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Wanandy T, Dwyer HE, McLean L, Davies NW, Nichols D, Gueven N, Brown SGA, Wiese MD. Factors influencing the quality ofMyrmecia pilosula(Jack Jumper) ant venom for use in in vitro and in vivo diagnoses of allergen sensitization and in allergen immunotherapy. Clin Exp Allergy 2017; 47:1478-1490. [DOI: 10.1111/cea.12987] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 07/12/2017] [Accepted: 07/18/2017] [Indexed: 11/30/2022]
Affiliation(s)
- T. Wanandy
- Jack Jumper Allergy Program; Royal Hobart Hospital; Hobart Tas. Australia
- Department of Pharmacy; Royal Hobart Hospital; Hobart Tas. Australia
- School of Medicine; University of Tasmania; Hobart Tas. Australia
- Division of Pharmacy, School of Medicine; University of Tasmania; Hobart Tas. Australia
| | - H. E. Dwyer
- Jack Jumper Allergy Program; Royal Hobart Hospital; Hobart Tas. Australia
| | - L. McLean
- Jack Jumper Allergy Program; Royal Hobart Hospital; Hobart Tas. Australia
| | - N. W. Davies
- Central Science Laboratory; University of Tasmania; Hobart Tas. Australia
| | - D. Nichols
- Central Science Laboratory; University of Tasmania; Hobart Tas. Australia
| | - N. Gueven
- Division of Pharmacy, School of Medicine; University of Tasmania; Hobart Tas. Australia
| | - S. G. A. Brown
- Jack Jumper Allergy Program; Royal Hobart Hospital; Hobart Tas. Australia
- School of Medicine; University of Tasmania; Hobart Tas. Australia
- Ambulance Tasmania; Hobart Tas. Australia
- Department of Emergency Medicine; Royal Hobart Hospital; Hobart Tas. Australia
| | - M. D. Wiese
- Jack Jumper Allergy Program; Royal Hobart Hospital; Hobart Tas. Australia
- School of Pharmacy and Medical Sciences; University of South Australia; Adelaide SA Australia
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Francis A, Bosio E, Stone SF, Fatovich DM, Arendts G, Nagree Y, Macdonald SPJ, Mitenko H, Rajee M, Burrows S, Brown SGA. Neutrophil activation during acute human anaphylaxis: analysis of MPO and sCD62L. Clin Exp Allergy 2017; 47:361-370. [DOI: 10.1111/cea.12868] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 10/14/2016] [Accepted: 11/18/2016] [Indexed: 12/01/2022]
Affiliation(s)
- A. Francis
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth WA Australia
- Discipline of Emergency Medicine; School of Primary; Aboriginal and Rural Health Care; University of Western Australia; Crawley WA Australia
| | - E. Bosio
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth WA Australia
- Discipline of Emergency Medicine; School of Primary; Aboriginal and Rural Health Care; University of Western Australia; Crawley WA Australia
| | - S. F. Stone
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth WA Australia
- Discipline of Emergency Medicine; School of Primary; Aboriginal and Rural Health Care; University of Western Australia; Crawley WA Australia
| | - D. M. Fatovich
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth WA Australia
- Discipline of Emergency Medicine; School of Primary; Aboriginal and Rural Health Care; University of Western Australia; Crawley WA Australia
- Emergency Department; Royal Perth Hospital; Perth WA Australia
| | - G. Arendts
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth WA Australia
- Discipline of Emergency Medicine; School of Primary; Aboriginal and Rural Health Care; University of Western Australia; Crawley WA Australia
- Emergency Department; Royal Perth Hospital; Perth WA Australia
- Emergency Department, Fiona Stanley Hospital; Murdoch WA Australia
| | - Y. Nagree
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth WA Australia
- Emergency Department, Fiona Stanley Hospital; Murdoch WA Australia
- Emergency Department; Fremantle Hospital; Fremantle WA Australia
| | - S. P. J. Macdonald
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth WA Australia
- Discipline of Emergency Medicine; School of Primary; Aboriginal and Rural Health Care; University of Western Australia; Crawley WA Australia
- Emergency Department; Royal Perth Hospital; Perth WA Australia
- Emergency Department; Armadale Kelmscott Memorial Hospital; Mount Nasura WA Australia
| | - H. Mitenko
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth WA Australia
- Emergency Department; South West Health Campus; Bunbury WA Australia
| | - M. Rajee
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth WA Australia
- Emergency Department; Austin Hospital; Heidelberg VIC Australia
| | - S. Burrows
- School of Medicine & Pharmacology; University of Western Australia; Perth WA Australia
| | - S. G. A. Brown
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth WA Australia
- Discipline of Emergency Medicine; School of Primary; Aboriginal and Rural Health Care; University of Western Australia; Crawley WA Australia
- Emergency Department; Royal Perth Hospital; Perth WA Australia
- Emergency Department; Royal Hobart Hospital; Hobart TAS Australia
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Brown SGA, Ball EL, Macdonald SPJ, Wright C, McD Taylor D. Spontaneous pneumothorax; a multicentre retrospective analysis of emergency treatment, complications and outcomes. Intern Med J 2015; 44:450-7. [PMID: 24612237 DOI: 10.1111/imj.12398] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 02/15/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Spontaneous pneumothorax can be managed initially by observation, aspiration or chest drain insertion. AIMS To determine the clinical features of spontaneous pneumothorax in patients presenting to the emergency department (ED), interventions, outcomes and potential risk factors for poor outcomes after treatment. METHODS Retrospective chart review from ED of three major referral and two general hospitals in Australia of presentations with primary spontaneous pneumothorax (PSP) or secondary spontaneous pneumothorax (SSP). Main outcomes were prolonged air leak (>5 days) and pneumothorax recurrence within 1 year. RESULTS We identified 225 people with PSP and 98 with SSP. There were no clinical tension pneumothoraces with hypotension. Hypoxaemia (haemoglobin oxygen saturation measured by pulse oximetry ≤92%) occurred only in SSP and in older patients (age >50 years) with PSP. Drainage was performed in 150 (67%) PSP and 82 (84%) SSP. Prolonged air leak occurred in 16% (95% confidence interval 10-23%) of PSP and 31% (21-42%) of SSP. Independent risk factors for prolonged drainage were non-asthma SSP and pneumothorax size >50%. Complications were recorded in 11% (7.5-16%) of those having drains inserted. Recurrences occurred in 5/91 (5%, 1.8-12%) of those treated without drainage versus 40/232 (17%, 13-23%) of those treated by drainage, of which half occurred in the first month after drainage. CONCLUSION Pneumothorax drainage is associated with substantial morbidity including prolonged air leak. As PSP appears to be well tolerated in younger people even with large pneumothoraces, conservative treatment in this subgroup may be a viable option to improve patient outcomes, but this needs to be confirmed in a clinical trial.
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Affiliation(s)
- S G A Brown
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia; Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, Australia; Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia
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Fatovich DM, Brown SGA. Stroke thrombolysis remains unproven: per ardua, ad astra ... Intern Med J 2014; 44:1261-2. [PMID: 25442765 DOI: 10.1111/imj.12606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 08/27/2014] [Indexed: 11/30/2022]
Affiliation(s)
- D M Fatovich
- Emergency Medicine, Royal Perth Hospital, University of Western Australia, Perth, Western Australia, Australia; Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
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Huddle N, Arendts G, Macdonald SPJ, Fatovich DM, Brown SGA. Is comorbid status the best predictor of one-year mortality in patients with severe sepsis and sepsis with shock? Anaesth Intensive Care 2013; 41:482-9. [PMID: 23808507 DOI: 10.1177/0310057x1304100408] [Citation(s) in RCA: 6] [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: 12/21/2022]
Abstract
Understanding longer term outcomes in critically ill patients will assist treatment decisions, allocation of scarce resources and clinical research in that population. The aim of this study was to compare a well-validated means of determining comorbidity, the Charlson Comorbidity Score, to other verified risk stratification models in predicting one-year mortality and other outcomes in emergency department patients with severe sepsis and sepsis with shock. We conducted a planned subgroup analysis of a prospective observational study, the Critical Illness and Shock Study, in adult patients with sepsis meeting study criteria for critical illness. From emergency department arrival, patients were prospectively enrolled with data collected for a minimum of one year post-enrolment. Scoring systems were derived from this data and compared using receiver-operating characteristic curves. One hundred and four patients were enrolled. The 28-day mortality was 18% and one-year mortality 40%. For predicting one-year mortality, the area under the receiver-operating characteristic curve for age-weighted Charlson Comorbidity Score (0.71, 95% confidence interval 0.61 to 0.81) was at least as good or superior to other scoring systems analysed. The intensive care unit admission rate was 45% and the median hospital length-of-stay was eight days. We conclude that in patients who present to the emergency department with severe sepsis or sepsis with shock, age-weighted Charlson Comorbidity Score is a predictor of one-year mortality that is simple to calculate and at least as accurate as other validated scoring systems.
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Affiliation(s)
- N Huddle
- Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia
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Isbister GK, Buckley NA, Page CB, Scorgie FE, Lincz LF, Seldon M, Brown SGA. A randomized controlled trial of fresh frozen plasma for treating venom-induced consumption coagulopathy in cases of Australian snakebite (ASP-18). J Thromb Haemost 2013; 11:1310-8. [PMID: 23565941 DOI: 10.1111/jth.12218] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND Venom-induced consumption coagulopathy (VICC) is a major effect of snake envenoming. OBJECTIVES To investigate whether fresh frozen plasma (FFP) given after antivenom resulted in more rapid correction of coagulation. PATIENTS/METHODS This was a multicenter open-label randomized controlled trial in patients with VICC of FFP vs. no FFP within 4 h of antivenom administration. Patients (> 2 years) recruited to the Australian snakebite project with VICC (International Normalized Ratio [INR] > 3) were eligible. Patients were randomized 2 : 1 to receive FFP or no FFP. The primary outcome was the proportion with an INR of < 2 at 6 h after antivenom administration. Secondary outcomes included time from antivenom administration to discharge, adverse effects, major hemorrhage, and death. RESULTS Of 70 eligible patients, 65 consented to be randomized: 41 to FFP, and 24 to no FFP. Six hours after antivenom administration, more patients randomized to FFP had an INR of < 2 (30/41 [73%] vs. 6/24 [25%]; absolute difference, 48%; 95% confidence interval 23-73%; P = 0.0002). The median time from antivenom administration to discharge was similar (34 h, range 14-230 h vs. 39 h, range 14-321 h; P = 0.44). Seven patients developed systemic hypersensitivity reactions after antivenom administration - two mild and one severe (FFP arm), and three mild and one severe (no FFP). One serious adverse event (intracranial hemorrhage and death) occurred in an FFP patient with pre-existing hypertension, who was hypertensive on admission, and developed a headache 6 h after FFP administration. Post hoc analysis showed that the median time from bite to FFP administration was significantly shorter for non-responders to FFP than for responders (4.7 h, interquartile range [IQR] 4.2-6.7 h vs. 7.3 h, IQR 6.1-8 h; P = 0.002). CONCLUSIONS FFP administration after antivenom administration results in more rapid restoration of clotting function in most patients, but no decrease in discharge time. Early FFP administration (< 6-8 h) post-bite is less likely to be effective.
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Affiliation(s)
- G K Isbister
- Department of Clinical Toxicology and Pharmacology, School of Medicine and Public Health, University of Newcastle, Calvary Mater Newcastle, Newcastle, NSW, Australia.
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Johnston CI, Brown SGA, O'Leary MA, Currie BJ, Greenberg R, Taylor M, Barnes C, White J, Isbister GK. Mulga snake (Pseudechis australis) envenoming: a spectrum of myotoxicity, anticoagulant coagulopathy, haemolysis and the role of early antivenom therapy - Australian Snakebite Project (ASP-19). Clin Toxicol (Phila) 2013; 51:417-24. [PMID: 23586640 DOI: 10.3109/15563650.2013.787535] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Mulga snakes (Pseudechis australis) are venomous snakes with a wide distribution in Australia. Objective. The objective of this study was to describe mulga snake envenoming and the response of envenoming to antivenom therapy. MATERIALS AND METHODS Definite mulga bites, based on expert identification or venom-specific enzyme immunoassay, were recruited from the Australian Snakebite Project. Demographics, information about the bite, clinical effects, laboratory investigations and antivenom treatment are recorded for all patients. Blood samples are collected to measure the serum venom concentrations pre- and post-antivenom therapy using enzyme immunoassay. RESULTS There were 17 patients with definite mulga snake bites. The median age was 37 years (6-70 years); 16 were male and six were snake handlers. Thirteen patients had systemic envenoming with non-specific systemic symptoms (11), anticoagulant coagulopathy (10), myotoxicity (7) and haemolysis (6). Antivenom was given to ten patients; the median dose was one vial (range, one-three vials). Three patients had systemic hypersensitivity reactions post-antivenom. Antivenom reversed the coagulopathy in all cases. Antivenom appeared to prevent myotoxicity in three patients with high venom concentrations, given antivenom within 2 h of the bite. Median peak venom concentration in 12 envenomed patients with samples was 29 ng/mL (range, 0.6-624 ng/mL). There was a good correlation between venom concentrations and the area under the curve of the creatine kinase for patients receiving antivenom after 2 h. Higher venom concentrations were also associated with coagulopathy and haemolysis. Venom was not detected after antivenom administration except in one patient who had a venom concentration of 8.3 ng/ml after one vial of antivenom, but immediate reversal of the coagulopathy. DISCUSSION Mulga snake envenoming is characterised by myotoxicity, anticoagulant coagulopathy and haemolysis, and has a spectrum of toxicity that is venom dose dependant. This study supports a dose of one vial of antivenom, given as soon as a systemic envenoming is identified, rather than waiting for the development of myotoxicity.
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Affiliation(s)
- C I Johnston
- School of Medicine Sydney, University of Notre Dame Australia, Darlinghurst, NSW, Australia
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Abstract
BACKGROUND Snakebites in snake handlers are an important clinical problem that may differ to bites in the general population. AIM To investigate the epidemiology and clinical presentation of bites in snake handlers. DESIGN Prospective observational study. METHODS Bites in snake handlers recruited as part of the Australian Snakebite Project (ASP) from 2004 to 2011 were included in the study. Data were extracted from the ASP database, which included demographic and clinical information, laboratory tests and antivenom treatment. RESULTS From 1089 snake bites recruited to ASP, there were 106 (9.7%) bites in snake handlers. The median age was 40 years (range: 16-81 years) and 104 (98%) were males. The commonest circumstances of the bites were handling snakes (47), catching snakes (22), feeding snakes (18) and cleaning cages (11). Bites were to the upper limb in 103 cases. Bites were most commonly by Red-bellied black snakes (20), Brown snakes (17), Taipan (15), Tiger snakes (14) and Death adders (14). Envenoming occurred in 77 patients: venom-induced consumption coagulopathy in 45 patients (58%), neurotoxicity in 10 (13%) and myotoxicity in 13 (17%). Systemic hypersensitivity reactions (SHSRs) to venom occurred in eight, satisfying clinical criteria for anaphylaxis in five, of which three were hypotensive. Antivenom was administered in 60 envenomed patients. SHSRs to antivenom occurred in 15 (25%; 95% CI:15-38%), including 2 (3%:1-13%) with severe (hypotensive) reactions. CONCLUSION Bites in snake handlers remain a common, important problem involving a broad range of snakes. Neurotoxicity and myotoxicity are relatively common, consistent with the snakes involved. Venom anaphylaxis occured, despite previously being a poorly recognized problem in snake handlers. The incidence of SHSRs to antivenoms, including anaphylaxis, was not higher than that observed in non-snake handlers.
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Affiliation(s)
- Geoffrey K Isbister
- Discipline of Clinical Pharmacology, University of Newcastle, Calvary Mater Newcastle, Waratah NSW 2298, Australia.
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Affiliation(s)
| | - S. F. Stone
- Centre for Clinical Research in Emergency Medicine; Western Australian Institute for Medical Research and the University of Western Australia; Perth; WA; Australia
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Isbister GK, White J, Currie BJ, O'Leary MA, Brown SGA. Clinical effects and treatment of envenoming by Hoplocephalus spp. snakes in Australia: Australian Snakebite Project (ASP-12). Toxicon 2011; 58:634-40. [PMID: 21967812 DOI: 10.1016/j.toxicon.2011.09.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 09/15/2011] [Accepted: 09/22/2011] [Indexed: 11/16/2022]
Abstract
There is limited information on envenoming by snakes of the genus Hoplocephalus from Eastern Australia. We investigated the clinical and laboratory features of patients with definite Hoplocephalus spp. bites including antivenom treatment, recruited to the Australian Snakebite Project. There were 15 definite Hoplocephalus spp. bites based on expert identification including eight by Hoplocephalus stephensi (Stephen's banded snakes), four by Hoplocephalus bungaroides (broad-headed snake) and three by H. bitorquatus (pale-headed snake). Envenoming occurred in 13 patients and was similar for the three species with venom induced consumption coagulopathy (VICC) in all envenomings. Seven patients had an INR >12 and partial VICC, with only incomplete fibrinogen consumption, occurred in three patients. Systemic symptoms occurred in eight patients. Myotoxicity and neurotoxicity did not occur. H. stephensi venom was detected in all three H. stephensi envenomings (1.1, 44 and 81 ng/mL) for whom pre-antivenom blood samples were available, and not detected in one without envenoming. In two cases with post-antivenom blood samples, venom was not detected after tiger snake antivenom (TSAV) was given. In vitro binding studies demonstrated that TSAV concentrations of 50mU/mL are sufficient to bind the majority of free H. stephensi venom components at concentrations above those detected in envenomed patients (100 ng/mL). Eleven patients received antivenom, median dose 2 vials (Range: 1 to 5 vials), which was TSAV in all but one case, where polyvalent antivenom was used. Immediate hypersensitivity reactions occurred in six cases including one case of anaphylaxis. Envenoming by Hoplocephalus spp. causes VICC and systemic symptoms, making it clinically similar to brown snake (Pseudonaja spp.) envenoming. Based on in vitro studies reported here, patients may be treated with one vial of TSAV, although one vial of brown snake antivenom may also be sufficient.
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Affiliation(s)
- G K Isbister
- Discipline of Clinical Pharmacology, University of Newcastle, Australia.
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Isbister GK, Scorgie FE, O'Leary MA, Seldon M, Brown SGA, Lincz LF. Factor deficiencies in venom-induced consumption coagulopathy resulting from Australian elapid envenomation: Australian Snakebite Project (ASP-10). J Thromb Haemost 2010; 8:2504-13. [PMID: 20831619 DOI: 10.1111/j.1538-7836.2010.04050.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Limited information exists on the dynamics of hemostasis in patients with venom-induced consumption coagulopathy (VICC) from snake envenomation. OBJECTIVE The aim of the present study was to investigate specific factor deficiencies and their time course in Australasian elapid envenomation. METHODS We measured coagulation parameters and factor concentrations in patients recruited to the Australian Snakebite Project, an observational cohort study. There were 112 patients with complete VICC, defined as an international normalized ratio (INR) > 3, and 18 with partial VICC. Serial citrated plasma samples were collected from 0.5 to 60 h post-bite. INR, activated partial thromboplastin time (aPTT), coagulation factors (F)I, II, V, VII, VIII, IX, X, von Willebrand factor antigen (VWF:Ag) and D-dimer concentrations were measured. RESULTS Complete VICC was characterized by near/total depletion of fibrinogen, FV and FVIII, with an INR and aPTT that exceeded the upper limits of detection, within 2 h of snakebite. Prothrombin levels never fell below 60% of normal, suggesting that the toxins were rapidly eliminated or inactivated and re-synthesis of clotting factors occurred irrespective of antivenom. Partial VICC caused limited depletion of fibrinogen and FV, and almost complete consumption of FVIII. Onset of VICC was more rapid with brown snake (Pseudonaja spp.) venom, which contains a group C prothrombin activator toxin, compared with the tiger snake group, which contains a group D prothrombin activator toxin and requires human FVa formation. Resolution of VICC occurred within 24-36 h irrespective of snake type. CONCLUSIONS These results suggest that Australasian elapid prothrombin activators have a potent but short duration of action. Antivenom is unlikely to be administered in time to prevent VICC.
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Affiliation(s)
- G K Isbister
- School of Medicine and Public Health, University of Newcastle, NSW, Australia.
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Kulawickrama S, O'Leary MA, Hodgson WC, Brown SGA, Jacoby T, Davern K, Isbister GK. Development of a sensitive enzyme immunoassay for measuring taipan venom in serum. Toxicon 2010; 55:1510-8. [PMID: 20223258 DOI: 10.1016/j.toxicon.2010.03.003] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Revised: 02/27/2010] [Accepted: 03/03/2010] [Indexed: 11/18/2022]
Abstract
The detection and measurement of snake venom in blood is important for confirming snake identification, determining when sufficient antivenom has been given, detecting recurrence of envenoming, and in forensic investigation. Venom enzyme immunoassays (EIA) have had persistent problems with poor sensitivity and high background absorbance leading to false positive results. This is particularly problematic with Australasian snakes where small amounts of highly potent venom are injected, resulting in low concentrations being associated with severe clinical effects. We aimed to develop a venom EIA with a limit of detection (LoD) sufficient to accurately distinguish mild envenoming from background absorbance at picogram concentrations of venom in blood. Serum samples were obtained from patients with taipan bites (Oxyuranus spp.) before and after antivenom, and from rats given known venom doses. A sandwich EIA was developed using biotinylated rabbit anti-snake venom antibodies for detection. For low venom concentrations (i.e. <1 ng/mL) the assay was done before and after addition of antivenom to the sample (antivenom difference method). The LoD was 0.15 ng/mL for the standard assay and 0.1 ng/mL for the antivenom difference method. In 11 pre-antivenom samples the median venom concentration was 10 ng/mL (Range: 0.3-3212 ng/mL). In four patients with incomplete venom-induced consumption coagulopathy the median venom concentration was 2.4 ng/mL compared to 30 ng/mL in seven patients with complete venom-induced consumption coagulopathy. No venom was detected in any post-antivenom sample and the median antivenom dose prior to this first post-antivenom sample was 1.5 vials (1-3 vials), including 7 patients administered only 1 vial. In rats the assay distinguished a 3-fold difference in venom dose administered and there was small inter-individual variability. There was small but measurable cross-reactivity with black snake (Pseudechis), tiger snake (Notechis) and rough-scale snake (Tropidechis carinatus) venoms with the assay for low venom concentrations (<1 ng/mL). The use of biotinylation and the antivenom difference method in venom EIA produces a highly sensitive assay that will be useful for determining antivenom dose, forensic and clinical diagnosis.
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Affiliation(s)
- S Kulawickrama
- Emergency Department, Gold Coast Hospital, Queensland, Australia
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Bruce DG, Davis WA, Casey GP, Clarnette RM, Brown SGA, Jacobs IG, Almeida OP, Davis TME. Severe hypoglycaemia and cognitive impairment in older patients with diabetes: the Fremantle Diabetes Study. Diabetologia 2009; 52:1808-15. [PMID: 19575177 DOI: 10.1007/s00125-009-1437-1] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2009] [Accepted: 06/04/2009] [Indexed: 02/06/2023]
Abstract
AIMS/HYPOTHESIS The aim was to investigate the relationship between severe hypoglycaemia and cognitive impairment in older patients with diabetes. METHODS A sample of 302 diabetic patients aged >/=70 years was assessed for dementia or cognitive impairment without dementia in 2001-2002 and a subsample of non-demented patients (n = 205) was followed to assess cognitive decline. A history of severe hypoglycaemia was determined from self-reports, physician assessments and records of health service use for hypoglycaemia (HSH). Prospective HSH was determined up to 2006. Data analysis, including multiple logistic and Cox regression models, was used to determine whether: (1) there were cross-sectional associations between hypoglycaemia and cognitive status, (2) historical hypoglycaemia predicted cognitive decline, and (3) baseline cognitive status predicted subsequent HSH. RESULTS There were significant cross-sectional associations between both cognitive impairment and dementia and hypoglycaemia. Independent risk factors for future HSH included dementia (hazard ratio 3.00, 95% CI 1.06-8.48) and inability to self-manage medications (hazard ratio 4.17, 95% CI 1.43-12.13). However, there were no significant associations between historical hypoglycaemia, incident HSH and cognitive decline. CONCLUSIONS/INTERPRETATION Dementia is an important risk factor for hypoglycaemia requiring health service utilisation. We found no evidence that hypoglycaemia contributes to cognitive impairment in older patients with diabetes.
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Affiliation(s)
- D G Bruce
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, PO Box 480, Fremantle, WA, 6959, Australia.
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Abstract
BACKGROUND Venom-induced consumption coagulopathy (VICC) is an important feature of snake envenoming. AIM To investigate the effect of antivenom and fresh frozen plasma (FFP) on recovery of VICC in Australian elapid snake envenoming. DESIGN Prospective cohort study. METHODS Patients with VICC were included from the Australian Snakebite Project (ASP). Time to recovery of VICC (defined as time until INR <2) was investigated using a time to event analysis in WinBUGS. The model considered the effects of age, sex, snake type, time of antivenom after bite, antivenom dose and use of FFP within 4 h. RESULTS The study included 167 cases of VICC, median age being 41 [interquartile range (IQR): 28-53) years, and 130 (78%) were males. Antivenom was administered at a median of 3.6 (IQR: 2.2-5.6) h after the bite at a median dose of four vials (IQR: 2-6 vials). Thirteen patients received FFP within 4 h. Recovery of VICC occurred after a median of 14.4 (IQR: 11.5-17.5) h, and only the use of FFP within 4 h influenced the time to recovery. Neither antivenom dose nor time of antivenom administration had an effect on recovery of VICC. In patients administered with FFP, 12% [credible interval (CrI): 6-21%] and 81% (CrI: 61-94%) had recovered at 6 and 12 h, respectively, vs 2.5% (CrI: 1.5-4%) and 28% (CrI: 22-34%) not receiving FFP. DISCUSSION Antivenom did not appear to be effective for the coagulopathy in snake envenoming in Australia. FFP appeared to shorten the time of VICC recovery.
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Affiliation(s)
- G K Isbister
- Tropical Toxinology Unit, Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
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Abstract
BACKGROUND Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. Adrenaline is recommended as the initial treatment of choice for anaphylaxis. OBJECTIVES To assess the benefits and harms of adrenaline in the treatment of anaphylaxis. METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1), MEDLINE (1966 to March 2007), EMBASE (1966 to March 2007), CINAHL (1982 to March 2007), BIOSIS (to March 2007), ISI Web of Knowledge (to March 2007) and LILACS (to March 2007). We also searched websites listing ongoing trials: http://www.clinicaltrials.gov/, http://www.controlledtrials.com and http://www.actr.org.au/ and contacted pharmaceutical companies and international experts in anaphylaxis in an attempt to locate unpublished material. Randomized and quasi-randomized controlled trials comparing adrenaline with no intervention, placebo or other adrenergic agonists were eligible for inclusion. Two authors independently assessed articles for inclusion. RESULTS We found no studies that satisfied the inclusion criteria. CONCLUSIONS On the basis of this review, we are unable to make any new recommendations on the use of adrenaline for the treatment of anaphylaxis. In the absence of appropriate trials, we recommend, albeit on the basis of less than optimal evidence, that adrenaline administration by intramuscular injection should still be regarded as first-line treatment for the management of anaphylaxis.
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Affiliation(s)
- A Sheikh
- Allergy & Respiratory Research Group, Division of Community Health Sciences: GP Section, The University of Edinburgh, Edinburgh, UK
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Isbister GK, Brown SGA, Miller M, Tankel A, Macdonald E, Stokes B, Ellis R, Nagree Y, Wilkes GJ, James R, Short A, Holdgate A. A randomised controlled trial of intramuscular vs. intravenous antivenom for latrodectism--the RAVE study. QJM 2008; 101:557-65. [PMID: 18400776 DOI: 10.1093/qjmed/hcn048] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Widow spider-bite causes latrodectism and is associated with significant morbidity worldwide. Antivenom is given by both the intravenous (IV) and intramuscular (IM) routes and it is unclear which is more effective. AIM To compare the effectiveness of IV vs. IM redback spider antivenom. DESIGN Randomized controlled trial. METHODS Patients with latrodectism were given either IV or IM antivenom according to a randomized double-dummy, double-blind protocol. The first antivenom treatment was followed by another identical treatment after two hours if required. The primary outcome was a clinically significant reduction in pain two hours after the last treatment. A fully Bayesian analysis was used to estimate the probability of the desired treatment effect, predetermined as an absolute difference of 20%. RESULTS We randomly allocated 126 patients to receive antivenom IV (64) and IM (62). After antivenom treatment pain improved in 40/64(62%) in the IV group vs. 33/62(53%) in the IM group (+9%; 95% Credible Interval [CrI]: -8% to +26%). The probability of a difference greater than zero (IV superior) was 85% but the probability of a difference >20% was only 10%. In 55 patients with systemic effects, these improved in 58% after IV antivenom vs. 65% after IM antivenom (-8%; 95% CrI: -32% to +17%). Twenty-four hours after antivenom pain had improved in 84% in the IV group vs. 71% in the IM group (+13%; 95% CrI: -2% to +27%). A meta-analysis including data from a previous trial found no difference in the primary outcome between IV and IM administration. DISCUSSION The difference between IV and IM routes of administration of widow spider antivenom is, at best, small and does not justify routinely choosing one route over the other. Furthermore, antivenom may provide no benefit over placebo.
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Affiliation(s)
- G K Isbister
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
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Isbister GK, Little M, Cull G, McCoubrie D, Lawton P, Szabo F, Kennedy J, Trethewy C, Luxton G, Brown SGA, Currie BJ. Thrombotic microangiopathy from Australian brown snake (Pseudonaja) envenoming. Intern Med J 2007; 37:523-8. [PMID: 17640187 DOI: 10.1111/j.1445-5994.2007.01407.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Australian brown snake (genus Pseudonaja) envenoming causes a venom-induced consumptive coagulopathy (VICC). A proportion of cases go on to develop thrombotic microangiopathy characterized by thrombocytopenia, microangiopathic haemolytic anaemia (MAHA) and acute renal failure (ARF). AIM The aim of the study was to define better the natural history and empirical treatments for thrombotic microangiopathy in brown snake envenoming. METHODS A review of brown snake bites recruited to the Australian Snakebite Project (ASP), a national multicentre study of snake envenoming was undertaken. Serial data are recorded on clinical effects and laboratory results, including measurement of venom concentrations. We describe cases of thrombotic microangiopathy and compare these to cases without thrombotic microangiopathy. RESULTS From 32 cases of brown snake envenoming with severe VICC, four (13%) developed thrombotic microangiopathy, we also included two cases of thrombotic microangiopathy from prior to ASP. All six developed severe thrombocytopenia (<20 x 10(-9)/L), worst 3 days after the bite and resolving over a week, MAHA with fragmented red blood cells on the blood film and five developed anuric ARF requiring dialysis and lasting 2-8 weeks. All six received antivenom, which was delayed compared with other brown snake-envenoming cases. Four were treated with plasmapheresis. The severity and recovery of the thrombocytopenia, anaemia and renal function were similar with and without plasmapheresis. The median length of stay for MAHA cases was 14 days (interquartile range (IQR) 12-14) compared to 1.8 days (IQR 1.3-2) for all other cases. CONCLUSION Thrombotic microangiopathy resulting from brown snake bite appears to have a good prognosis and management should focus on early antivenom therapy and supportive care including dialysis. The role of plasmapheresis is yet to be defined.
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Affiliation(s)
- G K Isbister
- Tropical Toxinology Unit, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.
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Abstract
BACKGROUND Anaphylaxis is an acute systemic allergic reaction, which can be life-threatening. H(1)-antihistamines are commonly used as an adjuvant therapy in the treatment of anaphylaxis. We sought to assess the benefits and harm of H(1)-antihistamines in the treatment of anaphylaxis. METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library); MEDLINE (1966 to June 2006); EMBASE (1966 to June 2006); CINAHL (1982 to June 2006) and ISI Web of Science (1945 to July 2006). We also contacted pharmaceutical companies and international experts in anaphylaxis in an attempt to locate unpublished material. Randomized and quasi-randomized-controlled trials comparing H(1)-antihistamines with placebo or no intervention were eligible for inclusion. Two authors independently assessed articles for inclusion. RESULTS We found no studies that satisfied the inclusion criteria. CONCLUSIONS Based on this review, we are unable to make any recommendations for clinical practice. Randomized-controlled trials are needed, although these are likely to prove challenging to design and execute.
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Affiliation(s)
- A Sheikh
- Division of Community Health Sciences: GP Section, University of Edinburgh, Edinburgh, UK
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Wiese MD, Brown SGA, Chataway TK, Davies NW, Milne RW, Aulfrey SJ, Heddle RJ. Myrmecia pilosula (Jack Jumper) ant venom: identification of allergens and revised nomenclature. Allergy 2007; 62:437-43. [PMID: 17362256 DOI: 10.1111/j.1398-9995.2007.01320.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The 'Jack Jumper Ant' (JJA; Myrmecia pilosula species complex) is the major cause of ant sting anaphylaxis in Australia. Our aims were to determine the allergenicity of previously described venom peptides in their native forms, identify additional allergens and if necessary, update nomenclature used to describe the allergens according to International Union of Immunological Societies criteria. METHODS Various polyacrylamide gel electrophoresis methods were used to separate JJA venom. Gel resolved venom was Western-blotted and probed with individual sera taken from patients with a history of JJA sting anaphylaxis and immunoglobulin E radioallergosorbent test (IgE RAST) tracer uptakes of >1% to whole venom. RESULTS Of 67 available sera, 54 had RAST uptakes >1%. Thirteen IgE binding bands were identified using these sera. Pilosulin 3, [Ile(5)]pilosulin 1, and pilosulin 4.1 were recognized by 42 (78%), 18 (33%) and nine (17%) of the 54 sera that were tested. Immunoglobulin E-binding proteins with estimated molecular masses of 6.6, 22.8, 25.6, 30.4, 32.1, 34.4 and 89.8 kDa were each recognized by three or more individual sera. Two of these (25.6 and 89.8 kDa) were recognized by 46% and 37% of sera, respectively. CONCLUSION Nomenclature used to describe JJA venom allergens has been revised. Pilosulin 3 (Myr p 2) is the only major allergen, whilst [Ile(5)]pilosulin 1 (Myr p 1), and pilosulin 4.1 (Myr p 3) are minor allergens. There are an additional five IgE-binding proteins that require further characterization before they can be named as allergens. These findings provide a framework for standardizing venom extracts for diagnosis and immunotherapy.
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Affiliation(s)
- M D Wiese
- Department of Pharmacy, Royal Hobart Hospital, Hobart, Tasmania, Australia
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Sheikh A, Shehata Y, Brown SGA, Simons FER. Adrenaline for the treatment of anaphylaxis with and without shock. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2007. [DOI: 10.1002/14651858.cd006312] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
BACKGROUND Anaphylaxis is an acute systemic allergic reaction, which can be life-threatening. H1-antihistamines are commonly used as an adjuvant therapy in the treatment of anaphylaxis. OBJECTIVES To assess the benefits and harm of H1-antihistamines in the treatment of anaphylaxis. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library), MEDLINE (1966 to June 2006);EMBASE (1966 to June 2006); CINAHL (1982 to June 2006) and ISI Web of Science (1945 to July 2006). We also contacted pharmaceutical companies and international experts in anaphylaxis in an attempt to locate unpublished material. SELECTION CRITERIA Randomized and quasi-randomized controlled trials comparing H1-antihistamines with placebo or no intervention. DATA COLLECTION AND ANALYSIS Two authors independently assessed articles for inclusion. MAIN RESULTS We found no studies that satisfied the inclusion criteria. AUTHORS' CONCLUSIONS Based on this review, we are unable to make any recommendations for clinical practice. Randomized controlled trials are needed, although these are likely to prove challenging to design and execute.
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Affiliation(s)
- A Sheikh
- University of Edinburgh, Division of Community Health Sciences: GP Section, 20 West Richmond Street, Edinburgh, UK, EH8 9DX.
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Brown SGA, Haas MA, Black JA, Parameswaran A, Woods GM, Heddle RJ. In vitro testing to diagnose venom allergy and monitor immunotherapy: a placebo-controlled, crossover trial. Clin Exp Allergy 2004; 34:792-800. [PMID: 15144473 DOI: 10.1111/j.1365-2222.2004.01949.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND In people with a history of sting allergy, only prior reaction severity and older age are known to predict subsequent reaction risk. Furthermore, no diagnostic test other than a deliberate sting challenge has been found to identify people in whom venom immunotherapy (VIT) has been unsuccessful. OBJECTIVE We aimed to assess the utility of a number of in vitro tests to diagnose venom allergy and to monitor immunotherapy. METHODS During a double-blind randomized placebo-controlled crossover trial of Myrmecia pilosula ant VIT the following venom-specific tests were performed at enrolment, and at completion of treatment prior to a diagnostic sting challenge; leucocyte stimulation index (SI), IL-4 production, IgE RAST, histamine release test (HRT), leukotriene release test (LRT) and basophil activation test (BAT). Intradermal venom skin testing (VST) was also performed at trial entry. RESULTS Only VST and HRT identified those at risk of sting anaphylaxis in the placebo group. Although IgE RAST, leucocyte SI and IL-4 production, LRT and BAT all correlated well with intradermal VSTs, they did not predict sting challenge outcome. After successful VIT, venom-induced leucocyte IL-4 production tended to fall, whereas IgE RAST increased and a natural decline in HRT reactivity was reversed. A confounding seasonal affect on laboratory results was suspected. CONCLUSION The HRT warrants further assessment for diagnosis of venom allergy. Uninformative performance of the commercially available LRT and BAT tests may be due to pre-incubation with IL-3. None of the tests evaluated appear to be reliable markers of successful VIT.
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Affiliation(s)
- S G A Brown
- Department of Emergency Medicine, Royal Hobart Hospital, Hobart, Tasmania 7001, Australia.
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