Queens of hearts: Exploring the lived experiences of mothers caring for infants with complex congenital heart disease in Sri Lanka.

This qualitative study explored the lived experiences of eight Sri Lankan mothers of infants with complex congenital heart disease (CCHD) using semi-structured interviews. Four themes were generated as: illness perception, communication with medical staff, challenges faced, and coping mechanisms. These provided insight into the multi-faceted nature of mothers' experiences, importance of medical-caregiver communications and their need for psychosocial services. The findings enhance the limited knowledge of South-Asian primary CCHD caregiver experiences and will help in improving psychosocial support services in Sri Lanka.

An unusual case of small intestinal obstruction secondary to a large primary enterolith.

Enterolithiasis is an uncommon entity in humans but frequently seen in equine mammals. A primary enterolith is a mineral concretion formed within the gastrointestinal tract due to the alteration in the anatomical integrity due to variety of conditions resulting in intestinal stasis. We report a patient with small intestinal obstruction due to a primary enterolith. A 65-year-old woman presented to the emergency department with central colicky abdominal pain, absolute constipation followed by vomiting. An enterolith located in distal ileum causing small intestinal obstruction was established with the aid of abdominal X-ray radiograph and computed tomography. Exploratory laparotomy was performed to extract the enterolith and to resect a strictured proximal jejunal segment which was suspected to be the original site of enterolith formation. Chemical analysis of the enterolith supports the speculation of a proximally formed primary enterolith eventually migrating to the site of impaction in the terminal ileum.

Investigation of the Flexural Behavior of Preloaded and Pre-Cracked Reinforced Concrete Beams Strengthened with CFRP Plates.

This paper investigates the flexural behavior of preloaded reinforced concrete (RC) beams, strengthened with Carbon Fiber Reinforced Polymer (CFRP) plates using an experimental program, analytical procedure, and Finite Element Method (FEM) simulation. The RC beams were subjected to preloads of 30%, 50% and 70% of the yielding load, prior to installation of the strengthening system. The eight RC-strengthened beams with a reinforcement configuration of 3Ø12 and two CarboDur S512 plates have been evaluated using bending tests. The failure modes of all the RC-strengthened beams were governed by the widening of flexural cracks within a constant bending zone, followed by debonding of the CFRP plates. The plates were debonding simultaneously or one plate prior to the other plate. The ultimate moment capacity is not significantly reduced while increasing preload levels from 0% to 70%. The moment capacity is increased by 70% to 80% in the CFRP strengthened beams, compared with un-strengthened beams indicating the potential of capacity enhancement that can be attained by externally bonded CFRP.

Use of in-filled trenches to screen ground vibration due to impact pile driving: experimental and numerical study.

Vibration generated by pile driving can cause discomfort to occupants of nearby buildings and disturb the activities carried out in the buildings. The transmitted vibration will depend on both the source and the transmitting medium (soil), while the acceptable levels of vibration will depend on the receiver characteristics. Existing structures in which some sensitive processes are ongoing such as hospitals and laboratories can easily be affected due to the received vibration. Introducing a trench into the path of wave propagation has become one of the solutions. There is however little experimental data available on the effects of trenches to screen such ground borne vibration, especially that caused by pile driving. This paper describes a series of experiments conducted to investigate the characteristics of impact pile induced vibrations and the effect of coal bottom ash filled trenches to screen this vibration. In addition to experimental testing, numerical simulations are also carried out using validated model to examine the effects of in-fill material, impact load, soil characteristics and distance from the source to the trench on the vibration screening ability. The results of the field experiments and the numerical study are analysed and interpreted to provide guidelines for future research and design.

Genotypic characterization of Orientia tsutsugamushi from patients in two geographical locations in Sri Lanka.

BACKGROUND: To date more than 20 antigenically distinct strains of Orientia tsutsugamushi (OT) reported within the tsutsugamushi triangle that cause an undifferentiated acute febrile illness in humans. Genotypic characterization of OT in different geographic regions or within the same country, is important in order to establish effective diagnostics, clinical management and to develop effective vaccines. Genetic and antigenic characterization of OT causing human disease in OT-endemic regions is not known for Sri Lanka. METHODS: Adult patients and children who were admitted with an acute febrile illness and presumed to having acute scrub typhus based on presence of an eschar and other supporting clinical features were recruited. Eschar biopsies and buffy coat samples collected from patients who were confirmed having OT by IFA were further studied by real time PCR (Orientia 47 kD) and nested PCR (Orientia 56 kD) amplification. DNA sequences were obtained for 56 kD gene amplicons and phylogenetic comparisons were analyzed using currently available data in GenBank [Neucleotide substitution per 100 residues, 1000 Bootstrap Trials]. RESULTS: Twenty eschar biopsies (Location1,19, Location 2,1) and eight buffy coat samples (Location1,6, Location2,2) examined by real time PCR revealed Orientia amplicons in 16 samples. DNA sequences were obtained for the 56 kD gene amplicons in 12 eschars and 4 buffy coat samples. The genotypes of the Location1 samples revealed that, 7 exhibiting close homology with JP1 [distantly related to UT177 Thai (Karp related)], five had close homology with Kato strain, two had close homology with JGv and JG AF [Distantly related to Kawasaki M63383] and one had close homology with Gilliam strain. The Location 2 strain was closely related to Kuroki-Boryong L04956, the genotype which is distributed in far eastern Asia. Similar to other patients in the cohort this patient also had never travelled out of Sri Lanka. CONCLUSIONS: We observed all three main OT genotypes in Sri Lanka, and the majority fell into Thai Karp related clade. These results demonstrate great antigenic diversity of OT in the studied areas of Sri Lanka.

Disseminated tuberculosis presenting as hemophagocytic lymphohistiocytosis in an immunocompetent adult patient: a case report.

BACKGROUND: Hemophagocytic lymphohistiocytosis is a frequently fatal and likely underdiagnosed disease. It is a rare occurrence in adults and usually secondary to an insult such as viral infections, bacterial infections, autoimmune connective tissue disorders, malignancies and immunocompromised states, in contrast to its childhood counterpart, which is due to a genetic defect but may share some of same genetic etiologies. It is characterized by multisystem inflammation due to unregulated proliferation and infiltration of macrophages and CD8 T cells in the bone marrow, which leads to phagocytosis of red blood cells, platelets, lymphocytes and their precursors. CASE PRESENTATION: A 40-year-old Sri Lankan woman presented with a high-grade fever of 2 weeks' duration and the initial workup, including a thorough clinical examination, and all the investigations, including a septic screen, were normal. On the 18th day of hospital admission, she was found to have yellowish retinal lesions, which were confirmed as choroid tubercles by the consultant eye surgeon. Two days later she became pancytopenic and a bone marrow biopsy confirmed the diagnosis of hemophagocytic lymphohistiocytosis. She was treated with conventional category-1 antituberculous drugs and an initial 2 weeks with high-dose oral dexamethasone. All the choroid tubercles gradually disappeared and she recovered completely without any complications. CONCLUSIONS: In an adult patient with hemophagocytic lymphohistiocytosis, it is pivotal to understand the underlying etiology, as it needs extensive immunosuppression. If this patient had been treated with immunosuppressants without antituberculous medications, it would have been lethal with disseminated or central nervous system tuberculosis. So, in areas where tuberculosis is endemic, if no underlying cause is found, it may be worth considering antituberculous treatment for these patients. Re-evaluation with thorough clinical examination is of utmost importance in any patient with pyrexia of unknown origin as well as in any disease with unusual manifestations.

The effects of Losartan on abdominal wall fascial healing.

PURPOSE: Losartan, a commonly used angiotensin II receptor blocker (ARB) for blood pressure control, also impairs cutaneous wound healing. Our current study will analyze how Losartan affects wound healing in the muscle and fascia from both biomechanical and histological aspects. METHODS: A total of 26 Sprague-Dawley rats were separated into one control group (NS, N = 13) and one experimental group (LG, N = 13) to receive normal saline and 40 mg/kg of Losartan by way of gastric lavage, respectively. 7 days later, all animals were subjected to a 5 cm midline laparotomy. The fascia and skin were then closed with 4-0 prolene and 5-0 vicryl. 15 days postoperatively, the animals were sacrificed and the abdominal wall harvested for wound tensiometric test and histological analysis. RESULTS: All 26 rats survived to the time of necropsy. Tensiometry detected significantly higher wound tensile strength in the NS group (1.6 ± 0.31 N/mm) than in the LG (1.3 ± 0.28 N/mm) group (p = 0.016). Transection histology with trichrome staining demonstrated higher degree of immature fibroplasia inside the wound in the LG group than in the NS group (p = <0.0001). The LG group also had larger incisional gaps than the NG group. CONCLUSION: The antihypertensive drug, Losartan, retards wound healing in the abdominal fascia and reduces wound tensile strength in our rat model. Attention should be paid to the potential effects of various medications on fascial wound healing to guarantee optimal surgical outcomes.

The impact of developing a comprehensive hernia center on the referral patterns and complexity of hernia care.

BACKGROUND: Complex hernia repairs represent a formidable surgical challenge. Several comprehensive hernia centers, including ours, with advanced expertise have recently emerged across the country. However, the effects of tertiary specialization remain largely unclear. We aimed to evaluate the impact of developing a comprehensive hernia center on the referral patterns and costs of patients with complex hernias. METHODS: A prospectively maintained database was used to identify all patients undergoing open ventral hernia repair (VHR) between 2006 and 2013 at the Case Comprehensive Hernia Center. Patients were separated into two groups by zip code: those traveling either <25 or >100 miles. Demographics, operative characteristics, length of stay and costs data were analyzed. RESULTS: Of all patients who underwent open VHR during the study period, 287 met the inclusion criteria. Hernia length, width and area were all significantly larger for patients traveling >100 miles (P < 0.01 for all). These patients were also more likely to have active mesh infections (OR 3.57) and non-healing wounds (OR 5.00) when compared with local patients. Length of hospital stay was significantly longer for patients traveling >100 miles compared to those traveling <25 miles (9.7 vs. 6.8; P < 0.0001). Surgical site occurrence, infection and hernia recurrence rates were similar between the two groups during the follow-up period. Patients who traveled >100 miles incurred significantly higher fixed direct and variable direct costs compared to those who traveled <25 miles (P < 0.05 for both). CONCLUSION: The development of a comprehensive hernia center results in centralization of complex hernia care. Patients traveling >100 miles for ventral hernia repair have significantly larger and more complex hernias. The implications for improved patient outcomes and potential reimbursement issues for providing this care should be carefully evaluated.

Use of culture and immunochromatographic technique for diagnosis of trichomoniasis in Sri Lanka.

As a majority of the trichomoniasis patients are asymptomatic, laboratory tests are crucial in case detection. The usefulness of culture and immunochromatographic technique (ICT) compared to microscopy for detection of trichomoniasis in Sri Lanka was assessed. Females (16-45 years) from Colombo district were screened for Trichomonas vaginalis using three laboratory tests namely, microscopy of wet smear, Trichomonas liquid culture and ICT (OSOM® trichomonas rapid test). Trichomoniasis by at least one test being positive was 4.8%. Microscopy, culture and ICT detected 2.8%, 4.2% and 10% cases respectively. Microscopy missed 32% of culture positives. ICT is a simple, practical and reliable alternative to microscopy in laboratory diagnosis of trichomoniasis.

Incidental finding of peripheral B-cell non-Hodgkin lymphoma, lymphocytic/CLL type, of the gallbladder in a patient with chronic cholecystitis.

Although lymphoma involvement of the gallbladder, especially by MALT and large-cell types, is rare, this possibility should be considered in patients with symptoms of acute cholecystitis. A cholecystectomy was performed in a 79-year-old male patient with a clinical diagnosis of chronic cholecystitis. Histologically, the specimen showed an incidental finding of a small lymphocytic lymphoma (CLL) by morphologic and immunophenotyping studies, subsequently confirmed with flow cytometric analysis of blood. During follow-up, multiple lymph node enlargement was detected. An axillary node, excised and submitted to our department, was positive for lymphoma involvement. The bone marrow was negative.

Total agranulocytosis caused by dapsone therapy for tuberculoid leprosy--an unappreciated serious side effect of anti-leprosy treatment with clinical implications.

Dapsone-induced agranulocytosis is a rare but potentially fatal adverse effect of treatment for tuberculoid leprosy. Publications distributed by the WHO Leprosy Elimination Campaign for patient information on leprosy do not contain any advice or guidelines for post-dapsone therapy follow-up. As a result of this major deficiency, the local anti-leprosy campaign in Sri Lanka has no such guidelines on dapsone therapy for leprosy patients. We report two patients with total agranulocytosis caused by dapsone therapy for tuberculoid leprosy including one fatality. As leprosy is more prevalent in developing countries such as Sri Lanka, we recommend that WHO publications on patient information should include post-dapsone therapy follow-up guidelines to avoid such catastrophes which are undetected until the patients are critically ill.

Determinants of acquisition and carriage of Staphylococcus aureus in infancy.

Nasal carriage of Staphylococcus aureus is a major risk factor for invasive S. aureus disease. The aim of this study was to define factors associated with carriage. We conducted a prospective, longitudinal community-based study of infants and their mothers for a period of 6 months following delivery. The epidemiology of carriage was examined for 100 infant-mother pairs. Infant carriage varied significantly with age, falling from 40 to 50% during the first 8 weeks to 21% by 6 months. Determinants of infant S. aureus carriage included maternal carriage, breastfeeding, and number of siblings. Bacterial typing of S. aureus was performed by pulsed-field gel electrophoresis and multilocus sequence typing. The majority of individuals carried a single strain of S. aureus over time, and the mother was the usual source for colonizing isolates in infants. The effect of other components of the normal nasal flora on the development of S. aureus carriage was examined in 157 consecutive infants. Negative associations (putative bacterial interference) between S. aureus and other species occurred early in infancy but were not sustained. An increasing antistaphylococcal effect observed over time was not attributable to bacterial interference. S. aureus carriage in infants is likely to be determined by a combination of host, environmental, and bacterial factors, but bacterial interference does not appear to be an ultimate determinant of carrier status.

Comparison of multilocus sequence typing and pulsed-field gel electrophoresis as tools for typing Staphylococcus aureus isolates in a microepidemiological setting.

Multilocus sequence typing (MLST) of Staphylococcus aureus is well suited to the study of global or long-term epidemiology, but its role in local epidemiology has not been defined. The present study has compared MLST with pulsed-field gel electrophoresis (PFGE) by using S. aureus isolates associated with carriage and disease in a busy regional renal unit. One hundred forty-four patients were prospectively recruited, of whom 103 were receiving hemodialysis and 41 were on continuous ambulatory peritoneal dialysis. Three nasal swab specimens were obtained 1 month apart on entering the study. A nasal swab was positive for S. aureus on at least one occasion in 50 patients (35%). Typing of the 104 carriage isolates demonstrated 21 PFGE types and 21 sequence types (STs). Thirty-one carriers had two or more positive nasal swabs; of these, the isolates in all swabs from a given carrier had identical PFGE types for 29 carriers; the isolates in all of the same 29 swabs had identical STs. The carriage strain in two patients changed both PFGE type and STs during the period of swabbing. Eight patients (6%) had an episode of S. aureus bacteremia during the 12-month study period, and two of these were nasal carriers. One of these invasive isolates had the same PFGE type and ST as the carriage isolate. There were no differences between Simpson's index of diversity for PFGE and Simpson's index of diversity for MLST for both invasive and carriage isolates, suggesting that the two methods have very similar discriminatory abilities. We conclude that PFGE and MLST performed equally in this study.

The ica operon and biofilm production in coagulase-negative Staphylococci associated with carriage and disease in a neonatal intensive care unit.

Coagulase-negative staphylococci (CoNS) are a major cause of sepsis in the neonatal intensive care unit (NICU). We evaluated the hypothesis that the ica operon and biofilm production are associated with CoNS disease in this setting. CoNS associated with bacteremia or blood culture contamination and from the skin of infants with CoNS bacteremia or healthy controls were obtained during a prospective case-control study on a busy NICU. A total of 180 strains were identified, of which 122 (68%) were Staphylococcus epidermidis and the remainder were S. capitis (n = 29), S. haemolyticus (n = 11), S. hominis (n = 9), S. warneri (n = 8), and S. auricularis (n = 1). The presence of the genes icaA, icaB, icaC, and icaD was determined by PCR, and biofilm production was examined using qualitative (Congo red agar [CRA]) and quantitative (microtiter plate) techniques. There were no significant differences in the presence of the ica operon or CRA positivity among the four groups of strains. However, quantitative biofilm production was significantly greater in strains isolated from either the blood or the skin of neonates with S. epidermidis bacteremia. We conclude that the quantity of biofilm produced may be associated with the ability to cause CoNS infection. This conclusion suggests that the regulation of biofilm expression may play a central role in the disease process.

Genetic population structure of coagulase-negative staphylococci associated with carriage and disease in preterm infants.

Coagulase-negative staphylococci (CoNS) are a leading cause of sepsis in the neonatal intensive care unit (NICU) setting. To evaluate the hypothesis that isolates of CoNS associated with disease belong to hypervirulent clones, as opposed to being drawn randomly from the neonatal unit carriage flora, we conducted a prospective, case-controlled study in a busy NICU. Using pulsed-field gel electrophoresis (PFGE), we compared the population structures of CoNS isolates associated with bacteremia with isolates from the skin of healthy and infected neonates and with blood culture contaminants. Endemic clones of CoNS were identified, but there was no difference in the distribution of the 6 species or 73 PFGE types between the carriage and disease isolate groups; this suggests that hypervirulent clones with an enhanced ability to cause disease were not present in this NICU setting.

Long-term efficacy of single-dose combinations of albendazole, ivermectin and diethylcarbamazine for the treatment of bancroftian filariasis.

In a 'blinded' trial (in Sri Lanka, 1996-98) of 47 male asymptomatic microfilaraemic subjects with Wuchereria bancrofti infection, the safety, tolerability and filaricidal efficacy of 3 single-dose combination regimens were compared: albendazole 400 mg with ivermectin 200 micrograms/kg, albendazole 400 mg with diethylcarbamazine citrate (DEC) 6 mg/kg or albendazole 600 mg with ivermectin 400 micrograms/kg. Treated subjects were followed-up for 24 months. This represents the first long-term study using combinations of albendazole with DEC or ivermectin in the above doses against bancroftian filariasis. All subjects had pre-treatment microfilaria (mf) counts over 100/mL. All 3 treatments significantly reduced mf counts, with the albendazole-DEC-treated group showing the lowest mf levels at 18 and 24 months post-treatment. Filarial antigen tests suggested that all 3 treatments had significant activity against adult W. bancrofti; albendazole-DEC combination had the greatest activity according to this test, with antigen levels decreasing to 30.5% of pre-treatment antigen levels, 24 months after therapy. All 3 treatments were clinically safe and well tolerated. These results suggest that a single dose of albendazole 400 mg together with DEC 6 mg/kg is a safe and effective combination for suppression of microfilaraemia of bancroftian filariasis that could be considered for use in filariasis control programmes based on mass treatment of endemic populations.

Obstetric performance, perinatal outcome and risk of infection to the newborn in spontaneous and artificial rupture of membranes during labour.

OBJECTIVE: To compare the obstetric performance, perinatal outcome and risk of neonatal infection in labour following spontaneous (SROM) and artificial (AROM) rupture of membranes. DESIGN: Prospective, non-randomised, comparative study during a one-month period in 1995. The study was approved by the ethics committee of the Faculty of Medicine, University of Colombo. SETTING: University Obstetrics Unit at De Soysa Hospital for Women, Colombo. PATIENTS: 324 women who were in early established labour after 37 weeks of gestation. 151 of these had SROM and 173 AROM. The AROM and SROM groups among primigravidae and multigravidae were considered separately. RESULTS: Oxytocin use in multigravidae was significantly higher in the AROM group than in the SROM group (p < 0.001). The emergency caesarean section (LSCS) rate in primigravidae was significantly higher in the AROM group than the SROM group (p < 0.001). A significantly larger number of primigravid AROM women had abnormal fetal heart rate changes on auscultation (p < 0.05) and cardiotopographic (CTG) patterns (p < 0.001) when compared with primigravid SROM women. Choreoamnionitis and funisitis were commoner in the AROM group although the difference was not statistically significant. CONCLUSIONS: AROM appears to be associated with a higher chance of fetal distress particularly in primigravidae. Both AROM and SROM are associated with a potential risk of infection at intrauterine sites.

PIP: Artificial rupture of the membranes during established labor is believed to augment labor progression, but this practice carries the risk of maternal and neonatal infection. A prospective study conducted at De Soysa Hospital for Women in Colombo, Ceylon, in 1995 compared the obstetric performance, perinatal outcome, and risk of neonatal infection in 151 women with spontaneous rupture of membranes (SROM) and 173 women with artificial rupture of membranes (AROM). The need for oxytocin was higher in both primi- and multigravidae in the AROM group (37.5% and 38.8%, respectively) than the SROM group (24.7% and 18.9%, respectively), but this association reached statistical significance only among multigravidae. Also higher in the AROM group than the SROM group, but not significantly, were the rates of instrumental delivery and emergency cesarean section. Compared with primigravid AROM women, a significantly larger number of primigravid AROM women had abnormal auscultated fetal heart rates and cardiotopographic patterns. The appearance of meconium in liquor and the occurrence of low Apgar scores were similar in both groups. There were no clinical maternal or neonatal infections, but the intrauterine sites showed evidence of inflammation soon after membrane rupture. 36.1% of women in the SROM group and 24.0% of those in the AROM group whose cord and membranes were evaluated had histologic evidence of inflammation. Choreoamnionitis and funisitis were slightly more common in the AROM group. The potential for infection at intrauterine sites had no linear relationship to the mean membrane rupture-delivery interval or the number of vaginal examinations.