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A STUDY ON “CLINICAL PROFILE OF PATIENTS WITH DENGUE FEVER AND A SCORING SYSTEM TO ASSESS ITS OUTCOME” Dissertation Submitted to THE TAMIL NADU DR.M.G.R.MEDICAL UNIVERSITY CHENNAI In partial fulfillment of the regulations for the award of the degree of M.D. BRANCH – I (GENERAL MEDICINE) DEPARTMENT OF GENERAL MEDICINE GOVERNMENT STANLEY MEDICAL COLLEGE, CHENNAI. THE TAMIL NADU DR. M.G.R.MEDICALUNIVERSITY TAMILNADU, INDIA MAY 2020
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Transcript of a study on - EPrints@Tamil Nadu Dr MGR Medical University
A STUDY ON “CLINICAL PROFILE OF PATIENTS WITH
DENGUE FEVER AND A SCORING SYSTEM TO ASSESS ITS OUTCOME”
Dissertation Submitted to
THE TAMIL NADU DR.M.G.R.MEDICAL UNIVERSITY
CHENNAI
In partial fulfillment of the regulations for the award of the degree of
M.D. BRANCH – I (GENERAL MEDICINE)
DEPARTMENT OF GENERAL MEDICINE
GOVERNMENT STANLEY MEDICAL COLLEGE, CHENNAI.
THE TAMIL NADU DR. M.G.R.MEDICALUNIVERSITY
TAMILNADU, INDIA
MAY 2020
CERTIFICATE
This is to certify that this dissertation entitled “CLINICAL PROFILE OF PATIENTS
WITH DENGUE FEVER AND A SCORING SYSTEM TO ASSESS ITS
OUTCOME” submitted by Dr.N.DEVASENA to the faculty of General Medicine, The
TamilNadu Dr. M.G.R Medical University, Chennai, Tamilnadu, in partial fulfillment of
the requirement for the award of M.D DEGREE BRANCH-I (GENERAL MEDICINE) is
a bonafide research work carried out by him under my direct supervision and guidance.
Prof. Dr. C. HARIHARAN M.D.,
Head of the Department,
Department of Medicine,
Stanley Medical College and Hospital,
Chennai- 1.
PROF. DR.R.SHANTHIMALAR, M.D., D.A.,
DEAN
Government Stanley Medical College and Hospital,
Chennai-1.
CERTIFICATE BY THE GUIDE
This is to certify that Dr.N.DEVASENA, Post Graduate student (May2017 to April
2020) in the Department of General Medicine, Government Stanley Medical College and
Hospital,Chennai-1,has done this dissertation work titled “CLINICAL PROFILE OF
PATIENTS WITH DENGUE FEVER AND A SCORING SYSTEM TO ASSESS
ITS OUTCOME” under my guidance and supervision in partial fulfillment of the
regulations laid down by The Tamilnadu Dr.M.G.R.Medical University, Chennai for
M.D.,(General Medicine),Degree examination to be held in May 2020.
Prof. Dr. C. HARIHARAN M.D.,
Chief, Medical Unit-I,
Department of Medicine,
Stanley Medical College and Hospital,
Chennai - 1.
DECLARATION
I, Dr.N.DEVASENA, solemnly declare that the dissertation titled “CLINICAL
PROFILE OF PATIENTS WITH DENGUE FEVER AND A SCORING SYSTEM
TO ASSESS ITS OUTCOME” is a bonafide work done by me at Government Stanley
Hospital, Chennai during May 2018 to MAY 2019 under the guidance and supervision of
Prof.Dr.C.HARIHAAN M.D., Professor of Medicine, Government Stanley Hospital,
Chennai. I also declare that this bonafide work or a part of this work was not submitted
by me or any other for any award, degree or diploma to any other university, board either
in India or abroad. This dissertation is submitted to the Tamilnadu Dr.M.G.R Medical
University, towards the partial fulfillment of requirement for the award of M.D. Degree
(Branch – I) in General Medicine.
Place: Chennai Signature of the candidate
Date : (Dr.N.DEVASENA)
CERTIFICATE – II
This is to certify that this dissertation work titled “CLINICAL PROFILE OF
PATIENTS WITH DENGUE FEVER AND A SCORING SYSTEM TO ASSESS
ITS OUTCOME” of the candidate Dr.N.DEVASENA with Registration Number
201711052 for the award of M.D., DEGREE in the branch of BRANCH-I
(GENERAL MEDICINE). I personally verified the urkund.com website for the purpose
of plagiarism check. I found that the uploaded thesis file contains from introduction to
conclusion pages and result shows eight percentage of plagiarism in the dissertation.
Guide & Supervisor sign with Seal
PLAGIARISM CERTIFICATE
SPECIAL ACKNOWLEDGEMENT
I gratefully acknowledge and thank
PROF. DR.R. SHANTHI MALAR M.D., D.A.,
DEAN
GOVERNMENT STANLEY MEDICAL COLLEGE AND HOSPITAL, CHENNAI.
For granting me permission to utilize the resources of this
Institution for my study
ACKNOWLEDGEMENT
I am extremely thankful to our beloved Superintendent Prof.Dr.DHANASEKAR, M.D.,
Government Stanley HospitalChennai-1, for having granted permission to do this
dissertation in Government Stanley Hospital, Chennai.
I am very grateful to our Professor and Head of the Department of Medicine
Prof Dr.C.HARIHARAN, M.D., for acceptance to do this dissertation.
I am extremely grateful to my unit chief Prof Dr.C.HARIHARAN. M.D, who taught
me the basic aspects and clinical skills in internal medicine which is an essential pre
requisite for pursuing any dissertation work. The guidance and encouragement he
provided need a special mention.
I recall with gratitude the other unit chiefs and Associate Professors of Department
of Medicine , Prof. Dr. I.ROHINI M.D.,Prof . Dr.G.RAJAN, M.D., Prof. Dr.
C.SRIDHAR M.D., Prof. Dr.A.SAMUEL DINESH, M.D., Prof.Dr.T.B.UMADEVI
M.D., Prof. Dr.A.RAVI M.D., , Prof. Dr. R.THILAKAVATHY M.D.,
Prof.Dr.P.MALARVIZHI M.D., Prof. Dr. KALPANA RAMANATHAN M.D., for
their valuable guidance.
I am extremely thankful to our Registrar Dr.N.RAVICHANDRAN M.D., and our unit
Asst. Professors Dr.N.SUKANYA M.D., Dr.S.PRAKASH M.D.,
Dr. G.SATHYA D.M., for their valuable suggestions, guidance and support.
I thank Prof.Dr.P.ARUNALATHA, M.D., Professor and Head of the Department
of Pathology, Government Stanley Hospital for allowing me in utilizing their laboratory
facilities for getting the hematological parameters in the thesis work which were very
crucial for the study.
I thank Prof. Dr. M.P. SARAVANAN, M.D., Professor and Head of the
Department of Biochemistry for providing me with facilities for accurate measurement of
the biochemical parameters involved in the thesis work which were very crucial for the
study.
I also thank Prof .Dr.C.AMARNATH M.D.,(RD), Professor and Head of the
Department, Department of Radiology, for allowing me to utilise the USG facility of
their department to in age my patients, and also in helping to interpret them.
I also thank all our patients and their attenders, without whom the study would not be
possible.
I extend my love and gratitude to my family and friends for their immense help for
this study.
I owe my thanks to almighty for successful completion of this study.
ABBREVIATIONS
USG : Ultrasound
DF : Dengue fever
DHF : Dengue Hemorrhagic fever
DSS : Dengue shock syndrome
PLT : Platelets
SS : Sample size
Ig M : Immunoglobulin M
APTT : Activated partial thromboplastin time
PT : Prothrombin time
CRP : C-reactive protein
ESR : Erythrocyte sedimentation rate
GGT : Gamma glutamyl transferase
CBC : Complete Blood count
RFT : Renal function test
LFT : Liver function test
BUN : Blood urea nitrogen
BP : Blood Pressure
WHO : World Health Organisation
CDC : Centre for Disease Control
MODS : Multi Organ Dysfunction Syndrome
DIC : Disseminated Intravascular Coagulation
CNS : Central Nervous System
Hct : Hematocrit
PCV : Packed Cell Volume
KEYWORDS:
Dengue;
Dengue shock syndrome,
Dengue score,
Severity of dengue
Acute febrile illness
TABLE OF CONTENTS
S.No CHAPTERS
1 PLAGIARISM CERTIFICATE
2 INTRODUCTION
3 AIM AND OBJECTIVES OF THE STUDY
4 REVIEW OF LITERATURE
5 MATERIALS AND METHODS
6 STATISTICAL ANALYSIS
7 RESULTS
8 DISCUSSION
9 CONCLUSION AND LIMITATIONS
10 BIBLIOGRAPHY
11 PROFORMA
12 ETHICAL COMMITTEE
13. INFORMED CONSENT
14. MASTER CHART
LIST OF TABLES
TABLE No TABLE
1 P value significance
2 Age distribution
3 Sex distribution
4 Day of fever on admission
5 Fever during admission
6 Comorbidities
7 Hypotension in the study
8 Pulse rate
9 Respiratory rate
10 Total leukocyte count
11 Platelet count
12 Packed cell volume
13 SGOT levels
14 Albumin levels
15 Comobidities
16 Urine output
17 Urine sugar
18 Hematuria
19 USG and day done
20 Hepatomegaly
21 Splenomegaly
22 Hepatosplenomegaly
23 Pleural effusion
24 Ascites
25 Gall bladder wall edema
26 Bleeding
27 Blood transfusion
28 ICU Care
29 Recovery
30 Dengue score
31 Dengue score and pleural effusion
32 Dengue score and ascites
33 Dengue score and bleeding
34 Dengue score and platelet count
LIST OF IMAGES
IMAGE NUMBER TOPIC
1 Phases in symptomatic dengue infection
2 Course of dengue fever
3 Warning signs in dengue fever
4 Evidence of plasma leakage
5 Medical complications in various phases of dengue
6 Worsening of Dengue fever
7 Dengue case classification by severity
8 Differential diagnosis of Dengue fever
9 Dengue diagnostics
10 Seroconversion in Dengue
11 Dengue diagnosis and interpretation of results
12 Dengue case management and classification
13 Management of Group A
14 Management of Group B
15 Management of Group C – Compensated shock
16 Management of Group C – Decompensated shock
17 Scoring of parameters
18 Age distribution
19 Sex distribution
20 Non- fever complaints
21 List of comorbidities in the study
22 Pulse pressure
23 Platelet count
24 Hematocrit
25 SGOT
26 Albumin levels
27 Comorbidities
28 Urine output
29 Urine sugar
30 Hematuria
31 USG and day done
32 Hepatomegaly
33 Splenomegaly
34 Hepatosplenomegaly
35 Pleural effusion
36 Ascites
37 Gall bladder wall edema
38 Bleeding
39 ICU Care
40 Dengue score
41 Dengue score and platelet count
1
INTRODUCTION
Dengue is a common viral infection worldwide, especially in the tropics. In-
fact, the most common mosquito borne arbo-viral disease is Dengue, putting half of
world’s population at risk. The disease manifests from a self-limiting fever to death.
Most deaths from dengue occur in patients with profound and prolonged shock
resulting from plasma leakage and complicated by bleeding.
Thrombocytopenia is a major sign of plasma leakage and third space loss in
dengue infected patients. Platelet damage in dengue patients , may result in the release
of VEGF (vascular endothelial growth factor). VEGF is responsible for the occurrence
of third space fluid loss viz., pleural effusion and / or ascites. Third space loss is
usually preceded by thrombocytopenia, raising haematocrit, falling albumin levels.
Any test/ tests that act as a predictor for these severity factors helps in
selectively monitoring patients prone for plasma leak, bleeding and or shock, thereby
helping in reducing morbidity and mortality.
2
AIMS AND OBJECTIVES OF THE STUDY
The aim is to determine the clinical and laboratory profile of patients with
Dengue fever and a scoring system to assess its outcome.
The primary objective is to analyse and validate a scoring system from the
laboratory profile of dengue fever patients.
3
REVIEW OF LITERATURE
Dengue, a mosquito-borne acute febrile illness is a major public health
problem in the subtropics as well as the tropics worldwide. Severe dengue
epidemics have been reported in just nine countries worldwide before 1970. But
dengue is endemic now, in over a hundred countries, according to WHO (World
Health Organisation).
Nearly forty percentage of the world's population, reside in dengue-
endemic areas. Almost four hundred million people are infected with dengue virus
every year, of which a hundred million become ill and twenty one thousand deaths
are attributed to it.
In India, Dengue’s epidemiology was first reported in Chennai (1780) while
the first outbreak occurred in Kolkata (1963). Subsequent outbreaks have been
document in different parts of India. Dengue was endemic in both southern and
northern states, in early 2000s. Increase in number and severity of the disease, in
urban and rural areas have been a major shift in the epidemiology of the disease.
4
Dengue’s expansion in India is related to unplanned urbanization with
changes in environmental factors and the host–pathogen interaction, along with
population immunological factors. There has been a 30-fold increase in number of
cases globally over the past fifty years.
Distribution trends
The number of cases reported has increased in the recent years. Even in
America, with one of the best health infrastructure, 2.35 million dengue cases
were reported in 2015 alone, of which about ten thousand cases were severe
dengue and the deaths were 1181 in number. In 2015, Delhi-the capital city of
India, with over 15 000 cases, recorded its worst outbreak since the year 2006.
The increase in number of cases is explosive in the recent years. Also this
spread has not spared Europe or the other developed nations. Dengue stands next
to malaria as a cause of fever among those returning from low- and middle-
income nations.
The year 2016 was no exception and was showing large dengue outbreaks
worldwide. But in 2017, there was a fortunate reduction in the number of cases in
5
the Americas, representing a reduction of 73%. Similarly, there was a 53%
reduction in severe dengue cases during 2017.
Virus, Vector and Transmission:
Dengue virus (DENV) causes of dengue fever.
DENV is a mosquito-borne, single-stranded RNA virus.
Virus: Dengue virus
Family: Flaviviridae
Genus: Flavivirus.
Number of serotypes: 5
(All the five serotypes can cause the full spectrum of disease.)
Vector : Aedes aegypti (Mosquito)
Aedes aegypti is the primary vector.
Infected female mosquitoes’ bite transmits the disease to humans.
After an incubation period of 4–10 days in the mosquito, the infected
mosquito can transmit the virus for the rest of its life.
6
Image 1: Dengue Transmission
Infected asymptomatic or symptomatic humans are the main multipliers and
carriers of the dengue virus and serves as a source for uninfected
mosquitoes.
Infected patients can transmit the infection via these vectors after their first
symptoms appear.
Man-made containers containing water act as urban habitat for the Aedes
aegypti mosquito.
This mosquito is a day-time feeder and its peak biting period is early in the
morning and also in the evening before dusk.
7
The female Aedes aegypti bites many people during each feeding period.
In the breeding habitat, its eggs remain dry for upto a year and capable of
hatching when come in contact with water.
Another mosquito, Aedes albopictus is a secondary dengue vector,
especially in Asia.
Course of dengue illness:
Dengue viruses can cause asymptomatic sero-conversion or symptomatic
infections. Symptomatic dengue infection is a systemic disease. Its clinical
spectrum is wide that includes both severe and non-severe manifestations.
After the intrinsic incubation period, there is an abrupt beginning of illness.
In patients with moderate to severe disease, the onset is followed by three phases
− febrile, critical and recovery.
Table 1: Phases in symptomatic dengue infection
Phases in Symptomatic Dengue Infection
1
Febrile Phase
2
Critical Phase
3
Recovery Phase
8
The severity of the disease, due to its dynamic nature, will manifest usually
only around defervescence (Defervescence is the transition from febrile to afebrile
phase). This coincides with the onset of the critical phase, often.
The course of dengue illness
Image 2: Course of dengue fever
Ig = immunoglobulin. Temperature - in degrees Celsius (°C)
(Source: adapted from Yip, 1980 (2)
9
Febrile phase
Infected patients develop a sudden high-grade fever typically.
This phase lasts 2−7 days usually.
Accompanying features: Facial flushing, generalized body ache, myalgia,
skin erythema, arthralgia, retro-orbital eye pain, rubelliform exanthema,
photophobia and headache(1).
A sore throat, an injected pharynx, and conjunctival injection may be
present in few patients.
Also anorexia, nausea and vomiting are common.
Distinguishing dengue from non-dengue febrile diseases clinically in the early
febrile phase can be difficult. A positive tourniquet test may be a sign of dengue
during this phase (3, 4). But as these features do not foretell the severity of
disease, it is essential to monitor for warning signs of the illness and other clinical
parameters in order to identify evolution to the critical phase. Also any cumulative
score system to predict the future severity can also be helpful, although such
scoring is sparse.
Image 3: Warning signs in dengue fever
10
Mild hemorrhagic manifestations may be seen. These may be petechiae and
mucosal membrane bleeding (of the nose and gums etc). In some cases, easy
bruising and bleeding at venipuncture sites may be seen. Rarely, massive vaginal
bleeding and gastrointestinal bleeding may occur during this phase. There may be
hepatomegaly and it may be tender. A progressive decrease in total leucocytes is
the earliest abnormality in the whole blood count.
Critical phase
During defervescence, patients without a rise in capillary permeability will
recover without going through the critical phase. Instead of improving with
defervescence; patients with raised capillary permeability may have warning
signs. This is due to plasma leakage.
The beginning of the critical phase is marked by the warning signs.
Defervescence makes these patients worse, usually on days 3–8 of illness. Plasma
leakage is usually preceded by progressive leukopenia followed by a swift
decrease in platelet count. A rising hematocrit above the baseline may be an
additional sign (5,6). The duration of clinically significant plasma leakage is
usually 24−48 hours. The severity of plasma leakage may vary. Increasing
hematocrit usually precedes changes in BP and pulse volume.
11
The severity of plasma leakage is reflected by the degree of
hemoconcentration above the baseline, though early intravenous fluid therapy
may interfere with this. Frequent hematocrit determinations are crucial because
they sign the need for possible alterations to intravenous fluid therapy. In resource
poor settings like India, predicting patients prone for severe disease and
channelizing the available resources may prove beneficial. Pleural effusion and
ascites are typically only clinically demonstrable after intravenous fluid therapy,
unless plasma leakage is substantial.
Evidence of plasma leakage
1. Right lateral decubitus chest radiograph detection of pleural effusion
2. Ultrasound detection of free fluid in the chest or abdomen
3. Gall bladder wall edema
Image 4: Evidence of plasma leakage
12
Shock may occur after a critical volume of plasma is lost through leakage.
It is preceded often by warning signs. There may be subnormal body temperature
when shock occurs. Hypo-perfusion from profound shock may cause progressive
organ impairment, metabolic acidosis and disseminated intravascular coagulation,
which in turn may cause severe hemorrhage. This may lead to decreased
hematocrit in severe shock. In patients with severe bleeding, the expected
leucopenia may be replaced by stress leukocytosis. Severe organ involvement
such as, encephalitis, myocarditis, severe hepatitis, and/or severe bleeding may
occur with or without shock.
The critical phase of plasma leakage and shock is possible before
defervescence; and a rising hematocrit and swift onset of thrombocytopenia or the
warning signs, may indicate the onset of plasma leakage in such patients. The
cases of dengue with warning signs will frequently recover with intravenous
rehydration. Few cases may deteriorate to severe dengue.
13
Warning signs of dengue
Warning signs usually appear towards the end of the febrile phase (days 3–
7 of illness) and precede the manifestations of shock. Severe abdominal pain and
persistent vomiting are early indications of plasma leakage. Mentally alert patient
may become lethargic. And these symptoms may continue into shock. Bleeding at
previous venipuncture sites and spontaneous mucosal bleeding are significant
hemorrhagic manifestations. Increasing liver size and a tender liver is frequently
observed. A quick and progressive reduction in platelet count to about 100 000
cells/mm3 and a increasing hematocrit above the baseline may be the initial sign
of plasma leakage. This is usually preceded by leukopenia (≤ 5000 cells/mm3)(7).
World Health Organization defines DHF by the following four criteria:
• Fever or recent history of fever lasting 2–7 days.
• Any hemorrhagic manifestation.
• Thrombocytopenia (platelet count of < 100000/cu.mm).
• Evidence of increased vascular permeability.
Dengue shock syndrome (DSS):
-any case that meets the four criteria for DHF and
- evidence of circulatory failure manifested by rapid, weak pulse and narrow pulse
pressure (≤20 mmHg ) or hypotension for age, restlessness, and cold, clammy
skin.
14
Dengue patients can rapidly progress into dengue shock syndrome. DSS, if
not treated properly, can lead to severe complications and even death.
Recovery phase
After the 24−48 hours critical period, as gradual reabsorption of
extravasated fluid takes place in the following 48−72 hours there is improvement
in the general well-being, appetite, gastrointestinal symptoms, hemodynamic
status, and diuresis results. A confluent petechial or erythematous rash with small
areas of normal skin (“isles of white in the sea of red”) develop in some patients.
Generalized pruritus occur in some people. Bradycardia and ECG changes are
frequent during this stage. The hematocrit stabilizes or the dilutional effect of
reabsorbed fluid may bring the hematocrit lower. The white leukocyte usually
starts to rise soon after defervescence than the recovery of the platelet count
(typically later). Respiratory distress may occur and may result from ascites and
pleural effusion, pulmonary edema or congestive heart failure. This occur during
the critical and/or recovery phases. Excessive use of intravenous fluids increase
the risk.
15
Image 5
Patients in compensated shock are often conscious and lucid. An inexpert
physician may measure a normal pulse-oximetry reading and a normal systolic
pressure in a conscious patient and misjudge the critical state of the patient.
Worsening hypovolaemic shock usually manifests as peripheral
vasoconstriction and increasing tachycardia. Not only are the extremities cyanosed
16
and cold but the limbs may become mottled, cold and clammy. The breathing may
increase in depth and become more rapid − Kussmaul’s breathing, for the
metabolic acidosis. When decompensation occur, both systolic and diastolic BPs
disappear dramatically and suddenly , and now these patients are said to have
decompensated shock or hypotension.
Prolonged hypotension and hypoxia will lead to multiple organ failure and
severe metabolic acidosis. Patients to progress from warning signs to compensated
shock and then from compensated shock to hypotensive shock, but very rapid
progression to cardiorespiratory collapse and cardiac arrest.
17
Image 6: Worsening of Dengue fever
Hypotension is associated with prolonged shock which may be complicated
by major bleeding, often. Major bleeding is almost always associated with
profound shock because this, in combination with hypoxia, acidosis and
thrombocytopenia, can lead to multiple organ failure with advanced disseminated
intravascular coagulation.
Massive bleeding without prolonged shock may occur when aspirin,
ibuprofen, or corticosteroids are taken. Patients with previous peptic or duodenal
ulcers may bleed (8,9). Acute renal and liver failure and encephalopathy may occur
18
in severe shock. Encephalitis and cardiomyopathy have also been reported. Most
deaths occur in patients with prolonged and profound shock resulting from plasma
leakage, complicated by fluid overload or bleeding.
Prompt fluid replacement avoids shock even in patients with severe plasma
leakage. But such patients may develop respiratory distress due to ascites and
massive pleural effusion.
Dengue case classification by severity
Image 7
19
Dengue diagnostics:
Dengue laboratory diagnosis are for
(i) the clinical diagnosis confirmation
(ii) epidemiological surveillance
Clinical management does not necessitate laboratory diagnosis except in few
atypical cases or when differential diagnosis is considered.
Image 8: Differential diagnosis of Dengue fever
20
Laboratory diagnosis is made by detecting the virus or its components like
infective virus, virus genome, dengue antigen or by serological responses after
infection (IgM and IgG responses).
Image 9: Dengue diagnostics
21
Virological and serological markers of dengue infection in relation to time:
During the incubation period the virus replicates leading to an antibody
response. Viraemia and symptoms correlate in most dengue cases. Disappearance
of viraemia and fever marks the development of IgM antibody response (10).
.
Viraemia develops from a couple of days before the onset of fever, in a primary
infection, until 4–5 days after. And anti-dengue IgM antibodies are detected 3−6
days after onset of fever.
Days of fever % Cases with anti-dengue IgM
positivity
3-5 50%
6-10 95-98%
IgM antibodies are detectable around 1-3 months after fever, though in low levels.
22
Image 10: Seroconversion in Dengue
Dengue diagnosis and interpretation of results
Image 11: Dengue diagnosis and interpretation of results
23
Dengue case management(CDC guidelines)
Image 12: Dengue case management and classification
24
Depending on the presence of warning signs the dengue cases can be grouped among A-
C groups and the proposed management strategy is as follows (CDC guidelines).
Image 13: Management of Group A
25
Image 14: Management of Group B
26
Image 15: Management of Group C
27
Image 16: Management of Group C – Decompensated shock
28
Clinical parameters including conscious level, capillary refill, extremities’
temperature, peripheral pulse volume, heart rate, blood pressure, respiratory rate and
urine output are used in assessing the hemodynamic status.
Complications of Dengue:
Several complications seen in dengue are avoidable if clinical team members
are aware of the physiological problems of various phases. Adequately
management of hypovolemic phase makes the patients “sail out” of the critical
phase just with parenteral fluids.
Causes of complications in dengue include the following:
• Missing the diagnosis;
• insufficient monitoring and misinterpretation of vital signs;
• improper monitoring of fluid intake and urine output;
• recognizing shock late,
• late recognition of severe bleeding;
• inappropriate intravenous fluids administration
• carelessness towards aseptic techniques.
29
The complications include one or a combination of
• profound shock;
• severe bleeding with severe DIC;
• fluid overload with respiratory distress and failure;
• multi-organ dysfunction
• irreversible shock and finally death.
Co-infection
Gram-negative bacterial co-infection has been reported in patients with renal
failure and diabetes mellitus. A high index of suspicion may help in co-
infection with other tropical infections, especially in those with atypical
presentations.
It is not uncommon in patients with severe dengue to acquire a nosocomial
infection. Timely and appropriate antibiotic therapy can be lifesaving.
Mortality:
An estimated 2.5% case fatality is seen in severe dengue. However, with
efficient improvement in managing cases through capacity building, developed
30
countries have reduced the case fatality rate to < 1% and worldwide a 28% decline
in case fatality has been documented between 2010 and 2016. The mortality rate in
treated and not treated severe dengue cases was <5% and up-to 20%, respectively.
5.7% of patients with evidence of plasma leak developed cardiorespiratory
dysfunction increasing the mortality further (18). Thus, there is a close association
between predictors of plasma leakage and mortality.
Early identification and prognostication may avoid these severe
complications (11,12). The risk factors and different laboratory parameters were
studied in exploring their roles in predicting the severity of dengue. Among them
were thrombocytopenia (13), hemoconcentration (13) and elevated liver enzyme
aspartate aminotransferase (AST) (14). PELOD (Pediatric Logistic Organ
Dysfunction) score and the DIC (Disseminated Intravascular Coagulation) score
were proposed to forecast mortality in Dengue shock syndrome. Also, Pongpan et
al’s dengue infection severity score includes hematocrit, platelet count among
other variables (15). In another study of 1207 dengue shock syndrome children, the
variables used in scoring include raising hematocrit(16).
A study paper by Suwarto et al (parent study, 17) had been done in Cipto
Mangunkusumo and Persahabatan Hospitals, Indonesia among dengue infected
patients between 2010 and 2015. It dealt with a dengue severity score based on
31
hemoconcentration, albumin, AST and platelet count and the score’s ability to
determine occurrence of evidence of plasma leakage – pleural effusion and ascites
studied.
S.NO PARAMETER SCORE 1, if
1 Platelet count ≤49,500/ uL
2 Degree of hematocrit % ≥15.1%
3 Elevated ratio of SGOT ≥2.51
4 Serum albumin ≤3.49 g/dl
Image 17 : Scoring of parameters
At a cut off of ≥ 2, the score had a sensitivity of 82.47%, specificity of 70.42%
and correctly predicted pleural effusion and / or ascites diagnosis(by USG (19-22)) at a
rate of 77.38%. In this study, the same score is assessed (modified as in the methods) in
its ability to predict the occurrence of severity features so that care can be maximized in
such patients.
32
MATERIALS AND METHODS
STUDY SETTING
Patient who are admitted in the medical and fever wards in the Department of
Internal Medicine , Government Stanley Medical College and Hospital,
Chennai-01.
ETHICAL APPROVAL
Approval was obtained from the Institute ethical committee in order to perform the
study.
STUDY GROUP
Inclusion criteria:
Patient presenting with AFI duration of 1-7 days,
IgM Dengue positive,
Age > 13years
Exclusion criteria:
- Patients presenting with evidence of shock and serositis
- IgM Dengue negative patients
- Fever more than 7 days
- Patients with chronic liver and renal disease
- Patients with known bleeding disorders
33
- Patients with known cardiac failure
- Patients presenting in sepsis
STUDY DESIGN
Cross-sectional study
SAMPLE SIZE: 168
- Based on parent study(17), sample size was calculated using the formula
4 σ²/ d2 with an odds ratio of 1.75, with α=0.05, and β = 0.20 and the sample
size is 168.
DURATION OF THE STUDY
1 Year (May 2018 to May 2019)
CONSENT
Consent form will be written in both English and Tamil and also orally
explained in their own language and consent will be obtained from participants,
and confidentiality will be maintained.
MATERIALS USED
Ultrasonogram
Chest X-ray
Blood samples for CBC, RFT and LFT, PT-INT, aPTT
34
METHOD OF DATA COLLECTION
Sample size: 168
Protocol of the study:
Patients who satisfy the criteria are recruited into the study (with informed
consent).
The medical details and records are assessed.
Complete blood count, renal function test and liver function test, INR, Stool
occult blood (once after day 5 or when melena is suspected), IgM Dengue
by ELISA (on or after day 5), Chest X ray (on day of admission) USG
abdomen are done and results noted.
Chest x-ray and USG proven pleural effusion and ascites, circulatory
shock- Systolic BP < 90 mmHg are noted.
A score from the parent study(17) is attempted for every patient using the
following parameters – platelet count, haematocrit, SGOT, serum albumin
from the investigations done at the time of admission are obtained.
S.NO PARAMETER SCORE 1, if
1 Platelet count ≤49,500/ uL
2 Degree of hematocrit % ≥15.1%
3 Elevated ratio of SGOT ≥2.51
4 Serum albumin ≤3.49 g/dl
35
The parameters in % and ratio are obtained from the following methods:
The minimum haematocrit is taken as 45 and the upper limit of AST
reference is taken as 40, and used in estimation of score of each variable.
Total score is the summation of score of each individual parameter of a
patient.
Whether patients are progressing to serositis (third space loss) / shock are
looked upon and any relation to the score estimated.
CONFLICT OF INTEREST
None
36
STATISTICAL ANALYSIS
The collected data were analysed with IBM.SPSS statistics software
23.0 Version.
With respect to data description ,the mean & S.D were used for
continuous variables and descriptive statistics frequency analysis,
percentage analysis were used for categorical variables and
To find the significant difference between the bivariate samples in
independent groups , the unpaired sample t-test was used.
To find the significant variables which are influencing, the Logistic
regression model with Backward Wald method was used.
With regard to the significance in categorical data, Chi-Square test
was used. In all the above statistical tools the probability value (p
0.05) is considered as significant level
Table 1: P value significance
P value Significance
P ≤ 0.01 Highly significant
0.01 < P ≤ 0.05 Significant
P >0.05 Not significant
In our study, a total of 188 patients admitted in the General Medicine ward over a study
period of 12 month, were included as per the inclusion and exclusion criteria.
37
RESULTS
The study’s population comprised mostly of younger patients with 58% of people under
eighteen years of age. Patients above 58 years of age comprises 5 % of the study
population. This reflects the trend in vector borne illness, especially mosquito borne
illness across the world and one postulated reason behind this is increased exposure of
these younger people to the vectors.
Age Group Frequency Percent
Up to 18 Years 49 26.1
19 to 28 Years 60 31.9
29 to 38 Years 41 21.8
39 to 48 Years 16 8.5
49 to 58 Years 12 6.4
Above 58 Years 10 5.3
Total 188 100.0
Table 2: Age distribution
38
Image 18: Age distribution
Also the incidence of Dengue illness is twice more common in men than in women.
SEX Frequency Percent
Male 123 65.4
Female 65 34.6
Total 188 100.0
Table 3: Sex distribution
0
5
10
15
20
25
30
35
Up to 18 Years 19 to 28 Years 29 to 38 Years 39 to 48 Years 49 to 58 Years Above 58 Years
Age_Group
39
Image 19: Sex distribution
Nearly either percent of patients got admitted within the first five days of fever.
DAY_OF_FEVER_ON_ADMISSION Frequency Percent
1.00 5 2.7
2.00 29 15.4
3.00 34 18.1
4.00 43 22.9
5.00 40 21.3
6.00 27 14.4
7.00 10 5.3
Total 188 100.0
Table 4: Day of fever on admission
Male, 65.4
Female, 34.6
40
Of all the patients admitted, around thirty percentage of people had fever on admission to
the hospital.
FEBRILE_ON_ADMISSION
Frequency Percent Valid Percent Cumulative Percent
Valid
No 131 69.7 69.7 69.7
Yes 57 30.3 30.3 100.0
Total 188 100.0 100.0
Table 5: Fever during admission
And of the symptoms discussed in the literature review, the majority in our study were
fever, myalgia(8 %), headache (5.9%) and G.I symptoms(8%). Others have no specific
complaints with/ without fever.
Image 20: Non- fever complaints
Around 6% of patients in our study have comorbidities reflecting again the fact that
relatively large number of people were young. And only conscious patients(during
admission) have been taken for the study.
0%5%
10%
Myalgia G.Isymptoms
Headache
Non fever complaints
41
Table 6: COMORBIDITIES
Frequency Percent Valid Percent Cumulative Percent
No 177 94.1 94.1 94.1
Yes 11 5.9 5.9 100.0
Total 188 100.0 100.0
The co-morbidities found were diabetes , hypertension, COPD among few others.
Image 21: List of comorbidities in the study
Our tertiary care centre, in addition to catering to referral cases also takes in a
relatively large number of patients whose first medical contact is here.
SBP Frequency Percent
>=90 169 89.9
<90 19 10.1
Total 188 100.0
3 2 2 1 1
Comorbidities
42
Table 7: Hypotension in the study
And the trend in the healthy systolic blood pressure in our study also reflects the same.
Out of all patients taken in for the study, only around ten percent have their systolic BP of
less than 90 mmHg on admission. Also, this may also account for very few number of
patients having narrow pulse pressure (defined as pulse pressure < 20).
Image 22: Pulse pressure
Around 15% of people had tachycardia and this also correlates well with the nearly thirty
percent of patients having fever on admission.
Pulse_rate Frequency Percent
<100 159 84.6
>=100 29 15.4
Total 188 100.0
Table 8: Pulse rate
1.1
98.9
0 20 40 60 80 100 120
Pulse pressure
<20
>=20
43
Image 23: Pulse rate
Majority of patients have a respiratory rate of 14-16 breaths per minute. TtT
RESPIRATORY_RATE Frequency Percent
12.00 15 8.0
14.00 82 43.6
15.00 3 1.6
16.00 31 16.5
17.00 1 .5
18.00 27 14.4
19.00 5 2.7
20.00 21 11.2
21.00 3 1.6
Total 188 100.0
Table 9: Respiratory rate
84.6
15.4
Pulse_rate
<100 >=100
44
The investigations of these patients revealed that 19% of the subjects had leukopenia with
total leukocytes count of less than 4000 on admission.
Total count Frequency Percent
<4000 36 19.1
>=4000 152 80.9
Total 188 100.0
Table 10: Total leukocyte count
Around half of these patients had thrombocytopenia of < 50,000/cu.mm of
platelets. This also coincides with the high incidence of thrombocytopenia in dengue
patients.
Platelet group Frequency Percent
<50000 95 50.5
>=50000 93 49.5
Total 188 100.0
Table 11: Platelet count
45
Image 23: Platelet count
More than the platelets, the current management focuses on detecting increased
capillary permeability and thus detecting hemoconcentration is important in effectively
managing these patients. On admission, nearly 9% had haematocrit of more than 45.
Packed cell volume Frequency Percent
<45 172 91.5
>=45 16 8.5
Total 188 100.0
Table 12: Packed cell volume
50.5
49.5
Platelet count
<50000 >=50000
46
Image 24: Hematocrit
Increased levels of liver enzymes especially, aspartate aminotransferase(AST) and
alanine aminotransferase(ALT) levels are seen in patients with Dengue. In this study, a
substantial number of patients (66%) had elevated SGOT levels.
Table 13: SGOT levels
SGOT Frequency Percent
<40 64 34.0
>=40 124 66.0
Total 188 100.0
91.5
8.5
PCV/Hematocrit
<45 >=45
47
Image: SGOT
Serum albumin is low (<3.5) in about one fifth of patients with dengue fever,
whereas almost one third of patients have elevated SGOT levels. Also the rise in SGOT is
greater than the rise in SGPT.
Serum albumin Frequency Percent
<3.5 34 18.1
>=3.5 154 81.9
Total 188 100.0
Table 14: Albumin levels
34
66
SGOT
<40
>=40
48
Image 26: Albumin levels
COMORBIDITIES Frequency Percent
No 177 94.1
Yes 11 5.9
Total 188 100.0
Table 15: Comorbidities
18.1
81.9
Serum albumin (data in percentage)
<3.5 >=3.5
49
Image 27: Comorbidities
All patients have normal urine output during the day of admission. The normal urine
output may denote that patients with realtively normal hemodynamics during admission
were considered for the study. Three patients have proteinuria (2+ in dipstick) while all
others have normal urine output.
URINE_ROUTINE Frequency Percent
Normal 185 98.4
Proteinuria 3 1.6
Total 188 100.0
Table 16: Urine output
94.1
5.9
COMORBIDITIES
NO YES
50
Image 28: Urine Output
Similarly, three patients have glycosuria while others have normal urine routine testing.
These are the same patients with proteinuria.
URINE SUGAR Frequency Percent
Normal 185 98.4
Glycosuria 3 1.6
Total 188 100.0
Table 17: Urine sugar
98%
2%
URINE ROUTINE
Normal
Proteinuria
51
Image 29: Urine sugar
Three patients have hematuria and these are considered to be bleeding manifestations of
the illness after excluding urinary tract infections and calculi.
HEMATURIA Frequency Percent
No 185 98.4
Yes 3 1.6
Total 188 100.0
Table 18: Hematuria
98.4
1.6
UINE SUGAR
Normal Glycosuria
52
Image 30: Hematuria
USG was done to every patient and majority of patients had undergone their first
ultrasonogram after admission between days 5 and 6 (60.1%)
98.4
1.6
HEMATURIA
NO YES
53
FIRST USG DONE ON
DAY
Frequency Percent
2.00 1 .5
3.00 3 1.6
4.00 14 7.4
5.00 60 31.9
6.00 53 28.2
7.00 26 13.8
8.00 25 13.3
10.00 1 .5
11.00 5 2.7
Total 188 100.0
Table 19: USG and day done
Image 30: USG and day done
0.5 1.6
7.4
31.9
28.2
13.8 13.3
0.5 2.7
0
5
10
15
20
25
30
35
2 3 4 5 6 7 8 10 11
USG_DONE_ON_DAY
54
Clinical hepatomegaly was observed in about 6 % of people on admission and
hepatomegaly was not present in all people who have elevated liver enzyme levels.
Table 20: Hepatomegaly
HEPATOMEGALY Frequency Percent
No 176 93.6
Yes 12 6.4
Total 188 100.0
Image 32: Hepatomegaly
Splenomegaly was observed in almost one fifth of people and hepatosplenomegaly is
present in just 2% of patients.
93.6
6.4
HEPATOMEGALY
NO YES
55
Table 21: Splenomegaly
SPLENOMEGALY Frequency Percent
No 150 79.8
Yes 38 20.2
Total 188 100.0
Image 33: Splenomegaly
79.8
20.2
SPLENOMEGALY
NO YES
56
Table 22: Hepatosplenomegaly
HEPATOSPLENOMEGALY Frequency Percent
No 184 97.9
Yes 4 2.1
Total 188 100.0
Image 34: Hepatosplenomegaly
Clinical, or chest X –ray, or ultrasonogram proven pleural effusion was present in almost
5 % of people after admission while ascites another evidence of plasma leakage was seen
in almost 15% of people.
97.9
2.1
HEPATOSPLENOMEGALY
NO YES
57
Table 23: Pleural effusion
PLEURAL_EFFUSION Frequency Percent
No 179 95.2
Yes 9 4.8
Total 188 100.0
Image 35: Pleural effusion
95.2
4.8
PLEURAL_EFFUSION
NO YES
58
Table 24: Ascities
Image 36: Ascites
Gall bladder wall edema another well-known finding of Dengue fever is seen in
ultrasonogram in 8% of people.
85.1
14.9
0
10
20
30
40
50
60
70
80
90
NO YES
ASCITES
ASCITES Frequency Percent
No 160 85.1
Yes 28 14.9
Total 188 100.0
59
Table 25: Gall bladder wall edema
GALL_BLADDER_EDEMA Frequency Percent
No 173 92.0
Yes 15 8.0
Total 188 100.0
Image 37: Gall bladder wall edema
Bleeding manifestations including mucosal bleed as bleeding gums, macroscopic
hematuria and melena was seen in nearly three percent of people. Three people have
marginally elevated pro-thrombin time.
92
8
GALL_BLADDER_EDEMA
NO YES
60
Table 26: Bleeding
BLEEDING Frequency Percent
No 183 97.3
Yes 5 2.7
Total 188 100.0
Image 38: Bleeding
Blood transfusion was done in 13% percent of patients as the clinical grounds warrents,
according to the institutional protocol.
97.3
2.7
BLEEDING
NO YES
61
Table 27: Blood transfusion
BLOOD__TRANSFUSION Frequency Percent
No 164 87.2
Yes 24 12.8
Total 188 100.0
Out of 188 patients, one patient was shifted for ICU care for his deteriorating status. This
may be because patients admitted with hemodynamic stability and monitored in a tertiary
care setting during defervescence was considered for the study.
Table 28: ICU Care
ICU_CARE Frequency Percent
No 187 99.5
Yes 1 .5
Total 188 100.0
62
Image 39: ICU Care
Off the 188 considered for the study, all patients recovered mirroring the importance of
close monitoring and adequate fluid management.
Table 29: Recovery
RECOVERED Frequency Percent
Yes 188 100.0
The modified Dengue score was calculated and majority of patients(79.3%) have score of
less than or equal to 2, based on the investigatory values on the day of admission.
99.5
0.5
ICU_CARE
NO YES
63
Table 30: Dengue score
DENGUE_SCORE Frequency Percent
1.00 75 39.9
2.00 74 39.4
3.00 33 17.6
4.00 6 3.2
Total 188 100.0
Image 40: Dengue score
Reflecting the parent study, the association of pleural effusion with Dengue score seems
to be maximum when the dengue score is 2 (almost 7% chance of pleural effusion). As
the dengue score increase or decrease the chances of pleural effusion comes down. But
the p-value of the association is not significant.
39.9 39.4
17.6
3.2
0
10
20
30
40
50
1 2 3 4
DENGUE_SCORE
64
Table 31: Dengue score and pleural effusion
The chances of ascites increase as the Dengue score increase (significant p-value) as
shown in the table below.
65
Table 32: Dengue score and ascites
Out of 28 ascites 25 Patients were having high dengue score of >2 (p: 0.001).
The dengue score of 2 or more does not satisfactorily predict the occurrence of bleeding
manifestations, though as the score increase the chances of bleeding are higher.- i.e., at a
score of 4 the risk is maximal.
66
Table 33: Dengue score and bleeding
Out of 5 pts 3 were having 4 score
Dengue score of 2 or more is associated with thrombocytopenia of < 50,000.
67
Crosstab
PLT_group Total
<50000 >=50000
DENGUE_SCORE
1.00
Count 6 69 75
% within PLT_group 6.3% 74.2% 39.9%
2.00
Count 56 18 74
% within PLT_group 58.9% 19.4% 39.4%
3.00
Count 27 6 33
% within PLT_group 28.4% 6.5% 17.6%
4.00
Count 6 0 6
% within PLT_group 6.3% 0.0% 3.2%
Total
Count 95 93 188
% within PLT_group 100.0% 100.0% 100.0%
Pearson Chi-Square=91.786** p<0.001
Table 34: Dengue score and platelet count
68
Image 41: Dengue score and platelet count
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
1 2 3 4
6.30%
58.90%
28.40%
6.30%
74.20%
19.40%
6.50%
0.00%
<50000 >=50000
69
DISCUSSION
The study’s population comprised mostly of younger patients with 58% of people
under twenty eight years of age, as in the study by Cucunawangsih et al (23) and Suwarto
et al(17). Patients above 58 years of age comprises 5 % of the study population. This
reflects the trend in vector borne illness, especially mosquito borne illness across the
world and one postulated reason behind this is increased exposure of these younger
people to the vectors.
Dengue fever occurred twice more common in men than in women as in the study
by Ing-kit Lee et al(24). Nearly either percent of patients got admitted within the first five
days of fever as reported by Cucunawangsih (23).
Of the symptoms discussed, the majority in our study were fever(all), myalgia
(8 %), headache (5.9%) and G.I symptoms(8%) in contrast to myalgia occurring in more
than one fifth of patients as reported by Pongpan et al. Viral typing may shed some light
on the differences in presentation. Around 6% of patients in our study have
comorbidities reflecting again the fact that relatively large number of people were young
as reported by ing-kit Lee et al(24). And only conscious patients (during admission) have
been taken for the study.
70
The co-morbidities found were diabetes, hypertension, COPD among few others.
Our tertiary care centre, in addition to catering to referral cases also takes in a
relatively large number of patients whose first medical contact is here. And the trend in
the healthy systolic blood pressure in our study also reflects the same. Out of all patients
taken in for the study, only around ten percent have their systolic BP of less than 90
mmHg on admission. Also, this may also account for very few number of patients having
narrow pulse pressure (defined as pulse pressure < 20). Around 15% of people had
tachycardia and this also correlates well with the nearly thirty percent of patients having
fever on admission. Majority of patients have a normal respiratory rate reflecting closely
the good hemodynamics on admission.
The investigations of these patients revealed that 19% of the subjects had
leukopenia with total leukocytes count of less than 4000 on admission, again correlating
with the literature. Around half of the patients had thrombocytopenia of < 50,000/cu.mm
of platelets. This also coincides with the high incidence of thrombocytopenia in dengue
patients.
71
More than the platelets, the current management focuses on detecting increased
capillary permeability and thus detecting hemoconcentration is important in effectively
managing these patients. On admission, nearly 9% had haematocrit of more than 45.
Increased levels of liver enzymes especially, aspartate amino-transferase(AST)
and alanine aminotransferase(ALT) levels are seen in patients with Dengue. In this
study, a substantial number of patients (66%) had elevated SGOT levels. Serum albumin
is low (<3.5) in about one fifth of patients with dengue fever, whereas almost one third of
patients have elevated SGOT levels. Also the rise in SGOT is greater than the rise in
SGPT.
All patients have normal urine output during the day of admission. The normal
urine output may denote that patients with realtively normal hemodynamics during
admission were considered for the study. Three patients have proteinuria (2+ in dipstick)
while all others have normal urine output. Similarly, three patients have glycosuria while
others have normal urine routine testing.
Three patients have hematuria and these are considered to be bleeding
manifestations. The relatively small number of bleeding may be explained by the close
monitoring and adequate fluid resuscitation done at the study centre which is a tertiary
care centre.
72
Majority of patients had undergone their first ultrasonogram after admission
between days 5 and 6 (60.1%). Clinical hepatomegaly was observed in about 6 % of
people on admission and hepatomegaly was not present in all people who have elevated
liver enzyme levels.
Splenomegaly was observed in almost one fifth of people.
Pleural effusion was present in almost 5 % of people after admission while ascites
another evidence of plasma leakage was seen in almost 15% of people. Gall bladder wall
edema another well-known finding of dengue fever is seen in ultrasonogram in 8% of
people.
Bleeding manifestations including mucosal bleed as bleeding gums, macroscopic
hematuria and melena was seen in nearly three percent of people. Blood transfusion was
done in 13% percent of patients as the clinical grounds warrents, according to the
institutional protocol.
Out of 188 patients, one patient was shifted for ICU care for his deteriorating
status. This may be because patients admitted with hemodynamic stability and monitored
in a tertiary care setting during defervescence, was considered for the study.
73
Off the 188 considered for the study, all patients recovered mirroring the
importance of close monitoring and adequate fluid management. The modified Dengue
score was calculated and majority of patients(79.3%) have score of less than or equal to
2, based on the investigatory values on the day of admission. Reflecting the parent study,
the association of pleural effusion with Dengue score seems to be maximum when the
dengue score is 2. As the dengue score increases or decreases the chances of pleural
effusion comes down. But the p-value of the association is not significant.
The chances of ascites increase as the Dengue score increases (significant p-
value).Out of 28 ascites 25 Patients were having high dengue score of >2. The dengue
score of 2 or more does not satisfactorily predict the occurrence of bleeding
manifestations, though as the score increase the chances of bleeding are higher.- i.e., at a
score of 4 the risk is maximal.
74
CONCLUSION
From this study we can conclude that,
1. Dengue is more common in young men.
2. Early admission reduces mortality.
3. Leukopenia is common in dengue infection.
4. Thrombocytopenia is common.
5. Inspite of thrombocytopenia, adequate fluid resuscitation seems to reduce the
incidence of bleeding manifestations.
6. Dengue score calculated from the admission day’s haematological profile pedicts
ascites occurrence.
7. Dengue score does not predict with sufficient satisfaction the occurrence of pleural
effusion, and the need for ICU care.
75
Limitations:
Sample size is small to extrapolate the results to the population
The patient variables are considered on day of admission for score estimation
irrespective of the day of fever.
Study was done at a tertiary care hospital, which may alter the course of illness
due to early intervention.
76
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PROFORMA
81
ETHICAL COMMITTEE CLEARANCE CERTIFICATE
82
CONSENT FORM
83
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SION
CO
PD
OTH
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OM
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BID
ITIESH
EMO
GLO
BIN
TOTA
L CO
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TD
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PLA
TELETSRBC
PC
VTO
TAL B
ILIRU
BIN
SGO
TSG
PT
ALP
TOTA
LPR
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SERU
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LBU
MIN
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HEM
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HEP
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SPLEN
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NA
SCITES
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BLEED
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BLO
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TRA
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REC
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16
MD
AY 4Y
NY
99
11
0/76N
34
90
16
99
N1
55
20
06
6/2
2/1
245
00
04
.73
8.30
.59
48
79
36.8
4.2
21
0.9
13
83.6
NN
NN
1-2 PU
SNN
OD
AY 4
NY
NN
NN
NN
NY
3
29
MD
AY 5Y
Y1
02
10
0/70N
40
86
14
97
N1
86
40
06
9/3
0/1
69
00
05
.74
71
.11
18
49
42
7.73
.62
41
.21
34
3.4N
NN
N0-2 P
USN
NO
DA
Y 6N
NN
NN
NN
NN
Y3
23
MD
AY 3Y
NY
Y9
91
10
/80N3
09
62
19
8Y
TB1
53
70
06
6/2
7/7
59
00
05
.14
2.70
.32
64
43
06
46.5
3.1
17
1.1
13
03.8
NN
NN
1-2 PU
SNN
OD
AY 6
NN
YN
NN
NN
NY
3
15
MD
AY 2Y
Y1
00
10
0/60N
40
11
21
49
8Y
EPILEP
SY1
44
50
06
7/2
0/3
48
00
04
.61
40.2
0.3
12
05
93
02
6.54
.21
70
.91
32
4.8N
NN
N2-3 P
USN
NO
DA
Y 5N
NN
YY
NN
NN
Y3
37
MD
AY 5Y
NY
99
11
0/70N
40
76
14
97
N1
52
50
05
0/3
7/1
253
00
04
.98
40
0.4
61
31
06.2
3.7
11
.51
35
3.9N
NN
N1-2 P
USN
NO
DA
Y 6N
NN
NN
NN
NN
Y1
43
MD
AY 6Y
YY
99
10
0/70N
30
82
16
98
N1
87
80
59
/23
/168
50
00
5.6
54
3.62
.42
58
61
02
6.23
.33
36
11
34
3.7N
NN
TRA
CE2-3 P
USN
NO
DA
Y 6N
NN
NN
NN
NN
Y1
43
MD
AY 4Y
N9
91
00
/70N3
08
81
99
8N
16
15
90
06
9/2
2/9
96
00
05
.77
3.1
0.6
46
38
76
7.14
24
11
36
3.8N
NN
N0-2 P
USN
NO
DA
Y 5N
NN
NN
NN
NN
Y1
80
MD
AY 2Y
NY
Y9
84
14
0/90N
50
72
12
98
N1
36
90
06
6/2
1/1
3203
00
04
.17
35.4
0.3
23
20
72
6.24
36
1.8
12
64.5
NN
NN
1-2 PU
SNN
OD
AY 6
NN
NN
NN
REN
AL D
ISN
NN
Y1
38
MD
AY 5Y
NY
99
10
0/70N
30
10
61
49
8N
13
67
00
70
/20
/95
90
00
3.7
73
7.13
.88
52
35
95
2.6
25
1.1
12
03.3
NN
NN
0-3 PU
SNN
OD
AY 5
NY
NN
NN
NN
NY
3
32
FD
AY4Y
N9
91
00
/70N3
08
81
89
8N
14
50
00
71
/25
/424
50
00
4.8
3.4
0.9
17
24
12
26
63
.21
6.9
0.9
13
33.6
NN
NN
1-2 PU
SNN
OD
AY 5
NN
NY
NN
NY
NY
2
40
FD
AY 3Y
NY
99
11
0/70N
40
89
19
99
N1
14
90
06
0/3
7/31
73
00
03
.93
70
.47
64
85
26.1
3.9
19
0.8
13
73.9
NN
NN
0-2 PU
SNN
OD
AY 5
NN
NN
NN
NN
NY
1
13
FD
AY 5Y
YY
10
01
00
/70N3
08
01
49
8N
12
32
00
48
/34
/161
43
00
5.1
38.8
0.5
46
35
14
55.6
3.9
15
0.9
13
63.9
NN
NN
1-2 PU
SNN
OD
AY 6
NN
NN
NN
NN
NY
1
15
MD
AY 5Y
NY
98
11
0/70N
40
80
18
98
N1
65
60
03
8/3
2/3
044
00
05
.74
3.70
.92
84
61
31
74
.51
80
.91
31
4.6N
NN
N0-2 P
USN
NO
DA
Y 7N
NN
NY
NN
NN
Y1
53
FD
AY 4Y
N1
00
10
0/70N
30
80
14
98
N1
19
40
07
6/2
0/4
78
00
03
.39
28.2
0.6
43
39
17
76.3
3.8
40
2.1
13
64.6
NN
NN
1-2 PU
SNN
OD
AY 5
NN
NN
NN
NN
NY
1
46
MD
AY 4Y
N9
91
10
/80N3
08
82
09
8N
15
70
00
6/20
/82
30
00
4.9
64
0.91
.73
64
28
36.8
3.8
32
11
37
4.2N
NN
N0-2 P
USN
NO
DA
Y 5N
NN
NN
NN
NN
Y2
27
FD
AY 4Y
N9
91
20
/80N4
08
01
49
8N
13
62
00
70
/21
/93
60
00
0.3
37.6
0.2
47
35
49
74
.11
31
13
54.6
PT
NN
NN
1-3 PU
SNN
OD
AY 5
NN
NN
NN
NN
NY
2
14
FD
AY 4Y
N9
81
10
/70N4
07
21
49
8N
14
45
00
67
/21
12
42
00
04
.63
6.21
.63
23
51
64
7.24
13
0.8
13
74
NN
NN
0-3 PU
SNN
OD
AY 6
NY
NN
YN
NN
NY
2
42
MD
AY 3Y
Y1
02
13
0/80N
50
11
61
69
8N
16
64
00
76
/11
/13
39
00
5.7
44
0.9
85
27
78
6.43
.52
21
.21
39
4.2N
NN
N1-2 P
USN
NO
DA
Y 5N
NN
NY
YN
YN
Y2
14
MD
AY 1Y
N9
99
0/6
0Y
30
90
14
98
N8
.21
46
00
58
/24
/1817
50
00
4.7
83
50
.83
02
34
06
42
80
.71
39
4.4N
NN
N0-2 P
USN
NO
DA
Y 6N
NN
NN
NN
NN
Y1
27
MD
AY 3Y
N1
00
11
0/80N
30
86
14
97
N1
84
20
06
2/2
3/4
32
00
05
.84
8.60
.87
34
84
96.9
4.5
32
11
29
4.4N
NN
N0-2 P
US
NN
OD
AY 5
YN
NN
NN
NY
NY
2
17
MD
AY 5T
NY
Y9
81
00
/70N2
07
81
89
9N
18
44
00
34
/37
/282
80
00
6.1
46
1,4
51
44
68
6.14
.51
80
.91
36
1.7N
NN
N1-2 P
USN
NO
DA
Y 6N
NN
NN
YN
NN
Y2
78
FD
AY 1Y
Y1
00
11
0/70N
40
13
01
49
8N
11
14
80
08
1/1
1/62
40
00
04
.08
30.4
0.7
29
26
56.1
32
60
.71
39
3.7N
NN
N0-2 P
USN
NO
DA
Y 6N
NN
NN
NN
NN
Y2
25
FD
AY 5Y
Y1
02
10
0/70N
30
80
14
96
N1
07
70
01
00
33
00
04
.23
1.10
.34
84
71
12
6.84
.52
01
13
83.9
NN
NN
1-2 PU
SNN
OD
AY 5
NN
NN
NY
NY
NY
2
13
FD
AY 3Y
NY
10
08
0/5
0Y
30
86
20
98
N1
34
30
06
2/2
3/1
445
00
04
.53
60
.22
72
51
19
7.64
.41
81
.11
32
3.6N
NN
N1-2 P
USN
NO
DA
Y 5N
NN
YY
YY
YY
Y2
16
FD
AY 3Y
NY
Y9
91
00
/70N3
08
01
69
9N
12
64
00
36
/44
/195
50
00
4.7
63
2.60
.31
02
10
53
96.5
3.9
14
0.8
12
15.7
NN
NN
1-2 PU
SNN
OD
AY 6
NN
NN
YN
NN
NY
2
27
MD
AY 4Y
N1
00
13
0/90N
40
70
20
98
N1
44
10
05
4/3
8/8
66
00
04
.83
39
0.8
17
51
51
43
7.33
.91
40
.91
37
3.8N
NN
N0-3 P
USN
NO
DA
Y 5N
NN
NN
NN
NN
Y2
30
MD
AY 4Y
N9
91
10
/80N3
08
61
49
7N
19
53
00
38
/36
/253
60
00
5.8
53.1
0.6
62
50
41
7.33
.93
60
.61
37
3.8N
NN
N3-4 P
USN
NO
DA
Y 5N
NN
NN
NC
HO
ELIHIA
SISN
NN
Y2
25
MD
AY 5Y
N9
91
30
/90N4
08
61
49
8N
15
41
00
66
/24
/91
40
00
4.9
44
12
.41
51
80
68
6.94
.41
60
.91
33
3.7N
NN
N1-2 P
USN
NO
DA
Y 6N
YN
YY
YN
NN
Y3
21
MD
AY 4Y
Y1
03
11
0/70N
40
98
14
98
N1
22
80
00
61
/33
/64
40
00
4.1
33
4.11
.61
71
33
26.3
3.9
22
1.2
13
63.7
NN
NN
1-2 PU
SNN
OD
AY 5
NY
NN
NN
HN
/UR
ETERIC
CLIC
NN
NY
2
33
MD
AY 5Y
Y1
02
10
0/70N
30
87
18
99
N1
17
90
06
0/2
9/1
123
00
05
.63
2.90
.73
72
96
75.9
2.9
21
1.1
13
73.8
NN
NN
1-2 PU
SNN
OD
AY 6
NY
NN
NN
NN
NY
2
29
FD
AY 5Y
N9
92
10
0/80N
20
80
14
98
N8
.34
20
05
9/1
2/2
839
00
04
.85
24.5
0.7
19
01
51
58
5.63
.91
41
13
73.4
NN
NN
2-3 PU
SNN
OD
AY 5
NN
NN
YN
NN
NY
3
19
MD
AY 4Y
Y1
00
10
0/60N
40
86
17
99
N5
.79
80
03
8/3
4/2
7147
00
05
.63
50
.62
53
68
77.1
4.6
10
0.9
13
24
NN
NN
1-2 PU
SNN
OD
AY 5
NN
NN
NN
NN
NY
1
33
MD
AY 3Y
Y1
01
10
0/70N
30
98
18
98
N1
57
20
07
7/8
/14
35
00
05
.66
40.2
0.7
38
29
79
6.53
.51
31
.41
34
3.2N
NN
N0-2 P
USN
NO
DA
Y 6N
YN
NN
NN
NN
Y2
19
MD
AY 4Y
N9
81
10
/70N4
07
61
29
9N
17
83
00
38
/36
/254
00
00
5.3
33.6
0.6
30
28
47
6.33
.22
80
.71
39
3.6N
NN
N0-2 P
USN
NO
DA
Y 5N
NN
NN
NB
YN
Y3
59
FD
AY1Y
NY
98
15
0/10
0N5
08
81
29
8N
9.5
36
00
27
/33
/381
80
00
3.5
20.7
1.4
11
77
34
76
3.7
19
0.9
13
84.2
NN
NN
0-2 PU
SNN
OD
AY 7
NY
NN
YY
NN
NY
3
55
MD
AY 2Y
N1
00
11
0/70N
40
92
14
97
N1
23
70
05
3/2
9/1
651
00
03
.63
5.13
.92
72
39
77.1
3.8
46
11
25
3.8N
NN
N1-3 P
USN
NO
DA
Y 8N
YN
NN
NN
NN
Y1
28
MD
AY 5Y
NY
98
11
0/80N
30
84
18
98
YY
16
74
00
74
/26
23
00
06
.27
41.5
0.6
84
77
71
6.34
.12
31
13
84.4
NN
NN
0-3 PU
SNN
OD
AY 6
NN
NN
NN
NN
NY
2
13
MD
AY 2Y
N9
91
00
/70N3
07
21
29
8N
14
11
40
05
9/2
8/8
2192
00
05
.07
35
0.4
28
21
12
17.2
3.5
22
0.9
13
34.6
NN
NN
1-2 PU
S N
NO
DA
Y 7N
NN
NN
NN
NN
Y1
19
FD
AY 4Y
N9
81
00
/60N4
08
71
49
8N
10
47
00
51
/29
/205
20
00
4.7
34
0.8
29
23
67
6.74
.51
40
.81
38
4.3N
NN
N2-3 P
USN
NO
DA
Y 5N
YN
NN
NN
NN
Y1
18
MD
AY 4Y
NY
99
11
0/80N
30
90
18
99
N1
55
80
06
0/2
9/1
122
00
05
.14
21
.27
35
76
6.84
.22
61
.11
31
3.9N
NN
N1-2 P
USN
NO
DA
Y 6N
NN
NY
NN
NN
Y2
28
MD
AY 5Y
N9
81
20
/80N4
09
01
29
8N
18
10
20
07
4/1
5/1
09
00
06
.14
2.61
12
56
67
06.5
3.5
47
1.2
14
43.2
NN
NN
1-3 PU
SNN
OD
AY 5
NN
NN
YN
NN
NY
3
20
MD
AY 2Y
Y1
02
80
/60
Y2
01
18
15
98
N1
54
70
06
3/2
2/1
536
00
04
.84
11
.22
63
76
05.1
3.9
20
1.3
13
43.4
NN
NN
0-2 PU
SNN
OD
AY 5
NY
NN
NN
NN
NY
2
31
MD
AY 2Y
N1
00
10
0/70N
30
98
19
97
N1
25
50
06
2/3
81
36
00
04
.75
39.4
1.1
64
36
82
6.64
.22
01
.21
35
4.2N
NN
N1-3 P
USN
NO
DA
Y 5N
NN
YN
NN
NN
Y1
12
MD
AY 5Y
Y1
02
90
/60
Y3
01
10
20
99
N1
43
40
05
0/4
4/6
26
00
05
.54
0.20
.31
30
59
17
58.1
3.7
13
31
13
04.6
NN
NN
2-3 PU
S N
NO
DA
Y 6N
NN
NN
NN
NN
Y3
70
MD
AY 5Y
N9
97
0/5
0Y
20
99
14
99
N1
11
23
00
83
/8/9
22
00
03
.71
30
0.8
45
48
87
6.73
.32
40
.81
37
3.8N
NN
N1-2P
USN
NO
DA
Y 5N
NN
NN
NN
NN
Y2
24
MD
AY 5Y
N9
91
00
/80N2
08
52
09
9N
16
37
00
53
/29
/181
80
00
5.4
45
0.7
24
91
79
58
6.44
42
1.4
13
74
NN
NN
0-2 PU
SNN
OD
AT 6
NY
NN
NN
NN
NY
3
17
MD
AY 2Y
N9
81
00
/60N4
08
61
29
9N
15
90
00
20
/37
/414
20
00
5.3
43
0.3
12
41
04
67
6.94
.21
70
.91
35
3.5N
NN
N1-2 P
US
NN
OD
AY 7
NN
NN
NN
NN
NY
Y3
18
MD
AY 5Y
N9
99
0/5
0Y
40
12
61
49
7N
12
73
00
85
/15
67
00
03
.82
30
2.9
21
15
66.2
3.8
15
0.9
13
03.4
NN
NN
0-2 PU
SNN
OD
AY 6
NN
NN
NN
NN
NY
1
23
MD
AY 4Y
Y1
01
10
0/70N
30
80
14
96
N1
74
00
05
3/3
2/1
834
00
05
.14
2.30
.83
54
45
54
6.54
.38
0.9
13
94.2
NN
NN
0-3 PU
S N
NO
DA
Y 5N
NN
NN
NN
NN
Y3
47
MD
Y5Y
Y1
02
13
0/90N
40
93
16
97
N1
41
19
00
56
/37
/66
00
00
4.5
38
0.4
43
25
50
7.84
.12
61
.21
28
3.5N
NN
N1-2 P
USN
NO
DA
Y 5N
NN
NN
NN
NN
Y1
20
FD
AY 5Y
NY
98
10
0/60N
40
78
12
99
N1
15
00
06
9/3
13
90
00
3.7
33
0.20
.34
63
33
55.7
3.3
20
0.6
13
94.1
NN
NN
0-2 PU
S N
NO
DA
Y 6N
NN
NN
NN
NN
Y3
29
MD
AY 3Y
Y1
01
10
0/70N
30
80
14
98
N1
23
40
07
5/2
0/5
39
00
05
.13
91
.71
24
10
65
76.1
41
91
.11
33
3.9N
NN
N1-2 P
USN
NO
DA
Y 7N
NN
NN
NN
NN
Y3
29
FD
AY 5Y
N9
91
10
/80N3
01
00
20
97
N1
47
50
06
6/3
36
70
00
43
90
.73
52
51
40
6.73
.11
20
.81
38
3.6N
NN
N0-2 P
USN
NO
DA
Y 6Y
NN
NN
NN
NN
Y2
30
MD
AY 3Y
Y9
99
0/6
0Y
30
92
20
98
N1
33
10
07
2/1
5/1
339
00
04
.95
38.4
0.7
41
32
47
5.93
.71
70
.81
36
3.6N
NN
N1-2 P
USN
NO
DA
Y 4N
YN
NN
NN
NN
Y2
41
MD
AY 2Y
NY
10
01
00
/70N3
08
81
59
8Y
Y1
41
01
00
75
/13
/71
50
00
4.0
32
4.80
.94
54
15
96.3
3.1
37
0.6
13
44.1
NN
NN
2-3 PU
SNN
OD
AY 5
NN
NN
NN
NY
NY
2
17
FA
Y 5Y
N9
91
00
/60N4
08
42
19
9N
11
38
00
43
/40
/1615
10
00
4.4
53
3.40
.68
95
87
26.9
3.6
15
0.9
14
03.6
NN
NN
0-3 PU
SNN
OD
AY 6
NN
NN
NN
NN
NY
1
23
MD
AY 5Y
N9
91
00
/60N4
08
61
49
9N
16
42
00
32
/45
/225
10
00
5.5
44
.40
.62
21
24
95.6
2.9
13
0.6
14
04.1
NN
NN
1-2 PU
SNN
OD
AY 6
NY
NN
NN
NN
NY
2
35
MD
AY4Y
N9
91
10
/70N4
01
10
19
99
N1
49
50
08
1/1
6/2
30
00
04
.14
38
3.2
36
75
45
73
.84
21
.61
33
4.4N
NN
N0-2 P
USN
NO
DA
Y 5N
NN
NN
NN
NN
Y3
22
MD
AY 3Y
N9
91
10
/80N3
08
01
89
8N
13
39
00
51
/36
/117
50
00
4.6
13
6.70
.35
04
84
26
41
20
.91
35
4.2N
NN
N0-2 P
USN
NO
DA
Y 6N
NN
NN
NN
NN
Y1
17
MD
AY 4Y
Y1
00
12
0/90N
30
90
12
99
N1
34
50
04
0/4
1/1
893
00
03
.73
6.80
.77
93
91
22
6.23
.72
10
.91
35
3.8N
NN
N1-2 P
USN
NO
DA
Y 5N
NN
NN
NN
NN
Y1
17
MD
AY5Y
Y1
00
10
0/70N
30
98
12
99
N1
53
00
06
1/2
7/1
123
00
04
.63
9.80
.63
81
96
45.7
3.8
14
11
35
3.6N
NN
N1-3 P
USN
NO
DA
Y 6N
NN
NN
NN
NN
Y2
33
FD
AY 3Y
N9
91
20
/80N4
07
01
69
8N
16
17
60
06
1/3
92
40
00
3.9
39.9
0.7
22
18
47
8.84
.42
01
.11
40
3.7N
NN
N1-2 P
USN
NO
DA
Y 5N
NN
NN
NN
NN
Y2
30
MD
AY 7Y
Y1
03
12
0/60N
60
11
22
99
N1
57
20
08
0/1
5/3
70
00
04
.53
7.41
.96
08
01
22
6.63
.92
91
.51
45
0.7N
NN
N1-2 P
USN
NO
DA
Y 8N
YN
NN
NN
NN
Y1
21
FD
AY 7
YN
99
11
0/70N
40
80
14
98
N1
24
50
07
0/2
0/1
0179
00
04
.32
34.6
0.2
39
31
62
74
.41
10
.91
31
3.8N
NN
N0-2 P
USN
NO
DA
Y 8N
NN
NN
NN
NN
Y1
38
MD
AY 7Y
N9
81
30
/90N4
08
01
49
8N
15
10
90
04
3/3
6/2
061
00
04
.54
0.20
.84
57
17
57
3.7
34
0.8
13
83.6
NN
NN
0-3 PU
SNN
OD
AY 6
NN
NN
NN
NN
NY
1
28
FD
AY7Y
N9
61
10
/80N3
07
61
29
9N
12
45
00
62
/21
/137
00
00
4.6
33
0.3
72
10
81
07
6.14
18
0.8
13
43.6
NN
NN
1-2 PU
SNN
OD
AY 8
NN
NN
NN
NN
NY
1
18
MD
AY7Y
N9
91
00
/70N3
08
01
49
8N
12
84
00
57
/23
/1919
40
00
4.7
37
0.3
51
52
10
26.7
41
20
.71
36
4.1N
NN
N0-2 P
USN
NO
DA
Y 8N
NN
NN
NN
NN
Y1
21
FD
AY 7Y
N9
91
10
/70N4
08
62
09
9N
11
40
00
75
/20
/56
70
00
3.7
30
0.4
30
14
42
5.93
50
0.5
13
43.9
NN
NN
1-2 PU
SNN
OD
AY 8
NN
NN
NN
NN
NY
2
24
FD
AY 6Y
Y9
91
10
/70N4
09
21
89
9N
11
49
00
77
/20
/33
30
00
4.7
33.8
0.6
90
40
10
37.2
3.9
15
0.7
12
93.4
NN
NN
0-2 PU
S N
NO
DA
Y 7N
NN
NN
YN
NN
Y2
38
MD
AY 6Y
N9
91
20
/100N
20
68
14
99
YY
15
29
00
46
/37
/71
40
00
5.2
45.1
0.9
59
31
68
6.54
.23
51
.41
31
3.7N
NN
N0-2 P
USN
NO
DA
Y 7N
NN
NN
NN
NN
Y2
50
MD
AY 7Y
Y9
91
10
/70N4
08
01
49
8N
13
89
00
71
/25
/42
00
00
3.9
34.4
0.4
16
71
33
94
6.73
.34
81
.41
37
35
NN
NN
1-2 PU
S N
NO
DA
Y 8Y
NN
NN
NN
NN
Y4
19
FD
AY 7Y
N9
91
10
/70N4
07
21
49
9N
8.3
60
00
68
/32
70
00
03
.09
33.7
0.6
67
48
44
7.44
.32
11
13
73.2
NN
NN
0-2 PU
SNN
OD
AY 7
NN
NN
NN
NN
NY
1
14
FD
AY 6Y
N9
91
10
/70N4
08
81
49
7N
11
75
00
34
/47
/185
10
00
4.5
33.6
0.3
42
21
42
7.13
.71
30
.91
38
3.5N
NN
N1-2 P
US
NN
OD
AY 7
NN
NN
NN
NN
NY
1
17
MD
AY 7
YN
10
29
0/6
0Y
30
13
01
49
9N
12
89
00
60
/33
/721
10
00
4.2
33
0.9
82
33
72
6.94
.51
60
.61
28
3.7N
NN
N0-2 P
USN
NO
DA
Y 8N
NN
NN
NN
NN
Y1
60
MD
AY 7Y
NY
10
01
20
/70N5
08
01
49
7N
18
93
00
63
/21
/1137
10
00
5.8
64
6.61
.62
43
34
77.3
3.6
39
1.2
13
34.6
NN
NN
1-2 PU
SNN
OD
AY 8
NN
NN
NN
NN
NY
1
17
FD
AY 6Y
N9
91
10
/70N4
08
82
09
9N
10
41
00
49
/24
/262
90
00
4.1
13
00
.48
68
14
66.1
43
80
.81
35
3.5N
NN
N1-2 P
US
NN
OD
AY7
NN
NN
YN
NN
NY
2
18
MD
AY 5Y
YY
10
01
00
/90Y1
08
01
49
8N
16
34
00
45
/44
/101
50
00
4.6
33
0.6
11
35
48
27.9
4.4
47
1.2
13
64.7
NN
NN
3-6 PU
SNN
OD
AY 11
NY
NN
YN
NY
NY
3
55
MD
AY6Y
Y9
91
40
/90Y5
07
41
49
7N
14
14
10
07
5/1
2/8
30
00
04
.83
23
18
81
30
36
96.2
3.5
41
1.2
12
75.4
NY
+ ++
20-25 PU
SY
NO
DA
Y 6Y
YY
NY
NY
YN
Y4
31
MD
AY 5Y
Y9
81
20
/80N4
07
41
59
9N
13
64
00
58
/27
/148
10
00
4.5
37.1
2.6
39
31
10
56.2
3.5
36
0.8
13
84.8
NN
NN
1-2 PU
SNN
OD
AY 11
NN
NN
NN
NN
NY
1
39
MD
AY 4Y
NY
98
11
0/70N
40
10
41
49
8N
13
66
00
70
/20
/95
90
00
3.7
63
7.13
.68
52
36
05
2.6
24
1.1
12
63.3
NN
NN
0-2 PU
SNN
OD
AY 6
NY
NN
NN
NN
NY
3
33
FD
AY 3Y
N9
91
00
/70N3
08
61
69
9N
13
51
00
72
/23
/424
50
00
4.7
73
.40
.91
72
41
22
56
3.2
17
0.8
13
33.6
NN
NN
1-2 PU
SNN
OD
AY 5
NN
NY
NN
NY
NY
2
32
FD
AY 2Y
NY
99
11
0/70N
40
88
18
99
N1
24
80
05
9/3
8/31
73
00
03
.86
37
0.5
76
48
52
6.13
.91
80
.71
37
3.8N
NN
N0-2 P
USN
NO
DA
Y 6N
NN
NN
NN
NN
Y1
14
FD
AY 3Y
Y1
00
11
0/70N
40
82
14
98
N1
23
30
04
8/3
4/1
614
30
05
.23
8.80
.54
63
51
44
5.63
.91
60
.81
36
3.9N
NN
N1-3 P
USN
NO
DA
Y 6N
NN
NN
NN
NN
Y1
13
MD
AY 4Y
N9
81
00
/70N3
07
81
89
7N
16
55
00
38
/32
/304
40
00
5.8
43.7
0.7
28
46
13
17
4.5
18
0.9
13
14.5
NN
NN
0-2 PU
SNN
OD
AY 7
NN
NN
YN
NN
NY
1
54
FD
AY 3Y
N1
00
10
0/70N
30
82
14
98
N1
29
50
07
6/2
0/4
78
00
03
.42
8.20
.94
33
91
76
6.33
.84
12
13
64.6
NN
NN
1-2 PU
SNN
OD
AY 5
NN
NN
NN
NN
NY
1
47
MD
AY 3Y
N9
91
20
/80N4
09
01
89
8N
15
71
00
69
/20
/72
30
00
4.9
54
0.91
.73
64
28
36.8
3.8
33
1.1
13
74.2
NN
NN
1-2 PU
SNN
OD
AY 5
NN
NN
NN
NN
NY
2
28
FD
AY 3Y
N9
91
20
/80N4
08
21
49
9N
13
61
00
71
/20
/93
60
00
3.9
37.6
0.4
47
35
51
74
.11
41
13
54.6
NN
NN
1-3 PU
SNN
OD
AY 5
NN
NN
NN
NN
NY
2
15
FD
AY 3Y
NY
98
11
0/70N
40
74
16
98
N1
44
40
06
8/2
2/1
242
00
04
.73
6.21
.53
23
51
64
7.24
13
0.7
13
74
NN
NN
0-2 PU
SNN
OD
AY 6
NY
NN
YN
NN
NY
2
43
MD
AY 2Y
YY
10
21
20
/80N5
01
14
16
98
NC
ON
J CO
NG
ESTION
15
64
00
77
/12
/12
39
00
5.8
44
0.8
85
27
76
6.43
.52
2.4
1.1
13
94.2
NN
NN
1-2 PU
SNN
OD
AY 5
NN
NN
YY
NY
NY
2
13
MD
AY 2Y
N9
99
0/6
0Y
30
92
14
99
N8
.41
46
00
59
/25
/1717
50
00
4.6
83
50
.73
02
34
06
42
70
.81
39
4.3N
NN
N1-2 P
USN
NO
DA
Y 6N
NN
NN
NN
NN
Y1
26
MD
AY 2Y
NY
99
11
0/80N
30
84
14
97
N1
84
20
06
3/2
2/4
32
00
05
.58
48.6
0.9
73
48
48
6.94
.53
21
12
94.4
NN
NN
0-2 PU
S N
NO
DA
Y 5Y
NN
NN
NN
YN
Y2
17
MD
AY 4T
N9
81
00
/70N3
08
01
69
8N
18
43
00
39
/37
/282
80
00
6.2
46
1.5
51
44
68
6.14
.51
90
.81
36
1.7N
NN
N0-2 P
USN
NO
DA
Y 6N
NN
NN
YN
NN
Y2
79
FD
AY 2Y
Y1
00
11
0/70N
40
12
81
49
6N
11
14
70
08
0/1
2/62
40
00
04
.18
30.4
0.8
29
26
40
6.13
26
0.7
13
93.5
NN
NN
0-2 PU
SNN
OD
AY 5
NN
NN
NN
NN
NY
2
26
FD
AY 4Y
Y1
02
10
0/70N
30
82
16
98
N1
07
60
06
0/2
3/1
033
00
04
.22
31.1
0.4
48
47
11
26.8
4.5
21
1.1
13
83.9
NN
NN
1-2 PU
SNN
OD
AY 5
NN
NN
NY
NY
NY
2
56
MD
AY 2Y
N1
00
11
0/70N
40
94
14
97
N1
23
70
05
3/2
9/1
651
00
03
.66
35.1
42
72
39
67.1
3.8
45
11
25
3.7N
NN
N1-2 P
USN
NO
DA
Y 6N
YN
NN
NN
NN
Y1
24
MD
AY 4Y
N9
81
10
/80N3
08
61
89
8Y
Y1
67
30
07
4/2
6/5
23
00
06
.57
41.5
0.7
84
77
71
6.34
.12
40
.91
38
4.4N
NN
N0-3 P
USN
NO
DA
Y 5N
NN
NN
NN
NN
Y2
16
MD
AY 3Y
NY
99
10
0/70N
30
74
14
98
N1
41
14
00
58
/27
/819
20
00
53
50
.52
82
11
22
7.23
.52
20
.91
33
4.4N
NN
N1-2 P
US
NN
OD
AY 7
NN
NN
NN
NN
NY
1
20
FD
AY 3Y
NY
99
10
0/70N
30
86
14
98
N1
14
70
05
7/2
7/1
552
00
04
.63
40
.72
92
36
76.7
4.5
15
0.7
13
84.7
NN
NN
2-3 PU
SNN
OD
AY 5
NY
NN
NN
NN
NY
1
17
MD
AY 3Y
N9
91
10
/80N3
09
21
89
6N
15
57
00
62
/27
/102
20
00
5.3
42
1.3
73
57
56.8
4.2
26
11
31
4.3N
NN
N1-2 P
USN
NO
DA
Y 5N
NN
NY
NN
NN
Y2
26
MD
AY 4Y
N9
91
10
/80N3
09
01
49
8N
17
10
20
07
3/2
0/7
90
00
6.3
42.6
1.1
12
56
67
06.5
3.5
48
1.2
14
43.4
NN
NN
1-3 PU
SNN
OD
AY 5
NN
NN
YN
NN
NY
3
21
MD
AY 3Y
Y1
02
80
/60
Y2
01
16
16
98
N1
44
70
06
3/2
3/1
536
00
04
.28
41
1.3
26
37
66
5.13
.92
00
.91
34
3.5N
NN
N0-2 P
USN
NO
DA
Y 6N
YN
NN
NN
NN
Y2
32
MD
AY 1Y
N9
91
10
/70N4
09
61
89
9N
12
54
00
62
/38
/1013
60
00
4.5
39.4
16
43
68
26.6
4.2
21
1.2
13
54.1
NN
NN
2-3 PU
SNN
OD
AY 6
NN
NY
NN
NN
NY
1
13
MD
AY 4Y
Y1
02
90
/60
Y3
01
12
20
99
N1
43
40
05
7/4
5/6
26
00
05
.54
0.20
.41
30
59
17
58.1
3.7
13
30
.81
30
4.6N
NN
N2-3 P
US
NN
OD
AY 3
NN
NN
NN
NN
NY
3
68
MD
AY 4Y
N9
97
0/5
0Y
20
98
14
99
N1
11
22
00
83
/8/9
22
00
03
.61
30
0.6
45
48
87
6.73
.32
50
.81
37
3.5N
NN
N1-2 P
USN
NO
DA
Y 4N
NN
NN
NN
NN
Y2
22
MD
AY 4Y
N9
91
00
/70N3
08
62
09
8N
16
38
00
54
/28
/171
80
00
5.4
45
0.9
24
91
79
57
6.44
42
1.3
13
74.1
NN
NN
1-2 PU
SNN
OD
AT 5
NY
NN
NN
NN
NY
3
16
MD
AY 3Y
N9
81
00
/70N3
08
41
49
9N
15
91
00
30
/37
/414
20
00
5.2
34
30
.71
24
10
46
66.9
4.2
16
0.8
13
53.4
NN
NN
1-2 PU
S N
NO
DA
Y 3N
NN
NN
NN
NN
YY
3
17
MD
AY 4Y
N9
99
0/5
0Y
40
12
41
49
7N
12
74
00
85
/15
67
00
03
.82
30
0.3
21
15
60
6.23
.81
50
.91
30
3.3N
NN
N0-2 P
USN
NO
DA
Y 6N
NN
NN
NN
NN
Y1
24
MD
AY 3Y
Y1
01
11
0/70N
40
82
14
97
N1
74
10
05
3/3
2/1
834
00
05
42.3
1.2
35
44
55
56.5
4.3
10
0.7
13
94
NN
NN
1-3 PU
S N
NO
DA
Y 4N
NN
NN
NN
NN
Y3
45
MD
AY 4Y
YY
10
21
30
/80N5
09
21
69
7N
15
11
80
05
6/3
7/6
60
00
04
.53
81
43
25
52
7.84
.12
61
.11
28
3.6N
NN
N1-2 P
USN
NO
DA
Y 5N
NN
NN
NN
NN
Y1
22
FD
AY 4Y
N9
81
00
/70N3
08
01
69
9N
10
51
00
69
/31
39
00
03
.63
30.2
1.3
46
33
35
5.73
.32
10
.71
39
4.2N
NN
N0-2 P
US
NN
OD
AY 6
NN
NN
NN
NN
NY
3
27
MD
AY 2Y
Y1
01
10
0/70N
30
82
14
98
N1
33
50
07
6/2
0/5
39
00
05
.33
91
.11
24
10
65
86.1
41
91
13
33.7
NN
NN
0-2 PU
SNN
OD
AY 4
NN
NN
NN
NN
NY
3
34
FD
AY 4Y
N9
91
00
/60N4
01
00
20
96
N1
37
40
06
6/3
36
70
00
4.2
39
0.8
35
25
14
26.7
3.1
13
0.8
13
83.5
NN
NN
0-2 PU
SNN
OD
AY 5
YN
NN
NN
NN
NY
2
28
MD
AY 2Y
YY
99
90
/60
Y3
09
42
09
8N
13
32
00
72
/15
/133
90
00
4.5
83
8.40
.64
13
24
75.9
3.7
17
0.9
13
63.8
NN
NN
1-2 PU
SNN
OD
AY 4
NY
NN
NN
NN
NY
2
40
MD
AY 3Y
N1
00
11
0/70N
40
90
16
98
YY
14
10
00
07
5/1
2/7
15
00
04
.23
24.8
0.7
45
41
60
6.33
.13
80
.71
34
4.2N
NN
N2-3 P
USN
NO
DA
Y 3N
NN
NN
NN
YN
Y2
16
FD
AY 4Y
N9
91
00
/60N4
08
62
19
9N
12
37
00
43
/40
/1615
10
00
4.4
53
3.41
.18
95
87
26.9
3.6
14
0.9
14
04
NN
NN
0-3 PU
SNN
OD
AY 5
NN
NN
NN
NN
NY
1
22
MD
AY 4Y
N9
91
00
/60N4
08
41
49
8N
15
43
00
32
/44
/225
10
00
5.5
44
.40
.42
21
25
15.6
2.9
13
0.5
14
03.9
NN
NN
0-2 PU
SNN
OD
AY 6
NY
NN
NN
NN
NY
2
35
MD
AY 3Y
N9
91
10
/70N4
01
12
19
99
N1
39
50
08
1/1
6/2
30
00
04
.14
38
0.6
36
75
45
73
.84
11
.61
33
4.2N
NN
N0-2 P
USN
NO
DA
Y 6N
NN
NN
NN
NN
Y3
26
MD
AY 2Y
N9
91
20
/80N4
08
21
69
8N
13
40
00
51
/36
/117
50
00
4.6
13
6.70
.35
04
84
26
41
10
.91
35
4N
NN
N1-2 P
USN
NO
DA
Y 4N
NN
NN
NN
NN
Y1
17
MD
AY 3Y
Y1
00
12
0/80N
40
92
12
98
N1
24
50
04
0/4
1/1
893
00
03
.73
6.80
.57
93
91
20
6.23
.72
20
.91
35
4.3N
NN
N1-2 P
USN
NO
DA
Y 5N
NN
NN
NN
NN
Y1
21
MD
AY 4Y
Y1
00
10
0/70N
30
96
12
99
N1
43
10
06
1/2
9/1
123
00
04
.63
9.81
38
19
66
5.73
.81
51
13
53.8
NN
NN
2-3 PU
SNN
OD
AY 5
NN
NN
NN
NN
NY
2
33
FD
AY 2Y
N9
91
20
/70N5
07
21
69
8N
15
17
60
06
1/3
92
40
00
3.9
39.9
1.2
22
18
47
8.84
.42
01
.11
40
4N
NN
N1-2 P
USN
NO
DA
Y 4N
NN
NN
NN
NN
Y2
38
MD
AY 6Y
Y1
02
11
0/60N
50
11
41
49
8N
14
72
00
80
/15
/37
00
00
4.5
37.4
1.1
60
80
12
36.6
3.9
30
1.5
45
3.6N
NN
N1-2 P
USN
NO
DA
Y 8N
YN
NN
NN
NN
Y1
26
FD
AY 6Y
NY
99
11
0/70N
40
82
14
98
N1
34
60
07
0/1
9/1
0179
00
04
.32
34.6
0.8
39
31
62
74
.41
10
.91
31
3.9N
NN
N0-2 P
USN
NO
DA
Y 7N
NN
NN
NN
NN
Y1
36
MD
AY 6Y
N9
81
30
/80N5
07
81
69
7N
14
10
90
04
3/3
6/2
061
00
04
.54
0.20
.44
57
17
77
3.7
35
0.8
13
84.1
NN
NN
1-3 PU
SNN
OD
AY 8
NN
NN
NN
NN
NY
1
27
FD
AY 6Y
N9
61
10
/80N3
08
01
29
9N
13
45
00
62
/21
/137
00
00
4.6
33
17
21
08
10
76.1
41
80
.81
34
3.4N
NN
N1-2 P
USN
NO
DA
Y 8N
NN
NN
NN
NN
Y1
19
MD
AY 6Y
N9
91
10
/70N3
08
21
69
9N
12
84
00
56
/23
/1919
40
00
4.7
37
1.1
51
52
10
46.7
41
30
.71
36
4N
NN
N0-2 P
USN
NO
DA
Y 8N
NN
NN
NN
NN
Y1
22
FD
AY 6Y
N1
00
11
0/70N
40
84
18
99
N1
14
10
07
5/2
0/5
67
00
03
.73
00
.73
01
44
35.9
34
90
.51
34
4.2N
NN
N1-2 P
USN
NO
DA
Y 8N
NN
NN
NN
NN
Y2
25
FD
AY 5Y
Y9
91
20
/70N5
09
01
89
9N
12
49
00
77
/20
/33
30
00
4.7
33.8
0.5
90
40
10
57.2
3.9
16
0.7
12
93.4
NN
NN
0-2 PU
S N
NO
DA
Y 7N
NN
NN
YN
NN
Y2
37
MD
AY 5Y
N9
91
20
/100N
20
66
16
97
YY
15
30
00
46
/38
/71
40
00
5.2
45.1
1.3
59
31
70
6.54
.23
51
.41
31
3.5N
NN
N0-2 P
USN
NO
DA
Y 7N
NN
NN
NN
NN
Y2
51
MD
AY 6Y
YY
99
11
0/70N
40
80
18
98
N1
38
80
07
1/2
5/4
20
00
03
.93
4.41
.11
67
13
39
66.7
3.3
47
1.3
13
74.1
NN
NN
2-3 PU
S N
NO
DA
Y 8Y
NN
NN
NN
NN
Y4
20
FD
AY 6Y
N9
91
10
/60N5
07
01
49
9N
8.5
59
00
69
/32
70
00
03
.09
33.7
1.5
67
48
42
7.44
.32
21
13
73.9
NN
NN
0-2 PU
SNN
OD
AY 7
NN
NN
NN
NN
NY
1
17
FD
AY 5Y
N9
91
10
/70N4
08
61
49
6N
11
70
03
4/4
7/1
851
00
04
.53
3.60
.54
22
14
57.1
3.7
14
0.7
13
84.2
NN
NN
2-3 PU
S N
NO
DA
Y 7N
NN
NN
NN
NN
Y1
15
MD
AY 6Y
N1
02
90
/60
Y3
01
28
14
99
N1
28
80
06
0/3
3/72
11
00
04
.23
30
.88
23
37
46.9
4.5
15
0.5
12
84
NN
NN
0-2 PU
SNN
OD
AY 8
NN
NN
NN
NN
NY
1
63
MD
AY 6Y
N9
91
20
/80N4
08
21
69
7N
17
90
06
3/2
2/1
1371
00
05
.86
46.6
0.9
24
33
48
7.33
.64
01
.11
33
3.8P
TN
NN
N1-2 P
USN
NO
DA
Y 8N
NN
NN
NN
NN
Y1
18
FD
AY 5Y
N1
00
11
0/70N
40
90
18
99
N1
04
20
04
9/2
4/2
629
00
04
.11
30
1.1
86
81
45
6.14
37
0.9
13
53.5
NN
NN
1-2 PU
S N
NO
DA
Y 7N
NN
NY
NN
NN
Y2
19
MD
AY 5Y
Y1
00
11
0/90N
20
82
14
96
N1
63
40
04
5/4
4/1
015
00
04
.63
31
.31
13
54
86
7.94
.44
81
.11
36
4.4N
NN
N3-6 P
USN
NO
DA
Y 11N
YN
NY
NN
YN
Y3
52
MD
AY 5Y
Y9
91
40
/80Y6
07
61
49
8N
14
14
20
07
5/1
2/9
30
00
04
.83
20
.61
88
13
03
67
6.23
.54
01
.21
27
3.4N
Y +
++20-25 P
US
YN
OD
AY 6
YY
YN
YN
YY
NY
4
29
MD
AY 5Y
Y9
81
20
/80N4
07
41
89
9N
13
64
00
58
/28
/138
10
00
4.6
37.1
1.1
39
31
10
86.2
3.5
37
0.7
13
84.9
NN
NN
1-2 PU
SNN
OD
AY 10
NN
NN
NN
NN
NY
1
37
MD
AY 4Y
N9
81
10
/70N4
01
04
14
98
N1
36
70
07
0/2
0/9
59
00
03
.77
37.1
0.8
85
23
62
52
.62
41
.11
20
3.4N
NN
N0-3 P
USN
NO
DA
Y 5N
YN
NN
NN
NN
Y3
35
FD
AY 3Y
N9
91
00
/70N3
09
01
69
7N
13
49
00
70
/26
/424
50
00
4.8
3.4
0.6
17
24
12
26
63
.21
70
.91
33
4.1N
NN
N1-2 P
USN
NO
DA
Y 5N
NN
YN
NN
YN
Y2
31
FD
AY 2Y
N9
91
20
/70N5
08
81
89
9N
11
49
00
60
/37
/317
30
00
3.9
37
1.1
76
48
53
6.13
.92
00
.81
37
3.8N
NN
N0-2 P
SNN
OD
AY 4
NN
NN
NN
NN
NY
1
28
MD
AY 2Y
Y1
01
10
0/60N
40
82
14
98
N1
23
40
07
5/2
0/5
39
00
05
.13
90
.91
24
10
65
76.1
41
91
.11
33
4N
NN
N0-2 P
USN
NO
DA
Y 4N
NN
NN
NN
NN
Y3
26
FD
AY 4Y
N9
91
10
/80N3
01
00
20
97
N1
37
60
06
6/3
36
70
00
43
91
.13
52
51
43
6.73
.11
30
.71
38
3.5N
NN
N0-2 P
USN
NO
DA
Y 6Y
NN
NN
NN
NN
Y2
32
MD
AY 2Y
Y9
99
0/6
0Y
30
94
20
99
N1
43
10
07
3/1
5/1
239
00
04
.95
38.4
0.9
41
32
48
5.93
.71
70
.91
36
4.2N
NN
N1-2 P
USN
NO
DA
Y 4N
YN
NN
NN
NN
Y2
43
MD
AY 1Y
N1
00
11
0/70N
40
78
14
98
YY
14
10
10
07
5/1
3/8
15
00
04
.03
24.8
1.1
45
41
59
6.33
.13
60
.51
34
4.3N
NN
N2-3 P
USN
NO
DA
Y 5N
NN
NN
NN
YN
Y2
16
FD
AY 4Y
N9
91
00
/60N4
08
02
09
9N
11
38
00
43
/40
/1615
10
00
4.4
53
3.41
.18
95
87
36.9
3.6
15
11
40
3.7N
NN
N1-3 P
USN
NO
DA
Y 5N
NN
NN
NN
NN
Y1
21
MD
AY 4Y
N9
91
10
/60N5
08
81
49
7N
16
43
00
32
/44
/225
10
00
5.5
44
.41
.42
21
24
85.6
2.9
14
0.7
14
04.1
NN
NN
1-2 PU
SNN
OD
AY 6
NY
NN
NN
NN
NY
2
36
MD
AY 3Y
N9
91
10
/70N4
01
12
20
99
N1
49
50
08
1/1
6/2
30
00
04
.14
38
13
67
54
57
3.8
42
1.4
13
33.6
NN
NN
0-2 PU
SNN
OD
AY 5
NN
NN
NN
NN
NY
3
23
MD
AY 2Y
N9
91
10
/90N2
08
41
89
8N
13
39
00
53
/37
/127
50
00
4.6
13
6.70
.55
04
84
36
41
30
.81
35
4.1N
NN
N1-2P
USN
NO
DA
Y 4N
NN
NN
NN
NN
Y1
16
MD
AY 3Y
Y1
00
12
0/80N
40
92
12
96
N1
34
60
04
0/4
2/1
893
00
03
.73
6.81
.17
93
91
22
6.23
.72
10
.71
35
4N
NN
N1-2 P
USN
NO
DA
Y 5N
NN
NN
NN
NN
Y1
18
MD
AY 4Y
Y1
00
10
0/70N
30
86
14
99
N1
53
00
06
1/2
7/1
123
00
04
.73
9.80
.83
81
96
65.7
3.8
15
1.1
13
53.5
NN
NN
1-3 PU
SNN
OD
AY 6
NN
NN
NN
NN
NY
2
35
FD
AY 2Y
N9
91
20
/80N4
07
61
49
8N
16
17
50
05
8/3
92
40
00
4.1
39.9
1.1
22
18
47
8.84
.42
01
14
03.5
NN
NN
1-2 PU
SNN
OD
AY 4
NN
NN
NN
NN
NY
2
32
MD
AY 6Y
Y1
02
11
0/60N
50
11
42
09
8N
14
72
00
80
/14
/47
00
00
4.4
37.4
0.8
60
80
12
46.6
3.9
30
1.4
14
53.4
NN
NN
1-2 PU
SNN
OD
AY 8
NY
NN
NN
NN
NY
1
22
FD
AY 6Y
NY
Y9
91
10
/70N4
08
21
69
7N
12
45
00
68
/20
/1017
90
00
4.3
34.6
0.9
39
31
62
74
.41
20
.71
31
3.6N
NN
N0-2 P
USN
NO
DA
Y 7N
NN
NN
NN
NN
Y1
39
MD
AY 6Y
N9
81
30
/90N4
07
81
69
8N
14
11
00
04
4/3
5/2
061
00
04
.54
0.21
.14
57
17
77
3.7
35
0.8
13
83.8
NN
NN
1-3 PU
SNN
OD
AY 8
NN
NN
NN
NN
NY
1
29
FD
AY 6Y
N9
61
10
/70N4
07
21
29
9N
12
45
00
62
/21
/137
00
00
4.2
63
30
.57
21
08
10
76.1
41
90
.91
34
3.6N
NN
N1-2 P
USN
NO
DA
Y 8N
NN
NN
NN
NN
Y1
19
MD
AY 6Y
NY
99
11
0/70N
40
78
14
98
N1
28
40
05
6/2
4/1
9194
00
04
.68
37
0.4
51
52
10
46.7
41
30
.61
36
4N
NN
N0-2 P
USN
NO
DA
Y 7N
NN
NN
NN
NN
Y1
23
FD
AY 6Y
N9
91
10
/70N4
08
81
89
7N
11
41
00
75
/20
/56
70
00
3.2
73
01
.13
01
44
45.9
35
10
.51
34
4.1N
NN
N0-2 P
USN
NO
DA
Y 8N
NN
NN
NN
NN
Y2
27
FD
AY 5Y
Y9
91
10
/70N4
09
01
89
9N
12
49
00
77
/20
/33
30
00
4.7
33.8
19
04
01
03
7.23
.91
60
.81
29
3.5N
NN
N0-2 P
US
NN
OD
AY 7
NN
NN
NY
NN
NY
2
37
MD
AY 5Y
N9
91
30
/100N
30
66
14
99
YY
15
29
00
46
/37
/71
40
00
5.2
24
5.10
.85
93
17
06.5
4.2
36
1.2
13
13.7
NN
NN
1-2 PU
SN N
OD
AY 8
NN
NN
NN
NN
NY
2
51
MD
AY 6Y
Y9
91
20
/70N5
08
21
69
6N
13
90
00
73
/22
/42
00
00
3.9
34.4
1.1
16
71
33
96
6.73
.35
01
.21
37
4.1N
NN
N1-2 P
US
NN
OD
AY 8
YN
NN
NN
NN
NY
4
21
FD
AY 6Y
NY
99
11
0/70N
40
74
14
99
N8
.56
00
06
8/3
47
00
00
3.2
93
3.70
.36
74
84
57.4
4.3
19
11
37
3.4N
NN
N0-2 P
USN
NO
DA
Y 7N
NN
NN
NN
NN
Y1
17
FD
AY 5Y
N9
91
10
/60N5
08
41
49
9N
11
75
00
34
/46
/185
10
00
4.5
33.6
14
22
14
37.1
3.7
15
0.7
13
84
NN
NN
2-3 PU
S N
NO
DA
Y 6N
NN
NN
NN
NN
Y1
18
MD
AY 6Y
N1
01
90
/60
Y3
01
26
14
98
N1
28
90
06
2/3
0/72
11
00
04
.12
33
1.1
82
33
72
6.94
.51
70
.61
28
3.5N
NN
N0-2 P
USN
NO
DA
Y 8N
NN
NN
NN
NN
Y1
62
MD
AY 6Y
N9
91
20
/80N4
08
41
69
7N
17
94
00
62
/21
/1137
10
00
5.8
64
6.60
.72
43
34
87.3
3.6
40
1.2
13
34.5
NN
NN
1-2 PU
SNN
OD
AY 8
NN
NN
NN
NN
NY
1
18
FD
AY 5Y
N1
00
11
0/70N
40
86
20
99
N1
04
10
04
9/2
5/2
629
00
04
.22
30
1.1
86
81
45
6.14
39
0.7
13
53.6
NN
NN
1-2 PU
S N
NO
DA
Y 7N
NN
NY
NN
NN
Y2
17
MD
AY 6Y
Y1
00
10
0/90Y
10
82
14
98
N1
73
40
04
6/4
4/8
15
00
04
.56
33
0.7
11
35
48
27.9
4.4
45
11
36
4.7N
NN
N3-6 P
USN
NO
DA
Y 11N
YN
NY
NN
YN
Y3
54
MD
AY 5Y
YY
99
13
0/90Y
40
76
14
97
N1
41
42
00
77
/11
/93
00
00
4.7
83
20
.51
88
13
03
66
6.23
.54
11
.21
27
5N
Y +
++20-25 P
US
YN
OD
AY 7
YY
YN
YN
YY
NY
4
33
MD
AY 5Y
Y9
81
20
/90N3
07
41
69
9N
13
64
00
59
/27
/138
10
00
4.6
37.1
0.7
39
31
10
76.2
3.5
37
0.7
13
84.8
NN
NN
1-3 PU
SNN
OD
AY 11
NN
NN
NN
NN
NY
1
35
MD
AY 4Y
N9
91
00
/70N3
01
04
14
98
N1
36
70
07
0/2
0/9
59
00
03
.77
37.1
1.1
85
23
61
52
.62
61
.11
20
3.5N
NN
N0-2 P
USN
NO
DA
Y 5N
YN
NN
NN
NN
Y3
33
FD
AY 3Y
N9
91
10
/70N4
09
01
89
8N
13
50
00
72
/25
/424
50
00
4.7
83
.40
.81
72
41
22
46
3.2
17
0.7
13
33.6
NN
NN
1-2 PU
SNN
OD
AY 5
NN
NY
NN
NY
NY
2
31
FD
AY 2Y
NY
99
11
0/70N
40
88
20
99
N1
15
00
06
0/3
8/31
73
00
03
.83
71
.17
64
85
46.1
3.9
18
0.8
13
74
NN
NN
0-2 PSN
NO
DA
Y 4N
NN
NN
NN
NN
Y1
14
FD
AY 4Y
Y1
00
11
0/80N
30
82
14
98
N1
23
20
04
7/3
5/1
514
30
05
38.8
0.6
46
35
14
45.6
3.9
16
0.8
13
63.9
NN
NN
0-2 PSN
NO
DA
Y 6N
NN
NN
NN
NN
Y1
17
MD
AY 4Y
N9
91
10
/70N4
08
41
69
8N
16
56
00
40
/33
/304
40
00
5.6
43.7
0.9
28
46
13
27
4.5
20
0.9
13
14.3
NN
NN
1-2 PU
SNN
OD
AY 7
NN
NN
YN
NN
NY
1
57
FD
AY 3Y
N9
91
00
/70N3
07
61
49
7N
11
94
00
74
/24
/47
80
00
3.4
22
8.21
.14
33
91
74
6.33
.83
92
13
64.6
NN
NN
1-2 PU
SNN
OD
AY 5
NN
NN
NN
NN
NY
1
43
MD
AY 5Y
N9
91
10
/70N4
08
42
09
8N
15
71
00
60
/20
/82
30
00
4.9
44
0.91
.53
64
28
56.8
3.8
33
1.1
13
73.5
NN
NN
0-2 PU
SNN
OD
AY 6
NN
NN
NN
NN
NY
2
25
FD
AY 4Y
N9
91
20
/80N4
07
81
49
8N
13
62
00
68
/21
/93
60
00
3.3
37.6
1.1
47
35
52
74
.11
41
13
54.6
NN
NN
1-2 PU
SNN
OD
AY 5
NN
NN
NN
NN
NY
2
15
FD
AY5Y
N9
81
10
/70N4
07
41
49
6N
14
45
00
65
/21
/124
20
00
4.8
36.2
0.6
32
35
16
37.2
41
50
.91
37
3.8N
NN
N0-2 P
USN
NO
DA
Y 6N
YN
NY
NN
NN
Y2
44
MD
AY 2Y
Y1
01
13
0/90N
40
11
81
69
8N
16
65
00
76
/11
/13
39
00
5.6
44
0.8
85
27
77
6.43
.52
31
.11
39
4.2N
NN
N1-2 P
USN
NO
DA
Y 5N
NN
NY
YN
YN
Y2
17
MD
AY 2Y
N9
99
0/6
0Y
30
92
14
98
N8
.31
46
00
60
/24
/1517
50
00
4.7
63
51
.53
02
34
26
42
80
.81
39
4.2N
NN
N1-2 P
USN
NO
DA
Y 6N
NN
NN
NN
NN
Y1
22
MD
AY 3Y
N9
91
10
/80N3
08
81
69
7N
18
43
00
64
/23
/43
20
00
5.7
84
8.60
.77
34
85
06.9
4.5
33
11
29
4.5N
NN
N0-2 P
US
NN
OD
AY 5
YN
NN
NN
NY
NY
2
16
MD
AY 4T
NY
9.3
11
0/70N
40
76
18
99
N1
74
50
03
4/3
7/2
828
00
06
.21
46
0.6
51
44
66
6.14
.51
80
.81
36
3.3N
NN
N1-2 P
USN
NO
DA
Y 6N
NN
NN
YN
NN
Y2
76
FD
AY 2Y
Y1
00
11
0/70N
40
13
01
49
8N
11
14
80
08
0/1
1/62
40
00
04
.18
30.4
0.9
29
26
55
6.13
27
0.9
13
93.6
PT
NN
NN
0-3 PU
SNN
OD
AY 6
NN
NN
NN
NN
NY
2
27
FD
AY 3Y
Y1
00
11
0/60N
50
82
14
99
N1
17
70
06
8/2
0/1
033
00
04
.22
31.1
1.1
48
47
10
26.8
4.5
20
1.1
13
83.9
NN
NN
1-2 PU
SNN
OD
AY 5
NN
NN
NY
NY
NY
2
54
MD
AY 2Y
N1
00
11
0/70N
40
94
16
98
N1
23
60
05
5/2
9/1
651
00
03
.56
35.1
1.3
27
23
96
7.13
.84
51
12
53.8
NN
NN
0-3 PU
SNN
OD
AY 6
NY
NN
NN
NN
NY
1
21
MD
AY 3Y
N9
81
10
/80N3
08
41
89
9Y
Y1
67
40
07
3/2
62
30
00
6.3
41.5
0.4
84
77
72
6.34
.12
30
.91
38
4.3N
NN
N0-3 P
USN
NO
DA
Y 5N
NN
NN
NN
NN
Y2
22
MD
AY2Y
N9
91
00
/70N3
07
01
49
8N
13
11
50
05
7/2
6/81
92
00
05
.17
35
0.3
28
21
12
27.2
3.5
24
0.7
13
34.6
NN
NN
0-2 PU
S N
NO
DA
Y 6N
NN
NN
NN
NN
Y1
23
FD
AY 5Y
N9
81
10
/60N5
08
61
49
7N
10
48
00
49
/32
/205
20
00
4.6
34
1.4
29
23
65
6.74
.51
50
.91
38
4N
NN
N1-3 P
USN
NO
DA
Y 7N
YN
NN
NN
NN
Y1
