Molecular mechanisms of antidiabetic effect of betulinic acid in lotus rhizome.

OBJECTIVES: To explain the bio-physiological mechanisms of the antidiabetic effect of betulinic acid in Lotus rhizome. BACKGROUND: Even though Sri Lankan native medicine uses Lotus rhizome as a medicinal food for diabetes mellitus, its antidiabetic property has not been scientifically explained yet. It is found to compose several medicinally active components with antidiabetic properties, including Betulinic acid. METHODS: A narrator review was conducted with a literature search in PubMed and Google Scholar databases using the search terms "Nelumbo nucifera rhizome", "Lotus rhizome", "phytochemicals", "antidiabetic effect", "hypoglycaemic effect" "Betulinic acid", and "molecular mechanism". RESULTS: The triterpenoid, Betulinic acid exerts its antidiabetic effect via seven bio-physiological mechanisms including, inhibiting α-glucosidase and α-amylase, upregulating the expression of peroxisome proliferator-activated receptor gamma coactivator-1 α, enhancing AS160 protein phosphorylation, stimulating adenosine monophosphate-activated protein kinase activation, stimulating Glucose transporter type 4 synthesis and translocation, inhibiting Protein Tyrosine Phosphatase 1 B activity preventing dephosphorylation of insulin receptor and stimulating Takeda-G-protein-receptor-5 resulting in an increased release of insulin from insulin-containing granulesCONCLUSION: The available scientific knowledge explains that betulinic acid in Lotus rhizome can improve glucose homeostasis contributing to the antidiabetic effect of this root (Tab. 1, Fig. 6, Ref. 29).

Validity and reliability of the Sinhalese version of the perceived stress scale questionnaire among Sri Lankans.

Introduction: Despite the availability of validated psychometrics tools to assess depression, there has not been any validated and reliable tool established to test perceived stress among Sri Lankans. The objective of this study is to test the validity and reliability of the Sinhalese Version of the Sheldon Cohen Perceived Stress Scale. Materials and methods: Standard and systematic procedures were adopted to translate the original English version of the Perceived Stress Scale-10 questionnaire into Sinhalese. Consecutive sampling was employed to recruit the Type 2 Diabetes mellitus (T2DM) sample (n = 321), and a convenient sampling was used to recruit the Age and Sex matched Healthy Controls (ASMHC) (n = 101) and the Healthy Community Controls (HCC) groups (n = 75). Cronbach alpha was used to assess internal consistency and reliability was determined using test-retest method utilizing Spearman's correlation coefficient. Sensitivity was evaluated by comparing the mean scores of the Sinhalese Perceived Stress Scale (S-PSS-10) and Sinhalese Patient Health Questionnaire (S-PHQ-9) scores. Post-hoc comparisons were done using Bonferroni's method. Mean scores were compared between the T2DM, ASMHC, and HCC groups using the independent t-test. Explanatory Factor Analysis (EFA) was conducted using the principal component and Varimax rotation while the Confirmatory Factor Analysis (CFA) was performed to assess the goodness-of-fit of the factor structure extracted from the EFA. Concurrent validity was assessed using the Pearson correlation between the S-PSS-10 and Patient Health Questionnaire measured by S-PHQ-9 (p < 0.05). Results: Cronbach alpha values of the three groups T2DM, ASMHC and HCC were 0.85, 0.81, and 0.79, respectively. Results of the ANOVA test suggested that there was a significant difference in the mean scores between groups (p < 0.00). EFA analysis revealed the existence of two factors with eigenvalues greater than 1.0. The factor loadings for the items ranged from 0.71-0.83. The CFA analysis demonstrated a good model fit for the two-factor model S-PSS-10. The S-PSS-10 significantly correlated with S-PHQ-9, indicating an acceptable concurrent validity. Conclusion: Findings revealed that the S-PSS-10 questionnaire can be used to screen perceived stress among the majority of the Sri Lankan Sinhalese-speaking population specially with chronic illnesses. Further studies with higher sample sizes across different populations would enhance the validity and reliability of S-PSS-10.

A comparison of observed feeding practices of infants and young children aged 6-23 months to national responsive feeding recommendations in Sri Lanka.

To describe the extent to which Sri Lankan caregivers follow current national responsive feeding recommendations and the factors limiting and enabling those behaviours. Study design. This ethnographic substudy was conducted using a four-phase, mixed methods formative research design across rural, estate and urban sectors of Sri Lanka. Data collection methods. Data were collected using direct meal observations and semistructured interviews. Participants including infants and young children aged 6-23 months (n = 72), community leaders (n = 10), caregivers (n = 58) and community members (n = 37) were purposefully sampled to participate in this study. Data analysis. Observational data were summarized using descriptive statistics while textual data were analysed thematically using Dedoose. Findings were then interpreted vis-à-vis six national responsive feeding recommendations. During observed feeding episodes, caregivers were responsive to nearly all food requests (87.2% [34/39]) made by infants and young children. Many caregivers (61.1% [44/72]) also positively encouraged their infant and young child during feeding. Despite some responsive feeding practices being observed, 36.1% (22/61) of caregivers across sectors used forceful feeding practices if their infant or young child refused to eat. Interviews data indicated that force-feeding practices were used because caregivers wanted their infants and young children to maintain adequate weight gain for fear of reprimand from Public Health Midwives. Despite overall high caregiver knowledge of national responsive feeding recommendations in Sri Lanka, direct observations revealed suboptimal responsive feeding practices, suggesting that other factors in the knowledge-behaviour gap may need to be addressed.

Potential role of microRNAs in selective hepatic insulin resistance: From paradox to the paradigm.

The paradoxical action of insulin on hepatic glucose metabolism and lipid metabolism in the insulin-resistant state has been of much research interest in recent years. Generally, insulin resistance would promote hepatic gluconeogenesis and demote hepatic de novo lipogenesis. The underlying major drivers of these mechanisms were insulin-dependent, via FOXO-1-mediated gluconeogenesis and SREBP1c-mediated lipogenesis. However, insulin-resistant mouse models have shown high glucose levels as well as excess lipid accumulation. As suggested, the inert insulin resistance causes the activation of the FOXO-1 pathway promoting gluconeogenesis. However, it does not affect the SREBP1c pathway; therefore, cells continue de novo lipogenesis. Many hypotheses were suggested for this paradoxical action occurring in insulin-resistant rodent models. A "downstream branch point" in the insulin-mediated pathway was suggested to act differentially on the FOXO-1 and SREBP1c pathways. MicroRNAs have been widely studied for their action of pathway mediation via suppressing the intermediate protein expressions. Many in vitro studies have postulated the roles of hepato-specific expressions of miRNAs on insulin cascade. Thus, miRNA would play a pivotal role in selective hepatic insulin resistance. As observed, there were confirmations and contradictions between the outcomes of gene knockout studies conducted on selective hepatic insulin resistance and hepato-specific miRNA expression studies. Furthermore, these studies had evaluated only the effect of miRNAs on glucose metabolism and few on hepatic de novo lipogenesis, limiting the ability to conclude their role in selective hepatic insulin resistance. Future studies conducted on the role of miRNAs on selective hepatic insulin resistance warrant the understanding of this paradoxical action of insulin.

Assessment of knowledge and perceptions on leishmaniasis: An island-wide study in Sri Lanka.

Cutaneous leishmaniasis (CL) is a notifiable disease in Sri Lanka with increasing case numbers reported from every part of the country. In addition to disease treatment and vector control measures, knowledge and perceptions in a community are key contributors to a successful intervention program. An island-wide survey was carried out to assess the knowledge and perceptions regarding CL across the island, with 252 confirmed CL cases and 2,608 controls. Data was collected by trained personnel, using a pre-tested Case Reporting Form (CRF). Although the percentage who referred to CL by its correct name was low (1.4%), majority stated that it is a fly induced skin disease (79.1%). Knowledge on the symptoms, curability and the name of the vector was high in these communities, but specific knowledge on vector breeding places, biting times and preventive methods were poor. The patients were more knowledgeable when compared to the controls. Differences in the level of knowledge could be identified according to the level of education of the participants as well as across the different areas of the country. The main source of information was through the healthcare system, but the involvement of media in educating the communities on the disease was minimal. While this study population was unaccustomed to the use of repellants or sprays, the use of bed nets was high (77.7% of the participants) in this study population. Although misconceptions and incorrect practices are rare in Sri Lankan communities, promoting health education programs which may improve disease awareness and knowledge on vector and its control will further strengthen the control and prevention strategies.

Risk factors for upper limb fractures due to unintentional injuries among adolescents: a case control study from Sri Lanka.

BACKGROUND: Injuries are the number one cause for morbidity and mortality among adolescents. Adolescent fractures are a hidden public health problem in Sri Lanka. Upper limb fractures are common in adolescents due to various risk factors. Many injuries are predictable and can be prevented by identifying the risk factors. The aim of the study was to determine the risk factors for upper limb fractures among adolescents in Sri Lanka. METHODS: A case control study was undertaken with 450 cases and 450 controls. Cases were recruited consecutively from all major hospitals among the adolescent victims who had admitted with newly diagnosed upper limb fractures in the district of Colombo. Controls were apparently healthy adolescents from the same district and excluded who had previous upper limb fractures. The age and gender were not matched in selecting controls since these two factors were potential risk factors for adolescent fractures according to previous literature. Risk factors for upper limb fractures were assessed by odds ratio (OR) with 95% confidence interval (CI) and adjusted for possible confounding by performing logistic regression analysis. RESULTS: The mean age of the cases was 13.62 years with a Standard Deviation (SD) of 2.8 and controls was 12.75 years (SD = 2.7) respectively. Having a high standard of living index (OR = 3.52; 95%CI: 2.3-5.2, p < 0.001), being in a high social class category (social class I & II) (OR = 2.58, 95%CI: 1.7-3.92, p < 0.001), engage in physical or sports activity (OR = 9.36; 95%CI: 3.31-26.47, p < 0.001), watching television (OR = 1.95; 95%CI: 1.18 -3.22, p = 0.009), playing video or computer games (OR = 2.35; 95%CI: 1.7-3.24, p < 0.001), and attending extra classes (OR = 1.82; 95%CI: 1.2-2.7, p = 0.007) were risk factors for having a upper limb fracture. Risk factors for upper limb fractures following adjusted for confounders were siblings in the family (aOR = 11.62, 95% CI: 6.95-41.29, p = 0.03) and attend extra classes after school hours (aOR = 2.51, 95%CI: 0.68-0.93, p = 0.04). Two significant effect modifications between being a Buddhist and low standard of living index (p < 0.001) and having one sibling in the family and attend extra classes after school hours (p = 0.01) were observed. CONCLUSIONS: Modifiable risk factors in relation to lifestyle factors and socioeconomic position were important determinants of upper limb fracture risk in adolescents. Many fractures can be prevented by strengthening awareness programmes in the community.

Is abdominal adiposity in healthy Sri Lankan neonates different from the rest of the world?

BACKGROUND AND OBJECTIVES: Adiposity at birth is a predictor of childhood obesity. Abdominal circumference (AC) at birth has been shown to correlate well with visceral adipose tissue and abdominal subcutaneous adipose tissue. Adiposity differs according to ethnicity and geography. The aim of this study was to describe the anthropometry derived adiposity phenotype in neonates from Colombo, Sri Lanka and compare it with global data. METHODS AND STUDY DESIGN: Birth anthropometry was performed within 12-24 hours by the same investigator as part of a prospective cohort study on healthy term babies, at a tertiary care hospital in Colombo, Sri Lanka, 2015-2019. The anthropometry derived adiposity phenotype was indicated by skinfold thickness, AC and upper arm fat area (UFA) derived from the mid-upper arm circumference (MUAC). RESULTS: Sri Lankan neonates had a significantly lower weight with significantly higher AC (n=337, 2.9±0.4 kg, 30.6±2.3 cm) compared to Canadian (n=389, 3.5±0.02 kg, 29.9±2.1 cm; p<0.001) and Australian (n=1270, 3.4±0.4 kg, 28.5±1.9 cm; p<0.001) neonates. Anthropometry derived adiposity at birth showed a significant correlation with weight and BMI of both mother and father (p<0.05) as opposed to their income or education (p>0.05). CONCLUSIONS: Healthy neonates from Colombo, Sri Lanka demonstrated significantly higher AC despite significantly lower weight, indicating increased abdominal adiposity compared to neonates from high-income countries as well as Indian neonates with the thin-fat phenotype.

Spatiotemporal distribution of cutaneous leishmaniasis in Sri Lanka and future case burden estimates.

BACKGROUND: Leishmaniasis is a neglected tropical vector-borne disease, which is on the rise in Sri Lanka. Spatiotemporal and risk factor analyses are useful for understanding transmission dynamics, spatial clustering and predicting future disease distribution and trends to facilitate effective infection control. METHODS: The nationwide clinically confirmed cutaneous leishmaniasis and climatic data were collected from 2001 to 2019. Hierarchical clustering and spatiotemporal cross-correlation analysis were used to measure the region-wide and local (between neighboring districts) synchrony of transmission. A mixed spatiotemporal regression-autoregression model was built to study the effects of climatic, neighboring-district dispersal, and infection carryover variables on leishmaniasis dynamics and spatial distribution. Same model without climatic variables was used to predict the future distribution and trends of leishmaniasis cases in Sri Lanka. RESULTS: A total of 19,361 clinically confirmed leishmaniasis cases have been reported in Sri Lanka from 2001-2019. There were three phases identified: low-transmission phase (2001-2010), parasite population buildup phase (2011-2017), and outbreak phase (2018-2019). Spatially, the districts were divided into three groups based on similarity in temporal dynamics. The global mean correlation among district incidence dynamics was 0.30 (95% CI 0.25-0.35), and the localized mean correlation between neighboring districts was 0.58 (95% CI 0.42-0.73). Risk analysis for the seven districts with the highest incidence rates indicated that precipitation, neighboring-district effect, and infection carryover effect exhibited significant correlation with district-level incidence dynamics. Model-predicted incidence dynamics and case distribution matched well with observed results, except for the outbreak in 2018. The model-predicted 2020 case number is about 5,400 cases, with intensified transmission and expansion of high-transmission area. The predicted case number will be 9115 in 2022 and 19212 in 2025. CONCLUSIONS: The drastic upsurge in leishmaniasis cases in Sri Lanka in the last few year was unprecedented and it was strongly linked to precipitation, high burden of localized infections and inter-district dispersal. Targeted interventions are urgently needed to arrest an uncontrollable disease spread.

Disciplining in Sri Lankan Schools: A Cross-Sectional Study.

An integral part of a teacher's job is to correct misbehavior of students. There is scarcity of information on disciplinary methods used by teachers in schools in Sri Lanka. As a part of a larger research, this study was undertaken to fill this gap. A culturally validated questionnaire was used to assess the various disciplinary methods used by 459 teachers, on 948 students, in six districts in Sri Lanka. National, provincial, special education, and private schools were included in this study. The study revealed that teachers used aversive disciplinary methods such as corporal punishment and psychological aggression. During the past term, 80.4% of students reported experiencing at least one strategy of corporal punishment and 72.5% reported experiencing psychological aggression. It was alarming to note that 53% of students reported experiencing at least one strategy of physical abuse in the schools in Sri Lanka. In all, 79.3% of students reported experiencing at least one strategy of positive discipline. Although teachers did use positive discipline, it was lesser than the use of aversive disciplinary methods. Hence, the use of force as a tool of discipline on young people in schools in Sri Lanka is widespread. The findings of this study should raise grave concern and ring alarm bells among authorities in Sri Lanka. Therefore, several recommendations to rectify this situation are also presented herein.

Birth anthropometry from a tertiary care hospital in Sri Lanka: Differs from the WHO growth standards.

BACKGROUND AND OBJECTIVES: The nutritional status of infants is assessed using the WHO growth references, based on the Multicenter Growth Reference Study (MGRS) in many countries including Sri Lanka. Birth parameters define infant growth curves. The aim of this study was to compare the birth anthropometric data of a healthy population of babies born in Colombo, Sri Lanka with the WHO MGRS birth data and determine its suitability for assessment of growth in this population. METHODS AND STUDY DESIGN: Birth data were obtained as part of a study on longitudinal infant body composition from birth to 2 years from 2015-2019. Healthy babies, born to non-smoking mothers, >18 years old, with a singleton pregnancy at term, living in the study area and intending to breastfeed, were recruited. The Ethical Review Committee of the Faculty of Medicine, University of Colombo, approved the study. RESULTS: Compared to WHO data, the mean birth weight (2.9±0.4 kg), length (48.2±2.7 cm) and head circumference (33.6±1.2 cm) of our study population (n=337) was significantly lower with a left shift in the z score distribution. This was despite similar background characteristics except for significantly lower income (USD 200) and lower maternal (154.2±9.0 cm) and paternal height (165±11.6 cm) in our study population. A significant change in birth parameters was only seen with maternal height when disaggregated. CONCLUSIONS: WHO birth parameters were significantly higher and underestimated the growth of healthy babies in Sri Lanka.

A clinicopathological study of triple-negative breast carcinoma in a patient cohort from a tertiary care center in Sri Lanka.

BACKGROUND: Triple negative breast carcinoma (TNBC) and basal-like breast carcinoma (BLBC) are subtypes of breast carcinoma (BCa) that are associated with poor survival. AIMS: To study the prevalence, clinicopathological profile and survival of TNBC among a Sri Lankan patient cohort and to determine the proportion and predictive histological features of BLBC among TNBCs. STUDY SETTING AND DESIGN: A cohort of 221 women undergoing primary surgery for BCa at a tertiary-care center in Sri Lanka was studied. MATERIALS AND METHODS: Clinicopathological and follow-up information were collected by patient interviews and review of slides and clinical records. Estrogen, progesterone, HER2 receptors, and basal markers (CK5/6, CK14, EGFR, 34ßE12) were evaluated immunohistochemically. STATISTICAL ANALYSIS: Data was analyzed with Chi-square test, multinomial logistic regression, and Cox regression using SPSS20.0. RESULTS: Fifty-three (24%) tumors were triple-negative (95%CI = 18.37%-29.63%). On multivariate analysis, young age (P = 0.002), high Nottingham grade (P = 0.005), moderate to severe tumor necrosis (P = 0.004), absent ductal carcinoma in situ (DCIS) (P = 0.04), reduced vascular density at tumor edge (P = 0.016) and distinct cell margins (P = 0.047) predicted TNBC over luminal subgroups, whereas reduced vascular density (P = 0.004) and low TNM stage (P = 0.011) distinguished TNBC and HER2. BLBC accounted for 45.28% (95%CI 32.66%-58.55%-24/53) of TNBC. The presence of extensive necrosis in TNBC correlated significantly with BLBC (P = 0.03). The survival among the TNBC subgroup did not differ significantly from other subgroups. CONCLUSION: Twenty four percent were TNBCs by immunohistochemical analysis, comparable to studies in the Indian subcontinent, however higher than the West. TNBC status correlated with younger age, high tumor grade, necrosis, absent DCIS, reduced vascular density at tumor edge, and distinct cell margins. The presence of moderate to extensive necrosis in TNBC was predictive of BLBC.

Undiagnosed diabetes, hypertension, and hypercholesterolaemia in an overweight or obese population: implications for cardiovascular disease risk screening programme.

INTRODUCTION: Establishing the burden of undiagnosed CVD risk factors is critical to monitoring public health efforts related to screening and diagnosis. OBJECTIVE: To assess the proportion and determinants of undiagnosed diabetes, hypertension, and hypercholesterolaemia, among overweight or obese adults. METHODS: A sample of 1200 participants aged 35-64 years with a BMI ≥25 kg/m2 was selected from the Colombo district. Data were collected through a questionnaire, anthropometry, blood pressure measurement, and blood sampling for fasting plasma glucose, HbA1c, and lipid profile. Undiagnosed diabetes, hypertension, and hypercholesterolaemia were defined as fasting plasma glucose ≥126 mg/dL or HbA1c ≥6.5%; systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg; total cholesterol ≥240 mg/dl respectively, in a person without a previous diagnosis. Multiple logistic regression analyses were carried out to identify determinants. RESULTS: The prevalence (95%CI) of diabetes was 28% (25.5, 30.5), hypertension, 33.4% (30.7, 36.1) and hypercholesterolaemia, 31.9% (29.2, 34.5). The proportion of undiagnosed diabetes was 13.8% (11.9, 15.8), undiagnosed hypertension 11.3% (9.5, 13.1), and undiagnosed hypercholesterolaemia 17.8% (15.6, 19.9). Undiagnosed cases accounted for almost half of all diabetes cases, one-third of all hypertension cases, and more than half (56%) of all high cholesterol cases. The key determinants for undiagnosed CVD risk were: male sex, low or middle income, rural residence, and relatively younger age. CONCLUSION: CVD screening programmes should be tailored to target populations based on these determinants and provide basic diagnostic facilities in all health centres. The 'proportion undiagnosed' in the population may be a useful indicator to evaluate their effectiveness.

mHealth nutrition and lifestyle intervention (mHENAL) to reduce cardiovascular disease risk in a middle-aged, overweight and obese population in Sri Lanka: Study protocol for a randomized controlled trial.

Mobile phone-based health interventions (mHealth) are viewed as an attractive approach to foster behaviour change, and found to be effective in promoting physical activity and healthy diets. The present study aims to investigate whether mHealth with advice for dietary and lifestyle modifications would reduce 10-year cardio vascular disease (CVD) risk among overweight or obese adults aged 35-64 years in Sri Lanka. A two-group parallel-arm randomized controlled trial (RCT) was conducted in Colombo district, recruiting 1200 individuals aged 35-64 years with a body mass index (BMI) of ≥25 kgm-2. Participants were randomly assigned either to mHealth package (intervention arm, n = 600) or usual care (control arm, n = 600). The intervention package contains a series of dietary and lifestyle improvement messages, a mobile application to register participants, and a web application to deliver these messages. Participants in the intervention arm receive 2 voice and 2 text messages per week to their mobile phones for a period of 12 months. The primary outcome (10-year CVD risk) will be assessed according to sex, age, smoking status, blood pressure, serum cholesterol and glycaemic status. Data are collected at enrollment and after 12 months of intervention on: dietary practices, physical activity, smoking, anthropometry, body composition, blood pressure, fasting plasma glucose, HbA1c and lipid profile. Analysis of effect will be performed by intention-to-treat principle, comparing the outcomes between intervention and control arms. The study resulted in a comprehensive mHealth nutrition and lifestyle package (mHENAL) and successfully completed recruitment and baseline assessment of participants. The message delivery is in progress.

Health in rural Sri Lanka: A cross-sectional survey of three rural districts

Introduction: Sri Lanka has a predominantly rural population. However, there is a dearth of research on health and socioeconomic issues in this group. Objective: To describe basic socioeconomic characteristics and health profile in a rural population. Methods: A descriptive cross-sectional household survey was conducted in 1950 households in three rural districts, selected by a three-stage stratified cluster sampling method. Results: The population pyramid showed an ageing population (dependency ratio of 50%). Only 39% had completed GCE (ordinary level). Unemployment rates were high (25% males, 76% females). Agriculture and related work were main occupations. Most lacked amenities (e.g. 61% households lacked a refrigerator) and practiced inappropriate methods of waste disposal (e.g. open burning by 72%). Household illnesses were frequent: episodes of acute illness within two weeks, injuries within past year and chronic illness were reported from 35.9%, 14.9% and 48.3% households. The prevalence of chronic diseases in adults >20 years were high: diabetes 13.5%, hypertension 16.7% and overweight/obesity 28.2%. Of the males, 22.1% smoked and 12.3% took alcohol. Almost 25% adults chewed betel. Reports of snake bite, dog bites and suicide/attempted suicide were seen in 15.5%, 9.7% and 3.0% households respectively. Conclusions: This study shows a unique clustering of health-related problems in rural Sri Lanka. This was characterized by demographic transition, burden from snake bites, chronic diseases and acute illnesses. There were resource limitations and low levels of education. Cohort studies and comparisons with urban areas will enable further elucidation of determinants of health and other issues in rural Sri Lanka.

Health related quality of life of preterm born children at three years in a sub urban district in Sri Lanka: a retrospective cohort study.

BACKGROUND: Preterm birth leads to multiple morbidities affecting the health of a child. Lack of information on the health impact of prematurity hinders the possibility of any effective public health interventions in this regard. Our aim was to determine the association between preterm birth and Health-Related Quality of Life (HRQOL) among 3 years old children in the Gampaha district, Sri Lanka. METHODS: A community-based retrospective cohort study was conducted among 790 preterm and term born children who were 03 years old. Multi-stage cluster sampling technique was used to identify children. The exposure status, a preterm birth, was established using the maternal pregnancy records. Outcome status was measured using a validated health related quality of life questionnaire (prepared in Sinhala) for preschool-aged children. Mothers of the children responded to an interviewer-administered questionnaire which had variables on the exposure status, outcome and additional variables such as child development status and birth related information. Quality of life was measured in twelve different domains of health (subscales). The impact was analyzed using the multiple linear regression. RESULTS: Response rate was 95.5% (n = 379) for preterm group and 95.2% (n = 378) for term-born group. Health-Related Quality of Life scores obtained by preterm children were lower than the term born children in eight subscales. Preterm birth showed statistically significant association with subscales on sleep wellbeing, general wellbeing and abdominal symptoms in the adjusted analysis (p < 0.05). Among preterm children prolonged illness, delayed development status, socio economic status and maternal perception on the health status of the child were common predictors of quality of life. CONCLUSION: Preterm birth affected health related quality of life of preschool aged children.

Management, characteristics and outcomes of patients with acute coronary syndrome in Sri Lanka.

BACKGROUND: Ischaemic heart disease is the leading cause of in-hospital mortality in Sri Lanka. Acute Coronary Syndrome Sri Lanka Audit Project (ACSSLAP) is the first national clinical-audit project that evaluated patient characteristics, clinical outcomes and care provided by state-sector hospitals. METHODS: ACSSLAP prospectively evaluated acute care, in-hospital care and discharge plans provided by all state-sector hospitals managing patients with ACS. Data were collected from 30 consecutive patients from each hospital during 2-4 weeks window. Local and international recommendations were used as audit standards. RESULTS: Data from 87/98 (88.7%) hospitals recruited 2177 patients, with 2116 confirmed as having ACS. Mean age was 61.4±11.8 years (range 20-95) and 58.7% (n=1242) were males. There were 813 (38.4%) patients with unstable angina, 695 (32.8%) with non-ST-elevation myocardial infarction (NSTEMI) and 608 (28.7%) with ST-elevation myocardial infarction (STEMI). Both STEMI (69.9%) and NSTEMI (61.4%) were more in males (P<0.001). Aspirin, clopidogrel and statins were given to over 90% in acute setting and on discharge. In STEMI, 407 (66.9%) were reperfused; 384 (63.2%) were given fibrinolytics and only 23 (3.8%) underwent primary percutaneous coronary intervention (PCI). Only 42.3 % had thrombolysis in <30 min and 62.5% had PCI in <90 min. On discharge, beta-blockers and ACE inhibitors/angiotensin II receptor blockers were given to only 50.7% and 69.2%, respectively and only 17.6% had coronary interventions planned. CONCLUSIONS: In patients with ACS, aspirin, clopidogrel and statin use met audit standards in acute setting and on discharge. Vast majority of patients with STEMI underwent fibrinolyisis than PCI, due to limited resources. Primary PCI, planned coronary interventions and timely thrombolysis need improvement in Sri Lanka.

Emotional intelligence and academic performance of medical undergraduates: a cross-sectional study in a selected university in Sri Lanka.

BACKGROUND: Emotional intelligence (EI) has been linked with academic and professional success. Such data are scarce in Sri Lanka. This study was conducted to describe the pattern of EI, to determine its predictors and to determine the effect of EI on academic performance at the final MBBS examination, in medical undergraduates of a Sri Lankan university. METHODS: This is a cross-sectional study in a selected university, involving those who did final MBBS examination in 2016. Consecutive sampling was done. EI was assessed with self-administered Genos Emotional Intelligence Full Version (7 domains; 70 questions equally weighted; total score 350). Socio-demographic data were obtained using a self-administered questionnaire. Academic performance was assessed with final MBBS results in the first attempt. RESULTS: Of 148 eligible students 130 responded (response rate-88%); 61.5% were females; mean age was 26.3 ± 1 years. Mean total EI score was 241.5 (females-245.5, males-235.1; p = 0.045).Among different domains, mean score was highest for Emotional Self-Awareness (36.8/50) and lowest for Emotional Expression (32.6/50). Multiple linear regression analysis indicated that having good family support (p = 0.002), socializing well in university (p = 0.024) and being satisfied with facilities available for learning (p = 0.002), were independent predictors of EI. At the final MBBS examination 51.6% obtained classes, 31.5% passed the examination without classes and 16.9% got repeated. Females had better academic performance than males (p = 0.009). Mean EI of second-class upper division, second-class lower division, pass and repeat groups were 249.4, 246.6, 240.2 and 226.9, respectively (with one-way ANOVA p = 0.015). After adjusting for gender, ordinal regression analysis indicated that, total EI score was an independent predictor of final MBBS results [ß-0.018 (95% CI 0.005-0.031); p = 0.006]. CONCLUSIONS: In the study population, both EI and academic performance were higher among females. Independent of gender, academic performance was better in those who were more emotionally intelligent. Several psychosocial factors were found to be independent predictors of EI. These results suggest that emotional skills development might enhance academic performance of medical undergraduates in Sri Lanka. Further research is needed in this under-explored area.

Analysis of stakeholders networks of infant and young child nutrition programmes in Sri Lanka, India, Nepal, Bangladesh and Pakistan.

BACKGROUND: Effective public policies are needed to support appropriate infant and young child feeding (IYCF) to ensure adequate child growth and development, especially in low and middle income countries. The aim of this study was to: (i) capture stakeholder networks in relation to funding and technical support for IYCF policy across five countries in South Asia (i.e. Sri Lanka, India, Nepal, Bangladesh and Pakistan); and (ii) understand how stakeholder networks differed between countries, and identify common actors and their patterns in network engagement across the region. METHODS: The Net-Map method, which is an interview-based mapping technique to visualise and capture connections among different stakeholders that collaborate towards achieving a focused goal, has been used to map funding and technical support networks in all study sites. Our study was conducted at the national level in Bangladesh, India, Nepal, and Sri Lanka, as well as in selected states or provinces in India and Pakistan during 2013-2014. We analysed the network data using a social network analysis software (NodeXL). RESULTS: The number of stakeholders identified as providing technical support was higher than the number of stakeholders providing funding support, across all study sites. India (New Delhi site - national level) site had the highest number of influential stakeholders for both funding (43) and technical support (86) activities. Among all nine study sites, India (New Delhi - national level) and Sri Lanka had the highest number of participating government stakeholders (22) in their respective funding networks. Sri Lanka also had the highest number of participating government stakeholders for technical support (34) among all the study sites. Government stakeholders are more engaged in technical support activities compared with their involvement in funding activities. The United Nations Children's Emergency Fund (UNICEF) and the World Health Organization (WHO) were highly engaged stakeholders for both funding and technical support activities across all study sites. CONCLUSION: International stakeholders were highly involved in both the funding and technical support activities related to IYCF practices across these nine study sites. Government stakeholders received more support for funding and technical support activities from other stakeholders compared with the support that they offered. Stakeholders were, in general, more engaged for technical support activities compared with the funding activities.

Policy and stakeholder analysis of infant and young child feeding programmes in Sri Lanka.

BACKGROUND: Infant and young child feeding practices (IYCF) play a critical role in growth and development of children. A favourable environment supported by appropriate policies and positive contributions from all stakeholders are prerequisites for achieving optimal IYCF practices. This study aimed to assess the IYCF-related policy environment and role of stakeholders in policy making in Sri Lanka, in order to identify opportunities to strengthen the policy environment to better support appropriate IYCF and reduce childhood malnutrition. METHODS: We mapped national level policy-related documents on IYCF, and conducted a stakeholder analysis of IYCF policy making. A matrix was designed to capture data from IYCF policy-related documents using a thematic approach. A narrative synthesis of data from different documents was conducted to achieve the first objective. We then conducted an analysis of technical and funding links of stakeholders who shape IYCF policies and programmes in Sri Lanka using the Net-Map technique, to achieve the second objective. A total of 35 respondents were purposively selected based on their knowledge on the topic, and individual interviews were conducted. RESULTS: Twenty four policies were identified that contained provisions in line with global recommendations for best-practice IYCF, marketing of breast milk substitutes, strengthening health and non-health systems, maternity benefits, inter-sectoral collaboration, capacity building, health education and supplementation. However, there is no separate, written policy on IYCF in Sri Lanka. Participants identified 56 actors involved in shaping IYCF policies and programmes through technical support, and 36 through funding support. The Government Health Sector was the most connected as well as influential, followed by development partners. Almost all actors in the networks were supportive for IYCF policies and programmes. CONCLUSIONS AND RECOMMENDATIONS: All evidence-based recommendations are covered in related policies. However, advocacy should be targeted towards strategic support for IYCF in high-level policy documents. The stakeholder analysis confirmed a network led by the government health sector. Enhancing the multi-sectoral commitments stressed in policy documents is an opportunity to strengthen IYCF policy process in Sri Lanka.

Opportunities for strengthening infant and young child feeding policies in South Asia: Insights from the SAIFRN policy analysis project.

BACKGROUND: South Asian countries experience some of the highest levels of child undernutrition in the world, strongly linked to poor infant and young child feeding (IYCF) practices. Strong and responsive policy support is essential for effective interventions to improve IYCF. This study aimed to identify opportunities for strengthening the policy environment in the region to better support appropriate infant and young child feeding. METHODS: We mapped policies relevant to infant and young child feeding in India, Pakistan, Bangladesh, Sri Lanka and Nepal, based on a common matrix. The matrix described potentially relevant policies ranging from high-level strategic policy documents to implementation-level guidelines. We analyzed the data based on themes focused on caregiver interactions with IYCF interventions: provision of correct information to mothers, training of frontline workers, enabling mothers to engage with service providers and strategic support for IYCF. RESULTS: Policy support for IYCF was present in relation to each of the themes assessed. In all countries, there was support for nutrition in National Development Plans, and all countries had some level of maternity protection and restrictions on marketing of breast milk substitutes. Sectoral and implementation-level policy documents contained provisions for system strengthening for IYCF and for training of frontline workers. CONCLUSIONS: The key opportunities for strengthening IYCF policy support were in relation to translating strategic directives into implementation level documents; improving multi-sectoral support and coordination; and increased clarity regarding roles and responsibilities of frontline workers interacting with mothers. These findings can support efforts to strengthen IYCF policy at the national and regional level.