Systemic cytokine response in children bitten by snakes in Costa Rica.

BACKGROUND: To characterize the host response to venom from snakes of the family Viperidae in Costa Rica, we investigated the release of cytokines: IL-1, IL-6, IL-8, TNF-alpha, MIP-1beta, and RANTES in pediatric patients who were bitten by a snake. METHODS: Patients were included in this study if they were admitted to the hospital within 24 hours of the snakebite. Blood samples were taken immediately on admission to the hospital, and then at intervals of 3, 12, and 24 hours, and on days 3, 5, and 7 after the accident. Patients received gentamicin plus clindamycin or gentamicin plus penicillin intravenously for a minimum of 3 days or longer if necessary. IL-1, IL-8, TNF-alpha, MIP-1beta, and RANTES were determined by monoclonal antibody-based ELISAs, while IL-6 was determined by bioassay. RESULTS: Eighteen patients were included in this study; 15 were bitten by Bothrops asper and three by B. lateralis. Eleven patients were male. Median (range) age was 9 (1-12) years. Nine patients had detectable serum concentrations of IL-6 (200 pg/ mL) and IL-8 (51 pg/mL) on admission, increasing to 500 pg/mL and 115 pg/mL for IL-6 and IL-8, respectively, during the first 12-24 hours. Cytokine concentrations returned to normal or undetectable ranges by 72 hours. TNF-alpha concentrations peaked at 12 hours (mean: 48 pg/mL). Low, but detectable concentrations of MIP-1beta were observed in some patients at various time intervals (48 pg/mL), whereas IL-1 was not detectable at any time point. Regulated on Activation Normal T cell Expressed and Secreted (RANTES) concentrations were evaluated in only five patients, being elevated in all of them. Patients with elevated cytokine concentrations required early fasciotomy (<24 hours after the accident) more often than those who had normal or undetectable cytokine concentrations (P < 0.05). There were no statistically significant associations between severity of envenomation, or outcome, and elevated serum cytokine concentrations (P > 0.05). CONCLUSIONS: Bothrops sp snake venoms induce clinical and pathophysiologic alterations similar to acute trauma, with release of proinflammatory cytokines. A better understanding of the role of the inflammatory response could lead to the development of new therapeutic strategies to improve the outcome in snakebitten patients.

Venomous snakebites in children and adolescents: a 12 year retrospective review

Snakebite envenomation is a worldwide problem and in Costa Rica. The following is a retrospective review of 79 patients admitted to the Hospital Nacional de Ninos (HNN) from January 1985 to September 1996. Child's age ranged from 9 months to 14 years. The M: F ratio was 1.5:1. Sixty percent of the patients lived in remote rural areas. The most common clinical signs at the time of hospitalization were pain and edema. Fifty patients (63.29 per cent) showed moderate to severe envenomation grades. Fifty-one (64,55 per cent) was caused by Bothrops asper. Complications during hospitalization were compartment syndrome and secondary infection. Three children died, one from disseminated intravascular coagulation, another from renal insufficiency, and the third from a perforated duodenal ulcer. Patients who underwent early fasciotomy had signficantly less hospitalization and fewer infectious complications, (p<0.001). There was no relationship between the envenomation grade and length of hospitalization (p=0.4). The most common pathogen isolated was S. aureus. Early fasciotomy seemed to reduce the complications seen in these patients. Further studies are necessary to identify the factors that may clinicians to decide those who should undergo fasciotomy, as well as the best moment to perform it

Handwashing practices in a tertiary-care, pediatric hospital and the effect on an educational program.

OBJECTIVE: To study the frequency of handwashing and the effects of an educational program. DESIGN: A prospective study. SETTING: A tertiary-care, pediatric hospital. PARTICIPANTS: Three divisions (two general pediatric wards and one infectious disease ward). The personnel observed included 60 medical staff (interns, residents, and attending, including consulting, physicians), 37 nurses, and 15 paramedical staff. INTERVENTIONS: The study was carried out in 5 phases: (1) unobtrusive observation to obtain a baseline handwashing rate; (2) observation after written notification; (3) observation after providing motivating devices: movies, brochures, posters; (4) discontinuation of observation and motivation; (5) unobtrusive observation, to obtain a residual handwashing rate. RESULTS: During this study, 1,123 patient contacts were observed. The baseline handwashing rates before and after patient contact were 52% and 49%, respectively. During phase 2, handwashing rates before and after patient contact increased slightly to 56% and 52%, respectively. During phase 3, rates increased to 74% and 69% (P < .01). However, rates fell during the final phases to 49% and 52%, respectively (P < .01). There were no significant differences among hospital staff in any phase of this study (P > .05). CONCLUSIONS: Constant motivation, using movies, brochures, and posters, transiently increased the frequency of handwashing among the house staff of a tertiary-care facility; however, to be effective, this motivation needs to be sustained.

[Factors involved in bacterial translocation in an experimental model of intestinal obstruction]. / Factores involucrados en la translocación bacteriana en un modelo experimental de obstrucción intestinal.

We designed a model of intestinal obstruction (IO) to study the histological alterations in the intestinal wall and the mesenteric lymph nodes (MLN). Therefore we used 32 Sprague-Dawley rats and under anesthesia a laparotomy was performed and the distal ileum was ligated with 3-0 silk, producing a complete occlusion. At different interval (24, 48, 72 and 96 hours) the animals were sacrificed by cervical dislocation and were histologically analyzed. At 24 hours post IO, congestion, edema and a inflammatory infiltrate were observed at the level of the lamina propia and the MLN were reactive. At 48 hours the congestion and edema increased and the intestinal mucosa began to fragment, allowing the bacteria to translocate and getting to the lymph nodes in the intestinal wall. The reactivity at the MLN increased. The observation of bacterial translocation in IO widen the scope of the alterations in this pathology, were not only absorption of toxic products and endotoxin occurs in the compromise segment and this phenomenon could explain the incidence of bacteremia and sepsis in the IO patients.