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Olin S, Schildt J, Lane M, Odunayo A, Springer C, Call D, Jones S, Geiser D, Millis D, Drum M. The effects of hyperbaric oxygen therapy on snake-bite-associated wounds in dogs. J Vet Emerg Crit Care (San Antonio) 2024. [PMID: 38761038 DOI: 10.1111/vec.13383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 03/03/2023] [Accepted: 03/08/2023] [Indexed: 05/20/2024]
Abstract
OBJECTIVE To assess the effect of hyperbaric oxygen therapy (HBOT) on Crotalinae envenomation-induced wound swelling and severity and pain in dogs, and to describe the safety and complications of HBOT. DESIGN Prospective, randomized, controlled, blinded study (2017-2021). SETTING University teaching hospital, private veterinary practice. ANIMALS Thirty-six client-owned dogs presenting within 24 hours of a confirmed or suspected naturally occurring Crotalinae snake bite injury were enrolled between 2017 and 2021. INTERVENTIONS In addition to the standard of care treatment, dogs received 2 interventions with either HBOT (n = 19) or control (n = 16) within 24 hours of hospital admission. Dogs receiving HBOT were pressurized over 15 minutes (1 psi/min), maintained at a target pressure of 2 atmosphere absolute (ATA) for 30 minutes, and decompressed over 15 minutes. Control dogs received 1 ATA for 1 hour. Local wound swelling, wound severity score, and pain score were assessed at admission, before and after each intervention, and at hospital discharge. MEASUREMENTS AND MAIN RESULTS There was no significant difference in wound swelling (P = 0.414), severity score (P = 1.000), or pain score (P = 0.689) between HBOT and control groups. Pain decreased significantly over time regardless of the study intervention (P < 0.001). There were no major adverse effects associated with either study intervention. CONCLUSIONS HBOT did not significantly alter the short-term recovery from Crotalinae envenomation in this study population. However, the study might be underpowered to detect a significant treatment effect.
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Affiliation(s)
- Shelly Olin
- Department of Small Animal Clinical Science, University of Tennessee College of Veterinary Medicine, Knoxville, Tennessee, USA
| | - Julie Schildt
- Department of Small Animal Clinical Science, University of Tennessee College of Veterinary Medicine, Knoxville, Tennessee, USA
| | | | - Adesola Odunayo
- Department of Small Animal Clinical Science, University of Florida, Gainesville, Florida, USA
| | - Cary Springer
- Research Computing Support, Office of Information Technology, University of Tennessee, Knoxville, Tennessee, USA
| | - Dana Call
- Neel Veterinary Hospital, Oklahoma City, Oklahoma, USA
| | - Selene Jones
- Allergy Skin and Ear Clinic for Pets, Livonia, Michigan, USA
| | - Dennis Geiser
- Hospital Administration, University of Tennessee College of Veterinary Medicine, Knoxville, Tennessee, USA
| | - Daryl Millis
- Department of Small Animal Clinical Science, University of Tennessee College of Veterinary Medicine, Knoxville, Tennessee, USA
| | - Marti Drum
- Department of Small Animal Clinical Science, University of Tennessee College of Veterinary Medicine, Knoxville, Tennessee, USA
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Sachett A, Strand E, Serrão-Pinto T, da Silva Neto A, Pinto Nascimento T, Rodrigues Jati S, Dos Santos Rocha G, Ambrósio Andrade S, Wen FH, Berto Pucca M, Vissoci J, Gerardo CJ, Sachett J, Seabra de Farias A, Monteiro W. Capacity of community health centers to treat snakebite envenoming in indigenous territories of the Brazilian Amazon. Toxicon 2024; 241:107681. [PMID: 38461896 DOI: 10.1016/j.toxicon.2024.107681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 02/26/2024] [Accepted: 03/04/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION The deaths from and morbidities associated with snakebites - amputations, loss of function in the limb, visible scarring or tissue damage - have a vast economic, social, and psychological impact on indigenous communities in the Brazilian Amazon, especially children, and represent a real and pressing health crisis in this population. Snakebite clinical and research experts have therefore proposed expanding antivenom access from only hospitals to include the community health centers (CHC) located near and within indigenous communities. However, there are no studies examining the capacity of CHCs to store, administer, and manage antivenom treatment. In response to this gap, the research team calling for antivenom decentralization developed and validated an expert-based checklist outlining the minimum requirements for a CHC to provide antivenom. METHODS The objective of this study was thus to survey a sample of CHCs in indigenous territories and evaluate their capacity to provide antivenom treatment according to this accredited checklist. The checklist was administered to nurses and doctors from 16 CHCs, two per indigenous district in Amazonas/Roraima states. RESULTS Our results can be conceptualized into three central findings: 1) most CHCs have the capacity to provide antivenom treatment, 2) challenges to capacity are human resources and specialized items, and 3) antivenom decentralization is feasible and appropriate in indigenous communities. CONCLUSION Decentralization would provide culturally and contextually appropriate care accessibility to a historically marginalized and underserved population of the Brazilian Amazon. Future studies should examine optimal resource allocation in indigenous territories and develop an implementation strategy in partnership with indigenous leaders. Beyond the indigenous population, the checklist utilized could be applied to community health centers treating the general population and/or adapted to other low-resource settings.
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Affiliation(s)
- André Sachett
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus, Brazil; Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | - Eleanor Strand
- Department of Emergency Medicine, Duke University School of Medicine, Durham, United States
| | - Thiago Serrão-Pinto
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus, Brazil; Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil; Faculdade de Ciências Farmacêuticas, Universidade Federal do Amazonas, Manaus, Brazil
| | - Alexandre da Silva Neto
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus, Brazil; Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | - Thais Pinto Nascimento
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus, Brazil; Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | - Sewbert Rodrigues Jati
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus, Brazil; Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil; Secretaria de Estado de Educação e Cultura de Roraima, Boa Vista, Brazil
| | - Gisele Dos Santos Rocha
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus, Brazil; Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | | | | | - Manuela Berto Pucca
- Departamento de Análises Clínicas, Faculdade de Ciências Farmacêuticas de Araraquara, Universidade Estadual Paulista, Araraquara, Brazil
| | - João Vissoci
- Department of Emergency Medicine, Duke University School of Medicine, Durham, United States
| | - Charles J Gerardo
- Department of Emergency Medicine, Duke University School of Medicine, Durham, United States
| | - Jacqueline Sachett
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus, Brazil; Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | - Altair Seabra de Farias
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus, Brazil; Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | - Wuelton Monteiro
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus, Brazil; Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil.
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Uko SO, Malami I, Ibrahim KG, Lawal N, Bello MB, Abubakar MB, Imam MU. Revolutionizing snakebite care with novel antivenoms: Breakthroughs and barriers. Heliyon 2024; 10:e25531. [PMID: 38333815 PMCID: PMC10850593 DOI: 10.1016/j.heliyon.2024.e25531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/10/2024] Open
Abstract
Snakebite envenoming (SBE) is a global public health concern, primarily due to the lack of effective antivenom for treating snakebites inflicted by medically significant venomous snakes prevalent across various geographic locations. The rising demand for safe, cost-effective, and potent snakebite treatments highlights the urgent need to develop alternative therapeutics targeting relevant toxins. This development could provide promising discoveries to create novel recombinant solutions, leveraging human monoclonal antibodies, synthetic peptides and nanobodies. Such technologies as recombinant DNA, peptide and epitope mapping phage display etc) have the potential to exceed the traditional use of equine polyclonal antibodies, which have long been used in antivenom production. Recombinant antivenom can be engineered to target certain toxins that play a critical role in snakebite pathology. This approach has the potential to produce antivenom with improved efficacy and safety profiles. However, there are limitations and challenges associated with these emerging technologies. Therefore, identifying the limitations is critical for overcoming the associated challenges and optimizing the development of recombinant antivenoms. This review is aimed at presenting a thorough overview of diverse technologies used in the development of recombinant antivenom, emphasizing their limitations and offering insights into prospects for advancing recombinant antivenoms.
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Affiliation(s)
- Samuel Odo Uko
- Centre for Advanced Medical Research and Training, Usmanu Danfodiyo University Sokoto, Nigeria
- Department of Biochemistry and Molecular Biology, Faculty of Chemical and Life Sciecnes, Usmanu Danfodiyo University Sokoto, Nigeria
| | - Ibrahim Malami
- Centre for Advanced Medical Research and Training, Usmanu Danfodiyo University Sokoto, Nigeria
- Department of Pharmacognosy and Ethnopharmacy, Faculty of Pharmaceutical Sciences, Usmanu Danfodiyo University Sokoto, Nigeria
| | - Kasimu Ghandi Ibrahim
- Department of Basic Medical and Dental Sciences, Faculty of Dentistry, Zarqa University, P. O. Box 2000, Zarqa, 13110, Jordan
| | - Nafiu Lawal
- Centre for Advanced Medical Research and Training, Usmanu Danfodiyo University Sokoto, Nigeria
- Department of Veterinary Microbiology, Faculty of Veterinary Medicine, Usmanu Danfodiyo University Sokoto, Nigeria
| | - Muhammad Bashir Bello
- Centre for Advanced Medical Research and Training, Usmanu Danfodiyo University Sokoto, Nigeria
- Department of Veterinary Microbiology, Faculty of Veterinary Medicine, Usmanu Danfodiyo University Sokoto, Nigeria
- Vaccine Development Unit, Infectious Disease Research Department, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Murtala Bello Abubakar
- Centre for Advanced Medical Research and Training, Usmanu Danfodiyo University Sokoto, Nigeria
- Department of Physiology, College of Health Sciences, Usmanu Danfodiyo University Sokoto, Nigeria
- Department of Physiology, College of Medicine and Health Sciences, Baze University, Abuja, Nigeria
| | - Mustapha Umar Imam
- Centre for Advanced Medical Research and Training, Usmanu Danfodiyo University Sokoto, Nigeria
- Department of Medical Biochemistry, College of Health Sciences, Usmanu Danfodiyo University Sokoto, Nigeria
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Hack JB, Brewer KL, Meggs WJ. Comparing cost of F(.ab') 2AV vs FabAV in the treatment of copperhead envenomation-One center's experience. Am J Emerg Med 2023; 73:17-19. [PMID: 37573662 DOI: 10.1016/j.ajem.2023.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/31/2023] [Accepted: 08/06/2023] [Indexed: 08/15/2023] Open
Abstract
The definitive treatment of North American crotalid snakebites is antivenin. In 2000, an FabAV antivenom (CroFab®) was introduced and in 2022, F(ab')2AV (Anavip®) was approved for treatment of copperhead bites. Our center that sees primarily copperhead snake bites added the recently approved treatment as a second option for the 2022 snake bite season. This brief report we describe our initial experience with the two antivenins via retrospective chart review: the cost, charge, laboratory differences, response to therapy, complications and duration of hospitalization of admitted patients with copperhead envenomation. Using three independent reviewers in this IRB exempt report we found 31 patients with copperhead bites (7 exclusions) leaving 19 adults and 7 children for analysis. We found there was no difference in age, sex, presence of lab abnormalities, total vials administered, or length of stay. There was significant differences in hospital costs and charges to the patient. Future research should include multi-center experiences comparing the two antivenins.
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Affiliation(s)
- Jason B Hack
- Division of Medical Toxicology, United States of America; Department of Emergency Medicine, East Carolina University, Greenville, NC 27858, United States of America.
| | - Kori L Brewer
- Department of Emergency Medicine, East Carolina University, Greenville, NC 27858, United States of America
| | - William J Meggs
- Department of Emergency Medicine, East Carolina University, Greenville, NC 27858, United States of America
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Brandehoff N, Dalton A, Daugherty C, Dart RC, Monte AA. Total CroFab and Anavip Antivenom Vial Administration in US Rattlesnake Envenomations: 2019-2021. J Med Toxicol 2023:10.1007/s13181-023-00941-7. [PMID: 37115482 DOI: 10.1007/s13181-023-00941-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 04/29/2023] Open
Abstract
INTRODUCTION In 2018, Anavip became available for the treatment of rattlesnake envenomations in the USA. No comparisons between the treatment characteristics of patients have been made since Anavip and CroFab have both been widely available. The objective of this study was to compare the number of antivenom vials administered of CroFab and Anavip during the treatment of rattlesnake envenomations in the USA. METHODS This was a secondary analysis of rattlesnake envenomations utilizing the North American Snakebite Registry (NASBR) from 2019 through 2021. Frequencies and proportions were used to summarize demographics and baseline clinical characteristics. The primary outcome was total antivenom vials administered during treatment. Secondary outcomes included the number antivenom administration events, total treatment time, and hospital length of stay. RESULTS Two hundred ninety-one rattlesnake envenomations were analyzed; most occurred in the Western USA (n = 279, 96 %). One hundred one patients (35%) received only CroFab, 110 (38%) received Anavip only, and 80 (27%) received both products. The median number of vials used was 10 for CroFab, 18 for Anavip, and 20 for both antivenoms. More than one antivenom administration was necessary in thirty-nine (39%) patients that received only CroFab and 76 (69%) patients that received Anavip only. The median total treatment time was 5.5 hours for CroFab, 6.5 for Anavip, and 15.5 hours when both antivenoms were administered. All antivenom groups had a median hospital length of stay of 2 days. CONCLUSIONS Rattlesnake envenomated patients in the Western USA treated with CroFab had fewer antivenom vials and fewer antivenom administrations compared to patients treated with Anavip.
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Affiliation(s)
- Nicklaus Brandehoff
- Rocky Mountain Poison & Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Asclepius Snakebite Foundation, Seattle, WA, USA
| | - Alicia Dalton
- Rocky Mountain Poison & Drug Center, Denver Health and Hospital Authority, Denver, CO, USA.
| | | | - Richard C Dart
- Rocky Mountain Poison & Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Andrew A Monte
- Rocky Mountain Poison & Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Bhaumik S, Beri D, Tyagi J, Clarke M, Sharma SK, Williamson PR, Jagnoor J. Outcomes in intervention research on snakebite envenomation: a systematic review. F1000Res 2022; 11:628. [PMID: 36300033 PMCID: PMC9579743 DOI: 10.12688/f1000research.122116.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION A core outcome set (COS) is a minimal list of consensus outcomes that should be used in all intervention research in a specific domain. COS enhance the ability to undertake meaningful comparisons and to understand the benefits or harms of different treatments. A first step in developing a COS is to identify outcomes that have been used previously. We did this global systematic review to provide the foundation for development of a region-specific COS for snakebite envenomation. Methods: We searched 15 electronic databases, eight trial registries, and reference lists of included studies to identify reports of relevant trials, protocols, registry records and systematic reviews. We extracted verbatim data on outcomes, their definitions, measures, and time-points. Outcomes were classified as per an existing outcome taxonomy, and we identified unique outcomes based on similarities in the definition and measurement of the verbatim outcomes. RESULTS We included 107 records for 97 studies which met our inclusion criteria. These reported 538 outcomes, with a wide variety of outcome measures, definitions, and time points for measurement. We consolidated these into 88 unique outcomes, which we classified into core areas of mortality (1, 1.14 %), life impact (6, 6.82%), resource use (15, 17.05%), adverse events (7, 7.95%), physiological/clinical (51, 57.95%), and composite (8, 9.09%) outcomes. The types of outcomes varied by the type of intervention, and by geographic region. Only 15 of the 97 trials (17.04%) listed Patient Related Outcome Measures (PROMS). CONCLUSION Trials evaluating interventions for snakebite demonstrate heterogeneity on outcomes and often omit important information related to outcome measurement (definitions, instruments, and time points). Developing high quality, region-specific COS for snakebite could inform the design of future trials and improve outcome reporting. Measurement of PROMS, resource use and life impact outcomes in trials on snakebite remains a gap.
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Affiliation(s)
- Soumyadeep Bhaumik
- Injury Division, The George Institute for Global Health, Faculty of Medicine, University of New South Wales,, Sydney, New South Wales, 2042, Australia,Injury Division, The George Institute for Global Health, New Delhi, Delhi, 110025, India,Meta-research and Evidence Synthesis Unit, George Institute for Global Health, New Delhi, Delhi, 110025, India,
| | - Deepti Beri
- Injury Division, The George Institute for Global Health, New Delhi, Delhi, 110025, India
| | - Jyoti Tyagi
- Meta-research and Evidence Synthesis Unit, George Institute for Global Health, New Delhi, Delhi, 110025, India
| | - Mike Clarke
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Sanjib Kumar Sharma
- Department of Internal Medicine, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Paula R Williamson
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Jagnoor Jagnoor
- Injury Division, The George Institute for Global Health, Faculty of Medicine, University of New South Wales,, Sydney, New South Wales, 2042, Australia,Injury Division, The George Institute for Global Health, New Delhi, Delhi, 110025, India
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Tupetz A, Barcenas LK, Phillips AJ, Vissoci JRN, Gerardo CJ. BITES study: A qualitative analysis among emergency medicine physicians on snake envenomation management practices. PLoS One 2022; 17:e0262215. [PMID: 34995326 PMCID: PMC8741014 DOI: 10.1371/journal.pone.0262215] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 12/19/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Antivenom is currently considered standard treatment across the full spectrum of severity for snake envenomation in the United States. Although safe and effective antivenoms exist, their use in clinical practice is not universal. OBJECTIVE This study explored physicians' perceptions of antivenom use and experience with snake envenomation treatment in order to identify factors that influence treatment decisions and willingness to administer. METHODS We conducted a qualitative study including in-depth interviews via online video conferencing with physicians practicing in emergency departments across the United States. Participants were selected based on purposive sampling methods. Data analysis followed inductive strategies, conducted by two researchers. The codebook and findings were discussed within the research team. FINDINGS Sixteen in-depth interviews with physicians from nine states across the US were conducted. The participants' specialties include emergency medicine (EM), pediatric EM, and toxicology. The experience of treating snakebites ranged from only didactic education to having treated over 100 cases. Emergent themes for this manuscript from the interview data included perceptions of antivenom, willingness to administer antivenom and influencing factors to antivenom usage. Overall, cost-related concerns were a major barrier to antivenom administration, especially in cases where the indications and effectiveness did not clearly outweigh the potential financial burden on the patient in non-life- or limb-threatening cases. The potential to decrease recovery time and long-term functional impairments was not commonly reported by participants as an indication for antivenom. In addition, level of exposure and perceived competence, based on prior education and clinical experience, further impacted the decision to treat. Resources such as Poison Center Call lines were well received and commonly used to guide the treatment plan. The need for better clinical guidelines and updated treatment algorithms with clinical and measurable indicators was stated to help the decision-making process, especially among those with low exposure to snake envenomation patients. CONCLUSIONS A major barrier to physician use of antivenom is a concern about cost, cost transparency and cost-benefit for the patients. Those concerns, in addition to the varying degrees of awareness of potential long-term benefits, further influence inconsistent clinical treatment practices.
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Affiliation(s)
- Anna Tupetz
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Loren K. Barcenas
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Ashley J. Phillips
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Joao Ricardo Nickenig Vissoci
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Charles J. Gerardo
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- * E-mail:
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Abstract
SNAKE ENVENOMATION REPRESENTS AN IMPORTANT HEALTH PROBLEM IN much of the world. In 2009, it was recognized by the World Health Organization (WHO) as a neglected tropical disease, and in 2017, it was elevated into Category A of the Neglected Tropical Diseases list, further expanding access to funding for research and antivenoms. However, snake envenomation occurs in both tropical and temperate climates and on all continents except Antarctica. Worldwide, the estimated number of annual deaths due to snake envenomation (80,000 to 130,000) is similar to the estimate for drug-resistant tuberculosis and for multiple myeloma., In countries with adequate resources, deaths are infrequent (e.g., <6 deaths per year in the United States, despite the occurrence of 7000 to 8000 bites), but in countries without adequate resources, deaths may number in the tens of thousands. Venomous snakes kept as pets are not rare, and physicians anywhere might be called on to manage envenomation by a nonnative snake. Important advances have occurred in our understanding of the biology of venom and the management of snake envenomation since this topic was last addressed in the Journal two decades ago. For the general provider, it is important to understand the spectrum of snake envenomation effects and approaches to management and to obtain specific guidance, when needed.
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Affiliation(s)
- Steven A Seifert
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
| | - James O Armitage
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
| | - Elda E Sanchez
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
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Ramirez-Cueva F, Larsen A, Knowlton E, Baab K, Rainey Kiehl R, Hendrix A, Condren M, Woslager M. Predictors of FabAV use in copperhead envenomation. Clin Toxicol (Phila) 2022; 60:609-614. [PMID: 34989644 DOI: 10.1080/15563650.2021.2018454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
CONTEXT Crotaline snake envenomation is a serious medical condition affecting thousands of Americans each year. Variation in the treatment of Crotaline snakebites exists among physicians in the United States. Management of copperhead snakebites is controversial with some experts advocating minimal intervention, rarely necessitating antivenom use and, even more rarely, surgical intervention. This study assessed the use of Crotaline Polyvalent Immune Fab antivenom (Ovine) (FabAV) and explored factors influencing the decision to prescribe antivenom for copperhead envenomation in patients in Northeastern Oklahoma. METHODS A retrospective cohort study examining electronic medical records of patients with copperhead snakebites from July 1, 2014 to August 31, 2019. Data collected included: patient demographics, transfer information, snake species, bite site, progression of local tissue effects, additional clinical and lab results, patient comorbidities, and treatment strategy. Associations between patient variables and treatment were evaluated using the chi-square test of independence, median test, and logistic regression analysis. Associations were statistically significant if p < 0.05. DISCUSSION Of the 130 patients bitten by a copperhead, a majority (75%) received FabAV. Symptoms of copperhead envenomation were mostly limited to the progression of tissue damage. Predictors of treatment with FabAV included progression of venom effects across major joints, younger age, comorbidities, and upper extremity bites. CONCLUSIONS Patients who have multiple comorbidities, upper extremity bites and progression of venom effects across major joints are more likely to be treated with FabAV. The high usage of FabAV at the study site underscores the need for continued work to optimize the use of antivenom for copperhead envenomations.
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Affiliation(s)
| | - Adam Larsen
- Department of Pediatrics, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Elise Knowlton
- Department of Pediatrics, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Kelsey Baab
- College of Medicine, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Robin Rainey Kiehl
- College of Medicine, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Amy Hendrix
- Department of Pediatrics, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Michelle Condren
- Department of Pediatrics, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Megan Woslager
- Department of Pediatrics, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
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Tsai TS, Liu CC, Chuang PC. Personal Experience of Daboia siamensis Envenomation. Case Rep Med 2021; 2021:3396373. [PMID: 34976069 DOI: 10.1155/2021/3396373] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/08/2021] [Indexed: 11/24/2022] Open
Abstract
Reports of envenomation induced by Daboia siamensis, a medically important venomous snake in Taiwan, are rare, and species identification might not be definitive. This article reports the complete course of a definite D. siamensis bite. The patient in this report was one of the authors who was bitten on the right palm near the base of the index finger by D. siamensis. The patient experienced local effects, neurological manifestations, and acute kidney injury. The laboratory analysis revealed elevated D-dimer and coagulopathy. The patient was administered 8 vials of antivenom and did not undergo surgical intervention or endotracheal tube intubation, but serum sickness occurred 8 days after antivenom administration. The horse immunoglobulin produced by the Centers for Disease Control, R. O. C. (Taiwan), against D. siamensis was effective and safe in the treatment of the patient. However, the best antivenom administration strategy remains unclear and requires further study.
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Knudsen C, Jürgensen JA, Føns S, Haack AM, Friis RUW, Dam SH, Bush SP, White J, Laustsen AH. Snakebite Envenoming Diagnosis and Diagnostics. Front Immunol 2021; 12:661457. [PMID: 33995385 PMCID: PMC8113877 DOI: 10.3389/fimmu.2021.661457] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/29/2021] [Indexed: 11/13/2022] Open
Abstract
Snakebite envenoming is predominantly an occupational disease of the rural tropics, causing death or permanent disability to hundreds of thousands of victims annually. The diagnosis of snakebite envenoming is commonly based on a combination of patient history and a syndromic approach. However, the availability of auxiliary diagnostic tests at the disposal of the clinicians vary from country to country, and the level of experience within snakebite diagnosis and intervention may be quite different for clinicians from different hospitals. As such, achieving timely diagnosis, and thus treatment, is a challenge faced by treating personnel around the globe. For years, much effort has gone into developing novel diagnostics to support diagnosis of snakebite victims, especially in rural areas of the tropics. Gaining access to affordable and rapid diagnostics could potentially facilitate more favorable patient outcomes due to early and appropriate treatment. This review aims to highlight regional differences in epidemiology and clinical snakebite management on a global scale, including an overview of the past and ongoing research efforts within snakebite diagnostics. Finally, the review is rounded off with a discussion on design considerations and potential benefits of novel snakebite diagnostics.
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Affiliation(s)
- Cecilie Knudsen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
- BioPorto Diagnostics A/S, Hellerup, Denmark
| | - Jonas A. Jürgensen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Sofie Føns
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Aleksander M. Haack
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Rasmus U. W. Friis
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Søren H. Dam
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Sean P. Bush
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Julian White
- Toxinology Department, Women’s and Children’s Hospital, North Adelaide, SA, Australia
| | - Andreas H. Laustsen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
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12
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Gerardo CJ, Silvius E, Schobel S, Eppensteiner JC, McGowan LM, Elster EA, Kirk AD, Limkakeng AT. Association of a Network of Immunologic Response and Clinical Features With the Functional Recovery From Crotalinae Snakebite Envenoming. Front Immunol 2021; 12:628113. [PMID: 33790901 PMCID: PMC8006329 DOI: 10.3389/fimmu.2021.628113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/26/2021] [Indexed: 11/26/2022] Open
Abstract
Background The immunologic pathways activated during snakebite envenoming (SBE) are poorly described, and their association with recovery is unclear. The immunologic response in SBE could inform a prognostic model to predict recovery. The purpose of this study was to develop pre- and post-antivenom prognostic models comprised of clinical features and immunologic cytokine data that are associated with recovery from SBE. Materials and Methods We performed a prospective cohort study in an academic medical center emergency department. We enrolled consecutive patients with Crotalinae SBE and obtained serum samples based on previously described criteria for the Surgical Critical Care Initiative (SC2i)(ClinicalTrials.gov Identifier: NCT02182180). We assessed a standard set of clinical variables and measured 35 unique cytokines using Luminex Cytokine 35-Plex Human Panel pre- and post-antivenom administration. The Patient-Specific Functional Scale (PSFS), a well-validated patient-reported outcome of functional recovery, was assessed at 0, 7, 14, 21 and 28 days and the area under the patient curve (PSFS AUPC) determined. We performed Bayesian Belief Network (BBN) modeling to represent relationships with a diagram composed of nodes and arcs. Each node represents a cytokine or clinical feature and each arc represents a joint-probability distribution (JPD). Results Twenty-eight SBE patients were enrolled. Preliminary results from 24 patients with clinical data, 9 patients with pre-antivenom and 11 patients with post-antivenom cytokine data are presented. The group was mostly female (82%) with a mean age of 38.1 (SD ± 9.8) years. In the pre-antivenom model, the variables most closely associated with the PSFS AUPC are predominantly clinical features. In the post-antivenom model, cytokines are more fully incorporated into the model. The variables most closely associated with the PSFS AUPC are age, antihistamines, white blood cell count (WBC), HGF, CCL5 and VEGF. The most influential variables are age, antihistamines and EGF. Both the pre- and post-antivenom models perform well with AUCs of 0.87 and 0.90 respectively. Discussion Pre- and post-antivenom networks of cytokines and clinical features were associated with functional recovery measured by the PSFS AUPC over 28 days. With additional data, we can identify prognostic models using immunologic and clinical variables to predict recovery from SBE.
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Affiliation(s)
| | | | - Seth Schobel
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | | | - Lauren M McGowan
- Department of Surgery, Duke University, Durham, NC, United States
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Allan D Kirk
- Department of Surgery, Duke University, Durham, NC, United States
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13
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Wilson BZ, Larsen J, Smelski G, Dudley S, Shirazi FM. Use of Crotalidae equine immune F(ab') 2 antivenom for treatment of an Agkistrodon envenomation. Clin Toxicol (Phila) 2021; 59:1023-1026. [PMID: 33703984 DOI: 10.1080/15563650.2021.1892718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Anavip (F(ab')2AV) is a lyophilized F(ab')2 immunoglobulin fragment derived from horses immunized with venom from Bothrops asper and Crotalus durissus. It was approved by the FDA in 2015 for treatment of North American rattlesnake envenomation but not for Agkistrodon envenomation. Published data regarding the efficacy and safety of Anavip in treating Agkistrodon envenomations is limited. We present a case of a patient treated with Anavip after confirmed Agkistrodon laticinctus envenomation. CASE DETAILS A 77 year-old man was bitten on his fifth finger by a captive A. laticinctus. He was taken to a local emergency department where he received a 10 vial initial dose of F(ab')2AV for pain and swelling and was transferred. At the receiving facility, his pain had improved and his swelling had not progressed. Over the next 30 h, his platelets declined to 132,000/mm3 and he received an additional 4 vials of F(ab')2AV. The remainder of his course was unremarkable with complete recovery by 3 months. DISCUSSION This case provides an additional published datapoint on the use of this F(ab')2AV in the treatment of envenomation by Agkistrodon.
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Affiliation(s)
- B Z Wilson
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.,Arizona Poison and Drug Information Center, University of Arizona, Tucson, AZ, USA
| | - J Larsen
- Arizona Poison and Drug Information Center, University of Arizona, Tucson, AZ, USA
| | - G Smelski
- Arizona Poison and Drug Information Center, University of Arizona, Tucson, AZ, USA
| | - S Dudley
- Arizona Poison and Drug Information Center, University of Arizona, Tucson, AZ, USA
| | - F M Shirazi
- Arizona Poison and Drug Information Center, University of Arizona, Tucson, AZ, USA
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14
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Greene S, Cheng D, Vilke GM, Winkler G. How Should Native Crotalid Envenomation Be Managed in the Emergency Department? J Emerg Med 2021; 61:41-48. [PMID: 33622584 DOI: 10.1016/j.jemermed.2021.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 01/17/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pit vipers, also known as crotalids, are a group of snakes including rattlesnakes, copperheads, and cottonmouths (water moccasins). Crotalids have a broad geographic distribution across the United States, and bites from these snakes can carry significant morbidity. Their envenomations are characterized by local tissue effects, hematologic effects, and systemic effects. Envenomations are generally treated with 1 of 2 antivenoms available in the United States. OBJECTIVE We developed a series of clinical questions to assist and guide the emergency physician in the acute management of a patient envenomated by a crotalid. METHODS We conducted a PubMed literature review from January 1970 to May 2020 in English for articles with the keywords "bite" and "crotalidae." RESULTS Our literature search resulted in 177 articles. A total of 33 articles met criteria for rigorous review and citation in the development of these consensus guidelines. CONCLUSIONS Patients should be initially evaluated, stabilized, and assessed for local effects, hematologic effects, and systemic toxicity suggestive of envenomation. Antivenom should be given if toxic effects are present. Surgical intervention including debridement and fasciotomy should be avoided. Prophylactic antibiotics are not necessary.
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Affiliation(s)
- Spencer Greene
- Department of Emergency Medicine, HCA Houston Healthcare-Kingwood, University of Houston College of Medicine, Kingwood, Texas
| | - David Cheng
- Department of Emergency Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - Gary M Vilke
- Department of Emergency Medicine, University of California at San Diego Medical Center, San Diego, California
| | - Garret Winkler
- Division of Medical Toxicology, Department of Emergency Medicine, University of California San Diego Health, VA San Diego Healthcare System, San Diego, California
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15
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Martin AM, Wang GS, Poel K. Use of both Fab and F(ab') 2 fragment antivenom in a pediatric patient for treatment of a North American Crotalidae envenomation. Am J Emerg Med 2020; 45:677.e1-677.e3. [PMID: 33293188 DOI: 10.1016/j.ajem.2020.11.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 10/22/2020] [Accepted: 11/05/2020] [Indexed: 11/28/2022] Open
Abstract
Crotalidae envenomation has been managed successfully in emergency departments across the world with antivenom. Over the years, antivenom has evolved and newer agents have been studied with the possibility of eliminating maintenance antivenom therapy. Here we report a patient who had worsening platelet and fibrinogen concentrations, as well as complaints of swelling and pain at the site of a rattlesnake envenomation following an initial dose of F(ab')2AV (Crotalidae immune F(ab')2 (equine) [ANAVIP®]) Crotalidae antivenom. The patient was subsequently transferred to a tertiary children's hospital for a higher level of care and received FabAV (Crotalidae polyvalent immune Fab (ovine) [CroFab®]) Crotalidae antivenom. The details of this patient's treatment course highlight the possibility that patients who receive F(ab')2AV, may require additional antivenom treatment. Furthermore, it appears that based on our single patient experience, giving FabAV after F(ab')2AV is safe and effective.
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Affiliation(s)
- Ashley M Martin
- Department of Pharmacy, Children's Hospital Colorado, 13123 East 16th Avenue, Box 375, Aurora, CO 80045, United States.
| | - George S Wang
- Department of Pediatrics, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, 13123 East 16th Avenue, Box 065, Aurora, CO 80045, United States
| | - Kevin Poel
- Department of Pharmacy, Children's Hospital Colorado, 13123 East 16th Avenue, Box 375, Aurora, CO 80045, United States
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16
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Miller SW, Osterhoudt KC, Korenoski AS, Patel K, Vaiyapuri S. Exotic Snakebites Reported to Pennsylvania Poison Control Centers: Lessons Learned on the Demographics, Clinical Effects, and Treatment of These Cases. Toxins (Basel) 2020; 12:toxins12120755. [PMID: 33260454 PMCID: PMC7760318 DOI: 10.3390/toxins12120755] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 11/23/2020] [Accepted: 11/26/2020] [Indexed: 01/27/2023] Open
Abstract
Exotic snakebites (i.e. from non-native species) are a rare occurrence, but they present a unique challenge to clinicians treating these patients. Poison control centers are often contacted to assist in the management and care of these medical emergencies. In this study, we analyzed case records of the two Pennsylvania poison control centers from 2004 to 2018 to describe clinical features reported as a result of exotic snakebite envenomation. For the 15-year period reviewed, 18 exotic snakebites were reported with effects ranging from mild local tissue injury to patients who were treated with mechanical ventilation due to respiratory failure. The mean age of the patients was 35 years and males accounted for 83% of the cases. Antivenom, the only specific treatment, was administered in seven of 18 patients within an average of four h of envenomation. The procurement of antivenom against these exotic species may require substantial logistical efforts due to limited stocking of this rarely used treatment. Newer, targeted, small molecule treatments that are being currently investigated may aid in the treatment of snakebites in general. However, people should be cautious when handling these exotic species, and clinicians should be aware of these bites and relevant clinical effects in order to manage these when reported.
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Affiliation(s)
- Stephen W. Miller
- School of Pharmacy, University of Reading, Reading RG6 6UB, UK
- The Poison Control Center, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA;
- Correspondence: (S.W.M.); (S.V.)
| | - Kevin C. Osterhoudt
- The Poison Control Center, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA;
| | - Amanda S. Korenoski
- Pittsburgh Poison Center, University of Pittsburgh, Pittsburgh, PA 15213, USA;
| | - Ketan Patel
- School of Biological Sciences, University of Reading, Reading RG6 6UB, UK;
| | - Sakthivel Vaiyapuri
- School of Pharmacy, University of Reading, Reading RG6 6UB, UK
- Correspondence: (S.W.M.); (S.V.)
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Abstract
PURPOSE For the first time in nearly 20 years, 2 antigen-binding fragment (Fab) antivenoms are available to treat patients who incur North American pit viper snakebites: Crotalidae polyvalent immune Fab (ovine), or simply FabAV; and Crotalidae immune F(ab')2 (equine), or simply F(ab')2. Pharmacists are in a key position for the selection, dosing, reconstitution, administration, and monitoring of antivenom therapy; however, they encounter inconsistent exposure and experience with these drugs. Thus, an updated review of the literature is necessary. METHODS The search strategy and selection incorporated both controlled vocabulary terms and keywords to describe concepts relevant to the search. Retrieval was limited to literature published from 1997 to the present in English, Portuguese, or Spanish. RESULTS Given the paucity of available prospective literature, the authors elected to include all prospective evidence to best describe the role of antivenom. For the primary literature review, manuscripts were excluded if they were observational studies, conference abstracts, narrative or opinion articles, letters to the editor, or in-progress studies. CONCLUSION While there is limited evidence-based guidance on the superiority of F(ab')2 to FabAV, or vice versa, individual and regional considerations should contribute to formulary decisions. Pharmacists must play a role in the development of clinical pathways to ensure appropriate evaluation, supportive care, and antivenom procurement, administration, and monitoring.
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Affiliation(s)
| | - Jami Johnson
- Oklahoma Center for Poison and Drug Information, Oklahoma City, OK, and University of Oklahoma College of Pharmacy, Oklahoma City, OK
| | - Shari Clifton
- Reference & Instructional Services, Robert M. Bird Health Sciences Library, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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18
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Chuang PC, Chang KW, Cheng SY, Pan HY, Huang KC, Huang YT, Li CJ. Benefits of Early In-Hospital Antivenom Administration to Patients with Protobothrops mucrosquamatus Envenomation. Am J Trop Med Hyg 2020; 104:323-328. [PMID: 33146122 DOI: 10.4269/ajtmh.20-0659] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Protobothrops mucrosquamatus is one of the common venomous snakes in Southeast Asia. This retrospective cohort study conducted in six medical institutions in Taiwan aimed to obtain information on the optimal management strategies for P. mucrosquamatus snakebite envenomation. Data were extracted from the Chang Gung Research Database from January 2006 to December 2016. The association between early antivenom administration and patient demographics, pain requiring treatment with analgesic injections, and hospital length of stay was analyzed. A total of 195 patients were enrolled; 130 were administered antivenom within 1 hour after emergency department arrival (early group), whereas 65 were treated later than 1 hour after arrival (late group). No in-hospital mortality was identified. The difference in surgical intervention rates between the early and late groups was statistically insignificant (P = 0.417). Compared with the early group, the late group showed a higher rate of antivenom skin test performance (46.9% versus 63.1%, respectively, P = 0.033), longer hospital stay (42 ± 62 hours versus 99 ± 70 hours, respectively, P = 0.016), and higher rate of incidences of pain requiring treatment with analgesic injections (29.2% versus 46.2%, respectively, P = 0.019). After adjusting for confounding factors, early antivenom administration was associated with decreased pain requiring treatment with analgesic injections (adjusted odds ratio: 0.51, 95% CI: 0.260-0.985). Antivenom administration within 1 hour of arrival was associated with a decreased likelihood of experiencing pain and hospital length of stay in patients with P. mucrosquamatus snakebites. Antivenom skin testing was associated with delays in antivenom administration.
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Affiliation(s)
- Po-Chun Chuang
- 1Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Kang-Wei Chang
- 1Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Shih-Yu Cheng
- 1Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Hsiu-Yung Pan
- 1Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan.,2Chang Gung University College of Medicine, Taoyuan City, Taiwan
| | - Kuo-Chen Huang
- 1Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Yii-Ting Huang
- 1Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Chao-Jui Li
- 1Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan
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Lin JH, Sung WC, Liao JW, Hung DZ. A Rapid and International Applicable Diagnostic Device for Cobra (Genus Naja) Snakebites. Toxins (Basel) 2020; 12:toxins12090572. [PMID: 32899472 PMCID: PMC7551368 DOI: 10.3390/toxins12090572] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 08/31/2020] [Accepted: 09/03/2020] [Indexed: 11/16/2022] Open
Abstract
Cobra snakes (genus Naja) are some of the most dangerous snake species in Asia and Africa, as their bites cause severe life-threatening respiratory failure and local tissue destruction, especially in the case of late diagnosis. The differential diagnosis of snakebite envenomation still mainly relies upon symptomatology, the patient’s description, and the experience of physicians. We have designed a rapid test, immunochromatographic test of cobra (ICT-Cobra), which obtained fair results in improving the diagnosis and treatment of Naja (N.) atra snakebites in Taiwan. In this study, we further investigated the feasibility of applying the kit for the detection of other cobra venoms based on the potential interspecies similarity. We firstly demonstrated the cross-reactivity between eight venoms of medically important cobra species and the rabbit anti-N. atra IgG that was used in ICT-Cobra by Western blotting and sandwich enzyme-linked immunosorbent assay. Then, ICT-Cobra was used to detect various concentrations of the eight venoms to elucidate its performance. Noticeable correlations between the cross-reactivity of venoms from genus Naja snakes and existing geographical characteristics were found. ICT-Cobra could detect venoms from other Asian cobras with variable detection limits comparable to those observed for N. atra, but the kit was less successful in the detection of venom from African cobras. The similar but slightly different venom components and the interaction between venom and rabbit anti-N. atra IgG led to variations in the detection limits. The transcontinental usage of ICT-Cobra might be possible due to the cross-reactivity of antibodies and similarities among the larger-sized proteins. This study showed that the close immunological relationships in the genus Naja could be used to develop a venom detection kit for the diagnosis of cobra envenomation in both Asian and African regions. Additional clinical studies and technical adjustments are still needed to improve the efficacy and broadening the application of ICT-Cobra in the future.
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Affiliation(s)
- Jing-Hua Lin
- Graduate Institute of Veterinary Pathobiology, National Chung Hsing University, Taichung 40227, Taiwan;
| | - Wang-Chou Sung
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli 35053, Taiwan;
| | - Jiunn-Wang Liao
- Graduate Institute of Veterinary Pathobiology, National Chung Hsing University, Taichung 40227, Taiwan;
- Correspondence: (J.-W.L.); (D.-Z.H.); Tel.: +886-4-2284-0894 (J.-W.L.); +886-4-2205-2121 (D.-Z.H.)
| | - Dong-Zong Hung
- Division of Toxicology, China Medical University Hospital, Taichung 40447, Taiwan
- Correspondence: (J.-W.L.); (D.-Z.H.); Tel.: +886-4-2284-0894 (J.-W.L.); +886-4-2205-2121 (D.-Z.H.)
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20
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Lin JH, Lo CM, Chuang SH, Chiang CH, Wang SD, Lin TY, Liao JW, Hung DZ. Collocation of avian and mammal antibodies to develop a rapid and sensitive diagnostic tool for Russell's Vipers Snakebite. PLoS Negl Trop Dis 2020; 14:e0008701. [PMID: 32956365 PMCID: PMC7529284 DOI: 10.1371/journal.pntd.0008701] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 10/01/2020] [Accepted: 08/12/2020] [Indexed: 12/13/2022] Open
Abstract
Russell's vipers (RVs) envenoming is an important public health issue in South-East Asia. Disseminated intravascular coagulopathy, systemic bleeding, hemolysis, and acute renal injury are obvious problems that develop in most cases, and neuromuscular junction blocks are an additional problem caused by western RV snakebite. The complex presentations usually are an obstacle to early diagnosis and antivenom administration. Here, we tried to produce highly specific antibodies in goose yolks for use in a paper-based microfluidic diagnostic kit, immunochromatographic test of viper (ICT-Viper), to distinguish RVs from other vipers and even cobra snakebite in Asia. We used indirect ELISA to monitor specific goose IgY production and western blotting to illustrate the interaction of avian or mammal antibody with venom proteins. The ICT-Viper was tested not only in prepared samples but also in stored patient serum to demonstrate its preliminary efficacy. The results revealed that specific anti-Daboia russelii IgY could be raised in goose eggs effectively without inducing adverse effects. When it was collocated with horse anti-Daboia siamensis antibody, which broadly reacted with most of the venom proteins of both types of Russell's viper, the false cross-reactivity was reduced, and the test showed good performance. The limit of detection was reduced to 10 ng/ml in vitro, and the test showed good detection ability in clinical snake envenoming case samples. The ICT-Viper performed well and could be combined with a cobra venom detection kit (ICT-Cobra) to create a multiple detection strip (ICT-VC), which broadens its applications while maintaining its detection ability for snake envenomation identification. Nonetheless, the use of the ICT-Viper in the South-East Asia region is pending additional laboratory and field investigations and regional collaboration. We believe that the development of this practical diagnostic tool marks the beginning of positive efforts to face the global snakebite issue.
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Affiliation(s)
- Jing-Hua Lin
- Graduate Institute of Veterinary Pathobiology, National Chung Hsing University, Taichung, Taiwan
- Division of Toxicology, China Medical University Hospital, Taichung, Taiwan
| | - Che-Min Lo
- Division of Toxicology, China Medical University Hospital, Taichung, Taiwan
| | - Ssu-Han Chuang
- Changhua Animal Propagation Station, Livestock Research Institute, Council of Agriculture, Executive Yuan, Changhua, Taiwan
| | - Chao-Hung Chiang
- Changhua Animal Propagation Station, Livestock Research Institute, Council of Agriculture, Executive Yuan, Changhua, Taiwan
| | - Sheng-Der Wang
- Changhua Animal Propagation Station, Livestock Research Institute, Council of Agriculture, Executive Yuan, Changhua, Taiwan
| | - Tsung-Yi Lin
- Changhua Animal Propagation Station, Livestock Research Institute, Council of Agriculture, Executive Yuan, Changhua, Taiwan
| | - Jiunn-Wang Liao
- Graduate Institute of Veterinary Pathobiology, National Chung Hsing University, Taichung, Taiwan
| | - Dong-Zong Hung
- Division of Toxicology, China Medical University Hospital, Taichung, Taiwan
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Greene SC, Morales-Perez L, Pallini M, Vences C, Carnell J. LTE: comment on “Incidence of allergic reactions to crotalidae polyvalent immune fab”. Clin Toxicol (Phila) 2020; 58:214-215. [DOI: 10.1080/15563650.2019.1618467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Spencer C. Greene
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | | | - Michael Pallini
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Carlos Vences
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jennifer Carnell
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
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Lavonas EJ, Burnham RI, Schwarz J, Quackenbush E, Lewis B, Rose SR, Greene S, Toschlog EA, Charlton NP, Mullins ME, Schwartz R, Denning D, Sharma K, Kleinschmidt K, Bush SP, Anderson VE, Ginde AA, Gerardo CJ. Recovery from Copperhead Snake Envenomation: Role of Age, Sex, Bite Location, Severity, and Treatment. J Med Toxicol 2019; 16:17-23. [PMID: 31482319 DOI: 10.1007/s13181-019-00733-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 07/23/2019] [Accepted: 08/19/2019] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Few data exist to understand the recovery phase of pit viper envenomation. A recently published placebo-controlled clinical trial affords this opportunity. The purpose of this study is to examine the time course of recovery from copperhead snake (Agkistrodon contortrix) envenomation patients managed with and without the use of antivenom, stratified by age, sex, anatomic site of envenomation, initial severity of envenomation, and geographic region. METHODS This is a post-hoc subgroup analysis of data from a multi-center double-blinded clinical trial of Fab antivenom (FabAV) vs. placebo. Outcomes were the Patient-Specific Functional Scale (PSFS) score at 3, 7, 10, and 14 days after envenomation. Least-squares mean PSFS score curves were calculated for each subgroup, and repeated measures ANOVA was used to estimate between-group comparisons. RESULTS Seventy-two subjects were included, of whom 44 received FabAV. Males demonstrated better overall recovery than females (model predicted PSFS score 6.18 vs 4.99; difference 1.19; 95% CI 0.12 to 2.25; p = 0.029). No sex difference was found in response to FabAV. Overall recovery and effect of FabAV were similar in adult vs adolescent patients, patients with upper vs lower extremity envenomation, and patients with initially mild vs moderate envenomation signs. Analysis by geographic location was not successful due to ANOVA mode instability. CONCLUSIONS Male victims of copperhead snake envenomation demonstrate slightly better recovery than females, but response to Fab antivenom overall is similar across all subgroups studied.
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Affiliation(s)
- Eric J Lavonas
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA. .,Department of Emergency Medicine, Denver Health and Hospital Authority, Denver, CO, USA. .,Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Randy I Burnham
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - John Schwarz
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - Eugenia Quackenbush
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Brandon Lewis
- Texas A&M Health Science Center, College Station, TX, USA
| | - S Rutherfoord Rose
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Spencer Greene
- Henry J. N. Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Eric A Toschlog
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Nathan P Charlton
- Division of Medical Toxicology, University of Virginia, Charlottesville, VA, USA
| | - Michael E Mullins
- Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Richard Schwartz
- Department of Emergency Medicine and Hospital Services, Medical College of Georgia, Augusta, GA, USA
| | - David Denning
- Department of Surgery, Marshall Health, Huntington, WV, USA
| | - Kapil Sharma
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kurt Kleinschmidt
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sean P Bush
- Department of Emergency Medicine, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Victoria E Anderson
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Charles J Gerardo
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, NC, USA
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Affiliation(s)
- Eric J Lavonas
- Department of Emergency Medicine and Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | | | - Charles J Gerardo
- Division of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA
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Carpenter J, Murray BP, Rothstein LS, Steck A. In reply to: “Early administration of fab antivenom resulted in faster limb recovery in copperhead snake envenomation patients” by Anderson et al., CLIN TOXICOL 2018, ahead of print. Clin Toxicol (Phila) 2019; 57:673-674. [DOI: 10.1080/15563650.2018.1541180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Joseph Carpenter
- Georgia Poison Center, Atlanta, GA, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Alaina Steck
- Georgia Poison Center, Atlanta, GA, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Shah KR, Beuhler MC. Comment on "Early administration of fab antivenom resulted in faster limb recovery in copperhead snake envenomation patients". Clin Toxicol (Phila) 2019; 58:222-223. [PMID: 31140332 DOI: 10.1080/15563650.2019.1620263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Kartik R Shah
- Division of Medical Toxicology, Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, NC, USA
| | - Michael C Beuhler
- Division of Medical Toxicology, Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, NC, USA
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Baumgartner KT, Fishburn SJ, Mullins ME. Current Management of Copperhead Snakebites in Missouri. Mo Med 2019; 116:201-205. [PMID: 31527942 PMCID: PMC6690278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The past two decades have seen changes to the management of copperhead snakebites. We review the current use of antivenom, analgesics, and laboratory testing as well as the declining role of surgical management.
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Affiliation(s)
- Kevin T Baumgartner
- Kevin T. Baumgartner, MD, is a senior resident in emergency medicine and will begin a fellowship in medical toxicology in July 2019. Steven J. Fishburn, MD, MSCR, is a fellow in medical toxicology and a specialist in occupational medicine. Michael E. Mullins MD, FACEP, FAACT, is an associate professor in emergency medicine at Washington university school of Medicine in St. Louis. He serves as an attending emergency physician at Barnes-Jewish Hospital and a medical toxicology consultant at Barnes-Jewish Hospital and Saint Louis Children's Hospital
| | - Steven J Fishburn
- Kevin T. Baumgartner, MD, is a senior resident in emergency medicine and will begin a fellowship in medical toxicology in July 2019. Steven J. Fishburn, MD, MSCR, is a fellow in medical toxicology and a specialist in occupational medicine. Michael E. Mullins MD, FACEP, FAACT, is an associate professor in emergency medicine at Washington university school of Medicine in St. Louis. He serves as an attending emergency physician at Barnes-Jewish Hospital and a medical toxicology consultant at Barnes-Jewish Hospital and Saint Louis Children's Hospital
| | - Michael E Mullins
- Kevin T. Baumgartner, MD, is a senior resident in emergency medicine and will begin a fellowship in medical toxicology in July 2019. Steven J. Fishburn, MD, MSCR, is a fellow in medical toxicology and a specialist in occupational medicine. Michael E. Mullins MD, FACEP, FAACT, is an associate professor in emergency medicine at Washington university school of Medicine in St. Louis. He serves as an attending emergency physician at Barnes-Jewish Hospital and a medical toxicology consultant at Barnes-Jewish Hospital and Saint Louis Children's Hospital
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