Prevalence and correlates of carotid artery stenosis in a cohort of Sri Lankan ischaemic stroke patients

Background

Large artery atherosclerotic disease is an important cause of stroke, accounting for 15–46% of ischaemic strokes in population-based studies. Therefore, current guidelines from west recommend urgent carotid imaging in all ischaemic strokes or transient ischaemic attacks and referral for carotid endarterectomy. However, the clinical features and epidemiology of stroke in Asians are different from those in Caucasians and therefore the applicability of these recommendations to Asians is controversial. Data on the prevalence of carotid artery stenosis (CAS) among South Asian stroke patients is limited. Therefore, we sought to determine the prevalence and associated factors of significant CAS in a cohort of Sri Lankan patients with ischaemic stroke.

Methods

We prospectively studied all ischaemic stroke patients who underwent carotid doppler ultrasonography admitted to the stroke unit of a Sri Lankan tertiary care hospital over 5 years. We defined carotid stenosis as low (< 50%), moderate (50–69%) or severe (70–99%) or total-occlusion (100%) by North American Symptomatic Trial Collaborators (NASCET) criteria. We identified the factors associated with CAS ≥ 50% and ≥ 70% by stepwise multiple logistic regression analysis.

Results

A total of 550 ischaemic stroke patients (326 (59.3%) male, mean age was 58.9 ± 10.2 years) had carotid doppler ultrasonography. Of them, 528 (96.0%) had low-grade, 12 (2.2%) moderate and 7 (1.3%) severe stenosis and 3 (0.5%) had total occlusion. On multivariate logistic regression, age was associated with CAS ≥ 50% (OR 1.12, p = 0.001) and CAS ≥ 70% (OR 1.14, p = 0.016), but none of the other vascular risk factors studied (sex, hypertension, diabetes mellitus, smoking, past history of TIA, stroke or ischemic heart disease) showed significant associations.

Conclusions

Carotid stenosis is a minor cause of ischemic stroke in Sri Lankans compared to western populations with only 4.0% having CAS ≥ 50 and 3.5% eligible for carotid endarterectomy. Our findings have implications for the management of acute strokes in Sri Lanka.

Can pain flares in knee osteoarthritis be predicted?

Objectives: This study examined whether risk factors for knee osteoarthritis (KOA) pain such as age, gender, body mass index (BMI), baseline pain, and other putative risk factors for knee osteoarthritis pain flares (KOAF) (e.g. knee buckling, injury, mood/stress/social support scores, and footwear) could predict KOAF.Method: People with KOA and previous history of KOAF were selected from a 3 month web-based longitudinal study. KOAF was defined as an increase of ≥ 2 points on a numeric rating scale (compared with background pain) which resolved within 20 days. Predictors assessed at baseline were gender, age, duration of KOA, BMI, pain, knee injury (7 days before), knee buckling (2 days before), Lubben Social Support, Knee Injury and Osteoarthritis Outcome Score, Intermittent and Constant Osteoarthritis Pain score (ICOAP), Positive/Negative Affect Score, and footwear stability/heel height. Outcome was occurrence of any KOAF during the ensuing 30 days. The combined ability of the above variables to predict occurrence of any KOAF was evaluated by multiple logistic regression with a 10-fold cross-validation method to build and internally validate the model. Variables that assessed similar domains were eliminated using receiver operating characteristics curve assessment for best fit.Results: Complete data were available for 313 people (66.6% female, mean ± sd age 62.3 ± 8.2 years, BMI 29.7 ± 6.5 kg/m²). Increasing age, years of osteoarthritis, BMI, background/worst levels of pain, knee injury, knee buckling, ICOAP, and footwear category/heel height significantly predicted the occurrence of KOAF during the following 30 days, with an area under the curve of 0.73 (95% confidence interval 0.67-0.80).Conclusion: A combination of risk factors assessed at baseline, including exposures with potential to vary, successfully predicts the KOAF in the ensuing 30 days.

Percentage of small platelets on peripheral blood smear and Child-Turcott-Pugh class can predict the presence of oesophageal varices in newly diagnosed patients with cirrhosis: development of a prediction model for resource limited settings

Background

In cirrhosis upper-gastrointestinal-endoscopy (UGIE) identifies oesophageal varices (OV). UGIE is unavailable in most resource-limited settings. Therefore, we assessed prediction of presence of OV using hematological parameters (HP) and Child-Turcott-Pugh (CTP) class.

Methods

A prospective study was carried out on consecutive, consenting, newly-diagnosed patients with cirrhosis, in the University Medical Unit, Colombo North Teaching Hospital, Ragama, Sri Lanka from April 2014–April 2016. All patients had UGIE to evaluate presence and degree of OV, prior to appropriate therapy. HP (full blood count with indices using automated analyzer and peripheral blood smear using Leishmann stain) and CTP class were assessed on admission. Linear logistic regression model was developed to predict OV using HP and CTP class.

Results

54-patients with cirrhosis were included [14(26%), 24(44%) and 16(30%) belonged to CTP class A, B and C respectively]. 37 had varices [CTP-A 4/14(26.6%), CTP-B 19/24(79.2%), CTP-C 14/16(87.5%)] on UGIE. Generalized linear model fitting showed decreasing percentage of small platelets (%SP) (P = 0.002), CTP-B (P = 0.003) and CTP-C (P = 0.003) compared to CTP-A had higher probability of having OV. The model predicts the log odds for having OV = − 0.189 – (0.046*%SP) + 2.9 [if CTP-B] + 3.7 [if CTP-C]. Based on receiver operating characteristic (ROC) analysis, a model value > − 0.19 was selected as the cutoff point to predict OV with 89%-sensitivity, 76%-specificity, 89%-positive predictive value and 76%-negative predictive value.

Conclusions

We constructed a model using %SP on peripheral blood smear and CTP class. This model may be used to predict the presence of OV, in newly diagnosed patients with cirrhosis, with acceptable sensitivity and specificity, to prioritize the patients who deserve early UGIE in limited resource settings.

Electronic supplementary material

The online version of this article (10.1186/s12876-019-1054-5) contains supplementary material, which is available to authorized users.

A lifestyle intervention programme for the prevention of Type 2 diabetes mellitus among South Asian women with gestational diabetes mellitus [LIVING study]: protocol for a randomized trial

AIM

This study aims to determine whether a resource- and culturally appropriate lifestyle intervention programme in South Asian countries, provided to women with gestational diabetes (GDM) after childbirth, will reduce the incidence of worsening of glycaemic status in a manner that is affordable, acceptable and scalable.

METHODS

Women with GDM (diagnosed by oral glucose tolerance test using the International Association of the Diabetes and Pregnancy Study Groups criteria) will be recruited from 16 hospitals in India, Sri Lanka and Bangladesh. Participants will undergo a repeat oral glucose tolerance test at 6 ± 3 months postpartum and those without Type 2 diabetes, a total sample size of 1414, will be randomly allocated to the intervention or usual care. The intervention will consist of four group sessions, 84 SMS or voice messages and review phone calls over the first year. Participants requiring intensification of the intervention will receive two additional individual sessions over the latter half of the first year. Median follow-up will be 2 years. The primary outcome is the proportion of women with a change in glycaemic category, using the American Diabetes Association criteria: (i) normal glucose tolerance to impaired fasting glucose, or impaired glucose tolerance, or Type 2 diabetes; or (ii) impaired fasting glucose or impaired glucose tolerance to Type 2 diabetes. Process evaluation will explore barriers and facilitators of implementation of the intervention in each local context, while trial-based and modelled economic evaluations will assess cost-effectiveness.

DISCUSSION

The study will generate important new evidence about a potential strategy to address the long-term sequelae of GDM, a major and growing problem among women in South Asia. (Clinical Trials Registry of India No: CTRI/2017/06/008744; Sri Lanka Clinical Trials Registry No: SLCTR/2017/001; and ClinicalTrials.gov Identifier No: NCT03305939).

Lean non-alcoholic fatty liver disease (lean NAFLD): characteristics, metabolic outcomes and risk factors from a 7-year prospective, community cohort study from Sri Lanka

INTRODUCTION

While patients with non-alcoholic fatty liver disease (NAFLD) are mostly overweight or obese, some are lean.

METHODS

In a community-based follow-up study (baseline and follow-up surveys performed in 2007 and 2014), we investigated and compared the clinical characteristics, body composition, metabolic associations and outcomes, and other risk factors among individuals with lean (BMI < 23 kg/m²) NAFLD, non-lean (BMI ≥ 23 kg/m²) NAFLD and those without NAFLD. To investigate associations of selected genetic variants, we performed a case-control study between lean NAFLD cases and lean non-NAFLD controls.

RESULTS

Of the 2985 participants in 2007, 120 (4.0%) had lean NAFLD and 816 (27.3%) had non-lean NAFLD. 1206 (40.4%) had no evidence of NAFLD (non-NAFLD). Compared to non-lean NAFLD, lean NAFLD was commoner among males (p < 0.001), and had a lower prevalence of hypertension (p < 0.001) and central obesity (WC < 90 cm for males, < 80 cm for females) (p < 0.001) without prominent differences in the prevalence of other metabolic comorbidities at baseline survey. Of 2142 individuals deemed as either NAFLD or non-NAFLD in 2007, 704 NAFLD individuals [84 lean NAFLD, 620 non-lean NAFLD] and 834 individuals with non-NAFLD in 2007 presented for follow-up in 2014. There was no difference in the occurrence of incident metabolic comorbidities between lean NAFLD and non-lean NAFLD. Of 294 individuals who were non-NAFLD in 2007 and lean in both 2007 and 2014, 84 (28.6%) had developed lean NAFLD, giving an annual incidence of 4.1%. Logistic regression identified the presence of diabetes at baseline, increase in weight from baseline to follow-up and a higher educational level as independent risk factors for the development of incident lean NAFLD. NAFLD association of PNPLA3 rs738409 was more pronounced among lean individuals (one-tailed p < 0.05) compared to the whole cohort sample.

CONCLUSION

Although lean NAFLD constitutes a small proportion of NAFLD, the risk of developing incident metabolic comorbidities is similar to that of non-lean NAFLD. A PNPLA3 variant showed association with lean NAFLD in the studied population. Therefore, lean NAFLD also warrants careful evaluation and follow-up.

Effect of audio and visual distraction on patients undergoing colonoscopy: a randomized controlled study

Background and study aims: Colonoscopy can cause anxiety and discomfort in patients. Sedation and analgesia as premedication can lead to complications in the elderly and those with comorbidities. This has led to an interest in the use of audio-visual distraction during the colonoscopy. We compared the effects of audio (AD) versus visual distraction (VD) in reducing discomfort and the need for sedation during colonoscopy. Patients and methods: Consecutive patients undergoing colonoscopy were randomized into three groups: one group was allowed to listen to the music of their choice (AD), the second group was allowed to watch a movie of their choice (VD), and the third group was not allowed either distraction during colonoscopy and acted as a control (C). Patient controlled analgesia and sedation were administered to all three groups. We used 25 mg of pethidine in 5-mg aliquots and 2.5 mg of midazolam in 0.5-mg aliquots. All patients were assessed for perceived pain and willingness to repeat the procedure. Number of "top-ups" of sedation and total dose of pethidine and midazolam were noted. Patient cooperation and ease of procedure were assessed by the colonoscopist. Results: In total, 200 patients were recruited [AD, n = 66 (32 males, median age 57 years); VD, n = 67 (43 males, median age 58 years); C, n = 67 (35 males, median age 59 years)]. The AD group had significantly less pain (P = 0.001), better patient cooperation (P = 0.001) and willingness to undergo a repeat procedure (P = 0.024) compared with VD and C groups. Conclusions: AD reduces pain and discomfort, improves patient cooperation and willingness to undergo a repeat procedure, and seems a useful, simple adjunct to low dose sedation during colonoscopy.

STUDY REGISTRATION

SLCTR/2014/031.

Efficacy of rivastigmine on activities of daily living in Sri Lankan patients with Alzheimer disease and on improving caregiver burden: a prospective study

OBJECTIVE

This open label, parallel group, prospective cohort study investigated the efficacy of rivastigmine treatment on activities of daily living (ADL) in patients with mild to moderate Alzheimer's disease (AD) and the possible benefits of this therapy on caregiver stress levels.

METHODS

Thirty eight consecutive patients with mild to moderate AD were recruited; 22 received rivastigmine 3-6 mg twice daily (treatment group) for 20 weeks. Sixteen patients who did not receive rivastigmine served as the control group. The 17-item ADL Index was used to assess ADL and to determine the presence of functional deterioration. Caregivers were evaluated with the Caregiver Stress Scale (CSS). Each patient was required to have a committed caregiver and all caregivers were interviewed and administered the ADL Index and the Caregiver Stress Scale (CSS) at the start of treatment (week 0) and at the end of 20 weeks of treatment (week 20).

RESULTS

Patients in the control group showed a significant decline in ADL Index score at 20 weeks compared to rivastigmine-treated patients (difference in mean ADL Index score = 8.5; p < 0.001). At week 20, mean change from baseline scores for CSS total and individual domain scores were better for caregivers in the treatment group than those in the control group (CSS total mean difference = 19.2).

CONCLUSION

We conclude that treatment of AD patients with rivastigmine for 20 weeks produces a significant improvement in patient ADL functioning, and lower levels of caregiver stress.

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.

Histopathology reporting in colorectal cancer: a proforma improves quality

AIM

The histopathology report is vital to determine the need for adjuvant therapy and prognosis in colorectal cancer (CRC). Completeness of those in text format is inadequate. This study evaluated the improvement of quality of histopathology reports following the introduction of a template proforma, based on standards set by the Royal College of Pathologists (RCP), UK.

METHOD

Sixty-eight consecutive histopathology reports based on 19 items for rectal cancer (RC) and 15 items for colon cancer (CC) using the proforma were prospectively analysed and compared with results of a previous audit of 82 consecutive histopathology reports in text format. The percentage of reports containing a statement for each data item for both series was compared using the Normal test for difference between two proportions. Completeness of each report was assessed and a percentage score (percentage completeness) was given. Mean percentage completeness was calculated for each format and compared using the two sample t-test.

RESULTS

Except for comments on the presence of 'histologically confirmed liver metastases' in CC and RC, 'distance from dentate line' and 'distance to circumferential margin' in RC, all other items were commented in more than 90% of reports, where 71% of the items based on the minimum data set were present in all reports. Compared to prose format, the mean percentage completeness (SD) improved from 74% (8) to 91% (4) (P < 0.0001) and from 81% (5) to 99% (1) (P < 0.0001) for RC and CC respectively in template proforma format.

CONCLUSION

A template proforma and surgeon's contribution in relation to operative findings improves the quality of the histopathology report in CRC.

Effects of placental infarctions on the fetal outcome in pregnancies complicated by hypertension

OBJECTIVE

To determine the frequency of placental infarcts and its effects on the fetal outcome in pregnancies complicated by hypertension.

STUDY DESIGN

Case control.

PLACE AND DURATION OF STUDY

Obstetrics Unit of North Colombo Teaching Hospital, Ragama, Sri Lanka, from January 2003 to January 2004.

PATIENTS AND METHODS

Placentae of 150 normotensive women and 200 hypertensive women were studied to detect the number of placentae with infarctions. Apgar score, birth weight and the head circumference of the newborns were measured and analyzed.

RESULTS

The frequency of placental infarcts was significantly higher in hypertensive group (30%) compared to normotensive group (18.7%). An association between placental infarction and low Apgar score of the newborn was seen in the hypertensive group (p<0.001). The difference in the birth weight of the newborns in hypertensive and normotensive groups in relation to placental infarction was statistically significant (2.2 vs. 3.1 kg, p<0.001). A highly significant difference was observed in the head circumference of the newborns of hypertensive group compared to normotensive group in relation to placental infarctions (30.7 cm vs. 32.3 cm, p<0.001).

CONCLUSION

The frequency of placental infarcts was higher in hypertensive women when compared to normotensives. Placental infarctions had an adverse effect on growth and development of the newborns. This information can be useful in planning and management of future pregnancies.

Concurrent validity of the alcohol use disorders identification test (AUDIT)

AIMS

To determine cut-offs for the Alcohol Use Disorders Identification Test (AUDIT) 10-item questionnaire, differentiating hazardous drinking (HZD) and alcohol use disorders (AUD) from low risk drinking (LRD), and AUD from HZD and LRD among married men in a Sri Lankan sample.

METHODS

Using 62 low risk drinkers and 88 each from hazardous drinkers and AUD, the AUDIT instrument was compared with adapted and translated versions of a beverage-specific, quantity-frequency questionnaire, and the alcohol use module of the Composite International Diagnostic Interview (CIDI), and two receiver operating characteristic (ROC) curves were plotted.

RESULTS

The area under the ROC curves to differentiate HZD + AUD from LRD and AUD from HZD + LRD were 0.96 (95% CI: 0.94-0.99) and 0.97 (95% CI: 0.95-0.99) respectively. The cut-off values of 7 and 16 were observed to have the best trade-offs between sensitivity, specificity, the ratio of positive likelihood to negative likelihood ratios, and positive predictive values.

CONCLUSION

The AUDIT could be used to screen for LRD, HZD, and AUD among Sinhalese married men in Sri Lanka.

Intestinal parasites and the growth status of internally displaced children in Sri Lanka

The growth status and intestinal parasitic infections among a group of children displaced by war in Sri Lanka was investigated. There was a high prevalence of growth retardation (wasting, stunting and underweight being 41%, 28% and 69.9%, respectively) and intestinal parasitic infections (40.2%) among the study population. Provision of adequate food, purified drinking water, sanitation and broad-spectrum anthelmintics is recommended.

Modified Dermatology Life Quality Index as a measure of quality of life in patients with filarial lymphoedema

The quality of life (QoL) and correlates of the QoL of lymphoedema patients attending filariasis clinics and a hospital outpatient department were studied using a Life Quality Index (LQI) in a region endemic for Bancroftian filariasis in Sri Lanka. The index was derived by modifying a previously validated Dermatology Life Quality Index (DLQI) to focus on the oedematous limb rather than the skin. The index was scored from 0 (normal) to 30 (severely affects QoL). Lymphoedema was graded using criteria recommended by the WHO. Another semi-structured questionnaire was used to assess the patient's socioeconomic status, frequency of acute adenolymphangitis attacks (ADLA) and measures practiced for morbidity control. Ninety-one patients (62 females, 29 males; mean age 50.4 years) were studied. A single lower limb, both lower limbs or a single upper limb were affected in 78 (85.7%), 10 (11.0%) and 3 (3.3%) patients, respectively. The severity of lymphoedema ranged from stage 1 (mild) to stage 6 (severe). The mean LQI was 8.2 (SD 5.2, range 0-20). The modified DLQI scores showed a significant positive correlation with severity of lymphoedema and a negative correlation with age (R=0.59 and R=-0.1, respectively). The frequency of ADLAs correlated with an increased modified DLQI score. Local pain, embarrassment and limitations of physical activities were the most distressing aspects of lymphoedema. Disease severity and early onset lymphoedema were found to be significantly associated with poorer QoL in filarial lymphoedema.

Factors associated with home deliveries in Thampalakamam, Trincomalee

INTRODUCTION

In Sri Lanka, more than 95% of women deliver in hospital. There is regional variation in the rate of home deliveries, and in some areas a significant number of mothers deliver at home.

OBJECTIVE

The objective of the present study was to identify the factors associated with home deliveries in Thampalakamam, Trincomalee.

METHODOLOGY

Ours was a community based, exploratory type of case control study. Cases were home deliveries during the period from Jan 1, 2000 to Dec 31, 2002 in Thampalakamam Divisonal Director of Health Services (DDHS) area. Controls were institutional deliveries among women residing in Thampalakamam DDHS area during the same period. A total of 139 cases and 278 controls were identified for this study. Data was collected at the household level using an interviewer-administered questionnaire.

RESULTS

The following factors were found to have strong association with home deliveries: being a Muslim (OR = 33.0, 95% CI 16.8-64.8), low (< grade 5) maternal education (OR = 3.5, 95% CI 1.8-6.6), parity more than 3 (OR = 3.2, 95% CI 1.5-6.6) not being visited by a public health midwife (OR = 2.4, 95% CI 0.8-6.9), not being seen by a medical officer during the antenatal period (OR = 7.0, 95% CI 0.6-83.3). Lack of transport (35.5%) was mentioned as main reason for home deliveries by the women. Of the home deliveries 95% were assisted by a traditional birth attendant.

CONCLUSIONS

Poor education of women and deficiencies in the delivery of antenatal care were found to be important risk factors for home deliveries.

Identifying the biting species in snakebite by clinical features: an epidemiological tool for community surveys

The outcome of snakebite is related to the biting species but it is often difficult to identify the biting snake, particularly in community settings. We have developed a clinical scoring system suitable for use in epidemiological surveys, with the main aim of identifying the presumed biting species in those with systemic envenoming who require treatment. The score took into account ten features relating to bites of the five medically important snakes in Sri Lanka, and an algorithm was developed applying different weightings for each feature for different species. A systematically developed artificial data set was used to fine tune the score and to develop criteria for definitive identification. The score was prospectively validated using 134 species-confirmed snakebites. It correctly differentiated the bites caused by the three snakes that commonly cause major clinical problems (Russell's viper (RV), kraits and cobra) from other snakes (hump-nosed viper (HNV) and saw-scaled viper (SSV)) with 80% sensitivity and 100% specificity. For individual species, sensitivity and specificity were, respectively: cobra 76%, 99%; kraits 85%, 99%; and RV 70%, 99%. As anticipated, the score was insensitive in the identification of bites due to HNV and SSV.

Health status of primary schoolchildren in Sri Lanka

OBJECTIVE

To assess health status of 9-10-year old school children in Sri Lanka.

DESIGN

A cross-sectional, descriptive study. Schools were selected to obtain a sample representative at national and provincial levels and 20 children were randomly selected from Grade 5 classes in each school.

MEASUREMENTS

Children were examined for Bitot's spots and goitre. Height, weight, and visual acuity were measured according to standard procedures. Haemoglobin level was measured using finger-prick blood and a HemoCue meter. Geohelminth infections were quantified by faecal examination using the modified Kato-Katz technique. Height for age Z-scores (HAZ) and body mass index (BMI) were calculated as indicators of nutritional status.

RESULTS

Two thousand five hundred and twenty eight children (1351 boys) from 144 schools (140 state schools and four private schools) were examined. Nationally, 15.5% of children were stunted (HAZ lower than -2.0 SD); 52.6% were thin (BMI < 5th centile of age- and sex-matched reference population); 3.1% were overweight (BMI > 85th centile); 12.1% were anaemic; 0.3% had Bitot's spots; 3% had a visible or palpable goitre; 4.6% were shortsighted; and 6.9% had one or more soil-transmitted nematode infection. Among children on whom anthropometry, haemoglobin and faecal examinations were all done, 64.6% (1332/2063) were thin, stunted, anaemic or infected with worms. A much higher proportion of children in the Northern and Eastern provinces had health problems when compared to the other provinces.

CONCLUSIONS

The majority of older primary schoolchildren in Sri Lanka are undernourished. Anaemia, vitamin A deficiency, iodine deficiency and soil-transmitted nematode infections affect a much smaller proportion of them.

Endosonographic characteristics of the anal sphincter complex in primigravid Sri Lankan women

OBJECTIVE

To determine the endosonographic anatomy of the anal sphincter complex in primigravid Sri Lankan women.

METHOD

This is an observational study of 95 primigravid women admitted to an antenatal ward. They were examined using anal endosonography and data from subjects without sphincter injury were analyzed to describe anal sphincter morphology. Individual anal canal components were measured at defined levels, and the relationship of individual measurements with age and body mass index was calculated.

RESULTS

Ninety-three of 95 women had no anal sphincter damage. The puborectalis sling (mean 5.5 mm, S.D. 0.77) forms the upper most border of the sphincter complex. The mean width of the deep external sphincter was 4.3 mm (S.D. 0.61); that of the superficial external sphincter was 4.5 mm (S.D. 0.56); and that of the internal anal sphincter at the mid anal canal was 2.1 mm (S.D. 0.21). The intersphincteric space (mean 2.1 mm, S.D. 0.26) could be distinguished sonographically in all subjects. The mean width of the anterior ring of the subcutaneous component was 3.8 mm (S.D. 1.01). The perineal body was sonographically identified in 60%.

CONCLUSION

A set of normal values for the anal sphincter components in Sri Lankan primigravid women was established.

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.

Nutritional status and productivity of Sri Lankan tea pluckers

OBJECTIVE

To assess the impact of nutritional status on productivity of tea pluckers.

DESIGN

Cross-sectional, analytical. SETTING AND PARTICIPANTS OF STUDY: All tea pluckers in five divisions of a tea estate in Hatton.

MEASUREMENTS

A dietary survey was conducted using the 24 h dietary recall method. Nutritional status was assessed by measurement of body mass index (BMI) and haemoglobin (Hb) levels, and faeces were examined for helminth ova. The daily weight of tea leaves plucked and the number of days worked by each woman during the preceding month were noted from production records.

RESULTS

Three hundred and four women (mean age 37.8 years, SD 8.4) were examined. The majority (59.9%) had evidence of chronic energy deficiency (BMI < 18.5). Almost all (94.4%) were anaemic (Hb < 13.3 g/dl, altitude adjusted cutoff). Mean daily iron intake was 8.7 mg (SD 2.3 mg), 45.9% of the national recommended dietary allowance. Only 10.1% had hookworm infection, all of light intensity. Multivariate regression analysis showed that dietary iron intake, the number of children and the number of children below 5 years, but not hookworm infection, were independently associated with Hb (p < 0.05). There was a strong positive correlation between monthly productivity and Hb, but not with BMI. Variation in Hb levels accounted for 65% of variation in productivity (adjusted R2 = 0.651).

CONCLUSIONS

Most of the study population had chronic energy deficiency and anaemia. Dietary inadequacy of iron is a much more important causative factor than hookworm infection. Productivity was strongly associated with the degree of anaemia but not with BMI.

Multiple-dose activated charcoal for treatment of yellow oleander poisoning: a single-blind, randomised, placebo-controlled trial

BACKGROUND

Deliberate self-poisoning with yellow oleander seeds is common in Sri Lanka and is associated with severe cardiac toxicity and a mortality rate of about 10%. Specialised treatment with antidigoxin Fab fragments and temporary cardiac pacing is expensive and not widely available. Multiple-dose activated charcoal binds cardiac glycosides in the gut lumen and promotes their elimination. We aimed to assess the efficacy of multiple-dose activated charcoal in the treatment of patients with yellow-oleander poisoning.

METHODS

On admission, participants received one dose of activated charcoal and were then randomly assigned either 50 g of activated charcoal every 6 h for 3 days or sterile water as placebo. A standard treatment protocol was used in all patients. We monitored cardiac rhythm and did 12-lead electocardiographs as needed. Death was the primary endpoint, and secondary endpoints were life-threatening cardiac arrhythmias, dose of atropine used, need for cardiac pacing, admission to intensive care, and number of days in hospital. Analysis was by intention to treat.

FINDINGS

201 patients received multiple-dose activated charcoal and 200 placebo. There were fewer deaths in the treatment group (five [2.5%] vs 16 [8%]; percentage difference 5.5%; 95% CI 0.6-10.3; p=0.025), and we noted difference in favour of the treatment group for all secondary endpoints, apart from number of days in hospital. The drug was safe and well tolerated.

INTERPRETATION

Multiple-dose activated charcoal is effective in reducing deaths and life-threatening cardiac arrhythmias after yellow oleander poisoning and should be considered in all patients. Use of activated charcoal could reduce the cost of treatment.

Liv.52 in alcoholic liver disease: a prospective, controlled trial

Liv.52, a hepatoprotective agent of herbal origin, is used empirically for the treatment of alcoholic liver disease in Sri Lanka. We conducted a controlled trial to assess the efficacy of Liv.52 in patients with alcoholic liver disease. Patients with evidence of alcoholic liver disease attending outpatient clinics were included in a prospective, double blind, randomized, placebo controlled trial. During the trial period, 80 patients who fulfilled inclusion criteria were randomly assigned Liv.52 (cases; n = 40) or placebo (controls) the recommended dose of three capsules twice daily for 6 months. All patients underwent clinical examination (for which a clinical score was computed), and laboratory investigations for routine blood chemistry and liver function before commencement of therapy (baseline). Thereafter, clinical assessments were done monthly for 6 months, while laboratory investigations were done after 1 and 6 months of therapy. There was no significant difference in the age composition, alcohol intake and baseline liver function between the two groups. The two-sample t-test was used to analyze data obtained after 1 and 6 months of therapy against baseline values. There was no significant difference in clinical outcome and liver chemistry between the two groups at any time point. There were no reports of adverse effects attributable to the drug. Our results suggest that Liv.52 may not be useful in the management of patients with alcohol induced liver disease.

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.

Using clinical indicators to identify areas for quality improvement

Clinical indicators (CI) are increasingly being used to assess the quality of health care being provided by physicians and hospitals. However, a standardised reporting format and a methodology to assess the utility of the CI data has not been developed. This paper provides the reporting format that has been developed for the clinical colleges. The results for four surgical indicators are used to illustrate how the CI data can determine the potential to improve the quality of care. Numerical estimates of the potential gains that could be made are calculated by: (i) determining the outcome if the current mean rate was shifted to the rate for the best 20% of hospitals and (ii) identifying units with unusual variation in rates and shifting their rate to the average. All four indicators reveal gains that could impact on health policy and clinical practice.