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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Disseminated tuberculosis presenting as meningitis and spondylodiscitis in an immunocompetent adult(Medknow Publications, 2023) Arumugam, J.; de Silva, S.Rationale: Disseminated tuberculosis involves the central nervous system in up to a third of cases. However, meningitis and spondylodiscitis due to miliary tuberculosis rarely occur together, particularly in the immuno-competent population. Patient concerns: A 37-year-old immunocompetent male presented with altered level of consciousness for one week and lower back pain with evening pyrexia for one month. Examination revealed spastic paraplegia and left hemiparesis. Diagnosis: Disseminated tuberculosis presenting with meningitis and spondylodiscitis. Interventions: Category I anti-tuberculous therapy with a tapering regimen of intravenous dexamethasone was administered. Outcomes: There was clinical improvement after nine months of treatment. Lessons: Tuberculosis may present with atypical clinical manifestations. Contrast enhanced computed tomography scan or magnetic resonance imaging combined with histopathological features, a high index of suspicion and clinical improvement with anti-tuberculous treatment can confirm the diagnosis in the absence of microbiological evidence, especially in extrapulmonary tuberculosis.Item Genetic and metabolic aspects of non-alcoholic fatty liver disease (NAFLD) pathogenicity(Springer, 2023) Samarasinghe, S.M.; Hewage, A.S.; Siriwardana, R.C.; Tennekoon, K.H.; Niriella, M.A.; de Silva, S.BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease showing a risingprevalence globally. Genetic predisposition plays a key role in the development and progression of the disease pathogenicity. MAIN BODY: This paper summarizes genetic associations based on their influence on several metabolic aspects such as lipid metabolism, glucose metabolism, hepatic iron accumulation and cholesterol metabolism toward the NAFLD pathogenicity. Furthermore, we present variations in some epigenetic characters and the microRNA profile with regard to NAFLD. CONCLUSION: As reported in many studies, the PNPLA3 rs738409 variant seems to be significantly associated with NAFLD susceptibility. Other gene variants like TM6SF2 rs58542926, MBOAT7 rs641738 and GCKR variants also appear to be more prevalent among NAFLD patients. We believe these genetic variants may provide insights into new trends in developing noninvasive biomarkers and identify their suitability in clinical practice in the future.Item Autoimmune hepatitis in a patient with cryoglobulinemic vasculitis: A rare association(Springer Nature Group, 2023) Jeyapraniya, A.; de Silva, S.When a patient with cryoglobulinemic vasculitis develops a concurrent liver disease, it is typically associated with hepatitis C. Here, we report the case of a patient with cryoglobulinemic vasculitis and autoimmune hepatitis. A 54-year-old previously healthy woman presented with chronic urticaria. A skin biopsy revealed leukocytoclastic vasculitis and elevated serum cryoglobulins, leading to a diagnosis of cryoglobulinemic vasculitis. She also had abnormal liver functions, high IgG levels, positive antinuclear antibodies, and anti-smooth muscle antibodies. Liver biopsy revealed interface hepatitis confirming the diagnosis of autoimmune hepatitis. This case represents the rare occurrence of autoimmune hepatitis in a patient with cryoglobulinemic vasculitis.Item Anaemia due to chronic kidney disease: A cross-sectional analysis from a tertiary referral centre in Sri Lanka(Ceylon College of Physicians, 2023) Lakmini, S.; Dilhani, N.; Luke, W. A. N. V.; de Silva, S.INTRODUCTION: Anaemia is a common complication of chronic kidney disease (CKD) that adversely affects cardiovascular health and quality of life. Data on anaemia in Sri Lankan CKD patients is scarce. OBJECTIVES: This study was conducted to assess the prevalence, associations, and treatment response of anaemia in a cohort of patients with CKD. METHODOLOGY: A descriptive cross-sectional study was conducted among consecutive, consenting adult patients with stable CKD attending clinics and wards of the University Medical Unit, Colombo North Teaching Hospital, Ragama. RESULTS: Of 149 patients with CKD (males 57.7%), 70.5% had diabetes, 83.9% had hypertension and 37.6% had ischemic heart disease. Anaemia was present in 90.6% of females and 93% of males. The severity of anaemia was significantly (p=<.05) associated with female gender, advancing CKD stage, diabetes, chronic liver cell disease, being on dialysis, and increasing degree of proteinuria. Of 91 patients investigated for the cause of anaemia, 60.4% had iron deficiency with anaemia of chronic disease, while 27.5% had anaemia of chronic disease based on the blood picture. Of 88 patients with haemoglobin <10g/dl, only 45.4% were on erythropoietin and 56.8% had received blood transfusions. 76.1% of the anaemic patients had hemoglobin below 10g/dL at follow-up despite treatment. CONCLUSIONS: Anaemia was highly prevalent in the CKD cohort with a significant number requiring transfusions. Patients continued to have anaemia despite being treated with nutritional supplements and erythropoietin.Item Paraspinal extramcduallry erythropoiesis- a rare cause of spinal cord compression: two case reports(Sri Lanka Medical Association, 2004) Arambepola, M.; Premawardhena, A.P.; de Silva, S.; Olivieri, N.; Weatherall, D.J.INTRODUCTION: Extrameduallry erythropoiesis (EME) is characterized by the appearance of haemopoietic tissue outside the bone marrow. When EME occurs, albeit rarely, outside the liver and spleen problems may occur. We describe two patients with haemoglobin E- [β thalassaemia who had spinal cord compression, due to EME masses which was reversed with treatment with hydroxyurea and hypertransfusion. PATIENT A: Was a 27year old with HbE -(β thalassaemia. His mean pre transfusion haemoglobin level was 5.5 g/dl. He presented with a six-month history of progressive numbness of his legs. On examination he was found to be paraparetic. The magnetic resonance scan (MRI) showed external compression of the spinal cord between the 4th and 8th thoracic vertebrae. Patient was put on a hypertransfusion regimen and hydroxyurea and made a complete recovery within 4 weeks. Patient B: Was a 9 year old boy with a diagnosis of Haemoglobin E [β thalassaemia who presented with paraplegia which had developed over 3 months. His spinal MRI showed two masses one in the upper thoracic vertebrae and the other at the 1st lumbar level. He was commenced on hydroxyurea and hypertransfusiion to maintain pre-transfusion haemoglobin at >9.5g/dl) and his neurological recover was remarkable. Six months later he had no neurological deficit. DISCUSSION: The above cases highlight the potentially dangerous complications of EME when it involves the spinal cord. They also highlight that even lesions which are sufficiently large to cause complete paraplegia are potentially reversible. Hypertransfusion, hydroxyurea, surgery and previously been used with varying success. The problem remains in deciding the optimal method of management.Item Myocardial infarction in patients with severe beta thalassaemia: A case series(BioMed Central, 2023) Premawardhena, A.; de Silva, S.; Rajapaksha, M.; Ratnamalala, V.; Nallarajah, J.; Galappatthy, G.BACKGROUND: Cardiac disease remains a dominant if not the most important cause of morbidity and mortality in patients with thalassaemia, particularly in those with thalassaemia major. Myocardial infarction and coronary artery disease however are rarely reported. CASE PRESENTATIONS: Three older patients with three distinct thalassaemia syndromes presented with acute coronary syndrome. Two were heavily transfused whilst the other was a minimally transfused patient. Both heavily transfused patients had ST-elevation myocardial infarctions (STEMI) while the minimally transfused patient had unstable angina. Coronary angiogram (CA) was normal in two patients. One patient who developed a STEMI had a 50% plaque. All three were managed as standard ACS, although the aetiology appeared non-atherogenic. CONCLUSIONS: The exact etiology of the presentation, remains a mystery and therefore the rational use of thrombolytic therapy, carrying out angiogram in the primary setting, using and continuing antiplatelet and high dose statins all remains unclear in this sub group of patients.Item Prevalence of covishield COVID-19 vaccine (ChAdOx1 nCoV-19) adverse effects among health care workers in Sri Lanka(Elsevier, 2022) Manilgama, S.R.; Hettiarachchi, N.M.; Jayasinghe, K.I.; de Silva, S.; Wanigaratne, T.; Jayalath, T.; Bandusiri, R.P.; Suganthan, N.; Sudarshan, P.; Pathirage, M.; Rajaratnam, N.; Senaratne, G.; Rajapaksha, V.; Wickramasinghe, A.; Kulaweera, M.T.D.PURPOSEA Community vaccination programme is the best approach to combat COVID-19 pandemic. The first priority was given to the health care workers (HCWs) with the introduction of Indian Covishield (ChAdOx1 nCoV-19) vaccine to Sri Lanka since February 2021. An independent post-vaccine surveillance is important to identify the occurrence of adverse effects(A/E) in the population. METHODS & MATERIALSA multicentered cross-sectional survey was conducted in four provinces of Sri Lanka to estimate the prevalence of A/E after covishield vaccination A/E among HCWs after the first dose. A self-administered questionnaire was used to gather demographic data and A/E. Data was analysed using descriptive statistics. RESULTS Of 4834 participants, 3500(72.4%) were females. The median age was 42.23(SD±9.64) years. Only 0.8%(n=31) persons has had Covid infection in the past. 2.2% were breastfeeding mothers and 0.2% were pregnant ladies.87.4% of persons had at least one A/E and 53.1% had local A/E. Body aches(68.2%), headaches(63.8%), fever(58%), chills 51.4%), fatigue(41.2%), arthralgia(38.1%) and rigors (32%) were the most commonly reported systemic A/E. Most of the systemic A/E were more prevalent among the ≤42-year-old group, and females. Their duration was mainly 24 hours. Mean duration of onset of fever is 9.76 hours. Pain and redness at the site were the most commonly reported local A/E. All of the local A/E were more prevalent among the ≤42-year-old group and females. Mean duration of pain at the site is 4.47 hours. 1.7%(n=61) had reactions within first 20 minutes. 0.08%(n=4) developed anaphylaxis, 0.8%(n=31) had urticaria. 15.4% had at least one comorbidities but there were no significant association between having a comorbidity and developing systemic or local. 1.3% had history of drug or food allergies, they did not show significant relation to current vaccine induced allergies or anaphylaxis. 69.2% attended the routine work despite having minor A/E. 0.13%(n=7) were hospitalised and treated. 22.4% were stayed at home and rested for 24-48 hours due to A/E. CONCLUSION Eventhough more than 60% reported minor A/E, there were only a few serious A/E. A/E were more prevalent in younger age and females. Overall, the first dose of the Covishield vaccine was well-tolerated by HCWs.Item Desidustat in anemia due to Non-Dialysis-Dependent Chronic Kidney Disease: A phase 3 study (DREAM-ND)(Karger,New York, 2022) Agrawal, D.; Varade, D.; Shah, H.; Nazar, A.; Krishnan, J.; Shukla, V.; Ramakrishna, C.; Bandara, G.M.C.; Mavani, S.B.; Rajanna, S.; Jikki, P.; de Silva, S.; Ruhela, V.; Koradia, P.; Kansagra, K.; Kanani, P.; Sharma, N.; Zala, K.; Parmar, D.Background: Desidustat, an oral hypoxia-inducible factor prolyl hydroxylase inhibitor, is being developed to treat anemia in patients with chronic kidney disease (CKD) without dialysis dependency.Methods: In total, 588 patients with a clinical diagnosis of anemia due to CKD without dialysis need and with baseline hemoglobin of 7.0-10.0 g/dL (inclusive) were randomized in a 1:1 ratio to receive either desidustat 100 mg oral tablets thrice a week for 24 weeks or biosimilar darbepoetin subcutaneous injection 0.75 μg/kg once in 2 weeks for 24 weeks. The primary outcome was the change from baseline in hemoglobin to evaluation period of Weeks 16-24. Key secondary outcomes included the number of patients with hemoglobin response, changes in the hepcidin levels, changes in the vascular endothelial growth factor (VEGF) levels, and changes in the lipid and lipoprotein profiles.Results: Hemoglobin change from baseline to Weeks 16-24 was 1.95 g/dL in the desidustat group and 1.83 g/dL in the darbepoetin group (difference: 0.11 g/dL; 95% CI: -0.12, 0.34), which met prespecified non-inferiority margin (-0.75 g/dL). The hemoglobin responders were significantly higher (p = 0.0181) in the desidustat group (196 [77.78%]) compared to the darbepoetin group (176 [68.48%]). The difference of change in hepcidin from baseline to Week 12 and Week 24 (p = 0.0032 at Week 12, p = 0.0016 at Week 24) and the difference of change in low-density lipoprotein from baseline to Week 24 (p value = 0.0269) between the two groups was statistically significant. The difference of change from baseline in VEGF to Weeks 12 and 24 between the two groups was not statistically significant.Conclusion: Desidustat is non-inferior to darbepoetin in the treatment of anemia due to non-dialysis dependent CKD and it is well-tolerated.Item Prevalence and correlates of depression in patients with epilepsy in Sri Lanka(The Sri Lanka Medical Association, 2021) de Silva, S.; Isuru, A.; Rodrigo, A.; Kuruppuarachchi, L.Background: Depression is one of the most common psychiatric disorder in patients with epilepsy and it is often associated with poor quality of life, increased risk of suicide and poor seizure control, yet remains underdiagnosed and undertreated. The prevalence and associations for depression in patients with epilepsy vary between studies reflecting regional and cultural influences. Therefore, it is important to identify unique attributes within a community on this phenomenon This is the first study from Sri Lanka on the prevalence and correlates of depression in patients with epilepsy. Method: We conducted this cross-sectional study at the Epilepsy clinic, Colombo North Teaching Hospital, Ragama. All consenting patients with a diagnosis of epilepsy followed up at the clinic, during study period, were enrolled. Symptoms of depression were screened with Beck Depression Inventory II and diagnosis was confirmed with a clinical assessment by psychiatrist. Results: Of 150 participants, majority were female 63.3%. (95) and 36.7% (55) of the sample were between 26-45 years. The prevalence of depressive disorder was 22% (33). The prevalence of depression was significantly associated with the recent diagnosis of epilepsy, use of multiple antiepileptic medications and duration of seizure free period (p<0.05). There is a statistically significant association between prevalence of depression with the use of carbamazepine, topiramate, clobazam and phenobarbitone. Regression analysis revealed higher the duration individuals suffering from epilepsy were at lower odds of having depression compared with that of individuals suffering from lower duration of epilepsy. For each year in increase of duration of epilepsy, the odds of depression decreased by 2% (95% CI 0.3% to 5.1%) Conclusion: The prevalence of depression is high in patients with epilepsy. Risk of having depression is higher during the early phase of the illness. Therefore, it is important to screen patients with epilepsy for depressive disorder during the early course of the illness.Item Morbidity and mortality patterns in patients with thalassaemia during the COVID-19 pandemic in Sri Lanka;A single centre experience(Sri Lanka College of Internal Medicine, 2022) Nisansala, R.; de Silva, S.; Ediriweera, D.; Premawardhena, A.Introduction: Patients with thalassaemia syndromes (TS) affected with COVID-19 attending a thalassaemia centre in Sri Lanka situated in the region most affected with COVID-19 were studied over a 16-month period. Methods: To assess the collateral effects on overall thalassaemia care in the centre, data on transfusion, chelation and clinic attendance were analysed. Morbidity events and deaths recorded during the COVID-19 period and during a similar period before the beginning of COVID-19 infection in Sri Lanka were recorded in all clinic registrants. Results: Seven patients (of 502) with TS had developed COVID-19 during the 16-month period; all were minimally symptomatic and had recovered without complications. Number of monthly clinic visits reduced from 338 pre-COVID to 268 during COVID (p=0.004). Iron chelator usage too reduced during the pandemic period (p<0.001). Though admissions related to morbidity reduced during the pandemic (58 vs 16, p<0.001) there were more non-COVID deaths (8 vs 4). Conclusions: Numbers affected with COVID-19 were low and severity of infection was mild in this cohort of patients with TS. Collateral effect on the management of the unit and effects on mortality in this vulnerable population appears to have been substantial.