Changing phenotype, early clinical course and clinical predictors of inflammatory bowel disease in Sri Lanka: a retrospective, tertiary care-based, multi-centre study.

BACKGROUND: Inflammatory bowel disease (IBD) is increasing in the Asia-Pacific region, with changes in disease phenotype and course. We aimed to assess the changing phenotypes of IBD over ten years, describe the early clinical course (ECC) and identify the clinical predictors (CP) of poor outcomes among a large, multi-centre, cohort of Sri Lankan IBD patients. METHODS: We included patients [diagnosed between June/2003-December/2009-Group-1(G1), January/2010-June/2016-Group-2(G2)] with ulcerative colitis (UC) and Crohn disease (CD) from five national-referral centres. Changing phenotype from G1 to G2, ECC (disease duration < 3-years) and CP of poor outcomes (disease duration ≥ 1-year) was assessed. Poor outcomes were complicated-disease (CompD-stricturing/penetrating-CD, extensive-UC/pancolitis, perforation/bleeding/colectomy/malignancy) and treatment-refractory disease (TRD-frequently-relapsing, steroid-dependent/refractory and biologic use). RESULTS: 375 (UC-227, CD-148) patients were recruited. Both G1/G2 had more UC than CD (77% vs 23%, 54.5 vs 45.5 respectively, p < 0.01). Increase of CD from G1-to-G2 was significant (23-45.4%, p < 0.001). In both groups, left-sided colitis (E2) and ileo-colonic (L3)/non-stricturing, non-penetrating disease behaviour (B1) CD predominated. Extensive-colitis (E3) (36.4% vs 22.7, p < 0.05) and stricturing-CD (B2) (26.1% vs 4.0%, p < 0.01) was commoner in G1. ECC was assessed in 173-patients (UC-94, CD-79). Aggressive disease behaviour and TRD were low among both UC and CD. Immunomodulator use was significantly higher among CD than UC (61.5% vs 29.0% respectively, p < 0.01). Anti-TNF use was low among both groups (UC-3.2%, CD-7.7%). Disease complications among UC [bleeding (2.1%), malignancy-(1.1%), surgery-(2.1%)] and CD [stricture-(3.9%), perforation-(1.3%), malignancy-(1.3%), surgery-(8.9%)] were generally low. CPs were assessed in 271-patients (UC-163, CD-108). Having a family history of IBD (for UC), extraintestinal manifestation (EIM), severe disease at presentation, being in younger age categories and severe disease at presentation, (for both UC and CD) predicted poor outcomes. CONCLUSION: There was an increase in CD over time without change in disease phenotype for both UC and CD. A relatively benign ECC was observed. Family history (UC), EIMs (UC/CD), severe disease at presentation (UC/CD), younger age (CD/UC) CPs of poor outcomes.

Spectrum of low-density lipoprotein receptor (LDLR) mutations in a cohort of Sri Lankan patients with familial hypercholesterolemia - a preliminary report.

BACKGROUND: Hypercholesterolemia is a major determinant of cardiovascular disease-associated morbidity and mortality. Mutations in the LDL-receptor (LDLR) gene are implicated in the majority of the cases with familial hypercholesterolemia (FH). However, the spectrum of mutations in the LDLR gene in Sri Lankan patients has not been investigated. The objective of this study was to report the frequency and spectrum of variants in LDLR in a cohort of Sri Lankan patients with FH. METHODS: A series of consecutive patients with FH, diagnosed according to Modified Simon Broome criteria or Dutch Lipid Clinic Network criteria at the University Medical Unit, Colombo, were recruited. Clinical data was recorded. DNA was extracted from peripheral blood samples. The LDLR gene was screened for genetic variants by Sanger sequencing. RESULTS: A total of 27 patients [13 (48%) males, 14 (52%) females; age range 24-73 years] were tested. Clinical features found among these 27 patients were: xanthelasma in 5 (18.5%), corneal arcus in 1 (3.7%), coronary artery disease (CAD) in 10 (37%), and a family history of hypercholesterolemia and/or CAD in 24 (88.9%) patients. In the entire cohort, mean total cholesterol was 356.8 mg/dl (±66.4) and mean LDL-cholesterol was 250.3 mg/dl (±67.7). Sanger sequencing of the 27 patients resulted in the identification of known pathogenic missense mutations in 5 (18.5%) patients. Four were heterozygotes for 1 mutation each. They were c.682G > C in 2 patients, c.1720C > A in 1 patient, and c.1855 T > A in 1 patient. One patient with severe FH phenotypes was a compound heterozygote for one known mutation, c.2289G > T, and another missense variant, c.1670C > G (p.Thr557Ser), with unknown functional impact. This latter variant has not been reported in any other population previously. CONCLUSIONS: The frequency of known mutations in the LDLR gene in this cohort of patients was markedly low compared to frequencies reported in other populations. This highlights the likelihood of a complex, polygenic inheritance of FH in Sri Lankan patients, indicating the need for a comprehensive genetic evaluation that includes the screening for mutations in other genes that cause FH, such as APOB, PCSK9, and LDLRAP1.

Forensic age estimation in anti-piracy trials in Seychelles: Experiences and challenges faced.

Forensic age estimation (FAE) was conducted using a multifactorial method on thirteen Somali detainees claiming juvenile status during the anti-piracy trials of the Seychelles Supreme Court in 2014/2015. A multidisciplinary team, comprising of four of the authors covering specialties in forensic medicine, forensic odontology and radiology, conducted the FAE using a five-stage protocol. Each detainee was interviewed with an interpreter and examined for disorders affecting dental/skeletal development and for assessment of genital development through Tanner staging. Dental maturity was assessed clinically and radiologically. Eruption stage was assessed using Olze et al. and mandibular third-molar maturity was assessed using Demirjian's classification. Skeletal maturity was assessed from hand-wrist X-rays according to Greulich & Pyle and from CT-clavicle according to Kellinghaus et al. and Schultz et al. Interpretation of findings was done using reference population data from similar ethnic and social backgrounds wherever possible. Final age-ranges were calculated by combining dental and clavicle maturity stages using the regression formula developed by Bassed et al. followed by a 10% correction factor. The team later testified on their findings under cross-examination. The protocol adopted by the authors increased the scientific validity of the findings and was useful in addressing cross-examination queries on exclusion of developmental disorders, ethnic/socioeconomic variability and maintaining chain of custody. Unforeseen jurisdictional and practical limitations were experienced but did not affect the outcome. Combining dental and clavicle developmental data provided the court with a much clearer picture on the likelihood of the detainees' juvenile status which emphasizes the importance of conducting more population studies using combinations of different developmental sites. The authors note that available reference data is mostly from affluent populations whereas FAE is mostly required in individuals from less-developed regions. Regional networks that collate and share population-specific data need to be established to overcome these limitations.

The Prevalence of the Prothrombin (F2) 20210G>A Mutation in a Cohort of Sri Lankan Patients with Thromboembolic Disorders.

Prothrombin (F2) 20210G>A [rs1799963 G>A] mutation is a genetic variant which predisposes to inherited thrombophilia. Highest prevalence of this rare mutation has been reported among Caucasian and Mediterranean populations with thrombophilic conditions compared to healthy controls. It is absent or occurs in a very low frequency in both thrombophilic patients and healthy controls of most South Asian populations. A previous study has demonstrated that the mutant allele is absent among Sri Lankan healthy controls. This study was conducted to determine the prevalence of the F2 20210G>A mutation among Sri Lankan patients with thrombo-embolic disorders. F2 20210G>A mutation analysis was carried out on 825 patients. These included 374 with arterial thromboembolic disorders, 303 with venous thromboembolic disorders (VTE) and 148 with pregnancy related complications. Genotyping was done using polymerase chain reaction followed by restriction fragment length polymorphism. The overall prevalence of the individuals detected with the mutation was 0.8 % (7/825) with a mutant allele frequency of 0.4 % (7/1,650), and all were heterozygotes. Further classification according to the types of thrombotic events showed a prevalence of 0.5 % (2/374), 1.3 % (4/303), and 0.7 % (1/148) respectively, in the three groups with arterial thrombosis, VTE and pregnancy complications. The respective mutant allele frequencies in the three different groups were 0.3 % (2/748), 0.7 % (4/606) and 0.3 % (1/296). Although these figures are lower than that of Caucasian and Mediterranean populations, they are relatively higher compared to other South Asian populations. Therefore, the F2 20210G>A mutant allele is not entirely absent among Sri Lankan patients with thrombo-embolic disorders.

Androgen insensitivity syndrome in a cohort of Sri Lankan children with 46, XY disorders of sex development (46, XY DSD).

INTRODUCTION: There are several conditions giving rise to 46, XY disorders of sex development (DSD) with different modes of inheritance. Therefore definitive diagnosis based on molecular genetic confirmation would be the ideal to counsel parents regarding the future implications of the condition affecting their baby. This is the first report from Sri Lanka documenting the presence of mutations in the androgen receptor (AR) gene in a cohort of children with 46, XY DSD. OBJECTIVES: To describe the socio-demographic and clinical features and document the presence of mutations in the androgen receptor (AR) gene in a cohort of children with 46, XY DSD. METHODS: 46, XY patients with ambiguous genitalia followed up in the University Unit at the Lady Ridgeway Hospital, Colombo, and clinically identified as having androgen insensitivity syndrome (AIS) or a testosterone biosynthetic defect were recruited for the study. Their socio-demographic details and clinical features were documented. Exons 1 to 8 of the AR gene were screened for mutations by DNA sequencing on a venous blood sample. SRY gene mutations were also assayed. RESULTS: Thirty-four patients were studied, 3 of whom were clinically diagnosed as having complete androgen insensitivity syndrome (CAIS). Sex of rearing was female and male in 4 and 30 respectively. AR gene mutations were detected in 6 patients (17.6%). None of the patients had SRY gene mutations. CONCLUSIONS: Majority (88%) of the patients were raised as males. Six patients (17.6%) including the 3 with CAIS, had genetically confirmed AIS with the detection of AR gene mutations.

Hypoxia-inducible factor-1α gene polymorphisms in early and late onset preeclampsia in Sinhalese women.

INTRODUCTION: Early (EPE) and late (LPE) onset preeclampsia are increasingly being recognized as two distinct disorders. Placental vascular defects are more common in EPE. Hypoxia Inducible Factor 1α (HIF1α) regulates the expression of many angiogenic growth factors in the placenta. We studied the association of two polymorphisms in the HIF1α gene (rs11549465 and rs10873142) with EPE and LPE. METHODS: 175 nulliparous Sinhalese women with preeclampsia and 171 normotensive women matched for age, ethnicity, parity and BMI were recruited at two tertiary care hospitals in Colombo. Preeclampsia was diagnosed using international guidelines. DNA extracted from peripheral blood was genotyped using Sequenom MassARRAY. RESULTS: HIF1α rs11549465 dominant model and T allele were reduced in women who developed EPE compared to controls [P = 0.002, OR (95% CI) = 0.3 (0.1-0.7)], in preeclamptic women who delivered small for gestational age babies [P = 0.02, OR (95% CI) = 0.5 (0.2-0.9)] compared to controls and in women who developed EPE compared to those who developed LPE [P = 0.006, OR (95% CI) = 0.3 (0.1-0.7)]. CONCLUSION: Our results demonstrate a protective effect of the T allele in LPE and normal pregnancy, which is relatively lacking in EPE due to low prevalence of this protective allele. HIF1α rs11549465 T allele was previously demonstrated to be associated with a higher transcriptional activity and increased angiogenesis. Inherited susceptibility to increased HIF1α expression resulting in the up-regulation of angiogenic genes may mediate a protective effect in normal pregnancy and pregnancy complicated by LPE.

Polymorphism in the epidermal growth factor gene is associated with birthweight in Sinhalese and white Western Europeans.

Birthweight predicts health later in life and is influenced by inherited factors. We investigated the association of the c.61G > A, and c.2566G > A polymorphisms in the epidermal growth factor (EGF) gene [GenBank NM_001963] with birthweight in three groups of healthy pregnant women, and in women with pregnancies affected by fetal growth restriction (FGR). Subjects comprised 171 Sinhalese women with normal pregnancies (Group A), 64 white Western European women with normal pregnancies (Group B), 101 white Western European women with normal pregnancies and their babies (Group C) and 107 women with pregnancies affected by FGR, their partners and their babies (Group D). Maternal EGF genotypes were associated with birthweight of healthy babies of women in Groups A (P = 0.03), B (P = 0.001) and C (P = 0.01). The association persisted following adjustment for confounding by gestational age, sex, maternal weight, parity and smoking habit. The trend from heaviest to lightest birthweights in all these groups was c.61AA > c.61GA > c.61GG and c.2566GG > c.2566GA > c.2566AA. The EGF haplotype associated with lower birthweight (c.61G, c.2566A) was transmitted at increased frequency from heterozygous parents to babies affected by FGR in Group D (P = 0.02). These findings support the hypothesis that growth factors expressed by the feto-maternal unit affect birthweight, and implicates polymorphism in the EGF gene in the aetiology of birthweight variability.

Contemplating choice: attitudes towards intervening in human reproduction in Sri Lanka.

To date, relatively little is known about the ethical, legal and social responses to recent advances in reproductive and genetic technology outside Europe and North America. This article reports on a survey carried out among doctors (n=278) and medical students (n=1256) in Sri Lanka to find out more about their responses to novel interventions in human reproduction such as In-Vitro Fertilization, Pre-Implantation Genetic Diagnosis and genetic engineering. In the first part of the paper comparisons are drawn between this survey and a survey carried out in 1985 which also considered issues surrounding amniocentesis and therapeutic termination. The second part of the paper deals with more recent developments. The analysis reveals high levels of support for the use of new technologies in treating infertility and identifying genetic disorders. However, differences are apparent among the major religious communities represented in the sample and these are particularly in evidence in relation to prenatal genetic diagnosis. An important theme throughout both surveys is the continuing tension surrounding State policy and termination of pregnancy and the implications this has for the development of screening and counseling services where genetic disorders are concerned.

Prenatal testing and pregnancy termination in Sri Lanka: views of medical students and doctors.

INTRODUCTION: Prenatal diagnosis and pregnancy termination generate complex ethical issues. Surveys conducted in Sri Lanka among doctors and medical students in 1986 supported a change in law in favour of pregnancy termination when gross genetic defects are detected antenatally. A new generation of prenatal tests has focused attention again on the topic of termination and under what circumstances it might be legally done. The present survey contributes to the debate by means of a survey of doctors and medical students. METHOD: A self-administered questionnaire given to doctors and medical students. RESULTS: Ninety three per cent of doctors and 81% of students accept pregnancy termination as an appropriate course of action if a gross genetic defect is detected antenatally, and 87% of doctors and 80% of students support a change in the law to allow termination of the pregnancy. The corresponding figures in previous surveys were 80%, 69% and 96%, 88% respectively. CONCLUSIONS: A majority of doctors and medical students support a change in law in favour of liberalising pregnancy termination when a genetic defect is detected antenatally.

Pattern of use of medical information made available via an Internet website.

INTRODUCTION: The Internet is probably the fastest growing means of public communication. Those who seek health and medical information are using it increasingly. We decided to study the pattern of use of information made available via an Internet website. METHOD: Retrospective analysis of the entries made on the guest book and direct inquiries made to the webmaster of an established and well known Sri Lankan medical website from 1 February 1997 to 20 November 1998. RESULTS: During this period 23,373 web surfers visited the site. There were 222 guest book entries and 12 direct inquiries to the webmaster. The analysis of these entries and inquiries show that there is a wide gap in use of the information available at this website between web surfers from the developed and the developing countries. CONCLUSION: Governments in developing countries must plan to make computers and information technology as well as telecommunication services affordable and widely available.

The attitudes of doctors and students towards a genetic service in an Asian country: Sri Lanka.

A study comparing the views on the acceptance of a genetic service of 302 doctors and 143 final year medical students from Colombo, Sri Lanka, showed both groups have strong positive views on the provision and use of genetic counselling, prenatal diagnosis of genetic disorders and therapeutic abortion. The students responded with greater restraint possibly due to being a younger cohort with less clinical experience. Both groups, however, showed little support for the use of prenatal diagnosis purely to determine fetal sex.