A.P. de Silva

Randomized, double-blind, placebo-controlled trial of oral aloe vera gel for active ulcerative colitis

Background : The herbal preparation, aloe vera, has been claimed to have anti‐inflammatory effects and, despite a lack of evidence of its therapeutic efficacy, is widely used by patients with inflammatory bowel disease.

Genotype-phenotype analysis of the Crohn’s disease susceptibility haplotype on chromosome 5q31

Background and aims: Recent molecular data suggest that genetic factors may underlie the disease heterogeneity observed in both ulcerative colitis (UC) and Crohn’s disease (CD). A locus on chromosome 5q has been implicated in susceptibility to CD, and recently refined by linkage disequilibrium mapping to a conserved 250 kb haplotype (5q31). No data regarding the contribution of this locus to clinical phenotype exist. In this case control study, we investigated the contribution of this haplotype to both susceptibility and phenotype of CD and UC. Patients and methods: We studied 330 Caucasian CD and 457 UC patients recruited from a single UK centre. Association with disease susceptibility and phenotype was analysed with haplotypes reconstructed from three single nucleotide polymorphisms chosen to span this susceptibility region. Evidence for possible genetic epistasis between IBD5 and NOD2/CARD15 was sought. Results: Linkage disequilibrium across this region was confirmed, with two haplotypes comprising 88% of all chromosomes. Susceptibility to CD, but not to UC, was associated with homozygosity for a common haplotype, H2 (pc=0.002; relative risk (RR) 2.0). Genotype-phenotype analyses demonstrated that this association was particularly strong in patients with perianal disease (pc=0.0005; RR 1.7), especially in individuals homozygous for this haplotype (pc=0.0005; RR 3.0). Importantly, no association with H2 was found in 186 patients without perianal disease. No evidence of epistasis between IBD5 and NOD2/CARD15 was demonstrated. Conclusions: The IBD5 risk haplotype is associated with CD only. Genotype-phenotype analysis reveals that the strongest association is observed in patients with perianal CD. While the precise gene involved is unclear, these data provide further molecular evidence for a genetic basis of the clinical heterogeneity of CD.

Frequent and potentially fatal envenoming by hump-nosed pit vipers (Hypnale hypnale and H. nepa) in Sri Lanka: lack of effective antivenom

In a prospective study of snake bites involving 10 hospitals in Sri Lanka, 302 (35%) of 860 patients with bites by identified snakes proved to have been bitten by hump-nosed pit vipers (301 by Hypnale hypnale and 1 by H. nepa). Most victims were males aged between 11 years and 50 years who had been bitten on their feet or ankles while walking at night close to their homes. There was local swelling in 276 (91%) and local necrosis in 48 (16%). Eleven (4%) required amputation of fingers or toes and 12 (4%) received skin grafts. In 117 patients (39%) blood incoagulability was first detected between 15 min and 48 h after the bite, and in 116 of them this was present on admission to hospital. Spontaneous systemic bleeding was observed in 55 patients (18%). Acute renal failure developed in 10%, five of whom died to give an overall case fatality rate of 1.7%. Thus, bites by hump-nosed pit vipers can cause debilitating local and fatal systemic envenoming. In Sri Lanka and southwestern India where bites by these snakes are common, the only available antivenoms (raised against cobra, krait, Russells viper and saw-scaled viper venoms) are ineffective and carry a high risk of reactions.

Revisiting saw-scaled viper (Echis carinatus) bites in the Jaffna Peninsula of Sri Lanka: Distribution, epidemiology and clinical manifestations

In Sri Lanka, the saw-scaled viper (Echis carinatus) is distributed in the arid, dry and sandy coastal plains and in a prospective study we describe its bites in the Jaffna peninsula. Of the 304 snake bite admissions to the Jaffna Hospital in 2009, 217 (71.4%) were bitten by either venomous species or envenomed by unidentified snakes. There were 99 (45.6%) reported saw-scaled viper bites, of which 26 were confirmed cases. The length of the offending snakes ranged from 228-310mm and bites mainly occurred in the nearby islands. The median age of the confirmed cases was 34 years (range 1.5-72 years); occupations included housewives (8, 31%), school children (4, 15%) and farmers (2, 8%). In 18 patients (69%), bites occurred in daylight and in 8 (31%) within or near the compounds. The fingers were bitten in 8 (31%) and toes/foot in 11 (42%) cases. There were 2 (8%) dry bites and 19 patients (73%) developed local swelling; one patient developed haemorrhagic blisters. In 24 patients (92%), blood incoagulability manifested between 40 and 1095min after the bite, and three patients (12%) developed spontaneous bleeding. One patient (4%) developed mild acute renal dysfunction. The median time for correction of coagulopathy was 802min (range 180-1669min) with Indian polyvalent antivenom. All recovered. The saw scaled viper is responsible for most venomous bites in the Jaffna peninsula.

Collagenous colitis in adult Sri Lankans: experience from the Indian subcontinent

The literature contains few data on the clinical features and demographics of collagenous colitic patients from the Indian subcontinent. Almost all published articles describe various clinicopathological facets of collagenous colitis in the West, which is now classified as a variant of microscopic colitis, where diagnosis is missed by failure to biopsy the normal or “near normal” looking mucosa at endoscopy for histological examination. The case notes of 210 patients who underwent colonoscopy at Base Hospital-Panadura (Medical Unit), Sri Lanka (equivalent to a district general hospital in the UK, with a bed strength of 350), for various reasons, from 20 July 1999 to 20 January 2002, were retrospectively reviewed. Clinical features and results of other routine investigations of patients who were histologically diagnosed as having collagenous …

The young woman who could not stop vomiting.

Accepted 23 April 1998 An unmarried, unemployed, 28-year-old woman presented to us with self-induced vomiting, reduced sleep, and crying spells. Four years ago, she had begun thinking that she and her family were obese. She started taking only liquids and induced vomiting. She used bees honey and lemon juice in the belief that these would reduce her weight. One year later she developed spontaneous vomiting. She lost weight rapidly and developed amenorrhoea a few months later. She was third in a family of seven. The family system was one of parental dominance, with no emotional support. On examination, she was depressed and emaciated, with parotid enlargement, bradycardia and fine lanugo hair. Other systems were clinically normal. A barium meal was done (figure). The following investigations were also performed: haemoglobin 7 g/dl, prolactin 52 ng/ml (normal 0.33-27.3), follicle-stimulating hormone (FSH) 1.57 IU/l (18-153), luteinising hormone (LH) 0.45 IU/l (16-24), potassium 3 mmol/l, sodium 125 mmol/l. Serum cholesterol, serum proteins, creatinine, erythrocyte sedimentation rate, urine examination, and chest X-ray were normal. Subsequently, a surgical procedure was performed. She recovered from surgery but after initial improvement, she started inducing vomiting again, and refused food. There was no response to prokinetic drugs.

Closing the theory to practice gap for newly qualified doctors: evaluation of a peer-delivered practical skills training course for newly qualified doctors in preparation for clinical practice

Purpose The Good Intern Programme (GIP) in Sri Lanka has been implemented to bridge the ’theory to practice gap’ of doctors preparing for their internship. This paper evaluates the impact of a 2-day peer-delivered Acute Care Skills Training (ACST) course as part of the GIP. Study design The ACST course was developed by an interprofessional faculty, including newly graduated doctors awaiting internship (pre-intern), focusing on the recognition and management of common medical and surgical emergencies. Course delivery was entirely by pre-intern doctors to their peers. Knowledge was evaluated by a pre- and post-course multiple choice test. Participants’ confidence (post-course) and 12 acute care skills (pre- and post-course) were assessed using Likert scale-based questions. A subset of participants provided feedback on the peer learning experience. Results Seventeen courses were delivered by a faculty consisting of eight peer trainers over 4 months, training 320 participants. The mean (SD) multiple choice questionnaire score was 71.03 (13.19) pre-course compared with 77.98 (7.7) post-course (p<0.05). Increased overall confidence in managing ward emergencies was reported by 97.2% (n=283) of respondents. Participants rated their post-course skills to be significantly higher (p<0.05) than pre-course in all 12 assessed skills. Extended feedback on the peer learning experience was overwhelmingly positive and 96.5% would recommend the course to a colleague. Conclusions A peer-delivered ACST course was extremely well received and can improve newly qualified medical graduates’ knowledge, skills and confidence in managing medical and surgical emergencies. This peer-based model may have utility beyond pre-interns and beyond Sri Lanka.

Effect of audio and visual distraction on patients undergoing colonoscopy: a randomized controlled study

Background and study aims: Colonoscopy can cause anxiety and discomfort in patients. Sedation and analgesia as premedication can lead to complications in the elderly and those with comorbidities. This has led to an interest in the use of audio-visual distraction during the colonoscopy. We compared the effects of audio (AD) versus visual distraction (VD) in reducing discomfort and the need for sedation during colonoscopy. Patients and methods: Consecutive patients undergoing colonoscopy were randomized into three groups: one group was allowed to listen to the music of their choice (AD), the second group was allowed to watch a movie of their choice (VD), and the third group was not allowed either distraction during colonoscopy and acted as a control (C). Patient controlled analgesia and sedation were administered to all three groups. We used 25 mg of pethidine in 5-mg aliquots and 2.5 mg of midazolam in 0.5-mg aliquots. All patients were assessed for perceived pain and willingness to repeat the procedure. Number of “top-ups” of sedation and total dose of pethidine and midazolam were noted. Patient cooperation and ease of procedure were assessed by the colonoscopist. Results: In total, 200 patients were recruited [AD, n = 66 (32 males, median age 57 years); VD, n = 67 (43 males, median age 58 years); C, n = 67 (35 males, median age 59 years)]. The AD group had significantly less pain (P = 0.001), better patient cooperation (P = 0.001) and willingness to undergo a repeat procedure (P = 0.024) compared with VD and C groups. Conclusions: AD reduces pain and discomfort, improves patient cooperation and willingness to undergo a repeat procedure, and seems a useful, simple adjunct to low dose sedation during colonoscopy. Study registration: SLCTR/2014/031.

Predicting acute liver failure in dengue infection

In a retrospective study involving 240 patients with dengue infection, we attempted to identify early predictors of acute liver failure (ALF). Sixteen out of 41 patients with serum AST more than 1000 IU/ml developed ALF compared to none with serum AST less than 1000 IU/ml. Among patients with serum AST more than 1000 IU/ml, presence of two of the three following phenomena, within the first 5 days of illness: elevated serum bilirubin, elevated alkaline phosphatise or persistent nausea and vomiting, predicted development of ALF (93.8% sensitivity, 98.7% specificity, 83.3% positive predictive and 99% negative predictive value). The presence of elevated serum bilirubin, alkaline phosphatase and persistent nausea and vomiting in patients with very high serum AST during the early phase of dengue infection should alert the physician of impending ALF.

Outcome of early coronary intervention for acute ST elevation myocardial infarction in a tertiary care cardiac centre in Sri Lanka

OBJECTIVES To describe the outcomes of early percutaneous coronary intervention (PCI) for the treatment of acute ST elevation myocardial infarction (STEMI) in a tertiary care cardiac centre in Colombo, Sri Lanka. METHODS Medical records of 139 consecutive patients presenting to Cardiology Unit 5, National Hospital of Sri Lanka from March 2013 to June 2014 with acute STEMI, and treated with early PCI as a mode of reperfusion were reviewed. These patients were then followed up for 6 months to determine survival, target-vessel revascularization, in-stent thrombosis and other major adverse cardiac events (MACE). RESULTS Of 139 patients, 116 (83.5%) were male. Mean age was 52.3±SD11.1 years. Eighty eight (63.3%) patients underwent primary PCI and 51 (36.7%) underwent rescue PCI. There were six deaths (4.3%). One occurred on-table and three occurred after discharge. Four patients who died had cardiogenic shock. Mean door-to-balloon (DTB) time was 147 minutes for the primary PCI patients who were transferred from ETU. At six months, of 106 patients who attended follow up, two had been re-hospitalised for heart failure but none underwent coronary artery bypass grafting (CABG). CONCLUSIONS This report from the national tertiary care cardiology referral centre in Sri Lanka, found that the study population was relatively younger, similar to other Asian countries. There was high rate of initial success (98.6%) and good short-term survival (95.7%), particularly in the subset presenting without cardiogenic shock (98.4%) despite the long DTB time. Loss to follow up at 6 months in this centre was 23.7% (33 patients).