Asia-Pacific consensus on long-term and sequential therapy for osteoporosis.

Objectives: This study aimed to present the Asia-Pacific consensus on long-term and sequential therapy for osteoporosis, offering evidence-based recommendations for the effective management of this chronic condition. The primary focus is on achieving optimal fracture prevention through a comprehensive, individualized approach. Methods: A panel of experts convened to develop consensus statements by synthesizing the current literature and leveraging clinical expertise. The review encompassed long-term anti-osteoporosis medication goals, first-line treatments for individuals at very high fracture risk, and the strategic integration of anabolic and antiresorptive agents in sequential therapy approaches. Results: The panelists reached a consensus on 12 statements. Key recommendations included advocating for anabolic agents as the first-line treatment for individuals at very high fracture risk and transitioning to antiresorptive agents following the completion of anabolic therapy. Anabolic therapy remains an option for individuals experiencing new fractures or persistent high fracture risk despite antiresorptive treatment. In cases of inadequate response, the consensus recommended considering a switch to more potent medications. The consensus also addressed the management of medication-related complications, proposing alternatives instead of discontinuation of treatment. Conclusions: This consensus provides a comprehensive, cost-effective strategy for fracture prevention with an emphasis on shared decision-making and the incorporation of country-specific case management systems, such as fracture liaison services. It serves as a valuable guide for healthcare professionals in the Asia-Pacific region, contributing to the ongoing evolution of osteoporosis management.

Age-dependent FRAX-based assessment and intervention thresholds for therapeutic decision making in osteoporosis in the Malaysian population.

Fracture risk stratification is crucial in countries with limited access to bone density measurement. 24.8% women were in the high-risk category while 30.4% were in the low-risk category. In the intermediate risk group, after recalculation of fracture risk with bone density, 38.3% required treatment. In more than half, treatment decisions can be made without bone density. PURPOSE: We aimed to examine the role of age-dependent intervention thresholds (ITs) applied to the Fracture Risk Assessment (FRAX) tool in therapeutic decision making for osteoporosis in the Malaysian population. METHODS: Data were collated from 1380 treatment-naïve postmenopausal women aged 40-85 years who underwent bone mineral density (BMD) measurements for clinical reasons. Age-dependent ITs, for both major osteoporotic fracture (MOF) and hip fracture (HF), were calculated considering a woman with a BMI of 25 kg/m2, aged between 40 and 85years, with a prior fragility fracture, sans other clinical risk factors. Those with fracture probabilities equal to or above upper assessment thresholds (UATs) were considered to have high fracture risk. Those below the lower assessment thresholds (LATs) were considered to have low fracture risk. RESULTS: The ITs of MOF and HF ranged from 0.7 to 18% and 0.2 to 8%, between 40 and 85years. The LATs of MOF ranged from 0.3 to 11%, while those of HF ranged from 0.1 to 5.2%. The UATs of MOF and HF were 0.8 to 21.6% and 0.2 to 9.6%, respectively. In this study, 24.8% women were in the high-risk category while 30.4% were in the low-risk category. Of the 44.8% (n=618) in the intermediate risk group, after recalculation of fracture risk with BMD input, 38.3% (237/618) were above the ITs while the rest (n=381, 61.7%) were below the ITs. Judged by the Youden Index, 11.5% MOF probability which was associated with a sensitivity of 0.62 and specificity of 0.83 and 4.0% HF probability associated with a sensitivity of 0.63 and a specificity 0.82 were found to be the most appropriate fixed ITs in this analysis. CONCLUSION: Less than half of the study population (44.8%) required BMD for osteoporosis management when age-specific assessment thresholds were applied. Therefore, in more than half, therapeutic decisions can be made without BMD based on these assessment thresholds.

Cultural adaptation and validation of the Sinhala version of the Frail Non-disabled tool (FiND).

BACKGROUND: Frailty, a common geriatric syndrome of vulnerability, is associated with a decline in health and function. The most problematic expression of population ageing is associated with weakness, slowing, decreased energy, lower activity and when severe, unintended weight loss. Frailty is not consciously identified in clinical practice and is not widely studied in Sri Lanka. A validated tool for screening frailty in a busy clinical setting is therefore much needed. This study was done as a part of validating the Sinhala version of the Frail Non-Disabled (S-FiND) tool. METHODS: The FiND tool was translated from English to Sinhala by two translators, blinded to each other. They were combined and translated back to the original language by two separate translators. After verifying the content validity, unambiguity and clarity of items in a focused group discussion, the pre-final version was piloted among 30 volunteers. After assessing the psychometric properties of the pre-final version, the final version was tested among 100 adults older than 65 years from the Colombo South Teaching Hospital. The tool was compared with Fried's frailty phenotype taken as the gold standard. RESULTS: Data were analysed for the agreement with the reference standard, the Fried Phenotype. The mean (SD) age of subjects was 73.9 (7.8) years. The overall time taken to fill out the questionnaire was 2 min. The agreement (Kappa) between the S-FiND questionnaire and the Fried phenotype was 0.7 (P < 001). The sensitivity and specificity of FiND in detecting frailty were 92% and 74%, respectively. The agreements (Kappa) between the individual items of S-Find: involuntary loss of weight/ more than 4.5 kg over one year, the feeling of effort/ not getting going and level of physical activity, with the Fried phenotype, were 0.28 (p = 0.001), 0.06 (p = 0.045) and 0.339 (p < 0.001). respectively. When subjects were categorized frail and robust based on FiND, frail subjects reported a higher incidence of falls (50%) during the previous 12 months, compared to those robust (13%) (p < 0.001 for Chi stat). CONCLUSION: The S-FiND is a reliable, valid and well-received tool that can be used in detecting the frailty of non-disabled Sinhala-speaking older adults.

Approach to Study the Efficacy and Safety of New Complementary and Alternative Medicine Formulations: Lesson during COVID-19 from Sri Lanka.

COVID-19 affected Sri Lanka from early 2020, a time of considerable ignorance accompanied by wide media coverage of a devastating epidemic in Italy and Europe. Many were attracted to complementary and alternative medicine (CAM) or traditional medicine (TM) in this desperate situation. Several preparations were claimed to be effective against COVID-19 globally. Dammika Bandara Syrup© was one such preparation promoted for preventing and treating SARS-CoV-2 infection. It was based on bees' honey, pericarp and mace of Myristica fragrans (nutmeg), the seed of Foeniculum vulgare and fresh rhizome of Zingiber officinale, all believed to have anti-viral properties. Following an unpublished clinical study claiming efficacy, Dammika Bandara Syrup© gained wide media publicity and political patronage. The producer claimed of Goddess Kali revealing the formula added an anthropological, cultural, and religious complexity to the issue. The demand for the product increased rapidly as a debate raged both in public and in the parliament on utilizing such products in combating COVID-19. The Department of Ayurveda, which is statutorily responsible for regulating CAM/TM had to respond to the situation. The legislation to regulate such indigenous medicinal products was weak, and the crisis deepened as thousands converged to the production facility, defying mobility restrictions introduced to control COVID-19. This led to the Ministry of Health requesting academics to form a team and conduct a clinical trial to prove its efficacy. This paper outlines the process and issues faced during the regulatory approval for the trial in a polarized political environment. Some health professionals accused the researchers of bowing to political pressure and questioned the scientific justification for the trial. However, the team considered this as an opportunity to streamline a path for research into CAM/TM therapies in situations such as COVID-19. Several processes were identified and addressed, such as the provisional registration of CAM preparations, assessing the potential efficacy of a CAM product, confirmation of authenticity and safety, standardization and supervision of production respecting cultural identities, obtaining approval for human use, choice of comparators, and ethical issues. We believe the study has helped set standards and a benchmark for CAM and TM research in Sri Lanka.

Associations between body composition and cardiovascular disease risk in pre- and postmenopausal women.

BACKGROUND: Menopause transition is a critical phase of women's life since body composition and cardiovascular risk factors begin to change during this period. This study investigated the associations between body composition and cardiovascular disease risk (CVDR) in pre (PrMW) and postmenopausal women (PMW). METHODS: A community-based cross-sectional study involving 184 PrMW and 166 PMW, selected randomly from Bope-Poddala area in Galle, Sri Lanka was carried out. Total-body fat mass (TBFM, kg), total body skeletal muscle mass (TBSMM, kg), total body bone mineral density (TBBMD, g/cm2) and total body bone mineral content (TBBMC, g) were measured with total body DXA scanner and they were taken as indices of body composition. CVDR was evaluated using Framingham risk score (FRS%) and individual CVDR factors, such as systolic blood pressure (SBP, mmHg), diastolic blood pressure (DBP, mmHg), fasting blood sugar (FBS, mg/dl), total cholesterol, (TC, mg/dl), tryglycerides (TG, mg/dl), high-density lipoprotein (HDL, mg/dl) and low-density lipoprotein (LDL, mg/dl). Correlations between indices of body composition and CVDR factors were assessed with adjusted partial correlation (adjusted for socio-demographic and gynecologic status, age, daily calorie consumption and physical activity level). RESULTS: Mean(SD) age of PrMW and PMW were 42.4(6.0) and 55.8(3.8) years respectively. TBFM correlated with SBP and DBP (r range; 0.15 to 0.21) and TBSMM correlated with SBP, DBP and HDL (r range; - 0.24 to 0.17) only in PrMW (p < 0.05). TBBMD correlated only with FBS in PMW (r; - 0.21, p = 0.01). TBBMC did not show correlations with CVDR factors (p > 0.05). Body composition indices did not show correlations with total CVDR estimated by FRS and in both groups of women (p > 0.05). CONCLUSIONS: Both SBP and DBP are associated with FM and SMM in different ways among PrMW. This association, however, was not seen among PMW. FBS is associated with BMD only in PMW.

Service availability and readiness for hip fracture care in low- and middle-income countries in South and Southeast Asia.

Aims: The aim of this study was to describe the current pathways of care for patients with a fracture of the hip in five low- and middle-income countries (LMIC) in South Asia (Nepal and Sri Lanka) and Southeast Asia (Malaysia, Thailand, and the Philippines). Methods: The World Health Organization Service Availability and Readiness Assessment tool was used to collect data on the care of hip fractures in Malaysia, Thailand, the Philippines, Sri Lanka, and Nepal. Respondents were asked to provide details about the current pathway of care for patients with hip fracture, including pre-hospital transport, time to admission, time to surgery, and time to weightbearing, along with healthcare professionals involved at different stages of care, information on discharge, and patient follow-up. Results: Responses were received from 98 representative hospitals across the five countries. Most hospitals were publicly funded. There was consistency in clinical pathways of care within country, but considerable variation between countries. Patients mostly travel to hospital via ambulance (both publicly- and privately-funded) or private transport, with only half arriving at hospital within 12 hours of their injury. Access to surgery was variable and time to surgery ranged between one day and more than five days. The majority of hospitals mobilized patients on the first or second day after surgery, but there was notable variation in postoperative weightbearing protocols. Senior medical input was variable and specialist orthogeriatric expertise was unavailable in most hospitals. Conclusion: This study provides the first step in mapping care pathways for patients with hip fracture in LMIC in South Asia. The previous lack of data in these countries hampers efforts to identify quality standards (key performance indicators) that are relevant to each different healthcare system.

Katz index of activities of daily living in assessing functional status of older people: Reliability and validity of Sinhala version.

Purpose: This study evaluated the reliability and validity of the Sinhala version of Katz index of activities of daily living (ADL) in assessing the functional status of older people aged >65 years. Materials and methods: The Katz index was translated to Sinhala, cross-culturally adapted and administered in two stages. In stage 01, 200 patients aged ≥65 years, selected randomly from out-patient medical clinics, were asked to fill the Sinhala version of Katz index along with the Sinhala version of the 10-item Barthel index (BI). The Katz index was re-administered after two weeks among a subgroup of 45 patients selected randomly. In stage 02, Katz index was administered among randomly selected 200 community dwelling older people, aged ≥65 years. In addition, performance-based physical functions [gait speed (GS) and short physical performance battery (SPPB)] were also measured. Results: The analysis of stage 01 data showed internal consistency measured with Cronbach's alpha of 0.82 and test-retest reliability evaluated with intra-class correlation (ICC) (95% CI) of 0.94 (0.89-0.96) (p < 0.001). Exploratory Factor Analysis with the Principal Component Analysis revealed the presence of two factors with Eigen value exceeding 01, explaining 75.9% of cumulative variance. Further, the Sinhala version of Katz index total score showed a strong correlation with the BI total score (r = 0.91, p < 0.001) indicating strong concurrent validity. The stage 02 data revealed that older people with poor perception of general health status had lower mean (SD) Katz index score (3.58 ± 1.82) compared to those with good perception of health (5.56 ± 0.79) (p < 0.001). Similarly older people with prevalent diseases had comparatively lower scores of Katz index, compared to those without, indicating the known group validity (p < 0.05). Further, moderate correlations between the Katz index and performance based physical functions were observed showing the agreement (with GS - r; -0.26, p < 0.001, with SPPB - r; 0.31, p < 0.001). Conclusions: We conclude that the Sinhala version of Katz index has satisfactory psychometric properties and it is a reliable and valid tool to assess the functional status of Sinhala conversant older people in Sri Lanka.

Age Related Trends in Structural Indices of Proximal Femur in Women Aged 20-70 in Southern Sri Lanka.

Age related trends of the indices of hip structure help understanding how bone strength changes with age and the increased bone fragility in old age. Community-dwelling women aged 20-70years (n = 419) were selected by stratified random method and divided into age categories; 20-29years (n-69), 30-39years (n = 60), 40-49years (n = 69), 50-59years (n = 107) and 60-70years (n = 114). All subjects underwent dual energy x-ray absorptiometry (DXA) and hip structure analysis using Hologic Discovery scanner (Hologic Inc, Bedford, USA). Measured indices included hip axis length (HAL) and neck shaft angle (NSA) of the proximal femur. Cross sectional area (CSA), cross sectional moment of inertia (CSMI), section modulus (SM), cortical thickness (CT), buckling ration (BR) of three regions of interest; narrow neck, intertrochanteric region and femoral shaft, were also measured. Age related trends of all indices were studied with Locally Weighted Scatterplot Smoothing lines (LOESS) and ANOVA. Mean HAL and NSA values were not different between age categories. CSA, CSMI, SM and CT in three different regions showed curvilinear relationships with age. These indices gradually increased with age between 20-50 years and the maximum values were seen in the 40-49years age category and they declined afterwards. The decline of these indices was more rapid in the narrow neck and intertrochanter regions when compared with femoral shaft and the lowest mean CSA, CSMI, SM and CT in these two regions were seen in the 60-70 age category. BR showed a gradual decrease with age between 20-50 years and the lowest mean value was seen in the 40-49 age category. BR increased afterwards and the maximum mean value was seen in the 60-70 age category. This study demonstrates the dynamics of structural properties of proximal femur in the three selected cross sections of community-dwelling women aged 20-70 years and the increased bone fragility in old age.

Age-dependent assessment thresholds to optimize patient care in a resource-limited setting: an analysis based on the Sri Lankan FRAX model.

Age-dependent upper and lower assessment thresholds help categorizing women aged 40 years or more according to their fracture risk, independent of BMD information. INTRODUCTION: Age-dependent assessment thresholds of the FRAX algorithm help stratifying men and women aged 40 years or more according to their fracture risk. This allows clinicians to decide on those who require interventions without BMD assessment and those who require BMD input for further assessment. METHODS: Intervention thresholds were defined by 10-year probabilities of a major osteoporotic fracture (MOF) and hip fracture (HF) considering a woman with a BMI of 25.0 kg/m2 having a prior fragility fracture but no other clinical risk factors. The lower assessment thresholds (LAT) were set at 0.8 times the 10-year probabilities of a MOF and HF in a woman with a BMI of 25.0 kg/m2, without previous fracture or other clinical risk factors. The upper assessment thresholds (UAT) were set at 1.2 times the intervention thresholds of MOF and HF. Fracture probabilities were estimated for the age range of 40-80 years, without BMD input. These values were applied to a group of women who underwent DXA for clinical reasons in a single center. RESULTS: The LATs of MOF and HF varied from 0.7 to 8.8% and 0.1 to 3.7%, from 40 to 80 years, respectively. The corresponding values for UATs were 2.5 to 21.6% and 0.3 to 8.4%. ITs of MOF and HF varied from 2.1 to 18% and 0.2 to 7%, respectively. When applied to a group of 315 postmenopausal women who underwent DXA for clinical indications, 22.9% of women were above the UATs (high-risk category) while 8.6% were below the LATs (low-risk category). The proportion of women in the intermediate category who require BMD for further assessment was 68.6% (95% CI 59.7 to 77.5%). CONCLUSIONS: In nearly one-third of women aged 40 years or more, the decision to treat or not to treat can be achieved without BMD estimation. The remaining two-thirds will require a BMD assessment for further evaluation.

Age-Related Trends in Body Composition among Women Aged 20-80 Years: A Cross-Sectional Study.

The determinants of body composition are likely to vary geographically due to the diversity of genetic and environmental factors between populations. Age-related trends in body composition in a population help understanding the health issues that are linked with different body compartments. In general, such studies are scarce in the South Asian region and this cross-sectional study examined the age-related trends in body composition in a selected group of healthy women aged 20-80 years in Sri Lanka. The study included randomly selected 784 healthy women aged 20-80 years from the Southern province, Sri Lanka. Women were divided into five age groups: 20-29 years (n = 79), 30-39 years (n = 144), 40-49 years (n = 185), 50-59 years (n = 281), and ≥60 years (n = 85). Total body bone mineral density (TBBMD, g/cm2), total body bone mineral content (TBBMC, g), total body fat mass (TBFM, kg), and total body lean mass (TBLM, kg) were measured with central-type dual-energy X-ray absorptiometry (DXA). Multivariate analysis of variance with Bonferroni post hoc test was performed. The age-related trends of TBBMD and TBBMC were similar with a peak in 40-49-year age group. Between 50 and 59 and ≥60 age categories, TBBMD and TBBMC showed a rapid decline: 16% and 23%, respectively. The rate of TBBMD decline was 0.008 g/cm2 per year after 50 years. TBFM increased by 14% between age categories 20-29 and 40-49 years and remained unchanged after 49 years. TBLM increased by 15% between age groups 20-29 and 40-49 years and then decreased by 13% between age categories 50-59 and ≥60 years. Of the 13% decrease in TBLM after 50 years, 9% loss occurred after 59 years. The trends observed help to understand the occurrence of diseases linked with body composition.

Trimester-specific thyroid hormone reference data in Sri Lankan women.

Introduction: Regional differences in thyroid hormones are noted, especially during pregnancy. Objectives: Establish reference values for thyroid function tests for Sri Lankan pregnant women and to determine their comparability with regional data; and determine the prevalence of 2. Thyroid Peroxidase (TPO) antibody positivity and 3. Iodine deficiency among pregnant women with uncomplicated clinical history. Methods: A cross-sectional study conducted in antenatal clinics of a tertiary care maternity center recruited a minimum of 56 women in each trimester in a multistep approach to derive an "ideal-reference population"; Participants with clinically manifested thyroid disease, followed by subjects with sonographically abnormal thyroids and finally those at high risk for thyroid disease as shown by positive TPO levels and urine iodine deficiency were excluded in sequence. Thyroid hormones were measured by chemiluminescence in the ideal reference population. Reference ranges were derived using median and 5th and 95th centiles. Results: Final sample included 369 women. TSH reference ranges of the first (n=64), second (n=188) and third (n=117) trimesters were 0.014-2.77mIU/L, 0.31-3.2 mIU/L and 0.34-3.4 mIU/L, respectively. TPO antibody level showed a weak but significant correlation with TSH (r=0.10,p 0.021) in the final sample. No significant association was found between urine iodine and thyroid function tests. Conclusions: TSH reference ranges observed in this study are concordant with the Caucasian reference values more than the regional values. Discrepancies in study methodology, defining and selection of reference population and methods employed in measuring thyroid hormones in different studies may have accounted for these differences.

Age-related trends and reference intervals of cross-linked C-telopeptide of type I collagen and procollagen type I N-propeptide from a reference population of Sri Lankan adult women.

Refer ence values of bone turnover markers (BTMs) are determined by factors that are country-specific. In Sri Lanka, unavailability of BTM reference data has led to their non-use in management of osteoporosis. The results of this study can be used as reference data for women in Sri Lanka. INTRODUCTION: This study was performed to establish age-related reference intervals for bone resorption marker; cross-linked C-telopeptide of type I collagen (CTX) and bone formation marker; procollagen type I N-propeptide (PINP) in a group of Sri Lankan adult women. METHODS: Adult women (n = 347) aged 20-70 years were recruited using age-stratified random sampling technique and categorized into age groups by decades. Serum CTX and PINP concentration were measured using enzyme-linked immunosorbent assay (ELISA). The geometric mean (95% confidence interval) and 2.5th and 97.5th percentiles were calculated. ANOVA was used to compare the means between groups. RESULTS: Mean CTX levels were relatively low and remained unchanged between 20 and 49 years. After the age of 49 years, mean CTXconcentration elevated significantly until the age of 70 years (43%, p < 0.001). Mean PINP concentrations were not significantly different between age categories (p > 0.05). Reference intervals of CTX and PINP were based on 2.5th and 97.5th percentile values. Reference intervals of CTX for the age groups of 20-29, 30-39, 40-49, 50-59, and 60-70 years were 0.19-0.97 ng/mL, 0.18-0.95 ng/mL, 0.20-1.29 ng/mL, 0.17-2.20 ng/mL, and 0.17-2.85 ng/mL respectively. Reference intervals of PINP for the same age groups were 118-810 pg/mL, 119-772 pg/mL, 116-645 pg/mL, 108-684 pg/mL, and 108-715 pg/mL respectively. CONCLUSION: In Sri Lanka, bone turnover markers are not used in evaluating patients mainly due to lack of normative data. These values can be used as reference data for women in this age group.

Intervention thresholds to identify postmenopausal women with high fracture risk: A single center study based on the Philippines FRAX model.

OBJECTIVES: This study is designed to estimate appropriate intervention thresholds for the Philippines Fracture Risk Assessment Tool (FRAX) model to identify postmenopausal women with high fracture risk. METHODS: Age dependent intervention thresholds were calculated for a woman of body mass index 25 kg/m2 aged 50-80 years with a previous fragility fracture without other clinical risk factors. Fixed thresholds were developed using a database of 1546 postmenopausal women who underwent dual-energy X-ray absorptiometry for clinical reasons. Major and hip fracture risks were estimated using clinical risk factors with and without bone mineral density (BMD) input. Women were categorized to high risk and low risk groups according to the age dependent thresholds. The best cut-points were determined considering the optimum sensitivity and specificity using receiver operating characteristic analysis. RESULTS: The age dependent intervention thresholds of major fracture risk ranged from 2.8 to 6.9% while hip fracture risk ranged from 0.4 to 3.0% between 50 and 80 years of age. Major fracture threshold of 3.75% and hip fracture threshold of 1.25% were the best fixed thresholds observed and non-inclusion BMD in the fracture risk estimations did not change the values. As a hybrid method, 3% major fracture and 1% hip fracture risks for those < 70 years old and age-dependent thresholds for those aged 70 years and above can be recommended. CONCLUSIONS: The intervention thresholds estimated in the current study can be applied to identify Filipino postmenopausal women with a high fracture risk. Clinicians should decide on the type of thresholds most appropriate.

Prevalence and factors associated with recurrent falls among middle-aged community-dwelling women.

OBJECTIVE: This community-based study evaluated the prevalence and associated risk factors of recurrent falls among middle-aged community-dwelling women in Southern-Sri Lanka. METHODS: Randomly selected 285 middle-aged women (40-60years, Mean±SD;51.7±6.1years) participated. History of falls within the previous 12-months was inquired and those who reported two or more falls within 6-month period were considered as recurrent fallers. Age, menopausal status, weight (kg), height (m), waist-circumference (WC, cm), appendicular-skeletal-muscle-mass (ASMM, kg by DXA), hand-grip-strength (HGS, kg) and gait-speed (GS, m/s) were evaluated. Body-mass-index (BMI, kg/m2) and relative-ASMM-index (RSMI, kg/m2) were calculated. RESULTS: The prevalence of recurrent falls was 13% (95%CI; 9.4%-17.5%) (n=37). Recurrent falls were higher among postmenopausal women compared to premenopausal women, older middle-aged women (51-60years) compared to young middle-aged women (40-50years), those with low RSMI compared to normal RSMI, low HGS compared to normal HGS and low GS compared to normal GS (p<0.01). BMI and WC did not show significant associations with recurrent falls. Risk factors associated with recurrent falls were age (OR;7.41, 95%CI; 1.23-44.43, p=0.02), RSMI (OR;3.21, 95%CI; 1.00-10.32, p=0.04) and HGS (OR;3.19, 95%CI; 1.26-8.09, p=0.01). CONCLUSIONS: The prevalence of falls among middle-aged women was considerably high. Falls were associated with advanced age, low muscle mass and muscle strength.

Factors Related to Antibiotic Supply without a Prescription for Common Infections: A Cross-Sectional National Survey in Sri Lanka.

Inappropriate antibiotic use is a problem in Sri Lanka. We investigated pharmacy staff's attitudes towards antibiotic supply for common infections in Sri Lanka. A self-reported cross-sectional survey was conducted among a random sample (n = 369) of pharmacies. We assessed staff's beliefs and attitudes to antibiotic supplying for common infections (common cold and cough, sore throat, diarrhoea, wound and urinary tract infections (UTI)). Pharmacists (n = 210; 79%) and pharmacy assistants (n = 55: 21%) responded. About 30% (80/265) had supplied antibiotics without a prescription for common infections, including common cold (15.8%), sore throat (13.6%) and diarrhoea (10.2%). Overall, pharmacists were less likely to supply than non-pharmacists. Pharmacy staff with more positive beliefs about their professional competency to supply and monitor antibiotic use were more likely to supply antibiotics without a prescription for common cold (Adj.OR = 1.08; 95% CI: 1.01-1.15; p = 0.032), wound infections (Adj. OR = 1.06; 95% CI: 1.00-1.13; p = 0.059), and UTI (Adj.OR = 1.07; 95% CI: 0.99-1.15; p = 0.097). Pharmacy staff who believed in the effectiveness of antibiotics against common infections were more likely to supply antibiotics for common infections. Supply of antibiotics without a prescription was associated with staff's beliefs about antibiotics' effectiveness and their professional competency. Our findings could be used to strengthen regulatory strategies to improve practice.

Effect of vitamin D therapy on bone mineral density in patients with diabetic nephropathy; a randomized, double-blind placebo controlled clinical trial.

PURPOSE: Diabetes compromises bone strength resulting increased risk of osteoporosis. Objective of this study was to determine the effect of vitamin D given to patients with early diabetic renal disease on BMD and BMC. METHODS: Patients with diabetic nephropathy were recruited. Treatment group received 50,000 IU of vitamin D3 intramuscularly and the control group was given an equal volume of distilled water (0.25 mL) monthly for six months. Baseline BMD, BMC in the total body, lumbar spine and proximal femur were measured by DXA. After six months measurements were repeated. When trial period was over, a randomly selected subgroup of patients (25 from each group) was followed up for further six-months and measurements were repeated. RESULTS: Selected patients were randomly assigned to two groups. After six months, the treatment group total body BMD, total body BMC and BMDs of spine, femoral neck and total hip regions increased by 2.0%, 2.2%, 1.8%, 2.1% and 2.6% (P < 0.05 for all within-group differences), respectively. In the Control group, BMD or BMC of any region mentioned above did not change significantly during the initial 6 months (P < 0.05 for the between-groups differences). After 6 months of stopping treatment, a statistically significant reduction of total BMD and BMC was observed in the treatment group (P = 0.009). CONCLUSION: This study showed that treatment with high dose vitamin D significantly influences total body BMC, total body BMD, BMDs of spine, femoral neck and hip among patients with diabetic nephropathy.

Quality of Life and Functional Independence of Hip Fracture Patients: Data from a Single Center Follow-Up Study in Sri Lanka.

BACKGROUND: Data on the functional outcomes of hip fracture patients in Sri Lanka are limited. As this information is required for the design of long-term care plans, we assessed the physical activities (activities of daily living [ADL]) and quality of life (QoL) of hip fracture survivors in Sri Lanka. METHODS: A group of 180 consecutive patients with incident hip fractures admitted to a tertiary care center in Southern Sri Lanka were followed up for 12 months. The Sinhala versions of the Barthel Index, 36-Item Short-Form Survey, and Mini-Mental State Examination were used to assess ADL, QoL, and mental status, respectively. RESULTS: Of the 180 patients (149 women), 107 underwent surgery. An initial sharp decline and partial recovery of ADL and QoL were observed among patients with hip fractures. Furthermore, patients who underwent surgical treatment showed faster recovery of ADL and QoL than did patients who were managed conservatively. Similarly, patients who did not have complications during the hospital stay showed faster recovery of ADL and QoL than did patients with one or more complications. Conclusions: Hip fractures profoundly affected both ADL and QoL, and recovery remained incomplete at 12 months post fracture. Patients who underwent surgery had a faster recovery than did patients who did not undergo surgery; similarly, patients without complications also had a faster recovery than did those with complications.

Self-medication Behavior with antibiotics: a national cross-sectional survey in Sri Lanka.

BACKGROUND: Antibiotic self-medication is common in low- and middle-income countries. This study aimed to evaluate the Sri Lankan public's knowledge about and attitudes toward antibiotic use and self-medication, and factors associated with self-medication. METHODS: A national cross-sectional, interviewer-administered, survey of a random household sample (N = 1100) was conducted. Factor analysis of the attitudinal items was conducted to investigate the factors associated with antibiotic self-medication. RESULTS: A response rate of ninety-one percent (n = 998) responded. Knowledge about antibiotics was poor (mean = 12.5; SD = 3.5; (scale 0-27)). Half had previously used an antibiotic once in the past three months. About 11% (108/998) had self-medicated the last time they took antibiotics; mostly obtained from a pharmacy (82%; 89/108). Three attitudinal factors were obtained, explaining 56.1% of the variance. Respondents were less likely to self-medicate if they did not support ease of access to antibiotics from pharmacies (p< 0.001) and situational use of antibiotics (p= 0.001); supported appropriate use of antibiotics (p= 0.003); and had greater knowledge about prescription requirements for antibiotics (p= 0.004). CONCLUSION: There is limited knowledge about, and a high rate of self-medication with antibiotics.Factors contributing to self-medication could be addressed with appropriate public education campaigns, and policy changes.