Medicine
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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
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Item 6542 Clinical profiles of children less than 5 years presenting with or high risk of cerebral palsy in the Western Province of Sri Lanka(BMJ, 2024) Sumanasena, S.; Heiyanthuduwage, T.M.; Fernando, R.; Sheedy, H.S.; Jagoda, J.; Wijesekara, S.; Wanigasinghe, J.; Muttiah, N.; Rathnayake, P.; Kitnasamy, G.; Khandaker, G.OBJECTIVES Cerebral palsy (CP) is the commonest physical disability in children globally.1 It is a clinical diagnosis based on clinical and neurological findings. International clinical practice guidelines recommend early diagnosis and CP specific interventions to invest in neural plasticity and achieve optimal functional levels.2 In the past diagnosis was confirmed at 12–24 months but now it is advanced to confirm or identify as high risk for CP before the age of six months.3 4 Sri Lanka is one of the few Asian countries that initiated a CP register and National Guidelines on management of CP.5 The objective of this paper is to describe the clinical profiles of children less than 5 years presenting to Western Province hospitals in Sri Lanka based on the data from the Sri Lanka Cerebral Palsy Register (SLCPR).METHODS A cross sectional hospital-based study was conducted in the Western Province from September 2018 – October 2021 in three teaching hospitals to collect a minimum data set for the Sri Lanka SLCPR. Data of children less than 60 months was extracted with a confirmed clinical diagnosis of CP or identified formally as ‘high risk’ of CP.Information on sociodemographic, pre/peri/neonatal, and post neonatal risk factors, and associated impairments were collected using hospital records and clinic notes. Clinical motor type, topography, and associated impairments were evaluated.RESULTS Data of 431 children were extracted, 254 (58.9%) were males. Mean age at diagnosis was 28.73 months (median 27, SD 14.98). Most children (n= 422, 97.9%) acquired CP in the pre/peri/neonatal period. The mean birth weight was 2304.4 g (median 37, SD 825.58g) and the mean POA was 35.82 months (median 37, SD 4.88). Main risk factors identified were prematurity (n=190, 44.1%), hypoxic ischaemic encephalopathy (HIE) (n= 234, 54.3%), jaundice (n=31, 7.2%) and sepsis (n= 13, 3.0%). While 183 children (42.5%) showed evidence of definitive spastic motor type, 184 (42.7%) showed predominant dyskinesia.CONCLUSION The age at diagnosis of this population from Sri Lanka is significantly lower than from other LMICs. HIE and prematurity, both preventable conditions remain the highest risk factors. Longitudinal follow up will ascertain the final motor outcomes as a higher proportion of children showed dyskinesia. The SLCPR is an important resource which will support new research towards investigating opportunities for prevention and service planning for children.Item 6503 Using anthropometric data to investigate the nutritional status of children included on the Sri Lankan cerebral palsy register.(BMJ Publishing Group Ltd, 2024) Sumanasena, S.; Fernando, R.; Kurukulaarachchi, S.; Heiyanthuduwage, T.M.; Sheedy, H.S.; Wijesekara, S.; Jagoda, J.; Muttiah, N.OBJECTIVES The nutritional data from children with cerebral palsy (CP) in low and middle income countries (LMIC) is sparse. In high income countries (HICs) well established nutritional care plans, commercial products and good psycho-social support are available.1 A multitude of complications arise due to malnutrition leading to poor quality of life.2 Here we investigated the nutritional status of children included in the Sri Lankan Cerebral Palsy Register (SLCPR).METHODS The study included 768 children aged 0–18 years with CP, attending three teaching hospitals in the Western Province, from September 2018 to November 2021. Data included clinical profile and anthropometry [weight (Kg), height (cm), BMI, mid upper arm circumference (MUAC) (cm), and OFC (cm)] based on WHO. Average was calculated using three repeated measurements. Children who could not stand independently (GMFCS level 4/5) underwent height estimations with the knee height equation: height = (2.69 X Knee height) + 24.2.Indicators used to measure the nutritional status were: weight for age Z score (WAZ), height for age Z score (HAZ), weight for height Z score (WHZ), BMI for age Z score (BAZ), and MUAC for age Z score (MUACZ). WHO Anthro and WHO AnthroPlus software calculated all Z scores.4 HAZ and BAZ were calculated for children aged <18 years, WAZ was calculated for children aged <10.1 years, and WHZ and MUACZ were calculated for children aged <5.1 years. The z scores < -2.0 SD were categorized as underweight (WAZ), stunted (HAZ), wasted (WHZ or MUAC), thin (BAZ).RESULTS Total of 768 children (mean age 59.6 months, SD 44.9, 62.5% males) participated. There were (n=431) children under 61 months and (n=520) from 0–10 years. Of them, 51.3% (n = 267/520) were underweight, 59.8% (n = 258/431) were stunted and 27.3% (n = 210/768) were thin. Among children aged < 5 years, 26.7% (n = 115/431) had severe wasting and severe acute malnutrition (SAM) according to MUACZ < -3SD. Both underweight and stunting were significantly higher among children with spastic CP compared with others (p<0.05). In the 5–19 year group 16.9% (n= 57/337) were obese (BAZ > + 2SD).CONCLUSION Predominant stunting and underweight in this population calls for urgent action to minimize chronic malnutrition. It is imperative to further explore nutritional intake and feeding difficulties in this group and offer structured nutritional care plans. The trend observed in older children towards obesity possibly indicates the need for coordinated nutrition and exercise programmes. It is recommended to regularly monitor growth and nutritional status of all children with CP as there may be serious implications for their activity levels.Item Improving psychological well-being among healthcare workers during the COVID-19 pandemic with an online mindfulness intervention: A randomised waitlist-controlled trial(Wiley, 2024) Baminiwatta, A.; Fernando, R.; Solangaarachchi, I.; Abayabandara-Herath, T.; Wickremasinghe, A.R.; Hapangama, A.The high prevalence of psychological problems observed among healthcare workers (HCWs) during the COVID-19 pandemic called for interventions to safeguard their mental health. We assessed the effectiveness of a 6-week online mindfulness-based intervention in improving well-being and reducing stress among HCWs in Sri Lanka. Eighty HCWs were recruited and randomised into two groups: waitlist-control (WLC) and intervention groups. In the intervention, 1-hour online sessions were conducted at weekly intervals and participants were encouraged to do daily home practice. Stress and well-being were measured pre- and post-intervention using the Perceived Stress Scale and WHO-5 Well-being Index, respectively. One-way analysis of covariance was used to evaluate the effectiveness, in both intention-to-treat (ITT) and complete-case (CC) analyses. A significantly greater improvement in well-being occurred in the intervention arm compared to WLC on both ITT (p = .002) and CC analyses (p < .001), with medium-to-large effect sizes (partial η2 = .117-.278). However, the reduction in stress following the intervention was not significant compared to the WLC group on both ITT (p = .636) and CC analyses (p = .262). In the intervention arm, the median number of sessions attended by participants was 3. Low adherence to the intervention may have contributed to the apparent non-significant effect on stress.Item Improving medical students' understanding of dementia using a movie ( The Father)(Taylor & Francis, 2023) Baminiwatta, A.; Fernando, R.; Williams, S.No abstract availableItem 2021 Asia-Pacific Graves' Disease consortium survey of clinical practice patterns in the management of graves' disease(Humana Press, 2023) Parameswaran, R.; de Jong, M.C.; Kit, J.L.W.; Sek, K.; Nam, T.Q.; Thang, T.V.; Khue, N.T.; Aye, T.T.; Tun, P.M.; Cole, T.; Miller, J.A.; Villa, M.; Khiewvan, B.; Sirinvaravong, S.; Sin, Y.L.; Muhammad, R.; Jap, T.S.; Agrawal, A.; Rajput, R.; Fernando, R.; Sumanatilleke, M.; Suastika, K.; Shong, Y.K.; Lang, B.; Bartalena, L.; Yang, S.P.; Asian Graves Consortium Study.Aim: Although Graves' disease (GD) is common in endocrine practices worldwide, global differences in diagnosis and management remain. We sought to assess the current practices for GD in countries across Asia and the Pacific (APAC), and to compare these with previously published surveys from North America and Europe.Methods: A web-based survey on GD management was conducted on practicing clinicians. Responses from 542 clinicians were received and subsequently analysed and compared to outcomes from similar surveys from other regions. Results: A total of 542 respondents participated in the survey, 515 (95%) of whom completed all sections. Of these, 86% were medical specialists, 11% surgeons, and 3% nuclear medicine physicians. In addition to serum thyroid-stimulating hormone (TSH) and free thyroxine assays, most respondents would request TSH-receptor autoantibody (TRAb) measurement (68%) during initial work-up. Thyroid ultrasound is requested by about half of respondents (53%), while the use of nuclear medicine scans is limited. The preferred first-line treatment is anti-thyroid drug (ATD) therapy (79%) with methimazole (MMI) or carbimazole (CBZ), followed by radioiodine (RAI; 19%) and surgery (2%). In case of surgery, one-third of respondents would opt for a subtotal rather than a total thyroidectomy. In case of mild Graves orbitopathy (GO), ATDs (67%) remains the preferred treatment, but a larger proportion of clinicians prefer surgery (20%). For a patient with intention to conceive, the preferred treatment pattern remained unchanged, although propylthiouracil (PTU) became the preferred ATD-agent during the first trimester. In comparison to European and American practices, marked differences were noted in the relatively infrequent usage of nuclear medicine scans and the overall higher use of a ATDs and β-blockers and adjunctive ATD-treatment during RAI in the APAC-group.Conclusion: Although regional differences regarding the diagnosis and management of GD are apparent in this first pan-Asia-Pacific survey, this study reveals the overall approach to the management of this disease in Asia-Pacific generally tends to fall between the trends appreciated in the American and European cohorts.Item Elective cholecystectomy is associated with increased morbidity and mortality in patients with severe Thalassemia: A retrospective case control study.(Ferrata Storti Foundation, 2015) Premawardhena, A.; Fernando, R.; Kumarage, S.; Nishad, N.; de Silva, I.BACKGROUND: Haemoglobin disorders including thalassemia and sickle cell disease are often complicated with gall stone formation. The co-existence of Gilbert's syndrome together with these diseases further increases the risk of gall bladder disease. Some of these patients develop symptomatic disease which necessitates surgical intervention. At present the timing of cholecystectomy for thalassemia is no different from that of the general population with the exception of removal of the gall bladder at the time of splenectomy. This is no longer the case in sickle cell disease where, laparoscopic cholecystectomy is recommended even in asymptomatic patients. This practice however has not been extended to other types of haemoglobin disorders. AIM(S): 1.To assess the perioperative complications of patients with thalassaemia during cholecytetomy and to compare it with non thalassaemics who undergo the procedure. 2. To see if there is enough evidence to recommend elective cholecystectomy for thalassaemics. METHOD(S): We retrospectively studied case notes of thalassemia patients who had cholecystectomy (cases) in two of the biggest thalassaemia centres in Sri Lanka and also of 62 non-thalassaemics (controls) with gall bladder disease who had been scheduled to have gall bladder surgery in the same hospitals and looked at their peri-operative complications. RESULT(S): 98 out of 540 (18%) thalassaemics in the two centres had gall stones. Mean age of cases was 26.8 (SD 10.9) years and of controls 47.5 (SD 19.7) years. 19 (19%) thalassaemics with gall stones had undergone cholecystectomy. Ten patients had cholecystectomy simultaneously with splenectomy. The majority of non-thalassaemic "controls" had laparoscopic cholecystectomy 53/55 (96.3%) whilst the patients with thalassaemia were mostly operated with laparotomy 13/19 (68%). There was a significant excess complications occurring in both early (42.11 vs. 18.1%) and late (31.5 vs. 12.7%) phases in the thalassaemic patients compared with the controls. Among the early complications, sepsis (10.5% vs. 1.8%) and liver abscess formation (5.2 vs. 0%) was significantly different in the groups, adversely affecting the thalassaemics. Recurrent abdominal pain was more common among the thalassaemics as a late complication (P<0.05). Six thalassaemic patients with gall stone disease died during this study, 5(5%) while awaiting surgery and 1(1%) after surgery. There were no deaths among the controls. Out of the deaths, 3 (50%) were directly attributable to gallstone disease. In all three septicemia precipitated heart failure. We found a significant increase of both early and late post-surgical complications in the thalassemia group and also increased mortality most of which was related to severe sepsis. Higher perioperative mortality and morbidity were seen among symptomatic thalassaemic patients with gall stone disease undergoing cholecystectomy. This seems to suggest a strong case for supporting elective cholecystectomy in thalassemics before they develop symptoms. SUMMARY AND CONCLUSION(S): We suggest that laparoscopic elective cholecystectomy be considered for non-sickle, thalassemia patients too who have asymptomatic gall bladder disease, in an attempt to reduce this morbidity and mortality.Item Awareness regarding electroconvulsive therapy (ECT) among service users at a tertiary care hospital(Sri Lanka Medical Association, 2019) Hapangama, A.; Gunasekera, T.; Pieris, M.U.P.K.; Fernando, R.; Kuruppuarachchi, K.A.L.A.INTRODUCTION & OBJECTIVES: ECT saves lives and is extremely effective in treatment resistant psychiatric conditions. Despite this there appear to be an unease and stigma attached to ECT. Exploration about the awareness regarding ECT among service users can improve the practice of ECT. Objective was to demonstrate awareness about ECT among services users at a tertiary care hospital. METHODS: Cross-sectional study carried among all consenting service users at a tertiary care Hospital in Sri Lanka using an interviewer administered questionnaire. RESULTS: Out of 221 participants, 54% were careers. 65% thought ECT is a treatment for psychiatric conditions while 58% and 19% thought ECT is used to violence in the absence of a mental illness and to punish opponents respectively. There was no-significant association between educational level and awareness about ECT (p>0.05). The commonest source of ECT was doctors (43%). Cognitive side effects (46%) and headache (59%) were the commonly feared side effects. 5% thought ECT doesn’t 't have a scientific basis-and 20% felt it is an inhuman mode of treatment. 38% felt they would receive ECT if recommended. CONCLUSION: Doctors were the commonest source of information regarding ECT and more than half of the participants knew it was used to treat a psychiatric condition. Surprisingly only a minority thought ECT didn't have scientific basis however 20% felt it was an inhumane mode of treatment. However, a considerable proportion were willing to undergo ECT if recommended. Despite popular beliefs this cohort of participants appeared to have a more favourable awareness about ECT.Item Awareness and usage patterns of substances among pre-clinical phase students at a Medical Faculty in Sri Lanka(Sri Lanka Medical Association., 2019) Hapangama, A.; Fernando, R.; Pathmeswaran, A.; Kuruppuarachchi, K.A.L.A.INTRODUCTION AND OBJECTIVES: Availability and usage patterns of psychoactive substances have changed worldwide. Knowledge about new trends of substance use is important for future generation of medical professionals to deliver appropriate treatment. Objective of the study was to determine the awareness and prevalence of substance use among pre- clinical phase medical students in a university in the Western Province, Sri Lanka. METHODS: A cross-sectional descriptive study was carried out using a self-administered questionnaire. RESULTS: Out of 162 students, 61.7% were female, 97.5% were between 20-25 years. 99% were aware of alcohol being a substance of abuse. 34% and 30% were not aware that heroin and cannabis were substances of abuse. Less than half of participants were aware of corex-D (44.4%), volatile substances (39.5%), and methamphetamines (32.7%). Figures for awareness about Psilocybin (9.9%), MDMA (8.6%), LSD (8%), GHB (4.3%), DXM (2.5%). Main sources of information regarding substances were peers and internet. 21% and 18 % of participants had used alcohol and betel respectively at least once while tobacco and corex-D was used among 7.4% and 6.2% respectively. 69% of substance users were male. Use of substances was significantly associated with male gender. CONCLUSION: Alarmingly majority of the participating pre-clinical phase students were not aware of the abuse potential of heroin and cannabis as well as of newer generation recreational drugs. Awareness regarding current trends and misuse potential of psychoactive substances and their consequences should be enhanced among medical students.Item Hypocalcemia and hoarseness following total thyroidectomy for benign disease: Relationship of incidence to the size of the gland(Jaypee Brothers Medical Publishers (P) Ltd, 2011) Fernando, R.; Chandrasinghe, P.C.; Bandara, M.; Renuka, M.B.S.; Athulugama, N.S.INTRODUCTION: Total thyroidectomy is considered as the standard surgical procedure for most malignancies and benign disease involving both lobes of the thyroid gland. Postoperative complications are likely to be commoner when the thyroid gland is large in size due to the alteration of structural anatomy. METHODS: Postoperative complications of 102 patients who underwent total thyroidectomy for benign disease, by the same surgeon, were analyzed. Patients were prospectively followed up and presence of hoarseness and hypocalcemia, both transient and temporary, were compared with the weight of the gland. RESULTS: Fourteen patients developed hypocalcemia of which 12 (11.7%) had transient and 2 (1.96%) had permanent deficiencies. Eight patients developed hoarseness following surgery of which seven (6.86%) had transient and only one (0.98%) had permanent hoarseness. A mean thyroid weight of 91.78 gm was observed in the uncomplicated group. Those who developed postoperative hypocalcemia and transient hoarseness had a mean thyroid weight over 100 gm. One patient, who had a thyroid weighing 195 gm developed permanent hoarseness due to RLN injury. CONCLUSION: There is no statistically significant difference in the incidence of transient RLN and transient or permanent hypocalcemia. With increased size of the thyroid gland increased rate of complications was observed with a mean thyroid weight above 100 gm. There may be a significant risk of permanent RLN injury when the thyroid gland is enlarged over 10 times (closer to 200 gm) its normal size. © Jaypee Brothers Medical Publishers (P) Ltd. AUTHOR KEYWORDS: Complications; Size of the gland; Thyroidectomy. INDEX KEYWORDS: adult; aged; article; controlled study; female; goiter; hoarseness; human; hypocalcemia; incidence; major clinical study; male; nerve injury; postoperative complication; recurrent laryngeal nerve injury; risk assessment; thyroid weight; thyroidectomyItem Use of laryngeal mask airway in total thyroidectomy in a patient with ocular myasthenia and graves’ disease(Jaypee Brothers Medical Publishers (P) Ltd, 2019) Shilpage, S.; Fernando, R.; Munasinghe, N.; Gunetilleke, B.ABSTRACT: BACKGROUND: The association between Graves’ disease (GD) and ocular myasthenia (OM) is well known. Total thyroidectomy gives a permanent “cure” for GD and the literature reports a varying progression of myasthenia gravis (MG) in such patients after surgery. The main issue in patients with MG is the difficulties with the use of muscle relaxants during anesthesia. In the ensuing case report, a patient with OM and GD who had a total thyroidectomy under general anesthesia (GA) with laryngeal mask airway (LMA) without muscle relaxants is described. CASE REPORT: A 40-year-old man was clinically and biochemically diagnosed to have GD. Subsequently, he developed bilateral ptosis which was diagnosed as OM by a neurologist. Though his OM responded to treatment, his GD was not well controlled. He was admitted, monitored, and made euthyroid by adjusting the carbimazole dose. A decision was made to undertake total thyroidectomy for GD, with total intravenous anesthesia and Proseal® LMA without muscle relaxants following a discussion with the anesthetic team. A conventional total thyroidectomy was performed using nerve encountering, parathyroid preserving, and capsular dissection technique. The patient made an uncomplicated recovery. CONCLUSION: A technique combining total intravenous anesthesia and a LMA without muscle relaxants for thyroid surgery in a patient with MG has advantages over a standard method. The use of LMA in other thyroid surgeries must be further evaluated for future use. CLINICAL SIGNIFICANCE: Coexistence of MG and GD should be in mind when treating the patients with GD. Individualize the use of muscle relaxants in GA and best to avoid whenever possible. © The Author(s). 2019.