Heart disease complicating pregnancy as a leading cause of maternal deaths in LMIC settings: the Sri Lankan experience.

Background: Heart disease (HD) is one of the leading indirect causes of maternal deaths worldwide, both in high- and low- and middle-income countries (LMICs). This study aims to describe maternal deaths due to cardiovascular disease complicating pregnancy in Sri Lanka. Methods: The national Maternal Death Surveillance Response (MDSR) system in Sri Lanka investigates all female deaths during pregnancy and 12 months after delivery. These maternal death investigation records were perused in this analysis. Maternal deaths from 2006 to 2018 with HD complicating pregnancy as the immediate or underlying cause of death were re-coded using the ICD-11 classification. Findings: Of the 2855 pregnancy-related deaths reported to the MDSR from 2006 to 2018, 1646 (57.7%) were confirmed as maternal deaths. Of those, 284 (17.25%) were attributed to HD complicating pregnancy. The cause-specific maternal mortality ratio due to heart disease from 2006 to 2018 was 7.24 per 100,000 live births. Rheumatic heart disease was the leading cause of HD (60, 21.1%), while cardiomyopathies (59, 20.7%) and congenital anomalies (34, 12.0%) accounted for a sizeable share. Medically contraindicated pregnancies accounted for 54 (19%) deaths. Application of the 3-delay model identified 186 (65.5%) cases with possible delays. Out of all deaths, 158 (55.6%) cases were categorized as preventable. Interpretation: Preventing maternal mortality from HD in LMICs requires a lifecycle approach with situation-specific interventions and highly specialized care. Community awareness, capacity building related to management, and specific infrastructure development will be key strategies. Funding: None.

Demographic, exposure, clinical, biochemical and diagnostic data of febrile patients recruited for the largest field study on leptospirosis in Sri Lanka.

This dataset includes data from febrile patients recruited for a large hospital-based study in Sri Lanka from 2016 to 2019. The variables include primary socio-demographic data, exposure data, clinical data, biochemical and investigation data. Some of these data are available as serial data from admission to discharge daily. Microscopic agglutination test, quantitative PCR of whole blood, urine and serum and culture isolation was performed to diagnose the patients with leptospirosis.

Disease burden of cardiovascular conditions complicating pregnancy in Sri Lanka: a protocol.

Background: Cardiovascular diseases (CVD) are the commonest indirect medical cause of maternal deaths worldwide, both in high-income and low and middle-income countries. To minimize the effects of CVD in pregnancy, proper risk assessment and appropriate referral is required. In Sri Lanka, cardiovascular disease complicating pregnancy is a significant cause of maternal mortality, second only to postpartum hemorrhage. Screening for CVD in pregnancy in Sri Lanka is limited to a routine clinical assessment. Evidence-based guidelines are yet to be developed, and this deficit may have resulted in a substantial underestimation of the CVD burden. This study aims to determine the burden of CVD in early pregnancy and develop a risk prediction model to be used in field pregnancy clinics in Sri Lanka to reduce CVD effects in pregnancy. Methods: A prospective cohort study was carried out in the Anuradhapura district, Sri Lanka. Following registration to the antenatal care, pregnant women fulfilling the eligibility criteria were invited to attend a special clinic at their relevant Medical Officer of Health (MOH) area. Risk assessment was done through history and a clinical examination, and suspected/probable cases were referred for an echocardiogram by a consultant cardiologist. All the recruited participants in the first trimester were prospectively followed up and screened again between 24-28 weeks of the period of amenorrhoea (POA). Antenatal ward admissions with CVD complicating pregnancy will be extracted, and a telephone interview will be carried out between 6-12 weeks after the expected delivery date to cover postpartum morbidities. Discussion: This proposed study will be the largest of its kind carried out in the local setting. The study's findings will be beneficial for policymakers to develop guidelines to reduce maternal cardiovascular disease morbidities and mortalities in Sri Lanka.

Time delays in treatment of snakebite patients in rural Sri Lanka and the need for rapid diagnostic tests.

Delays in treatment seeking and antivenom administration remain problematic for snake envenoming. We aimed to describe the treatment seeking pattern and delays in admission to hospital and administration of antivenom in a cohort of authenticated snakebite patients. Adults (> 16 years), who presented with a confirmed snakebite from August 2013 to October 2014 were recruited from Anuradhapura Hospital. Demographic data, information on the circumstances of the bite, first aid, health-seeking behaviour, hospital admission, clinical features, outcomes and antivenom treatment were documented prospectively. There were 742 snakebite patients [median age: 40 years (IQR:27-51; males: 476 (64%)]. One hundred and five (14%) patients intentionally delayed treatment by a median of 45min (IQR:20-120min). Antivenom was administered a median of 230min (IQR:180-360min) post-bite, which didn't differ between directly admitted and transferred patients; 21 (8%) receiving antivenom within 2h and 141 (55%) within 4h of the bite. However, transferred patients received antivenom sooner after admission to Anuradhapura hospital than those directly admitted (60min [IQR:30-120min] versus 120min [IQR:52-265min; p<0.0001]). A significantly greater proportion of transferred patients had features of systemic envenoming on admission compared to those directly admitted (166/212 [78%] versus 5/43 [12%]; p<0.0001), and had positive clotting tests on admission (123/212 [58%] versus 10/43 [23%]; p<0.0001). Sri Lankan snakebite patients present early to hospital, but there remains a delay until antivenom administration. This delay reflects a delay in the appearance of observable or measurable features of envenoming and a lack of reliable early diagnostic tests. Improved early antivenom treatment will require reliable, rapid diagnostics for systemic envenoming.

Bites by snakes of lesser medical importance in a cohort of snakebite patients from rural Sri Lanka.

Reporting of snakebite is poor in areas where they are most common. Comparatively, bites by snakes of high medical importance are likely to be documented than snakes of lesser medical importance. This study aims to describe the demographic, epidemiological and, clinical data of patients who were presented during a 49-month study period to a tertiary care center in rural Sri Lanka following authenticated bites by snakes of lesser medical importance. Of the total of 2362 confirmed snakebite patients during the study period, 517 (22%) presented with the offending snake specimen. Of them, 76 (15%) were identified as snakes of lesser medical importance and were included in this study. There were 41 (54%) females. The median ages of females and males were 35 and 43 years respectively. Most patients (86%) were bitten indoors or at home gardens. More than half of them were bitten between 1800 and 0000 h. Most bites (54%) had occurred to the ankle or below. The patients were bitten by 12 species of colubrids, one pythonid (Python molurus), and one viperid (Trimeresurus trigonocephalus). The snake species that caused the most-number of bites was the Trinket snake (Coelognathus helena) (n = 15). Three species of wolf-snakes, Lycodon aulicus, L. anamallensis, and L. striatus were responsible for 12, 11, and 5 bites respectively. Most of the patients (55%) presented to the local hospital and subsequently transferred to the study hospital for further management. None of the patients developed systemic envenoming and five developed mild local pain and swelling. Fifty-six (74%) patients were discharged on the following day, while 18 (24%) were discharged on the third day. There is a need to educate medical personnel working the peripheral hospital on how to identify medically lesser important snakes to avoid unnecessary transfers.

The Rajarata Pregnancy Cohort (RaPCo): study protocol.

BACKGROUND: Ending preventable maternal deaths remains a global priority and in the later stages of obstetric transition, identifying the social determinants of maternal health outcomes is essential to address stagnating maternal mortality rates. Countries would hardly achieve the Sustainable Development Goal (SGD) targets on maternal health, unless the complex and context-specific socio-economic aetiologies associated with maternal mental health and suicide are identified. The Rajarata Pregnancy Cohort (RaPCo) is a prospective cohort study, designed to explore the interactions between social determinants and maternal mental health in determining pregnancy and new-born outcomes. METHODS: The study will recruit all eligible pregnant women in the maternal care programme of Anuradhapura district, Sri Lanka from July to September 2019. The estimated sample size is 2400. We will assess the socio-demographic and economic status, social capital, gender-based violence and mental health, including a clinical examination and biochemical investigations during the first trimester. Participants will undergo four follow-ups at 2nd and 3rd trimesters, at delivery and in early postpartum. The new-borns will be followed up at birth, neonatal period, at 6 six months and at 1 year. Pregnancy and child outcome data will be collected using direct contact. Qualitative studies will be carried out to understand the complex social factors and behavioural dimensions related to abortion, antenatal depression, maternal deaths and near misses. DISCUSSION: This is the first reported maternal cohort in Sri Lanka focusing on social determinants and mental health. As a country in stage four of obstetric transition, these findings will provide generalizable evidence on achieving SGD targets in low- and middle-income countries. The study will be conducted in a district with multi-cultural, multi-ethnic and diverse community characteristics; thus, will enable the evidence generated to be applied in many different contexts. The study also possesses the strength of using direct participant contact, data collection, measurement, examination and biochemical testing to minimise errors in routinely collected data. The RaPCo study will be able to generate evidence to strengthen policies to further reduce maternal deaths in the local, regional and global contexts particularly focusing on social factors and mental health, which are not optimally addressed in the global agenda.

Effects of "plate model" as a part of dietary intervention for rehabilitation following myocardial infarction: a randomized controlled trial.

BACKGROUND: Reducing body weight by nutritional management is an integral element of cardiac rehabilitation and in secondary prevention of cardiovascular diseases. Administration of a "plate model" is one practical aspect to control calorie intake. The study aimed to evaluate the effectiveness of the plate model as a part of dietary modification in losing excess weight in post-myocardial infarction (MI) patients. METHODS: An interventional, randomized, single-blinded study with parallel subject allocation was conducted among patients with a history of troponin-positive acute coronary syndrome (ACS). A total of 120 patients were recruited to intervention and control groups. The Intervention cluster was provided with 'plate model' and both groups received standard cardiac rehabilitation care. Anthropometric, clinical and metabolic parameters were measured at recruitment and repeated during 4th and 12th week. RESULTS: A sample of 79 patients (the intervention group: 40, the control group: 39) completed the study. At the end of 12 weeks participants in the intervention group exhibited a significant weight loss (-1.27±3.58 vs. -0.26±2.42 kg; P=0.029) and a significant reduction in BMI (-0.48±1.31 vs. -0.10±0.89 kg/m2; P=0.023). Overweight and obese patients (BMI >23 kg/m2) displayed greater weight loss (-2.13±3.46 vs. 0.12±2.62 kg; P=0.013). Many of overweight and obese patients in the test group (35.7%) experienced a weight loss ≥5% compared to the control group (13.04%) which was a nearly significant result (P=0.065). No significant changes observed in other metabolic parameters. CONCLUSIONS: Plate model is an effective dietary intervention in view of weight reduction in post-MI patients.

Effects of the "plate model" as part of dietary intervention on modification of selected cardiometabolic risk factors in post-myocardial infarction patients: study protocol for a randomized controlled trial.

BACKGROUND: Cardiovascular disease remains the leading cause of morbidity and mortality worldwide, and there is a rising global burden. The effects of diet on cardiometabolic risk factors have been studied extensively. Healthy eating as a cost-effective approach to risk reduction in post-myocardial infarction patients is proven to be beneficial, and the "plate model" is one of the practical methods to achieve this objective. METHODS/DESIGN: The study will be conducted as a randomized, single-blind, controlled clinical trial for a period of 3 months. A total of 120 overweight (body mass index >23 kg/m2) inpatients (aged 20-70 years) with a history of troponin-positive acute coronary syndrome (ACS) within the 1 month preceding the study will be recruited. Simple randomization will be used in participant allocation. The intervention group will receive the model plate diet. The control group will be provided with routine dietary advice. Other domains, such as advice on exercise and lifestyle modification, will be equalized among patients in both the groups. The visits and evaluations will be done at recruitment (visit 0), 4 weeks, and 12 weeks after the intervention. The primary outcome will be a mean body weight reduction of 10%, and the secondary outcomes will include mean reduction of systolic and diastolic blood pressure, improvement of anthropometric parameters, and improvement of lipid profile and liver enzymes in the test group compared with the control group at 12 weeks following the plate model diet. DISCUSSION: This study protocol is designed to establish the effects of the plate model diet on modification of cardiometabolic risk factors in patients with ACS. This will also be a pioneering study designed to investigate the practicality of the model plate in local settings and in the South Asian region. TRIAL REGISTRATION: Sri Lanka Clinical Trials Registry identifier: SLCTR/2016/22. Registered on 22 September 2016 ( http://www.slctr.lk/trials/483 ).

Body weight perception among Sri Lankan cardiac patients.

BACKGROUND: Misperception of body weight by individuals is a known occurrence. However, it is a potential target for implementing obesity reduction interventions in patients with cardiovascular and metabolic diseases. The aim of this study was to describe the association between self-perception of body weight and objectively measured body mass index (BMI) among cardiac patients in a specialist cardiology institution in Sri Lanka. METHOD: During the study period, 322 (61 %) males and 204 (39 %) females were recruited from consecutive admissions to the Institute of Cardiology, National Hospital, Colombo, Sri Lanka. An interviewer-administered questionnaire was used to assess demographic characteristics, medical records and body weight perception. Weight, height and waist circumference (WC) were measured and Asian anthropometric cut-off points for BMI and WC were applied. RESULTS: The mean BMI of the study population was 23.61 kg/m(2). Body size misperception was seen in a significant proportion of the cohort. 85.2 % of overweight patients reported themselves to be of 'normal weight' or even 'underweight'. Moreover, 36 % of obese patients misperceived body weight as being of 'normal weight' while 10.9 % considered themselves to be 'underweight'. 61.9 % of males and 68.8 % of females with central obesity reported themselves to be 'underweight' or 'normal weight'. Among a subgroup with co-morbid metabolic diseases, significant under-perception of body size was seen. CONCLUSIONS: Significant body size misperceptions were noted in this group of cardiac patients. The disparity of perception was seen increasingly with increasing BMI. More than two thirds of overweight and more than half of obese patients believed themselves to have normal or less than normal weight.

Pneumopyopericardium mimicking an inferior ST elevation myocardial infarction with regional electrocardiogram changes: a case report.

BACKGROUND: Pneumopyopericardium is a rare disease with poor prognosis. The usual presentation is with fever, shortness of breath and haemodynamic compromise. The Electrocardiogram changes associated with this disease entity would be similar to pericarditis such as concave shaped ST elevations in all leads with PR sagging. Pneumopyopericardium mimicking an acute ST Elevation Myocardial Infarction, with regional Electrocardiogram changes has hitherto not been described in world literature. CASE PRESENTATION: We describe the case of a 48 year old native Sri Lankan man, presenting with chest pain and Electrocardiogram changes compatible with an Acute ST Elevation Myocardial Infarction, subsequently found to have Pneumopyopericardium secondary to an oesophageal tear. Retrospective history revealed repetitive vomiting due to heavy alcohol consumption, prior to presentation. It unfortunately led to a fatal outcome. CONCLUSION: Pneumopyopericardium may mimic an acute ST elevation myocardial infarction with associated regional Electrocardiogram changes. A high degree of suspicion should be maintained and an adequate history should always be obtained prior to any intervention in all ST Elevation Myocardial Infarction patients.

Prevalence of hospital malnutrition among cardiac patients: results from six nutrition screening tools.

Malnutrition is highly prevalent among hospitalized patients, ranging from 30% to 50% depending on the patient population and the criteria used for diagnosis. Identifying early those who are malnourished and at risk of malnutrition and intervening at an early stage will improve patients overall prognosis and will reduce the costs to the state. Even though cardiac patients are at risk of malnutrition, data on the prevalence of malnutrition among cardiology inpatients is limited. The aim of the study was to assess malnutrition status of the newly admitted patients in a specialist cardiology institution in Sri Lanka by internationally recommended nutrition screening and assessment tools. During study period, 322 (61.22%) males and 204 (38.78%) females were recruited. Malnutrition status assessed by each screening tool had a wide variation. According to Mini Nutritional Assessment tool 69.6% were having possible malnutrition. Malnutrition Screening Tool 47.9% to be at risk of malnutrition. Subjective Global Assessments categorized only 4.2% as malnourished on the other hand Malnutrition Universal Screening Tool categorized 20.4% and 19.6% subjects as at medium risk and high risk of malnutrition respectively. Nutritional Risk Screening detected 6.3%, 25.1% and 24.9% patients to be mildly, moderately and severely malnourished respectively. Short Nutrition Assessment Questionnaire categorized 5.0% and 17.7% patients to be moderately malnourished and severely malnourished correspondingly. In conclusion, Although malnutrition was prevalent among this population, a wide variation in the nutritional status when assessed by widely used internationally recognized tools was observed.

Knowledge assessment regarding secondary prevention of coronary heart disease--a multi centre survey.

BACKGROUND: Cardiovascular Disease (CVD) is a major cause of mortality worldwide. Control and reduction of cardiovascular risk factors such as elevated blood pressure, high cholesterol levels, excess of body weight, smoking and lack of exercise can contribute to a reduction of CVD mortality. METHODS: A standardized questionnaire was administered to all medical officers willing to participate in the study, who were working in the Cardiology Units all over Sri Lanka to assess the source of continuous medical education, attitudes on secondary prevention, barriers to secondary prevention and knowledge assessment of secondary prevention of cardiovascular diseases. Chi square was used to compare groups and p < 0.05 was considered significant. RESULTS: 132 participants with equal numbers of males and female doctors participated. While 56 doctors have had no training in cardiology, 75 doctors have had some training in a cardiology unit. The barriers for secondary prevention were, poor knowledge/understanding of patients 3.82 (1.06), too many drugs 3.74 (0.98), presence of co-morbid conditions 3.68(0.97), cost of medications 3.69 (0.97) and poor adherence to prevention strategies by patients 3.44 (1.15). Routine clinic visits 85 (65%) and public awareness day seminars 30 (22.2%) were the most effective methods of secondary prevention. Guidelines were the most popular method of continuous medical education. Those who have had some training in cardiology did not differ in their knowledge from those who have never had training in cardiology. Knowledge about prevention with regard to diet was inadequate and exercise and lipids were adequate but not good. Rates of knowledge on smoking cessation were much higher than for other CVD risk factors. CONCLUSION: There needs to be more adherences to clinical guidelines and attention paid to CVD prevention, in particular, the importance of dietary modifications, adequate exercise, and lipid control.

A kidney transplant patient on cyclosporine therapy presenting with dural venous sinus thrombosis: a case report.

Dural vein thrombosis is an important but rare cause of headache. Therapy with cyclosporine has been reported to result in thrombotic events. We report an unusual case of superior sagittal and transverse sinus thrombosis associated with cyclosporine therapy in a kidney transplant patient.