Effectiveness of clotting factor replacement therapy after antivenom treatment on coagulopathic envenomation following green pit viper bites: a retrospective observational study.

BACKGROUND: Green pit vipers (GPVs), namely Trimeresurus albolabris and Trimeresurus stejnegeri accounts for most snakebites in Southern China. Green pit viper venom contains thrombin-like enzymes, resulting in defibrination syndrome. Using of clotting factor replacement after antivenom administration is controversial. The objective of this study was to investigate the effects of clotting factor replacement in coagulopathic patients with T. albolabris and T. stejnegeri bites after antivenom administration. METHODS: We retrospectively reviewed 123 patients who were bitten by T. albolabris and T. stejnegeri and were admitted to the Emergency Department of a hospital in Guangzhou, Southern China, from 2013 to 2019. Recovery of prothrombin time (PT) and fibrinogen level were compared among (1) fresh-frozen plasma (FFP) group; (2) cryoprecipitate (cryo) group; (3) FFP and cryo group; and (4) control group after antivenom administration. RESULTS: The incidence of coagulopathy was 31%. Persistent and late coagulopathy were the most common patterns among four groups. The median reduction in PT was 20.1 ± 31.2 s for FFP and cryo group. The median increase in fibrinogen level was very small: 0.05 ± 0.20 g/L for FFP group, 0.09 ± 0.37 g/L for cryo group and 0.07 ± 0.31 g/L for FFP and cryo group, respectively. The percentage of unimproved PT was markedly higher in the FFP and cryo group than the control group (P = 0.01 by log-rank test, P = 0.02 by Gehan-Breslow-Wilcoxon test). The percentage of unimproved fibrinogen level tended to be worse in the FFP and cryo group than the control group, but the different was marginal (P = 0.05 by Gehan-Breslow-Wilcoxon test, P = 0.07 by log-rank test). A total of 7.8% (7/90) of the patients in the clotting factor replacement groups developed anaphylaxis and heart failure. CONCLUSION: There is no improvement in coagulopathy profile in patients with T. albolabris and T. stejnegeri bites who received clotting factor replacement after antivenom administration. But the results from GPVs may not be generalized to other species of venomous snakes.

Impacts of a Specific Cyclooxygenase-2 Inhibitor on Pressure Overload-Induced Myocardial Hypertrophy in Rats.

OBJECTIVE: The aim of this study was to observe the impacts of the specific cyclooxygenase-2 inhibitor celecoxib on cardiac structures, functions, and inflammatory factors during the process of pressure overload-induced myocardial hypertrophy. METHODS: Twenty-four male Sprague Dawley rats were randomly divided into 3 groups: the sham operation group, the surgery group, and the celecoxib group. The model was established according to the abdominal aortic coarctation method. RESULTS: At 16 weeks, rats in the celecoxib group were fed a celecoxib-mixed diet (10 mg/kg) for 8 consecutive weeks. At week 24 after model establishment, the cardiac structures and functions were observed; changes in the levels of tumor necrosis factor (TNF)-α, transforming growth factor (TGF)-ß, prostaglandin E2 (PGE2), C-reactive protein (CRP), and uric acid (UA) were detected; and the contents of Smad1/2/3 proteins (Smad1, Smad2, and Smad3)  were determined. Left ventricular mass index, the heart weight/body weight ratio, and TNF-α, TGF-ß, PGE2, CRP, and UA levels of the celecoxib group were all significantly decreased relative to those of the surgery group (P < .05); moreover, the cardiac functions were significantly improved compared to those of the surgery group (P < .05). CONCLUSIONS: These results show that inflammatory factors are involved in the myocardial hypertrophy process and that celecoxib may reverse myocardial hypertrophy through a variety of pathways.

Venomous snakebites in children: a 10 year experience in South China.

INTRODUCTION: Many studies have focused on snakebites in adults, but very few have described snakebites in children. METHODS: We reviewed the clinical characteristics and outcomes of children with venomous snakebites aged less than 15 years who presented to a regional medical centre in South China from January 2013 to December 2022. RESULTS: A total of 69 envenomed patients were analyzed in our study; 42 (60.9 per cent) patients were male, and 59 (85.5 per cent) reported lower limb bites. Most bites (89.8 per cent) occurred between April and October. Twenty-seven patients received first aid management, and 47 required admission to the general ward. Antivenom was administered to 58 patients, glucocorticoids to 43 patients, antibiotics to 48 patients, and tetanus antitoxin to 40 patients. No fatalities were reported. The most common snake identified was Trimeresurus albolabris. Four were classified as dry bites, 15 as mild, 43 as moderate, and seven as severe. The most common local signs were pain and swelling, while the most common systemic effects were haematological complications. Patients with high severity scores had significantly higher lactate dehydrogenase activities, creatine kinase isoenzyme activities, aspartate aminotransferase activities, D-dimer concentrations, prothrombin times and lower fibrinogen concentrations. In a receiver operating characteristic curve analysis of the values with the highest Youden index, the following cut-offs proved significant: lactate dehydrogenase activity > 248.1 U/L, creatine kinase isoenzyme activities > 17.5 U/L, fibrinogen concentration < 1,455 mg/L, D-dimer concentration > 437.0 µg/L, aspartate aminotransferase activity > 26.1 U/L, and prothrombin time > 15.2 seconds. DISCUSSION: This study provides insight into the epidemiology, clinical profile, and management of snakebites in children. Data from the present study were compared with those from our previous adult study. Limitations include that 50.7 per cent of our snakebites were attributed to Trimeresurus albolabris. Therefore, the results of our study may not be generalizable to all snakebites. CONCLUSION: The clinical symptoms were more severe in children than in adults in our previous study. Even though there were no fatalities, close monitoring should be performed to detect haematological and other potentially fatal complications promptly.

Case Report: Snake Venom Ophthalmia Caused by Cobra Exposure: A Report of 26 Cases.

We report 26 cases of eye injuries resulting from cobra venom sprayed by Naja atra. This accounts for 14.5% of patients (26/173) treated for cobra injuries who presented to the emergency department of a snakebite treatment center in Guangzhou, South China. Pain, blurred vision, lacrimation, photophobia, and foreign body sensation were the most common symptoms, found in 24 patients. Ophthalmic examination revealed eyelid swelling and conjunctival congestion. Eye slit lamp examination showed obvious punctate corneal epithelial defects in four patients. Five patients received an intravenous infusion of antivenom. All patients' eyes were rinsed completely with normal saline after their arrival at the hospital. Prophylactic topical antibiotics were given to all patients. All eyes were cured without long-term sequelae.

Intra-operative optical coherence tomography in corneal lamellar graft reinforcement for Boston type I keratoprosthesis corneal melt.

Corneal melt is a sight-threatening complication of Boston type 1 keratoprosthesis (KPro). Severe corneal melt may result in hypotony, choroidal hemorrhage, and even spontaneous extrusion of the KPro, which may lead to a poor visual prognosis. Lamellar keratoplasty is one surgical option for the management of mild corneal melt, especially when a new KPro is not available. Herein, we present a new surgical technique application, intra-operative optical coherence tomography (iOCT) for the management of cornea graft melt after Boston type 1 KPro implantation. The visual acuity and the intra-ocular maintained stable at 6 months post-operatively, and the KPro remained in place without corneal melting, epithelial ingrowth, or infection. iOCT may prove to be a real-time, non-invasive, and accurate treatment for corneal lamellar dissection and suturing beneath the anterior plate of the KPro, which can effectively help the surgeon to make surgical decisions and reduce post-operative complications.

Pediatric Chemical and Thermal Ocular Injuries Requiring Hospitalization in South China.

PURPOSE: To study the clinical characteristics of children with severe ocular chemical or thermal injuries in South China and evaluate prognostic factors affecting final visual acuity (VA). METHODS: A five-year retrospective study was conducted on pediatric patients who were first admitted to Zhongshan Ophthalmic Center with severe chemical or thermal ocular injuries. Data collected and analyzed comprised socioeconomic and socio-demographic data, details regarding their injury, subsequent treatment, and visual outcomes. RESULTS: Of the 105 children (121 eyes), severe ocular chemical and thermal injuries in South China were prevalent in preschool children (n = 51, 58.1%), predominantly male (n = 82, 78.1%), and primarily children in rural areas (n = 98, 93.3%). Seventy-one eyes (78.9%) had a final VA <0.05, and multivariate logistic regression analysis revealed that initial VA after injury (OR = 0.47), the maternal education level (OR = 0.23), and monthly household income (OR = 0.31) were significantly associated with final VA. CONCLUSION: Final VA was associated with the initial VA, the maternal level of education, and family income; necessitating an increased provision of public education to children from low-income families, especially in rural areas.

Proteomic characteristics of six snake venoms from the Viperidae and Elapidae families in China and their relation to local tissue necrosis.

Patients envenomed by snakes from the Viperidae and Elapidae families in China often have varying degrees of local tissue necrosis. Due to the relative clinical characteristics of local tissue necrosis and ulceration following envenoming, this study has analyzed the proteome of six snake venoms from the Viperidae and Elapidae family, and the toxin profiles of each snake were compared and correlated with the clinical manifestations that follow cytotoxic envenoming. Deinagkistrodon acutus and Naja atra envenomation induce severe ulceration, which is absent in Bungarus multicinctus envenomation and mild in the other three vipers. It is interesting to note that the proportion of c-type lectins (CTL) (20.63%) in Deinagkistrodon acutus venom was relatively high, which differs from the venom of other vipers. In addition, three-fingered toxin (3FTx) (2.15%) is present in the venom of Deinagkistrodon acutus, but has not been detected in the remaining three vipers. Snake venom metalloprotease (SVMP) (34.4%-44.7%), phospholipase A2 (PLA2) (9.81%-40.83%), and snake venom serine protease (SVSP) (9.44%-16.2%) represent the most abundant families of toxin in Viperidae venom. The Elapidae venom proteome was mainly composed of neurotoxins and cytotoxins, including 3FTx (39.28%-60.08%) and PLA2 (8.24%-58.95%) toxins, however, the proportion of CRISPS (26.36%) in Naja atra venom was relatively higher compared to Bungarus multicinctus venom. Significant differences in SVMP, SVSP, and 3FTx expression levels exist between the Viperidae and the Elapidae family. The main toxins responsible for the development of tissue necrosis and ulcerations following Viperidae envenoming are hematotoxins (SVSMP, SVSP) and myotoxins (PLA2). Deinagkistrodon acutus venom contains high levels of CTL and traces of 3FTx, leading to more severe local necrosis. However, Naja atra venom can also cause severe local necrosis through the effects of myotoxin (3FTx, CRISP, PLA2). Bungarus multicinctus venom does not contain myotoxins, resulting in pure systemic neurological manifestations no obvious necrosis of local tissue in patients.

Adverse reactions to four types of monovalent antivenom used in the treatment of snakebite envenoming in South China.

To evaluate the adverse reactions associated with the four types of monovalent antivenom currently used in China, we retrospectively analysed the data of all patients admitted for snakebites who received antivenom treatment at the main institution for the treatment of venomous snakebites in Guangzhou from January 2013 to December 2021. A total of 1658 patients were analysed in our study, and 60.7% (n = 1007) of the snakebite patients received antivenom treatment. The incidence rate of adverse reactions that occurred after the administration of all types of monovalent antivenom was 4.9% (n = 49), and the incidence rate of acute adverse reactions was 2.7% (n = 27). The number of adverse reactions that occurred was 38/744 (5.1%) in patients who received prophylactic application of glucocorticoids alone and 10/217 (4.6%) in those who received a combination of antihistamines and glucocorticoids (P = 0.83). The average doses of the antivenoms used in patients exhibiting acute adverse reactions and serum sickness were 3.31 ± 0.75 vials and 2.36 ± 0.26 vials, respectively (P = 0.28). The antivenom skin test showed high specificity (98.3%, 95% CI: 97.24%-99.01%) but low sensitivity (14.3%, 95% CI: 6.41%-27.86%). Our results showed that the four types of monovalent antivenom were safe. No significant difference was observed between the use of glucocorticoids alone and the use of antihistamines combined with glucocorticoids as premedication for the prevention of adverse reactions. Reducing the dose of antivenoms or reducing the combination of antivenoms did not help to reduce the occurrence of adverse reactions. Skin testing should not be recommended due to its low sensitivity.

Clinical Experience in Patients with Ocular Burns Treated with Boston Type I Keratoprosthesis Implantation with or Without Prophylactic Ahmed Glaucoma Valve Implantation.

INTRODUCTION: To compare outcomes in eyes with ocular burns following Boston Type I keratoprosthesis (KPro) implantation with and without prophylactic pars plana tube surgery. METHODS: A retrospective review of patients with ocular burns who underwent KPro surgery at Zhongshan Ophthalmic Center was performed. Twenty-six eyes of 26 patients without a preoperative diagnosis of glaucoma before KPro surgery met the inclusion criteria. Preoperative glaucoma was defined as a history of a durable elevated intraocular pressure (IOP) ≥ 25 mmHg at different time points, which resulted in the introduction of anti-glaucoma medication or surgical intervention. Sixteen eyes underwent KPro alone (Group 1), and 10 eyes received KPro with prophylactic pars plana tube surgery (Group 2). RESULTS: Group 1 and Group 2 were similar in the proportions of the ocular burn type and preoperative clock hours of peripheral anterior synechiae by ultrasound biomicroscopy (1.88 ± 1.63 vs. 2.30 ± 1.83; P = 0.54). Before KPro surgery, 62.5% of eyes in Group 1 and 50.0% of eyes in Group 2 had intraocular surgeries (P = 0.53). The follow-up time was 18 months. At the final follow-up time, the two groups had similar visual acuity (1.34 ± 0.87 logMAR, 1.03 ± 0.71 logMAR; P = 0.35) and eyes with a C/D ratio ≥ 0.8 (7/16, 2/10; P = 0.21), but more eyes in Group 1 developed glaucoma de novo than eyes in Group 2 (62.5%, 20%; P = 0.04) and had undergone secondary glaucoma surgery after KPro implantation (7/16 vs. 0/10; P = 0.02). CONCLUSION: In eyes injured with ocular burns, KPro implantation with prophylactic pars plana tube surgery may be a feasible option to rehabilitate visual acuity and decrease the incidence of glaucoma de novo.

Prone versus Supine Position Ventilation in Adult Patients with Acute Respiratory Distress Syndrome: A Meta-Analysis of Randomized Controlled Trials.

The purpose of this meta-analysis was to compare the efficacy and safety of prone versus supine position ventilation for adult acute respiratory distress syndrome (ARDS) patients. The electronic databases of PubMed, Embase, and the Cochrane Library were systematically searched from their inception up to September 2020. The relative risks (RRs) and weighted mean differences (WMDs) with corresponding 95% confidence intervals (CIs) were employed to calculate pooled outcomes using the random-effects models. Twelve randomized controlled trials that had recruited a total of 2264 adults with ARDS were selected for the final meta-analysis. The risk of mortality in patients who received prone position ventilation was 13% lower than for those who received supine ventilation, but this effect was not statistically significant (RR: 0.87; 95% CI: 0.75-1.00; P = 0.055). There were no significant differences between prone and supine position ventilation on the duration of mechanical ventilation (WMD: -0.22; P = 0.883) or ICU stays (WMD: -0.39; P = 0.738). The pooled RRs indicate that patients who received prone position ventilation had increased incidence of pressure scores (RR: 1.23; P = 0.003), displacement of a thoracotomy tube (RR: 3.14; P = 0.047), and endotracheal tube obstruction (RR: 2.45; P = 0.001). The results indicated that prone positioning during ventilation might have a beneficial effect on mortality, though incidence of several adverse events was significantly increased for these patients.

Comparing the efficacy of bag-valve mask, endotracheal intubation, and laryngeal mask airway for subjects with out-of-hospital cardiac arrest: an indirect meta-analysis.

BACKGROUND: For subjects with out-of-hospital cardiac arrest (OHCA), bag-valve mask (BVM), endotracheal intubation (ETI), and laryngeal mask airway (LMA) are the most common methods of ventilatory support; however, the best choice remains controversial. METHODS: A comprehensive search of online databases was performed. A traditional meta-analysis was performed to determine the risk ratio of BVM vs. LMA and ETI vs. LMA. Indirect treatment comparisons (ITCs) were conducted to compare BVM and ETI. RESULTS: A total of 13 full-text articles reporting the efficacy of BVM, ETI, and LMA were considered in this analysis. BVM and LMA had the same effect regarding return of spontaneous circulation (ROSC) (23% vs. 24%; RR =0.84), survival rate at admission (19% vs. 21%; RR =0.82) or discharge (6% vs. 4%; RR =0.61). ETI was superior to LMA in terms of ROSC (48% vs. 23%; RR =0.72) and survival rate at both admission (27% vs. 19%; RR =0.85) and discharge (12% vs. 4%; RR =0.90). BVM was inferior to ETI in terms of ROSC (24% vs. 48%; RR =0.86), survival to admission rate (21% vs. 27%; RR =1.037), and survival to discharge rate (6% vs. 12%; RR =1.476). CONCLUSIONS: ETI should be considered for airway management as early as possible, which can improve the subject's success rate of recovery and survival to admission rate. In future, large-scale, multi-center, randomized controlled studies should be conducted to evaluate the exact efficacy of BVM, ETI, and LMA for the first aid of subjects with OHCA.

Effect of Zhenwu Tang Granule on pressure-overloaded left ventricular myocardial hypertrophy in rats.

BACKGROUND: In the perspective of traditional Chinese medicine, few studies have focused on the compound preparations though there are many investigations. The present study was undertaken to investigate the effect of Zhenwu Tang Granule on chronic pressure-overloaded left ventricular hypertrophy in rats. METHODS: The study was performed at the laboratory of Guangzhou Institute of Respiratory Disease. Male SD rats were divided randomly into 3 groups: sham operation group (n=8), operation group (n=15) and traditional Chinese medicine (TCM) group (n=15). The model of myocardial hypertrophy was made by gradually constricting the abdominal aorta. Sixteen weeks later, cardiac ultrasonography was performed in all groups in order to ascertain post-operational left ventricular (LV) hypertrophy. And Zhenwu Tang Granule was added at a dose of 12 g/kg in the mixed feedstuff for 8 weeks in the TCM group. In the 24th week, weight, structure as well as function of the heart in each group were measured by high-frequency ultrasonography, and Masson's staining was performed on the cardiac muscles. Meanwhile, total collagen volume fraction (CVF-T) and non-coronary vessel collagen volume fraction (CVF-NV) were analyzed. RESULTS: There was an increase in the weight of the heart in the operation group, with the left ventricule dominated (P<0.05). The heart was enlarged, with diastolic interventricular septal distance (IVSd) and left ventricular posterior wall distance (LVPWd) dominated (P<0.01). There was a significant decrease in the cardiac function (P<0.05). The weight (P<0.01) and volume of the heart decreased in the TCM group compared with the operation group, with IVSd and systolic left ventricular posterior wall dominated (P<0.01). And the cardiac function was improved (P<0.05). Significant interstitial and collagen hyperplasia was shown in the operation group based on pathological analysis, and various improvements were proved in the TCM group, i.e. there was a significant decrease in CVF-T and CVF-NV (P<0.01) compared with the operation group; but no difference (P>0.05) was found when compared with the pseudo-operation group. CONCLUSION: Zhenwu Tang Granule could reduce the weight and volume of the heart, improve the cardiac function, inhibit hyperplasia of collagen, and reverse myocardial hypertrophy in rats with pressure-overloaded left ventricular hypertrophy.