Establishing a novel partnership model to deploy health services for children with autism in a low-resource setting - experience from Sri Lanka.

Sri Lanka is representative of challenges faced by low-income and middle-income countries, including the rise in the prevalence of autism and the lack of sufficient autism-specific services in the state sectors. The experience in establishing a Center to provide services for children with autism in Northern Sri Lanka is described. Funding and resourcing were accessed through an innovative partnership-based public/non-governmental organisation/charity model, where service-based outcomes were the main objectives. This model, incorporating state institutions, local and international charity organisations, and volunteers, devised a bespoke approach to care provision using the available resources under the clinical supervision of a consultant psychiatrist and the administrative purview of the Regional Director of Health Services. The evolution of this Center into a Learning Health System is described, reflecting how a minimalistic partnership approach focused on the integration of existing organisations and services could be a feasible model for the delivery of high-quality healthcare in low-resource settings.

Potential Drug-Drug Interactions Among Hospitalised Elderly Patients in Northern Sri Lanka, A Lower Middle-Income Country: A Retrospective Analysis.

BACKGROUND AND OBJECTIVES: Elderly individuals are more vulnerable to potential drug-drug interactions (pDDIs) as age-related physiological changes, polypharmacy and hospitalisations are known to increase the risk of pDDIs. The aims of this study were to assess the impact of hospitalisation and other associated factors on pDDIs in elderly patients, in a resource-limited setting. METHODS: This is a retrospective analysis of data of elderly patients (aged ≥ 65 years) admitted to the medical units of Jaffna Teaching Hospital. Preadmission and post-admission data were collected from clinic and hospital records, respectively. The British National Formulary was used to identify and categorise pDDIs. Point prevalence of pDDIs in elderly patients and the total number of pDDIs before and after hospitalisation were estimated. Factors contributing to pDDIs were determined by univariate and multivariable logistic regression. RESULTS: Two hundred and eighty-eight hospitalised elderly patients with a median age of 71 years (interquartile range 67-76 years) showed a significant increase in the prevalence of pDDIs post-admission compared with the preadmission values (77.1% vs 61.5%; p < 0.001) associated with an increase in total pDDIs (377 vs 488; p < 0.001) where the majority (> 75%) were potential pharmacodynamic interactions. An unadjusted analysis showed a significant association between pDDI and polypharmacy [taking five or more medications] (odds ratio [OR] = 14.17; 95% confidence interval [CI] 7.41-27.10), the presence of more than three underlying medical conditions (OR 4.14; 95% CI 1.70-10.06), ischaemic heart disease (OR 3.25; 95% CI 1.78-5.94) and asthma (OR 8.14; 95% CI 2.46-26.88). However, when adjusted for confounders only polypharmacy (OR 14.10; 95% CI 6.50-30.60) and the presence of underlying asthma (OR 11.61; 95% CI 2.82-47.85) were associated with pDDIs. CONCLUSIONS: The prevalence of pDDIs among elderly patients was high and increased with hospital admissions. Polypharmacy and relevant comorbidities were contributory factors. Increased awareness of the potential for pDDIs through appropriate training and simple measures including a proper drug history, creating a bespoke pDDI list and frequent medication reviews by healthcare professionals would help to mitigate pDDIs in resource-limited and technology-limited settings.

Regional Variation in Dengue Virus Serotypes in Sri Lanka and Its Clinical and Epidemiological Relevance.

Dengue is a significant health concern in Sri Lanka, but diagnosis of the infecting dengue virus (DENV) serotype has hitherto been largely restricted to the Colombo district in the western province. Salinity tolerant Aedes vectors are present in the island's northern Jaffna peninsula, which is undergoing rapid groundwater salinization. Virus serotypes were determined by RT-qPCR in 107 and 112 patients diagnosed by NS1 antigen positivity from the Jaffna district in 2018 and 2019, respectively, and related to clinical characteristics. DENV1 and DENV2 were the most common serotypes in both years. Infections with multiple serotypes were not detected. DENV1 was significantly more prevalent in 2019 than 2018, while DENV3 was significantly more prevalent in 2018 than 2019 among the Jaffna patients. Limited genomic sequencing identified DENV1 genotype-I and DENV3 genotype-I in Jaffna patients in 2018. Dengue was more prevalent in working age persons and males among the serotyped Jaffna patients. DENV1 and DENV2 were the predominant serotypes in 2019 in the Colombo district. However, DENV1 and DENV3 were significantly more prevalent in Colombo compared with Jaffna in 2019. The differences in the prevalence of DENV1 and DENV3 between the Jaffna and Colombo districts in 2019 have implications for dengue epidemiology and vaccination. Salinity-tolerant Aedes vector strains, widespread in the Jaffna peninsula, may have contributed to differences in serotype prevalence compared with the Colombo district in 2019. Significant associations were not identified between virus serotypes and clinical characteristics among Jaffna patients.

Kounis Syndrome and Multiorgan Failure Following Multiple Wasp Stings.

Wasp and bee stings are common in Sri Lanka, and systemic envenomation causes a spectrum of clinical manifestations that includes simple local allergic reaction to life-threatening multiple organ injury or failure. However, wasp toxin-induced acute myocardial infarction is very rare in the literature. Here, we describe a pregnant lady with mass wasp stings who developed toxin-induced acute myocardial infarction with multiorgan injury. The treating physician should anticipate the complications of massive envenomation following multiple wasp stings.

Rhabdomyolysis and acute kidney injury associated with thiocyclam hydrogen oxalate (Evisect) poisoning.

Thiocyclam hydrogen oxalate (Brand name: Evisect) is an insecticide with anti-cholinergic and cholinergic properties. Although there are few case reports and a case series of human toxicity of nereistoxin analogue insecticide such as cartap hydrochloride poisoning published in the literature, poisoning with thiocyclam hydrogen oxalate (Evisect), an another analogue of nereistoxin with its own molecular formula is only heard in animals, such as Nubian goats. Herein, we report a patient presented with rhabdomyolysis and acute kidney injury without significant symptoms of acute cholinergic syndrome following self-ingestion of thiocyclam hydrogen oxalate (Evisect) and he made an uneventful recovery with prompt supportive care.

Dengue fever complicated with acute liver failure: A case report of expanded dengue syndrome and literature review.

Dengue is the most common arboviral disease, the presentation of which ranges from asymptomatic illness to dengue shock syndrome. Liver is the most common organ affected in dengue, and liver involvement is asymptomatic in majority. Dengue fever is a rare, but a leading cause for acute liver failure in endemic regions. Here, we report a case of a 34-year-old male ethanol user (16 units per week), presented with typical features of dengue infection, which was confirmed serologically, complicated with acute liver failure without clinical, radiological or laboratory evidence of plasma leakage. He was managed with intravenous fresh frozen plasma and N-acetyl cysteine along with other recommended supportive therapies for acute hepatic failure. He made an uneventful recovery.

Vitamin D status among postmenopausal osteoporotic women: a hospital based cross-sectional study from Northern Sri Lanka.

BACKGROUND: Vitamin D deficiency is common among post-menopausal women and it is important to treat vitamin D deficiency to prevent falls and fractures in patients with osteoporosis. Few studies examined the prevalence of vitamin D deficiency in general population of Sri Lanka but no studies to date done among post-menopausal women with osteoporosis in Sri Lanka. This is the first study in Sri Lanka of such kind conducted to evaluate the serum vitamin D levels among postmenopausal women. METHODS: Cross-sectional study was conducted at the Endocrine Unit, Teaching Hospital Jaffna from January to December 2018. During this period 105 postmenopausal women who registered for bone density assessment were recruited to the study. Data collection was done by investigators and blood sample was taken from each participant by registered nurses and total 25-Hydroxy Vitamin D level (25(OH)-Vit D) was measured by competitive immunoassay with enhanced chemiluminiscence technique, levels were categorized and analysis was done using SPSS 26. RESULTS: Mean age of 105 postmenopausal women was 67.7 with minimum 33 and maximum 84 years. Mean total 25(OH)-Vit D was 27.5 (range11.7-52.5 ng/mL). 25(OH)-Vit D levels were adequate in only 36.2% (95%CI: 27-45), 44% had insufficient levels and deficiency was present in 19% (95%CI: 12-27) of postmenopausal women. Among total study participants 20% were vegetarian, 53, 76.2 and 64.8% were consuming milk, fish and egg respectively and 71.4% reported adequate level of sun exposure (> 30 min/day). Commonly reported vitamin D deficiency symptoms include paraesthesia (57.1%), bone-pain (55.2%), easy fatigability (54.3%), malaise (51.4%), muscle cramps (43.8%) and proximal myopathy (40.0%). Nevertheless, comparison of musculoskeletal symptoms between group with sufficient level and group with insufficient and deficient level showed no significant difference (P > 0.05). Among 71 participants (66.7%) who completed bone density assessment, 38% (95%CI: 27-49) showed osteoporosis. Vertebral Z score showed a significant correlation with 25(OH)-Vit D level (r-0.252, P-0.03). CONCLUSION: Prevalence of vitamin D deficiency is relatively high among the post-menopausal women with a provisional diagnosis of osteoporosis. It is essential to consider vitamin D supplementation when initiating treatment for osteoporosis. Hence, Vitamin D testing is desirable in decision making to treat or not to treat.

An unusual case of remitting seronegative symmetrical synovitis with pitting edema: Case report and literature review.

Remitting seronegative symmetrical synovitis with pitting edema is a rare but well-recognized clinical entity that is easily overlooked due to lack of clinical vigilance. It is classically described as an acute onset of symmetrical tenosynovitis of both upper and lower extremities with pitting edema, mostly noted in elderly population. Young patients with other rheumatological diseases and unilateral involvement had also been reported, but symmetrical remitting seronegative symmetrical synovitis with pitting edema in a young patient is a rare observation. We hereby report a case of a remitting seronegative symmetrical synovitis with pitting edema in a young male affected by no rheumatological diseases in the past, typically fulfilling the diagnostic criteria and well responded to low-dose steroid therapy. The salient features of the present case in terms of age, remitting seronegative symmetrical synovitis with pitting edema possibly related to undifferentiated arthropathy, reactive arthritis, or diabetes mellitus.

Entamoeba histolytica and amoebic liver abscess in northern Sri Lanka: a public health problem.

Entamoeba histolytica (E. histolytica) is a facultative protozoan parasite implicated in amoebic liver abscesses (ALA), the most common extraintestinal manifestation of this infection. E. histolytica is endemic to sub-tropical and tropical countries and has been a major public health concern in northern Sri Lanka (SLK) for the last three decades. This has been attributed to a multitude of factors such as poor sanitation, hygiene, male sex, middle age, overcrowding, unsanitary practices in the production of indigenous alcoholic beverages, and alcohol consumption. Additionally, while rates of E. histolytica have declined substantially throughout the rest of the island, largely due to better infrastructure, it remains pervasive in the northern peninsula, which is generally less developed. Infection arises primarily from fecal-oral transmission through the consumption of contaminated drinking water containing cysts. Upon ingestion, cysts multiply into trophozoites and colonize the host colonic mucosa using lectin and cysteine proteases as virulence factors, leading to host invasion. Symptoms occur along a spectrum, from asymptomatology, to pyrexia, abdominal cramping, and amoebic dysentery. Colonization of the colon results in the formation of distinct flask-shaped ulcers along the epithelium, and eventual penetration of the lamina propria via the production of matrix metalloproteinases. ALA then develops through trophozoite migration via the mesenteric hepatic portal circulation, where microabscesses coalesce to form a single, large right-lobe abscess, commonly on the posterior aspect. The progression of infection to invasive disease is contingent on the unique interplay between host and pathogen factors, such as the strength of host-immunity to overcome infection and inherent pathogenicity of the Entamoeba species. As a preventable illness, E. histolytica complications such as ALA impose a significant burden on the healthcare system. This mini-review highlights epidemiological trends, risk factors, diagnostic modalities, treatment approaches, and opportunities for prevention of E. histolytica-induced ALA, to help address this endemic problem on the island of SLK.

Factors Associated with Visit-to-Visit Variability of Blood Pressure Measured as Part of Routine Clinical Care among Patients Attending Cardiology Outpatient Department of a Tertiary Care Centre in Northern Sri Lanka.

Visit-to-visit variability (VVV) is a relatively new concept in the hypertensive arena. Data regarding VVV are lacking in our region, and factors associated with VVV are rarely examined in previous studies. This study was conducted among 406 patients attended to the cardiology outpatient department of Teaching Hospital, Jaffna, Sri Lanka, in 2018 to assess the long-term variability of blood pressure (BP) by reviewing last six consecutive BP readings from the records retrospectively. Data regarding sociodemographic variables and behavioural factors such as medication adherence, physical activity, smoking, alcohol consumption, and relevant comorbidities were taken through an interviewer-administered questionnaire. Data were analysed by using SPSS version 25 and VVV of systolic blood pressure (SBP) matrix expressed as mean of SD and association were examined with various factors and VVV of SBP. SBP showed high VVV among the participants as expressed by mean of SD which was 13.06 ± 5.64. When comparing mean SD among the categories of different variables, female sex (P=0.023) and comorbidities such as diabetes mellitus (DM) (P=0.013), chronic kidney disease (CKD) (P=0.007), and risk of developing obstructive sleep apnoea (OSA) (P=0.04) showed significant variation. Medication adherence to prescribed hypertensive medication was a major issue even though significant association was not found with high VVV (P=0.536). The SD of SBP was then classified into high and low VVV groups by means of a cutoff point at the 50th percentile. Bivariate analysis by using Chi-squared test revealed comorbidities such as DM, CKD, and physical activity (P=0.044) were significantly associated with high VVV. Further multivariate regression analysis revealed that comorbidities such as DM and CKD have 1.561 times and 5.999 times more risk to show high variability, respectively. In conclusion, we recommend simple practical measures to achieve sustainable BP control among hypertensive patients with DM and CKD to minimize the VVV and improve their cardiovascular outcome.

Combined Left Central Retinal Artery Occlusion and Bilateral Anterior Ischemic Optic Neuritis: A Rare Presentation of Giant Cell Arteritis.

Giant cell arteritis, a large vessel vasculitis is characterized by headache, visual impairment, constitutional symptoms, and increased inflammatory markers. Visual involvement in giant cell arteritis ranges from amaurosis fugax to permanent visual loss, and extensive bilateral visual impairment is a rare presentation. We hereby report a case of combined left central retinal artery occlusion and bilateral anterior ischemic optic neuritis in a patient who poorly responded to standard corticosteroid therapy.

Hypoparathyroidism, Sensorineural deafness and renal disease (Barakat syndrome) caused by a reduced gene dosage in GATA3: a case report and review of literature.

BACKGROUND: Barakat syndrome is an autosomal dominant rare genetic disease caused by haploinsufficiency of the GATA binding protein 3 (GATA3) gene. It is also known as HDR syndrome, and is characterized by varying degrees of hypoparathyroidism, sensorineural deafness and renal disease. This is the first report of a heterozygous GATA3 whole gene deletion causing HDR syndrome in a Sri Lankan family. CASE PRESENTATION: A 13-year-old boy with an acute febrile illness, hypocalcaemia and bilateral carpopedal spasm was referred for evaluation. A past medical history of treatment for persistent hypocalcaemic symptoms since the age of 7 months was obtained. Biochemical investigations showed persistent low serum corrected calcium levels with hyperphosphataemia, hypomagnesaemia, low parathyroid hormone levels, hypercalciuria, and low total 25-hydroxy vitamin D levels. His renal functions and renal sonography were normal. Audiometry showed bilateral moderate to severe sensorineural hearing loss. On screening, his mother was also found to have asymptomatic hypocalcaemia, hypomagnesaemia, hyperphosphataemia, hypercalciuria and low total 25-hydroxy vitamin D levels. She had impaired renal functions and chronic parenchymal changes in the renal scan. Audiometry showed bilateral profound sensorineural hearing loss. Genetic analysis using multiplex-ligation dependent probe amplification showed a reduced gene dosage for GATA3 that is consistent with a heterozygous whole gene deletion in both the child and mother. CONCLUSIONS: This report demonstrates the wide intra-familial phenotypic variability observed in HDR syndrome and adds further to the existing scientific literature on the genotype-phenotype correlation of this syndrome. It highlights the need for HDR syndrome to be considered in the differential diagnosis of persistent hypocalcaemia with sensorineural deafness and/or renal involvement, and for appropriate genetic evaluation to be done to confirm the diagnosis.

Nocturnal systolic blood pressure pattern of type 2 diabetic hypertensive men with erectile dysfunction: a cross sectional study from Northern Sri Lanka.

OBJECTIVE: This small scale cross-sectional study was done to identify the common systolic blood pressure pattern (dipping or non-dipping) among type 2 diabetic men with coexisting hypertension and erectile dysfunction(ED). A recent study in the same setting showed that prevalence of ED was high among diabetic men and co-existing hypertension was identified as an independent risk factor. There was a postulation about an association between ED and non-dipping nocturnal blood pressure pattern. So ambulatory blood pressure measurements (ABPM) was obtained for participants to test this prediction. Data was analysed using SPSS 25 Version. RESULTS: Among 29 participants who underwent ABPM, 21 showed non-dipping pattern of nocturnal systolic blood pressure (72.4%; CI 54.3-86.3). Mean SBP of participants was 125.55 +_14.1 and Mean DBP was 81.5 + _12.82. There was no statistical difference observed in mean SBP and DBP between patients with dipping nocturnal SBP and non-dipping pattern (P > 0.05). Variability of SBP was high among the participants (Mean SD-11.96 +/_2.74) and DBP also showed relatively high variability (SD-9.28 +/_2.9). Mean dipping percentage of the SBP during sleep was 5.54 +/_6.66. A significant difference in heart rate (HR) between patients with non-dipping and dipping pattern was noted (P-0.034).

Erectile dysfunction and associated factors among men with diabetes mellitus from a tertiary diabetic center in Northern Sri Lanka.

OBJECTIVE: Prevalence of erectile dysfunction (ED) in diabetic men is considerably high but it is often underdiagnosed and undermanaged. There were no data available about the prevalence and the risk factors of ED in our region. So a cross-sectional study was conducted to identify the prevalence and associated risk factors of ED in a tertiary care diabetic center in Northern Sri Lanka. RESULTS: 326 diabetic male patients between ages 18-60 years were interviewed. Majority (62.9%; 95% CI 57.5-68.0%) of the diabetic patients suffered from ED and 22.4% (95% CI 17.8-26.8%) were found to have severe ED. Most of the patients (98.8%) were not screened or treated for ED. Bivariate analysis showed age above 40, duration of DM (> 5 years), type of diabetes (type 2), having micro-vascular complications, co-existing hypertension, BMI, consuming unsafe level of alcohol and taking beta-blockers were associated with ED at 5% level (P < 0.05). This study failed to show association with dyslipidemia, macro vascular complications such as coronary artery disease (CAD, P-0.052), glycemic control (P-0.082) and smoking. Regression analysis revealed age > 40 (AOR: 2.13; 95% CI 1.05-4.33), duration of diabetes (AOR: 2.90; 95% CI 1.67-5.01), co-existing hypertension (AOR: 1.8; 95% CI 1.06-3.06), and unsafe level alcohol intake (AOR: 3.14; 95% CI 1.76-5.59) were independent risk factors.

Blistering skin lesion: A new observation of Hottentotta tamulus (white scorpion) sting.

White scorpion (Hottentotta tamulus) stings are an emerging health hazard in northern Sri Lanka and are increasingly recognized particularly during the last decade. The stings are usually harmless; however, fatal cardiovascular sequelae ensues following severe envenomation. It is often difficult to identify this miniature creature and its site of sting due to its nature of habitat and nonspecific local symptoms that develop after the sting. Here, we report a patient who had developed a blistering skin lesion soon after the sting which is not reported in the literature to date by the sting of this particular species. Recognizing it would help the clinicians of this subcontinent to consider scorpion sting as a differential diagnosis for the above presentation in the future.

Cheilitis: An unusual presentation of Mucocutaneous Leishmaniasis.

The Mucocutaneous Leishmaniasis (MCL) involving lip is extremely uncommon. A clinical diagnosis of Leishmaniasis of the lips is often challenging to the treating clinician and may result in delayed diagnosis as this case illustrates. MCL should be considered in the differential diagnosis of lip lesions in a Leishmania endemic area.

Blood group AB is associated with severe forms of dengue virus infection.

Several viral and host factors are believed to contribute to the development of severe forms of dengue such as dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS) following a dengue virus (DENV) infection. The pathogenesis of DHF/DSS is not fully understood, however, host factors like ABO blood groups have been shown to contribute to the severity of DENV infection. The present study investigated the association of blood groups with severity of DENV infection in the northern region of Sri Lanka. The blood-groups of 405 patients positive for DENV NS1 antigen and anti-DENV IgM/IgG were determined using the standard haemagglutination assay recommended by the national blood bank/s. The occurrence of severe dengue in patients with certain blood groups was significantly different (p < 0.001) to those with other blood groups. Patients with AB blood group had more than 2.5 times higher risk of developing DHF than those with other blood groups. On the other hand, patients with blood group O were significantly under represented for DHF relative to the proportion of this blood group in the general population. Thus dengue patients with blood group O appear to have a low risk of developing DHF than those with other blood groups.