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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 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 Thyroidectomy: no place for routine drainage- experience of two centres(The College of Surgeons of Sri Lanka and SAARC Surgical Care Society, 2003) Fernando, R.; Esufali, S. T.INTRODUCTION: Insertion of drains following thyroidectomy is considered a 'hallowed' practice. This practice has remained unchallenged because of fear and tradition. There is sufficient scientific evidence to show that routine drainage following thyroidectomy is not necessary. METHODS: Twosimultaneousprospective studieswere undertaken at University Surgical uriits of'Kelaniya and Peradeniya 150 patients undergoing elective thyroidectomy from 1999to 2002 were included in thestudy, The researcher in Kelaniya had NOT undertaken routine drainage for several years arid 100 consecutivepatientsundergoingthyroidectomywithout drainage were included in the study In Peradeniya 25 patients underwent thyroidectomy with drains and 25 patients underwent thyroidectomy without drains. All types of thyroidectomies were included in the study. Total- Thyroidectomy - 23 (Kelaniya) ,- 03 (Peradeniya) Subtoal - thyroidectomy - IO (Kelaniya),- 29 (Peradeniya) Thyroid- Lobectomy - 55 (Kelaniya) ,- 18 (Peradeniya) Redo- Thyroidectomies - 12 (Kelaniya) Parameters assessed: 1. Prospective complications - Wound infection, Haematoma, Hypocalcaernia and Recurrent laryngeal nerve injury 2 Re-exploration and indications RESULTS: Wound infection rate:With drains-8% Hypocalcaemia-1%(permanent) Without drains-0% (both groups) Wound Haematoma: With drains-6% Nerve injury-2% (transient) Without drains-2%(Seroma) (both groups) No patient required re-exploration for a life threatening complication in either group. CONCLUSIONS: 1. Thyroidectomy without drainage can be done safely. 2. Routine drainage in thyroidectomy is NOT indicatedItem Embryological Remnants of the Thyroid Gland and their Significance in Thyroidectomy(Jaypee Journals, 2014) Fernando, R.; Rajapaksha, A.; Ranasinghe, N.; Gunawardhana, D.Embryological Remnants of the Thyroid and Their Significance in Thyroidectomy Prof Ranil Fernando The Thyroid gland develops from the floor of the primitive pharynx & parts of the ultimobranchial body and descends into the anterior triangles of the neck. It is functional around the 7th week of gestation. There are anomalies associated with the embryological development which give rise to recognizable clinical disease in patients. The Thyroid gland may be absent, fail to descend, remnants of descent left in the neck or the thyroid gland may descend too far. All these are well recognized clinical entities. In addition, there are three (3) significant embryological components which are well recognized and need to be identified and removed during Thyroidectomy. These are the Pyramidal lobe, Tubercle of Zuckerkandl, and the Thyrothymic remnants. It is important to carefully dissect and identify these embryological remnants not only to prevent recurrence, but also because these are in close proximity to important structures such as the recurrent laryngeal Nerve and parathyroid gland and they assist the surgeon in identifying these important anatomical structure that need preservation. Recurrent goitres are mainly due to the embryological remnants left behind especially in the subtotal thyroidectomy era. These recurrences can isolated or occur in combination. Commonly recurrence from all three remnants is found. In our experience the Pyramidal lobe recurrences and tubercle of Zuckerkandl are found in about 50- 60% of the patients and the Thyrothymic remnants are found in about 30- 40 % of the patients Surgery for recurrent disease is fraught with danger and a sound knowledge of embryological remnants will enable an experienced surgeon to undertake redo thyroid surgery safely.Item Does the position of external branch of superior laryngeal nerve change with the height of the patients and the length of the larynx(Jaypee Publisher, 2012) Senanayake, K. J.; Fernando, R.; Salgado, S.; Jayanthi, M.When the external branch of superior laryngeal nerve (EBSLN) crosses the superior thyroid artery closer to thyroid upper pole, the EBSLN has a higher risk of getting damaged. Its anatomical position in relation to thyroid upper pole may vary with changing the height of patient and the length of larynx. We intended to test this hypothesis and predict the risk. Thirty cadavers of both sexes are dissected (29-87 years, mean 69). One cadaver excluded due to a goiter and five nerves were damaged during dissection. Therefore, 53 nerves were studied. The distance from upper pole of thyroid to the point where the nerve crosses the superior thyroid artery (TS) was measured. Cadaver length (CL), cricothyroid length (CT) and the cricohyoid length (CH) measured to the closest millimeter. Correlation of TS with CL, CT and CH was measured. The mean distance from the upper pole of the thyroid to the point where EBSLN crosses superior thyroid artery was 6.24 mm (SD 5.94). On right side, the mean distance was 4.03 mm (SD 5.34) and, on the left, 8.37 mm (SD 5.7 mm). The difference between two means was significant at 0.05 (t = 2.82, p = 0.007). There was a strong correlation between distance from the upper pole of the thyroid to the point where the nerve crosses the superior thyroid artery with CL (r = 0.98). There was moderate correlation with the CT and CH lengths (r = 0.55, 0.58 respectively). The position of EBSLN in relation to thyroid upper pole is strongly correlated with the height of the patient. The EBSLN crosses superior thyroid artery more closely to thyroid upper pole in right side.Item Incidental occult carcinomas in total thyroidectomy for benign diseases of the thyroid(Sri Lanka Medical Association, 2009) Fernando, R.; Mettananda, D.S.G.; Kariyakarawana, L.BACKGROUND: Total thyroidectomy is increasingly recognised as the preferred surgical option for benign diseases of the thyroid. One factor contributing towards this change in policy is reports of incidental carcinomas in the resected specimens. METHODS: This was a prospective study of patients, who underwent total thyroidectomy for benign diseases of the thyroid at the University Surgical Unit, Colombo North Teaching Hospital from January 2003 to December 2005. RESULTS: There were 68 patients (67 females) aged 28 to 67 years (mean 44.2 (SD=11.1). In 6 (8.8%) patients, histological examination of the post-operative specimen showed incidental carcinomas: 2 papillary, 2 medullary and 2 follicular carcinomas. There was no significant difference in age, clinical presentation and functional thyroid status of patients with incidental carcinomas and those with histologically confirmed benign diseases. CONCLUSIONS: Occurrence of incidental thyroid cancers was 8.8% in this series, and they were difficult to predict pre-operatively. The policy of performing total thyroidectomy for benign disease of the thyroid obviates the need for further surgery if an incidental carcinoma is found.Item Inorganic content of water and prevalence of goitre in Sri Lanka(College of Surgeons of Sri Lanka, 2009) Fernando, R.; Pathmeswaran, A.; Atulugama, N.S.; Mubarak, M.N.A; Edirisinghe, E.M.D.A.R.; Abeysinghe, A.P.S.D.; Fernanado, W.M.T.P.S.; Premathilaka, H.M.M.S.BACKGROUND: Total thyroidectomy is increasingly recognised as the preferred surgical option for benign diseases of the thyroid. One factor contributing towards this change in policy is reports of incidental carcinomas in the resected specimens. METHODS: This was a prospective study of patients, who underwent total thyroidectomy for benign diseases of the thyroid at the University Surgical Unit, Colombo North Teaching Hospital from January 2003 to December 2005. RESULTS: There were 68 patients (67 females) aged 28 to 67 years (mean 44.2 (SD=11.1). In 6 (8.8%) patients, histological examination of the post-operative specimen showed incidental carcinomas: 2 papillary, 2 medullary and 2 follicular carcinomas. There was no significant difference in age, clinical presentation and functional thyroid status of patients with incidental carcinomas and those with histologically confirmed benign diseases. CONCLUSIONS: Occurrence of incidental thyroid cancers was 8.8% in this series, and they were difficult to predict pre-operatively. The policy of performing total thyroidectomy for benign disease of the thyroid obviates the need for further surgery if an incidental carcinoma is found