Point-of-care infrared thermal imaging for differentiating venomous snakebites from non-venomous and dry bites

BackgroundLocal envenomation following snakebites is accompanied by thermal changes, which could be visualized using infrared imaging. We explored whether infrared thermal imaging could be used to differentiate venomous snakebites from non-venomous and dry bites.MethodsWe prospectively enrolled adult patients with a history of snakebite in the past 24 hours presenting to the emergency of a teaching hospital in southern India. A standardized clinical evaluation for symptoms and signs of envenomation including 20-minute whole-blood clotting test and prothrombin time was performed to assess envenomation status. Infrared thermal imaging was done at enrolment, 6 hours, and 24 hours later using a smartphone-based device under ambient conditions. Processed infrared thermal images were independently interpreted twice by a reference rater and once by three novice raters.FindingsWe studied 89 patients; 60 (67%) of them were male. Median (IQR) time from bite to enrolment was 11 (6.5–15) hours; 21 (24%) patients were enrolled within 6 hours of snakebite. In all, 48 patients had local envenomation with/without systemic envenomation, and 35 patients were classified as non-venomous/dry bites. Envenomation status was unclear in six patients. At enrolment, area of increased temperature around the bite site (Hot spot) was evident on infrared thermal imaging in 45 of the 48 patients with envenomation, while hot spot was evident in only 6 of the 35 patients without envenomation. Presence of hot spot on baseline infrared thermal images had a sensitivity of 93.7% (95% CI 82.8% to 98.7%) and a specificity of 82.9% (66.3% to 93.4%) to differentiate envenomed patients from those without envenomation. Interrater agreement for identifying hot spots was more than substantial (Kappa statistic >0.85), and intrarater agreement was almost perfect (Kappa = 0.93). Paradoxical thermal changes were observed in 14 patients.ConclusionsPoint-of-care infrared thermal imaging could be useful in the early identification of non-venomous and dry snakebites.     

Livestock herding and Fulani ethnicity are a combined risk factor for development of early adverse reactions to antivenom treatment: Findings from a cross-sectional study in Nigeria

BackgroundAdverse reactions to antivenom considerably complicate the clinical management of snakebite envenomed patients because it necessitates a temporary suspension of life-saving antivenom, increases costs and can compromise patient outcomes. This study sought to explore the association between cattle-herding occupation and ethnic group and the occurrence of early adverse reactions to antivenom.MethodsThis cross-sectional study was conducted between the 25th April and 11th July 2011 at the Kaltungo General Hospital in north east Nigeria. The exposure variable of cattle-herding occupation showed a strong correlation with the ethnic group variable, thus these were combined into a new variable with three categories (Fulani and herder, either Fulani or herder, and neither Fulani nor herder). The outcome variable was the occurrence of early adverse reactions, defined as any new symptoms occurring within 6 hours of antivenom administration. Odds Ratios were estimated using multivariable logistic regression models controlling for potential confounders.ResultsAmong 231 envenomed snakebite victims, the overall incidence of early adverse reactions was 11.9% (95% confidence intervals: 8.0–16.9%). Patients who were Fulani and herders had a higher incidence of early adverse reactions compared to patients who were neither Fulani nor herders (20% vs 5.7%). After adjusting for age and gender, victims who were Fulani and herders were 5.9 times more likely to have an early adverse reaction, compared to victims who were neither Fulani nor herders (95% CI: 1.88–18.59; p = 0.002).InterpretationTo the best of our knowledge, this is the first study to provide evidence of higher odds of early adverse reactions among patients from a particular occupation and/or ethnic group. We recommend that snake envenomed patients of Fulani origin be especially closely monitored for adverse reactions, that hospitals receiving these patients be appropriately resourced to manage both envenoming and adverse reactions and that premedication with adrenaline should be considered. Our findings provide an argument for speculation on the influence of immunological or lifestyle-related differences on the occurrence of early adverse reactions to antivenom.     

Snake bites accidents in Yopal and Leticia, Colombia, 1996-1997

Snakebites produce notable morbidity and mortality in the Amazonian and Orinocan regions of Colombia. A review was undertaken of 56 snakebite cases sent to hospitals in Leticia (Amazonas) and Yopal (Casanare) between September 1996 and June 1997. Of the total, 57% of the bites occurred in Leticia, 54% in men. The 14 to 44 year-old age group was most compromised (41%). Most encounters occurred in forests and open fields between 17:00 and 18:00 hours (57%). Nearly all bites were located on legs and feet (82%). One death occurred in Yopal; 3 fasciotomies and 2 amputations were performed. Snakebite incidence occurred with highest probability during evening hours. Although antibiotics are in general use, minor infections (16%) were frequent.     

Snakebites in Two Rural Districts in Lao PDR: Community-Based Surveys Disclose High Incidence of an Invisible Public Health Problem

BackgroundThe Lao PDR (Laos) is one of the least developed countries in Asia with an estimated 25% of the population living in poverty. It is the habitat of some highly venomous snakes and the majority of the population earns their living from agricultural activities. Under these circumstances the incidence of snakebites is expected to be high.MethodsTwo cross-sectional, community-based surveys were performed in Champone and Phin district, Savannakhet province, Lao PDR to estimate snakebite incidence. Multistage random sampling was used. In the first stage approximately 40% of all villages in each district were randomly selected. In the second stage 33% of all households in each village were randomly chosen. Members of the selected households were interviewed about snakebites during the previous 12 months.ResultsThirty-five of 9856 interviewees reported a snakebite in a 12 month period in Champone district and 79 of 7150 interviewees in Phin district. The estimated incidence is 355 snakebites per 100,000 persons per year and 1105 per 100,000 in Champone and Phin district respectively. All snakebite victims received treatment by traditional healers or self-treatment at home and nobody went to a hospital. Incidence of snakebites, calculated on the basis of hospital records of 14 district hospitals and Savannakhet provincial hospital, ranged from 3 to 14 cases per 100,000 persons per year between 2012 and 2014.ConclusionIncidence of snakebites is high in rural communities in Laos with significant regional differences. Poverty most likely contributes significantly to the higher number of snakebites in Phin district. Hospital statistics profoundly underestimates snakebite incidence, because the majority of snakebite victims receive only treatment by traditional healers or self-treatment in their village. There is an urgent need to train medical staff and students in management of snakebite patients and make snake antivenom available to cope effectively with this important public health problem in order to prevent fatalities and disabilities.     

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.     

毒蛇咬伤病人的血小板聚集功能初探

目的为了探讨血液毒及混合毒类毒蛇咬伤病人的血小板功能情况,了解临床中毒发病机理。方法对近年来在本院急诊科确诊的五步蛇(Da.),蝮蛇(Ah.),眼镜蛇(Nn.),眼镜王蛇(Oh.),蝰蛇(Vr.),烙铁头(Tm.)和竹叶青(Ts.)等各种血液毒及混合毒类毒蛇咬伤17例病人25个血样,进行最大血小板聚集率(MAR)的检查和分析研究。结果除了Da未见MAR下降外(仅1例1个样品),其余各蛇种咬伤的样品均有下降。在获得未经治疗(抗蛇毒血清)的15个样品的检查结果中,进行统计分析,Vr、Tm以及Ah的MAR比正常人对照组(51.3±16.0)%明显下降。结论蛇毒中的血小板集聚抑制因子,可引起蛇伤患者体内血小板聚集功能下降,血小板处于无用状态,结果有些蛇伤病人DIC样综合征时出现严重出血而无明显微循环血栓形成致器官受损的临床症状。     

Snakebite and Its Socio-Economic Impact on the Rural Population of Tamil Nadu,India

Background

Snakebite represents a significant health issue worldwide, affecting several million people each year with as many as 95,000 deaths. India is considered to be the country most affected, but much remains unknown about snakebite incidence in this country, its socio-economic impact and how snakebite management could be improved.

Methods/Principal Findings

We conducted a study within rural villages in Tamil Nadu, India, which combines a household survey (28,494 people) of snakebite incidence with a more detailed survey of victims in order to understand the health and socio-economic effects of the bite, the treatments obtained and their views about future improvements. Our survey suggests that snakebite incidence is higher than previously reported. 3.9% of those surveyed had suffered from snakebite and the number of deaths corresponds to 0.45% of the population. The socio-economic impact of this is very considerable in terms of the treatment costs and the long-term effects on the health and ability of survivors to work. To reduce this, the victims recommended improvements to the accessibility and affordability of antivenom treatment.

Conclusions

Snakebite has a considerable and disproportionate impact on rural populations, particularly in South Asia. This study provides an incentive for researchers and the public to work together to reduce the incidence and improve the outcomes for snake bite victims and their families.     

Avidity of sera-neutralizing snake venom

Avidity of antivenom sera used for the treatment of snake bites was studied. Sera against the venom of Vipera libetina obtained from producers immunized with crude venoms were more avid than analogous sera obtained to anavenoms. In studying the avidity of polyvalent serum neutralizing the Vipera libetina, echis and cobra venoms showed the serum obtained in immunization with the mixture of crude venoms to be highly avid to all the venoms composing the antigen; besides, it bound the venoms of Vipera libetina and echis more rapidly and more stably than the corresponding monovalent sera.     

3599例毒蛇咬伤流行病学研究

目的了解江苏省南通市及周边地区毒蛇咬伤病例流行病学特征,为本地区的蛇伤防治提供参考和指导。方法对2004~2013年南通市及周边地区3599例蛇伤患者,按地区分布、蛇伤种类、患者年龄、性别、职业、咬伤季节、就诊时间、严重程度、治疗转归进行分析。结果发病率较高的是如皋市、通州市、南通市、如东县等,共2500例,占69.46%;发病率较低的是海门市、海安县、启东市,总共217例,占6.03%。主要致伤蛇种为蝮蛇,占99.30%;患者职业主要为农民,占86.27%;男女比例为1∶1.16,女性略高于男性;发病年龄在40~69岁,占73.08%;夏秋农忙为高发季节,占92.59%;咬伤部位以四肢为多,占99.66%,尤以下肢更为多见;严重程度不高,重危症的比例在逐年下降,总体预后较好,死亡率亦明显下降。结论了解本地区毒蛇咬伤流行病学特征,加强蛇伤高危人群的知识宣教,对降低本地区蛇伤病死率及致残率具有重要意义。     

Bites by foreign venomous snakes in Britain.

In 1970-7 17 people in Britain were the victims of 32 bites by foreign venomous snakes. Crotalus atrox caused eight of these bites, Bitis arietans five, and the remaining 19 bites were caused by 12 different species. All the victims were bitten while handling the snake, and 24 bites were incurred by private individuals in their own homes. Poisoning was negligible in 17 of the 32 bites but life-threatening in at least two cases. Thus in the early stages snake bite may be unpredictable as a clinical problem. All victims of snake bite should be observed for at least 12 hours to assess the severity of poisoning and to ensure rational treatment. Local necrosis developed in six cases and resulted in prolonged illness in five of these cases; local incision was carried out and many have been a casual factor. Comprehensive stocks of antivenoms for treating bites by foreign venomous snakes are held by the National Health Services in Liverpool and London. Antivenom is indicated (a) for potentially serious systemic poisoning, as evidenced by hypotension, electrocardiographic changes, neurtrophilia, and acidosis (after viper or elapid bites), abnormal bleeding or non-clotting blood after viper bites; and ptosis or glossopharyngeal palsy after elapid bites; and (b) for bites from snakes whose venom causes local necrosis, to prevent or minimise this unpleasant complication. For effective antivenom treatment intravenous infusion is mandatory.     

Snake bite envenomation in Riyadh province of Saudi Arabia over the period (2005–2010)

The present investigation is a retrospective review of snake bites in Riyadh province over the period (2005–2010). A total of 1019 cases of bites admitted to the Ministry of Health medical centers in Riyadh province were analyzed on the basis of age, sex, time of bite and its site on the body, outcome of treatment, antiserum dose and type of snake. Bites occurred throughout the six years with the highest frequency in 2005 and least in 2006 where most of the bite cases were mild and all evolved to cure except four patients who died following the administration of antivenom during 24 h after snake bite. Most of the patients were males (81.7%) and the most attacked age was within the range of 11–30 years (51.5%). All the bites were mainly in the exposed limbs and the most frequently bitten anatomical regions were the lower limbs (427 cases, 41.9%), principally the feet. The study incriminates Cerastes cerastes gasperettii in most of the bites indicating it as the snake of medical importance in Riyadh province. Also, the study indicates low degree of threat in spite of high rate of snake bites as a result of the availability of the medical facilities and the antivenin use in medical centers in Riyadh province.     

Epidemiological features of suicides in Osijek County,Croatia, from 1986 to 2000

Suicide is a devastating tragedy associated with social, cultural and psychological factors. It takes approximately 1,060 lives in the Republic of Croatia each year. We retrospectively reviewed all cases referred to in the Registrar office and Police Department at Osijek County from 1986 to 2000. The cases of suicide totaled 1,017. All of the cases were analyzed as to age, gender, marital status, occupation, place and time of suicide and method of suicide. The suicide rate for the entire population of the County averaged 20.5/100,000 inhabitants per annum. The age of the suicides ranged from 15 to 92. The male to female ratio was 2.1:1. The highest suicide incidence was among the age groups from 55 to 64 (19.27%), followed by age group from 45 to 54 (16.12%). The lowest suicide incidence was among the age group < 19 (3.4%). The incidence in the group 85 > years was also low (2.06%). The suicide was frequent among people who live alone: single, widowed, divorced (47.29%). Eighty percent of victims were found in surroundings familiar to them. These included various premises of their residences. The retired, the laborers and the unemployed (67.36%) were predominant among suicide victims. The most common methods of suicide were hanging (43%), followed by firearms (24%). No correlation was found with the day of the week or the month of the year. The study showed a slightly increased rate of suicide, from 21 cases at the beginning of the investigation (in 1986) to 22.3/100,000 population fifteen years later (in 2000).     

Epidemiological study of snakebite cases in Sikkim: Risk modeling with regard to the habitat suitability of common venomous snakes

BackgroundSnakebite envenoming is listed as category ‘A’ Neglected Tropical Disease. To achieve the target of WHO (World Health Organization) 2019, it becomes necessary to understand various attributes associated with snakebite including community awareness, improvisation of medical facilities and to map the potential distribution of venomous snakes responsible for the bite. Hence this study is conducted in Sikkim, India to understand the epidemiology of snakebite in Sikkim. The potential distribution and risk mapping of five common venomous snakes are done for effective management of snakebite cases.Methods and findingsThe snakebite cases registered in six district hospitals and four PHCs (Primary Health Centers) of Sikkim were collected from the year 2011 to 2018. Community survey was also conducted to supplement the data. Ecological Niche Modeling (ENM) was performed to predict the potential habitat of five common venomous snakes of Sikkim. The risk modeling of snakebite cases was done at the level of Gram Panchayat Unit (GPU) using Geographically Weighted Regression (GWR) and Ordinary Linear Square (OLS) model. We found higher number of male victims inflicted with snakebite envenomation. The potential distribution of the five venomous snakes showed satisfactory mean AUC (Area under Curve) value. Both the models showed significant positive association of snakebite cases with habitat suitability of the venomous snakes. Hospital data revealed no death cases whereas community data reported 24 deaths.ConclusionsDeath from snakebite reflected in community data but not in hospital data strongly indicates the people’s belief in traditional medicine. Though people of Sikkim have rich traditional knowledge, in case of snakebite traditional practices may be ineffective leading to loss of life. Sensitizing people and improving medical facilities along with proper transport facilities in rural areas might significantly reduce the snakebite casualties in the state.     

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

BackgroundAccording 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.Methodology/Principal findingsData 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.ConclusionHealth 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.     

Cross neutralization of Afro-Asian cobra and Asian krait venoms by a Thai polyvalent snake antivenom (Neuro Polyvalent Snake Antivenom)

Background

Snake envenomation is a serious public health threat in the rural areas of Asian and African countries. To date, the only proven treatment for snake envenomation is antivenom therapy. Cross-neutralization of heterologous venoms by antivenom raised against venoms of closely related species has been reported. The present study examined the cross neutralizing potential of a newly developed polyvalent antivenom, termed Neuro Polyvalent Snake Antivenom (NPAV). NPAV was produced by immunization against 4 Thai elapid venoms.

Principal Findings

In vitro neutralization study using mice showed that NPAV was able to neutralize effectively the lethality of venoms of most common Asiatic cobras (Naja spp.), Ophiophagus hannah and kraits (Bungarus spp.) from Southeast Asia, but only moderately to weakly effective against venoms of Naja from India subcontinent and Africa. Studies with several venoms showed that the in vivo neutralization potency of the NPAV was comparable to the in vitro neutralization potency. NPAV could also fully protect against N. sputatrix venom-induced cardio-respiratory depressant and neuromuscular blocking effects in anesthetized rats, demonstrating that the NPAV could neutralize most of the major lethal toxins in the Naja venom.

Conclusions/Significance

The newly developed polyvalent antivenom NPAV may find potential application in the treatment of elapid bites in Southeast Asia, especially Malaysia, a neighboring nation of Thailand. Nevertheless, the applicability of NPAV in the treatment of cobra and krait envenomations in Southeast Asian victims needs to be confirmed by clinical trials. The cross-neutralization results may contribute to the design of broad-spectrum polyvalent antivenom.     

Availability,affordability and stock-outs of commodities for the treatment of snakebite in Kenya

BackgroundAnnually, about 2.7 million snakebite envenomings occur globally. Alongside antivenom, patients usually require additional care to treat envenoming symptoms and antivenom side effects. Efforts are underway to improve snakebite care, but evidence from the ground to inform this is scarce. This study, therefore, investigated the availability, affordability, and stock-outs of antivenom and commodities for supportive snakebite care in health facilities across Kenya.Methodology/principal findingsThis study used an adaptation of the standardised World Health Organization (WHO)/Health Action International methodology. Data on commodity availability, prices and stock-outs were collected in July-August 2020 from public (n = 85), private (n = 36), and private not-for-profit (n = 12) facilities in Kenya. Stock-outs were measured retrospectively for a twelve-month period, enabling a comparison of a pre-COVID-19 period to stock-outs during COVID-19. Affordability was calculated using the wage of a lowest-paid government worker (LPGW) and the impoverishment approach. Accessibility was assessed combining the WHO availability target (≥80%) and LPGW affordability (<1 day’s wage) measures. Overall availability of snakebite commodities was low (43.0%). Antivenom was available at 44.7% of public- and 19.4% of private facilities. Stock-outs of any snakebite commodity were common in the public- (18.6%) and private (11.7%) sectors, and had worsened during COVID-19 (10.6% versus 17.0% public sector, 8.4% versus 11.7% private sector). Affordability was not an issue in the public sector, while in the private sector the median cost of one vial of antivenom was 14.4 days’ wage for an LPGW. Five commodities in the public sector and two in the private sector were deemed accessible.ConclusionsAccess to snakebite care is problematic in Kenya and seemed to have worsened during COVID-19. To improve access, efforts should focus on ensuring availability at both lower- and higher-level facilities, and improving the supply chain to reduce stock-outs. Including antivenom into Universal Health Coverage benefits packages would further facilitate accessibility.     

银环蛇咬伤致急性呼吸衰竭的治疗及临床观察

目的观察抗银环蛇毒血清和机械通气对银环蛇咬伤致急性呼吸衰竭的疗效。方法应用抗蛇毒血清和机械通气救治23例银环蛇咬伤致急性呼吸衰竭患者。结果银环蛇咬伤患者及早应用抗银环蛇毒血清,毒蛇咬伤后发生急性呼吸衰竭时间为2.5～16h。当患者出现睁眼困难、吞咽困难、呼吸节律改变或呼吸困难时,即予气管插管行机械通气,可获得较好的疗效。结论机械通气辅助抗蛇毒血清是救治银环蛇咬伤致呼吸衰竭有效的方法。     

Snakebites in “Invisible Populations”: A cross-sectional survey in riverine populations in the remote western Brazilian Amazon

In the Brazilian Amazon, long distances, low healthcare coverage, common use of ineffective or deleterious self-care practices, and resistance to seeking medical assistance have an impact on access to antivenom treatment. This study aimed to estimate snakebite underreporting, and analyze barriers that prevent victims from obtaining healthcare in communities located in 15 municipalities on the banks of the Solimões, Juruá and Purus Rivers, in the remote Western Brazilian Amazon. Information on the participants’ demographics, previous snakebites, access to healthcare, time taken to reach medical assistance, use of self-care practices, and the reason for not accessing healthcare were collected through semi-structured interviews. In the case of deaths, information was collected by interviewing parents, relatives or acquaintances. A total of 172 participants who reported having suffered snakebites during their lifetime were interviewed. A total of 73 different treatment procedures was reported by 65.1% of the participants. Participants living in different river basins share few self-care procedures that use traditional medicine, and 91 (52.9%) participants reported that they had access to healthcare. Living in communities along the Juruá River [OR = 12.6 (95% CI = 3.2–49.7; p<0.001)] and the use of traditional medicine [OR = 11.6 (95% CI = 3.4–39.8; p<0.001)] were variables that were independently associated to the lack of access to healthcare. The main reasons for not accessing healthcare were the pprioritization of traditional treatments (70.4%), and the failure to recognize the situation as being potentially severe (50.6%). Four deaths from complications arising from the snakebite were reported, and three of these were from communities on the banks of the Juruá River. Only one of these received medical assistance. We found an unexpectedly high underreporting of snakebite cases and associated deaths. Snakebite victims utilized three main different healing systems: 1) self-care using miscellaneous techniques; 2) official medical healthcare generally combined with traditional practices; and 3) self-care using traditional practices combined with Western medicines. To mitigate snakebite burden in the Brazilian Amazon, an innovative intervention that would optimize timely delivery of care, including antivenom distribution among existing community healthcare centers, is needed.     

Progression of optic neuritis to multiple sclerosis in the County of Split-Dalmatia, Croatia

The aim of this study was to determine the incidence of monosymptomatic optic neuritis (MON) and progression of MON to multiple sclerosis (MS) from the Mediterranean region of southern Europe in the County of Split-Dalmatia, Croatia during the 11 years period from 1991 to 2001. This study was made retrospectively on the 87 cases (59 female, aged 25.9 +/- 11.3 and 28 male aged 29.9 +/- 9.2) of MON, which were treated at the Department of Ophthalmology and Department of Neurology, Split, University Hospital, from January 1991 to December 2001. In each case the diagnosis was confirmed by a chart review and cases were ascribed to the data of admittance at hospital. The annual incidence of MON was 1.9 per 100,000 (95% CI, 0.4-3.5). The incidence among males was 1.2 (95% CI, 0-2.9) cases / 100,000 per year and 2.5 (95% CI, 0.1-4.9) among females. A significant seasonal variations in the incidence of MON was not found (chi2 = 6.81, p = 0.08). MS developed in 20 of 87 patients (22.9%) and median time was 25 (SE 8) months, (95% CI, 9-41) after the MON onset. After two years 12.6% of patients with MON developed MS, 20.6% after 5 years and 22.9% after 10 years. MS was slightly but not significantly more frequent in women than in men (chi2 = 0.72, p = 0.3). In conclusion, the progression of MON to MS in the County of Split-Dalmatia, Croatia was at a relatively moderate frequency.