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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 The recto-anal inhibitory reflex (rair): abnormal response in diabetics suggests an intrinsic neuro-enteropathy(Sri Lanka Medical Association, 1997) Deen, K.I.; Premaratna, R.; Fonseka, M.M.D.; de Silva, H.J.INTRODUCTION: The recto-anal inhihilory reflex (RAIR) is characterized by reflex relaxation of die anal canal in response to electrical stimulation of the rectaJ mucosa, and is mediated by nitrergic neural plexuses within the wall. Im-painnent of this reflex may lead lo incontinence. AIM: To measure anal canal pressures, anal mueosal electrosensation and RAIR in diabetic patients and corre¬late these measurements with incontinence for gas or faeces. METHODS: Anal canal pressure, RAIR and continence was evaluated in 30 diabetic patients [Male : Female = 13:17, median age 57 years (range 37 - 70) ], and these data were compared with similar data obtained from 22 age and sex matched 'healthy' controls [Male:Female = 9:13,age51 years (range 19-65)]. Median duration of diabetes was 8 years(rangc 3-30). 12 (40%) of Uic 30 diabetes had impaired continence for gas (n = 12) and liquid faeces (n =3). None oi'the controls had incontinence. RESULTS : Maximum resting anal canal pressure (MRP) was [median (range)]: Patients 30 mml Ig (20 -75) vs. Controls 40mmHg (20-105). P=0.61. Maximum squeeze pressure (MSP) [median (range)] : Patients 65 mmllg (30-150) vs. Controls 84mmHg (35 -230), P = 0.59. Threshold rectal mueosal elec(rosensation (RMES-T) [median(range)]: Patients 27 mA (5-40) vs. Controls 13mA (5-28), P = 0.03. Maximum tolerable rectal mueosal electrosensation [median(rangc)]: Patients 40mA (20-60) vs. Controls 20mA (10-30), P=0.042 (all comparisons using Wiicoxon rank test). RAIR was present in 8, abnormal in 5 (1 with inconti¬nence), and absent in 17 (11 with incontinence) diabetics while it was present in 18 and abnormal in 4 controls (testof proportion, P = 0.031). CONCLUSIONS: RAIR was impaired in significantly more patients with diabetes than controls implying impairment of intrinsic neuronal function. All diabetic patients with incontinence had impaired or absent RAIR. Impairment of this reflex may be a useful predictor of incontinence in diabetics.Item Estimates of disease burden due to snakebite in Sri Lankan hospitals(Sri Lanka Medical Association, 2003) Kasturiratne, A.; Pathmeswaran, A.; Fonseka, M.M.D.; Lalloo, D.G.; Brooker, S.; de Silva, H.J.INTRODUCTION: There have been no country-wide studies or estimates of disease burden due to snakebite in Sri Lankan hospitals. OBJECTIVES: To assess disease burden due to snakebite and estimate relative frequency of the biting species in hospitals situated in different parts of the country. METHODS: Hospital morbidity and mortality data on snakebite was obtained for each administrative district. Sri Lanka was divided into 5 zones based on climate and available data on snake habitat (Zone 1-wet zone altitude <900m; Z2-intermediate zone; Z3-dry zone, Z4-wet zone altitude >900m; Z5-northern and north-western dry zone). Administrative districts were allocated to zones based on their geographical location and population using geographical information systems technology. Hospital morbidity and mortality data were collated for the 5 zones. A survey among physicians (37 physicians in 42 hospitals covering the 5 zones) was used (Delphi technique) to estimate the proportion of snakebites by different species and requirement of hospital resources, in each zone. Results: There was a clear difference in incidence of hospital admissions due to snakebite in the different zones (Z3-3.5 and Z4-0.4 per 1000 population). The distribution of bites by individual species also varied between zones (deadly venomous species Z3-85%, Z2-45%), moderately venomous and mildly-venomous species Z4-100%, Zl-70%). These trends corresponded to estimates of requirements for AVS and other hospital facilities (in 2000, Z3-86100 vials of AVS, 7380 Intensive care unit patient-days; Zl-26400 vials of AVS, 2640ICU patient-days). CONCLUSIONS: Incidence of hospital admissions due to snakebite and estimates of relative medical importance of different snake species show geographic variation within the country. This is reflected in estimates of requirements for facilities. Zoning based on environmental information rather than on political boundaries could lead to better distribution of health care resources for management of snakebite in hospitals situated in different parts of the country.Item Radiological features of chronic low back pain (LBP) in adult Sri Lankans; A case control study(Sri Lanka Medical Association, 2003) Karunanayake, A.L.; Fonseka, M.M.D.; Pathmeswaran, A.; Wijayaratne, L.S.BACKGROUND: Chronic LBP affects 30% of adult Sri Lankans. The presence of vertebral osteophytes, spondylolisthesis and disc space narrowing are thought to be important contributing factors of LBP. No studies have been done in Sri Lanka, investigating the importance of these in LBP. Objective: To determine the association between chronic LBP and vertebral osteophytes, spondylolisthesis and disc space narrowing. MATERIALS AND METHODS: A case control study was done in two hospitals in Ragama. Cases and controls were selected from medical, surgical and orthopaedic wards and clinics. They were matched for age and sex. Subjects who were 18 years and above with chronic LBP (more than three months) were selected as cases. Patients who were 18 years and above without LBP were selected as controls. They had symptoms such as abdominal pain and dysuria requiring radiography. In both groups postero-anterior and lateral radiographic appearances of the lumbar spine were studied. RESULTS: There were 130 cases and 130 controls. Age range was 18 -82 years. Mean age of patients was 49.3 years (SD 15). Mean age of controls was 51.4 years (SD 17). Females constituted 62% of cases and controls. Vertebral osteophytes were present in 72% of cases and 64% of controls (P = 0.184). Spondylolisthesis was present in 8% of cases and 7% of controls (P = 0.959). Disc space narrowing was present in 15% of cases and 2% of controls (OR = 7.8, P =0.0004). CONCLUSIONS: Disc space narrowing was significantly higher in patients with LBP.Item Safety of low dose subcutaneous adrenaline used as prophylaxis against acute reactions to anti-venom serum (AVS) in patients bitten by snakes(Sri Lanka Medical Association, 2002) Dassanayake, A.S.; Karunanayake, P.; Kasturiratne, K.T.A.A.; Fonseka, M.M.D.; Wijesiriwardena, B.; Gunatilake, S.B.; de Silva, H.J.INTRODUCTION: Low dose subcutaneous adrenaline significantly reduces acute adverse reactions to AVS in patients envenomed following snake bite. OBJECTIVES: To further study the safety of low dose subcutaneous adrenaline. METHODS: We prospectively studied patients with snake bite envenoming in two units of the Colombo North Teaching Hospital, Ragama, from April 2000 to October 2001. Patients who satisfied inclusion criteria were given 0.25ml 1:1000 adrenaline subcutaneously immediately before administration of AVS. They were observed for adverse effects, and pulse and blood pressure (BP) were recorded before and at frequent intervals for one hour after giving adrenaline. In patients who developed reactions to AVS, subsequent pulse and BP measurements were not included for analysis. Results: 51 patients [M:F=35:16; mean age 34.8yrs (SD 14)] were included in the study. No significant changes in mean pulse rate or BP were observed following administration of subcutaneous adrenaline. Adverse reactions to AVS occurred in 15 (29.4%) patients. There were 4 (7.8%) other complications: one (2%) death due to suspected intracerebral haemorr-hage in a 65yr old man who also had coagulopathy, and developed an adverse reaction to AVS which required treatment with adrenaline; 3 (5.9%) patients, who also had coagulopathy, developed small haematomas at the subcutaneous injection site. CONCLUSIONS: Low dose subcutaneous adrenaline did not cause significant changes in pulse rate or BP. The 3 small haematomas could be directly attributed to the injection. Although the death is unlikely to be directly related to subcutaneous adrenaline, we suggest further studies on the safety of this prophylactic treatment before recommending its routine use.Item Post mortem findings in yellow oleander poisoning(Sri Lanka Medical Association, 2001) Seneviratne, S.L.; de Silva, C.E.; Fonseka, M.M.D.; Gunatilake, S.B.; de Silva, H.J.INTRODUCTION: Death from yellow oleander poisoning (YOP) is mainly due to cardiac toxicity caused by its effect on the conducting system leading to bradyarrhythmias. Whether other organ systems are involved in YOP is not clear. No post-mortem studies of death due to YOP have been documented. OBJECTIVE: To study post-mortem (PM) abnormalities following YOP. METHODS: Post-mortems were performed on patients with YOP who died after admission to Base Hospital, Polonnaruwa (BHP), over a 20 month period from January 1998 to August 1999. Written consent was obtained from relatives for the PM examination. RESULTS: Thirty seven PMs were performed during the study period. There were 21 males and the age range was from 13 to 70 years. Twenty three patients died within 24 hours of admission while ten and two died on the 2" and 3rd days respectively. Two patients died after 72 hours of hospital stay. Almost all subjects (35) had myocardial and pericardial haemorrhages. Congested kidneys were found in 24 (64.8%) while nine had a congested liver. Cerebral oedema was found in 16(43.2%). No abnormalities were found in the lungs and other intra- abdominal organs. CONCLUSION: Deaths occur early in fatal YOP. Myocardial and pericardial haemorrhages were seen in almost all PMs and could have resulted from cardio-pulmonary resuscitation, at least in some patients. PM abnormalities seen in kidneys and brain were probably secondary to hypoperfusion following cardiac arrhythmias. YOP does not seem to cause direct damage to organ systems other than the heart. Further work needs to be done to determine the effects of YOP on the cardiac conducting tissue.Item Scrub typhus in an urban and semi-urban population(Sri Lanka Medical Association, 2001) Hirimuthugoda, L.; Dassanayake, A.S.; Fonseka, M.M.D.; Tillakeratne, Y.; Gunatilake, S.B.; de Silva, H.J.OBJECTIVE: Though it had been suggested that scrub typhus could be occurring in Sri Lanka, there are no properly documented case series. We document our experience with 17 cases of scrub typhus. METHODS: All patients were admitted to the University Medical Unit in North Colombo Teaching Hospital over a period of 18 months. Diagnosis of scrub typhus was made in febrile patients by the presence of an eschar, raised antibody titres to Proteus OX-K in the Weil-Felix test and the dramatic response to specific treatment with tetracycline. RESULTS: All patients presented with high fever and the duration of the fever before diagnosis varied from three days to 21 days with a mean of 9 days. Headache and myalgia were common to all. Sixteen patients were from urban and semi-urban surroundings. All patients had the eschar and in most it was in the groin and axilla. Generalised or regional lymphadenopathy was present in all patients. In nine patients the Weil-Felix test showed raised titres to Proteus OX-K antigen. Sixteen patients were treated with tetracycline and one pregnant patient with chloramphenicol. All patients responded dramatically with fever settling within 24,hours. CONCLUSIONS: Scrub typhus seems to be commoner than thought and occurs even in urban areas. This condition has to be considered in the differential diagnosis of any patient with fever and especially when the fever is not settling early. Eschar is the most useful diagnostic sign that should be looked for.Item Efficacy of Liv 52 in alcoholic liver disease(Sri Lanka Medical Association, 2001) de Silva, H.A.; Thabrew, M.I.; Saparamadu, P.A.M.; Pathmeswaran, A.; Fonseka, M.M.D.; de Silva, H.J.OBJECTIVE: To assess the efficacy of Liv 52 in patients with alcoholic liver disease. METHOD: A randomized, double-blind, placebo-controlled trial was conducted at Teaching Hospital. Ragama. 80 patients with alcoholic liver disease who fulfilled inclusion criteria were randomly assigned Liv 52 (cases; n=40) or placebo (controls) three capsules twice daily for six months. All subjects underwent clinical examination, and laboratory investigations for routine blood chemistry, serum cholesterol and liver function before commencement of therapy (baseline). Thereafter, clinical assessments were done monthly, while laboratory investigations were done after 1 month and 6 months of therapy. RESULTS: There was no significant difference in the age composition, alcohol intake and baseline liver function between the two groups. The two sample t-test was used to analyze data obtained after 2,3.4,5 and 6 months of therapy against baseline values. There was no significant difference in clinical outcome and liver chemistry between the two groups at any time point. No adverse effect attributable to the drug was reported. CONCLUSION: Liv 52 does not seem to be useful in the management of patients with alcohol induced liver disease.Item Low dose subcutaneous adrenaline to prevent acute adverse reactions to antivenom serum in snake bite patients(Sri Lanka Medical Association, 1999) Premawardhena, A.P.; de Silva, C.E.; Fonseka, M.M.D.; de Silva, H.J.OBJECTIVE: To test efficacy and safety of low dose adrenaline as pretreatment for prevention of such reactions to AVS in patients with snake bite envenoming. METHODS: A prospective, randomized, double-blind, placebo .controlled trial was conducted at Base Hospital, Polonnaruwa. Patients with snake bite envenoming, who were recruited for the study, received 0.25ml of 1:1000 adrenaline (cases) or placebo (controls) subcutaneously as the only pretreatment immediately prior to full dose (10 vials) AVS infusion. Results: Of 196 patients admitted to hospital with snake bite envenoming who required AVS, 105 were recruited for the study. The other 91 had one or more exclusion criteria: treatment started in peripheral hosp'ital-72; age <12 or >70years-G; history of atopy-2, wheezing-3, hypertension -3, IHD-2; too ill to get consent-3.56 cases received adrenaline and 49 controls received placebo. The two groups were similar for age, gender, species of offending snake, degree of envenomation, proportion receiving first aid, and delay in hospital admission. Six (10.7%) cases and 21 (42.8%) controls developed acute adverse reactions to AVS, RR 0.25, Cl 0.11 - 0-57, p=0.0002. Significant reductions in acute adverse reactions to AVS were also found after grading them as mild, moderate and severe. There were no adverse effects attributable to adrenaline. CONCLUSIONS: 0.25ml of 1:1000 adrenaline injected subcutaneojjsly immediately prior to AVS infusions in patients with envenomation following snake bite significantly reduces the rate of acute adverse reactions to antivenom. The use of adrenaline in this manner is safe.Item Identifying the offending species in snakebite: a clinical score for use in community based epidemiological surveys(Sri Lanka Medical Association, 2004) Pathmeswaran, A.; Fonseka, M.M.D.; Kasturiratne, A.; Nandasena, S.; Gnanatilaka, G.K.; Gunaratne, L.; de Silva, A.P.; Lalloo, D.C.; de Silva, H.J.INTRODUCTION: Hospital data on snakebite fails to account for victims who do not reach hospital or who seek alternative treatment. In community surveys, identification of biting species is very difficult because the offending snake may sometimes not even be seen, is infrequently captured or killed, and antigen detection cannot be used in this setting. OBJECTIVE: To develop and validate a clinical score to identify biting species. METHODS: We identified 10 features relating to bites of the 6 venomous snakes in Sri Lanka (3 relating to circumstances of a bite and 7 clinical features of envenoming). Based on these, we developed a score applying different weightings to individual features depending on the species of snake. We then constructed 60 artificiaLdata sets containing different clinical scenarios, typical and atypical, for bites of a particular species. They were used to make adjustments to the score and determine cut-off values for identification (total ≥60/100 + difference of ≥5/100 from second highest score). The score was prospectively validated on 134 cases of snakebite with definite species identification, six months after the incident. RESULTS: Data were available from 25 cobra bites, 32 hump-nosed viper bites, 27 krait bites, 30 Russel's viper bites and 20 saw-scaled viper bites. Sensitivity/specificity of the score were: cobra 76/99, kraits 85/99, RV 70/99, HNV 97/83, SSV 100/83. 114 (85%) cases were correctly identified. 17 (12.7%) were misidentified, and 3 (2.3%) could not be identified. Conclusions: This score identifies the offending snake species with reasonable accuracy, and may be suitable for use in epidemiologicai surveys.Item Effect of atherosclerosis on lumbar intervertebral disc cells in a sample of Sri Lankan population: a postmortem study(Sri Lanka Medical Association, 2004) Karunanayake, A.L.; Pathmeswaran, A.; Wijayaratne, L.S.; Fonseka, M.M.D.BACKGROUND: Disc degeneration is an important cause of low backache. The cartilage cells of the disc are important to maintain the structure and function of intervertebral discs. Lumbar arteries provide blood supply to lumbar discs. OBJECTIVE: To describe the association between cell density of fourth lumbar intervertebral disc and atherosclerotic changes of fourth lumbar artery openings. METHODS: Descriptive study was done on 4th lumbar intervertebral disc and 4lh lumbar arteries of postmortem specimens. H&E sections were prepared on the annulus fibrosus of lumbar discs. Atherosclerotic changes of lumbar artery openings were studied. By using a graticule number of cells per 4mm" were counted in each disc specimen in ten low power fields and mean cell density was calculated. Cell density of less than three was categorized as low cell density. Atherosclerotic changes of lumbar arteries were graded into three groups according to severity. Grade 1 was the least severe and grade 3 was the most severe. The chi-square for trend was used to find the association between the atherosclerotic changes of lumbar arteries and the cell density. RESULTS: 31 postmortem specimens. Age range 21 - 96 years. Median age 43 years. There was a significant association (P = 0.005) between atherosclerotic changes of lumbar arteries and low cell density. OR for gradcl, grade 2 and grade 3 was I, 4.5 and 18 respectively. CONCLUSIONS: Atherosclerotic changes of lumbar arteries had a significant negative association with the cell density.