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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Fish bone migration through a sigmoid colon diverticulum causing an anterior abdominal wall abscess(The College of Surgeons of Sri Lanka, 2024) Ekanayaka, E.M.M.; Gunasekara, K.; Fernando, R.; Chandrasinghe, P.C.; Kumarage, S.No abstract availableItem Trials, tribulations and the emergence of total thyroidectomy - A Sri Lankan perspective(The College of Surgeons of Sri Lanka, 2023) Fernando, R.Abstract The technique of thyroidectomy has emerged during the last 100 years, from a turbulent past’, due to the outstanding contributions made by many including the “Magnificent Seven” of thyroid surgery. The dissection of the gland, preservation Parathyroid function and protecting the Nerves are dealt with meticulously. Total thyroidectomy is associated with complications of bleeding, permanent injury to Nerves and permanent hypoparathyroidism. Many centres have reported incidence of complications around 1-3%. This is the bench mark for surgeons world over. Voice change is a major concern after thyroidectomy. A study has shown that RLN recovery much faster than the recovery of the EBSLN. The recovery will take up to 3 months in most patients. Assessment of the surgical practices related to thyroid disease in Sri Lanka has shown that the practices have changed over the last decade. More total thyroidectomies are undertaken. Younger surgeons are undertaking more total thyroidectomies. The quoted incidence of Incidental carcinoma is around 10-20% in the literature. In two studies done in the unit, an incidence between 8.8% and 11.38% was seen. This factor must be considered in surgical decision making for benign disease. Most common cause of recurrences is the enlargement of embryological remnants of the thyroid and a modern thyroid surgeon must excise the embryological remnants meticulously. Surgery for recurrent goitre is a difficult task. Data confirms that Lateral approach to the thyroid makes the task much easier. This must be considered a bench for Sri Lanka. Cosmetic issues and cost must also be considered in thyroidectomy. Data confirms that Mini incision open thyroidectomy is a safe cost effective alternative to endoscopic thyroidectomy The obituary of open total thyroidectomy shall not be written for a long time.Item Assessing motivation to lose weight: the psychometric properties of the Sinhala version of University of Rhode Island Change Assessment (URICA) scale(Sri Lanka Medical Association, 2023) Niriella, M.A.; de Silva, S.T.; Hapangama, A.; Baminiwatta, A.; Fernando, R.; Ediriweera, D.INTRODUCTION: Weight reduction through lifestyle modifications is an important component in the management of various chronic diseases. The degree of motivation to change has been shown to predict outcomes in weight reduction interventions. Thus, the availability of a validated self-report tool assessing the degree of motivation for weight management would be useful for both clinical and research purposes in Sri Lanka. OBJECTIVES: To examine the structural validity and internal consistency of the URICA for weight management in a sample of Sri Lankan adults with chronic medical conditions. METHODS: Standard procedures for cross-cultural adaptation of a questionnaire were followed in translating the 32-item URICA into Sinhala. The Sinhala version was administered to 208 patients aged 18-60 years attending outpatient clinical services for non-disabling chronic medical diseases. Psychometric testing included confirmatory factor analysis and the assessment of internal consistency (Cronbach α). RESULTS: The commonly accepted four-factor structure of URICA reflecting Prochaska and Di Clemente’s transtheoretical model (pre-contemplation, contemplation, action and maintenance) showed good model fit, after the removal of four items from the pre-contemplation subscale due to inadequate factor loadings (<0.4). In line with theory, factor correlations indicated that the pre-contemplation factor was inversely correlated with the other three factors, while the other three factors were positively correlated with one another. All four subscales showed good internal consistency (Cronbach α ranging from 0.73 to 0.89). CONCLUSIONS: The Sinhala version of a modified 28-item URICA was found to have sound psychometric properties as a measure of motivation for weight management among Sinhala-speaking adult patient.Item Identification of type 2 diabetes patients with non-alcoholic fatty liver disease who are at increased risk of significant hepatic fibrosis: a cross-sectional study(Sri Lanka Medical Association, 2023) Mettananda, K.C.D.; Egodage, T.; Dantanarayana, C.; Solangarachchi, M.B.; Fernando, R.; Ranaweera, L.; Siriwardhena, S.; Ranawaka, C.K.; Kottahachchi, D.; Pathmeswaran, A.; Dassanayake, A.S.; de Silva, H.J.INTRODUCTION: Annual screening of patients with diabetes for fatty liver, and identifying those with significant hepatic fibrosis using the FIB-4 score and vibration-controlled transient elastography (VCTE) has been recommended to detect patients who may progress to advanced hepatic fibrosis/cirrhosis. However, VCTE is not freely available in resource-limited settings. OBJECTIVES: To identify clinical and biochemical predictors of significant liver fibrosis in diabetics with fatty liver. METHODS: We conducted a cross-sectional study among all consenting adults with T2DM and non-alcoholic fatty liver disease (NAFLD) attending the Colombo North Teaching Hospital, Ragama, Sri Lanka from November 2021 to November 2022. FIB-4 scores were calculated and patients with a score ≥1.3 underwent VCTE. Risk associations for liver fibrosis were identified by comparing patients with significant fibrosis (LSM ≥8 kPa) with those without significant fibrosis (FIB-4<1.3). RESULTS: A total of 363 persons were investigated. Of these, 243 had a score of FIB-4 <1.3. Of the 120 with a FIB-4 ≥1.3, 76 had LSM ≥8 kPa. Significant fibrosis was individually associated with age (OR 1.01, p<0.0001), duration of diabetes (OR 1.02, p=0.006), family history of liver disease (OR 1.42, p=0.035), waist (OR 1.04, p=0.035), and FIB-4 (OR 2.08, p<0.0001). However, on adjusted analysis, significant fibrosis was only associated with a family history of liver disease (OR 2.69, p=0.044) and FIB-4 (OR 1.43, p<0.001). CONCLUSION: In patients with T2DM and fatty liver, advancing age, increased duration of diabetes, a family history of liver disease, waist circumference and a high FIB-4 score increase the risk of significant hepatic fibrosis. Targeted interventions in this group may help prevent progression to advanced hepatic fibrosis/cirrhosis.Item Measuring resilience among Sri Lankan healthcare workers: validation of the brief resilience scale in Sinhalese and Tamil languages(Sage Publishing, 2023) Baminiwatta, A.; Fernando, R.; Gadambanathan, T.; Jiyatha, F.; Sasala, R.; Kuruppuarachchi, L.; Wickremasinghe, R.; Hapangama, A.Resilience is the capacity for adaptation and “bouncing back” in the face of adversity.1,2 It protects against mental health problems such as depression, anxiety, and stress and improves well-being. 3 During the COVID-19 pandemic, there was a growing need for studies on protective factors in mental health, such as resilience, particularly among healthcare workers. 4 Psychometric assessment of resilience is a prerequisite for research in this area. A review of 19 resilience scales found a wide variation in their psychometric properties, with all of them posing some challenges. 5 However, the authors noted that the Resilience Scale for Adults, Brief Resilience Scale (BRS), and the Connor-Davidson Resilience Scale had the finest psychometric ratings. BRS may have an exceptional place in behavioral research because other resilience scales tend to assess resources that promote resilience rather than resilience itself. BRS is probably the only measure to assess resilience in its most basic meaning—the ability to “bounce back.” 2 Furthermore, among resilience scales, BRS is short and, therefore, would generate better response rates in research. As BRS was not available in local languages, its validation into Sinhalese and Tamil languages was needed to enable research on resilience in Sri Lanka. METHODS: Approval was obtained from the Ethics Review Committee. The procedure for questionnaire translation followed the recommendations of Beaton et al. (2000). 6 Firstly, BRS was translated into each local language (Sinhalese and Tamil) independently by two bilingual experts, and a consensus translation was prepared. The translated version was back-translated into English by two independent bilingual translators. They were compared with the original BRS for semantic, idiomatic, experiential, and conceptual equivalence by a group of experts comprising several Sinhalese- and Tamil-speaking psychiatrists, bilingual experts, and a methodologist. A few phrases in the original English version, such as “bounce back” and “snap back,” were replaced with conceptually equivalent phrases in the local languages. Face and content validity were discussed, and a consensus translation was prepared. After conducting a pre-test and cognitive debriefing with a purposive sample of 10 healthcare workers for each language, and further minor modifications, the translated scales were administered to 150 Sinhalese- and 110 Tamil-speaking healthcare workers (nurses, doctors, and other categories), after obtaining informed consent (see Table S1 for the sociodemographic profiles; the translated questionnaires are provided as supplementary files). Confirmatory factor analysis (CFA) was used to test the model fit for the one-factor structure of BRS, 2 using the following fit indices: comparative fit index (CFI), Tucker Lewis index (TLI), standardized root mean square residual (SRMR), and root mean square error of approximation (RMSEA). Depression, anxiety, and Stress Scale -21 (DASS-21) was administered to test expected inverse correlations with resilience. RESULTS: According to CFA, the six-item BRS formed a unitary construct, with satisfactory model fit for both the Sinhalese (CFI = 0.99, TLI = 0.99, RMSEA = 0.09, SRMR = 0.05) and Tamil versions (CFI = 0.98, TLI = 0.97, RMSEA = 0.14, SRMR = 0.07). Factor loadings of individual items ranged from 0.59 to 0.86 in the Sinhalese and 0.61 to 0.82 in the Tamil version (see Table S2 for item-level statistics). Cronbach alpha of the Sinhalese and Tamil BRS were 0.82 and 0.80, respectively, indicating good internal consistency. Removal of any single item did not significantly improve internal consistency. The Sinhalese BRS score had significant negative correlation with depression (r = –0.29, P = 0.002), anxiety (r = –0.27, P = 0.005), and stress (r = –0.20, P = 0.033), whereas the Tamil BRS score had significant negative correlation with anxiety (r = –0.18, P = 0.028) and stress (r = –0.25, P = 0.002) but not with depression. DISCUSSION: Our findings support the construct validity and internal reliability of the BRS as a measure of resilience. The one-factor structure proposed by the original developers 2 and replicated in subsequent studies 7 was observed in the present study. BRS has been previously translated and validated in several languages, including German, Polish, Spanish and Dutch.7–10 Similar to the observations in the original validation sample 2 and the Spanish validation, 7 resilience, as measured using BRS, showed significant inverse correlations with depression, anxiety, and stress in the present analysis. This provided further support for its construct validity through hypothesis testing. The absence of a significant inverse correlation of the Tamil BRS score with depression may be due to the comparatively small sample size available for the Tamil validation. Although our findings were based on healthcare workers, we expect the scale’s validity to extend to the general population. Thus, the Sinhalese and Tamil BRS can be used in future large-scale research on resilience in Sri Lanka. As high rates of mental health issues were reported among healthcare workers in Sri Lanka during the COVID-19 pandemic, 11 and the country is currently going through an unprecedented economic crisis, it is important to take measures to enhance resilience among Sri Lankan healthcare workers. The availability of a validated tool in both Sinhalese and Tamil languages would enable research on mental health and resilience among culturally-diverse populations in Sri Lanka, which would provide useful information to guide health policy development. Limitations of this study include the small sample sizes and the lack of test-retest reliability assessments to ascertain the temporal stability of the BRS scores.Item Identification of patients with type 2 diabetes with non-alcoholic fatty liver disease who are at increased risk of progressing to advanced fibrosis: a cross-sectional study(BMJ Publishing Group Ltd, 2023) Mettananda, C.; Egodage, T.; Dantanarayana, C.; Fernando, R.; Ranaweera, L.; Luke, N.; Ranawaka, C.; Kottahachchi, D.; Pathmeswaran, A.; de Silva, H.J.; Dassanayake, A.S.INTRODUCTION: Identification of advanced hepatic fibrosis in non-alcoholic fatty liver disease (NAFLD) is important as this may progress to cirrhosis and hepatocellular carcinoma. The risk of hepatic fibrosis is especially high among patients with diabetes with NAFLD. Annual screening of patients with diabetes for fatty liver and calculation of Fibrosis-4 (FIB-4) score and exclusion of significant fibrosis with vibration-controlled transient elastography (VCTE) have been recommended. However, VCTE is expensive and may not be freely available in resource-limited settings. We aim to identify predictors of significant liver fibrosis who are at increased risk of progression to advanced liver fibrosis and to develop a prediction model to prioritise referral of patients with diabetes and NAFLD for VCTE. METHODS AND ANALYSIS: This cross-sectional study is conducted among all consenting adults with type 2 diabetes mellitus with NAFLD at the Colombo North Teaching Hospital, Ragama, Sri Lanka. All patients get the FIB-4 score calculated. Those with FIB-4 ≥1.3 undergo VCTE (with FibroScan by Echosens). Risk associations for progression to advanced liver fibrosis/cirrhosis will be identified by comparing patients with significant fibrosis (liver stiffness measure (LSM) ≥8 kPa) and without significant fibrosis (LSM <8 kPa). A model to predict significant liver fibrosis will be developed using logistic regression. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Ethics Committee of the Faculty of Medicine, University of Kelaniya (P/66/07/2021). Results of the study will be disseminated as scientific publications in reputable journals.Item Incidental thyroid cancer in the pyramidal lobe and implications for thyroidectomy(The Sri Lanka Medical Associtation, 2022) Pinto, D.; Mahendra, G.; Fernando, R.The embryological remnants (ERs) must be removed to achieve a safe and complete ‘total’ thyroidectomy. Residual ERs, after thyroidectomy, may cause recurrence of the initial pathology. This poses management dilemmas, including a difficult reoperation. Active search and removal of the ERs intraoperatively is essential. Primary overt malignancy is rare in ERs. Literature reports several cohort studies of same. The incidence of a micropapillary carcinoma in an ER has not been reported and this brief report describes two patients with Incidental micropapillary carcinoma in the pyramidal lobe, reiterating the need to make removal of ERs the accepted norm in total thyroidectomies.Item Sri Lankan medical officers’ attitudes towards the elderly: a pilot study(Postgraduate Institute of Medicine University of Colombo, 2022) Fernando, R.; Ratnayake, G.; Liyanage, N.; Fonseka, M.; Perera, I.; Kuruppuarachchi, K.A.L.A.; Hapangama, A.Ageism among doctors influences treatment options and care of the elderly. Attitudes of Sri Lankan doctors towards the elderly have not been studied previously. This descriptive cross-sectional study using Fraboni’s scale of ageism explored doctors' attitudes towards older people in three selected hospitals in Sri Lanka and the relationship of such attitudes with demographic, employment, education and training-related factors. No association between the attitude of doctors toward the elderly and the factors studied in this pilot study were found.Item Autonomously functioning thyroid nodule: a patient-based review(The College of Surgeons of Sri Lanka, 2021) Pinto, D.; Fernando, R.Autonomously Functioning Thyroid Nodule (AFTN) is a rare cause of hyperthyroidism. AFTN, first described by Emil Goetsch in 1918, is the presence of a single hyperfunctioning thyroid nodule, which is not under the control of the pituitary/thyroid axis. The current theory on the development of hyperfunctioning nodules is the constitutive activation of Thyroid Stimulating Hormone Receptor (TSHR) due to a somatic point mutation and mutations of Gsa. The reported incidence of AFTN is about 1% on the investigation of thyroid nodules. Only about 10% - 30% become hyperfunction. Due to the rarity and lack of understanding of its characteristic clinical behaviour, AFTNs are often overlooked and undertreated. The ensuing review is based on a 36-year-old female who underwent left hemithyroidectomy for an AFTN and is well to date. There are two main issues in the diagnosis and management of AFTN. The first is that the diagnosis is not always made as most patients with AFTNs are functionally euthyroid. The other is the paucity of data in the literature to offer evidence-based individualized management for patients. As there are no tissue diagnostic criteria for AFTN; clinical, biochemical and radiological assessments to establish TSH independent nodular hyperfunction will clinch the diagnosis. Surgery and Radioiodine ablation remain the main forms of treatment for AFTN. Other methods such as percutaneous ethanol injection therapy (PEIT), laser ablation (LA), radiofrequency ablation (RFA) have a limited role in the management of an AFTN. The newer methods alluded to above will need further evaluation and a better definition of exact roles in the management of an AFTN.Item Anxiety and Depression among the patients with Dysphagia following Oral Maxillofacial and Neck surgeries in four selected hospitals in Western Province, Sri Lanka.(Faculty of Medicine, University of Kelaniya, Sri Lanka, 2021) Fernando, K.; Fernando, R.; de Silva, D.Introduction: Undiagnosed anxiety and depression are obstacles to effective management of post-operative dysphagia. In Sri Lanka, the prevalence of anxiety and depression among patients with postoperative dysphagia is not known. Objectives: This study aimed at determining the severity and the stage of dysphagia, presence of anxiety and depression, and to identify the association between the severity and the stage of dysphagia with anxiety and depression following Neck, Oral & Maxillo-Facial (OMF) Surgeries. Methods: A cross-sectional study was conducted among 97 participants, with post¬operative dysphagia following OMF and Neck surgeries at four selected hospitals. Oral-motor and cranial nerve examination, the 3 ml water test, Cervical auscultation, Dysphagia Severity Rating Scale and Hospital Anxiety and Depression Scale were used for data collection. Results: Among the participants 51% presented with pharyngeal phase dysphagia and severe dysphagia. Prevalence of depression was 51% and anxiety was 38%, while 35% and 45% were at the borderline range respectively. With the increasement of dysphagia severity, high levels of anxiety and depression were noted. There was a statistically significant association between the severity of anxiety with severity of dysphagia (p< 0.05). Conclusion: Psychological burden is high among the participants with dysphagia following OMF and neck surgeries. Holistic management of dysphagia following OMF and neck surgeries, should include an assessment of the mental state of these patients and the treatment of anxiety and depression if required.