Bothrops lanceolatus Envenoming in Martinique: A Historical Perspective of the Clinical Effectiveness of Bothrofav Antivenom Treatment.

Bothrofav, a monospecific antivenom, was introduced in June 1991 and has shown excellent effectiveness against life-threatening and thrombotic complications of Bothrops lanceolatus envenoming. Because of the reoccurrence of cerebral stroke events despite the timely administration of antivenom, new batches of Bothrofav were produced and introduced into clinical use in January 2011. This study's aim was to evaluate the effectiveness of Bothrofav generations at treating B. lanceolatus envenoming. During the first period of the study (2000-2010), 107 patients were treated with vials of antivenom produced in June 1991, while 282 envenomed patients were treated with vials of antivenom produced in January 2011 in the second study period (2011-2023). Despite timely antivenom administration, thrombotic complications reoccurred after an interval free of thrombotic events, and a timeframe analysis suggested that the clinical efficacy of Bothrofav declined after it reached its 10-year shelf-life. In of the case of an antivenom shortage due to the absence of regular batch production, no adverse effects were identified before the antivenom reached its 10-year shelf-life, which is beyond the accepted shelf-life for a liquid-formulation antivenom. While our study does not support the use of expired antivenom for potent, life-threatening B. lanceolatus envenoming, it can be a scientific message to public entities proving the necessity of new antivenom production for B. lanceolatus envenoming.

Bothrops (Fer-de-lance) snakebites in the French departments of the Americas (Martinique and Guyana): Clinical and experimental studies and treatment by immunotherapy.

Snakebite envenomation is a relevant medical hazard in French Guiana and Martinique, two French territories in the Americas. All snakebite envenomations in Martinique are inflicted by the endemic viperid species Bothrops lanceolatus, whereas Bothrops atrox is responsible for the majority of snakebites in French Guiana, although other venomous snake species also occur in this South American territory. This review summarizes some of the key aspects of the natural history of these species, as well as of their venom composition, the main clinical manifestations of envenomations, and their treatment by antivenoms. B. atrox venom induces the typical set of clinical manifestations characteristic of Bothrops sp. venoms, i.e., local tissue damage and systemic alterations associated with coagulopathies, hemorrhage, hemodynamic alterations, and acute kidney injury. In the case of B. lanceolatus venom, in addition to some typical features of bothropic envenomation, a unique and severe thrombotic effect occurs in some patients. The pathogenesis of this effect remains unknown but may be related to the action of venom components and inflammatory mediators on endothelial cells in the vasculature. A monospecific antivenom has been successfully used in Martinique to treat envenomations by B. lanceolatus. In the case of French Guiana, a polyvalent antivenom has been used for some years, but it is necessary to assess the preclinical and clinical efficacy against viperid venoms in this country of other antivenoms manufactured in the Americas.

Acute Rubigine® Poisoning in Martinique a French Overseas Department of America: Clinical Characteristics and Prognostic Factors.

Rubigine® is an anti-rust stain remover containing fluorides which is believed to have been the cause of many deaths in Martinique. However, after the modification of its composition in 2006, serious poisoning from old formulas containing fluorides persisted. Our main objective was to determine the clinical characteristics and prognostic factors of these intoxications. Methods: Any patient admitted to the Martinique University Hospital for acute Rubigine® poisoning was included from 1 January 2000 to 31 December 2016. Usual demographic and clinical data were collected and comparisons between surviving and deceased patients made using a univariate analysis and logistic regression. Results: Fifty-five patients were included (mean age: 43 years; sex ratio M/F: 1.1), and the main clinical characteristics were: changes in electrocardiogram (ECG) (80%), digestive system disorders (75%), and neurological disorders (12%). The main features linked to death were the presence of hydrofluoric acid (p < 0.0001), age over 55 years (p = 0.01), hypocalcemia after the initial intravenous calcium supplementation (p = 0.0003), diarrhea (p < 0.0001), hypersialorrhea (p < 0.0001), myocardial excitability (p < 0.0001), and state of shock (p < 0.0001). Three patients required circulatory support by venous-arterial ECMO. Mortality was 10.9%. Conclusions: Rubigine® poisoning is responsible for significant morbidity and mortality. Fortunately, its incidence as well as mortality has sharply decreased in Martinique thanks to the measures taken by the French state. This retrospective work nevertheless shows that acute intoxication by the old formula of Rubigine® remains the main factor of poor prognosis.

Clinical Characteristics of Ciguatera Poisoning in Martinique, French West Indies-A Case Series.

Ciguatera poisoning (CP) is one of the most common causes worldwide of marine poisoning associated with fish consumption from tropical areas. Its incidence is underreported. CP cases seem to increase with grouped cases reported during summer. Exposure to ciguatoxins, toxins responsible for CP with sodium-channel agonistic, voltage-gated potassium channel blocking, cholinergic, and adrenergic activities, may result in a large spectrum of manifestations. We aimed to describe the clinical characteristics, management, and outcome of CP in Martinique, French West Indies. We conducted an observational retrospective single-center study during six years (October 2012 to September 2018) including all CP patients managed by the prehospital medical services, admitted to the university hospital emergency department, or declared to the regional health agency. A total of 149 CP patients (81 females/63 males; median age, 46 years (interquartile range, 34-61)) were included. Acute features consisted in general (91%; mainly, myalgia pruritus, and asthenia), gastrointestinal (90%; mainly diarrhea, abdominal pain, and nausea), neurological (72%; mainly, paresthesia, dysgeusia, and impairment of hot/cold feeling), and cardiovascular manifestations (22%; bradycardia, hypotension, and heart conduction disorders). Management was supportive. No patient died but symptoms persisted in 40% of the 77 patients with follow-up at day 15. CP was mainly attributed to the ingestion of trevallies (59%), snappers (13%), and king mackerels (8%) with collective contaminations (71%). Unusual fish (tuna, salmon, and spider conchs) were suspected in rare cases. Ingestion of trevallies was associated with significantly higher persistent symptoms (odds ratio, 3.00; 95% confidence interval, (1.20-8.00); p = 0.03). CP incidence was 0.67 cases per 10,000 patient-years in Martinique over the study period. To conclude, CP represents an increasing public health issue in Martinique, as is the case in other Caribbean islands. Patients present usual but possibly life-threatening features. Outcome is excellent despite frequently prolonged manifestations.

Covid-19 in the Caribbean: lessons learned from the ongoing international medical and scientific cooperation.

The coronavirus disease (Covid-19) crisis presents as human, social and economic challenges. The advent of Covid-19, unfortunate as it is, has highlighted the need for close medical cooperation between states. Medical cooperation is the key counter to fight against the Covid-19 pandemic.

Critical care medicine in the French Territories in the Americas: Current situation and prospects

[ABSTRACT]. Hospitals in the French Territories in the Americas (FTA) work according to international and French standards. This paper aims to describe different aspects of critical care in the FTA. For this, we reviewed official information about population size and intensive care unit (ICU) bed capacity in the FTA and literature on FTA ICU specificities. Persons living in or visiting the FTA are exposed to specific risks, mainly severe road traffic injuries, envenoming, stab or ballistic wounds, and emergent tropical infectious diseases. These diseases may require specific knowledge and critical care management. However, there are not enough ICU beds in the FTA. Indeed, there are 7.2 ICU beds/100 000 population in Guadeloupe, 7.2 in Martinique, and 4.5 in French Guiana. In addition, seriously ill patients in remote areas regularly have to be transferred, most often by helicopter, resulting in a delay in admission to intensive care. The COVID-19 crisis has shown that the health care system in the FTA is unready to face such an epidemic and that intensive care bed capacity must be increased. In conclusion, the critical care sector in the FTA requires upgrading of infrastructure, human resources, and equipment as well as enhancement of multidisciplinary care. Also needed are promotion of training, research, and regional and international medical and scientific cooperation.

[RESUMEN]. Los hospitales en los territorios franceses de la Región de las Américas funcionan según las normas francesas e internacionales. El objetivo de este artículo es describir distintos aspectos de los cuidados intensivos en los territorios franceses. Para ello, hemos revisado los datos oficiales sobre el tamaño de la población y el número de camas de las unidades de cuidados intensivos (UCI), así como la bibliografía sobre algunos aspectos específicos de las UCI, en los territorios franceses. Las personas que viven en los territorios franceses, o que están de visita en ellos, están expuestas a riesgos específicos: principalmente traumatismos graves causados por el tránsito, envenenamiento por mordeduras, heridas de bala o por apuñalamiento, y enfermedades infecciosas tropicales emergentes. La atención de estos traumatismos y enfermedades puede requerir conocimientos específicos y cuidados intensivos. Sin embargo, no hay suficientes camas de UCI en los territorios franceses. De hecho, hay 7,2 camas de UCI por 100 000 habitantes en Guadalupe, 7,2 en Martinica y 4,5 en Guayana Francesa. Además, los pacientes gravemente enfermos que viven en zonas remotas a menudo tienen que ser trasladados, normalmente por helicóptero, lo que retrasa su ingreso en la unidad de cuidados intensivos. La crisis de la COVID-19 ha puesto de manifiesto que el sistema de atención de salud en los territorios franceses no está preparado para enfrentarse a una epidemia de estas dimensiones y que debe aumentarse la capacidad hospitalaria de las unidades de cuidados intensivos. En conclusión, el sector de los cuidados intensivos en los territorios franceses tiene que mejorar su infraestructura, recursos humanos y equipamiento, así como perfeccionar la atención multidisciplinaria. También es necesario promover la capacitación, la investigación y la cooperación médica y científica, tanto regional como internacional.

[RESUMO]. Os hospitais nos territórios ultramarinos franceses nas Américas funcionam segundo os padrões franceses e internacionais. O objetivo deste artigo é descrever os diversos aspectos da atenção intensiva nesta região. Analisamos os dados oficiais relativos ao tamanho da população e ao número de leitos de unidade de terapia intensiva (UTI) nestes territórios junto com uma revisão da literatura científica sobre as características particulares destes centros de terapia intensiva. Os residentes locais ou visitantes dos territórios ultramarinos franceses nas Américas são expostos a riscos específicos, sobretudo acidentes de trânsito graves, envenenamentos por animais peçonhentos, ferimentos por armas brancas ou armas de fogo e doenças infecciosas tropicais emergentes que requerem conhecimento especializado e atenção intensiva. Porém, não há leitos suficientes de UTI nos territórios ultramarinos franceses nas Américas: são 7,2 leitos de UTI por 100.000 habitantes em Guadalupe, 7,2 na Martinica e 4,5 na Guiana Francesa. Ademais, em áreas remotas, os pacientes em estado crítico frequentemente precisam ser transferidos por helicóptero, o que causa demora na internação em UTI. A crise da COVID-19 demonstra o despreparo do sistema de saúde para enfrentar a pandemia e a necessidade de aumentar o número de leitos de UTI nestes territórios. Em conclusão, é imprescindível modernizar a infraestrutura e os equipamentos, capacitar melhor os recursos humanos e melhorar a atenção multidisciplinar. Incentivar a formação profissional, pesquisa e cooperação médico-científica regional e mundial é também fundamental.

Sargassum seaweed health menace in the Caribbean: clinical characteristics of a population exposed to hydrogen sulfide during the 2018 massive stranding.

BACKGROUND: Since 2011, there have been ongoing massive unexplained increases of sargassum seaweed strandings along the coastlines of Caribbean countries. The objective of our study was to describe the clinical characteristics of patients exposed to noxious emissions of decomposing sargassum seaweed. METHODS: This observational study included patients from January 2018 to December 2018 for complaints attributed to decomposing sargassum seaweed. History and geographical characteristics of sargassum seaweed strandings as well as detection of ambient air hydrogen sulfide (H2S) levels were documented during the inclusion period. FINDINGS: A total of 154 patients were included. Mean exposure period was 3 months. Neurological (80%), digestive (77%) and respiratory (69%) disorders were the most frequent reasons for medical visit. Temporal distribution of medical visits was related to history of strandings. Geographical origins of patients were consistent with the most impacted areas of strandings as well as the most elevated ambient air H2S levels. INTERPRETATION: The toxicological syndrome induced by sargassum seaweed exposure is close to the toxidrome associated with acute H2S exposure in the range of 0-10 ppm. Our study suggests that patients living in massive stranding areas may be exposed to H2S > 5 ppm for 50 days per year.

Critical care medicine in the French Territories in the Americas: Current situation and prospects / La medicina intensiva en los territorios franceses de la Región de las Américas: situación actual y perspectivas / Medicina intensiva nos territórios ultramarinos franceses nas Américas: situação atual e perspectivas

ABSTRACT Hospitals in the French Territories in the Americas (FTA) work according to international and French standards. This paper aims to describe different aspects of critical care in the FTA. For this, we reviewed official information about population size and intensive care unit (ICU) bed capacity in the FTA and literature on FTA ICU specificities. Persons living in or visiting the FTA are exposed to specific risks, mainly severe road traffic injuries, envenoming, stab or ballistic wounds, and emergent tropical infectious diseases. These diseases may require specific knowledge and critical care management. However, there are not enough ICU beds in the FTA. Indeed, there are 7.2 ICU beds/100 000 population in Guadeloupe, 7.2 in Martinique, and 4.5 in French Guiana. In addition, seriously ill patients in remote areas regularly have to be transferred, most often by helicopter, resulting in a delay in admission to intensive care. The COVID-19 crisis has shown that the health care system in the FTA is unready to face such an epidemic and that intensive care bed capacity must be increased. In conclusion, the critical care sector in the FTA requires upgrading of infrastructure, human resources, and equipment as well as enhancement of multidisciplinary care. Also needed are promotion of training, research, and regional and international medical and scientific cooperation.

RESUMEN Los hospitales en los territorios franceses de la Región de las Américas funcionan según las normas francesas e internacionales. El objetivo de este artículo es describir distintos aspectos de los cuidados intensivos en los territorios franceses. Para ello, hemos revisado los datos oficiales sobre el tamaño de la población y el número de camas de las unidades de cuidados intensivos (UCI), así como la bibliografía sobre algunos aspectos específicos de las UCI, en los territorios franceses. Las personas que viven en los territorios franceses, o que están de visita en ellos, están expuestas a riesgos específicos: principalmente traumatismos graves causados por el tránsito, envenenamiento por mordeduras, heridas de bala o por apuñalamiento, y enfermedades infecciosas tropicales emergentes. La atención de estos traumatismos y enfermedades puede requerir conocimientos específicos y cuidados intensivos. Sin embargo, no hay suficientes camas de UCI en los territorios franceses. De hecho, hay 7,2 camas de UCI por 100 000 habitantes en Guadalupe, 7,2 en Martinica y 4,5 en Guayana Francesa. Además, los pacientes gravemente enfermos que viven en zonas remotas a menudo tienen que ser trasladados, normalmente por helicóptero, lo que retrasa su ingreso en la unidad de cuidados intensivos. La crisis de la COVID-19 ha puesto de manifiesto que el sistema de atención de salud en los territorios franceses no está preparado para enfrentarse a una epidemia de estas dimensiones y que debe aumentarse la capacidad hospitalaria de las unidades de cuidados intensivos. En conclusión, el sector de los cuidados intensivos en los territorios franceses tiene que mejorar su infraestructura, recursos humanos y equipamiento, así como perfeccionar la atención multidisciplinaria. También es necesario promover la capacitación, la investigación y la cooperación médica y científica, tanto regional como internacional.

RESUMO Os hospitais nos territórios ultramarinos franceses nas Américas funcionam segundo os padrões franceses e internacionais. O objetivo deste artigo é descrever os diversos aspectos da atenção intensiva nesta região. Analisamos os dados oficiais relativos ao tamanho da população e ao número de leitos de unidade de terapia intensiva (UTI) nestes territórios junto com uma revisão da literatura científica sobre as características particulares destes centros de terapia intensiva. Os residentes locais ou visitantes dos territórios ultramarinos franceses nas Américas são expostos a riscos específicos, sobretudo acidentes de trânsito graves, envenenamentos por animais peçonhentos, ferimentos por armas brancas ou armas de fogo e doenças infecciosas tropicais emergentes que requerem conhecimento especializado e atenção intensiva. Porém, não há leitos suficientes de UTI nos territórios ultramarinos franceses nas Américas: são 7,2 leitos de UTI por 100.000 habitantes em Guadalupe, 7,2 na Martinica e 4,5 na Guiana Francesa. Ademais, em áreas remotas, os pacientes em estado crítico frequentemente precisam ser transferidos por helicóptero, o que causa demora na internação em UTI. A crise da COVID-19 demonstra o despreparo do sistema de saúde para enfrentar a pandemia e a necessidade de aumentar o número de leitos de UTI nestes territórios. Em conclusão, é imprescindível modernizar a infraestrutura e os equipamentos, capacitar melhor os recursos humanos e melhorar a atenção multidisciplinar. Incentivar a formação profissional, pesquisa e cooperação médico-científica regional e mundial é também fundamental.

Spontaneous community-acquired bacterial meningitis in adults admitted to the intensive care units in the Caribbean French West Indies: Unusual prevalence of Klebsiella pneumonia.

An unusual prevalence of Klebsiella pneumoniae (24%) was observed in 25 adults admitted to the intensive care units of two University Hospitals in the French West Indies, for spontaneous community-acquired bacterial meningitis. All tested isolates had several prominent features of hypervirulent isolates, including rmpa and iuc genes, K1 or K2 capsular serotypes.

Clinical and Epidemiological Characteristics of Severe Acute Adult Poisoning Cases in Martinique: Implicated Toxic Exposures and Their Outcomes.

The epidemiology of severe acute poisonings in the French overseas departments of the Americas remains poorly reported. The main objective of this study was to determine the epidemiology and characteristics of severe acutely poisoned adult patients. METHODS: A retrospective descriptive study was conducted from 1 January 2000 to 31 December 2010 in severely poisoned patients presenting to the emergency department (ED) of the University Hospital of Martinique, and the general public hospitals of Lamentin and Trinité. RESULTS: During the study period, 291 patients were admitted for severe poisoning, giving an incidence rate of 7.7 severe cases/100,000 inhabitants. The mean age was 46 ± 19 years and 166 (57%) were male. Psychiatric disorders were recorded in 143 (49.8%) patients. Simplified Acute Psychological Score (SAPS II) at admission was 39 ± 23 points and Poisoning Severity Score (PSS) was 2.7 ± 0.8 points. Death was recorded in 30 (10.3%) patients and hospital length of stay was 6 ± 7 days. The mode of intoxication was intentional self-poisoning in 87% of cases and drug overdose was recorded in 13% of cases. The toxic agent involved was a therapeutic drug in 58% and a chemical product in 52% of cases. The predominant clinical manifestations were respiratory failure (59%), hemodynamic failure (27%), neurologic failure (45%), gastrointestinal manifestations (27%), and renal failure (11%). Polypnea, shock, ventricular fibrillation or tachycardia, and gastro-intestinal disorders were the main symptoms associated with death. The main biological abnormalities associated with death in our patients were metabolic acidosis, hypokalemia, hyperlactatemia, hypocalcemia, renal injury, rhabdomyolysis, increased aspartate aminotransferases, and thrombocytopenia. Extracorporal membrane oxygenation (ECMO) was used in three patients and specific antidotes were used in 21% of patients. CONCLUSIONS: Acute poisonings remain a major public health problem in Martinique with different epidemiological characteristics to those in mainland France, with a high incidence of poisoning by rural and household toxins.

Infectious Complications Following Snakebite by Bothrops lanceolatus in Martinique: A Case Series.

Infections secondary to snakebite occur in a number of patients and are potentially life-threatening. Bothrops lanceolatus bites in Martinique average 30 cases per year and may result in severe thrombotic and infectious complications. We aimed to investigate the infectious complications related to B. lanceolatus bite. A retrospective single-center observational study over 7 years (2011-2018) was carried out, including all patients admitted to the hospital because of B. lanceolatus bite. One hundred seventy snake-bitten patients (121 males and 49 females) were included. Thirty-nine patients (23%) presented grade 3 or 4 envenoming. Twenty patients (12%) developed wound infections. The isolated bacteria were Aeromonas hydrophila (3 cases), Morganella morganii (two cases), group A Streptococcus, and group B Streptococcus (one case each). Patients were treated empirically with third-generation cephalosporin (or amoxicillin-clavulanate), aminoglycoside, and metronidazole combinations. Outcome was favorable in all patients. The main factor significantly associated with the occurrence of infection following snakebite was the severity of envenoming (P < 0.05). Our findings clearly point toward the frequent onset of infectious complications in B. lanceolatus-bitten patients presenting with grade 3 and 4 envenoming. Thus, based on the bacteria identified in the wounds, we suggest that empiric antibiotic therapy including third-generation cephalosporin should be administered to those patients on hospital admission.

Snakebite envenoming in French Guiana: Assessment of the preclinical efficacy against the venom of Bothrops atrox of two polyspecific antivenoms.

Snakebite envenoming is a relevant public health problem in French Guiana, and Bothrops atrox is responsible for the vast majority of envenomings in this overseas French territory. The preclinical efficacy of freeze-dried antivenoms manufactured in Costa Rica (Polival-ICP®) and Mexico (Antivipmyn Tri®) was assessed against the lethal, hemorrhagic, in vitro coagulant, and myotoxic effects of Bothrops atrox venom from French Guiana. Antivenoms differ in protein concentration and in the type of active principle (IgG and F (ab')2, respectively). Polival-ICP® showed significantly higher neutralizing activity against lethal, hemorrhagic and in vitro coagulant activities of the venom. Antivenoms neutralized myotoxic effect to a similar extent. In the case of lethal activity, Antivipmyn Tri® did not neutralize the effect at the highest antivenom level tested (1 mg venom/mL antivenom).

Oral Microbiota of the Snake Bothrops lanceolatus in Martinique.

In Martinique, Bothrops lanceolatus snakebite, although relatively uncommon (~30 cases/year), may result in serious complications such as systemic thrombosis and local infections. Infections have been hypothesized to be related to bacteria present in the snake's oral cavity. In this investigation, we isolated, identified, and studied the susceptibility to beta-lactams of bacteria sampled from the oral cavity of twenty-six B. lanceolatus specimens collected from various areas in Martinique. Microbiota from B. lanceolatus oral cavity was polymicrobial. Isolated bacteria belonged to fifteen different taxa; the most frequent being Aeromonas hydrophyla (present in 50% of the samples), Morganella morganii, Klebsiella pneumoniae, Bacillus spp., and Enterococcus spp. Analysis of antibiotic susceptibility revealed that 66.7% of the isolated bacteria were resistant to amoxicillin/clavulanate. In contrast, the majority of isolated bacteria were susceptible to the third-generation cephalosporins (i.e., 73.3% with cefotaxime and 80.0% with ceftazidime). Microbiota from B. lanceolatus oral cavity is polymicrobial with bacteria mostly susceptible to third-generation cephalosporins but rarely to amoxicillin/clavulanate. In conclusion, our findings clearly support that first-line antibiotic therapy in the B. lanceolatus-bitten patients, when there is evidence of infection, should include a third-generation cephalosporin rather than amoxicillin/clavulanate.

Snakebites in French Guiana: Conclusions of an international symposium.

A workshop on epidemiology and management of snakebites in French Guiana was performed at Cayenne, French Guiana from September 15 to September 16, 2017, under the auspices of the French Regional Health Agency (ARS) and the Pan American Health Organization (PAHO). The activity was attended by experts from France (Angers, Martinique, French Guiana, Guadeloupe, and Paris), Costa Rica, Brazil, Saint Lucia, and Surinam. The epidemiology, clinical manifestations, clinical grading and the management of snakebite in French Guiana were discussed. The conclusions of this symposium illustrated the urgent need to ensure accessibility of effective and safe polyvalent viperid antivenom in French Guiana. Finally, the results of this symposium have forged ties based on mutual goals and objectives.

Severe snakebite envenomation in French Guiana: When antivenom is not available.

In French Guiana, Bothrops atrox, Bothrops brazili, Bothrops bilineatus, Lachesis muta and Micrurus sp are responsible for most cases of snakebite envenomation. The clinical features in patients suffering from envenomations by viperid snakes involve local tissue damage and systemic manifestations, such as hemorrhage, coagulopathies and hemodynamic instability. We report a severe case of envenomation in a patient bitten by a large unidentified pit viper in French Guiana. Due to lack of antivenom, the patient only received symptomatic management. Severe manifestations of local and systemic envenomation developed, and the patient needed multiple debridement procedures and ultimately required a transfemoral amputation. In addition, Aeromonas hydrophila was cultivated from the affected tissue, suggesting that infection contributed to necrotizing fasciitis. This case highlights the clinical features of a severe viperid snakebite envenomation, and illustrates the urgent need to ensure accessibility of effective and safe polyvalent viperid antivenom in French Guiana.

Preclinical evaluation of the neutralizing ability of a monospecific antivenom for the treatment of envenomings by Bothrops lanceolatus in Martinique.

Bothrops lanceolatus is an endemic viperid species in the Lesser Caribbean island of Martinique. Envenomings by this species are characterized by local and systemic effects, among which the development of thrombosis in various organs is the most severe complication. An experimental toxicological characterization of this venom was performed using in vivo mouse tests and various in vitro assays. The venom induced lethal, local and systemic hemorrhagic, edema-forming, myotoxic, thrombocytopenic, proteinase and phospholipase A2 activities. The preclinical efficacy of a batch of monospecific Bothrofav® antivenom currently in use in Martinique was assessed. The antivenom was highly effective in the neutralization of all activities tested, in agreement with its described clinical efficacy. This batch of antivenom showed a higher preclinical efficacy as compared to a previous batch used in the past.

Transoceanic Management and Treatment of Aneurysmal Subarachnoid Hemorrhage: A 10-Year Experience.

BACKGROUND AND PURPOSE: Because of the small number of yearly cases of ruptured cerebral aneurysms, endovascular treatment is not performed in Martinique. Therefore, patients from Martinique are sent 7000 km to Paris on commercial flights as soon as possible, where treatment is performed. Nontransportable patients are treated locally with either surgery or symptomatic care. The objective of our study was to assess patient outcomes and safety of this treatment strategy. METHODS: We retrospectively examined all cases of aneurysmal subarachnoid hemorrhage in Martinique diagnosed during 2004 to 2013. Medical case records were searched for the type and location of treatment, clinical status, and transfer duration. RESULTS: A total of 119 patients had an aneurysmal subarachnoid hemorrhage during the 10-year period. Of these, 91 were transferred to Paris, 12 were surgically treated locally, and 16 received symptomatic treatment. None of the transferred patients experienced any hemorrhagic recurrence, and none suffered a significant complication related to the air transportation. The median time between aneurysmal subarachnoid hemorrhage diagnosis and arrival at the referral center was 32 hours. The 30-day case fatality rate for treated cases was 14.6% (8.8% for those treated in Paris and 58.3% for those treated locally). CONCLUSIONS: Our treatment strategy for aneurysmal subarachnoid hemorrhage resulted in a 30-day case fatality rate similar to those observed elsewhere, despite an 8-hour flight and a median treatment delay of 32 hours. This strategy therefore seems to be safe and reliable for isolated regions with small populations.