Hemodialysis Catheter-Related Central Venous Thrombosis: Clinical Approach to Evaluation and Management.

Central venous catheter (CVC) use is common among patients undergoing hemodialysis. Catheter-related vascular thrombosis is a frequent complication, which results in catheter dysfunction. This may eliminate the affected vein as a potential route of vascular access and leads to significant morbidity of the limbs involved. Despite increasing prevalence, there is a dearth of evidence-based guidelines for managing such catheter-related thrombi, often leading to treatment dilemmas in clinical practice. Minimizing the use of CVCs for hemodialysis remains the best approach in preventing such adverse complications. Furthermore, meticulous planning and care when using such catheters in unavoidable circumstances along with vigilant surveillance to identify complications early will allow to avoid associated morbidity.

Star fruit nephrotoxicity: a case series and literature review.

BACKGROUND: Star fruit is a popular medicinal fruit in the tropics. Its hypoglycaemic properties are considered useful in achieving glycaemic control in diabetes. Star fruit induced nephrotoxicity is a rare cause of acute kidney injury in individuals with both normal and reduced baseline renal function. We present three cases of acute kidney injury due to star fruit nephrotoxicity from Sri Lanka, and discuss the published literature on this topic. CASE PRESENTATION: Three Sri Lankan patients, all with a background of diabetes, presented to us with acute nausea and anorexia following recent consumption of star fruit. Two patients complained of diarrhoea and one patient complained of intractable hiccoughs. They all had elevated serum creatinine on admission. Two were known to have normal baseline serum creatinine levels. On renal biopsy two had evidence of oxalate crystal deposition. One did not show crystal deposition but had acute interstitial nephritis for which no alternate cause could be identified. Two were treated with short courses of prednisolone and two required acute haemodialysis. All recovered renal function, with both patients with known baselines approaching their premorbid serum creatinine levels. CONCLUSION: Consumption of star fruit, especially on an empty stomach or in a state of dehydration may precipitate acute kidney injury. A history of star fruit ingestion must be actively looked for in patients presenting with unexplained acute kidney injury. The use of star fruit as a therapy for diabetes should be discouraged.

Low- Versus High-dose Cyclophosphamide in Class III/IV Lupus Nephritis: A Retrospective Study from South Asia.

Introduction: The comparative efficacy of low-dose cyclophosphamide (LD-CYC) and high-dose cyclophosphamide (HD-CYC) for treatment of lupus in South Asians is not well established. We aimed to compare treatment outcomes in South Asian patients with class III and IV lupus nephritis treated with either regimen. Method: This was a single-center, retrospective study conducted in Sri Lanka. Patients with biopsy-proven class III or IV lupus nephritis were recruited. The HD-CYC group was defined as having received ≥6 doses of 0.5-1 g/m2 cyclophosphamide (CYC) followed by quarterly doses. The LD-CYC group was defined as having received six doses of 500 mg CYC at two-weekly intervals. The primary outcome was treatment failure defined as persistent nephrotic range proteinuria or renal impairment at 6 months. Results: Sixty-seven patients were recruited (HD-CYC 34, LD-CYC 33), all South Asian ethnicity. The HD-CYC group had received treatment between 2000 and 2013, and the LD-CYC group from 2013 onward. The HD-CYC and LD-CYC groups had 30/33 (90.9%) and 31/34 (91.2%) females, respectively. Nephrotic syndrome and nephrotic range proteinuria on presentation were seen in 22/33 (67%) and 20/32 (62%) in the HD-CYC and LD-CYC groups, respectively, and renal impairment was seen in 5/33 (15%) of the HD-CYC group and 7/32 (22%) of the LD-CYC group (P > 0.05). Treatment failure and complete or partial remission occurred in 7/34 (21%) and 28/34 (82%), respectively, of HD-CYC and 10/33 (30%) and 24/33 (73%), respectively, of LD-CYC (P > 0.05). Adverse events rates were similar. Conclusion: This study suggests that LD-CYC and HD-CYC induction is comparable in South Asian patients with class III and IV lupus nephritis.

Acromegaly presenting with low insulin-like growth factor-1 levels and diabetes: a case report.

INTRODUCTION: Acromegaly is an endocrine disorder arising from excessive serum growth hormone levels in adulthood and is characterized by progressive somatic enlargement. Biochemical confirmation is achieved by demonstration of elevated baseline serum growth hormone levels which are not suppressed during an oral glucose tolerance test, and by increased levels of serum insulin-like growth factor-1. The serum insulin-like growth factor-1 level provides an assessment of integrated growth hormone secretion and is recommended for diagnosis, monitoring, and screening of acromegaly. We report a case of a patient with acromegaly secondary to a pituitary microadenoma who presented with low insulin-like growth factor-1. CASE PRESENTATION: An 83-year-old Sinhalese woman presented to our hospital with an enlarging multinodular goiter. She was observed to have macroglossia, thickened coarse skin, acral enlargement, and newly detected, uncontrolled diabetes. A diagnosis of acromegaly was suspected. She did not complain of recent headaches, vomiting, visual difficulties, or galactorrhea and was clinically euthyroid. Her pulse rate was 84 beats/min, and her blood pressure was 150/90 mmHg. A visual field assessment did not reveal a defect. Her random growth hormone levels were 149 mU/L (<10 mU/L), and her oral glucose tolerance test was supportive of acromegaly with a paradoxical rise of growth hormone. Her serum age-specific insulin-like growth factor-1 level was below normal at 124.7 ng/ml (normal range 150-350 ng/ml). Her serum insulin-like growth factor-1 level, measured after glycemic control was achieved with metformin and insulin, was elevated, which is characteristic of acromegaly. Magnetic resonance imaging of her pituitary revealed a pituitary microadenoma. Acromegaly secondary to a growth hormone-secreting pituitary microadenoma was confirmed. CONCLUSIONS: Systemic illnesses, including catabolic states, hepatic or renal failure, malnutrition, and diabetes mellitus, are known to decrease insulin-like growth factor-1 levels and may result in false-negative values in patients with acromegaly A low insulin-like growth factor-1 level does not exclude acromegaly in a patient with supportive clinical features and poorly controlled diabetes.

Lead toxicity among traffic wardens: a high risk group exposed to atmospheric lead, is it still a cause for concern?

BACKGROUND: Traffic policemen are identified to be at a higher risk of exposure to air pollution and its contaminants such as lead. A study done prior to the introduction of unleaded petroleum in Sri Lanka revealed a mean blood lead level of 53.07 µg/dL, which was well above the Center for Disease Control defined acceptable safe levels. This study aimed to determine whether unleading of fuel has made an impact on the blood lead levels of traffic police working in an urban area with high traffic density. METHOD: A cross-sectional survey of 168 traffic police personnel working within Colombo city limits of Sri Lanka, a high traffic density area, was conducted. Blood lead levels of participants were measured using nitric acid, perchloric acid ashing method and atomic absorption spectrophotometry. An interviewer administered questionnaire was used for a targeted history and examination. RESULTS AND DISCUSSION: Mean age of the sample population was 37 years. Thirty eight percent had detectable levels of lead in blood and 24.4% of the study sample had blood lead levels above Centre for disease control defined safe limits. Sample mean was 4.82 µg/dL (95% CI 3.58-6.04), and this is a 91% overall reduction when compared to data prior to unleading. Neither symptoms nor signs of classic lead toxicity showed significant correlation with toxic lead levels. CONCLUSION: Lead poisoning though still present in the high risk traffic warden population shows a considerable reduction following unleading. The need to have a low threshold to suspect lead poisoning is highlighted by the non-specific nature of the symptoms and signs of lead poisoning and its lack of association even in those found to have elevated lead levels. Further studies are required to elucidate a cause for the prevalence of lead poisoning despite cessation of using lead as an additive in petroleum.

Final-year medical students' perceptions regarding the curriculum in public health.

BACKGROUND: The Faculty of Medicine, University of Colombo, has an integrated curriculum in which teaching of public health takes place through a series of modules which span the full five-year study programme. AIM: To assess final year medical student perceptions regarding the public health curriculum and to identify factors which influence this. MATERIALS AND METHODS: The study was cross sectional. Convenience sampling was utilized on final-year students of the Faculty of Medicine, University of Colombo, Sri Lanka. A self-administered 4-point Likert scale questionnaire covered general opinion on public healthcare and perceptions about the curriculum. Data were analyzed using descriptive statistics and Chi-square tests. RESULTS: One hundred and eighty four students (94%) participated in the study. Eighty-two percent (148) viewed public health as an important field. Only 9% (16) were interested in a career in public health. A significant association was found between choosing public health as career and the following: perception of public health as an important field; holding a good opinion about public health prior to commencement of the course; having found the field-based experience enjoyable and beneficial to the community; and feeling competent to work in the community at the end of the course (P < 0.01). With regard to teaching methods, group activities and discussion-centered activities were identified positively (153, 83% and 125, 68% respectively). The majority of students indicated that they were not stimulated to read more on the subject or regularly revise what they have learnt, both during the introductory public health programme and during the final year. CONCLUSIONS: The curriculum has been able to create a positive opinion about public health. However, students lack enthusiasm to learn independently. Experiential, group-centered teaching activities and a constructivist approach may be more effective in promoting independent learning. Perceptions are important and should aid in structuring the curricula.