Adverse drug reactions of anti-snake venom among haemotoxic and neurotoxic snake bite: A prospective observational study

INTRODUCTION: Adverse Drug reactions (ADR) is defined as “any noxious change which is suspected to be due to a drug, occurs at doses normally used in man, requires treatment or decrease in dose or indicated caution in the future use of the same drug”. Anti-Snake venom (ASV) is the only promising lifesaving treatment for management of snake bite, till date. Snakebite is a terrifying experience at an individual level, as in India the low socio-economic people are mostly affected in all age groups. AIM OF THE STUDY: PRIMARY OBJECTIVE: 1. To analyze the prevalence of the Adverse Drug Reactions and dosage patterns of Anti-Snake Venom. 2. To compare the safety profile with regard to Anti-Snake Venom among three Manufacturers. SECONDARY OBJECTIVE: 1. To perform causality and severity assessment of the Adverse Drug Reactions. 2. To Study the Demographic and clinical Profile of Snake Bite Cases. MATERIALS AND METHOD: This prospective observational study was conducted in patients admitted with snake bite in three districts of Tamilnadu during January 2016 to December 2016. The Causality assessment was done by using Liverpool Causality Tool and the severity assessment was done by modified Hartwig Seigel scale. RESULTS: Among 476 patients, 370 (77.73%) were from Perambalur district, 64 (13.44%) from Ariyalur district and 42 (8.82%) from Erode district and 206 (43.2%) were administered ASV. Overall, 2330 vials were used and the mean ASV used was 11.59 ± 6.38 vials ranging between 1 to 30 vials per patient. Adverse reactions were seen in 55 (26.7%) patients. Among the three manufacturers, it was 17 (26.9%) in ASV I, 25 (24.7%) in ASV II and 13 (30.9%) in ASV III. There was a no significant correlation between the types of manufacturers and incidence of adverse reactions. There were 4 deaths (2 - respiratory failure and 2 - cardiac failure) recorded in this study. CONCLUSION: This study highlights that the 3 different manufacturers of ASV do not reflect the incidence of adverse reactions. ASV has relative variability in their batches and snake species and their geographical variations

Addressing the burden of snakebite: analysing policy prioritisation, evaluating health systems, and fostering research on treatments

Introduction The World Health Organization (WHO) estimates 5.4 million snakebites annually. In 2019, WHO released a strategy to halve the burden of snakebite by 2030. This doctoral research aimed to generate practice and policy relevant evidence at three levels: globally, by understanding the prioritisation process in the WHO; nationally, in India, by evaluating the primary health care (PHC) system; and regionally, in South Asia, by fostering research on treatments. Methods To understand the global prioritisation of snakebite, I conducted a policy analysis, using interviews and documents as data sources. To evaluate health systems in India, I analysed secondary data for the first nationwide assessment of structural capacity and continuum of snakebite care. To understand health systems resilience, I used quantitative (analysis of facility-level data) and qualitative (interviews) approaches to understand the effects of COVID-19 and conducted an evidence synthesis on the effect of climate change. Through an overview of systematic reviews of treatments, I identified the need for a core outcome set (COS) on snakebite. I developed a COS for snakebite research in South Asia, by conducting a systematic review of outcomes and a Delphi survey. Results The policy analysis identified factors which enabled prioritisation of snakebite, and identified unaddressed challenges of sustaining legitimacy, and acceptance within the neglected tropical disease community. I identified structural limitations of the PHC system and gaps in referral pathways, in India. Relevant to the context, I report, how COVID-19 accentuated existing barriers, and identified that the choice of provider is a complex process with multiple factors interplaying. Evidence synthesis indicates the need to prepare health systems for possible geographic shifts in snakebite burden due to climate change. The overview of systematic reviews identified gaps in the evidence ecosystem. By developing a COS for future intervention research on snakebite treatments, I addressed the gap of non-standardised measurement of outcomes. Conclusion The findings of the thesis, provides contextually relevant evidence aligned with pillars of the WHO strategy, to practice and policy at global, national, sub-national, and program level. The policy analysis and COS work provides broader methodological insights, beyond snakebite

Renal Failure

The book "Renal Failure - The Facts" consists of some facts about diagnosis, etiopathogenis and treatment of acute and chronic renal failure. Acute, as well as chronic renal failure is great medical problems and their treatment is a burden for the budget of each government. The purpose of the chapters is to present some important issues of diagnosis and causes of AKI, as well as caused by snakes and arthropods, after cardiac surgery, as well as some therapeutic achievements in AKI. Well presented are the psychological condition in patients on haemodialysis, as well as the treatment of diabetic uremics. The book is aimed at clinicians with a special interest in nephrology, but it should also prove to be a valuable resource for any generalists who encounter a nephrological problems in their day-to-day practice

Identification and therapeutic application of molecular parallels between parasites, parasitic vectors and snake venom

Neglected tropical diseases (NTDs) are a group of conditions that exert disability and poverty on populations that comprise the world’s poorest billion people. These conditions, although caused by different organisms and cause distinct disease, they share geographical distribution within tropical regions, occur during similar ecological conditions and most importantly have similar biological mechanisms that are utilized to facilitate the pathology of these diseases. Proteolytic enzymes like proteases are used in many biological mechanisms such as, migration through tissue and cellular compartments; haemoglobin digestion, evasion of immune system responses and cause necrosis and fibrosis to vital tissues and organs. Genomic, transcriptomic, and proteomic studies on parasites (S. mansoni and F. hepatica), parasitic vector (An. gambiae) salivary glands and snake venom show that these diverse pathogens appear to be utilizing similar molecules to perform similar biological mechanisms. Therefore, it is of interest to ascertain whether a cross-cutting approach in research could facilitate a better understanding of these diseases. Therefore, the initial aim of this work was to investigate molecular parallels of the mechanisms used by these tropical disease pathogens, including parasites, snake venom toxins, and haematophagic parasite vectors, to access their host’s blood stream. Using a bioinformatics-led approach, in combination with immunological and proteomic analyses, this study demonstrated the presence of similar compounds between shared molecular molecules (serine proteases and other proteins) causing pathology in parasites, parasitic vectors and snake venom. This similarity was not only at the bioinformatics level, but presence of cross-reactivity toward parasite proteins was detected using antivenoms and toxin-specific antibodies. In addition, sera collected from patients infected with S.mansoni exhibited an immune response to snake venom. One of this study aims was to investigate possibilities of using homologous proteins in parasitic vectors and snake venom as therapeutic applications. For this purpose, chimeric epitopes of homologous snake venom (Echis ocellatus) and mosquito salivary proteins were designed as primary vaccine that could be boosted by mosquito bites. If succeeded, this method would prevent, or at least reduce, the devastating pathology and death caused by snake venom at a low cost, with limited logistical complications

Public Health

Public health can be thought of as a series of complex systems. Many things that individual living in high income countries take for granted like the control of infectious disease, clean, potable water, low infant mortality rates require a high functioning systems comprised of numerous actors, locations and interactions to work. Many people only notice public health when that system fails. This book explores several systems in public health including aspects of the food system, health care system and emerging issues including waste minimization in nanosilver. Several chapters address global health concerns including non-communicable disease prevention, poverty and health-longevity medicine. The book also presents several novel methodologies for better modeling and assessment of essential public health issues

Compartment Syndrome

Compartment syndrome is a complex physiologic process with significant potential harm, and though an important clinical problem, the basic science and research surrounding this entity remains poorly understood. This unique open access book fills the gap in the knowledge of compartment syndrome, re-evaluating the current state of the art on this condition. The current clinical diagnostic criteria are presented, as well as the multiple dilemmas facing the surgeon. Pathophysiology, ischemic thresholds and pressure management techniques and limitations are discussed in detail. The main surgical management strategy, fasciotomy, is then described for both the upper and lower extremities, along with wound care. Compartment syndrome due to patient positioning, in children and polytrauma patients, and unusual presentations are likewise covered. Novel diagnosis and prevention strategies, as well as common misconceptions and legal ramifications stemming from compartment syndrome, round out the presentation. Unique and timely, Compartment Syndrome: A Guide to Diagnosis and Management will be indispensable for orthopedic and trauma surgeons confronted with this common yet challenging medical condition

Smoking and Second Hand Smoking in Adolescents with Chronic Kidney Disease: A Report from the Chronic Kidney Disease in Children (CKiD) Cohort Study

The goal of this study was to determine the prevalence of smoking and second hand smoking [SHS] in adolescents with CKD and their relationship to baseline parameters at enrollment in the CKiD, observational cohort study of 600 children (aged 1-16 yrs) with Schwartz estimated GFR of 30-90 ml/min/1.73m2. 239 adolescents had self-report survey data on smoking and SHS exposure: 21 [9%] subjects had “ever” smoked a cigarette. Among them, 4 were current and 17 were former smokers. Hypertension was more prevalent in those that had “ever” smoked a cigarette (42%) compared to non-smokers (9%), p\u3c0.01. Among 218 non-smokers, 130 (59%) were male, 142 (65%) were Caucasian; 60 (28%) reported SHS exposure compared to 158 (72%) with no exposure. Non-smoker adolescents with SHS exposure were compared to those without SHS exposure. There was no racial, age, or gender differences between both groups. Baseline creatinine, diastolic hypertension, C reactive protein, lipid profile, GFR and hemoglobin were not statistically different. Significantly higher protein to creatinine ratio (0.90 vs. 0.53, p\u3c0.01) was observed in those exposed to SHS compared to those not exposed. Exposed adolescents were heavier than non-exposed adolescents (85th percentile vs. 55th percentile for BMI, p\u3c 0.01). Uncontrolled casual systolic hypertension was twice as prevalent among those exposed to SHS (16%) compared to those not exposed to SHS (7%), though the difference was not statistically significant (p= 0.07). Adjusted multivariate regression analysis [OR (95% CI)] showed that increased protein to creatinine ratio [1.34 (1.03, 1.75)] and higher BMI [1.14 (1.02, 1.29)] were independently associated with exposure to SHS among non-smoker adolescents. These results reveal that among adolescents with CKD, cigarette use is low and SHS is highly prevalent. The association of smoking with hypertension and SHS with increased proteinuria suggests a possible role of these factors in CKD progression and cardiovascular outcomes