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Nuwan Darshana Wickramasinghe,1 Shamalee Wasana Jayarathne,2 Senaka Devendra Pilapitiya3 1Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, 50008, Sri Lanka; 2Medical Education Unit, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, 50008, Sri Lanka; 3Department of Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, 50008, Sri LankaCorrespondence: Nuwan Darshana WickramasingheDepartment of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, 50008, Sri LankaTel +94772975412Fax +942522234464Email nuwick74@yahoo.comPurpose: Since the coronavirus disease 2019 (COVID-19) pandemic is an opportune time to introduce the value-added roles of medical students, this study assessed medical students’ perceptions and willingness to assist in COVID-19 health sector preparedness and response via value-added roles in Sri Lanka.Methods: A cross-sectional online survey was conducted among all medical students studying in six batches of the Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, in June 2020. A Google form in English with 10 statements about individual perceptions of medical students’ roles and their willingness to assist in the COVID-19 health sector response via value-added roles was used to collect data. The responses were recorded on a five-point Likert scale. The chi-squared test for independence was used to explore the associations between the academic year and the responses to each statement.Results: Out of 856 (response rate 79.6%) study participants, the majority were females (n=601, 70.2%). The majority (n=804, 93.9%) reported that they have a responsibility to contribute to the country’s COVID-19 health sector response. There was a statistically significant association between medical students’ perceived level of clinical knowledge, having the clinical skills to assist in the COVID-19 health sector response and academic year (p< 0.001). The commonly identified value-added roles were developing (n=770, 89.9%) and disseminating (n=744, 86.9%) health education messages, and field contact tracing activities (n=653, 76.3%). Other value-added roles were assisting the curative health sector in COVID-19 patient management (n=380, 44.4%) and other non-COVID-19 patient management (n=463, 54.1%).Conclusion: Medical students are mostly willing to engage in preventive health sector value-added roles and, to a lesser extent, in curative health sector value-added roles during the COVID-19 outbreak. However, medical educators need to clearly define the value-added roles and provide adequate training and supervision for medical students across academic years to enable them to combine learning with making meaningful contributions to the health-care system during the COVID-19 pandemic.Keywords: COVID-19, health sector response, medical students, Sri Lanka, value-added roles

Background: Leptospirosis is a zoonotic disease with high prevalence in Sri Lanka predominantly in paddy cultivat­ing areas. Severe leptospirosis is rarely described in pregnancy and there is a scarcity of data regarding its effect on pregnant patients. Acute lung injury has been recognized as the commonest fatal complication of leptospirosis. We report a case of delayed presentation of fulminant leptospirosis in a pregnant patient complicated with acute respi­ratory distress syndrome (ARDS) and severe coagulopathy resulting in death despite the optimum medical care.Case Presentation: A-31-year-old woman in the twelfth-week of pregnancy admitted with a subacute history of frequent vomiting, dry cough, watery stools, vaginal spotting, hemoptysis, and progressive shortness of breath. She had tachycardia, hypotension, and acute severe respiratory distress with high-grade fever on admission. Her inflammatory markers were high with evidence of severe coagulopathy. With worsening clinical and biochemical parameters despite intensive medical intervention, patient had a fatal outcome. The autopsy revealed shock lung with multiple intra-alveolar hemorrhages. The serum Leptospira microscopic agglutination test (MAT) was positive confirming the fulminant leptospirosis.Conclusion: Prolongrespiratory symptoms; positive lung signs with acute respiratory distress can mimic the clinical picture of atypical pneumonia. Delayed presentation of ARDS limits the management options whilst increasing the risk of fatality. A high degree of suspicion is needed to diagnose leptospirosis in pregnancy.

Introduction Medical students who engage in clinical learning in healthcare settings can be potential methicillin-resistant Staphylococcus aureus (MRSA) carriers. Methods This is a descriptive cross-sectional study having a follow-up approach. Three batches of medical students who were studying at the Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka (1st, 3rd and 5th study years of MBBS course) were screened for nasal and axillary MRSA colonization. The first-year students were screened before and 6 months after clinical learning. The knowledge of the students about infection control was scored (percentage) using a questionnaire in the one week before and later one year after the hospital exposure. Data was compared using two-sample t test. Results The percentage of MRSA colonization was 6.36% (7/110) and 49.57% (59/119) before clinical exposure and after 2.5 years of exposure, respectively (p

BackgroundCOVID-19 pandemic is an opportune time to identify the value-added roles of medical students to utilize the services of this potential workforce effectively in the health-care system. Hence, this study assessed medical students’ perception and willingness to assist in COVID-19 health sector preparedness and response via value-added roles in Sri Lanka. MethodsA cross-sectional online survey was conducted among all medical students studying in six batches of the Faculty of Medicine and Allied Sciences (FMAS), Rajarata University of Sri Lanka (RUSL). A Google form prepared in English with statements about individual perception of medical students’ role and their willingness to assist in the COVID-19 health sector response via value-added roles was used to collect data. ResultsOut of 856 (79.6%) study participants, the majority was females (n=601, 70.2%). The majority (n=804, 93.9%) reported that they have a responsibility to contribute to the COVID-19 health sector response in the country. There was a statistically significant difference in medical students’ perceived level of clinical knowledge and clinical skills to assist in COVID-19 health sector response with advancing academic year (p

Delays in treatment seeking and antivenom administration remain problematic for snake envenoming. We aimed to describe the treatment seeking pattern and delays in admission to hospital and administration of antivenom in a cohort of authenticated snakebite patients. Adults (> 16 years), who presented with a confirmed snakebite from August 2013 to October 2014 were recruited from Anuradhapura Hospital. Demographic data, information on the circumstances of the bite, first aid, health-seeking behaviour, hospital admission, clinical features, outcomes and antivenom treatment were documented prospectively. There were 742 snakebite patients [median age: 40 years (IQR:27–51; males: 476 (64%)]. One hundred and five (14%) patients intentionally delayed treatment by a median of 45min (IQR:20-120min). Antivenom was administered a median of 230min (IQR:180–360min) post-bite, which didn’t differ between directly admitted and transferred patients; 21 (8%) receiving antivenom within 2h and 141 (55%) within 4h of the bite. However, transferred patients received antivenom sooner after admission to Anuradhapura hospital than those directly admitted (60min [IQR:30-120min] versus 120min [IQR:52-265min; p, Author summary Snakebite is a neglected tropical disease which is closely associated with underdevelopment. Poor accessibility to safe and effective antivenoms is a major issue in some regions highest-affected by snakebites. Antivenom can prevent severe effects of envenoming if given early. Therefore, educating communities and health care workers to improve treatment seeking after snakebite is a global priority. Many factors are associated with delayed presentation to hospital and early administration of antivenom. We found that most snakebite patients in Sri Lanka present to the first hospital within an hour of the bite. However, there remains a delay of about two more hours until the first dose of antivenom is administered. This delay is a reflection of a delay in the appearance of observable or measurable features of envenoming and a lack of reliable early diagnostic tests. We emphasise the need for reliable, rapid diagnostics for systemic envenoming.

INTRODUCTION: Medical students who engage in clinical learning in healthcare settings can be potential methicillin-resistant Staphylococcus aureus (MRSA) carriers. METHODS: This is a descriptive cross-sectional study having a follow-up approach. Three batches of medical students who were studying at the Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka (1(st), 3(rd) and 5(th) study years of MBBS course) were screened for nasal and axillary MRSA colonization. The first-year students were screened before and 6 months after clinical learning. The knowledge of the students about infection control was scored (percentage) using a questionnaire in the one week before and later one year after the hospital exposure. Data was compared using two-sample t test. RESULTS: The percentage of MRSA colonization was 6.36% (7/110) and 49.57% (59/119) before clinical exposure and after 2.5 years of exposure, respectively (p

Envenoming by hump-nosed pit vipers (genus Hypnale) causes local effects, mild coagulopathy, and rarely, acute kidney injury. Neuromuscular dysfunction has not been clinically reported but, in vitr...

Chronic Kidney Disease of Unknown aetiology is a significant public health problem in Sri Lanka. The final report by the WHO mission recommended regulation of herbal medicines containing aristolochic acid, which is an established nephrotoxin. The use of Complimentary and Alternative Medicine (CAM) has a history of more than 2500 years in Sri Lanka. Aristolochia species are rarely used in Ayurveda and traditional medicine in Sri Lanka. Before regulating the analysis of herbal preparations using Aristolochia, collecting data from CAM practitioners regarding the use of Aristolochia is necessary. Analysis of Ayurveda pharmacopeia shows the doses used are negligible and some preparations are used for external applications., Graphical abstract

A 43-year-old mother of two children presented with an episode of cerebral venous sinus thrombosis (CVST) complicated with haemorrhagic venous infarction and seizure. She had two first trimester miscarriages and was on combined oral contraceptive pills (COCP) for two months. Computed tomography (CT) venogram revealed venous sinus thrombosis with a right partial lobe haemorrhagic infarction. She was treated with subcutaneous enoxaparin for 14-days followed by oral warfarin for one year. The patient was started on oral levetiracetam but gradually tailed off over four months. Physiotherapy and occupational therapy were continued. She was advised on non-hormonal family planning methods. Thrombophilia and autoimmune screening were negative. Haemorrhagic venous infarction complicated with seizures is a rare manifestation of venous sinus thrombosis. Timely and personalized anticoagulation is the mainstay of treatment.

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare multisystemic small-vessel vasculitic disease. We report a case of non-severe eosinophilic granulomatosis with polyangiitis who was treated early in its course and remained in remission. A 57-year-old lady presented with new-onset episodic wheezing for six months. This was associated with rhinitis, sinusitis and chronic urticaria for the same duration. Examination revealed tender skin nodules. Investigations revealed elevated inflammatory markers with positive Myeloperoxidase (MPO) antibodies. She was diagnosed with the early stage of eosinophilic granulomatosis with polyangiitis. She was treated with oral prednisolone and mycophenolate mofetil as induction therapy and treatment is maintained with mycophenolate mofetil. She remains in remission to date. This case highlights the importance of early detection and treatment of Antineutrophil cytoplasmic antibodies (ANCA)-associated-vasculitis and explores the potential of mycophenolate mofetil as a therapeutic agent.

Community-acquired pneumonia (CAP) due to Methicillin Resistant Staphylococcus Aureus (MRSA) is uncommon. In this case series, wedescribe four young immune-competent healthy males presenting with severe respiratory distress progressing to necrotizing pneumonia. All required ventilation and recovered without sequelae. One patient developed myositis and the other three developed pleural effusions and pneumothoraxes; two of them needing intercostal tube (ICT) insertion and drainage.These cases highlight community acquired MRSA in developing countries where antibiotics are frequently used empirically with little laboratory guidance. DOI: http://dx.doi.org/10.4038/amj.v8i2.7528 Anuradhapura Medical Journal 2014;8(2):40-44

Flying snakes (Genus Chrysopelea) are a group of ophisthoglyphous colubrids in South and South East Asia known for gliding in the air. Of the five species of flying snakes, Sri Lankan flying snake, Chrysopelea taprobanica, is endemic to Sri Lanka. Authenticated bites and the venom characteristics of this uncommon snake remain unknown. We report the first authenticated case of C taprobanica bite, in which a 45-year-old woman had signs of mild local envenoming after the bite, with no evidence of systemic envenoming.

Background Intake of medicines and supplements is widespread among the professional athletes in developed countries and there are reports to suggest inappropriate self-administration of medicine. Data from South Asia on this area is lacking. This study examined self-medication practices with regard to use of allopathic and herbal/traditional medicines among national -level Sri Lankan athletes. Results 209 athletes from 15 national sport teams were assessed using an anonymous, interviewer administered questionnaire. Self-medication practices during the 3 months before data collection were evaluated. 60.8% athletes practiced self-medication. 58.3 and 9.4% consumed western and herbal/traditional medicines respectively, while a third used both. The most common symptom for which self-medication was practiced was musculoskeletal pain (73.2%). Oral non-steroidal anti-inflammatory drugs (NSAIDs) and antibiotics were used by 15.7 and 7.1% respectively. Musculoskeletal pain was the predominant symptom that prompted the use of allopathic medicines, while the majority of athletes with upper respiratory tract symptoms being the predominant symptoms, consumed herbal/traditional medicines. Two different commercially available preparations of herbal mixtures were consumed by 15.7 and 15%. Pain prophylaxis during or prior to a sport event was reported by 20.1%, mainly with topical medicines. Medicines were obtained by direct request from a pharmacy without an authorized prescription by a majority (77.2%), followed by using an old prescription in 12.6%. Conclusions This study finds that self-medication with both allopathic and herbal/traditional preparations among athletes in a Sri Lanka is high. The use of oral NSAIDs without an authorized prescription in a significant number of athletes is a potential health risk. Frequency of oral NSAID use is lower than that is reported in non-Asian studies from developed countries. The use of herbal/traditional medications increases the likelihood of inadvertent doping. Enhancing awareness regarding risk of such practices among athletes, trainers, pharmacists and prescribers is essential.

Background Heat stroke is a life-threatening condition with exertional heat stroke occurring frequently among soldiers and athletes. Because of its common occurrence, many military trainees practice preventive measures prior to any activity requiring severe exertion. Although it is said to be common in practice, different presentations of heat stroke are scarcely described in literature. Case Presentation We describe a case of an exertional heat stroke in a 23-year-old male Sinhalese soldier who developed early changes of renal failure, liver failure and rhabdomyolysis. The patient initially presented with convulsions, delirium and loss of consciousness to an outside health care facility before being transferred to our institution. Conclusion It is clear that heat stroke does occur in military trainees while preventive strategies are being practiced. It is important for those who provide healthcare to soldiers to provide proper advice on how to identify impending heat stroke prior to any exercises resulting in severe physical exertion. Further, treating physicians should educate all military trainees about preventive strategies.

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.To investigate the time course and severity of neuromuscular dysfunction in definite Russell's viper bites, including antivenom response.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.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.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.

Objective We aimed to investigate neurophysiological and clinical effects of common krait envenoming, including the time course and treatment response. Methodology Patients with definite common krait (Bungarus caeruleus) bites were recruited from a Sri Lankan hospital. All patients had serial neurological examinations and stimulated concentric needle single-fibre electromyography (sfEMG) of orbicularis oculi in hospital at 6wk and 6–9mth post-bite. Principal Findings There were 33 patients enrolled (median age 35y; 24 males). Eight did not develop neurotoxicity and had normal sfEMG. Eight had mild neurotoxicity with ptosis, normal sfEMG; six received antivenom and all recovered within 20–32h. Seventeen patients developed severe neurotoxicity with rapidly descending paralysis, from ptosis to complete ophthalmoplegia, facial, bulbar and neck weakness. All 17 received Indian polyvalent antivenom a median 3.5h post-bite (2.8–7.2h), which cleared unbound venom from blood. Despite this, the paralysis worsened requiring intubation and ventilation within 7h post-bite. sfEMG showed markedly increased jitter and neuromuscular blocks within 12h. sfEMG abnormalities gradually improved over 24h, corresponding with clinical recovery. Muscle recovery occurred in ascending order. Myotoxicity was not evident, clinically or biochemically, in any of the patients. Patients were extubated a median 96h post-bite (54–216h). On discharge, median 8 days (4–12days) post-bite, patients were clinically normal but had mild sfEMG abnormalities which persisted at 6wk post-bite. There were no clinical or neurophysiological abnormalities at 6–9mth. Conclusions Common krait envenoming causes rapid onset severe neuromuscular paralysis which takes days to recover clinically consistent with sfEMG. Subclinical neuromuscular dysfunction lasts weeks but was not permanent. Antivenom effectively cleared venom but did not prevent worsening or reverse neuromuscular paralysis., Author Summary Common krait bites cause muscular paralysis due to the venom disrupting communication between the nerves and muscles. This becomes life-threatening for the patient if there is paralysis of the muscles used for breathing. We studied the severity of paralysis, long term effects and the value of antivenom treatment in authenticated Indian krait bite patients from Sri Lanka. In addition to standard treatment with antivenom, the patients had single-fibre electromyography done, a sensitive neurophysiological test that detects the abnormalities of communication between the nerves and muscles. Half of the patients had severe paralysis and required mechanical ventilation, and the remainder had mild or no effects. Antivenom was given to all patients with severe paralysis and most with mild effects. However, despite antivenom binding all free venom after it was administered, it did not prevent or reverse already developed paralysis. Clinically evident paralysis resolved after a few days, but the neurophysiological abnormalities lasted for weeks. No permanent neurological damages were noted at 6 to 9 months after the snake bite.

Culturally, philosophically and religiously diverse medical systems including Western medicine, Traditional Chinese Medicine, Ayurvedic Medicine and Homeopathic Medicine, once situated in places and times relatively unconnected from each other, currently co-exist to a point where patients must choose which system to consult. These decisions require comparative analyses, yet the divergence in key underpinning assumptions is so great that comparisons cannot easily be made. However, diverse medical systems can be meaningfully juxtaposed for the purpose of making practical decisions if relevant information is presented appropriately. Information regarding privacy provisions inherent in the typical practice of each medical system is an important element in this juxtaposition. In this paper the information needs of patients making decisions regarding the selection of a medical system are examined.

Background Russell’s viper (Daboia russelli) bites lead to high morbidity and mortality in South Asia. Although variety of clinical manifestations is reported in viper bite victims, myocardial ischemic events are rare. Case presentation We report a unique case of inferior wall ST elevation myocardial infarction due to a Russell’s viper bite over a vein with possible direct intravenous envenoming, in a young male with no past history or family history suggestive of ischemic cardiac disease, from Sri Lanka. In addition, the possible mechanisms of myocardial ischemia in snake bite victims are also briefly discussed. Conclusion Importance of the awareness of physicians on the rare, yet fatal manifestations of snake envenoming is highlighted.

Spontaneous pneumothorax associated with menstruation is a rare entity named catamenial pneumothorax. A 36-year-old woman presented with recurrent right-sided pneumothorax requiring repeated chest tube insertions. She underwent video-assisted thoracoscopy (VATS). Histopathology was suggestive of thoracic endometriosis. When spontaneous pneumothorax occurs in ovulating women in relation to menstruation catamenial pneumothorax should be suspected. Correct diagnosis will lead to effective treatment and prevention of recurrences.

G6PD deficiency is an X-linked recessive hereditary disease. G6PD is involved in the production of NADPH which is important in the prevention of oxidative damage of red blood cells (1). Since it is an X-linked disorder the clinical manifestations should be seen almost exclusively in males. However, heterozygous females will also be affected if there is an inactivation of normal X chromosome which is an unfavourable lyonization.We present a case report of a 28-year old woman with G6PD deficiency, most likely due to random inactivation of normal X chromosome.

Snakebite is a common occupational health hazard among Sri Lankan agricultural workers, particularly in the North Central Province. Viperine snakes, mainly Russell’s viper envenomation, frequently lead to acute renal failure. During the last two decades, an agrochemical nephropathy, a chronic tubulointerstitial disease has rapidly spread over this area leading to high morbidity and mortality. Most of the epidemiological characteristics of these two conditions overlap, increasing the chances of co-occurrence. Herein, we describe four representative cases of viperine snakebites leading to variable clinical presentations, in patients with chronic agrochemical nephropathy, including two patients presented with acute and delayed anuria. These cases suggest the possibility of unusual manifestations of snakebite in patients with Sri Lankan agrochemical nephropathy, of which the clinicians should be aware. It could be postulated that the existing scenario in the Central America could also lead to similar clinical presentations.