Medical ethics: knowledge, attitude and practice among doctors in three teaching hospitals in Sri Lanka.

BACKGROUND: Medical ethics deals with the ethical obligations of doctors to their patients, colleagues and society. The annual reports of Sri Lanka Medical Council indicate that the number of complaints against doctors has increased over the years. We aimed to assess the level of knowledge, attitude and practice regarding medical ethics among doctors in three teaching hospitals in Sri Lanka. METHODS: A hospital-based cross-sectional study was conducted among doctors (n = 313) using a pre-tested self-administered, anonymous questionnaire. Chi Squared test, and ANOVA test were used to identify the significance of association between level of knowledge and selected factors. RESULTS: Most doctors (81.2%) had a poor level of knowledge on medical ethics, with postgraduate trainees showing significantly (p = 0.023, Chi square) higher level of knowledge. The average knowledge on medical ethics among doctors was significantly different between the three hospitals (p = 0.008, ANOVA). Over 95% had a favourable attitude towards gaining knowledge and advocated the need for training. The majority (69.3%) indicated awareness of unethical practices. 24.6% of respondents stated that they get a chaperone 'sometimes' during patient examination while 3.5% never do. The majority (54%) responded that they never accept gifts from pharmaceutical companies in recognition of their prescribing pattern. 12-41% of doctors participated in the study acknowledged that they 'sometime' engaged in unethical practices related to prescribing drugs, accepting gifts from pharmaceutical companies and when obtaining leave. CONCLUSION: Most doctors had a poor level of knowledge of medical ethics. Postgraduate trainees had a higher level of knowledge than other doctors. The majority showed a favourable attitude towards gaining knowledge and the need of training. Regular in-service training on medical ethics for doctors would help to improve their knowledge on medical ethics, as well as attitudes and ethical conduct.

Prevalence of oral cancer and pre-cancer and associated risk factors among tea estate workers in the central Sri Lanka.

BACKGROUND: To screen for oral cancer or not is being debated, but for high-risk populations with minimal access to regular dental care systematic oral examinations could provide some benefit. METHODS: We undertook oral mucosal examinations of labourers employed in tea estate plantations in Sri Lanka. In a two-stage screening procedure, first by estate medical officers and then by visiting specialists, we examined 12 716 persons at their workplaces achieving a coverage of one-sixth of the total workforce. RESULTS: Fourteen oral cancers and 848 subjects with oral pre-cancer (6.7%) were detected giving population prevalences of 46.1 per 1000 for leukoplakia and 16.4 per 1000 for oral submucous fibrosis. Among subjects with any oral mucosal disorder (n = 1159) proportions of current users of betel quid, smokers and alcohol use was recorded at 92%, 31% and 61% respectively. The synergistic effect of these three risk habits on the development of oral leukoplakia was evident in mixed habit groups. CONCLUSIONS: The prevalence of oral pre-cancer in tea estate labourers was higher than estimates reported in previous studies. In the absence of state-sponsored preventive activities, it is necessary to improve the capacity of individual health practitioners and small medical centres to participate in oral health promotion and oral cancer/pre-cancer screening.

Anxiety and personality traits in patients with muscle related temporomandibular disorders.

This study tested the hypothesis that muscle related temporomandibular disorder patients with cervical muscle pain exhibit greater degree of psychological distress compared with patients without cervical muscle pain and controls. Thirty-eight muscle related temporomandibular disorder patients including 10 patients with cervical muscle pain and 41 healthy individuals as controls participated in the study. State and trait anxiety levels were assessed with the Spielberger's state and trait anxiety inventory. Personality traits (extroversion, neuroticism, psychoticism and social desirability) were assessed using the Eysenck's personality questionnaire, and the pain intensities described over the muscles were recorded using a 100 mm visual analogue scale. The muscle related temporomandibular disorder patients, in general, exhibited significantly higher degrees of neuroticism and trait anxiety. The patients with cervical muscle pain demonstrated a significantly higher level of psychoticism compared with the patients without cervical muscle pain and the controls and a significantly higher state anxiety level than the controls. They also demonstrated higher pain intensities in masseter and temporalis muscles compared with patients without cervical muscle pain. It has been suggested that either subjects with psychological distress are prone to temporomandibular disorders, or psychological distress is a manifestation of existing chronic pain conditions. The present findings demand further investigations and broader approach in management, as muscle related temporomandibular disorder patients with cervical muscle pain were both physically and psychologically compromised to a greater degree compared with patients without cervical muscle pain.

Oral pemphigus vulgaris in children and adolescents: a review of the literature and a case report.

This paper describes a case of oral pemphigus vulgaris (PV) in a child that was diagnosed in its early stages and managed successfully. The authors also report a literature review. Although oral PV in children and adolescents is extremely rare, it should be included in the differential diagnosis of oral ulcerative disease. It is of utmost importance to diagnose PV in children and adolescents in its initial stages in order to prevent the serious morbidity that may result from the disease, and to institute phamacotherapeutic measures so that they have the greatest effect. Furthermore, it is essential for dentists to be aware of the existence of PV in child and adolescent patients so that they may refer such cases for specialist management without undue delay.

Focal epithelial hyperplasia (Heck's disease): report of two cases with PCR detection of human papillomavirus DNA.

Focal epithelial hyperplasia (FEH) (Heck's disease) is essentially a benign oral infection produced by the human papillomavirus (HPV). Although this condition is known to exist in numerous populations and ethnic groups, it is relatively rare in South-East Asia. The following report is based on two cases of adult FEH with histopathological features in favour of the disease. In addition, polymerase chain reaction was performed to detect the presence of HPV DNA in the lesions in order to confirm the histopathological diagnosis.

Influence of masticatory muscle pain on electromyographic activities of cervical muscles in patients with myogenous temporomandibular disorders.

The present study tested the hypothesis that the resting electromyographic (EMG) activities of sternocleidomastoid and trapezius muscles of myogenous temporomandibular disorder (TMD) patients would be significantly greater than healthy individuals. Eight masticatory muscle pain patients without disc interference disorders (DID) and 30 patients with DID along with 41 matched control subjects were included in the study. The resting EMG activities of sternocleidomastoid and trapezius muscles were recorded with a portable EMG machine. Pain intensities described over the muscles were recorded with a 100 mm visual analogue scale. The two groups of patients had significantly higher resting activities compared with control subjects. Patients (in both groups) who had pain in sternocleidomastoid and trapezius muscles reported significantly higher resting activities in the respective muscles than patients who were free of pain and the controls. The presence of pain over the examined muscles showed significant association with the myogenous TMDs without DID. The observed association of the cervical muscles with myogenous TMDs is expected to be a result of functional link between masticatory and cervical muscles. The present findings suggest that the myogenous TMDs without DID could be a distinct sub-group that can be a part of broader regional or generalized diseased entity.

Oral psoriasis in an 11-year-old child: a case report.

Psoriasis is a chronic inflammatory dermatosis that very rarely involves the oral mucosa. There is no consistent pattern of clinical presentation in the oral cavity. Furthermore, manifestations of intraoral psoriasis in paediatric patients are extremely rare and only one case appeared to have been reported in the literature to date. In this paper we report a case of intraoral psoriasis in an 11-year-old child who had been previously diagnosed as having dermal psoriasis.

Effects of hormonal contraceptives on the periodontium, in a population of rural Sri-Lankan women.

AIMS: Women using hormonal contraceptives can be considered to be a 'risk group' for periodontal disease, due to prolonged, sustained serum levels of oestrogens and progesterone. This investigation aims to study the effects of hormonal contraceptives on periodontal tissues. METHODS: 32 women using hormonal contraceptives for less than 2 years, 17 for 2-4 years and a matched control group of 39 non-users were selected for the study. They were clinically examined for plaque levels (plaque index: PLI), gingival condition (gingival index: GI) and loss of periodontal attachment (LA). RESULTS: Contraceptive users of less than 2 years and 2-4 years duration (n=32, n= 17 respectively) and non-users (n=39) had similar oral hygiene levels; yet the contraceptive users had a significantly higher level of gingival inflammation, compared to the non-users (p<0.001; 1-way ANOVA). Usage of hormonal contraceptives for 2-4 years (n= 17) caused a significantly higher LA (p<0.001) compared to that of controls (n=39). CONCLUSIONS: Usage of contraceptive preparations containing oestrogen and progesterone resulted in hormonal changes similar to those seen in pregnancy, associated with increased prevalence of gingivitis. There was significantly higher LA with prolonged usage of hormonal contraceptives, compared with controls.

Periodontal disease status during pregnancy and 3 months post-partum, in a rural population of Sri-Lankan women.

OBJECTIVES: The aim of this investigation was to study the effects of pregnancy on the periodontium, in a rural population of Sri-Lankan women. METHODS: The study group consisted of 47 pregnant women and 47 non-pregnant women who served as matched controls. All subjects were examined for plaque (plaque index: PLI), gingival condition (gingival index: GI) and loss of periodontal attachment (LA) levels, 4 x during the study, at 3-monthly intervals. RESULTS: Despite similar scores for plaque levels in both pregnant and non-pregnant women, the GI of pregnant women was significantly increased, during the 1st and 2nd trimesters compared to the controls (p<0.01, 2-way ANOVA). During the 3rd trimester, GI was further increased (p<0.001), but dropped at 3 months post-partum. Values for LA did not show significant differences from that of controls, during any of the stages of pregnancy. CONCLUSIONS: The results of this study show that pregnancy had an effect only on the gingivae and not on periodontal attachment levels. The effects of oestrogen and progesterone could give rise to a more florid response to the irritant effects of plaque, resulting in severe gingivitis.

Low prevalence of expression of p53 oncoprotein in oral carcinomas from Sri Lanka associated with betel and tobacco chewing.

Overexpression of p53 oncoprotein has been demonstrated in a wide range of human malignancies. We have examined the p53 expression amongst 38 Sri Lankan subjects with histologically confirmed oral squamous cell carcinomas. The mean age of the subjects was 59.4 years and betel chewing with tobacco was the most common habit (84%) with a high percentage of patients smoking (63%). Buccal mucosa was the most frequently affected site (68%) with a high proportion (79%) of well differentiated carcinomas. p53 expression was examined by standard immuno-histochemical methods on frozen sections using monoclonal antibodies PAb 1801, 240 and 421. Only 4 (11%) carcinomas showed nuclear reactivity mostly in random clusters of basal neoplastic cells. The low frequency of p53 expression could be due to deletion of both alleles or to premature truncated protein products due to nonsense mutations resulting in loss of antibody recognition sites. Alternatively the much lower prevalence than reported by others could be due to differences in aetiological agents and/or genetic predisposition of this population.

Iron deficiency reduces cytochrome concentrations of mitochondria isolated from hamster cheek pouch epithelium.

The effects of iron deficiency on the aerobic pathway of energy metabolism were studied using mitochondria isolated from epithelial cells from the hamster cheek pouch. A statistically significant reduction in the concentrations of cytochromes aa3, b and c (P less than 0.05), a reduction (P = 0.064) in cytochrome cl and altered cytochrome ratios were found in the mitochondria of iron deficient compared to normal animals. State 4 respiration was demonstrated in the mitochondria of both normal and iron deficient animals but state 3 respiration could not be demonstrated; this suggests uncoupling of oxidative phosphorylation which may be an artefact associated with the separation of epithelium from its connective tissue. Nevertheless we conclude that the reduction in cytochrome concentration is a real effect of iron deficiency which may explain, at least in part, the reduction of both energy production and cell proliferation seen in oral epithelia under these conditions.

Iron deficiency depresses cell proliferation in hamster cheek pouch epithelium.

Iron deficiency anaemia was induced in hamsters by feeding a low iron diet coupled with weekly bleeding. To assess cell proliferation, the stathmokinetic agent vinblastine sulphate was administered and cell birth rates were calculated from cumulative mitotic indices. The rate was significantly reduced in epithelium from iron-deficient animals. The uptake of tritiated thymidine [( 3H]TdR) was also significantly reduced in these animals. Results of both stathmokinetic and labelling experiments indicate that cell production in the cheek pouch epithelium of iron-deficient animals is impaired.

Lipid composition of cohesive and desquamated corneocytes from mouse ear skin.

An organ culture system has been used to examine differences in the lipid compositions of materials derived from cohesive and desquamated mouse ear stratum corneum. Within this culture system, skin explants display rates of cell replication and differentiation comparable to those observed in vivo for up to 2 weeks and, during this period, loosened or dishesive material accumulates at the surface. Lipid compositions were determined for both intact and loosened stratum corneum derived from cultured skin and also for freshly prepared stratum corneum. In all 3 cases, the profiles of the nonpolar lipids and the ceramides were essentially the same; some of the nonpolar lipids appeared to be of sebaceous origin. The only changes detected upon desquamation were reductions of cholesteryl sulfate and a second unidentified lipid of similar polarity. Cholesteryl sulfate constitutes 4-5% of the polar lipid in fresh stratum corneum or stratum corneum from organ culture. This is reduced to 0.4% in the desquamated material which accumulates in the culture system. The unidentified lipid decreases from 1-2% of the polar lipid in intact fresh or cultured stratum corneum to 0.1% in the desquamated material. The possible function of cholesteryl sulfate in corneocyte cohesion is discussed.

Effects of iron deficiency on respiration of hamster cheek-pouch epithelium in vitro.

Iron-deficiency anaemia was induced in hamsters by feeding a low-iron diet coupled with weekly bleeding. Respiration, assessed by measuring oxygen uptake, was significantly reduced (p less than 0.002) in cheek-pouch epithelia from iron-deficient animals. To relate data on oxygen consumption to cell numbers, the cell densities of the basal and maturation compartments were measured. The cell density of the maturation compartment in iron-deficient animals was significantly reduced (p less than 0.05), whereas that of the basal cell compartment was marginally higher than in control animals. However, the cell density of the tissue as a whole was similar in both groups. Thus, the reduced oxygen consumption in iron deficiency was not due to a reduction in cell numbers. Although there was a significant reduction in epithelial volume in the iron-deficient group, this was not sufficient to account for the reduced oxygen uptake in cheek-pouch epithelia from these animals. It is concluded that iron-deficiency anaemia affects cell respiration directly, probably by interfering with the amounts and/or functions of iron-containing enzymes or cytochromes in the electron-transport chain.

Experimental iron deficiency in Syrian hamsters (Mesocricetus auratus).

An animal model was developed in which the effect of iron deficiency on the oral mucosa could be studied. Iron deficiency was induced by feeding hamsters a low-iron powdered diet together with withdrawal of 0.5 ml of blood weekly, for a period of 9 weeks. At the end of this period the mean haematological values for control animals were, Hb 15.9 g/dl, plasma iron 40.3 mumol/l, TIBC 90.5 mumol/l and transferrin saturation 44.5%, compared with 7.4, 7.2, 111.4 and 6.5 respectively for experimental animals. These results were reproducible in successive groups of animals and indicate that this is a useful model for the study of iron deficiency anaemia.

Oral mucosal changes in iron deficiency anemia in a Sri Lankan female population.

The oral mucosal changes in iron deficiency anemia were studied in a selected hospital population. A high incidence of oral lesions was present in the anemic group as compared to age- and sex-matched controls. Atrophic changes of the tongue were quite characteristic clinically, and a significant reduction in the mean epithelial thickness of the buccal mucosa was determined histologically.