Outcomes among children and adults at risk of severe dengue in Sri Lanka: Opportunity for outpatient case management in countries with high disease burden

Background Healthcare systems in dengue-endemic countries are often overburdened due to the high number of patients hospitalized according to dengue management guidelines. We systematically evaluated clinical outcomes in a large cohort of patients hospitalized with acute dengue to support triaging of patients to ambulatory versus inpatient management in the future. Methods/Principal findings From June 2017- December 2018, we conducted surveillance among children and adults with fever within the prior 7 days who were hospitalized at the largest tertiary-care (1,800 bed) hospital in the Southern Province, Sri Lanka. Patients who developed platelet count ≤100,000/μL (threshold for hospital admission in Sri Lanka) and who met at least two clinical criteria consistent with dengue were eligible for enrollment. We confirmed acute dengue by testing sera collected at enrollment for dengue NS1 antigen or IgM antibodies. We defined primary outcomes as per the 1997 and 2009 World Health Organization (WHO) classification criteria: dengue hemorrhagic fever (DHF; WHO 1997), dengue shock syndrome (DSS; WHO 1997), and severe dengue (WHO 2009). Overall, 1064 patients were confirmed as having acute dengue: 318 (17.4%) by NS1 rapid antigen testing and 746 (40.7%) by IgM antibody testing. Of these 1064 patients, 994 (93.4%) were adults ≥18 years and 704 (66.2%) were male. The majority (56, 80%) of children and more than half of adults (544, 54.7%) developed DHF during hospitalization, while 6 (8.6%) children and 22 (2.2%) adults developed DSS. Overall, 10 (14.3%) children and 113 (11.4%) adults developed severe dengue. A total of 2 (0.2%) patients died during hospitalization. Conclusions One-half of patients hospitalized with acute dengue progressed to develop DHF and a very small number developed DSS or severe dengue. Developing an algorithm for triaging patients to ambulatory versus inpatient management should be the future goal to optimize utilization of healthcare resources in dengue-endemic countries.

A Comparison of Side Effects and Patient Perceptions towards Merocel and Rapid Rhino Packing in the Management of Epistaxis

Objectives: The aim of this study was to compare the efficacy and side effects of non-dissolvable packing for the management of epistaxis. Design: Prospective, observational cohort study. Setting: A large university teaching hospital with an emergency department. Participants: Consecutive adults requiring non-dissolvable packing for the management of acute epistaxis between March 2020 and March 2021. Main outcome measures: Likert-scale questions based on the SNOT-22 questionnaire to assess side effects associated with non-dissolvable packing; and pain scores on insertion, whilst in-situ and on removal. Results: A total of 80 adults requiring non-dissolvable packing were included. 47% of patients presented following a first episode of epistaxis and 52% required inpatient management. 70% of patients had a Rapid Rhino pack inserted. Rapid Rhino had an increased incidence of patient-perceived embarrassment (30%, n=17) compared to patients packed with Merocel (8%, n=2). Patients packed with Rapid Rhino also had an increased severity of embarrassment (0.46 ±0.11) compared to patients packed with Merocel (0.13 ±0.09). Merocel packs had a higher mean pain score on removal (6.09 ±0.73) compared to Rapid Rhino (4.05 ±0.43). No significant association was noted between rebleed rates and pack type or rebleed rates and inpatient versus outpatient management. Conclusion: Non-dissolvable nasal packs, Rapid Rhino and Merocel, have similar efficacy in controlling epistaxis. Rapid Rhino packs are more embarrassing for patients in comparison to Merocel packs but are less painful to remove. Patients were successfully managed in the outpatient setting without an increased complication rate.