Composite carotid intima-media thickness as a risk predictor of coronary heart disease in a selected population in Sri Lanka.

BACKGROUND: Segment-specific variations of carotid intima-media thickness (CIMT) have not been assessed in South Asian populations. The purpose of this study was to determine if segment-specific CIMTs or a composite-CIMT score is a better risk predictor of coronary heart disease in South Asian populations. METHODS: A comparative prospective study was conducted from November 2019 to October 2020 in a hospital in Colombo, Sri Lanka. Based on pre-defined inclusion and exclusion criteria, cases (having a diagnosis of Coronary Heart Disease (CHD), n = 338) and controls (non-CHD group, n = 356) were recruited. Ultrasound examination of the common carotid (CCA), the carotid bulb (CB) and the internal carotid segments (ICA) of the carotid vessels was conducted by a radiologist, and CIMTs were measured. A composite-CIMT score defined as the average value of all six segments of the left and right sides was derived. RESULTS: 694 participants were enrolled (male n = 399, 57.5%). The mean (±SD) age of the study sample was 60.2 (±9.86) years. There were variations in segment-specific values between the left and right vessels. The mean composite-CIMT value of the CHD group was significantly higher than that of the non-CHD group. A composite-CIMT score of 0.758 had a sensitivity of 98.4% and a specificity of 64.6% in distinguishing CHD from non-CHD groups (Area under the curve (AUC): 0.926). CONCLUSIONS: Carotid artery segment-specific CIMT variations were present in this population. The composite CIMT score is better than segment-specific CIMTs in predicting CHD and may be used to predict CHD in this population.

Postdischarge outcomes of COVID-19 patients from South Asia: a prospective study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) may cause clinical manifestations that last for weeks or months after hospital discharge. The manifestations are heterogeneous and vary in their frequency. Their multisystem nature requires a holistic approach to management. There are sparse data from the South Asian region on the outcomes of hospital-discharged COVID-19 patients. We assessed the posthospital discharge outcomes of a cohort of Sri Lankan COVID-19 patients and explored the factors that influenced these outcomes. METHODS: Data were prospectively collected from patients who were discharged following an admission to the Nawaloka Hospital, Sri Lanka with COVID-19 from March to June 2021. At discharge, their demographic, clinical and laboratory findings were recorded. The patients were categorised as having mild, moderate and severe COVID-19, based on the Sri Lanka Ministry of Health COVID-19 guidelines. Following discharge, information on health status, complications and outcomes was collected through clinic visits and preplanned telephone interviews. A validated (in Sri Lanka) version of the Short Form 36 health survey questionnaire (SF-36) was used to assess multi-item dimensions health status of the patients at 1, 2 and 3 mo postdischarge. RESULTS: We collected data on 203 patients (male, n=111 [54.7%]). The level of vaccination was significantly associated with disease severity (p<0.001). Early recovery was seen in the mild group compared with the moderate and severe groups. At 3 mo, on average 98% of mild and 90% of moderate/severe patients had recovered. Based on the SF-36, physical functioning dimensions, role limitation due to physical and emotional health, energy/ fatigue, emotional well-being, social functioning, pain and general health were significantly different in the moderate/severe vs mild COVID-19 groups at 1, 2 and 3 mo postdischarge (p<0.05). Twenty-three patients developed complications, of which the most common were myocardial infarction with heart failure (n=6/23; 26.1%), cerebrovascular accident (n=6/23; 26.1%) and respiratory tract infections (n=3/23; 13.01%) and there were six deaths. CONCLUSIONS: In our cohort, receiving two doses of the COVID-19 vaccine was associated with reduced disease severity. Those with mild disease recovered faster than those with moderate/severe disease. At 3 mo posthospital discharge, >90% had recovered.

Involvement of the Liver in COVID-19: A Systematic Review.

COVID-19, a respiratory viral infection, has affected 388 million individuals worldwide as of the February 4, 2022. In this review, we have outlined the important liver manifestations of COVID-19 and discussed the possible underlying pathophysiological mechanisms and their diagnosis and management. Factors that may contribute to hepatic involvement in COVID-19 include direct viral cytopathic effects, exaggerated immune responses/systemic inflammatory response syndrome, hypoxia-induced changes, vascular changes due to coagulopathy, endothelitis, cardiac congestion from right heart failure, and drug-induced liver injury. The majority of COVID-19-associated liver symptoms are mild and self-limiting. Thus management is generally supportive. Liver function tests and abdominal imaging are the primary investigations done in relation to liver involvement in COVID-19 patients. However, imaging findings are nonspecific. Severe acute respiratory syndrome coronavirus 2 RNA has been found in liver biopsies. However, there is limited place for liver biopsy in the clinical context, as it does not influence management. Although, the management is supportive in the majority of patients without previous liver disease, special emphasis is needed in those with nonalcoholic fatty liver disease, cirrhosis, hepatocellular carcinoma, hepatitis B and C infections, and alcoholic liver disease, and in liver transplant recipients.

The immature platelet fraction, a predictive tool for early recovery from dengue-related thrombocytopenia: a prospective study.

BACKGROUND: There is a paucity of predictive factors for early recovery from thrombocytopenia related to dengue. The immature platelet fraction (IPF%) is reflective of megakaryopoiesis and may correlate with recovery from dengue-related thrombocytopenia. Our objective was to assess the predictive value of IPF% on days 2 and 3 of illness for recovery from dengue-related thrombocytopenia. METHODS: A prospective study was conducted among patients with dengue admitted to our institution (Nawaloka Hospital PLC) from December 2019 to October 2020. Dengue was diagnosed based on positive non-structural antigen 1 or IgM. IPF% data were extracted from the Sysmex-XN-1000 automated hematology analyzer. Clinical data were obtained from electronic medical records. Statistical analyses were performed using SPSS version 20. RESULTS: We included 240 patients. An IPF% on day 2 of illness of >7.15% had a sensitivity of 80.0% and specificity of 70.4% for prediction of platelet recovery (defined as platelet count ≥60×109/L) on day 7 of illness. An IPF% of >7.25% on day 3 of illness had a sensitivity of 88.9% and specificity of 47.1% for predicting platelet recovery >60×109/L on day 8 of illness. The IPF% was significantly lower in patients with severe dengue. Platelet recovery was observed within 48 h after the peak IPF% was reached, regardless of severity. CONCLUSION: We propose that IPF% values on days 2 and 3 of illness are a promising predictive tool for early recovery from dengue-related thrombocytopenia.

Combination of cycle threshold time, absolute lymphocyte count and neutrophil:lymphocyte ratio is predictive of hypoxia in patients with SARS-CoV-2 infection.

BACKGROUND: There is currently no clinically validated biomarker to predict respiratory compromise in sudden acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Cycle threshold time (Ct), absolute lymphocyte count (AL) and neutrophil:lymphocyte ratio (NLR) have been previously evaluated for this purpose. We hypothesized that the combination of these parameters at presentation may be predictive of hypoxia (oxygen saturation <92%). METHODS: Data were collected on 118 patients with SARS-CoV-2 infection between May 2020 and April 2021. Demographics, clinical parameters and laboratory and radiological investigation results were recorded. Respiratory compromise (RC) was defined based on symptoms and signs, hypoxia and chest X-ray abnormalities. RESULTS: RC occurred in 61 (51.7%) of patients. The Ct, AL and NLR at median day 3 of illness were significantly different between patients with and without RC (Ct, RC vs not: 19.46±2.64 vs 22.62±3.37, p=0.0001; AL, RC vs not: 531.49±289.09 vs 764.69±481.79, p=0.0001; NLR, RC vs not: 3.42±0.75 vs 2.59±0.55, p=0.0001). Receiver operating characteristics analysis showed that a Ct <19.9, AL <630.8×103/µL and NLR >3.12 at median day 3 of symptoms was predictive of hypoxia on day 7 of illness (area under the curve 0.805, sensitivity 96.7%, specificity 69.1%). The predictive value for the parameters combined was significantly superior to their individual predictive power. CONCLUSIONS: Ct, AL and NLR used in combination on day 3 of symptoms are predictive of hypoxia on day 7 of SARS-CoV-2 illness.

Admission ultrasonography as a predictive tool for thrombocytopenia and disease severity in dengue infection.

BACKGROUND: Ultrasound (US) is an investigation available in many acute care settings. Thrombocytopenia is a well-described complication of dengue infection and has been shown to correlate with disease severity. The purpose of this study was to assess the utility of admission ultrasonography in predicting thrombocytopenia and disease severity in patients infected with dengue virus. METHODS: Data were collected prospectively on 176 patients (male, n=86; female, n=90) admitted to the Nawaloka Hospital, Sri Lanka with dengue infection between December 2016 and August 2018. All patients had an US scan on admission and disease severity was determined using the World Health Organization 2009 classification. RESULTS: There were 106 (60.2%) cases of dengue with/without warning signs and 70 (39.8%) cases of severe dengue. Patients with an abnormal US on admission were more likely to have severe dengue. Gallbladder wall thickening was the most common US abnormality. Abnormal US findings significantly correlated with more pronounced thrombocytopenia from day 2 of admission. CONCLUSIONS: An abnormal US scan on admission can aid in identification of patients at risk of developing severe dengue and can be used as a novel clinical tool to identify patients at risk of severe thrombocytopenia.

Gastrointestinal manifestations in COVID-19.

Coronavirus disease 2019 (COVID-19), a respiratory viral infection, has affected more than 78 million individuals worldwide as of the end of December 2020. Previous studies reported that severe acute respiratory syndrome coronavirus 1 and Middle East respiratory syndrome-related coronavirus infections may affect the gastrointestinal (GI) system. In this review we outline the important GI manifestations of COVID-19 and discuss the possible underlying pathophysiological mechanisms and their diagnosis and management. GI manifestations are reported in 11.4-61.1% of individuals with COVID-19, with variable onset and severity. The majority of COVID-19-associated GI symptoms are mild and self-limiting and include anorexia, diarrhoea, nausea, vomiting and abdominal pain/discomfort. A minority of patients present with an acute abdomen with aetiologies such as acute pancreatitis, acute appendicitis, intestinal obstruction, bowel ischaemia, haemoperitoneum or abdominal compartment syndrome. Severe acute respiratory syndrome coronavirus 2 RNA has been found in biopsies from all parts of the alimentary canal. Involvement of the GI tract may be due to direct viral injury and/or an inflammatory immune response and may lead to malabsorption, an imbalance in intestinal secretions and gut mucosal integrity and activation of the enteric nervous system. Supportive and symptomatic care is the mainstay of therapy. However, a minority may require surgical or endoscopic treatment for acute abdomen and GI bleeding.

Hematological Abnormalities in COVID-19: A Narrative Review.

COVID-19 is caused by SARS-CoV-2. Although pulmonary manifestations have been identified as the major symptoms, several hematological abnormalities have also been identified. This review summarizes the reported hematological abnormalities (changes in platelet, white blood cell, and hemoglobin, and coagulation/fibrinolytic alterations), explores their patho-mechanisms, and discusses its management. Common hematological abnormalities in COVID-19 are lymphopenia, thrombocytopenia, and elevated D-dimer levels. These alterations are significantly more common/prominent in patients with severe COVID-19 disease, and thus may serve as a possible biomarker for those needing hospitalization and intensive care unit care. Close attention needs to be paid to coagulation abnormalities, and steps should be taken to prevent these occurring or to mitigate their harmful effects. The effect of COVID-19 in patients with hematological abnormalities and recognized hematological drug toxicities of therapies for COVID-19 are also outlined.

Comparing the 2009 and 1997 World Health Organization dengue case classifications in a large cohort of South Asian patients.

INTRODUCTION: Due to the shortcomings in the 1997-World Health Organisation (WHO) dengue case classification (DCC), a revised classification was proposed in 2009. This study was aimed to assess the clinical usefulness of the two classifications during a large dengue epidemic. METHODOLOGY: Clinical data of dengue patients admitted to selected units at National Hospital of Sri Lanka, Panadura Base Hospital and Nawaloka Hospital Colombo between June and August 2017 were collected prospectively. Cases were classified using the 1997 and 2009 WHO DCCs. RESULTS: 1,878 patients [adult = 1,573 (83.8%)] were studied. Based on 1997-WHO-DCC-DF (Dengue Fever): 1,316 (70.1%), DHF (Dengue Haemorrhagic Fever) -1: 468 (24.9%), DHF-2: 86 (4.6%) and DHF-3: 8 (0.4%). Based on 2009-WHO-DCC-Dengue with warning signs (WS): 1647 (87.7%), Dengue without WS: 231 (12.3%) and severe dengue (SD): 41 (2.18%). A total of 1,088 (82.7%) DF and 559 (99.5%) DHF patients developed WS. Of those without WS, 228 (17.3%) were DF patients and 3 (0.5%) were DHF patients. Three (0.23%) DF and 38 (6.76%) DHF patients had SD. All SD patients had WS. The level of agreement between the two systems of classification was poor (Kappa = - 0.035, p < 0.001). CONCLUSIONS: The 2009-WHO-DCC was more useful than 1997-WHO-DCC in predicting dengue disease severity as few DF patients also had SD. Furthermore, the presence of WS identified patients with SD. However, the 2009-WHO-DCC may not suit the resource limited countries as WS are non-specific, and lack of diagnostic tests can result in case overload.

The impact of empirical hydrocortisone therapy on clinical outcomes in dengue fever: a retrospective chart review.

BACKGROUND: The role of steroids in dengue infection (DI) remains uncertain. METHODS: A retrospective chart review was conducted on patients ≥18 y of age diagnosed with DI based on positivity for dengue non-structural antigen 1 or immunoglobulin M between October 2017 and November 2018. RESULTS: Hydrocortisone was administered to 106 of 406 patients. DI with warning signs occurred in nine patients (9.5%) in the steroid cohort and eight patients (2.5%) in the non-steroid group. The incidence of severe DI, bleeding and admission duration were similar between the groups. CONCLUSIONS: Our study shows no significant benefit of empirical steroids in DI.

Triple positivity for nonstructural antigen 1, immunoglobulin M and immunoglobulin G is predictive of severe thrombocytopaenia related to dengue infection.

BACKGROUND: The early identification of patients at risk of severe dengue infection (DI) is critical to guide clinical management. Non-structural antigen 1 (NS-1), immunoglobulin M (IgM) and immunoglobulin G (IgG) are used routinely for the diagnosis of DI. OBJECTIVES: We sought to evaluate whether positivity for NS-1, IgM and IgG individually or together is predictive of severe complications of DI. METHODS & MATERIALS: A prospective study was conducted among patients with DI admitted to our institution between 2014 and 2019. DI was diagnosed based on a positive NS1 or IgM. IgG was also tested on all the patients. Clinical data was obtained from electronic medical records at NH. Statistical analyses were performed using SPSS version 20. RESULTS: We collected data on 3504 patients. Patients who were positive for NS1, IgM and IgG (triple positive: TP) were more likely to develop severe DI (63.8 %) in comparison to those who were only NS1 positive (single positive: SP) (3.0 %) and patients with positive NS1 and IgM (double positive: DP) (7.5 %). [p = 0.001]. Regression analysis confirmed that TP status on admission was predictive of severe complications. (p < 0.01). Receiver operator characteristic curve (ROC) analysis showed (AUC: 84.8; sensitivity = 90.7 and specificity = 83.2) that TP status on admission is predictive of thrombocytopenia on day 5. The predictive power of TP status was superior to that of NS1 and IgG positivity. CONCLUSIONS: We propose that TP status on admission is a novel predictive factor for severe DI. Further studies are required to explore the biological basis for this finding.

The atypical lymphocyte count: a novel predictive factor for severe thrombocytopenia related to dengue.

BACKGROUND: Early identification of patients at risk of severe dengue disease (DD) is critical to guide its management. We evaluated whether the atypical lymphocyte count (ALC), generated from the Sysmex automated full blood count analyzer, is predictive of severe thrombocytopenia secondary to Dengue infection. METHODS: We prospectively collected data on patients admitted with DD between December 2017 and October 2018. ALC data were extracted from the Sysmex XS500i analyzer from day 1 to day 7 of admission. Clinical data were obtained from patients' medical records. RESULTS: We enrolled 256 patients with DD. A negative correlation between ALC on admission and platelet count on day 5 to day 7 (Spearmen's correlation; day 5:-0.485, day 6:-0.428 and day 7:-0.344) (p=0.001) was observed. Based on receiver operator characteristic curve analysis, we found that an ALC of >0.5x103/L had 90% sensitivity and 70% specificity for severe thrombocytopenia (platelet count <50x109/L) on day 5. The positive and negative predictive values were 74.4 and 91.2%, respectively (power 84.7). CONCLUSIONS: We propose that ALC on admission may be a novel negative predictive factor for severe thrombocytopenia on day 5 to day 7 of DD. Further studies are required to validate our findings and evaluate whether ALC is predictive of other complications of DD.

Atypical lymphocyte count correlates with the severity of dengue infection.

INTRODUCTION: The early identification of patients at risk of severe dengue infection (DI) is critical to guide clinical management. There is currently no validated laboratory test which can predict severe complications of DI. The Atypical lymphocyte count (ALC) is a research parameter generated at no extra cost when an automated Full Blood Count (FBC) is performed. The purpose of this study was to assess the association of ALC with the severity of DI. METHODS: We prospectively collected data on patients admitted to Nawaloka Hospital Sri Lanka (NH) with DI between December 2016 and November 2017. DI was diagnosed based on a positive Non-structural antigen 1 (NS1) or dengue IgM antibody. ALC (absolute ALC and percentage) data were extracted from the Sysmex XS500i automated full blood count (FBC) analyzer (Sysmex Corporation Kobe, Japan). Clinical data was recorded from medical records and the computerized data base maintained by NH. RESULTS: 530 patients were enrolled. Patients with clinical manifestations of severe dengue have a significantly higher AL % compared to dengue without warning signs. Patients who presented with respiratory compromise had statistically significantly higher AL% compared to those without. (AL%; 8.65±12.09 vs 2.17±4.25 [p = 0.01]). Similarly, patients who developed hypotension had higher AL% compared to those who did not suffered from shock (AL%; 8.40±1.26 vs 2.18±4.25 [p = 0.001]). The AL% of dengue patients presenting with bleeding, at 4.07%, is also higher than those without bleeding complications, at 2.15%. There was a significant negative association between platelet count and AL% (p = 0.04). CONCLUSIONS: Clinical manifestations of severe dengue have a significantly higher AL % compared to dengue without warning signs. AL % at presentation may be predictive of severe DI and future larger prospective longitudinal studies should be done to determine if AL % on admission is predictive of the complications of DI.

A rare presentation of an acute abdomen: an ileal diverticular perforation.

BACKGROUND: This case report highlights the value of prompt intervention of diagnostic laparoscopy in a patient suspects of having an acute abdomen due to an intestinal perforation, where there is a limitation of performing Contrast Enhanced Computed Tomography of abdomen. A previously healthy young adult presenting with an acute abdomen due to a spontaneous ileal perforation, without any associated risk factors is a rare clinical entity in a developing country. Therefore, entertaining an early diagnosis will possibly prevent a fatal consequence. CASE PRESENTATION: A male patient, 29 years old, recently diagnosed as a young hypertensive without any associated factors, currently on antihypertensive treatment, was admitted to our hospital presenting with an acute severe abdominal pain. During initial assessment, the patient was febrile (101 °F), ill looking, tachycardic (pulse rate 121 bpm) with rapid shallow breathing. Abdominal examination reviled diffuse guarding and rigidity, more severe on right iliac fossa. Following history and clinical examination probable clinical diagnosis was made as an acute appendicitis with perforation. However, ultrasonography was found to have normal appendix. Contrast Enhanced Computed Tomography was not performed as a subsequent investigation because of the impairment of renal functions of this patient. Though, non-contrast CT would have been ascertained more diagnostic yield, given the critically ill status of this patient we decided to perform urgent diagnostic laparoscopy. It reviled pus in several abdominal cavities and dense adhesions. Therefore, the procedure was converted to a laparotomy and found to have an ileal perforation with diffuse peritoneal contamination. Diseased ileal segment was resected and anastomosed. Followed by peritoneal lavage. CONCLUSION: Ileal perforation due to diverticular disease in a healthy young adult is rare. This case report highlights the importance of considering this clinical entity as a differential diagnosis, the value of early diagnostic laparoscopy, especially in clinical settings with limitations to CT scan, since late diagnosis can give rise to fatal outcome.