Partial segmental thrombosis of the corpus cavernosum following Russell's viper bite

Snakebite envenoming (SBE) is common in rural communities living in tropical regions that often have fragile and/or overwhelmed healthcare systems. The complex scenarios around SBE lead to a high number of deaths, disabilities, and long-term consequences in patients. Russell's viper (Daboia russelii) is one of the most medically important snake species in India, which causes devastating pathological conditions characterised by a wide range of clinical manifestations. This broad spectrum of symptoms requires additional therapeutic interventions beyond the classical antivenom administration. Hence, positive outcomes for patients affected by SBE can be achieved with a better understanding of previous experiences describing clinical manifestations and various therapeutic interventions including for rare and underreported conditions. Here, we report an SBE victim who developed partial segmental thrombosis in the corpus cavernosum following Russell's viper envenomation and its diagnostic and treatment approaches. The patients received 180 ml of antivenom to resolve the abnormalities in their haematological parameters. Despite antivenom treatment, they developed severe pain in their genital region, and subsequent ultrasound and magnetic resonance imaging confirmed segmental thrombosis in the corpus cavernosum, which required supportive measures. The treatment using low molecular weight heparin, rivaroxaban and non-steroidal anti-inflammatory drugs resolved segmental thrombosis. In conclusion, this case report exemplifies the development of a rare segmental thrombosis in corpus cavernosum and how the medical, scientific, and general community can benefit from documenting clinical manifestations, medically relevant insights into patient care and the management of underreported complications.

Identifying key factors contributing to treatment costs for snakebite envenoming in private tertiary healthcare settings in Tamil Nadu, India

BACKGROUND

India suffers ~58,000 annual deaths due to snakebites. The 'Big Four' snakes (Russell's viper, Indian cobra, common krait, and saw-scaled viper) that are responsible for most bites cause diverse clinical effects. Delayed treatment increases the risk of serious complications and treatment costs. Although government hospitals offer free treatment for snakebites in India, most patients opt for private healthcare, which is an out-of-pocket expense as they often lack health insurance coverage. This study aims to analyse snakebite treatment costs in private tertiary care hospitals in Tamil Nadu, India and identifies the key factors contributing to treatment costs.

METHODOLOGY/PRINCIPAL FINDINGS

The treatment cost details for 913 snakebite victims were collected from 10 private tertiary care hospitals across Tamil Nadu. The data were classified into hospital, pharmacy, investigation, and laboratory costs, and analysed to determine various factors that contribute to the costs. The results demonstrate that the average treatment costs vary widely for different snakes. The hospital and pharmacy costs are higher than investigation and laboratory costs for all snakebites. Notably, Russell's viper bites cost significantly more than the bites from other snakes. Overall, the type of snake, nature of complications, specialist treatments required, and arrival time to hospitals were identified as some of the key factors for higher treatment costs.

CONCLUSIONS/SIGNIFICANCE

These data demonstrate that ~80% of snakebite patients can be treated with INR 100,000 (~GBP 1000 or USD 1200) or less. This study emphasises the urgent need to improve rural medical care by providing appropriate training for healthcare professionals and essential resources to facilitate early assessment of patients, administer the initial dose of antivenom and refer the patients to tertiary care only when needed. Moreover, the outcome of this study forms a basis for developing appropriate policies to regulate snakebite treatment costs and provide affordable medical insurance for vulnerable communities.

Neutrophil-mediated erythrophagocytosis following Russell's viper (Daboia russelii) bite

Snakebite envenomation is regarded as a high-priority neglected tropical disease by the World Health Organisation, as it results in significant loss of lives and permanent disabilities. Russell's viper is one of the snakes that causes morbidities, mortalities and disabilities in India. The clinical presentation of Russell's viper envenomation is characterised by local envenoming effects, tissue damage, venom-induced coagulopathy, neurotoxicity, and kidney injury. However, venom composition and its mechanisms of toxicity are highly variable even within snakes of the same species including Russell's viper. This variation in venom composition results in a broad range of clinical complications. Here we present a previously undocumented case of neutrophil-mediated erythrophagocytosis in a healthy 28-year-old female following Russell's viper bite. Systemic envenomation effects and bleeding abnormalities in this patient were corrected by the administration of polyvalent antivenom. Two days later, the patient developed progressive swelling and ecchymosis in the bitten limb. Observed abnormal limits within blood testing were followed up by a peripheral blood smear where it was found that 30% of neutrophils had phagocytosed erythrocytes as they were found within the cytoplasm. The patient underwent a fasciotomy for compartmental syndrome and received packed red cells and a course of corticosteroids. Following this treatment, the patient made a full recovery. This case report outlines a previously undocumented pathological event induced by Russell's viper envenomation, guiding diagnosis and treatment. Clinicians' knowledge of the mechanisms of toxicity of Russell's viper envenomation and its clinical manifestations are essential for improving the treatment of snakebites to achieve positive outcomes.

Peripheral Arterial Thrombosis following Russell's Viper Bites

Envenomings by Russell's viper ( Daboia russelii ), a species of high medical importance in India and other Asian countries, commonly result in hemorrhage, coagulopathies, necrosis, and acute kidney injury. Although bleeding complications are frequently reported following viper envenomings, thrombotic events occur rarely (reported only in coronary and carotid arteries) with serious consequences. For the first time, we report three serious cases of peripheral arterial thrombosis following Russell's viper bites and their diagnostic, clinical management, and mechanistic insights. These patients developed occlusive thrombi in their peripheral arteries and symptoms despite antivenom treatment. In addition to clinical features, computed tomography angiography was used to diagnose arterial thrombosis and ascertain its precise locations. They were treated using thrombectomy or amputation in one case that presented with gangrenous digits. Mechanistic insights into the pathology through investigations revealed the procoagulant actions of Russell's viper venom in standard clotting tests as well as in rotational thromboelastometry analysis. Notably, Russell's viper venom inhibited agonist-induced platelet activation. The procoagulant effects of Russell's viper venom were inhibited by a matrix metalloprotease inhibitor, marimastat, although a phospholipase A 2 inhibitor (varespladib) did not show any inhibitory effects. Russell's viper venom induced pulmonary thrombosis when injected intravenously in mice and thrombi in the microvasculature and affected skeletal muscle when administered locally. These data emphasize the significance of peripheral arterial thrombosis in snakebite victims and provide awareness, mechanisms, and robust strategies for clinicians to tackle this issue in patients.

Rapid identification of bilateral adrenal and pituitary haemorrhages induced by Russell's viper envenomation results in positive patient outcome

The clinical management of snakebite envenomation (SBE) is challenging in many tropical and subtropical regions of developing countries due to the complex clinical manifestations and inadequate medical infrastructure. Some venomous snakes, such as the Indian Russell's viper (Daboia russelii) cause a wide range of rare complications in addition to their classical envenomation effects. In general, these uncommon complications are often misdiagnosed or not treated promptly due to a lack of awareness about these conditions. Thus, it is critical to report such complications to draw the attention of the healthcare and research communities to improve the clinical management and scientific research of SBE, respectively. Here, we report bilateral adrenal and pituitary haemorrhages in an SBE patient following a bite by Russell's viper in India. The initial symptoms included gum bleeding, swelling, axillary lymphadenopathy and clotting abnormalities. Despite the administration of antivenom, the patient presented palpitation, nausea, and abdominal pain, which were not recovered by combinational therapy with epinephrine and dexamethasone. Further infusion of antivenom did not address these issues and the patient displayed persistent hypotension, hypoglycaemia and hyperkalaemia suggesting an adrenal crisis. Inadequate secretion of corticosteroids was confirmed by laboratory tests, and imaging investigations revealed haemorrhages in both the adrenal and pituitary glands. The patient made a full recovery after treatment with hydrocortisone and thyroxine. This report adds to the growing evidence of rare complications induced by Russell's viper envenomations and it provides relevant guidance to diagnose and treat such complications in SBE victims.

The Effectiveness of Antibiotics in Managing Bacterial Infections on Bite Sites following Snakebite Envenomation

Snakebite envenomation (SBE) is a life-threatening medical emergency with a high mortality rate. Common secondary complications following SBE, such as wound infections, are significant due to their impact on worsening local tissue damage and causing systemic infection. Antivenoms are not effective to treat wound infections following SBE. Moreover, in several rural clinical settings, broad-spectrum antibiotics are often used without clear guidelines or based on limited laboratory data, resulting in undesirable side effects and exacerbated treatment costs. Therefore, robust antibiotic strategies should be developed to tackle this critical issue. Currently, there is limited information available on the bacterial profiles of SBE-induced infections and antibiotic susceptibility. Hence, it is essential to improve the knowledge of bacterial profiles and their antibiotic sensitivity in SBE victims to develop better treatment strategies. This study aimed to address this issue by examining the bacterial profiles of SBE victims with a specific focus on Russell's viper envenomation. The most frequently found bacteria in the bites of SBE victims were Staphylococcus aureus, Klebsiella sp., Escherichia coli, and Pseudomonas aeruginosa. Linezolid, clindamycin, colistin, meropenem, and amikacin were some of the most effective antibiotics for commonly grown bacteria in SBE victims. Similarly, ciprofloxacin, ampicillin, amoxiclave, cefixime, and tetracyclin were the least effective antibiotics for common bacteria found in the wound swabs of SBE victims. These data provide robust guidance for infection management following SBE and offer useful insights to aid in designing effective treatment protocols for SBE with serious wound infections in rural areas where laboratory facilities may not be readily available.

Russell's viper envenomation induces rectus sheath haematoma

Snakebite envenomation causes systemic and local manifestations, which result from the individual or synergistic actions of multiple venom components. The pathological hallmarks of medically important venomous snakes such as the Indian Russell's viper (Daboia russelii) are well known. Envenomation by Russell's viper is typically characterised by coagulopathies, muscular damage, nephrotoxicity, and neurotoxicity. However, recent reports have revealed several unusual complications that provide a better understanding of Russell's viper envenomation effects. To further strengthen this, here, we report a case of Russell's viper bite that induced acute abdominal pain, which was intensified on day two and conservatively treated under medical supervision. Both Fothergill and Carnett signs were positive for this patient. An ultrasound imaging revealed a dissimilar dense mass, and the abdominal computed tomography scan confirmed rectus sheath haematoma. The clinical management involved the administration of polyvalent antivenom, packed red blood cells, fresh frozen plasma, and platelets. The patient recovered gradually and was discharged from the hospital eight days after the bite. Overall, this case presentation shares an uncommon experience and adds new insights into the complex series of rare pathological events associated with Russell's viper bites in India. The scientific documentation of relatively infrequent entities based on an ongoing living assessment of medical experiences, for example, this rectus sheath haematoma, constitutes valuable guidance for an adequate diagnosis and timely treatment. Essential awareness among clinicians and further research on understanding the molecular relationship between Russell's viper venom and rectus sheath haematoma will improve patient outcomes and understanding of this condition, respectively.

Bilateral Simultaneous Optic Neuritis Following Envenomations by Indian Cobra and Common Krait

In India, most snakebite envenomation (SBE) incidents are caused by the "Big Four" snakes which include Russell's viper, common krait, Indian cobra, and saw-scaled viper. Their common envenomation effects include neurotoxicity, myotoxicity, and coagulopathy. However, they also induce rare complications such as priapism, pseudoaneurysm, and sialolithiasis. Ocular manifestations such as optic neuritis develop rarely following envenomations by non-spitting snakes and they may cause temporary vision changes and blindness if untreated. While optic neuritis following Indian cobra envenomation has been reported previously, this was not encountered in victims of common kraits. Hence, for the first time, we report optic neuritis developed in a victim following envenomation by a common krait and compare its clinical features and diagnostic and therapeutic methods used with another case of optic neuritis in a victim of an Indian cobra bite. Both patients received antivenom treatment and made an initial recovery; however, optic neuritis developed several days later. The condition was diagnosed using ophthalmic examination together with computed tomography and/or magnetic resonance imaging methods. Due to very similar clinical features, both patients received intravenous corticosteroids which restored their vision and successfully treated optic neuritis. This case report suggests that the optic neuritis developed in a common krait envenomation is comparable to the one developed following a cobra bite, and therefore, the same diagnostic and therapeutic approaches can be used. This study also raises awareness of this rare complication and provides guidance for the diagnosis and treatment of SBE-induced optic neuritis.

Hirata's disease (insulin autoimmune syndrome) following envenomation by a common krait

Snakebite envenomation is known to cause local as well as systemic haematological, myotoxic and neurological effects. Adverse effects on the endocrine system following envenomation are rarely reported. Hirata's disease, also known as insulin autoimmune syndrome (IAS) is a rare disorder that causes hypoglycaemia due to excessive production of insulin autoantibodies. This report describes a rare case of IAS which developed in a snakebite victim following envenomation by a common krait and antivenom treatment. The patient was initially treated with dextrose and corticosteroids, although plasmapheresis was required to reduce the concentration of insulin antibodies and normalise the patient's glucose level. The patient then made an uneventful recovery without permanent sequelae. This report demonstrates the impacts of envenomation by a common krait on developing Hirata's disease and creates awareness among clinicians who treat snakebite envenomation.

Development of Wunderlich syndrome following a Russell's viper bite

Snakebite envenomation is a high priority neglected tropical disease that predominantly affects rural communities living in developing countries. Due to myriad of complications including coagulopathies, neurotoxicity, nephrotoxicity and local tissue destruction, treating snakebite victims is a major challenge for clinicians. Russell's viper (Daboia russelii) is one of the 'Big Four' venomous snakes in India, and it is responsible for the most snakebite-induced deaths and disabilities. Acute kidney injury occurs frequently following Russell's viper bites and it is a critical factor contributing to disabilities, deaths and excessive treatment costs. In addition to commonly observed envenomation effects, Russell's viper bites induce some rare complications such as priapism, sialolithiasis and splenic rupture. Here, we report a case of Wunderlich syndrome that developed in a 22-year-old male following a Russell's viper bite. The patient displayed severe coagulopathies, abdominal tenderness, and hypotension. Notably, a peri-nephric haematoma was identified through ultrasound and computerised tomographic imaging. The haemorrhage was successfully treated using angioembolisation, and the patient recovered without any difficulties. Although a clinical condition such as this is rare, it is important to create awareness among treating clinicians about its occurrence, diagnosis and clinical management.

Ultrasound-Guided Compression Method Effectively Counteracts Russell's Viper Bite-Induced Pseudoaneurysm

Russell's viper (Daboia russelii), one of the 'Big Four' venomous snakes in India, is responsible for the majority of snakebite-induced deaths and permanent disabilities. Russell's viper bites are known to induce bleeding/clotting abnormalities, as well as myotoxic, nephrotoxic, cytotoxic and neurotoxic envenomation effects. In addition, they have been reported to induce rare envenomation effects such as priapism, sialolithiasis and splenic rupture. However, Russell's viper bite-induced pseudoaneurysm (PA) has not been previously reported. PA or false aneurysm is a rare phenomenon that occurs in arteries following traumatic injuries including some animal bites, and it can become a life-threatening condition if not treated promptly. Here, we document two clinical cases of Russell's viper bites where PA has developed, despite antivenom treatment. Notably, a non-surgical procedure, ultrasound-guided compression (USGC), either alone, or in combination with thrombin was effectively used in both the cases to treat the PA. Following this procedure and additional measures, the patients made complete recoveries without the recurrence of PA which were confirmed by subsequent examination and ultrasound scans. These data demonstrate the development of PA as a rare complication following Russell's viper bites and the effective use of a simple, non-surgical procedure, USGC for the successful treatment of PA. These results will create awareness among healthcare professionals on the development of PA and the use of USGC in snakebite victims following bites from Russell's vipers, as well as other viper bites.

Rapid development of a salivary calculus in submandibular gland and its potential causes in a young victim following Russell's viper bite

Russell's viper bites are known to cause a range of haemotoxic, neurotoxic, myotoxic, cytotoxic and nephrotoxic complications. However, the impact of Russell's viper bites as well as bites from other venomous snakes on sialolithiasis has not been previously reported. Here, we present an interesting case where a Russell's viper bite induced the rapid development of a calculus in submandibular gland in a 10-year-old boy. Upon admission, the victim did not show any symptoms of swelling and/or pain around his oral cavity. He received antivenom treatment to normalise his coagulation parameters, however, on day three he developed swelling and extreme pain around his right mandibular region. An ultrasound investigation revealed the presence of a calculus in his submandibular gland, which was removed using a minor surgical procedure. The histopathological examination revealed this as a poorly calcified salivary calculus, which is composed of cell debris, mucopolysaccharides and lipids. The mechanisms behind its rapid development following a snakebite are unclear although this could be linked to excessive inflammation or modifications to the composition of saliva induced by venom toxins or other unknown factors. This report reveals an unusual complication induced by a Russell's viper bite and alerts clinicians who treat snakebites to be aware of such envenomation effects. Moreover, this will lead to novel research to explore the relationship between venom toxins and functions of salivary glands.

Snakebite Mimicking Brain Death: Bedside Clues

Agarwal et al.¹ have successfully managed three cases of snakebites who manifested features similar to brain death but were not true brain dead. Most likely these cases might have gone on to a status of locked-in syndrome (LIS). LIS is a status in which there is complete paralysis of voluntary muscles in all parts of the body except for those that control eye movements. Moreover, this condition makes an individual completely mute and paralyzed in a conscious patient.² In these individuals, communication may be possible through eye movements.

Oxygen Administration under Surgical Face Mask in COVID-19 Patients: A Game Changer

COVID-19 is a multifaceted infectious disease. The development of hypoxemic respiratory failure is not uncommon during the course of illness in some of them. The objectives of the present study were to assess the effect of the addition of a surgical face mask while delivering oxygen via nasal cannula in hypoxemic COVID-19 patients and highlight on the advantages and patient's comforts. We prospectively assessed 30 consecutive conscious and hypoxemic COVID-19 patients, requiring oxygen via nasal cannula. The mean PaO₂ without and with surgical face mask were 52 (+9) and 83 (−12) mm Hg respectively in the cohort, and the elevation in oxygen saturation was statistically significant (p <0.001). The present results encourage the delivery of oxygen under the surgical face mask in symptomatic COVID-19 patients, as it improves oxygen saturation and prevents aerosol dispersion with no change in PaCO₂. The other advantages of this method are a reduction in the total requirement of oxygen per patient, better utilization of scarce resources, and lessening of the expenses incurred for oxygen.

Splenic rupture and subsequent splenectomy in a young healthy victim following Russell's viper bite

Splenic rupture and/or splenectomy is/are not uncommon in clinical arena. Here we present this case of extensive haemorrhage-induced splenic rupture which resulted in splenectomy in a young healthy male (who did not have any previous medical conditions) following a Russell's viper bite. He developed upper abdominal and shoulder pain on his left side along with hypotension and reduced level of haemoglobin on the third day following bite despite antivenom treatment. Following confirmation of splenic rupture and haemoperitoneum by ultrasound and computed tomography scans, an emergency splenectomy was performed using laparotomy. Although Russell's viper bites are known to induce bleeding complications, splenic rupture due to haemorrhage in spleen has not been previously reported. Russell's viper venom toxins such as metalloproteases, serine proteases and phospholipase A2 might have affected the vascular permeability resulting in excessive bleeding and increased pressure in the spleen leading to rupture. Further investigations are required to underpin the impact of snake venom toxins on the architecture and functions of spleen. However, the clinicians who treat snakebites should be aware of this type of rare complications so as to provide appropriate management for such victims.

Neutrophil Gelatinase-Associated Lipocalin Acts as a Robust Early Diagnostic Marker for Renal Replacement Therapy in Patients with Russell's Viper Bite-Induced Acute Kidney Injuries

Snakebite-induced acute kidney injury (AKI) is frequently observed in patients following bites from vipers such as Russell's viper (Daboia russelii) in India. Currently, the levels of serum creatinine are mainly used as a marker to determine the necessity for renal replacement therapy (RRT) (haemodialysis) in severe cases of AKI. However, it takes up to 48 h to ascertain a distinct change in creatinine levels compared to its baseline level upon admission. The time lost between admission and the 48 h timepoint significantly affects the clinical management of snakebite victims. Moreover, early diagnosis of AKI and decision on the necessity for RRT in snakebite victims is critical in saving lives, reducing long-term complications, and minimising treatment costs arising from expensive haemodialysis. Neutrophil gelatinase-associated lipocalin (NGAL) has been recently studied as a robust early marker for AKI in non-snakebite patients. However, its suitability for clinical use in snakebite victims has not been rigorously established. Here, we demonstrate the clinical significance of plasma NGAL as a robust marker for RRT following AKI using a large cohort (309) of Russell's viper victims without any pre-existing health conditions. NGAL levels upon admission are positively correlated with creatinine levels at 48 h in different stages of AKI. Overall, NGAL acts as a robust early marker to ascertain the need for RRT following Russell's viper bites. The quantification of NGAL can be recommended as a routine test in hospitals that treat snakebites to decide on RRT at early time points instead of waiting for 48 h to confirm the increase in creatinine levels. The diagnostic use of NGAL in Russell's viper victims with pre-existing comorbidities and for other vipers should be evaluated in future studies.

Visual Hallucinations After a Russell's Viper Bite

Visual hallucinations (VHs) are extremely rare in snakebites. We report a case of Russell's viper bite in an otherwise healthy 55-y-old woman who presented to a hospital in south India with established clinical features of systemic and local envenomation, including coagulation failure, without any neurologic manifestations on admission. She reported simple VH on the third day, which abruptly stopped on the fifth day without any specific medications. Clinical, laboratory, imaging, and electrophysiological studies did not reveal any neuropsychiatric disorders. Including this case, only 5 cases of VH are documented in the literature, 2 following cobra and viper bites and 1 after a sea snake bite. Two cases were reported from Australia and 1 each from the United States, Iran, and India.

Priapism following a juvenile Russell's viper bite: An unusual case report

Following a bite from a juvenile Russell's viper (Daboia russelii), a priapism (painful erection) developed rapidly in a 16-year-old male and only subsided after administration of antivenom 3 hours later. Potential mechanisms for this snakebite-induced priapism are unclear but likely due to venom toxins causing nitric oxide (NO) release and subsequent vasodilation of endothelium in the corpus cavernosum, although the possible involvement of other mechanisms cannot be ruled out. We strongly believe that this unusual case report may lead to further scientific research in order to improve the clinical understanding of the pathophysiology of envenomation due to Russell's viper bites. Although it is too early to speculate, further research may also discover the possibilities of developing venom-based candidate molecules to treat sexual dysfunction in males and females.

Status of Acute Myocardial Infarction in Southern India During COVID-19 Lockdown: A Multicentric Study

There has been a reduction in the reported cases of acute myocardial infarction (MI) across the globe during the outbreak of coronavirus disease 2019 (COVID-19) (severe acute respiratory distress syndrome coronavirus 2). An attempt was made to find out the number of acute MI cases treated during the COVID-19 lockdown period (April 2020) and highlight the possible reasons for the changes in the occurrence. A multicentric retrospective observational study was performed to collect the selected data from 12 private hospitals distributed in 4 cities-Madurai, Trichy (Thiruchirapalli), Erode, and Salem-of the Tamil Nadu state in southern India. There was a significant (P<.001) reduction in ST-segment elevation MI (STEMI), non-STEMI (NSTEMI), and total (STEMI and NSTEMI together) cases during the lockdown period (April 1 to 30, 2020) as compared with no-lockdown periods such as January and February 2020 and April 2019 and April 2018 in all cities, whereas the reduction was not significant for NSTEMI in Trichy when data for the lockdown period was compared with those for January and February 2020. Overall, there is a reduction in acute MI cases, which may be due to alterations in modifiable risk factors during the COVID-19 lockdown period. Hence, implementation of public education and polices on controlling modifiable risk factors is likely to pay dividends.

Not Touching the Face is Harder Than It Sounds: Need for an Intervention

In the novel coronavirus (COVID-19) pandemic, preventive medicine has taken center stage, as there is no vaccine or specific antiviral drug regime used to treat patients. Public health authorities and governments are recommending the practice of social distancing and hand hygiene. Hands are a common vector for the transmission of infection, and frequent face touching is extremely common among the public. We developed and applied a new method to prevent face touching which is of utmost importance to break its cycle and subsequent inoculation of the virus through mucous membranes, thus reducing the risk of transmission of COVID-19.

Neutrophil Gelatinase-Associated Lipocalin as an Early Diagnostic Biomarker of Acute Kidney Injury in Snake Bite

Background:

Snakebite envenomation is a major public health problem in the developing world, and the effects of viper envenomation on renal tissues leading to acute kidney injury (AKI) are well known. However, the usefulness of neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker to detect AKI in viper envenomation cases were not studied much.

Aims and Objectives:

The present study was undertaken to find out plasma NGAL levels and assess its usefulness among the hospitalized Viperidae group of snakebite victims in predicting acute kidney injury.

Materials and Methods:

The plasma NGAL level was estimated within 6–8 h of all the 184 cases of viper bites along with other laboratory parameters.

Results:

It was elevated much before the elevation of serum creatinine levels, irrespective of the age, gender, and bite to hospital time. The sensitivity and specificity was 99.37 and 96.15, respectively. Elevated plasma NGAL levels in viper bite helped not only to detect AKI early but also assisted to plan for appropriate intervention.

Conclusion:

It is suggested to include estimation of plasma NGAL in the point of care testing, especially in emergency settings handling snakebite cases. However, more studies are recommended to find out its serial levels in snakebite cases following different kinds of snake envenomation with different clinical and laboratory manifestations in different age groups and gender belonging to different population so as to arrive at valid conclusions.

5-oxoprolinuria (Pyroglutamic Aciduria) and Metabolic Acidosis: Unraveling the Mystery

A case of high anion gap metabolic acidosis (HAGMA) and high level of 5-oxoprolinuria were noticed in an elderly female of 66 years who had multiple risk/precipitating factors and recovered well with N-acetyl cysteine infusion. This is reported in view of its rarity and to create awareness of this entity among medical students and practicing physicians who handles such cases in emergency room or critical care unit. Moreover they have to remember and investigate the cases of metabolic acidosis for 5-oxoprolinuia especially in susceptible individuals who are on paracetamol with or without other precipitating factors.

HOW TO CITE THIS ARTICLE

Senthilkumaran S, Benita F, Jena NN, Sasikumar S, Thirumalaikolundusubramanian P. 5-oxoprolinuria (Pyroglutamic Aciduria) and Metabolic Acidosis: Unraveling the Mystery. Indian J Crit Care Med 2019;23(7):342-343.

Anisocoria: Realities, Recognition, and Remedial Aspects

The realities, recognition, and remedial aspects of anisocoria at the bedside were highlighted by Adhikari et al.,¹ which is almost similar to an earlier report from India.² Since this condition involves patient safety and clinical assessment, we would like to touch upon 3 Ps (physiological, pathological, and pharmacological) of anisocoria. First and foremost is to elicit a thorough clinical history and then to assess the case in detail which not only rules out injuries, infections, instillation, or ingestion of medicines and instigating mechanisms but also helps rule out various other life-threatening conditions.

Super Vasmol Poisoning: Dangers of Darker Shade

How to cite this article: Senthilkumaran S, Jena NN, Thirumalaikolundusubramanian P. Super Vasmol Poisoning: Dangers of Darker Shade. Indian J Crit Care Med 2019;23(Suppl 4):S287-S289.

Russell's Viper Envenomation-Associated Addisonian Crisis

Snakebite envenomation is an important public health problem in tropical countries. We report a case of bilateral adrenal hemorrhage in a 28-y-old man with Russell's viper bite that occurred in the Sathyamangalam forest range in the Indian state of Tamil Nadu. In this case, a combination of early bite recognition, hospital-based supportive care, corticosteroid therapy, and timely administration of polyvalent antivenom resulted in a favorable clinical outcome.

Comparison of Bayes Classifiers for Breast Cancer Classification

Data analytics play vital roles in diagnosis and treatment in the health care sector. To enable practitioner decision-making, huge volumes of data should be processed with machine learning techniques to produce tools for prediction and classification. Diseases like breast cancer can be classified based on the nature of the tumor. Finding an effective algorithm for classification should help resolve the challenges present in analyzing large volume of data. The objective with this paper was to present a report on the performance of Bayes classifiers like Tree Augmented Naive Bayes (TAN), Boosted Augmented Naive Bayes (BAN) and Bayes Belief Network (BBN). Among the three approaches, TAN produced the best performance regarding classification and accuracy. The results obtained provide clear evidence for benefits of TAN usage in breast cancer classification. Applications of various machine learning algorithms could clearly assist breast cancer control efforts for identification, prediction, prevention and health care planning.

Post coital hemoperitoneum: The pain of love

Acute abdominal pain in women of reproductive age is common and frequent cause for visit to emergency department which warrants emergent evaluation. We present the case of a 23-year-old nulliparous women presenting with post-coital haemoperitoneum secondary to a ruptured corpus luteum cyst. This is a rare case demonstrating the need to elicit sexual history in patients presenting with an acute abdomen in emergency department.

A preliminary survey of professionalism teaching practices in anatomy education among Indian Medical Colleges

Professionalism and ethics have gained widespread recognition as competencies to be fulfilled, taught, and assessed within medical education. The role of the anatomy course in developed nations has evolved over time and now encompasses multiple domains, including knowledge, skills, and the inculcation of professionalism and ethics. The Medical Council of India recently recommended the integration of professionalism teaching in undergraduate medical curricula. The authors investigated whether the initial orientation lectures and instructions given by faculty at the outset of undergraduate medical anatomy courses throughout India served a "hidden curriculum" regarding professionalism practices, and whether these orientation messages could serve as an early exposure to medical professionalism and ethics for medical students. An online survey was carried out among 102 anatomy faculty members across India requesting details about specific professionalism protocols and instructions regarding behavior in the dissection hall that are routinely given to preclinical students, as well as the importance that they placed on professional behavior. It was found that most faculty members regularly instruct students regarding expected behavior during the anatomy course, including dissection practices. These instructions stress attributes of professionalism like humanism, accountability, and honesty. However, there needs to be a more concentrated effort by educators to prohibit such unprofessional practices like dissection hall photography, and better information is required regarding biomedical waste disposal. Despite the absence of clear guidelines for professionalism teaching in medical education in India, the existing framework of anatomy education provides an opportunity to introduce the concept of professionalism to the first-year medical student. This opportunity may provide an early foundation for designing a professionalism-integrated curriculum. Anat Sci Educ 10: 433-443. © 2017 American Association of Anatomists.