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The South Asia region is facing a high burden of chronic kidney disease (CKD) with limited health resources and low expenditure on health care. In addition to the burden of CKD and kidney failure from traditional risk factors, CKD of unknown etiologies from India and Sri Lanka compounds the challenges of optimal management of CKD in the region. From the third edition of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA), we present the status of CKD burden, infrastructure, funding, resources, and health care personnel using the World Health Organizations building blocks for health systems in the ISN South Asia region. The poor status of the public health care system and low health care expenditure resulted in high out-of-pocket expenditures for people with kidney disease, which further compounded the situation. There is insufficient country capacity across the region to provide kidney replacement therapies to cover the burden. The infrastructure was also not uniformly distributed among the countries in the region. There were no chronic hemodialysis centers in Afghanistan, and peritoneal dialysis services were only available in Bangladesh, India, Nepal, Pakistan, and Sri Lanka. Kidney transplantation was not available in Afghanistan, Bhutan, and Maldives. Conservative kidney management was reported as available in 63% (n = 5) of the countries, yet no country reported availability of the core CKM care components. There was a high hospitalization rate and early mortality because of inadequate kidney care. The lack of national registries and actual disease burden estimates reported in the region prevent policymakers attention to CKD as an important cause of morbidity and mortality. Data from the 2023 ISN-GKHA, although with some limitations, may be used for advocacy and improving CKD care in the region.

A study conducted from July 2019 to May 2022 at several hospitals in the Western Province, Sri Lanka, focused on dengue virus strains during the COVID-19 pandemic. Among 417 febrile patients, 47% were PCR-positive for dengue. Serotyping revealed DENV-1 (12.8%), DENV-2 (46.4%), DENV-3 (37.2%), and DENV-4 (3.6%). Sequencing identified two genotypically distinct variants of DENV-3 and two genotypically distinct variants of DENV-1, while DENV-2 showed a single genotype cluster. Notably, the study found concurrent circulation of two DENV-3 and two DENV-1 genotypes, along with DENV-2, during the pandemic in the area. This data suggests the presence of multiple dengue strains, including several DENV-1 and DENV-3 variants, without major epidemic outbreaks reported in the Western Province. Continuous monitoring and research are essential to understand the dynamics of these dengue strains in the context of the COVID-19 pandemic.

With the pandemic, academic activities of education institutes such as teaching, learning, and assessment as well as programmes targeted for educators' personal and professional development have been transformed to online from physical mode. The use of online platforms has become an essential pedagogical tool. This study investigated educators' acceptance of online platforms for their personal and professional development during the COVID-19 pandemic in Sri Lanka. One hundred and ninety-nine responses were received for the survey, and data were analysed using statistical methods. The study found the importance of belief structures- attitudinal, normative and control beliefs, and attitude toward the behaviour, subjective norms, and perceived behavioural control in determining educators' acceptance of online platforms for their personal and professional development purposes. This paper concludes with a discussion on implications of the findings for theory and practice on educators' acceptance of new technologies for teaching and learning purposes.

Dengue viral infections are one of the most important mosquito-borne diseases in the world. Presently dengue is endemic in 112 countries in the world. It has been estimated that almost 100 million cases of dengue fever and half a million cases of dengue hemorrhagic fever (DHF) occur worldwide. An increasing proportion of DHF is in children less than 15 years of age, especially in South East and South Asia. The unique structure of the dengue virus and the pathophysiologic responses of the host, different serotypes, and favorable conditions for vector breeding have led to the virulence and spread of the infections. The manifestations of dengue infections are protean from being asymptomatic to undifferentiated fever, severe dengue infections, and unusual complications. Early recognition and prompt initiation of appropriate supportive treatment are often delayed resulting in unnecessarily high morbidity and mortality. Attempts are underway for the development of a vaccine for preventing the burden of this neglected disease. This review outlines the epidemiology, clinical features, pathophysiologic mechanisms, management, and control of dengue infections.

According to the WHO 2009 classification, dengue with warning signs is at the risk of developing severe form of dengue disease. One of the most important warning signs is plasma leakage, which can be a serious complication associated with higher morbidity and mortality. We report that the frequency of CD4+CD8+ double-positive (DP) T cells is significantly increased in patients at risk of developing plasma leakage. Transcriptomic analysis demonstrated that CD4+CD8+ DP cells were distinct from CD4+ Single Positive (SP) T cells but co-clustered with CD8+ SP cells, indicating a largely similar transcriptional profile. Twenty significant differentially expressed (DE) genes were identified between CD4+CD8+ DP and CD8+ SP cells. These genes encode OX40 and CCR4 proteins as well as other molecules associated with cell signaling on the cell surface (NT5E, MXRA8, and PTPRK). While comparing the profile of gene expression in CD4+CD8+ DP cells from patients with and without warning signs of plasma leakage, similar expression profile was observed, implying a role of CD4+CD8+ DP cells in plasma leakage through a quantitative increase rather than functional alteration. This study provided novel insight into the host immune response during the acute febrile phase of DENV infection and the role of CD4+CD8+ DP T cells in the pathogenesis of plasma leakage.

A study conducted from July 2019 to May 2022 at several hospitals in the Western Province, Sri Lanka, focused on dengue virus strains during the COVID-19 pandemic. Among 417 febrile patients, 47% were PCR-positive for dengue. Serotyping revealed DENV-1 (12.8%), DENV-2 (46.4%), DENV-3 (37.2%), and DENV-4 (3.6%). Sequencing identified two genotypically distinct variants of DENV-3 and two genotypically distinct variants of DENV-1, while DENV-2 showed a single genotype cluster. Notably, the study found concurrent circulation of two DENV-3 and two DENV-1 genotypes, along with DENV-2, during the pandemic in the area. This data suggests the presence of multiple dengue strains, including several DENV-1 and DENV-3 variants, without major epidemic outbreaks reported in the Western Province. Continuous monitoring and research are essential to understand the dynamics of these dengue strains in the context of the COVID-19 pandemic.

Citrate is widely used as an anticoagulant for platelet function tests (PFTs). Due to an intrinsic inhibitory effect of citrate on platelet function, hirudin is used as an alternative. However, studies comparing the effect of these anticoagulants on rotational thromboelastometry (ROTEM) platelet whole blood impedance aggregometry in thrombocytopenic patients are scant. Cross-sectional study was done in 105 patients who entered the critical phase of Dengue hemorrhagic fever with plasma leakage and severe thrombocytopenia (

Introduction: Dengue illness, an acute viral infection, is endemic in Sri Lanka causing a substantial public health challenge today in all dimensions of health. Post-infectious fatigue (PIF) after dengue infection had been reported in several studies as well as in textbooks of medicine. Objectives: To describe the prevalence and correlates of PIF at one-month follow-up among adults confirmed with dengue infection admitted to selected healthcare institutions in Colombo District, Sri Lanka. Methods: A longitudinal study was conducted among 480 patients from July 2018 to January 2019. Participants were recruited on discharge from the hospital. We adopted systematic sampling method and followed them up one month after day 1 of the fever. Prevalence was assessed by the culturally adapted and validated Sinhala version of the Chalder Fatigue Questionnaire. Correlates were assessed by a pre-tested interviewer-administered questionnaire. A binomial multiple logistic regression analysis was carried out via the SPSS-21 version. Results: The response rate was 84.58 (406/480). The majority were between 18-35 years (69.2%) and male (60.15%). The prevalence of PIF at one month was 35% (95% CI: 30.3, 39.8). After controlling for confounders, age ≥35 years (adjusted OR (AOR)=4.05; 95% CI: 2.04, 8.04), not being married (AOR=2.7; 95% CI: 1.38, 5.28), having experience of stress full life events (AOR=1.98; 95%CI: 1.16, 3.36), not receiving an adequate quantity of sleep (AOR=2.51; 95% CI: 1.00, 6.31), poor quality of sleep (AOR=15.34; 95% CI: 3.25, 72.49), headache post-discharge (AOR=2.69; 95% CI: 1.6, 4.53), presence of myalgia post-discharge (AOR=3.63; 95% CI: 2.16, 6.11), haemoglobin

Objective: To analyze data on socio-demographic and clinical characteristics of SARS-CoV-2 infected population whose samples were received from Medical Research Institute, Sri Lanka. Methods: Laboratory based retrospective study was done on patient samples which were tested positive for SARS-CoV-2 by National Reference Virology Laboratory at the Medical Research Institute, Sri Lanka, from November, 2020 to November, 2021. Data on socio-demographic characteristics and clinical presentation of 13 126 patients were examined. Results: The mean age of the study population was (36.0±7.2) years and the majority were men (64.0%). The highest number of positive cases were found in the 21-30 years-of-age group. Two distinct peaks were noted in the incidence of SARS-CoV-2 positive individuals. In addition, 42.5% of the positive samples tested positive (42.5%) were from Medical Officer of Health collection centres. Furthermore, 60.6% (7 951) of the infected subjects were asymptomatic whereas the remaining were symptomatic. The highest percentage of symptomatic patients were observed in the 91-100 years-of-age group while the highest asymptomatic subjects were found in the 31-40 years-of-age group. The percentage of asymptomatic children (65.3%) was significantly (P

Baclofen is a derivative of gamma amino butyric acid and is used for control of pain and muscular spasms. It is primarily excreted via the kidneys. In patients with impaired renal functions, the half-life of baclofen is prolonged and symptoms of toxicity can occur with normal doses. Commonly reported symptoms of baclofen toxicity are somnolence, altered mentation, seizures and respiratory depression. Myoclonus secondary to baclofen toxicity is scarcely reported. This case series describes two patients with chronic kidney disease (CKD) who were prescribed regular doses of baclofen for analgesia, and subsequently developed generalized myoclonus. The symptoms resolved with omission of baclofen and haemodialysis. There is currently no consensus on dose modification of baclofen in renal impairment for prevention of adverse neurological events. However, considering the surmounting evidence for low threshold of baclofen toxicity in CKD, dose adjustment protocols or consensus on contraindication need to be established.

Background: Chronic kidney disease of uncertain etiology (CKDu) is an emergent health concern, particularly in tropical farming communities in several global hotspots, including Sri Lanka. This particular nephropathy is characterized by a progressive decline in kidney function in the absence of conventional chronic kidney disease (CKD) risk factors such as diabetes mellitus, hypertension, and other identifiable kidney disorders. As it is almost asymptomatic at early stages, CKDu is mostly diagnosed at late stages with significant kidney damage. Hence, the identification of disease susceptibility and vulnerable communities at the earliest possible instances is highly important for the management of the disease. Objective: We aimed to compare kidney health across three different farming communities in Sri Lanka to identify CKDu susceptibilities. Methods: A cross-sectional study was performed with three selected farming communities: paddy farmers (PF; N = 581), sugarcane farmers (SF; N = 550), and vegetable farmers (VF; N = 244) in comparison with an age-matched control group of nonfarming (NF; N = 225) individuals. A medical examination was performed to investigate health status and medical history, whereas a urinalysis was performed to determine creatinine and albumin contents. Estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio (ACR) were used for assessment of kidney function. CKDu susceptibility was determined based on eGFR, and urinary ACR adhering to the clinical practice guidelines in Sri Lanka. Results: The median (interquartile range [IQR]) eGFR levels of PF (85 mL/min/1.73 m 2 [72-97]) and SF (93 mL/min/1.73 m 2 [73-112]) were significantly lower than that of the NF group (103 mL/min/1.73 m 2 [87-125]) ( P < .0001), whereas eGFR of VF (100 mL/min/1.73 m 2 [80-111]) was not significantly different compared with NF. The median (IQR) urinary ACR levels of the study groups, PF, SF, VF, and NF, were 0.59 (0.26-1.45), 0.46 (0.28-0.88), 0.45 (0.34-0.90), and 0.44 (0.34-1.02) mg/mmol, respectively. However, urinary ACR did not differ significantly across the study groups ( P > .05). The prevalence of CKDu within PF (13.60%), SF (12.54%), and VF (6.67%) communities was significantly higher ( P < .05) compared with the NF (2.67%). Of the total CKD cases, CKDu susceptible cases represented 73%, 69%, 50%, and 25% in PF, SF, VF, and NF, respectively, indicating a high risk of CKDu susceptibility among farming communities. Moreover, a noteworthy association of CKDu was observed with agrochemical exposure (odds ratio [OR] = 3.11, 95% confidence interval [CI] = 1.36-7.09). Concerning the farming practices, sugarcane farming showed the highest association with CKDu prevalence (OR = 3.40, 95% CI = 1.49-7.78). Conclusions: Compared with the nonfarming group, a significant risk of CKDu was observed in the three farming communities, particularly among paddy and sugarcane farmers. Longitudinal epidemiological studies to identify vulnerable farming communities and associated risk factors are critically needed to develop effective management strategies against CKDu within farming communities.

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.

Abstract 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.

Intro: Combating AMR is a major challenge in current era. This study aims to investigate the distribution of AMR and the Extended Spectrum Beta Lactamase (ESBL) among livestock, wild animals and environment in an ecosystem with a high density of organized livestock farms in Sri Lanka. Methods: One square km area at Kosgama was mapped using GPS as the study area. In total 222 samples: feces from livestock and wild animals, soil and water from environment, were collected and Escherichia coli (E. coli) were isolated. Maximum of two E. coli per sample were tested to profile AMR for 12 antimicrobials. Among the E. coli, ESBL producers were screened and ESBL expressions were phenotypically detected using cefpodoxime combination disk kit. Prevalence of common ESBL genes: blaCTX-M, blaTEM, blaSHV was detected by PCR. Findings: Seventy seven percent (61/79) of livestock, 62% (42/68) of wild animals, 79% (35/44) of soil and 68% (21/31) of water samples were positive for E. coli. Of the E. coli tested for AMR in livestock, the highest resistance (51.7%) was detected against tetracycline followed by ampicillin (39.4%) and nalidixic acid (37.7%). E. coli from wildlife (45%) and soil/ water (46.5%) reflected the highest resistance against streptomycin. Of the E. coli isolates, 31.5% (36/114) of livestock, 7.3% (6/82) of wildlife, 12.1% (8/66) of soil and 31.4% (11/35) of water were Multi Drug Resistant (MDR). Among 37 E. coli screened as ESBL, two from a mongoose (Herpestes edwardsii) were phenotypically positive for ESBL. Prevalence of ESBL genes were ∼49% (18/37) of which 17 carried blaTEM gene and one that expressed ESBL phenotypically contained blaCTX-M gene. Gene bla SHV was not detected. Conclusion: Unexpected presence of AMR, MDR and ESBL E. coli particularly in wild animals and environment throw light on necessity of prudent use of antimicrobials.

Intro: While the role of adipokines in inducing and regulating inflammation is emerging, adipokines have not been studied in acute dengue. Therefore, we sought to determine different adipokine levels in patients with varying severity of acute dengue to understand their role in disease pathogenesis. Methods: We determined the levels of leptin, resistin, omentin and adiponectin, by using quantitative ELISA in patients with dengue fever (DF=27) and dengue haemorrhagic fever (DHF=13), at admission (≤ 4 day since onset of illness) (A) and at the time of discharge (day 7 to 8 since onset of illness) (D). Viral loads and the serotype of all samples were quantified using quantitative realtime RT- PCR. Findings: The levels of omentin were significantly higher in patients who proceeded to develop DHF compared to DF during admission (p=0.04). In patients with DHF and DF, the omentin levels declined at the time of discharge, which was significant (p=0.04) in patients with DF. The levels of resistin were higher in patients with DHF (median, 1.2, IQR 0.8 to 1.6 pg/ml) compared to those with DF (median 0.75, IQR 0.5 to 1.0 pg/ml) although this was not significant. There was no difference in adiponectin and leptin levels in patients with DF on admission and discharge. In patients who developed DHF, leptin levels increased during these two time points, whereas adiponectin levels decreased. 37/40 (92.5%) individuals were seropositive for DEN-2 and there was no difference in the viral loads in patients who progressed to develop DHF, compared to those who had DF. Conclusion: Omentin is known to be upregulated by type 2 cytokines and induce production of MCP-1. Resistin has shown to induce many proinflammatory cytokines. Therefore, it would be important to further investigate the possible role of these adipokines in dengue disease pathogenesis.