The role of corticosteroids in the treatment of severe leptospirosis is unclear. The rationale for their use is that, in severe leptospirosis, there is a severe immunological response that is harmful to the host resulting in multi-organ dysfunction, which is potentially offset by the nonspecific immunosuppression of high dose steroids. We conducted a systematic review of studies that have assessed the use of high dose corticosteroids in patients with severe leptospirosis by searching MEDLINE and Scopus SciVerse without any language or time restrictions. We identified five studies, including one open randomized clinical trial, which had assessed the use of high dose steroids in severe leptospirosis. Four studies demonstrated a benefit of corticosteroids in treating severe disease with pulmonary involvement when administered early in the course of the disease, but these studies had several methodological constraints as highlighted in the text. Only the randomized controlled trial study showed that corticosteroids are ineffective and may increase the risk of nosocomial infections. There is no robust evidence to suggest that high dose corticosteroids are effective in severe leptospirosis, and a well-designed randomized clinical trial is needed to resolve this.

BackgroundMigration of medical professionals is a long recognized problem in Sri Lanka, but it has not been studied in depth. Undergraduate and postgraduate medical education in Sri Lanka is state sponsored, and loss of trained personnel is a loss of investment. This study assessed the intention to migrate among medical students and newly passed out graduates from the largest medical school in Sri Lanka.MethodsA cross sectional descriptive study was conducted in the Faculty of Medicine, University of Colombo in September 2013 with the participation of first and fourth year medical students and pre-intern medical graduates. Data was collected using a self administered, pre-tested questionnaire that collected data on socio-demographic details, intention to migrate and factors influencing a decision for or against migration.ResultsThere were 374 respondents, 162 from first year (females; 104, 64.2%), 159 from fourth year (females; 85, 53.5%) and 53 pre interns (females; 22, 41.5%). Of the entire sample, 89 (23.8%) had already decided to migrate while another 121 (32.3%) were not sure of their decision. The most cited reasons for migration were a perceived better quality of life, better earnings and more training opportunities in the host country. There were no socio-demographic characteristics that had a significant association with the intention to migrate, indicating that it is a highly individualized decision.ConclusionsThe rate of intention to migrate in this sample is low when compared to international studies from Africa and South Asia, but is still significant. The core reasons which prompt doctors to migrate should be addressed by a multipronged approach to prevent brain drain.

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BackgroundDengue fever is a mosquito-borne viral disease with a very high incidence in Southeast Asia. Most patients with dengue fever recover following a self-limiting febrile illness, while a small proportion may progress to develop severe disease with complications such as acute liver failure, acute kidney injury, and multiorgan failure. Secondary bacterial infections and thrombotic events are very rare.Case presentationA 38-year-old previously healthy Sri Lankan woman from Colombo, Sri Lanka, presented with dengue shock syndrome leading to acute liver failure and kidney injury. She was managed with intravenously administered fluid resuscitation with close monitoring of her hemodynamic status, and hemodialysis. Her renal and liver functions and platelet count improved gradually, but the fever persisted and there was a neutrophil leukocytosis. A clinical examination and investigations to identify a focus of secondary infection revealed staphylococcal infective endocarditis. She was started on intravenously administered vancomycin, but as the response was poor the antibiotic was changed to intravenously administered linezolid, to which the response was good. She also developed right proximal femoral deep vein thrombosis, and was commenced on subcutaneous enoxaparin and warfarin. Enoxaparin was stopped after her international normalized ratio reached the desirable range, and warfarin was continued for 3 months.ConclusionsDengue virus is known to cause endothelial dysfunction that allows bacteria to invade tissues, defective functioning and reduction in the number of cells of the immune system, and alteration of cytokines leading to immune dysregulation, predisposing patients to develop secondary bacterial infections. Evidently, patients with dengue fever who have prolonged fever (more than 5 days) and acute kidney injury are at high risk for concurrent bacteremia. Dengue virus interferes with the components of the anti-clotting pathway, such as thrombomodulin-thrombin-protein C complex. It also activates endothelial cells and increases the expression of procoagulant factors. These factors may predispose patients with dengue viral infections to develop thrombotic complications. Therefore it is important to be aware of the possibility of serious secondary bacterial infections occurring following dengue viral infections, especially in patients with prolonged fever and acute kidney injury, and to keep in mind that thrombotic events may occur as complications of dengue viral infections.

Background Medical education has undergone drastic changes with the advent of novel technologies that enable e-learning. Medical students are increasingly using e-learning methods, and universities have incorporated them into their curricula. Objective This study aimed at delineating the pattern of use of e-learning methods among medical undergraduates and new graduates of the Faculty of Medicine, University of Colombo, and identifying the challenges faced by these students in using e-learning methods. Methods A cross-sectional descriptive study was conducted in the Faculty of Medicine, University of Colombo, in April 2020, with the participation of current undergraduates and pre-intern medical graduates, using a self-administered questionnaire that collected data on sociodemographic details, pattern of use of learning methods, and challenges faced using e-learning methods. Results There were 778 respondents, with a response rate of 65.1% (778/1195). All the study participants used e-learning resources with varying frequencies, and all of them had at least 1 smart device with access to the internet. Electronic versions of standard textbooks (e-books), nonmedical websites, online lectures, medical websites, and medical phone apps were used by the majority. When comparing the extent of use of different learning methods, it appeared that students preferentially used traditional learning methods. The preference was influenced by the year of study and family income. The 3 most commonly used modalities for learning new study material and revising previously learned content were notes on paper material, textbooks (paper version), and e-books. The majority (98.7% [n=768]) of participants have encountered problems using e-learning resources. The most commonly faced problems were unavailability of free-of-charge access to some e-learning methods, expenses related to internet connection, poor connectivity of mobile internet, distractions while using online resources, and lack of storage space on electronic devices. Conclusions There is a high uptake of e-learning methods among Sri Lankan medical students. However, when comparing the extent of use of different learning methods, it appeared that students preferentially used traditional learning methods. A majority of the students have encountered problems when using e-learning methods, and most of these problems were related to poor economic status. Universities should take these factors into consideration when developing curricula in medical education.

Unlike pharyngeal Neisseria gonorrhoeae, less is known about pharyngeal Chlamydia trachomatis in men who have sex with men (MSM). We reviewed cases of pharyngeal chlamydia in MSM from January to December 2019. The overall prevalence of pharyngeal chlamydia was 75/6613 (1.13%; 95% confidence interval (CI) = 0.9–1.14). The median number of sexual partners was three, four (5%) reported throat symptoms and 20 (26%) were HIV positive. Multi-site and concomitant infection was common: rectal chlamydia [39 (52%)], urethral chlamydia [12 (16%)], early syphilis [2 (3%)] and gonorrhoea [14 (19%)]. HIV-positive MSM with pharyngeal chlamydia were older (P = 0.02) and more likely to have had previous syphilis (odds ratio = 4.9; 95% CI = 1.6–14.7; P = 0.005). Further research is needed to explore the characteristics of pharyngeal chlamydia and benefits of increased screening for asymptomatic pharyngeal chlamydia in MSM.

IMPORTANCECumulative exposure to high blood pressure (BP) is an adverse prognostic marker. Assessments of BP control over time, such as time at target, have been developed but assessments of the effects of BP-lowering interventions on such measures are lacking.OBJECTIVE To evaluate whether low-dose triple combination antihypertensive therapy was associated with greater rates of time at target compared with usual care. DESIGN, SETTING, AND PARTICIPANTSThe Triple Pill vs Usual Care Management for Patients With Mild-to-Moderate Hypertension (TRIUMPH) trial was a open-label randomized clinical trial of low-dose triple BP therapy vs usual care conducted in urban hospital clinics in Sri Lanka from February 2016 to May 2017. Adults with hypertension (systolic BP >140 mm Hg and/or diastolic BP >90 mm Hg or in patients with diabetes or chronic kidney disease, systolic BP >130 mm Hg and/or diastolic BP >80 mm Hg) requiring initiation (untreated patients) or escalation (patients receiving monotherapy) of antihypertensive therapy were included. Patients were excluded if they were currently taking 2 or more blood pressure-lowering drugs or had severe or uncontrolled blood pressure, accelerated hypertension or physician-determined need for slower titration of treatment, a contraindication to the triple combination pill therapy, an unstable medical condition, or clinically significant laboratory values deemed by researchers to be unsuitable for the study. All 700 individuals in the original trial were included in the secondary analysis. This post hoc analysis was conducted from December 2020 to December 2021.INTERVENTION Once-daily fixed-dose triple combination pill (telmisartan 20 mg, amlodipine 2.5 mg, and chlorthalidone 12.5 mg) therapy vs usual care.MAIN OUTCOMES AND MEASURES Between-group differences in time at target were compared over 24 weeks of follow-up, with time at target defined as percentage of time at target BP. RESULTS There were a total of 700 randomized patients (mean [SD] age, 56 [11] years; 403 [57.6%] women). Patients allocated to the triple pill group (n = 349) had higher time at target compared with those in the usual care group (n = 351) over 24 weeks' follow-up (64% vs 43%; risk difference, 21%; 95% CI, 16-26; P < .001). Almost twice as many patients receiving triple pill therapy achieved more than 50% time at target during follow-up (64% vs 37%; P < .001). The association of the triple pill with an increase in time at target was seen early, with most patients achieving more than 50% time at target by 12 weeks. Those receiving the triple pill achieved a consistently higher time at target at all follow-up periods compared with those receiving usual care (mean [SD]: 0-6 weeks, 36.3% [30.9%] vs 21.7% [28.9%]; P < .001; 6-12 weeks, 55.2% [31.9%] vs 33.7% [33.0%]; P < .001; 12-24 weeks, 66.0% [31.1%] vs 43.5% [34.3%]; P < .001). CONCLUSIONS AND RELEVANCETo our knowledge, this analysis provides the first estimate of time at target as an outcome assessing longitudinal BP control in a randomized clinical trial...

ObjectivesRates of HIV, syphilis and gonorrhoea have increased over the past 20 years in men who have sex with men (MSM). Contact tracing strategies have increased the number of MSM attending clinics as sexual contacts. Understanding the outcomes of contact tracing could inform future public health policies to reduce the burden of STIs in MSM.MethodWe aimed to describe the contribution of MSM attending as notified sexual contacts of patients with HIV, syphilis and gonorrhoea to the overall diagnoses of HIV, syphilis and gonorrhoea in MSM in a cross-sectional study. We collected data on all MSM diagnosed with HIV, syphilis and gonorrhoea in 2019 and evaluated which of these MSM were tested due to attending as a sexual contact.ResultsSexual contacts of HIV, syphilis and gonorrhoea contributed to 20% (95% CI=17.3% to 23.7%) of all diagnoses of HIV (3 of 30, 10%), syphilis (28 of 183, 15%) or gonorrhoea (98 of 420, 23%) in the study period. Asymptomatic sexual contacts contributed to 12% (95% CI=9.6% to 14.9%) of all diagnoses of HIV (3 of 30, 10%), syphilis (16 of 183, 9%) and gonorrhoea (57 of 420, 14%). The proportion of MSM diagnosed with gonorrhoea attending as sexual contacts of gonorrhoea (21%) was significantly greater than MSM diagnosed with HIV, attending as sexual contacts of HIV (3%) or MSM diagnosed with syphilis, attending as a sexual contact of syphilis (4%) (p<0.001). Furthermore, the proportion of MSM diagnosed with syphilis, attending as a sexual contact of another STI (11%) was significantly greater than MSM diagnosed with HIV, attending as a contact of another STI (7%) or MSM diagnosed with gonorrhoea, attending as a sexual contact of another STI (2%) (p<0.001).ConclusionContact tracing contributes significantly to the overall diagnoses of HIV, syphilis and gonorrhoea including asymptomatic sexual contacts in our population. Further efforts to increase the yield from contact tracing may continue to reduce the burden of HIV, syphilis and gonorrhoea within sexual networks of MSM.