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    of 26

    Dr.

    PINNAMANENI
    SIDDHARTHA INSTITUTE OF MEDICAL
    SCIENCES & RESEARCH FOUNDATION
    Chinoutpalli—521 286

    DEPARTMENT OF GENERAL MEDICINE


    P.G DISSERTATION PROTOCOL SUBMISSION
    PROFORMA
    01. Name of the student and department:
    Post – graduate student : Dr. Ajith Balineni

    Department : General Medicine


    02. Title of the Dissertation : THE STUDY OF COMPLICATIONS
    AND SEVERITY OF SNAKE BITE AND ITS CORRELATION WITH
    SERUM CHOLESTEROL
    03. Guiding faculty: Dr. T.V.D. SASI SEKHAR, MD.
    04. HOD : Dr. ANJANEYA PRASAD. MD
    05. Duration of Research / Dissertation work:24 months (june
    2024 to may 2026)
    NEED FOR STUDY
     Snake bite is an occupational hazard causing significant morbidity and mortality all
    over the world commonly in rural, agricultural, and tropical regions.
     An estimated 5 million people worldwide are bitten by snake each year with 1.8
    million to 2.7 million envenoming’s. Around 80,000 to 1,37,000 people die among
    them.
     There are around 45,000-80,000 deaths per year in India making India one of the
    worst effected country.
     Winkler et al was the first to observe to observe the decrease in serum cholesterol
    in hematotoxic snake bites.
     But not many studies have demonstrated the decrease in serum cholesterol in
    snake bites
    • Hence there is a need of studying the correlation of serum cholesterol with the
    complication and severity of snake bite.
    AIM OF THE STUDY
     To study the changes in levels of total serum total
    cholesterol in patients with snake bite
    OBJECTIVES OF THE STUDY
    • To correlate the severity of envenomation at
    the time of admission with serum total
    cholesterol levels
    Inclusion criteria :
     All patients above18 yrs with history of snake
    bite.
    Exclusion Criteria :
     Patients below 18 years who will not give informed
    consent.
     Patient with history of hyper cholestrolemia or hypo
    cholesterolemia.
     On lipid lowering drugs.
     On anti-coagulant drugs.
     Patients with history of haematological disorders.
    06. Detailed Research Plan:
    SOURCE OF THE DATA
    50 patients with snake bite admitted in
    Dr. PINNAMANENI SIDDHARTHA INSTITUTE OF MEDICAL
    SCIENCES AND RESEARCH FOUNDATION
    METHODS AND MATERIALS:
    • Sample size: 50
    Methodology :
    • In this study, 50 patients who are admitted with
    history of snake bite and confirmed by fang marks to
    the ER of Dr.PSIMS and RF will be included in the
    study.
    • The study will be conducted for a period of 2 years.
    • All the basic investigations will be done immediately at
    the time of admission along with the total serum
    cholesterol and 20-min WBCT.
    • The lab values of serum total cholesterol will be
    analysed with the clinical profile and the outcome.
    • All statistical analysis will be performed using SPSS
    (software package used for statistical analysis) package
    • SNAKEBITE SEVERITY SCORE(1,2,3)
    PROFORMA

    • NAME:
    • AGE:
    • SEX:
    • IP No:
    • Identification of species of snake:
    • Presence of snake fang marks:
    • Snake bite duration:
    • History of:
    – Pain and swelling in the effected areas
    – Neurological symptoms
    – Bleeding symptoms
    – Other symptoms.
    –
    • Past history:
    – Dyslipidaemia:
    – Taking lipid lowering agents:
    – Haematological disorders:

    • General physical examination:


    • BP: PR: RR: sPO2: height: weight: BMI:
    • Local examination:
    – Fang marks:
    – Swelling:
    – Cellulitis:

    • Systemic examination:
    • CVS:
    • RS:
    • ABDMONEN:
    • CNS:
    • 20 MIN WBCT:
    INVESTIGATIONS REQUIRED

    CBP, LFT, RFT, LIPID PROFILE, SERUM ELECTROLTES, PT-INR, ECG,


    20 MINUTES WBCT,
    • Study design:
    A Cross sectional study
    • STATISTICAL ANALYSIS:
    • The collected data will be tabulated and statistically
    analysed .
    • For qualitative data, frequency and percentage
    distribution will be calculated and for comparison
    between groups, the chi square test will be used.
    • For quantitative data, mean and standard deviation
    will be calculated and for comparison between the
    groups, student t test will be used.
    • Analysis of variance (ANOVA) will be used to find out
    the significance of study parameters between three or
    more groups of patient.
    • REVIEW OF LITERATURE:

     Snake has been an important cultural symbol which


    has been used by various cults, religions, and
    societies.
     In Greeks, Apollo, the son of Zeus and Leto was
    attempted to be killed by Hera when she was
    pregnant by sending python
     The symbol of Medicine originated from Greeks.
    Asclepius (son of Apollo).
     There are over 3000 species of snakes in the world of
    which 600 species are considered Venomous.
    • LIPID METABOLISM• Lipids are utilised by living organisms
    as:
    – 1. Regulator of membrane fluidity;
    – 2. Precursor to steroid hormones and bile acids;
    – 3. Major source of energy in the post-absorptive state;
    – 4. Absorption, synthesis and transport of fat soluble vitamins;
    – 5. Maintenance of the cell membrane; and
    – 6. Other biological activities such as production of
    prostaglandins,leukotrienes, lipoxins, prostanoids,
    prostacyclines, thromboxanes and gangliosides
    All nucleated cells synthesize cholesterol, but only hepatocytes
    and enterocytes caneffectively excrete cholesterol from the body,
    into either the bile or the gut lumen. In theliver, cholesterol is
    secreted into the bile, either directly or after
    conversion to bileacids(7)
    • In study done in 2008 in Korea and published in korean jourmal of Medicine by
    Kim et al, 98 patients with snake bite were enrolled and further divided into
    coagulopathy and DIC group, and it was found that there was significant
    decrease in cholesterol levels in coagulopathy group as compared to normal
    patients (mean 108+/49 <0.022) and further there was significant decrease in
    cholesterol levels in DIC group compared to non-DIC coagulopathy group
    (mean 96.6+/- 42 p<0,044), signifying that serum total cholesterol levels were
    negatively correlated with severity of envenomation.(4)
    • Winkler et al in Israel, studied Vipera palestinae bite in 44 patients and studied
    the admission serum total cholesterol levels and found that cholesterol levels
    were significantly lower as the severity of envenomation increased and that
    concomitant decrease in serum albumin were not significant, suggesting that
    the traditionally known transcapillary leakage is not the only mechanism, and
    an alternative mechanism of decrease in serum cholesterol may exist, most
    probably involving changes in lipoprotein transport and metabolism by
    Phospholipase A2 component of snake venom. These findings were
    reciprocated in animal models, where dose-dependent decrease in cholesterol
    was seen after non-lethal injection of purified V. palaestinae venom.(5)
    • Ophitoxemia (Venomous Snakebite) by joseph L. Mathew and
    Tharun Gera, mentioned about similar role of Serum
    Cholesterol in assessing the severity of envenomation.(6)
    REFERENCES :
    1. Snakbite severity scale (SSS). Dart et al., 1996.
    2. Validation of a severity score for the assessment of crotalid snake bite. R
    C Dart et al. Ann Emerg Med, 1996 march.
    3. Docs the traditional snakebite severity score correctly classify
    envenomated patients? Seungho Kang et al Clin Exp Emerg Med 20163(1)
    34-40
    4. Coagulopathy in patients who experience snakebite, Kim et al. The
    KoreanJournal of Internal Medicine : 23:94-99, 2008
    5. Decreased serum cholesterol levels after snake bite (Vipera
    Palaestinae) as a marker of severity of envenomation. Wikler E et
    al J lab Clin med, 1993 jun;121(6):774-8.
    6. Ophitoxemia (Venomous snakebite) Joseph L. Mathew and tarun
    Gera.
    OTHER REFERENCES

    7. Lipids and lipoprotein metabolism, Soneil Guptha, Pg-1232, chapter 18.3, APIText Book
    of Medicine, 9* Edition.
    8. Menon JC, Joseph JK, Complications of hematotoxic snakebite in India, Toxinology:
    2014: 1 - 21.
    9. Mohapatra B, Warrell DA, Suraweera W, Bhatia P, Dhingra N, et al, Snakebite mortality
    in India: a nationally representative mortality survey. PLoS Negl Trop Dis, 2011: 5: e1018
    10. Gutierrez JM, Leon G, Burnouf T (2011). Antivenoms for the treatment of snakebite
    envenoming: The road ahead. Biologicals 39: 129-142
    11. Kini RM, Anticoagulant proteins from snake venoms: Structure, function and
    mechanism, Biochem J 2006: Aug 1: 397: 3: 377 - 387.
    12. Clinical Profile and Laboratory Parameters in 1051 victims of Snakebite from a Single
    Centre in Kerala, South India Menon et al Journal of the Association of Physicians of India
    Vol. 64 August 2016
    • Proforma for investigations of PG (MD/MS) students, 2023-2024
    Batch

    • Name of the Student :Dr. Ajith Balineni

    • Registration No :PG-23-37

    • Department :GENERAL MEDICINE

    • Guide :Dr. T.V.D. SASI SEKHAR, MD.

    • Dissertation Title : THE STUDY OF COMPLICATIONS AND


    SEVERITY OF SNAKE BITE AND ITS CORRELATION WITH SERUM
    CHOLESTEROL
    • INVESTIGATIONS REQUIRED FOR THE DISSERTATION WORK :
    • Total estimated cost : No financial aid needed
    Routine Specialized
    investigations investigations
    Estimat
    ed Cost
    Lab CBP, LFT, RFT, LIPID Nil No
    Investigations: PROFILE, SERUM
    financi
    ELECTROLTES, PT-INR,
    ECG, 20 MINUTES al aid
    WBCT needed
    Radiological Nil NIL No
    Investigations: financia
    l aid
    needed
    Any other NIL NIL No
    Interventions/P financia
    rocedures/ l aid
    Surgeries needed
    VI. CONSENT FORM:
    Title of the Project: THE STUDY OF COMPLICATIONS AND SEVERITY OF SNAKE BITE AND ITS
    CORRELATION WITH SERUM CHLOESTEROL
    NAME OF THE INVESTIGATOR: Dr Ajith Balineni
    Participants name:
    Contact Number:

    The details of the study have been provided to me in writing & explained in my own language. I

    confirm that I have understood the above study and had the opportunity to ask questions. I

    understand that my participation in the study is voluntary & that I’m free to withdraw at any time,

    without giving any reason, without the medical care that will normally be provided by the hospital

    being affected. I agree not to restrict the use of any data or results that arise from this study

    provided such a use is only for scientific purpose(s). I have been given an information sheet giving

    details of the study. I fully consent to participate in the above study.

    Signature of the participant: ___________________ Date:

    Signature of the witness: ______________________ Date:


    THANK YOU

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