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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Seven–minute neurocognitive test battery: A reliable test for dementia(Elsevier, Inc. (2020-Wiley), 2006) de Silva, A.; Pathmeswaran, A.; de-Jager, C.; Kuruppuarachi, L.A.BACKGROUND: The increasing prevalence of Alzheimer’s disease (AD) suggests that there is an increasing need for accurate and easily administered screening instruments to assess cognitive function. OBJECTIVE(S): To examine the reliability of the 7-minute screen as a cognitive screening instrument for AD in a Sri Lankan population. METHODS: 53 patients with mild-moderate AD, 34 with other dementias, 36 with mild cognitive impairment (MCI) referred to a memory clinic, and 60 patients with depression with no evidence of dementia and 56 healthy volunteers (controls) were recruited to the study after informed consent. All were community-dwelling and aged _60 years. Patients with severe dementia, receptive aphasia, visual and motor impairment, and severe depression were excluded. All diagnoses were made according to established criteria and the diagnosis of depression was confirmed after psychiatric evaluation. All subjects underwent cognitive assessment with the Mini Mental State Examination (MMSE) and the 7-minute screen. This screen consists of four components (enhanced cued recall, temporal orientation, verbal fluency, and clock drawing) that assess memory, orientation to time, fluency of expression, and executive function, cognitive functions typically compromised in AD. RESULTS: Baseline characteristics did not differ significantly in the five groups. (see the table). CONCLUSIONS: The 7-minute neurocognitive screen is a highly sensitive instrument to screen for AD and was more reliable than the MMSE to detect AD, MCI, and other dementias in this Sri Lankan population. However, the accuracy of the screen may be confounded by the presence of depression.Item Colonoscopic ultrasound is associated with a learning phenomenon despite previous rigid probe experience(Springer India, 2009) Siriwardana, P.N.; Hewavisenthi, S.J.de S.; Pathmeswaran, A.; Deen, K.I.Colonoscopic ultrasound (CUS) enables total colonoscopic examination combined with staging of tumor. Rigid probe transrectal ultrasound (TRUS) is reliable in assessing rectal cancer. Both the modalities are associated with an initial learning curve. We evaluated the predictability CUS in preoperative staging of rectal cancer during the learning curve, despite experience with TRUS. Forty-four patients with non-obstructing rectal cancer were assessed by colonoscopy and colonic ultrasound using a 7.5 MHz rotating transducer. Accuracy of ultrasound staging was compared with pathological staging. Tumor staging and nodal staging at pathology and ultrasound were named pT, pN and uT, uN, respectively. The pathological staging was pT1 in two (4.5%), pT2 in 16 (36%), pT3 in 21 (48%) and pT4 in five (11.5%) rectal cancer specimens. CUS understaged the tumor in 11 cases and overstaged it in 10 cases. Overall, the positive predictive value was 61%, negative predictive value 73%, sensitivity 61%, and specificity 73%. Lymph nodes were not visualized in 14. The overall un-weighted kappa of CUS staging of RC was 0.18 (poor). The predictive value in tumor staging of CUS is suboptimal in the learning phase, despite previous experience with TRUS.Item Histopathology reporting in colorectal cancer: a proforma improves quality(Wiely-Blackwell, 2009) Siriwardana, P.N.; Pathmeswaran, A.; Hewavisenthi, J.; Deen, K.I.AIM: The histopathology report is vital to determine the need for adjuvant therapy and prognosis in colorectal cancer (CRC). Completeness of those in text format is inadequate. This study evaluated the improvement of quality of histopathology reports following the introduction of a template proforma, based on standards set by the Royal College of Pathologists (RCP), UK. METHOD: Sixty-eight consecutive histopathology reports based on 19 items for rectal cancer (RC) and 15 items for colon cancer (CC) using the proforma were prospectively analysed and compared with results of a previous audit of 82 consecutive histopathology reports in text format. The percentage of reports containing a statement for each data item for both series was compared using the Normal test for difference between two proportions. Completeness of each report was assessed and a percentage score (percentage completeness) was given. Mean percentage completeness was calculated for each format and compared using the two sample t-test. RESULTS: Except for comments on the presence of 'histologically confirmed liver metastases' in CC and RC, 'distance from dentate line' and 'distance to circumferential margin' in RC, all other items were commented in more than 90% of reports, where 71% of the items based on the minimum data set were present in all reports. Compared to prose format, the mean percentage completeness (SD) improved from 74% (8) to 91% (4) (P < 0.0001) and from 81% (5) to 99% (1) (P < 0.0001) for RC and CC respectively in template proforma format. CONCLUSION: A template proforma and surgeon's contribution in relation to operative findings improves the quality of the histopathology report in CRC.Item A Composite symptom score using frequency and severity correlates better to an objective measure of Gastro-Oesophageal Reflux Disease (GERD) than one scoring frequency of symptoms alone(American Gastroenterological Association(AGA) Institute, Published by Elsevier Inc., 2008) Amarasiri, L.; Pathmeswaran, A.; Ranasinha, C.D.; de Silva, H.J.INTRODUCTION: The prevalence of GERD is increasing. Community prevalence in Sri Lanka is unknown. There is lack of a practical screening instrument to use in an epidemiological setting. OBJECTIVE : To develop a practical clinical score to screen for GERD in the community and assess whether a score using both symptom frequency and severity correlated better with an objective measure of GERD than one using only symptom frequency. METHODOLOGY: A cross-sectional validity study was performed in 100 GERD patients and 150 healthy controls comparable in age and gender. Ethical clearance was granted. GERD was diagnosed by upper gastro-intestinal endoscopy, including patients with all grades of oesophagitis. All subjects faced a GERD-specific interviewer-administered questionnaire with seven upper gastro-intestinal symptoms (heartburn, acid regurgitation, chest/abdominal pain, abdominal distension, dysphagia, cough, belching). Each symptom was graded using a 5-item Likert scale for frequency (never, monthly, 2-4 times per week, weekly, daily) and a 4-item scale for severity (no effect, mild, moderate, severe) and two scores generated. Score 1 being the sum of frequency of symptoms while score 2 was the sum of products of frequency and severity of each symptom. All GERD patients underwent 24h ambulatory pH monitoring. Face and content validity were assessed by expert consultation and literature review, internal consistency by Cronbach alpha statistics, reliability by intra class correlation coefficient estimation and concurrent validity by comparison of scores with 24 hour pH monitoring values as the gold standard. Cut-off values were determined by constructing receiver-operating characteristic curves. RESULTS: For both scores, mean scores of cases were significantly higher than controls (p<0.001) Cut-off score for score 1 was ≥ 10.50 (sensitivity 92.0%; specificity 78.7%; area under the curve 0.937 respectively). Cut-off score for score 2 was ≥ 12.50 (sensitivity 90.0%; specificity 78.0%; area under the curve 0.929 respectively). Intra class correlation coefficient for score 1 and 2 were 0.94 and 0.82 respectively. There was good correlation between both symptom scores and 24-h pH metry parameters (Spearman rank correlation, p=0.01), but score 2 showed a significantly better correlation (correlation of Total reflux time pH<4 with score 1 and score 2 was 0.491 and 0.651; p=0.001, and of Demeester score with score 1 and score 1 was 0.590 and 0.747; p<0.001). CONCLUSION: Our GERD questionnaire is valid, reliable and showed better correlation with an objective test when both severity and frequency of symptoms were scored rather than frequency of symptoms alone.Item Is a six hour fast after a rice meal sufficient before upper gastrointestinal endoscopy?(American Gastroenterological Association(AGA) Institute, Published by Elsevier Inc., 2009) de Silva, A.P.; Niriella, M.A.; Perera, N.J.A.H.D.; Aryasingha, J.S.; Kalubowila, U.P.; Dassanayake, A.S.; Pathmeswaran, A.; Manchanayake, M.M.J.H.; Devanarayana, N.M.; de Silva, H.J.OBJECTIVE: Rice is the staple diet in many Asian countries. Current endoscopic guidelines advice a 6 h fast for solids and a 4 h fast for liquids before the procedure. However, these guidelines focus on a Western type diet. The aim of the study was to determine if a 6 h fast for rice is sufficient prior to upper gastrointestinal endoscopy (UGIE). PATIENTS AND METHODS: After informed consent, 212 patients referred for UGIE, who had no alarm symptoms, were randomized into two groups in preparation for UGIE. Fasting 6 h after a rice meal (R6) or fasting 10 h after a rice meal (R10). All meals contained lentils and an egg, and were isocaloric. Endoscopic vision was graded as poor, average, or good. RESULTS: In the R10 group (n = 107) vision was poor in 2 (1.9%), average in 7 (6.5%), and good in 98 (91.6%). While in the R6 group (n = 105) vision was poor in 30 (28.6%), average in 19 (18.1%), good in 56 (53.3%). The observed difference of percentages among the two groups for endoscopic vision was significant (M-H Chi-Square for trend = 25.67; df = 1; p < 0.001). CONCLUSIONS: Fasting for 6 h after a rice based meal seems inadequate for UGIE. Fasting for 10 h significantly improves endoscopic vision. Current guidelines need to be re-evaluated for populations where rice is the staple diet.Item Endosonographic characteristics of the anal sphincter complex in primigravid sri lankan women(Sri Lanka College of Obstetricians and Gynaecologists, 2005) Mayooran, V.; Deen, K.I.; Wijesinghe, P.S.; Pathmeswaran, A.OBJECTIVE: To determine the endosonographic anatomy of the anal sphincter complex in primigravid Sri Lankan women. Method: This is an observational study of 95 primigravid women admitted to antenatal ward, university obstetric unit, North Colombo Teaching Hospital, Ragama. They were examined using anal endosonography and data from subjects without sphincter injury were analysed to describe the anal sphincter morphology. Individual anal canal components were measured at defined levels, and the relationship of individual measurements with age and body mass index was calculated. RESULTS: Ninety-three of 95 women had no anal sphincter damage. The puborectalis sling (mean 5.5mm, SD 0.77) forms the upper most border of the anal sphincter complex. The mean width of the deep external sphincter was 4-3rnrn (SD0.61); that of the superficial external sphincter was 4.5mm (SD 0.56); and that of the internal anal sphincter at the mid anal canal was 2.1mm (SD 0.21). The intersphincteric space (mean 2.1mm, SD 0.26) could be distinguished sonographically in all subjects. The mean width of the anterior ring of the subcutaneous component of the external sphincter was 3.8mm (SD 1.01). The perineal body was sonographically identified in 60% of subjects. CONCLUSION: A set of normal values for the anal sphincter components in Sri Lankan primigravid women was establishedItem Prevalence of post-obstetric faecal incontinence in sri lankan women: a prospective observational study(Sri Lanka College of Obstetricians and Gynaecologists, 2004) Mayooran, V.; Wijesinghe, P.S.; Fernandupulle, R.C.; Pathmeswaran, A.OBJECTIVES: To measure the prevalence and degree of post-obstetric faecal incontinence, to identify obstetric risk factors and to assess the impact of it on the quality of life. DESIGN: Prospective observational study. SETTING: Professorial obstetric unit, Teaching Hospital, Ragama. POPULATION: Seven hundred women who delivered during a period of two months in 2003 in the above unit. METHODS: Obstetric data were collected from case notes. Basic socio demographic data and the contact details were obtained by using a questionnaire administered by an interviewer within 24 hours of delivery. Information regarding symptoms related to faecal incontinence and its effect on quality of life was obtained by a self administered postal questionnaire at six weeks postpartum. MAIN OUTCOME MEASURES: frank faecal incontinence, fae.cal soiling and urgency. RESULTS: Four hundred and eleven questionnaires were returned, 58.7% response rate. Twenty-four women (5.8%) developed faecal incontinence after the index birth. Twenty-one (90%) of them had faecal urgency alone. Two of them had frank faecal incontinence, faecal soiling and urgency, one had frank faecal incontinence in addition to faecal urgency. Mode of delivery was the only risk factor found to be independently associated with faecal incontinence. Instrumental delivery was associated with increased risk of symptoms (OR 3.7, 95% CI 1.3-11.1) while caesarean section was marginally associated with reduced risk (OR 0.3, 95% CI 0.07-1.4) compared with normal vaginal delivery. No evidence of association was found between faecal incontinence and following factors- maternal age, maternal pre-pregnancy, body mass index, onset of labour, duration of 2" stage, episiotomy, perineal lacerations and fetal birth weight. All women with faecal incontinence except those who had occational urgency reported that this bowel problem affected their social, psychological, occupational, domestic, physical and sexual lives. CONCLUSIONS: Postpartum faecal incontinence is more common than previously realized, even though majority of them had only urgency. Women undergoing instrumental delivery had almost 4 times risk of developing faecal incontinence while caesarean section appeared to offer some protection. Faecal incontinence had considerable effect on the quality of life. Therefore identification and treatment is a priority.Item Antimicrobial susceptibility of urinary isolates and prescribing practices of empirical antimicrobials in patients with urinary tract infection in a tertiary care hospital(Sri Lanka College of Microbiologists, 2009) Wijekoon, C.N.; Dassanayake, K.M.M.P.; Perera, W.P.M.H.; Pathmeswaran, A.OBJECTIVE: Knowledge of local antimicrobial susceptibility is essential for prudent empiric therapy of urinary tract infection (DTI). We sought to describe antimicrobial susceptibility patterns in in-ward patients with UTI and compare it with prescribing practices. METHODS: A descriptive study was conducted at the Colombo North Teaching Hospital in consecutive patients with a positive urine culture between January 2007 and July 2008. Sensitivity testing was done using Joan Stokes method. RESULTS: Coliforms were the commonest (89.6%) isolates in 1206 specimens. The susceptibility was as follows; nitrofurantoin - 83.9% jgentamicin - 74.3%, coamoxiclav - 69.7%, cefalexin - 57.8%, norfloxacin - 57.7%, ciprofloxacin - 50%, cotrimoxazole-37.5%, ampicillin -23.3%. Clinical data analysed for 259 (females -67,95%,^12 years - 95.2%). 25.1% didn't receive empirical antimicrobials. Among the 194 who received an antimicrobial 52.1% received ciprofloxacin and 11.3% received nitrofurantoin. Concordance between the empirical antibiotic prescribed and the sensitivity of the isolated organism was seen only in 21.7%. In 16.5% urinary isolate was resistant to the empirical antibiotic and in 61.8% empirical antibiotic was not included in sensitivity testing. Overall, sensitivity of ciprofloxacin and nitrofurantoin was tested in 6.7% (susceptibility rate - 50%) and 94.3% (susceptibility rate - 83.9%), respectively. CONCLUSIONS: Coliforms were the commonest isolate irrespective of the origin, site and type of DTI. Resistance was high (£50%) to ampicillin, cotrimoxazole and ciprofloxacin. Ciprofloxacin was the most frequently prescribed empiric therapy but its sensitivity was tested in less than 10%. Despite high susceptibility rate nitrofurantoin was underutilised. There was obvious discrepancy between empirical prescribing practices and both the susceptibility pattern of isolates and sensitivity testing practices.Item Projected cost- effectivenes of rotavirus vaccination in Sri Lanka(The Bulletin of the Sri Lanka College of Microbiologists, 2007) Chandrasena, T.G.A.N.; Rajindrajith, S.; Gunawardane, R.; Adhihetty, D.; Ahmed, K.; Pathmeswaran, A.; Nakagomi, O.OBJECTIVES: The disease and economic burden of rotavirus infection among children hospitalised for gastroenteritis in Sri Lanka was assessed, in anticipation of the availability of new rotavirus vaccines. METHODS: A prospective gastroenteritis case surveillance was conducted between April 2005-October 2006 at the paediatric units of the Colombo North Teaching Hospital. Stool samples of children admitted with diarrhoea were screened for group A rotavirus antigens by enzyme-immuno assay (ElA)(Rotaclone®).Information regarding medical and non- medical costs during the event was obtained among randomly selected rotavirus cases (n=45) through an interviewer administered questionnaire. Cost effectiveness of universal rotavirus vaccination was investigated assuming a cost Of ≤ US$.7 per vaccine dose (two dose regime) in accordance with the World Bank cost effectiveness standard for low-income countries. RESULTS: Total of 606 children (335 males)[ mean age 27.3 months,(range 1-144) were analyzed. 116 (19.1%) had rotavirus antigens. The prevalence among the 0-5 years age group was 20.8. The average cost per episode of rotavirus gastroenteritis was Rs. 3004(US$ 27). Estimated initial and recurrent expenditure of universal vaccination was US$ 23.7 and five million respectively. Costs saved through averting rotavirus diarrhoea hospitaljsations per year (assuming a vaccine of 100% efficacy) were US$ 0.21 million. Deaths averted were eight per year. CONCLUSION: Universal rotavirus vaccination at 5 US$.7 per dose may not be cost-saving in Srilanka. However decisions regarding vaccine use should be based not only on whether the intervention provides cost savings but also on the value of preventing associated morbidity and mortality.Item Nutritional status of tea pluckers.on Norwood Estate, Hatton(Sri Lanka Medical Association, 2003) Selvaratnam, R.R.; Pathmeswaran, A.; de Silva, I.D.R.; de Silva, N.R.OBJECTIVES: To determine the nutritional status of tea pluckers and to identify factors contributing to anaemia, METHODS: All women tea pluckers of 5 randomly selected divisions of Norwood Estate in Bogawantalawa Plantations, Hatton, were recruited. A dietary survey was carried out using 24 hours recall method. Measurements of height and weight were taken. Haemoglobin (Hb) level in finger prick blood was measured by cyanmethaemoglobin method. Stools were examined for helminth eggs using saline smears and the Kato-Katz technique. Data were analyzed using Epilnfo 6 and SPSS 10. RESULTS: A total of 304 women with a mean age of 37.8 years (SD=8.4) were examined. Mean calorie, protein and iron adequacy were 52.5%, 45.9% and 45.9% respectively. The mean Body Mass Index (BMI) was 18.3 (SD=2.5), while 59.9 % (n=181) were undernourished (BMI<18.5). The mean Hb was 11.02 g/dl (SD=1.45); 76% (n=231) were anaemic (Hb<12 g/dl). 25/248 (10.1%) stool samples examined were hookworm positive. Several variables had a significant association with Hb in bivariate analysis. As most of the variables were related, multiple regression analysis was carried out to identify independent predictor variables. This showed that dietary iron and calorie adequacy, the number of children, and the number of children below 5 years of age, but not hookworm infection, had an independent significant association with Hb. CONCLUSIONS: Most of the study population had evidence of chronic under nutrition as indicated by low BMI and anaemia. Dietary inadequacy of iron appears to contribute more significantly to anaemia than hookworm.infection.