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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 impact of the National Programme to Eliminate Lymphatic Filariasis on filariasis morbidity in Sri Lanka: Comparison of current status with retrospective data following the elimination of lymphatic filariasis as a public health problem(Public Library of Science, 2024) Gunaratna, I.E.; Chandrasena, T.G.A.N.; Vallipuranathan, M.; Premaratna, R.; Ediriweera, D.; De Silva, N.R.INTRODUCTION Sri Lanka implemented the National Programme for Elimination of Lymphatic Filariasis (NPELF) in its endemic regions in 2002. Five annual rounds of mass drug administration using the two-drug combination diethylcarbamazine (DEC) and albendazole led to sustained reductions in infection rates below threshold levels. In 2016, WHO validated that Sri Lanka eliminated lymphatic filariasis as a public health problem.OBJECTIVE To explore the impact of the NPELF on lymphatic filariasis morbidity in Sri Lanka.METHODS Passive Case Detection (PCD) data maintained in filaria clinic registries from 2006-2022 for lymphoedema and hospital admission data for managing hydroceles/spermatoceles from 2007-2022 were analyzed. The morbidity status in 2022 and trends in overall and district-wise PCD rates were assessed. Poisson log-linear models were used to assess the trends in PCD for endemic regions, including district-wise trends and hospital admissions for the management of hydroceles/spermatoceles.RESULTS In 2022, there were 566 new lymphoedema case visits. The mean (SD) age was 53.9 (16.0) years. The staging was done for 94% of cases, of which 79% were in the early stages (57.3% and 21.4% in stages two and one, respectively). Western Province had the highest caseload (52%), followed by the Southern (32%) and Northwestern (16%) Provinces, respectively. The reported lymphoedema PCD rate in 2022 was 0.61 per 10,000 endemic population. The overall PCD rate showed a decline of 7.6% (95%CI: 4.9% - 10.3%) per year (P < 0.0001) from 2007 to 2022. A steady decline was observed in Colombo, Gampaha and Kurunegala districts, while Kalutara remained static and other districts showed a decline in recent years. Further, admissions for inpatient management of hydroceles/spermatoceles showed a declining trend after 2015.CONCLUSIONS The PCD rates of lymphoedema and hydroceles/spermatoceles showed a declining trend in Sri Lanka after the implementation of the NPELF.Item Detection of pathogenic Leptospira with rapid extraction followed by recombinase polymerase amplification (RPA) and quantitative polymerase chain reaction (qPCR) assay-A comprehensive study from Sri Lanka(Public Library of Science, 2024) Uduwawala, H.; Manamperi, A.; Gunaratna, G.P.S.; Karunanayake, L.; Ceruti, A.; Wahed, A.A.E.; Fernando, L.; Premaratna, R.; Hapugoda, M.Leptospirosis is the most widespread zoonosis in the world. The disease is more prevalent in tropical regions where the majority of developing countries are located. Leptospirosis is considered a protean manifestation zoonosis with severity of the disease ranging from a mild febrile illness to a severe and life-threatening illness. Clinical symptoms of leptospirosis overlap with other tropical febrile illnesses. Early, rapid, and definitive diagnosis is important for effective patient management. Since Polymerase Chain Reaction (PCR)-based assays are not readily available in most clinical settings, there is a need for an affordable, simple, and rapid diagnostic test. Quantitative PCR (qPCR) and Recombinase Polymerase Amplification (RPA) were implemented at the Faculty of Medicine, University of Kelaniya, and a prospective study to evaluate RPA for diagnosis of acute phase of leptospirosis was conducted. Results indicate that RPA and qPCR were positive in 81% (98/121) of the total positive and acute clinical samples. Of the 81 positive MAT confirmed patients 60 (74%) and 53 (65%) were positive with qPCR and RPA respectively. Retrospective evaluation revealed a high diagnostic accuracy (sensitivity-70% and specificity-87%) of RPA compared to MAT as the reference gold standard. Results further suggest that there is no significant difference between the two assays, qPCR and RPA-SwiftX (P = 0.40). Laboratory procedures for the extraction and detection by qPCR in the laboratory have been optimized to obtain results within 6 hours. However, the RPA-SwiftX method under field conditions took 35 minutes. The RPA-SwiftX method could replace the qPCR which shows similar sensitivity and specificity. Therefore, RPA established under the current study presents a powerful tool for the early and rapid diagnosis of leptospirosis at point-of-care.Item Procedural simulation in venipuncture for medical undergraduates and its transfer to the bedside: a cluster randomized study(Springer, 2024) Kodikara, K.; Seneviratne, T.; Premaratna, R.;Simulation is accepted as an effective method of learning procedural skills. However, the translational outcomes of skills acquired through simulation still warrants investigation. We designed this study to assess if skills laboratory training in addition to bedside learning (intervention group [IG]) would provide better learning results than bedside learning alone (control group [CG]) in the context of venipuncture training. This prospective, cluster-randomized, single-blind study took place at the Faculty of Medicine, University of Kelaniya, Sri Lanka. Seventeen clusters of second-year medical students were randomly assigned to either IG or CG. The IG trained on venipuncture in the skills laboratory, receiving instruction after modified Payton’s Four Step Method. Following the training, students of both IG and CG underwent bedside learning for one month. Afterward, students of both groups performed venipuncture on actual patients in a clinical setting. An independent, blinded assessor scored students’ performance using the Integrated Procedural Protocol Instrument (IPPI) and a checklist. Patients assessed students’ performance with the Communication Assessment Tool (CAT). Eight and nine clusters were randomized to the intervention and control groups, respectively. IG completed significantly more single steps of the procedure correctly (IG: 19.36 ± 3.87 for checklist items; CG: 15.57 ± 4.95; p < 0.001). IG also scored significantly better on IPPI ratings (median: IG: 27 (12) vs. CG: 21 (8); p < 0.001). Rated by patients, students’ communication skills did not significantly differ between the two groups. Simulation-based venipuncture training enabled students to perform the procedure on actual patients with a higher technical accuracy than students who learned venipuncture at the bedside. Students were able to transfer the skills acquired through venipuncture training at the skill laboratory to the bedside.Item Medical student’s experiences of training on simulated and real patients in education: A qualitative exploration(Penerbit Universiti Sains Malaysia, 2023) Kodikara, K.; Senaviratne, T.; Premaratna, R.Patient interaction is a key learning experience in undergraduate medical education. An actual or simulated/standardised patient (SP) can be used for this purpose. Although both real patients and SPs have inherent advantages and disadvantages, the value of SPs, as opposed to real patients, is recognised as an important area warranting research. The objective of this study was to explore the students’ perception of using real patients and SPs in their education. Six focus group interviews were conducted using medical undergraduates in the third, fourth, and fifth (final) year batches of the Faculty of Medicine, University of Kelaniya, Sri Lanka, from July to October 2020. The interviews were thematically analysed. All the participants considered real patient encounters more authentic than SP encounters. The students identified many strengths of SP interactions. SP encounters enabled them to prepare for real patient encounters. In particular, the participants appreciated the opportunity to practice communication skills with SPs. Students valued the feedback provided by SPs. The students identified real patient encounters enabled learning physical examination skills and procedural skills. Interestingly, most identified real patient encounters as more instructive, and some students identified that “the nervousness and anxiety” associated with real patient encounters helps improve selfconfidence. Students identified specific strengths and weaknesses in both real patient encounters and SP encounters. Participants appreciated SP encounters explicitly for learning communication skills and preparing for real patient encounters. Real patient encounters were valued for learning and improving clinical skills. The findings of the study support harnessing these specific strengths of each encounter and, thus, incorporating both in undergraduate medical education.Item Pre-clerkship procedural training in venipuncture: a prospective cohort study on skills acquisition and durability(BioMed Central, 2023) Kodikara, K.; Seneviratne, T.; Premaratna, R.BACKGROUND: The effectiveness of simulation-based training for skill acquisition is widely recognized. However, the impact of simulation-based procedural training (SBPT) on pre-clerkship medical students and the retention of procedural skills learned through this modality are rarely investigated. METHODS: A prospective cohort study was conducted among pre-clerkship medical students. Learners underwent SBPT in venipuncture in the skills laboratory. Assessments were conducted at two main points: 1) immediate assessment following the training and 2) delayed assessment one year after training. Learner self-assessments, independent assessor assessments for procedural competency, and communication skills assessments were conducted in both instances. The students were assessed for their competency in performing venipuncture by an independent assessor immediately following the training in the simulated setting and one-year post-training in the clinical setting, using the Integrated Procedural Protocol Instrument (IPPI). The student's communication skills were assessed by standardized patients (SP) and actual patients in the simulated and clinical settings, respectively, using the Communication Assessment Tool (CAT). RESULTS: Fifty-five pre-clerkship medical students were recruited for the study. A significant increase was observed in self-confidence [mean: 2.89 SD (Standard Deviation) (0.69)] and self-perceived competency [mean: 2.42 SD (0.57)] in performing venipuncture, which further improved at the delayed assessment conducted in the clinical setting (p < 0.001). Similarly, the IPPI ratings showed an improvement [immediate assessment: mean: 2.25 SD (1.62); delayed assessment: mean: 2.78 SD (0.53); p < 0.01] in venipuncture skills when assessed by an independent assessor blinded to the study design. A significant difference (p < 0.01) was also observed in doctor-patient communication when evaluated by SPs [mean: 2.49 SD (0.57)] and patients [mean: 3.76 SD (0.74)]. CONCLUSION: Simulation-based venipuncture training enabled students to perform the procedure with confidence and technical accuracy. Improved rating scores received at a one-year interval denote the impact of clinical training on skills acquisition. The durability of skills learned via SBPT needs to be further investigated.Item Challenges in learning procedural skills: Student perspectives and lessons learned for curricular design(Routledge, 2024) Kodikara, K.; Seneviratne, T.; Godamunne, P.; Premaratna, R.PHENOMENON: Developing foundational clinical procedural skills is essential to becoming a competent physician. Prior work has shown that medical students and interns lack confidence and competence in these skills. Thus, understanding the student's perspective on why these skills are more difficult to acquire is vital for developing and reforming medical curricula. APPROACH: This study explored procedural skills learning experiences of medical students with qualitative methods. Through purposive sampling, 52 medical students from the third, fourth, and final years were selected for inclusion. Data were collected using six audio-recorded, semi-structured focus group discussions. Transcripts were manually coded and analyzed using inductive content analysis. FINDINGS: Students provided rich and insightful perspectives regarding their experiences in learning procedural skills that fell into three broad categories: 1) barriers to procedural learning, 2) reasons for learning, and 3) suggestions for better learning outcomes. Students described a range of barriers that stemmed from both patient and clinician interactions. Students were reluctant to make demands for their own benefit during clerkships. The most commonly expressed reason for wanting to learn procedural skills was the desire to be a competent and independent intern. The motivators suggested that students felt empathetic toward interns and visualized a successful internship as a learning goal. Participants suggested peer learning, improved teaching of procedural skills, assessments, and feedback to improve their learning. INSIGHTS: This study generated valuable information to promote critical reflection on the existing curriculum and pedagogical approaches to procedural skills development. Medical educators need to sensitize the clinical teachers to student perspectives and what students are really learning to make impactful changes to teaching and learning procedural skills. Students' self-advocacy skills and self-directed learning skills need to be developed for them to seek out learning opportunities and to promote life-long learning. Lessons from this study may also apply to curriculum design in general, especially in teaching clinical skills. Empowering the learner and embracing a learner-centered approach to teaching and learning procedural skills will benefit future clinicians and their patients.Item Tender cervical lymphadenitis as a herald of multi-system inflammatory syndrome in COVID-19 infection of children and adolescents: a report of two cases(BioMed Central, London, 2022) Wanninayake, L.; de Abrew, G.; Logeshwaran, D.; Weerasinghe, C.; Gowinna, P.; Mettananda, S.; Premaratna, R.Background: Post-COVID-19 multisystem inflammatory syndrome (MIS) has been increasingly recognized but fever with isolated tender cervical lymphadenitis as the initial presentation has been rarely reported. We present 2 female patients one a child and the other an adolescent. Case presentation: Case 1 was a 13-year-old girl who presented with tender cervical lymphadenopathy and fever 3-weeks post-COVID-19, and then developed features of MIS 5 days later. Case 2, also female, was 18 years old. She had no history of COVID-19 infection or immunization but had a serologic diagnosis of COVID-19. She similarly presented with fever and tender cervical lymphadenopathy, and then progressed rapidly to develop features of MIS. Both patients responded well to treatment with immunosuppressants and intravenous immunoglobulin. Conclusion: Tender cervical lymphadenopathy could be the herald of multi-system inflammatory syndrome following COVID-19 infection among children and adolescents, which the clinicians must have a good suspicion about.Item Transient cerebral salt wasting following scrub typhus infection.(The Sri Lanka Medical Association, 2022) Francis, K.R; Premaratna, R.Cerebral salt wasting (hyponatraemia associated with renal sodium loss and hypovolumia) has been reported secondary to intra-cerebral pathology and following certain infections. Cerebral salt wasting following typhus infection has been reported rarely. We report a case of transient cerebral salt wasting that occurred during the convalescent phase of scrub typhus infection resulting in severe symptomatic hyponatraemia.Item Public knowledge, practices and perceptions on typhus fevers in Southern Sri Lanka(Wolters Kluwer Medknow Publications, 2022) Liyanage, A.; Chandrasena, N.; Gunathilaka, N.; Sanjeewa, R.; Premaratna, R.Objective: To assess public knowledge, practices and perceptions on typhus fevers in Sri Lanka. Methods: A descriptive study was done in four selected typhus- prone areas in Southern Sri Lanka. A mixed-method was employed using face-to-face interviews and questionnaire-based surveys among confirmed cases of typhus and at-risk populations, respectively. Frequencies, percentages, and means were used to characterize socio-demography and evaluate disease awareness. Results: The lay terms for typhus fevers reported in the studied region were “peacock fever”, “tick fever” and “bird fever”. A total of 499 subjects participated [mean±SD, (45±16) years] in the questionnaire-based survey, and 13.6% (n=68) reported past experience of typhus fever, 1.2% (n=6) identified the disease as “typhus” while 58.7% (n=293) and 11.8% (n=59) knew it as ‘peacock fever’ and ‘tick fever’, respectively. The etiological agent was unknown to 95.2% (n=475), but 53.5% ((n=267) were aware that it was vector-borne. Fever (57.3%, n=286), eschar (35.7%, n=178), headache (22.0%, n=267) and myalgia (19.2%, n=96) were identified as key symptoms. Past disease experience was significantly associated with higher awareness of the main disease symptoms (fever: χ2=15.713, P<0.001; headache: χ2=19.447, P<0.001; lymphadenopathy: Fisher’s exact test, P=0.023; eschar: χ2=12.049, P<0.001). None knew of any disease prevention methods. Participants with a past history of typhus fever had sought treatment at state hospitals (55.9%, 38/68) and private sector hospitals (5.9%, 4/68). Conclusions: Public awareness on preventive practices for typhus fevers was rare among the participants though vector-borne aspect was known to many. Clinical disease awareness was deficient among those without past experience of typhus fever. Community sensitization on vector avoidance strategies is highly recommended.Item Molecular characterization of rickettsial agents in ticks (Acari: Ixodidae) from Sri Lanka(Baltimore., 2022) Dasch, G.A.; Eremeeva, M.E.; Zambrano, M.L.; Premaratna, R.; Kularatne, S.A.M.; Rajapakse, R.P.V.J.Because the majority of spotted fever group rickettsiae are transmitted to humans by tick bites, it is important to understand which ticks might play a role in transmission of rickettsial pathogens in Sri Lanka. The purpose of our study was to conduct molecular surveillance of 847 ticks collected in different locations in central Sri Lanka to determine which were infected with Rickettsia and Anaplasmataceae. Molecular methods were used to identify the ticks and the agents detected. Most ticks (Amblyomma, Haemaphysalis, and Rhipicephalus) were collected by flagging, and lower number was collected from dogs, cattle, pigs, a pangolin, and tortoises. Five spotted fever genotypes were identified: a Rickettsia africae-like agent in Amblyomma larvae, Rhipicephalus massiliae and a related genotype identified in association with the tropical type of Rhipicephalus sanguineus from dogs and Rhipicephalus haemaphysaloides from dogs and cattle, and Candidatus R. kellyi and another novel genotype (SL94) in R. haemaphysaloides. Twenty-three ticks were positive for Anaplasmataceae, including one Anaplasma and two Ehrlichia genotypes. Because the sequence database for both ticks and rickettsial agents from Sri Lanka and southern India is not extensive, additional molecular characterization of the tick species of Sri Lanka and their rickettsial agents is required to understand their pathogenic potential more completely. However, several of the agents we identified in this survey may well be pathogenic for humans and domestic animals, and should be considered as a part of epidemiological surveillance and patient management.