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Snakebite envenoming is a neglected public health issue in many tropical and subtropical countries. To diagnosis and treat snakebites may be challenging to health care personnel since sufficient information has not been yet provided. This review presents the clinical, therapeutic, and laboratory aspects of Crotalus durissus (South American rattlesnakes) victims. The clinical setting may show local effects such as little or no pain, mild edema, and recurrent erythema. In contrast, the systemic effects may be quite remarkable, such as changes due to neurological damage, intense rhabdomyolysis, incoagulability of the blood, and variations in the peripheral blood elements. The main complication is acute kidney injury. The appropriate treatment depends mainly on the correct recognition of the aggressor snake and the symptoms expressed by the victim. Rattlesnake venom can cause irreparable damage and lead to death. Therefore, a prompt diagnosis allows the immediate onset of proper serotherapy., Competing Interests: We declare no relevant conflicts of interest.

Hand hygiene has the biggest impact and is the least expensive way to prevent and control health care-associated infections. In this study, we assessed the effectiveness of the multimodal strategy of the World Health Organization to improve health care-associated infection rates, hand hygiene compliance, and the related knowledge of health care professionals in a Brazilian university hospital. We observed the necessity for an alternative approach in hospitals with high staff turnover and low attendance of educational sessions.

Background:: Psoriasis is a chronic inflammatory disease that affects the skin and joints and has a multifactorial etiology. Recently, it has been suggested that Helicobacter pylori infection may contribute as a trigger for the development of the disease., Objectives:: To determine the prevalence of H. pylori seropositivity in patients with psoriasis and to evaluate the relation between disease severity and H. pylori infection., Methods:: H. pylori infection was assessed in psoriatic patients and controls by using H. pylori IgG quantitative enzyme immunoassay (ELISA test). The patients were classified according to the severity of the disease (PASI score)., Results:: One hundred and twenty six patients with psoriasis (73 females and 53 males); mean age 50.48 years; 65 patients (51.59%) had severe psoriasis, 40 (31.75%) moderate psoriasis and 21 (16.67%) mild psoriasis. Twenty one healthy volunteers included as a control group, mean age of 41.05 years, 13 females and 8 males. One hundred and eleven patients with psoriasis tested serologically, 80 (72.07%) were seropositive compared with 7 positive volunteers (33.33%; P=0.002). Forty-nine (75.38%) patients with severe psoriasis were positive, 25 (62.50%) with moderate psoriasis were positive and 6 (28.57%) with mild psoriasis were positive (P=0.045). Study limitations: none., Conclusions:: H. pylori infection influences the development of psoriasis and severity of the disease.

Many interventions demonstrate success in adapting the duration of intravenous antibiotic therapy, but few studies have been conducted in developing countries. The aim of this study was to evaluate the effectiveness of an intervention in the induction of early discontinuation of intravenous antimicrobial therapy and/or its switch to oral therapy. The study employed a before-after intervention design that consisted of displaying a message in the computerized prescription on the third day and suspension of the prescription on the fifth day of intravenous antimicrobial therapy. A total of 465 patients were followed during the control period (CP) and 440 in the intervention period (IP). The intravenous therapy was switched to oral therapy for 11 (2.4%) patients during the CP and 25 (5.7%) in the IP (p=0.011), and was discontinued for 82 (17.6%) patients during the CP and 106 (24.1%) in the IP (p=0.017). During the IP there was a significant increase of patients who had their antimicrobial treatment discontinued before the seventh day of intravenous treatment, 37.40% (49/131) in the IP and 16.13% (15/93) in the CP (p=0.0005). The duration of intravenous antimicrobial therapy decreased by one day, but it was not significant (p=0.136). It is concluded that the proposed intervention is effective in promoting the early discontinuation of antimicrobial treatment and/or switch to oral therapy. As long as a computerized system for prescription already exists, it is easy and inexpensive to be implemented, especially in hospitals in developing countries., (Copyright © 2016 Sociedade Brasileira de Infectologia. Published by Elsevier Editora Ltda. All rights reserved.)

Background and Objective: The increased use of epidural analgesia with catheter leads to the need to demonstrate the safety of this method and know the incidence of catheter colonization, inserted postoperatively for epidural analgesia, and the bacteria responsible for this colonization., Methods: From November 2011 to April 2012, patients electively operated and maintained under epidural catheter for postoperative analgesia were evaluated. The catheter tip was collected for semiquantitative and qualitative microbiological analysis., Results: Of 68 cultured catheters, six tips (8.8%) had positive cultures. No patient had superficial or deep infection. The mean duration of catheter use was 43.45 h (18-118) (p=0.0894). The type of surgery (contaminated or uncontaminated), physical status of patients, and surgical time showed no relation with the colonization of catheters. Microorganisms isolated from the catheter tip were Staphylococcus aureus, Pseudomonas aeruginosa and Sphingomonas paucimobilis., Conclusion: Postoperative epidural catheter analgesia, under these study conditions, was found to be low risk for bacterial colonization in patients at surgical wards., (Copyright © 2014 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.)

Background and Objective: The increased use of epidural analgesia with catheter leads to the need to demonstrate the safety of this method and know the incidence of catheter colonization, inserted postoperatively for epidural analgesia, and the bacteria responsible for this colonization., Methods: From November 2011 to April 2012, patients electively operated and maintained under epidural catheter for postoperative analgesia were evaluated. The catheter tip was collected for semiquantitative and qualitative microbiological analysis., Results: Of 68 cultured catheters, six tips (8.8%) had positive cultures. No patient had superficial or deep infection. The mean duration of catheter use was 43.45hours (18-118) (p=0.0894). The type of surgery (contaminated or uncontaminated), physical status of patients, and surgical time showed no relation with the colonization of catheters. Microorganisms isolated from the catheter tip were Staphylococcus aureus, Pseudomonas aeruginosa and Sphingomonas paucimobilis., Conclusion: Postoperative epidural catheter analgesia, under this study conditions, was found to be low risk for bacterial colonization in patients at surgical wards., (Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Objective: To evaluate the effectiveness of an intervention to adjust the indications for caesarean delivery in a Brazilian teaching hospital in accordance with a specific protocol., Methods: The present before-and-after study was carried out in three stages. In stages 1 and 3, data were obtained for 160 cesarean deliveries that occurred between May 20 and July 10 in 2011 and 2012, respectively. For stage 2, the protocol was implemented for 12 months. The deliveries in stages 1 and 3 were classified as high or low risk, and as consistent or inconsistent clinical cases on the basis of the protocol., Results: A total of 160 (61.1%; 95% confidence interval [CI] 55.2-67.0) of 262 deliveries in stage 1 were by cesarean, compared with 160 (71.4%; 95% CI 65.5-77.3) of 224 in stage 3 (P=0.67). In stage 1, 125 (78.1%; 95% CI 71.7-84.5) showed indications consistent with the protocol, compared with 136 (85.0%; 95% CI 79.5-90.5) in stage 3 (P=0.11). Among the low-risk cesarean deliveries, 27 (51.9%; 95% CI 38.3-65.5) of 52 were consistent with the protocol in stage 1, compared with 49 (72.1%; 95% CI 61.4-86.1) of 68 in stage 3 (P=0.02)., Conclusion: The proposed intervention improved the suitability of indications for cesarean delivery among low-risk pregnancies only., (Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

In Brazil, external causes are responsible for many disabilities. Most research has emphasized the mortality and the demand for hospital treatment, and little is known about the evolution of non-fatal injuries. The objective of this study was to identify the profile of victims and the characteristics of injuries from external causes, physical therapy and functional evolution of patients treated in a public rehabilitation center. Data were prospectively collected by interviews with patients who entered the Municipal Rehabilitation Center (CEREM) of Uberlândia, from January to July 2005. Most patients were male and predominated those from 20 to 59 years old, with low income and education. The main causes of injury were falls and traffic accidents, almost half of the events occurred on public roads, and fractures were common, especially in upper limbs. The resources most frequently used were physiotherapeutic kinesiotherapy, electrotherapy and thermotherapy by addition, and most treatments started was completed. The profile of patients that seeking CEREM due to injuries from external causes may reflect, above all, that people who suffer such injuries. Simple physiotherapy resources showed to be enough for a good outcome.

Introduction: Sequential antibiotic therapy (SAT) is safe and economical. However, the unnecessary use of intravenous (IV) administration usually occurs. The objective of this work was to get to know the effectiveness of an intervention to implement the SAT in a teaching hospital in Brazil., Methods: This was a prospective and interventional study, historically controlled, and was conducted in the Hospital de Clínicas, Universidade Federal de Uberlândia, State of Minas Gerais, Brazil, a high complexity teaching hospital having 503 beds. In each of the periods, from 04/04/05 to 07/20/05 (pre-intervention) and from 09/24/07 to 12/20/07 (intervention), 117 patients were evaluated. After the pre-intervention period, guidelines were developed which were implemented during the intervention period along with educational measures and a reminder system added to the patients' prescription., Results: In the pre-intervention and intervention periods, the IV antibiotics were used as treatment for a average time of 14.8 and 11.8 days, respectively. Ceftriaxone was the antibiotic most prescribed in both periods (23.4% and 21.6% respectively). Starting from the first prescription of antibiotics, the average length of hospitalization time was 21.8 and 17.5 days, respectively. The SAT occurred only in 4 and 5 courses of treatment, respectively, and 12.8% and 18.8% of the patients died in the respective periods., Conclusions: Under the presented conditions, the evaluated intervention strategy is ineffective in promoting the exchange of the antibiotic administration from IV to oral treatment (SAT).

Background: Citrobacter koseri has not been associated to infection caused by blood component transfusions., Case Report: A 46-year-old female patient presented sudden chills, dyspnoea, and tachycardia during a transfusion from a unit of packed red blood cells. Citrobacter koseri was isolated in the two sample collected from the patient and from the content of the packed red blood cells., Results: We report a case of bacteraemia due to a transfusion of contaminated red blood cells., Conclusion: C. koseri should be taken into account in bacteraemias caused by transfusion of blood components., (© 2012 The Authors. Transfusion Medicine © 2012 British Blood Transfusion Society.)

Background: Individuals with diabetes who are smokers have higher risks of cardiovascular disease, premature death, and microvascular complications. The present study aims to determine the prevalence of symptoms of depression and anxiety in smokers with type 2 diabetes mellitus (T2D) and to evaluate if the prevalence of symptoms of depression and anxiety differ between the three groups studied (patients with T2D who smoke; patients with T2D who do not smoke; smokers without T2D), and finally determine if the degree of nicotine dependence is related to symptoms of anxiety and depression in smokers (with or without T2D)., Methods: Three study groups were formed: 46 T2D smokers (DS), 46 T2D non-smokers (D), and 46 smokers without diabetes (S), totaling 138 participants. Hospital Anxiety and Depression (HAD) scale and Fagerström Test were applied., Results: The prevalence of symptoms of depression and anxiety in smokers with T2D was 30.4% and 50%, respectively. There was no significant difference in the proportion of individuals with symptoms of anxiety (p = 0.072) or depression (p = 0.657) in the DS group compared to group D or S. Among male patients with T2D, the smokers had a higher prevalence of anxiety symptoms (19.6%) than non-smokers (4,3%) (p = 0,025). The prevalence of high nicotine dependence among smokers with and without T2D was 39.1% and 37.1%, respectively (p = 0.999). Fagerström scores showed no significant correlation with the scores obtained on the subscale of anxiety (p = 0,735) or depression (p = 0,364)., Conclusions: The prevalence of depression and anxiety among smokers with and without diabetes and non-smokers T2D is similar. Among male individuals with T2D, the smokers have more symptoms of anxiety than the non-smokers. There is no difference in the prevalence of nicotine dependence among smokers with and without diabetes. The presence of symptoms of anxiety or depression is similar between patients who are dependent and not dependent on nicotine.

Introduction: Antibiotic-associated diarrhea (AAD) is an important side effect of this specific class of drugs. The objective of this study was to investigate the effect of the use of probiotics in the treatment of AAD., Methods: A group of hospitalized patients, who contracted diarrhea during or after 7 days of suspension of antimicrobial medication, was blindly randomized to receive a standardized diet associated with the use of the probiotics (Lactobacillus casei and Bifidobacterium breve) or its corresponding placebo, three times a day., Results: Seventy patients were studied. For the experimental (n=35) and control (n=35) groups, respectively, the average time of treatment was 5.06±2.18 and 5.49±3.17 days (p=0.95), and the average duration of diarrhea, among those who were healed, was 4.87±2.13 and 4.52±2.55 days (p=0.36). Four (11.4%) patients who received probiotics and ten (28.6%) who received the placebo were not cured (p=0.13), and relapse rates were similar between both groups. Seven patients from each group, in addition to diarrhea, presented cases of bloating and/or abdominal cramps and/or vomiting (p=1.00)., Conclusions: In this light, it is concluded that L. casei associated with B. breve, in the administered dosage and frequency, has no effect on the antibiotic-associated diarrhea. Similar studies need to be conducted with higher doses of these or other probiotics.

This study analyzes epidemiological and clinical aspects of violence against women, using three data sources: medical records at the University Hospital in Uberlândia, Minas Gerais State, Brazil; treatment forms from the nongovernmental organization SOS Action for Women and Families; forensic reports on bodily injuries and autopsies from the Medical Examiner's Office. At the University Hospital and Medical Examiner's Office, the records related mainly to physical aggression, with no reference to psychological abuse in the medical charts or forensic reports, revealing that in primary health care services, such violence is only identified through post-aggression interviews with victims. Records at the nongovernmental organization referred mainly to psychological and physical abuse. The three sources showed little reference to sexual violence, corroborating data from the literature on this issue's invisibility, especially conjugal sexual violence suffered by women that seek treatment at these services. According to the current study's findings, the types of violence against women recorded at these three public health and social services differ according to the specific characteristics of the services they provide.

This study had the aim of ascertaining epidemiological and clinical differences in envenoming caused by Bothrops spp between elderly adults (>60 years) and non-elderly adults (20 to 59 years). The data were obtained from 1,930 medical records of patients attended at the Butantan Institute between 1981 and 1992. The greater the patients age was, the higher the frequency of bites on the hands rather than on the feet was (p < 0.05). A slightly higher percentage of the elderly patients (17%, versus 11% of the non-elderly group) were attended >12 hours after the bite (p < 0.05). Necrosis was more common among the elderly patients (p < 0.05) and renal failure was more common among patients aged 50 years or over (p < 0.05), in relation to younger patients. It was concluded that elderly individuals are more often bitten on the hands and less often on the feet, and that they develop local necrosis and renal failure more frequently than do younger individuals.

This study analyzes epidemiological and clinic characteristics of victims of traffic accidents. Data were obtained from medical records of children under 15 years of age (n = 1,123) admitted to a university hospital in Uberlândia, Minas Gerais State, Brazil, from 1999 to 2003. Mean age was eight years, 65.7% were boys, 76.6% were cyclists or pedestrians, 45.9% suffered head injuries, and 9% remained in hospital for more than two weeks. Fourteen (1.2%) died, 78.6% of these within 48 hours of hospitalization, and 85.7% with brain injuries. Among the passengers of motorcycles and larger vehicles, 58.8% were not using security devices properly at the time of the accident. Among the cyclists, 61% suffered isolated limb injuries. Meanwhile, pedestrians tended to suffer multiple lesions (57.5%) and be admitted to intensive care (7.1%), and represented 66.7% of the deaths. Epidemiological data on pediatric traffic victims can be useful for accident prevention programs.

Bites by many species of venomous snake may result in local necrosis at, or extending from, the site of the bite. The use of prophylactic antibiotics to prevent infection as a complication of local necrotic envenoming is controversial. A double-blind randomized controlled trial was carried out to assess whether antibiotic therapy is effective in this situation. Two hundred and fifty-one patients, with proven envenoming by snakes of the genus Bothrops, admitted to two hospitals in Brazil, between 1990 and 1996, were randomized to receive either oral chloramphenicol (500 mg every six hours for five days) or placebo. One hundred and twenty-two of these patients received chloramphenicol (group 1) and 129 were given placebo (group 2). There were no significant differences between the groups at the time of admission. Necrosis developed in seven (5.7%) patients in group 1 and in five (3.9%) patients in group 2 (P>0.05) while abscesses occurred in six patients (4.9%) in group 1 and in six (4.7%) patients in group 2 (P>0.05). In conclusion, the use of orally-administered chloramphenicol for victims of Bothrops snake bite with signs of local envenoming on admission, is not effective for the prevention of local infections.

This study aimed at assessing, in the envenoming by Bothrops, factors that are associated with blood incoagulability. Information was obtained from the charts of 2,991 patients admitted to Instituto Butantan, from 1981 to 1990. Factors positively associated with blood incoagulability (p < 0.05) were: snake bite in the late months of the year; bites in the distal segments of the lower limbs; pain, edema, and bruising at the bite site; systemic bleeding and shock; dose of antivenom administered; time between bite and admission to Instituto Butantan. Size of the snake Bothrops jararaca; use of a tourniquet; and time between arrival to Instituto Butantan and start of the antivenom administration were negatively associated with blood incoagulability (p < 0.05). Factors not associated with blood incoagulability (p > 0.05) were: time of the bite; presence of recently swallowed prey in the snake gut; gender and age of the patient; blister, necrosis, and abscess at the bite site; occurrence of amputation, renal failure and death; presence of an incision at the bite site. We conclude that although blood incoagulability is associated with early manifestations of Bothrops envenoming, it is not associated with the clinical outcome.

The frequencies of each type of arrythmia were investigated, by age and sex, among 3056 Brazilian patients with cardiac arrhythmia. Each patient investigated had been tested serologically for American trypanosomiasis and 1013 had been found seropositive for the disease. In general, the seropositive 'chagasic' patients were each likely to be suffering from more types of arrhythmia than the seronegative 'non-chagasic', with means of 1.81 and 1.03 types/patient, respectively. Right-branch bundle blocks (RBBB), ventricular extrasystoles (VE) and left anterior hemiblocks (LAHB) were the commonest cardiac arrhythmias among the chagasic patients, and each of these types of arrhythmia (alone or with other types of arrythmia) was more frequent in the chagasic patients than the non-chagasic. The incidence of RBBB among the arrhythmic varied significantly with age in the non-chagasic patients (increasing with age among both the males and females) but not among the chagasic subjects. When the frequencies of each type of arrythmia and each combination of types were compared, the co-occurrence of RBBB and another type of arrhythmia was almost indicative of American trypanosomiasis (occurring in 30.6% of the chagasic subjects but only 2.6% of the non-chagasic). Similarly, only 0.4% of the non-chagasic patients but 7.4% of the chagasic had RBBB, VE and LAHB concurrently. However, the frequencies of RBBB in isolation (i.e. with no other, concurrent, electrocardiographic abnormality), VE in isolation, or LAHB in isolation were not significantly different in the chagasic and non-chagasic patients.

The aim of this article is to acquire knowledge about the aspects of snakebite epidemiology in a central region of Brazil. From 1993 to 1995, 90 cases of Crotalinae (Bothrops and Crotalus genera) and two cases of Micrurus snakebite were attended to in a general hospital. Epidemiological information about 73 out of the 90 Crotalinae victims was prospectively collected from interviews with the patients and/or their companions. Data from medical records were obtained for the 17 remaining cases. The snakes of Bothrops, Crotalus, and Micrurus genera were responsible for 74, 24 and 2% of the accidents, respectively. Most of the Crotalinae accidents occurred from October to March (68%) and from 06:00 to 12:00 a.m. (93%). Males (89%) and patients between 20 and 30 years-old (27%) were the most common victims. The main bite sites were: foot (24%), leg (23%), hand (22%) and ankle (21%). Among the 73 interviewed Crotalinae victims, farm workers were bitten more frequently (53%). The accidents often occurred during work (59%), and 90% of the patients wore footwear, but 30% were wearing only sandals. Tourniquet, squeezing, suction of the bite site and magic blessing were attempted in 47, 38, 8 and 10% of cases, respectively.

Aims: To describe the craniofacial morphology of a group of patients with Down's syndrome using a cephalometric analysis of the lateral skull radiograph., Materials and Methods: The studied sample consisted of 39 patients with Down's syndrome (24 boys, 15 girls) ranging from 7 to 18 years of age. The computerized cephalometric study of the lateral skull radiograph of each patient was carried out using the method described by Ricketts., Results: Anterior cross-bite was observed in 38.4% of patients and diminished interincisal angle in 77%. Skeletal parameters matched the clinical norm, indicating mesofacial biotype, i.e., normal maxillomandibular growth. The lower incisors protruded in 84.6% of the individuals studied and were proinclined in 77%; upper incisors were protruded in 77% of the sample. The lower lip protruded in 84.6%. Analysis of craniofacial parameters showed average values within the clinical norm. Analysis of the inner cranium demonstrated normal inclination of the cranial base, while the length of the anterior skull base was diminished in 53.8%., Conclusions: From the skeletal perspective, patients with Down's syndrome who are in a period of growth demonstrate a reduction of the anterior skull base. From the dentoalveolar perspective, they show protrusion and proinclination of lower incisors, which is related to a tendency to anterior cross-bite and, to a lesser extent, to diminished overbite. Likewise, the lower lip protrusion observed in this study is related to the position of the lower incisor.

The prognostic factors related to envenoming are not very well known. This study aims to identify prognostic factors for necrosis in envenoming by Bothrops jararaca. We analysed 779 medical records of patients bitten by B. jararaca and treated at the Hospital Vital Brazil, Butantan Institute, São Paulo, Brazil, between 1982 and 1990: 111 cases with necrosis were compared with the remaining cases. The length of the snake, the bite site, the month of the accident, pain, oedema, ecchymosis, blisters, systemic bleeding, shock, and the use of tourniquet were statistically associated with the presence of necrosis (P < 0.05) in the univariate analysis. The size of the snake, the bite site (leg and finger), the sex of the patient, the month of the accident, systemic bleeding, and the use of tourniquet were independent prognostic factors within the variables tested in the multivariate analysis. The size of the snake was the most important independent prognostic factor related to the presence of necrosis.

Between 1975 and 1992, 18 cases of envenoming by Bothrops neuwiedi presented at the Hospital Vital Brazil, in São Paulo. Most of these cases were male (67%) and most had been bitten during the day (83%), between November and May (83%), either on the foot/ankle (50%) or hand (39%). Most (72%) of the cases arrived at the hospital 1-6 h after the bite. All presented with pain and most (83%) had oedema, but fewer had ecchymosis (50%), necrosis (17%), abscess (5%) and/or systemic blood-coagulation disorders (12%). Polyspecific Bothrops antivenom was administered to 16 (89%) of the patients. The results of B. neuwiedi bites therefore appear very similar to those of the much better known B. jararaca, even in terms of the gravity of the envenoming. Impairment in blood coagulation, however, seems less frequent among those bitten by B. neuwiedi than in those bitten by B. jararaca.

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.

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.

Less than 10 cases of bites by Philodryas olfersii (Colubridae) have been reported in the literature. In this study, 43 patients admitted to the Instituto Butantan, São Paulo, Brazil, with the diagnosis of P. olfersii bite from 1982 to 1990 were reviewed. The 32 male (74.4%) and 11 female (25.6%) patients presented mainly from November to February (65%). The most common clinical features were local pain (37.2%), swelling (34.9%), erythema (18.6%) and ecchymosis (9.3%). The 20 minute whole blood clotting test was performed in 11 patients and in all of them the blood was coagulable. Most of the accidents occurred during the hottest months and during daylight hours. The most common bite site was the hands. Severe envenoming is not frequent in these accidents.

The prognostic factors for amputation following envenoming by snakes of the Bothrops genus were identified from the medical records of 3139 patients. Each of these patients had been bitten by Bothrops sp. and treated in the Hospital Vital Brazil, in São Paulo, Brazil, between 1981 and 1990. The 21 (0.67%) of the patients who had undergone amputation were compared with the 3118 who had not, with respect to the characteristics of the accident, the snake, the victim, the local and systemic manifestations of the envenoming and the treatment. There was an association between amputation and the month of the accident, the time of day when the accident happened, the length of the attacking snake, the anatomical region bitten, systemic bleeding and renal failure. Patients bitten in the fingers, during the cooler months, between 00.00 and 12.00 hours and/or by snakes > 60 cm in length, who developed blisters and abscesses at the site of the bite, systemic bleeding and/or renal failure underwent amputation more frequently than the others (P < 0.05 for each).

Unlabelled: The prognostic factors and the causes for obit occurrence in ophidian envenoming are yet not completely clear., Purpose: To determine the prognostic factors and the most probable causes for obit occurrence in ophidian envenoming., Methods: In the State of São Paulo were notified 12,639 cases of accidents by venomous snakes from 1988 to 1993. There were 43 deaths (0.34%). The variables from the accident notification reports were compared with the promptuary notes and/or with the death records (in lethal cases)., Results: The snake genus was classified in 11,297 accidents and in 41 from the lethal ones. Bothrops was responsible for 9,828 (87%) accidents and 28 (68.3%) deaths, Crotalus for 1,359 (12.0%) accidents and 13 deaths (31.7%) and Micrurus for 110 (1%) accidents and no death (p < 0.05). The information regarding to sex and age of the patients was available, respectively, in 12,620 and 12,527 accidents and in all lethal ones. There were 9,783 (77.5%) male patients in the accidents and 35 (81.4%) in the lethal cases (p > 0.05). Regarding to age, 15.9% of the patients and 41.8% of the ones who died were 50 years-old or more (p < 0.05). The most frequently bitten anatomic regions were: foot (42.2%), hand (20.6%), leg (17.6%), and ankle (13.1%) in the accidents, and foot (35.7%) and leg (35.7%) in the lethal cases (p < 0.05). Coagulation disorders occurred in 34 (91.9%) from 37 patients who died (those where this datum was available). The information above was not available in non lethal cases. The most common manifestations and complications implicated as possible death causes were: acute renal failure (34-79.1%), acute respiratory failure (28-65.1%), shock (18-41.9%), and sepsis (18-41.9%). Among all lethal cases but one without information, 29.4% of the patients died within the first two days after bite and 67.6% within the first 5 days. Acute respiratory failure was most common among the patients who died owing to crotalic envenoming, and sepsis was only seen in bothropic envenoming., Conclusion: Most of the accidents and obits are caused by Bothrops; Crotalus envenoming, leg bites, and accidents in 50 year-old patients (or more) are frequently lethal; the most common complication in lethal cases is acute renal failure.

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.

Medical records of 3,139 patients bitten by Bothrops snakes and attended at Vital Brazil Hospital (HVB) from 1981 to 1990 were reviewed. They were more frequent in males (75.7%). In 1,412 cases (45.0%) the snake was classified by species, and 1,376 were B. jararaca, 20 B. jararacussu, 11 B. neuwiedi, 2 B. moojeni, 2 B. alternatus e 1 B. pradoi. The most frequent bitten anatomic regions were: foot (47.5%) and hand (21.3%). Tourniquet was used in 38.2% of the cases and its frequency fell down during the study period (p < 0.05). The clinical features at the bite site were: pain (95.6%), swelling (95.4%), ecchymosis (56.1%), blisters (13.8%), necrosis (16.5%), and abscess (11.0%). Systemic manifestations were: bleeding (12.3%), acute renal failure (1.6%), and shock (0.7%). There were blood coagulation disorders in 1,730 (57.9%) of the 2,990 cases. There were 21 amputations (0.7%) and 9 deaths (0.3%). The average serum dose that was used in treatment fell down during the study period (p < 0.001).

The jararacuçu, one of the most dreaded snakes of Brazil, southern Bolivia, Paraguay and northeastern Argentina, is a heavily-built pit viper which may grow to a length of 2.2 m. Up to 1000 mg (dry weight) of highly-lethal venom may be milked from its venom glands on a single occasion. It has accounted for 0.8% to 10% of series of snake bites in São Paulo State, Brazil. We examined 29 cases of proven jararacuçu bites recruited over a 20-year period in two São Paulo hospitals. Severe signs of local and systemic envenoming, (local necrosis, shock, spontaneous systemic bleeding, renal failure) were seen only in patients bitten by snakes longer than 50 cm; bites by shorter specimens were more likely to cause incoagulable blood. Fourteen patients developed coagulopathy, six local necrosis (requiring amputation in one) and five local abscesses. Two became shocked and four developed renal failure. Three patients, aged 3, 11 and 65 years, died 18.75, 27.75 and 83 h after being bitten, with respiratory and circulatory failure despite large doses of specific antivenom and intensive-care-unit management. In two patients, autopsies revealed acute renal tubular necrosis, cerebral oedema, haemorrhagic rhabdomyolysis at the site of the bite and disseminated intravascular coagulation. In one survivor with chronic renal failure, renal biopsy showed bilateral cortical necrosis; the patient remains dependent on haemodialysis. Effects of polyspecific Bothrops antivenom were not impressive, and it has been suggested that anti-Bothrops and anti-Crotalus antivenoms should be given in combination.

The bushmaster (Lachesis muta) of Central and South America, the world's longest pit viper, is capable of injecting a large dose of potent venom when it bites. A 28-year-old man, bitten by a 1.82 m long L. m. muta in Brazil, developed pain and oedema at the bite site, nausea, vomiting, diarrhoea and sweating. There was peripheral neutrophil leucocytosis and evidence of fibrinogen consumption with secondary activation of the fibrinolytic system. Two hours after the bite, eight ampoules of Instituto Butantan Lachesis antivenom was administered, and haemostasis was normal 24 hr later. A review of reports of 20 cases of bites in humans reliably attributed to this snake in Costa Rica, French Guiana, Brazil, Colombia and Venezuela confirms a syndrome of nausea, vomiting, abdominal colic, diarrhoea, sweating, hypotension, bradycardia and shock, possibly autopharmacological or autonomic in origin, not seen in victims of other American crotaline snakes. These, and other symptoms of bushmaster envenoming, are explained by haemorrhagic, coagulant and neurotoxic venom activities. The therapeutic efficacy of non-specific Bothrops/Crotalus polyvalent antivenoms in these cases has been unimpressive. For the treatment of bites by a snake which potentially injects a large dose (> 300 mg dry weight) of venom with a range of life-threatening activities, there is an urgent need to develop more potent specific antivenoms and to treat the dramatic and life-threatening cardiovascular symptoms.

The attendance given to patients by ta specialized Hospital, in S. Paulo, Brazil, during 1988 is studied. The study is based on the medical records of 322 patients and on questionnaires filled out by author during interviews with 209 patients or their companions. The 322 snake-bites occurred mainly between October and April, in the diurnal period, mainly in the afternoon. Most of patients were adult males, mainly between 10 and 20 years of age. The parts of the body most frequently affected were the feet, hands and legs. The snakes of the genera Bothrops, Crotalus and Micrurus were responsible, respectively, for 306 (95.0%) 14 (4.4%) and 2 (0.6%) of the accidents under study. Among the 160 snakes that were classified at the Herpetological Section of the IB, 152 were Bothrops; 142 B. Jararaca, mostly young reptiles, and 8 were of the genus Crotalus. Of the patients, 90.4% recovered completely, 2.2% presented sequelae, 7.5% were transferred and thus it was impossible to follow them up. Of the 209 persons interviewed, the occupational group most prone to snake bites was agricultural workers, followed by studentes; nearly 60% of the accidents ocurred during work; most of the patients had their inferior extremities unprotected at the moment of the bite. On hundred and sixty patients (76.6%) submitted to some from of treatment before coming to the HVB-IB, the more common being the use of a tourniquet (50.2%), local squeezing in an attempt to remove part of the venom (33.5), application of substances on the site of the snake bite (36.8%) and the ingestion of others (12.9%). Slightly over a quarter of the patients underwent some kind of medical treatment before coming to the HVB-IB, the most common being antissepsis (8.2%), administration of antivenom (6.2%), antihistamines (5.7%) and analgesics (5.3%). The snake was seen before it struch by 187 (89.5%) of the 209 persons interviewed and in most cases it adopted the strike posture just before the first bite.

Unlabelled: In Brazil, the discussion about the quality of medical care evaluation is beginning., Purpose: Assessment of the cases of death by venomous snake bite in the State of São Paulo., Methods: Twenty one deaths caused by venomous snakebite, that occurred in the State of S-ao Paulo, Brazil, during 1988 and 1989 were analysed. The method of three audits implicit criteria was used to evaluate the care given to these cases. Two of the authors did also a qualitative analysis of the care., Results: The results showed a higher frequency of males and adults of 50 and more years of age. The answers to the question "if the death was predictable" were all negative, in 5 cases, and the majority agreed in 6 cases (52.4% of answers were "not predictable"). The question "if there was evidence that the complication was recognized" had answers as "yes" or "there was not sufficient information" in the majority. As to the question "all the appropriate measures were taken in view of the complications", in three cases the answer was "no"., Conclusion: The main question mentioned was the bad quality of the information in the medical records. The qualitative analysis of the two authors, showed, some inadequate procedures.

This study reports on the incidence of snakebites from January 1985 to December 1989 in Vale do Ribeira, S o Paulo, Brazil. Overall incidence ranged from 68.7 to 84.2/100,000. There were 840 snakebites during this period, with higher frequency from October to May. The highest incidence rates were observed in the districts of Jugui and Eldorado (159.4 and 131.4/100,000, respectively). Most of the patients were male. Agricultural workers were the most heavily affected. Most of the patients received treatment within 2 hours after the bite. Morbidity was not severe and lethality was 0.2%.

An earlier study in São Paulo state suggested that the dose for patients with mild or moderate envenoming by Bothrops snakes (mainly Bothrops jararaca) could be effectively decreased to 4 ampoules (40 mL) of Brazilian Brothrops polyspecific antivenom. The present 'blinded' study examined the lowest dose studied in the first trial (equivalent to 4 x 10 mL ampoules) and half that dose of antivenom (equivalent to 2 x 10 mL ampoules) in 2 similar groups of 170 patients who were comparable in all respects before treatment. The majority of patients showed rapid clinical improvement after treatment with either dose regimen and rapid restoration of blood coagulability and cessation of bleeding. There was no apparent difference between the 2 groups of patients in any respect. The study confirmed that, in such patients, the dose of antivenom can be decreased from 4 ampoules to 2 ampoules without reduction of therapeutic efficacy, and it is highly likely that this reduction will result in a decrease of early anaphylactic reactions caused by the antivenom.

Reliability of the simple 20 minute whole blood clotting test (WBCT20) as an indicator of low plasma fibrinogen concentration in patients envenomed by Bothrops snakes. Toxicon 32, 1045-1050, 1994.--A simple whole blood clotting test (WBCT20) was assessed for its efficacy in determination of severe defibrinogenation in patients envenomed by Bothrops snakes in Brazil. There was a close relationship between the results of the WBCT20 and plasma fibrinogen levels in 69 moderately envenomed patients. The advantage of the WBCT20 over estimation of plasma fibrinogen concentrations in patients is that it is a simpler, faster and more reliable test. It is also of use in assessing the effectiveness of antivenom therapy in relation to the restoration of blood coagulability.

Forty patients with abscesses at the site of Bothrops bite were evaluated. Ten brought the snake responsible for the bite, Bothrops jararaca in all cases. On admission a sample was collected from each case for aerobic and anaerobic culture, and no abscesses drained spontaneously. None of the patients had received antibacterial therapy at this time. The bacteria most frequently isolated were Morganella morganii (23 patients), Providencia rettgeri (7) Enterobacter sp. (4), Escherichia coli (3), group D streptococcus (11) and Bacteroides sp. (6). All enterobacteria tested were sensitive to chloramphenicol, aminoglycosides and cefotaxime. Group D streptococci were sensitive to chloramphenicol, ampicillin and penicillin G, whereas anaerobic bacteria were sensitive to chloramphenicol and tetracycline. These results suggest that in cases of abscess formation secondary to Bothrops bite, chloramphenicol alone is a good choice, being both safe and cheap.

The 50% effective intraperitoneal (ip) dose of Bothrops jararaca antivenom (ED50) was assessed in mice immediately (ED50 Oh) and thirty minutes (ED50 30') after the intramuscular (im) injection of two 50% lethal dose (LD50) of Bothrops jararaca venom. The efficacy of the antivenom injected at the venom inoculation site was assessed by the inoculation of two LD50 of the venom by im route, followed immediately (ED50 Oh) and 30 minutes later (ED50 30') by administration of the ED50 of the antivenom either entirely by the ip route or 50 percent ip plus 50 percent im, at the same inoculation site. It was shown that the ED50 30' was 3 times greater, than the ED50 Oh and that the antivenom was more protective to mice (lower death rate in 48 hours) when given entirely ip. It was concluded that, in this experimental model, a higher dose of bothropic antivenom is needed when the treatment is started lately, and that there is no benefit in its administration at the venom inoculation site.

Seven hundred and thirty accidents by Bothrops snake bite attended at Hospital Vital Brazil-Instituto Butantan (HVB-IB) were studied: 411 of in 1983/84 (group A) and 319 in 1986 (group B). All the patients were seen in the Hospital 6 hours after the bite. As an average, all the 411 patients of the group A and the 319 patients of the group B received antivenom capable of neutralizing 215 mg and 117 mg of Bothrops jararaca, respectively. Both groups were similar concerning to: sex and age of the patients; anatomic region bitten; frequency of incision and tourniquet use at the site bite; time in between of the accident and the admission at HVB-IB; classification of B. jararaca either young or adult; frequency of the coagulation impairment. There was no difference in the evolution of the local envenoming manifestations and there were no cases of death.

In São Paulo City, Brazil, 121 patients with moderately severe envenoming by Bothrops snakes (principally B. jararaca) were randomized for treatment with Brazilian polyspecific Bothrops antivenoms: Instituto Butantan (39 patients), Instituto Vital Brazil (41), Fundação Ezequiel Dias (FUNED) (41). The initial dose was four ampoules (40 ml) in 89 patients with less severe envenoming and eight ampoules (80 ml) in 32 patients with more severe envenoming. A second dose of four ampoules was required in 20 patients. Patients receiving the three antivenoms were comparable in all respects before treatment. There were no deaths. The majority showed rapid clinical improvement, resolution of local envenoming, cessation of bleeding and restoration of blood coagulability. No differences in the efficacy of the three antivenoms were revealed by clinical or laboratory observations, including measures of haematological, haemostatic and biochemical abnormalities. Twelve patients developed abscesses (Butantan 1, Vital Brazil 6, FUNED 5) and seven developed local necrosis (3,1,3). Of 88 patients followed up 20-30 days after the bite 33 (37.5%) still had symptoms or signs of local envenoming, especially swelling. Early (anaphylactic) reactions were unexpectedly frequent after all three antivenoms but were significantly more frequent with Butantan (87%) than with Vital Brazil (37%) or FUNED (56%) antivenoms (p < 0.001). A possible explanation was the higher total protein content and percentage immunoglobulin of Butantan antivenom. The doses of antivenom recommended in Brazil and used in this study may be unnecessarily high, resulting in an unacceptably high incidence of reactions. Results of the study should prompt a critical re-evaluation of antivenom production techniques and dosage recommendations in Brazil.

The efficacy of the Crotalus durissus terrificus antivenom administration by intramuscular (im) injection at the same place of the im inoculation, of the C. d. terrificus venom was evaluated in mice. In three experiments two DL50 of the venom were inoculated and the antivenom was administered in three different ways: half of the ED50 by intraperitoneal (ip) administration and half by injection, at the same place, immediately after the venom inoculation and thirty minutes after the im venom inoculation; four fifth of ED50 by ip administration and one fifth by injection, at the same place and thirty minutes after the venom inoculation. The antivenom that was administered by intraperitoneal route provided a higher protection to mice (a lower death rate in a 48 hours period) than when it was administered in parts, by intramuscular injection, at the same place of the venom inoculation (p < 0.05). Therefore, it is concluded that this should not be used in human beings bitten by snakes.

Under study were two hundred and forty-nine cases of accidents caused by South American rattlesnakes (Crotalus durissus) admitted to the Vital Brasil Hospital, São Paulo, Brasil, from 1974 to 1990. The accidents were more common in the afternoon, from January to April and from October to December. Ninety nine out of 100 snakes classified as subspecies were C. d. terrificus. Most of the patients were males (80.7%). The inferior and superior limbs were bitten in 66.4% and 29.2% of the cases, respectively. The more frequent clinical manifestations were pain (61.0%) and edema (55.0%) at site of the bite, palpebral ptosis (75.9%), darkening of the urine due to myoglobinuria (38.6%) and myalgia (36.1%). Nine (3.6%) out of 32 patients with acute renal failure were submitted to dialysis, three presented respiratory failure treated with intubation and/or tracheotomy and one presented an ischemic cerebral stroke. Alteration of the blood coagulation was present in 48.1% of the patients. The blood picture of some patients several hours after the accident showed leucocytosis with a left shift and a tendency to normal values with eosinophilia. Serum creatine kinase activity was increased in 20 of 21 patients, with higher values 24 hours after the bite reaching 2,377 times the reference value. Lethality was 0.8%.

Four hundred and fifteen cases of bites by adult Bothrops jararaca (group A) were admitted to the Hospital Vital Brasil between 1981 and 1987. These cases were compared to 562 cases of bites by young snakes of the same species (group B) during the same period and at the same hospital. In group B blood incoagulability was more frequent when compared to group A. However in group A bites in the leg, use of tourniquet, tecidual damage (blister, necroses and abscess), were more frequent when compared to group B. The doses of sero given for the group A was greater when compared to group B. Accidents month distribution, dates available were for the patients admitted between 1975 and 1988. The accidents were more frequent in the first and at the end of the year. In the first months of the year for the young snakes and mainly at the end of the year for the adult snakes.

The present article reviews the current knowledge on incidence, epidemiology, pathophysiology, clinical features, diagnosis and prognosis of accidents by poisonous snakes of Brazil. Bothrops, Crotalus, Lachesis and Micrurus are the genera responsible for more than 100 deaths per year. With the exception of Micrurus, all cause clotting disturbance; Lachesis and Bothrops cause destruction of the tissue at the region of the bite, Crotaius and Micrurus cause failure at the neuromuscular junction and only Crotalus cause systemic myotoxicity. The clinical aspect is normally sufficient for diagnosis, except for the distinction between bothropic and lachetic accidents. Treatment with the specific heterologous serum must be started precociously by endovenous route. It is also important to maintain the patient hydrated and, in the case of Micrurus bites, adequate aereation must be applied.

Data obtained from 515 victims of bites of wolf spiders (family Lycosidae) who were attended in Vital Brazil Hospital, São Paulo City, Brazil, in a 5-year period (1979-1983) were analysed. Bites were more frequent in males (56%). All age groups were involved. Foot and hand were the preferential sites of bite (79%), and pain, generally mild, was the predominant symptom (83%). No local necrosis, a severe complication described in the previous literature, was detected, suggesting that those old cases were due to misdiagnosed Loxosceles spider bites. Specific antivenom was employed in only three cases which is evidence that physicians do not consider wolf spider bites to be severe.