Cross-cultural adaptation and preliminary validation of a zygosity determination questionnaire for twins in Sri Lanka

We report the process of adaptation into Sinhala of a questionnaire given to mothers of twins to determine zygosity. Adaptation and validation was carried out in three stages. Firstly, we used a nominal group to translate the English version and to assess the extent of agreement (consensus measurement) on the appropriateness of the translation and resolve disagreement (consensus development). Secondly we used a qualitative interview with 25 mothers of twins. The three main stems of the translated questionnaire were used as a semi-structured interview, and the responses noted verbatim. These were categorised and analysed, and the translated full questionnaire was then presented as closed questions with fixed choice responses. The categorised responses generated during the qualitative interview were compared with the responses to the fixed choices in the full questionnaire. The third stage was the appraisal of the questionnaire by 17 bilingual parents of twins. The source and translated version of the questionnaire were given to them at least 3 days apart. The responses were rated and the total scores were computed to determine the zygosity. This step was carried out to measure the validity and reliability of the Sinhala version. A perfect correlation between the original and adapted version was obtained, with a kappa of 1. The results suggest that the Sinhala version of the questionnaire is conceptually equivalent to the original questionnaire. Comparison of the zygosity determination by using this adapted questionnaire with results from analysis of genetic markers on Sri Lankan twins is needed for final validation of the translated questionnaire. Twin Research (2000) 3, 205–212.

The internet and suicide: A double-edged tool

Many physicians are unaware of the power of the internet. In an era of an empowered public and patients, the internet may be a more powerful determinant of health-seeking behaviour than medical opinion. In the same way, it may provide more information for self-harm than was ever available to the public domain in the past. The internet is effective across cultural and geographical boundaries. In addition to reporting and romanticising suicide, it has a significant impact in assisting and promoting suicide. It provides services and information ranging from general information to online orders of prescription drugs or other poisons that bypass government regulations and custom controls. This bridges the gaps of locality and accessibility, which previously formed a natural divide in selecting the means of suicide. In addition to these negative effects, there is a vast potential to harness these properties to a beneficial effect. The wide acceptance of the internet makes it a powerful tool for recognition of the at-risk individual, for preventing suicide and supporting survivors, with chat rooms taking the place of telephone help lines. In an information age, it is vital for physicians to use all available means of informing and empowering the public and patients. The internet also has a role in training, providing accessible self-help sites for suicidal persons and web-based prevention services, all of which remain sadly under-utilised. The challenge to physicians of the 21st century is to harvest the internet in a beneficial manner.

Are we good at thromboembolic disease prophylaxis - an audit of the use of risk assessment forms in emergency medical admissions

Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalised patients. Thromboprophylaxis is an effective strategy for VTE prevention in high-risk patients. An initial audit in our district general hospital trust showed poor adherence to the thromboembolic risk factors consensus group recommendations and so a risk assessment form (RAF) was devised. We present repeated audits to assess the RAF uptake and its effects on VTE thromboprophylaxis. We also present data analysing perceptions among doctors of the RAF and reasons for its poor completion. We provide compelling evidence that the RAF is an invaluable tool in the assessment of VTE thromboprophylaxis.

A double blind randomised placebo controlled cross over study of a herbal preparation containing Salacia reticulata in the treatment of type 2 diabetes

We conducted a randomised single centre double blind cross over clinical trial to investigate the effects of a herbal tea containing Salacia reticulata (Kothala Himbutu tea) in patients with type II diabetes mellitus. Fifty-one patients with type II diabetes mellitus for longer than 6 months and with evidence of stable glycaemic control over the preceding 6 months (as assessed by HbA1C) participated in the study. They were randomised to receive a standard preparation of Kothala Himbutu tea for 3 months followed by placebo in similar tea bags for a further 3 months (n = 28) or in reverse order (n = 23). All patients received detailed advice on diet, exercise and lifestyle modification. HbA1C was measured at recruitment, at 3 months and on completion of the study at 6 months. Liver and renal functions were assessed biochemically at baseline, at 3 and 6 months and adverse events were recorded. There were no significant differences between the two groups in age, body mass index, male/female ratio, glycaemic control and baseline laboratory tests. All patients completed both arms of the trial. The HbA1C at the end of drug treatment was significantly lower than after treatment with placebo (6.29 +/- S.D. 1.02 versus 6.65 +/- S.D. 1.04; P = 0.008). A statistically significant fall in HBA1c was seen with the active drug compared to a rise in HbA1C with the placebo group (0. 54 +/- S.D. 0.93) versus -0.3 +/-S.D. 1.05; P < 0.001. The daily mean dose of Glibenclamide fell by 1.89 (S.D. 6.2) mg in the drug treated group but rose by 2.25 mg in the placebo treated group (P = 0.07). The differences in the metformin dose were not significantly significant in the two groups. We conclude that Kothala Himbutu tea is an effective and safe treatment for type 2 diabetes.

Excess maternal transmission and familial aggregation of Type 2 diabetes in Sri Lanka

INTRODUCTION

An excess of maternal transmission of Type 2 diabetes mellitus has been reported in Europid populations, but not in South India.

METHOD

A questionnaire-based survey was carried out in 1000 (502 male) people with Type 2 diabetes to establish whether there is an excess of maternal transmission and familial aggregation in a Sri Lankan population.

RESULTS

Mean age of onset was 47+/-12 (+/-S.D.) years and duration of diabetes was 9+/-7 years. Thirty-seven percent reported parents with diabetes, 46.9% had no parents with diabetes, 16.1% did not know the diabetes status of at least one parent and there was no diabetes in the other. Of the probands, 59.4% had at least one affected relative. When both parents' diabetes status was known and only one was affected, diabetes was more common among mothers (n = 156) than fathers (n = 125) of probands (P < 0.001). A further 54 probands had both parents with diabetes. Mean age of onset and duration of the disease among probands with parental diabetes was 43.1+/-(11.1) and 9.6+/-(6.8). In the previous generation, 21.2% of maternal grandmothers and 17.3% of maternal grandfathers in the maternal diabetes group and 4.8% of maternal grandmothers and 17% of maternal grandfathers in the paternal diabetes group had diabetes. Diabetes in siblings and children was more common in those with mothers who had diabetes (53.8% and 4.5%) when compared with those in whom fathers had diabetes (42.4% and 1.6%) (P < 0.0001 and P < 0.01).

CONCLUSION

Familial aggregation and excess maternal transmission were observed in people with Type 2 diabetes in Sri Lanka.

Audit of stroke care at the Institute of Neurology, National Hospital of Sri Lanka, 1994-1997

OBJECTIVE

To audit the process of stroke care.

DESIGN

Retrospective case record evaluation using an audit package designed by the Royal College of Physicians of London.

SETTING

Institute of Neurology, National Hospital of Sri Lanka, Colombo.

PATIENTS

263 patients with stroke admitted over a period of 3 years.

MEASUREMENTS

Documentation of 60 audit items related to 13 aspects of stroke care.

RESULTS

The process of care was considered 'very good' for only 11 (18.3%), and 'good' for only 9 (15%) of the audit items. Care was 'average' for 5 (8.3%), 'poor' for 9 (15%) and 'very poor' for 26 (43.3%) of the items.

CONCLUSIONS

Stroke care was suboptimal in many aspects. Care related to rehabilitation oriented neurological assessments, initiation of secondary preventive measures, rehabilitation planning and discharge planning were especially deficient. Competing interests: none declared. Some of the data reported in this paper have been presented at the Annual Scientific Sessions of the Sri Lanka Medical Association, 1998.

The internal jugular vein valve may have a significant role in the prevention of venous reflux: evidence from live and cadaveric human subjects

INTRODUCTION

The internal jugular vein valve (IJVV), which is situated just above the termination of the internal jugular vein, is the only valve between the heart and the brain. This means that it plays a role in the prevention of cephalad flow of venous blood. If the IJVV is damaged or becomes incompetent, increase in intrapleural pressure could result in raised intracranial pressure. Additionally, the jugular venous pulse (JVP) is used clinically to estimate right atrial pressure, a functional IJVV may prevent accurate estimation of the JVP.

OBJECTIVES

To describe the presence and the competence of the IJVV in post-mortem and live human subjects. DESIGN - setting and methods: The anatomical appearance of the IJVV from 30 cadavers was studied. Competence was checked by measuring maximum hydrostatic pressure before reflux occurred through the valve. The function of the valve was evaluated in 25 live subjects using colour duplex scanning.

RESULTS

The IJVV was present in all cadavers just before its termination (60 IJVVs from 30 subjects). The valve was bicuspid in most cases (93%). The competence of 41 IJVVs was checked of which only three (7%) were found to be incompetent. All IJVVs in live subjects were found to be competent.

CONCLUSION

This study confirms that a functional IJVV is present just above the termination of the internal jugular vein. The IJVV may therefore prevent reflux of venous blood from the right atrium into the internal jugular vein.