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.

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.

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).

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.

Fetal Doppler reference values in women with a normal body mass index

Objectives: To construct gestation specific reference limits for fetal umbilical (UA), middle cerebral artery (MCA) pulsatility indices (PI) and the cerebroplacental ratio (CPR) in singleton pregnancies with normal BMI between 16 and 40 weeks of gestation. Methods: We ultrasonographically examined 596 fetuses from women with normal nutritional and health status and minimal environmental constraints on fetal growth. Each mother was considered only once for measurement of fetal Doppler indices, at gestations between 16 and 40 weeks in a prospective cross-sectional study. Gestational age was confirmed by fetal crown-rump length measurement between 11 and 14 weeks. Pulsatility indices of umbilical and middle cerebral arteries were measured by real time and Doppler ultrasonography. CPR ratio was calculated by dividing MCA PI by UA PI. The fetal Doppler measurements obtained from the current study were compared with commonly used reference charts. For each parameter separate polynomial regression models were fitted to estimate the gestation specific means and standard deviations, assuming that the measurements have a normal distribution at each gestational age. Results: A significant difference of fetal Doppler indices was observed between our study and previously published reference charts for most gestational weeks. The fitted 10th, 50th and 90th centiles at 40 weeks of gestation were 0.65, 0.87 and 1.08 for UA PI; 0.93, 1.32 and 1.71 MCA PI; 1.02, 1.58 and 2.13 for CPR. Conclusions: These charts can be used for better defining the normal range of fetal arterial Doppler indices. This will be useful in the diagnosis and management of fetuses with abnormal fetal growth.

Comparison of ultrasound fetal biometry of singleton fetuses with a reference chart in pregnant women with normal nutritional and health status

Objetives: The aim of this study was to compare fetal biometry of singleton fetuses in pregnant women with normal nutritional and health status in the Ampara district, with a commonly used reference chart. Methods: A cross sectional study was carried out in the Ampara District. Women with normal nutritional and health status and minimal environmental constraints on fetal growth (n=714) were enrolled during the first trimester and gestational age was confirmed by fetal crown-rump length measurement between 11 weeks + 0 days and 13 weeks + 6 days. For this study, each mother was considered only once for measurement of fetal biometry, at gestations between 11 and 41 weeks. Fetal bi-parietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL) were measured using standard techniques, and separate regression models were fitted to estimate the means and standard deviations and derive gestation specific centiles for each parameter, assuming that the measurements have a normal distribution at each gestational age. The fetal biometry results obtained from the current study were compared with a commonly used reference chart. Results: The fitted 10th, 50th and 90th centiles at 40 weeks of gestation were, 87.9 mm, 93.2 mm and 98.5 mm for BPD, 313.8 mm, 328.9 mm and 344.0 mm for HC; 298.2 mm, 322.5 mm and 346.9 mm for AC and 69.7 mm, 75.0 mm and 80.2 mm for FL. When compared with the reference chart, significant differences of fetal biometry were seen in the third trimester but not in the second trimester. Conclusions: Ultrasound fetal biometry of singleton fetuses in pregnant women with normal nutritional and health status in the Ampara District were significantly different in the third trimester, from a routinely used reference chart.

Utility of glycosylated haemoglobin in diagnosing diabetes in an urban Sri Lankan community

Introduction: American Diabetes Association (ADA) has officially endorsed glycosylated haemoglobin (HbA1c) as a diagnostic tool. The recommended cut-off for diagnosing diabetes is  6.5%. Objectives: To compare use of HbA1c and fasting plasma glucose (FPG) to diagnose diabetes in an urban Sri Lankan community. Methods: This cross-sectional study is based on baseline data from a prospective study on non-communicable diseases in randomly selected individuals aged 35-64 years in a selected community. HbA1c was measured by National Glycohaemoglobin Standardization Program certified Bio Rad Variant HbA1c HPLC method. Diagnostic performance of HbA1c was evaluated in those without previous diabetes. Receiver Operating Characteristic Curve was used to identify optimum HbA1c threshold. Results: We studied 2516 individuals with no previous history of diabetes. Of these 53.8% were women. Mean age was 52 ± 7.9 years. FPG was 7mmol/l in 245 (9.7%). HbA1c was  6.5% in 173 (6.9%). Concordance between FPG and HbA1c was 95% (both criteria positive: 5.8%; both criteria negative: 89.2%). Compared to FPG, HbA1c cut-off of 6.5% had specificity of 98.9% (95% CI 98.3-99.3) and sensitivity of 60% (95% CI 53.6-66.2). Positive and negative predictive values were 85% (95% CI 78.8-89.9) and 95.8% (95% CI 94.9-96.6), respectively. Compared to FPG, optimum HbA1c threshold for diagnosing diabetes was 5.9% (sensitivity: 84%; specificity: 88.8%; area under the curve: 0.91). Conclusions: In the study population, detection of diabetes with ADA recommended HbA1ccriterion was 29% less than with FPG criterion. Compared to FPG, HbA1c had high specificity but sensitivity was low. Further research is needed to refine the optimum HbA1c threshold in Sri Lankans.

Symphysis-pubis fundal height charts to assess fetal size in women with a normal body mass index.

OBJECTIVES: To construct symphysis-pubis fundal height (SFH) charts to estimate fetal size in pregnant women with a normal body mass index (BMI) and to describe the variation of SFH measurements according to BMI. METHODS: cross sectional study was carried out at Ampara and Gampaha Districts in Sri Lanka. Women with normal nutritional and health status, normal BMI and minimal environmental constraints on fetal growth, with ultra sound confirmation of dates by fetal crown-rump length measurements between 11 weeks and 13 weeks + six days,had their SFH measured, using non-elastic tape and standard techniques, between 24 and 41 weeks gestation. Only one measurement of SFH was obtained from each pregnant woman. Linear and polynomial regression models were fitted separately to the means and standard deviations (SD) as functions of gestational age to identify the model with the best fit. Centiles were derived from the mean and SD at each gestational age. RESULTS: Pregnant women from the districts of Ampara (n=387) and Gampaha (n=200) were recruited. Other than a difference of -1.5 cm (95% CI -2.27 to -0.23) at 38 weeks of gestation, there were no significant differences between the SFH measurements obtained from women with normal BMI in Ampara and Gampaha Districts. Using the SFH measurements from the Ampara sample, charts were created for 10th, 50th and 90th centile values of SFH. At 40 weeks of gestation these were 34 cm, 37 cm and 41 cm respectively. At 40 weeks gestation, the variation in SFH measurements between BMI sub groups within the normal range was approximately 1.4 cm to 1.6 cm. CONCLUSIONS: These SFH charts could be used to estimate fetal size in pregnant women with normal BMI.

Risk estimates of cardiovascular diseases in a Sri Lankan community.

OBJECTIVES: Quantifying the risk of cardiovascular disease (CVD) in a community is important in planning preventive strategies, but such data are limited from developing countries, especially South Asia. We aimed to estimate the risks of coronary heart disease (CHD), total CVD, and CVD mortality in a Sri Lankan community. METHODS: A community survey was conducted in an urban health administrative area among individuals aged 35-64 years, selected by stratified random sampling. Their 10-year CHD, total CVD, and CVD mortality risks were estimated using three risk prediction tools: National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III), Systematic Coronary Risk Evaluation (SCORE), and World Health Organisation/ International Society of Hypertension (WHO/ISH) charts. RESULTS: Among study participants (n=2985), 54.5% were females, and mean age (SD) was 52.4 (7.8) years. According to NCEP-ATP III ('hard' CHD risk), WHO/ISH (total CVD risk), and SCORE (CVD mortality risk) criteria, 25.4% (95% CI 23.6-27.2), 8.2% (95% CI 7.3-9.2), and 11.8 (95% CI 10.5-13.1) respectively were classified as at 'high risk'. The proportion of high risk participants increased with age. 'High risk' was commoner among males (30.3% vs 20.6%, p<0.001) according to NCEPATP III criteria, but among females (9.7% vs. 6.7%, p<0.001) according to WHO/ISH criteria. No significant gender difference was noted in SCORE risk categories. CONCLUSIONS: A large proportion of individuals in this community are at risk of developing cardiovascular diseases, especially in older age groups. Risk estimates varied with the different prediction tools, and were comparatively higher with NCEP-ATP III charts.

The prevalence of upper respiratory symptoms in a cohort of adults presenting with symptoms of gastro-oesophageal reflux disease.

INTRODUCTION: Gastro-oesophageal reflux disease (GORD) is the pathological reflux of gastric contents into the oesophagus. The oesophagus and the upper respiratory tract have a common origin from the foregut. There is increasing evidence for multiple associations of GORD with the upper respiratory tract. OBJECTIVES: To study the presence of and association of upper respiratory symptoms (URS) with GORD. METHODS: Seventy adults scoring ≥12.5 on a previously validated GORD symptom score (GORD patients) and 70 healthy controls who had infrequent GORD symptoms or no upper gastro-intestinal complaints completed a pre-tested URS questionnaire on the frequency of 14 URS in 5 categories (laryngeal, nasal, pharyngeal, sinusal and aural). All GORD patients underwent upper gastro-intestinal endoscopy. The calculated URS score was correlated against the GORD symptom score and endoscopy findings. RESULTS: URS scores and individual symptom scores were higher in GORD patients compared to controls (mean ± SE, 4.7 ± 4.0; 1.9 ± 2.3). Individuals with higher GORD symptom scores reported more frequent URS. Pharyngeal symptoms had the highest correlation with the GORD symptom score (r=0.507, p<0.001). The presence of oeso-phagitis did not seem to influence the frequency of reporting URS. CONCLUSION: Upper respiratory symptoms are common in individuals with GORD symptoms though there appears to be no association with oesophageal mucosal damage.

Epidemiology of goitre in Sri Lanka in the post-iodization era.

INTRODUCTION: Previous studies of goitre in Sri Lanka proposed the presence of a goitre belt, which was refuted subsequently. Epidemiology of goitre in the post iodization era needs re-evaluation. Objectives To describe the epidemiology of goitre in Sri Lanka. METHODS: A descriptive cross-sectional study was conducted in designated zones except in conflict areas in 2006/2007. An interviewer administered questionnaire was used and patients were evaluated clinically, biochemically and cytologically. RESULTS: Among 5200 participans 426 had goitre. Mean age was 36.3 (SD 17.3) years. Goitre was commonest in the age group 40-49 years with a female pre-ponderance. The prevalence was similar in all zones with pockets of high prevalence in each zone. Overall islandwide adjusted prevalence was 6.8% (95% CI = 6.0-7.6). CONCLUSIONS: There was no identifiable goitre belt.There were pockets of high prevalence in all zones. Goitre remains a public health issue despite universal iodization.

Road rage in Sri Lanka: prevalence and psychiatric distress.

INTRODUCTION: Road traffic accidents are a major public health concern in Sri Lanka. Aggressive and reckless driving is an important contributor to the high rate of road traffic accidents. OBJECTIVE: We studied prevalence, nature, determinants and associated psychiatric morbidity of road rage among motorists in Sri Lanka. Methods Data were gathered from 238 randomly selected motorists in Sri Lanka using a modified questionnaire regarding road rage and the 6-item version of Kessler's psychological distress scale. RESULTS: While 98.7% participants reported being victims of road rage, 85.3% were involved in offending behaviour. However actual physical assault (0.8%) and damage to vehicles (2.5%) were rare. Male gender, young age, increased traffic density and driving a three-wheeler or bus were associated with daily road rage victimisation and perpetration. Psychiatric distress was associated with being a victim of road rage. CONCLUSIONS: High prevalence of road rage in Sri Lanka and significant psychiatric distress associated with it indicate the necessity of interventions at least for target groups.

Prevalence of hepatitis B and hepatitis C infections and their relationship to injectable drug use in a cohort of Sri Lankan prison inmates.

INTRODUCTION: Prisoners are considered to be at high risk for Hepatitis B (HBV) and Hepatitis C (HCV) virus infections. This is attributed to intravenous drug use and high-risk sexual behaviour. There are no published studies on HBV and HCV among prison inmates or injecting drug users in Sri Lanka. OBJECTIVES: To determine prevalence of HBV and HCV infections, and their relationship to injectable drug use among Sri Lankan prisoners. METHODS: We investigated 393 (median age 42 years (range 16 to 93); 82% males) randomly selected inmates of Mahara and Welikada prisons. RESULTS: Though 167 (42.5%) admitted drug abuse, only 17 (4.3%) had ever used intravenous drugs. Twelve (70.6%) of them reported sharing needles. One inmate was positive for HBsAg but was negative for HBV-DNA. Twenty seven (6.9%) were positive for anti-HCV antibodies, of whom only 2 (0.5%) were positive for HCV-RNA. None of the injecting drug users were positive for HBV-DNA or HCV-RNA. CONCLUSIONS: The prevalence of HBV and HCV infections as well as injecting drug use was very low among this cohort of Sri Lankan prison inmates.

Prevalence of postpartum anal incontinence: a cross sectional study in Northern Sri Lanka.

OBJECTIVES: To estimate the prevalence of postpartum anal incontinence (AI) and to highlight associated factors that account for variation in the prevalence in Vavuniya district in Northern Sri Lanka. METHODS: A community based cross sectional study was conducted. Sample included all mothers (hospital and home deliveries) who had completed postpartum period between 1st August and 30th September 2007. Participants were identified from the "expected date of delivery" registers maintained by public health midwives. Data were collected by trained public health midwives at the respondents' houses using an interviewer administered questionnaire. RESULTS: The mean age of the 540 postpartum mothers interviewed was 28 years (range: 16 - 44). Majority 78% (n=423) were Sri Lankan Tamils, 13% (n=68) Sinhalese and remaining 9% (n=49) Moors. Thirty nine percent (n=209) were primi parous, 81% (n=435) had a normal vaginal delivery and 79% (n=344) had an episiotomy. Out of 540 mothers, 16.5% (95% CI: 13.4 - 19.6) reported anal incontinence. Among them only 39.3% (n=35) had consulted a health worker for the symptom. In the bivariate analysis the following factors were significantly associated with anal incontinence: parity, history of an episiotomy, duration of labour >12hrs, mode of delivery (vaginal), family income and maternal age (teenage). But the multiple logistic regression analysis revealed only the episiotomy status as an independent risk factor (adjusted odd ratio: 3.4 (95% CI: 1.28 - 8.9). CONCLUSINS: Anal incontinence is not an uncommon symptom in postpartum mothers and majority of affected individuals avoided seeking medical attention. Factors associated with increased risk of anal sphincter damage should be considered during delivery and an attempt should be made to reduce it.

Substance use disorders among mentally ill patients in a General Hospital in Sri Lanka: prevalence and correlates.

OBJECTIVES: To determine the prevalence, and demographic and clinical correlates of substance use disorders among the mentally ill. DESIGN AND SETTING: Cross sectional analytical study. Data were collected from consecutive patients treated at a Tertiary care Psychiatry Unit, Western Province, Sri Lanka using an interview schedule administered by a senior registrar in psychiatry. MEASUREMENTS: Diagnosis was based on ICD 10 criteria and the Clinician Rating Scale: Alcohol Use Scale (AUS) and the Drug Use Scale (DUS). The data were analysed using SPSS and WinPepi software programmes, utilising the chi squared, t test and median test. RESULTS: Among a sample of 325 patients, 66% were male; 33% were diagnosed with depressive disorder, 30% with schizophrenia, 23% with bipolar affective disorder and 13% with other disorders. Prevalence of comorbid substance use disorders was 43% (95% CI 38 - 49%). Alcohol was the commonest type of substance used. Those who had a comorbid substance use diagnosis were more likely to be male, have a lower educational level, be unemployed and have a poorer level of social support. They were also found to have poorer treatment adherence, increased number of hospital admissions and an increased association with episodes of violence. CONCLUSION: A significant proportion of patients were found to have a comorbid substance use diagnosis and associated complications. These findings have important implications for service provision for mentally ill patients with a comorbid substance use disorder.

Validation of the Sinhala version of the Chronic Liver Disease Questionnaire (CLDQ) for assessment of health related quality of life among Sri Lankan cirrhotics.

OBJECTIVES: The Chronic Liver Disease Questionnaire (CLDQ) is a validated tool measuring Health Related Quality of Life among patients with cirrhosis. The aim of this study was to validate a Sinhala version of the CLDQ (sCLDQ) and to test its correlation with the degree of liver dysfunction in a cohort of Sri Lankan patients with cirrhosis. METHODS: A standard translation method was used. Pilot testing was done with relevant cultural and language adaptations. The final version and the WHO Quality of Life-BREF (WHOQOL-BREF) validated Sinhala version were administered to patients with chronic lever disease (CLD). sCLDQ was re-administered 4 weeks later to test internal consistency and reliability. The validaty and reliability were assessed by Cronabach's alpha, intraclass correlation coefficient (ICC) and Pearson's correlation coefficient. ANOVA and Pearson's correlation were used to assess correlation with the degree of liver dysfunction. RESULTS: Validation was done with 214 participants [mean age 55.6 years (SD 10.4) male 77.6%]. Cronabach's alpha was 0.926. Intra-class correlations varied from 0.431 to 0.912 and all were significant (p< 0.001). Retesting was done on a sub-sample of 18 participants. Test-retest correlation was 0.695 (p = 0.008). WHO-BREF was administered to a sub-sample of 48 subjects. There was a significant correlation (Pearson's r=0.391; p=0.004) between sCLDQ and WHOQOL BREF. sCLDQ was significantly associated with MELD (r=-0.13; p=0.038), MELD sodium (r=-0.223; p=0.002), serum bilirubin (r=-0.124; p=0.036), serum sodium (r=0.172; p=0.009), serum albumin (r=0.201; p=0.003) and Child grade (f=3.687; p=0.027). CONCLUSIONS: CLDQ is a reliable and valid tool to assess quality of life of Sri Lankan patients with cirrhosis and correlates well with known indices of disease severity.

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

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

Selection of medical students in Sri Lanka: time to re-think criteria?

OBJECTIVE: To examine the validity of selected entry level characteristics in relation to the GCE A/L examination as independent predictors of performance of students in medical school. METHODS: A retrospective, analytical study was done at the Faculty of Medicine, University of Kelaniya. Student characteristics at entry were described by sex, the average z-score, General English grade and attempt at GCE A/L examination, and average mark obtained at the English placement test on registration to medical school. Average marks at three summative examinations were used as indicators of performance in medical school. Multivariate analysis using multiple linear regression was carried out using these three outcome measures in relation to four entry point variables as predictors of performance in medical school. Causal path diagrams were constructed using standardised regression coefficients for the whole group and for male and female students separately. RESULTS: The A/L z-score, A/L attempt and English placement test marks were all significant predictors of outcome at the First Examination. Of the variables relating to the A/L examination, the attempt had a much higher path coefficient with performance at the First Examination than the A/L z-score, as did the English marks. Separate path analyses for male and female students showed that while the significance of the relationships remained the same, the magnitude of the correlation was different. CONCLUSIONS: Students who gain admission on their 3rd attempt at the AL examination fare much worse than those admitted to medical school on their 1st attempt. Differences between sexes in examination performance are probably linked to both A/L attempt and English language proficiency.

Validation of the World Health Organization/ International Society of Hypertension (WHO/ISH) cardiovascular risk predictions in Sri Lankans based on findings from a prospective cohort study.

INTRODUCTION AND OBJECTIVES: There are no cardiovascular (CV) risk prediction models for Sri Lankans. Different risk prediction models not validated for Sri Lankans are being used to predict CV risk of Sri Lankans. We validated the WHO/ISH (SEAR-B) risk prediction charts prospectively in a population-based cohort of Sri Lankans. METHOD: We selected 40-64 year-old participants from the Ragama Medical Officer of Health (MOH) area in 2007 by stratified random sampling and followed them up for 10 years. Ten-year risk predictions of a fatal/non-fatal cardiovascular event (CVE) in 2007 were calculated using WHO/ISH (SEAR-B) charts with and without cholesterol. The CVEs that occurred from 2007-2017 were ascertained. Risk predictions in 2007 were validated against observed CVEs in 2017. RESULTS: Of 2517 participants, the mean age was 53.7 year (SD: 6.7) and 1132 (45%) were males. Using WHO/ISH chart with cholesterol, the percentages of subjects with a 10-year CV risk <10%, 10-19%, 20%-29%, 30-39%, ≥40% were 80.7%, 9.9%, 3.8%, 2.5% and 3.1%, respectively. 142 non-fatal and 73 fatal CVEs were observed during follow-up. Among the cohort, 9.4% were predicted of having a CV risk ≥20% and 8.6% CVEs were observed in the risk category. CVEs were within the predictions of WHO/ISH charts with and without cholesterol in both high (≥20%) and low(<20%) risk males, but only in low(<20%) risk females. The predictions of WHO/ISH charts, with-and without-cholesterol were in agreement in 81% of subjects (ĸ = 0.429; p<0.001). CONCLUSIONS: WHO/ISH (SEAR B) risk prediction charts with-and without-cholesterol may be used in Sri Lanka. Risk charts are more predictive in males than in females and for lower-risk categories. The predictions when stratifying into 2 categories, low risk (<20%) and high risk (≥20%), are more appropriate in clinical practice.

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.