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Alshalah A, Williams DJ, Ferrario A. From fangs to antidotes: A scoping review on snakebite burden, species, and antivenoms in the Eastern Mediterranean Region. PLoS Negl Trop Dis 2024; 18:e0012200. [PMID: 39083539 PMCID: PMC11335162 DOI: 10.1371/journal.pntd.0012200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 08/20/2024] [Accepted: 05/07/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND Snake bites cause considerable morbidity and mortality worldwide, yet evidence from low- and middle-income countries remains fragmented. This is particularly the case in Eastern Mediterranean Region where available data on snake bites is relatively weak. Without reliable data, it is difficult to make the case for greater visibility and investment to address the snakebite burden in this Region. A scoping review was therefore conducted to summarize evidence on snake bites in countries of the Eastern Mediterranean. METHODOLOGY/PRINCIPAL FINDINGS The review employed manual and electronic searching methods of four databases plus Google Scholar, ultimately including 196 records from 20 countries published between 2000 and 2023. More than half originated from Iran, Morocco, and Pakistan. Many records lacked information on permanent sequalae, disability, snake species, and types and sources of antivenoms. When identified, offending snakes belonged to 30 species. Use of more than 12 types of antivenoms were described across the Region, and some were not specific to indigenous species. CONCLUSION/SIGNIFICANCE Despite the relatively large number of publications identified, the data were concentrated in just a few countries in the Region, and there was little or no information available for the remainder. As is the case worldwide, disability associated with snake bites was poorly characterized and quantified across the Region. There is an urgent need for concrete action at national and regional levels to enhance epidemiological surveillance, research, and the collection of clinical, disability and outcomes data to inform policy and public health investment. Greater regional cooperation and collaboration is also crucial for addressing this neglected disease throughout the Region.
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Affiliation(s)
- Ali Alshalah
- Information Systems for Health Unit, Department of Science, Information and Dissemination, WHO Regional Office for Eastern Mediterranean, Cairo, Egypt
| | - David J. Williams
- Regulation and Prequalification Department, World Health Organization, Geneva, Switzerland
| | - Alessandra Ferrario
- Information Systems for Health Unit, Department of Science, Information and Dissemination, WHO Regional Office for Eastern Mediterranean, Cairo, Egypt
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Dehghani R, Monzavi SM, Mehrpour O, Shirazi FM, Hassanian-Moghaddam H, Keyler DE, Wüster W, Westerström A, Warrell DA. Medically important snakes and snakebite envenoming in Iran. Toxicon 2023; 230:107149. [PMID: 37187227 DOI: 10.1016/j.toxicon.2023.107149] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/01/2023] [Accepted: 05/02/2023] [Indexed: 05/17/2023]
Abstract
Snakebite is a common health condition in Iran with a diverse snake fauna, especially in tropical southern and mountainous western areas of the country with plethora of snake species. The list of medically important snakes, circumstances and effects of their bite, and necessary medical care require critical appraisal and should be updated regularly. This study aims to review and map the distributions of medically important snake species of Iran, re-evaluate their taxonomy, review their venomics, describe the clinical effects of envenoming, and discuss medical management and treatment, including the use of antivenom. Nearly 350 published articles and 26 textbooks with information on venomous and mildly venomous snake species and snakebites of Iran, were reviewed, many in Persian (Farsi) language, making them relatively inaccessible to an international readership. This has resulted in a revised updated list of Iran's medically important snake species, with taxonomic revisions of some, compilation of their morphological features, remapping of their geographical distributions, and description of species-specific clinical effects of envenoming. Moreover, the antivenom manufactured in Iran is discussed, together with treatment protocols that have been developed for the hospital management of envenomed patients.
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Affiliation(s)
- Ruhollah Dehghani
- Department of Environmental Health, Kashan University of Medical Sciences, Kashan, Iran; Social Determinants of Health Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Seyed Mostafa Monzavi
- Medical Toxicology Center, Mashhad University of Medical Sciences, Mashhad, Iran; Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Omid Mehrpour
- Medical Toxicology and Drug Abuse Research Center, Birjand University of Medical Sciences, Birjand, Iran; Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA.
| | - Farshad M Shirazi
- Arizona Poison and Drug Information Center, University of Arizona, Tucson, AZ, USA
| | - Hossein Hassanian-Moghaddam
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Clinical Toxicology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Daniel E Keyler
- Department of Experimental & Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Wolfgang Wüster
- Molecular Ecology and Evolution at Bangor, School of Natural Sciences, Bangor University, Bangor, UK
| | | | - David A Warrell
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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Deka A, Bhatia S, Santra V, Bharti OK, Lalremsanga HT, Martin G, Wüster W, Owens JB, Graham S, Doley R, Malhotra A. Multilevel Comparison of Indian Naja Venoms and Their Cross-Reactivity with Indian Polyvalent Antivenoms. Toxins (Basel) 2023; 15:toxins15040258. [PMID: 37104196 PMCID: PMC10142961 DOI: 10.3390/toxins15040258] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/21/2023] [Accepted: 03/26/2023] [Indexed: 04/05/2023] Open
Abstract
Snake envenoming is caused by many biological species, rather than a single infectious agent, each with a multiplicity of toxins in their venom. Hence, developing effective treatments is challenging, especially in biodiverse and biogeographically complex countries such as India. The present study represents the first genus-wide proteomics analysis of venom composition across Naja species (N. naja, N. oxiana, and N. kaouthia) found in mainland India. Venom proteomes were consistent between individuals from the same localities in terms of the toxin families present, but not in the relative abundance of those in the venom. There appears to be more compositional variation among N. naja from different locations than among N. kaouthia. Immunoblotting and in vitro neutralization assays indicated cross-reactivity with Indian polyvalent antivenom, in which antibodies raised against N. naja are present. However, we observed ineffective neutralization of PLA2 activities of N. naja venoms from locations distant from the source of immunizing venoms. Antivenom immunoprofiling by antivenomics revealed differential antigenicity of venoms from N. kaouthia and N. oxiana, and poor reactivity towards 3FTxs and PLA2s. Moreover, there was considerable variation between antivenoms from different manufacturers. These data indicate that improvements to antivenom manufacturing in India are highly desirable.
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Affiliation(s)
- Archana Deka
- Molecular Toxinology Laboratory, Department of Molecular Biology and Biotechnology, Tezpur University, Tezpur 784028, Assam, India
| | - Siddharth Bhatia
- CSIR-Centre for Cellular and Molecular Biology, Laboratory for Conservation of Endangered Species, Hyderabad 500048, Telangana, India
| | - Vishal Santra
- Society for Nature Conservation, Research and Community Engagement (CONCERN), Nalikul, Hooghly 712407, West Bengal, India
- Captive and Field Herpetology, Anglesey LL65 1YU, UK
- Snake Research Institute, Gujarat Forest Department, Government of Gujarat, Valsad 396050, Gujarat, India
| | - Omesh K. Bharti
- State Institute of Health and Family Welfare, Shimla 171009, Himachal Pradesh, India
| | | | | | - Wolfgang Wüster
- Molecular Ecology and Evolution @ Bangor (MEEB), School of Natural Sciences, Bangor University, Gwynedd LL57 2UW, UK
| | - John B. Owens
- Captive and Field Herpetology, Anglesey LL65 1YU, UK
- Molecular Ecology and Evolution @ Bangor (MEEB), School of Natural Sciences, Bangor University, Gwynedd LL57 2UW, UK
| | - Stuart Graham
- Molecular Ecology and Evolution @ Bangor (MEEB), School of Natural Sciences, Bangor University, Gwynedd LL57 2UW, UK
| | - Robin Doley
- Molecular Toxinology Laboratory, Department of Molecular Biology and Biotechnology, Tezpur University, Tezpur 784028, Assam, India
| | - Anita Malhotra
- Molecular Ecology and Evolution @ Bangor (MEEB), School of Natural Sciences, Bangor University, Gwynedd LL57 2UW, UK
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HANBEYOĞLU O, URFALIOĞLU A, HÜNEREL T. Retrospective Analysis of the Demographic and Clinical Features of Snake Bites Followed in the Intensive Care Unit. KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2022. [DOI: 10.17517/ksutfd.1015725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objective
Cases of poisoning due to snake bite are a medical condition that requires an emergency treatment approach, which creates serious health problems that can be seen in our country and all over the world. In the Eastern Anatolia Region, poisoning cases due to the bites of viper snakes, especially from the Viperidae family, are frequently seen. The aim of this study is to examine the bite sites, clinical stages, antivenom needs and doses, changes in blood biochemistry, prognostic characteristics of patients treated in our intensive care unit for snake bites in our region, and to present our regional experience with snake bites.
Material and Methods
Our study included 44 patients who were treated in the intensive care clinic with the complaint of snake bite between August 1, 2018 and August 1, 2021. Symptoms, bite sites, clinical stages, need and doses of antivenom, length of hospital stay, changes in blood biochemistry and mortality of these patients who were exposed to snake bites were retrospectively investigated.
Results
A total of 44 patients, 13 female (29.55%) and 31 male (70.45%), aged between 18-72 years, who were followed up due to snake bites, were included in the study. In our study, 1 (2.27%) patients in Stage 0, 18 (40.90%) in Stage 1, 21 (47.7%) in Stage 2 and 4 (9.09%) patients in Stage 3 it was found that he was followed up due to snake bite. While total antivenom (4.33±2.18) vials were given to 10 intoxication cases with stage (0-1), vials of total antivenom were given to 25 (7.65±3.03) intoxication cases with stage (2-3).
Conclusion
We believe that in addition to antivenom treatment in sufficient doses and in an early time, the first correct intervention to snake bite can prevent problems that may develop after poisoning.
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Affiliation(s)
- Onur HANBEYOĞLU
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ELAZIĞ FETHİ SEKİN ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, CERRAHİ TIP BİLİMLERİ BÖLÜMÜ
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Snake Bite Management: A Scoping Review of the Literature. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3506. [PMID: 33936914 PMCID: PMC8084039 DOI: 10.1097/gox.0000000000003506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/21/2021] [Indexed: 01/20/2023]
Abstract
Background: Around the world, snake bite envenomation remains an underreported human health hazard. Envenomation can cause local and systemic complications, especially when there is a lack of antivenom availability. Although there are established guidelines regarding snake bite management acute care, there is a paucity of data regarding surgical intervention and the plastic surgeon’s role treating this unique patient population. Methods: A review was conducted identifying relevant published articles involving snake bite management and treatment in PubMed and EMBASE. Results: One hundred ten articles were identified and 77 met inclusion criteria. Snake bite envenomation can result in complications that are dependent upon a variety of variables. The literature has shown the best field treatment to be timely transportation to the nearest medical facility, along with antivenom administration. The cytotoxic, hemotoxic, and neurotoxic effects of venom can cause a variety of local soft tissue and systemic complications. Surgical interventions such as fasciotomies, wound debridements, skin grafts, and tissue flaps may be necessary in these patients to optimize functional and aesthetic outcomes. Disparities in access to care in resource limited settings are discussed. Conclusions: Global health disparities and insufficient antivenom distribution create an inequality of care in snake bite patients. Plastic surgeons have an important role in managing acute and chronic complications of snake bite envenomations that can lead to improved patient outcomes.
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Review of Scorpion Stings and Snakebites Treated by the French Military Health Service During Overseas Operations Between 2015 and 2017. Wilderness Environ Med 2020; 31:174-180. [PMID: 32331950 DOI: 10.1016/j.wem.2020.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/02/2019] [Accepted: 01/15/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Depending on their theatre of operation, French soldiers may potentially be exposed to scorpion stings and snakebites. Following the recommendations of a French military health service (FMHS) technical committee for envenomation, the FMHS provides antivenoms appropriate to each deployment. This work aimed to evaluate this risk of envenomation and to assess the antivenoms used by the FMHS in operational theatres since the creation of this committee in 2015. METHODS Cases were identified based on a review of temporary authorization of use application forms for the use of antivenom. Data were collected retrospectively from these forms, and prescribing physicians were contacted for any missing data. RESULTS Between 2015 and 2017, 28 requests for temporary authorization of use were identified: 19 for Scorpifav (Sanofi-Pasteur, Lyon, France) and 9 for Fav-Afrique (Sanofi-Pasteur). The FMHS treated 15 soldiers and 4 civilians for scorpion envenomation with Scorpifav: 15 in Mali, 3 in Chad, and 1 in Niger. Systemic signs were observed in 7 patients. Two soldiers and 7 civilians were treated with Fav-Afrique for ophidian envenomation: 5 in Djibouti, 3 in Mali, and 1 in the Republic of Côte d'Ivoire. These 28 patients were treated without sequelae. Other than moderate erythema that resolved with an antihistamine, no adverse effects were reported. Medical evacuation to France was unnecessary. CONCLUSIONS This study shows that the risk of envenomation for soldiers on deployment is low but real. Antivenoms used by the FMHS were efficient and well tolerated, preserving the operational capacity of deployed troops.
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Bolon I, Durso AM, Botero Mesa S, Ray N, Alcoba G, Chappuis F, Ruiz de Castañeda R. Identifying the snake: First scoping review on practices of communities and healthcare providers confronted with snakebite across the world. PLoS One 2020; 15:e0229989. [PMID: 32134964 PMCID: PMC7058330 DOI: 10.1371/journal.pone.0229989] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 02/18/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Snakebite envenoming is a major global health problem that kills or disables half a million people in the world's poorest countries. Biting snake identification is key to understanding snakebite eco-epidemiology and optimizing its clinical management. The role of snakebite victims and healthcare providers in biting snake identification has not been studied globally. OBJECTIVE This scoping review aims to identify and characterize the practices in biting snake identification across the globe. METHODS Epidemiological studies of snakebite in humans that provide information on biting snake identification were systematically searched in Web of Science and Pubmed from inception to 2nd February 2019. This search was further extended by snowball search, hand searching literature reviews, and using Google Scholar. Two independent reviewers screened publications and charted the data. RESULTS We analysed 150 publications reporting 33,827 snakebite cases across 35 countries. On average 70% of victims/bystanders spotted the snake responsible for the bite and 38% captured/killed it and brought it to the healthcare facility. This practice occurred in 30 countries with both fast-moving, active-foraging as well as more secretive snake species. Methods for identifying biting snakes included snake body examination, victim/bystander biting snake description, interpretation of clinical features, and laboratory tests. In nine publications, a picture of the biting snake was taken and examined by snake experts. Snakes were identified at the species/genus level in only 18,065/33,827 (53%) snakebite cases. 106 misidentifications led to inadequate victim management. The 8,885 biting snakes captured and identified were from 149 species including 71 (48%) non-venomous species. CONCLUSION Snakebite victims and healthcare providers can play a central role in biting snake identification and novel approaches (e.g. photographing the snake, crowdsourcing) could help increase biting snake taxonomy collection to better understand snake ecology and snakebite epidemiology and ultimately improve snakebite management.
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Affiliation(s)
- Isabelle Bolon
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Andrew M. Durso
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Sara Botero Mesa
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Nicolas Ray
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Institute for Environmental Sciences, University of Geneva, Geneva, Switzerland
| | - Gabriel Alcoba
- Médecins Sans Frontières, Geneva, Switzerland
- Division of Tropical and Humanitarian Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - François Chappuis
- Division of Tropical and Humanitarian Medicine, University Hospitals of Geneva, Geneva, Switzerland
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Qiu C, Qiu XF, Liu JJ, Wang YX, Gui L. An effective snakebite first aid training method for medics in the Chinese troops: a RCT. Mil Med Res 2019; 6:39. [PMID: 31831044 PMCID: PMC6909628 DOI: 10.1186/s40779-019-0230-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/27/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Snakebites can lead to lifelong consequences and is one of the main causes of death among military troops worldwide. However, few Chinese military medics know the proper first aid procedures for snakebites. Therefore, this study aimed to explore the impact of the Standard Operation Procedure (SOP) and checklist on Chinese military medics' ability to manage snakebite first aid. METHODS This study was a prospective single-blind randomized controlled trial conducted in a military medical university of China from May to June 2017. A questionnaire-based survey was performed to collect the participants' socio-demographic profiles before the baseline measurement. During the baseline measurement, participants were requested to provide corresponding first aid that was responsive to the simulative situation portrayed by the SPs (standardized patients) and the evaluators then scored their performances according to a checklist for snakebite first aid scoring table. After the baseline measurement, they were randomly assigned to one of three intervention groups after stratification according to their baseline performance scores: group A received a self-learning course with textbooks (n = 27), group B received a self-learning training on the SOP and checklist (n = 27) and group C was engaged in an interactive discussion panel regarding the SOP and checklist (n = 26). After the interventions, participants received outcome measurements about snakebite first aid key points capability from the same evaluator and SP for each group to avoid observational error. The reviewers were blinded about the grouping in the trial. RESULTS The baseline measurement yielded no significant difference (H = 1.647, P = 0.439) among the three groups. The post-intervention scores were higher than the pre-intervention scores for all three (A, B and C) groups (P = 0.008, P < 0.001 and P < 0.001, respectively). There was significant difference of the post-intervention scores among the three groups (F = 8.841, P < 0.001). Both post-intervention scores of group B and group C were higher than that of group A (P < 0.001 and P = 0.001, respectively), but no difference was found between group B and C (P = 0.695). The acceptance questionnaire score of SOP and checklist was mostly very satisfied, as the final scores of group B and group C were 4.62 ± 0.61 and 4.82 ± 0.45, respectively. CONCLUSIONS In this study, the implementation of an SOP and checklist for snakebite first aid was shown to update and improve first aid treatment concepts in military medics. These intervention methods played an important role in improving the medics' cognition and understanding of snakebite first aid. Therefore, this finding suggests that SOP and checklist training should be further implemented in Chinese troops for snakebite care.
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Affiliation(s)
- Chen Qiu
- First Medical Center, General Hospital of the PLA, Beijing, 100853 China
- Department of Emergency Nursing, School of Nursing, Naval Medical University, Shanghai, 200433 China
| | - Xiao-Feng Qiu
- Second Medical Center, General Hospital of the PLA, Beijing, 100853 China
| | - Jing-Jing Liu
- Department of Emergency Nursing, School of Nursing, Naval Medical University, Shanghai, 200433 China
| | - Yi-Xin Wang
- Department of Emergency Nursing, School of Nursing, Naval Medical University, Shanghai, 200433 China
| | - Li Gui
- Department of Emergency Nursing, School of Nursing, Naval Medical University, Shanghai, 200433 China
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Antivenom Costs Show Need for Education and Collaborative Efforts. Am J Med 2016; 129:e29. [PMID: 27215992 DOI: 10.1016/j.amjmed.2015.10.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 10/07/2015] [Accepted: 10/07/2015] [Indexed: 11/20/2022]
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Monzavi SM, Salarian AA, Khoshdel AR, Dadpour B, Afshari R. Effectiveness of a clinical protocol implemented to standardize snakebite management in Iran: initial evaluation. Wilderness Environ Med 2015; 26:115-23. [PMID: 25698180 DOI: 10.1016/j.wem.2014.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 08/13/2014] [Accepted: 09/06/2014] [Indexed: 02/08/2023]
Abstract
OBJECTIVE This study was designed to evaluate the effectiveness of a new protocol implemented to standardize snakebite management in Iran. METHODS In this study, 27 patients treated according to the new protocol in 2012 (P+) were compared with 22 patients treated according to the previous modality in the year before implementation of the protocol (P-) in Mashhad Medical Toxicology Centre (MTC). Demographic characteristics and treatment details of all patients were recorded prospectively. Envenomation severity of each victim was assessed according to snakebite severity score (SSS). RESULTS After implementation of the protocol, a smaller percentage of patients received antivenom (AV) therapy (78% vs 95%; P=.079). In spite of no significant difference in baseline severity of envenomation between the 2 groups (SSS [mean±SD], 34.8±18.1 vs 35.5±17.4; P=.801), the P+ group received significantly fewer AV vials (8.4±6.8 vs 12.1±5.6 vials; P=.042) and had a significantly shorter length of hospital stay (2.2±1.5 vs 3.2±1.8 days; P=.027). Moreover, smaller proportion of P+ patients experienced recurrence of venom-induced effects; however, the difference was not significant (18.5% vs 36%; P=.159). The reduction in use of antiallergy treatments to prevent or treat acute hypersensitivity reactions approached statistical significance (41% vs 68%; P=.051). These findings denote a reduction in AV use of approximately 4 vials and a reduction in hospital stay of 1 day for each patient, which translates to approximately $196/patient in healthcare cost savings. CONCLUSIONS Implementation of a snakebite management protocol at MTC reduced overall antivenom usage, use of antiallergy interventions, and length of hospital stay.
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Affiliation(s)
- Seyed Mostafa Monzavi
- AJA University of Medical Sciences, Tehran, Iran (Drs Monzavi, Salarian, and Khoshdel); Addiction Research Center, Department of Internal Medicine, Imam Reza Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran (Drs Monzavi, Dadpour, and Afshari)
| | - Amir Ahmad Salarian
- AJA University of Medical Sciences, Tehran, Iran (Drs Monzavi, Salarian, and Khoshdel)
| | - Ali Reza Khoshdel
- AJA University of Medical Sciences, Tehran, Iran (Drs Monzavi, Salarian, and Khoshdel)
| | - Bita Dadpour
- Addiction Research Center, Department of Internal Medicine, Imam Reza Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran (Drs Monzavi, Dadpour, and Afshari)
| | - Reza Afshari
- Addiction Research Center, Department of Internal Medicine, Imam Reza Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran (Drs Monzavi, Dadpour, and Afshari).
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