Dileepa Senajith Ediriweera

Mapping the Risk of Snakebite in Sri Lanka - A National Survey with Geospatial Analysis.

Background There is a paucity of robust epidemiological data on snakebite, and data available from hospitals and localized or time-limited surveys have major limitations. No study has investigated the incidence of snakebite across a whole country. We undertook a community-based national survey and model based geostatistics to determine incidence, envenoming, mortality and geographical pattern of snakebite in Sri Lanka. Methodology/Principal Findings The survey was designed to sample a population distributed equally among the nine provinces of the country. The number of data collection clusters was divided among districts in proportion to their population. Within districts clusters were randomly selected. Population based incidence of snakebite and significant envenoming were estimated. Model-based geostatistics was used to develop snakebite risk maps for Sri Lanka. 1118 of the total of 14022 GN divisions with a population of 165665 (0.8%of the country’s population) were surveyed. The crude overall community incidence of snakebite, envenoming and mortality were 398 (95% CI: 356–441), 151 (130–173) and 2.3 (0.2–4.4) per 100000 population, respectively. Risk maps showed wide variation in incidence within the country, and snakebite hotspots and cold spots were determined by considering the probability of exceeding the national incidence. Conclusions/Significance This study provides community based incidence rates of snakebite and envenoming for Sri Lanka. The within-country spatial variation of bites can inform healthcare decision making and highlights the limitations associated with estimates of incidence from hospital data or localized surveys. Our methods are replicable, and these models can be adapted to other geographic regions after re-estimating spatial covariance parameters for the particular region.

Pre-operative hypoalbuminaemia predicts poor overall survival in rectal cancer: a retrospective cohort analysis

BackgroundSerum albumin is a marker of nutrition and inflammation. It has recently emerged as a predictor of outcome after surgery for rectal cancer. Our aim was to evaluate if pre-operative serum albumin would predict survival after resection for rectal cancer.Method226 Patients with rectal cancer of all stages undergoing resection with curative intent were studied. Kaplan-Meier curves analysed survival based on a pre-operative albumin level of <35 g/L vs. >35 g/L. We sought for significant associations of survival with age, sex, stage, tumour site, use of neoadjuvant chemoradiation, microscopic positive resection margins, differentiation, angio, peri-neural, and lymphovascular invasion using individual variable analysis. Multifactorial analysis was performed using type III analysis with Weibull hazard model and Cox-proportional hazard model. Significance was assigned to a P value <0.05.ResultsOf 226 patients (median age- 59 years; range 19 – 88, Male - 54%), forty five (20%) had an albumin level < 35 g/L and was associated with a poor overall survival (P = 0.02). Mean survival in months for <35 g/L vs. >35 g/L was 64.7 (SE - 9.3) vs. 95.8 (SE – 7.0) and 5 year overall survival rates were 49% and 69%. Individual variable analysis revealed age, circumferential margin, stage, perineural, lympho-vascular and angio invasion to be also significant. With multifactorial analysis hypoalbuminaemia (HR = 0.58; 95% CI: 0.35 - 0.95, P = 0.03), advanced stage (HR = 2.0; 95% CI: 1.26 - 3.23, P < 0.01) and positive circumferential margin (HR = 2.2; 95% CI: 1.26 - 3.89, P < 0.01) remained significant.ConclusionPreoperative hypoalbuminaemia is an independent risk factor for poor overall survival in rectal cancer. Advanced tumour stage and circumferential margin positivity were the other associations with poor survival.

Health seeking behavior following snakebites in Sri Lanka: Results of an island wide community based survey

Introduction Sri Lanka has a population of 21 million and about 80,000 snakebites occur annually. However, there are limited data on health seeking behavior following bites. We investigated the effects of snakebite and envenoming on health seeking behavior in Sri Lanka. Methods In a community-based island-wide survey conducted in Sri Lanka 44,136 households were sampled using a multistage cluster sampling method. An individual who reported experiencing a snakebite within the preceding 12 months was considered a case. An interviewer-administered questionnaire was used to obtain details of the bite and health seeking behavior among cases. Results Among 165,665 individuals surveyed, there were 695 snakebite victims. 682 (98.1%) had sought health care after the bite; 381 (54.8%) sought allopathic treatment and 301 (43.3%) sought traditional treatment. 323 (46.5%) had evidence of probable envenoming, among them 227 (70.3%) sought allopathic treatment, 94 (29.1%) sought traditional treatment and 2 did not seek treatment. There was wide geographic variation in the proportion of seeking allopathic treatment from <20% in the Western province to > 90% in the Northern province. Multiple logistic regression analysis showed that seeking allopathic treatment was independently associated with being systemically envenomed (Odds Ratio = 1.99, 95% CI: 1.36–2.90, P < 0.001), distance to the healthcare facility (OR = 1.13 per kilometer, 95% CI: 1.09 to 1.17, P < 0.001), time duration from the bite (OR = 0.49 per day, 95% CI: 0.29–0.74, P = 0.002), and the local incidence of envenoming (OR = 1.31 for each 50 per 100,000, 95% CI: 1.19–1.46, P < 0.001) and snakebite (OR = 0.90 for each 50 per 100,000, 95% CI: 0.85–0.94, P < 0.001) in the relevant geographic area. Conclusions In Sri Lanka, both allopathic and traditional treatments are sought following snakebite. The presence of probable envenoming was a major contribution to seeking allopathic treatment.

Association of serum ferritin with diabetes and alcohol in patients with non-viral liver disease-related hepatocellular carcinoma

Introduction: Non-alcoholic fatty liver disease is a leading cause for hepatocellular carcinoma (HCC) in Sri Lanka. Diabetes mellitus, alcohol abuse, and liver inflammation are known to increase the risk of HCC. The present study evaluates serum ferritin levels in a cohort of patients with non-viral HCC (nvHCC). Methodology: Consecutive patients with nvHCC presenting to the Colombo North Liver transplant Service, Ragama, from January 2012 to July 2013 were investigated. All were negative for hepatitis B and C. At registration, 5 mL of serum was separated into plain tubes, stored at -80°C and analysed for ferritin using an enzyme-linked immunosorbent assay. Correlation between the serum ferritin and patient risk factors, liver status, and tumour characteristics were analysed. Results: There were 93 patients with nvHCC (median age 65 [12-82] years; 82 [88.2%] males). The median ferritin level was 246.2 μg/L, and 38 (40.86%) patients had elevated ferritin. Non-diabetics (median 363.5 mg/L, p = 0.003) and alcohol abusers (median 261.2 mg/L, p = 0.018) had higher ferritin levels. On multiple-variable analysis, being non-diabetic (p = 0.013) and alcoholic (p = 0.046) was significantly associated with high serum ferritin. No association was found with body mass index, tumour stage, size, macrovascular invasion, number of nodules, alpha-fetoprotein, bilirubin, international normalized ratio, and survival. Conclusion: In patients with nvHCC, serum ferritin levels are higher in non-diabetics and alcoholics.

Overall Survival of Elderly Patients Having Surgery for Colorectal Cancer Is Comparable to Younger Patients: Results from a South Asian Population

Introduction There has been a continuous debate on whether elderly patients with colorectal cancer (CRC) fair worse. The aim of this study is to assess the thirty-day mortality (TDM) and overall survival (OS) of elderly patients undergoing surgery for CRC. Method OS between two groups (≥70 versus <70 years) having surgery for CRC was analyzed. Demographics, tumour characteristics, and serological markers were considered as independent factors. Multivariable analysis was done using the Cox proportional hazard model. We also compared overall survival in the elderly versus those <60 and <50 years. Results 477 patients, 160 elderly (55% male; median age 75, range 70–89) and 317 younger patients (49% male; median age 55, range 16 to 69), were studied. Overall survival in CRC patients ≥70 is comparable to <70 (P = 0.45) and <60 years (P = 0.08). Poor OS was observed in the ≥70 versus <50 years (P = 0.03). TDM in the elderly was poor (P < 0.05). Postoperative cardiac complication was the only determinant affecting survival in the elderly (P = 0.01). Conclusion OS in elderly CRC patients having surgery is not worse compared to <70 and <60 years although the TDM was higher. Postoperative cardiac complications significantly affected OS in those ≥70 compared to those <50 years. Chronological age alone should not negatively influence surgical decision-making in the elderly.

Post war psychological morbidity among internally displaced, married females in Northern Sri Lanka

Background: A three-decade long conflict between the government military and Tamil rebels in Sri Lanka ended in 2009 with the defeat of the rebels. The civilians were the most affected in the war with reports of scant respect for human rights on both sides of the warring factions. Objective: To conduct a cross-sectional study to assess the prevalence of psychiatric morbidity among married females in two villages in Northern Sri Lanka that was affected significantly in the last phase of the war. Method: All married females in two resettled villages in the Mannar District were interviewed by trained data collectors using the translated K-10 and PSSR-17 questionnaires to estimate the prevalence of post-traumatic stress disorder (PTSD) and depressive disorder. All families in these villages were from internally displaced camps where they had been living for more than a year after having been displaced from their homes and having experienced direct war trauma for weeks. Data was collected from 135 married females between March to May 2011 with ethical approval for the study. Result: Criteria for diagnosis of severe PTSD were met in 57% of all participants and all participants had at least mild symptoms of PTSD. The screening tool for depression showed 63% to have significant depressive symptoms. Both depressive and severe PTSD features were present in 24%. Nearly 73% of participants were having either depression or severe PTSD. Conclusion: Psychiatric morbidity was high in the post-conflict period, in a highly vulnerable population of married females.

Comparison of hazard of death following surgery for colon versus rectal cancer

INTORDUCTION Prognosis in cancer is usually assessed by use of Kaplan-Meier survival function estimate curves, which reflect survival, or the proportion of patients that will remain alive after a particular event at a given time. By contrast, hazard function represents the proportion expected to be deceased among those surviving at a given time after an event. Objectives To evaluate survival and hazard of death, in patients with colon cancer (CC) and rectal cancer (RC), as indices of prognosis. METHODS Colon and rectal cancer patients who underwent surgical resection with curative intent from 1996 to 2011 were studied. The hazard of death and survival patterns were assessed with Weibull Hazard models and Kaplan- Meier survival function estimate curves. RESULTS There were 119 CC and 250 RC patients included in the study. Median (Inter-quartile range: IQR) age of both groups was 58 (49 - 66.5) years. The median (IQR) followup time was 30 (12 - 72) months for CC and 30 (13 - 70) months for RC. Both groups were similar in comparison with regard to age (p=0.96), gender (p=0.56), tumour stage (p=0.33), vascular invasion (p=0.69), lymphatic invasion (p=0.33), perineural invasion (p=0.94), degree of tumour differentiation (p=0.38) and preoperative carcinoembryonic antigen levels (p=0.77). CC showed better overall survival compared to RC (p=0.03) with a 5-year survival rate of 72% versus 60% respectively. After curative resection, CC showed a 6% decrease in hazard of death with time compared with RC which showed a 1% increase in the hazard of death with time. CONCLUSIONS Among patients who underwent resectional surgery, CC had a better prognosis than RC.