Graduate Studies
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Item Role of Mycoplasma pneumoniae in the exacerbation of childhood asthma in Sri Lanka(Faculty of Graduate Studies, University of Kelaniya Sri Lanka, 2022) Wijesooriya, L. I.; Chalker, V. J.; Perera, P.; Sunil Chandra, N. P.Asthma is a major public health concern, particularly in children. Exacerbation of asthma (EOA) is lifethreatening and respiratory infections (RIs) play a key role. Pediatric RIs are empirically treated with macrolides aiming M. pneumoniae. Although EOA and M. pneumoniae have been reported in many countries, no published data on them is in Sri Lanka. The present study aimed to identify the role of M. pneumoniae in EOA in children in Sri Lanka. A case-control study was conducted in the pediatric unit of North Colombo Teaching Hospital, Sri Lanka involving children between 3-15 years. Caseschildren with EOA. Controls-children with stable asthma without exacerbation. Each group consisted of 100 children. Sputum/throat swabs were tested for M. pneumoniae using GeneProof M. pneumoniae RT-PCR kit, which targets community-acquired respiratory distress syndrome (CARDS) toxin. Age distribution-80% of cases and 87% of controls were 5-10 years. Males and females were equally distributed in cases while it was 47% and 53% respectively in the control group. Of the samples, 78% were sputum and 22% were throat swabs in cases and 100% were throat swabs in controls. Macrolides were used to treat 42% of cases. As per M. pneumoniae RT- PCR data, 1/100 were positive from cases and none was positive from the control group. M. pneumoniae was uncommon in cases (1%) and absent from the control group. Macrolides are used widely in children for RIs aiming M. pneumoniae. Yet, it does not seem a major contributing factor to asthma exacerbation in the study cohort. However, a large proportion of cases receiving macrolides may have reduced the detection of M. pneumoniae. Empiric use of antibiotics in children with asthma may be better targeted with microbiological screening to inform treatment. Inappropriate use may result in the development of resistance to other common respiratory pathogens.Item Precipitating factors of acute severe asthma among children of 3–15 years: A descriptive cross-sectional study(Faculty of Graduate Studies, University of Kelaniya Sri Lanka, 2022) Wijesooriya, L. I.; Perera, P.; Sunil Chandra, N. P.Despite a better understanding of pathophysiology and novel treatment modalities, children presenting with acute exacerbation of asthma (AEA) are still common. Descriptive information on asthma and factors precipitating AEA would provide a better understanding of the reasons for AEA. The present study aimed to identify such factors in a cohort of children in Sri Lanka. A descriptive cross-sectional study was conducted at the Teaching Hospital, Ragama, Sri Lanka involving children between 3-15 years. The sample consisted of 100 children admitted with AEA. Events that led to AEA were obtained from the mother. Data were obtained using a questionnaire from parents/guardians/children and analyzed using R-statistical software. Around 80% of the recruited children were in the 5–10-year range, and there was no significant gender difference. Of the descriptive data, potential risk factors identified for AEA were indoor smoking 12%, use of mosquito coils 28%, use of joss sticks 43%, and specific foods such as goat milk, yogurt, curd, ice cream, etc.- 30% and use of firewood for cooking 39%. Regarding the risk factors for AEA, the intake of specific foods was significantly higher in association compared to indoor smoking (P=0.011). Sixty-six children had a full blood count which showed leukocytosis in 33.4%, neutrophilia in 62.1%, lymphocytosis in 6.1%, and eosinophilia in 9.1%. Neutrophilia was significantly higher compared to lymphocytosis (P=0.000) and eosinophilia (P=0.000) in the study cohort. CRP was available in six patients, of which three had increased levels. Blood cultures were available in 11 patients, but all were negative. None of the children had a microbiological diagnosis. Of the 21 children who underwent chest x-rays, only one had evidence of pneumonia. Fifty-two percent of children presenting with AEA were on regular inhaler therapy. Identified main risk factors for EOA were indoor smoking and burning of Joss sticks or firewood. In nearly one-third of the patients, food items were the precipitating factor. Though respiratory tract infections are implicated as a major cause of AEA, only a smaller percentage had evidence of infections. This may be because routine microbiological investigations were not employed. More than half of the children presenting with AEA were on regular inhaler therapy raising the question of the appropriateness of the medication used and the compliance with treatment.Item A descriptive study on infections acquired in an intensive care unit of a secondary healthcare center in Sri Lanka(Faculty of Graduate Studies, University of Kelaniya Sri Lanka, 2022) Madhusankha, A. T.; Iddamalgoda, H.; Jayawardana, G. P. C.; Karunasekara, H. C. I.; Wijesooriya, L. I.Nosocomial infections are a substantial burden, particularly in patients admitted to intensive care units (ICUs). Present study was aimed to find the incidence, risk factors, and associated mortality of ICUAIs. A descriptive cross-sectional study was conducted among patients who were admitted to the ICU of Base Hospital, Wathupitiwala, Sri Lanka for three months from April-2019. A total of 250 patients who were admitted to ICU or readmitted 72 hours after discharge from the ICU were included. Demographic data and risk factors for infections were gathered from bed-head tickets. Microbiological screening samples were cultured to identify infections on admission to ICU. Screening-negative patients underwent repeat sampling for culture and antibiotic sensitivity testing (ABST) on each 3rd day of ICU stay. Of 250 patients, mean age was 57.08±17.65 and (52.8%) were males. Major indications for ICU admission were monitoring (50.4%) and ventilatory support (47.2%). Of the 250 patients, 34 patients (13.6%) were diagnosed with ICUAIs. Of the patients with ICUAIs, 35.29% were in 61-70 years. At least one risk factor was shown by 132 patients (52.8%). Those risk factors were; hypertension (OR=2.09, P= 0.06), bronchial asthma (OR=1.26, P= 0.60), epilepsy (OR= 3.29, P=0.20), ischemic heart disease (OR=1.52, P=0.39), and rheumatoid arthritis (OR=1.06, P=1.0), but they were not significant. Besides, ventilation (OR=4.31, P=0.0007) and continuous positive airway pressure (CPAP) (OR=3.57, P=0.001) were identified as risked procedures for ICUAIs. As per type of ICUAIs, respiratory tract infections (RTIs) were detected in 91.18% (31/34), followed by bloodstream infections (5.88% (2/34)) and urinary tract infections (2.94% (1/34)). Types of pathogens causing ICUAIs were Acinetobacter spp.-70.6% (24/34,) followed by Escherichia coli-11.8% (4/34), Pseudomonas spp.-8.8% (3/34), methicillin-sensitive Staphylococcus aureus-5.9% (2/34), and methicillin-resistant S. aureus-2.9% (1/34). ABST results of Acinetobacter spp. were 100% resistant to ceftazidime (20/20), ciprofloxacin (20/20), levofloxacin (20/20), imipenem (7/7), and 95% resistant to amikacin (19/20), gentamicin (19/20), piperacillin-tazobactam (19/20), sulfamethoxazole-trimethoprim (19/20), and ticarcillin-clavulanic acid (19/20). However, 100% of Acinetobacter spp. were sensitive to polymyxin B (20/20). Mortality rate of patients with ICUAIs was 29.4% (10/34) whereas it was 24.07% (52/216) amongst the non-infected patients. In conclusion, the most frequent ICUAI was RTIs which were mainly caused by Acinetobacter spp. that was resistant to most of the routine antibiotics. The important risk factors for ICUAIs in the present study were intubation, nebulization, ventilation, and CPAP. Although the mortality rate of ICUAIs was slightly higher, there was no significant increase in the mortality rate due to ICUAIs.Item Imaging intra-abdominal abscesses; A pictorial essay(Faculty of Graduate Studies, University of Kelaniya Sri Lanka, 2022) Siriwardana, S. R.; Ratnayake, C. S.; Wijesooriya, L. I.Intra-abdominal abscesses are collections of pus surrounded by a wall of inflamed tissues. They would be confirmed in detail by imaging. Familiarization with imaging would facilitate the correct diagnosis and timely management. This report describes the imaging findings of five such cases. Case 1: A 61- year-old woman presented with low-grade fever and right lower chest pain. Abdominal ultrasonography showed a localized, thick-walled collection with copious, echogenic material at the right upper-posterior hypochondrium adjacent to segment VI of the liver. Contrast-enhanced CT (CECT) showed a thick-walled cystic lesion (28mm x 24mm x 25mm) at the same location. The collection laid outside the liver capsule causing indentation of the liver parenchyma. The lesion was diagnosed as a perihepatic abscess. Case 2: A 55-year-old man presented with fever, anorexia, and right-hypochondrial pain. Ultrasound abdomen showed a large, unilocular cyst with echogenic material and CECT detected a unilocular, well-defined and low-attenuated lesion in the right lobe of the liver. The arterial phase showed an enhancing cyst wall with a low-attenuating peripheral rim due to parenchymal oedema. This “double target sign” favored the diagnosis of abscess rather than cystic metastasis. Differential diagnoses were made as pyogenic or amoebic liver abscess and drained via an ultrasound-guided pig-tail catheter. Case 3: A 35-year-old woman presents with a high fever, continuous right lower abdominal pain, nausea, and vomiting for four days. The clinical diagnosis was made as acute appendicitis. Abdominal ultrasonography identified a localized fluid collection with surrounding echogenic fat in the right iliac fossa that was diagnosed as a localized abscess probably due to the ruptured appendix. CECT abdomen detected a thick-walled fluid collection with internal gas locules inferior to the caecum. The wall of the collection was enhanced with contrast. A partially collapsed appendix adjacent to the collection and surrounding inflammatory fat stranding were noted. The lesion was diagnosed as a ruptured appendix. Case 4: A 72-year-old female with uncontrolled diabetes mellitus presented with fever and right flank pain. Her abdominal examination revealed a significant right-sided renal angle tenderness. Ultrasonography showed right-sided pyelonephritis complicated with a perinephric abscess. CECT abdomen showed an enlarged right kidney with low renal cortical contrast enhancement and a perinephric abscess, abutting the psoas muscle. CT diagnosis was made as acute pyelonephritis complicated with a perinephric abscess. Ultrasoundguided drainage was performed. Case 5: A 72-year-old female with uncontrolled diabetes mellitus presented with fever and right hypochondrial pain. Ultrasonography showed a thick-walled gallbladder with internal sludge associated with adjacent fluid collection. CT-abdomen showed a thick enhancing gallbladder wall with an adjacent abscess. In conclusion, ultrasonography plays an important role in diagnosing a variety of intra-abdominal abscesses. Still, the CT-abdomen better characterizes the diagnosis. However, ultrasound-guided aspiration of intra-abdominal abscesses has become an important intervention in diagnosing and managing these patients.Item Virus infections in the exacerbation of asthma in children from a pediatric setting in Sri Lanka(Faculty of Graduate Studies, University of Kelaniya Sri Lanka, 2022) Wijesooriya, L. I.; Perera, P.; Sunil Chandra, N. P.Acute exacerbation of asthma (AEA) is a potentially life-threatening condition, which is often precipitated by respiratory infections. Particularly in children, viral respiratory tract infections are a common cause of acute exacerbation of asthma. There are limited Sri Lankan data on the role of viruses in acute respiratory tract infections among children. However, there are no data related to the role of viral infections causing acute exacerbation of asthma in Sri Lankan children needing hospital admission. A case-control study was conducted at the university pediatric unit, North Colombo Teaching Hospital, Ragama, Sri Lanka. Children between 3-15 years, admitted with AEA were recruited for the study as cases, along with another 100 children with a history of asthma without exacerbation as controls. Each group consisted of 100 children. Sputum/throat swabs were tested for the presence of antigens to five common viruses causing upper respiratory tract infections namely, adenovirus, influenza A virus, influenza B virus, parainfluenza viruses (1-3), and respiratory syncytial virus using commercially available indirect immunofluorescence assay (D3 Ultra DFA Respiratory Virus Screening & ID Kit by The Diagnostic Hybrids, Inc, Athens, USA). This part of the study of collecting samples was done throughout the years 2019 and 2020. The mean age of cases was nine years and 9.5 years in the control group. There was no significant difference in the gender distribution between the two groups (P>0.05). Sputum samples were collected from 78% of the cases, and the rest had throat swabs. Only throat swabs were taken from the children in the control group. Immunofluorescence was used to identify respiratory viruses. In cases, adenovirus, influenza A virus, influenza B virus, parainfluenza viruses, and respiratory syncytial virus were detected at 9%, 1%, 2%, 5%, and 3% respectively; in the control group, it was 2%, 1%, 1%, 5%, and 2%. There was a significantly higher detection rate of adenovirus in the cases compared to the controls (P = 0.040), but no significant difference was noted for other viruses. Children admitted with acute exacerbation of asthma were having significantly high infection rates with adenovirus compared to control groups. Hence, adenovirus infections seem to be an important causative factor for AEA. Other viruses identified from both cases and controls in the order of frequency were parainfluenza virus, respiratory syncytial virus, influenza B virus, and influenza A virus.