RESUMO
Low and middle-income countries (LMIC) are increasingly affected by non-communicable diseases (NCDs), which overburden the health system. With the rising prevalence of multimorbidity, polypharmacy is inevitable. Sri Lanka too faces the burden of polypharmacy and multimorbidity, and it is a strain on the economy as Sri Lankan health care is free-of-charge to all citizens. Therefore, steps to reduce inappropriate polypharmacy are a necessity. The aim of the study was to assess the prevalence and patterns of polypharmacy and its associated factors. In the medical clinics of a tertiary care hospital and a University primary care department, a descriptive cross-sectional study was carried out. Data were extracted from the clinical records of patients over the age of 20 years with a minimum of one NCD diagnosed by either a consultant physician or a consultant family physician. The sample size was 1600. Multimorbidity was present among 63.5% of patients. Polypharmacy (five or more than five drugs) was seen in 36.8% of the patients. Diabetes, hypertension, and coronary heart disease were the commonest of all diseases. Those on more than 11 drugs were found to have diabetes mellitus, hypertension, coronary heart disease, chronic kidney disease, and cardiac failure. 15% of the patients in the primary care setting and 59% of the patients in tertiary care experienced polypharmacy. Multiple regression analysis confirmed that polypharmacy increased with male gender, advancing age, and the degree of multimorbidity. Horizontal and vertical integration of multidisciplinary teams in all disciplines to manage patients is needed to combat inappropriate polypharmacy. This will help in optimizing the management of patients with NCDs.
RESUMO
BACKGROUND: Although antibody responses to dengue virus (DENV) in naturally infected individuals have been extensively studied, the functionality of DENV specific memory T cell responses in relation to clinical disease severity is incompletely understood. METHODOLOGY/PRINCIPAL FINDINGS: Using ex vivo IFNγ ELISpot assays, and by determining cytokines produced in ELISpot supernatants, we investigated the functionality of DENV-specific memory T cell responses in a large cohort of individuals from Sri Lanka (n=338), who were naturally infected and were either hospitalized due to dengue or had mild or sub clinical dengue infection. We found that T cells of individuals with both past mild or sub clinical dengue infection and who were hospitalized produced multiple cytokines when stimulated with DENV-NS3 peptides. However, while DENV-NS3 specific T cells of those with mild/sub clinical dengue infection were more likely to produce only granzyme B (p=0.02), those who were hospitalized were more likely to produce both TNFα and IFNγ (p=0.03) or TNFα alone. We have also investigated the usefulness of a novel T cell based assay, which can be used to determine the past infecting DENV serotype. 92.4% of DENV seropositive individuals responded to at least one DENV serotype of this assay and none of the seronegatives responded. Individuals who were seronegative, but had received the Japanese encephalitis vaccine too made no responses, suggesting that the peptides used in this assay did not cross react with the Japanese encephalitis virus. CONCLUSIONS/SIGNIFICANCE: The types of cytokines produced by DENV-specific memory T cells appear to influence the outcome of clinical disease severity. The novel T cell based assay, is likely to be useful in determining the past infecting DENV serotype in immune-epidemiological studies and also in dengue vaccine trials.