Theses - Faculty of Medicine
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Item Gastrointestinal mobility in chronic alcoholics(University of Kelaniya, 2001) Ferdinandis, T. G. H. C.The studies presented in this thesis attempt to extend the current understanding of the long-term effects of chronic alcoholism on gastrointestinal motility and the pathogenesis of alcohol related motility disturbances. Chapter 1 discusses the physiology of gastrointestinal motility and effects of alcohol on the gastrointestinal tract with special reference to the problem of alcoholism in Sri Lanka. Chapter 2 compares the results of ambulatory oesophageal manometry and pHmetry in 23 chronic alcoholics and 15 control subjects. The study shows for the first time that chronic alcoholism changes the circadian oesophageal motility pattern. Motility disturbances, such as the failure to increase the percentage of peristaltic waves during the meal period were found to be related to alcoholic autonomic neuropathy. Autonomic neuropathy was also found to be partly responsible for lower oesophageal sphincter hypertension in alcoholics. Changes in contraction amplitude and duration in the distal part of the oesophagus during meal and supine periods were also observed in alcoholics irrespective of the presence of alcoholic neuropathy. Chapter 3 studies the influence of meal consistency on gastric myoelectrical activity using iso-caloric (170 kcal) carbohydrate test meals of different consistency. According to the results obtained from 18 healthy subjects, the solid and the semisolid test meals are capable of increasing the power of the postprandial EGG, while the liquid meal failed to do so. In chapter 4 gastric myoelectrical activity was studied in 18 chronic alcoholics and 10 control subjects using a solid carbohydrate test meal (375kcal). Alcoholics with autonomic neuropathy showed a significantly lower incidence of normal 3cpm wave activity in the postprandial period. Irrespective of the presence of neuropathy, alcoholics failed to increase the power of the EGG following the test meal. In chapter 5, assessed mouth to caecum transit time and colonic transit time as a measure of intestinal motility in 18 alcoholics and 21 control subjects. Lactulose breath test showed a significantly shorter mouth to caecal transit time in alcoholics irrespective of whether they had diarrhoea or not. Rapid intestinal transit seems to have no association with the presence of alcoholic autonomic neuropathy. Assessment of colonic transit using the radiopaque marker ingestion technique failed to show any significant difference in the rate of marker excretion in the alcoholic group compared to the control group. Chronic alcoholism is associated with altered circadian oesophageal motor activity, disturbed postprandial gastric myoelectrical activity and rapid small intestinal transit. The presence of oesophageal motility disturbances and postprandial EGG disturbances together (in alcoholics subjected to both oesophageal manometry and electrogastrography) shows the ability of alcohol in interfering with motor functions of more than one organ at a time. Altered circadian oesophageal motility and postprandial EGG disturbances could partly be attributed to alcoholic autonomic neuropathy.Item Age related changes of the lumber spine and a study of causes and predisposing factors from low backache(University of Kelaniya, 2002) Karunanayake, A. L.Chronic low backache is an important health problem amongst Sri Lankans. The present study was undertaken to [i) determine the causes and risk factors for low backache.[ii) to describe age related changes in the number of cartilage cells in lumbar discs, intima media thickness of lumbar arteries and atherosclerosis of abdominal aorta and lumbar artery openings. I. [iii) to determine the association between such changes in the lumbar arteries and in the abdominal aorta with the number of cartilage cells in lumbar discs. iv) to describe the gross anatomical features of lumbar arteries. Initially, a case control study was carried out among 459 cases (patients with low backache) and 502 controls. Data was collected using a pretested structured interviewer administered questionnaire. Poor posture (OR=128.2), lack of exercise (24.5), positive family history (OR=16.2), education to less than the sixth grade (OR=2.2), daily alcohol consumption (OR =3.4), BMI\>24.9 (OR=1.5) and monthly income of more than Rs.20,000 (OR=2.6) were found to be significant independent risk factors for low backache. Another case control study was done on 130 cases (patients with low backache) and 133 controls assessing postero-anterior and lateral radiographs of the lumbar-sacral spine. Disc space narrowing (OR=16.9) and an Antero Posterior ratio of lumbar vertebra less than 0.9 (OR =10.1) were found to be significantly associated with low backache. Vertebral osteophytes and spondylolisthesis were not significantly associated with low backache. A descriptive cross sectional study was done on 31 adult postmortem specimens. Histological sections of the fourth lumbar discs and fourth lumbar arteries were prepared. The number of cartilage cells in lumbar discs (r= -0.45) and Intima Media Thickness (IMT) of lumbar arteries (r=-0.74) had a significant negative association with age. When compared to individuals under 43 years (median age of sample), individuals over this age were 12.5 times more likely to have atherosclerotic changes in abdominal aorta and lumbar artery openings. IMT of lumbar arteries and atherosclerotic changes in lumbar arteries did not have a significant association with the number of cartilage cells in the intervertebral discs when age was taken into account. Dissections were done on 109 adult cadavers to describe gross anatomical features of lumbar arteries. First to the fourth pair of lumbar arteries arose from a common single stem in 12 percent of cadavers and passed anterior to the crura of the diaphragm in 17 percent. There were several variations in the gross anatomical features of lumbar arteries from what is described in the literature. According to results of the present study, risk factors for backache among Sri Lankans are similar to risk factors found in other countries. In this study vertebral osteophytes and spondylolisthesis were not significantly associated with low backache. The present study was able to identify a new cut off value for A/P ratio that had a significant association with low backache, and for the first time demonstrate an association between the number of cartilage cells in annulus fibrosus and age of the subject. Several gross anatomical variations of lumbar arteries found in this study have also not been documented previously.Item Molecular diagnosis and transmission of dengue virus in Sri Lanka(University of Kelaniya, 2004) Hapugoda, G. P. G. M. D.Dengue virus is responsible for Dengue Fever (DF), Dengue Haemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS). Four circulating dengue serotypes (DEN 1-4) have been identified. Early diagnosis of dengue viral infection helps monitoring the disease, hospital admission when necessary and reduces case fatality. Detection of dengue viruses in mosquitoes is useful to study on transmission of dengue virus. Study on risk factors for dengue is useful to understand spatial and temporal dynamics of transmission the disease. A novel diagnostic assay, Reverse Transcription-Polymerase Chain Reaction-based Liquid Hybridization (RT-PCR-LH) was developed. Amplified products of Non Structural-3 (NS3) gene were hybridized with a mixture of the 4 dengue type specific Deoxyribonucleic Acid (DNA) probes in liquid phase. A high sensitivity of 2 fluorescent focus units of dengue virus/reaction was achieved and the assay was highly specific for dengue virus. This novel assay was first validated for clinical specimens in a preliminary retrospective study using serum specimens known to be dengue positive or negative, according to virus isolation method. Secondly, this assay was validated in a prospective study using serum specimens. As an early (<5 days of fever) laboratory diagnostic method for dengue virus, this assay had 100 percent and 46 percent sensitivity for detection of confirmed and suspected dengue patients respectively. This assay was found to be more sensitive than the other diagnostic techniques: virus isolation, enzyme linked immunosorbant assasy, Haemagglutination inhibition assay and molecular assays based on the same NS3 gene; RT-PCR- mixed phase hybridization, RT-PCR agarose gel electrophoresis (AGE), semi nested PCR-AGE and based on other regions of dengue viruses, for early definitive laboratory diagnosis of primary and secondary dengue infection. Patients with definitive dengue correlated only with few signs and symptoms, indicating that laboratory confirmation is critical to avoid over estimation. Fifty four serum samples were typed; DEN-3 (92 percent) and DEN-2 (7 percent) were found and DEN-3 infected patients in the study population had severe clinical manifestations. This novel technique was also validated to be used for detection of dengue virus in vectors, Aedes aegypti and Ae. albopictus. Wild-caught mosquito samples were collected from 136 dengue case-reported stations during outbreaks and a hot-spot during a period of 31 months. This assay could detect dengue virus in 7 percent of Ae. albopictus specimens. A high density of Ae. albopictus was also associated with the dengue case-reported stations/hot-spots. These results therefore demonstrate that Ae. albopictus acts as an important vector of transmission of dengue in some urban and semi-urban areas. Epidemiological, environmental, entomological and other possible risk factors affecting transmission of dengue were analyzed. Monthly total rainfall, relative humidity and mean temperature having a lag period of 3 months moving average ending with current month can be used to forecast an impending dengue epidemic in a selected hot-spot where a clear seasonal pattern of dengue was evident. Other risk factors affecting transmission are presence of Ae. albopictus, previous dengue patients, untidy garden with mosquito breeding sites and shade of the garden made by vegetation.Item Transmission of infection and disease burden of Bancroftian filariasis in the Colombo district, Sri Lanka(University of Kelaniya, 2004) Weerasinghe, C. A.Lymphatic filariasis is estimated to affect approximately 120 million people in 80 endemic countries worldwide. In Sri Lanka, lymphatic filariasis remains a public health problem, but the real burden of disease remains unknown. This study examines the correlation between varying rates of transmission and theoccurrence of clinical disease, among the residents of the Colombo District. The aggregation of infection at household level was also examined. A cross sectional survey was conducted from January 2001 to December 2002 to assess the prevalence of clinical disease and transmission indices in the Colombo District. A total of 3766 individuals participated in the study, with ages ranging from 10 - 92 years (mean 36.4 years); 54.8 precent were females. The overall prevalence of microfilaraemia and antigenaemia was 0.6 precent and 12.6 precent respectively. A higher prevalence of microfilaraemia was observed among males (1.1 precent) when compared to females (0.2 precent). Prevalence ofantigenaemia was significantly higher in males than infemales (15.8 precent vs 9.9 precent, 'l = 28.7, P\<0.005) and highest in the 30 - 39 year age group. All microfilaraemic persons were antigen-positive. Vector density varied from 10.2 to 33.5 man-hour catch within the study area. The highest Transmission Intensity Index observed was 0.25. Nocturnal cough of over two weeks duration was the most common clinical manifestation encountered. Males were more likely to be affected than females (6.3 precent vs 3.5 precent, odds ratio 1.9 [95 precent CI: 1.4 - 2.4]). The 30-39 year age group was the most severely affected. Hydrocoele affected 0.8 precent of the males in the study population. The prevalence of hydrocoele increased with age, with 1.0 precent of the 50-59 year age group showing this disease manifestation. Attacks of adenolymphangitis and lymphadenitis associated with fever were rare. Lymphoedema of the limbs was also uncommon, affecting only 0.3 precent of males and 0.4 precent of females. The highest age-specific prevalence oflymphoedema of 1.0 precent was observed in the 50-59 year age group. Elephantiasis was seen only in 3 individuals aged over 50 years. All 23 microfilaraemic individuals were asymptomatic; the prevalence of microfilaraemia among individuals with clinical features of lymphatic filariasis was O.However, the prevalence of antigenaemia among those with nocturnal cough suggestive ofTPE was 47.8 precent and 42.8 precent men with hydrocoele were also antigenaemic. The presence of antigenaemia was associated with a statistically significant relative risk of 6.4 (95 precent CI 4.8 - 8.4) for nocturnal cough suggestive of TPE, and a relative risk of 4.0 (95 precent CI 1.4 - 11.5) for hydrocoele. There was no significant association between antigenaemia and ADL, lymphoedema or elephantiasis. At the community level, there was a strong positive correlation between the prevalence of antigenaemia and the prevalence of prolonged nocturnal cough (R2=0.35) in the 12 DS areas, supporting the likelihood of a filarial aetiology to this symptom. Although the prevalence of hydrocoele was low, there was also a strong positive correlation between this rate and antigenaemia rates in the communit (R2=0.56). Correlation between infection fates in C. quinquefasciatus and theprevalence of nocturnal cough and hydrocoele at DS area level was 0.04 and 0.40 respectively. Aggregation of CF A positive individuals within households was notedItem Genetic composition of Plasmodium falciparum in relation to drug resistance and disease transmission in Sri Lanka(University of Kelaniya, 2006) Hapuarachchi, H. C.Malaria has been an important communicable disease in Sri Lanka. Even though P. vivax is the predominant species, there has been an increase in the proportion of chloroquine resistant P. falciparum infections in the country since the early 1990s. According to national data, the highest number of P. falciparum cases has been reported from the Northern Province for several years. This study examined the species distribution, antimalarial resistance, transmission potential and genetic structure of P. falciparum populations among security forces personnel in an operational area of the Mannar District of the Northern Province in 2002 and 2004 to understand their inter-related effects on clinical disease and transmission of malaria in the country. Some of these aspects were compared with those from other areas of the country to determine how they differed in the Northern Province. An attempt was also made for the first time to identify appropriate markers for molecular surveillance of sulfadoxine-pyrimethamine (S-P) resistance of P. falciparum in Sri Lanka. Screening of 1271 patients by light microscopy revealed that P. falciparum was the predominant species in the Northern Province study area. Clinical characteristics of P. falciparum infections (n = 151) suggested that parasite isolates, especially chloroquine resistant ones, in the Northern Province could be more virulent than isolates in other areas. Extended in vivo (n = 76) and in vitro micro test assays (n = 29) for chloroquine showed a treatment failure rate of more than 50 percent among P. falciparum infections in the Northern Province with a 3-fold rise in IC50 values for chloroquine within the two year period. Recrudescent infections caused significantly less severe disease and showed greater potential for transmission than sensitive infections suggesting that antimalarial resistance confers a survival advantage to P. falciparum isolates in the study area. None of the patients (n = 30) who completed in vivo assay for S-P showed evidence of treatment failure. Polymerase Chain Reaction (PCR) based genotyping of P. falciparum populations using size polymorphism in merozoite surface protein-1 (MSP-1), merozoite surface protein-2 (MSP-2) and glutamate rich protein (GLURP) showed a more complex parasite population in the Northern Province. Block 2 of MSP-1, MSP-2 and GLURP were identified as potential markers for genotyping of P. falciparum isolates in Sri Lanka. The proportion of mixed genotype infections and genotype composition of 'pure' P. falciparum infections appears to reflect the transmission intensity in the Northern Province study area. Longitudinal variation in genotype composition of 'pure' infections showed selection of genotypes 2 and 9, which were associated with resistance to chloroquine, providing indirect evidence for the presence of intrahost dynamics in this parasite population. PCR-restriction fragment length polymorphism based mutation analysis of P. falciparum dihydrofolate reductase (Pfdhfr) and dihydropteroate synthase (Pfdhps) genes that confer resistance to pyrimethamine and sulfadoxine respectively showed that the majority of field isolates in the Northern Province (88 percent) as well as in other areas of the country (75 percent) were double mutants (C59R + S108N) in Pfdhfr. Overall, 18 percent were also mutants in Pfdhps, especially at codon 581 (A581G). Despite the absence of clinical failures with S-P, in vitro yeast expression assay showed a 860-fold higher mean IC50 value for pyrimethamine in the double mutants than in wild type isolates in the Northern Province. In vitro response of those double mutants closely resembled that of yeast cells dependent upon a triple mutant (N51I + C59R + S108N) reference isolate, indicating impending clinical failure to S-P in the country. These results suggest that the mutant codon at residue 51 of Pfdhfr will be the potential marker of imminent S-P clinical failure in Sri Lanka. In conclusion, recrudescent infections appear to drive the phase of tolerance during the evolutionary process of antimalarial resistance as suggested in the "STR model", while primary infections appear to drive the phase of complete resistance in this area. By causing more clinical episodes, chloroquine resistant primary infections probably induce immunity against malaria among individuals, optimizing the evolutionary process of virulence at an intermediate level. A close inter-relationship was evident in P. falciparum genetic structure, antimalarial resistance, clinical disease and disease transmission in the Northern Province. Continued use of chloroquine probably drives the vicious cycle of increasing antimalarial resistance and virulence in the Northern Province. Thus, these results highlight the need to change the current antimalarial therapy in Sri Lanka, particularly in the Northern Province in order to contain the further spread of antimalarial resistance in the country.Item Gastric myoelectrical activity, gastric emptying time and oro-caecal transit time in children with Recurrent Abdominal Pain Syndrome(University of Kelaniya, 2006) Devanarayana, N.M.Recurrent abdominal pain syndrome is a common paediatric problem affecting approximately 10 percent children and adolescents worldwide. The exact aetiology of this troublesome syndrome is unclear in the majority of patients affected by this condition and attempts have been made to classify them into functional gastrointestinal diseases using Rome II and III criteria. Few studies have demonstrated gastrointestinal motility abnormalities in affected individuals. Despite the magnitude of the problem, knowledge on the effective management options is poor. This thesis attempts to answer some of the issues on pathophysiology and management of recurrent abdominal pain syndrome. The epidemiology and aetiology of recurrent abdominal pain syndrome in Sri Lankan children and adolescents was not known. An epidemiological survey was carried out in four randomly selected schools in Gampaha District of Sri Lanka using self-administered parental questionnaire. The study included 734 school children between 5 to 15 years and the prevalence, clinical profile, health care consultation behaviour, risk factors for recurrent abdominal pain syndrome, and its impact on education were determined. The epidemiology of childhood recurrent abdominal pain syndrome in Sri Lanka (prevalence 10.5 percent) is similar to other countries, except for health care consultation behaviour (70 percent ), which is higher than reported in previous studies. Fifty five recurrent abdominal pain patients identified in the epidemiological study were recruited for an aetiological investigation to detect possible organic and functional causes for recurrent abdominal pain. Clinical and laboratory evaluation revealed organic pathology in less than 24 percent of the affected children, and the majority had functional gastrointestinal diseases. A case control study to detect a possible association between Helicobacter pylori infection and recurrent abdominal pain syndrome performed in 39 patients and 20 healthy controls did not show a significant association between the two conditions. Gastrointestinal motility abnormalities have been suggested as a possible cause for symptoms in patients with non-organic recurrent abdominal pain, but very few studies have been done to prove or disprove this. Case controlled studies were performed in 42 patients and 20 healthy controls to investigate an association between gastric myoelectrical activity (electrogastrography), gastric motility (gastric emptying and antral motility), and oro-caecal transit (small intestinal transit) and non-organic recurrent abdominal pain. The results showed significantly decreased gastric emptying, decreased antral motility and delayed oro-caecal transit time in patients suggesting that gastrointestinal motility abnormalities may be responsible for generation of symptoms in non-organic recurrent abdominal pain. High dietary fat is proven to delay gastric emptying and small intestinal transit, and known to induce gastrointestinal symptoms in patients with functional gastrointestinal disease. Low fat diet has been suggested as a therapeutic option in patients with functional dyspepsia. There were no studies published on the value of a low fat diet in patients with recurrent abdominal pain. A single blind, randomized, controlled trial was conducted to investigate the therapeutic value of a low fat diet on 42 patients with non-organic recurrent abdominal pain. The results demonstrated a possible therapeutic value of low fat diet on recurrent abdominal pain patients with delayed gastric emptying.Item Isolation and characterization of influenza viruses circulating among avian, swine and human populations in Sri Lanka(University of Kelaniya, 2007) Perera, K. V. H. K. K.Ecological and phylogenic studies suggest that wild waterfowl are the natural reservoirs of influenza A viruses. All HA and NA subtypes are found in avian species especially wild aquatic birds, whereas viral subtypes of mammalian influenza viruses are limited. Restricted growth of avian influenza viruses in mammalian species is thought to be a barrier to the emergence of new pandemic strains with direct avian to human transmission. In Sri Lanka, although epidemiological and virological studies on outbreaks of influenza on humans have been carried out, there are no reported data on influenza subtypes circulating among human, swine and avian populations during any specified periods. In this study 300 nasopharyngeal aspirates (NPA) obtained from human patients with acute respiratory tract infection, 750 cloacal samples, 750 tracheal samples and 750 blood samples from birds , and 300 tracheal and 300 blood samples from pigs were analyzed to identify the influenza subtypes circulating among these different populations in the country. Of the 300 NPA samples, 138 were screened by the indirect immunofluorescence test followed by the direct immunofluorescence test (DFA) to identify the viral etiological agents responsible for the infection: Influenza A (20/138), para influenza group (2/138), adeno (3/138) and respiratory syncitial virus (3/138) were identified. All 300 NPA samples were inoculated on to MDCK cell cultures and haemagglutination and DFA test were performed on the cultures that showed CPE: 24 Influenza A and 9 Influenza B viruses were isolated and were characterized as Influenza A Panama/2000/99 (H3N2) and Influenza B/Sichuan/379/99-like virus, using reference antisera supplied by the World Health Organization. One virus (Influenza A/swine/Sri lanka/48/04) was isolated from a pig brought to the Government slaughter house in Dematagoda and was sub-typed as H3N2. Genetic studies carried out on this isolate showed that this virus was identical to the H3N2 viruses isolated in humans during the study period. Serological analysis revealed that 61.66 percent of the sampled population also had antibodies to this virus and that none had antibodies to the common subtypes of swine influenza A viruses namely, A/HK/4167/1999 H1N1, A/HK/2422/1998/H3N2 Sydney-like and A/HK/1774/1999 Europian swine-like control viruses. Influenza viruses could not be isolated from the tracheal and cloacal samples collected from poultry when the samples were inoculated into 9-11 day old embryonated eggs. However, the serum collected from this avian population when tested in a HAI assay using H6 (1720) and H9 (Y280) reference antigens, showed evidence of infection with both these subtypes: 12.8 percent (96/750) and 5.2 percent (39/750) of birds had antibodies against A/quail/HK 1721-30/99 (H6N2) and H9 A/duck/ Hong Kong /Y280 (H9N2) subtypes respectively and 3.6 percent had sero-converted to both subtypes of viruses indicating dual infection.Item Studies on Mycoplasma pneumoniae infections among patients with respiratory illness in Sri Lanka(University of Kelaniya, 2007) Wijesooriya, W. R. P. L. I.Mycoplasmas represent the smallest self-replicating organisms known on the planet. Mycoplasma pneumoniae is the most important human mycoplasma pathogen causing a range of respiratory tract infections including pneumonia. M. pneumoniae causes 50% of primary atypical pneumonia, of primary atypical pneumonia contributing to 15-20% of community acquired pneumonia (CAP).. Apart from pulmonary involvement, it is associated with a range of extra pulmonary manifestations namely; encephalitis, cerebellar syndrome, aseptic meningitis, erythematous / maculopapular rashes, arthralgias, polyarthropathies, myocarditis, pancreatitis, haemolytic anaemia, glomerulonephritis, conjunctivitis etc. As M. pneumoniae does not have a cell wall like bacteria, the conventional treatment (e.g. penicillins) for CAP is not effective. Hence there is a need for prompt and correct diagnosis for effective treatment. As the diagnosis relies on laboratory tests, these may take time. Therefore empirical therapy that is guided by the prevalence data of the particular locality may facilitate treatment. This study was carried out at the North Colombo Teaching Hospital, Ragama and the chest hospital, Welisara during the period from September 2003 to August 2004. The study was to determine the prevalence of M. pneumoniae infection among patients with respiratory tract infections - particularly in three patient groups (pneumonia, acute bronchitis, sore throat) and a control group. Each group consisted of 200 patients. Paired serum samples were obtained from each group for serology antibody tests using M. pneumoniae specific Enzyme-Linked Immunosorbent Assay (ELISA) (isotype specific) and Cold Agglutinin Test (CAT). Respiratory samples from each individual at first sampling were used for detection of M. pneumoniae DNA. Serologically confirmed cases of M. pneumoniae with age and gender were matched with serologically negative group of patients selected for M. pneumoniae DNA PCR. CAT was performed only for patients with pneumonia at acute stage. The prevalence of M. pneumoniae infection by antibody test was 15.5%, 6.6% and 1.2% in patients with pneumonia, acute bronchitis and sore throat respectively. M. pneumoniae DNA was detected in 52% of serology confirmed cases and 15 % of serology negative cases. CAT was positive in 20% of serology positive patients and 20% of serology negative patients. Isotype specific antibody assays are helpful for extended diagnosis. Detection of specific IgM in one sample enabled diagnosis but paired sera was necessary to demonstrate seroconversion when testing for specific IgG. In the study, IgA was shown to be a better indicator of severe infection as this antibody class was observed only in patients with pneumonia. However, specific IgA detection showed low sensitivity. PCR was available to diagnose 15% (4/26) serologically negative patients but it missed serologically positive patients. The combination of antibody serology and PCR detection for M. pneumoniae DNA enabled effective laboratory diagnosis in the clinical setting. The CAT was found to offer no distinct advantage and was no longer recommended even as a bed side screening test due to its poor sensitivity and specificity. In the treatment of pneumonia, the decision on empirical antibiotic regime needs to consider the prevalence rate (15.5%) of most common atypical bacterium M. pneumoniae in Sri Lanka.Item Effects of zinc on human semen quality and sexual behaviour of male rats(University of Kelaniya, 2008) Dissanayake, D.M.A.B.The main aim of this study was to evaluate the effects of serum and seminal plasma zinc levels on semen quality of a subfertile male population. At the same time, effects of zinc on different aspects of male reproduction were studied. The study was carried out as a prospective hospital and laboratory based study. Semen samples from 152 males were analyzed. Seminal plasma and serum levels of zinc, serum hormone levels, seminal plasma fructose and neutral a- glucosidase levels of same males were also measured. Relationship between seminal plasma zinc and semen quality was observed using two markers; zinc concentration and total zinc per ejaculate (Total zinc). Effects of zinc on various functions of spermatozoa were studied in-vitro and, the effects on sexual competence of males were observed using a rat model. Of the 152 semen samples 55 (36 %) were normozoospermic and 97 (64 %) were pathozoospermic. The mean (SD) serum and seminal plasma zinc concentrations of the population were 0.94 (ig/ml (0.36) and 121.87 (ig/ml (69.13) respectively. Seminal plasma total zinc was significantly low in samples with low volume and hyperviscosity compared to samples with normal volume and viscosity; 139.72 ]ig (73.72) vs. 377.40 (ig (231.06), p < 0.01 for volume and 220.06 jag (144.09) vs. 336.34 |Ag (236.33), p < 0.05 for viscosity. Conversely significantly high amount of total zinc was found in low viability group compared to normal; 437.67 ug (283.88) vs. 305.15 (ig (221.19), p < 0.05. Percentage of pathozoospermics and volume abnormalities were significantly higher in abnormal total seminal zinc group compared to normal (pathozoospermics, 27 % vs. 7.3 % and volume abnormalities, 55.3 % vs. 8.8 %, p < 0.05). Mean zinc concentratiorfwas significantly high in Asthenozoospermics compared to normal motile group; 138.11 u.g/ml (83.92) vs. 110.69 11 fig/ml (54.59), p < 0.05. Significantly positive correlations were found between total seminal plasma zinc and volume (r = 0.53, p < 0.01) as well as total sperm count (r = 0.21, p < 0.05). whereas correlation between seminal zinc and pH was inverse (r = -0,193, p < 0.05 for zinc concentration and r = -0.280, p < 0.01 for total zinc). In contrast serum zinc levels correlated positively with seminal plasma pH (r = 0.167, p < 0.05). Gonadotropin levels were significantly high in azoospermics compared to normozoospennics; LH - 12.82 mlU/ml (11.82) vs. 5.90 mlU/ml (2.78), FSH - 19.69 mlU/ml (9.93) vs. 4.18 mlU/ml (2.78), p < 0.05). FSH level was inversely correlated with sperm concentration (r = -0.203, p < 0.05) and total sperm count (r = -0.206, p < 0.05). There was an inverse correlation between seminal plasma zinc concentration and serum PRL levels (r = -0.198, p < 0.05). Serum zinc concentration showed a negative correlation with serum T levels (r = -0.207, p < 0.05). Both fructose concentrations and total fructose were significantly low in abnormal volume group compared to normal; 15.30 u.mol/ml (1.52) vs. 44.27 umol/ml (2.44) for fructose concentration and 19.06 umol (2.39) vs. 160.63 umol (16.0) for total fructose, p < 0,0001. Mean fructose concentration was significantly high in oligozoospermic group compared to normal; 45.33 umol/ml (5.02) vs. 35.07 umol/ml (2.39). p < 0.05. Total neutral a -glucosidase activity was significantly low in low volume group compared to normal; 55.37 mU (8.79) vs. 140.93 mU (15.36). p < 0.0001. Seminal plasma total zinc positively correlated with total fructose (r = 0.378, p < 0.001), and NAG (r = 0.247. p < 0.001). In-vitro incorporation of zinc. > 5.0 umol/ml into the processed sperm samples and, > 10 umol/zinc into unprocessed sperm samples, caused an impairment of the progressive motility of sperms. Incorporation of 1.2 umol/ml of zinc into sperm culture medium exerts a significantly beneficial effect on sperm recovery rate. The mean post wash sperm concentration showed an increase in the 1.2 umol/ml of zinc added group compared to the zinc devoid sample; 21.87 million/ml (6.61) vs. 18.34 million/ml (9.73), p < 0.05. The percentage of hyperactwated sperm also increased in 1.2 umol/ml zinc added group compared to zinc devoid group; 46.70 % (3.80) vs. 38.83 % (3.56), p < 0.05. In behavioural studies, supplementation of zinc (5 mg/day) for two weeks led to a prolonged ejaculatory latency; 711.6 Sec. (85.47) vs. 489.50 Sec. (67.66), p < 0.05 and an increase in penile thrusting compared to controls; 52.80 Sec (11.28) vs. 26.50 Sec (6.17), p< 0.05. Similarly the PRL and T levels were significantly increased after the treatment period compared to hormone levels before the treatment; PRL - 7.22 ng/dl (3.68) vs. 2.90 ng/dl (0.34) and T - 8.21 ng/ml (6.09; vs. 2.39 ng/ml (1.79), p < 0.05. In conclusion, this study revealed that zinc is beneficial in male reproduction in different aspects.Item Atopy, allergic diseases and soil transmitted nematode infections in children in Sri Lanka(University of Kelaniya, 2009) Amarasekera, N.D.D.M.Allergic diseases in children are a common paediatric problem affecting approximately one third of children worldwide. Attempts have been made to explain the rising prevalence of allergic diseases, of which the "Hygiene Hypothesis" gained much attention. Though an inverse association between a variety of infection and allergy has been demonstrated, the relationship between helminth infections and allergy remains unclear. A cross-sectional study was carried out in 640 school children selected by stratified random sampling from schools in the Western Province. Data regarding allergic diseases was collected using a validated questionnaire. Children were assessed for intestinal helminth infections by examining their stool samples using the modified Kato-Katz technique. Total IgE and specific IgE for a panel of five allergens (Dermatophagoides pteronyssinus, Blomia tropicalis, cockroach, cat dander and grass pollen) were studied using ImmunoCAP technique in a sub sample of 203. Prior exposure to Toxocara was determined using a commercially available ELISA kit, which detected IgG antibodies. A prevalence of 33.7% for allergic diseases (asthma, rhinitis and eczerna) was observed. Rhinitis was the commonest disease (21.4%). 15.5% of children had one or more intestinal nematode infections. 66.7% of children had antibodies indicative of prior exposure to Toxocara, while 30.6% had evidence of recent infection with Toxocara. Total IgE levels in our study population were intermediate between African and Western populations, but higher than other Asians. The levels were higher in children with intestinal nematode infections and those who were exposed to Toxocara. Total IgE correlated poorly with allergic disease status in the presence of helminth infections. 80.3% of children were found to be sensitized to one or more of the allergens tested; most commonly to dust mites. Children with rhinitis or eczema (but not asthma) were more likely to be sensitized to cat dander. No association was found between sensitization and helminth infections in our study population. Multivariate analysis using logistic regression showed that after adjusting for sex and atopy, children with intestinal nematode infections (especially trichuriasis) had a lower risk of having atopic diseases, especially asthma. Seropositivity for Toxocara spp. was not found to be associated with any atopic disease or atopy.Item The relationship between asthma and gastro-oesophageal reflux disease(GORD) in a Sri Lankan population(University of Kelaniya, 2009) Amarasiri, W.A.D.L.Gastro-oesophageal Reflux Disease (GORD) predisposes to asthma-like respiratory disease through several mechanisms all of which are thought to be vagally mediated. This study attempted to extend the current understanding of the relationship between GORD and asthma by investigating the prevalence of GORD symptoms, prevalence of upper gastrointestinal motility abnormalities and possible mechanisms of GORD-induced asthma in a group of adults with mild clinically stable asthma in Sri Lanka. The prevalence of GOR symptoms using an interviewer administered GORD questionnaire was 59.4 % in Sri Lankan adult asthmatics. The frequency and severity of GOR symptoms were higher and reflux associated respiratory symptoms were more prevalent in asthmatics when compared to non asthmatics. The severity of asthma showed a strong dose-response effect on the presence of GORD symptoms in asthmatics, though the use of asthma medication did not significantly influence the presence of GORD symptoms. This study reports the development and validation of the first interviewer administered GORD-specific questionnaire in Sri Lanka. This could be used as a case-finding tool in epidemiological studies and be used to assess the response of individuals to treatment. A GORD symptom score using both symptom frequency and severity was found to correlate better with an objective measure of GORD. Using stationary oesophageal manometry and twenty four hour ambulatory pH monitoring, this study demonstrated that asthmatics have abnormal oesophageal motility and increased gastro-oesophageal reflux compared to non-asthmatic healthy volunteers. Asthmatic were seen to have more proximal oesophageal reflux and experience reflux-associated respiratory symptoms, and in most instances, reflux episodes preceded the respiratory symptoms. The presence or severity of GORD symptoms or oesophagitis did not influence the abnormal oesophageal function parameters. Using cutaneous electrogastrography and real-time ultrasonography, this study gives the first report on gastric myoelectrical activity and gastric emptying in asthmatics. Asthmatics have more gastric myoelectrical abnormalities, a significantly lower percentage of gastric emptying and impaired antral mortility in response to both solid and liquid meals compared to non-asthmic healthy volunteers. The antral mortility index and gastric emptying rate of a liquid meal was positively correlated with lower oesophageal sphincter tone in asmatics supporting the theory that delayed gastric emptying and impaired antral mortility induces reflux. Asthmatics with higher GORD symptom scores had lower gastric emptying rates and more abnormal mortility in response to the solid meal. Finally, this study reports the first demonstration of vagal function following intra-oesophageal acid infusion in asthmatics. Asthmatics demonstrated a higher vagal response and a concomitant bronchoconstrictive response to artificially infused oesophageal acid when compared to infusion of normal saline, irrespestive of reflux state.Item Olfactory impairment in early dementia(University of Kelaniya, 2009) Williams, SIntroduction:The clinical significance of olfactory dysfunction in relation to early dementia has not been adequately studied before despite various studies demonstrating olfactory dysfunction in relation to neurodegenerative disorders especially dementia and more recently, mild cognitive impairment(MCI). Objectives: The objective of this study was to identify olfactory deficits in MCI, Alzheimer's disease (AD) and Dementia with Lewy bodies (DLB) and any differential effects. The specific focus being on establishing the utility of olfactory testing in differentiating MCI from normals, MCI from early AD and especially early DLB from early AD. Methods:We recruited patients with early AD(27), early DLB(21), MCI(21) and elderly normals(47) for our study. They were assessed using a 16 item olfactory identification test, an olfactory threshold test using sticks impregnated with differing concentrations of butanol, and an olfactory hedonic tone test with differing concentrations of isoamyl acetate/valeric acid. They also underwent a cognitive battery including the MMSE, HVL T, CLOX testing and a CAMDEX Learning work up when necessary. Medial temporal lobe volume estimation using temporal lobe oriented CT scans and Apolipoprotein E(APOE) status was determined. Results: Patients with MCI, AD and DLB had clinically significant olfactory deficits when compared with normal controls. Patients with mild DLB had the worst olfactory identification ability compared to those with mild AD or MCI, independent of age, cognitive function and sex. Olfactory tests showed useful discriminatory ability between AD and DLB. The decline in left medial temporal lobe width correlated with impaired olfactory function in those with MCI and AD. Smell identification score was a better predictor of AD and MCI from normals, than MTL width. APOE status in conjunction with olfactory dysfunction improved the sensitivity and specificity of a diagnosis of AD from normals. Conclusion: Simple bedside tests of olfactory identification demonstrate significant impairment in MCI, early AD and early DLB. These findings have diagnostic significance particularly in early detection. Smell tests are easier to apply across populations with different educational, language and cultural backgrounds, in comparison to cognitive tests which need extensive validation in different settings. Those with DLB are the most effected and the combination of olfactory dysfunction to existing criteria for diagnosis of DLB has the potential to improve ante-mortem detection of the condition. This has implications for treatment as those with DLB show better response to treatment with choline esterase inhibitors.Item The ileocaecal valve-functional morphology, blood supply and pressure charasteristics in humans(University of Kelaniya, 2009) Fernando, E.D.P.S.INTRODUCTION: The function of the ileocaecal valve still remains controversial, especially the importance of preservation of the valve during right hemicolectomy. This research was carried-out with an objective to study manometric characteristics combined with videography and the neuronal density to assess the capability of this structure to function as a sphincter. A detailed study of the arterial supply of the ileocaecal region was also done with a view of exploring the possibility of a modified right-hemicolectomy with a preserved ileocaecal valve with adequate arterial blood supply to the anastomosis. PATIENTS AND METHOD - The ganglion density of the ileocaecal region was studied in 73 cadavers within 12 hours of death using haematoxylin and eosin staining. The manometry of the ileocaecal region was studied using a water-filled balloon catheter in twenty-one individuals who underwent colonoscopy. Mean intra-luminal pressure (area under the curve/ duration) was also measured during this procedure. Further more, valve videography was performed in thirteen individuals. Fifty-four fresh human cadavers were studied with informed written consent from relatives. In this study, 20cm of terminal ileum with the ileocaecal segment and approximately 20cm of ascending colon were removed en-block with its mesentery and blood supply. The ileocolic artery was cannulated and injected with 10ml of water-soluble red-dye under pressure. The arterial supply was dissected to demonstrate a pattern. RESULTS: Study on density of the ganglia of myenteric plexus in the ileocaecal region Of 73 specimens studied, the ileocaecal valve had the highest number of ganglions found in one mm of area (mean 0.491 ganglions/mm ; SD 0.283). The terminal ileum had a mean of 0.322 ganglions/mm2; SD 0.209. The least number of ganglia was found in the caecal sections (mean 0.241 ganglions/mm ; SD 0.166). These findings showed a statistically significant (P<0.0001) higher number of ganglions per mm2 in the ileocaecal valve (ICV) than in the terminal ileum or caecum. Study of the pressure gradient across the ileocaecal valve in normal adults: In twenty individuals (95%), the intra-ileal pressure exceeded the intra-caecal pressure {ileal pressure [mean 4018.77, S.D. 4386.51] Pa vs. caecal pressure [mean 1742.64, S.D 4537.54] Pa}, P<0.001. Ante-grade pressure gradients were observed from terminal ileum to caecum in fifteen participants (71%). In five (24%), a high-pressure zone was observed within the ileocaecal valve. A reverse gradient was seen in one (5%). Study of the ileocaecal valve cusp movements in live normal adults using video ecordings during colonoscopy: Videography of the ileocaecal valve was analyzed in thirteen subjects for a total of 121 minutes (mean 9.3 minutes per subject). The valve orifice was observed to be at rest during alternating periods of contraction. Contractions of the valve cusps seemed to change the shape of its orifice. In 11 subjects, during the resting period of the valve, the orifice was semilunar and either closed or partially closed. These subjects had a longer and more curved superior cusp. The valve cusps were thickened in six subjects, while seven had narrow valve cusps. In all, 60 (mean — 5 per subject) active movements were observed in the ileocaecal valve cusps with 14 active caecal contractions. The frequency of active movements of the valve was 0.5 movements per minute. The ejection of effluent was observed on 49 occasions (mean - 4 ejections per XV subject). Chyme was ejected in 15 instances and air in 34 instances. The ejection of effluent was always associated with active movements of the valve cusps. By contrast, some cusp movements were observed to be independent of the onward flow of effluent. Caecal wall contractions were found to be less frequent and were observed on 14 occasions. Study of the arterial supply of the ileocaecal region: In fifty-six cadaveric specimens, the ICV was supplied by the ileocolic artery, a branch of the superior mesenteric, which divided into an anterior and a posterior caecal artery. A marginal branch of the right colic was noted to contribute to the ICV blood supply in only two (4%). Furthermore, study of the anastomosis at the ICV showed that the anterior caecal artery was present in all (100%), posterior caecal in 48(89%) and recurrent ileal artery present in fifty-three (98%). A rich anastomosis between vessels at the ICV: small 'windows', short tributaries, was seen in thirty-eight (70%) whilst a poor anastomotic network at the ICV: large 'windows', long tributaries, between these vessels was seen in twelve (22%). In four (8%), we were unable to determine clearly between rich and poor anastomotic networks. Other variants included an absent posterior caecal artery in six (11%) and absent recurrent ileal artery in one (2%). CONCLUSIONS: Manometry of the ileocaecal valve revealed a flap valve with an ante-grade pressure gradient in the majority. A reverse pressure gradient may explain valve incompetence. The ileocaecal valve had a predictable blood supply in the majority of patients. Preservation of the anterior caecal artery would ensure a vascularized ileocaecal valve in right hemicolectomy.Item Study on effect of silent transmission and clustering of cases on the transmission of dengue virus in gampaha and kurunegala districts, Sri Lanka(University of Kelaniya, 2010) Hapangama, H.A.D.C.Dengue infection has been an important flaviviral infection in Sri Lanka and is considered as an emerging and re-emerging disease causing epidemics from time to time. During the last 20 years hyperendemic transmission has been established over a geographically expanding area. Transmission of dengue virus is known to be influenced by overlapping and reinforcing factors related to human host, virus and mosquito vector. Present study is on the effect of silent transmission, clustering of dengue cases and the role of Aedes vectors on transmission of dengue in Gampaha and Kurunegala Districts of Sri Lanka. The present study was carried out using the cluster investigation method. Index clusters were selected from hospital based dengue cases. Control clusters were selected from low dengue transmission areas. Cluster enrolees recruited were residing within 100 m radius from the index case and blood samples and demographic data were collected. At each household, adult and larval mosquito surveillance was also carried out. Volunteer samples were tested for recent dengue infection by IgM EL1SA. A selected set of sera were tested for dengue Ag by Ag detection ELISA, and for dengue viral RNA by RT-PCR and Semi-Nested PCR. ffA I assay was done as a confirmatory test. Of the 629 volunteers recruited from 30 index clusters, 90 (14.3%) were positive for recent dengue infection while none of the 310 volunteers of 15 control clusters were positive. Of the 90, asymptomatic dengue infection was observed in 49 (54.4%) indicating symptomatic to asymptomatic rate of infection was 1:1.2 in the study locations. Previous dengue infected volunteers were more vulnerable to infection (r2=2.19, p<0.00!) and age was the most important factor determining asymptomatic infections (r=0.672, pO.OOl). Irrespective of the gender, dengue exposed population over 40 years of age were more likely to be asymptomatic (x2==21.87, pO.OOl). Of the 33 paired sera tested by HAI assay, dengue virus infection was confirmed in 4 volunteers, of them 3 were asymptomatic confirming the presence of silent transmission in the study population. Level of IgM antibody was less among asymptomatic volunteers compared to symptomatic volunteers and hospitalized patients (F=16.05, pO.OOl). Study confirmed the clustering of dengue cases around index cases (t=5.06, pO.OOl). Dengue infections were clustered centrally close to the index patient's house (F=5.894, pO.OOl) with a significant trend towards household risk of infection. There was a significant correlation between the presence of dengue infection with breteau index (+0.372) and Aedes albopictus was found in 70% of the localities. Of the 40 adult Aedes mosquito pools (3 Ae. Aegypti and 37^1e. albopctus) collected from index cluster localities, only one pool (Ae. albopictus) was positive for dengue viral RNA and it was found to be of dengue serotype 2 (DEN-2). Study confirms the presence of asymptomatic dengue infections, clustering of dengue cases and the probable role of Ae. albopictus on dengue transmission leading to silent spread of the disease.Item Molecular and entomological studies on the transmission and detection of lymohatic filariasis in Gampaha district, Sri Lanka(University of Kelaniya, 2010) Wijegunawardana, N.D.A.D.Entomological and epidemiological tools are considered important to monitor the chemotherapy-based filariasis eradication programs aimed at stopping the transmission of Wuchereria bancrofti by its obligatory mosquito vector. Objectives of this study were the comparison of dissection of mosquitoes and Polymerase Chain Reaction Enzyme-Linked Immunosorbent Assay (PCR-ELISA) tools for the detection of parasitic filariasis infections, identification of current epidemiological status in the Gampaha District, Sri Lanka. Field study was conducted in 45 sites in all Medical Officer of Health (MOH) areas in the Gampaha district, Sri Lanka; identified by the Anti Filariasis Campaign (AFC) as having high-risk for bancroftian filariasis transmission. Indoor-resting Culex quinquefasciatus mosquitoes were collected by aspiration from 20-30 houses per each site. Part of the mosquitos was used for dissection and the remainder was used for PCR-ELISA to detect the filarial parasites in C. quinquefasciatus mosquito. According to the results a total of 175 W. &a«cro/h"-infected mosquitoes were found in 32 batches (out of 90 batches), giving an overall infection rate of 8.20%. The site wise prevalence of infected and infective larvae ranged from 0% to 46.88% and 5.29% respectively, with a mean larval density of 5 larvae per infected mosquito. A total of 4050 mosquitoes in 270 pools of head, thorax and abdomen were processed by PCR-ELISA during two study periods. A significantly higher overall infection rate was observed in head and thorax pools than in abdomen pools (p = 0.05) (13.7% head, 14,4% thorax and 2.2% abdomen pools). Point estimates of prevalence of W. bancrofti infected C. quinquefasciatus mosquitoes, as assayed by PCR-ELISA, ranged from 0% to 62.96% and 55.56% respectively for the two study periods. Mosquito infection rates as assayed by PCR-ELISA for the two consecutive study periods were 12.59 and 7.65 respectively. The association of dissection based prevalence rates with PCR based rates as determined by the Pearson correlation coefficient were 0.176 and 0.890 for two study periods. Furthermore, the probability associated with a Student's paired t-test, with a two-tailed distribution for the infection prevalence rate resulted by dissection and PCR-ELISA were 0.394 and 0.023 respectively for the two study periods. Following mass treatment, W. bancrofti infection prevalence had not reduced significantly as observed by these two methods (P = 0.05 and P = 0.005). As an average, for two study periods, of the 30 sentinel sites, 41.7% was having C. quinquefasciatus mosquitoes positive for W. bancrofti transmission whereas it was 36.7% for the non-sentinel sites. Of the 1073 participants (286 children, 787 adult) screened, 6 were positive in 2 sites (Hekitta and Pethiyagoda) for mf, respectively giving microfilaremia prevalence rates of 0.5% and 3.4% which were greater than the country's present rate (0.18%). Also mean mf density (mf/60 ul blood) of 2 and 7 per positive slide were observed from above two sites respectively. The overall results indicated that PCR-ELISA could be used as a powerful entomological tool for rapid assessment of lymphatic filariasis transmission in endemic areas of Sri Lanka, and it was more sensitive than the traditional dissection technique.Item Extra-hepatic biliary-systems morphology, demographical charasteristics and surgical outcome in patients who undergo laparoscopic cholecystectomy for symptomatic galldladder disease(University of Kelaniya, 2010) Abeysuriya, V.INTRODUCTION: This study consists of descriptive-prospective cross sectional studies, which assessed the extra-hepatic biliary system morphology in human cadavers and patients, who underwent laparoscopic cholecystectomy for symptomatic gallstone disease, demographic characteristics of those patients, clinical manifestation in gallstone disease, pre and post symptomatic profile and surgical outcome of laparoscopic cholecystectomy. The outcome of endotherapy in iatrogenic bile duct injuries and microflora in human bile was assessed in separate studies. METHODS: A descriptive-prospective cross sectional study was performed in 60 fresh cadavers and 200 patients, who underwent LC for symptomatic gallstone disease with a view to observing variations in GB, cystic duct (CD), cystic artery (CA) and Calot's triangle. The patients were further evaluated for demographic characteristics, clinical symptoms, safety, efficacy, and morbidity of surgical procedure. Micro-flora and antibiotic sensitivity were assessed by a descriptive analytical study of 70 bile samples (35 cholesterol and 35 pigment stones) of patients who underwent laparoscopic cholecystectomy for uncomplicated cholelithiasis, and 20 controls who underwent laparotomy and had normal gallbladder ultrasound scans and no demonstrable stones. Another prospective descriptive study was done of 30 patients, who underwent therapeutic endoscopic procedures for iatrogenic injuries following laparoscopic cholecystectomy for symptomatic gallstone disease at the National Hospital of Sri Lanka to evaluate the endotherapeutic outcome. SETTINGS OF STUDY: Departments of Anatomy, Surgery, Microbiology, Pathology and Public Health, Faculty of Medicine, Ragama, University of Kelaniya. Departments of Anatomy, Surgery, Faculty of Medicine, University of Sri Jayawardenapura. Department of Surgery, Faculty of Medicine, University of Colombo. Department of Gastroenterology and Endoscopy, The National Hospital of Sri Lanka. Colombo North Teaching Hospital. Colombo South Teaching Hospital. Sri Jayawardenapura Teaching Hospital. STATISTICAL ANALYSIS: In descriptive studies, data were expressed as mean, Standard error of mean, median, range and frequencies. Data were analyzed using Statistical Package for Social Sciences ll(SPSS) (SPSS 11.0, Chicago, Illinois, USA). Significance was assigned to ap-value <0.05. ETHICAL CLEARANCE: Ethical clearance committee, Faculty of Medicine, Ragama, University of Kelaniya. Ref: P13/05/2006. Title: Extra-hepatic biliary system morphology, demographical characteristics and surgical outcome in patients who undergo laparoscopic cholecystectomy for symptomatic gallbladder disease.Conflict of interests: None Self finance RESULTS: The descriptive cadaveric study revealed that there were no intra-hepatic gall bladders or left-lobe situated gallbladders. The mophometry showed that the mean length and the width of the gallbladder was 6.48cm (range: 4.5cm - 9cm) and 3cm (range, 2.5cm - 4.5cm) respectively. The mean length and the inner diameter of the cystic duct was 2.5cm and 2.6mm respectively. The angular mode (flat down) union of cystic duct and the common hepatic duct were found to be the commonest type (84%). The mean lengths of the right and left hepatic ducts were 1.33cm and 1.32cm respectively. The mean length and the inner diameter of the common hepatic duct were 2.4cm and 3.8mm respectively. The mean length and the inner diameter of the common bile duct was 6.26cm and 7.86mm respectively. Hepato-Cystic ducts were found in 3.3% of the specimens. The mean lengths of right and left hepatic arteries were 2.8cm and 2.3cm respectively. The mean length of the proper hepatic artery was 3.1 cm. The mean length of the cystic artery was 1.4cm (range, 0.9cm - 2.1 cm) before its division into anterior and posterior branches. Seventy-five percent of the cystic arteries originated as a single artery from the right branch of the hepatic artery, while, 43% of the specimens of the right hepatic artery was lying in the triangle of Calot's. Among the patients who underwent LC, transversely septate, sessile and bipolar gall bladders were found in 1%. Agenesis of the gallbladder was not seen. Among the patients, 1% each had no cystic ducts or dual cystic ducts. The angular mode (flat down) of union of cystic duct and the common hepatic duct was found to be the commonest at 96%. Three percent had connective tissue ensheathing both the cystic duct and the common hepatic duct. The flat horizontal and parallel courses of cystic ducts were noted in 3% and 1% respectively. Eighty-nine percent of the cystic arteries originated as a single artery from the right branch of the hepatic artery. The origin of the cystic artery revealed that 5% had two cystic arteries originating separately from the right hepatic artery. The pathway of the cystic artery showed that 5 % had passed anterior to the common hepatic duct and 1% traversed over the cystic duct duct. Forty-one percent of the right hepatic artery lay in the triangle of Calot's, while, 2% had the right hepatic artery running over the common hepatic duct. Two-hundred patients were recruited for the demography, i.e. 162 women and 38 men whose age averaged 39.1 years (range, 17 to 77 years). All patients had symptomatic gallstone disease. The socio-demographic data revealed that most of the patients were either in grade 1 or 2 with regard to their level of income. The level of education among the patients was satisfactory, most of them being in the grade 2 and 3 levels of education. With regard to the surgical outcome and safety of the technique and its efficacy, the mean operating time was 48.5 ± 20 minutes and the mean hospital stay was 37.6 hours. Post¬operative pain relief requirements were limited to oral medications in more than 70% of the patients. A normal diet was tolerated by 83% of patients by the morning following the procedure. Median time of return to full activity was 10.8 ± 5.8 days after operation. In addition an analysis of the hospital-costs of these 200 cases demonstrates a modest cost advantage over standard open cholecystectomy (n = 38) (mean, Rs.3620.25 ± 1005.00 versus Rs.4251.76 ± 988.00). There were four cases of bile duct injury requiring laparotomy and t-tube insertion, three postoperative bile collections and one clinical diagnosis of a retained stone that passed out spontaneously. Four patients required conversion to open cholecystectomy because of technical difficulties with the dissection. No deaths were recorded. With regard to the clinical manifestations and symptomatic outcome of laparoscopic cholecystectomy, the symptoms that were relieved by cholecystectomy were nausea, vomiting, colicky abdominal pain, and back-pain. Flatulence, fat intolerance, and nagging abdominal pain were unaffected as shown by a benefit ratio. Post-cholecystectomy diarrhoea occurred in 11% of patients. The type of surgical access did not influence the symptomatic outcome but had a significant bearing on the time to return to work or full activity after surgery (laparoscopic cholecystectomy two weeks, open cholecystectomy eight weeks, P=0.001). Patient appreciation of a satisfactory cosmetic result was 72% in the open group compared to 100% in the case of patients who were treated by laparoscopic cholecysteetomy (P=0-001). In the assessment of microbiology of gallbladder bile in patients with uncomplicated symptomatic cholelithiasis, thirty-eight (54%) of 70 patients with gallstones had bacterial isolates. Nine (26%) isolates were from cholesterol stone containing bile while 29 (82%) isolates were from pigment stone containing bile (P=0.01). Twenty-eight of 38 (74%) bile samples showed positive cultures only after enrichment in brain heart infusion medium (BHI) (P=0.02). The overall bacterial isolates from bile samples revealed predominantly Echerichia coll, followed by Pseudomonas aeruginosa, Enterococcus spp, Klebsiella spp. and Staphylococcus epidermidis. There were no bacterial isolates in the bile of controls after either direct innoculation or enrichment in BHI. During the endoscopic management of post-operative iatrogenic bile duct injuries, patients who underwent laparoscopic cholecystectomy, and had bile leaks, were diagnosed with persistent abdominal pain 30%, jaundice with cholangitis 6.6%, abdominal distension 16.6% and persistent bile flow to the skin surface through and around the existing drains, 46.6%. The median duration between initial surgery and detection of bile leak was 3 days (range 0-12 days). Twenty-three patients (76.6%) had high-grade bile leaks while 7(23.4%) had low-grade leaks. Iatrogenic bile duct injuries were: hepato-cystic junction injuries 10(33.3%) (3, high grade: 7 low grade bile leaks), common bile duct injuries 16(53.3%) and right hepatic duct injuries 4(13.3%). Endotherapy inclusive of sphincterotomy with stone extraction followed by biliary stenting (10 patients), sphincterotomy with biliary stenting (15) and sphincterotomy alone (5). Bile leaks stopped in all patients at a median of 4 days (range 2-14 days), the drains were removed at a median duration of time of 6 days (range 5-16 days) and the stents were removed at a 6-8 weeks interval after endoscopic procedures. CONCLUSIONS: Abnormalities in the extra-hepatic biliary system, especially with its related vasculature are common. The presence of rare anomalies is not infrequent. Although there is a significant learning curve, laparoscopic cholecystectomy is a safe and effective procedure that can be performed with minimal risk but should be performed with meticulous attention to technique. This study also confirmed that laparoscopic cholecystectomy is associated with a quicker post-operative recovery and faster return to work or full activity. Bacterial isolates were significantly commoner in pigment stone containing bile than in cholesterol stone containing bile. Those without gallstones did not harbour bacteria in their bile. Antibiotic sensitivity patterns of isolated organisms were similar, irrespective of the type of stone contained in the bile. latrogenic bile duct injuries and bile leaks most commonly occur in the common bile duct. Residual stones were found in one-third of cases. No significant difference in healing was seen between the patients who had low-grade bile leaks due to hepato-cystic junction injuries and those whom were offered either sphincterotomy only or sphincterotomy with stenting.Item An investigation of the anti-carcinogenic mechanisms of a Sri Lankan herbalremedy and its ability to protect against radiation induced tissue injury(University of Kelaniya, 2011) Galhena, B.P.Decoction comprised of Nigella sativa (seeds). Hemidesmus indicus (roots) and Smilax glabra (rhizome) has traditionally been used to treat malignancies of various origins. Recent in-vivo and in-vitro studies have confirmed that the above decoction is effective against HCC, the commonest primary malignancy in the liver which accounts for highest mortality rate. However, the exact mechanism/s by which the decoction mediates its anti-hepatocarcinogenic activity is poorly understood. Use of herbs and their derivatives has also been reported to be beneficial for the patients suffering from severe adverse side effects during radiotherapy. Therefore the present study was carried out with the aims of investigating (a) the possible mechanisms by which the decoction mediates its claimed anti-hepatocarcinogenic activity, and (b) its ability to protect against radiation induced cellular damages. Anti-carcinogenic mechanisms were evaluated by assessing the effects of the decoction on (a) oxidative stress, (b) cell signaling and host immune response, (c) malignant cell proliferation, and (d) expression of key genes associated with carcinogenesis. Possible radioprotection mediated by the decoction was evaluated by examining the protection against cytogenetic damages induced by bleomycin, a known radiomimetic drug, in human peripheral blood lymphocytes in vitro. Results showed that the decoction could mediate a potent anti-oxidant effect by; (a) stimulating both enzymic (GPx, SOD, and GST activity) and non-enzymic (GSH) anti-oxidant defenses in rats bearing DEN-induced early hepatocarcinogenic changes in vivo, and (b) scavenging of nitric oxide (NO) and Diphenyl-2-picrylhyrazyl in vitro. Free radical induced activation of NF-KB plays a key role in cell proliferation. apoptosis and modulation of inflammation by activating an array of its down-stream targets. In the present study, it was observed that oral administration of the decoction could mediate a significant inhibition of hepatic NF-KB activity through hepatic IKKo/p suppression in C3H mice bearing early hepatocarcinogenic changes. Such inactivation was further confirmed by the down-regulation of two key down-stream targets of NF-KB transcription factor; TNFa and IL-6. These two cytokines actively participate in co-ordination of the host inflammatory response and are potent stimulators of NF-KB activation. Therefore, inhibition of these cytokines is considered to be vital in breaking the cytokine mediated NF-KB activation cycle, thus restricting the expression of its downstream targets associated with signal transduction, cell cycle regulation, apoptosis and inflammation. Generalized inhibition of inflammation mediated by the decoction was also evident by (a) significant reduction in carrageenan induced rat paw oedema formation, (b) human red cell membrane stabilization, and (c) inhibition of NO production by carrageenan induced rat peritoneal cell infiltrate. Reduction in CD4+ clonal expansion in response to oral administration of the decoction also supports the immunomodulatory potential of the decoction. Cellular oxidative stress induced mutations lead to expression of functionally defective genetic products. Altered and/or defective expression of onco-suppressor, p53wt and cell cycle regulator, p21 are considered to be more critical during carcinogenesis. Upregul#tion of hepatic p53%vt and p21WAri expression in C3H mice bearing early hepatocarcinogenic changes by the oral administration of the decoction observed in the present study strongly justify its claimed anti-hepatocarcinogenic activity. Human hepatoma (HepG2) cells treated with the decoction in-vitro also showed a significant; (a) morphological changes under microscope, (b) overall reduction in cell activity, (c) reduction in cell survival, and (d) cellular necrosis. Therefore, it is reasonable to hypothesize that the restriction of malignant cell survival and proliferation could be mediated by p53M and p2iWAF1 over-expression in the presence of the decoction. Claimed anti-oxidant role of the decoction may influence its observed protection against cytogenetic damages mediated by radiomimetic drug; bleomycin, in human peripheral blood lymphocytes. This protection was evident by a significant reduction in (a) chromosomal aberration, (b) formation of micronuclei, and (c) y-H2AX foci yield. Overall findings of the study suggest that the decoction mediates its anti-hepatocarcinogenic effects by modulating multiple targets that are closely associated with carcinogenesis. Further the ability of the decoction to modulate expression of key genes associated with carcinogenesis produce a new insight with the possible molecular mechanisms by which the decoction may be of benefit in the therapy of hepatocellular cancer. The decoction also has the ability to protect against radiation induced cytogenetic damages, thus provides an added advantage for cancer the patients who are treated with radiotherapy. Therefore, the present study strongly suseests for further investigation of the decoction in search for novel chemotherapeutic leads.Item Coagulation changes during mild hypothemia in neonates on extra corporeal membrane oxygenation(ECMO)(University of Kelaniya, 2011) Harischandra, D.V.T.Hypothermia is a promising intervention for reducing cerebral ischaemic damage. Neonates who need extracorporeal membrane oxygenation (ECMO) are inherently ill and are at risk of cerebral damage. Studies have shown hypothermia to be neuroprotective, but its effect on coagulation incorporating conventional and temperature adjusted blood tests have not been studied. We aimed to look for a difference in coagulation between neonates who undergo ECMO at mild hypothermia (34°C) and those at normothermia (37°C). A prospective, single-centre study was done from October 2006 to November 2008: Babies were randomised to "cooled" and "non-cooled" groups. Blood sampling was done at six time points. Thromboelastography (TEG) values at 34°C and 37°C, routine coagulation tests and cytokines were studied. Requirements of blood products and heparin and clinical effects were noted. There were 16 neonates and eight were cooled. Mean age was 1.2 days; mean weight, 3.4 kg and total ECMO, time 1877 (mean 117.3) hours. Eight (50%) were males. Mortality was one (6.3%). Data was analysed using the Mann-Whitney Test. Mild hypothermia caused reduced platelet count (p=0.00l) and function (p=0.03) at 12 hours post- ECMO and reduced clot formation by 24 hours (p=0.0£), after which differences disappeared. Temperature adjusted functional coagulation tests were needed to detect these effects. Heparin requirement was less in the cooled group (p=0.002). No differences in cytokines were evident. No adverse effects were noted due to hypothermia. This is the first study of functional and conventional coagulation tests during mild hypothermia in neonates on ECMOItem Investigation of dengue virus serotypes and genetic variability in relation to disease severity and transmission(University of Kelaniya, 2012) Jayasooriya, D.H.S.W.Sri Lanka has been experiencing more or less periodic dengue outbreaks. METHODOLOGY: Acute phase blood samples were collected from patients clinically suspected of having dengue as determined by the WHO criteria (WHO 1997) within 4 days of onset of fever, from the hospitals in the Sri Lankan districts of Colombo, Gampaha, Kandy, Kurunegala throughout the year. Dengue vector Aedes mosquitoes were colleted from the above geographical areas where positive cases were reported, Pooled mosquitoes and sera were subjected to analysis. RT-PCR and RT-PCR-LH established methods were used to detect dengue virus. Envelope glycoprotein gene (E gene) of DENY serotypes were sequenced and were compared with available sequences representative of the Americas, Oceania, Africa, South Asia, East Asia, and the Middle East. Deduced amino acid sequences of the Present Study Sri Lankan isolates (PSSL-iso) were compared with the past Sri Lankan isolates and South Asian isolates. Sequences of DF an DHF patients were compared as well. Clinical symptoms among serotypes in relation to severity were investigated. RESULTS AND DISCUSSION: In each district a minimum of 3 serotypes were in circulation. DEN-2 and DEN-3 were the most abundant .There was greater degree of conservation among the geographical isolates of DEN-2 compared to that of DEN-3. Evolutionary pressures act on the two serotypes differently despite both being co-transmitted within close proximities. Specific substitutions or substitution patters which could differentiate between DF and DHF/DSS were not found. However phylogentic analysis in DEN-3 revealed clustering of five isolates which showed an increased tendency to be associated with DHF or severe form of disease than the rest which harboured amino acid substitution Asn383^Lys383 on the lateral ridge of ED-III domain within the "informative sites" or sites known as unique conserved site for G-III. DEN-2 isolates belonged to the Cosmopolitan genotype were shown to have more of an Indian ancestry than a Sri Lankan one as they were closer in terms of phylogeny to the Indian origin isolates than to the previously existed Sri Lankan isolates. DEN-2 harboured unique Ile226 lying within the Previously Determined Antigenic Regions (PDAR) a substitution which was not present in any of the South Asian isolates analysed. Simultaneous co-infections by DEN-2& DEN-3 and DEN-4 &DEN-3 surprisingly lead to a reduction in disease severity. The results indicated that it is not in fact the number of amino acid substitutions which could determine the severity of disease but the type of substitution and the position within the domains which they occur. Most abundant vector species found in all districts was Aedes dlbopictus and all pools positive for DENY were Aedes albopictus pools. Moreover positive DENY transmission was observed in localities where Breteau index (BI) was as less as 5.55 suggesting the importance of the role of A .albopictus an "underrated vector". The findings in total suggest that all districts studied are hyperendemic to dengue and Sri Lanka is highly susceptible to successive outbreaks in the future while the difference of evolutionary pressures acting on the predominant serotypes and the reasons said above are likely to shape the nature of future outbreaksItem Evaluation of Iodine deficiency hypothyroidism in relation to neurodevelopmental outcome of children 5-9 years of age in the estates of Rathnapura district(University of Kelaniya, 2012) Abeysuriya, V.INTRODUCTION: The objective of this project was the assessment of Iodine deficiency hypothyroidism in relation to neurodevelopmental outcome of children 5-9 years of age in the estates of the Ratnapura district. This study consisted of development and validation of a tool to assess neuro-developmental outcome of children 5-9 years of age, a cross sectional study at baseline to determine iodine levels in household salt samples, a descriptive cross sectional study to determine the prevalence of poor neuro-developmental outcome and hypothyroidism, a case control study to identify risk factors of poor neuro-developmental outcome in children 5-9 years of age and a cross sectional study to determine iodine levels in water samples in selected estates in the Ratnapura district. METHODS: The development and validation of neuro developmental assessment tool was conducted in two stages. In stage one modifications were made to Griffiths'Mental Development Scale (GMDS) to adapt it to the Sri Lankan setting. The ROC curve analysis was used to determine the cutoff Genera! Quotient value to identify normal and poor neuro- developmental outcom.es. In stage two, 100 primary school children selected from the Ragama MOH area were tested using the new tool and the identified GQ cutoff value. The characteristics of salt usage and potable water sources in 1683 households in 20 randomly selected estates of the Ratnapura district were assessed in the selected estates, using a pre-tested interviewer administered questionnaire.. During the baseline survey, salt samples (n~1683) were tested for adequate iodine concentration (>30ppm of Iodine) by using a standard rapid iodine test kit. Using the validated neuro-developmental outcome assessment tool based on Griffiths Mental development scale, 1683 children were assessed for poor neuro-developmental outcome. Blood samples (2ml each) and a history relevant to hypothyroidism of 519 randomly selected 5-9 year old children from the same estates were obtained after obtaining informed written consent from the parents and/or guardians. TSH levels were assayed using the Immulite 3rd generation TSH Chemilu mines cent Immunometric assay. Water samples from 23 identified sources (wells, rivers and springs) were obtained and analyzed for iodine (I) levels by the catalytic reduction method. Based on neuro-developmental assessment screen, 64 children were randomly selected from the poor neuro developmental outcome group and 256 children (all in the 5-9 year age group) were selected from the normal neuro developmental outcome group to determine risk factors of poor neuro developmental outcome using a case control design. Data were analyzed using Statistical Package for Social Sciences 13 (SPSS) (SPSS 13.0, Chicago, Illinois, USA). Significance was considered when the p-value <0.05. Ethical clearance was obtained from the Ethics Committee of the Faculty of Medicine, University of Kelaniya. RESULTS: In the validation study a cut-off GQ value of 00 (p<0.05) best differentiated children with poor and normal neuro-developmental outcome (sensitivity 100% and specificity 100%). The commonest source of household salt products was the retail shop (36.4%). Salt powder (54.5%) was preferred more than salt crystals (44.5%), 80% of households did not wash salt crystals before use. In 9.6% of households salt was kept near the fire place. Salt was commonly stored in in glass bottles (19.3% in brown coloured bottles and 38.8% in clear bottles). 88.7% of household salt samples had adequate iodine levels (Iodine>30ppm). When salt crystals were washed or salt was kept near a fire place, the salt iodine concentration was significantly lower as compared to when salt was kept away from a fire place or when salt crystals were not washed before use (p<0.01). There was a significant difference in the mean TSH levels between poor and normal neuro-developmental outcome children in each age category (pO.OOl). 9.4 % (n=159) of children had a GQ< 100. 3.7% (n-19) of children had a TSH level >5.4u.IU/ml and 1.2% of children TSH level < 0.6[iIU/ml. 2.1% of children had both poor neuro developmental outcome and a TSH level >5.4nIU/ml. 15.8% of children had clinical symptoms of hypothyroidism. Goiter was visible or palpable in 15.7% of children who had TSH levels >5.41uIU/ml. Poor neuro developmental outcome (57.8%) and a history of consuming inadequately iodized salt (63.1%) were prominent feature among children who had TSH levels above normal limits. The prevalences of subclinical hypothyroidism and subclinical hyperthyroidism in 5-9 year old children were 3.08% and 0.76% respectively. The prevalences of hypothyroidism and hyperthyroidism in these children were 0.578% and 0.385%, respectively. The main source of potable water was water springs (83.7%). Low altitude spring water had a significantly higher Iodine concentration than those located at higher altitudes (p=0.002). The mean iodine levels of spring water was significantly lower than that of other sources (p=0.0001). A serum TSH concentration >5.41 uTU/ml (OR=5.325; 95% CI 1.425-19.898), consumption of adequately iodized salt products (OR=0.021; 95% CI 0.011-0.041), meconium aspiration (OR=5.094; 95% CI 1.633-15.889) and introduction of formula milk before completion of 6 months of age (OR-6.330; 95% CI 1.862-21.518) were significant predictors of poor neuro-developmental outcome of 5-9 year old children in the estates of the Ratnapura district. CONCLUSION: The developed neuro developmental outcome assessment tool is a valid and reliable instrument to screen neuro developmental outcome of Sri Lankan children aged 5-9 years of age. The majority of the estate population in the Ratnapura district had access to adequately iodized salt. Storing salt near the fire place and washing salt crystals before use reduced the iodine concentration of salt. Children with poor neuro- developmental outcome had significantly higher serum TSH levels than normal children. The majority of children with high TSH levels had features of subclinical hypothyroidism; poor neuro-development outcome was a common feature among them. The iodine concentration of spring water was significantly lower than in other sources and the Iodine levels of spring water were higher at lower altitudes as compared to those at higher altitudes. Sub clinical hypothyroidism is a major risk factor for poor neuro-developmental outcome of children. Consumption of adequately iodized salt will reduce the risk ofpoorneuro-developmental outcome among children 5-9 years of age.