Does aerobic exercise training promote changes in structural and biomechanical properties of the tendons in experimental animals? A systematic review.

To develop a systematic review to evaluate, through the best scientific evidence available, the effectiveness of aerobic exercise in improving the biomechanical characteristics of tendons in experimental animals. Two independent assessors conducted a systematic search in the databases Medline/PUBMED and Lilacs/BIREME, using the following descriptors of Mesh in animal models. The ultimate load of traction and the elastic modulus tendon were used as primary outcomes and transverse section area, ultimate stress and tendon strain as secondary outcomes. The assessment of risk of bias in the studies was carried out using the following methodological components: light/dark cycle, temperature, nutrition, housing, research undertaken in conjunction with an ethics committee, randomization, adaptation of the animals to the training and preparation for the mechanical test. Eight studies, comprising 384 animals, were selected; it was not possible to combine them into one meta-analysis due to the heterogeneity of the samples. There was a trend to increasing ultimate load without changes in the other outcomes studied. Only one study met more than 80% of the quality criteria. Physical training performed in a structured way with imposition of overloads seems to be able to promote changes in tendon structure of experimental models by increasing the ultimate load supported. However, the results of the influence of exercise on the elastic modulus parameters, strain, transverse section area and ultimate stress, remain controversial and inconclusive. Such a conclusion must be evaluated with reservation as there was low methodological control in the studies included in this review.

Alterations of tendons in patients with diabetes mellitus: a systematic review.

AIMS: To perform a systematic review of observational studies which analyse tendon alterations in patients with diabetes mellitus compared with healthy individuals. METHODS: Data collection was performed, with no language restriction, using the databases of PubMed/Medline, BIREME, CINAHL, LILACS and Cochrane, as well as the references found in these studies. Three reviewers performed independent extractions of articles. Subsequently, these reviewers analysed the articles, focusing on their methodological quality, using the appropriate scale to evaluate observational studies from the Agency for Healthcare Research and Quality. RESULTS: Six articles were included in the analysis. Of these, four had used ultrasonographic diagnostics, one computed tomography and one magnetic resonance imaging. The patient pool comprised 396 individuals. All the articles evaluated tendon thickness and presented heterogeneous results. Two articles stated thickening or increased volume of the tendons in diabetic people, one article did not report any alteration, the fourth failed to determine any alterations and the fifth showed thinning of the tendons. The arrangement of collagen fibrils and the presence of calcification were analysed in only one article (n = 80), showing that 88.10% (n = 68) of individuals with diabetes presented disorientation of collagen fibril arrangement, while only 10% (n = 1) of healthy individuals presented this condition. Regarding tendon calcification, the article showed diabetic individuals with higher values than healthy individuals. CONCLUSIONS: All the articles indicated some relation between diabetes mellitus and tendon alterations in human beings, but due to methodological drawbacks, this association could not be sustained.

A clinical and epidemiologic study of 292 cases of lance-headed viper bite in a Brazilian teaching hospital.

The records of 292 patients who were admitted to a teaching hospital from 1984 to 1990 in Uberlandia in southeastern Brazil after being bitten by snakes of the genus Bothrops were retrospectively surveyed. The patients were from 42 municipalities in three states of Brazil. Most (42%) bites occurred between 4:00 PM and 10:00 PM. Fourteen percent of the bites occurred in the month of April. In 54 (18%) of the cases, the snakes were captured and identified as belonging to the following species: B. moojeni (29), B. neuwiedi (18), and Bothrops species (7). A diagnosis was made based on clinical findings in 238 (82%) cases. The lower limbs were the commonest site of bite (74%). The median time interval between bite and admission to the hospital was 3 hr. Fang marks were recorded in 58% of the cases and swelling was recorded in 82%. Clotting time was greater than 15 min in (142 of 264) 54% of the cases. A tourniquet was used on 44 cases. The mean +/- SD dose of specific antivenom used was 187.48 +/- 93.44 mg. The complications that occurred included abscess formation in 18% of the cases, necrosis in 16%, and renal failure in 5%. Amputation was performed in three (1%) cases. The case fatality rate was also 1% (three cases). When all cases were analyzed, the chi-square test for trend showed an increased susceptibility of renal failure with age (P < 0.04). Clotting time greater than 15 min was associated with the development of abscesses (P < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

South American rattlesnake bite in a Brazilian teaching hospital. Clinical and epidemiological study of 87 cases, with analysis of factors predictive of renal failure.

Records of 87 victims of rattlesnake bite who were admitted to a teaching in south-eastern Brazil from 1984 to 1990 were retrospectively examined. The patients came from 27 municipalities in 3 states. Most of the bites (47%) occurred between 10.00 h and 18.00 h and in April (13%). Identification of the snake was possible in only 17% of the cases, diagnosis being made on clinical grounds in the others. The lower limbs were the most common site of bite (85%). The median time interval between bite and receiving medical help was 3 h. Fang marks were observed in 47% of the cases, neurotoxic facies in 61%, and myalgia in 29%. Dark urine was reported in 40% of the cases. Clotting time was above 15 min in 53% of the tested cases. Use of a tourniquet before admission to hospital was reported 11 times. The mean dose of specific antivenom was 190 +/- 95.69 mg. The case fatality rate was 1%; 13 cases (18%) developed renal failure, 10 of whom needed dialysis. The chi 2 test for trend showed that both increased age and increased time interval between bite and medical help significantly increased the risk of renal failure (P < 0.02). Myalgia and neurotoxic facies were predictive of renal failure in patients older than 40 years (Fisher's exact test, P < 0.002 and P < 0.02, respectively). There was no significant association between dark urine or prolonged clotting time and renal failure.

Philodryas patagoniensis bite and local envenoming.

A 5-year-old boy bitten by a specimen of Philodryas patagoniensis, a colubrid snake currently classified as nonvenomous, developed signs of local envenoming characterized by swelling and warmth on the bitten limb. This is the first time that local envenoming following Philodryas patagoniensis bite is recognized. Based on the clinical findings and misidentification of the snake, the patient was treated as a victim of Bothrops bite, having received unnecessarily the specific antivenom. Educational efforts to make doctors and health workers capable to identify correctly venomous snakes are necessary, to avoid inappropriate indication of antivenom and decrease the risk of its potentially harmful untoward effects. Examination of the bite site can be useful to the differential diagnosis between pit viper and colubrid bites.

Lance-headed viper (Bothrops moojeni) bite wounding the eye.

A 5-year-old girl was bitten in her left eye by a lance-headed viper identified as Bothrops moojeni, measuring 115 cm of length. There was severe facial swelling and left exophthalmus, and enucleation of the eye was necessary. The patient apparently had mild systemic envenoming, but local inflammatory signs and histological evidence of necrosis suggest that both the mechanical trauma and the local action of the venom had a role in the genesis of the eye lesion. It is arguable if the loss of the eye could be prevented even if the antivenom was administered earlier.

South American rattlesnake bite and soft-tissue infection: report of a case.

The case of a man bitten by a South American rattlesnake (Crotalus durissus) and who developed an abscess at the site of the bite is reported. Abcesses are a rare complication of this type of envenoming, possibly due to the lack of a strong cytotoxic action of Crotalus durissus venom.

Venomous snake bite without clinical envenoming ('dry-bite'). A neglected problem in Brazil.

Venomous snake bite without envenoming ('dry-bite') has been recognized throughout the world, but neglected in the Brazilian literature. Forty cases of patients bitten by venomous snakes of the genera Bothrops (lance-headed vipers) and Crotalus (South American rattlesnakes), confirmed by identification of the captured or dead snake, were seen in a 34-month prospective study carried out in a teaching hospital in southeastern Brazil. Out of the 33 cases of lance-headed viper and 7 of rattlesnake bite, respectively 10 (30.3%) and 3 (42.9%) had no clinical or laboratory evidence of local or systemic envenoming. Both within the Bothrops and Crotalus groups, there was no significant difference in sex and age of the patients, and time between bite and medical assistance between the patients who had from those who did not have clinical envenoming. The high prevalence of 'dry-bite' in this study may have several possible explanations, and has implications on the indication of antivenom for the treatment of venomous snake bite. Antivenom administration may be postponed or even not indicated for victims of snake bite presenting no manifestations of local or systemic envenoming.

Bite marks are useful for the differential diagnosis of snakebite in Brazil.

OBJECTIVE: To assess whether examination of the bite marks could be useful for the differential diagnosis between venomous and nonvenomous snakebite. DESIGN: Assessment of the validityof the bite marks in the differential diagnosis betweenvenomous and nonvenomous snakebite in a series of patients prospectively recruited in a 32-month period. SETTING: Teaching hospital in a southeastern Brazilian town. PATIENTS: Forty-two victims of snakebite who brought the captured or dead snake for identification and who had recognizable bite marks. INTERVENTION: Inspection of the bite site, recording the aspect of the marks either as isolated fang punctures or as multiple scratch-like teeth marks. RESULTS: The presence of isolated fang marks, when related to venomous snakebite, had a sensitivity of 100%, a specificity of 56%, and a predictive value of 89%. The finding of multiple, scratch-like teeth marks had a predictive value of 100% when related to nonvenomous snake bite. CONCLUSIONS: Examination of the bite marks showed to be useful for the differential diagnosis between venomous and nonvenomous snakebites in Brazil, which has implications for the option of empirical administration of antivenin to patients when the snake is not available for identification.

Occupational injuries with captive lance-headed vipers (Bothrops moojeni): experience from a snake farm in Brazil.

We studied occupational injuries with captive lance-headed vipers (Bothrops moojeni) that occurred in a snake farm in south-eastern Brazil from February 1981 to May 1999. The risk of injury, taking into account 13 cases of snake-associated injuries (12 of them snake bites) was 2.73 per 10,000 person-days of work, and 3.51 per 100,000 venom extractions. Thirteen cases of injury occurred in seven workers, whereas 18 workers were never injured, suggesting that some individuals have a higher risk of injury than others perhaps due to lack of concentration or overconfidence. Eight episodes of occupational injuries occurring in four technicians, including a case of eye injury due to splashed venom during extraction, are reported. Assessment of whether envenoming occurred was facilitated by knowledge of the snake species and size, history of recent venom extraction and snake feeding, and examination of snake venom glands. Hypersensitivity reactions (anaphylaxis and serum sickness) to antivenom are a risk particularly to those workers who were bitten more than once and medicated previously. Antivenom therefore should not be administered to these individuals unless there is clear evidence that envenoming occurred or is likely to have occurred. Hypersensitivity to the venom is also a health concern for workers from snake farms.

Clinical and epidemiological aspects of the 'urutu' lance-headed viper (Bothrops alternatus) bite in a Brazilian hospital.

Data on 32 cases of Bothrops alternatus (the 'urutu' lance-headed viper) bite admitted to a Brazilian teaching hospital from 1985 to 1992 were retrospectively surveyed. The majority of the bites occurred within the household area, i.e. in the house or its environs (56.3%), in the 15-49 years age group (74.2%), and in the lower limbs (84.3%). The male to female ratio was 1 to 1. 59.4% of the patients were given the antivenom within two hours of the bite. Bites in the household area were commonest in old ladies, whereas all the cases associated with leisure activities, and the majority of the bites associated with labour in the field occurred in men. All patients had local pain and oedema; prolonged clothing time was present in 96.9% of the cases, haemorrhage in 40.6%, blisters in 21.9% and necrosis in 9.4%. A tourniquet was used by 43.8% of the patients. A median of 4 ampoules of antivenom were administered. There was no death in this series. There was no significant trend between increasing age and necrosis, nor between time interval between bite and antivenom administration and occurrence of blisters or necrosis. Presence of blister(s) was associated with necrosis (p = 0.007), but use of a tourniquet, altered clotting time or presence of haemorrhage were not. These findings, compared with those of case series of bites of other species of Bothrops, and contrary to the popular belief, indicate that B. alternatus bite is not always severe, and has even a lower rate of complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Aeromonas hydrophila soft-tissue infection as a complication of snake bite: report of three cases.

Aeromonas hydrophila soft-tissue infection has been associated with fish and reptile bites. There have bee three recent cases from Brazil of abscesses complicating snake bites in which A. hydrophila was isolated from the purulent exudates. One of the snakes responsible for the bites was a specimen of Bothrops moojeni, and the others were most probably also lance-headed vipers. These snakes have a local necrotizing, myotoxic, oedema-inducing venom that must have favoured the multiplication in the injured tissue of A. hydrophila strains, which were probably present in the mouth, fangs or venom of the snakes. The use of a tourniquet by two of the patients probably worsened the local envenoming, and contributed to the occurrence of soft-tissue infection. The patients had a good outcome after the abscesses were incised and drained, and after being treated with chloramphenicol. Chloramphenicol appears to be a good alternative for the empirical treatment of soft-tissue infection complicating snake bite in Brazil, because: it is active against the majority of the anaerobic and aerobic bacteria found in these abscesses, including A. hydrophila; it can be administered by the oral route; and its is inexpensive. Suitable alternatives are cotrimoxazole or fluoroquinolones, to which aeromonads are usually susceptible in vitro, associated with antibiotics, such as clindamycin and metronidazole, with an anti-anaerobic spectrum.