Translation, cross-cultural adaptation, and validation of the Duke Activity Status Index (DASI) to Sinhala language.

BACKGROUND: Duke Activity Status Index (DASI) is a widely used tool to assess functional capacity among patients, but there is no Sinhala version validated for patients in Sri Lanka. This study aimed to cross-culturally adapt and test the validity and reliability of the Sinhala version of DASI (DASI-S). METHODS: The translation and cross-cultural adaptation of the DASI questionnaire were conducted following the standard guidelines. It was pre-tested on ten pre-operative patients and further modified. The construct validity and reliability of DASI-S were evaluated by administering the modified final DASI-S, which comprised 12 items, along with the physical functioning sub-scale of the 36-item short-form health survey (SF-36), consisting of 10 items to eighty-one patients who were awaiting non-cardiac surgeries at university surgical wards, National Hospital of Sri Lanka (NHSL), and Colombo North Teaching Hospital (CNTH), Sri Lanka. Reliability was assessed through Cronbach alpha, while the validity was evaluated using factor analysis and Spearman's correlation. The ethical approval was obtained from the Ethics Review Committee, Faculty of Medicine, University of Colombo, Sri Lanka. RESULTS: The mean age of the participants was 46.2 (± 16.6) years and the majority were females (54.3%). The mean height, weight, and body mass index of the sample were 160.5 (± 9.6) cm, 60.3 (± 11.9) kg, and 23.4 (± 4.5) kgm-2 respectively. The Cronbach's alpha coefficient for the internal consistency of DASI-S was 0.861. The concurrent validity of DASI-S was substantiated by positively correlating (p < 0.01, rs = 0.466) with the physical sub-scale of SF-36. There was a significant difference (p < 0.01) in the total score of DASI-S between the two age groups. CONCLUSIONS: Sinhala version of the DASI appears to be a valid, reliable and easy-to-administer tool to assess functional capacity among patients who are awaiting non-cardiac surgeries.

A novel structure for online surgical undergraduate teaching during the COVID-19 pandemic.

BACKGROUND: The Covid-19 pandemic necessitated the delivery of online higher education. Online learning is a novel experience for medical education in Sri Lanka. A novel approach to undergraduate surgical learning was taken up in an attempt to improve the interest amongst the students in clinical practice while maximizing the limited contact time. METHOD: Online learning activity was designed involving medical students from all stages and multi consultant panel discussions. The discussions were designed to cover each topic from basic sciences to high-level clinical management in an attempt to stimulate the student interest in clinical medicine. Online meeting platform with free to use basic plan and a social media platform were used in combination to communicate with the students. The student feedback was periodically assessed for individual topics as well as for general outcome. Lickert scales and numeric scales were used to acquire student agreement on the desired learning outcomes. RESULTS: A total of 1047 student responses for 7 questionnaires were analysed. During a 6-week period, 24 surgical topics were discussed with 51 contact hours. Eighty-seven per cent definitely agreed (highest agreement) with the statement 'students benefitted from the discussions'. Over 95% have either participated for all or most sessions. A majority of the respondents (83.4%) 'definitely agreed' that the discussions helped to improve their clinical sense. Of the total respondents, 79.3% definitely agreed that the discussions helped to build an interest in clinical medicine. Around 90% agreed that both exam-oriented and clinical practice-oriented topics were highly important and relevant. Most widely raised concerns were the poor Internet connectivity and limitation of access to the meeting platform. CONCLUSION: Online teaching with a novel structure is feasible and effective in a resource-limited setting. Students agree that it could improve clinical interest while meeting the expected learning outcomes.

Technical variations and feasibility of transanal ileal pouch-anal anastomosis for ulcerative colitis and inflammatory bowel disease unclassified across continents.

PURPOSE: Initial reports of transanal ileal pouch-anal anastomosis (taIPAA) suggest safety and feasibility compared with transabdominal IPAA. The purpose of this study was to evaluate differences in technique and results of taIPAA in three centers performing taIPAA across two continents. METHODS: Prospective IPAA registries from three institutions in the US and Europe were queried for patients undergoing taIPAA. Demographic, preoperative, intraoperative, and postoperative data were compiled into a single database and evaluated. RESULTS: Sixty-two patients (median age 38 years; range 16-68 years, 43 (69%) male) underwent taIPAA in the three centers (USA 24, UK 23, Italy 15). Most patients had had a subtotal colectomy before taIPAA [n = 55 (89%)]. Median surgical time was 266 min (range 180-576 min) and blood loss 100 ml (range 10-500 ml). Technical variations across the three institutions included proctectomy plane of dissection (intramesorectal or total mesorectal excision plane), specimen extraction site (future ileostomy site vs. anus), ileo-anal anastomosis technique (stapled vs. hand sewn) and use of fluorescence angiography. Despite technical differences, anastomotic leak rates (5/62; 8%) and overall complications (18/62; 29%) were acceptable across the three centers. CONCLUSIONS: This is the first collaborative report showing safety and feasibility of taIPAA. Despite technical variations, outcomes are similar across centers. A large multi-institutional, international IPAA collaborative is needed to compare technical factors and outcomes.

Role of SMAD proteins in colitis-associated cancer: from known to the unknown.

Small mothers against decapentaplegic (SMAD) proteins are a family of signal transduction molecules in transforming growth factor ß (TGFß) ligand pathways that have been found to have a key role in the pathogenesis of inflammatory bowel disease (IBD). Long standing IBD predisposes individuals to colitis-associated colorectal cancer (CAC), an entity that possess unique characteristics compared to hereditary and sporadic cancer. The ligands of the TGFß super family along with SMADs have also been implicated in several aspects of colorectal cancer formation. SMAD proteins are shown to be involved in a number of potentially carcinogenic mechanisms such as altering gene transcription, controlling stem cell differentiation to causing epigenetic changes. Modulation of these proteins has emerged as a novel therapeutic intervention for IBD although its effect on carcinogenesis remains elusive. This account reviews available evidence linking SMAD proteins to CAC and explores the potential areas for future research in this area.

Colorectal cancer burden and trends in a South Asian cohort: experience from a regional tertiary care center in Sri Lanka.

OBJECTIVE: Colorectal cancer (CRC) burden is increasing in the south Asian region due to the changing socio-economic landscape and population demographics. There is a lack of robust high quality data from this region in order to evaluate the disease pattern and comparison. Using generalized linear models assuming Poisson distribution and model fitting, authors describe the variation in the landscape of CRC burden along time since 1997 at a regional tertiary care center in Sri Lanka. RESULTS: Analyzing 679 patients, it is observed that both colon and rectal cancers have significantly increased over time (pre 2000-61, 2000 to 2004-178, 2005 to 2009-190, 2010 to 2014-250; P < 0.05). Majority of the cancers were left sided (82%) while 77% were rectosigmoid. Over 25% of all CRC were diagnosed in patients less than 50 years and the median age at diagnosis is < 62 years. Increasing trend is seen in the stage at presentation while 33% of the rectal cancers received neoadjuvant chemoradiation. Left sided preponderance, younger age at presentation and advanced stage at presentation was observed. CRC disease pattern in the South Asian population may vary from that observed in the western population which has implications on disease surveillance and treatment.

The MACC1-SPON2 axis: a new biomarker and therapeutic target in colorectal cancer.

In this issue of the Journal, Schmid et al identify Spondin 2 (SPON2) as a prominent downstream signaling target of metastasis-associated in colon cancer 1 (MACC1) in colorectal cancer (CRC). It is shown that SPON2 mediates MACC1-induced CRC cell proliferation, invasion and metastasis in vitro and in vivo, while its high expression correlates with adverse disease free survival in clinical samples. Therefore, not only does this study shed further light into the complexity of colorectal carcinogenesis, but it also puts forward a potential novel prognostic biomarker to predict high-risk tumors before they metastasize. The MACC1/SPON2 axis may also have utility beyond an indicator of tumor aggressiveness and lends itself as a promising therapeutic target for colorectal and potentially other solid tumors.

The prevalence of autoimmune thyroiditis after universal salt iodisation in Sri Lanka.

INTRODUCTION: Sri Lanka is endemic for goiters. Iodine deficiency is thought to be the main cause. The global iodisation programme was implemented in the country in 1995. Several studies done in school children have shown a reduction in the goiter prevalence (3.8%) in the initial post iodisation period. An island wide, community based study was carried out to study the prevalence of goiters. METHODS: A multistage cluster sampling method was used. Examination of goiters was done by two trained investigators and graded according to the WHO grading. Fine needle aspiration cytology of the goitres was also undertaken in the field. A sample of urine was collected from all participants. In a random sample of 153 individuals with a goiter, serum was checked for anti thyroid peroxidase antibodies. RESULTS: Out of 5200 individuals screened, 426 had a clinically detectable goiter. Adjusted prevalence rate was 6.8%. Both serological and cytological evidence of autoimmune thyroiditis was seen in 19.6% of goiters. Mean urinary iodine concentration was 235 µg/l range 11.1 - 425 µg/l). Association between elevated antithyroperoxidase antibodies and median urinary iodine concentration was significant. CONCLUSION: Goiter prevalence in Sri Lanka has increased after an initial drop following the iodisation. A significant proportion of goiters is due to AIT. Urinary excretion of Iodine in the community is high and has a positive correlation with the prevalence of aTPO anti vodies. Increase in AIT due to a high Iodine intake may account for the rise in goiter prevalence.