Conference Papers
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This collection contains abstracts of conference papers, presented at local and international conferences by the staff of the Faculty of Medicine
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Item 6379 Pre-admission management of children presenting with febrile illness in a tertiary hospital of Sri Lanka(BMJ, 2024) Arunath, V.; Mettananda, S.OBJECTIVES To describe the symptoms and pre-admission management of children presenting with febrile illness to the Colombo North Teaching Hospital, Ragama, Sri Lanka.METHODS A retrospective descriptive study was conducted at University Paediatric Unit of Colombo North Teaching Hospital, Ragama, Sri Lanka. Data on pre-admission management of all children admitted with febrile illness from July to December 2019 were extracted from patient records. Children who were transferred from other units, children with chronic illnesses and children developed fever following vaccinations were excluded. Ethical approval was obtained from Ethics Review Committee of Sri Lanka College of Paediatricians and data was analysed using SPSS version 22.RESULTS A total of 366 children were admitted; 56% were males. Mean age was 53.5 ± 41.7 months and the majority were from Gampaha district. Mean duration of illness on admission was 3.6 ± 2.5 days. 236 (65.6%) patients had recorded fever spikes at home while 150 (60.7%) reported a contact history of fever. Common associated symptoms were cough (62.3%), cold (56%) and vomiting (39.6%). 199 (54.5%) underwent investigations prior to admission and full blood count was the commonest (47.5%) investigation. Although 357 (97.8%) had taken medication prior to admission, only 87.3% had consulted a doctor. 356 (97.3%) received paracetamol at home of which 24 (7.9%) and 123 (40.6%) received sub-therapeutic and supra-therapeutic doses respectively. Significantly higher proportion (44.9%) of children who consulted a doctor received appropriate dose of paracetamol compared to others (3.7%), (c2=11.9, p=0.003, p<001). Higher proportion children who had recorded fever spikes consulted a doctor (c2=3.99, p=0.046, p<0.05) and received therapeutic doses of paracetamol prior to admission (c2=4.94, p=0.026, p<0.05).CONCLUSION Use of sub- and supra-therapeutic doses of paracetamol was common before admission to the hospital. Recording temperature at home and medical consultation prior to admission were associated with appropriate dose paracetamol usage (p<005).Item 6542 Clinical profiles of children less than 5 years presenting with or high risk of cerebral palsy in the Western Province of Sri Lanka(BMJ, 2024) Sumanasena, S.; Heiyanthuduwage, T.M.; Fernando, R.; Sheedy, H.S.; Jagoda, J.; Wijesekara, S.; Wanigasinghe, J.; Muttiah, N.; Rathnayake, P.; Kitnasamy, G.; Khandaker, G.OBJECTIVES Cerebral palsy (CP) is the commonest physical disability in children globally.1 It is a clinical diagnosis based on clinical and neurological findings. International clinical practice guidelines recommend early diagnosis and CP specific interventions to invest in neural plasticity and achieve optimal functional levels.2 In the past diagnosis was confirmed at 12–24 months but now it is advanced to confirm or identify as high risk for CP before the age of six months.3 4 Sri Lanka is one of the few Asian countries that initiated a CP register and National Guidelines on management of CP.5 The objective of this paper is to describe the clinical profiles of children less than 5 years presenting to Western Province hospitals in Sri Lanka based on the data from the Sri Lanka Cerebral Palsy Register (SLCPR).METHODS A cross sectional hospital-based study was conducted in the Western Province from September 2018 – October 2021 in three teaching hospitals to collect a minimum data set for the Sri Lanka SLCPR. Data of children less than 60 months was extracted with a confirmed clinical diagnosis of CP or identified formally as ‘high risk’ of CP.Information on sociodemographic, pre/peri/neonatal, and post neonatal risk factors, and associated impairments were collected using hospital records and clinic notes. Clinical motor type, topography, and associated impairments were evaluated.RESULTS Data of 431 children were extracted, 254 (58.9%) were males. Mean age at diagnosis was 28.73 months (median 27, SD 14.98). Most children (n= 422, 97.9%) acquired CP in the pre/peri/neonatal period. The mean birth weight was 2304.4 g (median 37, SD 825.58g) and the mean POA was 35.82 months (median 37, SD 4.88). Main risk factors identified were prematurity (n=190, 44.1%), hypoxic ischaemic encephalopathy (HIE) (n= 234, 54.3%), jaundice (n=31, 7.2%) and sepsis (n= 13, 3.0%). While 183 children (42.5%) showed evidence of definitive spastic motor type, 184 (42.7%) showed predominant dyskinesia.CONCLUSION The age at diagnosis of this population from Sri Lanka is significantly lower than from other LMICs. HIE and prematurity, both preventable conditions remain the highest risk factors. Longitudinal follow up will ascertain the final motor outcomes as a higher proportion of children showed dyskinesia. The SLCPR is an important resource which will support new research towards investigating opportunities for prevention and service planning for children.Item 6460 Children’s perception of the health effects of climate change – a mixed-method study in urban Sri Lanka(BMJ, 2024) Dayasiri, K.; Anand, G.OBJECTIVES While children bear the least responsibility for global climate change, they suffer the most from its consequences, including a higher incidence of non-communicable diseases and exposure to natural disasters. The United Nations has emphasised that failing to act on climate change infringes upon children’s rights to live in a secure environment. Our study focuses on examining the perspectives of Sri Lankan adolescents on climate change, its effects, and their roles in addressing this issue.METHODS This mixed-method cross-sectional study involved 104 adolescents attending schools in Colombo, Sri Lanka. We randomly selected participants from both governmental and private schools and invited them to complete a self-administered questionnaire. The questionnaire covered their perceptions of climate change, their contributions to addressing climate change, and their views on the regional and global implications of climate change. Qualitative data analysis was conducted using a second-order descriptive analysis of themes.RESULTS 104 adolescents participated in the study and 75.8% were female children. Median age =17 years (range 13–19 years). Majority (93.1%) expressed concern about the potential future health impacts of climate change. While most adolescents correctly understood the concept of climate change, some revealed misconceptions about it. The major health impacts associated with climate change, as reported by the participants, included asthma, the rise of non-communicable diseases, skin conditions, cancer, and increased stress. Notably, 25% of the participants felt that they had not received education on climate change. Nearly 60% reported feeling anxious over the issue of climate change. Regarding their contributions to addressing climate change, 29.8% of the children admitted that they had not taken sufficient actions. However, those who had acted mentioned activities such as tree planting, increased use of public transportation, and educating others about climate change. Almost half of the cohort were unaware of useful resources for learning about climate change. A significant 76% of the adolescents believed that adults were not actively taking measures to address climate change.CONCLUSION This study showed that children are evidently anxious over the issue of climate change. There is an urgent need for improved awareness of information sources among children through public health measures. It is essential for adults including those in the medical profession to serve as role models in educating and guiding children on how to make a positive impact on global climate change.Item OP59 Ultra-processed food consumption in South Asia: quantification of regional variation in intakes and the assessment of their sociodemographic correlates. Findings from the South Asia Biobank in four South Asian countrie(BMJ, 2024) Bhagtani, D.; Adams, J.; Imamura, F.; Lahiri, A.; Irfan, K.; Jha, V.; Kasturiratne, A.; Katulanda, P.; Mridha, M.; Anjana, R.M.BACKGROUND Escalation of ultra-processed foods (UPFs) sales has been recorded in low-to-middle-income countries, including in South Asia. However, individual consumption levels and sociodemographic characteristics influencing UPF consumption remain largely unknown in South Asia. We aimed to quantify UPF consumption and investigate its sociodemographic correlates in South Asia.METHODS We analysed data from 60,714 participants in the South Asia Biobank that recruited adults in Bangladesh, Pakistan, Sri Lanka, North India, and South India. Dietary assessment was conducted using interviewer-led 24h dietary recalls with a South Asia-specific digital tool. Foods were classified by the degree of industrial processing using the NOVA classification. Adjusted two-part multivariable regression models examined associations between sociodemographic factors and any UPF consumption and quantity of UPF consumption in consumers.RESULTS In Bangladesh, Sri Lanka and North India, approximately 75% of the participants reported consuming any UPFs in the previous 24h while in South India and Pakistan this was 40%. Median contribution of UPFs to total energy among UPF consumers ranged between 17% in Pakistan, 15% in North India, and 13% in Bangladesh, Sri Lanka, and South India. Biscuits were a common source of UPF across all regions. Other commonly consumed UPFs among consumers included sweetened beverages in Pakistan, packaged salty snacks in South India, and breakfast cereals in Bangladesh. Diverse associations between sociodemographic factors and any UPF consumption were seen across regions. Younger age was associated with any UPF consumption in Pakistan and Sri Lanka whereas in Bangladesh and North India, older age was. In all regions except Bangladesh, female sex was associated with any UPF consumption. Higher education was associated with UPF consumption in Bangladesh (odds ratio 2.01; 95% confidence interval 1.71 to 2.35), Pakistan (1.69; 1.55 to 1.85), and North India (1.40; 1.13 to 1.73). Paid employment was not associated with UPF consumption in any region. Among UPF consumers, in all regions, UPF consumption was lower in married or cohabitating than in single people. In Bangladesh and Sri Lanka UPF consumption was higher in rural residents, while in Pakistan, consumption was higher in urban participants.CONCLUSION Younger age, female sex, higher education, employment, and income exhibited associations with UPF, but this varied across South Asia. This heterogeneity should be considered when developing regionally specific interventions to support dietary public health. Our findings of regional consumption of specific UPFs, such as biscuits, breakfast cereals, sweetened beverages, and salty snacks, provide valuable insights for targeted interventions.Item 6503 Using anthropometric data to investigate the nutritional status of children included on the Sri Lankan cerebral palsy register.(BMJ Publishing Group Ltd, 2024) Sumanasena, S.; Fernando, R.; Kurukulaarachchi, S.; Heiyanthuduwage, T.M.; Sheedy, H.S.; Wijesekara, S.; Jagoda, J.; Muttiah, N.OBJECTIVES The nutritional data from children with cerebral palsy (CP) in low and middle income countries (LMIC) is sparse. In high income countries (HICs) well established nutritional care plans, commercial products and good psycho-social support are available.1 A multitude of complications arise due to malnutrition leading to poor quality of life.2 Here we investigated the nutritional status of children included in the Sri Lankan Cerebral Palsy Register (SLCPR).METHODS The study included 768 children aged 0–18 years with CP, attending three teaching hospitals in the Western Province, from September 2018 to November 2021. Data included clinical profile and anthropometry [weight (Kg), height (cm), BMI, mid upper arm circumference (MUAC) (cm), and OFC (cm)] based on WHO. Average was calculated using three repeated measurements. Children who could not stand independently (GMFCS level 4/5) underwent height estimations with the knee height equation: height = (2.69 X Knee height) + 24.2.Indicators used to measure the nutritional status were: weight for age Z score (WAZ), height for age Z score (HAZ), weight for height Z score (WHZ), BMI for age Z score (BAZ), and MUAC for age Z score (MUACZ). WHO Anthro and WHO AnthroPlus software calculated all Z scores.4 HAZ and BAZ were calculated for children aged <18 years, WAZ was calculated for children aged <10.1 years, and WHZ and MUACZ were calculated for children aged <5.1 years. The z scores < -2.0 SD were categorized as underweight (WAZ), stunted (HAZ), wasted (WHZ or MUAC), thin (BAZ).RESULTS Total of 768 children (mean age 59.6 months, SD 44.9, 62.5% males) participated. There were (n=431) children under 61 months and (n=520) from 0–10 years. Of them, 51.3% (n = 267/520) were underweight, 59.8% (n = 258/431) were stunted and 27.3% (n = 210/768) were thin. Among children aged < 5 years, 26.7% (n = 115/431) had severe wasting and severe acute malnutrition (SAM) according to MUACZ < -3SD. Both underweight and stunting were significantly higher among children with spastic CP compared with others (p<0.05). In the 5–19 year group 16.9% (n= 57/337) were obese (BAZ > + 2SD).CONCLUSION Predominant stunting and underweight in this population calls for urgent action to minimize chronic malnutrition. It is imperative to further explore nutritional intake and feeding difficulties in this group and offer structured nutritional care plans. The trend observed in older children towards obesity possibly indicates the need for coordinated nutrition and exercise programmes. It is recommended to regularly monitor growth and nutritional status of all children with CP as there may be serious implications for their activity levels.Item Hypertension,hyperkalaemia and metabolic acidosis and low serum renin activity: a case report on psuedohypoaldosteronism type 2 in a six-year-old child(College of Chemical Pathologists of Sri Lanka, 2024) Fernando, K.; Lankapriya, K.R.; Kumarasiri, I.M.; Wijesuriya, H.T.S.K.; Seneviratne, S.N.INTRODUCTION Pseudohypoaldosteronism type 2 (PHA II), also known as Gordon syndrome or familial hyperkalaemia and hypertension syndrome, is a rare cause of monogenic low renin hypertension.Its clinical profile commonly includes hyperkalaemia, metabolic acidosis, diminished serum renin and normal aldosterone levels. It typically follows an autosomal dominant inheritance pattern, involving mutations in WNK1, WNK4, KLHL3, and CUL3 genes. Timely detection and management are crucial as these children are prone to complications arising from hypertension and hyperkalaemia.Here, we present a case where biochemical investigations played a pivotal role in arriving at the final diagnosis of PHAII.CASE PRESENTATION Apparently well 6 years and 2 months old girl presented with bilateral frontal headache persisting for three months. Upon examination, her blood pressure consistently exceeded the 99th percentile for age. Laboratory investigations revealed hyperkalaemia, mild hyperchloridemia and low-normal calcium level and metabolic acidosis, in the background of normal renal functions which raised suspicion on PHA II. Her plasma aldosterone concentration was markedly low, while plasma direct renin concentration fell within the low-normal range.Observation of low plasma renin activity provided further evidence of PHA II.Treatment with age-appropriate doses of thiazide diuretics was given in combination with prazosin.The normalization of blood pressure and serum potassium levels following treatment further supported the diagnosis.DISCUSSION AND CONCLUSIONS Patients with PHA II typically exhibit hyperkalaemia and metabolic acidosis (resembling renal tubular acidosis type IV), in the background of normal renal functions.Further they may present with mild hyperchloremia and hypocalcaemia, as observed in our case.In settings where genetic testing resources are limited, the combination of hyperkalaemia, metabolic acidosis, and low serum renin activity serves as a reliable diagnostic hallmark for PHA II.Item Impact of acalypha indica (Kuppamenia) phytochemicals on glucose-6-phosphate dehydrogenase deficiency: two clinical case studies(College of Chemical Pathologists of Sri Lanka, 2024) Fernando, K.; Fernando, N.; Dayanath, B.K.T.P.; Williams, S.; Premawardhena, A.INTRODUCTION Acalypha indica, known as “kuppamenia” in Sinhala, plays a significant role in ayurvedic medicine in Sri Lanka. Despite its medicinal use, certain phytochemicals within the plant have been linked to oxidative stress-induced haemolysis in individuals deficient in glucose-6-phosphate dehydrogenase (G6PD) enzyme activity. However, we know very little regarding those chemicals due to a dearth of literature. Here, we present two cases highlighting the impact of Acalypha indica ingestion on individuals with G6PD deficiency.CASE PRESENTATION Case 1: A 65-year-old man presented with jaundice, pallor, and haematuria after consuming “Kuppamenia mallum”. His peripheral blood picture showed bite cells and Heinz bodies. Positive Brewer’s test raised the clinical suspicion of G6PD deficiency. He received blood transfusions during the acute phase and was discharged upon improvement of symptoms. Low levels of G6PD enzyme at the follow-up visit confirmed the diagnosis. Case 2: A 61-year-old male presented with respiratory distress, jaundice and haematuria, accompanied by peripheral cyanosis and hypotension. He was admitted following four days of continuous ingestion of Acalypha indica. Peripheral oxygen saturation was low, and Heinz bodies were evident in the peripheral blood film. Blotting paper methaemoglobinaemia assessment revealed a level of 70%. Despite optimal medical management, he succumbed to a cardiac arrest on the fourth day of admission.DISCUSSION AND CONCLUSIONS Despite its antioxidant properties, Acalypha indica can precipitate acute haemolysis in G6PD-deficient individuals. Symptomatology and outcomes vary with the amount ingested, underscoring the necessity for research into identifying potentially toxic phytochemicals and their concentrations.Item Evaluation of point-of-care testing (poct) devices for cardiac troponin i in screening patients with myocardial infarction(College of Chemical Pathologists of Sri Lanka, 2024) Fernando, K.; Jayasekara, D.; Kulasinghe, M.; Silva, P.; Harshanee, K.G.A.T.; Bandara, S.R.R.; Dayanath, B.K.T.P.INTRODUCTION AND OBJECTIVES Cardiac troponin I (cTnI) is a crucial biomarker for diagnosing myocardial infarction (MI). However, many remote hospitals lack access to cTnI assessment facilities. This study investigates the feasibility of using Point-of Care Testing (POCT) devices to triage MI patients in such settings, facilitating their transfer to tertiary care hospitals. Assessing the quality of POCT devices is essential for this purpose. This report outlines the assessment methodology of two POCT devices and presents the obtained results.METHODS Two POCT devices, labelled X and Y, for measuring cTnI were compared against the Ortho-Vitros 3600, serving as the reference method, with optimum internal and external quality control measures. Basic specifications of the POCT devices and the comparator were obtained from their respective kit inserts. Routine patient samples were analyzed in singlicate using POCT devices and the reference method. Linear regression analysis was conducted, and correlation graphs were generated. Within-run precision was evaluated using a patient sample and imprecision (CV) was calculated for the POCT devices.RESULTS The linearity ranges for cTnI measurement with POCT devices X and Y were 0.01–15 ng/mL and 0.03–30 ng/ mL, respectively, with decision-making cutoff values for diagnosing MI established at 0.04 ng/mL and 0.5 ng/ mL, respectively. Regression analysis demonstrated acceptable linearity for both POCT devices, with correlation of R2=0.7388 for device X and R2=0.8881 for device Y. However, higher imprecision was observed for both analyzers, with a CV of 26% for device X and 20% for device Y at decision-making cutoff levels.CONCLUSIONS This study highlights major challenges associated with the implementing POCT devices for cTnI assays in triage settings aimed at diagnosing MI in acute care. Specifically, the adoption of higher cutoff levels in the POCT devices, not aligned with the recommended 99th percentile for the healthy population, and the poor precision observed at these cutoff values emerge as significant hurdles.Item Comparative analysis of alkaline phosphatase with two assays using different buffers; diethanolamine (dea) and 2-amino-2-methyl-1-propanol (amp): establishing correlation factors for diagnostic consistency(College of Chemical Pathologists of Sri Lanka, 2024) Jayasekara, D.; Fernando, K.; Kulasinghe, M.; Silva, P.; Madurangi, D.W.D.D.; De Silva, D.D.S.; Harshanee, K.G.A.T.; Bandara, S.R.R.; Dayanath, B.K.T.P.INTRODUCTION AND OBJECTIVES Alkaline phosphatase (ALP) serves as a pivotal biomarker for bone and liver diseases, employing assays utilizing either 2-amino-2-methyl-1-propanol (AMP) (IFCC recommended) or diethanolamine (DEA) buffers, with the latter consistently yielding higher values. This study aimed to develop a correlation factor for ALP reagents using DEA buffer from supplier X, in comparison to routine automated ALP assay at the central laboratory using AMP.METHODS Twenty-five serum samples were analyzed in the central laboratory assay using AMP buffer in a fully automated analyzer with dedicated reagents and the test assay using DEA buffer on a semi-automated biochemistry analyzer within two hours of receipt. Both assays employed the same biochemical reaction, differing only in buffer composition. The linearity ranges for the test assay with DEA buffer and the routine assay with AMP buffer were determined as 1600 U/L and 800 U/L, respectively. RESULTS Patient samples exhibited ALP levels ranging from 0 to 339 U/L by routine assay. The correlation graph demonstrated a satisfactory R2>0.75, indicating adequate number of sample inclusion and quality. A correction factor of 1.2 was calculated for the ALP assay utilizing DEA, compared to the AMP-based assay, employing simple linear regression analysis.CONCLUSIONS According to the sample availability, only ALP levels up to 339 U/L by AMP-based assay were included. Therefore, the correction factor of 1.2 is applicable only up to an ALP level of 400 U/L with the DEA-based assay, necessitating dilution of samples with higher values for the correlation factor’s application. This study indicates a correction factor of 1.2, which is deviated from factors close to 2, observed in literature because of reagents being from different manufacturers and running two assays on two different platforms (automated/ semiautomated). It is important to derive a factor for an ALP assay with DEA buffer to make the results comparable to IFCC recommended AMP buffer used ALP assay.Item Comparative Analysis of Albumin Measurement by Bromocresol Green Versus Capillary Zone Electrophoresis(College of Chemical Pathologists of Sri Lanka, 2024) Harshanee, T.; Jayasekara, D.; Fernando, K.; Kulasinghe, M.; Silva, P.; Bandara, S.; Dayanath, B.K.P.T.INTRODUCTION Quantitative assessment of albumin and globulins in serum protein electrophoresis (SPE) relies on the calculation derived from total protein measurements obtained from the biuret assay. Validation of these results involves comparing sample albumin concentration assessed using the bromocresol green (BCG) method to those obtained from capillary zone electrophoresis (CZE). This study aimed to assess the relationship between albumin values derived from SPE and routine spectrophotometric analysis with BCG method, and to establish a cut-off value to identify significant differences between the two values in SPE validation process. METHODS 187 serum samples were subjected to total protein assessment by biuret method, albumin assessment by BCG method, and SPE by CZE method. SPE derived albumin level using total protein values and BCG method indicated albumin values were analyzed by correlation analysis. The standard error for the difference (SEdif) between the two albumin results were calculated, with statistical significance set at p <0.05. Internal and external quality assessments were deemed acceptable for all three analytical procedures. RESULTS Mean albumin levels obtained via BCG and CZE methods were 38.3 mg/dL and 33.2 mg/dL, respectively, indicating a negative bias for the latter method. A strong correlation (r=0.844, p<0.001) was observed between albumin levels measured by BCG and CZE methods, with Bland-Altman analysis revealing an average negative bias of 5 mg/dL. Using SEdif at 95% significance, the maximum acceptable difference between the two albumin values was determined to be -5.4 mg/dL. CONCLUSIONS BCG method yielded higher albumin results compared to CZE method. This positive bias could be attributed to potential lack of specificity of BCG assay for albumin. A maximum allowable difference of 5.5 mg/dL between the two methods is suggested. Exceeding this threshold indicates potential issues with either the BCG albumin assay, biuret total protein assay, or SPE assay, necessitating further investigation for assay reliability, particularly in reporting SPE by CZE.