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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Standards of care of management of diabetes among rural cohort in Sri Lanka - a descriptive study(Sri Lanka College of Internal Medicine, 2021) Chathuranga, P.A.D.U.; Meegodawidanage, N.; Rathnayaka, T.M.; Luke, W.A.N.V.; Mettananda, K.C.D.Introduction: Type 2 Diabetes mellitus (T2DM) is a challenge to health care leading to increase in morbidity and mortality. Objective: We conducted a descriptive study in rural Sri Lanka to assess the standards of care and disease control among patients with diabetes to identify areas for improvement. Methods: A retrospective follow-up study was conducted in five hospitals in Anuradhapura district. All type 2 diabetic patients, diagnosed and started on oral hypoglycemic drugs 24 months prior to recruitment, who attended the above clinics during the study period were enrolled to the study. Data on demographics, medications and blood sugar control were collected using an interviewer-administered questionnaire and perusing medical records. Drug compliance was studied using a self-administered questionnaire. Results: Control of Diabetes and other cardiovascular risk factors 2 years following initiation of oral hypoglycaemic drugs in 421 patients (19.2% male, mean age 58.3±10.4 years) were studied. Even after 2 years of medications, 48.2% were overweight, 34.0% obese and 53.9% were physically inactive. Prevalence of medication use among them were, metformin 96.7%, statins 64.1 % and anti-hypertensives 49.4%. Their mean Fasting Blood Sugar(FBS) was 139±54.3 mg/dl and Body Mass Index(BMI) was 26.5±4.5kgm-2. Poor compliance to medication was found in 60.3%. Sub-optimal risk factor control, FBS >130mg/dl, blood pressure >130/80mmHg, and LDL >100mg/dl were seen in 45.1.%, 19.94% and 16.1%, respectively. Conclusion: Even though majority were started on necessary medicines, FBS control was poor in this rural population. The reasons behind poor FBS control need to be studied and addressed to improve care of patients with diabetes in rural Sri Lanka.Item Prevalence, associations and treatment outcome of anaemia in a cohort of patients with Chronic Kidney Disease(Sri Lanka Medical Association, 2019) Luke, W.A.N.V.; Lakmini, K.M.S.; Nadeeka, D.; de Silva, S.T.INTRODUCTION & OBJECTIVES: Anaemia is a common complication of chronic kidney disease (CKD) that can adversely affect cardiovascular health and quality of life. We conducted a study to assess prevalence, associations and treatment response of anaemia in a cohort of patients with CKD. METHODS: A descriptive cross sectional study was conducted among consecutive, consenting adult patients with stable CKD attending clinics and wards of University Medical Unit, Colombo North Teaching Hospital, Ragama. RESULTS: Of 149 patients with CKD [86/149 males (57.7%)], 105 (70.5%) had diabetes, 125 (83.9%) had hypertension and 57 (37.6%) had ischemic heart disease. 58/63 (90.6%) females and 80/86 (93%) males had anaemia. Severity of anaemia was associated with female sex (p=0.02), advancing CKD stage (p<0.01), diabetes (p=0.03), chronic liver cell disease (p=0.03), being on dialysis (p<0.005) and increasing degree of proteinuria (p<0.001). Of 91 patients investigated for the cause of anaemia, 55/91 (60.4%) had iron deficiency with anaemia of chronic disease while 25/91 (27.5%) had anaemia of chronic disease only. Of 88 patients with haemoglobin <10g/dL, only 40 (45.4%) were on erythropoietin and 50 (56.8%) had received blood transfusions. 76.1% (67/88) of the anaemic patients continued to have hemoglobin below 10g/dL at follow up despite treatment. CONCLUSION: Anaemia was highly prevalent in the CKD cohort we studied, compared to similar populations in other countries. Timely evaluation of anaemia, treatment of coexistent nutritional deficiencies and initiation of erythropoietin therapy are important to prevent anaemia-related complications and minimize the need for transfusions.Item Prevalence and patterns of dyslipidaemia among hypertensive patients in North Western Sri Lanka: A cross sectional study(Sri Lanka Medical Association, 2018) Luke, W.A.N.V.; Ediriweera, N.S.; de Silva, C.K.; Perera, K.M.N.; Ranasinha, C.D.; Kasturiratne, A.; de Silva, H.A.INTRODUCTION AND OBJECTIVES: Dyslipidaemia and hypertension are major risk factors for cardiovascular disease. Data on prevalence and patterns of dyslipidaemia in rural settings of Sri Lanka are limited. We conducted a study to determine the prevalence of dyslipidaemia among hypertensive adults over 40 years of age in the Puttalam district. METHODS: A community-based study was conducted in selected Grama Niladhari divisions in ten Medical Officer of Health areas in the Puttalam district. Socio-demographic data were obtained from adult hypertensive and basic investigations were carried out. RESULTS: Total of 798 hypertensive patients (546 females and 252 males) were included in the study. Median (Interquartile range) levels of total cholesterol, HDL, LDL and TG of the patients were 205 (173 - 238), 55 (48 - 63), 125 (96 - 155), 109 (85 - 143) respectively. Elevated levels of total cholesterol, LDL, TG and non HDL were reported in 192 (24. %), 371(46.4%), 173 (21.6%) and 527 (66%) respectively and low HDL was observed among 40 (5%) patients. High non HDL cholesterol was associated with female gender (P=0.03) and advancing age showed a negative association (P<0.01). CONCLUSION: Prevalence of dyslipidaemia is high in this hypertensive adult cohort. Suboptimal level of modifiable risk factor control is observed in this population which should be addressed to further reduce cardiovascular morbidity and mortalityItem Prevalence of hypertension in a rural district of Sri Lanka(Sri Lanka Medical Association, 2017) Luke, W.A.N.V.; Ediriweera, D.S.; de Silva, K.C.; Balasooriya, E.R.; Perera, K.M.N.; Ranasinha, C.D.; Kasturiratne, A.; de Silva, H.A.INTRODUCTION & OBJECTIVES: Hypertension is a leading cause of cardiovascular morbidity and mortality. Data on prevalence of hypertension in rural settings of Sri Lanka is limited. We conducted a study to determine the prevalence of hypertension among adults over 40 years of age in the Puttalam district.METHODS: A community-based prevalence study was conducted in selected Grama Niladhari divisions in ten Medical Officer of Health areas in the Puttalam district. Adults over 40 years of age living in consecutive households were screened by trained research assistants using digital blood pressure (BP) meters. Basic demographic data were obtained using an intervieweradministered questionnaire. Previously undiagnosed adults with persistent elevation of BP (SBP > 140 and /or DBP > 90 mmHg on two readings) and those already on treatment for hypertension were identified. RESULTS: A total of 2289 were screened. The mean (SD) of SBP and DBP were 134.5(21.3) and 82.1 (13.5) mmHg respectively. The overall hypertension prevalence was 458.5 (95% CI 438.1– 478.8) per 1000 population. 16.3% were newly diagnosed. Prevalence of uncontrolled hypertension among those on treatment was 516.2 (95% CI 479.4–552.9) per 1000. 98.7 (95% CI 86.6–110.9) per 1000 had blood pressure >160/110 mmHg. There was an increasing trend in blood pressure with increasing age (OR=1.07, 95% CI 1.06–1.08, p<0.01) but not with the male sex. CONCLUSION: Prevalence of hypertension is high in this rural adult cohort. Previously undetected hypertension and uncontrolled hypertension among those already on treatment are common. Community-based approaches targeting screening and BP control are essential to reduce adverse outcomes of hypertension.Item Factors associated with urinary tract infections caused by extended spectrum β-lactamase producing organisms (ESBL-UTI) among hospitalized patients in a tertiary care hospital(Sri Lanka Medical Association, 2016) Fernando, S.C.; Wickramasinghe, R.D.S.S.; Luke, W.A.N.V.; Gunathilake, M.P.M.L.; Sebastiampillai, B.S.; Miththinda, J.K.N.D.; Silva, F.H.D.S.; Premaratna, B.A.H.R.INTRODUCTION AND OBJECTIVES: Management of infections caused by ESBL producers is a challenge and expensive. Known associations for ESBL-UTI include recent hospitalizations, recent treatment with cephalosporins, quinolones or penicillin, age over 60 years, male gender, diabetes mellitus, recent Klebsiella pneumoniae infection and obstructive uropathy. Associations for ESBL-UTI in Sri Lanka are not known. METHOD: In order to identify associations of urinary tract infections (UTIs) caused by ESBL producers (ESBL-UTI),a descriptive cross-sectional study was carried out in patients with culture positive ESBL-UTIs admitted to the Professorial Medical unit, Colombo North Teaching Hospital. Patients’ medical records and an interviewer administered questionnaire were used to obtain data. RESULTS: There were 61 patients, 30 (49.1%) males with a mean age of 64.1 years. Of them, 54 (88.5%) had diabetes mellitus,38 (62.2%) had hypertension and 10 (16.3%) had chronic liver disease (CLD). 21 (34.4%) had acute pyelonephritis, 19 (31.1%) had evidence of chronic kidney disease,8 (13%) had obstructive uropathy by ultrasonography. A history of constipation was given in 27 (44.2%), hospitalization during the past 3 months in 30 (49.2%), urinary catheterization in 20 (32.7%) and antibiotic treatment within the past 3 months in 39 (63.9%). CONCLUSION: Most associations for ESBL-UTI in Sri Lanka were similar to that had been previously described. However the observed higher incidence of CLD, hypertension and CKD needs further evaluation. The fact that 50.8% did not have a history of recent hospitalization and 36.1% did not have recent antibiotic therapy suggest high community prevalence of ESBL producing organisms.Item Antibiotic sensitivity patterns among extended spectrum β-lactamase (ESBL) producing organisms causing urinary tract infections in Sri Lanka(Sri Lanka Medical Association, 2016) Luke, W.A.N.V.; Fernando, S.C.; Wickremasinghe, R.D.S.S.; Sebastiampillai, B.S.; Gunathilake, M.P.M.L.; Miththinda, J.K.N.D.; Silva, F.H.D.S.; Premaratna, B.A.H.R.INTRODUCTION AND OBJECTIVES: ESBLs are enzymes that confer resistance to all penicillins, cephalosporins, and aztreonam. ESBL producing organisms causing urinary tract infections (ESBL-UTI) are increasing in incidence and pose a major burden to health care requiring treatment with expensive antimicrobials and prolonged hospital stay. Documented antibiotic susceptibility of ESBL organisms include meropenem (95-100%) and aminoglycosides (45-60%). This study evaluated the antibiotic sensitivity patterns of ESBL-UTI in Sri Lanka. METHOD: Patients with ESBL-UTI admitted to Professorial Medical Unit, Colombo North Teaching Hospital (CNTH) from January – June 2015 were recruited to the study. Their Urine culture and ABST reports were evaluated after obtaining informed written consent. RESULTS: Of 61 culture positive ESBL-UTIs, E. coli accounted for 53 (86.8%), followed by Klebsiella in the 8 (13.1%). The ESBL organisms were mostly sensitive to carbapenems; 58 (95%) to Meropenem and 45 (73.7%) to Imipenem. The other sensitivity patterns were 37 (60.6%) to Amikacin, and 28 (45.9%) to Nitrofurantoin. Meropenem resistance was observed in 3 (4.9%) and were E.coli. These three patients had received multiple antibiotics including meropenem in the recent past for recurrent UTI. CONCLUSIONS: It is evident from the above data that Carbapenems remain as the first line therapy for the majority of ESBL-UTI in the local setting. However 4.9 % prevalence of meropenem resistance is alarming compared to 0.4% prevalence in Pakistan and 0.02% prevalence in Germany. Such high prevalence of meropenem resistance should draw attention of clinicians and needs to implement measures to prevent emergence and spread of carbapenum resistant ESBL organisms in the country.Item Cluster randomized trial on integrated primary care strategies to reduce high blood pressure in rural communities in Sri Lanka: Report from the feasibility study(Sri Lanka Medical Association, 2016) de Silva, H.A.; Kasturiratne, A.; Luke, W.A.N.V.; Ediriweera, D.S.INTRODUCTION: Hypertension is the leading cause of mortality worldwide. Control of Blood Pressure and Risk Attenuation (COBRA) trial conducted in Pakistan, demonstrated that the combined intervention of home health education (HHE) plus training general practitioners (GPs)was more effective for lowering blood pressure (BP) compared to usual care. OBJECTIVES: A feasibility study was conducted to adapt and integrate evidence-based strategies to control hypertension in the primary healthcare system in rural Sri Lanka. METHOD: Public Health Midwives (PHMs) in three Medical Officer of Health areas in Kurunegala district were trained on digital BP measurement and health education of hypertensive patients and their families PHMs screened household members above 40 years of age to identify individuals with hypertension. Socio-demographic data was collected and HHE was delivered as per training manual.PHMs referred probable patients to trained medical officers in the closest divisional hospital for further care and regular follow up. A referral loop was maintained by tracking the referred patients at the rural hospital by supervising PHM and medical officers. RESULTS: 142 hypertensive individuals were recruited and 129(90.8%) of them presented to the health care facility for follow up. At the end of follow up mean systolic blood pressure reduction of 13.8 mmHg (p-0.001) in those with poorly controlled BP (SBP≥160or DBP≥100 ) was demonstrated. CONCLUSIONS: It is feasible to implement this community-based strategy integrated to routine care for improving the management of hypertension in rural communities. Findings of this feasibility study will be fully evaluated in a large randomized controlled trial.Item Tuberculous monoarthritis of the wrist in a patient with systemic lupus erythematosus: a case report(Biomed Central, 2017) Luke, W.A.N.V.; Gunathilake, M.P.M.L.; Munidasa, D.; de Silva, S.T.BACKGROUND: Unusual forms of tuberculosis are common among immune-suppressed patients, leading to challenges in diagnosis and management. We present a Sri Lankan patient with systemic lupus erythematosis, investigated for chronic wrist pain with low inflammatory markers and without systemic symptoms, who was subsequently diagnosed to have tuberculosis of the joint. CASE PRESENTATION: A 31-year-old woman with systemic lupus erythematosis in remission was evaluated for chronic left wrist pain without significant examination findings on presentation. She did not have any constitutional symptoms. Basic investigations did not reveal any significant abnormalities. She was treated with increasing immunosuppression as for lupus related arthritis. Subsequently she developed a wrist effusion with high inflammatory markers, and was treated as septic arthritis. Synovial biopsy features suggested tuberculosis. The patient's symptoms improved with surgical intervention and anti-tuberculosis treatment. CONCLUSION: Tuberculosis should be considered in patients with systemic arthritis with unusual symptoms. Delayed diagnosis along with continuing immunosuppression can lead to extensive tissue damage. Clinically detectable effusions should be analyzed along with synovial biopsy in order to exclude concurrent infections. Radiography of the joint has poor sensitivity to detect early joint damage, but changes may be evident early on magnetic resonance imaging, sothis should be considered in patients with unusual features.Item Extended spectrum beta lactamase producing organisms causing urinary tract infections in Sri Lanka and their antibiotic susceptibility pattern -A hospital based cross sectional study(BioMed Central, 2017) Fernando, , M.M.P.S.C.; Luke, W.A.N.V.; Miththinda, J.K.N.D.; Wickramasinghe, R.D.S.S.; Sebastiampillai, B.S.; Gunathilake, M.P.M.L.; Silva, F.H.; Premaratna, R.BACKGROUND: Extended Spectrum Beta- Lactamase producing organisms causing urinary tract infections (ESBL-UTI) are increasing in incidence and pose a major burden to health care. While ESBL producing Klebsiella species seem to account for most nosocomial outbreaks, ESBL-producing E. coli have been isolated from both hospitalized and non-hospitalized patients. Although 95-100% ESBL organisms are still considered sensitive to meropenem, rapid emergence of carbapenem resistance has been documented in many countries. The objective of this study was to evaluate urinary tract infections caused by ESBL producers and the antibiotic susceptibility patterns in Sri Lanka. METHODS: Patients with confirmed ESBL-UTI admitted to Professorial Medical Unit, Colombo North Teaching Hospital from January - June 2015 were recruited to the study. Their urine culture and antibiotic susceptibility reports were evaluated after obtaining informed written consent. RESULTS: Of 61 culture positive ESBL-UTIs, E. coli caused 53 (86.8%), followed by Klebsiella in 8 (13.1%).30 (49.1%) had a history of hospitalization within the past three months and included 6/8(75%) of Klebsiella UTI and 24/53(45.2%) of E.coli UTI. Antibiotic susceptibility of ESBL organisms were; Meropenem 58 (95%), Imipenem 45 (73.7%), Amikacin 37 (60.6%) and Nitrofurantoin 28(45.9%). In 3(4.9%), E.coli were resistant to Meropenem. These three patients had received multiple antibiotics including meropenem in the recent past for recurrent UTI. CONCLUSIONS: We observed a higher percentage of E. coli over Klebsiella as ESBL producing organisms suggesting most ESBL-UTIs to be community acquired, Carbapenems seem to remain as the first line therapy for majority of ESBL-UTIs in the local setting. However 4.9% prevalence of meropenem resistance is alarming compared to other countries. Although prior antibiotic utilization and hospitalization may contribute to emergence of ESBL producing Klebsiella and E.coli in Sri Lanka, high prevalence of community acquired ESBL-E. coli needs further investigations to identify potential causes . Being a third world country with a free health care system, observed alarming rate of carbapenem resistance is likely to add a significant burden to health budget. We feel that treatment of infections in general needs a careful approach adhering to recommended antibiotic guidelines in order to prevent emergence of multi drug resistant organisms.Item Thyrotoxic crisis presenting with jaundice(Biomed Central, 2016) Wickramasinghe, R.D.S.S.; Luke, W.A.N.V.; Sebastiampillai, B.S.; Gunathilake, M.P.M.L.; Premaratna, R.BACKGROUND: Thyrotoxic crisis is a medical emergency requiring early diagnosis and urgent management, which can be challenging due to its diverse clinical presentations. While common presentations include fever, sweating, palpitations, tremors and confusion, presence of jaundice is rare. CASE PRESENTATION: We report a 35-year-old male who presented with jaundice due to cholestasis along with other features of thyrotoxic crisis due to Graves' disease. He had a good clinical recovery with resolution of cholestasis following treatment for thyrotoxic crisis. CONCLUSION: Jaundice can be a rare manifestation of thyrotoxic crisis, and should be considered in the differential diagnosis when other clinical features of thyrotoxic crisis are present. However secondary causes of jaundice should be looked into and excluded.