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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Redesigning new policy options for thalassemia prevention in Sri Lanka(Multidisciplinary Digital Publishing Institute, 2022) Amarasinghe, N.; Amarasena, A.; Thabrew, A.; Werawatte, P.; Premawardhena, A.; Malik, F.; Abusayeed, M.; Wickramasinghe, C.Sri Lanka, a country with 22 million people, has nearly 2000 thalassemia patients with severe thalassemia, two-thirds of whom have beta thalassemia major (TM). The current prevention program based on promoting “safe marriages”, which has been in existence for over 15 years, has failed to reduce thalassemia major births. We set about to examine the cost-effectiveness of novel policy options for thalassemia prevention in Sri Lanka. METHODS: The current cost for treatment of a thalassemia major patient (USD 2602/yr) was compared against the cost per reduction of single birth with three novel strategies, namely intensifying the screening in the current five districts combined with an education program (policy option 1), a nationwide screening program (policy option 2), and antenatal screening combined with the termination of pregnancy (policy option 3). The incremental cost-effectiveness ratio (ICER) of the different strategies was calculated. RESULTS: The status quo was considered to reduce one TM birth whilst the new policy options were able to reduce births by 14, 35, and 48, respectively. The costs incurred for the program for a year for status quo and the three novel programs were USD 104,788, 173,884, 781,372, and 904,186 respectively. Cost per prevention of a thalassemia major birth was USD 87,324, 12,420, 22,324, and 20,084, respectively. The lifetime cost per treatment of a thalassemia major patient was USD 34,653. CONCLUSIONS: Given the current legal restriction on termination of pregnancy for fetal indications, policy option 2, an island-wide screening with mass education, is the most cost-effective and will be expected to deliver a substantial reduction in new births.Item Devising a cure for β-thalassaemia by targeting α-globin(The Sri Lanka College of Haematologists, 2019) Mettananda, S.ABSTRACT: β-Thalassaemia is a disorder of haemoglobin synthesis which does not have an effective cure for a majority of patients affected. Most patients have poor quality of life and die prematurely. The basic pathophysiology of β-thalassaemia is haemolysis and ineffective erythropoiesis due to the imbalance of α-globin chains in red blood cells. Studies done on the molecular pathology and naturally occurring mutations among patients have conclusively shown that decreasing the synthesis of a-globin chains ameliorates the severity of anaemia in β-thalassaemia. A series of recent in vitro and animal studies described in this paper shows that therapeutic inhibition of α-globin synthesis is feasible through genome editing of its major enhancer and pharmacological disruption of epigenetic enzymes. These novel pathways would invariably pave the way for an effective cure for β-thalassaemia which will be available for all patients in the future.Item Non-adherence to chelation therapy and associated psychosocial factors among transfusion-dependent thalassaemia patients in Kandy, Sri Lanka(Sri Lanka College of Paediatricians, 2021) Baminiwatta, A.; Gunathilake, R.; Arambepola, S.; Arambepola, M.BACKGROUND: Poor adherence to iron chelation may underlie the detrimental levels of iron overload previously reported among transfusion-dependent thalassaemia (TDT) patients in Sri Lanka. Given the many challenges faced by these patients and families, psychosocial factors may have a significant impact on medication adherence. OBJECTIVE: To assess chelation adherence among TDT patients and explore associated psychosocial factors. METHOD: TDT patients, aged over 4 years, admitted for blood transfusion to a tertiary care hospital, as well as their mothers, were recruited. Medication adherence was assessed using a questionnaire adapted from Brief Adherence Rating Scale. Serum ferritin (SF) values were recorded as objective measures of non-adherence. Mental health status of patients and their mothers was assessed using Strengths and Difficulties Questionnaire (SDQ) and General Health Questionnaire-30 (GHQ) respectively. Associated psychosocial factors were analysed using multiple linear regression. RESULTS: Fifty-two patients aged 4 to 28 years participated. Thirty-four (65%) were female. The average adherence rate was 90%. One fifth of patients had an adherence percentage less than 80%. The mean ferritin level was 3260 ng/ml, whereas 46.2% of patients had SF levels exceeding 2500ng/ml. SF levels correlated positively with non-adherence (r=0.34, 95%CI: 0.071-0.606, p=0.014). Based on multivariate analysis, increasing age and lower SDQ score of patient, lower educational level and greater GHQ-30 score of mother were independent predictors of higher SF levels, but not of adherence rates. CONCLUSIONS: In the paediatric unit of National Hospital, Kandy, 46% of patients had SF levels >2500 ng/ml. There was a significant correlation between SF levels and medication non-adherence (r=0.34, p=0.014). On multivariate analysis, increasing age and lower SDQ score of the patient, lower educational level and greater GHQ-30 score of the mother were independent predictors of higher SF levels, but not of adherence rates.Item A child with Imerslund-Gräsbeck syndrome concealed by co-existing α-thalassaemia presenting with subacute combined degeneration of the spinal cord: a case report(BioMed Central, 2021) Arunath, V.; Hoole, T. J.; Rathnasri, A.; Muthukumarana, O.; Kumarasiri, I.M.; Liyanage, N.D.; Costa, Y.; Mettananda, S.BACKGROUND: Imerslund-Gräsbeck syndrome is a rare genetic disease characterised by vitamin B12 deficiency and proteinuria. CASE PRESENTATION: A 4-year old Sri Lankan boy presented with gradually worsening difficulty in walking for two weeks duration. He was previously diagnosed and managed as having non-transfusion-dependent α-thalassaemia based on the presence of hypochromic microcytic anaemia, haemoglobin H inclusion bodies in the blood film and compound heterozygous α-thalassaemia genotype with a gene deletion. However, his transfusion requirement increased over the past three months and he gradually lost his motor developmental milestones during two weeks before admission. The neurological examination revealed generalised hypotonia, exaggerated knee jerks and extensor plantar response. His complete blood count showed pancytopenia, and bone marrow biopsy revealed megaloblastic changes. Serum vitamin B12 and red blood cell folate levels were low. MRI revealed sub-acute combined degeneration of the spinal cord with characteristic 'inverted V sign'. Urine analysis showed non-nephrotic range proteinuria. The diagnosis of Imerslund-Gräsbeck syndrome was made due to the presence of non-nutritional vitamin B12 deficiency and asymptomatic proteinuria. He showed a rapid haematological and neurological improvement to intramuscular hydroxocobalamin. CONCLUSIONS: This case report presents a rare occurrence of severe vitamin B12 deficiency due to Imerslund-Gräsbeck syndrome masked by co-existent α-thalassaemia, resulting in serious consequences. It highlights the need for a high index of suspicion in evaluating children with severe anaemia, especially in the presence of mixed pathologies. KEYWORDS: Anaemia; Hypopigmented hair; Imerslund-Gräsbeck syndrome; Inverted V sign; Megaloblastic changes; Subacute combined degeneration of the spinal cord; Thalassaemia; Vitamin B12.Item Marriage patterns in Sri Lanka and the role of consanguinity in thalassaemia: A cross sectional descriptive analysis(Sri Lanka Medical Association, 2019) Goonatilleke, M.D.D.C.; de Silva, S.T.; Rodrigo, R.; Perera, S.; Goonathilaka, G.W.M.R.G.B.; Ramees, L.; Mettananda, S.; Weatherall, D.L.; Premawardhena, A.P.INTRODUCTION & OBJECTIVES: Consanguineous marriages play an important role in the propagation of thalassaemia. There is a paucity of data on consanguineous marriages in modern Sri Lankan society and its effect on thalassaemia births. We studied sociological aspects of Sri Lankan marriages with emphasis on consanguinity, and the prevalence of consanguinity in the parents of patients with thalassaemia. METHODS: Three marriage registrars from each district were asked to record details about the partners of all marriages they registered for 6 months, from July 2009. Parents of patients with thalassemia were interviewed separately, to identify any consanguinity. RESULTS: A total of 5249 marriages were recorded from 22 districts. Average age at marriage was 27.2 9 years for males and 24.0 8 years for females. 3737/5249 (71.2%) of all marriages were Love Marriages, except in the Moor community where 89.2% were Arranged Marriages. Female literacy and education tier levels were higher than in males. Overall national consanguinity rate was 6.4% (337/5249). It was highest among Tamils (20.4%), but only 3.3% among Sinhalese and 3.1% among Moors. In the parents of 405 patients with thalassaemia, overall consanguinity rate was 11.1% (45/405): it was highest among Tamils (33.3%) and lowest among Sinhalese (9.4%). CONCLUSION: Consanguinity among patients with Thalassaemia was almost double the national average. Though not the dominant cause, more emphasis should be given to consanguinity when conducting thalassaemia prevention campaigns. Since they are older and better educated at marriage, female partners should be better targeted in such health education campaigns.Item Recent developments in the treatment of transfusion dependent thalassaemia(The Sri Lanka Medical Association, 2020) Mettananda, S.No Abstract availableItem Improving standards of care for children with thalassaemia in Sri Lanka(Sri Lanka College of Paediatricians, 2020) Mettananda, S.No abstract availableItem Micro-mapping of common α+ thalassaemia deletions (3.7 kb, 4.2 kb) in Sri Lanka and assessment of the contribution of α thalassaemia to hypochromic microcytosis(Faculty of Medicine, University of Kelaniya, Sri Lanka, 2016) Premawardhena, A.P.Alpha thalassaemia is one of the most common haemoglobinopathies, but the exact prevalence and distribution of α thalassaemia in Sri Lanka is not well known. This study was an attempt to micro-map the distribution of the common α thalassaemia deletions in Sri Lanka and to assess its contribution to hypochromic microcytosis in the community. A national survey on haemoglobin disorders was carried out between 2009 and 2010, covering all 25 districts. A total of 7539 school children, 300 from each district were screened for haemoglobin disorders and anaemia. 3.7 kb and 4.2 kb common α+ deletional forms were analysed using PCR in 2038 individuals with hypochromic microcytic anaemia and 1305 individuals with non-anaemia individuals, representing all districts. The overall prevalence of α-thalassaemia was 9.5%, and 3.7 kb was the commonest deletion (8.3%) while the 4.2 kb deletion accounted for 1.2%. The prevalence of α-thalassaemia showed a remarkable variability within districts, ranging from 16.3% in Kurunegala to 3.0% in Galle. Contrary to common belief, it was found that α-thalassaemia due to single gene deletions was almost always associated with hypochromic microcytic anaemia.Item Parental awareness and cascade screening of thalassaemia(Sri Lanka Medical Association, 2010) Nishad, A.A.N.; Premawardhena, A.P.INTRODUCTION: A strategy to prevent new births with thalassaemia major in countries where abortion is illegal is to screen the at risk population for the carrier state and advocating "safe marriages". One of the highest risk groups for the thalassaemia gene are relatives of individuals with a child with 'thalassaemia major'. 'Cascade screening' of such relatives is an effective way to initiate and precede a much wider population screen. We wanted to identify the level of awareness of disease transmission and the extent to which cascade screening was already happening in Sri Lanka. METHODS: A self-administered questionnaire was used on 100 parents of children with transfusion dependent thalassaemia attending the thalassaemia units at Ragama and Kurunegala from 1st January to 31st December 2009. RESULTS: 73% fathers and 91% mothers knew their carrier state and 59 (64.1%) fathers and 98 (88.1%) mothers knew their carrier state bad caused the illness to the child. Mothers had 382 and fathers had 291 siblings. Those siblings had 714 and 610 children respectively. 40 (10.8%) of maternal siblings and 15 (5%) of the paternal siblings had been screened for thalassaemia. Only 48 (6.72%) of maternal side children and 23 (3.77%) of paternal side children had been screened. CONCLUSION: Screening of relatives of patients with thalassaemia in this group of people seems to be limited. A screening programme targeting those at high risk is necessary.Item Pulmonary arterial hypertension in thalassaemia patients- does splenectomy and disease severity increase the risk?(Sri Lanka Medical Association, 2011) Premawardana, N.P.; Nandasiri, A.S.D.; Ranaweera, A.G.R.M.A.; Nishad, A.A.N.; Silva, D.P.S.I.; Premawardhena, A.P.INTRODUCTION AND OBJECTIVES: Pulmonary arterial hypertension (PAH) has been described in patients with thalassaemia. A causative association with splenectomy has been postulated. Our previous observations differed from this. We aimed to study these factors in our patients. METHODS: Pulmonary artery pressure (PAP) and other data of thaiassaemics attending the Thalassaemia Unit, Ragarna were studied using clinic records. PAP was measured using trans-thoracic 2D echocardiography. Four categories were separately analysed: thalassaemia major (TM) with splenectomy (A) and without (B), thalassaemia intermedia (TI) with splenectomy (C) and without (D). PAH was defined as PAP over 25 mm Hg. RESULTS: A total of 74 patients were studied, 60 (81%) with TM and 14 (19%) with TI. 25 of TMs (41%) and 10 of TIs (71%) had splenectomy (p <0.05). Mean ages (SD) of TM and TI were 20.71(8.4) and 32.6 (13.3) years respectively. Those of categories ABCD were 20.9 (7.4), 20.7 (9.1), 27 (9.6) and 46 (12.3) years. A total of 16 (21.6%) of all patients had PAH (95% CI13.8-32.3). This included 13 (21.7%) TM patients and three (21.4%) with TI (p-0.98). The prevalence of PAH was 17.1% (95 CI 8.4-33.5) in splenectomised thalassaemia patients and 25.6% (95% CI 16.5-43.8) in non splenectomised patients (p= 0.37), and in categories A,B,C,D were 16%, 23%, 20% and 25% respectively. Mean of PAP of splenectomised with PAH is 39 mmHg (SD=4.5) and in non splenectomised with PAH was 34.9 mmHg (SD=5.3) (p=0.8). CONCLUSIONS: PAH is a significant complication in patients with thalassaemia. However the severity of disease nor the splenectomy status were found to be causatively linked in our study.