Snake bites are a major public health problem affecting millions each year, especially in rural areas of developing countries. Common symptoms include local swelling, bleeding disorders, paralysis, and kidney injury. Treatment involves supportive care, antivenom therapy, and monitoring for complications. Early administration of the correct antivenom within 4 hours of the bite is important to prevent mortality and morbidity from snake envenomation.
Concise discussion on essential clinical and microbiological aspects of Candia, Pneumocystis and Aspergillus infections in HIV and other immunocompromised patients.
Concise discussion on essential clinical and microbiological aspects of Candia, Pneumocystis and Aspergillus infections in HIV and other immunocompromised patients.
A type of virus that causes herpes infections and has DNA as its genetic material. There are two types of human herpesviruses. Infections with type 1 viruses cause cold sores on the lips or nostrils. Infections with type 2 viruses cause sores on the genitals (external and internal sex organs and glands).
A comprehensive description of leischmaniasis with its types, transmission, epidemiology, pathogenesis, prevention and control. It also includes details regarding lab diagnosis, disease agent, vector and host.
Cryptococcosis also called as Torulosis is a subacute or chronic fungal infection caused by Cryptococcus neoformans. It leads to compications such as fatal meningoencephalitis. It is an opportunistic infection in HIV-infected patients. The PPT discuss on the morphology of the fungus, pathogenesis, laboratory diagnosis and treatment.
Leishmaniasis is caused by a protozoa parasite from over 20 Leishmania species. Over 90 sandfly species are known to transmit Leishmania parasites. There are 3 main forms of the disease:
Visceral leishmaniasis (VL), also known as kala-azar is fatal if left untreated in over 95% of cases. It is characterized by irregular bouts of fever, weight loss, enlargement of the spleen and liver, and anaemia. Most cases occur in Brazil, East Africa and in South-East Asia. An estimated 50 000 to 90 000 new cases of VL occur worldwide each year out of which only an estimated 25–45% are reported to WHO. In 2017, more than 95% of new cases reported to WHO occurred in 10 countries: Bangladesh, Brazil, China, Ethiopia, India, Kenya, Nepal, Somalia, South Sudan and Sudan.
Cutaneous leishmaniasis (CL) is the most common form of leishmaniasis and causes skin lesions, mainly ulcers, on exposed parts of the body, leaving life-long scars and serious disability or stigma. About 95% of CL cases occur in the Americas, the Mediterranean basin, the Middle East and Central Asia. In 2017 over 95% of new CL cases occurred in 6 countries: Afghanistan, Algeria, Brazil, Colombia, Iran (Islamic Republic of), Iraq and the Syrian Arab Republic. It is estimated that between 600 000 to 1 million new cases occur worldwide annually.
Mucocutaneous leishmaniasis leads to partial or total destruction of mucous membranes of the nose, mouth and throat. Over 90% of mucocutaneous leishmaniasis cases occur in Bolivia (the Plurinational State of), Brazil, Ethiopia and Peru.
Transmission
Leishmania parasites are transmitted through the bites of infected female phlebotomine sandflies, which feed on blood to produce eggs. The epidemiology of leishmaniasis depends on the characteristics of the parasite and sandfly species, the local ecological characteristics of the transmission sites, current and past exposure of the human population to the parasite, and human behaviour. Some 70 animal species, including humans, have been found as natural reservoir hosts of Leishmania parasites.
(WHO, 2019)
https://www.who.int/news-room/fact-sheets/detail/leishmaniasis
A type of virus that causes herpes infections and has DNA as its genetic material. There are two types of human herpesviruses. Infections with type 1 viruses cause cold sores on the lips or nostrils. Infections with type 2 viruses cause sores on the genitals (external and internal sex organs and glands).
A comprehensive description of leischmaniasis with its types, transmission, epidemiology, pathogenesis, prevention and control. It also includes details regarding lab diagnosis, disease agent, vector and host.
Cryptococcosis also called as Torulosis is a subacute or chronic fungal infection caused by Cryptococcus neoformans. It leads to compications such as fatal meningoencephalitis. It is an opportunistic infection in HIV-infected patients. The PPT discuss on the morphology of the fungus, pathogenesis, laboratory diagnosis and treatment.
Leishmaniasis is caused by a protozoa parasite from over 20 Leishmania species. Over 90 sandfly species are known to transmit Leishmania parasites. There are 3 main forms of the disease:
Visceral leishmaniasis (VL), also known as kala-azar is fatal if left untreated in over 95% of cases. It is characterized by irregular bouts of fever, weight loss, enlargement of the spleen and liver, and anaemia. Most cases occur in Brazil, East Africa and in South-East Asia. An estimated 50 000 to 90 000 new cases of VL occur worldwide each year out of which only an estimated 25–45% are reported to WHO. In 2017, more than 95% of new cases reported to WHO occurred in 10 countries: Bangladesh, Brazil, China, Ethiopia, India, Kenya, Nepal, Somalia, South Sudan and Sudan.
Cutaneous leishmaniasis (CL) is the most common form of leishmaniasis and causes skin lesions, mainly ulcers, on exposed parts of the body, leaving life-long scars and serious disability or stigma. About 95% of CL cases occur in the Americas, the Mediterranean basin, the Middle East and Central Asia. In 2017 over 95% of new CL cases occurred in 6 countries: Afghanistan, Algeria, Brazil, Colombia, Iran (Islamic Republic of), Iraq and the Syrian Arab Republic. It is estimated that between 600 000 to 1 million new cases occur worldwide annually.
Mucocutaneous leishmaniasis leads to partial or total destruction of mucous membranes of the nose, mouth and throat. Over 90% of mucocutaneous leishmaniasis cases occur in Bolivia (the Plurinational State of), Brazil, Ethiopia and Peru.
Transmission
Leishmania parasites are transmitted through the bites of infected female phlebotomine sandflies, which feed on blood to produce eggs. The epidemiology of leishmaniasis depends on the characteristics of the parasite and sandfly species, the local ecological characteristics of the transmission sites, current and past exposure of the human population to the parasite, and human behaviour. Some 70 animal species, including humans, have been found as natural reservoir hosts of Leishmania parasites.
(WHO, 2019)
https://www.who.int/news-room/fact-sheets/detail/leishmaniasis
Toward Precision Medicine in Neurological Disease by David GoldsteinKnome_Inc
View the webinar at http://www.knome.com/webinar-toward-precision-medicine-neurological-disease. In this presentation, Dr. Goldstein reports progress in identifying pathogenic mutations large-scale scale studies in epilepsy, in particular focusing on identifying de novo mutations as a cause of the epileptic encephalopathies. Next he discusses how sequencing is being used to diagnose rare serious unresolved genetic conditions. Finally, Dr. Goldstein describes a number of examples in which a secure genetic diagnosis has led directly to a change in clinical management.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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1. SNAKE BITE:
CLINICAL PRESENTATION AND
MANAGEMENT
Prof. GARBATI, MA
Infectious Diseases
UMTH, Maiduguri, Borno State
FACULTY OF INTERNAL MEDICINE
NPMCN GENERAL MEDICINE UPDATE COURSE, JULY 2022
2. Introduction
• Snakebite:
• More than 5 million snakebites
• 2.5 million envenomations
• Deaths - 81,000 to 138,000.
• Most occur in developing countries with poorly developed health reporting
systems.
• Regions with the highest incidence:
• Southeast and South Asia
• sub-Saharan Africa
• Latin America
• Many have limited access to health care.
WHO, 2017. Warrell Lancet 2010; Kasturiratne et al, 2008
7/29/2022 NPMCN_GM_UPDATE COURSE 2022 2
3. Introduction cont’d
• WHO designated snakebite as an NTD in 2017
• Snakebites affect poorer populations in rural areas.
• Common patterns of bites:
• to the arm, foot, ankle, or lower leg.
• on the head or trunk.
• The risk of snakebite also increases during the rainy season and after
floods.
WHO 2017; Bawaskar, Lancet 2019; Hunter et al, Lancet 2019;
7/29/2022 NPMCN_GM_UPDATE COURSE 2022 3
4. Introduction cont’d
• Nigeria:
• Incidence - 20,000 cases of snakebite
• Mortality - 2,000 deaths occur each year
• Amputations - 1,700-2,000
• High incidence States– Adamawa, Bauchi, Benue, Borno, Enugu, Gombe, Kebbi, Kogi, Nassarawa, Oyo,
Plateau and Taraba.
• Common families of venomous snakes:
• Viperidae
• Elapidae
• Colubridae
• Actraspididae or Stiletto snakes
• Most important snakes – carpet viper (Echis ocellatus), black-necked spitting cobra (Naja nigricollis) and
puff adder (Bitis arietans).
• Habib et al, 2001
7/29/2022 NPMCN_GM_UPDATE COURSE 2022 4
8. Pathogenesis
• Venoms exert a wide range of toxic activities in the body.
• Elapid venoms, and some viperid venoms, induce neuromuscular paralysis.
• Most viperid venoms, and some elapid venoms, inflict prominent local
tissue damage.
• Viperid venoms cause systemic haemorrhage, which, together with
increased vascular permeability, can lead to cardiovascular shock.
• Viperid and some elapid and some colubroid venoms act at various levels
of the coagulation cascade and on platelets, thereby affecting haemostasis.
• Some venoms cause rhabdomyolysis.
• Acute kidney injury can result from a multifactorial pathogenesis.
7/29/2022 NPMCN_GM_UPDATE COURSE 2022 8
9. Pathophysiology
• Cytotoxins act on tissue at the site of the bite or on tissues that directly
absorbs the venom.
• Neurotoxins act on nervous system.
• Myotoxins targets skeletal muscles
• Hemotoxins act on the blood coagulation system and may cause bleeding.
• Cardiotoxins act on heart tissue.
7/29/2022 NPMCN_GM_UPDATE COURSE 2022 9
10. Pathophysiology cont’d
• The spectrum of clinical features depends on components
and physiologic sites of action for snake venom:
• Locally acting toxins
• Swelling, blistering, ecchymosis, tissue necrosis, and pain
• Local effects are minimal or absent after bites of many elapid
snakes
• However, other elapid snakes can cause serious tissue necrosis (eg,
some African and Asian cobras)
7/29/2022 NPMCN_GM_UPDATE COURSE 2022 10
11. Pathophysiology cont’d
• Systemically acting toxins
• Targets nervous system, skeletal muscles, heart, circulatory system and the
kidneys:
• Neurotoxins:
• target the neuromuscular junction (NMJ) presynaptically, postsynaptically, or
at both sites.
• Presynaptic – PLA2 and damage the terminal axon at the NMJ.
• This type of paralysis is not reversible with antivenom or anticholinesterase and may take days to
weeks for recovery of function.
• Postsynaptic – peptides which target the acetylcholine receptor on the
muscle endplate, blocking response to acetylcholine.
• This type of paralysis can sometimes be fully reversed with antivenom, or the neuromuscular block
overcome with anticholinesterases (eg, neostigmine).
Ranawaka UK, 2013
7/29/2022 NPMCN_GM_UPDATE COURSE 2022 11
12. Pathophysiology cont’d
• Myotoxins –may act either systemically or locally.
• Rhabdomyolysis which occurs from enzymatic tissue damage adjacent to the bite wound (sea
snakes, some kraits, rattlesnakes, and some vipers).
• Secondary hyperkalemia and AKI
• Cardiotoxins – usually due to:
• Hemorrhage or hypovolemia.
• Less commonly, angiotensin-converting enzyme inhibitors and natriuretic peptides.
• Nephrotoxic – may occur due to:
• direct action of some venoms (especially following bites by vipers).
• AKI can also occur as a result of hypotension, coagulopathy or rhabdomyolysis.
7/29/2022 NPMCN_GM_UPDATE COURSE 2022 12
13. Pathophysiology cont’d
Systemic hemostasis toxins
• Interference with blood clotting and results in consumptive coagulopathy
and hemorrhage.
• Usually reversed by timely administration of antivenom.
• There may be clotting and thrombosis resulting in DVT, PE and cerebral
infarction.
• Vascular toxicity due to damage to blood vessels
• Toxins targeting the coagulation cascade include factor X, IX, and V
activators.
• Toxins inhibiting or stimulating platelet activation.
• The hemorrhagins target blood vessel walls.
7/29/2022 NPMCN_GM_UPDATE COURSE 2022 13
14. Clinical Manifestations
History
• Where and when the bite occurred
• A description of the snake
• How the bite occurred and whether there was more than one bite
• Any signs or symptoms and the timing of onset, some may be non-specific
• Initial treatment and first aid that was provided
• Any recent ethanol or recreational drug use
• Past medical history
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15. Physical examination
• Frequent measurement of vital signs.
• Monitoring for ptosis and partial ophthalmoplegia (neurotoxic snakes)
or persistent oozing from any wounds or gums (venom-induced
coagulopathy).
• Monitor urine output and quality.
• Wound site
• Presence of fang marks
• Local evidence of envenomation.
• Repeated examinations.
• Examine regional lymph nodes.
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16. Systemic examination
Cardiovascular
• Tachycardia and findings of shock, including hypotension and/or poor
tissue perfusion:
• prolonged capillary refill time, altered mental status, and decreased urine
output.
Tissue and muscle toxicity
• Muscle pain on palpation or with muscle use, muscle weakness, and
dark urine may indicate the presence of rhabdomyolysis.
• Look out for compartment syndrome – repeated compartment
measurements maybe required.
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17. Systemic examination – Neurotoxicity
• Ptosis
• Ophthalmoplegia (partial or
complete)
• Pupillary dilation (often
unresponsive to light)
• Poor facial tone
• Limited mouth opening or
tongue extrusion
• Drooling
• Limb weakness or flaccid
paralysis
• Gait disturbance
• Decreased or absent reflexes
• Cranial nerve effects are
generally observed first.
• Frequent assessment of the
patients’ airway and breathing,
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18. Asymptomatic (dry bite)
• A snake bite victim can present without any symptoms.
• Admit for observation for monitoring in case of suspected neurotoxic
bites.
• In regions with neurotoxic snakes, observe victims for up to 24 hours
post-bite.
• Bites that will result in coagulopathy usually manifest within 12 hours
after envenomation.
• Do not hasten discharge from the emergency.
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19. Nonvenomous Snakebite
• A nonvenomous (nonpoisonous) snake bite should be distinguished
from a dry bite.
• A dry bite is a bite by a venomous snake that does not inject any
venom.
• Bites assumed to be nonvenomous need to be evaluated as they can
lead to significant tissue damage or infections.
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20. Clinical effects of snake venoms.
A B
C D
E F
G
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21. Investigations
Coagulopathy
• Complete blood count with platelets
• Prothrombin time (PT)/International normalized ratio (INR) and activated partial
thromboplastin time (aPTT)
• Fibrinogen
• Fibrinogen and fibrin degradation products or D-dimer
• The 20 minute whole blood clotting test (20WBCT) - using a clean glass tube.
• Sensitivity was only 40 percent
• specificity of 100 percent in this study.
Sano-Martins IS et al. Toxicon 1994. Isbister GK et al. QJM 2013.
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22. Investigations cont’d
Rhabdomyolysis — can be identified with the following tests:
• Rapid urine dipstick for RBCs
• Urine for myoglobin
• Microscopic hematuria
• Serum creatine kinase
• Serum electrolytes, calcium, phosphate, uric acid, blood urea
nitrogen, and creatinine
• 12-lead electrocardiogram
7/29/2022 Images courtesy of D.A.W., University of Oxford, UK. 22
23. Pre-hospital Care
• The first priority is scene safety.
• Prevent creating additional victims.
• Do not insist on catching the snake.
• Killed snakes can still bite and inject venom.
• Obtain a photograph of the snake, if feasible to identify the
specie of snake.
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25. Initial evaluation
Shock
• Hypovolemia from hemorrhage secondary to coagulopathy, fluid shift into
the bitten limb, and/or direct venom effects.
• Treat with rapid infusion of crystalloid solution or blood or vasoactive
medications.
• Monitor central venous pressure to avoid fluid overload.
Coma
• Patient may be comatous unable to give a history.
• Support airway, breathing, and circulation
• Exclude hypoglycemia
• May require neuroimaging.
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26. 20 Minute whole-blood clothing test
• A 20min bedside whole-blood clothing test (20WBCT) can indicate the presence
of a coagulopathy.
• Add 2mls of venous blood, into a clean, dry, glass bottle or vial and allow to stand
undisturbed for 20mins at room temperature and is then inverted.
• The presence of a clot, renders the test negative, whereas if the blood remains
liquid, the test result is positive for coagulopathy, therefore, the need for
antivenom treatment.
• Avoid IM injections
• Manage pain with paracetamol or narcotic analgesics
• Avoid NSAIDS & Aspirin
• Give tetanus toxoid to all patients and antibiotics if there is secondary bacterial
infection.
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27. Treatment
• Patients receiving antivenom require frequent monitoring
• Resuscitation equipment and medications to treat anaphylaxis should
be made available.
• Commence antivenom immediately with the early symptoms
• In Nigeria, no deaths among 400 patients with bites due to Echis spp.
compared with a historical mortality of 10 to 20 percent among
untreated patients with similar bites.
• In the United States, mortality from snakebite dropped from as high
as 36 percent to 0.06 percent following the introduction of ASV.
Abubakar IS et al, PLoS Negl Trop Dis 2010
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28. Anti Venom Therapy
Route of administration
• The IV route of administration is preferred to intramuscular (IM)
injection
• In small children, if IV access is not possible, use intraosseous
route.
• Snake antivenom can be administered in one of two ways:
• Antivenom diluted in a compatible solution (eg, normal saline) and
infused over 30 to 60 minutes.
• Reconstituted (if required; eg, lyophilized antivenoms) and given
by slow IV injection over 10 to 20 minutes.
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29. Anti Venom Therapy2
• Ideally administer within 4 hrs of the bite but effective if given within
24 hrs.
• In mild cases-5 vials (50 ml)
• In moderate cases-5 to 10 vials
• In severe cases-10 to 20 vials
• Additional 5 to 10 vials might be required in cases with slow
response.
• Avoid local injection of ASV.
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30. Monitoring of patients
Response to treatment
• Administration of inadequate amounts of antivenom or use of the wrong
antivenom.
• Late administration antivenom to be effective, in advanced paralysis due to a
neurotoxic venom.
Coagulopathy
• Spontaneous bleeding ceases by about 20 minutes.
• Coagulation tests normalize by about six to eight hours.
Hypotension and cardiotoxicity
• Marked improvement should occur within 20 to 30 minutes.
Neurotoxicity
• Detectable improvement within 30 minutes.
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31. Adjunctive therapy
• Cobra spit ophthalmia
• The venom of the spitting cobras (Naja spp.) can cause corneal damage
• Irrigate eyes with copious quantities of water or saline.
• Slit lamp examination should be performed to evaluate for corneal ulceration
• Use topical antibiotic ointment.
• Tetanus prophylaxis
• This should be considered tetanus in all cases
• Antibiotics
• To be used on case by cases basis
• Blood products
• whole blood or fresh frozen plasma (FFP) can be given to address coagulopathy.
• platelet transfusions are indicated in patients with thrombocytopenia and bleeding.
Goldman DR et al, 2010.
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33. Adverse reactions to antivenom
• Allergic reactions
• Early allergic reactions
• Pyrogenic reactions
• Late allergic reactions (serum sickness)
• resuscitation equipment and medications to treat anaphylaxis should be
made available.
• Rates of anaphylaxis can be as high as 80 percent
• Serum sickness can occur several days or weeks after treatment
• Symptoms include fever, chills, rash, muscle aches, joint aches, itching, and
hematuria.
Lalloo DG, 2003; Alirol E, 2010
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34. Adverse reactions to antivenom
Seen in 20 % patients
Early anaphylactic reaction-
• Seen within 3 min to 60 min
• Urticaria, pruritus, bronchospasm, angioedema, diarrhoea,
tachycardia, fever, hypotension.
Late reactions (Serum Sickness)
• May occur 5-24 days
• Fever, itching, urticaria, nausea, vomiting, diarrhoea,
arthritis, nephritis, myoglobinuria.
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35. PROGNOSIS
• Prognosis usually good if managed early and appropriately.
• Delayed treatment often leads to unfavorable outcomes.
• Retrospective review of cases (2007-2009) in Kaltungo General Hospital
(KGH), Gombe State.
• Overall snakebite mortality of 1.41%.
• Potential reasons of increased mortality:
• Obtaining antivenoms from the retail outlets.
• Use of insufficient amount of ASV.
• Delay in buying antivenoms because of prohibitive cost.
• Use of unreliable or fake products.
• Use of geographically inappropriate antivenoms.
Habib and Abubakar, 2011
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36. PREVENTION OF SNAKEBITE
• Public education especially in high-risk communities.
• Using the media using radio, TV, social media, posters, and drama
performances.
• People should watch out for snakes during walking, working and
sleeping.
• Early transportation to clinics where they can receive medical care.
• People should be discouraged regarding visiting traditional therapists.
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37. PREVENTION OF SNAKEBITE
• Avoid handling snakes..
• A US study showed that about 40% of all snake bites occur in people
that consumed alcoholic.
• Wear protective clothes in endemic areas.
• Avoid walking or putting hands in dark places.
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38. SUMMARY
• Snakebite is one of the neglected tropical diseases
• Potentially life-threatening disease.
• High-risk groups mainly in rural communities
• Occasionally bites can be dry
• Every snake bite case should be treated as a medical emergency
• Prevention of bites should be given priority
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