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The proliferation of the Internet of Things (IoT) has attracted different sectors such as agriculture, manufacturing, smart cities, transportation, etc. to adopt these technologies. Most IoT networks utilize Routing Protocol for Low Power and Lossy Networks (RPL) to exchange control and data packets across the network. However, RPL is susceptible to routing attacks such as rank attacks, DIS-flooding, etc. In recent years different defense techniques have been proposed to act against these attacks i.e., Secure-Protocol, conventional Intrusion Detection Systems (IDS), and Machine Learning (ML)-based. This systematic literature review explores 39 published papers in the domain of defense techniques against routing attacks in RPL-based IoT. We review. The findings of this study suggest that most Secure-Protocol can detect and mitigate routing attacks utilizing distributed placement, ML-based can detect most attacks but lack mitigation mechanisms, and conventional IDS technique utilizes a hybrid approach in detection and placement strategies. Additionally, this study reveals that India publishes more research papers in ML-based and Secure-Protocol. Furthermore, flooding attacks are the most discussed attacks in the selected studies. Finally, Cooja Contiki is the most used simulation tool.

The Internet of Things (IoT) has become increasingly popular, opening vast application possibilities in different fields including smart cities, healthcare, manufacturing, agriculture, etc. IoT comprises resource-constrained devices deployed in Low Power and Lossy Networks (LLNs). To satisfy the routing requirements of these networks, the Internet Engineering Task Force (IETF) created a standardised Routing Protocol for low-power and Lossy Networks (RPL). However, this routing protocol is vulnerable to routing attacks, prompting researchers to propose several techniques to defend the network against such attacks. Machine learning approaches demonstrate effective ways to detect such attacks in large quantities. Therefore, this paper systematically synthesised 17 publications to compare the performance of traditional and advanced machine learning algorithms to identify the best algorithm for detecting RPL-based IoT routing attacks. The findings of this paper show that machine learning algorithms are capable of effective detection of many routing attacks with high accuracy and a low False Positive Rate. Furthermore, the results demonstrate that on average, advanced machine learning algorithms can achieve an accuracy of 96.03% compared to traditional machine learning algorithms which achieved 91.67%. Traditional machine learning algorithms demonstrated the best performance on average False Positive Rate by achieving 2.75% compared to their counterparts which gained 4.79%. However, Random Forest showed the best performance and outperformed all the algorithms in the selected publications by achieving over 99% accuracy, precision and recall.

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard in the endoscopic management of biliary disease. An average of 700,000 ERCPs are performed every year, and most are performed using a reusable flexible duodenoscope. The innovation of disposable duodenoscopes has changed the dynamic in the advanced endoscopy field of study to primarily reduce or eliminate the risk of cross-contamination between patients. Many factors affect whether institutions can convert from standard reusable duodenoscopes to single-use duodenoscopes including the cost of the devices, reimbursement from insurance companies for the new devices, and the overall environmental impact. However, the reduction of cross-contamination leading to active infection in patients, environmental waste produced with high-level disinfection procedures, staff and equipment required for reprocessing, and the inability to frequently upgrade duodenoscopes for optimal performance are all factors that favor transitioning to single-use duodenoscopes. As these devices are new to the field of gastroenterology, the purpose of this review is to analyze the advantages and disadvantages of transitioning to single-use devices and a brief mention of alternative options for institutions unable to make this change., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Endoscopic retrograde cholangiopancreatography (ERCP) may be unsuccessful in patients with duodenal stenosis or malignant ampullary infiltration. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has been proposed as an alternative. We aimed to assess the efficacy and safety of EUS-BD for malignant distal bile duct obstruction using the newly introduced smaller caliber 6 or 8 mm cautery-enhanced lumen-apposing metal stent., Methods: A multicenter retrospective study was performed on patients with unresectable malignant distal bile duct obstruction who underwent EUS-BD between 2021 and 2022 after unsuccessful ERCP., Results: Thirty-two patients were included [7 (53.13%) males], with a mean age of 72.2 ± 12.5 years. The technical success rate was 100%. Altered anatomy was present in 2 (6.25%). The indication for drainage was biliary obstruction from pancreatic cancer in 26 patients (84.5%), cholangiocarcinoma in 3 (9.4%), and ampullary mass in 3 (9.4%). The procedure was performed mostly in an outpatient setting (n = 19, 59.38%). The clinical success rate was 92.3% [bilirubin: 14.1 (SD: 8.9) preprocedure vs 4.9 (SD: 1.1) postprocedure; P = 0.0001]. There was one early adverse event of a perforation, which was closed endoscopically and drained percutaneously. Delayed adverse events included food impaction of the stent (n = 1), which was resolved with a repeat procedure and insertion of a double pigtail stent., Conclusion: This study demonstrates the feasibility of EUS-BD drainage using smaller caliber 6 or 8 mm lumen-apposing metal stent to relieve malignant distal bile duct obstruction in patients who fail conventional ERCP., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Sickle cell disease (SCD) predominantly affects African-Americans (AAs) in the United States (US). Due to increasing life expectancy in developed countries, SCD-associated cardiomyopathy is typically seen in adults. The aim of this study was to distinguish hospitalization for this phenotype from traditional heart failure (HF) in AAs. We used the National Inpatient Sample (NIS) database to identify HF hospitalizations in AAs between 2005 and 2014 and stratified them according to SCD status. We compared the characteristics and outcomes before and after matching in a 1:3 ratio for age, gender, insurance, smoking status and admission year. Amongst the 1,195,718 HF admissions in AAs, SCD accounted for 7835. The age (mean ± SD) in the SCD cohort was significantly younger (45.66 ± 13.2) vs non-SCD (64.8 ± 15.2), p<0.001. SCD adults had significantly higher rates of pulmonary hypertension (PH), deep vein thrombosis, and pulmonary embolism while non-SCD adults had higher rates of cardiogenic shock and respiratory failure requiring intubation. The national hospitalization rate for HF in AAs increased from 151 to 257 per million between 2005 and 2011 before declining to 241 per million in 2014. There was a decrease in in-hospital mortality in AAs from 4.8% in 2005 to 3.6% in 2014. We also identified independent predictors of in-hospital mortality in SCD with HF. In conclusion, we described hospitalizations for an emerging heart failure phenotype in AAs. Although there is a national decreasing rate of HF hospitalizations in the US, this may not be reflective of the AA population., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2019, Fadiran et al.)

Background: Acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) are used in clinical management to confirm the diagnosis and indicate the severity of organophosphorus and carbamate poisoning. ChE check mobile is a new portable cholinesterase testing system developed in Germany. The study aims to evaluate the accuracy of ChE check mobile compared to the standard reference method and Test-mate ChE system., Methods: Patients with organophosphorus and carbamate poisoning were recruited from two general hospitals in Sri Lanka between September 2013 and November 2014. The AChE was measured using the three methods., Results: Blood samples were collected from 185 self-poisoned patients (170 organophosphorus and 15 carbamate) and 20 normal individuals. ChE check mobile correlated well with spectrophotometer readings (Pearson's correlation coefficient 0.87) but gave higher values (Mean bias for AChE: +6.55 (95% CI: -11 to 24) U/g Hb). A similar positive bias from Test-mate results was also observed. Applying a correction factor derived from the volunteer samples (dividing by 1.353) greatly improved agreement in pesticide poisoned patients., Conclusions: ChE check mobile system allowed for rapid determination of AChE activity but gave somewhat higher AChE compared to other methods. Applying a correction factor of 1.353 provide a good agreement to both reference and Test-mate ChE machine in this setting.

Objective: Arthropod stinging and bites are common environmental hazards in Sri Lanka. However, their medical importance has not been fully evaluated yet. This study aims to study the burden, epidemiology, and outcome of stings and bites in primary hospitals in the Kurunegala district in North Western Province (NWP) of Sri Lanka., Methodology: The study was conducted one year from 25th May 2013 to 25th May 2014. Details of all stings and bites admissions and their outcomes were retrospectively extracted from hospital records in all 44 primary hospitals in the district., Results: There were 623 stings and bites with population incidence of 38/100,000 (95% CI 27-52). There were no deaths. Median age was 38 years (IQR: 19-53 years), and 351 (56%) were males. Most of stings and bites (75%) occurred in the daytime. Median time to hospital arrival was 55 minutes (IQR: 30 min to 2 h). The offending arthropods had been identified in 557 (89%) cases, of them, 357 (57%) were Hymenoptera (hornet and bees), 99 centipedes, 61 spiders and 40 scorpions. Local pain occurred in 346 (56%) cases - centipede 69 (70%), Scorpion 24 (60%), spider 36 (59%), Hymenoptera 187 (52%) and unidentified 30 (45%). Hymenoptera stings and spider bites occurred between 06 am to 12 noon, and scorpion stings and centipede bites mostly occurred between 06 pm to 12 midnight. Mild, moderate to severe anaphylaxis reactions occurred in 173 (28%) patients including 110 Hymenoptera stings - mild 39, moderate 62 and severe 9. From primary hospitals, 53(9%) cases had been transferred to tertiary care units for further management. Of them, 41 cases were Hymenoptera stings and 24 (58%) of them had mild, moderate to severe anaphylaxis. In the entire group, 27% severe cases received adrenaline., Conclusions: The primary hospitals in NW province of Sri Lanka manage large numbers of arthropod stings and bites. These include Hymenoptera (hornet and bee), centipedes, spiders, and scorpions. Pain, swellings and anaphylactic reactions were the most common adverse effects.

Context: Intentional self-poisoning with the herbicide paraquat has a very high case-fatality and is a major problem in rural Asia and Pacific., Objectives: We aimed to determine whether the addition of immunosuppression to supportive care offers benefit in resource poor Asian district hospitals., Materials and Methods: We performed a randomised placebo-controlled trial comparing immunosuppression (intravenous cyclophosphamide up to 1 g/day for two days and methylprednisolone 1 g/day for three days, and then oral dexamethasone 8 mg three-times-a-day for 14 days) with saline and placebo tablets, in addition to standard care, in patients with acute paraquat self-poisoning admitted to six Sri Lankan hospitals between 1st March 2007 and 15th November 2010. The primary outcome was in-hospital mortality., Results: 299 patients were randomised to receive immunosuppression (147) or saline/placebo (152). There was no significant difference in in-hospital mortality rates between the groups (immunosuppression 78 [53%] vs. placebo 94 [62%] (Chi squared test 2.4, p = .12). There was no difference in mortality at three months between the immunosuppression (101/147 [69%]) and placebo groups (108/152 [71%]); (mortality reduction 2%, 95% CI: -8 to +12%). A Cox model did not support benefit from high-dose immunosuppression but suggested potential benefit from the subsequent two weeks of dexamethasone., Conclusions: We found no evidence that high dose immunosuppression improves survival in paraquat-poisoned patients. The continuing high mortality means further research on the use of dexamethasone and other potential treatments is urgently needed.

Aim: Acute kidney injury (AKI) is common following deliberate self-poisoning with a combination washing powder containing oxalic acid (H 2 C 2 O 4 ) and potassium permanganate (KMnO 4 ). Early and rapid increases in serum creatinine (sCr) follow severe poisoning. We investigated the relationship of these increases with direct nephrotoxicity in an ongoing multicenter prospective cohort study in Sri Lanka exploring AKI following poisoning., Methods: Multiple measures of change in kidney function were evaluated in 48 consenting patients who had serial sCr and serum cystatin C (sCysC) data available., Results: Thirty-eight (38/48, 79%) patients developed AKI (AKIN criteria). Twenty-eight (58%) had AKIN stage 2 or 3. Initial increases in urine creatinine (uCr) excretion were followed by a substantial loss of renal function. The AKIN stage 2 and 3 (AKIN2/3) group had very rapid rises in sCr (a median of 118% at 24 h and by 400% at 72 h post ingestion). We excluded the possibility that the rapid rise resulted from the assay used or muscle damage. In contrast, the average sCysC increase was 65% by 72 h., Conclusions: In most AKI, sCysC increases to the same extent but more rapidly than sCr, as sCysC has a shorter half-life. This suggests either a reduction in Cystatin C production or, conversely, that the rapid early rise of sCr results from increased production of creatine and creatinine to meet energy demands following severe oxidative stress mediated by H 2 C 2 O 4 and KMnO 4 . Increased early creatinine excretion supports the latter explanation, since creatinine excretion usually decreases transiently in AKIN2/3 from other causes.

Toxoplasmosis is an infection caused by the intracellular protozoan parasite Toxoplasma gondii, and is associated with clinically significant infection in immunocompromised individuals. Vertical transmission during pregnancy can manifest as congenital toxoplasmosis in the neonate, and can have serious consequences. This review aims to describe the modalities for prophylaxis of toxoplasmosis in susceptible populations, and focuses on the following: (1) prophylaxis of congenital toxoplasmosis; (2) prophylaxis of toxoplasmosis in patients with HIV/AIDS; and (3) prophylaxis of toxoplasmosis in transplant recipients.

Pesticides applied on agricultural lands reach groundwater by leaching, and move to offsite water bodies by direct runoff, erosion and spray drift. Therefore, an assessment of the mobility of pesticides in water resources is important to safeguard such resources. Mobility of pesticides on agricultural lands of Mahaweli river basin in Sri Lanka has not been reported to date. In this context, the mobility potential of 32 pesticides on surface water and groundwater was assessed by widely used pesticide risk indicators, such as Attenuation Factor (AF) index and the Pesticide Impact Rating Index (PIRI) with some modifications. Four surface water bodies having greater than 20% land use of the catchment under agriculture, and shallow groundwater table at 3.0 m depth were selected for the risk assessment. According to AF, carbofuran, quinclorac and thiamethoxam are three most leachable pesticides having AF values 1.44 × 10 -2 , 1.87 × 10 -3 and 5.70 × 10 -4 , respectively. Using PIRI, offsite movement of pesticides by direct runoff was found to be greater than with the erosion of soil particles for the study area. Carbofuran and quinclorac are most mobile pesticides by direct runoff with runoff fractions of 0.01 and 0.08, respectively, at the studied area. Thiamethoxam and novaluron are the most mobile pesticides by erosion with erosion factions of 1.02 × 10 -4 and 1.05 × 10 -4 , respectively. Expected pesticide residue levels in both surface and groundwater were predicted to remain below the USEPA health advisory levels, except for carbofuran, indicating that pesticide pollution is unlikely to exceed the available health guidelines in the Mahaweli river basin in Sri Lanka.

Pesticide self-poisoning is now considered one of the two most common methods of suicide worldwide. Encouraging safe storage of pesticides is one particular approach aimed at reducing pesticide self-poisoning. CropLife Sri Lanka (the local association of pesticide manufacturers), with the aid of the Department of Agriculture, distributed lockable in-house pesticide storage boxes free of charge to a farming community in a rural district of Sri Lanka. Padlocks were not provided with the boxes. These storage boxes were distributed to the farmers without prior education. The authors carried out a cross-sectional follow-up survey to assess the usage of boxes at 7 months after distribution. In an inspection of a sample of 239 box recipients' households, 142 households stored pesticides in the provided box at the time of survey. Among them, only 42 (42/142, 29.65%) households had locked the box; the remaining households (100/142, 70.4%) had not locked the box. A simple hand over of in-house pesticide storage boxes without awareness/education results in poor use of boxes. Additionally, providing in-house storage boxes may encourage farmers to store pesticides in and around houses and, if they are not locked, may lead to unplanned adverse effects.

Background: Highly hazardous organophosphorus (OP) insecticides are responsible for most pesticide poisoning deaths. As they are removed from agricultural practice, they are often replaced by carbamate insecticides of perceived lower toxicity. However, relatively little is known about poisoning with these insecticides., Methods: We prospectively studied 1288 patients self-poisoned with carbamate insecticides admitted to six Sri Lankan hospitals. Clinical outcomes were recorded for each patient and plasma carbamate concentration measured in a sample to confirm the carbamate ingested., Findings: Patients had ingested 3% carbofuran powder (719), carbosulfan EC25 liquid (25% w/v, 389), or fenobucarb EC50 liquid (50% w/v, 127) formulations, carbamate insecticides of WHO Toxicity Classes Ib, II, and II, respectively. Intubation and ventilation was required for 183 (14.2%) patients while 71 (5.5%) died. Compared with carbofuran, poisoning with carbosulfan or fenobucarb was associated with significantly higher risk of death [carbofuran 2.2%; carbosulfan 11.1%, OR 5.5 (95% CI 3.0-9.8); fenobucarb 6.3%, OR 3.0 (1.2-7.1)] and intubation [carbofuran 6.1%; carbosulfan 27.0%, OR 5.7 (3.9-8.3); fenobucarb 18.9%, OR 3.6 (2.1-6.1)]. The clinical presentation and cause of death did not differ markedly between carbamates. Median time to death was similar: carbofuran 42.3 h (IQR 5.5-67.3), carbosulfan 21.3 h (11.5-71.3), and fenobucarb 25.3 h (17.3-72.1) (p = 0.99); no patients showed delayed onset of toxicity akin to the intermediate syndrome seen after OP insecticide poisoning. For survivors, median duration of intubation was 67.8 h (IQR 27.5-118.8) with no difference in duration between carbamates. Reduced GCS at presentation was associated with worse outcome although some patients with carbosulfan died after presentation with normal GCS., Conclusions: We did not find carbamate insecticide self-poisoning to vary markedly according to the carbamate ingested although the case fatality varied according to the concentration and formulation of the insecticide. Carbamate poisoning did not appear to be much less toxic than poisoning with some liquid OP insecticide formulations, e.g., chlorpyrifos EC40, that we have previously noted in these same hospitals (Lancet 2005, 366:1452-1459; QJM 2006, 99:513-522). Replacement of WHO Class II Toxicity OP insecticides in agriculture with high-strength liquid carbamate formulations may not substantially reduce case fatality after pesticide poisoning and, therefore, global suicide rates.

Context: Russell's viper is more medically important than any other Asian snake, due to number of envenoming's and fatalities. Russell's viper populations in South India and Sri Lanka (Daboia russelii) cause unique neuromuscular paralysis not seen in other Russell's vipers., Objective: To investigate the time course and severity of neuromuscular dysfunction in definite Russell's viper bites, including antivenom response., Methodology: We prospectively enrolled all patients (>16 years) presenting with Russell's viper bites over 14 months. Cases were confirmed by snake identification and/or enzyme immunoassay. All patients had serial neurological examinations and in some, single fibre electromyography (sfEMG) of the orbicularis oculi was performed., Results: 245 definite Russell's viper bite patients (median age: 41 years; 171 males) presented a median 2.5 h (interquartile range: 1.75-4.0 h) post-bite. All but one had local envenoming and 199 (78%) had systemic envenoming: coagulopathy in 166 (68%), neurotoxicity in 130 (53%), and oliguria in 19 (8%). Neurotoxicity was characterised by ptosis (100%), blurred vision (93%), and ophthalmoplegia (90%) with weak extraocular movements, strabismus, and diplopia. Neurotoxicity developed within 8 h post-bite in all patients. No bulbar, respiratory or limb muscle weakness occurred. Neurotoxicity was associated with bites by larger snakes (p < 0.0001) and higher peak serum venom concentrations (p = 0.0025). Antivenom immediately decreased unbound venom in blood. Of 52 patients without neurotoxicity when they received antivenom, 31 developed neurotoxicity. sfEMG in 27 patients with neurotoxicity and 23 without had slightly elevated median jitter on day 1 compared to 29 normal subjects but normalised thereafter. Neurological features resolved in 80% of patients by day 3 with ptosis and weak eye movements resolving last. No clinical or neurophysiological abnormality was detected at 6 weeks or 6 months., Conclusion: Sri Lankan Russell's viper envenoming causes mild neuromuscular dysfunction with no long-term effects. Indian polyvalent antivenom effectively binds free venom in blood but does not reverse neurotoxicity.

We aimed to determine the effect of task-specific kinetic finger tremor, as indexed by surface electromyography (EMG), on the accuracy of a carrom stroke. Surface EMG of extensor digitorum communis muscle of the playing arm was recorded during rest, isometric contraction and stroke execution in 17 male carrom players with clinically observed finger tremor and 18 skill- and age-matched controls. Log-transformed power spectral densities (LogPSDs) of surface EMG activity (signifying tremor severity) at a 1-s pre-execution period correlated with angular error of the stroke. LogPSDs in 4-10 Hz range were higher in players with tremor than controls during pre-execution (P < 0.001), but not during the resting state (P = 0.067). Pre-execution tremor amplitude correlated with angular deviation (r = 0.45, P = 0.007). For the first time, we document a task-specific kinetic finger tremor in carrom players. This finger tremor during the immediate pre-execution phase appears to be a significant determinant of stroke accuracy.

Being the most common endocrinopathy of young women, polycystic ovary syndrome has much variation in its clinical expression based on ancestry. Ethnic differences of the phenotype are closely linked to its complex pathophysiology. This paper reviews data of the past three decades ensuring a precise diagnosis and taking into account underlying factors, effects of migration including heterogeneity, and diversity within each identified ethnic group. Differing expressions of hyperandrogenism, obesity, insulin resistance and metabolic manifestations of polycystic ovary syndrome occur among women from distinct geographic locations and ancestry. These ethnic phenotypes correlate with their inherent metabolic risks, skin sensitivity to androgens and social outlook that particularly affects their quality of life and health-seeking behavior. It is recommended that such ethnic variations are recognized in routine clinical practice and longitudinal data be maintained to study the true impact of such differences on disease outcomes.