Retinopathy among young adults with Diabetes Mellitus from a tertiary care setting in Sri Lanka.

BACKGROUND: Diabetic retinopathy (DR) is one of the leading causes for complete loss of vision among working-aged adults around the world. The present study aims to evaluate the rate of DR and its risk factors among the adults with young-onset diabetes from a tertiary care setting in Sri Lanka. METHODS: A consecutive sample of 1,007 individuals referred from multiple centers, were invited for the study. Ophthalmological evaluation was done, with dilated indirect ophthalmoscopy by an Ophthalmologist. Retinopathy was classified according to the International Clinical DR Disease Severity Scale. An interviewer-administered questionnaire was used to collect socio-demographic and anthropometric details. Seated blood pressure, Fasting Blood Glucose (FBG), HbA1c and urine microalbumin were also measured. Data were analysed using SPSSv14. A binary logistic regression analysis was performed in all patients, with 'presence of DR' as the dichotomous dependent variable and other independent covariates. RESULTS: Sample size was 684 (response rate-67.9%), mean age was 37.1 ± 5.9 years and 36.0% were males. Mean duration of diabetes was 5.2 ± 4.0 years. Previous retinal screening had been done in 51.0% by a non-specialist doctor and in 41.5% by a consultant ophthalmologist. Rate of any degree of DR in the study population was 18.1% (Males 16.4%, Females 20.0%; P = NS). In patients with DR, majority had mild Non-Proliferative DR (NPDR) (57.2%), while 32.2% had moderate NPDR, 0.8% had severe NPDR and 9.7% had maculopathy. Mean age, duration of diabetes, systolic (SBP) and diastolic blood pressure (DBP), FBG, HbA1c and urine microalbumin levels were significantly higher amongst the patients with DR. The results of the binary logistic regression indicate that the duration of diabetes (OR:1.24), HbA1c (OR:1.19), age (OR:1.11), urine Microalbumin (OR:1.11) and DBP (OR:1.04) all were significantly associated with DR. CONCLUSIONS: In this large multi center study, nearly one in five adults with young-onset diabetes was found to have retinopathy. Age, duration of diabetes, HbA1C and urine Microalbumin levels were significantly associated with the presence of retinopathy, while HbA1c was also a significant factor determining severity. Nearly 50% of the study population has never undergone retinal screening by an ophthalmologist, highlighting the need for well organized screening programs.

Prevalence, patterns and correlates of alcohol consumption and its' association with tobacco smoking among Sri Lankan adults: a cross-sectional study.

BACKGROUND: Most studies on alcohol consumption carried out in Sri Lanka are limited to single/few provinces in the island. The objective of this study was to determine the prevalence, patterns and correlates of alcohol consumption among a larger sample of adults in Sri Lanka. METHODS: This cross-sectional study was conducted in seven of all nine provinces in Sri Lanka, between 2005 and 2006. A nationally representative sample of 5000 adults aged ≥18 years was selected using multi-stage random cluster sampling. Data of 4532 participants were collected using an interviewer administered questionnaire. Data analysis included chi-squared test, multiple logistic regression analysis and Spearman correlation using Stata/SE 10.0 (StataCorp LP., Texas, USA) software package. RESULTS: Males were 40%; mean age was 46.1 years (±15.1). The overall, urban and rural prevalence (95% CI) of current drinking was 23.7% (21.7 - 25.7), 29.5% (25.7 - 33.3) and 22.2% (19.8 - 24.7) respectively (p = 0.001). Current (M: 48.1%, F: 1.2%, p < 0.0001) and former (M: 21.4%, F: 0.7%, p < 0.0001) drinking was much higher in males. The highest prevalence of drinking in males (58.9%) and females (2.2%) was in the 30 - 39 and <20 year age groups respectively. Lowest prevalence in men (24.6%) and women (0%) was in the >70 years age-group. Hazardous drinking was seen in 5.2% of men and 0.02% of women. Male sex, urban living and current smoking correlated with both current and hazardous drinking. Lower level of education, and age >70 years positively correlated with hazardous drinking. CONCLUSIONS: Alcohol is predominantly a problem in Sri Lankan males. In males, both current and hazardous drinking positively correlated with urban living, white collar occupation, Burgher ethnicity and current smoking. Hazardous drinking positively correlated with lower level of education and older age. The data shown here are useful in planning interventions simultaneously targeting alcohol and tobacco.

Chronic peritoneal dialysis in South Asia - challenges and future.

Chronic peritoneal dialysis (PD), especially continuous ambulatory PD (CAPD), is being increasingly utilized in South Asian countries (population of 1.4 billion). There are divergent geopolitical and socioeconomic factors that influence the growth and expansion of CAPD in this region. The majority of the countries in South Asia are lacking in government healthcare system for reimbursing renal replacement therapy. The largest utilization of chronic PD is in India, with nearly 6500 patients on this treatment by the end of 2006. A large majority of patients are doing 2 L exchanges 3 times per day, using glucose-based dialysis solution manufactured in India. Chronic PD is not being utilized in Myanmar, Bhutan, or Seychelles. Affirmative action by the manufacturing industry, medical professionals, government policy makers, and nongovernmental organizations for reducing the cost of chronic PD will enable the growth and utilization of this life-saving therapy.

Prevalence, patterns, and associations of dyslipidemia among Sri Lankan adults-Sri Lanka Diabetes and Cardiovascular Study in 2005-2006.

BACKGROUND: Dyslipidemia is a major risk factor for cardiovascular disease. Prevalence patterns and determinants of dyslipidemia in Sri Lanka are unkown. OBJECTIVES: We aimed to determine the prevalence and correlates of dyslipidemia among Sri Lankan adults. METHODS: A nationally representative sample was recruited by multistage random cluster sampling in Sri Lanka Diabetes and Cardiovascular Study, a cross-sectional study. Data collected by an interviewer-administered questionnaire, physical examination, anthropometric measurements lipid analysis from take 12-hour fasting blood samples were used. RESULTS: Among 4451 participants 60.5% were women and mean age was 46 years. Mean (standard deviation) total cholesterol (TC), high-density lipoprotein cholesterol (HDLC), low-density lipoprotein cholesterol (LDLC), triglycerides (TGs), and TC/HDLC levels were 206.7 mg/dL (±43.5), 46.8 mg/dL (±10.6), 135.5 mg/dL (±37.6), 121.7 mg/dL (±66.8), and 4.6 (±1.1), respectively. Women had higher mean TC, HDLC, LDLC, and TG values compared to men across all age groups. Mean TC, LDLC, and TGs increased with age in both genders; 77.4% of participants had some form of dyslipidemia. Low HDLC was the commonest type (49.6%) of dyslipidemia. Increasing age, female sex, living in urban sector, high body mass index, central obesity, diabetes, hypertension, insufficient physical activity, and smoking were associated with having some form of dyslipidemia. CONCLUSION: Three in four Sri Lankan adults have some form of dyslipidemia. Physical inactivity, obesity, hypertension, and diabetes are the leading modifiable risk factors.

Pregnancy outcomes and contraceptive use in patients with systemic lupus Erythematosus, rheumatoid arthritis and women without a chronic illness: a comparative study.

OBJECTIVES: To compare the pregnancy outcomes and contraceptive practices in systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and women with no chronic illness (WNCI) in a tertiary care referral center in Colombo, Sri Lanka. METHODS: Patients with SLE satisfying American College of Rheumatology criteria for diagnosis and history of pregnancies were recruited from university lupus clinic, National Hospital of Sri Lanka (NHSL). Age-matched women with history of pregnancy and RA were recruited from the rheumatology clinic, NHSL and WNCI from a surgical clinic. RESULTS: In 71 patients with SLE, 79 pregnancies occurred in 38 patients. The number of total pregnancies in SLE, RA and WNCI (79, 80 and 85 respectively) were not significantly different (P > 0.05), but most occurred before diagnosis of SLE and RA. Pregnancies occurring after diagnosis were significantly higher in SLE compared to RA (P = 0.013, χ2 = 6.169). Mean age at diagnosis was higher (P < 0.01) in RA (35 years) than in SLE (26 years). Percentage live births after diagnosis was significantly lower (P < 0.01) in SLE (9/20; 45%) compared to RA (6/8; 75%) and WNCI (77/85; 91%). Adverse fetal outcomes (fetal loss, pre-maturity, low birth weight) and assisted deliveries were significantly more (P < 0.001) in SLE than in WNCI. Unplanned pregnancies were significantly higher (P < 0.01) in SLE (80%) compared to RA (25%) and in WNCI (9.4%). Contraceptive usage was lower in patients with SLE (25.6%) and RA (33%) compared to WNCI (56.4%). Disease exacerbations occurred in 20% of SLE patients during pregnancy. CONCLUSIONS: More pregnancies occur in SLE than in RA after diagnosis of illness. Unplanned pregnancies and adverse pregnancy outcomes need to be addressed more in SLE than in RA or in WNCI.

Chronic kidney disease hotspots in developing countries in South Asia.

In many developing countries in the South Asian region, screening for chronic diseases in the community has shown a widely varying prevalence. However, certain geographical regions have shown a high prevalence of chronic kidney disease (CKD) of unknown etiology. This predominantly affects the young and middle-aged population with a lower socioeconomic status. Here, we describe the hotspots of CKD of undiagnosed etiology in South Asian countries including the North, Central and Eastern provinces of Sri Lanka and the coastal region of the state of Andhra Pradesh in India. Screening of these populations has revealed cases of CKD in various stages. Race has also been shown to be a factor, with a much lower prevalence of CKD in whites compared to Asians, which could be related to the known influence of ethnicity on CKD development as well as environmental factors. The difference between developed and developing nations is most stark in the realm of healthcare, which translates into CKD hotspots in many regions of South Asian countries. Additionally, the burden of CKD stage G5 remains unknown due to the lack of registry reports, poor access to healthcare and lack of an organized chronic disease management program. The population receiving various forms of renal replacement therapy has dramatically increased in the last decade due to better access to point of care, despite the disproportionate increase in nephrology manpower. In this article we will discuss the nephrology care provided in various countries in South Asia, including India, Bangladesh, Pakistan, Nepal, Bhutan, Sri Lanka and Afghanistan.

International educational partnerships for doctors in training: a collaborative framework with the RCP.

The UK offers excellent postgraduate medical education, and overseas doctors in training often covet a period of training in the UK. Some overseas training authorities make UK training mandatory prior to appointment as a consultant. Unfortunately, the organisation of such training often proves to be ad hoc, and may lack educational value. UK training faces challenges as a result of reduced hours of work, more structured and intensive educational needs, and pressures of increasing clinical demand. A plethora of new 'trust' posts have developed, often with limited educational value, creating a risk that training quality for overseas doctors is reduced. Against this background, such posts can be used to create international training partnerships such as that at Sherwood Forest Hospitals NHS Trust (SFHT), providing high-quality general and specialty training. Given the success of this strategy, it would be desirable for other UK trusts to provide similar schemes offering specialties not covered at SFHT.

Constrictive pericarditis in a post-renal transplant patient: a case report.

INTRODUCTION: Constrictive pericarditis is a rare complication in the post-renal transplant period. It poses a diagnostic dilemma even in the modern era. Its incidence is not known and tuberculosis is implicated in some of the cases. CASE PRESENTATION: A 54-year-old Sri Lankan man, in the sixth year of transplant presented with resistant ascites, shortness of breath and elevated creatinine from the baseline. Pre-transplant he was empirically treated for tuberculosis pericarditis and was on isoniazid prophylaxis for 1 year following transplantation. Two-dimensional echocardiography and cardiac catheterization confirmed the diagnosis, and pericardiectomy was performed, which resulted in full resolution of the symptoms as well as the graft function. The histology or bacteriology failed to demonstrate features suggestive of tuberculosis in the surgical specimen. CONCLUSION: In constrictive pericarditis, a causative factor is difficult to find. Isoniazid prophylaxis shows benefit in preventing tuberculosis-associated constrictive pericarditis.

Incidences and clinical outcomes of acute kidney injury in ICU: a prospective observational study in Sri Lanka.

BACKGROUND: Acute kidney injury (AKI) is a common and a serious complication among patients admitted to intensive care units (ICUs), and has been the focus of many studies leading to recent advances in diagnosis and classification. The incidence and outcome of AKI in Sri Lankan ICUs is largely unknown. The aim of this study was to describe the incidence, severity and outcome of AKI among patients admitted to the medical ICU, National Hospital, Colombo, Sri Lanka (NHSL). METHODS: Patients admitted to the medical ICU, NHSL, over a period of 6 months were studied prospectively.Standard demographic, physiological and clinical data were collected. Severity of illness was assessed using SOFA (Sequential Organ Failure Assessment) score. Diagnosis of AKI was based on Acute Kidney Injury Network (AKIN) criteria. RESULTS: Of 212 patients screened, 108 satisfied the inclusion criteria; males 67(61.5%); mean age 47.8 years(SD 19.4, range 12-94). Mean duration of ICU stay was 11.6 days (SD 10.6, range 2-55). Eighty one (75.0%) received mechanical ventilation. Forty nine (45.4%) had sepsis. ICU mortality was 38.9% and AKI was present in 60.2%. The majority of AKI patients (38, 58.5%) had AKI stage 3. Patients with AKI were at higher risk of death (p < 0.01). Neither age, gender, nor the presence of co-morbidities were associated with increased risk of AKI. Patients with AKI had significantly longer ICU stay (Log-Rank Chi Square: 23.186, p < 0.0001). Both the incidence of AKI and ICU mortality were higher in patients with SOFA scores over 9 (Pearson Chi-Square 7.581, p = 0.006, and 11.288, p = 0.001 respectively). CONCLUSIONS: The incidence of AKI is high at 60% among our ICU patients, and those with AKI had higher mortality and longer duration of ICU stay. Age, gender or the presence of co-morbidities was not associated with a higher risk of AKI. Patients with SOFA scores over 9 within the first 24 hours were more likely to develop AKI and had higher risk of death.

Kidney disease in the elderly: a Sri Lankan perspective.

Renal disease in the elderly in Sri Lanka is a largely neglected area in the literature with hardly any publications. We carried out a hospital-based survey of elderly patients (elderly is defined in this article as patients aged 65 years or above) with renal disease. This prospective study included all patients aged 65 years or above admitted to the University Medical Unit, National Hospital of Sri Lanka, over a period of 1 year with a primary renal-related illness as the reason for hospitalization. This hospital-based survey is the first of its kind to look into the nephrological disease profile of elderly patients in Sri Lanka. Based on our findings, we have made several pertinent recommendations regarding the care of the elderly with renal disease in Sri Lanka that may be relevant to other developing nations as well.

Metabolic syndrome among Sri Lankan adults: prevalence, patterns and correlates.

Metabolic Syndrome (MS) increases the risk for Coronary Artery Disease, stroke and diabetes. MS is twice more common amongst South Asian immigrants in US compared to native Caucasians. There are no nationally representative studies on prevalence of MS from any of the South Asian countries. The present study aims to evaluate the prevalence of MS among Sri Lankan adults and investigates its relationships with socio-demographic, clinical and biochemical parameters. Data on MS and its associated details were obtained from a population-based cross-sectional study conducted between years 2005-2006. MS was defined according to the International Diabetes Federation criteria. A binary logistic regression analysis was performed using the dichotomous variable MS (0 = absent, 1 = present). The independent co-variants were: gender, age category, area of residence, ethnicity, level of education, income and physical activity. Sample size was 4,485 (Response rate-89.7%), 39.5% were males and mean age was 46.1 ± 15.1 years. The crude prevalence of MS was 27.1% (95% CI: 25.8-28.5), and age-adjusted prevalence was 24.3% (95% CI: 23.0-25.6). Prevalence in males and females were 18.4% (95% CI: 16.5-20.3) and 28.3% (95% CI: 26.6-30.0) respectively (p < 0.001). Urban adults (34.8% [95% CI: 31.8-37.9]) had a significantly higher prevalence than rural adults (21.6% [95% CI: 20.2-23.0]). Among ethnic groups, the highest prevalence of MS was observed in Sri Lankan Moors (43.0% [95% CI: 37.2-48.9]). In all adults, MS was observed in those with the highest level of education and monthly household income. Prevalence of MS in the different physical activity categories of the IPAQ were; 'inactive'-38.8% (95% CI 34.5-43.2), 'moderately active'-33.5% (95% CI 30.9-36.1) and 'active'-21.1% (95% CI 19.6-22.7). The results of the binary logistic regression analysis indicates that female gender (OR:1.7), increasing age, urban living (OR:1.7), Moor ethnicity (OR:2.6), secondary (OR:1.5) and tertiary levels of education (OR:2.3), monthly household income LKR 7,000-24,999 (OR:1.5) and >50,000 (OR:2.1), and physical inactivity (OR:1.6), all significantly increased risk of developing MS. MS is common among Sri Lankan adults affecting nearly one-fourth of the population. Female gender, increasing age, urban living, higher socio-economical status and physical inactivity were important associated factors.

A two-year retrospective analysis of renal transplant patients in Sri Lanka.

This retrospective analytical study aimed at making a database of patients who underwent renal transplant from 31 December 2004 to 31 December 2006 under the Faculty of Medicine renal transplant program. The objective was to build a profile of renal transplant patients with focus on post KT infections and complications of renal transplants. An interviewer administered questionnaire was used. A total of 72 patients were studied; 18 (25%) had died by February 2007. Forty-three patients (58.3%) were interviewed in person, 17 were interviewed over the phone and 12 patients could not be contacted. Of those who were interviewed, 28 (38.9%) were on azathioprine, prednisolone and cyclosporine, while 15 (20.8%) were on prednisolone, cyclosporin and mycophenolate mofetil. Four patients had symptomatic cytomegalovirus infection and five had tuberculosis post transplant. Of all infections, the most commonly reported was urinary tract infection (11 cases). Thirty-three (45.8 %) had received induction therapy with either basiliximab (n = 8) or daclizumab (n = 25). Acute rejection was the most commonly encountered complication, with nine cases (12.5%) being reported over the study period. Of late complications, most were due to immunosuppression. Overall, the 2-year survival was 75%. There was no significant difference between the centers of transplant.

Prevalence and correlates of tobacco smoking in Sri Lanka.

OBJECTIVES: This study aimed to determine the prevalence and underlying sociodemographic correlates of smoking among Sri Lankans. METHODS: A cross-sectional sample (N = 5000, age >18 years) was selected using a multistage random cluster sampling. Data were collected using an interviewer-administered questionnaire. RESULTS: Response rate was 91% (n = 4532); males 40%; mean age 46.1 years (±15.1). Overall, urban and rural prevalence of current smoking (smoking) was 18.3%, 17.2%, and 18.5%, respectively (P = nonsignificant, urban vs rural). Smoking was much higher in males than in females (38.0% vs 0.1%, P < .0001). Ex-smokers comprised 10.0% (males 20.7%, females 0.1%, P < .0001). Among the smokers 87.0% smoked <10 cigarettes per day. The male age groups < 20 and 20 to 29 years had the lowest (15.6%) and the highest (44.6%) prevalence of smoking, respectively. In males, smoking was highest in the least educated (odds ratio = 1.96, P = .001). CONCLUSIONS: Smoking is common among Sri Lankan males and is associated with lower education, income, and middle age.

Epidemiology of chronic kidney disease in a Sri Lankan population: experience of a tertiary care center.

Chronic kidney disease (CKD) is a growing problem in Sri Lanka. Diabetes and hypertension are the main contributors to the disease burden. A new form of CKD of uncertain etiology (CKD-u) is the predominant form of CKD in certain parts of Sri Lanka, threatening to reach epidemic proportions. A cross-sectional descriptive study was carried out over a three-month period at the National Hospital of Sri Lanka to identify the underlying etiologic factors for the disease in a cohort of patients with CKD. A total of 200 patients were studied with a mean age of 50.57 years. Of them, 108 (54%) were in CKD stage V. Majority of the patients were from the western province (137, 68.5%) with only five (2.5%) from provinces with high prevalence of CKD-u. The most common underlying causes of CKD were diabetes (88, 44%) and hypertension (34, 17%). However, in patients younger than 40 years of age the most common cause was glomerulonephritis (20, 42.6%). Diabetes was the most common cause of CKD among patients from the western province (74, 54%). The prevalence of CKD-u was twice as high in patients from areas outside the western province compared with patients from this province (P > 0.05). The low prevalence of CKD-u in the study population could be the result of poor representation of patients from provinces with high prevalence of CKD-u.

Plasma homocysteine in polycystic ovary syndrome: does it correlate with insulin resistance and ethnicity?

BACKGROUND: Polycystic ovary syndrome (PCOS) is associated with insulin resistance and premature coronary artery disease (CAD). Hyperhomocysteinaemia is a recognized risk factor for atherosclerosis, particularly among migrant South Asians, and has recently been shown to be correlated positively with the degree of insulin resistance/hyperinsulinaemia. OBJECTIVES: To compare total plasma homocysteine (Hcy) in PCOS with controls from ethnic groups at high and low risk of insulin resistance. METHODS: Case control study of three ethnic groups, Sri Lankans (SL), British Asians (BA) and white Europeans (C), with and without PCOS at specialist centres in Sri Lanka and Yorkshire, UK. Fasting total plasma Hcy concentration was analysed by fluorescence polarization immunoassay and examined for any correlation with age, body mass index (BMI), central obesity, fasting insulin and insulin sensitivity [calculated by the Quantitative Insulin Sensitivity Check Index (QUICKI) method], lipids and testosterone in each ethnic group. RESULTS: Eighty SL with PCOS and 45 controls, 47 BA with PCOS and 11 controls, and 40 C with PCOS and 22 controls were studied. Both Asian groups with PCOS were younger than affected Europeans (P = 0.008). Sri Lankans with PCOS had significantly lower BMI values than other affected groups: mean +/- SEM (SL) 26.3 +/- 0.95; (BA) 30.59 +/- 7.54; (C) 32.1 +/- 5.95 kg/m2 (P = 0.006). However, waist : hip ratios (WHR) of Sri Lankans with PCOS were similar to others: mean +/- SEM (SL) 0.97 +/- 0.01 (BA) 1.04 +/- 0.02 (C) 0.92 +/- 0.01, P = 0.33. Mean plasma Hcy was significantly higher in all PCOS groups than in their ethnically matched controls (Student's t-test): (SL) 10.2 +/- 1.9 vs 9.0 +/- 3.8, P = 0.01; (BA) 7.9 +/- 1.9 vs 6.8 +/- 2.5, P < 0.0001; (C) 8.3 +/- 2.3 vs 6.8 +/- 1.5, P = 0.0007 micromol/l. Sri Lankans with PCOS had significantly greater Hcy concentrations than British Asians and Europeans with PCOS [P = 0.001; single-factor analysis of variance (anova)] and also significantly greater fasting insulin concentrations [(SL) 242.9 +/- 38.9; (BA) 89.4 +/- 8.9; (C) 48.6 +/- 4.8 pmol/l (P = 0.0003)] and significantly lower QUICKI [(SL) 0.308 +/- 0.004; (BA) 0.335 +/- 0.005; (C) 0.375 +/- 0.002 (P = 0.0007)]. Fasting plasma Hcy correlated best with fasting insulin (r = 0.56, P = 0.0001) and QUICKI (r =-0.53, P < 0.0001) in Sri Lankans with PCOS. Hcy in PCOS subjects from all three ethnic groups correlated significantly with fasting insulin following adjustment for age, BMI and WHR (r = 0.45, P = 0.0001), but this was not evident in the controls (r =-0.32, P = 0.1). CONCLUSIONS: Elevation of fasting plasma homocysteine in PCOS varies with ethnicity and correlates significantly with fasting insulin. High homocysteine in young Sri Lankans with PCOS has major implications for their long-term risk for atherosclerosis.

Pesticide poisoning in the developing world--a minimum pesticides list.

In parts of the developing world, pesticide poisoning causes more deaths than infectious diseases. Use of pesticides is poorly regulated and often dangerous; their easy availability also makes them a popular method of self-harm. In 1985, the UN Food and Agriculture Organisation (FAO) produced a voluntary code of conduct for the pesticide industry in an attempt to limit the harmful effects of pesticides. Unfortunately, a lack of adequate government resources in the developing world makes this code ineffective, and thousands of deaths continue today. WHO has recommended that access to highly toxic pesticides be restricted--where this has been done, suicide rates have fallen. Since an Essential Drugs List was established in 1977, use of a few essential drugs has rationalised drug use in many regions. An analogous Minimum Pesticides List would identify a restricted number of less dangerous pesticides to do specific tasks within an integrated pest management system. Use of safer pesticides should result in fewer deaths, just as the change from barbiturates to benzodiazepines has reduced the number of deaths from pharmaceutical self-poisoning.