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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Frozen shoulder following cardiac surgery; Sri Lankan experience(Sri Lanka Medical Association, 2023) Kurukulasuriya, S.A.F.; Mettananda, K.C.D.; Jayaratne, K.I.W.G.M.N.INTRODUCTION: A high incidence of frozen shoulder (FS), of up to 33% is reported in patients undergoing cardiac surgery, which is tenfold higher than in the normal population. Early diagnosis and treatment may prevent progression to chronic, treatment-resistant disease. OBJECTIVES: To study the incidence and associations of acute FS among a cohort of Sri Lankans undergoing coronary artery bypass graft, valve replacement or both cardiac surgeries. METHODS: An observational study was conducted in selected private-sector hospitals in Colombo. Sample size computed was 142 (110 males, mean age 60.28 yrs.) and convenience sampling technique was used where consecutive eligible patients were selected until the required sample size was S149 fulfilled. Patients were recruited to the study while in hospital and reviewed at the two-week and three-month routine follow-up visits. Interviewer administered questionnaire was used to document the demographic data and risk factor associations. Patients presenting with pain and restricted movement of the shoulder joint with positive limitation in lateral rotation, abduction, and medial rotation (LAM test) were considered as having frozen shoulders. RESULTS: Of the142 patients 40.1%(n=57) developed shoulder pain 38.7%(n=55) were LAM test positive. 38.7% (n=55) with both LAM test positivity and shoulder pain were confirmed as having FS. The highest number of patients developing FS were from the 50-60year age group (n=25). Of the associations, dyslipidaemia and ischemic heart disease had significant correlation with the diagnosis of FS (p value<0.05). CONCLUSIONS: More than one third of patients undergoing cardiac surgery developed FS. Ishaemic heat disease and dyslipidaemia showed significant correlation.Item Prevalence and associations of polypharmacy among Sri Lankans: A hospital-based study(Sri Lanka Medical Association, 2021) Mettananda, K.C.D.; Fernando, R.K.R.; Peiris, H.H.I.; Arangala, D.M.P.Introduction and Objectives Polypharmacy is a global health problem but the prevalence in Sri Lanka is not known. Therefore, we studied the prevalence and associations of polypharmacy in Sri Lanka. Methods We conducted a cross-sectional study of all medical clinics of Colombo North Teaching Hospital from 15 August 2020 to 15 February 2021. 50 patients of each clinic were randomly selected. Data were collected using an interviewer-administered questionnaire by interviewing patients and perusing medical recodes. Polypharmacy was defined as being on five or more medications regularly for one month before enrolment. Data were analyzed using SPSS-22. Results 504 patients; 215(42.7%) males, mean age 59.7+14.3 years were studied from 4 general-medical and 8 speciality clinics. 352(69.8%) were on polypharmacy. 159(46%) were on allopathic and complementary medicines. Polypharmacy prevalence was not different between general-medical (71.3%) and speciality clinics (69.2%), p=0.67. Prevalence was more in patients above 60 years (77.3%), p<0.0001. Polypharmacy was associated with diabetes (OR 3.3, p<0.0001), hypertension (OR 2.5, p<0.001), chronic kidney disease (OR 3.9, p<0.0001) and ischaemic heart disease (OR 3.3, p<0.002) but was not associated with gender (OR 1.1, p=0.776), dyslipidemia (OR 1.2, p=0.407) or stroke (OR 1.2, p<0.521). Of patients on polypharmacy, 68(47.7%) were not complaining while others were worried due to different reasons; kidney/ liver damage (46(13,1%), high-cost (21(6.0%)), side effects (22(6.3%)), frustration (16(4.5%). 72((20.5%) had more than one worry. Conclusion Polypharmacy is a common problem in this hospital-based urban/ semi-urban cohort of Sri Lankans and is more with old age, diabetes mellitus, hypertension, kidney disease and ischemic heart disease.Item Hydroxyurea for transfusion dependent β-thalassaemia: A randomized double-blind placebo-controlled clinical trial(Sri Lanka Medical Association, 2021) Yasara, N.; Wickramarathne, N.; Silva, I.; Hameed, N.; Attanayaka, A.M.K.R.; Jayasinghe, V.L.; Gunathilaka, P.A.C.K.; Wickramasinghe, N.; Rodrigo, R.; Perera, L; Perera, P.S.; Mettananda, K.C.D.; Manamperi, A.; Premawardhena, A.; Mettananda, S.Introduction and objectives Hydroxyurea induces fetal haemoglobin in vitro however, its clinical usefulness in β-thalassaemia is unclear. Here, we aim to assess the efficacy and safety of oral hydroxyurea in patients with transfusion dependent β-thalassaemia. Methods A phase 3 randomized double-blind placebo-controlled clinical trial was conducted at Colombo North Teaching Hospital in 2019/20. Sixty patients with transfusion dependent β-thalassaemia were randomized into hydroxyurea (10-20mg/kg/day) or placebo groups. Transfused blood volume, pre-transfusion haemoglobin, fetal haemoglobin and adverse effects were monitored during 6-month treatment and post-treatment periods. The study was approved by the ethics committee of University of Kelaniya and registered in Sri Lanka Clinical Trials Registry (SLCTR/2018/024). Results Fifty-four (hydroxyurea-27; placebo-27) patients completed the trial. Mean pre-transfusion haemoglobin (8.2±0.8g/ dLvs8.0±0.88g/dL, p=0.43) and fetal haemoglobin levels (7.9±11.2%vs4.6±4.3%, p=0.17) were higher in hydroxyurea group compared to placebo. Also, transfused blood volume was lower in the hydroxyurea group (94±29ml/kgvs102±28ml/kg, p=0.34). However, none were statistically significant. Based on elevation of fetal haemoglobin (>1.5% from baseline), we identified 12/27 patients who respond well to hydroxyurea (hydroxyurea-responders). Hydroxyurea-responders required significantly lower blood volume (77±27ml/kg) compared to non-responders (108±24ml/kg, p<0.01) and placebo group (102±28ml/kg, p<0.05). HbE β-thalassaemia sub-type (p<0.01) and Xmn1 polymorphism of γ-globin gene (p<0.05) were significant predictors of response to hydroxyurea. No serious side effects due to hydroxyurea were reported. Conclusion Over 40% of patients with transfusion dependent β-thalassaemia- specifically those with HbE β-thalassaemia and Xmn1 polymorphism of γ-globin gene- responded to hydroxyurea and required 25% less blood compared to controls. No serious adverse effects were reported following hydroxyurea treatment.Item Development of cardiovascular disease risk prediction model for Sri Lankans(Sri Lanka Medical Association, 2021) Mettananda, K.C.D.; Thampoe, R.S.; Batagoda, B.M.S.M.; Arangala, D.M.P.; Abeysena, H.T.C.S.INTRODUCTION AND OBJECTIVES: There are no Cardiovascular (CV) risk prediction models derived from Sri Lankans. Therefore, we aimed to develop a model to predict the risk of cardiovascular diseases (CVD) among Sri Lankans. METHODS: We developed a model to predict the risk of developing CVDs among Sri Lankans by comparing risk factors of patients who have had and haven’t had acute CVDs. Risk factors were selected depending on the odds ratios of each risk predictor and the feasibility of using those in clinical practice. Two separate models were developed for diabetics and non-diabetics. A scoring system [diabetics; 0-23 and non-diabetics 0-14] was designed based on weighted scores of each risk predictor. Predictive validity of the model was tested by calibration and discrimination. Receiver Operator Characteristic (ROC) curve was used to determine the cut-off value. RESULTS: The model consisted of five predictors; sex, current-smoking status, premorbid systolic blood pressure > 140 mmHg, antihypertensive medication usage and high-density-lipoprotein(HDL) < 45 mg/dL. Discrimination of the model was measured by the area under the ROC curve (diabetics; 0.76, 95% Confidence Interval: 0.68-0.84, non-diabetic; 0.91, 0.86-0.96). Calibration with goodness of fit by Hosmer and Lemeshow test (diabetics; p=0.75, non-diabetics; 0.66) was satisfactory. The tool demonstrated a good predictive ability with sensitivity and specificity of 71.1% (95%CI: 61.3% - 80.8%) and 68.4%(65.3% - 80.5%) in diabetics and 82.2% (95%CI: 72.7% - 91.7%) and 90.9% (95%CI: 84.9% - 96.9%) in non-diabetics. CONCLUSION: The model demonstrated good discrimination and well calibration. It can be used in screening high-risk Sri Lankans for developing cardiovascular diseases.Item Epidemiology of Stroke Subtypes and Aetiologies Among Sri Lankan Stroke Patients(Sri Lanka Medical Association, 2020) Mettananda, K.C.D.; Eshani, M.D.P.; Wettasinghe, L.M.; Ranawaka, U.K.INTRODUCTION AND OBJECTIVES: Epidemiology of stroke subtypes in Asian countries is different from western countries. Data on stroke subtypes and aetiologies are limited from Sri Lanka. Therefore, we aimed to describe the same in Sri Lankans stroke patients. METHODS: We analyzed all the acute stroke admissions to Colombo North stroke unit over 5 years from 2013-2018 using the stroke registry. Data were collected prospectively using an interviewer-administered questionnaire and perusing medical records. Ischaemic strokes were classified into clinical subtypes using Oxfordshire Community Stroke Project (OCSP) and aetiological subtypes using Trial of Org 10172 in Acute Stroke Treatment (TOAST) classifications. RESULTS: 891 patients were admitted over 5 years; 765(85.5%) ischaemic strokes and 129 (14.5%) intracerebral haemorrhages (ICH). Of the ischemic strokes, 16(1.8%) were total anterior circulation, 253(29.0%) partial anterior circulation, 543(62.3%) lacunar, 59(6.8%) posterior circulation infarcts on OCSP classification. 542 ischaemic stroke patients who had complete investigations for TOAST classification were studied for aetiology of stroke. 17(3.1%) were of large artery atherosclerosis, 369(68.1%) small vessel occlusion, 11(2.0%) cardioembolic and 145(26.8%) of undermined aetiology. CONCLUSIONS: Prevalence of ischaemic strokes and ICH were not different from western statistics but ischemic stroke subtypes and aetiologies were different in Sri Lankans. Total anterior circulation strokes were significantly lower and lacunar strokes were significantly higher among Sri Lankans compared to Western populations. Small vessel disease was the commonest cause of ischemic strokes and cardio-embolic and large artery strokes were less common compared to White Caucasians.Item Efficacy and Safety of Oral Hydroxyurea in Patients with Transfusion Dependent β Thalassaemia: a Randomized Double-Blind Placebo-Controlled Clinical Trial(Sri Lanka Medical Association, 2020) Yasara, N.; Wickramarathne, N.; Silva, I.; Hameed, N.; Attanayaka, A.M.K.R.; Jayasinghe, V.L.; Wickramasinghe, N.; Rodrigo, R.; Perera, L.; Mettananda, K.C.D.; Manamperi, A.; Premawardhena, A.; Mettananda, S.INTRODUCTION AND OBJECTIVES: Patients with β- thalassaemia require blood transfusions and iron chelation for life. Hydroxyurea is a licenced medication for sickle cell disease but its usefulness in transfusion dependent β-thalassaemia is unclear. Here, we aim to assess the efficacy and safety of oral hydroxyurea in patients with transfusion dependent β-thalassaemia. METHODS: A phase III randomized double-blind placebo-controlled clinical trial was conducted at Thalassaemia Unit of Colombo North Teaching Hospital in 2019. Forty-one patients with transfusion dependent β-thalassaemia were randomized into hydroxyurea (10-20mg/kg/day) or placebo (pharmaceutically inert capsule identical to hydroxyurea) groups. Transfused blood volume, pre-transfusion haemoglobin, haemoglobin F level and side effects were monitored monthly during 6- month treatment and 6-month follow-up periods. Adverse events were assessed by trained medical officers. The study was approved by ethics committee of University of Kelaniya and registered in Sri Lanka Clinical Trials Registry (SLCTR/ 2018/024). RESULTS: Of the 41 (hydroxyurea-20; placebo-21) patients, three discontinued treatment due to thrombocytopenia (hydroxyurea-2) and rash (placebo-1). Baseline characteristics of two groups were similar. Mean pre-transfusion haemoglobin (8.52+0.57 vs 8.38+0.55, p=0.45) and haemoglobin F levels (4.3+7.1% vs 3.1+1.9%, p=0.48) were higher in hydroxyurea group compared to placebo. Also, transfused blood volume was lower in hydroxyurea group (102+24ml/kg vs 111+27ml/kg, p=0.3). However, none were statistically significant. Based on elevation of haemoglobin F (>1.5% from baseline), we identified 6/18 patients as hydroxyurea responders. Hydroxyurea responders required significantly lower blood volume (87+13ml/kg) compared to non-responders (110+25ml/kg, p=0.05) and placebo group (111+27ml/kg, p<0.05) while maintaining higher pre-transfusion haemoglobin level (8.6+0.5 vs 8.4+0.5 and 8.3+0.5). No serious side effects were reported. CONCLUSIONS: One-third of patients with transfusion dependent β-thalassaemia responded to hydroxyurea treatment requiring 20% less blood compared to controls. No serious side effects were reported following hydroxyurea treatment.Item Place of cardiovascular risk prediction models in South Asians; Agreement between Framingham risk score and WHO/ISH risk charts(Wiley Publishing, 2021) Mettananda, K.C.D.; Gunasekara, N.; Thampoe, R.; Madurangi, S.; Pathmeswaran, A.INTRODUCTION AND OBJECTIVES: There are no cardiovascular risk prediction models developed in South Asian cohorts. Therefore, different risk models not validated in South Asians are being used. We aimed to compare cardiovascular risk predictions of Framingham risk score (FRS) and World Health Organization/International Society of Hypertension (WHO/ISH) charts for agreement in a sample of South Asians. METHODS: Ten-year cardiovascular risk predictions of patients without previous cardiovascular diseases attending a non-communicable disease clinic were calculated using FRS (with BMI and with cholesterol) and WHO/ISH charts (with and without cholesterol). Patients were categorised into low (<20%) and high (≥20%) cardiovascular risk groups on risk predictions. Agreement in risk categorisation with different prediction models was compared using Cohen's kappa coefficient (κ). RESULTS: One hundred sixty-nine patients (females 130 (81.1%)) mean age 65 ± 6.9 years were studied. Of the participants, 80 (47.3%), 62 (36.7%), 18 (10.7%), 16 (9.5%), were predicted high risk by FRS BMI-based, FRS cholesterol-based, WHO/ISH without-cholesterol and WHO/ISH with-cholesterol models, respectively. Agreement between the two FRS models (κ = 0.736, P < .0001) and the two WHO/ISH models (κ = 0.804, P < .0001) in stratifying patients into high and low-risk groups, was "good." However, the agreements between FRS BMI-based and WHO/ISH without-cholesterol models (κ = 0.234, P < .0001) and FRS cholesterol-based and WHO/ISH with-cholesterol models (κ = 0.306, P < .0001) were only "fair." CONCLUSION: Cardiovascular risk predictions of FRS were higher than WHO/ISH charts and the agreement in risk stratification was not satisfactory in Sri Lankans. Therefore, different cardiovascular risk prediction models should not be used interchangeably in the follow-up of South Asians.Item Body iron status of children with transfusion dependent thalassaemia: Trends of serum ferritin and associations of optimal body iron control(Sri Lanka Medical Association, 2018) Suriapperuma, T. N. P.; Peiris, K. R. R.; Mettananda, K.C.D.; Premawardhena, A.; Mettananda, S.INTRODUCTION AND OBJECTIVES: Iron overload due to regular transfusions is one of the most troublesome complications ofthalassaemia. Here we aim to describe body iron status, trends of serum ferritin and associations of optimal body iron control among patients with transfusion dependent thalassaemia. METHODS: A cross sectional descriptive study was conducted at Paediatric and Adolescent Thalassaemia Centres of Colombo North Teaching Hospital from October to December 2017. All children with transfusion dependent thalassaemia aged 16 years and below attending for blood transfusions were recruited. Data was collected using an interviewer-administered questionnaire by interviewing patients and perusing medical records and analysed using SPSS. Ethical approval was obtained from Ethics Committee of University of Kelaniya. RESULTS: Fifty-four children were recruited; 52% were males. Age groups were; <2 years:3.7%, 2-5 years:9.3%,6-10 years:29.6% and 11-16 years:57.4%. Majority (80%) were diagnosed with thalassaemia within the first year of life; 83% had thalassaemia major while 13% had HbE/thalassaemia. Serum ferritin levels were;4999ng/ml:3.7%. Trend of mean serum ferritin at yearly intervals showed gradual rise until 5 years and plateauing thereafter. Children with serum ferritin Rs.25000/=) was significantly associated with optimal body iron control (OR-4.81;95%Cll.17-19.67; p<0.05).CONCLUSION: Mean serum ferritin level gradually rose until 5-years of age and plateaued off in this sample. Optimal body iron control was positively associated with older age at diagnosis of thalassemia and higher family income.Item An audit of pharmacological management of blood sugar in patients with co-existent cirrhosis and diabetes mellitus of a Sri Lankan liver-unit(Sri Lanka Medical Association, 2018) Nizla, M. F.; Mettananda, K.C.D.; Wickramarathna, K.B.M.INTRODUCTION AND OBJECTIVES: Diabetes mellitus (DM) and cirrhosis often coexist. Pharmacological management of DM in them is challenging as most oral hypoglycaemic drugs (OHG) are either metabolised by the liver or cause side effects. However, there are no guidelines on blood sugar control in cirrhotic patients with DM. METHODS: Therefore, we did a descriptive study on pharmacological management of blood sugar in all consenting, consecutive cirrhosis patients with DM attending the Liver-Unit of a Teaching-Hospital, Sri Lanka during September-2017 using an interviewer administered questionnaire.RESULTS: A total of 80 patients (male - 52 (65%), mean age 61±9.1 years) were studied. 59(73.8%) of them have developed cirrhosis after diagnosis of DM. Aetiology of cirrhosis were; cryptogenic - 38(47.5%), alcohol- 21(28.3%), Non-alcoholic fatty liver disease - 18(22.5%). 53 (66.3%) had decompensated-cirrhosis, of all cirrhotic patients 71(88.8%) were on OHG,17(21.3%) on insulin and 10 (12.5%) on both. Main side effects of anti-diabetic medications were, hypoglycaemia -19 (23.8%), poor appetite -10 (12.5%) and upper gastro-intestinal symptoms -3(3.8%).64 (80.0%) of patient's anti-diabetic medications were changed after diagnosis of cirrhosis,and the main changes were; metformin stopped - 25(31.3%), insulin started - 14(17.5%), metformin was changed to sulphonylurea -13(16.3%), sitagliptan added - 8(10%), conversion of long-acting drugs to short-acting ones -3 (3.8%), Compensated- cirrhotic patients 21 (77.8%) were on metformin while 16 (59.3%) were on short-acting• sulphonylureas. Decompensated- cirrhotic patients; 29 (54.7%) were on metformin and 36(67.9%) were on short• acting-sulphonylureas. CONCLUSION: Majority of compensated-cirrhotic patients were on metformin while a significant proportion of decompensated cirrhotic patients were on short-acting-sulphonylureas without major complications.Item Quality of life and psychological morbidity among children with transfusion dependent thalassaemia and their parents(Sri Lanka Medical Association, 2018) Mettananda, S.; Pathiraja, H.; Peiris, R.; Bandara, D.; de Silva, T.U.N.; Mettananda, K.C.D.; Premawardhena, A.INTRODUCTION AND OBJECTIVES: Thalassaemia is a chronic illness which requires life-long supportive care. We aim to describe quality of life and psychological morbidity among children with transfusion-dependent thalassaemia and their parents.METHODS: This case-control study was conducted from September to December 2017. All patients with transfusion-dependent thalassaemia aged 2-18 years attending three largest thalassemia centers of Sri Lanka (Kurunegala, Anuradhapura and Ragama) were recruited as cases Children without chronic diseases admitting to same hospitals for acute non-life threatening illnesses were recruited as controls. Data were collected using an interviewer-administered questionnaire with validated questionnaires to measure quality of life (PedsQL 4.0 Generic core scales) and psychological morbidity (Strengths and difficulties questionnaire) of children and depressive symptoms of parents (Centre for epidemiological studies depression scale). Ethical approval was obtained from Ethics Committee of University of Kelaniya. RESULTS: 321 (male-46.4%; mean age-9 9±4 2years) cases and 194 (male-47.4% mean age- 8.9±3 7years) controls were recruited Mean quality of life score was significantly lower in cases (72.6±12.0%) compared to controls (88.6±11.6%), (p<0 001) Prevalence of psychological issues were significantly higher among patients with thalassaemia compared to controls in emotional (17 6% vs 0%; 2=32.8, p<0 001), conduct (18.6% vs 0 6%;2=35.4, p<0 001), hyperactive (9 5% vs 0%; 2=18 9 p<0.001) and peer relationship (14.4% vs 2 5%; 2=15 7 p<0 001) domains Significantly higher proportion of mothers of cases reported depressive symptoms compared to controls (40 1% vs 8.9%; 2=57 0 p<0.001).CONCLUSION: Patients with transfusion-dependent thalassaemia experience a poor quality of life and are victims of psychological and behavioural problems compared to their peers. Similarly, mothers of children with thalassaemia have higher prevalence of depression Psychological support should be an essential component in management of thalassaemia