Medicine
Permanent URI for this communityhttp://repository.kln.ac.lk/handle/123456789/12
This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
Browse
85 results
Search Results
Item Management of anaemia in pregnancy: experience from a Sri Lankan tertiary hospital unit(Wiley-Blackwell, 2015) Palihawadana, T.; Dias, T.; Motha, C.; Thulya, S.D.; Herath, R.; Wijesinghe, P.S.INTRODUCTION: Higher rates of pregnancy complications have been reported among anaemic pregnant women. Universal iron supplementation during pregnancy is recommended in countries where iron deficiency anaemia (IDA) prevalence rates are high. Sri Lanka also carries out a policy of such supplementation. The effectiveness of such programmes in different settings is variable. A retrospective analysis of the effectiveness of our current policy on prevention and treatment of anaemia was done for programme evaluation. METHODS: The North Colombo Obstetric Database (NORCOD) was used retrospectively to analyse the data between March and August 2014, at the university obstetric unit of the North Colombo Teaching Hospital, Sri Lanka. All singleton pregnancies without medical comorbidities were included in the analysis. Those who did not have haemoglobin (Hb) recording in the first trimester or in the third trimester were excluded at the data cleaning stage. An Hb level of <11 g/dL and a level of <10.5 g/dL were considered as anaemia in first and third trimesters respectively. The prevalence of anaemia at booking, and the Hb status in the third trimester were assessed. RESULTS: A total of 1340 singleton pregnancies were included in the analysis and 74 were excluded from the analysis due to incomplete data. 28.9% (n = 366) were found to be anaemic at booking while 63.9% (n = 809) were with a normal Hb and 7.1% (n = 91) were with an Hb of >13 g/dL. In the third trimester the prevalence of anaemia was 11.5% (n = 146) while 64.7% (n = 820) were with normal Hb and 23.6% (n = 300) were with an Hb of >13 g/dL. Among the anaemic women at booking, 22% (n = 81) persisted to be anaemic in the third trimester while 65% (n = 238) became normal and 12.8% (n = 47) developed a higher Hb level. Among those with a high Hb at booking only 1% became anaemic by third trimester while 40.6% persisted to have a high Hb level. CONCLUSION The prevalence of anaemia in this population was of moderate severity (>20% but <40%) as defined by the WHO. Major shortcoming in our practice is that we were unable to successfully treat nearly quarter of women who present with anaemia at booking, thus highlighting sub-optimal treatment. Furthermore, a policy of universal supplementation seems to over treat women with a high Hb at booking. Therefore, a more individualised supplementation and treatment policy should be encouraged in routine clinical practice.Item A Case report of Meningioma with uncal herniation in pregnancy(Sri Lanka College of Obstetricians & Gynaecologists, 2017) Suthakaran, V.; Perera, M.N.I.; Herath, H.M.R.P.; Dias, T.D.; Wijesinghe, P.S.INTRODUCTION: The diagnosis and management of meningioma during pregnancy is a challenge, with growth and regression both reported. The occurrence of meningioma during pregnancy is rare, comparable with that in non-pregnant woman in the same age group. We report a case of meningioma with uncal herniation leading to maternal death during pregnancy. CASE: Thirty-year-old woman was referred to our unit on her 20th weeks of gestation for severe headache and vomiting. This is her third pregnancy with two living children, both delivered by caesarean section. She had early morning headache, lasting for 1 to 2 hours which resolved following vomiting from16th week of gestation. She did not have visual impairment, photophobia or focal neurological ymptoms. She was admitted to base hospital for increased frequency and severity of headache on her 18th week of gestation. Neurological examination was normal. Her blood pressure was normal throughout this pregnancy. She defaulted herneurology appointment. She was readmitted for same symptoms and transferred to our hospital. She complained severe headache, vomiting and blurred vision on day of admission followed by difficulty in breathing. Her SPO was 84 % on air and respiratory rate was 32/minutes. Ophthalmoscopy was normal. She was intubated for impending respiratory arrest and non-contrast CT was performed. CT showed Right sided sphenoidal wing tumour suggestive of a meningioma with midline shift and uncal herniation. She developed repeated episodes of a systole before transfer to neurosurgical unit and did not recover. Postmortem findings and histology confirmed the diagnosis of meningothelial type of meningioma. DISCUSSION: Intracranial tumours in pregnant woman are serious and life threatening conditions. The clinical presentation of intracranial mass mimics the symptoms of hyperemesis gravidarum, eclampsia and puerperal psychosis. MRI of the brain is the investigation of choice for prompt diagnosis of meningioma. Surgery is the key in the management of meningioma depend on the site of tumour. The general recommendation in pregnancy is for caesarean section as first surgery followed by neurosurgical interventions. Urgent neurosurgical linterventions are indicated for patients with malignant tumours, active hydrocephalus or benign tumours with impending herniation or progressive neurological deficits.Item Cut-off Scores for International Consultation on Incontinence Modular Questionnaire on Vaginal Symptoms (ICIQ-VS) in Sinhala and Tamil(Sri Lanka College of Obstetricians & Gynaecologists, 2017) Amarasekara, A.M.A.K.G.; Ekanayake, C.D.; Pathmeswaran, A.; Wijesinghe, P.S.; Liyanage, L.L.C.; Kulasinghe, I.R.M.M.; Perera, H.S.S.INTRODUCTION: It is clinically beneficial to have cut-off scores for screening questionnaires, above which a patient can be referred for further evaluation at a specialist center especially in developing countries. OBJECTIVE: To calculate cut off scores for ICIQ-VS-Sinhala and ICIQ-VS- Tamil questionnaires. METHODS: The ICIQ-VS- Sinhala and ICIQ-VS-Tamil was administered to women attending the gynaecology clinics at North Colombo teaching hospital, Ragama, District General hospitals, Mannar and Vavuniya. The vaginal symptoms score (VSS), sexual symptoms score (SSS) and the quality of life score (QoL) were analysed against the clinician’s diagnosis of significant prolapse using receiver operating characteristic curves (ROC). Results: The AUC (area under curve) for ROC curves of VSS, SSS and QoL for ICIQ-VS-Sinhala were 0.89 (p<0.001), 0.64 (p<0.02) and 0.75 (p<0.001) respectively. The AUC for ROC curves VSS, SSS and QoL of ICIQ-VS-Tamil were 0.88 (p<0.001), 0.70 (p<0.02) and 0.82 (p<0.001) respectively. The optimal MCIDs for ICIQ-VS-Sinhala were VSS ≥≥ 8 (sensitivity 88.1%, specificity 73.9%), SSS ≥ 1 (sensitivity 59%, specificity 65%), QoL ≥ 3 (sensitivity 77.8%, specificity 60.4%) while for ICIQ-VS-Tamil VSS ≥ 9 (sensitivity 87.1%, specificity 80.9%), SSS ≥ 1 (sensitivity 76.5%, specificity 61.1%) and QoL ≥3 (sensitivity 77.8%, specificity 79.8%). CONCLUSION: Both questionnaires yielded promising cut off scores for VSS, SSS and QoL. Cut-off scores of VSS ≥9, SSS ≥1 and QoL≥3 for ICIQ-VS-Tamil and VSS ≥8, SSS ≥1 and QoL ≥3 for ICIQ-VS-Sinhala can be used as a guide for specialist referral when using ICIQ-VS to screen for pelvic floor dysfunction in Sri Lanka.Item First episode of genital herpes simplex virus infection in the third trimester of Pregnancy; diagnostic limitations and effects on mode of delivery: a case study(Sri Lanka College of Obstetricians & Gynaecologists, 2017) Pannala, W.S.; Ranatunga, J.D.; Wijesinghe, P.S.BACKGROUND: Risk of herpes simplex viral (HSV) transmission to the baby during vaginal delivery following maternal primary genital herpes in the third trimester is 41%. Caesarean section is recommended in such instances to minimize the risk of neonatal herpes.DNA-PCR is the gold standard of diagnosis of HSV infection. Crossreactivity of HSV1 and HSV2 IgM, variable IgM response in relation to time make these tests less useful. Furthermore, raised IgM may not always indicate primary infection. DNA-PCR does not differentiate primary infection from a recurrence which has lower risk of neonatal herpes (0- 3%). IgG has a lower positive predictive value in low prevalence settings. CASE: A 19-year-old primigravida at 36 weeks presented with four days’ history of dysuria, multiple painful superficial genital ulcerson both labia with painful bilateral inguinal nodes. Neither she nor her partner had genital or oral lesions before. Syphilis serology, dark ground examination and HIV antibody test were negative whereas Tzanck smear was positive. Clinical diagnosis of primary HSV infection was made and she was treated with acyclovir which was continued until five days after delivery. Two weeks later, she was positive for HSV1+HSV2 IgM antibody ELISA, and negative for type common IgG. Elective LSCS resulted in a healthy baby weighing 3.02kg. Serology four days later had a slightly higher IgG index than previous assay. CONCLUSION: High risk of neonatal herpes following primary genital herpes during third trimester, inability to differentiate primary infection from recurrence by available investigations, and practical difficulties of performing these investigations, necessitate management decisions to be based on clinical diagnosis in resource limited settings.Item Translation and Validation of ICIQ-FLUTS for Tamil speaking Women(Sri Lanka College of Obstetricians & Gynaecologists, 2017) Pieris, T.R.; Ekanayake, C.D.; Basith, F.D.A.; Wickramaratna, D.K.U.; Peries, E.E.; Antonythas, R.; Pathmeswaran, A.; Wijesinghe, P.S.OBJECTIVES: Research in to lower urinary tract symptoms in South Asia is hampered by lack of validated tools. There fore ouraimwas to validate the International Consultation onIncontinencemodular questionnaire on female lower urinary tracts ymptoms (ICIQ-FLUTS) from English toTamil. METHODS: The ICIQ-FLUTS was translated to Tamil and a validation study was carried out among women attending the gynaecology clinic at district general hospital-Mannar. RESULTS: Content validity assessed by the level of missing data was less than 2%. Construct validity was assessed by the ability of the questionnaire to identify patients with incontinence (n=45) from controls (n=93) using the incontinence score (patients=7.7 SD=4.7, controls=1.4 SD=2.2, p<0.001) andthose with symptomatic anterior wall prolapse (n=16) fromcontrols (n=93) using the voiding symptoms score (patients=4.8SD=2.3, controls=0.3 SD=0.8, p<0.001). Internal consistency was assessed using Cronbach’scoefficient alpha score (0.80 (0.77-0.81). Test–retest reliability assessed by weighted kappa (k) ranged from 0.73to0.87. Patients with incontinence (n=30, pre-treatment incontinence score=7.9, SD=4.9 versus post-treatment incontinence score=3.3, SD=3.1) and symptomatic anterior wall prolapse (n=14, pre-operative voiding symptoms score=4.9 SD=2.5 versus post-operative voiding symptoms score=0.9 SD=1.5) showed an improvement with treatment (Wilcoxon matched –pairs signedranktestp<0.001 and p<0.01 respectively). An incontinence score≥3 (sensitivity=86.7%, specificity=78.4%) and a voiding symptoms score≥3 (sensitivity=87.5%, specificity=96.2%) detected any form of incontinence and symptomatic anterior wall prolapse respectively.CONCLUSION: The Tamil translation of ICIQ-FLUTS has retained the psychometric properties of the original English questionnaire and will be an invaluable tool to elicit LUTS among Tamil speaking women.Item Cost-effectiveness of three routes of hysterectomy: a multi-centre randomized controlled trial(Sri Lanka College of Obstetricians & Gynaecologists, 2018) Ekanayake, C.D.; Pathmeswaran, A.; Kularatna, S.; Herath, R.P.; Wijesinghe, P.S.BACKGROUND: Hysterectomy is the commonest major gynaecological surgical procedure. The aim of this study was to evaluate the cost-effectiveness of non-descent vaginal hysterectomy (NDVH) and total laparoscopic hysterectomy (TLH) compared to total abdominal hysterectomy (TAH). METHODS: A randomized controlled trial was conducted at the gynaecology unit, District General Hospital, Mannar and professorial gynaecology unit, North Colombo Teaching Hospital, Ragama. Study population (n=49 per arm) were women needing hysterectomy for non-malignant uterine causes. Exclusion criteria were uterus 14 weeks, previous pelvic surgery, those requiring incontinence/pelvic floor surgery, comorbidities which preclude laparoscopic surgery and women who were illiterate. Primary outcome was the time to recover following hysterectomy which was considered as the earliest time to resume activities done prior to surgery. A Kaplan-Meier survival analysis was done with pairwise comparison through log-rank test for the primary outcome. A micro-costing approach calculated utilization of hospital resources from the time of presentation up to six months after surgery. Incremental costeffectiveness ratios (ICER) were obtained by calculating the incremental costs divided by the incremental effects (time to recover) for the intervention groups (NDVH and TLH) over the standard care (TAH) group. RESULTS: The overall combined results from both centres did not show a significant difference in time to recover (median, 95% confidence interval) between TLH [30 days (29.0-31.0)], NDVH [32 days, (28.3-35.7)] and TAH [35 days (32.0-38.0)] (Kruskal-Wallis test, p=0.373). There was a significant difference in direct cost (median, inter quartile range) between TAH [Rs.41943, (38256-44476)] versus TLH [50608 (46670-54859)], Mann-Whitney U test, p<0.001, NDVH [Rs.40373 (3693244212) versus TLH, Mann-Whitney U test, p<0.001. There was no significant difference between TAH and NDVH, Mann-Whitney U test, p=0.076. ICERTLH-TAH was Rs. 1733/ day compared to TAH. ICERNDVH-TAH was not calculated as both the cost and effect were more favourable than TAH. ICERTLH-NDVH was Rs.3412/day compared to NDVH. CONCLUSIONS: There was no significant difference in time to recover between TLH, NDVH and TAH. The optimum approach to hysterectomy appears to be NDVH in terms of costeffectiveness due to its lower cost, a fact that was suggested from the interim analysis presented at SLCOG sessions in 2017.Item Challenges of costing a surgical procedure: a case study on hysterectomy(Sri Lanka College of Obstetricians & Gynaecologists, 2018) Ranasinghe, S.W.; Liyanage, L.; Peiris, R.; Bandaranayake, H.; Ekanayake, C.D.; Pathmeswaran, A.; Kularatna, S.; Wijesinghe, P.S.INTRODUCTION: It is vital to enquire in to cost of healthcare to ensure that maximum value for money is obtained with available resources. However, there is a dearth of information on cost of healthcare in lower-middle income countries. Our aim was to study the costs for three routes of hysterectomy in benign uterine conditions; total abdominal (TAH), non-descent vaginal (NDVH) and total laparoscopic hysterectomy (TLH). METHOD: A societal perspective with a micro-costing approach was applied to find out direct and indirect costs. Patients were recruited from a district general hospital (Mannar) and an urban tertiary care hospital (Ragama). The total cost incurred during pre-operative, operative, post-operative periods and convalescence included direct costs of labour, equipment, investigations, medications and utilities. Indirect costs included of out-of-pocket expenses, productivity losses, carer costs and travelling. Time-driven activity-based costing was used for labour costs and top down micro-costing was used for utilities. RESULTS: The median direct cost [(interquartile range), number] of TAH was Rs. 43054 [(41604 - 46243), n=24] versus Rs. 39430 [(37690 - 43054), n=25] (Mann-Whitney U test, p<0.01), NDVH was Rs. 40590 [(36965 - 44793), n=23] versus Rs.40155 [(36676 - 43779), n=26] (Mann-Whitney U test, p=0.984) and TLH was Rs. 47258 [(44359 - 51897), n=24] versus Rs. 53056 [(48128 - 55811), n=25] (Mann-Whitney U test, p=0.16) at Mannar and Ragama respectively. The median indirect cost (interquartile range) of TAH was Rs. 4204 (2174 12757) versus Rs. 9857 (5219 - 17251) (Mann-Whitney U test, p<0.05), NDVH was Rs.4349 (2174 - 8263) versus Rs. 10872 (5943 - 34646) (Mann-Whitney U test, p<0.01) and TLH was Rs. 6668 (2754 - 12902) versus Rs. 7538 (4929 - 21454) (MannWhitney U test, p=0.28) at Mannar and Ragama respectively. Sensitivity analysis using the best case scenario and a minimum wage of Rs. 1500 per day till time to recovery for TAH, NDVH and TLH showed a total cost of Rs. 87557, 78715 and 79150 respectively. CONCLUSION: Time-driven activity-based costing for labour and top down micro-costing of utilities helped to overcome logistical difficulties. Indirect costs at Ragama were significantly more than that at Mannar. Sensitivity analysis adjusted for the best case scenario and minimum wage suggested that NDVH and TLH may in fact be cheaper than TAH. The costing method used in this study is a simple and reproducible way of calculating costs of a surgical procedure which will serve as a guide for clinicians and policy makers in similar settings.Item Cost-effectiveness of TLH versus NDVH versus TAH: a multi-centre randomized controlled trial.(Sri Lanka College of Obstetricians & Gynaecologists, 2018) Ekanayake, C.D.; Pathmeswaran, A.; Pieris, R.; Wijesinghe, P.S.OBJECTIVE: Hysterectomy is the commonest major gynaecological surgical procedure. There are many approaches in performing a hysterectomy which depend on clinical criteria. However certain patients are suitable to be operated through any approach. The objective of this study was to provide evidence on the optimal approach in terms of cost-effectiveness between non-descent vaginal hysterectomy (NDVH), total laparoscopic hysterectomy (TLH) and total abdominal hysterectomy (TAH). METHODS: A multi-centre three arm randomized controlled trial is being conducted at the professorial gynaecology unit, North Colombo Teaching Hospital, Ragama and gynaecology unit, District General Hospital, Mannar. Results of the Mannar arm are presented. Study population were women needing hysterectomy for non-malignant uterine causes. Exclusion criteria were uterus 14 weeks, previous pelvic surgery, those requiring incontinence/pelvic floor surgery, co-morbidities which precludes laparoscopic surgery and women who are illiterate. Primary outcome was time taken to resume all activities done prior to surgery. A micro-costing approach was adopted to calculate utilization of hospital resources from the time of presentation to the gynaecology clinic up to six months after surgery. The treatment groups were compared using a one-way analysis of variance (ANOVA) followed by Tukey's HSD for post hoc comparisons of the mean values. Incremental cost-effectiveness ratios (ICER) were obtained by calculating the incremental costs divided by the incremental effects (time to recover) for the intervention groups (NDVH and TLH) over the standard care (TAH) group. RESULTS: There was a significant difference in time to recover in TLH [28.9 days (26.2-31.2), p<0.02] and NDVH [29.8 days (26.8-32.9), p<0.05] versus TAH [35.5 days (32.0-39.0)]. There was no significant difference between TAH and NDVH [p=0.90].The direct cost of a TLH [Rs. 45371 (43770-46972)] was significantly more than TAH [Rs. 34060 (32521-35599), p<0.001] or NDVH [Rs. 33038 (29720-36356), p<0.001]. There was no significant difference between TAH and NDVH (p=0.81). The incremental costs of a TLH was significantly more than TAH [Rs.11311 (9710 to 12912), p<0.001]. The incremental cost of a NDVH was [Rs. 1022(-4340 to 2296), p=0.81) less than TAH. ICER-TLH was Rs.1714/day. As both the cost as well as the time to recover was more favourable than TAH, ICER-NDVH was not calculated. CONCLUSION: This interim analysis shows that TLH and NDVH have a faster recovery compared to TAH. However, the incremental costs for a TLH were considerably higher. The optimum approach to hysterectomy appears to be NDVH in terms of cost-effectivenessItem Case report: Giantadenomatoidtumour of uterus mimicking like large leiomyoma(Sri Lanka College of Obstetricians & Gynaecologists, 2016) Kajendran, J.; Gunarathna, S.M.S.G.; Wijesinghe, P.S.; Hewavisenthi, S.J.INTRODUCTION: Adenomatoidtumours of uterus are rare benign neoplastic disorder of the female genital tract. Even though reported incidence is around 1-2% true incidence is probably more than that as they are not usually symptomatic. Most cases are under 3 cm in diameter, but giant variants up to 15 cm in diameter are also described. Here, we describe a case of giant adenomatoid tumor of the uterus that was managed surgically. CASE HISTORY: A 24-year-old nulliparous woman presented with abdominal distension, regurgitation and early satiety of five months duration. She did not have any menstrual disorders. Abdominal examination revealed a large pelvic tumourcorresponding to 20 weeks gravid uterus. Ultrasonography revealed a large uterus with multiple fibroid. She underwent a laparotomy,a subserosal mass arising from the posterior uterine wall near the fundus and extending to the left uterine cornuwas found. It was not a welldefined mass and consistency was firm in nature. Tumour was easily enucleated and sent for histology. Uterus was repaired into two layers.Post-operative recovery was uneventful.The histology report revealed as adenomatoid tumor of the uterus. DISCUSSION: Adenomatoidtumour arises from the germinal epithelium of abdomen and thorax. It is a variant of mesothelioma. They can beassociated with fibroids and tend to mimic them clinically, making pre-operative diagnosis difficult. Macroscopically, most appear as nodular formations with ill- defined margins and can occur in ovary, mesentery, adrenal glands, and omentum. Rarely do they recur even after conservative surgery and so far no malignant transformation has been reported. Therefore, the recommended treatment is simple excision of the tumor, if possibleItem Translation and validation of generic questionnaire on lower urinary tract symptoms for females (ICIQ-FLUTS) inTamil language(Sri Lanka College of Obstetricians & Gynaecologists, 2016) Ekanayake, C.D.; Wijesinghe, P.S.; Pathmeswaran, A.; Abdul Basith, F.D.; Srikrishnan, K.; Wickramaratna, D.K.U.OBJECTIVE: Lower urinary tract symptomsare often underreported by women. Therefore, we wanted to translate and validate the International Consultation on Incontinence Modular Questionnaire on female lower urinary tract symptoms (ICIQ FLUTS) from English to Tamil language. METHODS: With permission, the ICIQ-FLUTS questionnaire was translated to Tamil using the standard procedure. A validation study was carried out among women attending the gynaecology clinicat district general hospital-Mannar. RESULTS: Basic characteristics were as follows; patients with incontinence (n=33) age 50.8 (SD 14.8),median parity=3 (IQ11Q3=2-4), BMI 25.8 kg/m2 (SD 5.2), patients with voiding symptoms (n=15) age 60.6 (SD 11.6), median parity=4(IQ11Q3=3-4), BMI 24.8 kg/m2 (SD 3.5) and controls (n=74) age 42.8 (SD 15.1), median parity=2 (IQ1-1Q3=1-3), BMI 25.4 kg/m2 (SD 4.4).Content validityassessed by the level of missing data was less than 3% for each item.For the internal consistency,Cronbach’s coefficient alpha scores ranged from 0.79-0.83. Kappa values for test–retest reliabilityin all items were 0.56 to 0.79. Construct validity was assessed by the ability of the questionnaire to identify patients with incontinence from controls (p<0.001) and those with voiding symptoms from controls (p<0.001).Patients with incontinence (n=10)and voiding symptoms (n=9)showed an improvement with treatment (Wilcoxon matched –pairs signedrank test p<0.01 and p<0.05 respectively). CONCLUSIONS: The preliminary results of the Tamil validation of the ICIQ FLUTS are satisfactory and once completed it will be invaluable to elicit female lower urinary tract symptoms in Tamil speaking patients.