The Effect of Salacia Reticulata Extract Biscuits on Blood Sugar Control of Type 2 Diabetes Mellitus Patients: A Two-Period, Two-Sequence, Crossover, Randomized, Triple-Blind, Placebo-Controlled, Clinical Trial.

Background Traditional physicians in Sri Lanka and India use extracts from the plant Salacia reticulata,or Kothala Himbutu (KH) to treat diabetes. The effect of a KH biscuit, taken as a snack, on glycemic control was investigated in patients with type 2 diabetes. Methodology This triple-blind, randomized, placebo-controlled, two-period, two-sequence, crossover study was conducted in the Internal Medical Clinic, Teaching Hospital Anuradhapura. A research assistant opened computer-generated random numbers enclosed in a sealed envelope and performed treatment allocation. The group outcome was masked from the researchers, patients, and analysts. Both the placebo and the KH biscuit were identical. The primary outcome measure was HbA1c. Intention to treat analyses was used. Glycemic stability was assured in the run-in period, and patients with severe renal, liver, or heart disease were excluded. If patients needed insulin, they were withdrawn from the trial. Results From January 2014 to May 2016, 230 patients were screened, and 136 were randomized. Of them, 62 were allocated, 58 completed the placebo biscuit, 71 were allocated, and 69 completed the KH biscuit. After the washout period and crossover, 57 completed the KH and 65 completed the placebo biscuit. The baseline mean HbA1c level was 8.45% (68.9 mmol/mol) and 8.65% (71.0 mmol/mol) for the placebo-KH biscuit and KH-placebo biscuit groups. At the end of the trial, the HbA1c levels in the placebo-KH biscuit group and the KH-placebo biscuit group were 8.23% (66.4 mmol/mol) and 8.53% (69.3 mmol/mol), respectively. The unadjusted mean HbA1c reduced from the baseline with 0.10% (95% CI = -0.12, 0.32) after the placebo biscuit and 0.35% (95% CI = 0.10, 0.60) after the KH biscuit. After the placebo and KH biscuits, the HbA1c values were 8.46% (95% CI = 8.19, 8.73) (69 mmol/mol with 95% CI = 66, 72) and 8.19% (95% CI = 7.90, 8.48) (66 mmol/mol with 95% CI = 63, 69), respectively. The paired sample t-test shows that the reduction was not significant for placebo biscuits (p = 0.324), while it is significant for KH biscuits (p = 0.003). Analysis with multiple imputations confirmed a significant difference between the placebo and KH biscuit in reducing the HbA1c level. Conclusions KH biscuit taken as a snack reduces HbA1c by 0.25% compared to placebo without serious renal or liver adverse effects. The biscuit can be safely recommended as a snack to patients with type 2 diabetes.

Strongyloidiasis infection in a borderline lepromatous leprosy patient with adrenocorticoid insufficiency undergoing corticosteroid treatment: a case report.

BACKGROUND: Strongyloidiasis is a soil-transmitted helminthiasis mainly caused by Strongyloides stercoralis. It is endemic to the tropics and subtropics. Sri Lanka has a 0-1.6% prevalence rate. S. stercoralis infection was identified in a 33-year-old Sri Lankan male patient treated with corticosteroids for borderline lepromatous leprosy with adrenocortical dysfunction. CASE PRESENTATION: In March 2020, a 33-year-old Sri Lankan (Sinhalese) male patient presented with watery diarrhea, lower abdominal pain, and post-prandial abdominal fullness. Previously, he was diagnosed with borderline lepromatous leprosy and was treated with rifampicin, clofazimine, and prednisolone 60 mg daily since July 2019. After developing gastrointestinal symptoms, he had defaulted leprosy treatment including the prednisolone for 3 months. Duodenal biopsy revealed numerous intraepithelial nematodes within the lumina of glands in the duodenum whose appearance favored Strongyloides. Fecal wet smear revealed numerous Strongyloidis stercoralis L1 rhabditiform larvae. Larval tracks were seen in the agar plate culture. L3 filariform larvae of Strongyloidis stercoralis were seen in the Harada-Mori culture. In addition, the short synacthen test revealed adrenocortical insufficiency, and oral hydrocortisone and fludrocortisone were started with albendazole treatment against strongyloidiasis. Fecal wet smear and culture repeated after treatment with albendazole were negative for Strongyloidis stercoralis. The patient was discharged in July 2020 on oral hydrocortisone. One month later his condition was reviewed and the repeated fecal wet smear and agar plate culture was normal. He is being followed up every 3 months. CONCLUSION: This is the first case of strongyloidiasis diagnosed in a patient with borderline lepromatous leprosy from Sri Lanka. The patient manifested symptoms of strongyloidiasis while on high-dose steroid therapy for his lepromatous reaction. Subsequently, the patient not only discontinued his steroid therapy, but also developed adrenocortical insufficiency as a complication of leprosy. Therefore, although diagnosis of strongyloidiasis was delayed, his subsequent low steroid levels probably protected him from disseminated disease. This is an interesting case where symptomatic strongyloidiasis was diagnosed in a patient who was initially treated with high-dose steroids but subsequently developed adrenocortical insufficiency. We emphasize the need to screen all patients prior to the commencement of immunosuppressive therapy.

Zoster-associated limb paralysis mimicking acute stroke: a case report.

BACKGROUND: Varicella zoster virus is a Deoxyribonucleic acid (DNA) virus exclusively affecting humans. Reactivation of varicella zoster virus causes herpes zoster with vesicular eruptions in a restricted dermatomal distribution. Peripheral motor neuropathy is a very rare complication of varicella zoster virus. CASE PRESENTATION: A 57-year-old previously well Sri Lankan female presented with acute onset painful weakness of the left upper limb with a preceding history of a febrile illness. Subsequently she developed vesicular eruptions in the dermatomal distribution of cervical 5, 6, and 7. Electromyography was suggestive of acute denervation of cervical 5, 6, and 7 myotomes. Diagnosis of zoster-associated brachial plexopathy was made, and the patient was treated with acyclovir, steroids, and analgesics. She made a good recovery. CONCLUSION: Brachial plexus neuritis due to varicella zoster infection should be considered in an acute monoparesis of a limb as it is a treatable and reversible condition.

Atypical case of hantavirus infection in Sri Lanka mimicking leptospirosis: a case report.

BACKGROUND: Hantavirus infection is an emerging zoonotic infection which has two characteristic patterns of presentation: hantavirus pulmonary syndrome and hemorrhagic fever with renal syndrome. The clinical presentation of hantavirus infection closely mimics leptospirosis. CASE PRESENTATION: This case report describes a previously apparently well 36-year-old Sri Lankan Sinhalese man who presented with an acute febrile illness with myalgia, with liver involvement in the form of transaminitis, cardiac involvement in the form of myocarditis, acute kidney injury, and pulmonary involvement. He was initially managed as severe leptospirosis with multiorgan dysfunction with antibiotics, steroids, and N-acetyl cysteine. A diagnosis of acute hantavirus infection was made subsequently. He made an uneventful recovery. CONCLUSION: Hantavirus infections need to considered in the differential diagnosis of patients presenting with acute febrile illness with multiorgan involvement. Larger studies are needed to evaluate the seroprevalence of hantavirus in Sri Lanka because it could be an emerging serious public health problem.

Risk Factors Associated with Fatal Dengue Hemorrhagic Fever in Adults: A Case Control Study.

BACKGROUND: Dengue is endemic in most parts of the tropics with a significant mortality of 1-5%. Although individual case reports and case series have been published, large-scale case controls studies are few. The objective of this study was to find clinical and laboratory predictors of mortality in dengue. METHODS: Hospital case record based case control study was performed. RESULTS: Twenty fatalities with 80 controls were analyzed. Clinical parameters of postural dizziness (OR 3.2; 95% CI 1.1-8.9), bleeding (OR 31.9; 95% CI 6.08-167.34), presence of plasma leakage (OR 64.6; 95% CI 7.45-560.5), abdominal tenderness (OR 2.24; 95% CI 0.79-6.38), and signs of cardiorespiratory instability at admission increased the risk of dying from dengue. Altered consciousness was exclusively seen in 20% of cases. Laboratory parameters of elevated CRP (OR 1.652; 95% CI 1.28-2.14), AST, or ALT > 500 IU/L (OR 52.5; 95% CI 12.52-220.1) and acute kidney injury (AKI) (OR 103.5; 95% CI 13.26-807.78) during hospital stay increased the odds of dying. Need for assisted ventilation and multiorgan dysfunction (MOD) were exclusively seen in the cases. Multivariate logistic regression revealed bleeding at admission, AKI, and elevated hepatic transaminase >500 IU/L to be independent predictors of mortality. CONCLUSIONS: This case control study revealed that mortality from dengue could be predicted using clinical parameters at admission and low cost routine laboratory investigations.

Dengue hemorrhagic fever presenting as encephalitis: a case report.

BACKGROUND: Dengue fever and dengue hemorrhagic fever incidence is increasing in Sri Lanka, especially among the young population. Uncommon presentations of this common illness make diagnostic dilemmas and can delay standard treatment which leads to unfavorable outcomes. CASE PRESENTATION: An 18-year-old Sri Lankan Sinhalese boy presented with a history of 1 day of fever and an episode of seizure followed by left-side hemiparesis. He was diagnosed to have dengue complicated by dengue hemorrhagic fever and recovered with minimal residual weakness. He presented with neurological symptoms; cerebrospinal fluid analysis, electroencephalogram, and magnetic resonance imaging showed evidence of encephalitis. Positive dengue antigen and antibody in serum and cerebrospinal fluid with the exclusion of other possible etiologies confirmed parainfectious dengue encephalitis. He was started on sodium valproate 200 mg 8 hourly and made a slow neurological recovery with mild residual weakness (grade 4+ power) in his left upper limb at 2 months with intensive supervised physiotherapy. CONCLUSION: Standard national guideline-based management of dengue illness has significantly reduced its mortality rates in Sri Lanka. However, uncommon presentations of a common illness often cause diagnostic dilemmas. Hence, reporting of these presentations and knowing the epidemiologic patterns of the disease help physicians to arrive at the correct diagnosis even though they do not have sophisticated serological investigations. Overall, this can improve the quality of health care and reduce mortalities, especially in a resource-poor setup.

Comorbidities and Ethnocultural Factors Limit the Physical Activity of Rural Sri Lankan Patients with Diabetes Mellitus.

South Asians have high prevalence of diabetes, cardiovascular risk, and physical inactivity. Reasons for physical inactivity have not been explored among Asians living within their endogenous environments. During phase 1 of the study, we assessed the physical activity (PA) of the population using a quantitative, descriptive, cross-sectional research method. During phase 2 of the study, a qualitative method with in-depth interviews was used to collect data on barriers of PA. Four hundred patients with type 2 diabetes, comprising 113 (28.2%) males and 287 (71.7%) females, were enrolled. The overall prevalence of physical inactivity was 21.5% (males: 15.9%, females: 23.7%). The majority (44.8%) of the study population was active and 33.8% were minimally active. The mean weekly MET minutes was 4381.6 (SD 4962). The qualitative study (n = 45) identified health-related issues-lifestyle and time management and social embarrassment, prioritizing household activities over PA as significant factors that limited PA.

Lack of infrastructure, social and cultural factors limit physical activity among patients with type 2 diabetes in rural Sri Lanka, a qualitative study.

INTRODUCTION: South Asians have high prevalence of diabetes, increased cardiovascular risk and low levels of physical activity (PA). Reasons for low levels of PA have not previously been explored among Asians living within their endogenous environment. This qualitative study was performed to explore the contextual reasons that limited PA among type 2 diabetic patients living in a rural community. METHODS: Purposeful sampling recruited 40 participants with long standing type 2 diabetes for this qualitative study. Semi-structered questions utilising in-depth interviews were used to collect data on PA patterns, barriers to PA and factors that would facilitate PA. The interviews were digitally recorded and transcribed. Data were analyzed using a framework approach. RESULTS: The sample consisted of 11 males and 29 females. Mean age was 55.4 (SD 8.9) years. The mean duration of diabetes in the study population was 8.5 (SD 6.8) years. Inability to differentitate household and daily activities from PA emerged as a recurring theme. Most did not have a clear understanding of the type or duration of PA that they should perform. Health related issues, lifestyle and time management, envronmental and social factors like social embarrassment, prioritizing household activities over PA were important factors that limited PA. Most stated that the concept of exercising was alien to their culture and lifestyle. CONCLUSION: Culturally appropriate programmes that strengthen health education and empower communities to overcome socio-economic barriers that limit PA should be implemented to better manage diabetes among rural Sri Lankan diabetic patients.

Physical activity patterns and socio-demographic correlates of physical activity among medical undergraduates in Sri Lanka: an observational study.

BACKGROUND: Physical inactivity is the fourth leading risk factor for mortality worldwide and a leading risk factor for type 2 diabetes and cardiovascular disease. Medical undergraduates are a group of young adults expected to have a sound knowledge of the benefits of physical activity (PA) and have an active lifestyle. OBJECTIVE: To quantifyPA levels among medical undergraduates of a Sri Lankan university and to determine the socio-demographic correlates of physical inactivity. METHODS: Medical undergraduates in their third, fourth and fifth years of study were recruited for this quantitative, descriptive, cross-sectional study using a self-administered questionnaire. RESULTS: A total of 421 students were recruited. Overall 41% were physically inactive. Females (47%) were more inactive than males (34%). The total mean weekly metabolic equivalent (MET)-minutes was 1468.2±1873. Males (1676.2±1629) had a higher mean weekly MET minutes than females (1319±20102), p=0.05. 88% owned a portable internet device such as a smartphone or tablet. Students using health-related apps on their devices had significantly higherPA (p=0.01) and lower body mass index (BMI) (p=0.04), than those who did not. Binary logistic regression revealed physical inactivity to be significantly associated with gender (p=0.01), not using a health-promoting app on their portable device (p=0.01) and the year of study (p=0.03). CONCLUSION: Physical inactivity is a significant problem among medical undergraduates. The use of health applications was associated with a higher PA and lower BMI. The reasons for inactivity and the discrepancy in activity levels between males and females needs to be explored in greater detail.

The availability and validity of safety information of over the counter herbal products for use in diabetes in Sri Lanka: A cross sectional study.

AIMS: There is an increase of over-the-counter (OTC) herbal products for use in diabetes mellitus. The aim of this study is to evaluate the safety information provided with OTC herbal remedies intended for diabetic patients in Sri Lanka and to assess the completeness of the information provided. METHODS: Inclusion criteria consisted of OTC herbal remedies meant for use in diabetes. They were bought from local Sri Lankan supermarkets and non-ayurvedic pharmacies and product information regarding the risk of hypoglycemia, precautions for use, adverse events, dose, and interactions were assessed using a scoring system. The accuracy of the information was then compared against published data. RESULTS: 11 products fulfilled the inclusion criteria. Five products contained a single constituent and five contained more than one. None had complete and accurate safety information according to our criteria. None specifically warned against the risk of hypoglycemia. 9 out of 11 products (81.8%) carried ≤3 items of the five essential factual information we expected. Hypoglycemic coma, gastrointestinal symptoms, hepatotoxicity, carcinogenesis, and interactions causing elevated drug levels of Carbamazepine were some of the safety information that was missing. CONCLUSIONS: Key safety information was absent in most products. Regulation of sale, provision of key safety information and adverse event reporting should be a priority.

Energy and nutrient intakes of Sri Lankan patients with type 2 diabetes mellitus: a cross-sectional survey.

BACKGROUND: Sri Lanka has a high prevalence of type 2 diabetes mellitus. Energy and macronutrient intakes of diabetic patients have not been previously studied in this population. We aimed to clarify the energy and nutrient intakes among a group of type 2 diabetic patients attending a tertiary care diabetes facility in Sri Lanka. METHODS: Nutritional and energy intake of 123 randomly selected patients with type 2 diabetes, aged 30-74 years was assessed using a 24-h dietary recall. RESULTS: The mean energy intake for all participants was 1438 (SD 412) Kcal/day. The mean proportions of total carbohydrate, protein and fat comprising total energy intake were 68.1, 11.5 and 20.2 % respectively. The mean carbohydrate intake of 249.7 g/day comprised 50 % of rice. The mean daily protein, fat and dietary fibre intake was 42.5, 33 and 18.1 g respectively with a major contribution from plant sources. There was no significant difference in energy and nutrient intakes among the male and female participants. CONCLUSION: The present study provides the first pilot data on the energy and macronutrient intakes of diabetes patients in Sri Lanka. We clarified that these patients consumed an energy restricted, high-carbohydrate low fat diet compared to western diabetic patients. A larger nationwide dietary survey is recommended to confirm our findings.

Management of acute coronary syndromes in a developing country; time for a paradigm shift? an observational study.

BACKGROUND: There are limited contemporary data on the presentation, management and outcomes of acute coronary syndromes (ACS) in Sri Lanka. We aimed to identify the critical issues that limit optimal management of ACS in Sri Lanka. METHODS: We performed a prospectively observational study of 256 consecutive patients who presented with ACS between November 2011 and May 2012 at a tertiary care general medical unit in Sri Lanka. RESULTS: We evaluated data on presentation, management, in-hospital mortality, and major adverse cardiovascular events (MACE) of participants. Smoking, alcohol abuse, and obesity were more common in patients with ST elevation myocardial infarction (STEMI) (P < 0.05). Discharge diagnoses were STEMI in 32.8 % (84/256) and unstable angina (UA)/non-ST elevation myocardial infarction [NSTEMI] in 67.1 % (172/256) of participants. The median time (IQR) from onset of pain to presentation was 60 (319) minutes for STEMI and 120 (420) for UA/NSTEMI (P = 0.058). A median delay of 240 min was noted in patients who had presented initially to smaller hospitals. Cardiac markers were assessed in only 35 % of participants. In-hospital anti-platelet use was high (>92 %). Only 70.2 % of STEMI patients received fibrinolytic therapy. Fewer than 20 % of patients were received fibrinolytic therapy within 30 min of arrival. Major adverse cardiac events (MACE) were recorded in 11.9 % of subjects with STEMI and 11.6 % of those with UA/NSTEMI (P = 0.5). According to logistic regression analysis, body mass index (P = 0.045) and duration of diabetes (P = 0.03) were significant predictors of in-hospital MACE. On discharge, aspirin, thienopyridine, and statins were prescribed to more than 90 % of patients. Only one patient underwent coronary angiography during the index admission. CONCLUSIONS: Delays in presentation and in initiation of thrombolytic therapy and coronary interventions are key hurdles that need attention to optimize ACS care in Sri Lanka.

The glycaemic outcomes of Cinnamon, a review of the experimental evidence and clinical trials.

INTRODUCTION: Cinnamon is currently marketed as a remedy for obesity, glucose intolerance, diabetes mellitus and dyslipidaemia. Integrative medicine is a new concept that combines conventional treatment with evidence-based complementary therapies. AIM: The aim of this review is to critically evaluate the experimental evidence available for cinnamon in improving glycaemic targets in animal models and humans. RESULTS: Insulin receptor auto-phosphorlylation and de-phosphorylation, glucose transporter 4 (GLUT-4 ) receptor synthesis and translocation, modulation of hepatic glucose metabolism through changes in Pyruvate kinase (PK) and Phosphenol Pyruvate Carboxikinase (PEPCK), altering the expression of PPAR (γ) and inhibition of intestinal glucosidases are some of the mechanisms responsible for improving glycaemic control with cinnamon therapy. We reviewed 8 clinical trials that used Cinnamomum cassia in aqueous or powder form in doses ranging from 500 mg to 6 g per day for a duration lasting from 40 days to 4 months as well as 2 clinical trials that used cinnamon on treatment naïve patients with pre-diabetes. An improvement in glycaemic control was seen in patients who received Cinnamon as the sole therapy for diabetes, those with pre-diabetes (IFG or IGT) and in those with high pre-treatment HbA1c. In animal models, cinnamon reduced fasting and postprandial plasma glucose and HbA1c. CONCLUSION: Cinnamon has the potential to be a useful add-on therapy in the discipline of integrative medicine in managing type 2 diabetes. At present the evidence is inconclusive and long-term trials aiming to establish the efficacy and safety of cinnamon is needed. However, high coumarin content of Cinnamomum cassia is a concern, but Cinnamomum zeylanicum with its low coumarin content would be a safer alternate.

Use of household ingredients as complementary medicines for perceived hypoglycemic benefit among Sri Lankan diabetic patients; a cross-sectional survey.

BACKGROUND: Biologic based therapies are frequently used as complementary medicines in diabetes. The aim of this study was to identify the commonly used herbal remedies and their preparations in Sri Lankan patients with Type 2 diabetes. METHODS: This is a descriptive, cross-sectional study on 220 diabetic patients using herbal remedies for perceived glycemic benefit. RESULTS: All the patients used their regular conventional medications together with herbal remedies. The most commonly used medication was metformin (91.4%). Ivy gourd (Coccinia grandis) was the most commonly used herbal remedy (32%), followed by crepe ginger (Costus speciosus) (25%) and bitter gourd (Momordica charantia) (20%). Herbal remedies used less frequently were finger millet (Eleusine corocana) (5%), anguna leaves (Wattakaka volubilis) (5%), goat weed (Scoparia dulcis) (4%), Salacia reticulata (4%), fenugreek (Trigonella foenum-graecum) (3%) and tree turmeric (Coscinium fenestratum) (0.5%). None of the patients used commercially available over-the-counter herbal products. The common preparations were salads (72.8%), curries (12.8%), herbal tea (6%), and herbal porridges (6%). CONCLUSION: The practice of using household ingredients as complementary medicines is common in Sri Lanka. Few herbal remedies and their methods of preparation have limited evidence for efficacy. In view of the frequent use by diabetic patients each needs to be documented for reference and scientifically explored about their hypoglycemic potential.

Salacia reticulata (Kothala himbutu) revisited; a missed opportunity to treat diabetes and obesity?

BACKGROUND: Nearly 50% of diabetic patients worldwide use complementary medicines to treat or supplement their conventional diabetes treatment. Salacia reticulata (Kothala himbutu) is a woody climber used widely in the Ayurvedic system to treat diabetes and obesity. OBJECTIVE: In this review I critically analyze the evidence for using Salacia reticulata for treating type 2 diabetes and obesity. The available evidence is described in terms of in-vitro studies, animal studies and clinical trials. RESULTS AND CONCLUSIONS: In vitro studies demonstrate the ability of Salacia to inhibit intestinal alpha glucosidase. In mouse mesenteric fat it enhances the mRNA expression for hormone sensitive lipase (HSL) and adiponectin; thus increasing lipolysis and reducing insulin resistance respectively. In 3 T3-L-1 adipocytes lipogenesis factors are down regulated and lipolysis factors are up regulated with Salacia reticulata treatment. Animal studies and clinical trials are consistent in demonstrating improvement of glucose concentrations in the fasted and sucrose and maltose loaded states. Clinically significant reductions of HbA1C and plasma Insulin are reported with treatment of 6 weeks to 3 months. One clinical trial reported significant reduction of weight and BMI when Salacia is used in combination with vitamin D. Salacia reticulata effectively improves insulin resistance, glucose metabolism and reduces obesity. A larger evidence base is required from well-planned studies to confirm its efficacy and safety.

Management and outcomes of acute ST-segment-elevation myocardial infarction at a tertiary-care hospital in Sri Lanka: an observational study.

BACKGROUND: Sri Lanka is a developing country with a high rate of cardiovascular mortality. It is still largely dependent on thrombolysis for primary management of acute myocardial infarction. The aim of this study was to present current data on the presentation, management, and outcomes of acute ST-segment-elevation myocardial infarction (STEMI) at a tertiary-care hospital in Sri Lanka. METHODS: Eighty-one patients with acute STEMI presenting to a teaching hospital in Peradeniya, Sri Lanka, were included in this observational study. RESULTS: Median interval between symptom onset and hospital presentation was 60 min (mean 212 min). Thrombolysis was performed in 73% of patients. The most common single reason for not performing thrombolysis was delayed presentation. Median door-to-needle time was 64 min (mean, 98 min). Only 16.9% of patients received thrombolysis within 30 min, and none underwent primary PCI. Over 98% of patients received aspirin, clopidogrel, and a statin on admission. Intravenous and oral beta blockers were rarely used. Follow-up data were available for 93.8% of patients at 1 year. One-year mortality rate was 12.3%. Coronary intervention was performed in only 7.3% of patients post infarction. CONCLUSION: Late presentation to hospital remains a critical factor in thrombolysis of STEMI patients in Sri Lanka. Thrombolysis was not performed within 30 min of admission in the majority of patients. First-contact physicians should receive further training on effective thrombolysis, and there is an urgent need to explore the ways in which PCI and post-infarction interventions can be incorporated into treatment protocols.

Use of Complementary and Alternative Medicines (CAMs) among type 2 diabetes patients in Sri Lanka: a cross sectional survey.

BACKGROUND: The incidence of chronic illnesses has increased worldwide. Diabetes is one such illness and 80% of the diabetic population lives in the developing world. There is a rapidly growing trend towards the use of Complementary and Alternative Medical practices in Diabetes. Sri Lanka is a developing Asian nation with a rich culture of Ayurvedic and native medical culture. The objective of this study was to find the prevalence of use of CAMs in a diabetic population attending a large multiethnic diabetes facility in a University unit and to assess whether there is an increase in the incidence of hypoglycaemic episodes among users of CAMs. METHODS: A cross sectional study was performed at Teaching Hospital Peradeniya between April and August 2012. Following verbal consent, 254 type 2 adult diabetic patients attending the diabetes facility were interviewed regarding the use of CAM and hypoglycaemia using an interviewer-administered questionnaire. RESULTS: Of the 252 valid results, 192 patients (76%) admitted to the use of a CAM to reduce blood glucose. Bitter gourd, ivy gourd and crepe ginger were used by 128, 113 and 92 individuals. While 19% used a single agent, 34%, 21% and 2.4% used 2,3 and more than 3 agents. The incidence of hypoglycaemia in CAM users was 21% and 16.6% in non-users. The difference was statistically not significant. (p = 0.57) Ingestion of Costus speciosus (Crepe ginger) was associated with higher incidence of hypoglycaemia (P = 0.01).Female gender was significantly associated with CAM use (p = 0.01), while the age, duration of diabetes, presence of co-morbidities and complications of diabetes failed to show a significant association. CONCLUSION: Sri Lanka has a very high use of herbal supplementation in type 2 diabetes patients. Although the overall incidence of hypoglycaemia is not increased among CAM users, crepe ginger is associated with significant hypoglycaemia and warrants further research.

The use of complementary and alternative medicines (CAMs) in the treatment of diabetes mellitus: is continued use safe and effective?

INTRODUCTION: Diabetes mellitus is a major cause of morbidity and mortality worldwide, with a prevalence of 347 million in 2013. Complementary and Alternative Medicines (CAM) are a group of remedies that is fast gaining acceptance among individuals. Cinnamon, Bitter gourd (Momordica charantia) and Fenugreek (Trigonella foenum-graecum) are 3 widely used CAMs used worldwide for the treatment of diabetes. Data on safety and efficacy is limited, but the consumption is wide. Crepe ginger (Costus speciosus) and Ivy gourd (Coccinia grandis) are 2 plants used widely in the Asian region for their presumed hypoglycaemic properties. OBJECTIVE: In this review, we analyzed the available evidence for the 5 CAMs mentioned above in terms of in-vitro studies, animal studies sand clinical trials. We also describe the mechanisms of hypoglycaemia and safety concerns where there is available evidence. RESULTS AND CONCLUSIONS: Clinical trials that studied the hypoglycaemic effects of Cinnamon, bitter gourd, fenugreek and ivy gourd showed conflicting results. Direct comparison between studies remains a challenge in view of the baseline heterogeneity of subjects, differences in substrate preparation, variable end points and poor trial design. Short durations of study and small number of subjects studied is universal. Crepe ginger has not been studied adequately in humans to draw conclusions.In view of the high prevalence of use and safety and efficacy issues, there is an urgent need to study their hypoglycaemic and adverse effects in well-designed long-term clinical trials.

Topiramate-induced acute onset myopia: a case report.

BACKGROUND: Topiramate is a drug which emerged from its anticonvulsant properties and now over the years is used for a wider range of indications, including migraine prophylaxis. We described a very rare case of topiramate induced acute onset myopia during use for migraine. It is the first reported case of its kind from Sri Lanka with only a handful of reported cases in world literature. CASE PRESENTATION: A 35-year-old Sri Lankan female presented with long standing history of intermittent headache with recent worsening. A diagnosis of migraine was made and due to poor response to other medication was initiated on topiramate. Two weeks later patient developed visual impairment which was finally attributed to topiramate. Following discontinuation of the drug, within 3 days the symptoms started to improve with full recovery in 10 days. CONCLUSION: All clinicians should be aware of the potential ocular side effects of topiramate. Although relatively rare, prompt recognition is key to appropriate management.