Journal/Magazine Articles

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This collection contains original research articles, review articles and case reports published in local and international peer reviewed journals by the staff members of the Faculty of Medicine

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    Pseudoainhum associated with lepromatous leprosy: A very rare association in modern world
    (Chinese Medical Association Publishing House, 2023) Nishad, A.A.N.; Pathman, M.; Uwyse, S.A.; Mendis, A.; Abeysundara, P.K.; de Silva, A.P.
    INTRODUCTION: Pseudoainhum (dactylolysis spontanea) is characterized by the development of a fibrous band around the digit that gradually leads to autoamputation. Digital pain associated with Pseudoainhum may not be evident in patients with neuropathic conditions. Here, we present a rare case of pseudoainhum patient, which describes a very rare association of pseudoainhum with leprosy. CASE PRESENTATION: A 48 year old male with lepromatous leprosy, with resorption of digits, charcot joints and tropical ulcers was seen in the clinic. The forth digit of the left hand had a narrowing due to a fibrous band at the 2nd inter phalangeal joint with shiny tethering distal phalanx. He could not recall the duration of the ainhum. He was not suffering from any pain.DISCUSSION: The current report describes a very rare association of pseudoainhum with leprosy. The case involved a 48-year-old man in the dermatology ward with lepromatous leprosy presenting with a pseudoainhum. CONCLUSION: This case highlights the possibility of delayed presentation of patients with pseudoainhum to physicians when the patients have underlying neuropathic conditions that prevent feeling finger pain and cause abnormal appearance of the digits, especially in leprosy.
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    Using FIB-4 score as a screening tool in the assessment of significant liver fibrosis (F2) in patients with transfusion-dependent beta thalassaemia: a cross-sectional study
    (BMJ Publishing Group Ltd, 2022) Padeniya, P.; Ediriweera, D.S.; de Silva, A.P.; Niriella, M.A.; Premawardhena, A.
    Objective: To evaluate the performance of the fibrosis-4 (FIB-4) score as a screening tool to detect significant liver fibrosis (F2) compared with transient elastography (TE), among chronic transfusion-dependent beta-thalassaemia (TDT) patients in a resource-poor setting. Design: A cross-sectional study. Setting: Adolescent and Adult Thalassaemia Care Centre (University Medical Unit), Kiribathgoda, Sri Lanka. Participants: 45 TDT patients who had undergone more than 100 blood transfusions with elevated serum ferritin >2000 ng/mL were selected for the study. Patients who were serologically positive for hepatitis C antibodies were excluded. Outcome measures: TE and FIB-4 scores were estimated at the time of recruitment in all participants. Predefined cut-off values for F2, extracted from previous TE and FIB-4 scores studies, were compared. A new cut-off value for the FIB-4 score was estimated using receiver operating characteristics curve analysis to improve the sensitivity for F2 prediction. Results: Of the selected 45 TDT patients, 22 (49%) were males. FIB-4 score showed a significant linear correlation with TE (r=0.52;p<0.0003). The FIB-4 score was improbable to lead to a false classification of TDT patients to have F2 when the FIB-4 cut-off value was 1.3. On the other hand, it had a very low diagnostic yield in missing almost all (except one) of those who had F2. Using a much-lowered cut-off point of 0.32 for FIB-4, we improved the pick-up rate of F2 to 72%. Conclusions: Regardless of the cut-off point, the FIB-4 score cannot be used as a good screening tool to pick up F2 in patients with TDT, irrespective of their splenectomy status. On the contrary, at a 1.3 cut-off value, though FIB-4 is a very poor detector for F2 fibrosis, it will not erroneously diagnose F2 fibrosis in those who do not have it.
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    Postdischarge outcomes of COVID-19 patients from South Asia: a prospective study
    (Royal Society of Tropical Medicine and Hygiene, 2022) Abeysuriya, V.; Seneviratne, S.L.; de Silva, A.P.; Mowjood, R.; Mowjood, S.; de Silva, T.; de Mel, P.; de Mel, C.; Wijesinha, R.S.; Fernando, A.; de Mel, S.; Chandrasena, L.
    Background: Coronavirus disease 2019 (COVID-19) may cause clinical manifestations that last for weeks or months after hospital discharge. The manifestations are heterogeneous and vary in their frequency. Their multisystem nature requires a holistic approach to management. There are sparse data from the South Asian region on the outcomes of hospital-discharged COVID-19 patients. We assessed the posthospital discharge outcomes of a cohort of Sri Lankan COVID-19 patients and explored the factors that influenced these outcomes. Methods: Data were prospectively collected from patients who were discharged following an admission to the Nawaloka Hospital, Sri Lanka with COVID-19 from March to June 2021. At discharge, their demographic, clinical and laboratory findings were recorded. The patients were categorised as having mild, moderate and severe COVID-19, based on the Sri Lanka Ministry of Health COVID-19 guidelines. Following discharge, information on health status, complications and outcomes was collected through clinic visits and preplanned telephone interviews. A validated (in Sri Lanka) version of the Short Form 36 health survey questionnaire (SF-36) was used to assess multi-item dimensions health status of the patients at 1, 2 and 3 mo postdischarge. Results: We collected data on 203 patients (male, n=111 [54.7%]). The level of vaccination was significantly associated with disease severity (p<0.001). Early recovery was seen in the mild group compared with the moderate and severe groups. At 3 mo, on average 98% of mild and 90% of moderate/severe patients had recovered. Based on the SF-36, physical functioning dimensions, role limitation due to physical and emotional health, energy/ fatigue, emotional well-being, social functioning, pain and general health were significantly different in the moderate/severe vs mild COVID-19 groups at 1, 2 and 3 mo postdischarge (p<0.05). Twenty-three patients developed complications, of which the most common were myocardial infarction with heart failure (n=6/23; 26.1%), cerebrovascular accident (n=6/23; 26.1%) and respiratory tract infections (n=3/23; 13.01%) and there were six deaths. Conclusions: In our cohort, receiving two doses of the COVID-19 vaccine was associated with reduced disease severity. Those with mild disease recovered faster than those with moderate/severe disease. At 3 mo posthospital discharge, >90% had recovered.
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    Combination of cycle threshold time, absolute lymphocyte count and neutrophil:lymphocyte ratio is predictive of hypoxia in patients with SARS-CoV-2 infection
    (Royal Society of Tropical Medicine and Hygiene, 2022) Abeysuriya, V.; Seneviratne, S.L.; de Silva, A.P.; Mowjood, R.; Mowjood, S.; de Silva, T.; de Mel, P.; de Mel, C.; Chandrasena, L.; Wijesinha, R.S.; Fernando, A.; de Mel, S.
    Background: There is currently no clinically validated biomarker to predict respiratory compromise in sudden acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Cycle threshold time (Ct), absolute lymphocyte count (AL) and neutrophil:lymphocyte ratio (NLR) have been previously evaluated for this purpose. We hypothesized that the combination of these parameters at presentation may be predictive of hypoxia (oxygen saturation <92%). Methods: Data were collected on 118 patients with SARS-CoV-2 infection between May 2020 and April 2021. Demographics, clinical parameters and laboratory and radiological investigation results were recorded. Respiratory compromise (RC) was defined based on symptoms and signs, hypoxia and chest X-ray abnormalities. Results: RC occurred in 61 (51.7%) of patients. The Ct, AL and NLR at median day 3 of illness were significantly different between patients with and without RC (Ct, RC vs not: 19.46±2.64 vs 22.62±3.37, p=0.0001; AL, RC vs not: 531.49±289.09 vs 764.69±481.79, p=0.0001; NLR, RC vs not: 3.42±0.75 vs 2.59±0.55, p=0.0001). Receiver operating characteristics analysis showed that a Ct <19.9, AL <630.8×103/μL and NLR >3.12 at median day 3 of symptoms was predictive of hypoxia on day 7 of illness (area under the curve 0.805, sensitivity 96.7%, specificity 69.1%). The predictive value for the parameters combined was significantly superior to their individual predictive power. Conclusions: Ct, AL and NLR used in combination on day 3 of symptoms are predictive of hypoxia on day 7 of SARS-CoV-2 illness.
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    Effects of probiotics combined with dietary and lifestyle modification on clinical, biochemical, and radiological parameters in obese children with nonalcoholic fatty liver disease/nonalcoholic steatohepatitis: a randomized clinical trial
    (Korean Pediatric Society, 2022) Rodrigo, T.; Samaranayake, D.; Seneviratne, S.N.; de Silva, A.P.; Fernando, J.; de Silva, H.J.; Jayasekera; Wickramasinghe, V.P.
    Background: Childhood obesity is a global problem associated with metabolic abnormalities. The gut-liver axis is thought to play a major role in its pathogenesis. Probiotics are known to alter the gut microbiota and, therefore, could be a therapeutic option in the management of childhood obesity-related complications. Purpose: This double-blind randomized placebo-controlled trial evaluated the effects of probiotics on metabolic derangement in obese children with nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH). Methods: Obese children with NAFLD/NASH treated at the nutrition clinic of the University Paediatric Unit at Lady Ridgeway Hospital, Colombo, were recruited. Anthropometry, body fat, metabolic derangement, and liver ultrasound scan (USS) results were evaluated at baseline and after 6 months. Transient elastography (FibroScan®) was performed on a subsample of these patients. Eighty-four patients were recruited and randomized into the probiotics (n = 43) and placebo (n = 41) groups. The mean age was 11.3±1.9 versus 12.1±1.5 years in the probiotic and placebo groups, respectively. Baseline parameters including liver disease stage on USS, body fat percentage, fasting blood sugar, lipid profile, liver function, and C-reactive protein showed no significant intergroup differences. Results: In the probiotic group, a statistically significant reduction in body mass index was noted from the baseline value. However, the reduction was not significant compared with the placebo group. There was a significant reduction in triglycerides, aspartate transaminase (AST), alanine aminotransferase (ALT), AST/ALT ratio, and alkaline phosphatase in the placebo group over the treatment period. Although the liver disease stage on USS improved from stage II-III to stage I in a small number of patients in the probiotic-treated group, transient elastography performed in a subsample did not demonstrate significant improvement in either group. Conclusion: Our results indicate that probiotics have no advantage over lifestyle modification for improving obesity-associated metabolic derangement in children.
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    Screening for performance enhancing substances and quantification of ethanol in different Arishta manufactured in Sri Lanka
    (The Sri Lanka Medical Association., 2020) Fernando, P.N.J.; Pigera, S.; Rashani, S.A.N.; Fernando, R.; Weerasinghe, P.; Godakumbura, T.D.; Niriella, M.A.; Jayawickreme, S.; de Silva, A.P.
    BACKGROUND: Arishta have been used in Ayurveda medicine for over thousands of years in Sri Lanka to treat various diseases. Ashwagandharishta, Balarishta and Dashamoolarishta are usually prescribed to obtain an anabolic effect, and Ashwagandharishta and Dashamoolarishta for androgenic effect in males. Thus, these arishta have been shown to have similar effect as anabolic androgenic steroids and stimulants in Western medicine. Therefore, arishta could potentially be used by athletes to improve their performance in sports leading to unintentional doping. Additionally, ethanol develops in-source during arista fermentation, which can affect athletes health. OBJECTIVE: The aim of this study is to investigate whether the anabolic androgenic steroids or stimulants banned by World Anti-Doping Agency are present in these arishta, and to determine their ethanol content. METHODS: Methanol extractions of Ashwagandarishta, Balarishta, Dashamoolarishta from four different manufacturers were screened for 21 stimulant and 22 anabolic androgenic steroids banned by World Anti-Doping Agency, using Gas Chromatography Mass Spectrometer. Ethanol content of the twelve Arishta samples were also measured. RESULTS: Anabolic androgenic steroids or stimulants were not present in the tested Arishta samples, and percentage volume / volume ethanol content of all Arishta was between (5.80–8.35) ±0.5. CONCLUSION: The tested brands of Ashwagandharishta, Balarishta and Dashamoolarishta did not contain stimulants or anabolic androgenic steroids banned by World Anti-Doping Agency.
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    On the proposed definition of metabolic-associated fatty liver disease [Letter to the Editor]
    (Elsevier, 2022) Niriella, M.A.; de Silva, A.P.; de Silva, H.J.
    No abstract available, Comment on Wai-Sun Wong V, et al, Clinical Gastroenterology and Hepatology. 2021;19(5):865-870. [Epub 2021 Jan 13.]
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    Dengue and leptospirosis infection during the coronavirus 2019 outbreak in Sri Lanka
    (Oxford University Press, 2021) Niriella, M.A.; Ediriweera, D.S.; de Silva, A.P.; Premaratna, B.A.H.R.; Jayasinghe, S.; de Silva, H.J.
    ABSTRACT: A significant decrease in dengue fever cases and a contrasting increase in leptospirosis cases were reported for the second quarter of 2020 compared with 2019 in Sri Lanka. In the absence of significant environmental and weather-related differences to account for these changes in incidence, we investigated the possibility that the effects of the COVID-19 pandemic on public health, social behaviour and the restrictions imposed during the lockdown influenced the fluctuations in dengue and leptospirosis infections. KEYWORDS: COVID-19; dengue fever; leptospirosis; pandemic; tropical infections.
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    Impact of COVID-19 Pandemic on Medical Education: Insights and Recommendations
    (South East Asia Regional Association for Medical Education (SEARAME), 2020) Niriella, M.A.; Chandratilake, M.; de Silva, S.T.; de Silva, A.P.
    ABSTRACT: Disruptions in medical education are inevitable as healthcare systems across the world are set to be further stretched with the increasing burden of COVID-19 pandemic. Given the risks of nosocomial infection and other unique, similar challenges, there is difficulty in adapting required changes in medical education, particularly for the medical students and training junior doctors. This paper discusses the different elements affecting and the widespread impact of COVID-19 pandemic on medical education. It concludes with strategies to minimize the impact of these factors and a call to action for the medical education system to adapt so it can meet the needs of healthcare learners during this pandemic and beyond. These include online learning, telemedicine and simulations that may help in both teaching/learning and assessment in basic and clinical education. The adaptation of these approaches, however, should be based on the intended learning outcomes and availability of resources. Teaching/learning strategies to develop reasoning skill and increasing the focus on formative assessments appears to be a fundamental requirement in the current context. The programme should adopt flexibility and collaboration as the guiding principles to mitigate the ill-effects of the pandemic on medical education. KEYWORDS: COVID-19, Pandemic, Medical education, Undergraduate, Postgraduate, Continuing, Impact
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    Changing phenotype, early clinical course and clinical predictors of inflammatory bowel disease in Sri Lanka: a retrospective, tertiary care-based, multi-centre study
    (BioMed Central, 2021) Niriella, M.A.; Liyanage, I.K.; Kodisinghe, S.K.; de Silva, A.P.; Jayatissa, A.V.G.A.M.; Navarathne, N.M.M.; Peiris, R.K.; Kalubovila, U.P.; Kumarasena, S.R.; Jayasekara, R.W.; de Silva, H.J.
    BACKGROUND: Inflammatory bowel disease (IBD) is increasing in the Asia-Pacific region, with changes in disease phenotype and course. We aimed to assess the changing phenotypes of IBD over ten years, describe the early clinical course (ECC) and identify the clinical predictors (CP) of poor outcomes among a large, multi-centre, cohort of Sri Lankan IBD patients. METHODS: We included patients [diagnosed between June/2003-December/2009-Group-1(G1), January/2010-June/2016-Group-2(G2)] with ulcerative colitis (UC) and Crohn disease (CD) from five national-referral centres. Changing phenotype from G1 to G2, ECC (disease duration < 3-years) and CP of poor outcomes (disease duration ≥ 1-year) was assessed. Poor outcomes were complicated-disease (CompD-stricturing/penetrating-CD, extensive-UC/pancolitis, perforation/bleeding/colectomy/malignancy) and treatment-refractory disease (TRD-frequently-relapsing, steroid-dependent/refractory and biologic use). RESULTS: 375 (UC-227, CD-148) patients were recruited. Both G1/G2 had more UC than CD (77% vs 23%, 54.5 vs 45.5 respectively, p < 0.01). Increase of CD from G1-to-G2 was significant (23-45.4%, p < 0.001). In both groups, left-sided colitis (E2) and ileo-colonic (L3)/non-stricturing, non-penetrating disease behaviour (B1) CD predominated. Extensive-colitis (E3) (36.4% vs 22.7, p < 0.05) and stricturing-CD (B2) (26.1% vs 4.0%, p < 0.01) was commoner in G1. ECC was assessed in 173-patients (UC-94, CD-79). Aggressive disease behaviour and TRD were low among both UC and CD. Immunomodulator use was significantly higher among CD than UC (61.5% vs 29.0% respectively, p < 0.01). Anti-TNF use was low among both groups (UC-3.2%, CD-7.7%). Disease complications among UC [bleeding (2.1%), malignancy-(1.1%), surgery-(2.1%)] and CD [stricture-(3.9%), perforation-(1.3%), malignancy-(1.3%), surgery-(8.9%)] were generally low. CPs were assessed in 271-patients (UC-163, CD-108). Having a family history of IBD (for UC), extraintestinal manifestation (EIM), severe disease at presentation, being in younger age categories and severe disease at presentation, (for both UC and CD) predicted poor outcomes. CONCLUSION: There was an increase in CD over time without change in disease phenotype for both UC and CD. A relatively benign ECC was observed. Family history (UC), EIMs (UC/CD), severe disease at presentation (UC/CD), younger age (CD/UC) CPs of poor outcomes. KEYWORDS: Clinical course; Clinical predictors; Crohn disease; Inflammatory bowel disease; Phenotype; Sri Lanka; Ulcerative colitis.