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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Unilateral basal ganglia infarction presenting as sudden onset daytime sleepiness(Sri Lanka College of Internal Medicine, 2024) Mettananda, K.C.D.; De Saram, E.M.T.K.; Wickramasinghe, M.K.I.I.; Siriwardana, S.A.S.R.Basal ganglia (BG) are involved in motor coordination. BG strokes usually present with problems controlling speech, movements, mood and posture leading to abulia which is a prominent feature. BG stroke presenting with daytime sleepiness is not well reported. We report a 63-year- old Asian woman with hypertension presenting with sudden onset daytime sleepiness due to basal ganglia infarction. This case highlights the importance of considering BG infarction as a differential diagnosis for sudden onset daytime sleepiness.Item Prevalence of acute frozen shoulder with functional limitation following cardiac surgery: A descriptive study from Sri Lanka(Ceylon College of Physicians, 2023) Kurukulasuriya, S.A.F.; Mettananda, K.C.D.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, treatmentresistant disease. However, data on the prevalence of acute FS following cardiac surgery in Sri Lanka is not known. The aim of this study was to identify the prevalence and associations of acute FS following coronary artery bypass graft with or without valve replacement in two cardiac surgical units in Sri Lanka. METHODS: We studied consecutive patients who underwent cardiac surgery from April 2022 to November 2022. Patients were recruited to the study before discharge from the hospital and were reviewed at 2 and 12 weeks following surgery. Acute FS was diagnosed in the presence of pain and limitation in lateral rotation, abduction, and medial rotation. Data on demographics and risk factors were collected using an interviewer-administered questionnaire. RESULTS: We studied 142 patients, 110 (77%) males, mean age of 60.3 SD years (range 28-78 years), 142 had coronary artery bypass grafting (CABG) and 3 of them additionally had valve replacement. Of them, 55 (38.7%) developed FS at 12 weeks post-surgery. Prevalence of FS was highest among the 50-60-year age group, 25 (45%). Development of post-surgical acute FS was more in patients with ischaemic heart disease (OR 5.5, p <0.01), hyperlipidaemia (OR 15.1, p<0.01), and who did not have regular post-op physiotherapy (6.1 p<0.01). CONCLUSION: More than one-third of patients undergoing cardiac surgery developed acute FS at 12 weeks. Patients with ischaemic heart disease, and hyperlipidaemia, and who did not engage in regular post-op physiotherapy were at high risk of developing acute FS.Item Adherence to good pharmacy practices of community pharmacies in the Gampaha District, Sri Lanka(Sri Lanka Medical Association, 2023) Basnayaka, B.M.T.D.D.; Ashara, S.F.; Ashik, K.J.M.; Bandara, B.M.M.P.; Bandara, H.M.A.C.; Basnayake, B.M.M.S.M.; Mettananda, K.C.D.INTRODUCTION: The guidelines for good pharmacy practices (GPP) were introduced in 2019 in Sri Lanka but their adherence is not studied. We studied the adherence to GPP of community pharmacies in the Gampaha district of Sri Lanka. OBJECTIVES: To determine the adherence to good pharmacy practices (GPP) of community pharmacies in the Gampaha district, Sri Lanka. METHODS: We did a descriptive cross-sectional study of all community pharmacies in the Gampaha district from 18th January to 8th February 2023. Data were collected using a self-administered online questionnaire developed using the guideline of GPP-2019 issued by the National Medicine Regulatory Authority (NMRA). The questionnaire comprised of 50-questions covering five broad areas of GPP; characteristics of the pharmacists, services and facilities provided, medicine storage, data management, and dispensing/distribution of medicines. Each question was given a mark and the final score was converted to a percentage. RESULTS: We received responses from 194 pharmacies. The mean adherence score was 68.8 (SD 12.8, range 24-97) %. 53.1% of the pharmacies had a score of more than 70% and 79.4% of pharmacies were aware of the GPP guideline by NMRA. 75% of pharmacies had a licensed pharmacist constantly. 92.3% of pharmacies were equipped with air conditioners, and 96.9% were equipped with a refrigerator. However, only 34% of pharmacies had a facade, “pharmacy” written in all three languages (Sinhala, Tamil, English) and 23.71% of pharmacies dispensed antibiotics without a prescription. CONCLUSIONS: Only half of the community pharmacies in the Gampaha district were adherent to GPP.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 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 Impact of COVID-19 on stroke admissions in a Sri Lankan tertiary care hospital:Data from the Ragama stroke registry(Ceylon College of Physicians, 2021) Deelaka, A.G.S.; Dep WDC, W.D.C.; Nanayakkara, Y.P.; Chandrasiri, H.M.J.; Mettananda, K.C.D.; Pathmeswaran, A.; Ranawaka, U.K.Introduction and Objectives The coronavirus disease 2019 (COVID-19) pandemic has had a tremendous impact on stroke care globally. We investigated the impact of the pandemic on stroke admissions in a Sri Lankan tertiary care hospital. Methods We studied the number of admissions to the Stroke Unit and the University Medical Unit, Colombo North Teaching Hospital (CNTH) over four years, and delays in seeking medical care of patients admitted to the Stroke Unit. We compared data during a calendar year of COVID pandemic (01.04.2020 - 31.03.2021) with the preceding 3 pre-COVID years (01.04.2017 一 31.03.2020). Data regarding COVID year was compared with pre-COVID years using independent-samples t-test and nonparametric test. Results Mean number of stroke admissions per month during the pandemic was significantly lower compared to that of pre-COVID years: Stroke Unit (monthly mean admissions, COVID year vs pre-COVID years; 11 ± 3.5 vs 20 ± 3.1; pv0.01); University Medical Unit (12 ± .2 vs 18 ± 3.4; p<0.01). The lowest number of admissions was reported during the period with the highest COVID caseload in Sri Lanka. However, there was no significant difference in the median delays to seeking medical care between the COVID pandemic and pre-COVID years: delay to first medical contact: 2.0 h vs 2.4 h, p=0.208; first hospital admission: 3.0 h vs 3.0 h; p=0.993, admission to CNTH: 3.4 h vs 5.0 h; p=0.174. Conclusions Stroke admissions were significantly lower during the COVID pandemic, but there was no difference in the delays in seeking medical care during the same period.Item Spontaneous intracerebral haemorrhages from a Sri Lankan tertiary care center: 5-year data(Ceylon College of Physicians, 2021) Dep, W.D.C.; Deelaka, A.G.S.; Somaratne, K.G.S.K.; Meegahapola, H.; Premadasa, H.M.S.D.; Kurukulasuriya, S.A.F.; Mettananda, K.C.D.; Ranawaka, U.K.Introduction and Objectives Epidemiological data on spontaneous intracerebral haemorrhage (sICH) is limited from South Asia. We sought to describe epidemiology of sICH in a Sri Lankan cohort. Methods We studied all patients with stroke admitted to the Stroke Unit, Colombo North Teaching Hospital over five years. Data from sICH patients regarding treatment seeking delays, clinical char-jcteristics, risk factors, stroke severity and functional outcome were compared with ischa-mic stroke (IS) patients. Resists 984 patients (mean age 58.7 years; 62.1% males) were studied: sICH 15.0% (147 patients), IS 85.0%. sICH patients: mean age 58.0 years; 67.3% males. sICH patients presented to hospital earlier (<3h sICH 70.6%, IS 37.2%, p<0.001) and had more severe strokes (NIHSS>15) (sICH 21.3%, IS 12.2%; p<0.001). Hypertension was commoner in sICH group (sICH 72.6%, IS 63.5%; p=0.034), whereas diabetes (sICH 39.0%, IS 51.6%; p=0.005) and smoking (sICH 16.6%, IS 25.5%; p=0.021) were less common. Altered consciousness (sICH 30.3%, IS 18.3%; p=0.001), dysphagia (sICH 55.9%, IS 34.4%; p<0.001), bladder involvement (sICH 56.6%, IS 28.7%; p<0.001), and seizures (sICH 4.1%, IS 1.5%; p=0.029) were commoner among sICH patients. sICH patients had more severe disability on discharge (Barthel index 0-60: sICH 71.1%, IS 45.2%; p<0.001; modified Rankin scale (mRS) 3-6: sICH 76.7%, IS 52.1%; p<0.001). sICH location (lobar vs. deep) and presence of intraventricular haemorrhage was not associated with stroke severity. Lobar ICHs had more severe disability on discharge (Barthel index <60: p=0.037; mRS>3: p=0.020). On logistic regression, sICH was independently associated with early presentation to hospital (OR 1.79; p=0.039), and severe disability on discharge (Barthel index <60: OR 2.42, p=0.028; mRS>3: OR 2.70, p=0.012). Conclusions sICH patients sought medical attention early and had different clinical profiles, more severe strokes and more severe disabilities.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 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.