Conference Papers
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This collection contains abstracts of conference papers, presented at local and international conferences by the staff of the Faculty of Medicine
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Item Early hepatitis is the strongest risk factor for the development of severe dengue infection: A points-based risk-score to predict critical disease in dengue fever(Sri Lanka Medical Association, 2018) Niriella, M.A.; Udeshika, A.K.M.A.; Liyanage, I.K.; de Silva, A.P.; de Silva, H.J.INTRODUCTION AND OBJECTIVES: Some dengue fever (DF) patients develop plasma leakage [critical-phase (CP)], which may progress to multi-organ failure. We attempted to identify early predictors ofCP in DF. METHODS: This was a retrospective, case-record-based study. Clinical, laboratory features in the first three-days (Dl-3) of illness was used to formulate a risk prediction model (RPM). Patients with serologically confirmed DF, admitted to the University Medical Unit, Teaching Hospital, Ragama, from 01.01.2017-30.06.2017 were included. Patients were randomly assigned to training (TD) and validation datasets (VD) of equal size. Stepwise multivariate logistic regression (p<0.05) was used to identify risk factors in TD. Versions of RPM were compared using Akaike criteria and McFadden's adjusted R2. Coefficients from the best RPM were used to derive weighted risk scores. Best RPM was validated in VD using C-statistic. RESULTS: 697 patients were included (mean-age:34.7±16.1 years, females-48.8%, TD=350, VD=346). CP developed inJ27 (32.6%). Mortality was I%. Risk predictors (p<0.05) were: female gender (OR=2.l), diabetes (OR=l.8), vomiting (OR=l.9), platelets60 IU/L (OR=3.3). In multivariate analysis, female gender (score=2), vomiting (score=3), platelets<120,000/mm-3 (score=3) and AST>60 IU/L 3 (score=4) were significant while diabetes was non-significant. Calculated RPM score ranged from 0-12. C-statistic for the TD was 0.78 and VD 0.77 (Hosmer-Lemeshow test: p=0.19 and 0.34 respectively). A cut-off of 5 was selected to maximise sensitivity (0.96), negative predictive value (0.95) with specificity of 0.44. CONCLUSION: This simple risk score seems useful in identifying those at risk ofCP within Dl-3 of the onset ofDF. The early presence of dengue hepatitis was the strongest predictor of CP.Item A Statistical Approach to Define Thresholds for Dengue Epidemic Management in Akurana Medical Officer of Health Area, Kandy District of Sri Lanka(19th Conference on Postgraduate Research, International Postgraduate Research Conference 2018, Faculty of Graduate Studies,University of Kelaniya, Sri Lanka, 2018) Udayanga, N.W.B.A.L.; Gunathilaka, P.A.D.H.N.; Iqbal, M.C.M.; Fernando, M.A.S.T.; Abeyewickreme, W.Stegomyia indices, namely; Premise Index (PI), Breteau Index (BI) and Container Index (CI) are used forvector management approaches in Sri Lanka. Properly defined threshold values for larval indices are of higher importance to provide forecasts on dengue epidemics and also for effective larval management of dengue vectors. However, such critical thresholds are poorly defined for Sri Lanka. The present study aimed to define threshold values forabove larval indices for dengue epidemic management in the Akurana Medical Officer of Health (MOH) in the Kandy District. Larval surveys were conducted on a monthly basis from January, 2016 to June, 2018. Four larval indices, namely BI for Aedesaegypti (BIA) and Aedesalbopictus (BIB), PI and CI were calculated. Further, monthly larval indices of AkuranaMOH area from January, 2012 to December, 2015, were obtained from the MOH office, along with monthly reported dengue cases for the entire study period. Receiver Operating Characteristic (ROC) curves in SPSS (version 23) were used to assess the discriminative power of the larval indices in determiningdengue epidemics and thresholds based on larval indices. As indicated by the area of ROC curve (AUC), the BIA (0.661) and PI (0.637) were having a notable discriminative power to forecast dengue epidemics at a two-month lag period. Both BIB (0.397) and CI (0.526) were non-informative influencers at one and two-month lag periods. The BIA and PI were better predictors of dengue incidence than BIB and CI. Based on the ROC curve, three risk thresholds were defined for BIA as Low Risk (BIA≤2.1), Moderate Risk (3.9≤BIA<4.85), and High Risk (BIA≥4.85), with respect to Ae. aegypti. According to the PI, thresholds were defined as Low Risk (PI≤6.2), Moderate Risk (7.7≤ PI<9.9), and High Risk (PI≥ 9.9). Threshold values defined for BI of Ae. aegypti and PI, could be recommended to be considered in implementing vector control efforts in the above study area for effective dengue epidemic management, through pre planned entomological management of dengue vectors.Item Predicting acute liver failure in dengue Infection(American Gastroenterological Association(AGA) Institute, Published by Elsevier Inc., 2013) Ranawaka, C.; Niriella, M.A.; Kumarasena, R.S.; Miththinda, J.K.N.D.; de Silva, A.P.; Premaratna, R.; de Silva, H.J.BACKGROUND: Dengue infections (DI) can range from being asymptomatic to severe illness. Unusual manifestations such as encephalitis, myocarditis, and acute liver failure (ALF) have been recognized. ALF is uncommon, but has a poor prognosis. The aim of this study was to identify predictors of ALF in DI. METHODS: Serologically confirmed patients with DI who were admitted to hospital from January 2009 to March 2010 were included. Patients consisted of direct admissions as well as referrals, some with deranged liver functions. Data was obtained from patient records. Clinical details and serum biochemistry was evaluated for up to five days from onset of illness. ALF in DI was defined as evidence of coagulation abnormality [International normalised ratio (INR) ≥ 1.5], and any degree of mental alteration (encephalopathy) in a patient without pre-existing cirrhosis. RESULTS: Out of 240 patients [57.7% male, 42.3% female; mean age 35.6 years (SD 15.4 years)], 164 had dengue with warning signs, 27 had dengue without warning signs and 49 had severe dengue. 15/49 severe dengue patients had profound shock. Abdominal pain, persistent nausea and vomiting (PNV), bleeding, hepatomegaly and ascites were present in 125, 92, 39, 129 and 28 cases respectively. Elevated aspartate aminotransferase (AST), serum bilirubin (SB), alkaline phosphatase (ALP) and gamma glutamyl transpeptide (GGT) were observed in 208, 20, 18 and 60 patients respectively. Of the 240 patients 41 had AST .1000 IU/ml (this included 4/ 15 with profound shock). 16/41 patients with AST .1000 IU/ml, including 4 with profound shock, developed ALF while none with AST ,1000 IU/ml developed ALF. In patients with AST .1000 IU/ml, presence of 2 or 3 of elevated SB, elevated ALP or PNV predicted the development of ALF with 93.8% sensitivity, 98.7% specificity, 83.3% positive predictive value and 99% negative predictive value (Fisher's exact test). CONCLUSIONS: Dengue patients with AST,1000 IU/ml are not at risk of developing ALF. Patients with AST .1000 (regardless of presence or absence of profound shock), with 2 or 3 of elevated SB, elevated ALP or PNV seem to be at risk of developing ALF. These findings need to be validated in a larger cohort of patients.Item Dengue fever with bleeding manifestations in pregnancy: our experience(Sri Lanka College of Obstetricians and Gynaecologists, 2004) de Silva, B.A.; Palihawadana, T.S.; Fernando, W.S.; Wijesinghe, P.S.Dengue fever, a mosquito borne flavivirus infection is endemic in Sri Lanka. An increased number of cases are seen in the recent past. An increase in the number of patients with secondary infection who are prone to develop complications such as bleeding manifestations, are expected due to repeated outbreaks of the disease, We report four cases of serologically confirmed Dengue fever. Different management strategies were adopted in each patient according to the clinical circumstances. Three antenatal mothers presented in 33, 38 and 39 weeks of POA and bleeding manifestations were present in all three of them. One of them died of an intracerebral haemorrhage after Caesarean section to deliver a stillborn following intrauterine death. Post Partum Haemorrhage (PPH) was experienced in another mother following caesarean section. In one patient bleeding manifestation appeared 2 days following normal delivery. She was managed conservatively. Though the clinical presentations may be similar to that of non pregnant patients, there can be many pitfalls in diagnosis and management of dengue fever occurring in pregnancy. Two of the patients described above developed acute dengue viral hepatitis, which needs to be differentiated from HELLP syndrome and acute fatty liver of pregnancy. Serological tests have a special place in diagnosis than in the non pregnant patients. The classical criteria used to identify Dengue Haemorrhagic fever (DHF), such as an increased haemotocrit and postural hypotension were not present in these patients. In management, the administration of intravenous fluids needed to be more closely observed. They seemed to be more prone to develop bleeding manifestations than non pregnant patients and therefore platelet transfusions were required in early stages. Early interventions to deliver the baby, if the other circumstances permit, seem to offer a better outcome in patients presenting in the antenatal period.Item Evaluation of a rapid whole blood assay for testing dengue patients at point of care(Sri Lanka College of Microbiologists, 2004) Sunil-Chandra, N.P.; Karunasekera, E.W.S.; Somasiri, D.A.D.H.; Samarakoon, S.M.R.M.; Jayawardena, K.A.T.M.; Fernando, W.M.D.; Wijesooriya, W.R.P.L.I.; Garcia, M.INTRODUCTION: Dengue is the most significant mosquito borne viral disease affecting nations from Asia to the Americas. Symptoms associated with dengue infection range in severity. . The presentation of disease is impacted by age, prior exposure to the virus and the infecting strain of virus. The more severe form of the disease (haemorrhagic fever) can lead to mortality are generally associated with Secondary infections. Clinically, the measurement of dengue-specific IgM and elevated IgG, allows for the detection and differentiation of Primary and Secondary dengue infection. This discrimination is particularly important in situations such as outbreaks where the allocation of resources needs to be directed to those at greatest risk. In cities and major regional centers worldwide clinicians have access to traditional serological techniques such as ELISA and HAI that measure IgM and IgG levels. Unfortunately, clinicians in rural and remote areas generally do not have the resources available for this technology. Hence there is high clinical utility in a field diagnostic device which has the ability to rapidly and accurately detect and differentiate dengue infections. OBJECTIVES: To evaluate a novel dengue whole blood assay (PanBio) having the capacity for qualitative detection of both dengue-specific IgM and IgG, and differentiate between primary and secondary dengue with regard to sensitivity and specificity. To meet the demand for testing at the point of care or in the near patient environment, the test was required to have the capacity to detect antibodies in whole blood. DESIGN, SETTING AND METHODS: This assay device was used at the bed site of patients to evaluate its performance. The test is simply performed by adding the specimen to the sample well followed by running buffer to the buffer well, wait 15 minutes and visually reading the results. No additional materials required. 231 hospital inpatients in the Gampaha district of Sri Lanka, using a finger prick drop of blood as the analyte were assessed against PanBio Dengue Capture IgM and IgG ELISA for the period of 6 weeks starting from 10Ih November 2003. The capacity to detect and differentiate presumptive primary and secondary dengue was evaluated. RESULTS: The whole blood dengue cassette was able to detect 151 positive and 80 negative samples where as the ELISA could detect 126 positive samples and 105 negative patients. The detection of IgM and IgG positive samples by the cassette gave a relative sensitivity of 94.5%, specificity of 86% and 87.1% agreement between the assays. The cassette was able to identify 71% of positive samples as primary infections (IgM positive) and 96.7% as secondary infections (IgG positive with or without IgM) compared to ELISA. CONCLUSION: These data indicate that the Whole Blood Dengue Cassette has good utility in the detection of primary and secondary dengue with a very high accuracy in discriminating patients at greatest risk and represents a valuable field based assay to support the clinical evaluation of patients presenting with symptoms suggestive of dengue fever. ACKNOWLEDGEMENTS: PanBio Ltd, Australia for the financial assistance and Directors of Teaching hospital Ragama and Base hospitals of Negombo, Gampaha and Wathupitiwala.Item A comparison of serological diagnostic techniques in Dengue fever(Sri Lanka College of Microbiologists, 2005) Gunasekera, H.A.K.M.; Senanayake, C.P.; Sunil-Chandra, N.P.; Mendis, L.INTRODUCTION: The Dengue Duo IgM and IgG Rapid Strip test (PanBio Pvt. Ltd., Brisbane, Australia) is a commercially available immunochromatographic test. The Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok Thailand, has developed an in-house anti-dengue/anti-JE IgM and IgG reference enzyme-linked immunosorbent assay (ELISA). OBJECTIVE: To compare the usefulness of the AFRIMS ELISA and PanBio Dengue Duo IgM and IgG Rapid Strip test (PanBio Strip test) in the diagnosis of dengue infections. MATERIALS AND METHOD: 93 non-bacterial undifferentiated fever cases and 50 suspected dengue fever cases were screened for dengue and JE virus infections by the AFRIMS ELISA and also by the PanBio Strip test for dengue. All cases positive for dengue antibodies by either test were also tested by the Haemagglutination Inhibition test. RESULTS: Results were considered conclusive when at least 2 or all 3 of the above tests agreed. The AFRIMS ELISA had a sensitivity of 91.7% and specificity of 100% while the PanBio Strip test has a sensitivity of 93.8% and specificity of 96.8% in diagnosing dengue infections. 91.7% primary and 91.4% secondary infections were correctly classified by the AFRIMS ELISA. The PanBio Strip test identified 100% primary infections and 65.7% of secondary infections. CONCLUSIONS: The PanBio Strip test has a sensitivity and specificity comparable to the AFRIMS ELISA in diagnosing dengue infections although it tends to underestimate the number of secondary infections.Item Repeated dengue shock syndrome and "Dengue myocarditis" responding dramatically to a single dose methyl prednisolone(Sri Lanka Medical Association, 2012) Premaratna, R.; Rodrigo, K.M.D.; Anuratha, A.; de Alwis, V.K.D.; Perera, U.D.C.A.; de Silva, H.J.INTRODUCTION: Place of steroids in the management of severe dengue is unclear. A retrospective observational study appeared to show benefit of methylprednisolone (MP) in a highly selected group of patients. CASE REPORT: A 14-year-old schoolboy developed "myocarditis" (4th day) and on the fifth day, he collapsed with Dengue shock syndrome DSS needing rapid resuscitation with intravenous fluid boluses and dextran. He continued to have high fever (39-410C), and pulse rate (PR)>110/min and developed two further episodes of DSS and was resuscitated with further boluses of dextran. As there was no response with temperature 40.20C, PR 160/min, mid-arm systolic BP 70 mmHg, confused, restless, respiratory rate 36/min, dropping capillary 02 saturation, moderate pleural effusions and ascites, urine output <0.2ml/kg/Hr, made it extremely difficult to select the amount and type of fluid for resuscitation. Due to rapid deterioration a single dose of methylprednisolone (MP) (SOOmg in 200ml saline iv over 20 minutes) was administered as a rescue medication. He had deferversence within 30 minutes, became conscious and alert in 1 hour, PR reduced to 96/minute, BP remained stable above 100/80mmHg and urine output increased to 0.8-1.4ml/Kg/Hr. His ECG became normal after 3 hours, and the echo cardiogram in 12 hours (EF-55%). CONCLUSIONS: This patient with dengue developed three episodes of severe haemodynamic compromise within 12 hours while having third space fluid accumulation, "myocardits" and altered level of consciousness making it difficult to institute fluid therapy. A single dose of MP given as rescue measure resulted in a dramatic recovery suggesting a beneficial effect of MP in sever dengue.byItem Predictors of duration and degree of third space fluid accumulation in adult patients with dengue(Sri Lanka Medical Association, 2012) Premaratna, R.; Ragupathy, A.; Miththinda, J.K.N.D.; de Silva, H.J.INTRODUCTION: Fluid leakage is the hallmark of dengue shock syndrome. It is important to identify clinical and biochemical parameters which predict duration and degree of fluid leakage in dengue. METHODS: 102 patients with confirmed dengue were prospectively followed up for clinical, haematological and biochemical parameters, and they were correlated with ultrasonographic evidence of third space fluid accumulation (TSFA). RESULTS: Of the 102 patients (52 males; mean age 28.3 years(SD=11.8), TSFA was detected in 34/95(36%) after hospital admission; 33/95 had pleural effusions which included all except one of 21/95 who had ascites. 72.7% pleural effusions lasted 3 or more days and 52.4% ascites lasted less than 3 days. Duration of pleural effusion showed a significant positive correlation with maximum percentage rises of PCV (r=0.526,p=0.001) and Hb(r=0.525, p=0.001) and negatively correlated with WBC count (r=-0.361, p=0.020) and platelet count (r=-0.585, p=0.000). There was no correlation with any of the other parameters. The mean lowest WBC count of 3005/mm3that was recorded for patients who developed bilateral pleural effusions (n=21) was significantly less (p=0.042) than the mean lowest WBC count of 4091/mm3 that was detected for unilateral effusions(n=12). Duration of ascites was significantly positively correlated with highest AST(r=0.598, p=0.002) and highest ALT(n=0.721, p=.001. CONCLUSIONS: Maximum percentage rise of Hb and PCV, lower WBC and platelet counts seem to be associated TSFA. Among these, lower WBC counts appear to be more predictive of the degree of fluid leakage. Higher ALT and AST levels seem to be useful in predicting the duration of ascites.Item Predicting acute liver failure in dengue infection(Wiley Blackwell Scientific Publications, 2012) Ranawaka, C.K.; Kumarasena, R.S.; Niriella, M.A.; Miththinda, J.K.N.D.; Pathmeswaran, A.; Dassanayake, A.S.; de Silva, A.P.; Premaratna, R.; de Silva, H.J.BACKGROUND AND AIM: Dengue infections (DI) have a diverse clinical spectrum ranging from asymptomatic illness to severe dengue. Unusual manifestations such as encephalitis, myocarditis, and acute liver failure (ALF) are increasingly recognized. Though ALF is less common has a poor prognosis. Aim of this study was to identify possible predictors of ALF in DI. METHOD: Serologically confirmed patients with DI, admitted to university medical unit, Ragama, Sri Lanka from January 2009 to March 2010 were included. Patients were consisted of direct admission as well as referrals with deranged liver functions. Data was obtained from patient records. RESULTS AND DISCUSSION: Out of 240 patients (male : female 57.7%:42.5%; mean age 35.6 years [SD 15.4 years]), 164 had dengue with warning signs, 27 had dengue without warning signs and 49 had severe dengue. 15/49 severe dengue patients had profound shock. Abdominal pain, persistent vomiting (PV), bleeding, hepatomegaly and ascites were present in 125, 92, 39,129 and 28 cases respectively. Elevated AST/ALT, serum bilirubin (SB), alkaline phosphatase (ALP) and gamma glutamyl transpeptide (GGT) were observed in 208, 20, 18 and 60 patients respectively. Of the 240 patients 41 had AST/ALT > 1000 IU/ml and 199 had AST/ALT < 1000 IU/ml. Only 16/41 patients with AST/ALT > 1000 IU/ml developed ALF while none from the AST/ALT < 1000 IU/ml group. Only 4/15 of profound shock had ALF. Patients with AST/ALT > 1000 IU/ml, presence of 2 or 3 of; elevated SB, elevated ALP or PV predicted the development of ALF with 93.8% sensitivity, 98.7% specificity, 83.3% positive predictive value (PPV) and 99% negative predictive value (NPV) with p < 0.001. CONCLUSIONS: Dengue patients who’s AST/ALT < 1000 IU/ml, excluded patients at risk of ALF. Presence of 2 or 3 of: PV, elevated SB or elevated ALP in a patient with AST/ALT > 1000 IU/ml may indicate impending ALF. This needs further validation in a larger populationItem Evaluation of the spatial and temporal trends of dengue outbreaks in Gampola, Central Province, Sri Lanka(University of Peradeniya, 2015) Udayanaga, N.W.B.A.L.; Gunathilaka, H.N.; Iqbal, M.C.M.; Abeyewickreme, W.Dengue is the world's fastest growing vector borne disease, and it has become one of the major health concerns in many countries including Sri Lanka. Despite immense efforts and control strategies it claims 30,000 - 35,000 deaths per year, making dengue a priority heath issue in Sri Lanka. Investigation of the recent trends of dengue outbreaks on both a spatial and temporal scale is of high importance in drafting and implementing effective management/action plans to ensure successful management and control of dengue epidemics on a regional scale. Hence, a statistic and geo informatics based analysis of the recent trends in dengue distribution was carried out to identify spatial and temporal trends in distribution patterns of dengue in the Gampola Medical Officer of Health (MOH) division. Monthly records of reported dengue cases from 2009 to 2013 of the Gampola MOH division were collected. A scatter plot analysis in MINITAB (version 14.12.0) was devised to identify the temporal patterns in the reported dengue cases. Arc GIS (version 10.1) was devised to develop spatial maps (at the GND level) of the recorded dengue case distribution for each month and for the whole study period, for Gampola. Furthermore, spatial (at GND level) and temporal (annual) variations in dengue outbreak distribution within the Gampola MOH were analyzed to recognize the recent trends in dengue distribution. Gampola East, Gampola West, Illawathura, Keerapane, Kahatapitiya, Egodakalugamuwa and Pussellawa localities emerged as high-risk areas, while Polkumbura, Kurukude, Galgediyawa, Amuhena and Hunukotugama emerged as low risk areas for dengue outbreaks. Further localities, namely Godagama, Kalugalhinna, Kekulanda, Millagaspitiya, Sinhapitiya North, Sinhapitiya South, Pussellawagama, Ranawala and Wanahapuwa remained unchallenged by dengue throughout 2009 - 2013. The paired-Chi square test revealed significant spatial and temporal variations in the emergence of dengue outbreaks within the Gampola MOH throughout the study period \>x2 w. 0.95} = 65.156]. Regionalized evaluation of recent trends in temporal and spatial distribution of dengue outbreaks are recommended in the design and implementation of management plans to control the rise of dengue, and also in the evaluation of the effectiveness of already implemented practices taken to reduce and control dengue outbreaks, by the government sector and other relevant entities.