.2, p < 0.05) were found in children in the terminal stage of uraemia, GHPx was as compared with the group of healthy children elevated in all groups of sick children. In dialysed children GHPx was highest (p < 0.01) and correlated with urinary selenium concentrations (r = -0.86, p < 0.05). The SOD activity depended on the serum copper concentrations (r = 0.78, p < 0.05). The highest renal zinc and selenium excretion was recorded in patients with glomerulonephritis (p < 0.05). CONCLUSIONS: The results support the hypothesis on a causal relationship between trace elements and antioxidant enzymes.

[Antioxidant enzyme activity in erythrocytes in children with kidney diseases]. / Aktivita antioxidacných enzýmov v erytrocytoch u detí s oblickovými chorobami.

BACKGROUND: An important place is ascribed to the formation and action of free oxygen radicals in the pathogenesis of some kidney diseases. The objective of the present work was to examine the antioxidant enzyme defence mechanism in children with different nephropathies. METHODS AND RESULTS: In a group of 58 children (32 boys and 26 girls, mean age 13.9 years) with different renal diseases (35 children with chronic glomerulonephritis-GN, 8 children with a relapse of the nephrotic syndrome and 15 patients with chronic renal insufficiency-CHRI) the concentration of superoxide dismutase and catalase (KAT) was examined. The SOD and KAT activity in erythrocytes was assessed spectrophotometrically at 240 nm. In the whole group of patients the mean SOD values (632 +/- 102 U/g Hb) and KAT values (3.29 +/- 0.54 mukat/g Hb) were within the reference range. The highest mean SOD and KAT values were recorded in children with a relapse of nephrotic syndrome. In the group with chronic GN the SOD concentration in erythrocytes correlated significantly with total protein levels and serum creatinine resp. (r = 0.350, p < 0.05 and r = -0.458, p < 0.01 resp.). In the CHRI stage the authors revealed a significant relationship between the SOD activity and total protein levels (r = 0.550, p < 0.05). CONCLUSIONS: The activity of basic antioxidant enzymes SOD and KAT in erythrocytes of children with nephropathies is not significantly reduced. In patients with chronic GN there is a significant correlation between renal functions and SOD.

Glutathione peroxidase in blood of diabetic and nondiabetic BB rats.

The activity of glutathione peroxidase (GPX), an antioxidant selenoenzyme (EC.1.11.1.9.), was investigated in blood of BB rats developing spontaneous diabetes mellitus. The activity of the enzyme was significantly higher in the 4th and 5th inbred generation (G(4-5)) of BB rats as compared with their counterparts of lower degree of inbreeding (G(1-3)). Overt diabetes (actual blood glucose over 10 mM) appeared only in 8 out of 25 G(5) animals but oral and intravenous glucose tolerance tests revealed a gradual worsening of glucose metabolism already in rats with lower degree of inbreeding. No difference in GPX activity was found between diabetic and nondiabetic members of G(5) group. In the whole group of 69 rats positive correlation was found between the blood GPX activity and the age, weight and actual blood glucose value of the rats and negative correlation between GPX and the P/F value (ratio of peak blood glucose after intravenous tolerance test and fasting blood glucose). In the diabetic animals the enzyme activity showed inverse relationships with every measured or calculated parameter of glucose metabolism. Our findings indicate a relationship between age and blood GPX activity of BB rats and suggest the possibility of deleterious effect of elevated blood glucose level on the blood GPX activity after development of overt diabetes.

[Antioxidative enzymes in red blood cells in women with late gestosis]. / Antioxidacné enzýmy v cervených krvinkách zien s neskorou gestózou.

The authors investigated a group of 30 pregnant women with severe late gestosis and focused attention on assessment of the glucose-6-phosphate dehydrogenase and catalase activity in red blood cells of these patients. They found a statistically significant decline of G6PD activity in red blood cells, as compared with controls, i.e. healthy pregnant women. The decline of catalase activity is smaller and not statistically significant. Based on the assembled results they assume that the equilibrium between oxidation processes and anti-oxidation protection of red blood cells is impaired and this has an impact on their functional capacity and may play an important role in the development of various pathological conditions during pregnancy, incl. late gestosis.

[Newly diagnosed diabetes mellitus in patients with focal cerebral ischemia]. / Novozistený diabetes mellitus u chorých s loziskovou ischémiou mozgu.

The authors analyze a group of 121 patients with focal cerebral ischaemia, hospitalized at the Neurological Clinic in Kosice in 1987-1989. Forty-three patients were treated before the development of the vascular attack for diabetes. In the second group of patients, comprising 78, diabetes was newly detected in 26, i. e. in one third of the group. Glycaemic compensation of 40% of the treated diabetics, evaluated on the basis of glycaemic profiles and the concentration of glycohaemoglobin, was not satisfactory. High glycohaemoglobin levels in five patients with newly detected diabetes suggested that diabetes had persisted for a long time and was probably asymptomatic. The mortality from a cerebral attack was higher in diabetics than in non-diabetics. The highest mortality was recorded in a group of women with newly detected diabetes where of nine six died. In the authors' opinion it is particularly important that in patients with newly detected diabetes death occurred at a younger age as compared with non-diabetics and with treated diabetics. Based on these results the authors confirm the view that undiagnosed and untreated diabetes is a serious risk factor for the development of focal cerebral ischaemia and that it plays moreover an important role in its subsequent course and provides a poorer perspective of recovery in the affected patients.

[Glucose-6-phosphate dehydrogenase and catalase in the erythrocytes of patients with cerebral ischemia attacks]. / Glukóza-6-fosfátdehydrogenáza a kataláza v erytrocytoch chorých s ischemickou mozgovou príhodou.

The authors assessed the activity of glucose-6-phosphate dehydrogenase and catalase in 73 patients with ischaemic cerebral attacks. They compared the results with a control group of 23 patients with vertebrogenic diseases. They recorded a mild decrease of activity of the above enzymes and draw attention to possible oxidation damage under conditions of cerebral hypoxia.