Future of medical research in Sri Lanka: amidst economic chaos.

Sri Lanka is facing an economic crisis and medical research is significantly affected at present with researchers facing many obstacles. Urgent remedial measures are required to overcome the current situation if medical research is to continue in Sri Lanka.

Neurological disorders associated with COVID-19 in Sri Lanka.

BACKGROUND: Neurological manifestations of SARS-CoV-2 infection have been reported from many countries around the world, including the South Asian region. This surveillance study aimed to describe the spectrum of neurological disorders associated with COVID-19 in Sri Lanka. METHODS: COVID-19 patients manifesting neurological disorders one week prior and up to six weeks after infection were recruited from all the neurology centres of the government hospitals in Sri Lanka from May 2021 - May 2022. Data was collected using a structured data form that was electronically transmitted to a central repository. All patients were evaluated and managed by a neurologist. Data were analysed using simple descriptive analysis to characterise demographic and disease related variables, and simple comparisons and logistic regression were performed to analyse outcomes and their associations. RESULTS: One hundred and eighty-four patients with neurological manifestations associated with COVID-19 were recruited from all nine provinces in Sri Lanka. Ischaemic stroke (31%) was the commonest neurological manifestation followed by encephalopathy (13.6%), Guillain-Barre syndrome (GBS) (9.2%) and encephalitis (7.6%). Ischaemic stroke, encephalitis and encephalopathy presented within 6 days of onset of COVID-19 symptoms, whereas GBS and myelitis presented up to 10 days post onset while epilepsy and Bell palsy presented up to 20 - 40 days post onset. Haemorrhagic stroke presented either just prior to or at onset, or 10 - 25 days post onset of COVID-19 symptomatic infection. An increased frequency of children presenting with encephalitis and encephalopathy was observed during the Omicron variant predominant period. A poor outcome (no recovery or death) was associated with supplemental oxygen requirement during admission (Odds Ratio: 12.94; p = 0.046). CONCLUSIONS: The spectrum and frequencies of COVID-19 associated neurological disorders in Sri Lanka were similar to that reported from other countries, with strokes and encephalopathy being the commonest. Requiring supplemental oxygen during hospitalisation was associated with a poor outcome.

The professional practice and training of neurology in the Asian and Oceanian Region: A cross-sectional survey by the Asian and Oceanian Association of Neurology (AOAN).

OBJECTIVE: To survey AOAN member countries regarding their organizational structure, postgraduate neurology training program, and resources for neurological care provision. METHODOLOGY: A cross-sectional survey using a 36-item questionnaire was conducted among country representatives to AOAN from August 2015 to August 2016. RESULTS: A total of 18/20 AOAN member countries participated in the survey. All the countries have organized association with regular meetings, election of officers and neurology training program. In 9/18 countries, professionals other than neurologists were eligible for affiliation. In 11/18 countries, prior Internal medicine training (or equivalent postgraduate housemanship) is prerequisite to neurology program. Recertification examination is not a practice, but submission of CME is required in 7/18 countries to maintain membership. 12/18 countries publish peer-reviewed journals with at least 1 issue per year. Subspecialty training is offered in 14/18 countries. The ratio of neurologist to population ranges from 1:14,000 to as low as 1:32 million with 9/18 having <1 neurologist per 100,000 population. 6/18 countries have at least 1 specialized center solely for neurological diseases. In government-funded hospitals, the lag time to be seen by a neurologist and/or obtain neuroimaging scan ranges from 1day to 3months. All except one country have several medical- and lay- advocacy or support groups for different neurological conditions. IMPLICATIONS: The data generated can be used for benchmarking to improve neurological care, training, collaborative work and research in the field of neurosciences among the AOAN member countries. The paper presented several strategies used by the different organizations to increase their number of neurologists and improve the quality of training. Sharing of best practices, academic networking, exchange programs and use of telemedicine have been suggested.

Bilateral posterior fracture-dislocation of the shoulders following epileptic seizures: a case report and review of the literature.

BACKGROUND: Bilateral posterior fracture-dislocation of the shoulders is an uncommon complication of grand mal seizures. We report a case of bilateral posterior dislocation of the shoulders with proximal humeral fractures following epileptic seizures. A posterior fracture-dislocation of the shoulder is very rare and can be caused by epileptic seizures, trauma, electrocution or electroconvulsive therapy. CASE PRESENTATION: A 62-year-old Sri Lankan male was admitted to our medical unit following four repeated generalized tonic-clonic convulsions, each lasting for several minutes. Following the second seizure he reported an inability to move both upper arms due to intense pain. There was no history of fall during the episodes of convulsions however but the bystanders have forcibly restrained his movements during the tonic-clonic convulsions. Clinical examination revealed severely restricted range of movement in both shoulders, with associated swelling and bruising of the shoulder joints and upper arms. Radiographs of the shoulders confirmed fractures at the level of surgical neck with posterior dislocation. CONCLUSION: Bilateral posterior fracture-dislocation of shoulders complicating epileptic seizures are rare. Forcible restraining of the patient's upper limbs during seizures is the likely cause for the fracture dislocations in our patient and this had not been reported before.

Ventricular trigeminy in a patient with serologically confirmed dengue haemorrhagic fever.

BACKGROUND: Cardiac arrhythmias occur during the acute stage of Dengue Haemorrhagic Fever. Dengue myocarditis is the most likely cause of the arrhythmias. CASE PRESENTATION: We report a 55-year-old patient with Dengue Haemorrhagic Fever presenting with transient ventricular trigeminy which has not been reported before. CONCLUSION: Among many other known cardiac arrhythmia seen in DHF, ventricular trigeminy is also a possibility. Clinicians should be aware of this cardiac rhythm abnormality that can occur in dengue patients.

Neurophobia among medical students and non-specialist doctors in Sri Lanka.

BACKGROUND: Neurophobia is the fear of neurosciences held by medical students and doctors. The present study aims to identify whether Neurology is considered a difficult subject by medical students and non-specialist doctors from Sri Lanka and evaluate reasons for such perceived difficulties. METHODS: The study was conducted from May-June 2008. One hundred non-specialist doctors from the Colombo South Teaching Hospital and 150 medical students from the University of Sri Jayewardenepura were invited for the study. Data were collected by a pre-tested expert-validated self-administered questionnaire, designed to assess the degree of perceived difficulty, confidence, interest and knowledge of Neurology as compared to other subjects. It also evaluated reasons and probable strategies to overcome the perceived difficulties and/or lack of interests. RESULTS: All non-specialist doctors and 148 medical students responded to the questionnaire (response rate-99.2%). The most favourite subject among medical students and non-specialist doctors were Cardiology and Endocrinology respectively, while Neurology was ranked third. In all participants the current level of interest was most for Cardiology (3.52±1.36), while Neurology was the least interesting specialty for majority of medical students (18.5%) and non-specialist doctors (25.0%). The current level of knowledge among medical students was most for Cardiology (3.12±0.86), while Neurology (2.53±0.96) was ranked fifth. The most difficult specialty for majority of medical students (50.0%) and non-specialist doctors (41.7%) was Neurology. All the participants were least confident when dealing with patients with headache (2.20±0.81), numbness of feet (2.07±0.79) and dizziness (2.07±0.78) when compared to dealing with other non-neurological complaints. The commonest reasons 'why Neurology was felt to be a difficult subject' were; the need to know basic neuro-anatomy and having a complex clinical examination. Participants' felt that clinical/hospital based teaching (3.49±0.65), case discussions (3.45±0.68) and teaching aids (3.10±0.89) would be the most important teaching strategies to improve their competency in Neurology. CONCLUSION: Neurology is considered a difficult subject by undergraduates and non-specialist doctors of Sri Lanka. The main reason for the perceived difficulty was the lack of understanding of basic sciences and deficiencies in clinical teaching. This lack of confidence could have a significant impact on patient care.

In vitro erythrocyte membrane stabilization properties of Carica papaya L. leaf extracts.

BACKGROUND: Carica papaya L. fruit juice and leaf extracts are known to have many beneficial medical properties. Recent reports have claimed possible beneficial effects of C. papaya L. leaf juice in treating patients with dengue viral infections. This study aims to evaluate the membrane stabilization potential of C. papaya L. leaf extracts using an in vitro hemolytic assay. MATERIALS AND METHODS: The study was conducted in between June and August 2010. Two milliliters of blood from healthy volunteers and patients with serologically confirmed current dengue infection were freshly collected and used in the assays. Fresh papaya leaves at three different maturity stages (immature, partly matured, and matured) were cleaned with distilled water, crushed, and the juice was extracted with 10 ml of cold distilled water. Freshly prepared cold water extracts of papaya leaves (1 ml containing 30 µl of papaya leaf extracts, 20 µl from 40% erythrocytes suspension, and 950 µl of phosphate buffered saline) were used in the heat-induced and hypotonic-induced hemolytic assays. In dose response experiments, six different concentrations (9.375, 18.75, 37.5, 75, 150, and 300 µg/ml) of freeze dried extracts of the partly matured leaves were used. Membrane stabilization properties were investigated with heat-induced and hypotonicity-induced hemolysis assays. RESULTS: Extracts of papaya leaves of all three maturity levels showed a significant reduction in heat-induced hemolysis compared to controls (P < 0.05). Papaya leaf extracts of all three maturity levels showed more than 25% inhibition at a concentration of 37.5 µg/ml. The highest inhibition of heat-induced hemolysis was observed at 37.5 µg/ml. Inhibition activity of different maturity levels was not significantly (P < 0.05) different from one another. Heat-induced hemolysis inhibition activity did not demonstrate a linear dose response relationship. At 37.5 µg/ml concentration of the extract, a marked inhibition of hypotonicity-induced hemolysis was observed. CONCLUSION: C. papaya L. leaf extracts showed a significant inhibition of hemolysis in vitro and could have a potential therapeutic effect on disease processes causing destabilization of biological membranes.

Non-cognitive characteristics predicting academic success among medical students in Sri Lanka.

BACKGROUND: To identify non-cognitive and socio-demographic characteristics determining academic success of Sri Lankan medical undergraduates. METHODS: A retrospective study among 90 recently graduated students of the Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka. Students were stratified into two equal groups; 'High-achievers' (honours degree at the final MBBS examination) and 'Low-achievers' (repeated one or more subjects at the same examination). A revised version of the Non-cognitive Questionnaire (NQ) with additional socio-demographic data was the study instrument. Academic performance indicator was performance at the final MBBS examinations. A binary logistic regression analysis was performed using the dichotomous variable 'Honours degree at final MBBS' as the dependant factor. RESULTS: Males were 56.7%. Mean age ± SD was 26.4 ± 0.9 years. 'High-achievers' were significantly younger than 'Low-achievers'. Significant proportion of 'High-achievers' were from the Western province and selected to university from Colombo district. A significant majority of 'High-achievers' entered medical school from their first attempt at GCE A/L examination and obtained 'Distinctions' at the GCE A/L English subject. 'High-achievers' demonstrated a significantly higher mean score for the following domains of NQ; Positive self-concept and confidence, realistic self-appraisal, leadership, preference of long range goals and academic familiarity.The binary logistic regression indicates that age, being selected to university from Colombo district, residency in Western province, entering university from GCE A/L first attempt, obtaining a 'Distinction' for GCE A/L English subject, higher number of patient-oriented case discussions, positive self-concept and confidence, leadership qualities, preference of long range goals and academic familiarity all significantly increased the odds of obtaining a Honours degree. CONCLUSION: A combined system incorporating both past academic performance and non-cognitive characteristics might help improve the selection process and early recognition of strugglers.

Medial temporal lobe atrophy, apolipoprotein genotype, and plasma homocysteine in Sri Lankan patients with Alzheimer's disease.

The authors studied the association of Alzheimer's disease (AD) with total plasma homocysteine (tHcy) and apolipoprotein E (apoE) genotype, and the usefulness of measuring medial temporal lobe thickness (MTL) thickness for the diagnosis of AD in Sri Lankan patients. Using criteria of the NINCDS-ADRDA, 23 AD patients and 21 controls were recruited. All underwent MTL-oriented computed tomographic (CT) scans, measurement of plasma tHcy, and apoE genotyping. Mean plasma tHcy was significantly higher in AD patients than controls (p=.001). This association was independent of age, sex, body mass index (BMI), serum folate and vitamin B12, and serum creatinine. The frequency of apoE4 allele was significantly higher (p=.003) in AD patients, and the adjusted odds ratio of AD for the presence of one or more apoE4 alleles compared with none was 10.39 (95% CI 1.77-61.10; p=.010). The mean minimum MTL thickness was significantly higher in control subjects compared to that of AD patients (p<.001). This first report of apoE4, plasma tHcy, MTL thickness, and AD from Sri Lanka shows that high plasma tHcy, the presence of apoE4 allele, and MTL atrophy are associated with AD.