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Papers by Vipula Bataduwaarachchi

The Lancet

In patients hospitalised for COVID-19 with clinical hypoxia who required either no oxygen or simp... more In patients hospitalised for COVID-19 with clinical hypoxia who required either no oxygen or simple oxygen only, higher dose corticosteroids significantly increased the risk of death compared with usual care, which included low-dose corticosteroids. The RECOVERY trial continues to assess the effects of higher dose corticosteroids in patients hospitalised with COVID-19 who require non-invasive ventilation, invasive mechanical ventilation, or extracorporeal membrane oxygenation.

SUMMARYBackgroundWe evaluated the use of baricitinib, a Janus kinase (JAK) 1/2 inhibitor, for the... more SUMMARYBackgroundWe evaluated the use of baricitinib, a Janus kinase (JAK) 1/2 inhibitor, for the treatment of patients admitted to hospital because of COVID-19.MethodsThis randomised, controlled, open-label platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), is assessing multiple possible treatments in patients hospitalised for COVID-19. Eligible and consenting patients were randomly allocated (1:1) to either usual standard of care alone (usual care group) or usual care plus baricitinib 4 mg once daily by mouth for 10 days or until discharge if sooner (baricitinib group). The primary outcome was 28-day mortality assessed in the intention-to-treat population. A meta-analysis was conducted that included the results from the RECOVERY trial and all previous randomised controlled trials of baricitinib or other JAK inhibitor in patients hospitalised with COVID-19. The RECOVERY trial is registered with ISRCTN (50189673) and clinicaltrials.gov (NCT04381936).FindingsBetwe...

Background: Granulomatosis with polyangiitis is a rare multisystemic autoimmune disorder predomin... more Background: Granulomatosis with polyangiitis is a rare multisystemic autoimmune disorder predominantly affecting the upper and lower respiratory tracts and the kidneys, and rarely affecting other organ systems. Tuberculosis can mimic the presentation of granulomatosis with polyangiitis, and both can occur simultaneously in the same patient. Here we report what we believe to be the first case of concurrent granulomatous breast lesions and hemorrhagic retinal angiopathy in a Sri Lankan woman with refractory granulomatosis with polyangiitis complicated by probable tuberculosis. Case presentation: A 48-year-old Sri Lankan Moorish woman presented with a 6-month history of ulcerating bilateral breast lumps, a 3-month history of non-healing painful ulcers on the palate, and sudden bilateral painless loss of vision. Retinoscopy confirmed left-sided retinal hemorrhages and bilateral panuveitis. An examination of her respiratory system showed bilateral coarse crepitations. Histologic examinat...

Anatomical relations of the superficial sensory branches of the radial nerve: a cadaveric study w... more Anatomical relations of the superficial sensory branches of the radial nerve: a cadaveric study with clinical implications

International Journal of Anatomical Variations, 2011

The “corona mortis” or crown of death is defined as the vascular connection between the obturator... more The “corona mortis” or crown of death is defined as the vascular connection between the obturator and external iliac systems crossing the superior pubic ramus. It has a great clinical significance as it could be accidentally cut during any surgery in that area causing fatal hemorrhage. We present a rare variant of bilateral arterial and venous corona mortis in a male cadaver with bilateral indirect inguinal hernia. Laparoscopic repair is indicated in bilateral case and there is a greater risk of damaging corona mortis during pre-peritoneal dissection. Surgeons must deliberately look for the above vascular variant in every case for its presence to avoid unnecessary risk to the patient.

Cardiology Research and Practice, 2020

Objective. To assess sex-based differences in the prevalence of risk factor, their management, an... more Objective. To assess sex-based differences in the prevalence of risk factor, their management, and differences in the prognosis among acute coronary syndrome (ACS) in Sri Lanka. Methods. Patients diagnosed with ACS were recruited from hospitals throughout the island. The Joint European Societies guidelines were used to assess recommended targets for coronary heart disease risk factors, and the GRACE score was used to assess the post-ACS prognosis. Age-adjusted regression was performed to calculate odds ratios for men versus women in risk factor control. Results. A total of 2116 patients, of whom 1242 (58.7%) were men, were included. Significant proportion of women were nonsmokers; OR = 0.11 (95% CI 0.09 to 0.13). The prevalence of hypertension (p<0.001), diabetes (p<0.001), and dyslipidemia (p=0.004) was higher in women. The LDL-C target was achieved in a significantly higher percentage of women (12.6%); OR = 0.33 (95% CI 0.10 to 1.05). When stratified by age, no significant d...

International Journal of Respiratory and Pulmonary Medicine, 2018

Background: This case discusses the importance of thoroughly investigating a haemorrhagic effusio... more Background: This case discusses the importance of thoroughly investigating a haemorrhagic effusion in a setting where the tuberculosis is endemic. Case report: A young woman presented with an asymptomatic recurrent right sided pleural effusion. Pleural fluid full report showed neutrophilic and haemorrhagic effusion. Adenosine deaminase level in the pleural fluid was elevated and the Mantoux test was positive. Microbiological diagnosis was negative, and she was started on anti-tuberculous therapy on clinical grounds for extrapulmonary tuberculosis. Diagnostic Thoracoscopy revealed characteristic appearance suggestive of thoracic endometriosis which was confirmed by histology. Conclusions: Thoracoscopy is valuable in rapid diagnosis of pleural based diseases such as thoracic endometriosis. It also provides option to drain tuberculous and other complicated effusions completely minimising the chance of later complications. This case discusses the importance of thoroughly investigating a haemorrhagic effusion in a setting where the tuberculosis is endemic.

Heart (British Cardiac Society), Jan 16, 2018

Ischaemic heart disease is the leading cause of in-hospital mortality in Sri Lanka. Acute Coronar... more Ischaemic heart disease is the leading cause of in-hospital mortality in Sri Lanka. Acute Coronary Syndrome Sri Lanka Audit Project (ACSSLAP) is the first national clinical-audit project that evaluated patient characteristics, clinical outcomes and care provided by state-sector hospitals. ACSSLAP prospectively evaluated acute care, in-hospital care and discharge plans provided by all state-sector hospitals managing patients with ACS. Data were collected from 30 consecutive patients from each hospital during 2-4 weeks window. Local and international recommendations were used as audit standards. Data from 87/98 (88.7%) hospitals recruited 2177 patients, with 2116 confirmed as having ACS. Mean age was 61.4±11.8 years (range 20-95) and 58.7% (n=1242) were males. There were 813 (38.4%) patients with unstable angina, 695 (32.8%) with non-ST-elevation myocardial infarction (NSTEMI) and 608 (28.7%) with ST-elevation myocardial infarction (STEMI). Both STEMI (69.9%) and NSTEMI (61.4%) were m...

International Journal of Basic and Clinical Pharmacology, 2016

BMC Medical Imaging, 2016

Background: Paraneoplastic limbic encephalitis is an uncommon association of common malignancies ... more Background: Paraneoplastic limbic encephalitis is an uncommon association of common malignancies such as small cell lung carcinoma, testicular teratoma, and breast carcinoma. The nonspecific nature of the clinical presentation, lack of freely available diagnostic markers, and requirement for advanced imaging techniques pose a great challenge in the diagnosis of this disease in resource-poor settings. Care presentation: A 64-year-old previously healthy Sri Lankan man was admitted to the general medical unit with subacute memory impairment regarding recent events that had occurred during the previous 3 weeks. Initial noncontrast computed tomography of the brain revealed a hyperdensity in the hypothalamic region surrounded by hypodensities extending toward the bilateral temporal lobes; these findings were consistent with a possible hypothalamic tumor with perilesional edema. The patient later developed cranial diabetes insipidus, which was further suggestive of hypothalamic disease. Interestingly, gadolinium-enhanced magnetic resonance imaging of the brain showed no such lesions; instead, it showed prominent T2-weighted signals in the inner mesial region, characteristic of encephalitis. The possibility of tuberculosis and viral encephalitis was excluded based on cerebrospinal fluid analysis results. Limbic encephalitis with predominant hypothalamitis was suspected based on the radiological pattern. Subsequent screening for underlying malignancy revealed a mass lesion in the right hilum on chest radiographs. Histological examination of the lesion showed small cell lung cancer of the "oat cell" variety. Conclusion: We suggest that the initial appearance of a hyperdensity in the hypothalamus region on noncontrast computed tomography is probably due to hyperemia caused by hypothalamitis. If hypothalamitis is predominant in a patient with paraneoplastic limbic encephalitis, magnetic resonance imaging will help to differentiate it from a hypothalamic secondary deposit. Limbic encephalitis should be considered in a patient with computed tomographic evidence of a central hyperdensity surrounded by bitemporal hypodensities. This pattern of identification will be useful for early diagnosis in resource-poor settings.

Journal of Medical Case Reports, 2015

Background: Granulomatosis with polyangiitis is a rare multisystemic autoimmune disorder predomin... more Background: Granulomatosis with polyangiitis is a rare multisystemic autoimmune disorder predominantly affecting the upper and lower respiratory tracts and the kidneys, and rarely affecting other organ systems. Tuberculosis can mimic the presentation of granulomatosis with polyangiitis, and both can occur simultaneously in the same patient. Here we report what we believe to be the first case of concurrent granulomatous breast lesions and hemorrhagic retinal angiopathy in a Sri Lankan woman with refractory granulomatosis with polyangiitis complicated by probable tuberculosis. Case presentation: A 48-year-old Sri Lankan Moorish woman presented with a 6-month history of ulcerating bilateral breast lumps, a 3-month history of non-healing painful ulcers on the palate, and sudden bilateral painless loss of vision. Retinoscopy confirmed left-sided retinal hemorrhages and bilateral panuveitis. An examination of her respiratory system showed bilateral coarse crepitations. Histologic examination of the palatal and breast lesions showed chronic granulomatous inflammation. Her levels of immune markers were elevated but her renal function was normal. Chest radiography showed bilateral mid-zone and lower-zone infiltrates with cavitation and small pleural effusions. Her serum proteinase 3 anti-neutrophil cytoplasmic antibody titer and the level of adenosine deaminase in her pleural fluid were significantly elevated. She was diagnosed with generalized granulomatosis with polyangiitis complicated with probable pulmonary tuberculosis, and was started on methylprednisolone and cyclophosphamide pulse therapy with anti-tuberculous treatment. She later developed cerebral vasculitis, indicating refractory disease, and was treated with second-line rituximab with excellent response. Conclusion: Proteinase 3 anti-neutrophil cytoplasmic antibody may be a valuable diagnostic marker in patients with atypical symptoms of granulomatosis with polyangiitis or in the presence of probable tuberculosis. Retinal vascular angiopathy needs to be diagnosed and treated early to prevent the development of complete blindness. Concomitant cytotoxic and anti-tuberculous treatments may be safe and effective in patients with simultaneous refractory disease with probable tuberculosis.

Journal of Medical Case Reports, 2015

Introduction: Tuberculosis is a progressive and disabling infection predominantly seen in low-inc... more Introduction: Tuberculosis is a progressive and disabling infection predominantly seen in low-income and middleincome countries. Immunocompromised patients are at a higher risk of contracting tuberculosis than the healthy population. The presentation may also be atypical, leading to delay in diagnosis. We report the first case of tuberculous cerebral vasculitis presenting with epilepsia partialis continua. Case presentation: A 17-year-old adolescent boy of Sri Lankan Moor heritage was taking long-term immunosuppressants for nephrotic syndrome. He presented to hospital with focal fits affecting his left arm. He later developed choreiform movements of the same arm, progressing to epilepsia partialis continua and weakness. The gradually evolving focal neurological signs and underlying immunosuppression raised the possibility of localized cerebral infection or inflammation. Analysis of his cerebrospinal fluid showed lymphocytosis with normal cellular morphology. Magnetic resonance imaging was suggestive of progressive vasculitic infarctions of the cerebral cortex and basal ganglia. There was no evidence of active autoimmune or viral disease on hematological investigations, but molecular amplification detected Mycobacterium tuberculosis in his cerebrospinal fluid. Although our patient had been established on isoniazid preventive treatment for eight months before the episode, tuberculosis was nonetheless considered to be the most likely cause of the cerebral vasculitis. He was treated with a trial of anti-tuberculosis treatment, including streptomycin and adjunctive steroids, and made an uneventful recovery. Conclusion: Clinicians should have a high index of suspicion for tuberculosis infection in patients with compromised immunity and other risk factors. The pathophysiological mechanisms underpinning cerebral vasculitis and epilepsia partialis continua are not completely understood. The efficacy of isoniazid prophylaxis in patients with immune suppression warrants further study. We present a regimen that successfully treated tuberculous cerebral vasculitis.

International Journal of Infection Control, 2011

Intravenous access is one of the most commonly performed invasive procedures in the clinical prac... more Intravenous access is one of the most commonly performed invasive procedures in the clinical practice, during which the improper practice of the aseptic precautions could lead to fatal healthcare associated infections. a descriptive cross sectional study was conducted to assess the compliance with aseptic precautions during intravenous access and to identify the determinants of the substandard practice and practical difficulties encountered at the National Hospital of Sri Lanka using a self administered questionnaire and an observational check list. The majority (60.2%) of the participants fell in to the 'substandard' practice category. Compliance for the accepted method of hand washing was 8.4%. Compliance was significantly better among the nursing students (P=0.001), nursing staff that had less experience (P=0.001) and who had updated their knowledge recently (P=0.043). The work overload (95.2%) and the shortage of equipment (65.1%) were the main practical difficulties identified. Hand washing practice should be further encouraged in the hospital setting. Continuing education and provisions of the necessary equipment are equally important.

Patient Safety in Surgery, 2011

Background Anatomically, it is difficult to give a systematic description of the superficial bran... more Background Anatomically, it is difficult to give a systematic description of the superficial branch of the radial nerve (SBRN). Our aim was to describe the exact relationship of the SBRN to fixed bony points of radial styloid and Lister's tubercle, and to the cephalic vein. We also compared our data with other international studies. Methods The study was a descriptive anatomical study. Twenty-five forearms were dissected. Measurements were made from predefined fixed reference points. Results The mean distance to the point of emergence of the nerve from the radial styloid was 8.54 cm (SD = 1.32). The nerve branched at a mean distance of 5.57 cm (SD = 1.43) from the radial styloid. The mean distance to the point where the most medial and most lateral branches of the nerve crossing the wrist joint, measured from the Lister's tubercle were 2.51 cm (SD = 0.53) and 3.90 cm (SD = 0.64). In 17 specimens(68%) cephalic vein crossed the SBRN superficially once. Mean distance from the r...

BMC Gastroenterology, 2014

Background: Crohn's disease is a relapsing, systemic inflammatory disease affecting the gastroint... more Background: Crohn's disease is a relapsing, systemic inflammatory disease affecting the gastrointestinal tract with associated extraintestinal manifestations and immune disorders. Among the few cases reported, the association of Crohn's disease with polymyositis varies in its complexity and severity. We report here the first known case of inflammatory polymyositis leading to rhabdomyolysis in a male patient diagnosed with Crohn's ileocolitis. Case presentation: A 42-year-old previously healthy man presented with acute polymyositis leading to rhabdomyolysis. The acute nature of the illness raised the suspicion of an infective, toxic, or metabolic insult, which was excluded during further investigations. Prolonged low-grade fever and raised inflammatory markers led to the suspicion of inflammatory polymyositis, which was confirmed by electromyography and muscle histology. In the absence of an infective cause, the concurrent association of prolonged diarrhea containing blood and mucous after recovery from an acute phase of myositis proved a diagnostic challenge. Ileocolonoscopy findings of extensive aphthous ulceration with skip lesions extending to the terminal ileum, and histology showing polymorph infiltration of the lamina propria, transmural involvement, and micro abscess formation was suggestive of Crohn's disease. Sensory motor axonal peripheral neuropathy, which is another rare association of inflammatory bowel disease, was also present. Conclusion: An unrecognized genetic predisposition or altered gut permeability causing disruption of the gut immune barrier triggering an immune response against skeletal muscles may have contributed to this unique association. Both polymyositis and Crohn's ileocolitis responded well to corticosteroids and azathioprine, which is supportive of their immune pathogenesis. Myositis can be considered to be a rare extraintestinal manifestation of Crohn's disease and can be used in the differential diagnosis of corticosteroid or hypokalemia-induced myopathy in Crohn's disease.

International Journal of Basic & Clinical Pharmacology, 2020

Background: Unwanted medicines are defined as expired, unused, damaged or contaminated pharmaceut... more Background: Unwanted medicines are defined as expired, unused, damaged or contaminated pharmaceutical products. Improper disposal of unwanted medicines leads to many health and environmental hazards. The World Health Organisation recommends that unwanted medicines should always be disposed properly. The main objective of this study was to assess the knowledge, practices and perceptions on the disposal of unwanted medicines among pharmacists in Sri Lanka.Methods: A cross-sectional study was carried out among pharmacists in 40 private retail pharmacies in the Northern, Eastern and the Western provinces within a period of three months. The pharmacies were selected via stratified randomised sampling in each district. The most experienced pharmacist in each pharmacy was recruited for data collection. A pre-tested, self-administered questionnaire was used. The ethics approval was obtained (Ref: EC-12-190). The data was represented using simple descriptive statistics.Results: The data was ...

International Journal of Basic & Clinical Pharmacology, 2018

Background: Medication waste has major implications on human and animal health, environmental saf... more Background: Medication waste has major implications on human and animal health, environmental safety and the health economy. Low and middle income countries have paid less attention to proper medication waste disposal at household and community level. This is the first baseline assessment on medication waste disposal practices among the general public in Sri Lanka.Methods: This was a descriptive, cross-sectional survey, conducted via face to face interviews using a structured questionnaire among selected outpatient clinics at the National Hospital of Sri Lanka. A non-probability sampling technique was used to achieve a representative sample from each clinic. The data collectors were trained prior to administering the questionnaire. Data was presented as descriptive statistics using percentages. Chi-square test was used to find associations.Results: From the total number of participants (n=200) majority were females 135 (67.5%). Majority of the participants (78%) stated that they hav...

South-East Asian Journal of Medical Education, 2013

Objectives: This paper investigates the perceptions of the current teaching strategies among firs... more Objectives: This paper investigates the perceptions of the current teaching strategies among first year medical students. It further assessed the predominant learning style preferences using the VARK (Visual, Auditory, Reading/Writing and Kinesthetic) questionnaire and the gender differences for learning style preferences. Methods: This study was conducted among the first year medical students in the Faculty of Medicine, University of Colombo (n=192) and descriptive cross sectional design was adopted. Data was collected using a self-administered multiple choice questionnaire. Frequencies were calculated followed by cross-tabulations to generate descriptive statistics and analyzed with Chi Square distribution test. Results: Majority of the students found lectures and small group activities as useful learning experiences most of the time; 60.4% and 47.4% respectively. The multimodal preference was commoner, 59.8% (n=115) than the unimodal preference, 40.2% (n=77). Among the unimodal learners, the majority preferred aural modality, 55.8% (n=43). Bimodal preference was the most common among multimodal learners, 31.2% (N=60). Learning styles did not significantly differ between male and female students (p=0.115, n=192). Conclusions: To facilitate multimodal learning, combination of teaching techniques should be employed. Active learning should be further encouraged using a variety of learning tools such as video clips, computer simulations and interactive models.

The Lancet

In patients hospitalised for COVID-19 with clinical hypoxia who required either no oxygen or simp... more In patients hospitalised for COVID-19 with clinical hypoxia who required either no oxygen or simple oxygen only, higher dose corticosteroids significantly increased the risk of death compared with usual care, which included low-dose corticosteroids. The RECOVERY trial continues to assess the effects of higher dose corticosteroids in patients hospitalised with COVID-19 who require non-invasive ventilation, invasive mechanical ventilation, or extracorporeal membrane oxygenation.

SUMMARYBackgroundWe evaluated the use of baricitinib, a Janus kinase (JAK) 1/2 inhibitor, for the... more SUMMARYBackgroundWe evaluated the use of baricitinib, a Janus kinase (JAK) 1/2 inhibitor, for the treatment of patients admitted to hospital because of COVID-19.MethodsThis randomised, controlled, open-label platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), is assessing multiple possible treatments in patients hospitalised for COVID-19. Eligible and consenting patients were randomly allocated (1:1) to either usual standard of care alone (usual care group) or usual care plus baricitinib 4 mg once daily by mouth for 10 days or until discharge if sooner (baricitinib group). The primary outcome was 28-day mortality assessed in the intention-to-treat population. A meta-analysis was conducted that included the results from the RECOVERY trial and all previous randomised controlled trials of baricitinib or other JAK inhibitor in patients hospitalised with COVID-19. The RECOVERY trial is registered with ISRCTN (50189673) and clinicaltrials.gov (NCT04381936).FindingsBetwe...

Background: Granulomatosis with polyangiitis is a rare multisystemic autoimmune disorder predomin... more Background: Granulomatosis with polyangiitis is a rare multisystemic autoimmune disorder predominantly affecting the upper and lower respiratory tracts and the kidneys, and rarely affecting other organ systems. Tuberculosis can mimic the presentation of granulomatosis with polyangiitis, and both can occur simultaneously in the same patient. Here we report what we believe to be the first case of concurrent granulomatous breast lesions and hemorrhagic retinal angiopathy in a Sri Lankan woman with refractory granulomatosis with polyangiitis complicated by probable tuberculosis. Case presentation: A 48-year-old Sri Lankan Moorish woman presented with a 6-month history of ulcerating bilateral breast lumps, a 3-month history of non-healing painful ulcers on the palate, and sudden bilateral painless loss of vision. Retinoscopy confirmed left-sided retinal hemorrhages and bilateral panuveitis. An examination of her respiratory system showed bilateral coarse crepitations. Histologic examinat...

Anatomical relations of the superficial sensory branches of the radial nerve: a cadaveric study w... more Anatomical relations of the superficial sensory branches of the radial nerve: a cadaveric study with clinical implications

International Journal of Anatomical Variations, 2011

The “corona mortis” or crown of death is defined as the vascular connection between the obturator... more The “corona mortis” or crown of death is defined as the vascular connection between the obturator and external iliac systems crossing the superior pubic ramus. It has a great clinical significance as it could be accidentally cut during any surgery in that area causing fatal hemorrhage. We present a rare variant of bilateral arterial and venous corona mortis in a male cadaver with bilateral indirect inguinal hernia. Laparoscopic repair is indicated in bilateral case and there is a greater risk of damaging corona mortis during pre-peritoneal dissection. Surgeons must deliberately look for the above vascular variant in every case for its presence to avoid unnecessary risk to the patient.

Cardiology Research and Practice, 2020

Objective. To assess sex-based differences in the prevalence of risk factor, their management, an... more Objective. To assess sex-based differences in the prevalence of risk factor, their management, and differences in the prognosis among acute coronary syndrome (ACS) in Sri Lanka. Methods. Patients diagnosed with ACS were recruited from hospitals throughout the island. The Joint European Societies guidelines were used to assess recommended targets for coronary heart disease risk factors, and the GRACE score was used to assess the post-ACS prognosis. Age-adjusted regression was performed to calculate odds ratios for men versus women in risk factor control. Results. A total of 2116 patients, of whom 1242 (58.7%) were men, were included. Significant proportion of women were nonsmokers; OR = 0.11 (95% CI 0.09 to 0.13). The prevalence of hypertension (p<0.001), diabetes (p<0.001), and dyslipidemia (p=0.004) was higher in women. The LDL-C target was achieved in a significantly higher percentage of women (12.6%); OR = 0.33 (95% CI 0.10 to 1.05). When stratified by age, no significant d...

International Journal of Respiratory and Pulmonary Medicine, 2018

Background: This case discusses the importance of thoroughly investigating a haemorrhagic effusio... more Background: This case discusses the importance of thoroughly investigating a haemorrhagic effusion in a setting where the tuberculosis is endemic. Case report: A young woman presented with an asymptomatic recurrent right sided pleural effusion. Pleural fluid full report showed neutrophilic and haemorrhagic effusion. Adenosine deaminase level in the pleural fluid was elevated and the Mantoux test was positive. Microbiological diagnosis was negative, and she was started on anti-tuberculous therapy on clinical grounds for extrapulmonary tuberculosis. Diagnostic Thoracoscopy revealed characteristic appearance suggestive of thoracic endometriosis which was confirmed by histology. Conclusions: Thoracoscopy is valuable in rapid diagnosis of pleural based diseases such as thoracic endometriosis. It also provides option to drain tuberculous and other complicated effusions completely minimising the chance of later complications. This case discusses the importance of thoroughly investigating a haemorrhagic effusion in a setting where the tuberculosis is endemic.

Heart (British Cardiac Society), Jan 16, 2018

Ischaemic heart disease is the leading cause of in-hospital mortality in Sri Lanka. Acute Coronar... more Ischaemic heart disease is the leading cause of in-hospital mortality in Sri Lanka. Acute Coronary Syndrome Sri Lanka Audit Project (ACSSLAP) is the first national clinical-audit project that evaluated patient characteristics, clinical outcomes and care provided by state-sector hospitals. ACSSLAP prospectively evaluated acute care, in-hospital care and discharge plans provided by all state-sector hospitals managing patients with ACS. Data were collected from 30 consecutive patients from each hospital during 2-4 weeks window. Local and international recommendations were used as audit standards. Data from 87/98 (88.7%) hospitals recruited 2177 patients, with 2116 confirmed as having ACS. Mean age was 61.4±11.8 years (range 20-95) and 58.7% (n=1242) were males. There were 813 (38.4%) patients with unstable angina, 695 (32.8%) with non-ST-elevation myocardial infarction (NSTEMI) and 608 (28.7%) with ST-elevation myocardial infarction (STEMI). Both STEMI (69.9%) and NSTEMI (61.4%) were m...

International Journal of Basic and Clinical Pharmacology, 2016

BMC Medical Imaging, 2016

Background: Paraneoplastic limbic encephalitis is an uncommon association of common malignancies ... more Background: Paraneoplastic limbic encephalitis is an uncommon association of common malignancies such as small cell lung carcinoma, testicular teratoma, and breast carcinoma. The nonspecific nature of the clinical presentation, lack of freely available diagnostic markers, and requirement for advanced imaging techniques pose a great challenge in the diagnosis of this disease in resource-poor settings. Care presentation: A 64-year-old previously healthy Sri Lankan man was admitted to the general medical unit with subacute memory impairment regarding recent events that had occurred during the previous 3 weeks. Initial noncontrast computed tomography of the brain revealed a hyperdensity in the hypothalamic region surrounded by hypodensities extending toward the bilateral temporal lobes; these findings were consistent with a possible hypothalamic tumor with perilesional edema. The patient later developed cranial diabetes insipidus, which was further suggestive of hypothalamic disease. Interestingly, gadolinium-enhanced magnetic resonance imaging of the brain showed no such lesions; instead, it showed prominent T2-weighted signals in the inner mesial region, characteristic of encephalitis. The possibility of tuberculosis and viral encephalitis was excluded based on cerebrospinal fluid analysis results. Limbic encephalitis with predominant hypothalamitis was suspected based on the radiological pattern. Subsequent screening for underlying malignancy revealed a mass lesion in the right hilum on chest radiographs. Histological examination of the lesion showed small cell lung cancer of the "oat cell" variety. Conclusion: We suggest that the initial appearance of a hyperdensity in the hypothalamus region on noncontrast computed tomography is probably due to hyperemia caused by hypothalamitis. If hypothalamitis is predominant in a patient with paraneoplastic limbic encephalitis, magnetic resonance imaging will help to differentiate it from a hypothalamic secondary deposit. Limbic encephalitis should be considered in a patient with computed tomographic evidence of a central hyperdensity surrounded by bitemporal hypodensities. This pattern of identification will be useful for early diagnosis in resource-poor settings.

Journal of Medical Case Reports, 2015

Background: Granulomatosis with polyangiitis is a rare multisystemic autoimmune disorder predomin... more Background: Granulomatosis with polyangiitis is a rare multisystemic autoimmune disorder predominantly affecting the upper and lower respiratory tracts and the kidneys, and rarely affecting other organ systems. Tuberculosis can mimic the presentation of granulomatosis with polyangiitis, and both can occur simultaneously in the same patient. Here we report what we believe to be the first case of concurrent granulomatous breast lesions and hemorrhagic retinal angiopathy in a Sri Lankan woman with refractory granulomatosis with polyangiitis complicated by probable tuberculosis. Case presentation: A 48-year-old Sri Lankan Moorish woman presented with a 6-month history of ulcerating bilateral breast lumps, a 3-month history of non-healing painful ulcers on the palate, and sudden bilateral painless loss of vision. Retinoscopy confirmed left-sided retinal hemorrhages and bilateral panuveitis. An examination of her respiratory system showed bilateral coarse crepitations. Histologic examination of the palatal and breast lesions showed chronic granulomatous inflammation. Her levels of immune markers were elevated but her renal function was normal. Chest radiography showed bilateral mid-zone and lower-zone infiltrates with cavitation and small pleural effusions. Her serum proteinase 3 anti-neutrophil cytoplasmic antibody titer and the level of adenosine deaminase in her pleural fluid were significantly elevated. She was diagnosed with generalized granulomatosis with polyangiitis complicated with probable pulmonary tuberculosis, and was started on methylprednisolone and cyclophosphamide pulse therapy with anti-tuberculous treatment. She later developed cerebral vasculitis, indicating refractory disease, and was treated with second-line rituximab with excellent response. Conclusion: Proteinase 3 anti-neutrophil cytoplasmic antibody may be a valuable diagnostic marker in patients with atypical symptoms of granulomatosis with polyangiitis or in the presence of probable tuberculosis. Retinal vascular angiopathy needs to be diagnosed and treated early to prevent the development of complete blindness. Concomitant cytotoxic and anti-tuberculous treatments may be safe and effective in patients with simultaneous refractory disease with probable tuberculosis.

Journal of Medical Case Reports, 2015

Introduction: Tuberculosis is a progressive and disabling infection predominantly seen in low-inc... more Introduction: Tuberculosis is a progressive and disabling infection predominantly seen in low-income and middleincome countries. Immunocompromised patients are at a higher risk of contracting tuberculosis than the healthy population. The presentation may also be atypical, leading to delay in diagnosis. We report the first case of tuberculous cerebral vasculitis presenting with epilepsia partialis continua. Case presentation: A 17-year-old adolescent boy of Sri Lankan Moor heritage was taking long-term immunosuppressants for nephrotic syndrome. He presented to hospital with focal fits affecting his left arm. He later developed choreiform movements of the same arm, progressing to epilepsia partialis continua and weakness. The gradually evolving focal neurological signs and underlying immunosuppression raised the possibility of localized cerebral infection or inflammation. Analysis of his cerebrospinal fluid showed lymphocytosis with normal cellular morphology. Magnetic resonance imaging was suggestive of progressive vasculitic infarctions of the cerebral cortex and basal ganglia. There was no evidence of active autoimmune or viral disease on hematological investigations, but molecular amplification detected Mycobacterium tuberculosis in his cerebrospinal fluid. Although our patient had been established on isoniazid preventive treatment for eight months before the episode, tuberculosis was nonetheless considered to be the most likely cause of the cerebral vasculitis. He was treated with a trial of anti-tuberculosis treatment, including streptomycin and adjunctive steroids, and made an uneventful recovery. Conclusion: Clinicians should have a high index of suspicion for tuberculosis infection in patients with compromised immunity and other risk factors. The pathophysiological mechanisms underpinning cerebral vasculitis and epilepsia partialis continua are not completely understood. The efficacy of isoniazid prophylaxis in patients with immune suppression warrants further study. We present a regimen that successfully treated tuberculous cerebral vasculitis.

International Journal of Infection Control, 2011

Intravenous access is one of the most commonly performed invasive procedures in the clinical prac... more Intravenous access is one of the most commonly performed invasive procedures in the clinical practice, during which the improper practice of the aseptic precautions could lead to fatal healthcare associated infections. a descriptive cross sectional study was conducted to assess the compliance with aseptic precautions during intravenous access and to identify the determinants of the substandard practice and practical difficulties encountered at the National Hospital of Sri Lanka using a self administered questionnaire and an observational check list. The majority (60.2%) of the participants fell in to the 'substandard' practice category. Compliance for the accepted method of hand washing was 8.4%. Compliance was significantly better among the nursing students (P=0.001), nursing staff that had less experience (P=0.001) and who had updated their knowledge recently (P=0.043). The work overload (95.2%) and the shortage of equipment (65.1%) were the main practical difficulties identified. Hand washing practice should be further encouraged in the hospital setting. Continuing education and provisions of the necessary equipment are equally important.

Patient Safety in Surgery, 2011

Background Anatomically, it is difficult to give a systematic description of the superficial bran... more Background Anatomically, it is difficult to give a systematic description of the superficial branch of the radial nerve (SBRN). Our aim was to describe the exact relationship of the SBRN to fixed bony points of radial styloid and Lister's tubercle, and to the cephalic vein. We also compared our data with other international studies. Methods The study was a descriptive anatomical study. Twenty-five forearms were dissected. Measurements were made from predefined fixed reference points. Results The mean distance to the point of emergence of the nerve from the radial styloid was 8.54 cm (SD = 1.32). The nerve branched at a mean distance of 5.57 cm (SD = 1.43) from the radial styloid. The mean distance to the point where the most medial and most lateral branches of the nerve crossing the wrist joint, measured from the Lister's tubercle were 2.51 cm (SD = 0.53) and 3.90 cm (SD = 0.64). In 17 specimens(68%) cephalic vein crossed the SBRN superficially once. Mean distance from the r...

BMC Gastroenterology, 2014

Background: Crohn's disease is a relapsing, systemic inflammatory disease affecting the gastroint... more Background: Crohn's disease is a relapsing, systemic inflammatory disease affecting the gastrointestinal tract with associated extraintestinal manifestations and immune disorders. Among the few cases reported, the association of Crohn's disease with polymyositis varies in its complexity and severity. We report here the first known case of inflammatory polymyositis leading to rhabdomyolysis in a male patient diagnosed with Crohn's ileocolitis. Case presentation: A 42-year-old previously healthy man presented with acute polymyositis leading to rhabdomyolysis. The acute nature of the illness raised the suspicion of an infective, toxic, or metabolic insult, which was excluded during further investigations. Prolonged low-grade fever and raised inflammatory markers led to the suspicion of inflammatory polymyositis, which was confirmed by electromyography and muscle histology. In the absence of an infective cause, the concurrent association of prolonged diarrhea containing blood and mucous after recovery from an acute phase of myositis proved a diagnostic challenge. Ileocolonoscopy findings of extensive aphthous ulceration with skip lesions extending to the terminal ileum, and histology showing polymorph infiltration of the lamina propria, transmural involvement, and micro abscess formation was suggestive of Crohn's disease. Sensory motor axonal peripheral neuropathy, which is another rare association of inflammatory bowel disease, was also present. Conclusion: An unrecognized genetic predisposition or altered gut permeability causing disruption of the gut immune barrier triggering an immune response against skeletal muscles may have contributed to this unique association. Both polymyositis and Crohn's ileocolitis responded well to corticosteroids and azathioprine, which is supportive of their immune pathogenesis. Myositis can be considered to be a rare extraintestinal manifestation of Crohn's disease and can be used in the differential diagnosis of corticosteroid or hypokalemia-induced myopathy in Crohn's disease.

International Journal of Basic & Clinical Pharmacology, 2020

Background: Unwanted medicines are defined as expired, unused, damaged or contaminated pharmaceut... more Background: Unwanted medicines are defined as expired, unused, damaged or contaminated pharmaceutical products. Improper disposal of unwanted medicines leads to many health and environmental hazards. The World Health Organisation recommends that unwanted medicines should always be disposed properly. The main objective of this study was to assess the knowledge, practices and perceptions on the disposal of unwanted medicines among pharmacists in Sri Lanka.Methods: A cross-sectional study was carried out among pharmacists in 40 private retail pharmacies in the Northern, Eastern and the Western provinces within a period of three months. The pharmacies were selected via stratified randomised sampling in each district. The most experienced pharmacist in each pharmacy was recruited for data collection. A pre-tested, self-administered questionnaire was used. The ethics approval was obtained (Ref: EC-12-190). The data was represented using simple descriptive statistics.Results: The data was ...

International Journal of Basic & Clinical Pharmacology, 2018

Background: Medication waste has major implications on human and animal health, environmental saf... more Background: Medication waste has major implications on human and animal health, environmental safety and the health economy. Low and middle income countries have paid less attention to proper medication waste disposal at household and community level. This is the first baseline assessment on medication waste disposal practices among the general public in Sri Lanka.Methods: This was a descriptive, cross-sectional survey, conducted via face to face interviews using a structured questionnaire among selected outpatient clinics at the National Hospital of Sri Lanka. A non-probability sampling technique was used to achieve a representative sample from each clinic. The data collectors were trained prior to administering the questionnaire. Data was presented as descriptive statistics using percentages. Chi-square test was used to find associations.Results: From the total number of participants (n=200) majority were females 135 (67.5%). Majority of the participants (78%) stated that they hav...

South-East Asian Journal of Medical Education, 2013

Objectives: This paper investigates the perceptions of the current teaching strategies among firs... more Objectives: This paper investigates the perceptions of the current teaching strategies among first year medical students. It further assessed the predominant learning style preferences using the VARK (Visual, Auditory, Reading/Writing and Kinesthetic) questionnaire and the gender differences for learning style preferences. Methods: This study was conducted among the first year medical students in the Faculty of Medicine, University of Colombo (n=192) and descriptive cross sectional design was adopted. Data was collected using a self-administered multiple choice questionnaire. Frequencies were calculated followed by cross-tabulations to generate descriptive statistics and analyzed with Chi Square distribution test. Results: Majority of the students found lectures and small group activities as useful learning experiences most of the time; 60.4% and 47.4% respectively. The multimodal preference was commoner, 59.8% (n=115) than the unimodal preference, 40.2% (n=77). Among the unimodal learners, the majority preferred aural modality, 55.8% (n=43). Bimodal preference was the most common among multimodal learners, 31.2% (N=60). Learning styles did not significantly differ between male and female students (p=0.115, n=192). Conclusions: To facilitate multimodal learning, combination of teaching techniques should be employed. Active learning should be further encouraged using a variety of learning tools such as video clips, computer simulations and interactive models.