Fatal intracranial bleedings in a viper bite: A case report / 中华创伤杂志(英文版)

Viper bite envenomation represents a significant occupational hazard among agricultural workers in India. The viper bite envenomation is usually suspected when a patient presents with predominant local symptoms at the bitten site, including pain, swelling, and necrosis. Further, systemic findings such as diffuse intravascular coagulation, hypotension, and shock may alert physicians of viper bite envenomation rather than a neurotoxic snake bite. However, cerebral complications are rare in viper bites but may potentially fatal. Central nervous system involvement in a viper bite is either due to neurotoxins or hemorrhagins present in the venom, which may induce cerebral thrombosis, ischemia, infarction, and hemorrhage. Here we present a case of a previously healthy adult male who succumbed to extensive subarachnoid, intracerebral, and intraventricular hemorrhages involving bilateral cerebral hemispheres following viper snake bite envenomation. This report highlights the importance of anticipating cerebral complications in viper bite envenomation, a rare occurrence. It also emphasizes the need for early antisnake venom administration to prevent and control systemic envenomation and its complications.

Variaciones de caracteres morfológicos dentro de la especie Bothrops alternatus / Morphological characters variations within the Bothrops alternatus species

Resumen El género Bothrops (yarará) es responsable de más del 95% de los accidentes por ofidios venenosos en Argentina. La mayoría de éstos son notificados en provincias del Nordeste y Noroeste. Bothrops alternatus, es la especie más frecuentementehallada, siendo el vipérido de gran talla más meridional del mundo y una de las especies de mayor importancia sanitaria en Argentina, pudiendo hallarse en relación a núcleos urbanos. Presentan en el dorso figuras arriñonadas características, que remedan atubos de teléfono o porotos unidos, completos o incompletos, hasta la forma fusionada. Presenta foseta loreal, órgano termore-ceptor ubicado entre el ojo y la fosa nasal. Su dentición es solenoglifa, dientes inoculadores huecos, con conducto cerrado, fijosa un hueso maxilar móvil. Si bien se describen variaciones entre animales, se considera una especie monotípica. Su identificaciónes importante dada la abundancia de especímenes y de hallazgos en regiones periurbanas.

Abstract The Bothrops genus is responsible for more than 95% of ophidian accidents in Argentina, most of these are reported in the Northeast and Northwest provinces. Bothrops alternatus, is the most frequent species of the genus Bothrops (yarará), themost southern large-scale viperid in the world and one of the most important species in Argentina, being able to be found in rela-tion to urban nucleus. Their characteristic features are kidney-like figures in the skin, that mimic phone tubes or beans, completeor incomplete, until the merged form. It presents a loreal pit, thermoreceptor organ located between the eye and the nostril. Itsdentition is solenoglyphous, hollow inoculating teeth, with closed duct, fixed to a mobile maxillary bone. Although variationsbetween animals are described, it is considered a monotypic species. The identification of this snake is important due their abun-dance in around urban regions and its frequency of finding.

Hemorragia cerebral fatal después de una mordedura de serpiente Bothrops asper en la región del Catatumbo, Colombia / Fatal brain hemorrhage after Bothrops asper bite in the Catatumbo region of Colombia

Resumen: Las mordeduras de serpientes son un problema de salud pública en regiones tropicales y subtropicales del mundo. Ocurren, especialmente, en trabajadores rurales, y son una importante fuente de discapacidad y mortalidad. Se presenta el caso de un hombre de 59 años, agricultor de la región del Catatumbo (Colombia), quien sufrió la mordedura de una serpiente Bothrops asper, la cual le produjo una hemorragia cerebral fatal. Se llama la atención sobre el grave trastorno hemorrágico en contraste con los leves cambios en el sitio de la mordedura, así como sobre la necesidad del tratamiento temprano de la intoxicación con el suero antiofídico, incluso, en ausencia de manifestaciones cutáneas significativas.

Abstract: Snake bites are a public health problem in tropical and subtropical regions of the world. They occur especially in rural workers and are an important source of disability and mortality. We present the case of a 59-year-old farmer from the Catatumbo region of Colombia who was bitten by a B. asper snake and suffered a fatal brain hemorrhage after the event. We draw attention to the severe bleeding disorder in contrast with the slight changes at the site of the bite, as well as on the importance of the early treatment of poisoning with antivenom even in the absence of significant skin manifestations.

Snake bite induced delayed hypopituitarism: a rare case report

Hypopituitarism following snake bite induced AKI and dialysis is an uncommon complication. Often the presentation is delayed and Can present with a myriad of features. We present a case of a 27 year old male patient, with past history of snake bite and acute kidney injury (AKI) requiring dialysis and which subsequently resolved, presenting to us with fatigability and weakness, absence of secondary sexual character and poor academic performance. On examination, the patient had pale white and coarse skin. Hoarseness of voice was present. There was proximal upper and lower limb muscle weakness present with pseudo myotonia on examination. There was loss of axillary and pubic hair with low testicular volume. Routine reports suggested mildly elevated creatinine with severely elevated Triglyceride levels. Creatine phosphokinase (CPK) was raised. Hormonal profile revealed low free thyroxine (FT4) and serum 8 a.m. Cortisol but an inadequate increase in thyroid stimulating hormone (TSH) and adrenocorticotropic hormone (ACTH) levels were suggestive of central hypopituitarism. Luteinizing hormone (LH), follicle-stimulating hormone (FSH), Insulin-like growth factor 1 (IGF-1) levels were reduced. Neuroimaging revealed empty sella suggestive of pituitary apoplexy. The above were suggestive of delayed hypopituitarism following post snake bite dialysis mediated pituitary apoplexy. In all cases of snake bite, a common occurrence in our country the possibility of hypopituitarism should be kept in mind and the hormonal profile followed up closely along with the renal parameters.

A Clinico-Epidemiological Profile of Neuroparalytic Snake Bite, Using Low Dose ASV in a Tertiary Care Centre from Western Maharashtra

According to the World Health Organization, snakebites cause more death and disability and are more notorious than some tropical diseases. Snakebite is a leading medical emergency in Asia/Pacific. It is one of the major causes of mortality in India. The objective of this study was to determine the clinico-epidemiological profile of a neuroparalytic snake bite at the Department of Medicine, Krishna Institute of Medical Sciences, Karad, one of the tertiary care centers of Western Maharashtra, in India.METHODSA descriptive study of 80 patients was carried out at the Department of Medicine, KIMS, Karad, a tertiary care center of Western Maharashtra, India. Present study showed outcome, delay in arrival, and epidemiology of patients with low dose of ASV in neuroparalytic snakebites and ventilator support. Descriptive statistics were shown by using MS Excel and SPSS Version 25.RESULTSOut of 80 cases 56.2% were males and 43.8% were females with a mean age of 28.16 years. 63.7% of the snakebite victims were bitten outside and 85% of the snakebites occurred on the lower extremity. On an average, 15.24 vials of ASV were administered. 80% patient were in Intensive Care and they were on ventilator support and 91% patients recovered from these snake bites. 51.25% of the patients reached the hospital within the interval of 3-7 hours.CONCLUSIONSStudy signifies the importance of snakebite threat to the community. Delay in reaching a hospital in time where snakebite patients can be treated, was the most important cause of death. Public health programs should be strengthened. Administration of Low dose ASV and ventilator support can provide sufficient cure if patients reach on time. Lack of awareness, delay in reaching the hospital, and treatment by non-medical persons are important factors that should to be addressed.

Practice and performance of lupus anticoagulant tests: A single centre experience

@#Introduction: Lupus anticoagulant (LA) is a well-known risk factor for thrombosis. Correct diagnosis of LA is essential in patient management with anticoagulation. The objectives of this study were to document the clinical and laboratory characteristics of patients tested for LA and to evaluate existing LA testing methods in our laboratory with the aim of improving the performance of LA test interpretation and reporting. Methods: Tests for LA include dilute Russell’s viper venom time (dRVVT) and Kaolin clotting time (KCT). Patients with LA ratio (dRVVT screen ratio/dRVVT confirm ratio) of ≥1.2 were considered as LA positive irrespective of KCT results. KCT was considered positive if there was a prolongation in KCT screening test which was not corrected on mixing with normal plasma. Results: Of 577 patients’ results, 295 were normal, 178 were KCT positive with negative dRVVT and 104 were LA positive. Incidences of thrombosis, connective tissue disease (CTD) and bad obstetric events were noted in 13%, 16% and 44% of normal patients, 9%, 22% and 49% of KCT+ patients and 23%, 37% and 17% of LA+ patients respectively. On further evaluation of dRVVT screen ratios, 431 had a ratio of <1.1, 59 had a ratio between 1.1 and 1.2 and 87 had a ratio of >1.2. Positive LA results were found in 3%, 29% and 87% of patients with dRVVT screen ratios of <1.1, 1.1 - 1.2 and >1.2 respectively. Conclusion: LA+ patients had higher incidences of thrombosis and CTD as compared to normal and KCT only positive patients. There was no significant difference in clinical characteristics between normal and KCT+ patients which suggests the presence of a high rate of false-positive KCT results. Since confirmatory testing for KCT is not widely used, the option of using another LA screening test method should be considered. In regard to dRVVT testing, confirmatory test should only be performed in patients with prolonged dRVVT screening result which was not corrected upon mixing with normal plasma as required by the International Society of Thrombosis and Haemostasis guidelines on LA testing. This practice will not only result in significant cost reduction but also avoid diagnostic confusion.

Envenomation by Trimeresurus stejnegeri stejnegeri: clinical manifestations, treatment and associated factors for wound necrosis

Trimeresurus stejnegeri stejnegeri bite induces tissue swelling, pain, thrombocytopenia, rhabdomyolysis, and acute renal failure. However, the incidence of coagulopathy, factors associated with wound necrosis, and the appropriate management of this condition have not been well characterized yet. Materials: This study included patients bitten by T. s. stejnegeri that were admitted to the study hospitals from 2001 to 2016. Patient characteristics, laboratory data, and management approaches were compared in victims with and without wound necrosis. Results: A total of 185 patients were evaluated: three patients (1.6%) were asymptomatic; whereas tissue swelling and pain, local ecchymosis, wound necrosis, coagulopathy, thrombocytopenia, rhabdomyolysis, and renal impairment were present in 182, 53, 13, 15, 10, 1, and 3 patients, respectively. One patient died from coagulopathy and hemorrhagic shock. Antivenom was administered to all envenomed patients at a median time of 1.8 h after the bite. The median total dose of antivenom was five vials. Chi-square analysis showed that bitten fingers, using cold packs during first aid, presence of bullae or blisters, lymphangitis or lymphadenitis, local numbness and suspected infection to be significantly associated with wound necrosis. After adjustment using a multivariate logistic regression model, only cold packs as first aid, bulla or blister formation, and wound infection remained significant. Conclusions: The main effects of T. s. stejnegeri envenomation are tissue swelling, pain, and local ecchymosis. We do not recommend the use of cold packs during first aid to reduce wound pain, as this may be a risk factor for wound necrosis. In addition, patients with bulla or blister formation should be carefully examined for subsequent wound necrosis. Antiplatelet use may worsen systemic bleeding. No severe rhabdomyolysis or renal failure was observed in this large case series, we therefore considered that they were not prominent effects of T. s. stejnegeri bite.(AU)

Cytotoxic and anticancer properties of the Malaysian mangrove pit viper (Trimeresurus purpureomaculatus) venom and its disintegrin (purpureomaculin)

The Asiatic pit vipers from the Trimeresurus complex are medically important venomous snakes. These pit vipers are often associated with snakebite that leads to fatal coagulopathy and tissue necrosis. The cytotoxic venoms of Trimeresurus spp.; however, hold great potential for the development of peptide-based anticancer drugs. Methods: This study investigated the cytotoxic effect of the venom from Trimeresurus purpureomaculatus, the mangrove pit viper (also known as shore pit viper) which is native in Malaysia, across a panel of human cancer cell lines from breast, lung, colon and prostate as well as the corresponding normal cell lines of each tissue. Results: The venom exhibited dose-dependent cytotoxic activities on all cell lines tested, with median inhibition concentrations (IC50) ranging from 0.42 to 6.98 µg/mL. The venom has a high selectivity index (SI = 14.54) on breast cancer cell line (MCF7), indicating that it is significantly more cytotoxic toward the cancer than to normal cell lines. Furthermore, the venom was fractionated using C18 reversed-phase high-performance liquid chromatography and the anticancer effect of each protein fraction was examined. Fraction 1 that contains a hydrophilic low molecular weight (approximately 7.5 kDa) protein was found to be the most cytotoxic and selective toward the breast cancer cell line (MCF7). The protein was identified using liquid chromatography-tandem mass spectrometry as a venom disintegrin, termed purpureomaculin in this study. Conclusion: Taken together, the findings revealed the potent and selective cytotoxicity of a disintegrin protein isolated from the Malaysian T. purpureomaculatus venom and suggested its anticancer potential in drug discovery.(AU)

Proteomics and antivenom immunoprofiling of Russell's viper (Daboia siamensis) venoms from Thailand and Indonesia

The Eastern Russell's viper, Daboia siamensis, is a WHO Category 1 medically important venomous snake. It has a wide but disjunct distribution in Southeast Asia. The specific antivenom, D. siamensis Monovalent Antivenom (DsMAV-Thailand) is produced in Thailand but not available in Indonesia, where a heterologous trivalent antivenom, Serum Anti Bisa Ular (SABU), is used instead. This study aimed to investigate the geographical venom variation of D. siamensis from Thailand (Ds-Thailand) and Indonesia (Ds-Indonesia), and the immunorecognition of the venom proteins by antivenoms. Methods: The venom proteins were decomplexed with reverse-phase high-performance liquid chromatography and sodium dodecyl sulfate-polyacrylamide gel electrophoresis, followed by in-solution tryptic digestion, nano-liquid chromatography-tandem mass spectrometry and protein identification. The efficacies of DsMAV-Thailand and SABU in binding the various venom fractions were assessed using an enzyme-linked immunosorbent assay optimized for immunorecognition profiling. Results: The two most abundant protein families in Ds-Thailand venom are phospholipase A2 (PLA2) and Kunitz-type serine protease inhibitor (KSPI). Those abundant in Ds-Indonesia venom are PLA2 and serine protease. KSPI and vascular endothelial growth factor were detected in Ds-Thailand venom, whereas L-amino acid oxidase and disintegrin were present in Ds-Indonesia venom. Common proteins shared between the two included snaclecs, serine proteases, metalloproteinases, phosphodiesterases, 5'nucleotidases and nerve growth factors at varying abundances. DsMAV-Thailand exhibited strong immunorecognition of the major protein fractions in both venoms, but low immunoreactivity toward the low molecular weight proteins e.g. KSPI and disintegrins. On the other hand, SABU was virtually ineffective in binding all fractionated venom proteins. Conclusion: D. siamensis venoms from Thailand and Indonesia varied geographically in the protein subtypes and abundances. The venoms, nevertheless, shared conserved antigenicity that allowed effective immunorecognition by DsMAV-Thailand but not by SABU, consistent with the neutralization efficacy of the antivenoms. A specific, appropriate antivenom is needed in Indonesia to treat Russell's viper envenomation.(AU)

Study of clinical and epidemiological profile of poisonous snake bite in a tertiary centre in North Kerala

Background: Snakebites are well-known medical emergencies in many parts of the world, especially in rural areas.The incidence of snakebite mortality is particularly high in South-East Asia. Rational use of snake anti-venom can substantially reduce mortality and morbidity due to snakebites. Snake bite is an important health problem in India also especially in North Kerala which has an agricultural background. There is a lack of study regarding this topic in this area. North Kerala differs from other areas in the country as hump nosed pit viper bites are more common here due to its proximity to western Ghats where it .Anti snake venom is ineffective to bites by hump nosed pit viper. Authors objectives  was to assess the clinical and epidemiological profile and outcome of poisonous snake bites.Methods: Retrospective observational study done among patients with snake bite with envenomation admitted in Academy of Medical education, Pariyaram, Kannur, Kerala from January 2018 to September 2018.Results: There were 90 cases of venomous snake bite during the study period. Of these males were predominant (70%). Majority were in the age group between 20 and 40. Majority of bites occurred in the months of June and July. Bite in the extremities were more common. Nine patients were brought 1 day after the bite. Snake identified most common was Russell’s viper followed by pit viper. Majority of the systemic envenomation was hemotoxic 80 patients (85%).Conclusions: The study stress the fact that snake bite is an important problem in North Kerala. The study also shows that delay in treatment is a major risk factor for morbidity. Hump nosed pit viper bites are more common in this area.

Evaluation of management of snake bites in a teaching hospital in northern Ghana: a retrospective descriptive study

Background: Snakebite is a public health problem afflicting mainly rural farmers. We seek to examine the profile and management of snakebite cases presenting to the Tamale Teaching Hospital of Ghana over a 30-month period.Methods: One hundred and ninety-two cases of snakebites presenting to the Tamale Teaching Hospital over a 30-month period from January 2016 to June 2018 were retrospectively analyzed. Information about the clinical manifestation of the snakebites, treatment instituted as well as the outcome was extracted from patient folders for the analysis.Results: Out of the 192 cases of snakebite, 131 (68.2%) occurred in males. The mean age of the victims was 26.5 years. The major patterns of envenomation were coagulopathy (84.9%) and local swelling/pain (82.8%). The causative snake species was identified in only 11.5% of cases, all of which were vipers. Antivenom was administered in 94.8% of the victims and the average amount administered was 84.64 milliliters (approximately 8 vials). Reaction to antivenoms was observed in 13.5% of cases, comprising mostly minor reactions. Antibiotics were utilized in 99.5% of cases with more than half receiving more than one type of antibiotic. Steroids use was common (62%) whilst 22.9% received antifibrinolytics despite the absence of evidence supporting their use in snakebite.Conclusions: Snakebite is an occupational health hazard of mainly rural farmers. The unwarranted use of non-beneficial medications is still rife. In addition to ensuring the continuous availability of effective antivenoms, there is the need for the development and adherence to protocols that take into consideration the prevailing local conditions.

Cytotoxic effects of Pseudocerastes persicus venom and its HPLC fractions on lung cancer cells

Several studies have pointed out that certain snake venoms contain compounds presenting cytotoxic activities that selectively interfere with cancer cell metabolism. In this study, Pseudocerastes persicus venom and its fractions were investigated for their anticancer potential on lung cancer cells. Methods: Lung cancer cells (A549) and normal fibroblast cells (Hu02) were treated with the P. persicus venom and its HPLC fractions and the cell cytotoxic effects were analyzed using MTT and lactate dehydrogenase release assays. Apoptosis was determined in venom-treated cell cultures using caspase-3 and caspase-9 assay kits. Results: The treatment of cells with HPLC fraction 21 (25-35 kDa) of P. persicus venom resulted in high LDH release in normal fibroblast cells and high caspase-3 and caspase-9 activities in lung cancer cells. These results indicate that fraction 21 induces apoptosis in cancer cells, whereas necrosis is predominantly caused by cell death in the normal cells. Fraction 21 at the final concentration of 10 μg/mL killed approximately 60% of lung cancer cells, while in normal fibroblast cells very low cell cytotoxic effect was observed. Conclusion: HPLC fraction 21 at low concentrations displayed promising anticancer properties with apoptosis induction in the lung cancer cells. This fraction may, therefore, be considered a promising candidate for further studies.(AU)

A study on clinical and laboratory features of pit viper envenomation from Central Kerala, India

Background: Snakebite envenomation is an important public health problem faced by the tropical countries with India, the worst affected in terms of mortality and morbidity. In spite of increasing reports of other snake species causing envenomation, the existing research and management strategies including antivenom are still focused on the “Big Four” species- Russel’s viper, saw scaled viper, common krait and spectacled cobra. Pit vipers as a group are being increasingly reported to cause human bites from different parts of the country. Hence, we decided to study the clinico-epidemiology of pit viper bites.Methods: 30 cases of proven pit viper bites who attended our Department during the study period of 18 months were analysed for the epidemiological factors, clinical features and abnormalities in laboratory parameters.Results: Hump nosed pit viper (Hypnale hypnale) was responsible for all the thirty cases. 57% of cases were females. Mean age of victims was 41.8 years. 17 patients had exclusively local envenomation. Ten cases had coagulopathy along with local envenomation. Three patients developed acute kidney injury of whom three underwent dialysis. No mortality was observed in the study. Low fibrinogen levels were observed in all cases with coagulopathy and some had low levels of factor V (70%) and factor VIII (40%).Conclusions: Hump nosed viper bites were observed to be common in this part of the country. Significant envenomation can occur. Further epidemiologic studies involving more centres will be helpful in quantifying the true incidence of bites. Since no specific antivenom is available, further researches in this direction are warranted.

Delayed double reading of whole blood clotting test (WBCT) results at 20 and 30 minutes enhances diagnosis and treatment of viper evenomation

The whole blood clotting test (WBCT) is a simple test of coagulation that is often used in the assessment, diagnosis, and therapeutic monitoring of snakebite patients in sub-Saharan Africa. WBCT requires only a clean glass tube and several milliliters of venous blood and is ideal for use in poorly equipped health centers throughout the rural areas where 95% of snakebites occur. However, questions surrounding the accuracy and reliability of the test remain unanswered due to variations in testing conditions and a lack of comparative research with which to validate them. This is the first study to evaluate WBCT results at both 20-min (WBCT20) and 30-min (WBCT30) reading times in the same group of snakebite patients. Methods In order to define the best reading time, the authors compared the results of serial WBCT evaluation at both 20 and 30 min after collection in 23 patients treated for snake envenomation in Bembèrèkè, northern Benin. Results WBCT results were identical at both reading times in patients without coagulopathy or when coagulation was restored permanently following a single dose of antivenom. Out of 17 patients with coagulopathy, 14 showed discrepancies between WBCT20 and WBCT30 results in at least one pair of serial evaluations. These could be completely contradictory results (e.g. normal clot at WBCT20 and no clot at WBCT30) or a marked difference in the quality of the clot (e.g. no clotting activity at WBCT20 and an unstable partial clot at WBCT30). WBCT discrepancies were encountered most frequently in three situations: initial normalization of hemostasis following antivenom therapy, detection of a secondary resumption of coagulopathy, or final restoration of hemostasis after a secondary resumption had occurred. Conclusions This study suggests that the WBCT is robust and that a sequential reading should improve the diagnosis and monitoring of venom-induced coagulopathies. It also indicates the possibility of discrepancies in the sensitivity of WBCT20 and WBCT30 for detecting the resolution or reoccurrence of coagulopathy and identifies how these findings, if confirmed, may be used to increase the efficacy and efficiency of antivenom treatment in the field.(AU)

Estudio descriptivo del accidente ofídico, Casanare-Colombia, 2012-2014 / ADescriptive Study of Ophidian Accidents, Casanare-Colombia, from 2012 to 2014 / Estudo descritivo do acidente ofídico, Casanare-Colômbia, 2012-2014

Introducción: Entre las lesiones de causa externa, el accidente ofídico es de notificación obligatoria en Colombia. En el departamento de Casanare, la susceptibilidad de sufrir una mordedura de serpiente aumenta dadas sus características geográficas, climáticas, socioculturales y demográficas que favorecen el incremento de morbilidad y mortalidad. Objetivo: Describir la ocurrencia del evento en Casanare entre 2012-2014, con el propósito de fortalecer las acciones de promoción y prevención. Metodología: Estudio descriptivo transversal a partir de registros de la notificación del evento al Sistema de Vigilancia en Salud Pública durante el período a estudio; la información se almacenó en el programa Excel de Microsoft Office®, y se realizó un análisis descriptivo de las variables tiempo, lugar y persona en el programa estadístico Epi-Info 7.1.5®. Resultados: Se registraron 485 casos: en 2012 (175 casos; 36.1%), 2013 (168 casos; 34.6%), 2014 (142 casos; 29.3%); de los cuales 315 fueron en hombres (64.9%), 417 casos del área rural (85.9%), con una edad promedio de 32.4 ± 19.9. En relación a la pertenencia étnica se presentaron 49 casos (10.1%), de los cuales el 83.7% fue en indígenas (41/49). Las actividades más frecuentes al momento de la agresión fueron caminatas por senderos abiertos o labores de agricultura 280 casos (57.7%); realizar trabajos agropecuarios, forestales o pesqueros 124 casos (25.6%). La localización anatómica de la mordedura en orden de frecuencia fue: Miembros inferiores 351 casos (72.4%) y superiores 113 casos (23.3%). Según la atención inicial: Inmovilización de miembro 71 casos (14.7%); sometidos a prácticas no médicas 181 casos (37.3%), y el 54.7% (99/181) se había realizado rezos. La Tasa de incidencia fue de 47.1/100,000 habitantes y de letalidad 0.2% (1/485). Conclusiones: La tasa de incidencia evidenciada superó la del país de 9.2/100,000 habitantes. Afectó a hombres en edad productiva, dependientes del trabajo agrícola; y la atención inicial fue inadecuada en la mayoría de casos, persistiendo el uso de prácticas no médicas. Todas las lesiones son prevenibles, por tanto, las medidas preventivas deben constituirse en la principal herramienta para reducir la incidencia del evento. [Manosalva-Sánchez C, Zuleta-Dueñas LP, Castañeda-Porras O. Estudio descriptivo del accidente ofídico, Casanare-Colombia, 2012-2014. MedUNAB 2017-2018; 20(3): 338-348].

Introduction: Among the injuries of external cause, the ophidian accident is notifiable in Colombia. In the department of Casanare, the susceptibility to suffer a snake bite increases given its geographical, climatic, sociocultural and demographic characteristics that favor the growth of morbidity and mortality. Objective: To describe the occurrence of the event in Casanare between 2012 and 2014, with the purpose of strengthening the actions of promotion and prevention. Methodology:Atransversal descriptive study from records of the notification of the event to the Public Health Surveillance System during the study period. The information was stored in the Microsoft Office® Excel program, and a descriptive analysis of the time, place and person variables was performed in the Epi-Info 7.1.5® statistical program. Results: 485 cases were registered; in 2012 (175 cases; 36.1%), 2013 (168 cases; 34.6%), 2014 (142 cases; 29.3%); cases of which 315 were caused in men (64.9%), 417 cases in the rural area (85.9%), with an average age of 32.4 ± 19.9. Regarding ethnicity, 49 cases were presented (10.1%), of which 83.7% were indigenous (41/49). The most frequent activities at the time of the attack were hiking on open trails or agricultural work with 280 cases (57.7%); performing agricultural, forestry or fishing jobs with 124 cases (25.6%). The anatomical location of the bite in order of frequency was: lower limbs 351 cases (72.4%) and upper limbs 113 cases (23.3%). According to the initial care: immobilization of limbs 71 cases (14.7%); undergoing non-medical practices 181 cases (37.3%), and 54.7% (99/181) preferred to undergo to prays. The incidence rate was 47.1 / 100,000 inhabitants and lethality 0.2% (1/485). Conclusions: The observed incidence rate exceeded the one of the country of 9.2 / 100,000 inhabitants. It affected men of productive age, who were dependent on agricultural work; and their initial care was inadequate in most cases, and the use of non-medical practices was persistent. All injuries are preventable; therefore, preventive measures should be the main tool to reduce the incidence of this accident. [Manosalva-Sánchez C, Zuleta-Dueñas LP, Castañeda-Porras O. A Descriptive Study of Ophidian Accidents, Casanare-Colombia, from 2012 to 2014. MedUNAB 2017-2018; 20(3): 338-348].

Introdução: Entre os feridos de causas externas, o acidente ofídico é uma notificação obrigatória na Colômbia. No estado do Casanare, a suscetibilidade a uma mordida de cobra aumenta devido às características geográficas, climáticas, socioculturais e demográficas que favorecem o aumento da morbidade e mortalidade. Objetivo: Descreva a ocorrência do evento em Casanare entre 2012-2014, com o objetivo de fortalecer as ações de promoção e prevenção. Metodologia: Estudo descritivo transversal de registos da notificação do evento ao Sistema de Vigilância de Saúde Pública durante o período de estudo; a informação foi armazenada no programa Microsoft Office® Excel e uma análise descritiva das variáveis tempo, lugar e pessoa foi realizada no programa estatístico Epi-Info 7.1.5®. Resultados: 485 casos foram registrados: em 2012 (175 casos, 36.1%), 2013 (168 casos, 34.6%), 2014 (142 casos, 29.3%); dos quais 315 eram homens (64.9%), 417 casos na área rural (85.9%), com idade média de 32.4 ± 19.9. Em relação à etnia, houve 49 casos (10.1%), dos quais 83.7% eram indígenas (41/49). As atividades mais freqüentes no momento da agressão foram caminhadas em trilhas abertas ou trabalho agrícola 280 casos (57.7%); realizar trabalhos agrícolas, florestais ou de pesca 124 casos (25.6%). A localização anatômica da mordida em ordem de freqüência foi: membros mais baixos 351 casos (72.4%) e maiores 113 casos (23.3%). De acordo com os cuidados iniciais: Imobilização de 71 casos (14.7%); passando por práticas não médicas 181 casos (37.3%) e 54.7% (99/181) rezaram. A taxa de incidência foi de 47.1/100,000 habitantes e letalidade 0.2% (1/485). Conclusões: A taxa de incidência evidenciada excedeu a do país em 9.2/100,000 habitantes. Isso afetou homens em idade produtiva, dependentes do trabalho agrícola; e o cuidado inicial foi inadequado na maioria dos casos, persistindo o uso de práticas não médicas. Todas as lesões são evitáveis, portanto, as medidas preventivas devem ser a principal ferramenta para reduzir a incidência do evento. [Manosalva-Sánchez C, Zuleta-Dueñas LP, Castañeda-Porras O. Estudo descritivo do acidente ofídico, Casanare-Colômbia, 2012-2014. MedUNAB 2017-2018; 20(3): 338-348].

Delayed double reading of whole blood clotting test (WBCT) results at 20 and 30 minutes enhances diagnosis and treatment of viper evenomation

The whole blood clotting test (WBCT) is a simple test of coagulation that is often used in the assessment, diagnosis, and therapeutic monitoring of snakebite patients in sub-Saharan Africa. WBCT requires only a clean glass tube and several milliliters of venous blood and is ideal for use in poorly equipped health centers throughout the rural areas where 95% of snakebites occur. However, questions surrounding the accuracy and reliability of the test remain unanswered due to variations in testing conditions and a lack of comparative research with which to validate them. This is the first study to evaluate WBCT results at both 20-min (WBCT20) and 30-min (WBCT30) reading times in the same group of snakebite patients. Methods In order to define the best reading time, the authors compared the results of serial WBCT evaluation at both 20 and 30 min after collection in 23 patients treated for snake envenomation in Bembèrèkè, northern Benin. Results WBCT results were identical at both reading times in patients without coagulopathy or when coagulation was restored permanently following a single dose of antivenom. Out of 17 patients with coagulopathy, 14 showed discrepancies between WBCT20 and WBCT30 results in at least one pair of serial evaluations. These could be completely contradictory results (e.g. normal clot at WBCT20 and no clot at WBCT30) or a marked difference in the quality of the clot (e.g. no clotting activity at WBCT20 and an unstable partial clot at WBCT30)...

Morphometric characteristics and seasonal proximity to water of the Cypriot bluntnosed viper Macrovipera lebetina lebetina (Linnaeus, 1758)

The blunt-nosed viper Macrovipera lebetina (Linnaeus, 1758) is a medically important snake species in the Middle East. Its nominate subspecies Macrovipera l. lebetina is confined to Cyprus, where it is the only dangerously venomous snake species and heavily pursued. Despite the viper's large size, data on its body mass and sex-specific morphological differences are scarce. It is commonly believed that M. l. lebetina prefers freshwater proximity during summer. Hence, we aimed at investigating M. l. lebetina sex-specific morphological differences and its possible attraction to freshwater bodies in late summer. Methods: Morphometric characteristics, proximity to water and conservation status of M. l. lebetina were investigated in Paphos district (Cyprus) in 2014, 2015 and 2017. Vipers were caught in different habitats, examined morphologically for metric and meristic characters, and released back into their habitat. Additionally, local people were interviewed about the conservation situation of the species. Results: Of 38 recorded blunt-nosed vipers, morphological characteristics were collected from 34 (10 adult males, 16 adult females, eight unsexed juveniles). Rounded total length (ToL) ranged from 23.5 cm to 133.0 cm and weight between 10 g and 1456 g. Adult males significantly exceeded adult females in tail length (TaL), ToL and head length (HL). No significant sex-specific differences were found in snout-vent length (SVL), head width (HW), weight or body condition index (BCI), nor for the ratios TaL / SVL, TaL / ToL, HL / SVL or HL / HW. Adult females from late summer (2015) had a significantly lower mean BCI than those from spring (2014). Distances of blunt-nosed vipers to the nearest water bodies (natural and artificial, respectively) did not differ significantly between spring (2014) and late summer (2015). There was also no significant difference between the distances of vipers to natural and to artificial water bodies in spring (and late summer). Conclusions: Adult male blunt-nosed vipers exceed adult females in TaL, ToL and HL. Adult females are likely in a more vulnerable body condition in late summer than in spring. Periodic drying out of freshwater bodies in summer probably does not affect the species' occurrence. Educational workshops and habitat conservation are recommended for reducing human-viper conflict.(AU)

Comparación de plataformas automatizadas para la genotipificación del virus del papiloma humano / Comparison of automated platforms for the HPV genotypification

Resumen OBJETIVO: comparar el desempeño operativo y la concordancia de los resultados de la genotipificación del virus del papiloma humano obtenidos en los sistemas automatizados Cobas® 4800 y BD Viper™ LT a partir de muestras de citología en base líquida. MATERIALES Y MÉTODOS: estudio retrospectivo efectuado con base en el análisis de las mujeres que asistieron a las clínicas de Salud Digna para Todos entre los meses de abril a junio de 2016 para estudio de Papanicolaou. Las muestras se almacenaron en colectores BD SurePath™ de citología en base líquida. Se emplearon los sistema Cobas® 4800 y BD Viper™ LT para la genotipificación del virus. Los resultados se analizaron con la prueba de χ2 de Pearson, y la concordancia se obtuvo por medio del índice Kappa de Cohen. RESULTADOS: se analizaron 1934 muestras de citología en base líquida en las plataformas Cobas® 4800 y BD Viper™ LT. El grado de acuerdo entre los resultados obtenidos por ambas plataformas tuvo un valor de κ = 0.832. Se observaron diferencias entre el número de resultados positivos y negativos reportados, así como en las proporciones de los distintos genotipos, sin que fueran estadísticamente significativas. CONCLUSIÓN: no existen diferencias significativas entre los resultados obtenidos para la detección del virus del papiloma humano conseguidos con las plataformas Cobas® 4800 y BD Viper™ LT. En el ámbito operativo existen diferencias significativas que deben tenerse en cuenta al momento de implementar cualquiera de estas plataformas.

Abstract OBJECTIVE: To compare operative performance and concordance of human papillomavirus genotyping results obtained on Cobas® 4800 and BD Viper™ LT automated systems from liquid-based cytology samples. MATERIALS AND METHODS: Retrospective study in 1964 women attending the clinics of Salud Digna para todos I.A.P. from April to June 2016 to perform the Papanicolaou study; samples were stored in the BD SurePath™ liquid-based cytology collectors. The Cobas® 4800 and BD Viper™ LT systems were used for virus genotyping. The results were analyzed with the Pearson χ2 test, and concordance was obtained using the Cohen Kappa index. RESULTS: 1934 of liquid-based cytology samples were analyzed on the Cobas® 4800 and BD Viper™ LT platforms. The concordance between the results obtained by both platforms was very high (κ = 0.832). Moreover, there are differences between the number of positive and negative results reported, as well as in the proportions of the different genotypes, however, these were not statistically significant. CONCLUSION: There are no significant differences between the results obtained for the detection of the human papillomavirus obtained by the Cobas® 4800 and BD Viper™ LT platforms. However, at the operational level, there are important differences that must be taken into account when implementing any of these platforms.

Laboratory measurement of bleeding risk for patients receiving Dabigatran / 临床检验杂志

Objective To observe the correlation between conventional coagulation tests and Dabigatran concentration in order to find proper test method to predict the bleeding risk of patients receiving Dabigatran.Methods The clinical data of forty-nine non-valvular atrial fibrillation (NVAF) patients who took Dabigatran in Peking University Third Hospital from 2015 to 2017 were analyzed and the bleeding rates were calculated.The plasma samples from twenty healthy volunteers were collected and mixed up into normal pooled plasma (NPP).Different doses of active Dabigatran were mixed with NPP,making Dabigatran concentrations from 0 to 1 000 ng/mL.Prothrombin time (PT),activated partial thromboplastin time (APTT),thrombin time (TT),fibrinogen (Fib) and diluted Russell viper venom time (dRVVT) were determined.Fresh whole blood samples from three normal volunteers were collected and mixed with Dabigatran in the same way to perform thromboelastogram (TEG).Results The total bleeding rate of NVAF patients receiving Dabigatran was 28.6％,among which gastrointestinal bleeding accounts for the most.APTT,dRVVT,R time (R) and clot index (CI) showed a good linear correlation with Dabigatran concentration.The sensitivity of dRVVT was the best,followed by APTT.R and CI showed low sensitivity compared with APTT and dRVVT.Conclusion APTT and dRVVT should be good parameters for monitoring the bleeding risk of Dabigatran and helpful for physicians to choose proper point-in-time for withdrawal of Dabigatran and reduce bleeding events.

Dabigatran en plasma: tiempos de trombina diluido, Ecarin y veneno de víbora de Russell diluido / Plasma dabigatran: diluted thrombin time, Ecarin and diluted Russell Viper Venom Time / Dabigatrana em plasma: tempos de trombina diluído, Ecarin e veneno de víbora de Russell diluído

Los objetivos del trabajo fueron verificar la calidad analítica del ensayo tiempo de trombina diluido (DTI) para medición de la concentración plasmática (cc) de dabigatran comparando dos coagulómetros de detección foto-óptica, comparar los resultados con el tiempo de Ecarin (ECT) y correlacionar las cc con las pruebas básicas de coagulación Tiempo de protrombina (TP), APTT y Tiempo de trombina (TT), y tiempo de veneno de víbora de Russell con fosfolípidos concentrados (DRVVTC). Se tomaron 43 muestras de plasma en el valle (10-14 h de la última toma) de 40 pacientes que recibían dabigatran. DTI y ECT presentaron (%) repetitividad <5,4% y <7,5%, CV interensayo <6% y <9%, respectivamente, en el protocolo EP15A2, aceptables para un Error Total permitido (TEa) <15%. Las cc medidas en pacientes fueron: mediana 83 (4-945) ng/mL. La comparación de equipos ACL TOP 300 y 500 dio resultados equivalentes por procedimiento alternativo de comparación de métodos. La comparación ECT vs. DTI fue satisfactoria por regresión de Deming (pendiente 1,143, ordenada al origen -19,33). Las correlaciones de cc vs. APTT, TP y DRVVTC fueron moderadas y no lineales tendiendo a plateau a cc>350 ng/mL, r2 0,59, 0,66 y 0,59, respectivamente. El TT fue extremadamente sensible: >120 s a cc 50 ng/mL. DTI presentó un buen desempeño analítico y permitió cuantificar dabigatran plasmático a cc bajas y altas en ambos equipos utilizados. ECT presentó resultados comparables a DTI. Se verifica una correlación moderada entre cc de dabigatran y las pruebas clásicas y DRVVTC, pudiendo ser estimadores de cc a partir de los 50 ng/mL.

The aims of the study were to verify the analytical performance of Dilute Thrombin Time (DTI) test to measure plasma dabigatran concentration (cc) in two photo-optical coagulometers, compare Ecarin clotting Time (ECT) and DTI results, and correlate cc with classical coagulation tests: prothrombin time (PT), APTT, thrombin time (TT) and diluted Russell Viper Venom Time tests with high phospholipid concentration (DRVVTC). Forty three plasma samples from 40 patients taking dabigatran were drown at through (10-14 hs.since last dose). DTI and ECT showed repetitivity (%) <5.4% and <7.5%, interassay CV <6% and <9%, respectively, following EP15A2 protocol, acceptable considering a Allowed Total Error (TEa)<15%. Patients` cc: median 83 (4-945) ng/mL. The comparison between ACL TOP 300 and 500 coagulometers showed equivalent results by using the alternative method comparison test. ECT vs. DTI: acceptable by Deming`s regression (slope 1.143, Y insert -19.33). cc vs. APTT, TP and DRVVTC: nonlinear and moderate correlations with plateau reached at cc >350 ng/mL, r2 0.59, 0.66 y 0.59, respectively. TT is extremely prolonged at cc >50 ng/mL. In conclusion: DTI showed a good analytical performance in both coagulometers. ECT showed comparable results to DTI. We verified that dabigatran cc presented moderate correlations with PT, APTT and DRVVTC, and that these tests could only qualitative estimate cc >50 ng/mL.

Os objetivos do trabalho foram verificar a qualidade analítica do ensaio tempo de trombina diluído (DTI) para medição da concentração plasmática (cc) de dabigatrana, comparando dois coagulômetros de detecção foto-óptica, comparar os resultados com o tempo de Ecarina (ECT) e correlacionar as cc com os testes básicos de coagulação Tempo de protrombina (TP), APTT e Tempo de trombina (TT), e tempo de veneno de víbora de Russell com fosfolipídios concentrados (DRVVTC). Foram tomadas 43 amostras de plasma no vale (10-14 h. da última toma) de 40 pacientes que recebiam dabigatrana. DTI e ECT apresentaram (%) repetitividade <5,4% e <7,5%, CV interensaio <6% e <9%, respectivamente, no protocolo EP15A2, aceitáveis para um Erro Total permitido (TEa) <15%. Cc medidas em pacientes: mediana 83 (4-945) ng/mL. Comparação de equipamentos ACL TOP 300 e 500: resultados equivalentes por procedimento alternativo de comparação de métodos. Comparação ECT vs. DTI: satisfatória por regressão de Deming (pendente 1,143, ordenada à origem -19,33). Correlações cc vs. APTT, TP e DRVVTC: moderadas e não lineares tendendo a plateau a cc>350 ng/mL, r2 0,59; 0,66 e 0,59, respectivamente. O TT é extremamente sensível: >120 s a cc 50 ng/mL. DTI apresentou um bom desempenho analítico e permitiu quantificar dabigatrana plasmática a cc baixas e altas em ambos os equipamentos utilizados. ECT apresentou resultados comparáveis com DTI. Verifica-se uma correlação moderada entre cc de dabigatrana e os testes clássicos e DRVVTC, podendo ser estimadores de cc a partir dos 50 ng/mL.