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OBJECTIVE There is limited information on the effect of ethnicity on the development of referable sight-threatening diabetic retinopathy (STDR) in people with type 1 diabetes. This study describes the risk factors for STDR in a diverse cohort of people with type 1 diabetes attending a regional diabetes eye screening service. RESEARCH DESIGN AND METHODS Clinical and digital retinal imaging data from 1,876 people with type 1 diabetes (50% women, 72.1% Caucasian, 17.3% African Caribbean, 2.9% Asian, and 7.6% other) with no retinopathy at baseline, attending surveillance eye screening were reviewed. Referable STDR was defined as the presence of any moderate to severe nonproliferative or preproliferative diabetic retinopathy or proliferative diabetic retinopathy or maculopathy in either eye as per U.K. National Diabetic Eye Screening criteria. Median follow-up was 6 years. RESULTS The median (interquartile range) age of the cohort was 29 (21, 41) years. Of the cohort of 1,876 people, 359 (19%) developed STDR. People who developed STDR had higher baseline HbA1c, raised systolic blood pressure (SBP), longer diabetes duration, and were more often of African Caribbean origin (24% vs. 15.6%; P < 0.05 for all). In multivariable Cox regression analyses, African Caribbean ethnicity (hazard ratio [HR] 1.39, 95% CI 1.09–1.78, P = 0.009), baseline SBP (HR 1.01, 95% CI 1.00–1.01, P = 0.033), and baseline HbA1c (HR 1.01, 95% CI 1.00–1.01, P = 0.0001) emerged as independent risk factors for STDR. CONCLUSIONS We observed that people with type 1 diabetes of African Caribbean ethnicity are at significantly greater risk of STDR. Further research is required to understand the mechanisms that explain this novel observation.

There is an increasing number of people with diabetes on peritoneal dialysis (PD) worldwide. However, there is a lack of guidelines and clinical recommendations for managing glucose control in people with diabetes on PD. The aim of this review is to provide a summary of the relevant literature and highlight key clinical considerations with practical aspects in the management of diabetes in people undergoing PD. A formal systematic review was not conducted because of the lack of sufficient and suitable clinical studies. A literature search was performed using PubMed, MEDLINE, Central, Google Scholar and ClinicalTrials.gov., from 1980 through February 2022. The search was limited to publications in English. This narrative review and related guidance have been developed jointly by diabetologists and nephrologists, who reviewed all available current global evidence regarding the management of diabetes in people on PD.We focus on the importance of individualized care for people with diabetes on PD, the burden of hypoglycemia, glycemic variability in the context of PD and treatment choices for optimizing glucose control. In this review, we have summarized the clinical considerations to guide and inform clinicians providing care for people with diabetes on PD.

Background: Allergic rhinitis and asthma are common diseases of the immune system that negatively affect general health, quality of life, and social relationships. Many studies have been conducted to evaluate treatment options for these conditions, particularly using herbal remedies. Complementary alternative medicines are extensively used in the treatment of type 1 hypersensitivity-related allergic rhinitis and asthma. There is a dearth of scientific evidence even though the Sri Lankan population uses traditional medical treatments to effectively manage these conditions. Aims and Objectives: To review the evidence-based recommendations for traditional natural plants with scientifically proven anti-allergic rhinitis and asthmatic activity in Sri Lanka. This review focuses on ten selected medicinal plants used by a traditional ayurvedic practitioner in Sri Lanka to treat allergic rhinitis and asthma. The selected 10 plants are: Piper longum, Clerodendrum indicum, Clerodendrum serratum, Zingiber officinale, Piper nigrum, Allium cepa, Aegle marmelos, Vitex negundo, Coriendrum sativum, and Curcuma longa. Materials and Methods: Therefore, to provide evidence-based recommendations for these traditional natural plants used, a comprehensive literature survey was carried out using PubMed® (U.S. National Library of Medicine, USA), Google Scholar, and Hinary© (WHO, Switzerland). Studies released between 2006 and 2022 were incorporated after two rounds of evaluation and shortlisting; approximately 450 comprehensive database searches were used to find study articles. Then after evaluating the papers' titles and abstracts and evaluating the relevant complete texts for eligibility, the systematic review comprised 54 empirical investigations. It was carried out independently by two reviewers. Results and Discussion: Herbal plant-based medications have several advantages: they are less expensive, have a long history of use, are better tolerated by patients, and have fewer or no side effects. These plants exert their anti-allergy effects by inhibiting various cytokines and interleukins and decreasing immunoglobulin levels. According to scientific evidence, Clerodendrum indicum, Clerodendrum serratum, Piper longum, Piper nigrum, Zingiber officinale, Allium cepa, and Curcuma longa are the most studied plants. The plants Vitex negundo, Coriendrum sativum, and Clerodendrum indicum have received the least amount of research of the selected ten plants. Conclusion: These plants exert their anti-allergy effects by inhibiting various cytokines and interleukins and decreasing immunoglobulin levels. In addition, these essential herbal plants can be tested experimentally to treat these common type-1 hypersensitivities linked to allergic rhinitis and asthma.

The effectiveness of software testing frameworks on software quality is an important area in software engineering. This paper evaluates the effectiveness of popular software testing frameworks, namely Selenium, TestNG, Cucumber, JMeter, and Cypress, on different software qualities, including maintainability, security, code quality, reliability, performance, and usability. The study includes a literature review of previous studies on the effectiveness of these testing frameworks and an empirical study that compares the performance of these frameworks on the selected software qualities using a set of benchmark applications. The results show that the effectiveness of a software testing framework on a particular software quality depends on the specific requirements of the project. For example, Selenium and Cypress are effective for testing user interface functionality and usability, while JMeter is effective for load and stress testing. Thus, software developers and testers should carefully evaluate the different testing frameworks in relation to the software quality requirements of their project before selecting a testing framework. The study concludes that software testing frameworks play a crucial role in ensuring software quality, and selecting the appropriate testing framework is important for achieving the desired software quality goals.

PurposeThe purpose of this paper is twofold: firstly, to identify the information-centric strategies of external stakeholders that influence the quality assurance (QA) in the reverse logistics supply chains (RLSC) of demolition waste (DW) and, secondly, to recognize the determinants for using each strategy.Design/methodology/approachSemi-structured interviews were conducted with 21 professionals representing five external stakeholder groups: state and local government agencies, non-government organizations (NGOs), forward supply chain upstream and downstream actors. The data was analyzed based on Creswell's five-step process, and the conventional content analysis was used for coding and generating themes.FindingsThe study found seven information-centric influence strategies: regulating, monitoring, leading, incentivizing, demolition approval, forming contracts and specifications. The state government organizations were the most dominant in influencing the QA in RLSC. All external stakeholders use both aggressive and cooperative strategies. The urgent, legitimate and economic core of the issue decides the type of strategy to exert an information-centric influence over the QA in RLSC of DW.Originality/valueTo the author's best knowledge, this study is one of the first investigations performed based on a theoretical basis within the context of RLSC in the construction industry (CI). This study used empirical data to elaborate the stakeholder theory while providing new knowledge on stakeholder influence, particularly those relevant to information sharing. Thus, this study developed a theoretical base that future researchers in the study domain could use.

Objective There is limited information on the effect of ethnicity on the development of referable sight-threatening diabetic retinopathy (STDR) in people with type 1 diabetes. To describe the risk-factors for STDR in a diverse cohort of people with type 1 diabetes attending a regional diabetes eye screening service Research design and methods Clinical and digital retinal imaging data from 1876 people with type 1 diabetes (50% female, 72.1% Caucasian, 17.3% African-Caribbean, 2.9 % Asian and 7.6% other) with no retinopathy at baseline, attending surveillance eye screening were reviewed. Referable STDR was defined as presence of any moderate to severe non-proliferative or pre-proliferative diabetic retinopathy or proliferative diabetic retinopathy or maculopathy in either eye as per United Kingdom National Diabetic Eye Screening criteria. Median follow-up was 6 years. Results The median (interquartile range) age of the cohort was 29 (21, 41) years. Of the cohort of 1876 people, 359 (19%) developed STDR. People who developed STDR had higher baseline HbA1c, raised systolic blood pressure (SBP), longer diabetes duration and were more often of African-Caribbean origin (24% vs 15.6%), p Conclusions We observed that people with type 1 diabetes of African-Caribbean ethnicity are at significantly greater risk of STDR. Further research is required to understand the mechanisms that explain this novel observation.

To characterize the IgG and IgA responses to different SARS-CoV-2 proteins, we investigated the antibody responses to SARS-CoV-2 following natural infection and following a single dose of AZD1222 (Covishield), in Sri Lankan individuals. The IgG and IgA responses were assessed to S1, S2, RBD, and N proteins in patients at 4 weeks and 12 weeks since the onset of illness or following vaccination. Antibodies to the receptor-binding domain of SARS-CoV-2 wild type (WT), α, β, and λ and ACE2 (Angiotensin Converting Enzyme 2) receptor blocking antibodies were also assessed in these cohorts. For those with mild illness and in vaccines, the IgG responses to S1, S2, RBD, and N protein increased from 4 weeks to 12 weeks, while it remained unchanged in those with moderate/severe illness. In the vaccines, IgG antibodies to the S2 subunit had the highest significant rise (P < 0.0001). Vaccines had several-fold lower IgA antibodies to all the SARS-CoV-2 proteins tested than those with natural infection. At 12 weeks, the haemagglutination test (HAT) titres were significantly lower to the α in vaccines and significantly lower in those with mild illness and in vaccines to β and for λ. No such difference was seen in those with moderate/severe illness. Vaccines had significantly less IgA to SARS-CoV-2, but comparable IgG responses those with natural infection. However, following a single dose vaccines had reduced antibody levels to the VOCs, which further declined with time, suggesting the need to reduce the gap between the two doses, in countries experiencing outbreaks due to VOCs.

Some native plants expand their populations rapidly in their home ranges, altering their structure and composition. Bambusa bambos, a native bamboo species, shows a rapid population expansion in tropical moist evergreen forests in the intermediate climatic zone, Sri Lanka. The present study was conducted to evaluate its impacts on the regeneration potential of other native forest species. The seedling emergence, survival and mortality were observed for a period of one year using quadrats laid along 18 transects marked from the forest edge towards the forest interior in forest patches with and without bamboo (+Bb and –Bb, respectively). The results revealed a higher abundance, richness and diversity of seedlings in +Bb than in -Bb, with lianas and herbs contributing more to these differences. However, tree seedlings showed higher turnover rates (recruitment and mortality) in -Bb, indicating their preference for undisturbed habitats. Tree and shrub seedlings survived better in -Bb forests while liana and herbaceous seedlings displaying the opposite. The results indicate that B. bambos spread showed an ability to alter the regeneration potential of native forests probably resulting bamboo-driven changes to micro-environmental conditions in the forest floor.

Adipokines have not been studied in acute dengue, despite their emerging role in inducing and regulating inflammation. Therefore, we sought to identify adipokine levels in patients with varying severities of acute dengue to understand their role in disease pathogenesis. We determined the levels of leptin, resistin, omentin, adiponectin, as well as IFNβ, and NS1 using quantitative ELISA in patients with dengue fever (DF=49) and dengue haemorrhagic fever (DHF=22) at admission (febrile phase) and at the time of discharge (recovery phase). The viral loads and serotypes of all samples were quantified using quantitative real-time RT-PCR.Resistin levels (p =0.04) and omentin (p=0.006) levels were significantly higher in patients who developed DHF. Omentin levels in the febrile phase also correlated with the AST (Spearman’s r=0.38, p=0.001) and ALT levels (Spearman’s r=0.24, p=0.04); as well as serum leptin levels with both AST (Spearman’s r=0.27, p=0.02) and ALT (Spearman’s r=0.28, p=0.02). Serum adiponectin levels in the febrile phase did not correlate with any of the other adipokines or with liver enzymes, but inversely correlated with CRP levels (Spearman’s r=-0.31, p=0.008). Although not significant (p=0.14) serum IFNβ levels were lower in the febrile phase in those who progressed to develop DHF (median 0, IQR 0 to 39.4 pg/ml), compared to those who had DF (median 37.1, IQR 0 to 65.6 pg.ml). The data suggest that adipokines are likely to play a role in the pathogenesis of dengue, which should be further explored for the potential to be used as prognostic markers and as therapeutic targets.

BackgroundAs there are limited data on B cell epitopes for the nucleocapsid protein in SARS-CoV-2, we sought to identify the immunodominant regions within the N protein, recognized by patients with varying severity of natural infection with the Wuhan strain (WT), delta, omicron and in those who received the Sinopharm vaccines, which is an inactivated, whole virus vaccine.MethodsUsing overlapping peptides representing the N protein, with an in-house ELISA, we mapped the immunodominant regions within the N protein, in seronegative (n=30), WT infected (n=30), delta infected (n=30), omicron infected+vaccinated (n=20) and Sinopharm (BBIBP-CorV) vaccinees (n=30). We then investigated the sensitivity and specificity of these immunodominant regions and analysed their conservation with other SARS-CoV-2 variants of concern, seasonal human coronaviruses and bat Sarbecoviruses. We then investigated the kinetics of responses to these regions in those with varying severity of acute COVID-19.ResultsWe identified four immunodominant regions aa 29-52, aa 155-178, aa 274 to 297 and aa 365 to 388, were highly conserved within SARS-CoV-2 and the bat coronaviruses. The magnitude of responses to these regions varied based on the infecting SARS-CoV-2 variants, with WT infected individuals predominantly recognizing aa155 to 178 regions, delta infected individuals and vaccinated+omicron infected individuals predominantly recognizing regions aa 29 to 52 and aa 274 to 294 regions. Sinopharm vaccinees recognized all four regions, with the magnitude of responses significantly lower than other groups. >80% of individuals gave responses above the positive cut-off threshold to many of the four regions, with some differences with individuals who were infected with different VoCs. These regions were found to be 100% specific, as none of the seronegative individuals gave any responses.ConclusionsN-protein specific responses appear to be detectable in over 90% of those who were naturally infected or vaccinated with a whole virus inactivated vaccine, with responses mainly directed against four regions of the protein, which were highly conserved. As these regions were highly specific with high sensitivity, they have a potential to be used to develop diagnostic assays and to be used in development of vaccines.

Background: As secretory phospholipase A2 (sPLA2) was shown to be elevated in patients who progress to severe dengue, it would be important to evaluate the usefulness of therapeutics that inhibit sPLA2 enzymes to prevent progression to severe dengue. Methods: Aqueous and butanol extracts of Tragia hispida, Justicia adathoda and tubers of Cyperus rotundus were screened for the presence of potential sPLA2 inhibitors using a commercial assay measuring sPLA2 activity. Results: Both the aqueous (THA) and butanol extracts (THB) of Tragia hispida had sPLA2 inhibition levels comparable to the levels seen with the commercial sPLA2 inhibitor CAY10590. THB at concentrations of 0.1 µg/µL and 0.2 µg/µL, significantly reduced the sPLA2 activity (pConclusions:T. hispida aqueous and butanol soluble fraction had potent sPLA2 inhibitory activities, which should be further explored for their potential to be used for treatment of dengue.

Conventional method of calculation of reference interval (RI) for complete blood count (CBC) parameters for elderly population is challenging as finding healthy elderly volunteers is difficult. This study was carried out to assess the possibility of use of stored patient data of CBC reports of elderly patients in calculation of RI for CBC parameters. A retrospective, cross sectional study was carried out in a hospital laboratory using stored data of patients >65 years of age (n=3094). Relevant clinical criteria and statistical tools were used to refine data to obtain representative samples for each CBC parameter. RI were calculated using standard statistical tools. Calculated RI were compared with RI provided by the manufacturer (RI for >18years old) and with RI defined in five other countries. All data sets showed normal distribution thus, parametric approach was adopted to calculate RI. The RI of all CBC parameters were similar to those of other countries. The RI obtained in this study for red cell indices, platelet count and white blood cells are similar to the RI provided by the manufacturer for adults. The RI obtained for RBC, Hb, PCV were clinically significantly lower compared to the RI provided by the manufacturer for adults. When appropriate selection criteria and relevant statistical tools are applied, patient data can be effectively used to calculate RI for CBC parameters in elderly.

Diabetes is the commonest cause of end-stage kidney disease in many parts of the world, and many people on dialysis programmes live with diabetes. Such people are vulnerable to complications from their diabetes, and their care may be fragmented due to the many specialists involved. This updated guidance from the Joint British Diabetes Societies aims to review and update the 2016 guidance, with particular emphasis on glycaemic monitoring in the light of recent advances in this area. In addition, the guidance covers clinical issues related to the management of diabetes in people on peritoneal dialysis, along with acute complications such as hypoglycaemia and ketoacidosis, and chronic complications such as foot and eye disease.

BackgroundAs secretory phospholipase A2 (sPLA2) was shown to be elevated in patients who progress to severe dengue, it would be important to evaluate the usefulness of therapeutics that inhibit sPLA2 enzymes to prevent progression to severe dengue.ObjectivesTo explore the presence of sPLA2 inhibitors in plant extracts used in traditional medicine for treatment of fever in Sri Lanka.Study designAqueous and butanol extracts ofTragia hispida, Justicia adathodaand tubers ofCyperus rotunduswere screened for the presence of potential sPLA2 inhibitors using a commercial assay measuring sPLA2 activity.ResultsBoth the aqueous (THA) and butanol extracts (THB) ofTragia hispidahad sPLA2 inhibition levels comparable to the levels seen with the commercial sPLA2 inhibitor CAY10590. THB at concentrations of 0.1 µg/µL and 0.2 µg/µL, significantly reduced the sPLA2 activity (pConclusionsT. hispidaaqueous and butanol soluble fraction had potent sPLA2 inhibitory activities, which should be further explored for their potential to be used for treatment of dengue.

BackgroundDengue haemorrhagic fever (DHF) causes significant morbidity and mortality. Judicious fluid resuscitation is the cornerstone of managing vascular leakage in DHF and haematocrit (HCT) measurement is used to monitor the response to fluid resuscitation. Serum lactate level is a measure of tissue perfusion which can be a useful parameter to monitor adequate fluid therapy. The usefulness of lactate in the management of DHF is poorly investigated.Methodology and Principal FindingsA prospective observational study was conducted in two treatment centers in Sri Lanka recruiting 162 DHF patients, to study the correlation of venous lactate and HCT during fluid resuscitation. Patients were recruited within 12 hours of diagnosis of the critical phase and venous lactate level was measured at each time of performing HCT, using a pre-validated handheld lactate analyzer. Median lactate level was 1.3 (range 0.3 - 6 mmol/L) in the study population and 154 (95.2%) patients had median lactate levels less than 2 mmol/L. The HCT values in the study participants ranged from 28 to 62, with a median value of 43. There was no statistically significant correlation between the lactate and HCT values obtained at the same time. In addition, a statistically significant reduction in venous lactate was not observed following administration of fluid boluses. However, HCT reduction expected by administration of the fluid boluses was seen following dextran and crystalloid/dextran combination. Capillary HCT increased following blood transfusion. The highest lactate level measured in a patient was associated with an increase in hospital stay.ConclusionsThis study concludes that venous lactate is not an appropriate parameter to monitor response to fluid therapy in uncomplicated DHF.Author SummaryDengue viral infection causes asymptomatic disease to severe haemorrhagic fever causing organ failure and death. Severe manifestations occur due to fluid extravasation during the critical phase of the illness and these patients with dengue haemorrhagic fever (DHF) require close monitoring and guided fluid therapy. Adequacy of fluid resuscitation is guided by capillary haematocrit (HCT) measurement. However, HCT does not reflect the tissue perfusion. Venous lactate is a reliable measure of tissue perfusion is circulatory collapse. Lactate is known to be a useful marker in identifying severe dengue disease. The usefulness of venous lactate to predict tissue perfusion during fluid resuscitation of DHF has not been performed. The present study was done to identify the usefulness of venous lactate measured by a hand-held lactate analyser in fluid resuscitation of DHF and to find the correlation of HCT and lactate values. Results revealed that uncomplicated DHF patients did not have significantly elevated lactate levels and the HCT and lactate levels performed at the same time did not correlate. Highest lactate level measured in a patient was associated with a longer hospital stay. Therefore, venous lactate is not an appropriate marker to guide fluid therapy in uncomplicated DHF.

The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected patients with kidney disease, causing significant challenges in disease management, kidney research and trainee education. For patients, increased infection risk and disease severity, often complicated by acute kidney injury, have contributed to high mortality. Clinicians were faced with high clinical demands, resource shortages and novel ethical dilemmas in providing patient care. In this review, we address the impact of COVID-19 on the entire spectrum of kidney care, including acute kidney injury, chronic kidney disease, dialysis and transplantation, trainee education, disparities in health care, changes in health care policies, moral distress and the patient perspective. Based on current evidence, we provide a framework for the management and support of patients with kidney disease, infection mitigation strategies, resource allocation and support systems for the nephrology workforce.

Objectives To explore the experiences, and main driving forces of stigma and discrimination among COVID-19 patients, following hospital discharge, in Sri Lanka. Study design A qualitative study was used in order to gain insight and explore the depth and complexity of COVID-19 patients’ experiences. Methods Semi-structured interviews were conducted via telephone in a purposively selected sample of 139 COVID-19 patients. Participants were interviewed during the first 3 weeks following discharge from four main state hospitals that were treating COVID-19 patients during the early phase of the pandemic. Questions on stigma and discrimination were open-ended, enabling patients to provide responses about their different experiences and settings; results were analysed using thematic analysis. Results The majority of participants were men (n = 80; 57.6%), with a mean age of 43 years (SD = 11.2). In total, up to one-third of the study participants experienced stigma related to COVID-19 and were discriminated against by the community, co-workers and healthcare workers in Sri Lanka. Social discrimination included barriers in accessing basic needs, insulting, blaming, defaming, spreading rumours and receiving no support during emergencies. Workplace discrimination included loss of jobs, not allowing re-entry and loss of earnings due to self-employment. Discrimination by healthcare workers included breaching of confidentiality, lack of respect, not providing health services and communication barriers. Discrimination has led to social isolation, not seeking help and severe psychosocial issues impacting their family relationships. Irresponsible media reporting and sensationalism of news coverage leading to breaching of privacy and confidentiality, defaming, false allegations and reporting household details without consent were perceived as the main factors underlying the views and opinions of the general public. Conclusions Stigma and discrimination experienced by COVID-19 patients in society, workplaces and healthcare facilities have serious negative consequences at the individual and family level. Regulations on responsible media reporting, including an effective risk communication strategy to counteract its effects, are strongly recommended.

Background Parathyroid carcinoma is an uncommon cause of PTH-dependent hypercalcemia. Only a handful of cases have been reported of parathyroid carcinoma during pregnancy. Case presentation Twenty-four – Year – old female presented with proximal myopathy was found to have hypercalcemia. Her serum corrected total calcium was – 15 mg/dl (8.5 – 10.3), serum phosphate – 2.3 mg/dl (2.5 – 4.5), intact PTH – 118 pg/ml (20 – 80), Vitamin D – 15 ng/ml and Urine Ca/Cr ratio – 2.1 (0.1 – 0.2). Her CECT–neck revealed a well-defined mass lesion posterior to the right lobe of the thyroid – 2.6 cm × 2.5 cm × 2.9 cm in size. She was started on vitamin D supplementation, and she underwent right lower focal parathyroidectomy. Her PTH levels normalized following surgery. Her histology revealed an atypical parathyroid adenoma. She was treated with calcium and vitamin D. Her follow up was uneventful. One year following initial surgery the patient became pregnant and at 16 weeks of POA, the patient presented with a rapidly enhancing neck mass for one week duration. Her biochemical investigations were suggestive of a recurrence of primary hyperparathyroidism. Her ultrasound scan of the neck revealed a well-defined discreate hypoechoic nodule, superior to the thyroid isthmus which was confirmed by a non-contrast MRI scan of the neck. She underwent an uncomplicated second trimester parathyroid tumour excision with normalization of post op PTH. Her histology revealed a parathyroid carcinoma with vascular and capsular invasion. Her genetic studies revealed a novel frameshift mutation of the CDC73 gene. She was treated with calcium and vitamin D supplementation and closely followed up with ionized calcium and PTH levels which were normal throughout the pregnancy. She had an uncomplicated caesarean section at a POA of 37 weeks. Currently she is twelve weeks post-partum, in remission of disease. Conclusion This case shows the importance of stringent follow up of atypical parathyroid adenoma patients, the benefit of second trimester surgery in management of hypercalcemia due to parathyroid carcinoma during pregnancy and the importance of identifying the novel CDC73 gene mutation.

Background Water and sodium imbalances are common following sellar/suprasellar surgeries. The aim of the current study was to analyse the incidence, associations and management of sodium and water imbalances following sellar/ suprasellar surgeries in Sri Lanka. Methods A prospective cross-sectional study carried out in the National Hospital of Sri Lanka over 18 months from September 2019. All patients undergoing sellar/suprasellar surgeries fulfilling the inclusion criteria were followed up to 7 days after surgery, to collect clinical, biochemical and intake-output parameters. Results Out of 139 patients, 108 were trans-sphenoidal surgeries (TSS), 31 had craniotomies. Majority had non-functioning pituitary adenomas (NFPA) (n=81,58.2%) followed by craniopharyngioma (n=22,15.8%), acromegaly (n=20,14.3%), Cushing’s-disease (n=9,6.4%), suprasellar meningioma (n=6,4.3%) and prolactinoma (n=1,0.7%). Post-operative hyponatremia occurred in 18.5% TSS and 38.7% craniotomy patients, with syndrome-of-inappropriate-ADH-secretion (SIADH) being the commonest cause. First surgery (p:0.004, Adjusted-OR:1.38(1.23-1.53)), craniotomy compared to TSS (p:0.001, Adjusted-OR:2.61(1.86-4.66)), tumour size>3cm (p:2cm (p:0.018, Adjusted-OR:1.29(1.01-1,62)), craniopharyngioma (p:Conclusion Diagnosis and management of water and sodium imbalances following sellar/suprasellar surgeries is challenging, needing specialist endocrinology input. Post-operative hyponatremia, SIADH, transient polyuria and transient CDI are common. This is the first study carried out in Sri Lanka to analyse the patterns of sodium and water disorders following sellar/ suprasellar surgeries. These findings highlight that certain pre-operative characteristics could predict post-operative water and sodium imbalances and will be useful in early identification of high-risk patients.

The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected patients with kidney disease, causing significant challenges in disease management, kidney research and trainee education. For patients, increased infection risk and disease severity, often complicated by acute kidney injury, have contributed to high mortality. Clinicians were faced with high clinical demands, resource shortages and novel ethical dilemmas in providing patient care. In this review, we address the impact of COVID-19 on the entire spectrum of kidney care, including acute kidney injury, chronic kidney disease, dialysis and transplantation, trainee education, disparities in health care, changes in health care policies, moral distress and the patient perspective. Based on current evidence, we provide a framework for the management and support of patients with kidney disease, infection mitigation strategies, resource allocation and support systems for the nephrology workforce.

A systemic inquiry into an emerging evolutionary-developmental model of psychological trauma and common psychological conditions

Access to essential medicines for treatment of non-communicable diseases (NCDs) is lacking in low- and low-middle income countries. In nephrology, access to essential medicines is especially important to reduce risk of chronic kidney disease (CKD) progression, as kidney replacement therapy is unavailable or cost-prohibitive in many regions of the world. As part of the International Society of Nephrology (ISN) Emerging Leaders Program’s mandate to improve health promotion and access to prevention and management of kidney diseases globally, this scoping review aims to understand the extent of evidence regarding: 1) access to essential medicines for CKD and related NCDs, 2) barriers to access, and 3) interventions to improve access.

Adrenal hemorrhage is an uncommon underrecognized condition that can be encountered in several clinical contexts. Diagnosing adrenal hemorrhage is challenging due to the non-specific clinical features. Therefore, it remains a diagnosis that is made serendipitously on imaging of acutely unwell patients rather than with prospective clinical suspicion. Adrenal hemorrhage can follow abdominal trauma or on a background of predisposing conditions such as adrenal tumors, sepsis, or coagulopathy. Adrenal hemorrhage is also increasingly reported in patients with COVID-19 infection and in the context of vaccine-induced immune thrombocytopenia and thrombosis, in both cases likely as a consequence of adrenal vein thrombosis. Unexplained abdominal pain with hemodynamic instability in a patient with a predisposing condition should alert the physician to the possibility of adrenal hemorrhage. Bilateral adrenal hemorrhage can lead to adrenal insufficiency and potentially fatal adrenal crisis without timely recognition and treatment. In this article, we highlight the clinical circumstances that are associated with higher risk of adrenal hemorrhage, encouraging clinicians to prospectively consider the diagnosis, and share a diagnostic and management strategy.

Calculation of reference intervals (RI) for each quantitative test for the population served is mandatory in clinical care. Standard method of calculation of RI is costly and tedious. Literature show success in using patient data in calculating RI for some tests but, those related to complete blood count (CBC) are sparse. Therefore, this study was conducted to assess the applicability of stored patient data of CBC in calculating RI as a less costly and reliable method. A retrospective cross-sectional study was performed using a large database of CBC reports of adults (18-60 years) in a hospital laboratory. Data were grouped in to patients and routine health checkup category and then partitioned according to gender. Data were refined using clinically relevant criteria and statistical tools to harness reference data sets for each parameter. RI were calculated using standard statistical methods. Obtained values were compared with those in the literature and of the manufacturer. All data sets showed Gaussian distribution. The RI calculated using patient data showed no clinically significant differences when compared with those of the healthy subjects, manufacturer and literature. When appropriate selection criteria and statistical tools are applied, large patient databases can be used to calculate RI for CBC parameters.

The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected patients with kidney disease, causing significant challenges in disease management, kidney research and trainee education. For patients, increased infection risk and disease severity, often complicated by acute kidney injury, have contributed to high mortality. Clinicians were faced with high clinical demands, resource shortages and novel ethical dilemmas in providing patient care. In this review, we address the impact of COVID-19 on the entire spectrum of kidney care, including acute kidney injury, chronic kidney disease, dialysis and transplantation, trainee education, disparities in health care, changes in health care policies, moral distress and the patient perspective. Based on current evidence, we provide a framework for the management and support of patients with kidney disease, infection mitigation strategies, resource allocation and support systems for the nephrology workforce.

BackgroundThe dengue NS1 antigen is a secretory protein and was shown to associate with apolipoprotein A1 (ApoA1). Therefore, we sought to investigate the changes in ApoA1 levels in patients with varying severity of acute dengue and then proceeded to investigate how ApoA1 and NS1 interactions affect cytokine production from primary human monocytes.Methodology/Principal FindingsSerial measurements of ApoA1, viral loads, NS1 antigen levels and lipid profiles were done in adult patients with dengue fever (DF= 21) and dengue haemorrhagic fever (DHF =28). To investigate the effect of ApoA1-NS1 interactions in cytokine production from primary human monocytes, cells were harvested from healthy individuals (n=6) and co-cultured with varying concentrations of ApoA1 and levels of IL-6 and TNF-α measured in culture supernatants.The ApoA1 levels were significantly lower in patients with DHF on day 5 of illness (p=0.04) compared to those with DF. ApoA1 levels did not show any correlation with either the NS1 antigen levels or the viral loads in patients with DF or DHF, although they did significantly and inversely correlate with liver transaminases, AST (Spearmans R=-0.55, p Conclusions/SignificanceHDL, LDL and ApoA1 levels were significantly lower in those who have severe dengue, especially in the critical phase and ApoA1 levels inversely correlated with the extent of rise in liver enzymes. While co-culture of ApoA1 with NS1 in primary human monocytes induced high IL-6 levels in a dose dependent manner, this was not seen for TNFα suggesting that the interaction of ApoA1 with NS1 could give rise to different outcomes.Author summaryThe dengue NS1 antigen is a secretory protein and was shown to associate with apolipoprotein A1 (ApoA1). Therefore, we sought to investigate the changes in ApoA1 levels in patients with varying severity of acute dengue and then proceeded to investigate how ApoA1 and NS1 interactions affect cytokine production from primary human monocytes. Serial measurements of ApoA1, viral loads, NS1 antigen levels and lipid profiles were done in adult patients with dengue fever (DF) and dengue haemorrhagic fever (DHF). HDL, LDL and ApoA1 levels were significantly lower in those who have severe dengue, especially in the critical phase and ApoA1 levels inversely correlated with the extent of rise in liver enzymes. While co-culture of ApoA1 with NS1 in primary human monocytes induced high IL-6 levels in a dose dependent manner, this was not seen for TNFα, suggesting that the interaction of ApoA1 with NS1 could give rise to different outcomes.

PURPOSE There is a significant disparity in global cancer care and outcome between countries. Progress in the treatment of symptomatic plasma cell myeloma (PCM) in high-income countries is not seen in low- and middle-income countries. MATERIALS AND METHODS This is was a retrospective cohort study of all patients diagnosed with PCM between May 1, 2013, and September 30, 2021, at the first hemato-oncology center in Sri Lanka. We aimed to provide data on clinicopathologic characteristics, response, and survival estimates. RESULTS A total of 79 patients with PCM received first-line therapy during the study period. The median age was 64 years, and approximately one third (33%) of patients were older than 70 years. There were 42 (53%) males and 37 females. Hypercalcemia, renal impairment, anemia, and bone disease were detected in 36.7%, 38%, 72.1%, and 81%, respectively. Thirty-nine, 34, and six patients received a combination of cyclophosphamide, thalidomide, and dexamethasone; bortezomib, thalidomide, and dexamethasone; and other treatments, respectively. The overall response rate (≥ partial response) was approximately 97% for both cyclophosphamide, thalidomide, and dexamethasone and bortezomib, thalidomide, and dexamethasone. Twenty-three (29%) of these patients died during the study period, but only 14 (18%) died due to PCM or associated sepsis. After a median follow-up of 40.6 months (range, 35.2-59.07 months), the median overall survival was 84.2 months (95% CI, 60.87 to not available). The 5-year estimated overall survival was 65%. CONCLUSION To our knowledge, this is the only well-characterized study on long-term survival of patients with PCM in Sri Lanka. We have shown that it is possible to successfully apply Western treatment and supportive care protocols to the local population. These published data will help to benchmark and improve the treatment and develop blood cancer care in the local setting.

PurposeThe purpose of this paper is to select a suitable procurement method for steel building construction in Sri Lanka following a systematic method which weigh, both procurement selection factors and existing procurement systems.Design/methodology/approachAn abductive research stance is followed in this empirical study. Procurement selection factors were selected through a critical literature review which was followed by a quantitative questionnaire survey. The collected data were analysed using descriptive statistical analysis and relative important index.FindingsThe critical literature review outlined 46 procurement selection factors, out of which 26 factors were very important in steel building procurement selection. Short construction period and higher constructability of design are ranked at the top with the highest priority rating factors. Management-oriented procurement system was selected as the most appropriate procurement system for steel building constructions within the Sri Lankan context.Research limitations/implicationsThe study is limited to widely use three procurement systems in Sri Lankan construction industry. Yet, the process followed in selecting the most appropriate procurement system could be applied for other contexts. The implications of the study are mainly identifying management-oriented procurement as the most suitable procurement method for steel building construction in Sri Lanka.Practical implicationsThe systematic procedure of procurement method selection for steel building construction may use in the Sri Lankan construction industry to limit the resource loss due to wrong selection of procurement.Originality/valueA study which critically and comprehensively presenting a procurement selection process for steel building construction is not recorded in Sri Lanka prior to this study.

Introduction. Hypoparathyroidism, which is a common complication following total thyroidectomy can be transient in majority and permanent in 1.5% of the patients and usually occurs secondary to an inadvertent removal of parathyroid glands, mechanical or thermal injury or disruption of the vasculature. In some patients, it is observed that symptoms of hypocalcemia can occur for the first time several years after the surgery, which is known as “delayed hypoparathyroidism.” We report three cases of delayed hypoparathyroidism from Sri Lanka, presenting several years after total thyroidectomy.Case Presentation.Case 1- a 60-year-old Sri Lankan woman who presented with symptomatic hypocalcemia for the first time, 30 years after total thyroidectomy for follicular thyroid carcinoma. Case 2- a 53-year-old Sri Lankan woman presenting with neuropsychiatric manifestations of hypocalcemia for the first time, 12 years after total thyroidectomy for papillary thyroid carcinoma. Case 3- a 49-year-old Sri Lankan woman developing symptoms of hypocalcemia for the first time, 11 years after completion of thyroidectomy for papillary thyroid carcinoma. All these patients were detected to have low parathyroid hormone levels, without an alternative etiology for hypoparathyroidism, hence leading to a diagnosis of delayed post-thyroidectomy hypoparathyroidism.Conclusion. Delayed hypoparathyroidism is a rare phenomenon, which is secondary to progressive atrophy of parathyroid glands and slowly progressive hypovascularization of parathyroids due to scar tissue retraction following thyroidectomy. The nonspecific nature of hypocalcemic symptoms and lack of continuous follow-up for a long time after thyroidectomy could contribute to a further delay in diagnosis. However, it is an important diagnosis to consider in any patient with a history of neck surgery presenting with hypocalcemia, irrespective of the time duration of surgery, as timely diagnosis and treatment can prevent long-term complications of hypocalcemia and improve the quality of life.

Acute kidney injury (AKI) is the most serious clinical manifestation of the Sri Lankan hump-nosed pit viper (Hypnale spp.) bites. Thrombotic microangiopathy (TMA) is increasingly recognized in asso...

The coronavirus disease 2019 (COVID-19) pandemic has emerged as one of the greatest challenges faced by humankind in the recent past. People with diabetes and related comorbidities are at increased risk of its complications and of COVID-19-related death. Older age, multi-morbidity, hyperglycaemia, cardiac injury and severe inflammatory response are predictors of poor outcome. The complex interplay between COVID-19, diabetes and the effects of related therapies is being explored. Most patients experience a mild illness with COVID-19, while people with diabetes are at increased risk of severe disease. Optimising glycaemic control and adopting measures to prevent disease spread are critical aspects. The management of mild disease is supportive, while very many immunomodulatory and antiviral therapies are being investigated for the treatment of severe disease. Several of these agents have specific considerations for use in people with diabetes. Since mass population lockdowns are considered a key step in controlling disease spread, it follows that, in addition to the direct vulnerability to severe COVID-19, people with diabetes can be affected by limited access to healthcare, insulin, other medications and blood glucose monitoring equipment. Measures to prevent disease spread at the individual and community level are the key to mitigating the rapidly escalating pandemic, while agents for chemoprophylaxis and vaccines are being explored. People with diabetes should be recognised as a vulnerable group for complicated disease and are at risk during times of disturbed social systems. Strategies are needed to safeguard the health of patients with diabetes during the pandemic. This review summarises the current knowledge and perceived challenges for prevention and management of COVID-19 in people with diabetes. Electronic supplementary material The online version of this article (10.1007/s00125-020-05164-x) contains peer-reviewed but unedited supplementary material including a slideset of the figures for download, which is available to authorised users.

Context: Thrombotic microangiopathy (TMA) resulting in acute kidney injury (AKI) is an important complication of venomous snakebites. We aimed to describe TMA secondary to Russell’s viper (Daboia r...