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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Identification of patients with type 2 diabetes with non-alcoholic fatty liver disease who are at increased risk of progressing to advanced fibrosis: a cross-sectional study(BMJ Publishing Group Ltd, 2023) Mettananda, C.; Egodage, T.; Dantanarayana, C.; Fernando, R.; Ranaweera, L.; Luke, N.; Ranawaka, C.; Kottahachchi, D.; Pathmeswaran, A.; de Silva, H.J.; Dassanayake, A.S.INTRODUCTION: Identification of advanced hepatic fibrosis in non-alcoholic fatty liver disease (NAFLD) is important as this may progress to cirrhosis and hepatocellular carcinoma. The risk of hepatic fibrosis is especially high among patients with diabetes with NAFLD. Annual screening of patients with diabetes for fatty liver and calculation of Fibrosis-4 (FIB-4) score and exclusion of significant fibrosis with vibration-controlled transient elastography (VCTE) have been recommended. However, VCTE is expensive and may not be freely available in resource-limited settings. We aim to identify predictors of significant liver fibrosis who are at increased risk of progression to advanced liver fibrosis and to develop a prediction model to prioritise referral of patients with diabetes and NAFLD for VCTE. METHODS AND ANALYSIS: This cross-sectional study is conducted among all consenting adults with type 2 diabetes mellitus with NAFLD at the Colombo North Teaching Hospital, Ragama, Sri Lanka. All patients get the FIB-4 score calculated. Those with FIB-4 ≥1.3 undergo VCTE (with FibroScan by Echosens). Risk associations for progression to advanced liver fibrosis/cirrhosis will be identified by comparing patients with significant fibrosis (liver stiffness measure (LSM) ≥8 kPa) and without significant fibrosis (LSM <8 kPa). A model to predict significant liver fibrosis will be developed using logistic regression. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Ethics Committee of the Faculty of Medicine, University of Kelaniya (P/66/07/2021). Results of the study will be disseminated as scientific publications in reputable journals.Item Young patients with colorectal cancer have poor survival in the first twenty months after operation and predictable survival in the medium and long-term: analysis of survival and prognostic markers(BioMed Central, 2010) Chan, K.K.; Dassanayake, B.; Deen, R.; Wickramarachchi, R.E.; Kumarage, S.K.; Samita, S.; Deen, K.I.OBJECTIVES: This study compares clinico-pathological features in young (<40 years) and older patients (>50 years) with colorectal cancer, survival in the young and the influence of pre-operative clinical and histological factors on survival. MATERIALS AND METHODS: A twelve-year prospective database of colorectal cancer was analysed. Fifty-three young patients were compared with forty-seven consecutive older patients over fifty years old. An analysis of survival was undertaken in young patients using Kaplan Meier graphs, non-parametric methods, Cox's Proportional Hazard Ratios and Weibull Hazard models. RESULTS: Young patients comprised 13.4 percent of 397 with colorectal cancer. Duration of symptoms and presentation in the young was similar to older patients (median, range; young patients; 6 months, 2 weeks to 2 years, older patients; 4 months, 4 weeks to 3 years, p > 0.05). In both groups, the majority presented without bowel obstruction (young--81%, older--94%). Cancer proximal to the splenic flexure was present more in young than in older patients. Synchronous cancers were found exclusively in the young. Mucinous tumours were seen in 16% of young and 4% of older patients (p < 0.05). Ninety-four percent of young cancer deaths were within 20 months of operation. At median follow up of 50 months in the young, overall survival was 70% and disease free survival 66%. American Joint Committee on Cancer (AJCC) stage 4 and use of pre-operative chemoradiation in rectal cancer was associated with poor survival in the young. CONCLUSION: If patients, who are less than 40 years old with colorectal cancer, survive twenty months after operation, the prognosis improves and their survival becomes predictable.Item Opportunities for pharmacists to optimise quality use of medicines in a Sri Lankan hospital: An observational, prospective, cohort study(Wiley-Blackwell, 2017) Perera, D.M.P.; Coombes, J.A.; Shanika, L.G.T.; Dawson, A.; Lynch, C.; Mohamed, F.; Kalupahana, N.; de Silva, H.A.; Jayamanne, S.F.; Peters, N.B.; Myers, B.; Coombes, I.D.BACKGROUND: Quality use of medicines (QUM) has been identified as a priority in Sri Lanka. Aim: To identify opportunities to optimise QUM, and evaluate medication appropriateness and medication information exchanged with patients and carers on discharge in a Sri Lankan tertiary care hospital. METHODS: An observational, prospective, cohort study of patients systematically sampled from two medical wards. A research pharmacist determined their pre-admission medication regimen via interview at time of discharge. Issues of poor adherence and discrepancies between the pre- and post-admission medication regimens were recorded. Drug-related problems were categorised into opportunities to optimise drug therapy. The appropriateness of discharge medications was evaluated using a validated tool. The patient or carer was interviewed after discharge regarding the quality of medicine information exchanged in hospital. RESULTS: The 578 recruited patients were taking 1756 medications prior to admission, and 657 (37.4%) of these medications were not continued during admission. Opportunities to optimise drug therapy were identified on 1496 occasions during admission (median, 2.0 opportunities/patient), 215 opportunities, (14.4%) were resolved spontaneously by the medical team prior to discharge. The median score for appropriateness of medications on discharge was 1.5 per patient (interquartile range, 0.0–3.5). Of 427 patients surveyed after discharge, 52% recalled being asked about their medications on admission to hospital, 75% about previous adverse medication reactions and 39% recalled being informed about changes to their medications on discharge. CONCLUSION: Significant opportunities exist for pharmacists to enhance quality use of medicines for patients in the current hospitalbased healthcare system in Sri Lanka. © 2017 The Society of Hospital Pharmacists of Australia.Item Early identification of acute kidney injury in Russell's viper (Daboia russelii) envenoming using renal biomarkers(Public Library of Science, 2019) Ratnayake, I.; Mohamed, F.; Buckley, N.A.; Gawarammana, I.B.; Dissanayake, D.M.; Chathuranga, U.; Munasinghe, M.; Maduwage, K.; Jayamanne, S.; Endre, Z.H.; Isbister, G.K.BACKGROUND: Acute kidney injury (AKI) is a major complication of snake envenoming, but early diagnosis remains problematic. We aimed to investigate the time course of novel renal biomarkers in AKI following Russell's viper (Daboia russelii) bites. METHODOLOGY/PRINCIPAL FINDINGS: We recruited a cohort of patients with definite Russell's viper envenoming and collected serial blood and urine samples on admission (<4h post-bite), 4-8h, 8-16h, 16-24h, 1 month and 3 months post-bite. AKI stage (1-3) was defined using the Acute Kidney Injury Network criteria. AKI stages (1-3) were defined by the Acute Kidney Injury Network (AKIN) criteria. There were 65 Russell's viper envenomings and 49 developed AKI: 24 AKIN stage 1, 13 stage 2 and 12 stage 3. There was a significant correlation between venom concentrations and AKI stage (p = 0.007), and between AKI stage and six peak biomarker concentrations. Although most biomarker concentrations were elevated within 8h, no biomarker performed well in diagnosing AKI <4h post-bite. Three biomarkers were superior to serum creatinine (sCr) in predicting AKI (stage 2/3) 4-8h post-bite: serum cystatin C (sCysC) with an area under the receiver operating curve (AUC-ROC), 0.78 (95%CI:0.64-0.93), urine neutrophil gelatinase-associated lipocalin (uNGAL), 0.74 (95%CI:0.59-0.87) and urine clusterin (uClu), 0.81 (95%CI:0.69-0.93). No biomarker was better than sCr after 8h. Six other urine biomarkers urine albumin, urine beta2-microglobulin, urine kidney injury molecule-1, urine cystatin C, urine trefoil factor-3 and urine osteopontin either had minimal elevation, and/or minimal prediction for AKI stage 2/3 (AUC-ROC<0.7). CONCLUSIONS/SIGNIFICANCE: AKI was common and sometimes severe following Russell's viper bites. Three biomarkers uClu, uNGAL and sCysC, appeared to become abnormal in AKI earlier than sCr, and may be useful in early identification of envenoming.Item Association of Hantavirus infections and Leptospirosis with the occurrence of Chronic Kidney Disease of Uncertain Etiology in the North Central Province of Sri Lanka: A prospective study with patients and healthy persons(Frontiers Media SA, 2020) Sunil-Chandra, N.P.; Jayaweera, J.A.A.S.; Kumbukgolla, W.; Jayasundara, M.V.M.L.ABSTRACT: Chronic Kidney disease of uncertain etiology (CKDu) has become a significant disease burden, affecting farming community of Sri Lanka and the exact etiology, which could be multifactorial, is not hitherto established. This study is aimed to determine the association of past hantavirus infection and leptospirosis with the occurrence of CKDu. A cohort (n = 179) of known CKDu patients living in high-CKDu prevalent areas of Anuradhapura district of Sri Lanka was compared with a group of 49 healthy, sex-matched younger blood relatives of CKDu patients (control-1) and another 48 healthy, age, and sex-matched individuals living in low-CKDu prevalent area (control-2) of the same district where same life style and climate conditions prevail. Fifty out of 179 (27.9%) CKDu patients, 16/49 (32.7%) of control-1 and 7/48 (14.6%) of control-2 were found positive for IgG antibodies to Puumala, Hantaan or both strains of hantaviruses. Hantaan strain specificity was found to be predominant in all study groups. Hantavirus IgG sero-prevalence of healthy individuals living in low-CKDu prevalent area was significantly lower compared to CKDu patients and healthy younger blood relatives living in high-CKDu prevalent areas (p = 0.03). Past hantavirus infection possesses a significant risk for the occurrence of CKDu (OR = 4.5; 95% CI-3.1-5.4, p = 0.02). In contrast, IgG seroprevalence to hantaviruses was not significantly different in CKDu patients and healthy younger blood relatives living in high-CKDu prevalent areas indicating past hantavirus infection has no association with the occurrence of CKDu or possibly, younger relatives may develop CKDu in subsequent years. Seroprevalence to leptospirosis showed no significant difference between CKDu patients and healthy controls. KEYWORDS: CKDu; chronic kidney disease; hantaviruses; leptospira; sero-prevalence. Erratum in: Front Cell Infect Microbiol. 2020;10:631515Item Epidemiology of multidrug-resistant Enterobacteriaceae in Sri Lanka: First evidence of bla KPC harboring Klebsiella pneumoniae.(Elsevier., 2020) Kumudunie, W.G.M.; Wijesooriya, L.I.; Namalie, K.D.; Sunil-Chandra, N.P.; Wijayasinghe, Y.S.BACKGROUND: Extended-spectrum β-lactamase producing Enterobacteriaceae (ESBL-PE) and carbapenem-resistant Enterobacteriaceae (CRE) are disseminated worldwide posing a serious public health concern. Although, the presence of ESBL-PE and CRE in Sri Lanka has been reported, the prevalence is unknown. This study aimed to provide up-to-date epidemiological data on multidrug-resistant Enterobacteriaceae and to characterize the molecular determinants of carbapenemase-producing Enterobacteriaceae (CPE) in Sri Lanka.METHODS: A prospective cross-sectional study was conducted at a tertiary care hospital in Sri Lanka between December 2017 and February 2018. ESBL-PE and CRE were identified by disc diffusion method. Carbapenemase production was determined by carbapenem inactivation method and the presence of selected carbapenemase genes were detected by PCR. RESULTS: Five hundred and ninety-three Enterobacteriaceae were isolated from variety of clinical samples. Overall prevalence of ESBL-PE and CRE were 26.0% (n = 154) and 9.6% (n = 57), respectively. The highest rate of ESBL-PE (30.8%) was found in urine samples, while the highest occurrence of CRE (20.8%) was seen in respiratory specimens. The most common CRE species identified was K. pneumoniae (n = 46, 80.7%), followed by C. freundii (n = 4, 7.0%), E. coli (n = 3, 5.3%), P. rettgeri (n = 2, 3.5%), E. cloacae (n = 1, 1.7%), and K. aerogenes (n = 1, 1.7%). Carbapenemase production was observed in 54 (94.7%) of CRE isolates. Fifty eight carbapenemase encoding genes were identified in 54 CPE. The most prevalent carbapenemase gene was blaOXA-48-like (n = 48, 88.9%), followed by blaNDM (n = 8, 14.8%), and blaKPC (n = 2, 3.7%). CONCLUSIONS: This study reports an alarming rate of CRE and the emergence of blaKPC harboring K. pneumoniae in Sri Lanka. The need for preventive measures is highlighted to limit the spread of these difficult-to-treat bacteria in the country. KEYWORDS: Carbapenem resistance; Carbapenemase; ESBL; Enterobacteriaceae; KPC; Sri Lanka.Item Prevalence of cutaneous leishmaniasis infection and clinico-epidemiological patterns among military personnel in Mullaitivu and Kilinochchi districts of the Northern Province, early war-torn areas in Sri Lanka.(BioMed Central, 2020) Gunathilaka, N.; Semege, S.; Pathirana, N.; Manamperi, N.; Udayanga, L.; Wijesinghe, H.; Premaratne, P.; Fernando, D.BACKGROUND: The 30-year-old armed conflict in Sri Lanka resulted in a general breakdown of civil administration in the Northern and Eastern provinces, leading to mobilisation of many armed forces personnel to assist with reconstruction and resettlement. This occupational group has been identified as a priority risk group for leishmaniasis. METHODS: Individuals enlisted at all military establishments in Mullaitivu and Kilinochchi districts, Northern Province of Sri Lanka were included. Five thousand individuals were screened for skin lesions between September 2018 and August 2019. Persons with lesions suspected as cutaneous leishmaniasis (CL) were further investigated. Information on sociodemographic/other potential risk factors was obtained through an interviewer-administered structured questionnaire. The diagnosis was confirmed by microscopic visualization of parasitic stages from different samples obtained (skin scraping, lesion aspirate and tissue impression smears), histopathology and polymerase chain reaction DNA amplification. RESULTS: Among 5000 individuals screened, 74 individuals were suspected of having CL. Of these, 67.6% (n = 50) patients were confirmed for CL by microscopy. Around two third of both males (67.6%; n = 48) and females (66.6%; n = 2) were positive for Leishmania. The soldiers belonging to 26-35-year age group reported the highest susceptibility (83.3%; OR: 4.83, 95% CI: 3.49-6.20%). Of the sociodemographic factors, age, wearing short-sleeved upper body clothing as the uniform and non-use of insect repellents were identified as significant risk factors. Most of the CL patients had a single lesion (86.0%; n = 43) of an ulcerative type (34.0%; n = 17), mostly on their upper limb (67.9%; n = 34). Lesions were mostly 5-10 mm diameter (59.9%; n = 30) in size with poorly defined margins (72.0%; n = 36). Amongst the diagnostic techniques, microscopic examination of slit skin smear and tissue impression smear were able to discriminate the majority of patients (92.1%; n = 46) for CL. CONCLUSIONS: In order to highlight the true burden of leishmaniasis in the military personnel, cases of leishmaniasis from military institutes should be recognized as a different entity per say and be included in the national figures so as to depict the real magnitude of the disease burden amongst this high-risk group. KEYWORDS: Clinical; Cutaneous leishmaniasis; Epidemiological; War-torn areas.Item Emerging pesticides responsible for suicide in rural Sri Lanka following the 2008-2014 pesticide bans.(BioMed Central, 2020) Weerasinghe, M.; Pearson, M.; Konradsen, F.; Agampodi, S.; Sumith, J. A.; Jayamanne, S.; Senanayake, S. M. H. M. K.; Rajapaksha, S.; Eddleston, M.BACKGROUND: Sri Lanka has reduced its overall suicide rate by 70% over the last two decades through means restriction, through a series of government regulations and bans removing highly hazardous pesticides from agriculture. We aimed to identify the key pesticide(s) now responsible for suicides in rural Sri Lanka to provide data for further pesticide regulation. METHODS: We performed a secondary analysis of data collected prospectively during a cluster randomized controlled trial in the Anuradhapura district of Sri Lanka from 2011 to 16. The identity of pesticides responsible for suicides were sought from medical or judicial medical notes, coroners' records, and the person's family. Trend analysis was done using a regression analysis with curve estimation to identify relative importance of key pesticides. RESULTS: We identified 337 suicidal deaths. Among them, the majority 193 (57.3%) were due to ingestion of pesticides while 82 (24.3%) were due to hanging. A specific pesticide was identified in 105 (54.4%) of the pesticide suicides. Ingestion of carbosulfan or profenofos was responsible for 59 (56.2%) of the suicides with a known pesticide and 17.5% of all suicides. The increasing trend of suicides due to carbosulfan and profenofos over time was statistically significant (R square 0.846, F 16.541, p 0.027). CONCLUSIONS: Ingestion of pesticides remains the most important means of suicides in rural Sri Lanka. The pesticides that were once responsible for most pesticide suicides have now been replaced by carbosulfan and profenofos. Their regulation and replacement in agriculture with less hazardous pesticides will further reduce the incidence of both pesticide and overall suicides in rural Sri Lanka. KEYWORDS: Pesticide; Pesticide regulation; Self-poisoning; Sri Lanka; Suicide.Item Splenic Syndrome in a young man at high altitude with undetected Sickle Cell Trait(Sage, 2018) Fernando, C.H.K.A.; Mendis, S.; Upasena, A.P.; Costa, Y.J.; Williams, H.S.A.; Moratuwagama, D.INTRODUCTION: Splenic syndrome is a rare presentation of sickle cell disease. It is important to rule out this possibility when an ethnically vulnerable patient presents with an acute abdominal symptoms in a background of precipitating events. CASE REPORT: A 26-year-old man who developed a severe abdominal pain at high altitude, found to have a tender splenomegaly. However, further inquiry revealed he is from an area where sickle cell disease is prevalent. Screening for sickle cell disease was positive. Radiological investigations confirmed a massive splenic infarction keeping with a diagnosis of splenic syndrome. Patient was managed conservatively. CONCLUSION: Sickle cell trait is considered a benign carrier state. However, rarely they can present with life-threatening conditions. Therefore, a high degree of clinical suspicion is required for early diagnosis of these specific entities to avoid increased morbidity and mortality of these patients.Item Screening of cushings syndrome in patients with poorly controlled type 2 diabetes with hypertension and obesity(2018) Karuppiah, D.; Cooray, M.S.A.; Somasundaram, N.; Ediriweera, D.S.INTRODUCTION: Cushing’s syndrome (CS) may be unrecognized in patients with diabetes. There is no consensus on routine screening for CS in patients with type 2 diabetes (T2DM). Aim of the study was to evaluate the prevalence of unsuspected CS in out-patients with diabetes. METHODS: Cross sectional prospective study was conducted at diabetes clinic in National Hospital of Sri Lanka among patients with diabetes who were attending for out-patient visit from January-2016 to January- 2017. Total of 287 patients were investigated with over-night dexamethasone- suppression test (ODST) as a screening test. Patients who fail to suppress serum cortisol less than 50nmol/l were further tested by Low-dose-dexamethasone-suppression test (LDDST). A third step midnight cortisol measurement was performed in patients who were failed to suppress cortisol less than 50nmol/l on LDDST. Fourth step imaging studies with pituitary MRI, abdominal-CT or CT-scan of chest abdomen and pelvis depending on the ACTH levels were performed. RESULTS: Out of 287, 46.18% (133) patients failed to suppress cortisol to less than 50nmol/l on ODST. Among these 133, 23(11.49% of total) patients failed to suppress cortisol less than 50nmol/l on LDDST. Nine out of 23 patients had cortisol more than 140nmol/l on midnight cortisol test, confirming true CS. Further investigations with imaging revealed one with pituitary adenoma, one with adrenal adenoma and 6 had normal imaging. CONCLUSION: Considering the prevalence of definitive CS of 3.18% among poorly controlled T2DM patients with hypertension and obesity suggest that CS is not rare as previously thought. But in our Asian population with T2DM and high prevalence of co-morbidities, taking overnight dexamethasone suppression test alone as a screening test would not be a suitable test to screen CS.