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Carter RW, Gerardo CJ, Samuel SP, Kumar S, Kotehal SD, Mukherjee PP, Shirazi FM, Akpunonu PD, Bammigatti C, Bhalla A, Manikath N, Platts-Mills TF, Lewin MR. The BRAVO Clinical Study Protocol: Oral Varespladib for Inhibition of Secretory Phospholipase A2 in the Treatment of Snakebite Envenoming. Toxins (Basel) 2022; 15:22. [PMID: 36668842 PMCID: PMC9862656 DOI: 10.3390/toxins15010022] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/19/2022] [Accepted: 12/24/2022] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Snakebite is an urgent, unmet global medical need causing significant morbidity and mortality worldwide. Varespladib is a potent inhibitor of venom secretory phospholipase A2 (sPLA2) that can be administered orally via its prodrug, varespladib-methyl. Extensive preclinical data support clinical evaluation of varespladib as a treatment for snakebite envenoming (SBE). The protocol reported here was designed to evaluate varespladib-methyl for SBE from any snake species in multiple geographies. METHODS AND ANALYSIS BRAVO (Broad-spectrum Rapid Antidote: Varespladib Oral for snakebite) is a multicenter, randomized, double-blind, placebo-controlled, phase 2 study to evaluate the safety, tolerability, and efficacy of oral varespladib-methyl plus standard of care (SoC) vs. SoC plus placebo in patients presenting with acute SBE by any venomous snake species. Male and female patients 5 years of age and older who meet eligibility criteria will be randomly assigned 1:1 to varespladib-methyl or placebo. The primary outcome is the Snakebite Severity Score (SSS) that has been modified for international use. This composite outcome is based on the sum of the pulmonary, cardiovascular, nervous, hematologic, and renal systems components of the updated SSS. ETHICS AND DISSEMINATION This protocol was submitted to regulatory authorities in India and the US. A Clinical Trial No Objection Certificate from the India Central Drugs Standard Control Organisation, Drug Controller General-India, and a Notice to Proceed from the US Food and Drug Administration have been obtained. The study protocol was approved by properly constituted, valid institutional review boards or ethics committees at each study site. This study is being conducted in compliance with the April 1996 ICH Guidance for Industry GCP E6, the Integrated Addendum to ICH E6 (R2) of November 2016, and the applicable regulations of the country in which the study is conducted. The trial is registered on Clinical trials.gov, NCT#04996264 and Clinical Trials Registry-India, 2021/07/045079 000062.
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Affiliation(s)
| | - Charles J. Gerardo
- Department of Emergency Medicine, Duke University, Durham, NC 27708, USA
| | | | - Surendra Kumar
- Department of Medicine, Sardar Patel Medical College, PBM Hospital, Bikaner 334001, India
| | - Suneetha D. Kotehal
- Department of Medicine, Mysore Medical College and Research Institute, Mysore 570001, India
| | - Partha P. Mukherjee
- Department of General Medicine, Calcutta National Medical College, Kolkata 700014, India
| | - Farshad M. Shirazi
- Arizona Poison & Drug Information Center, College of Pharmacy and University of Arizona College of Medicine, University of Arizona, Tucson, AZ 85721, USA
| | - Peter D. Akpunonu
- Department of Emergency Medicine and Medical Toxicology, University of Kentucky College of Medicine, Lexington, KY 40506, USA
| | - Chanaveerappa Bammigatti
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Ashish Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Neeraj Manikath
- Department of Emergency Medicine, Government Medical College, Kozhikode 673008, India
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Bhaumik S, Beri D, Tyagi J, Clarke M, Sharma SK, Williamson PR, Jagnoor J. Outcomes in intervention research on snakebite envenomation: a systematic review. F1000Res 2022; 11:628. [PMID: 36300033 PMCID: PMC9579743 DOI: 10.12688/f1000research.122116.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION A core outcome set (COS) is a minimal list of consensus outcomes that should be used in all intervention research in a specific domain. COS enhance the ability to undertake meaningful comparisons and to understand the benefits or harms of different treatments. A first step in developing a COS is to identify outcomes that have been used previously. We did this global systematic review to provide the foundation for development of a region-specific COS for snakebite envenomation. Methods: We searched 15 electronic databases, eight trial registries, and reference lists of included studies to identify reports of relevant trials, protocols, registry records and systematic reviews. We extracted verbatim data on outcomes, their definitions, measures, and time-points. Outcomes were classified as per an existing outcome taxonomy, and we identified unique outcomes based on similarities in the definition and measurement of the verbatim outcomes. RESULTS We included 107 records for 97 studies which met our inclusion criteria. These reported 538 outcomes, with a wide variety of outcome measures, definitions, and time points for measurement. We consolidated these into 88 unique outcomes, which we classified into core areas of mortality (1, 1.14 %), life impact (6, 6.82%), resource use (15, 17.05%), adverse events (7, 7.95%), physiological/clinical (51, 57.95%), and composite (8, 9.09%) outcomes. The types of outcomes varied by the type of intervention, and by geographic region. Only 15 of the 97 trials (17.04%) listed Patient Related Outcome Measures (PROMS). CONCLUSION Trials evaluating interventions for snakebite demonstrate heterogeneity on outcomes and often omit important information related to outcome measurement (definitions, instruments, and time points). Developing high quality, region-specific COS for snakebite could inform the design of future trials and improve outcome reporting. Measurement of PROMS, resource use and life impact outcomes in trials on snakebite remains a gap.
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Affiliation(s)
- Soumyadeep Bhaumik
- Injury Division, The George Institute for Global Health, Faculty of Medicine, University of New South Wales,, Sydney, New South Wales, 2042, Australia
- Injury Division, The George Institute for Global Health, New Delhi, Delhi, 110025, India
- Meta-research and Evidence Synthesis Unit, George Institute for Global Health, New Delhi, Delhi, 110025, India
| | - Deepti Beri
- Injury Division, The George Institute for Global Health, New Delhi, Delhi, 110025, India
| | - Jyoti Tyagi
- Meta-research and Evidence Synthesis Unit, George Institute for Global Health, New Delhi, Delhi, 110025, India
| | - Mike Clarke
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Sanjib Kumar Sharma
- Department of Internal Medicine, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Paula R Williamson
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Jagnoor Jagnoor
- Injury Division, The George Institute for Global Health, Faculty of Medicine, University of New South Wales,, Sydney, New South Wales, 2042, Australia
- Injury Division, The George Institute for Global Health, New Delhi, Delhi, 110025, India
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Measurement Properties of the Patient-Specific Functional Scale and Its Current Uses: An Updated Systematic Review of 57 Studies Using COSMIN Guidelines. J Orthop Sports Phys Ther 2022; 52:262-275. [PMID: 35128944 DOI: 10.2519/jospt.2022.10727] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To systematically review measurement properties, including acceptability, feasibility, and interpretability, and current uses of the Patient-Specific Functional Scale (PSFS). DESIGN Systematic review of a patient-reported outcome measure using the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) guidelines. LITERATURE SEARCH We searched 11 databases from January 2010 to July 2020 for articles on measurement properties or use of PSFS. STUDY SELECTION CRITERIA Published primary articles without language restrictions. DATA SYNTHESIS Two independent reviewers screened all records, extracted data, and performed risk of bias assessments using COSMIN guidelines. We qualitatively synthesized findings for each measurement property in musculoskeletal and nonmusculoskeletal conditions, and 2 reviewers independently performed Grading of Recommendations Assessment, Development and Evaluation assessments. This study was preregistered with the Open Science Framework (https://doi.org/10.17605/OSF.IO/42UZT). RESULTS Of the 985 articles screened, we included 57 articles on measurement properties and 255 articles on the use of PSFS. The PSFS had sufficient test-retest reliability in musculoskeletal (22 studies, 845 participants, low-to-moderate certainty) and nonmusculoskeletal conditions (6 studies, 197 participants, very low certainty), insufficient construct validity as a measure of physical function (21 studies, 2 945 participants, low-to-moderate certainty), and sufficient responsiveness (32 studies, 13 770 participants, moderate-to-high certainty). The standard error of measurement ranged from 0.35 to 1.5. The PSFS was used in 87 unique health conditions, some without prior evidence of validity. CONCLUSION The PSFS is an easy-to-use, reliable, and responsive scale in numerous musculoskeletal conditions, but the construct validity of PSFS remains uncertain. Further study of the measurement properties of the PSFS in nonmusculoskeletal conditions is necessary before clinical use. J Orthop Sports Phys Ther 2022;52(5):262-275. Epub: 05 Feb 2022. doi:10.2519/jospt.2022.10727.
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Gopalakrishnan M, Saurabh S, Sagar P, Bammigatti C, Dutta TK. A simple mortality risk prediction score for viper envenoming in India (VENOMS): A model development and validation study. PLoS Negl Trop Dis 2022; 16:e0010183. [PMID: 35192642 PMCID: PMC8896694 DOI: 10.1371/journal.pntd.0010183] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 03/04/2022] [Accepted: 01/20/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Snakebite is a neglected problem with a high mortality in India. There are no simple clinical prognostic tools which can predict mortality in viper envenomings. We aimed to develop and validate a mortality-risk prediction score for patients of viper envenoming from Southern India. METHODS We used clinical predictors from a prospective cohort of 248 patients with syndromic diagnosis of viper envenoming and had a positive 20-minute whole blood clotting test (WBCT 20) from a tertiary-care hospital in Puducherry, India. We applied multivariable logistic regression with backward elimination approach. External validation of this score was done among 140 patients from the same centre and its performance was assessed with concordance statistic and calibration plots. FINDINGS The final model termed VENOMS from the term "Viper ENvenOming Mortality Score included 7 admission clinical parameters (recorded in the first 48 hours after bite): presence of overt bleeding manifestations, presence of capillary leak syndrome, haemoglobin <10 g/dL, bite to antivenom administration time > 6.5 h, systolic blood pressure < 100 mm Hg, urine output <20 mL/h in 24 h and female gender. The lowest possible VENOMS score of 0 predicted an in-hospital mortality risk of 0.06% while highest score of 12 predicted a mortality of 99.1%. The model had a concordance statistic of 0·86 (95% CI 0·79-0·94) in the validation cohort. Calibration plots indicated good agreement of predicted and observed outcomes. CONCLUSIONS The VENOMS score is a good predictor of the mortality in viper envenoming in southern India where Russell's viper envenoming burden is high. The score may have potential applications in triaging patients and guiding management after further validation.
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Affiliation(s)
- Maya Gopalakrishnan
- Department of Internal Medicine, All India Institute of Medical Sciences Jodhpur, Rajasthan, India
| | - Suman Saurabh
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pramod Sagar
- Department of Cardiology, Madras Medical Mission, Chennai, Tamil Nadu, India
| | - Chanaveerappa Bammigatti
- Department of Medicine, Jawaharlal Institute of Medical Education and Research, Puducherry, India
| | - Tarun Kumar Dutta
- Department of Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
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Contextualizing the Impact of Snakebite Envenoming on Patients: A Qualitative Content Analysis of Patient-Specific Functional Scale Activities Using the International Classification of Functioning, Disability and Health. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18189608. [PMID: 34574532 PMCID: PMC8469450 DOI: 10.3390/ijerph18189608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/03/2021] [Accepted: 09/08/2021] [Indexed: 11/17/2022]
Abstract
To categorize the Patient-specific Functional Scale (PSFS) activities in snakebite envenoming (SBE) using the International Classification of Function (ICF) model in order to describe the impact of SBE on patients’ activities and daily lives and to develop a theoretical SBE model of functioning, we performed a post-hoc analysis of two multi-center, prospective studies, conducted at 14 clinical sites in the United States with consecutive SBE patients presenting to the emergency department. Qualitative content analysis and natural language processing were used to categorize activities reported in the PSFS using the ICF model. Our sample included 93 patients. The mean age was 43.0 (SD 17.9) years, most had lower extremity injuries (59%). A total of 99 unique activities representing eight domains came within the Activity and Participation component of the ICF model, with the majority in the Mobility and General Tasks and Demands domains. The main concerns of SBE patients are the ability to perform daily activities and to engage within their social environment. Applying the ICF model to SBE can facilitate the creation of a patient-centered treatment approach, moving beyond body-structural impairments towards a function-based treatment approach and facilitate early integration of rehabilitation services.
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Abouyannis M, Aggarwal D, Lalloo DG, Casewell NR, Hamaluba M, Esmail H. Clinical outcomes and outcome measurement tools reported in randomised controlled trials of treatment for snakebite envenoming: A systematic review. PLoS Negl Trop Dis 2021; 15:e0009589. [PMID: 34339410 PMCID: PMC8360524 DOI: 10.1371/journal.pntd.0009589] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 08/12/2021] [Accepted: 06/24/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Snakebite is a priority neglected tropical disease and causes a range of complications that vary depending on the snake species. Randomised clinical trials have used varied outcome measures that do not allow results to be compared or combined. In accordance with the Core Outcomes Measurements in Effectiveness Trials (COMET) initiative, this systematic review aims to support the development of a globally relevant core outcome set for snakebite. METHODS All randomised controlled trials, secondary analyses of randomised controlled trials and study protocols investigating the efficacy of therapeutics for human snakebite envenoming were eligible for inclusion. Study screening and data extraction were conducted in duplicate by two independent reviewers. All primary and secondary outcome measures were extracted and compiled, as were adverse event outcome measures. Similar outcome measures were grouped into domains. The study was prospectively registered with PROSPERO: CRD42020196160. RESULTS This systematic review included 43 randomised controlled trials, two secondary analyses and 13 study protocols. A total of 382 outcome measures were extracted and, after duplicates were merged, there were 153 unique outcomes. The most frequently used outcome domain ('venom antigenaemia') was included in less than one third of the studies. The unique outcomes were classified into 60 outcome domains. Patient-centred outcomes were used in only three of the studies. DISCUSSION Significant heterogeneity in outcome measures exists in snakebite clinical trials. Consensus is needed to select outcome measures that are valid, reliable, patient-centred and feasible. The results of this systematic review strongly support the development of a core outcome set for use in snakebite clinical trials.
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Affiliation(s)
- Michael Abouyannis
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- KEMRI-Wellcome Research Programme, Kilifi, Kenya
| | - Dinesh Aggarwal
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - David G. Lalloo
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Nicholas R. Casewell
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Mainga Hamaluba
- KEMRI-Wellcome Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, Oxford, United Kingdom
| | - Hanif Esmail
- MRC clinical trials unit at UCL, London, United Kingdom
- Institute for Global Health, University College London, London, United Kingdom
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Kasturiratne A, Lalloo DG, Janaka de Silva H. Chronic health effects and cost of snakebite. Toxicon X 2021; 9-10:100074. [PMID: 34355162 PMCID: PMC8321925 DOI: 10.1016/j.toxcx.2021.100074] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/29/2021] [Accepted: 07/07/2021] [Indexed: 11/29/2022] Open
Abstract
The burden of disability among survivors and the socio-economic impact of snakebite have not been adequately researched. We reviewed original research articles, case reports and small case series relating to chronic physical, mental and psycho-social disability and economic burden of snakebite. Both physical and psychological health problems seem common in snakebite survivors and can lead to disability and loss of productivity. Chronic physical health effects, musculoskeletal disability being the commonest, can be largely attributed to limited and delayed access to optimal treatment of acute envenoming. The economic burden is considerable, and includes health system costs, out-of-pocket expenditure and opportunity costs, with regional variations. Health systems should be more responsive to needs and circumstances of bite victims, and a more holistic approach should be developed in the treatment of snakebite which incorporates the management of chronic health effects. Limited attention has been paid to chronic disability and the socio-economic impact of snakebite. Physical and psychological health problems occur in snakebite survivors leading to disability and loss of productivity. Chronic health effects can be largely attributed to limited and delayed access to optimal treatment of acute envenoming. Economic burden includes health system costs, out-of-pocket expenditure and opportunity costs. Health systems should be responsive to needs and circumstances of bite victims including care of chronic health effects.
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Chala MB, Donnelly C, Wondie Y, Ghahari S, Miller J. Cross-cultural adaptation and validation of the Amharic version of Roland Morris Disability Questionnaire in people with low back pain in Ethiopia. Disabil Rehabil 2021; 44:5638-5648. [PMID: 34167417 DOI: 10.1080/09638288.2021.1939798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE Cross-culturally translate, adapt, and validate Roland Morris Disability Questionnaire (RMDQ) in Amharic language in Ethiopia. METHODS The English version RMDQ was translated into Amharic and back-translated into English. An expert review committee reviewed the translations and created Amharic version of the RMDQ (RMDQ-Am). Pilot testing and cognitive debriefing of the RMDQ-Am were conducted with a sample of 20 individuals with LBP. The RMDQ-Am was administered to 240 individuals with LBP from three rehabilitation centers to determine its psychometric properties. Internal consistency of the tool was determined by Cronbach's alpha. Test-retest reliability was determined by the Intraclass correlation coefficient. The Standard Error of Measurement (SEM), Minimum Detectable Change (MDC), and the Bland Altman Limit of Agreement (LOA) was also determined. The Short-Form Health Survey (SF-36) Bodily Pain and Physical Functioning subscales were used to assess convergent validity. Exploratory Factor Analysis (EFA) was used to determine the dimensionality of the tool. RESULTS RMDQ-Am demonstrated good internal consistency (α = 0.88), excellent test-retest reliability (ICC = 0.91), SEM (1.64), MDC (3.55), and good LOA. There is a significant moderate correlation between RMDQ-Am and the Physical Functioning (Rho = -0.62, p < 0.01) and Bodily Pain (BP) (Rho = -0.41, p < 0.01) subscales of the SF-36. Exploratory Factor Analysis demonstrates that the Amharic version of RMDQ is a primary one and secondary four-factor model [The Kaiser Meyer Olkin = 0.877, X2 (df) =1413.278/190, p < 0.001]. CONCLUSION RMDQ-Am is a reliable and valid tool that can be used in both clinical practice and research with the Ethiopian LBP population.IMPLICATION FOR REHABILITATIONDespite LBP being a concern in Ethiopia, the magnitude of disability related to this phenomenon is not studied in the country, mainly due to the absence of validated LBP specific patient-reported outcome measures such as the Roland Morris Disability Questionnaire (RMDQ).The RMDQ was successfully translated, adapted, and validated into the Amharic language and the Ethiopian context (RMDQ-Am).The RMDQ-Am is a reliable outcome measure among the Ethiopian population with LBP, as demonstrated by the good internal consistency (α = 0.88) and excellent test-retest reliability (ICC = 0.91).There is a moderate negative correlation between the RMDQ-Am and the Physical Functioning (Rho = -0.62, p < 0.01) and Bodily Pain (Rho = -0.41, p < 0.01) subscales of the SF-36.The RMDQ-Am can be used in clinical and research settings to measure LBP-related disability and its impact among individuals living with LBP in Ethiopia.
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Affiliation(s)
| | | | - Yemataw Wondie
- Department of Psychology, University of Gondar, Gondar, Ethiopia
| | - Setareh Ghahari
- School of Rehabilitation Therapy, Queen's University, Kingston, Canada
| | - Jordan Miller
- School of Rehabilitation Therapy, Queen's University, Kingston, Canada
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Cocchio C, Johnson J, Clifton S. Review of North American pit viper antivenoms. Am J Health Syst Pharm 2020; 77:175-187. [PMID: 31974558 DOI: 10.1093/ajhp/zxz278] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE For the first time in nearly 20 years, 2 antigen-binding fragment (Fab) antivenoms are available to treat patients who incur North American pit viper snakebites: Crotalidae polyvalent immune Fab (ovine), or simply FabAV; and Crotalidae immune F(ab')2 (equine), or simply F(ab')2. Pharmacists are in a key position for the selection, dosing, reconstitution, administration, and monitoring of antivenom therapy; however, they encounter inconsistent exposure and experience with these drugs. Thus, an updated review of the literature is necessary. METHODS The search strategy and selection incorporated both controlled vocabulary terms and keywords to describe concepts relevant to the search. Retrieval was limited to literature published from 1997 to the present in English, Portuguese, or Spanish. RESULTS Given the paucity of available prospective literature, the authors elected to include all prospective evidence to best describe the role of antivenom. For the primary literature review, manuscripts were excluded if they were observational studies, conference abstracts, narrative or opinion articles, letters to the editor, or in-progress studies. CONCLUSION While there is limited evidence-based guidance on the superiority of F(ab')2 to FabAV, or vice versa, individual and regional considerations should contribute to formulary decisions. Pharmacists must play a role in the development of clinical pathways to ensure appropriate evaluation, supportive care, and antivenom procurement, administration, and monitoring.
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Affiliation(s)
| | - Jami Johnson
- Oklahoma Center for Poison and Drug Information, Oklahoma City, OK, and University of Oklahoma College of Pharmacy, Oklahoma City, OK
| | - Shari Clifton
- Reference & Instructional Services, Robert M. Bird Health Sciences Library, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Lavonas EJ, Burnham RI, Schwarz J, Quackenbush E, Lewis B, Rose SR, Greene S, Toschlog EA, Charlton NP, Mullins ME, Schwartz R, Denning D, Sharma K, Kleinschmidt K, Bush SP, Anderson VE, Ginde AA, Gerardo CJ. Recovery from Copperhead Snake Envenomation: Role of Age, Sex, Bite Location, Severity, and Treatment. J Med Toxicol 2020; 16:17-23. [PMID: 31482319 PMCID: PMC6942102 DOI: 10.1007/s13181-019-00733-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 07/23/2019] [Accepted: 08/19/2019] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Few data exist to understand the recovery phase of pit viper envenomation. A recently published placebo-controlled clinical trial affords this opportunity. The purpose of this study is to examine the time course of recovery from copperhead snake (Agkistrodon contortrix) envenomation patients managed with and without the use of antivenom, stratified by age, sex, anatomic site of envenomation, initial severity of envenomation, and geographic region. METHODS This is a post-hoc subgroup analysis of data from a multi-center double-blinded clinical trial of Fab antivenom (FabAV) vs. placebo. Outcomes were the Patient-Specific Functional Scale (PSFS) score at 3, 7, 10, and 14 days after envenomation. Least-squares mean PSFS score curves were calculated for each subgroup, and repeated measures ANOVA was used to estimate between-group comparisons. RESULTS Seventy-two subjects were included, of whom 44 received FabAV. Males demonstrated better overall recovery than females (model predicted PSFS score 6.18 vs 4.99; difference 1.19; 95% CI 0.12 to 2.25; p = 0.029). No sex difference was found in response to FabAV. Overall recovery and effect of FabAV were similar in adult vs adolescent patients, patients with upper vs lower extremity envenomation, and patients with initially mild vs moderate envenomation signs. Analysis by geographic location was not successful due to ANOVA mode instability. CONCLUSIONS Male victims of copperhead snake envenomation demonstrate slightly better recovery than females, but response to Fab antivenom overall is similar across all subgroups studied.
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Affiliation(s)
- Eric J Lavonas
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA.
- Department of Emergency Medicine, Denver Health and Hospital Authority, Denver, CO, USA.
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Randy I Burnham
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - John Schwarz
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - Eugenia Quackenbush
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Brandon Lewis
- Texas A&M Health Science Center, College Station, TX, USA
| | - S Rutherfoord Rose
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Spencer Greene
- Henry J. N. Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Eric A Toschlog
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Nathan P Charlton
- Division of Medical Toxicology, University of Virginia, Charlottesville, VA, USA
| | - Michael E Mullins
- Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Richard Schwartz
- Department of Emergency Medicine and Hospital Services, Medical College of Georgia, Augusta, GA, USA
| | - David Denning
- Department of Surgery, Marshall Health, Huntington, WV, USA
| | - Kapil Sharma
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kurt Kleinschmidt
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sean P Bush
- Department of Emergency Medicine, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Victoria E Anderson
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Charles J Gerardo
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, NC, USA
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Theophanous RG, Vissoci JRN, Wen FH, Griffin SM, Anderson VE, Mullins ME, Brandehoff NP, Quackenbush EB, Bush SP, Toschlog EA, Greene SC, Sharma K, Kleinschmidt K, Charlton NP, Rose SR, Schwartz R, Lewis B, Lavonas EJ, Gerardo CJ. Validity and reliability of telephone administration of the patient-specific functional scale for the assessment of recovery from snakebite envenomation. PLoS Negl Trop Dis 2019; 13:e0007935. [PMID: 31834923 PMCID: PMC6934321 DOI: 10.1371/journal.pntd.0007935] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 12/27/2019] [Accepted: 11/19/2019] [Indexed: 11/29/2022] Open
Abstract
Objectives Although more than 1.8 million people survive snakebite envenomation each year, their recovery is understudied. Obtaining long-term follow-up is challenging in both high- and low-resource settings. The Patient-Specific Functional Scale (PSFS) is an easily administered, well-accepted patient-reported outcome that is validated for assessing limb recovery from snakebite envenomation. We studied whether the PSFS is valid and reliable when administered by telephone. Methods This is a secondary analysis of data from a randomized clinical trial. We analyzed the results of PSFS collected in-person on days 3, 7, 14, 21, and 28 and by telephone on days 10, 17, and 24. We assessed the following scale psychometric properties: (a) content validity (ceiling and floor effects), (b) internal structure and consistency (Cronbach’s alpha), and (c) temporal and external validity using Intraclass Correlation Coefficient (ICC). Temporal stability was assessed using Spearman’s correlation coefficient and agreement between adjacent in-person and telephonic assessments with Cohen’s kappa. Bland Altman analysis was used to assess differential bias in low and high score results. Results Data from 74 patients were available for analysis. Floor effects were seen in the early post-injury time points (median: 3 (IQR: 0, 5) at 3 days post-enrollment) and ceiling effects in the late time points (median: 9 (IQR: 8, 10). Internal consistency was good to excellent with both in-person (Cronbach α: 0.91 (95%CI 0.88, 0.95)) and telephone administration (0.81 (0.73, 0.89). Temporal stability was also good (ICC: 0.83 (0.72, 0.89) in-person, 0.80 (0.68, 0.88) telephone). A strong linear correlation was found between in-person and telephone administration (Spearman’s ρ: 0.83 (CI: 0.78, 0.84), consistency was assessed as excellent (Cohen’s κ 0.81 (CI: 0.78, 0.84), and Bland Altman analysis showed no systematic bias. Conclusions Telephone administration of the PSFS provides valid, reliable, and consistent data for the assessment of recovery from snakebite envenomation. Snakebite envenomation is an important but neglected tropical disease that impacts millions of people worldwide each year. These bites lead to both death and permanent disability. As they occur in tropical and subtropical regions, they primarily impact people from low-income areas of the world. As potential new treatments are being developed, we must understand their potential benefit in humans before they can be widely disseminated. Performing these human studies requires the ability to determine how patients recovered with these treatments. Having people return for evaluation during recovery is difficult in these low-income regions. We evaluated the ability to use a telephone version of an already accepted measurement of recovery in snakebite, the Patient-Specific Functional Scale. This study demonstrates that using this telephone-administered measure is feasible, valid, and reliable. With the results of this study, we now have an important tool to easily measure recovery in areas where snakebite predominates. This tool will help snakebite envenomation researchers evaluate the potential benefit of new treatments and accelerate the process of bringing new effective treatments to those snakebite patients in the most need.
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Affiliation(s)
- Rebecca G. Theophanous
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
| | - Joao Ricardo Nickenig Vissoci
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
| | - Fan Hui Wen
- Hospital Vital, Instituto Butantan, São Paulo, Brazil
| | - S. Michelle Griffin
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
| | - Victoria E. Anderson
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, United States of America
| | - Michael E. Mullins
- Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Nicklaus P. Brandehoff
- Department of Emergency Medicine, University of California San Francisco Fresno, Fresno, CA, United States of America
| | - Eugenia B. Quackenbush
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - Sean P. Bush
- Department of Emergency Medicine, Brody School of Medicine at East Carolina University, Greenville, NC, United States of America
| | - Eric A. Toschlog
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, United States of America
| | - Spencer C. Greene
- Henry J. N. Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, United States of America
| | - Kapil Sharma
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Kurt Kleinschmidt
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Nathan P. Charlton
- Division of Medical Toxicology, University of Virginia, Charlottesville, VA, United States of America
| | - S. Rutherfoord Rose
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA, United States of America
| | - Richard Schwartz
- Department of Emergency Medicine and Hospital Services, Medical College of Georgia, Augusta, GA, United States of America
| | - Brandon Lewis
- Texas A&M Health Science Center, College Station, TX, United States of America
| | - Eric J. Lavonas
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, United States of America
- Department of Emergency Medicine, Denver Health and Hospital Authority, Denver, CO, United States of America
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Charles J. Gerardo
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
- * E-mail:
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Affiliation(s)
- Eric J Lavonas
- Department of Emergency Medicine and Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | | | - Charles J Gerardo
- Division of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA
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Shah KR, Beuhler MC. Comment on "Early administration of fab antivenom resulted in faster limb recovery in copperhead snake envenomation patients". Clin Toxicol (Phila) 2019; 58:222-223. [PMID: 31140332 DOI: 10.1080/15563650.2019.1620263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Kartik R Shah
- Division of Medical Toxicology, Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, NC, USA
| | - Michael C Beuhler
- Division of Medical Toxicology, Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, NC, USA
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