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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 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 Antibiotic sensitivity patterns of Extended-Spectrum β-Lactamase urinary tract infections in Sri Lanka(Faculty of Medicine, University of Kelaniya, Sri Lanka, 2016) Sebastiampillai, B.S.; Premaratna, B.A.H.R.; Luke, W.A.N.V.; Wickramasinghe, R.D.S.S.; Gunathilake, M.P.M.L.; Miththinda, J.K.N.D.BACKGROUND: Extended-spectrum β-lactamase (ESBL) producing organisms causing urinary tract infections (UTI) are increasing in incidence and poses a major burden to health care requiring treatment with expensive antimicrobials and prolonged hospital stay. The prevalence of ESBL producing organisms particularly in the Asian region remains unknown. OBJECTIVES: To identify common ESBL producing organisms and to evaluate the antibiotic sensitivity patterns of ESBL UTIs in Sri Lanka. METHODS: Patients admitted with ESBL-UTI to Professorial Medical Unit, Colombo North Teaching Hospital, Ragama over a period of 6 months from January 2015 were recruited. Their Urine culture and ABST reports were analysed after obtaining informed written consent. RESULTS: Of the 52 patients who consented to be on the study, 30 (57.7%) were males. Mean age was 64.11 (SD=12.59) years. E. coli was the commonest organisms (84.6%; n=44), causing the ESBL-UTI followed by Klebsiella (15.4%; n=8). Fifty (96.2%) patients were sensitive to meropenem, 38 (73.1%) to imipenem, 30 (57.7%) to amikacin and 24 (46.2%) to nitrofurantoin. Meropenem resistance was found in 2 (3.8%) cases which were due to infection with E. coli.These two patients had received multiple antibiotics including meropenem in the recent past for recurrent UTI. CONCLUSIONS: While E. coli and Klebsiella are the commonest ESBL producing organisms causing UTI, carbapenems remain as the first line therapy. However 3.8% prevalence of meropenem resistance among the study population should draw attention of clinicians and needs implementation of measures to prevent emergence of carbapenum resistant ESBL organisms.Item A study to determine quantitative predictors for development of third space fluid accumulation in adult patients with dengue(Sri Lanka Medical Association, 2012) Premaratna, R.; Ragupathy, A.; Miththinda, J.K.N.D.; de Silva, H.J.INTRODUCTION: Prediction of severe illness remains the most important measure in preventing mortality associated with dengue. Increased vascular permeability leading to reduced intravascular volume is the hallmark of dengue shock syndrome. Third space fluid accumulation (TSFA) reflects severe vascular permeability and therefore, it is important to quantitatively identify parameters which predict the occurrence of TSFA in dengue. METHODS:102 patients with confirmed dengue were prospectively followed up for clinical, haematological, biochemical parameters and for evidence of TSFA by serial utrasonography. These parameters were tested against development of TSFA using Receiver Operating Characteristic [ROC] curves to identify quantitative predictors of development of TSFA. RESULTS: 102 patients (52 males) with mean age 28.3 years (SD 11.8), TSFA was detected in 34/95 [36%) after admission; 21/95 developed ascites at mean 5.7 days of illness (SD 1.3) and 33/95 had pleural effusion at 5.4 days (SD 1.5). Onset of TSFA could be identified using percentage rises of highest PCV (p= 0.002) where 6.5% rise of PCV predicted TSFA(sensitivity 61%, specificity 62%)], highest Hb (p=0.017) where rise of 6.1% in Hb predicted TSFA (sensitivity 55%, specificity 64%), lowest recorded platelet count (p<0.000) where platelet count of 48500/mm3 or less predicted TSFA (sensitivity of 83%, specificity 51) post-admission fluid input-output balance per day (p 0.002) where positive balance more than 777cc/day predicted TSFA (sensitivity 65%, specificity 64%). CONCLUSIONS: Rise of PCV and Hb, platelet count, WBC count and daily fluid balance appear to be useful quantitative predictors of TSFA in dengue.Item Predictors of duration and degree of third space fluid accumulation in adult patients with dengue(Sri Lanka Medical Association, 2012) Premaratna, R.; Ragupathy, A.; Miththinda, J.K.N.D.; de Silva, H.J.INTRODUCTION: Fluid leakage is the hallmark of dengue shock syndrome. It is important to identify clinical and biochemical parameters which predict duration and degree of fluid leakage in dengue. METHODS: 102 patients with confirmed dengue were prospectively followed up for clinical, haematological and biochemical parameters, and they were correlated with ultrasonographic evidence of third space fluid accumulation (TSFA). RESULTS: Of the 102 patients (52 males; mean age 28.3 years(SD=11.8), TSFA was detected in 34/95(36%) after hospital admission; 33/95 had pleural effusions which included all except one of 21/95 who had ascites. 72.7% pleural effusions lasted 3 or more days and 52.4% ascites lasted less than 3 days. Duration of pleural effusion showed a significant positive correlation with maximum percentage rises of PCV (r=0.526,p=0.001) and Hb(r=0.525, p=0.001) and negatively correlated with WBC count (r=-0.361, p=0.020) and platelet count (r=-0.585, p=0.000). There was no correlation with any of the other parameters. The mean lowest WBC count of 3005/mm3that was recorded for patients who developed bilateral pleural effusions (n=21) was significantly less (p=0.042) than the mean lowest WBC count of 4091/mm3 that was detected for unilateral effusions(n=12). Duration of ascites was significantly positively correlated with highest AST(r=0.598, p=0.002) and highest ALT(n=0.721, p=.001. CONCLUSIONS: Maximum percentage rise of Hb and PCV, lower WBC and platelet counts seem to be associated TSFA. Among these, lower WBC counts appear to be more predictive of the degree of fluid leakage. Higher ALT and AST levels seem to be useful in predicting the duration of ascites.Item Profile of gastric varices among Sri Lankan cirrhotics(Sri Lanka Medical Association, 2012) Ranawaka, C.K.; Mettananda, K.C.D.; de Alwis, W.H.S.; Miththinda, J.K.N.D.; Mriella, M.A.; de Silva, A.P.; de Silva, H.J.INTRODUCTION: Gastric varices (GV) can result in life threatening bleeding. There have been no studies on the characteristics of GV among Sri Lankan cirrhotics. Aims: To perform a descriptive analysis of GV among a Sri Lankan cirrhotic population METHODS: Medical records of all upper gastrointestinal endoscopies performed on cirrhotics at presentation, in the University Endoscopy Unit, Colombo North Teaching Hospital, Ragama, from 2006 to 2011 were screened. Demographics, indication and findings of endoscopy were analysed. RESULTS: 628/641(98%] of the cirrhotic population screened had a complete data set for analysis. 70/628(11%) patients had GV[ma!e-61(87%), female-9(13%); mean age 55(SD = +/- 10.7, range 23-81 years]]. 48/70(69%] had oesophageal varices (Gastro Oesophageal Varices (GOVl-18/48(38%), GOV2- 30/48(62%] in addition to GV and 22/70(31%] had Isolated GV (JGV1 -10(45%], IGV2 -12(55%]]. 38/70(54%] had portal hypertensive gastropathy and 3/70(4%] had gastric antral vascular ectasia in addition to GV. 51/70 (73%] were detected on initial screening of cirrhotics, while 19/70(27%][6/22(27%] with IGV] were detected at presentation with upper gastrointestinal bleed (UGIB]. 288/628(46%] had oesophageal varices (EV). 240/288(83%] had only EV without GV. 163/240(68%) were detected on initial screening of cirrhotics, while 77/240(32%) were detected at presentation with UGIB. There was no statistical significance between proportion of patients detected to have isolated EV or IGV at presentation with UGIB (p=0.64; ?2=0.2) CONCLUSIONS: The profile of GV among our patients is comparable to what is previously described elsewhere. Findings suggest in cirrhotic patients presenting with UGIB searching for presence of GV, by retroflexion at endoscopy, is as important as identifying EV.Item To identify the role of haemoglobin, pack cell volume and puise pressure in predicting fluid leakage in patients with dengue who consume adequate amounts of fluids(Sri Lanka Medical Association, 2012) Ranjan, P.; Ragupathy, A.; Miththinda, J.K.N.D.; de Silva, H.J.INTRODUCTION: Early detection of fluid leakage is important in identifying patients who are likely to develop shock syndrome in dengue. As patients are advised to consume adequate amounts of fluids such behaviours may alter the clinical and haematological parameters predicting fluid leakage. Methods: fn 102 confirmed dengue patients admitted to a single medical unit, CNTH, Ragama from September 2011,quantity and quality of fluids consumed, Hb, PCV, pulse pressure(PP) and their percentage rise or decline were documented and compared between those who developed and did not develop third space fluid accumulation(TSFA) [either pieural effusions, ascites or both detected by ultrasonography]. RESULTS: In 102 patients (52 males) with mean age 28.3(SD=11.8) years, TSFA was detected in 34/95(37%) on follow up. fn those who developed TSFA and did not develop TSFA, average consumption of water 620cc/day vs 491cc/day fp=0.14); solutes 1461cc/day vs 1481cc/day (p=0.83); the mean(SD) values of highest Hb 14.66(1.82)g/dl vs 14.28(1.6)g/dl (p=0.3) and highest PCV 44.16 (5.19) vs 43.4 (4.5) 0=0.46); pulse pressure 29.9mmHg vs 28.4 0=0.29); The maximum percentage rise in Hb 8%vs 4.6% (p=0.02); PCV 8.6% vs 4.5% 0=0-006); mean pulse pressure drop 6.9% vs 5.9% 0=0.84). Conclusions: In the presence of fluid consumption the quality or quantity of fluids consumed did not seems to contribute to TSFA. A single value of Hb, PCV or pulse pressure was not helpful in predicting early fluid leakage. While percentage reduction in pulse pressure was not helpful, percentage rise in Hb and PCV remained predictive of early fluid leakage in dengue.Item Predicting acute liver failure in dengue infection(Sri Lanka Medical Association, 2012) Ranawaka, C.K.; Kumarasena, R.S.; Niriella, M.A.; Miththinda, J.K.N.D.; Pathmeswaran, A.; Dassanayake, A.S.; de Silva, A.P.; de Silva, H.J.INTRODUCTION: Dengue infections (Dl) have a diverse clinical spectrum ranging from asymptomatic illness to severe dengue. Unusual manifestations such as encephalitis, myocarditis, and acute liver failure (ALF) are increasingly recognised. AIMS: To describe the spectrum of liver dysfunction and identify possible predictors of ALF in DI Methods: Serologically confirmed patients with Dl admitted to university medical unit, Ragama from January 2009 to March 2010 were included. Data were obtained from patient records. Results: Out of 240 patients (maleifemale 57.7%:42.5%; mean age 35.6 years[SD 15.4 years]], 49(20.4%) had severe dengue, 164(68.3%) had dengue with warning signs and 27(11.2%) had dengue without warning signs. Abdominal pain, persistent nausea and vomiting (PNV), skin or mucosal bleeding, hepatomegaly and ascites was present in 52.1%J 38.3%, 16.2%, 50% and 11.7% cases respectively. Deranged AST or ALT(ASTALT), serum bilirubin(SB), alkaline phosphatase(ALP), gamma glutamyl transpeptide(GGT), and 1NR were observed in 86.7%, 8.3%, 7.5%, 25% and 10% of patients respectively. Of the 240 patients 41(17.1%) had ASTALT>1000 IU and 199(82.9%) had ASTALT<1000 1U. Only 16/41 patients with ASTALT>1000 IU developed ALF while none from the ASTALT<1000 IU group developed ALF. Presence of 2 or more of elevated SB, elevated ALP or PNV predicted the development of ALF with 93.8% sensitivity, 98.7% specificity, 83.3% positive predictive value and 99% negative predictive value withp<0.001. CONCLUSIONS: ASTALT<1000 IU excluded patients at risk of ALF. Presence of 2 or more of PNV, elevated SB or ALP in patients with Dl may indicate impending ALF. This needs further validation in a larger population.Item Validation of Sinhala version of the Chronic Liver Disease Questionnaire (CLDQ) and evaluation of health related quality of fife among patients with cirrhosis in Sri Lanka(Sri Lanka Medical Association, 2013) Miththinda, J.K.N.D.; Ranawaka, C.K.; Pathmeswaran, A.; Dassanayake, A.S.; de Alwis, W.R.S.; Mufeena, M.N.F.; Senanayake, S.M.; Niriella, M.A.; de Silva, A.P.; de Silva, H.J.AIMS: Our aim was to validate a Sinhala version of the CLDQ (sCLDQ) and to test its correlation with the degree of liver dysfunction in a cohort of Sri Lankan cirrhotics. METHODS: A standard method was used to translate the CLDQ to Sinhala. Pilot testing was done and relevant cultural and language adaptations made. The final version was self-administered to stable chronic liver disease (CLD) patients, together with the WHO Quality of Life-BREF (WHOQOL-BREF) validated Sinhala version, for comparison. The sCLDQ was re-administered 4 weeks later to test internal consistency and reliability. The validation was assessed using Cronabach's alpha, intraclass correlation coefficient (ICC) and Pearson's correlation coefficient. ANOVA and Pearson's correlation were used to test correlation with the degree of liver dysfunction. RESULTS: Validation was done with 48 subjects, mean age 55.6 (SD 10) years; male 79%. Item total correlations of sCLDQ varied from 0.30-0.82. Overall Cronabach's alpha was 0.92. Re-administration of sCLDQ yielded an ICC of 0.54 (p=0.02). There was a significant correlation between sCLDQ and WHOQOL-BREF (r=0.34; p=0.03). Validated sCLDQ xvas administered to a different cohort of 202 cirrhotics with mean age of 55.3 years (SD 10,5); male 77%; mean duration of cirrhosis 2.7 years (SD 2.9) years. Higher Child class (F=0.000; p-0.017) and hyponatraemia (r=0.2I3; p=0.005) were associated with worse sCLDQ scores. There was no significant association between sCLDQ score and MELD (r=-0.128, p=0.072). CONCLUSIONS: The sCLDQ is a reliable and valid tool to assess QOL of Sri Lankan cirrhotics and it correlates with known indices of disease severity.Item Comparison of clinical and laboratory parameters between Rickettsiosis positive and negative children(Sri Lanka Medical Association, 2013) Premaratna, R.; Karunasekara, K.A.W.; Fernando, M.A.M.; de Silva, L.; Chandrasena, T.G.A.N.; de Silva, H.J.; Miththinda, J.K.N.D.; Mufeena, M.N.F.; Madeena, K.S.K.; Bandara, N.K.B.K.R.G.W.INTRODUCTION AND OBJECTIVES: Identification of clinical or biochemical parameters that differentiate rickettsioses from other fevers would help in clinical practice to reduce morbidity and mortality associated with childhood rickettsioses. METHODS: Clinical and laboratory parameters of 22 confirmed paediatric rickettsioses (SFG-16/22, ST-5/22, Mixed-1) were compared with those of 24 with fever who were negative for rickettsioses, based on data received by the Rickettsial Disease Diagnostic and Research Laboratory (RDDRL), Faculty of Medicine, University ofKelaniya. Results: Comparisons of clinical and laboratory parameters between rickettsioses vs non-rickettsioses were mean(SD); age in months 56.59 (43.9) vs 78.13 (42.08) (p=0.1); fever duration 9.81 days (4.5) vslO.68 days (8.79) (p-0.68); fever intensity 102.80F (1.03) vs 102.440F (1.23) (p=0.4); fever spikes per day 2.33 (0.67) vs 2.68 (0.75) (p=0.186); headache 12/22 vs 11/24 (p=0.64); body-aches 9/22 vs 9/24 (p-0.52); pain in arms and legs 6/9 vs 7/9 (p=0.5); joint pains 6/22 vs 7/24 (p=O.S9); cough 14/22 vs 9/24 (p=0.0*7); shortness of breath 5/22 vs 2/24 (p=0.19); eschar (all ST) 4/22 vs 0/24 (p=0.02); rash 14/22 vs 14/24 (p=0.69); maculo-papular rash!3/14 vs 12/14 (p=0.91); diarrhoea 4/22 vs 4/24 (p-0.89); lymphadenopathy 7/22 vs 8/24 (p=0.913); spleenl/22 vs 5/24 (p=0.18); total WBC 11.U109/L (4.8) vs 9.8xl09/L (4.8) (p=0.36); N-84.8% (13.8) vs 5.4(2) (p=0.29); ESR IstHr 46.3mm (26.7) vs 81.8mm (10.2) (p=0.37); CRP 42.1mg/dl vs 56.7mg/dl (6.7) (p=0.46); SCOT 51.2iu/L (32.1) vs 248.7iu/L (678) (p=0.43); SGPT 50.2iu/L (51.4) vs 170.7iu/L (404) (p=0.44). CONCLUSIONS: In paediatric patients, no clinical or biochemical parameter could differentiate rickettsioses from other aetiologies. Presence of eschars would help to diagnose scrub typhus. However laboratory confirmation is needed to differentiate SFG from other fevers.