Hyponatraemia compounding pre-eclamptic toxaemia in a patient with type 1 diabetes.

We report a case of profound, symptomatic hyponatraemia in association with pre-eclamptic toxaemia (PET) in a 38-year-old nulliparous woman with type 1 diabetes mellitus. This patient developed hypertension and proteinuria at 31+6 weeks' gestation and was admitted for management of pre-eclampsia. Severe headache, visual disturbance and nausea were associated with a hyponatraemia of 115 mmol/L followed by ketoacidosis. This was reversed through fluid restriction, supplementation with 1.8%-3.0% hypertonic saline and a volume-reduced variable-rate insulin infusion. Clinical stability was achieved and she was subsequently worked up for an induction of labour for worsening pre-eclampsia. Hyponatraemia in the context of PET has been previously reported as rare. However, it has complications that may significantly compound the sequelae of severe PET. We propose that specific and focused monitoring of serum sodium levels should become common practice in the management of women with this condition to allow for timely, measured correction of abnormalities.

Adult Intestinal Toxemia Botulism.

Intoxication with botulinum neurotoxin can occur through various routes. Foodborne botulism results after consumption of food in which botulinum neurotoxin-producing clostridia (i.e., Clostridium botulinum or strains of Clostridiumbutyricum type E or Clostridiumbaratii type F) have replicated and produced botulinum neurotoxin. Infection of a wound with C. botulinum and in situ production of botulinum neurotoxin leads to wound botulism. Colonization of the intestine by neurotoxigenic clostridia, with consequent production of botulinum toxin in the intestine, leads to intestinal toxemia botulism. When this occurs in an infant, it is referred to as infant botulism, whereas in adults or children over 1 year of age, it is intestinal colonization botulism. Predisposing factors for intestinal colonization in children or adults include previous bowel or gastric surgery, anatomical bowel abnormalities, Crohn's disease, inflammatory bowel disease, antimicrobial therapy, or foodborne botulism. Intestinal colonization botulism is confirmed by detection of botulinum toxin in serum and/or stool, or isolation of neurotoxigenic clostridia from the stool, without finding a toxic food. Shedding of neurotoxigenic clostridia in the stool may occur for a period of several weeks. Adult intestinal botulism occurs as isolated cases, and may go undiagnosed, contributing to the low reported incidence of this rare disease.

Combination therapy with antibiotics and anthrax immune globulin intravenous (AIGIV) is potentially more effective than antibiotics alone in rabbit model of inhalational anthrax.

BACKGROUND: We have evaluated the therapeutic efficacy of AIGIV when given in combination with levofloxacin and the effective window of treatment to assess the added benefit provided by AIGIV over standard antibiotic treatment alone in a New Zealand white rabbit model of inhalational anthrax. METHODS: Rabbits were exposed to lethal dose of aerosolized spores of Bacillus anthracis (Ames strain) and treated intravenously with either placebo, (normal immune globulin intravenous, IGIV) or 15 U/kg of AIGIV, along with oral levofloxacin treatment at various time points (30-96 hours) after anthrax exposure. RESULTS: The majority of treated animals (>88%) survived in both treatment groups when treatment was initiated within 60 hours of post-exposure. However, reduced survival of 55%, 33% and 25% was observed for placebo + levofloxacin group when the treatment was initiated at 72, 84 and 96 hours post-exposure, respectively. Conversely, a survival rate of 65%, 40% and 71% was observed in the AIGIV + levofloxacin treated groups at these time points. CONCLUSIONS: The combination of AIGIV with antibiotics provided an improvement in survival compared to levofloxacin treatment alone when treatment was delayed up to 96 hours post-anthrax exposure. Additionally, AIGIV treatment when given as an adjunct therapy at any of the time points tested did not interfere with the efficacy of levofloxacin.

Anesthetic management of maternal Mirror syndrome.

Mirror syndrome (Ballantyne syndrome, triple edema, maternal hydrops, pseudotoxemia) is a rarely diagnosed condition associated with pregnancy that can be life-threatening for both the mother and fetus. There is limited literature on its pathogenesis and anesthetic management, making prevention and treatment complex. The duration of pregnancy and severity of maternal or fetal presentation often determines outcome. We describe the anesthetic considerations of a morbidly obese parturient with Mirror syndrome.

[The efficiency of reamberinum in infusion therapy of acetonemic syndrome in children].

The current paper presents the results of monitoring of 69 patients with acute respiratory viral infection, acetonemic syndrome. It was shown the effectiveness of inclusion of Reamberinum into complex therapy as a means for reduction of with acetonemic syndrome and for detoxic effect.

Adsorption of endotoxin by beta2-microglobulin adsorbent column (Lixelle): the new approach for endotoxinemia.

We previously reported that Lixelle, which was used for beta2-microglobulin (BMG) adsorption columns, could adsorb not only BMG but also inflammatory cytokines. We became interested in the application of Lixelle for patients with endotoxinemia and researched its ability to adsorb microorganism components in vitro using lipopolysaccharide (LPS) (Escherichia coli B8), endotoxin (ET) contaminated water. The initial concentrations of each water solution were LPS (ET 29,135 EU/L) and contaminated water (ET 3,523 EU/L) whole blood solution was LPS (ET 1,197.6 EU/L). Each 2.5 ml of the stock solution and adjusted diluted solutions contained 0.5 ml of Lixelle beads. After shaking at 37 degrees C for 2 h, ET in the solutions was determined using the endotoxin specific-limulus amebocyte lysate method. The results revealed that even though ET concentrations in LPS and contaminated water incubated in water solution and in whole blood were high, the samples containing Lixelle beads showed significant decreases. Thus, Lixelle beads can adsorb not only BMG but also microorganism components such as LPS and ET. These findings together with the ability of Lixelle to adsorb ET show the possibility of the application for treatment of endotoxinemia.

[Hemosorption in serotherapy (serosorption) in experimental acute diphtheric toxemia with the use of affinity sorbents]. / Gemosorbtsiia na fone seroterapii (serosorbtsiia) pri éksperimental'noi ostroi difteriinoi toksemii s ispol'zovaniem affinnykh sorbentov.

In modeling acute diphtheric toxemia in guinea pigs, the authors propose to perform hemosorption using selective sorbents under continuous introduction of antitoxic immune sera into extracorporeal contour in front of sorption column. Combination of hemosorption with serotherapy in the same time interval may be denoted as serosorption. As specific sorbents, affine preparations imasorb A-700 and Imasorb G-700 were used. They selectively eliminate from the blood flow CIC produced by diphtheric toxin (anatoxin) and antitoxic rabbit and horse antibodies. Changes in the titers of the diphtheric toxin (anatoxin) and CIC in blood evidence for efficiency of selective sorbents were confirmed by immunohistochemical analysis of the preparations' granules after hemoperfusion.

[Endogenic intoxication in patients with acute general peritonitis and problems of its correction]. / Endogennaia intoksikatsiia u bol'nykh s ostrym rasprostranennym peritonitom i problemy ee korrektsii.

This study was carried out for improvement of extracorporeal detoxication results. Distribution of middle-mass molecules (MM) in various media and vascular beds in patients with acute general peritonitis (AGP) and correlation between central hemodynamics (CH) and level of MM-intoxication were studied. Results of treatment were analyzed in 72 patients with AGP. Ultraviolet irradiation of autoblood (UVIA) had negative influence on circulation in patients with AGP in terminal stage who had more severe primary disorders of CH. Therefore, UVIA without hemosorption (HS) in these patients is potentially dangerous because of undesirable hemodynamic effects due to increase of MM-concentration in blood plasma. HS was performed 1.5-2 hours after UVIA and resulted in decrease of MM-concentration in caval system blood by 28.1% with subsequent slow increase, MM-level restored 24 hours after HS. If HS and UVIA were carried out simultaneously, MM-concentration in caval system blood decreased by 13.9% only, an in 3 of 7 cases MM-concentration didn't change. Combination of UVIA and HS with 1.5-2 h interval is most effective.

[Diagnostic significance of evaluating erythrocyte membrane permeability as an intoxication syndrome criterion]. / Diagnosticheskaia tsennost' otsenki pronitsaemosti membran éritrotsitov v kachestve kriteriia intoksikatsionnogo sindroma.

Twenty-five patients with pyoinflammatory maxillofacial diseases treated in an inpatient setting in the Regional Dentistry Clinic of Krasnodar and 8 healthy volunteers were examined. After opening and draining of the purulent focus the patients were divided into 2 groups. Group 1 consisted of 21 patients treated by intravenous 0.04% sodium hypochlorite (SHC) and intravenous infusions of SHC-oxidized autoblood for 2-3 days. Group 2 (6 pts) was treated by intravenous infusions of SHC-oxidized autoblood for 6 days. The criteria of intoxication were erythrocyte resistance tests in hypotonic sodium chloride and at different concentrations of urea in isotonic medium. A new method for evaluating erythrogram deviations from reference values is proposed, which helps adequately assess the severity of intoxication.

The medical threat of biological weapons.

There is a heightened threat of biological weapons being used for biological warfare or bioterrorism. Many of the microorganisms and toxins that may be used as such biological weapons can easily be acquired and mass produced. Dissemination of aerosols of these biological agents can produce mass casualties. If used by a terrorist they may overwhelm our current public health system. Some biological agents, such as Bacillus anthracis (anthrax) and botulinum toxin, are considered far more likely than others to be used as biological weapons; smallpox virus was apparently produced in mass quantities by the former Soviet Union and may also be a serious threat. The release of such agents could go undetected for several hours or days and would be followed by mass illnesses and a first line of response by the public health community. Rapid epidemiological investigation to identify the nature of the disease outbreak would be critical for limiting casualties. For many, but not all, biological agents there are medical treatments that can greatly lower the mortality rate. There currently are, however, insufficient supplies of medicinals and trained personnel to cope with a massive bioterrorist or biological warfare use of biological weapons. Increasing our preparedness is critical.

[The efficacy of using synthetic carbon-mineral sorbents in combined radiation-thermal lesions]. / Effektivnost' primeneniia sinteticheskikh uglerod-mineral'nykh sorbentov pri kombinirovannykh radiatsionno-termicheskikh porazheniiakh.

The effect of enterosorbents of group "SUMS" on the manifestations of endogenous intoxication syndrome and dysfunction of small intestine was studied in rats with combined radiational-thermal injuries. The "SUMS" enterosorbents are shown to reduce the general toxemia, and promote the recovery of intestinal wall digestion enzyme activity and glucose absorption.

Endotoxemia: methods of detection and clinical correlates.

As an assay for endotoxin, the Limulus amebocyte lysate assay has several desirable properties: sensitivity, specificity, and potential for adaptation to a quantitative format. Several modifications have been developed to enhance its potential for clinical application. The modifications that allow quantitative measurement of endotoxin and also improve its application to blood samples are described in this review. In fluids other than blood, the detection of endotoxin with the Limulus amebocyte lysate assay can be used as an aid to identify the presence of gram-negative bacteria, and the assay has established utility. With blood, however, there are a range of factors that interfere with the detection of endotoxemia and there are disparate views with respect to the diagnostic and prognostic significance of the test results. In general, the clinical significance of the finding of endotoxemia broadly parallels the frequency and importance of gram-negative sepsis in the patient groups studied and a decline in endotoxin levels accompanies clinical improvement. However, with therapies designed to reduce levels of endotoxin, or to antagonize its effects, it is unclear whether clinical improvement occurs as a consequence of changes in the levels of endotoxemia.

Pathogenesis of hemorrhage-induced bacteria/endotoxin translocation in rats. Effects of recombinant bactericidal/permeability-increasing protein.

OBJECTIVES: This study was conducted to determine the role of gut-derived bacteria/endotoxin in the pathogenesis of the multiple-organ damage and mortality, the possible beneficial effect of recombinant bactericidal/permeability-increasing protein (rBPl21), and whether neutralizing endotoxemia by rBPl21 treatment influences tumor necrosis factor (TNF) formation in rats after hemorrhagic shock and resuscitation. SUMMARY BACKGROUND DATA: Hypovolemic shock might be associated with bacterial or endotoxin translocation as well as systemic sepsis. Similar to bactericidal/permeability-increasing (BPl) protein, rBPl21 has been found to bind endotoxin and inhibit TNF production. METHODS: A rat model of prolonged hemorrhagic shock (30 to 35 mm Hg for 180 min) followed by adequate resuscitation was employed. Recombinant bactericidal/permeability-increasing protein was administered at 5 mg/kg intravenously. The control group was treated similarly to the BPl group, but received thaumatin as a protein-control preparation in the same dose as rBPl21. RESULTS: Immediately after resuscitation (230 min), plasma endotoxin levels in the control group (61.0 +/- 16.3 pg/mL) were almost neutralized by rBPl21 treatment (13.8 +/- 4.8 pg/mL, p < 0.05). Plasma TNF levels were not significantly influenced by rBPl21 treatment. The 48-hour survival rate was 68.8% in the treatment group versus 37.5% in the control group (p = 0.08). Microscopic histopathologic examination revealed relatively minor damage to various organs in the treatment group. CONCLUSIONS: These data suggest that hemorrhagic shock may lead to bacterial/endotoxin translocation with concomitant TNF formation, endogenous endotoxemia may play an important role in the pathogenesis of multiple-organ failure after shock and trauma, TNF formation at an early stage might be related mainly to mechanisms other than Kupffer's cells activation via lipopolysaccharide, and rBPl21 might be a useful therapeutic agent against endogenous bacteria/endotoxin related disorders in severe hemorrhagic shock.

Endotoxin versus bacteremia: a comparison focusing on clinical relevance.

All phenomena seen under ovine endotoxemia or bacteremia are typically observed in septic humans as well. The lethality (approximately 20%) in both sepsis models underlines the severity of the experimental sepsis in these models. As mentioned above, both models are ideal to objectify the effects of new therapeutic approaches for the treatment of sepsis, because they provide stable conditions. We tested the inhibition of nitric oxide synthase in both models: Nitric oxide is the main mediator of the vasodilation and the hyperdynamic circulation seen in sepsis. Since the restoration of the perfusion pressure is the major therapeutic goal to prevent further tissue damage (Chernow et al. 1990), the blockade of the nitric oxide synthase seems to be a logical approach for the treatment of hyperdynamic sepsis. Therefore, we tested the nitric oxide synthase inhibitor N(W)-nitro-L-arginine methyl ester (L-NAME) in the endotoxemic sheep model as well as in the bacteremic model. L-NAME reversed the hyperdynamic circulation of sepsis (Meyer et al.1992; Dehring et al.1993). The cardiac output was lowered back to baseline, and at the same time, the arterial pressure was elevated to baseline niveau, both resulting in a marked increase in systemic vascular resistance (figure 3). The pulmonary artery pressure showed only a slight increase, but due to the marked reduction in cardiac output the pulmonary vascular resistance increased significantly. The oxygen extraction was elevated to an extent, which prevented the oxygen consumption to fall, although the oxygen delivery dropped significantly because of the lowered cardiac output (figure 4). The intrapulmonary shunt was brought back to baseline (Meyer et al.1994a), allowing an improved pulmonary oxygen uptake. The renal function improved significantly after nitric oxide synthase inhibition in endotoxemia as well as in bacteremia (Hinder et al.1994; Lingnau et al.1994). Not only was the creatinine clearance elevated, but the urine output also increased, lowering the positive fluid balance. Another inhibitor of nitric oxide synthase N(W)-Mono-Methyl-L-Arginine (L-NMMA) was recently tested in these models as well. This drug is now already in clinical trials. The fact that the effects of these nitric oxide synthase inhibitors in septic humans are similar to the effects in the described experimental sepsis models proves the clinical relevance of the endotoxemic and the bacterimic sheep model.