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 Hepatocellular carcinoma in Sri Lanka: Where do we stand?(Sri Lanka Medical Association, 2013) Siriwardana, R.C.; Liyanage, C.A.H.L.; Jayatunge, D.S.P.; Dassanayaka, A.; Gunetileke, M.G.; Niriella, M.A.; Sirigampola, C.; Upasena, A.; de Silva, H.J.INTRODUCTION AND OBJECTIVES:Hepato-cellular carcinoma (HCC) is the sixth commonest cancer worldwide. We studied 105 consecutive patients with HCC in a single tertiary care centre. METHODS: North Colombo Liver Unit maintains a prospective database of HCC since September 2011. There were 105 entries by February 2013. Decision on the best form of treatment was taken at a multidisciplinary meeting. RESULTS: The median age at presentation was 63 years (range 12-79). Patients were predominantly male 93 (87%). Alcohol consumption above the safe limit was reported in 47 (45%). Hepatitis B surface antigen or C antibody was not detected in any of the patients. Background liver cirrhosis was evident in 59 (79%). Forty two (46%) patients had single nodular tumours while in 20 (21%) it was diffusely infiltrating. Portal vein invasion was seen in 22 (20 %). Median alpha-feto protein (AFP) level was 57.25 mg/ml (1.16- 94120 ng/ml; n=72). Twenty four (33%) patients had AFP level > 400u/l. Surgery was performed in 20 (19%), liver transplant in 2 (1.9%), radio frequency ablation or alcohol ablation in 8 (7.6%), trans arterial chemo embolization (TACE) in 44 (41.9%) and sorafmib was prescribed in four patients. Overall mean survival was 15 months. In the ‘no treatment’ group, mean survival was 4 months. Surgery group had a mean survival of 20 months. CONCLUSION: Hepatitis B is not a risk factor for HCC in Sri Lankans. Median survival without treatment is 4 months.Item Prevalence, predictors and outcome of chronic kidney disease in a cohort of aging urban, adult Sri Lankans(Sri Lanka Medical Association, 2021) de Silva, S.T.; Ediriweera, D.D.; Niriella, M.A.; Kasturiratne, A.; Kato, N.; Wickremasinghe, A.R.; de Silva, H.J.Introduction and Objectives Chronic kidney disease (CKD) affects 700 million people worldwide. In 2017, deaths due to CKD accounted for 4.6% of mortality globally. Prevalence of CKD is increasing worldwide, with increasing diabetes and hypertension in aging populations. Our objective was to determine prevalence of CKD in an urban, adult cohort, since such data is scarce in Sri Lanka. Methods The study population was selected by stratified random sampling from Ragama MOH area initially in 2007 (aged 35-64 years) and re-assessed in 2014. On both occasions, participants were assessed by structured interview, anthropometric measurements and biochemical tests. CKD was assessed in 2014. Estimated glomerular filtration rate (eGFR) was calculated using CKD-EPI formula. CKD was defined as eGFR<60ml/min/1.72m2, using KDIGO/KDOQI classification. The cohort was further followed up in 2017 when all-cause and cardiovascular (CV) mortality and CV morbidity were also assessed. Results Of 2985 individuals recruited in 2007, 2148(71.6%) attended follow-up in 2014. 2032/2148 (94.6%) had CKD data [57.0% women, mean age 52.3(SD 7.7) years]. Age adjusted prevalence of CKD was 3.03(1.98–4.11) per 100 population in 2014; 41/61(67.2%) were in CKD Stage-3A, 14/61(23%) in Stage-3B, 6/61(9.8%) in Stage-4 and none in end-stage. Independent predictors of CKD in 2014 were older age (p<0.001), male gender (P<0.05) and presence of diabetes (p<0.001) and hypertension (p<0,001) in 2007. CKD was not associated with all-cause mortality, CV mortality or morbidity (p>0.05) in 2017.Conclusion Diabetes and hypertension were associated with CKD. Most with CKD were in Stage 3, where early recognition and better control of co-morbidities retard progression of CKD.Item Factors affecting Post- Embolization fever and liver failure after Trans- Arterial Chemo-Embolization in a cohort without background infective hepatitis- A prospective analysis.(College of Surgeons of Sri Lanka, 2015) Bandara, L.M.P.M.; Siriwardana, R.C.; Niriella, M.A.; Dassanayake, A.S.; Liyanage, C.A.H.; Sirigampala, C.; Upasena, A.; de Silva, H.J.INTRODUCTION: Transarterial-chemo-embolization (TACE) is used for palliation of unresectable hepatocellular carcinoma (HCC). We studied the tolerability of TACE in a cohort of patients with NASH and alcoholic cirrhosis related HCC. MATERIAL AND METHODS: Of 290 patients with HCC(July 2011 - December 2014), 84 underwent TACE. They were monitored for post-TACE complications: post embolization fever(PEF), nausea and vomiting (NV), abdominal pain, infection, acute hepatic decompensation (AHD) and acute kidney injury (AKI). RESULTS: 84 patients [90.5% males, 89.2% cirrhotics, 89.2% nodular HCC, median age 63(34-84) years] underwent 111 TACE sessions. All were Child class A [69.4% sessions(n=77)] or B; ascites and portal vein invasion was present in 18(16.2%) and 15(13.6%), respectively. 42 (38.2%) TACE procedures resulted in complications [PEF 28(25.2 %), NV 4(3.6%), abdominal pain 9(8.1%), infection 7(6.3%), AHD 13(11.7%), AKI 3(2.7%)]. There were no immediate post-TACE deaths. On univariate analysis elevated serum bilirubin (p=0.046) and low serum albumin (p=0.035) predicted PEF while low serum albumin (p=0.021) and low platelet counts (p=0.041) predicted AHD. In the multivariate model, factors with p 5 cm (p=0.049,OR=2.410)and elevated serum bilirubin (p=0.036,OR=1.517) predicted AHD. CONCLUSIONS: In NASH and alcoholic cirrhosis related HCC patients pre- procedure serum bilirubin, ascites, tumour size and female gender predicted PEF post-TACE. Tumours larger 5cm with elevated bilirubin predicted AHD post-TACE.Item Predictors of mortality in a cohort of adult Sri Lankans(Sri Lanka Medical Association., 2019) Kasturiratne, A.; Beddage, T.; de Silva, S.T.; Niriella, M.A.; Pathmeswaran, A.; Kato, N.; Wickremasinghe, A.R.; de Silva, H.J.INTRODUCTION & OBJECTIVES: There is limited knowledge on early predictors of mortality among Sri Lankans. We investigated predictors of mortality in the Ragama Health Study cohort 10 years after recruitment. METHODS: The study population (35-64-year-olds selected by age-stratified random sampling from the Ragama Medical Officer of Health area) was initially screened in 2007 for socio-demographic, lifestyle, anthropometric and clinical risk factors with informed written consent. Their vital status was assessed in 2017 and the causes of death of the deceased were retrieved from death certificates available with the next-of-kin or declaration of death records from the hospital where the death occurred. RESULTS: Of the 2986 enrolled in 2007, 169 [Males: 107 (63.3%)] had died over the 10-year period, giving an overall mortality rate of 5.7% (95% CI: 5.0 % - 6.4%). The number of deaths due to cardiovascular and cancer related causes were 73/169 and 31/169, respectively. On multivariate analysis using Cox's proportional hazards model, advancing age, male sex, lower educational level, unsafe alcohol consumption and the presence of metabolic syndrome at baseline were independent predictors of all-cause mortality. Advancing age, male sex, unsafe alcohol consumption and the presence of metabolic syndrome at baseline were independent predictors of cardiovascular mortality, while advancing age and unsafe alcohol consumption were the only independent predictors of cancer-related mortality. CONCLUSION: Unsafe alcohol consumption and the presence of metabolic syndrome were important modifiable risks for mortality in this population. Addressing these risks in early adulthood will help to improve longevity.Item Development of a model for a resource limited setting, to predict the presence of oesophageal varices among newly diagnosed patients with cirrhosis.(Sri Lanka Medical Association., 2019) Perera, K.; Kodisinghe, S.K.; Ediriweera, D.; Moratuwagama, H.M.D.; Williams, S.; Pathmeswaran, A.; Niriella, M.A.; de Silva, H.J.INTRODUCTION & OBJECTIVES: In cirrhosis upper-gastrointestinal-endoscopy (UGIE) identifies oesophageal varices (OV). UGIE is unavailable in most resource-limited settings. Therefore, we assessed prediction of presence OV using hematological parameters (HP) and Child-Turcott-Pugh (CTP) class. METHODS: A prospective study was carried out on consecutive, consenting, newly-diagnosed patients with cirrhosis, in the University Medical Unit, Colombo North Teaching Hospital, Ragama, from April 20 I 4-April 2016. All patients had UGIE to evaluate presence and degree of OV, prior to appropriate therapy. HP (FBC with indices using automated analyzer and peripheral blood smear using Leishmann stain) and CTP class were assessed. Linear logistic regression model was developed to predict OV using HP and CTP class. RESULTS: 54-patients with cirrhosis were included [14(26%), 24(44%) and 16(30%) belonged to CTP class A, B and C respectively]. 37 had varices [CTP-A 4/14(26.6%), CTP-B 19/24(79.2%), CTP-C 14/16(87.5%)] on UGIE. Generalized linear model fitting showed decreasing percentage of small platelets (%SP) (P=0.002), CTP-B (P=0.003) and CTP-C (P=0.003) compared to CTP-A had higher probability of having OV. The model predicts the log odds for having OV = - 0.189 - (0.046*%SP) + 2.9 [if CTP-B] + 3.7 [if CTP-C]. Based on ROC analysis, a model value >-0.19 was selected as the cutoff point to predict OV with 89%-sensitivity, 76%-specificity, 89% positive predictive value and 76%-negative predictive value. CONCLUSION: We constructed a model using %SP on peripheral blood smear and CTP class. This model can be used to predict the presence of OV, in newly diagnosed patients with cirrhosis, with high sensitivity and specificity, avoiding the need for initial UGIE.Item Prevalence of menopausal symptoms and their impact on daily activities: A community based longitudinal study in Ragama, Sri Lanka(Sri Lanka College of Obstetricians & Gynaecologists, 2016) Heenatigala, C.S.N.; Gunathilaka, S.N.M.P.K.; Dias, T.D.; Palihawadana, T.S.; Motha, M.B.C.; de Silva, H.J.OBJECTIVES: To determine the prevalence and severity of menopausal symptoms among women. DESIGN,SETTING AND METHODS: A community-based cross sectional study was done in a study population of a larger ongoing longitudinal study named ‘Ragama Health Study’. Randomly selected 954 women from Ragama Medical Officer of Health (MOH) area were included. Data was collected using a self-administered questionnaire. Impact on daily activities by menopausal symptoms were scored using a scale from 1-10.RESULTS: Out of 954 women in the study, 814(85.3%) were postmenopausal. Age of the population distributed from 41-74 years with mean of 59.51 years. Mean age of onset of the menopausal symptoms was 52.16(SD=8.095) years. Among the symptoms inquired, the domain of sexual activity contained the most commonly experienced symptom, decreased libido, with a 65.4% (n=937) positive responses while 20.5% of women experienced vaginal dryness.. Mean score on impact on daily activities by this was 7.79(SD 2.36). Psychosocial symptoms of forgetfulness, bad temper, irritability and poor concentration was present in 60.5%, 33.8%, 25.4% and 24.8% of positive responses respectively. Mean scores on impact on daily activities by psychosocial symptoms lied within the range of 4.55-5.52. Presence of experiencing hot flushes and increased sweating were 24.8% and 22.1% with a mean score of effect on daily activities at 5.24 and 5.65, respectively. CONCLUSIONS The rate of menopausal symptoms among this perimenopausal age group was significant and the impact on daily activities in this population was comparable to the global contextItem A study on the rate of symptoms of pelvic floor dysfunction among healthy women in pre and post-menopausal age and its impact on their day-to-day life.(Sri Lanka College of Obstetricians & Gynaecologists, 2016) Pieris, K.V.M.; Prasanga, D.P.G.G.M.; Dias, T.D.; Palihawadana, T.S.; Motha, M. .C.; de Silva, H.J.OBJECTIVES: Aim of the study was to analyze the rate of symptoms of pelvic floor dysfunction, the presence of pelvic organ prolapse and to study how the symptoms affect the day to day life activities in a population of women living in the Ragama Medical Officer of Health (MOH) area.DESIGN, SETTING AND METHODS: A community-based cross sectional study was done in a study population of a larger ongoing longitudinal study named ‘Ragama Health Study’. Randomly selected 951 women from Ragama Medical Officer of Health (MOH) area were included. The symptoms of pelvic floor dysfunction were elicited using a self-administered questionnaire and a vaginal examination was performed to assess the presence and grade of pelvic organ prolapse. RESULTS: Among the 951 women 881(92.6%) did not have symptoms of pelvic floor dysfunction. Among the symptomatic women (n=70), urgency was the commonest symptom (26.8%) while 23.5% admitted urinary incontinence and 16.1% of women experienced fecal incontinence. Among the women with such symptoms of pelvic organ prolapse only 5.6% complained of these interfering with their sexual activities while 10.8% admitted them having an effect on their day-to-day activities. Pelvic organ prolapse was not elicited on clinical examination in 32.1% of symptomatic women while 60.7% had a prolapse up to the hymen and 7.2% had a prolapse beyond the level of hymen. CONCLUSIONS: Rate of symptoms of pelvic floor dysfunction was around 7.5% among this sample of women in peri and postmenopausal age. Urinary incontinence and fecal incontinence were the most frequent symptoms. Only a few symptomatic women considered this to have an effect on their sexual function (5%) and day-to-day activities (10%). More than two thirds of women with symptoms had genital prolapse with over 7% having a significant prolapse protruding beyond the hymen.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 Evaluating temporal patterns of snakebite in Sri Lanka: The potential for higher snakebite burdens with climate change(Sri Lanka Medical Association, 2018) Ediriweera, D.S.; Diggle, P.J.; Kasturiratne, A.; Pathmeswaran, A.; Gunawardena, N.K.; Jayamanne, S.F.; Isbister, J.K.; Dawson, A.; Lalloo, D.G.; de Silva, H.J.INTRODUCTION AND OBJECTIVES: Snakebite is a neglected tropical disease that has been overlooked by healthcare decision makers in many countries. Previous studies have reported seasonal variation in hospital admission rates due to snakebites in endemic countries including Sri Lanka, but seasonal patterns have not been investigated in detail. METHODS: A national community-based survey was conducted during the period of August 2012 to June 2013. The survey used a multistage cluster design, sampled 165,665 individuals living in 44,136 households and recorded all recalled snakebite events that had occurred during the preceding year Log-linear models were fitted to describe the expected number of snakebites occurring in each month taking into account seasonal trends and weather conditions, and addressing the effects of variation in survey effort during the study and due to recall bias amongst survey respondents RESULTS: Snakebite events showed a clear seasonal variation. Typically, snakebite incidence was highest during November to December followed by March to May and August, but this varied between years due to variations in relative humidity, which is also a risk-factor. Low relative humidity levels was associated with high snakebite incidence. If current climate change projections are correct, this could lead to an increase in the annual snakebite of burden of 35,086 (95% CI: 4 202 a€" 69,232) during the next 25 to 50 years. CONCLUSION: Snakebite in Sri Lanka shows seasonal variation Additionally, more snakebites can be expected during periods of lower than expected humidity. Global climate change is likely to increase the incidence of snakebite in Sri Lanka.Item 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.