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 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.Item Do doctors really know about “hs-cTnI”? A comprehensive evaluation of knowledge regarding high-sensitivity cardiac troponin I (hs-cTnI) assay among medical officers in Gampaha district(College of Chemical Pathologists of Sri Lanka, 2024) Fernando, N.; Fernando, K.; Gallage, T.; Dayanath, B.K.T.P.; De Silva, S.INTRODUCTION AND OBJECTIVES The high-sensitivity cardiac troponin I (hs-cTnI) assay is a crucial diagnostic marker in the triage of patients presenting with chest pain. Notably, errors in interpreting the testing method have been identified among medical officers, leading to an increased likelihood of inaccuracies in testing and interpretation. This study aims to evaluate the level of understanding among medical officers regarding the hs-cTnI assay in relation to the most recent European Society of Cardiology (ESC) guideline released in 2020. METHODS A cross sectional questionnaire-based study was conducted at two government hospitals in Gampaha District during June 2022. A self-administered e-questionnaire was used to assess knowledge regarding hs-cTnI. Knowledge was measured through cumulative scoring of questionnaire responses, subsequently categorized as either good or poor knowledge. Scores below 60% were designated as poor, and vice versa. Descriptive statistics were employed for data summarization. RESULTS Out of 300 participants, 76% (227) responded. Only 14.5% (33/227) exhibited proficient knowledge of the analytical component, while 41.9% (95/227) demonstrated good knowledge of the clinical component. A score ≥60% on the analytical component knowledge correlated significantly with factors such as designation being a senior registrar or consultant (p<0.001), postgraduate enrolment (p<0.001), participation in continuous professional development programmes (p<0.001), and employment in a teaching hospital (p=0.025). Conversely, no significant associations were observed with age (p=0.066) or private practice (p=0.118). Clinical component knowledge scores ≥60% were significantly associated with age between 25 and 35 years (p=0.006), postgraduate enrolment (p<0.001), participation in continuous professional development programs (p<0.001), and employment in a teaching hospital (p=0.001) but not with doing private practice (p=0.170). CONCLUSIONS In Sri Lanka, medical officers’ analytical knowledge on the hs-cTnI assay seems lacking. Ongoing training programmes are essential to enhance their knowledge and proficiency in hs-cTnI testing.