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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 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 Incidence and predictors of metabolic syndrome among urban, adult Sri Lankans: a community cohort, 7-year follow-up study(European Association for the Study of Diabetes, 2017) de Silva, S.T.; Niriella, M.A.; Kasturiratne, A.; Kottahachchi, D.; Ranawaka, U.K.; Dassanayake, A.; de Silva, A.P.; Pathmeswaran, P.; Wickremasinghe, R.; Kato, N.; de Silva, H.J.BACKGROUND AND AIMS In 2007, we reported a 38.9% prevalence of metabolic syndrome (MetS) in an urban, adult population. Published data on incident MetS from South Asia is lacking. This study investigated the incidence and risk factors for MetS after a 7-year follow-up of the initial cohort. MATERIALS AND METHODS: The study population (selected by age-stratified random sampling from the Ragama MOH area) was screened in 2007 (aged 35-64 years) and re-evaluated in 2014 (aged 42-71 years). On both occasions, structured interview, anthropometric measurements, liver ultrasound, biochemical and serological tests were performed. MetS was diagnosed on established International Diabetes Federation (IDF 2012) criteria. Total body fat (TBF) and visceral fat percentage (VFP) were measured in 2014, using impedance. Abnormal TBF was defined as >32% for females and >25% for males. Abnormal VFP was defined as >10% for both sexes. Non-alcoholic fatty liver disease (NAFLD) was diagnosed on established ultrasound criteria, safe alcohol consumption (Asian standards: <14 units/week for men, <7 units/week for women) and absence of hepatitis B and C markers. RESULTS: 2137/2967 (72.0%) of the initial cohort attended follow-up [1229 (57.5%) women; mean-age 52.4 (SD-7.7) years]. 1000/2137 [548 (54.8%) women; mean age 57.5 years (SD-7.74)] had MetS (prevalence-46.8%). Out of 1246 individuals who initially did not have MetS in 2007, 318 [225 (70.8%) women; mean age 57.5 (SD 7.7) years] had developed incident MetS after 7 years (annual incidence-2.13%). Comparison of incident MetS with those with no MetS in 2014 is shown in Table 1. On logistic regression, female sex (OR 3.6, p<0.001), central obesity [OR 4.58, p<0.001], BMI >23kg/m2 [OR 4.84, p<0.001], increase in weight 2%-5% [OR 2.02, p<0.001], increase in weight >5% [OR 5.3, p<0.001), increase in waist circumference (WC) 5-10-cm [OR 3.68, p<0.001], increase in WC >10cm [OR 10.34, p<0.001] and NAFLD (OR 2.44, p<0.001) in 2007 were independently predictive of incident MetS in 2014. Abnormal VFP [OR 4.23, p<0.001] and abnormal TBF [OR 5.25, p<0.001] were also associated with incident MetS. CONCLUSION: In this prospective community study, the annual incidence of MetS was 2.13%. Female gender, increase in weight and WC from baseline and the presence of NAFLD predicted the development of incident MetS. Obesity at baseline was the only defining individual component of MetS that predicted future MetS.Item Sero-prevalence of rickettsial infections in patients with Parkinson’s disease(Sri Lanka Medical Association, 2017) Gunathilake, M.P.M.L.; Luke, N.; Benedict, S.; Wickremasinghe, S.; Ranawaka, U.K.; Premaratna, R.INTRODUCTION & OBJECTIVES: Role of infections in Parkinson’s disease (PD) pathogenesis has been proposed. A patient who had features of PD during scrub typhus infection fully recovered following treatment. Two years later, he developed features suggestive of early PD and raised the question, whether rickettsial infections could trigger development of PD. METHODS: In order to study the sero-prevalence of rickettsioses, a descriptive cross-sectional study was carried out in patients with diagnosed PD. Their IFA-IgG titres against O. tsutsugamushi (IFA-IgG-OT) antigens at 1:32 and 1:128 dilutions were compared with the population seroprevalence. Statistical analysis was performed using SPSS. RESULTS: A total of 35 patients; 20 (57.1%) males [mean age 62 years (SD 8.8)], 15 (42.9%) females [mean age 68.5 years (SD 7.4)]. Mean age at diagnosis of PD; males: 57.2 years (SD 9.7), females: 64.7 years (7.5). 10/35 (29.8%) had IFA-IgG-OT titre 1:32 (p=0.19 compared to population sero-prevalence of 19.8%) and one had a titre 1:128 (2.8% compared to population prevalence of 3.17%). At the time of assessment for sero-prevalence of rickettsioses, the mean (SD) duration of diagnosis of PD between IFA-IgG +ve vs IFA-IgG –ve were 4.3(3.9) vs 4.2(4.4) years. CONCLUSION: Although patients with PD had a higher percentage sero-prevalence compared to the population, it was not significantly different. The drawback of this study was the long duration of PD at the time IFA-IgG levels were done. Following up of patients who present with extrapyramidal features due to acute rickettsioses and assessing whether they later develop PD would help to arrive at conclusions.Item Quality of clinical trial registration at the Sri Lanka clinical trials registry: a 5-year analysis(Sri Lanka Medical Association, 2017) Ranawaka, U.K.; de Abrew, A.; Ranasinghe, R.M.A.G.; Kulathunga, K.A.C.J.; Wimalachandra, M.; Samaranayake, N.; Goonaratna, C.INTRODUCTION & OBJECTIVES: Previous studies have highlighted the poor quality of clinical trial registration in international registries. We sought to evaluate the quality of trial registration in the Sri Lanka Clinical Trials Registry (SLCTR). METHODS: We studied all trial records at SLCTR over a 5-year period (2012-2016). Records were evaluated for data quality, using pre-defined criteria, regarding the following: WHO minimum trial registration data set (WHO-TRDS), ethics review approval, and detailed analysis of contact information, interventions and outcomes. RESULTS: A total of 144 trial records were studied. All records had meaningful entries for 12 out of the 20 items in WHO-TRDS, and over 95% of records had meaningful entries for 16 items, while the mean TRDS score was 17.76 ±1.03. Details of ethics approval were provided in all records. Intervention specifics were recorded for 174 experimental or active comparator arms. Meaningful information was provided regarding intervention name, dose, duration, frequency and route in 173 (99.4%). 156 (89.7%), 123 (70.7%), 132 (75.9%) and 109 (62.6%) arms respectively. A total of 388 primary outcome measures were recorded. Of them, 79.1% (n=307) were considered to be of good quality (specific – 76%; safety monitoring – 3.1%). Recording of time frame was considered to be of good quality for 94.4% (n=366) of outcomes (meaningful – 83.8%; irrelevant – 10.6%). All records provided either email address or telephone number of contact person; 98% (n= 141) had both. CONCLUSION: Quality of clinical trial registration at the SLCTR is better compared to other international registries in almost all the domains studied. Trial registration of good quality is feasible and sustainable in a resource-limited setting.Item Anthropometric correlates of total body fat, visceral adiposity and cardio-metabolic health risk: a community cohort study of urban, adult Sri Lankans(Sri Lanka Medical Association, 2016) Niriella, M.A.; de Silva, S.T.; Kasturiratne, A.; Kottachchi, D.; Ranawaka, U.K.; Dassanayake, A.S.; de Silva, A.P.; Pathmeswaran, A.; de Silva, H.J.INTRODUCTION: Anthropometric measurements (AM) are used as proxies for more direct measurements of body fat (BF) and its distribution. Several studies have examined the association between AM, BF and health outcomes such as cardiovascular risk (CVR). However, correlation of such simple AM and advanced measures of BF and the ability of these to predict CVR has not been studied in community follow up studies. OBJECTIVES: To examine the relationship between simple and advanced anthropometric measurements and their ability to predict cardiovascular risk factors in an urban adult Sri Lankan population. METHOD: The data was collected from a community cohort of adults (aged 42-71 years) selected by age-stratified random sampling from electoral lists of the Medical Officer of Health area, Ragama. Individual simple measurements [body weight, height, waist circumference (WC), hip circumference (HC)], advanced measurements [total body fat (TBF), visceral fat percentage (VFP) by Omron® body fat monitor] and cardiovascular risk factors [blood pressure, HbA1c, triglycerides, low-density (LDL-C), high-density-lipoprotein cholesterol (HDL-C) level, cardio-metabloic risk (CMR) (2 or more risk factors)] were assessed and their relationships were examined. RESULTS: 2155 individuals [1244 (57.7%) women, mean age 59.2 years (SD, 7.7)] participated. Complete data were available for 2000 (92.8%) [1147 (57.4%) women, mean age 59.2 years (SD, 7.7)]. Mean (SD) for anthropometric measurements were: males WC-85.9 (10.8) cm, HC-93.4 (8.0) cm, WHpR (waist-to-hip ratio) -0.92 (0.06), WhtR (waist-to-height ratio) -0.52 (0.06), BMI (body mass index) -23.5 (3.8) kg/m2, TBF -27.0 (5.7)%, VFP -10.7 (5.2)%; females WC -84.8 (10.7) cm, HC-97.2 (9.5) cm, WHpR-0.87(0.08), WhtR-0.52 (0.07), BMI -25.4 (4.4) kg/m2, TBF -38.2 (4.2)%, VFP-9.6 (4.9)%. BMI and WC correlated well with VFP (Pearson’s r for males: 0.94 and 0.85, females: 0.96 and 0.78, respectively). In both sexes, increasing BMI, WC, WHtR, TBF and VFP, were significantly associated with higher risks of hypertension, diabetes, dyslipidemia and combined CMR (ROC area under the curve>0.6). CONCLUSIONS: In this cohort of urban, adult Sri Lanka, simple anthropometric measurements correlated strongly with VFP, and were equally good in predicting cardiovascular risk factors.Item Incidence and predictors of metabolic syndrome in an urban, adult Sri Lankan population – a community cohort follow-up study(Sri Lanka Medical Association, 2016) de Silva, S.T.; Niriella, M.A.; Kasturiratne, A.; Kottahachchi, D.; Ranawaka, U.K.; Dassanayake, A.S.; de Silva, A.P.; Pathmeswaran, A.; Wickremasinghe, A.R.; Kato, N.; de Silva, H.J.INTRODUCTION: There is limited data on the incidence of metabolic syndrome (MetS) from the South Asian region. In 2007, we reported a 38.9% prevalence of MetS in an urban, adult Sri Lankan population. OBJECTIVES: This study investigated incidence and risk factors for MetS in this population cohort after seven years’ follow-up. METHOD: The study population (42-71-year-olds, selected by age-stratified random sampling from the Ragama MOH area) was screened initially in 2007 and invited for re-evaluation in 2014. On both occasions they were assessed by structured interview, anthropometric measurements, liver ultrasound, and biochemical and serological tests. MetS was diagnosed on established International Diabetes Federation (IDF 2006) criteria. RESULTS: 2155/2985 (72.2%) of the original cohort attended follow-up [1244 women, 911 men; mean-age 59.2 (SD 7.7) years]. 1227 fulfilled IDF criteria for MetS (prevalence 59.3%). Out of 1246 individuals who initially did not have MetS in 2007, 318 [225 women; mean age 57.5 (SD 7.7) years] had developed MetS after 7 years (annual incidence 3.65%). On logistical regression, female sex (OR 3.41; p<0.001), central obesity (OR=1.50, p=0.022), BMI >=23 (OR=3.82, p<0.001) and presence of non-alcoholic fatty liver disease (NAFLD) (OR=1.83, p=0.001) in 2007 were independently predictive of incident MetS. CONCLUSIONS: In this community cohort follow-up study, the annual incidence of MetS was 3.65%. Female gender, presence of NAFLD, central obesity and increased BMI predicted the development of future MetS.Item Awareness of clinical trial registration(Sri Lanka Medical Association, 2012) Wimalachandra, B.C.M.; Ranawaka, U.K.; de Abrew, K.A.G.; Wanigatunga, C.A.; Rajapaksa, L.C.; Goonaratna, C.INTRODUCTION: Prospective registration in a freely accessible public domain is mandatory for clinical trials. Little is known regarding awareness of clinical trial registration among the scientific community. AIMS: To assess awareness of clinical trial registration among participants attending a scientific meeting in Sri Lanka. METHODS: Knowledge of trial registration was assessed using a self-administered questionnaire. Results: Only 251 out of 714 participants (35.6%) returned completed valid questionnaires. Of them, 53.4% were males, 74.9% were below the age of 40 years, and 49% had less than 5 years of professional experience. Majority (56.6%) were currently involved in research. Registration was considered necessary for trial publication by 73.3%, for presentation of findings by 56.2%, and for ethics approval by 54.6%. Over 70% agreed that trials should be registered prospectively. Majority felt it was beneficial to have research findings freely accessible to other researchers (81.3%), clinicians (84.5%) and research participants (76.7%). Many agreed on the positive effects of trial registration - access to findings of all trials (61.4%), access to negative results (47.8%), preventing trial duplication (69.3%) and preventing multiple publications (70.1%). Increasing research workload (49.8%), additional restrictions on research (52.2%) and possibility of'intellectual theft' (56.2%) were seen as potential negative effects. Awareness of access to registration mechanisms for trials conducted in Sri Lanka (49%), and a Sri Lankan trial registry (31.5%) was poor. CONCLUSIONS: Awareness of clinical trial registration was satisfactory in some aspects, but several areas need improvement.Item Recurrent vs. first presentation with acute coronary syndrome in a tertiary care hospital(Sri Lanka Medical Association, 2012) Thirumavalavan, K.; Premawansa, G.; Bandara, G.M.T.R.; Fonseka, V.N.R.M.; Danansuriya, D.S.T.; Premawansa, G.; Samarakoon, S.M.S.B.; de Silva, A.P.; de Silva, S.T.; Ranawaka, U.K.INTRODUCTION: Profile of recurrent acute coronary events may differ from first-ever events, but no data is available from South Asia where morbidity and mortality are high. AIMS: To describe characteristics of patients with recurrent acute coronary syndrome (ACS) admitted to a tertiary care hospital. METHODS: Data was prospectively collected from all patients admitted with ACS to the Colombo North Teaching Hospital over 18 months. Differences in demographic data, presentation, risk factors, management and early outcome between those with first and recurrent ACS were analysed. Results: Of 765 patients admitted with ACS, 501 (65.5%) presented with the first episode, while 264 (34.5%) presented with a second or subsequent episode. Those with recurrent ACS were more likely to:- present with unstable angina (61.4% vs 39.5%, p<0.001), present directly to hospital instead of a primary care provider (84.1% vs 71.3%, p<0.001), have hypertension (74.1% vs 50.1%, p<0.001) and hyperlipidaemia (51.5% vs 34.3%, p<0.001), and be ex-smokers (28% vs 19.3%, p<0.001). Those with the first episode were more likely to be current smokers (23.8% vs 11%, p<0.001). No differences were noted between the two groups in:- age and sex distribution, presenting symptoms, presence of diabetes, family history of coronary artery disease, alcohol use, in-hospital management, duration of hospital stay and early outcome. CONCLUSIONS: Patients with recurrent ACS were more likely to have unstable angina than myocardial infarction. They were more likely to present directly to hospital, and to have stopped smoking. Hypertension and hyperlipidaemia were commoner among them, highlighting the need for better secondary preventive measures.Item The Sri Lanka Clinical Trials Registry - a 5 year audit(Sri Lanka Medical Association, 2012) de Abrew, K.A.G.; Ranawaka, U.K.; Wanigatunge, C.A.; Wimalachandra, M.; Goonaratna, C.INTRODUCTION: Prospective registration is mandatory for the conduct and publication of clinical trials. The Sri Lanka Clinical Trials Registry (SLCTRJ was established in November 2006. It is a Primary Registry of the International Clinical Trials Registry Network of the WHO. AIMS: To audit the process of trial registration at the SLCTR during the 5 year period from the first trial registration (February 2007-January 2012). Methods: An internal audit of the online registry and the functioning of the SLCTR was carried out. We evaluated- (1J all trial applications, including those rejected, for accuracy and completeness of the Trial Registration Data Set (TRDS), (2) all registered trials for maintenance of records and (3) in-house procedures related to trial registration. RESULTS: Seventy trials were registered; 14 were rejected. Over half (n=37) were prospective registrations. All registrations since July 2010 (n=21) were prospective. Four were international multi-centre trials; 13 were industry sponsored. Median time from submission of all relevant documentation to registration was 7 days. All applications from 2010 were registered within 7 working days. Majority (n=41J were drug trials, including herbal preparations (n=7), while 19 were for procedures. 39 trials have been completed, 8 have published their findings and 7 reported protocol changes. Eight trials (11.4%) do not have current progress reports. CONCLUSIONS: The SLCTR has provided a platform for registration of clinical trials in Sri Lanka. In-house registration processes have improved with time. There is a need to improve awareness among trial registrants regarding maintenance of trial records.Item Hyperhomocysteinaemia and stroke: a case-control study(Sri Lanka Medical Assosiation, 2004) Ranawaka, U.K.; Niriella, M.A.; Hewamadduma, C.A.A.; Kanakkahewa, N.; Thilakarathna, N.T.; Wickremasinghe, A.R.; Wijesekera, J.C.OBJECTIVES: We sought to identify the importance of hyperhomocysteinaemia as an independent risk factor for stroke. METHODOLOGY: This was a case control study of patients with stroke (n=48) and pair matched controls (age and sex matched; n=48) at the Institute of Neurology, NHSL. Prior ethical approval was obtained from the Ethical Review Committee of the SLMA. Fasting total plasma homocysteine (tHcy) was compared between the two groups. Logistic regression analysis was performed to determine the contribution of hyperhomocysteinaemia as a risk factor for stroke, after controlling for other risk factors, using the 50th percentile of tHcy among controls (tHcy 50) as cut-off value. All strokes (n=48) and ischaemic strokes (n=43) were analysed separately. RESULTS: Cases (mean age = 55.69 years) and controls (mean age = 54.64 years) were well matched. tHcy among controls (mean=16.5l umol/1) was higher than observed from elsewhere, even after excluding those with vascular risk factors (mean=13.8 umol/1). The mean tHcy levels were significantly higher in cases (23.12 umol/1) than in controls (16.51 umol/1, p<0.001). There was no significant difference in tHcy between ischaemic and haemorrhagic strokes, and lacunar and non-lacunar strokes. Logistic regression analysis showed that tHcy 50 was an independent risk factor for haemorrhagic strokes (OR 2.583, p=0.05), and for ischaemic strokes (OR 2.663, p=0.05). CONCLUSION: tHcy levels may be higher than usual among Sri Lankan populations. Hyperhocysteinaemia is an independent risk factor for stroke.