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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Splenic stiffness measurement combined with liver stiffness measurement compared with Baveno VII criteria in predicting the presence of Oesophageal and Gastric varices in patients with compensated advanced liver cell disease (cALCD)(Cureus, 2024) De Silva, A.P.; Niriella, M.A.; Nishad, N.; Jayasundara, H.; Jayasena, H.; Samarawickrama, V.T.; Ranawaka, C.; Basnayake, K.; De Silva, S.T.; De Silva, H.J.INTRODUCTION Liver stiffness measurement (LSM) using vibration-controlled transient elastography (VCTE) is being increasingly used as a screening tool to predict varices. Our aim was to test the utility of Baveno VII criteria and other combinations of LSM, platelet count (PC), and splenic stiffness measurement (SSM) to predict the presence of varices in a cohort of Sri Lankan patients with compensated advanced liver cell disease (cALCD).METHODS Consecutive patients with newly diagnosed Child-Pugh class A cALCD (non-viral, BMI<30) were recruited prospectively. They underwent gastroscopy. LSM and SSM were taken using vibration-controlled transient elastography (VCTE) (Echosens FibroScan 502 Touch; Echosens SA, Paris, France) by a single operator who was unaware of endoscopy findings. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of different Baveno VII criteria to predict the varices and different combinations of LSM, SSM, and PC were also explored.RESULTS One hundred and seventy-four individuals were recruited. The mean age was 61.4 ((95% CI: 59.7-62.8) years. A total of 110 individuals were males, and 106 had varices. Our results indicated that the three Baveno VII criteria had sensitivities of 61%, 63%, and 42%, and specificities of 79%, 77%, and 87% to predict varices. SSM>30kPa alone and in combination with LSM>15kPa had sensitivities of 81 and 75%, specificities of 72 and 83%, PPVs of 82 and 87%, NPVs of 71% and 67%, and accuracies of 78 and 78%, respectively, to predict varices.CONCLUSION Baveno VII criteria had a low sensitivity but high specificity in predicting the presence of varices. However, SSM>30kPa alone or in combination with LSM>15kPa had better sensitivity, specificity, PPV, NPV, and accuracy in predicting varices.Item Elective cholecystectomy is associated with increased morbidity and mortality in patients with severe Thalassemia: A retrospective case control study.(Ferrata Storti Foundation, 2015) Premawardhena, A.; Fernando, R.; Kumarage, S.; Nishad, N.; de Silva, I.BACKGROUND: Haemoglobin disorders including thalassemia and sickle cell disease are often complicated with gall stone formation. The co-existence of Gilbert's syndrome together with these diseases further increases the risk of gall bladder disease. Some of these patients develop symptomatic disease which necessitates surgical intervention. At present the timing of cholecystectomy for thalassemia is no different from that of the general population with the exception of removal of the gall bladder at the time of splenectomy. This is no longer the case in sickle cell disease where, laparoscopic cholecystectomy is recommended even in asymptomatic patients. This practice however has not been extended to other types of haemoglobin disorders. AIM(S): 1.To assess the perioperative complications of patients with thalassaemia during cholecytetomy and to compare it with non thalassaemics who undergo the procedure. 2. To see if there is enough evidence to recommend elective cholecystectomy for thalassaemics. METHOD(S): We retrospectively studied case notes of thalassemia patients who had cholecystectomy (cases) in two of the biggest thalassaemia centres in Sri Lanka and also of 62 non-thalassaemics (controls) with gall bladder disease who had been scheduled to have gall bladder surgery in the same hospitals and looked at their peri-operative complications. RESULT(S): 98 out of 540 (18%) thalassaemics in the two centres had gall stones. Mean age of cases was 26.8 (SD 10.9) years and of controls 47.5 (SD 19.7) years. 19 (19%) thalassaemics with gall stones had undergone cholecystectomy. Ten patients had cholecystectomy simultaneously with splenectomy. The majority of non-thalassaemic "controls" had laparoscopic cholecystectomy 53/55 (96.3%) whilst the patients with thalassaemia were mostly operated with laparotomy 13/19 (68%). There was a significant excess complications occurring in both early (42.11 vs. 18.1%) and late (31.5 vs. 12.7%) phases in the thalassaemic patients compared with the controls. Among the early complications, sepsis (10.5% vs. 1.8%) and liver abscess formation (5.2 vs. 0%) was significantly different in the groups, adversely affecting the thalassaemics. Recurrent abdominal pain was more common among the thalassaemics as a late complication (P<0.05). Six thalassaemic patients with gall stone disease died during this study, 5(5%) while awaiting surgery and 1(1%) after surgery. There were no deaths among the controls. Out of the deaths, 3 (50%) were directly attributable to gallstone disease. In all three septicemia precipitated heart failure. We found a significant increase of both early and late post-surgical complications in the thalassemia group and also increased mortality most of which was related to severe sepsis. Higher perioperative mortality and morbidity were seen among symptomatic thalassaemic patients with gall stone disease undergoing cholecystectomy. This seems to suggest a strong case for supporting elective cholecystectomy in thalassemics before they develop symptoms. SUMMARY AND CONCLUSION(S): We suggest that laparoscopic elective cholecystectomy be considered for non-sickle, thalassemia patients too who have asymptomatic gall bladder disease, in an attempt to reduce this morbidity and mortality.Item Zinc supplementation in chronic kidney disease of unknown aetiology in Sri Lanka: a pilot study. (ZisCKDu-P)(Ceylon College of Physicians, 2020) Abeysundara, P.K.; Nishad, N.; de Silva, S.T.; Dassanayake, R.T.; Galabada, D.P.; Jayawardane, U.G.W.; Premawardana, N.P.; Kumara, G.M.S.S.; Dilani, P.M.; Herath, H.M.T.D.; Wijesinghe, P.S.INTRODUCTION: It was hypothesized that the antioxidant properties of zinc retard the progression of chronic kidney disease of unknown etiology in the North Central Province of Sri Lanka. METHODS: The pilot study was a randomized, placebo-controlled, single blinded, parallel group, single-center clinical trial with two arms (Z and P) and a 1:1 allocation ratio. Participants in group Z (n=20) received 60 mg of elemental zinc daily, in the form of zinc sulfate, and group P (n=21) received a starch tablet per day. Clinical, hematological parameters and kidney function were measured at the baseline and following three months of the intervention. RESULTS: A total of 86 CKDu patients were screened; only 35 males and 6 females were selected. Mean age and estimated glomerular filtration rate of the study population were 51.2±6.2 years and 38.9±8.8 mL/min/1.73 m2 respectively. At the end of three months there was non-significant increase in urine protein creatinine ratio (Z arm: 65±54 vs. 82± 86 mg/mmol; P=0.46, P arm: 72.4±113 vs. 120± 209 mg/mmol; P=0.36) and non-significant decline in estimated glomerular filtration rate (Z arm: 40.9±10.4 vs. 39.7±9.2 mL/min/1.73 m2; P=0.31, P arm: 37.1±6.8 vs. 36.4±10 mL/min/1.73m2; P=0.31) in both groups. Body mass index was significantly reduced (23±4 vs. 22.7± 3.9 kg/m2; P=0.01) and diastolic blood pressure was significantly increased (78±6 vs. 86±10 mmHg; P=0.001) in the placebo arm. Haemoglobin levelshowed a decline in the study group; 0.33±1 g/dl, while there was an increase in the placebo group, 0.34±0.7 g/dl, (P=0.02). There were no major side effects. CONCLUSIONS: The change of urine protein: creatinine ratio and estimated glomerular filtration rate did not show a significant difference between the two groups. A future trial should test effectiveness of same dose of zinc for a similar duration of time in a larger sample. Extended follow-up of the study subjects for one year after the intervention would be useful to assess the long-term effects of zinc on kidney function and side effects.Item Should male doctors in Sri Lanka wear a necktie to be recognized and respected?(Open Learning on Enteric Pathogens, 2019) Abeysundara, P.K.; Nishad, N.; Balendran, K.; Pabasara, M.; Bandara, P.K.; Perera, N.M.; de Silva, H.; de Silva, S.; Umakanth, M.; Wijesinghe, P.INTRODUCTION: European cultural norms have influenced physicians' attire in Sri Lanka. The necktie is one such item of clothing which is worn to be recognized and respected as professionals. This study was carried out to assess the perceptions of doctors and patients towards male doctors wearing neckties while providing patient care. METHODOLOGY: A descriptive cross-sectional study was carried out at the National Hospital of Sri Lanka. An interviewer-administered questionnaire was used to collect data from doctors and patients. RESULTS: The study included 105 doctors (57% males) and 333 patients (54% males). Mean ages of the doctors and patients were 37 years (95% C.I. 36-39) and 47 years (95% C.I. 45-49) respectively. Sixty-nine percent of the patients had completed secondary education or above. None of the patients were aware of the risk of spreading infections by wearing a necktie. Of the 41% of doctors who thought it was unnecessary to wear a necktie, 95% believed the necktie can spread infections. Ninety-five percent of patients believed doctors should wear neckties to be identified and respected and to maintain trustworthiness.CONCLUSIONS: None of the patients were aware of the possible risk of spreading infections by wearing a necktie, while most of the doctors who thought neckties were unnecessary also believed neckties can spread infections. Almost all patients thought that doctors should wear a necktie to be recognized and respected. Therefore, implementing a change in dress policy for doctors is a challenging task in Sri Lanka. KEYWORDS: doctors; hospital infections; neckties.Item Barriers for cataract treatment among elderly in Sri Lanka(Hindawi Publication Corporation, 2019) Nishad, N.; Hewage, S.A.; Arulmoly, K.; Amaratunge, M.S.; de Silva, J.; Kasturiratne, K.T.A.A.; Abeysundara, P.K.; Wickremasinghe, A.R.Cataract is still the leading cause of blindness. Many government institutes and voluntary organizations in Sri Lanka are providing free treatment services to patients with cataract. Still people are not patronizing the available free services; thus they have to live with impaired vision or blindness. This paper describes the barriers for cataract treatment among the population over 60 years of age. Out of 470 elders, 379 were found to have some kind of cataract. This study demonstrated lack of awareness and knowledge, socioeconomic factors, and misconceptions as the main barriers for cataract treatment which has led to a lower cataract surgery rate irrespective of the high cataract prevalence reported. Findings of this study highlight the importance of cataract as a common health problem in elderly and need for removal of the barriers for its treatment which should be given due prominence in the formulation of public health policy in Sri Lanka at the earliest.Item Place for elective cholecystectomy for patients with severe thalassaemia: a retrospective case control study.(BioMed Central,London, 2019) Premawardhena, A.; Fernando, R.; Kumarage, S.; Nishad, N.; Goonatilleke, D.; Silva, I.; Mettananda, S.OBJECTIVE:At present, cholecystectomy is carried out for thalassaemia patients with gall stone disease only if they develop symptoms of cholecystitis, except in the rare instance where an un-inflammed gall bladder is removed simultaneously with splenectomy. We carried out this retrospective analysis of case records to examine if patients with thalassaemia have a higher rate of peri operative complications compared to non-thalassaemics with gall stone disease, warranting a change of policy to justify elective cholecystectomy.RESULTS:Case records of 540 patients with thalassaemia were retrospectively analysed of which 98 were found to have gallstones. Records of 62 patients without thalassaemia with gall stone disease too were used for comparison. 19 of patients with thalassaemia and 52 of non-thalassaemic who had gallstones had undergone cholecystectomy. In all but 5 patients with thalassaemia cholecystectomy was done following attacks of acute cholecystitis as was the case in the non-thalassaemic controls. A significantly higher proportion of early and late complications had occurred in thalassaemia patients compared to non-thalassaemic patients post operatively. Six deaths related to sepsis following acute cholecystitis in the peri operative period were reported among 19 thalassaemia patients whereas no deaths were reported among 55 non-thalassaemic patients who underwent cholecystectomy for gallstones.Item Comparison of metformin versus other treatment modalities in gestational diabetes mellitus(Society for Advance Healthcare Research, Maharashtra, India, 2016) Ekanayake, C.D.; Wijesinghe, P.S.; Herath, R.; Puliyadda, N.; Nishad, N.INTRODUCTION: Despite evidence to prove both its efficacy and safety, use of metformin is at most restricted to only as an adjunct to insulin preparations. We compared the maternal, fetal and neonatal outcomes associated with GDM in women treated with metformin versus those treated with diet alone and diet plus insulin. Method: An observational study was carried out over a period of six months in 104 GDM patients. Study groups were 43 patients on diet alone (group A), 42 on metformin plus diet (group B), and 19 on diet plus insulin (group C). Maternal, fetal and neonatal outcomes were compared. Results: Fourteen patients in group B subsequently required supplemental insulin. Gestational hypertension 5(12%), 4(10%), 5(26%) (p=0.8) and wound infection among 2(5%), 1(2%), 0(0%) (p=0.6) were seen in groups A, B and C respectively. Four patients with polyhydramnios were seen in group B. Mean birth weights were A=3.07kg, B=3.07kg, C=3.1kg (p=0.96). Macrosomia 5 (12%), 3 (7%), 3 (16%) (p=0.2), neonatal hypoglycemia 2 (5%), 2 (5%), 2 (11%) (p=0.4), five minute Apgar scores 9.9, 9.7, 9.9, and neonatal jaundice 5(12%), 4(10%), 3(16%) (p=0.04) were noted in in groups A, B and C respectively. Single case of respiratory distress was seen in the insulin group. Shoulder dystocia and perinatal deaths were not observed. Conclusion: Maternal and perinatal outcomes were similar among diet alone, diet plus metformin, and diet plus insulin groups. Cost-effectiveness, easy administration, safety profile and convenience of storage would make metformin an attractive option in the management of gestational diabetes mellitus.Item Early predictors of severe dengue in adults(Elsevier, 2012) Wijewantha, H.; Premaratna, R.; Mabharana, I.; Nishad, N.; de Silva, A.; de Silva, H.J.BACKGROUND: Dengue is the main infectious disease causing high morbidity and mortality among adults in dengue endemic regions of Sri Lanka. Prediction of severe illness at an earlier stage of infection helps to arrive at management decisions. Studies to identify predictors of severe dengue in adults are sparse. METHODS: In order to identify predictors of severe dengue by the third day of illness, symptoms, signs and investigation results of first 3 days of illness between two groups A and B (defined below) were compared in a prospective cohort study of consecutive 117 adult patients (age>12 years) with serologically confirmed dengue admitted to the professorial medical unit, Colombo North Teaching Hospital, Ragama, Sri Lanka over 6 month from 1st of March 2011. Group A (Severe illness): development of ascites or pleural effusions (evidence of fluid leakage), compensated shock and profound shock (as defined by WHO guidelines for Dengue 2010), Group B: all others who did not fall into Group A. Severity of symptoms was assessed by a visual analogue scale, and rest of the clinical parameters, investigation results were documented prospectively. RESULTS: Of the 117 adults (95 males) mean age 31.95years (SD=13.34); 27 fell into Group A and 90 into group B. On the 3rd day of illness, mean Aspartate aminotransferase (AST); Group A 260 iu/L (SD=168.8) vs Group B-145 iu/L (SD=135.11) (p=0.005). Mean Alanine aminotransferase (ALT); Group A-247 iu/L (SD=161.5) vs Group B-105iu/L (SD-91.5) (p=0.002). None of the symptoms, signs and other investigations including platelet count, packed cell volume (PCV) and white blood cell count was significantly different. Analysis of the whole 117, pearson correlation test showed a positive correlation of AST(r=0.3) (p=0.038) and ALT(r=0.3) (P=0.045) with PCV and a negative correlation (r=-0.3) with platelet count (p=0.014). AST(r=0.25) and ALT (r=0.3) on day 3 was positively correlated with development of malena at any stage (p=0.05). CONCLUSION: Higher AST and ALT levels on 3rd day of dengue seems to be useful predictors of severe dengue. © 2012 Elsevier Inc.