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 Is splenic stiffness measurement(SSM) better than Baveno VII criteria to predict oesophageal and cardio- fundal varices in patients with compensated advanced liver cell disease (cACLD)?(Sri Lanka Medical Association, 2023) de Silva, A.P.; Niriella, M.A.; Nishad, A.A.N.; Samarawickrama, V.T.; Jayasundara, H.; Ranawaka, C.K.; de Silva, S.T.; Withanage, M.; Ediriweera, D.; de Silva, H.J.INTRODUCTION: Liver and splenic stiffness measurements (LSM and SSM) using transient elastography (TE) are being increasingly used as a screening tool to predict varices. OBJECTIVES: We aimed to test the utility of Baveno-VII criteria (LSM>25kPa, LSM>20kPa with platelet count <130,000 and LSM>15kPa with platelet count <110,000) and SSM to predict oesophageal and cardio-fundal varices in a cohort of Sri Lankan patients with aALCD. METHODS: Consecutive patients with newly diagnosed Child’s class A cALCD (non-viral, BMI<30) were recruited prospectively. They underwent upper gastrointestinal endoscopy by an endoscopist followed by a Fibroscan by an operator who is unaware of endoscopy findings using ECHOSENS-Fibroscan-502 to measure LSM and SSM. Validity measurements of three Baveno-VII criteria and SSM values to predict oesophageal and cardio-fundal varices were calculated. RESULTS: One hundred and seventy-four individuals were recruited [Mean (95%CI) age 61.4 (59.7-62.8) years, 110 males], and 106 had varices. Our results indicate that the three Baveno VII criteria had sensitivities of 61%, 63% and 42%, and specificities of 79%, 77% and 87%. SSM>30kPa alone or in combination with LSM>15kPa had sensitivity of 81&75%, specificity of 72&83%, PPV of 82&87%, NPV of 71&67% and accuracy of 78&78% consecutively to predict oesophageal and cardio-fundal varices. CONCLUSION: Baveno VII criteria had low sensitivity but high specificity to predict oesophageal and cardio-fundal varices. SSM>30kPa alone or in combination with LSM>15kPa seemed to predict oesophageal and cardio-fundal varices better.Item The Health Effects of the Combined Use of Protein, Multivitamins and Electrolyte Dietary Supplements on Sri Lankan Athletes: A Pilot Study(Sri Lanka Medical Association, 2020) Fernando, P.N.J.; Pigera, S.; Rashani, S.A.N.; Niriella, M.A.; Jayawickreme, S.; de Silva, A.P.INTRODUCTION AND OBJECTIVES: The combine use of protein, multivitamins and electrolyte dietary supplements daily; multiple supplement (MS), is a common practice among Sri Lankan Athletes. The aim of this study was to determine the relative risk for developing adverse health effects from multiple supplements use. METHOD: A Retrospective Cohort, pilot study was conducted with 45 healthy athletes (23 males and 22 females), age between 22-31. Participants were composed of non-supplement users (n=19) and MS users for 2-5 months’ time (n=25). Their lipid, kidney, liver profiles, full blood count, fasting blood glucose, serum testosterone, urine full report and urine protein/creatinine were tested. Food frequency questionnaire was also filled from each athlete. RESULTS: Increase in total cholesterol and LDL cholesterol was significantly higher among multiple supplements users than non-users (P<0.05). Relative risk in increasing total cholesterol between 200-240 mg/dL was 8.7, increasing LDL cholesterol between 160-171 mg/dL was 2.9 and being overweight was 1.3, in MS users compared to non-users. Relative Risk in increasing total cholesterol was 2.9 in female and 7.1 in male while increasing LDL cholesterol was 2.3 in female and 4 in male. There were no statistically significant changes in the other parameters studied. CONCLUSION: Combined use of MS between 2-5 months, has a negative effect on the lipid profile of athletes. More pronounced in male. The clinical implication of this finding needs further study.Item Perioperative outcome following establishment of deceased donor liver transplantation: A single center experience in Ragama, Sri Lanka(Sri Lanka Medical Association, 2018) Withanachchi, A.D.; Thalagala, T.A.E.S.; Liyanage, I.K.; Dassanayake, A.S.; de Silva, A.P.; Gunetilleke, M.B.; Siriwardana, R.C.; Niriella, M.A.INTRODUCTION AND OBJECTIVES: Liver transplant (LT) perioperative mortality is a good performance indicator among transplant centres. Colombo North Teaching Hospital (CNTH) is the first LT program in Sri Lanka. We aimed to evaluate the perioperative (30 day) outcomes and complications of patients who underwent deceased donor liver transplantation (DOLT) at CNTH between the first 9 DDLTs that were carried out before 2016 (Tl) and the last 10 DDLTs after 2016 (T2). METHODS: Retrospective analysis of pre-operative records, operation notes, discharge and follow up notes were carried out on all patients who underwent DOLT at CNTH. RESULTS: A total of 19-DDLTs were performed during this period. Mean age of the recipients was 50.3 (Tl :52.9, T2:47.9) years: Indications (n) for DDLT were: advanced cirrhosis with high MELD (12), other complications of cirrhosis (3),."cirrhosis with hepatocellular carcinoma (3) and acute liver failure (1 ). Aetiology of cirrhosis (n) were: cryptogenic (13), alcohol (3), autoimmune hepatitis (1), other (1). Pre transplant MELD was 16 in Tl and 18 in T2. Average hospital stay was 11.1 days (7.4 days in the intensive care). Perioperative mortality was 4/9 (44%) in Tl and 2/10 (20%) in T2. Mortality was due to PNF (3), sepsis (2) and post-operative reperfusion syndrome (1). Other post-operative complications (in Tl and T2) were: hepatic artery thrombosis (0,0), cholestasis (0, 1 ), acute cellular rejection (0,2), hydrothorax (0,3), clinically significant tacrolimus toxicity (1,o) and acute renal failure (4,2). CONCLUSION: Perioperative mortality has reduced and outcomes improved in the second half indicating success of the CNTH LT program.Item Do common arishta preparations manufactured in Sri Lanka contain anabolic androgenic steroids (AAS), stimulants or ethanol?(Sri Lanka Medical Association, 2018) Fernando, P.N.J.; Pigera, S.; Rashani, S.A.N.; Fernando, R.; Weerasinghe, D.P.P.; Godakumbura, K.K.D.T.D.; Niriella, M.A.; Jayawickreme, S.; de Silva, A.P.INTRODUCTION AND OBJECTIVES: The common arishta preparations which are available in the local market are .'Ashwagandharishta', 'Balarishta' and 'Dashamoolarishta'. These contain a wide range of chemical constituents including alkaloids and steroidal lactones. Moreover, fermented decoctions and infusions are also used in ayurveda therapeutics and the fermentation process as well generates alcohol. The possible presence of substances prohibited within the world anti-doping agency (WADA) code in the arishta preparations may threaten the careers of athletes who consume herbal supplements. The objective of this study is to analyse commonly available arishta samples for the presence of prohibited AAS, stimulants as per WADA code and determination of ethanol content. METHODS: Compounds were segregated by adjusting pH after dissolving in methanol. Organic layer was evaporated and residue was reconstituted with derivatizing agent. The derivatized solutions were utilized for gas chromatography- mass spectrometry (GC-MS) analysis. In addition to that ethanol content of arishta samples was quantified by using gas chromatography. RESULTS: The GC-MS studies showed the absence of prohibited AAS and stimulants in the arishta samples analysed. Moreover, glycerol and ethanol were identified to be present in all samples and ethanol content of the all arishta samples was (5.80 - 8.35 ±0.5) % (v/v) and the limit of detection was about 2 g/ml. CONCLUSION: This study showed the absence of any AAS or stimulants as per the WADA code in the arishta samples analysed. However, alcohol content below 8.35±0.5% (v/v) was detected. To the best of our knowledge this is the first study showing these findings.Item Early hepatitis is the strongest risk factor for the development of severe dengue infection: A points-based risk-score to predict critical disease in dengue fever(Sri Lanka Medical Association, 2018) Niriella, M.A.; Udeshika, A.K.M.A.; Liyanage, I.K.; de Silva, A.P.; de Silva, H.J.INTRODUCTION AND OBJECTIVES: Some dengue fever (DF) patients develop plasma leakage [critical-phase (CP)], which may progress to multi-organ failure. We attempted to identify early predictors ofCP in DF. METHODS: This was a retrospective, case-record-based study. Clinical, laboratory features in the first three-days (Dl-3) of illness was used to formulate a risk prediction model (RPM). Patients with serologically confirmed DF, admitted to the University Medical Unit, Teaching Hospital, Ragama, from 01.01.2017-30.06.2017 were included. Patients were randomly assigned to training (TD) and validation datasets (VD) of equal size. Stepwise multivariate logistic regression (p<0.05) was used to identify risk factors in TD. Versions of RPM were compared using Akaike criteria and McFadden's adjusted R2. Coefficients from the best RPM were used to derive weighted risk scores. Best RPM was validated in VD using C-statistic. RESULTS: 697 patients were included (mean-age:34.7±16.1 years, females-48.8%, TD=350, VD=346). CP developed inJ27 (32.6%). Mortality was I%. Risk predictors (p<0.05) were: female gender (OR=2.l), diabetes (OR=l.8), vomiting (OR=l.9), platelets60 IU/L (OR=3.3). In multivariate analysis, female gender (score=2), vomiting (score=3), platelets<120,000/mm-3 (score=3) and AST>60 IU/L 3 (score=4) were significant while diabetes was non-significant. Calculated RPM score ranged from 0-12. C-statistic for the TD was 0.78 and VD 0.77 (Hosmer-Lemeshow test: p=0.19 and 0.34 respectively). A cut-off of 5 was selected to maximise sensitivity (0.96), negative predictive value (0.95) with specificity of 0.44. CONCLUSION: This simple risk score seems useful in identifying those at risk ofCP within Dl-3 of the onset ofDF. The early presence of dengue hepatitis was the strongest predictor of CP.Item Prevalence and correlates of colonic diverticular disease in patients undergoing colonoscopy at a tertiary referral centre, Sri Lanka(Sri Lanka Medical Association, 2018) Thalagala, T. A. E. S.; Withanachchi, A. D.; Liyanage, I. K.; de Silva, A.P.; Niriella, M.A.INTRODUCTION & OBJECTIVES: Diverticula disease (DD) is increasing in prevalence across the world. We aimed to prevalence and correlates of DD in a tertiary referral centre in Sri Lanka.METHODS:This was a retrospective case record review, conducted at the University Gastroenterology Unit, Colombo North Teaching Hospital. All patients undergoing colonoscopies from January 2015-December 2017 were included. Failed or incomplete procedures (due to poor bowel preparation and technical difficulties) and repeat procedures in same individuals were excluded. Presence of one or more colonic diverticuli was considered as DD. RESULTS:2438/2486 (98%) patients [1283 (53%) males, mean-age 54.3 years] were included in this analysis DD was present in 203/2438 (8.3%) Distribution of diverticuli 58% right colon 25% left colon and 17% throughout Prevalence increased with age (p<0.05) (20% among patients >60 years) Gastrointestinal symptoms were present (either due to DD or other pathology) in 179 (90%). Amongst patients in whom DD was the only detectable pathology,adominal pain (17%), bleeding per rectum (17%), constipation (15%) and altered bowel habits (12%) were the common symptoms. Specific gender distribution or presence of ilea! or colonic inflammation, inflammatory bowel disease, malignancies were not associated with DD. Although during univariate analysis presence of polyps was associated with DD (OR=l.6, p=0.02), in multivariate analysis this was confirmed to bean effect of age.CONCLUSION: DD was present in 8.3% undergoing colonoscopy in present study. Prevalence increased with age. Abdominal pain, bleeding per rectum and constipation were the common symptoms. Presence of DD was not associated with other sinister colonic pathologyItem Incidence and predictors of metabolic syndrome among urban, adult Sri Lankans: a community cohort, 7-year follow-up study(European Association for the Study of Diabetes, 2017) de Silva, S.T.; Niriella, M.A.; Kasturiratne, A.; Kottahachchi, D.; Ranawaka, U.K.; Dassanayake, A.; de Silva, A.P.; Pathmeswaran, P.; Wickremasinghe, R.; Kato, N.; de Silva, H.J.BACKGROUND AND AIMS In 2007, we reported a 38.9% prevalence of metabolic syndrome (MetS) in an urban, adult population. Published data on incident MetS from South Asia is lacking. This study investigated the incidence and risk factors for MetS after a 7-year follow-up of the initial cohort. MATERIALS AND METHODS: The study population (selected by age-stratified random sampling from the Ragama MOH area) was screened in 2007 (aged 35-64 years) and re-evaluated in 2014 (aged 42-71 years). On both occasions, structured interview, anthropometric measurements, liver ultrasound, biochemical and serological tests were performed. MetS was diagnosed on established International Diabetes Federation (IDF 2012) criteria. Total body fat (TBF) and visceral fat percentage (VFP) were measured in 2014, using impedance. Abnormal TBF was defined as >32% for females and >25% for males. Abnormal VFP was defined as >10% for both sexes. Non-alcoholic fatty liver disease (NAFLD) was diagnosed on established ultrasound criteria, safe alcohol consumption (Asian standards: <14 units/week for men, <7 units/week for women) and absence of hepatitis B and C markers. RESULTS: 2137/2967 (72.0%) of the initial cohort attended follow-up [1229 (57.5%) women; mean-age 52.4 (SD-7.7) years]. 1000/2137 [548 (54.8%) women; mean age 57.5 years (SD-7.74)] had MetS (prevalence-46.8%). Out of 1246 individuals who initially did not have MetS in 2007, 318 [225 (70.8%) women; mean age 57.5 (SD 7.7) years] had developed incident MetS after 7 years (annual incidence-2.13%). Comparison of incident MetS with those with no MetS in 2014 is shown in Table 1. On logistic regression, female sex (OR 3.6, p<0.001), central obesity [OR 4.58, p<0.001], BMI >23kg/m2 [OR 4.84, p<0.001], increase in weight 2%-5% [OR 2.02, p<0.001], increase in weight >5% [OR 5.3, p<0.001), increase in waist circumference (WC) 5-10-cm [OR 3.68, p<0.001], increase in WC >10cm [OR 10.34, p<0.001] and NAFLD (OR 2.44, p<0.001) in 2007 were independently predictive of incident MetS in 2014. Abnormal VFP [OR 4.23, p<0.001] and abnormal TBF [OR 5.25, p<0.001] were also associated with incident MetS. CONCLUSION: In this prospective community study, the annual incidence of MetS was 2.13%. Female gender, increase in weight and WC from baseline and the presence of NAFLD predicted the development of incident MetS. Obesity at baseline was the only defining individual component of MetS that predicted future MetS.Item Serious thiopurine adverse effects and discontinuation among inflammatory bowel disease patients in Sri Lanka(Sri Lanka Medical Association, 2017) Niriella, M.A.; Kodisinghe, S.K.; Dassanayake, S.U.B.; Rajapakshe, N.; Nanayakkara, S.D.; Luke, H.P.D.P.; Silva, K.T.M.; de Silva, A.P.; Navarathne, N.M.M.; de Silva, H.J.INTRODUCTION & OBJECTIVES: Thiopurines such as azathioprine and 6-mercaptopurine use for long term is not uncommon for patients with inflammatory bowel disease (IBD). Severe thiopurine adverse effects are dependent on thiopurine methyltransferase (TPMT) activity. TPMT testing prior to commencing thiopurine has been suggested to identify individuals with low TPMT activity, so that thiopurine use can be avoided in such patients. There is very limited data on thiopurine adverse effects among IBD patients in South Asia. METHODS: Patients with histologically proven IBD [ulcerative colitis (UC), Crohn’s disease (CD)], diagnosed over a ten year period from May 2005 to April 2015, with at least one year of regular follow up, were included from Colombo North Teaching Hospital and National Hospital of Sri Lanka (two main IBD referral centers). Frequency of thiopurine use, thiopurine adverse effects (myelosuppression and hepatotoxicity), and drug discontinuation were noted. RESULTS: A total of 214 patients were eligible for inclusion [UC-148 (69.2%), 75 (50.7%) males, median follow up (IQR) 55.0 (30-81) months; CD-66 (30.8%), 31 (47.0%) males, median follow up (IQR) 41.5 (26.5-68) months]. Thiopurine was used in 74 (50.0%) and 60 (90.9%) of UC and CD patients, respectively. Very few had severe thiopurine adverse effects that led to discontinuation of treatment [UC-4 (2.7%); CD-4 (6%)]. These were myelosuppression (6 patients) and hepatotoxicity (2 patients). CONCLUSION: In this cohort of Sri Lankan IBD patients, severe thiopurine adverse effects resulting in discontinuation of treatment was uncommon. Routine TPMT testing prior to thiopurine use does not seem warranted in the Sri Lankan setting.Item Changing phenotype, early clinical course and clinical predictors of irritable bowel syndrome in Sri Lanka: a prospective, multi-centre descriptive study(Sri Lanka Medical Association, 2017) Niriella, M.A.; Kodisinghe, S.K.; Nanayakkara, S.D.; Silva, K.T.M.; Rajapakshe, N.; Luke, D.; de Silva, A.P.; Navarathne, N.M.M.; Dissanayake, V.H.W.; Jayasekara, R.W.; de Silva, H.J.INTRODUCTION & OBJECTIVES: Incidence of inflammatory bowel disease (IBD) is increasing in the Asia Pacific, with changes in phenotype and disease course been reported. METHODS: Ulcerative colitis (UC) and Crohn disease (CD) cases from four national referral centres were included. Phenotype was compared for cases [Group-1/G1-diagnosed between June/2003-December/2009, Group-2/G2-January/2010-June/2016]. Early clinical course (ECC) [complicated disease (Comp D-stricturing/penetrating CD, extensive-UC/pancolitis), treatment refractory disease (TRD-frequently-relapsing, steroid-dependent/refractory, biologics), disease complications (DC-perforation/bleeding/colectomy/malignancy)] among disease duration <3 years, and clinical predictors (CP) of CompD/TRD/DC among disease duration >1 year were also assessed. RESULTS: A total of 452-cases [G1: UC-89 (78.8%), CD-24 (21.2%); G2: UC-197 (58.1%), CD-142 (41.9%)] were included. G2 had a higher proportion of CD (p<0.001). In both groups, leftsided colitis (E2) for UC, ileo-colonic (L3)/non-stricturing, non-penetrating (B1) for CD predominated. More penetrating-CD (B3) in G2 (p<0.01) and more stricturing-CD (B2) in G1 (p<0.05) were noted. ECC was assessed in 293 patients [UC-168 (57.3%), CD-125 (42.7%)]. Among UC: extensive/pan-colitis (E3)-40 (24.5%), severe (S3)-38 (42.2%); among CD:severe episodes-15 (25.9%), stricturing (B2)/penetrating(B3)-18 (14.7%), perianal-disease (P)-29 (23.4%). TRD was seen in 19 (11.3%)-UC and 17 (10.1%)-CD. Immunomodulator use was-70 (41.7%)/93 (74.4%), and anti-TNF use was 3 (1.8%)/12 (9.6%) respectively for UC and CD. Complications for UC: bleeding-6 (3.6%), malignancy-1 (0.6%), surgery-3 (1.8%); for CD: stricture-6 (4.9%), perforation-3 (2.4%), malignancy-1 (0.8%), surgery-2 (1.6%). CP were assessed in 373 [UC-266 (71.3%), CD 107 (28.7%)]. EIM of joints predicted CompD in UC/CD (OR-1.94/OR-2.28). Family history (OR=8.64) and EIM of joints (OR=10.07) predicted DC in UC. CONCLUSION: There was an increase in CD during the study period, but no changes in disease phenotype for UC or CD. Although admissions with CompD were common for UC (but not CD), few patients had TRD or DCs indicating a relatively benign early disease course. Family history, EIM of joints predicted poor outcomes in UC, EIM of joints predicted a poor outcome in CD.Item Influence of urban/rural and coastal/inland environment on the phenotype and clinical course of inflammatory bowel disease patients from Sri Lanka: a cross-sectional study(Sri Lanka Medical Association, 2017) Niriella, M.A.; Kodisinghe, S.K.; Dinamithra, N.P.; Rajapakshe, N.; Nanayakkara, S.D.; Luke, H.P.D.P.; Silva, K.T.M.; de Silva, A.P.; Navarathne, N.M.M.; de Silva, H.J.INTRODUCTION & OBJECTIVES: Rural/urban and coastal/inland environmental influences on inflammatory bowel disease (IBD) is poorly studied. We investigated such environmental influences on IBD. METHODS: Patients with histologically proven IBD [ulcerative colitis (UC), Crohn disease (CD)] with a permanent residence and regular follow up, were included. Urban areas (UA) were defined as those administered by Municipal and Urban councils. Coastal areas (CA) were defined as areas with elevation <30 meters above sea level. Patients in different groups were compared with regard to phenotype of IBD [sex, age at diagnosis, Montreal subgroups, severity, extraintestinal manifestation (EIM) at diagnosis, and highest therapy during follow-up]. Fisher’s exact test was used to compare categorical variables. RESULTS: A total of 387 patients were included [UC-251 (64.8%), males-122 (48.6%), median followup (IQR)-22.5 (2-59) months; CD-136 (35.2%), males-65 (47.8%), median follow-up (IQR)- 63.0 (23-115) months; urban/rural distribution: UC-1.7:1, CD-1.5:1; coastal/inland distribution: both UC and CD-0.7:1]. Urban/rural or coastal/inland location did not affect the distribution of type of IBD, gender, age at diagnosis or presence of EIM. UC patients from rural areas had extensive disease (E3) (42.4% vs 24.5%, p=0.029) and used long term immunomodulator drugs more frequently (60.2% vs 47.3%; P=0.006) than UA patients. CD patients living in CA had more frequent ileo-colonic disease (L3) compared to inland patients (53.2% vs 38.0%, p=0.016). Patients with both UC and CD from inland areas needed immunomodulators or anti-TNF more frequently than coastal patients (56.7% vs 44.9%, p=0.026 and 82.1% vs 69.9%, p=0.023). CONCLUSION: IBD was more common among patients from inland, UA. Urban/rural or coastal/inland location did not affect gender, age at diagnosis or presence of EIM. However, UC patients from rural areas and CD patients from inland areas had more severe disease.