Inflammatory Profile Associated with Secondary Infection from Bothrops atrox Snakebites in the Brazilian Amazon.

Bothrops snakebite envenomation (SBE) is consider an important health problem in Brazil, where Bothrops atrox is mainly responsible in the Brazilian Amazon. Local effects represent a relevant clinical issue, in which inflammatory signs and symptoms in the bite site represent a potential risk for short and long-term disabilities. Among local complications, secondary infections (SIs) are a common clinical finding during Bothrops atrox SBE and are described by the appearance of signs such as abscess, cellulitis or necrotizing fasciitis in the affected site. However, the influence of SI in the local events is still poorly understood. Therefore, the present study describes for the first time the impact of SBE wound infection on local manifestations and inflammatory response from patients of Bothrops atrox SBE in the Brazilian Amazon. This was an observational study carried out at the Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus (Brazil), involving victims of Bothrops SBE. Clinical and laboratorial data were collected along with blood samples for the quantification of circulating cytokines and chemokines before antivenom administrations (T0) and 24 h (T1), 48 h (T2), 72 h (T3) and 7 days after (T4). From the 94 patients included in this study, 42 presented SI (44.7%) and 52 were without SI (NSI, 55.3%). Patients classified as moderate envenoming presented an increased risk of developing SI (OR = 2.69; CI 95% = 1.08-6.66, p = 0.033), while patients with bites in hands showed a lower risk (OR = 0.20; CI 95% = 0.04-0.96, p = 0.045). During follow-up, SI patients presented a worsening of local temperature along with a sustained profile of edema and pain, while NSI patients showed a tendency to restore and were highlighted in patients where SI was diagnosed at T2. As for laboratorial parameters, leukocytes, erythrocyte sedimentation ratio, fibrinogen and C-reactive protein were found increased in patients with SI and more frequently in patients diagnosed with SI at T3. Higher levels of circulating IL-2, IL-10, IL-6, TNF, INF-γ and CXCL-10 were observed in SI patients along with marked correlations between these mediators and IL-4 and IL-17, showing a plurality in the profile with a mix of Th1/Th2/Th17 response. The present study reports for the first time the synergistic effects of local infection and envenoming on the inflammatory response represented by local manifestations, which reflected on laboratorial parameters and inflammatory mediators and thus help improve the clinical management of SI associated to Bothrops SBE.

The severity of acute kidney injury correlates with plasma venom levels in Bothrops atrox envenomings.

The Brazilian Amazon has high rates of snakebite envenomings (SBEs), with ∼90% caused by Bothrops atrox. Envenomings by this species can trigger local and systemic effects, such as acute kidney injury (AKI). Our aim was to identify predictors of AKI in Bothrops SBEs in patients from Manaus, Western Brazilian Amazon. A total of 127 patients were enrolled, with a predominance of men between 16 and 45 years old from rural areas. Of the 127 patients, 38.6% developed AKI, with 61.2% presenting stage I, 34.7% presenting stage II and 4.1% presenting stage III severity. The age groups 0-10 years and ≥60 years presented a significantly higher frequency of AKI compared to the 11-40 years group. Moderate/severe edema in the affeccted limb was significantly associated with lower risk of AKI [p = 0.01; OR = 0.11 (95%CI 0.02-0.53)]. Nausea [p = 0.01; OR = 54.44 (95%CI = 3.26-909.27)] and high blood urea levels [p = 0.01; OR = 5.38 (95%CI = 2.12-13.66)] were risk factors for AKI. There was a significant positive correlation between circulating venom levels and the highest creatinine serum values during the hospital stay (p = 0.03) and with the difference between the maximum creatinine levels and the creatinine levels on admission (p = 0.02). A positive correlation between serum venom concentrations and creatinine levels suggests a direct or indirect dose-dependent participation of the venom toxins in the pathogenesis of AKI.

Bothrops snakebites in the Amazon: recovery from hemostatic disorders after Brazilian antivenom therapy.

Introduction:Bothrops atrox snakebites are a major public health problem in the Amazon region and also cause hemostatic disorders. In this study, we assessed the recovery from hemostatic disorders in Bothrops snakebite patients after being given antivenom therapy.Methods: This is a prospective study of Bothrops snakebite patients (n = 100) treated at the Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazilian Amazon, between January 2016 and December 2017. Blood samples were taken for the measurement of venom concentrations, platelets, clotting time and factors of patients on admission, 12, 24 and 48 h after antivenom therapy, and taken again on discharge. The presence of systemic bleeding was recorded during the follow-up.Results: On admission, systemic bleeding was observed in 14% of the patients. Thrombocytopenia was noted in 10% of the patients. A total of 54% of the patients presented unclottable blood with low levels of fibrinogen and alpha 2-antiplasmin, and high levels of fibrin/fibrinogen degradation product (FDP) and D-dimers. Unclottable blood and systemic bleeding were overcome in most patients 12 h after the antivenom therapy. Three patients developed systemic bleeding 48 h after antivenom therapy. Levels of fibrinogen and alpha 2-antiplasmin, FDP and D-dimer returned to normal around 48 h after the treatment or on discharge. The frequency of thrombocytopenia with high mean platelet volume increased in the first 24 h after antivenom therapy, and decreased on discharge. Bothrops venom levels in patients decreased 12 h after antivenom therapy and were not correlated with coagulation and fibrinolytic parameters. There were no deaths.Conclusion: Laboratorial parameters of coagulopathy returned to normal values within 48 h after the antivenom therapy until discharge. A few patients still presented bleeding signs within 48 h after beginning antivenom therapy. However, the Brazilian antivenom was able to overcome the hemostatic disorders in these cases of envenomation.

Bleeding Disorders in Bothrops atrox Envenomations in the Brazilian Amazon: Participation of Hemostatic Factors and the Impact of Tissue Factor.

Bleeding is a common hemostatic disorder that occurs in Bothrops envenomations. We evaluated the changes in coagulation, fibrinolysis components, and platelets in Bothrops atrox envenomations with bleeding. This is an observational study with B. atrox snakebite patients (n = 100) treated in Manaus, Brazilian Amazon. Bleeding was recorded on admission and during hospitalization. We found that the platelet count in our patients presented a weak correlation to tissue factor, factor II, and plasminogen. Tissue factor presented weak correlation to factor V, II, D-dimer, plasminogen, alpha 2-antiplasmin, and moderate correlation to fibrinogen and fibrin/fibrinogen degradation product (FDP). Patients with systemic bleeding (n = 20) presented low levels of factor V, II, fibrinogen, plasminogen, and alpha 2-antiplasmin, and high levels of tissue factor and FDP compared to those without bleeding. Patients with only local bleeding (n = 41) and without bleeding showed similar levels of hemostatic factors. Thrombocytopenia was observed mainly in patients with systemic bleeding and increased levels of serum venom. No association was found between venom levels and systemic bleeding, or between venom levels and clinical severity of envenomation. This is the first report that shows the participation of the extrinsic coagulation pathway in the consumption coagulopathy of B. atrox envenomations with systemic bleeding due to tissue factor release.

Accuracy of the Lee-White Clotting Time Performed in the Hospital Routine to Detect Coagulopathy in Bothrops atrox Envenomation.

Snake envenomation is a major public health problem in Brazil. Systemic complications that may arise from snakebites are mainly related to coagulopathy. The Lee-White clotting time (LWCT) is a simple and inexpensive test and available even in remote health facilities. However, the diagnostic value of such test needs to be evaluated to accurately diagnose coagulopathy in the clinical practice. This study aimed to assess the reliability of the LWCT performed in hospital routine to diagnose venom-induced coagulopathy. We studied 186 patients admitted at the Tropical Medicine Foundation Dr. Heitor Vieira Dourado in Manaus, Amazonas, Brazil, with Bothrops envenomation diagnosis. At admission, blood samples were collected for performing LWCT and the concentration of fibrinogen. Sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios, diagnostic odds ratio, and accuracy were calculated with 95% confidence intervals. From the total, 85.5% had hypofibrinogenemia. The sensitivity of the LWCT to the diagnosis of hypofibrinogenemia was 78.0% and the specificity 40.7%. The accuracy of the test was 72.6%, and patients with a prolonged LWCT had 2.4 higher odds of developing hypofibrinogenemia. In addition, the LWCT was also compared with venom antigen levels and systemic hemorrhage. The LWCT showed moderate sensitivity to detect consumption coagulopathy and constitutes a valuable tool for the diagnosis of Bothrops snake envenomation and indication of antivenom therapy.

Poor efficacy of preemptive amoxicillin clavulanate for preventing secondary infection from Bothrops snakebites in the Brazilian Amazon: A randomized controlled clinical trial.

BACKGROUND: Secondary bacterial infections from snakebites contribute to the high complication rates that can lead to permanent function loss and disabilities. Although common in endemic areas, routine empirical prophylactic use of antibiotics aiming to prevent secondary infection lacks a clearly defined policy. The aim of this work was to estimate the efficacy of amoxicillin clavulanate for reducing the secondary infection incidence in patients bitten by Bothrops snakes, and, secondarily, identify risk factors for secondary infections from snakebites in the Western Brazilian Amazon. METHODS AND FINDINGS: This was an open-label, two-arm individually randomized superiority trial to prevent secondary infection from Bothrops snakebites. The antibiotic chosen for this clinical trial was oral amoxicillin clavulanate per seven days compared to no intervention. A total of 345 patients were assessed for eligibility in the study period. From this total, 187 accomplished the inclusion criteria and were randomized, 93 in the interventional group and 94 in the untreated control group. All randomized participants completed the 7 days follow-up period. Enzyme immunoassay confirmed Bothrops envenoming diagnosis in all participants. Primary outcome was defined as secondary infection (abscess and/or cellulitis) until day 7 after admission. Secondary infection incidence until 7 days after admission was 35.5% in the intervention group and 44.1% in the control group [RR = 0.80 (95%CI = 0.56 to 1.15; p = 0.235)]. Survival analysis demonstrated that the time from patient admission to the onset of secondary infection was not different between amoxicillin clavulanate treated and control group (Log-rank = 2.23; p = 0.789).Secondary infections incidence in 7 days of follow-up was independently associated to fibrinogen >400 mg/dL [AOR = 4.78 (95%CI = 2.17 to 10.55; p<0.001)], alanine transaminase >44 IU/L [AOR = 2.52 (95%CI = 1.06 to 5.98; p = 0.037)], C-reactive protein >6.5 mg/L [AOR = 2.98 (95%CI = 1.40 to 6.35; p = 0.005)], moderate pain [AOR = 24.30 (95%CI = 4.69 to 125.84; p<0.001)] and moderate snakebites [AOR = 2.43 (95%CI = 1.07 to 5.50; p = 0.034)]. CONCLUSIONS/SIGNIFICANCE: Preemptive amoxicillin clavulanate was not effective for preventing secondary infections from Bothrops snakebites. Laboratorial markers, such as high fibrinogen, alanine transaminase and C-reactive protein levels, and severity clinical grading of snakebites, may help to accurately diagnose secondary infections. TRIAL REGISTRATION: Brazilian Clinical Trials Registry (ReBec): RBR-3h33wy; UTN Number: U1111-1169-1005.

Impacto da farinha de mandioca fortificada com ferro aminoácido quelato no nível de hemoglobina de pré-escolares / Impact of cassava flour fortified with iron amino acid chelate on the hemoglobin level in pre-schools

OBJETIVO: Avaliou-se o impacto da farinha de mandioca fortificada com ferro aminoácido quelato em 80 pré-escolares de uma Unidade Filantrópica de Manaus, AM, distribuídos aleatoriamente em quatro grupos de 20 crianças cada, por um período de 120 dias. MÉTODOS: Foram utilizadas farinha de mandioca sem fortificação (Grupo zero) e fortificada com 1, 2 e 3mg de Fe/dia, correspondendo a quantias diárias de 5, 10 e 15g de farinha, respectivamente, as quais foram distribuídas no horário do almoço, sendo ainda entregue às famílias a quantidade destinada ao consumo do final de semana. O estado nutricional das crianças foi avaliado no início e ao final do experimento, adotando-se como limite discriminatório entre eutrofia/desnutrição o ponto de corte <-2 escores-Z, de acordo com os critérios da Organização Mundial da Saúde, e estabelecendo-se como ponto de corte para a ocorrência de anemia ferropriva o teor de hemoglobina inferior a 11g/dL. RESULTADOS: Houve uma recuperação das crianças com desnutrição crônica ao final do estudo, e ocorreu um aumento significativo (p<5 por cento) dos valores de hemoglobina de todos os pré-escolares, independentemente da concentração de ferro, de 11,4 ± 0,9g/dL para 12,2 ± 0,8g/dL. As crianças anêmicas que receberam a farinha de mandioca fortificada com 2mg de Fe/dia foram plenamente recuperadas ao final da pesquisa, demonstrando um bom desempenho desse grupo em relação aos demais. CONCLUSÃO: Sugere-se um estudo duplo cego para a consolidação da recomendação da farinha de mandioca fortificada com ferro na prevenção de anemia ferropriva em pré-escolares da região amazônica

Influência da cafeína no comportamento da pressäo arterial e da agregaçäo plaquetária / Influence of caffeine on blood pressure and platelet aggregation

OBJECTIVE: Studies have demonstrated that methylxanthines, such as caffeine, are A1 and A2 adenosine receptor antagonists found in the brain, heart, lungs, peripheral vessels, and platelets. Considering the high consumption of products with caffeine in their composition, in Brazil and throughout the rest of the world, the authors proposed to observe the effects of this substance on blood pressure and platelet aggregation. METHODS: Thirteen young adults, ranging from 21 to 27 years of age, participated in this study. Each individual took 750mg/day of caffeine (250mg tid), over a period of seven days. The effects on blood pressure were analyzed through the pressor test with handgrip, and platelet aggregation was analyzed using adenosine diphosphate, collagen, and adrenaline. RESULTS: Diastolic pressure showed a significant increase 24 hours after the first intake (p<0.05). This effect, however, disappeared in the subsequent days. The platelet aggregation tests did not reveal statistically significant alterations, at any time during the study. CONCLUSION: The data suggest that caffeine increases diastolic blood pressure at the beginning of caffeine intake. This hypertensive effect disappears with chronic use. The absence of alterations in platelet aggregation indicates the need for larger randomized studies.

Açaí (Euterpe oleracea mart.) e camu-camu (Myrciaria dubia (H.B.K.) Mc Vaugh) possuem ação anti anêmica?

It was evaluated the impact of the use of açaí and camu-camu in pre scholars of a Philanthropic Unit of Manaus-AM. Eight-five volunteers with age two to six-years old of both sexes were selected, randomly distributed in five groups, having açaí and açaí + camu-camu as sources of iron (2 mg) and vitamin C (40 mg), as well as iron aminoacid chelate with concentrations of 1 and 2 mg of iron. The iron was distributed daily in the lunch by a period of 120 days. In the characterization of the anemia, the cutting point of hemoglobin was 11g/dL. The results demonstrated that of a total of 85 children, 6 (7%) presented a chronic malnutrition state, being at the end of the study reduced to 4 (4%). The most impact of the use of the açaí was as energy source, resulting in a significant weight gain (1.76 kg) by the children, even when camu-camu was added (1.69 kg). Regarding hemoglobin concentration no significant difference was observed among the children of the groups gave received different sources of iron: açaí (0.71 g/dL); açaí + camu-camu (0.60 g/dL), iron 2 mg (0.88 g/dL); water (0.85 g/dL) and iron 1 mg (0.54 g/dL). However, the recovery of the anemic children was better in the group gave received iron aminoacid chelate in the concentration of 2 mg of iron. It was concluded that açaí has a great potential as energy source and little importance as an iron source, even with the addition of camu-camu.

Avaliou-se o impacto da utilização do açaí e camu-camu em pré-escolares de uma Unidade Filantrópica de Manaus-AM. Foram selecionadas 85 crianças voluntárias, de dois a seis anos incompletos, de ambos os sexos, distribuídas aleatoriamente em 5 grupos, tendo como fonte de ferro e vitamina C: açaí e açaí + camu-camu, perfazendo um total de 2 mg de ferro e 40 mg de ácido ascórbico, assim como o ferro aminoácido quelato na concentração de 1 e 2 mg de ferro. O ferro foi distribuído diariamente na colação por um período de 120 dias. Na caracterização da anemia considerou-se o ponto de corte de hemoglobina 11g/dL. Os resultados demonstraram que de um universo de 85 crianças 6 (7%) apresentaram um quadro de desnutrição crônica, sendo ao final da intervenção reduzido para 4 (4,7%). O maior impacto da utilização do açaí foi como fonte energética, refletido no ganho de peso significativo das crianças (1,76 kg), mesmo quando adicionado de camu-camu (1,69 kg). Em relação a concentração de hemoglobina, não foi constatada diferença significativa entre as crianças dos diferentes grupos, independente da fonte de ferro: açaí (0,71 g/dL); açaí + camu-camu (0,60 g/dL), Ferro 2 mg (0,88 g/dL); água (0,85 g/ dL) e Ferro 1 mg (0,54 g/dL). Entretanto, a recuperação de crianças anêmicas foi maior no grupo que recebeu ferro aminoácido quelato na concentração de 2 mg de ferro. Conclui-se que o açaí tem um grande potencial como fonte energética e pouca expressividade como fonte de ferro, mesmo adicionado de camu-camu.