Genetic associations of inflammatory bowel disease in a South Asian population

AIM To estimate prevalence and phenotypic associations of selected inflammatory bowel disease(IBD)-associated genetic variants among Sri Lankan patients. METHODS A case study of histologically confirmed ulcerative colitis(UC) or Crohn's disease(CD) patients with ≥ 1 year disease duration, who were compared to unrelated, gender-matched, healthy individuals as controls, was conducted at four major centers in Sri Lanka. Phenotypic data of the cases were obtained and all participants were genotyped for 16 selected genetic variants: IL12 B :rs1045431, IL23 R :rs11805303, ARPC2 :rs12612347, IRGM :rs13361189, IL26/IL22 :rs1558744, CDH1 :rs1728785, IL10 :rs3024505, FCGR2 A :rs3737240, PTGER4 :rs4613763, IL17 REL/PIM3 :rs5771069, HNF4 a :rs6017342, STAT3 :rs744166, SMURF1 :rs7809799, LAMB1 :rs886774, HLA-DRB5, DQA1, DRB1, DRA :rs9268853, MST1, UBA7, and APEH :rs9822268. The genotypes of all variants were in Hardy-Weinberg Equilibrium(P > 10^(-3)). To account for multiple hypothesis testing, P-values < 0.003 were considered significant.RESULTS A total of 415 patients and 465 controls were recruited. Out of the single nucleotide polymorphisms(SNPs) tested, the majority were not associated with IBD in Sri Lankans. Significant positive associations were noted between rs886774(LAMB1-gene) and UC(odds ratio(OR) = 1.42, P = 0.001). UC patients with rs886774 had mild disease(OR = 1.66, P < 0.001) and remained in remission(OR = 1.48, P < 0.001). A positive association was noted between rs10045431(IL 12 B gene) and upper gastrointestinal involvement in CD(OR = 4.76, P = 0.002). CONCLUSION This confirms the heterogeneity of allelic mutations in South Asians compared to Caucasians. Most SNPs and disease associations reported here have not been described in South Asians.

A Study on Risk Factors for Venous Thromboembolism and the Requirement of Thromboprophylaxis in Pregnancy and Postpartum Period in a Tertiary Care Centre in South Asian Country: A Cross Sectional Study

Introduction: Thrombosis is a major cause of maternal death worldwide. During pregnancy, the risk of venous thromboembolism (VTE) increases fourfold to five-fold and contributes towards maternal morbidity and mortality. Sri Lanka does not have a proper assessment tool to detect and manage it in the antenatal care. Objectives: To identify risks factors for VTE among pregnant mothers, postpartum mothers according to RCOG (Royal College of Obstetricians) risk categorization and to assess the requirement of thromboprophylaxis. Method: A cross sectional study was conducted at the antenatal clinics and obstetrics and gynaecology wards (ward 2, 5, 8) of De Soysa Hospital for Women in 2021. Obstetric thromboprophylaxis risk assessment tool recommended by the RCOG was used for the risk assessment of pregnant mothers during the antenatal and postpartum period. Results: In antenatal period, obesity (BMI > 35), age more than 35 years and parity more than 3 were the commonest risk factors. Out of 404 mothers, 67.33% did not have any risk factors. Among others, 18.56%, 0.40%, 2.72%, 0.99% had a score of 1, 2, 3 and 4 respectively. Patients with intermediate (0.99%) and high risk (2.72%) were commenced on thromboprophylaxis from 28 weeks. The low-risk category was not started on any treatment (28.96%, n = 97). Approximately 96% of mothers did not require any thromboprophylaxis during antenatal period. Another 404 postnatal mothers were recruited for the study group. Elective caesarean section and caesarean section during labour were the main risks identified other than pre-existing antenatal risks. 39.95 % of mothers did not have any risk factors and 37.22% of mothers had a score of 1. Conclusions: VTE risk assessment tool can be implemented at national level to detect patients at risk of VTE and improve maternal care.

Abnormal Thyroid Stimulating Hormone Level and Heavy Menstrual Bleeding

Heavy Menstrual Bleeding is one of the common Gynaecological issues. There are several causes. Some of the women presented with these issues found to have underling thyroid abnormality which was not discovered earlier. This research tries to find the prevalence of the Thyroid Disorder among the women present with Heavy menstrual bleeding in Sri Lankan women.

Association of Squatting Activities of Pregnant Women during the Antenatal Period and Labor Outcomes

Aim: To investigate impact of antenatal squatting activities on labour outcomes. Methods: All eligible primigravida women, with singleton cephalic fetuses, who presented to ward 18 of Colombo South Teaching Hospital, Sri Lanka, during the period 1st of February to 28th of May 2017 were invited into the study. Those who were already in active stage of labor (at least more than two moderate contractions per 10 minutes) on admission were excluded. Demographic data such as age, ethnicity, religion, educational level, occupation, latrine type in use, and booking Body mass index (BMI) were collected via an interviewer administered questionnaire. Data related to labor (modified Bishop score at onset of active labor, labor augmentation, pain relief, labor duration, mode of delivery, episiotomy or tears) and neonatal outcome (birth weight, APGAR score at 1, 5, 10 minutes) were collected from delivery notes. A pre tested interviewer administered questionnaire was used to obtain data regarding routine squatting activities during the previous 6 months. Pain visual analogue scale was used on day after delivery to assess the degree of labour pain. Duration of each squatting activity per day and number of days engaged with the activity per week;were used to calculate total squatting hours per week. In the absence of an accepted threshold for adequate squatting, we employed the sample mean as an operational data-driven threshold to define “more” against “less” squatting activities. Women who did not have squatting activities were considered as the controls. We used chi-square and Fisher’s exact tests to compare characteristics and outcomes between those engaging in more and less levels of squatting activity. We fitted a series of logistic regression models with each dichotomized outcome as the dependent variable, more/less squatting activity as the main independent variable of interest, and age, gestation period, BMI and patient’s occupation as covariates. The resulting adjusted odds ratios (AOR) and their 95% confidence intervals (CI) and statistical significance (p < 0.05) were used to draw conclusions of adjusted associations. Results: We recruited 430 women into this study. Overall, 68% of the women were of 20 - 30 years old, 47% had normal body mass index and 65% were housewives. The most frequent squatting activities were for urination/defecation and clothes washing (146 and 62 minutes/week, respectively). Mean total time was 246 minutes per week, of which more than 147 women (34%) achieved above this level of squatting activities. Those with more squatting activities had a greater modified Bishop Score ≥ 6/10 (92% vs 82%;p < 0.01);labor duration of <6 hours (82% vs 56%;p < 0.01), less likely for labour augmentation (39% vs 51%;p < 0.01) and pain relief (53% vs 65%;p = 0.013). Similar results were obtained after adjustments for maternal age, BMI, gestational age and occupation. However, there were no significant differences in the mode of delivery (normal vaginal vs instrumental vs caesarean), episiotomy rate, birth weight and neonatal Apgar scores. Conclusion: Squatting activities of more than 246 minutes per week may improve labor outcome. Women should be encouraged to increase squatting exercises or incorporate more habitual squatting activities antenatally.

Dengue fever may mislead the surgeons when it presents as an acute abdomen

Objective: To review the management experience of a consecutive series of patients presenting as acute surgical abdomen whom were ultimately diagnosed to have DF(Dengue fever)/ DHF(Dengue heamorrhagic fever),Methods: Clinical data of all cases of apparent acute abdomen(AA) which were later confirmed as having DF/DHF reviewed by two surgical units from December 2012 to December 2013 were analyzed,Initially confirmed patients with DF/DHF who developed abdominal symptoms were not considered,Results: Out of the seventeen cases(7 males,age range 10-71 years) presented with fever and AA; appendicitis,cholecystitis,pancreatitis and non-specific peritonitis were suspected initially in 8,5,1 and 3 cases,respectively,Neutropenia or thrombocytopenia signifying DF/DHF occurred only in 11 patients at first evaluation thus six remained as surgical candidates beyond 24 h,One patient underwent appendicectomy with a prolonged hospital stay,DF was confirmed by serology in all patients,latest by fourth day of admission,One required blood product transfusion,4 needed critical care treatment and there was 1 death,Conclusions: DF/DHF misleads the clinicians when it presents as AA,Initial heamatological and ultrasonographic findings may be equivocal creating a diagnostic and management dilemma,Vigilant clinical suspicion and early dengue serological assessment is advisable in equivocal cases of AAs with fever in dengue endemic areas,to confirm/exclude the infection in order to avoid unnecessary surgical morbidity in the presence of DF.

Cystoscopic extraction of an inadvertently placed ureteral stent in inferior vena cava

Dear Editor,A stent is a tube kept within a tubular structure to maintain luminal patency or protect an anastomosis or graft.In urological practice ureteral stents are inserted to relieve ureteral obstruction,to support ureteral anastomoses and repairs,to treat minor ureteric injuries,and to identify the ureters at open surgery.During insertion,ureteral stents may pierce the ureteric wall and enter adjacent structures.

Prostate cancer in Asia:A collaborative report--The situation in Sri Lanka

Dear editor,I read with interest the article on Prostate cancer in Asia published in the inaugural issue of the Asian Journal of Urology[1].The authors should be commended for their effort in compiling a comprehensive report.A note on the situation of prostate cancer in Sri Lanka would make it more complete;hence this letter.

Pre-Induction Cervical Ripening Using a Transcervical Foley Catheter Combined with ISMN Vaginal Tablets for Vaginal Birth after Previous Caesarean Section (VBAC)—A Comparative Study

Objective: To compare the effectiveness, safety and client acceptability of concurrent application of transcervical Foley catheter with vaginal ISMN-sustained release (SR) 60 mg tablet versus transcervical Foley catheter alone for pre-induction cervical ripening in women who are undergoing Vaginal birth after C-section (VBAC). Method: A prospective single blind randomized control study was carried out including 110 pregnant women who had unfavorable cervix (MBS less than 6) at 40 weeks and 3 days of gestation. The two groups received either the trans-cervical foley catheter with a vaginal ISMN 60 mg sustained release (SR) tablet on 40 weeks and 3 days (Treatment arm 1, n = 57), or trans-cervical Foley alone on 40 weeks and 3 days (Treatment arm 2, n = 53). Results: At 40 weeks + 3 days gestation, the mean age, mean parity and the mean modified Bishop Score (MBS) were comparable among the two treatment groups. Majority (n = 98, 89.1%) remained without spontaneously establishing labour at 24 hours of intervention. The difference in mean MBS at 40 weeks + 4 days (24-hours following the intervention) in the two groups was statistically not significant (P > 0.05). The group who received concurrent ISMN vaginal tablets achieved a higher number of successful VBACs (n = 33, 62.3%) over the group who received the Foley catheter only method (n = 29, 50.9%), however, not statistically significant (P > 0.05). Conclusions: The concurrent use of vaginal ISMN tablets (60 mg SR) with a transcervical Foley catheter failed to show higher effectiveness compared to a transcervical Foley catheter alone as an induction method.

A case of follicular cystitis treated successfully with diethylcarbamazine

Follicular cystitis is a non-specific inflammatory condition of the bladder where the aetiology is unknown.The extent of the disease can be mild or proliferative and bulky.Antibiotics,steroids,therapies used for interstitial cystitis,palliative cystectomy and radiotherapy have been reported as successful treatment options.We report a case of follicular cystitis that responded to a course of oral diethyl carbamazine.

Changing clinical profile,management strategies and outcome of patients with biliary tract injuries at atertiary care center in SriLanka

BACKGROUND: Biliary tract injuries are mostly iatrogenic Related data are limited in developing countries. There are lessons to be learned by revisiting the clinical profiles management issues and outcome of patients referred to a tertiary care center in Sri Lanka, compared with the previous data from the same center published in 2006. Such a review is particularly relevant at a time of changing global perceptions of iatrogenic biliary injuries. This study aimed to analyze and compare the changes in the injury pattern, management and outcome following biliary tract injury in a Sri Lankan study population treated at a tertiary care center. METHODS: A retrospective analysis was made of 67 patients treated between May 2002 and February 2011. The profiles of the last 38 patients treated from October 2006 to February 2011 were compared with those of the first 29 patients treated from May 2002 to September 2006. Definitive management options included endoscopic biliary stenting, reconstructive hepaticojejunostomy with creation of gastric access loops and biliary stricture dilation. Post-treatment jaundice cholangitis and abdominal pain needing intervention were considered as treatment failures. RESULTS: In the 67 patients, 55 were women and 12 men Their mean age was 40.6 (range 19-80) years. Five patients had traumatic injuries. Thirty-seven injuries (23 during the second study period) were due to laparoscopic cholecystectomy and 25 (10 during the second study period) to open cholecystectomy The identification rate of intra-operative injury was 19% in the laparoscopic group and 8% in the open group. Bismuth typeI, II, III and IV injuries were seen in 18, 18, 15 and 12 patients, respectively. Endoscopic stenting was the definitive treatment in 20 patients. In 35 patients who had hepaticojejunostomy, 33 underwent creation of the gastric access loop. Twenty- two reconstructions were performed during the second study period. A gastric access loop was used for endotherapy in three patients with anastomotic occlusion at the site of hepaticojejunostomy. The overall outcome was satisfactory in the majority of patients. There were four injury-related deaths. CONCLUSIONS: Biliary tract injuries associated with laparoscopic cholecystectomy have become the most frequent cause of biliary injury management at our center. Although endotherapy was useful in selected patients, in the majority, surgical reconstruction with hepaticojejunostomy was required as the definitive treatment. Creation of the gastric access loop was found to be a useful adjunct in the management of hepaticojejunostomy strictures.

Antimicrobial susceptibility and serotypes of Neisseria meningitidis and Streptococcus pneumoniae in Sri Lanka:Experience from the National Reference Laboratory

Objective:To determine the antimicrobial susceptibility and serotypes of Neisseria(N.)meningitidis and Streptococcus(S.)pneumoniae in Sri Lankan patients.Methods:We retrospectively analyzed 11 blood culture specimens from suspected patients with invasive meningococcal disease and 26 S.pneumoniae clinical isolates.We tested 6 antimicrobials against N.meningitidis and 12 antimicrobials against S.pneumoniae.Meningococcal serogroup was determined by realtime PCR and Quellung serotyping was used for pneumococcal analysis.Results:N.meningitidis serogroup B was the most common in this study.Intermediate-susceptibility to penicillin was seen in 75.0%(6/8)of strains.Susceptibility to ciprofloxacin,levofloxacin and cotrimoxazole was 62.5%(5/8),62.5%(5/8)and 87.5%(7/8),respectively.Excellent susceptibility was seen in cefotaxime and meropenem.In S.pneumoniae,the most common serotype was 19F in both invasive and non-invasive pneumococcal diseases.The majority of strains showed multidrug resistance.Penicillin non-susceptibility in non-meningeal strains were 13.6%and all meningeal strains were penicillin resistant.Erythromycin was highly resistant in both groups.Amoxicillin showed excellent susceptibility in non-invasive pneumococcal diseases strains.Linezolid,levofloxacin and vancomycin showed 100.0%susceptibility in all pneumococcal isolates.Conclusions:Implementation of vaccines should be considered,especially for children and high-risk populations.This may contribute to reducing pneumococcal and meningococcal invasive disease burden and help prevent emergence of antimicrobial resistant strains.

New Sri Lankan Crown Rump Length Chart

Introduction Accurate pregnancy dating is important for many aspects of obstetric care at individual level as well as population level. Traditionally, pregnancy dating has done by adding 9 months and 7 days to the last menstrual period (LMP) using Naegele’s formula. Determination of gestational age by ultrasound is more precise. Most commonly used parameters are mean sac diameter, gestation sac volume, crown-rump length (CRL), biparietal diameter (BPD), head circumference (HC) and femur length (FL). After 24 weeks, gestational age cannot be accurately determined by ultrasound scans. The biological variability of CRL is small and growth is very rapid. There are many factors that can affect CRL such as measurement errors, differences in growth rates between individuals, fetal sex and maternal conditions such as diabetes mellitus. A correctly performed measurement of CRL is the most accurate way of estimating the gestational age in early pregnancy from 8 weeks to 13 weeks + 6 days. Objectives Our study aims were to prepare a new Crown Rump Length chart with Sri Lankan population data and to compare new CRL chart with existing intergrowth CRL chart. Method Prospective observational study with recruitment of subjects by Quota sampling technique was carried out from April 2015 to March 2016. Spontaneously conceived uncomplicated singleton pregnancies with normal Body Mass Index (BMI) 18.5 - 23 kg/m2 were recruited at the time of registration to antenatal care. Consenting woman with known LMP with regular cycles in preceding 3 months were undergone ultrasound examination only once at gestational age (GA) ranging from 8 weeks to 13 weeks + 6 days. If ultrasound dating was different from LMP dating by more than 5 days in pregnancies with POA less than 9 weeks and dating differences more than 7 days in pregnancies between 9 weeks and 14 weeks were excluded. Pregnancies complicated with uncertain viability, congenital anomalies and spontaneous miscarriage were excluded from statistical analysis. Data collection done with pre-tested interviewer administered form and analysis was carried out using the Statistical Package for Social Sciences (SPSS) version 21. Results A total of 653 subjects were recruited for the study and 557 turned up for ultrasound dating assessment. Dating discrepancy and multiple pregnancies excluded 31 subjects, uncertain viability and spontaneous miscarriage excluded 15 subjects resulting 511 subjects for final statistical analysis. The mean CRL increased with GA almost linearly from day 56 to 97. Conclusions We have produced new CRL chart based on Sri Lankan data and it can be used for clinical practice in Sri Lanka. There is no statistically significant difference between our CRL chart and intergrowth CRL chart.