Medicine
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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
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Item Challenges faced in establishing a pediatric liver transplant program in a lower‐middle‐income country with free healthcare service(Wiley, 2024) Fernando, M.; Tillakaratne, S.; Gunetilleke, B.; Liyanage, C.; Appuhamy, C.; Weerasuriya, A.; Uragoda, B.; Welikala, N.; Ranaweera, L.; Ganewatte, E.; Dissanayake, J.; Mudalige, A.; Siriwardana, R.ABSTRACT: BACKGROUND: Liver transplant is the cure for children with liver failure. Sri Lanka is a lower-middle-income country with a predominant free, state health system. Pediatric liver transplant program in Sri Lanka is still in the budding state where the initial experience of the program is yet to be documented. METHODS: A retrospective review was performed including the clinical characteristics of all pediatric liver transplant recipients of Colombo North Centre for Liver Diseases since the inception of the program from June 2020 to May 2023. RESULTS: There were 14 PLT performed in 3 years. The median recipient age and weight were 8 years (6 months–15 years) and 23.3 kg (6.4–49.2), respectively. The majority were boys (64%). All were from low-income backgrounds. Indications for LT were acute liver failure (5/14), decompensated chronic liver disease (5/14), and acute on chronic liver failure (4/14). Underlying liver diseases were Wilson disease (6/14), autoimmune liver disease (3/14), biliary atresia (2/14) and progressive familial intrahepatic cholestasis type 3 (1/14), and unknown etiology (2/14). The majority were living donor liver transplants (86%). Of the living donors, 42% (5/12) were Buddhist priests. There were three immediate deaths and two late deaths. The 3-month survival was 78%, and overall survival was 64%. Living donor transplants carried a higher success rate (92%) compared to diseased donor transplants (0%; 2/2). CONCLUSIONS: Initial experience of pediatric liver transplant program of Sri Lanka is promising despite being established in a free healthcare system amidst the crisis circumstances.Item Item Neonatal and infantile cholestasis:an overlooked health burden with unmet needs(Indian Society of Gastroenterology,, 2020) Fernando, M.; Rajindrajith, S.No abstract available.Item Potential of coconut oil and medium-chain triglycerides in the prevention and treatment of Alzheimer's disease(Elsevier Science Ireland, 2020) Chatterjee, P.; Fernando, M.; Fernando, B.; Dias, C.B.; Shah, T.; Silva, R.; Williams, S.; Pedrini, S.; Hillebrandt, H.; Goozee, K.; Barin, E.; Sohrabi, H.R.; Garg, M.; Cunnane, S.; Martins, R.N.ABSTRACT:Alzheimer's disease (AD) is the most common form of dementia. Currently, there is no effective medication for the prevention or treatment of AD. This has led to the search for alternative therapeutic strategies. Coconut oil(CO) has a unique fatty acid composition that is rich in medium chain fatty acids(MCFA), a major portion of which directly reaches the liver via the portal vein, thereby bypassing the lymphatic system. Given that brain glucose hypometabolism is a major early hallmark of AD, detectable well before the onset of symptoms, ketone bodies from MCFA metabolism can potentially serve as an alternative energy source to compensate for lack of glucose utilisation in the brain. Additionally, neuroprotective antioxidant properties of CO have been attributed to its polyphenolic content. This review discusses how the metabolism of CO and MCFA may aid in compensating the glucose hypometabolism observed in the AD brain. Furthermore, we present the current evidence of the neuroprotective properties of CO on cognition, amyloid-β pathogenicity, inflammation and oxidative stress. The current review addresses the influence of CO/MCFA on other chronic disorders that are risk factors for AD, and addresses existing gaps in the literature regarding the use of CO/MCFA as a potential treatment for AD. KEYWORDS: Alzheimer’s disease; Amyloid-β; Cerebral glucose hypometabolism; Coconut oil; Medium chain triglycerides.Item Microcytic anemia in children: Parallel screening for iron deficiency and Thalassemia provides a useful opportunity for Thalassemia prevention in low- and middle-income countries(Hemisphere Pub. Corp., 2020) Mettananda, S.; Paranamana, S.; Fernando, R.; Suranjan, M.; Rodrigo, R.; Perera, L.; Vipulaguna, T.; Fernando, P.; Fernando, M.; Dayanath, B.K.T.P.; Costa, Y.; Premawardhena, A.ABSTRACT:Microcytic anemia in children is commonly attributed to iron deficiency without attempting to find the cause. Inadequate investigations to exclude hemoglobinopathies lead to missed opportunities for identification of thalassemia carriers. Here we aim to describe the relative contribution of iron deficiency and thalassemia to microcytic anemia in children. This hospital-based prospective study was conducted at the Colombo North Teaching Hospital, Ragama, Sri Lanka. All newly diagnosed patients with microcytic anemia were recruited and data were collected using an interviewer-administered questionnaire. Full blood count, blood film, serum ferritin, c-reactive protein, quantification of hemoglobin sub-types and α-globin genotype were performed using 4 ml of venous blood. A total of 104 children (Male- 60.5%) were recruited. Iron deficiency was the cause for anemia in 49% whilst 16% and 10% had α- and β-thalassemia trait respectively. Seven (6.7%) children had co-existing iron deficiency and thalassemia trait while two coinherited α- and β-thalassemia trait. Children with β-thalassemia trait had significantly higher red cell count and lower mean corpuscular volume compared to children with iron deficiency. However, none of the red cell parameters were significantly different between children with α-thalassemia trait and iron deficiency. Iron deficiency contributes only to half of children with microcytic anemia; one-fourth had thalassemia trait. Co-existence of iron deficiency and thalassemia trait or co-inheritance of α- and β-thalassemia trait were found in 9%. Parallel investigation of children with microcytic anemia to diagnose iron deficiency and thalassemia provides an opportunity to identify thalassemia carriers which is beneficial for thalassemia prevention.Item Fixed low-dose triple combination Antihypertensive Medication vs usual care for blood pressure control in patients with mild to moderate hypertension in Sri Lanka: A Randomized Clinical Trial(American Medical Association, 2018) Webster, R.; Salam, A.; de Silva, H.A.; Selak, V.; Stepien, S.; Rajapakse, S.; Amarasekara, N.; Amarasena, N.; Billotm, L.; de Silva, A.P.; Fernando, M.; Guggilla, R.; Jan, S.; Jayawardena, J.; Maulik, P.K.; Mendis, S.; Mendis, S.; Munasinghe, J.; Naik, N.; Prabhakaran, D.; Ranasinghe, G.; Thom, S.; Thisserra, N.; Senaratne, V.; Wijekoon, S.; Wijeyasingham, S.; Rodgers, A.; Patel, A.; TRIUMPH Study GroupIMPORTANCE: Poorly controlled hypertension is a leading global public health problem requiring new treatment strategies. OBJECTIVE: To assess whether a low-dose triple combination antihypertensive medication would achieve better blood pressure (BP) control vs usual care. DESIGN, SETTING, AND PARTICIPANTS: Randomized, open-label trial of a low-dose triple BP therapy vs usual care for adults with hypertension (systolic BP >140 mm Hg and/or diastolic BP >90 mm Hg; or in patients with diabetes or chronic kidney disease: >130 mm Hg and/or >80 mm Hg) requiring initiation (untreated patients) or escalation (patients receiving monotherapy) of antihypertensive therapy. Patients were enrolled from 11 urban hospital clinics in Sri Lanka from February 2016 to May 2017; follow-up ended in October 2017. INTERVENTIONS: A once-daily fixed-dose triple combination pill (20 mg of telmisartan, 2.5 mg of amlodipine, and 12.5 mg of chlorthalidone) therapy (n = 349) or usual care (n = 351). MAIN OUTCOMES AND MEASURES: The primary outcome was the proportion achieving target systolic/diastolic BP (<140/90 mm Hg or <130/80 mm Hg in patients with diabetes or chronic kidney disease) at 6 months. Secondary outcomes included mean systolic/diastolic BP difference during follow-up and withdrawal of BP medications due to an adverse event. RESULTS: Among 700 randomized patients (mean age, 56 years; 58% women; 29% had diabetes; mean baseline systolic/diastolic BP, 154/90 mm Hg), 675 (96%) completed the trial. The triple combination pill increased the proportion achieving target BP vs usual care at 6 months (70% vs 55%, respectively; risk difference, 12.7% [95% CI, 3.2% to 22.0%]; P < .001). Mean systolic/diastolic BP at 6 months was 125/76 mm Hg for the triple combination pill vs 134/81 mm Hg for usual care (adjusted difference in postrandomization BP over the entire follow-up: systolic BP, -9.8 [95% CI, -7.9 to -11.6] mm Hg; diastolic BP, -5.0 [95% CI, -3.9 to -6.1] mm Hg; P < .001 for both comparisons). Overall, 419 adverse events were reported in 255 patients (38.1% for triple combination pill vs 34.8% for usual care) with the most common being musculoskeletal pain (6.0% and 8.0%, respectively) and dizziness, presyncope, or syncope (5.2% and 2.8%). There were no significant between-group differences in the proportion of patient withdrawal from BP-lowering therapy due to adverse events (6.6% for triple combination pill vs 6.8% for usual care). CONCLUSIONS AND RELEVANCE: Among patients with mild to moderate hypertension, treatment with a pill containing low doses of 3 antihypertensive drugs led to an increased proportion of patients achieving their target BP goal vs usual care. Use of such medication as initial therapy or to replace monotherapy may be an effective way to improve BP control.Item Achieving millennium development goal 4 in 2015: are we really on track?(Sri Lanka College of Paediatricians, 2011) Mettananda, S.; Rajindrajith, S.; Warnakulasuriya, T.; Fernando, M.; Devanarayana, N.M.; Gunawardena, N.K.INTRODUCTION: Millennium development goal (MDG) 4 aims to reduce under 5 mortality by two thirds from 1990 (22.2 per 1000 live births) to 2015 (7.4 per 1000 live births). In achieving this, proper and accurate description of the causes of deaths is crucial. OBJECTIVES: To describe the timing, causes and distribution of under 5 child deaths in Sri Lanka and to predict the likelihood of achieving MDG 4. DESIGN, SETTING AND METHOD: Information regarding all under 5 child deaths between 2002-2006 was obtained from the Registrar Generals' Department. Place, sex and age at death were retrieved. Causes of deaths documented accordingly to the ICD-10 classification were reclassified into clinically relevant and user-friendly categories. Mortality rates and predictions for 2015 were calculated using Microsoft Excel. RESULTS: A total of 26,273 deaths have occurred during 2002-2006 [55% neonatal, 21% post-neonatal infant and 24% child (l-5year)]. Tsunami wave in 2004 had caused 2,868 (11%) deaths and they were excluded from further analysis. Prematurity had caused 4,603 (31.8%) neonatal deaths; 2389 (16.5%) were due to infections and 1149 (7.9%) were due to birth asphyxia. Congenital anomalies have contributed to 1830 (12.6%) neonatal deaths, of which, the majority [1389 (9.6%)] were heart diseases. Leading causes for post-neonatal infant deaths include congenital anomalies [1772 (35%)], infections [1516 (29.9%)] and trauma [393 (7.7%)]. in children, 910 (23.4%) deaths were due to infections (10.2% respiratory, 2.0% gastroenteritis and 0.9% dengue). One fifth of deaths were due to congenital anomalies of which half were due to heart defects. Trauma/ accidents and malignancies had contributed to 731 (18.8%) and 279 (7.1%) deaths respectively. Colombo district reported the highest number of deaths (24%). More males (54.7%) have died compared to females. Reduction in mortality rates were observed from 2002-2006; neonatal mortality from 8.3 to 7.6, infant mortality from 11.4 to 10.4 and under 5 mortality from 13.7 to 12.3. Projections of data showed that the neonatal, infant and under 5 mortality rates in 2015 would be 4.6, 6.7 and 7.7 per 1000 live births respectively. CONCLUSIONS: Prematurity was the leading cause of neonatal mortality. Congenital heart diseases are an important cause of death throughout childhood. Trauma and accidents contribute to a significant proportion of child deaths. Predictions from data suggest that Sri Lanka may fall marginally short of achieving MDG 4.Item Levamisole induced toxic epidermal necrolysis in a patient with nephrotic syndrome: A case report(Faculty of Medicine, University of Kelaniya, Sri Lanka, 2016) Prasangika, T.G.C.; Warnasuriya, W.; Mendis, W.J.S.; Fernando, M.; Jayasinghe, C.INTRODUCTION: Toxic epidermal necrolysis (TEN) is an uncommon, potentially life-threatening muco-cutaneous condition, which may occur as an adverse reaction (Type IV hypersensitivity) to a number of drugs. It is characterized by variable degrees of epidermal necrosis and detachment leading to increase morbidity and mortality. We describe the case of a patient with nephrotic syndrome who developed TEN, presumably induced by Levamisole. To our knowledge, this is the first report of TEN arising during levamisole treatment. CASE REPORT: A 11 year old girl, who has steroid dependent nephrotic syndrome, was started on levamisole. She developed skin and mucosal lesions suggestive of TEN 3 weeks after taking levamisole. The diagnosis of TEN in our patient was made clinically and confirmed histologically. Based on the temporal relationship of levamisole therapy and the development of her adverse cutaneous reaction, we concluded that levamisole was the offending agent. CONCLUSION: We report this case to increase awareness of this potential life-threatening complication of levamisole.Item Knowledge of mothers regarding helminth infections and patterns of anthelminthic usage in children(Sri Lanka Medical Association, 2012) Perera, P.; Dissanayaka, D.; Fernando, M.; Ranathanga, N.INTRODUCTION: Intestinal helminth infections are a global problem. There are lot of misbelieves among people regarding helminth infections, which often leads to inappropriate use of anthelmintics. AIMS: To assess the knowledge of mothers regarding helminth infections and to describe the patterns of anthelmintic usage in children. METHODS: A descriptive cross sectional study was carried out at University Paediatric unit. Teaching hospital Ragama, during September 2011 to November 2011. Two Hundred children and their mothers admitted to the Paediatrics university unit with at least one child above 18 months were recruited with informed written consent. Socio-demographic data, availability of sanitary facilities and safe drinking water, knowledge on intestinal infections and practices related to anthelmintic treatment were collected using a pretested Interviewer administered questionnaire. RESULTS: Nearly all families had access to a safe toilet and 62% had safe drinking water. 84% of children had regular anthelmintic treatment and out of them 39.3% had 3 monthly, 55.3% six monthly and 5.3% annually. Out of them only 81.4% had risk factors to get helminth infections, while 36,9% had no evidence in the past of worm infection. There was no statistically significant association between regular anthelmintics usage and presence of risk factors (odds ratio 1.799, CI 0.849-3.815). Knowledge of mothers regarding transmission of worm infections and clinical features was poor. CONCLUSIONS: Considering the high literacy rate among Sri Lankan mothers knowledge about worm infections was surprisingly poor. A lot of children are receiving unnecessary anthelmintic treatment. Health education programs addressing these issues are indicated.Item Feeding practices of children attending well baby clinics in Ragama MOH area: a descriptive cross sectional study(Sri Lanka Medical Association, 2011) Perera, K.P.J.; Fernando, M.; Warnakulasuria, T.; Ranathunga, N.INTRODUCTION AND OBJECTIVES: Feeding during early childhood is important for growth and health. Objectives of this study were to evaluate the current feeding practices during first few years of life among Sri Lankan children. METHODS: A descriptive cross sectional study conducted in Ragama MOH area during the period of 10th august 2010 and 30th October 2010. 410 children between 2 -5 years of age, attending well baby clinics were included in the study. Interviewer administered questionnaire was used to collect data regarding socio-demographic characteristics and feeding practices. Open ended questions were used. SSPS version 16 was used for data analysis. RESULTS: The study population consisted of 208 boys and 202 girls. 62.2% children were exclusively breastfed for 6 months. 351 have received formula milk. 61 had formula milk started before the age of 6 months and 212 by one year. 330 children had sugar added to formula milk. 144 of them had sugar added within first year. 29 children had complementary food started before 4 months. 294 mothers continued to breastfeed beyond 2 years and 41.6% of them were breast feeding at regular intervals. 82.5% children were receiving overnight feeding either as breast milk or formula beyond 2 years. . CONCLUSIONS: Though high rate of exclusive breast feeding is prevalent in Sri Lanka, there seem to be other issues related to feeding. Too early introduction of complementary food, adding sugar to formula, prolonged breast feeding too frequently and prolonged overnight feeding are among them.