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Sarcoidosis is a multisystem inflammatory disorder of unknown aetiology affecting a wide range of organs and is characterised by the presence of noncaseating granulomas. It has rarely been reported in Sri Lanka. This case describes a 36-year-old male presenting with a loss of weight despite a preserved appetite. He had evidence of sarcoidosis with pulmonary, lymph node, eye, hepatosplenomegaly, thyroid and parotid gland involvement with hypercalcaemia. He was successfully treated with glucocorticoids.

Background Dengue fever is a common infection with increasing numbers of patients affected. Muscle haematomas are a rare complication of dengue fever. In most cases haematomas resolve spontaneously. Case presentation We report a case of spontaneous psoas muscle haematoma, formed during the critical phase of dengue haemorrhagic fever. A 28-year-old gentleman presented with features of severe dengue and was admitted to the Dengue High Dependency Unit. He was treated with intravenous fluid therapy and supportive measures, and gradually improved initially. However, as the critical phase ended, he suddenly developed pain in the left groin and inguinal region and physical examination was normal. Ultrasound scan revealed a left psoas haematoma. As the patient deteriorated haemodynamically blood was transfused. He recovered without further complication and was discharged home. Conclusions Dengue fever is a common tropical infection. Recognizing serious complications such as psoas haematoma presenting as simple complaints such as back pain and inguinal pain are important to prevent mortality.

The limited knowledge on aetiology, epidemiology and risk factors for multimorbidity especially evident from low and middle-income countries curtail the development and implementation of sustainable healthcare models. Sri Lanka, boasting for one of South Asia's most efficient public health systems that is accessible free-of-charge by the citizens is presently transitioning from lower-middle to upper-middle-income tier. Faced with the triple burden of disease, it is imperative for Sri Lanka to incorporate an integrated model to manage multimorbidity. A descriptive cross-sectional study was carried out in medical clinics of a tertiary care hospital and a University primary care department. Data were extracted on to a form from the clinical records of patients over the age of 20 years with at least one non-communicable disease (NCD) and analysed. Multimorbidity was present among 64.1% of patients (n = 1600). Nearly 44.44% of the patients aged 20-35 years have a minimum of two disorders, and by the time they reach 50 years, nearly 64% of the patients have two or more non-communicable diseases. Nearly 7% of those aged over 65 years were diagnosed with four or more disorders. A fourth of the sample was affected by co-morbid diabetes mellitus and hypertension, whereas the combinations of coronary heart disease with hypertension and diabetes mellitus were also found to be significantly prevalent. A salient revelation of the binomial logistic regression analysis was that the number of disorders was positively correlated to the presence of mental disorders 7.25 (95% CI = 5.82-8.68). Multimorbidity is highly prevalent among this population and seemingly has a detrimental effect on the psychological wellbeing of those affected. Therefore, the need for horizontal integration of all primary to tertiary care disciplines, including mental health, to manage multimorbidity by policymakers is emphasized as a priority task.

ObjectivesThis study aimed to determine the prevalence of non-communicable diseases (NCDs) among pregnant women in Sri Lanka and examine the association between NCDs and maternal and fetal outcomes.DesignA hospital-based, descriptive cross-sectional study.SettingThe study was conducted in three tertiary care hospitals in the Western Province and one intermediate obstetrics care facility in the Southern Province of Sri Lanka, encompassing diverse, multiethnic populations, over 3 months.ParticipantsData from 1350 pregnant women were collected from discharged bed head tickets of the postnatal obstetric wards using a standardised checklist.Primary and secondary outcome measuresThe primary outcomes were the prevalence of NCDs. Secondary outcomes included associations between maternal NCDs and adverse fetal outcomes such as preterm births and neonatal complications.ResultsAmong the participants, 68.5% (n=926) had one or more NCDs, with anaemia (37.9%), obesity (18.1%), gestational diabetes mellitus (14.9%) and hypertensive disorders (13.6%) being the most prevalent. Women with NCDs were at significantly higher odds of adverse fetal outcomes, including preterm birth (OR=2.3, 95% CI: 1.5 to 3.4), neonatal sepsis (OR=2.5, 95% CI: 1.5 to 4.04) and hypoglycaemia (OR=3.5, 95% CI: 1.2 to 10.0). Maternal complications, including postpartum haemorrhage (3.3%) and placental abruption (0.7%), were also more frequent in this group.ConclusionsNCDs are highly prevalent among pregnant women in Sri Lanka and are significantly associated with adverse maternal and fetal outcomes. Enhanced screening and management strategies during antenatal care are essential to mitigate risks and improve health outcomes, aligning with global efforts to reduce maternal and neonatal morbidity and mortality.

Tuberculosis is a leading cause of death worldwide, especially in developing countries. It can affect any site in the body and have a myriad of presentations making diagnosis challenging. Tuberculous lymphadenitis in the abdomen is rare. We present a case of a 42-year-old man who presented with non-specific abdominal symptoms and was found to have an intraabdominal abscess on computed tomography scan of the abdomen. Endoscopic ultrasound-guided aspiration was performed, and tuberculosis was confirmed. This case highlights the importance of having a high clinical suspicion of tuberculosis even with vague symptoms in tuberculosis endemic countries. This would prevent unnecessary surgery as tuberculosis is responsive to anti-tuberculosis drugs.

Objectives There has been a global increase in the incidence and prevalence of NAFLD. We assessed the knowledge and awareness of NAFLD among gastroenterology doctors in three state sector hospitals. Results 80 medical officers and 58 post-graduate trainee doctors/consultants responded. 110 (79.7%) considered NAFLD a major health problem whilst 97 (70.3%) thought the prevalence of NAFLD was 10–40%. 52.9% saw 12–24 patients with NAFLD/year. A vast majority knew the risk factors for NAFLD: 127 (92.7%) diabetes mellitus, 135 (97.8%) Obesity, 132 (95.7%) Dyslipidemia and 87 (63%) PCOS. The methods for diagnosis were recognized by: USS 132 (95.7%), MRI 34 (24.6%), transient elastography 23 (16.7%) and liver biopsy 88 (63.8%) while, 53 (38.4%) recognized the non-invasive methods available for diagnosis. The trends in referral were lower than expected: 85 (61.6%) refer to a Gastroenterologist/Physician, 53 (38.4%) to a Gym, 67 (48.6%) to a weight loss clinic and 45 (32.6%) to a dietician. Significantly more postgraduate trainee doctors: recognized the availability of non-invasive investigations for NAFLD (P = 0.01) and read guidelines on NAFLD (P = 0.02) compared to non-trainee doctors. As a whole, a majority (57.2%) had not attended a lecture or read a guideline on NAFLD. The barriers for management included: lack of confidence 70 (50.7%) and time constraints 58 (42%).

Background: Hypoglycemia has been an often‐neglected complication of diabetes therapy. Mild hypoglycemia reduces quality of life, while severe hypoglycemia is life‐threatening and can precipitate major cardiovascular and cerebrovascular events. Methods: A multicenter cross‐sectional study was conducted on hypoglycemia among adults with diabetes attending 19 medical clinics in government hospitals in Sri Lanka using an interviewer‐administered questionnaire. Results: There were 2005 participants, and 1110 (55.4%) were < 65 years of age and 895 (44.6%) were > 65 years of age; the mean age was 62.12 ± 11.94 years (58.1% female). The median duration of diabetes was 8 (IQR11) years. Among them, 808 (43%), 757 (37.8%), and 376 (18.8%) had neuropathy, retinopathy, and nephropathy, respectively, while 415 (20.7%), 50 (2.5%), and 22 (1%) had ischemic heart disease, strokes, and peripheral vascular disease, respectively. One thousand three hundred forty‐nine (67.3%) experienced at least one episode of hypoglycemia, and 462 (34.2%) had hospital admissions (9 (0.7%) intensive care admissions) over the past year. Older adults ( n = 584) experienced significantly more symptomatic hypoglycemia compared to the younger population ( p ≤ 0.001). Their mean CBS during hypoglycemic episodes was 57.04 ± 18.15 mg/dL. Among them, 1552 (77.4%) were on oral hypoglycemic medications, 453 (22.6%) were on insulin, and 126 (6.3%) were on both. The most typical reasons for hypoglycemia were skipping meals while taking regular medications (511, 37.9%), consumption of sugar‐reducing native food items (203, 15%) and taking higher doses of insulin (112, 8.3%) and oral medication (74, 5.5%) than prescribed. To self‐manage hypoglycemia, 1070 (79.3%) took sugary drinks, food, or glucose, and 279 (20.7%) did not do anything. There were 304 (34%) frail older adults, and 238 (78.3%) got hypoglycemia. They were taking similar prescriptions as young adults. They displayed significant hypoglycemic symptoms such as dizziness, irritability, nausea, speech impediment, and blurred vision compared to nonfrail elders ( p ≤ 0.01). There were 485 diabetic patients who either drove or rode in a vehicle; 51 (10.5%) of them had experienced hypoglycemia during driving or riding. Conclusion: Hypoglycemia is a significant issue which needs to be addressed. There is no difference in prescription medication in age categories and frail patients. Driving and hypoglycemia are also a concerning issue. Patients need advice on the prevention and treatment of hypoglycemia.

Background Thrombotic thrombocytopenic purpura (TTP) is a life-threatening hematological condition associated with deficiency in ADAMTS13. Ocular manifestations associated with TTP are uncommon. Case presentation Here we report a case where a 44 year old female patient with a history of symptomatic anemia and cotton wool appearance in retina during ophthalmological examination and subsequently, she was diagnosed to have TTP. The proper management with Therapeutic Plasma Exchange (TPE) and IV methylprednisolone improved the condition of the patient markedly. Conclusion It concludes that even though the presence of cotton wool appearance in retina is a nonspecific sign it needs to be properly evaluated as there can be underlying serious illnesses as in our patient. Cotton wool spots can be an early sign of underlying retinal compromise and it should be identified early.

Background A subdural hematoma refers to a collection of blood between the dura and the arachnoid membranes and is classified into acute, sub acute and chronic. Subdural hematoma has been referred to as the “great neurologic imitator” as it can mimic many neurological conditions. Case presentation Forty-three year old Sri Lankan female presented 2 weeks following traumatic head injury with bilateral flaccid complete paraplegia and urinary retention. Her non-contrast computer tomography of the brain revealed bilateral acute, chronic subdural hematomas. Both subdural hematomas were aspirated and she recovered completely. Conclusions Chronic subdural hematoma can present in many different unusual ways including bilateral complete paraplegia and acute urinary retention mimicking acute spinal cord pathology. The exact mechanism of this clinical presentation is not clear and may be due to direct compression of the motor cortex to the falx or due to compression of the anterior cerebral artery due to subfalcine herniation. This case illustrates the importance of considering subdural hematoma as a rare cause for acute paraplegia and the importance of performing a computer tomography scan in traumatic brain injury when indicated. Failure to consider non-spinal causes of paraplegia results in potential mismanagement. According to our knowledge this is the first case report of acute on chronic subdural hematoma presenting as acute flaccid complete paraplegia with urinary retention.

Background Spinal cord infarction is an uncommon condition. Anterior cord syndrome present with paraparesis or quadriparesis with sparing of vibration and proprioceptive senses. The common causes of anterior cord syndrome are aortic dissection and aortic surgical interventions. Spontaneous unruptured nondissected aortic aneurysms with intramural thrombus can rarely cause anterior cord infarctions. Case presentation We report a case of anterior spinal cord syndrome due to aneurysm of the thoracic aorta with a mural thrombus. A 64 year old male presented with sudden onset paraparesis with a sensory level at T1 with preserved sense of proprioception and vibration. The MRI panspine revealed increased T2 intensity in the anterior portion of the spinal cord from C5 to T10 level with characteristic ‘owl eye’ appearance on axial imaging. The CT aortogram detected aneurysmal dilatation of the ascending aortic, arch and descending thoracic aorta with significant intimal irregularities, calcified atherosclerotic plaques and a small mural thrombus. Conclusion The possible mechanisms postulated are occlusion of ostia of radicular arteries by the atherosclerotic plaques and mural thrombus or thromboembolism to the anterior spinal artery. Nondissected atherosclerotic aortic aneurysms should be considered in patients presenting with spinal cord infarctions especially in the presence of vascular risk factors and smoking.