BackgroundNeurological manifestations in dengue fever occur in <1 % of the patients and known to be due to multisystem dysfunction secondary to vascular leakage. Occurrence of wide spread cerebral haemorrhages with subdural hematoma during the leakage phase without profound thrombocytopenia and occurrence of cranial diabetes insipidus are extremely rare and had not been reported in published literature earlier, thus we report the first case.Case presentationA 24 year old previously healthy lady was admitted on third day of fever with thrombocytopenia. Critical phase started on fifth day with evidence of pleural effusion and moderate ascites. Thirty one hours into critical phase she developed headache, altered level of consciousness, limb rigidity and respiratory depression without definite seizures. Non-contrast CT brain done at tertiary care level revealed diffuse intracranial haemorrhages and sub arachnoid haemorrhages in right frontal, parietal, occipital lobes and brainstem, cerebral oedema with an acute subdural hematoma in right temporo- parietal region. Her platelet count was 40,000 at this time with signs of vascular leakage. She was intubated and ventilated with supportive care. Later on she developed features of cranial diabetes insipidus and it responded to intranasal desmopressin therapy. In spite of above measures signs of brainstem herniation developed and she succumbed to the illness on day 8. Dengue was confirmed serologically.ConclusionsExact pathophysiological mechanism of diffuse cerebral haemorrhages without profound thrombocytopenia is not well understood. Increased awareness and high degree of clinical suspicion is needed among clinicians for timely diagnosis of this extremely rare complication of dengue fever. We postulate that immunological mechanisms may play a role in pathogenesis. However further comprehensive research and studies are needed to understand the pathophysiological mechanisms leading to this complication.

Factor structure and internal consistency of the current Sinhalese version of the self reported SDQ is not satisfactory. Revalidation of this version of SDQ is recommended to capture the intended objectives of the SDQ.

Studies on medical student perceptions of their lecturers, in a resource poor setting is scarce. Lack of basic infrastructure hampers learning. Quality lecturers can compensate this handicap to some extent. In 2009, as a new medical school located in rural Sri Lanka 220 km away from Colombo, the Faculty of Medicine and Allied Sciences at Rajarata University had scarce human resources and lacked sufficient lecture halls, labs, and clinical space. In order to understand qualities students sought in a lecturer, 55 medical students were given a single, self-administered open-ended question, and responses were subjected to direct thematic analysis. Themes of -Lecturer Qualities,‖ -Lecture Preparation Procedure,‖ and -Lecture Delivery Procedure‖ were identified, and then further divided into sub-themes, the most common of which being -Speaking Style,‖ -Content Design,‖ and -Content Organization.‖ While the findings in this study closely mirrored those of similar studies, identified qualities were underpinned by implicit meaning that accurately reflects the emotional stressors among students coping with limited educational resources. Students emphasized the importance of clear communication due to language barriers and a strong desire for lecturer loyalty to their faculty and country. The examination of these real-life perceptions will not only help us better identify how to improve medical education in this medical faculty and may be useful to similar resource poor rural medical colleges around the world.

Rationale, aims and objectives: Sri Lanka has a well-established government-funded universal health coverage which provides free health care to all citizens. The aim of this qualitative study was to examine the out-of-pocket expenses incurred by patients with cirrhosis during admission to a tertiary care government hospital in Sri Lanka, and the impact such expenses might have on equity of care and patient outcome. Methods This is a qualitative study conducted among patients with cirrhosis admitted to a tertiary-care hospital, their caregivers and physicians. Quota sampling was used until data saturation was achieved. Data was collected through individual interviews and small group discussions using directed and open-ended questions. Thematic framework method was used to analyze data. Out-of-pocket expenses incurred by patients, its impact on equity of patient care and outcome were investigated. Results Costs for laboratory investigations, drugs purchased from the private sector and hired caretakers for hospitalized patients were reported as direct expenses. Loss of work and other sources of income were the primary indirect expenses. The impact of such expenses was higher in patients and families from lower socioeconomic categories, especially among those who were dependent on a daily income. Health care workers actively tried to minimize these out-of-pocket expenses, resulting in choice on investigations, drugs and other interventions often being made by the clinician and occasionally not being discussed with the patient, resulting in poor patient satisfaction. Conclusion This study reveals a substantial direct and indirect economic impact on patients despite being cared for in a government hospital with universal health coverage. The impact was more in patients from lower socioeconomic strata, potentially resulting in inequity in the care provided as well as the health outcomes.