Hepatitis B virus (HBV) genotypes in a group of Sri Lankan patients with chronic infection

Hepatitis B infection causes a wide spectrum of liver diseases. Previous analyses of hepatitis B virus (HBV) genome have revealed eight HBV genotypes (A-H), with distinct geographical distribution worldwide. The epidemiology of HBV genotypes and their implications for natural history of disease progression and response to anti viral therapy have been increasingly recognized. This study was undertaken to determine the HBV genotypes in a group of Sri Lankan patients with chronic infection who presented for investigation prior to treatment. Genotypes were determined (2007-2009) in 25 patients with evidence of chronic HBV infection. A genotyping system based on multiplex-nested PCR using type-specific primers was employed in assigning genotypes A through F. Genotypes G and H were not determined. Among the 25 patients tested, genotypes B [9 (36%)], C [4 (16%)], D [3 (12%)], A [2 (8%)] and E [1 (4%)] were detected. There was a relatively high prevalence of mixed infections with genotypes B+C (3), A+D (1), and B+D (2), which overall constituted 24% of patients. Although this is a non-representative sample, HBV infections among this group of Sri Lankan patients were predominantly genotypes B, C and D.

Accidental scrotal burns from paraquat while handling a patient.

The main risk of paraquat poisoning is from deliberate ingestion. Serious accidental or occupational poisoning is comparatively rare. We report two patients who had accidental exposure to paraquat, resulting in scrotal burns in both and systemic poisoning in one, while attending to a patient who had ingested paraquat for deliberate self harm.

Use of ambulatory oesophageal pH monitoring to diagnose gastrooesophageal reflux disease.

OBJECTIVES: To investigate the characteristics of patients referred for ambulatory oesophageal pHmetry, the referral pattern, and the role of oesophageal pHmetry as a diagnostic tool in a tertiary care hospital in Sri Lanka. DESIGN: Data obtained from patients referred to the Gastrointestinal Research Laboratory at Teaching Hospital Ragama for 24-hour ambulatory oesophageal pHmetry from 1998 to 2005 were reviewed. Patients' upper gastrointestinal endoscopy reports and stationary oesophageal manometry reports were also reviewed. RESULTS: 140 pHmetry studies were performed during the study period. The majority of patients (> 90%) were referred by specialists in gastroenterology practicing in hospitals in or around Colombo. There were 88 males and the median age was 37 years (range 0.5-74). The median duration of symptoms was 4.1 years (range 0.2 -25). Typical symptoms of gastro-oesophageal reflux disease (GORD) were present in 53 (38%) patients, atypical symptoms of GORD in 31 (22%), and nonspecific upper gastrointestinal symptoms in 56 (40%). Pathological acid reflux was found in 43 (31%) patients. Of them, 29 (67%) had typical GORD symptoms, 7 (16%) had atypical symptoms, and 7 (16%) had non-specific upper gastrointestinal symptoms. No significant association was found between endoscopy and pHmetry results. CONCLUSION: Oesophageal pH monitoring helped to establish a cause for the morbidity in a significant number of patients with GORD symptoms, but not in the majority of patients referred for the test. In our experience the investigation does not seem to be optimally used as a diagnostic tool.

Admission to medical schools in Sri Lanka: predictive validity of selection criteria.

OBJECTIVE: To assess the extent to which current selection criteria predict success in Sri Lanka's medical schools. METHODS: The study sample consisted of all students selected to all six medical schools in two consecutive entry cohorts. The aggregate marks of these students at the General Certificate of Education (GCE) Advanced Level examination, the district of entry, admission category, candidate type (school/private) and gender, were identified as entry point variables. Success in medical school was measured in four ways: the ability to pass the first summative examination and the final examination at the first attempt, and obtaining honours in either examination. Multivariate analysis using logistic regression was used to assess the extent to which these entry point factors predict variability in outcome measures. RESULTS: Aggregate scores among the 1740 students in the study sample ranged from 212 to 356, with a median of 285. The male:female ratio was 1.4:1. Private candidates (taking the examination for the third time) accounted for 22% of students. Being a school candidate, female and having a higher aggregate score, were the only independent predictors of success for all four outcome measures. The aggregate score alone accounted for only 1-7% of the variation in performance in medical school. CONCLUSIONS: Marks obtained at the A Level examination (the only academic criterion currently used for selection of medical students in Sri Lanka) is a poor predictor of success in medical school.

Clinical, biochemical and histological characteristics of a Sri Lankan population of non-alcoholic steatohepatitis (NASH) patients.

BACKGROUND: Non-alcoholic steatohepatitis (NASH) is common and can progress to cirrhosis. It has been regarded as a 'disease of affluence' and there are only a few reports from developing countries. OBJECTIVE: To describe the clinical, biochemical, and histological characteristics of a cohort of NASH patients in Sri Lanka, and to determine their short term outcome following modifications of lifestyle. METHOD: Patients who had a liver biopsy for investigation of raised hepatic enzymes were assessed during the period May 1999 - May 2003. Patients who had an alcohol intake of over 40 g/week were excluded. Detailed clinical and biochemical data of patients with histologically confirmed NASH were compiled. Histological grading and staging was done using the Brunt system. The patients were advised on lifestyle modifications and the control of diseases known to be associated with NASH. They were followed up at 3 -monthly intervals. RESULTS: During the study period liver biopsies were performed on 296 patients and 100 ( 35.1%) were diagnosed as having NASH. (Men = 79, Mean age 37.2 years, SD 10.6). Risk factors for NASH included diabetes mellitus (55%), obesity (52%), hyperlipidaemia (54%), a family history of risk factors (66%) and a high dietary fat intake (66%). However, 44.3% of men and 33.3% of women were not overweight. The histological grading and staging of 80 biopsies showed Grade 1 in 31 (38.8%), Grade 2 in 29 (36.3%), Grade 3 in 20 (25%), Stage 1 in 57 (71.3%) Stage 2 in 13 (16.3%), Stage 3 in 2 (2.5%) and Stage 4 in 8 (10%). In 55/91 (60.4%) patients who were followed up for a median of 2.5 years (range 1-4 years) the serum transaminases returned to normal in a median of 7 months (range 3-14 months). CONCLUSION: The clinical, biochemical and histological features of NASH patients in our series are similar to that reported in western countries. However "lean males" accounted for a significant proportion. In the short term a majority of patients showed improvement in serum transaminases with lifestyle modification.

Estimates of disease burden due to land-snake bite in Sri Lankan hospitals.

Snake bite is a common cause of hospital admission in Sri Lanka. Despite this, there have been no countrywide studies or national estimates of disease burden due to snake bites in Sri Lankan hospitals. We assessed the disease burden due to snake bite in our hospitals and estimated the frequency of admissions due to bites by different snake species. Sri Lanka was divided into four zones based on climate and topography. Hospital morbidity and mortality data, which are available on an administrative district basis, were collated for the four zones. A survey of opinion among specialist physicians (the Delphi technique) was used to estimate the proportion of bites by different species, and requirements for anti-venom (AV) and intensive care facilities for management of snake bites in hospitals in each of the four zones. A study of hospital admissions due to snake bites in seven selected hospitals was also performed to validate the opinion survey. There was a clear difference in the incidence of hospital admissions due to snake bites in the different zones. Estimates of hospital admissions due to bites by different species also varied considerably between zones. These trends corresponded to estimates of requirements of AV and other supportive health care. Health care planning using data based on environmental information, rather than merely on political boundaries, could lead to targeted distribution of AV and intensive care requirements to manage snake bites.

Comparison of one week and two weeks of triple therapy for the eradication of Helicobacter pylori in a Sri Lankan population: a randomised, controlled study.

INTRODUCTION: Resistance of Helicobacter pylori to antibiotics may be particularly high in parts of the tropics. Infection may prove difficult to eradicate in such situations, and there is some evidence of benefit in increasing the duration of treatment (triple therapy) from 1 week to 2 or 3 weeks. AIM: To assess the efficacy and tolerability of 1 week versus 2 weeks of triple therapy for eradication of H. pylori in a Sri Lankan population. METHODS: Eighty two patients aged 18-70 years with gastritis or peptic ulcer and testing positive for H. pylori infection were randomly allocated to two treatment groups. Both groups received omeprazole 20 mg, clarithromycin 250 mg, and tinidazole 500 mg. Group A (n = 42) received the trial medication twice daily for 1 week and the Group B (n = 40) twice daily for 2 weeks. H. pylori eradication was defined as a negative 14C labelled urea breath test at 2 weeks after completion of the therapy. RESULTS: H. pylori infection was eradicated in 36 (85.7%) patients in Group A and 36 (90%) patients in Group B (p = 0.9). Twenty three (55%) patients in Group A and 17 (43%) in Group B reported adverse effects attributable to trial medication (p = 0.387); none were serious. Three (7.5%) patients in Group B discontinued treatment due to adverse events that developed on days 7, 9 and 10. CONCLUSION: Twice daily treatment with clarithromycin, tinidazole, and omeprazole for 1 week is well tolerated and provides as good a rate of H. pylori eradication as 2-week therapy in Sri Lankan patients.

Selection of students for admission to a medical school in Sri Lanka.

OBJECTIVES: To assess the extent to which selected entry point factors predicted success in a Sri Lankan medical school. METHODS: The study sample consisted of all students in two consecutive entry cohorts. Marks obtained at the national university entrance examination in physics, chemistry, botany and zoology; the aggregate marks of these four subjects (the only academic criterion used in selection); the district of entry (the other, non-academic criterion); and gender, were identified as entry point variables. Success in a medical school was measured in five ways, including whether a student had passed all examinations in the medical faculty at first attempt or not. Multiple logistic regression was used to assess the extent to which the selected entry point factors could predict variability in outcome measures. RESULTS: Of 331 students, 6.6% were merit quota admissions, and 19.4% were from 'underprivileged' districts; 46.8% were women. Of the entry point factors, being female and obtaining an aggregate of > or =280 (of a possible 400) were the only independent predictors of success in all outcome measures. Obtaining at least grade B in zoology was also an independent predictor of passing all examinations at first attempt. The aggregate score alone accounted for only 2-5% of variance in a medical school performance. There was no association between admission from an underprivileged district and any of the outcome measures. CONCLUSIONS: The one and only measure of academic performance used for selection of students admitted to our medical schools, is a very weak predictor of success in a medical school.

Detection and management of alcohol misuse by general practitioners.

INTRODUCTION: Alcohol misuse and related problems are common in Sri Lanka. The appropriateness of the primary care setting in dealing with alcohol misuse is well recognised, and general practitioners (GPs) constitute an important first contact setting. METHODS: One hundred and fifty randomly selected GPs practising in the Colombo and Gampaha districts were given a questionnaire to assess how they detect and manage alcohol misuse, and their attitudes towards persons who misuse alcohol. RESULTS: Seventy per cent of GPs responded [74 male; mean age 42 years (SD 6.7)]. Our results suggest that although a majority (81%) of GPs were frequently confronted with problems related to alcohol misuse, their efforts to detect the problem and knowledge regarding risk limits of alcohol consumption were poor. Only 25.7% had even heard of CAGE and MAST questionnaires. The majority of GPs felt inadequately trained to deal with alcohol misuse, but only a few made any self-directed efforts to improve their knowledge and skills regarding its management or referred their patients for specialised care. Participation in preventive programmes was minimal, and many GPs expressed negative attitudes towards persons misusing alcohol. CONCLUSIONS: The ability of general practitioners to detect and alcohol misuse appears to be inadequate.

Safety of subcutaneous adrenaline as prophylaxis against acute adverse reactions to anti-venom serum in snakebite.

OBJECTIVES: To study the safety of low dose subcutaneous adrenaline given as prophylaxis against acute adverse reactions to anti-venom serum (AVS) in patients bitten by snakes. METHODS: Patients admitted with snakebite envenoming who satisfied inclusion criteria were given 0.25 ml of 1:1000 adrenaline subcutaneously immediately before administration of AVS. They were observed for adverse effects, and pulse and blood pressure (BP) were monitored. RESULTS: 51 patients [35 males, mean age 34.8 years (SD 14)] were included in the study. Adverse reactions to AVS occurred in 15 (29.4%) patients. There was one death from suspected cerebral haemorrhage, and 3 (5.9%) patients developed small haematomas at the subcutaneous injection site. There were no significant changes in mean pulse or BP following administration of subcutaneous adrenaline. CONCLUSIONS: Low dose subcutaneous adrenaline did not cause significant changes in pulse rate or BP. Although the death was unlikely to be directly related to subcutaneous adrenaline, we suggest further studies on the safety of this prophylactic treatment before its routine use.

Compliance with the mass chemotherapy program for lymphatic filariasis.

OBJECTIVE: To evaluate compliance with the single dose mass chemotherapy program for control of filariasis, and to determine factors influencing compliance in the Gampaha district. DESIGN: A prospective study employing a pre-tested self-administered questionnaire. METHODS: Four groups comprising individuals over one year old with residence in the Gampaha district for over one year were surveyed. Data collection was started two weeks after the mass chemotherapy program. RESULTS: 2300 questionnaires were distributed, 1983 (86.2%) were returned, and 1935 (84.1%) were sufficiently complete for analysis (857 males; mean age 39 years, SD = 19.5). Over 96% had heard of filariasis and the mass chemotherapy program, but only 60.3% of those over 11 years of age were aware of asymptomatic carriage of the parasite. 1289 (66.6%) out of the total sample surveyed (1935 individuals) had obtained the diethylcarbamazine tablets, and 1221 (63.1%) had taken the drug. Of the possible demographic factors that could have influenced compliance only educational level seemed to play an independent significant role, compliance being lowest at both extremes of educational level. The main problem with compliance was obtaining the drug from distribution centres. CONCLUSIONS: Compliance with the mass chemotherapy program to control filariasis needs improvement. Strategies should include a better system for distributing the drug, and altering the content of the publicity material used by the program to target less compliant groups, and improve aspects of knowledge regarding filariasis that seem inadequate at present.

Severe hepatic dysfunction associated with falciparum malaria.

We describe severe hepatic dysfunction associated with an attack of falciparum malaria in six Sri Lankan patients. Clinicians working in areas endemic for malaria should be made aware of this unusual complication.