Snakebite Management Research Articles

Snake bite management in a toddler: a case report in Sumbawa Besar

Snake bite is an often-neglected,1 life-threatening emergency prevalent in rural areas of tropical countries such as Indonesia.2 The WHO reported a worldwide incidence of 5 million snake bites per year, with 100,000–200,000 deaths.3 The incidence rate and likelihood of subsequent complications are higher in children than adults.4 According to the WHO, 35% of child deaths related to poisonous animal bites are attributable to snake bites and occur more frequently in boys than girls.5 In Indonesia, no national epidemiological data on snake bites in children is available, but the WHO estimated that 5–8 snake bite cases occur weekly in Lombok, West Nusa Tenggara.6
 Lower limbs are the most common site for bites (72%), while facial bites are quite rare (10%).7 Bites involving children and/or the face are considered as severe envenomation and usually require antivenom at an appropriate dose and timing to be effective.8 Therefore, it is important that hospitals are equipped with life-saving intervention measures to optimize care and improve the chances of survival.9 Nevertheless, in developing countries, the use of antivenom is limited by the absence of standardized guidelines, scarcity/unavailability, and high cost.9 In Indonesia, the only antivenom, serum antibisa ular (SABU), is costly and difficult to obtain due to limited quantities, especially in rural areas. Furthermore, SABU is a polyvalent antivenom with low coverage, as it is only indicated for Naja sputatrix, Bungarus fasciatus, and Agkistrodon rhodostoma, despite the numerous other snake species endemic to Indonesia.2

Knowledge on prevention, diagnosis and treatment of snakebite envenoming among doctors in snakebite-dense regions in Sri Lanka.

Sri Lanka is one of the highest envenoming reporting countries globally with >80000 snakebites per year. Among other factors, knowledge of snakebite among doctors predominantly determines patient outcomes. Using a pretested 72-item self-administered questionnaire, we assessed knowledge on identifying common snake species, signs of envenoming and management of venomous snakebites among 280 doctors working in eight state hospitals in regions where snakebite prevalence is highest in Sri Lanka. Visually, 92.1% correctly identified a cobra and 74.3% identified a Russell's viper, but only 30% could identify a hump-nosed viper (HNV). Syndromic identification of snakes was best for the krait (71.8%) followed by the cobra (59.6%), but poor for the HNV (30%). The median knowledge scores of pictorial and syndromic snake identification, indoor preventive measures and indications of antivenom were <75% of the maximum score. Apart from 62.5% who expected the victim to bring the snake along to the hospital, most doctors selected the correct options of pre-hospital care. The duration of work experience did not influence the competency of syndromic identification. Utilisation of local guidelines was associated with better knowledge in antivenom usage (odds ratio 2.22 [95% confidence interval 1.04 to 5.36]; p=0.03). Specific deficiencies of core knowledge in snakebite management exist among doctors working in snakebite prevalent regions.

Ethnobotanical survey and phytochemical screening of anti-snakebite plants used in Bissok District of Gabon

Abstract. Mengome, Mewono L, Mboma R, Engohang-Ndong J, Angone SA. 2021. Ethnobotanical survey and phytochemical screening of anti-snakebite plants used in Bissok District of Gabon. Biodiversitas 22: 3264-3275. Snakebites remain a major health issue in tropical and subtropical regions in the world. The limited access of antivenom sera in remote areas of many countries forces populations to rely on plant-based remedies to manage snakebite-induced injury. In this study, we conducted an ethnobotanical survey of medicinal plants used for the management of snakebites in the district of Bissok (Northern Gabon). After collecting and verifying the authenticity of the plants, we further performed their phytochemical analysis. The procedure used in this study involved a structured questionnaire and direct interviews of local populations. Overall, data collected on-site included local names, the part of the plant used, the preparation, and the route of administration. The presence of some phytochemical compounds was determined according to standard methods. Overall, a total of 29 species of plants belonging to 20 different families were reported to be used to treat snakebites. The plants used were herbs (44.80%), trees (24.10%), shrubs (20.70%), liana (10.30%), and rhizomes (6.90%). They were mainly used as poultice or crush, and to a lesser extent as decoction and maceration. Regarding the route of administration, interviewees reported mainly external use on the site of the bite. Concerning the chemical composition, we found that the antivenom plants were rich in chemical compounds known to have antivenom, antipyretic and antimicrobial properties, e.g. alkaloids, terpenoids, flavonoids, steroids, coumarins, phenols, tannins gallic Our results open avenues to develop venom enzyme inhibitory assays.

Ethnopharmacologic screening of medicinal plants used traditionally by tribal people of Madhya Pradesh, India, for the treatment of snakebites

AimSnakebites are a serious health problem throughout the world, particularly in Asia. Several medicinal plants are used traditionally for the treatment of various ailments including snakebites. The aim of the study is to screen medicinal plants, which are traditionally used for the management of snakebites by tribal people and local practitioners of Madhya Pradesh in the central region of India. Materials and methodsThis ethnopharmacologic screening covered 12 medicinal plants that are generally used for snakebite management traditionally. Aqueous and ethanol extracts of medicinal plants were evaluated for qualitative phytochemical analysis, antioxidant activity, and in vitro enzyme-inhibition activity against enzymes. Naja naja venom neutralization assay was evaluated by minimum indirect hemolytic dose (MIHD) assay and in vitro tissue damaging method. Gas chromatography mass spectrometry (GC–MS) analysis identified major bioactive compounds. In silico molecular docking was performed to show interactions between the identified bioactive compounds and phospholipase A2. ResultsExtracts showed potential to inhibit phospholipase A2, hyaluronidase, deoxyribonuclease, and ribonuclease enzymes. Ethanolic extract of H. isora were capable of Naja naja venom neutralization and significantly exhibited lowest percentage tissue damage activity. GC–MS analysis of Helicteres isora showed the presence of 30 bioactive compounds, 6 of whom have interaction with phospholipase A2. ConclusionsThe authors conclude that H. isora ethanolic extract exhibits Naja naja venom enzyme-inhibition activity. These results suggest that Helicteres isora ethanolic extract contains anti-inflammatory agents and has potential as a functional material or novel herbal medicine for managing snake bite complications.

ROLE OF PARASURGICAL PROCEDURES IN THE MANAGEMENT OF SARPA VISHA

Agadatantra is one of the eight branches of Ayurveda. It is a branch in which treatment of various Sthavara(~plant origin) and Jangama(~animal origin)Visha(~poisons) are described with signs and symptoms. A general principle for the treatment of poisoning is explained in AyurvedicSamhithas like Charaka, Sushruta, and Vagbhata. Snakebite is one among JangamaVisha(~animal origin poison), its mortality in India is approximately 1300annually.The snakebite management protocol is elaborately prescribed by the World Health Organization (WHO). AcharyaCharaka has explained ChathurvimshathiUpakrama(~24 treatment procedures) for the management of all types of poison including snake bite.Agnikarma(~Cauterization), and Raktamokshana(~Blood letting), are the only two Para surgical procedures among 24 treatment modalities.Para surgical procedures help to get rid-off localized poison immediately thus preventing the spread and further complications.This article is an extensive review mainly focussed on the role of Para surgical procedures in the management of SarpaVisha(~Snakebite poison). KEYWORDS:Agnikarma,Ayurveda,Chaturvimshatiupakrama,Parasurgicalprocedures,Raktamokshana,Snakebite management.

Dealing with snakebite in rural Cameroon: A qualitative investigation among victims and traditional healers.

BackgroundSnakebite is a neglected tropical disease (NTD) affecting rural and remote populations globally, who are additionally burdened by poverty and the lack of effective healthcare systems. Delayed healthcare and use of traditional treatments are very frequent. The purpose of our study was to explore perceptions of snakes, impact of snakebite, and knowledge and opinions of different snakebite treatments with the aim of identifying opportunities for improving snakebite management.MethodsThis is a qualitative descriptive study based on semi-structured interviews with 21 snakebite victims and 4 traditional healers in 4 villages of Akonolinga health district, Center Region, Cameroon. Analysis focused on describing participants' perceptions of snakes, the impact of snakebite on the victims’ lives, and their opinions of different treatment options.ResultsRespondents were fearful of snakes and knowledgeable about envenoming symptoms and treatments. The experience of snakebite led to increased vigilance and avoidance behaviours, which sometimes resulted in financial loss for the victims. A range of traditional treatments were described, including tourniquets, black-stone application and medicinal plant decoctions. However, opinions were ambivalent regarding their efficacy, depending especially on previous personal experiences. Still, traditional treatments were said to be more available and cheaper than hospital care, and in particular, than antivenom. Nevertheless, most victims preferred hospital treatment if the financial and transportation barriers were lifted. Both snakebite victims and traditional healers were of the opinion that collaboration between health services and traditional healers could help to improve snakebite management and outcomes.ConclusionOur study shows that snakebite victims are in favour of using antivenom for the treatment of snakebite and would welcome better access to it. However, its current unavailability and high cost pushes them to turn to traditional treatments. On the other hand, traditional healers are in favour of collaborating with health facilities. These results are very encouraging for the improvement of snakebite management in Cameroon along the lines of the WHO Snakebite Envenoming Strategy for Prevention and Control: ensuring access to safe and effective treatment, and increasing partnership and coordination between communities, traditional healers, and conventional caregivers.

Health and economic burden estimates of snakebite management upon health facilities in three regions of southern Burkina Faso.

BackgroundSnakebite has become better recognized as a significant cause of death and disability in Sub-Saharan Africa, but the health economic consequences to victims and health infrastructures serving them remain poorly understood. This information gap is important as it provides an evidence-base guiding national and international health policy decision making on the most cost-effective interventions to better manage snakebite. Here, we assessed hospital-based data to estimate the health economic burden of snakebite in three regions of Burkina Faso (Centre-Ouest, Hauts Bassins and Sud-Ouest).MethodologyPrimary data of snakebite victims admitted to regional and district health facilities (eg, number of admissions, mortality, hospital bed days occupied) was collected in three regions over 17 months in 2013/14. The health burden of snakebite was assessed using Disability-Adjusted Life Years (DALYs) calculations based upon hospitalisation, mortality and disability data from admitted patients amongst other inputs from secondary sources (eg, populations, life-expectancy and age-weighting constants). An activity-based costing approach to determine the direct cost of snake envenoming included unit costs of clinical staff wages, antivenom, supportive care and equipment extracted from context-relevant literature.FindingsThe 10,165 snakebite victims admitted to hospital occupied 28,164 hospital bed days over 17 months. The annual rate of hospitalisation and mortality of admitted snakebite victims was 173 and 1.39/100,000 population, respectively. The estimated annual (i) DALYs lost was 2,153 (0.52/1,000) and (ii) cost to hospitals was USD 506,413 (USD 49/hospitalisation) in these three regions of Burkina Faso. These costs appeared to be influenced by the number of patients receiving antivenom (10.90% in total) in each area (highest in Sud-Ouest) and the type of health facility.ConclusionThe economic burden of snake envenoming is primarily shouldered by the rural health centres closest to snakebite victims–facilities that are typically least well equipped or resourced to manage this burden. Our study highlights the need for more research in other regions/countries to demonstrate the burden of snakebite and the socioeconomic benefits of its management. This evidence can guide the most cost-effective intervention from government and development partners to meet the snakebite-management needs of rural communities and their health centres.

Evaluating spatiotemporal dynamics of snakebite in Sri Lanka: Monthly incidence mapping from a national representative survey sample.

Snakebite incidence shows both spatial and temporal variation. However, no study has evaluated spatiotemporal patterns of snakebites across a country or region in detail. We used a nationally representative population sample to evaluate spatiotemporal patterns of snakebite in Sri Lanka. We conducted a community-based cross-sectional survey representing all nine provinces of Sri Lanka. We interviewed 165 665 people (0.8% of the national population), and snakebite events reported by the respondents were recorded. Sri Lanka is an agricultural country; its central, southern and western parts receive rain mainly from Southwest monsoon (May to September) and northern and eastern parts receive rain mainly from Northeast monsoon (November to February). We developed spatiotemporal models using multivariate Poisson process modelling to explain monthly snakebite and envenoming incidences in the country. These models were developed at the provincial level to explain local spatiotemporal patterns. Snakebites and envenomings showed clear spatiotemporal patterns. Snakebite hotspots were found in North-Central, North-West, South-West and Eastern Sri Lanka. They exhibited biannual seasonal patterns except in South-Western inlands, which showed triannual seasonality. Envenoming hotspots were confined to North-Central, East and South-West parts of the country. Hotspots in North-Central regions showed triannual seasonal patterns and South-West regions had annual patterns. Hotspots remained persistent throughout the year in Eastern regions. The overall monthly snakebite and envenoming incidences in Sri Lanka were 39 (95%CI: 38-40) and 19 (95%CI: 13-30) per 100 000, respectively, translating into 110 000 (95%CI: 107 500-112 500) snakebites and 45 000 (95%CI: 32 000-73 000) envenomings in a calendar year. This study provides information on community-based monthly incidence of snakebites and envenomings over the whole country. Thus, it provides useful insights into healthcare decision-making, such as, prioritizing locations to establish specialized centres for snakebite management and allocating resources based on risk assessments which take into account both location and season.

Snakebite Envenoming Diagnosis and Diagnostics.

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.

Snake Bite Management: A Scoping Review of the Literature.

Background:Around the world, snake bite envenomation remains an underreported human health hazard. Envenomation can cause local and systemic complications, especially when there is a lack of antivenom availability. Although there are established guidelines regarding snake bite management acute care, there is a paucity of data regarding surgical intervention and the plastic surgeon’s role treating this unique patient population.Methods:A review was conducted identifying relevant published articles involving snake bite management and treatment in PubMed and EMBASE.Results:One hundred ten articles were identified and 77 met inclusion criteria. Snake bite envenomation can result in complications that are dependent upon a variety of variables. The literature has shown the best field treatment to be timely transportation to the nearest medical facility, along with antivenom administration. The cytotoxic, hemotoxic, and neurotoxic effects of venom can cause a variety of local soft tissue and systemic complications. Surgical interventions such as fasciotomies, wound debridements, skin grafts, and tissue flaps may be necessary in these patients to optimize functional and aesthetic outcomes. Disparities in access to care in resource limited settings are discussed.Conclusions:Global health disparities and insufficient antivenom distribution create an inequality of care in snake bite patients. Plastic surgeons have an important role in managing acute and chronic complications of snake bite envenomations that can lead to improved patient outcomes.

Snakebite Outcome Study in Far west Provincial Hospital Of Nepal

Introduction: Snakebite is well known medical emergencies and cause of hospital admission with significant mortality in our country. Objective of this study is to find out the status and outcome of snake bites envenoming management.&#x0D; Methods: This is prospective observational study from 15th April 2018 to 14th April 2019.Data collected all snake bites presented this hospital and observed till discharged, death or referred. Case management was done as per the WHO guideline for the management of snake bite 2016. Permission for study was taken from Medical Superintendent of Seti provincial hospital and informed consent was taken. The data were entered in Microsoft Excel 2007 and analyzed using latest version of SPSS version and appropriate descriptive statistical tools.&#x0D; Results: A total of 362 snakebites were landed in the emergency of this hospital during one year period among them 71% non-poisonous and 29% poisonous snake bites. There were 17 deaths (case fatality rate 12%). Among poisonous Krait 36 % were identified snakes and half could not. Major features of envenoming were ptosis,nausea,vomiting and pain abdomen, parotid tenderness, numbness and blister and bleeding in bitten parts. Almost all 86% poisonous bites got 100ml snake venom antiserum. Few cases required additional 10 vials (100ml) and 13.5% required ventilation for respiratory paralysis. There was no mortality in Intensive Care Unit and ward.&#x0D; Conclusions: Snake bite is the seasonal life-threatening emergency public health problem; significant numbers of snakebite and mortality but timely intervention has excellent outcome. Community awareness and strengthening health systems are major activities to be done.

Evaluation of the Effect of Hydroethanolic Root Extract and Solvent Fractions of Cyphostemma adenocaule (Steud. ex A. Rich) Descoings ex Wild & Drummond on Cell-Mediated Immune Response and Blood Cell Count in Mice.

Introduction Cyphostemma adenocaule (Steud. ex A. Rich) Descoings ex wild & Drummond (Vitaceae) has been used in traditional medicine for the management of various immunological and hematological disorders in different areas of Ethiopia and the rest of the world. In Ethiopia, the plant is used for the management of enlarged spleen, rabies virus, helminthic infection, snake bite, and various types of tumors. Objective To evaluate the effect of hydroethanolic root extract and solvent fractions of Cyphostemma adenocaule on cell-mediated immunity (delayed-type hypersensitivity), organ index (spleen and liver), and blood cell count in Swiss albino mice. Materials and Methods Acute oral toxicity test was conducted using nulliparous and nonpregnant Swiss albino mice following OECD 425 limit test method. Delayed-type hypersensitivity model was used to evaluate the effect on cell-mediated immunity. The experimental animals were divided into twelve groups which were sensitized and challenged with sheep red blood cells on day 0 and day 7, respectively. Levamisole 50 mg/kg was used as stimulant control, whereas cyclophosphamide 30 mg/kg was used as suppressant control. Hydroethanolic root extract (100 mg/kg, 200 mg/kg, and 400 mg/kg), aqueous fraction (100 mg/kg, 200 mg/kg, and 400 mg/kg), and n-butanol fraction (100 mg/kg, 200 mg/kg, and 400 mg/kg) were administered for seven days. The paw volume was measured using a digital plethysmometer before challenge and 24 hours after challenge. Blood was collected, and organs (spleen and liver) were isolated from each challenged mouse to determine blood cell count and organ index, respectively. Results No mortality and noticeable behavioral changes were observed among all mice receiving hydroethanolic root extract and solvent fractions at a dose of 2000 mg/kg. Hydroethanolic root extract and solvent fractions of Cyphostemma adenocaule showed enhancement of delayed-type hypersensitivity, organ index, and blood cell count. Hydroethanolic root extract at a dose of 400 mg/kg showed the highest and statistically significant stimulation of delayed-type hypersensitivity (0.123 ± 0.010) and blood cell count compared to the vehicle. Conclusion Hydroethanolic root extract and solvent fractions of Cyphostemma adenocaule showed a stimulatory effect on cell-mediated immunity and hematopoiesis.

Anti-5 ′ -Nucleotidases (5 ′ -ND) and Acetylcholinesterase (AChE) Activities of Medicinal Plants to Combat Echis carinatus Venom-Induced Toxicities

Echis carinatus is one of the highly venomous snakes of Pakistan that is responsible for numerous cases of envenomation and deaths. In Pakistan, medicinal plants are commonly used traditionally for snakebite treatment because of their low cost and easy availability in comparison with antivenom. The current research is aimed at evaluating the inhibitory activity of Pakistani medicinal plants against acetylcholinesterase and 5′-nucleotidases present in Echis carinatus venom. Acetylcholinesterase and 5′-nucleotidase enzymatic assays were performed at different venom concentrations to check the activity of these enzymes. Methanolic extracts from different parts of plants were used for in vitro determination of their inhibitory activity against 5′-nucleotidases in snake venom. Active methanolic extracts were subsequently fractioned using different solvents, and these fractions were also assessed for their anti-5′-nucleotidase activity. Results of this study exhibited that Eugenia jambolana Willd. ex O. Berg, Rubia cordifolia L., Trichodesma indicum (L.) R. Br., Calotropis procera (Wild.) R. Br., Curcuma longa L., and Fagonia arabica L. were able to significantly (p > 0.5) neutralize the 5′-nucleotidase activity by 88%, 86%, 86%, 85%, 83.7%, and 83%, respectively, compared with a standard antidote (snake venom antiserum). Thus, this study indicates that these plants possess the potential to neutralize one of the toxic enzymatic components of Echis carinatus venom and hence can help to augment the future efforts of developing alternative therapy for the management of snakebites.

Unveiling the Potential Threat of Bacterial Oral Flora of Snake in Snake Bite Envenomation

Abstract Snakebite is an acute life-threatening and time-limited medical emergency. There is comparatively less evidence regarding the infections caused by pathogens present in the snake's oral flora that induce cellulites secondary to snake bite. Here, we report a case of 15-year-old male patient infected with Acinetobacter baumannii–induced sepsis who underwent hemodialysis posthemotoxic envenomation; inflicted by hemotoxic snake, Russell's viper (Daboia russelii) at right index finger, and he was treated with 20 vials of antisnake venom. He had acute kidney injury and underwent 10 cycles of hemodialysis. He had incidence of cellulites with sepsis, and pus culture showed the presence of A. baumannii isolates with extensive drug resistance. He was treated with piperacillin-tazobactam, vancomycin, imipenem, and colistin for the improvement of his health status. Thus, the management of snake bite–induced sepsis, bacterial susceptibility study of oral flora in local venomous snakes has to be studied.

Health professionals' overestimation of knowledge on snakebite management, a threat to the survival of snakebite victims-A cross-sectional study in Ghana.

According to the World Health Organization, snakebites, a common occupational hazard in developing countries accounts for an annual loss of between 81,000 and 138, 000 lives following 5 million bites of which 2.7 million results in envenomation. Since snakebite-associated morbidity and mortality are more prevalent in agricultural economies such as Ghana, health professionals should be optimally knowledgeable on how to manage the incidence of snakebites. Lack of knowledge or overestimation of a professional's knowledge can affect heath delivery especially for emergencies such as snakebites. The three rurally situated Tongu districts in South-Eastern Ghana with agriculture as the major source of livelihood for their inhabitants, are prone to snakebites. This study, therefore, brings up the need to assess whether the health professionals in these districts are well-equipped knowledge-wise to handle such emergencies and whether they can rightly estimate their knowledge with regards to snakebite management. Data was collected using a de novo semi-structured questionnaire administered through google form whose link was sent via WhatsApp to 186 health workers made up of nurses, midwives, physician assistants, medical doctors, pharmacists, and pharmacy technicians. This data was analyzed using Statistical Package for the Social Sciences (SPSS) Version 25. Association between variables was determined using the appropriate tools where necessary, using a confidence interval of 95% and significance assumed when p ≤ 0.05. This study found male health workers significantly more knowledgeable about snakebite management (11.53±5.67 vs 9.64±5.46; p = 0.022) but it was the females who overestimated their knowledge level (27.9% vs 24.1%). The medical doctors exhibited the best knowledge on snakebite management with the registered general nurses least knowledgeable. Although most professionals overestimated their knowledge, the registered general nurses were the worst at that (53.7%). Overall knowledge of health care professionals on snakebite management was below average [10.60±5.62/22 (48.2%)] but previous in-service training and involvement in the management of snakebite were associated with better knowledge. Respondents who had no previous training overestimated their knowledge level compared to those who had some post-qualification training on snakebite management (38.1% vs 7.5%). The greatest knowledge deficit of respondents was on the management of ASV associated adverse reactions. Health workers in rural Ghana overestimated their knowledge about snakebite management although their knowledge was low. Training schools, therefore, need to incorporate snakebite management in their curriculum and health authorities should also expose health workers to more in-service training on this neglected tropical disease.

Clinical implications of differential procoagulant toxicity of the palearctic viperid genus Macrovipera, and the relative neutralization efficacy of antivenoms and enzyme inhibitors

Species within the viperid genus Macrovipera are some of the most dangerous snakes in the Eurasian region, injecting copious amounts of potent venom. Despite their medical importance, the pathophysiological actions of their venoms have been neglected. Particularly poorly known are the coagulotoxic effects and thus the underlying mechanisms of lethal coagulopathy. In order to fill this knowledge gap, we ascertained the effects of venom upon human plasma for Macrovipera lebetina cernovi, M. l. lebetina, M. l. obtusa, M. l. turanica, and M. schweizeri using diverse coagulation analysing protocols. All five were extremely potent in their ability to promote clotting but varied in their relative activation of Factor X, being equipotent in this study to the venom of the better studied, and lethal, species Daboia russelii. The Insoserp European viper antivenom was shown to be highly effective against all the Macrovipera venoms, but performed poorly against the D. russelii venom. Reciprocally, while Daboia antivenoms performed well against D. russelii venom, they failed against Macrovipera venom. Thus despite the two genera sharing a venom phenotype (Factor X activation) driven by the same toxin type (P-IIId snake venom metalloproteases), the surface biochemistries of the toxins differed significantly enough to impede antivenom cross- neutralization. The differences in venom biochemistry were reflected in coagulation co-factor dependence. While both genera were absolutely dependent upon calcium for the activation of Factor X, dependence upon phospholipid varied. The Macrovipera venoms had low levels of dependence upon phospholipid while the Daboia venom was three times more dependent upon phospholipid for the activation of Factor X. This suggests that the sites on the molecular surface responsible for phospholipid dependence, are the same differential sites that prevent inter-genera antivenom cross- neutralization. Due to cold-chain requirements, antivenoms may not be stocked in rural settings where the need is at the greatest. Thus we tested the efficacy of enzyme inhibitor Prinomastat as a field-deployable treatment to stabilise patients while being transported to antivenom stocks, and showed that it was extremely effective in blocking the Factor X activating pathophysiological actions. Marimastat however was less effective. These results thus not only shed light on the coagulopathic mechanisms of Macrovipera venoms, but also provide data critical for evidence-based design of snakebite management strategies.

Appraisal of Antiophidian Properties of Cardiospermum halicacabum L. Leaf and Callus Extracts against Naja Naja Venom

Considering the limitations of antivenom therapy towards toxicity following envenomation, investigators are probing for effective phytochemicals with promising antivenom effects. In the current study, Cardiospermum halicacabum leaf and callus methanol extracts were investigated for their ability to neutralize Indian cobra (Najanaja) venom. Soxhlet extraction using methanol was performed since leaf and callus extracts demonstrated significant neutralization of N. najavemon in preliminary studies. In vitro neutralizing potential of both extracts were evaluated against phospholipase A2, preoteases and hyaluronidases. In addition, alleviation of N. naja-induced characteristic edema inducing activity, myotoxicity and coagulation, hemolytic activity were performed in mouse models and human blood samples. Leaf and callus methanol extract contained high concentrations of phenols, alkaloids, steroids and saponins and demonstrated significant in vitro inhibition of N. naja PLA2, proteases and hyaluronidase activities at 30-40 µg concentrations. Significant neutralization of N. naja-induced indirect hemolysis, edema, anticoagulant effect and myotoxicity was attained using both extracts. Overall leaf and callus extracts (1mg/kg) postponed animal survival by 33 ± 9.3 and 50 ± 12.4 mins, respectively. C. halicacabum leaf and callus methanol extracts demonstrated significant neutralization of N. naja enzymes that contribute to grievous effects on various tissues/organs. The study scientifically supports the anecdotal use of C. halicacabum in complementary medicine and demonstrates that callus extract is more potent antidote than leaf. Further, callus extract is a potent candidate for isolation of phytochemicals towards management of snakebite.

Knowledge assessment of anti-snake venom among healthcare practitioners in northern Nigeria.

Introduction:Anti-snake venom (ASV) is the standard therapy for the management of snakebite envenoming (SBE). Therefore, the knowledge of ASV among healthcare practitioners (HCPs) is essential for achieving optimal clinical outcomes in snakebite management. This study aimed to assess knowledge of ASV among the HCPs in northern Nigeria.Methods:We conducted a cross-sectional study involving eligible HCPs from different healthcare settings in northern Nigeria. The participants were recruited into the study using a combination of online (via Google Form) and face-to-face paper-based survey methods. The ASV knowledge of the respondents was measured using a validated anti-snake venom knowledge assessment tool (AKAT). Inadequate overall knowledge of ASV was defined as scores of 0–69.9%, and 70–100% were considered adequate overall knowledge scores. The predictors of ASV knowledge were determined using multiple logistic regression.Results:Three hundred and thirty-one (331) eligible HCPs were included in the study analysis (310 from online and 21 from paper-based survey). Overall, an estimated 12.7% of the participants had adequate knowledge of ASV. Adequate ASV knowledge was higher among physicians compared with other HCPs (21.7%; χ2 = 8.1; p = 0.04). Those without previous training on ASV (adjusted odds ratio [aOR], 0.37; 95% confidence interval [CI], 0.18–0.73; p = 0.004) and who have not previously administered/dispensed ASV (aOR, 0.31; 95% CI, 0.15–0.63; p < 0.001) were less likely to have adequate knowledge of ASV.Conclusion:The knowledge of ASV among healthcare practitioners in northern Nigeria is grossly inadequate. Experience with administering or dispensing ASV predicts ASV knowledge. Therefore, appropriate interventions are needed to improve ASV knowledge, particularly among the HCPs, for optimal healthcare outcomes.

Review on traditional diagnosis and management of snakebite in Ayurveda

Toxicology started right from the prehistoric era when man lived in caves of forests. Reptiles originated nearly 240 million years ago, but man was born only nearly about 4 million years back. A man had to survive; he had to fifth against many odds. Snake venom is one of these odds, and treatment of poisonous would have started with the first affliction by poison on man. It is believed that in India, about 2 million people are bitten by snakes annually of which 15,000 to 30000 cases prove fatal. The problem became more after urbanization and deforestation. In the early decades of the 19th century, it has been recorded by the scholars that the mortality rate in snakebite victims was higher chiefly in rural India by the unavailability of emergency medicines and poor transportation facilities. Still, recently this has been changed significantly by providing ASV (anti snake venom) as a primary treatment through hospitals of tertiary levels. Traditional poisoning healing system was also parallel to this in rural areas of south India, especially in the state of Kerala, belief in the Traditional poisoning healing system were the main motives for it. Here an attempt has been made to explore the Traditional Visha chikitsa Sampradaya of Kerala, which is quite different from classical Granthas of Ayurveda (textbook) such as Bruhatrayees along with mainly used formulations in Visha chikitsa.

Assessment of Knowledge about First Aid Methods, Diagnosis, and Management of Snakebite among Nursing Students: A Cross-Sectional Study from Palestine.

Background Snakebite is a serious and important medical emergency encountered in many parts of the world. The estimated number of victims of venomous snakebites in Palestine is about 100 to 150 annually, with death occurring in 2 to 3 of them. This study was designed to assess the level of knowledge on the diagnosis and management of snakebites among nursing students in Palestine, as well as their attitude towards snakebites. Methods This was a cross-sectional survey that took place at An-Najah National University. Two hundred nursing students were asked to fill a questionnaire that was developed to assess the participants' knowledge and attitude regarding snakebite's diagnosis and management. Different knowledge scores were calculated, and the relationships between students' knowledge and their characteristics were calculated by implementing the Mann–Whitney U test and the Kruskal–Wallis test. The statistical significance limit of p values was set at 0.05. Results The majority of the participants (57%) were fourth-year students with an average age of 20.7 ± 1. Areas of knowledge and the participants' mean scores on them were as follows: Vipera palaestinae snake, 5.1/13; signs and symptoms, 9.6/16; laboratory investigations, 6.1/10; anti-venom, 4.2/11; and first aid, 6.6/15. The only statistically significant differences in knowledge were between male and female students on Vipera palaestinae (male students scored higher, p value = 0.004) and between different types of residence (village dwellers scored the highest, p value = 0.041). Conclusions We found knowledge gaps in many aspects of snakebite's diagnosis and management among nursing students in Palestine. Based on the results of this study, we suggest integrating more materials on this topic in the curriculum of Palestinian nursing schools, as well as more practical training, which will positively reflect on the care for snakebite victims.