Low- Versus High-dose Cyclophosphamide in Class III/IV Lupus Nephritis: A Retrospective Study from South Asia.

Introduction: The comparative efficacy of low-dose cyclophosphamide (LD-CYC) and high-dose cyclophosphamide (HD-CYC) for treatment of lupus in South Asians is not well established. We aimed to compare treatment outcomes in South Asian patients with class III and IV lupus nephritis treated with either regimen. Method: This was a single-center, retrospective study conducted in Sri Lanka. Patients with biopsy-proven class III or IV lupus nephritis were recruited. The HD-CYC group was defined as having received ≥6 doses of 0.5-1 g/m2 cyclophosphamide (CYC) followed by quarterly doses. The LD-CYC group was defined as having received six doses of 500 mg CYC at two-weekly intervals. The primary outcome was treatment failure defined as persistent nephrotic range proteinuria or renal impairment at 6 months. Results: Sixty-seven patients were recruited (HD-CYC 34, LD-CYC 33), all South Asian ethnicity. The HD-CYC group had received treatment between 2000 and 2013, and the LD-CYC group from 2013 onward. The HD-CYC and LD-CYC groups had 30/33 (90.9%) and 31/34 (91.2%) females, respectively. Nephrotic syndrome and nephrotic range proteinuria on presentation were seen in 22/33 (67%) and 20/32 (62%) in the HD-CYC and LD-CYC groups, respectively, and renal impairment was seen in 5/33 (15%) of the HD-CYC group and 7/32 (22%) of the LD-CYC group (P > 0.05). Treatment failure and complete or partial remission occurred in 7/34 (21%) and 28/34 (82%), respectively, of HD-CYC and 10/33 (30%) and 24/33 (73%), respectively, of LD-CYC (P > 0.05). Adverse events rates were similar. Conclusion: This study suggests that LD-CYC and HD-CYC induction is comparable in South Asian patients with class III and IV lupus nephritis.

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.

Prevalence and associated factors of wheezing illnesses of children aged three to five years living in under-served settlements of the Colombo Municipal Council in Sri Lanka: a cross-sectional study.

BACKGROUND: A rising trend in Sri Lanka for asthma and wheezing illness is observed with higher morbidity in younger children and a paucity of related research. 'Under-served settlements' (USS) of Colombo Municipal Council (CMC) have poor living environments conducive to childhood wheezing. The objective was to describe the prevalence and associated factors of wheezing illnesses of three to five year old children living in low-income settlements in CMC. METHODS: A cross-sectional study was conducted on 460 three to five year old children and their caregivers using cluster sampling among residents of two randomly selected USSs of CMC. An interviewer-administered questionnaire, observation checklist and data extraction form were used in data collection. A physician's diagnosis of wheezing/whistling of the chest in their lifetime and a physician's diagnosis of wheezing/whistling within the past twelve months were considered as 'ever-wheezing illness' and 'current-wheezing illness' respectively. RESULTS: Mean age was 3.98 years (SD = ±0.64 years). A majority were males (51.3%) and Tamils (39.8%). Prevalence of 'ever wheezing illness' and 'current wheezing illness' were 38% (95% confidence interval (CI); 33.6%-42.5%) and 21.3% (95%CI; 17.6%-25.0%), respectively. Maternal (p < 0.001) and paternal (p < 0.001) histories of wheezing, playing with soft toys in the sleeping area (p = 0.004), place of cooking combined with the living area (p = 0.03), unsatisfactory ventilation in the sleeping area (p < 0.001) were found to be significantly associated with increased 'current wheezing' through multivariate analysis in this study. Use of formula milk before six months of age (p = 0.014) was found to be protective through multivariate analysis. CONCLUSIONS: The magnitude of wheezing illnesses among three to five year old children residing in urban low-income settlements was found to be high. Children with a history of maternal and/or paternal wheezing should be targeted for early interventions to prevent wheezing illnesses. Interventions to avoid exacerbations should focus on the indoor environmental factors that were found to be associated with wheezing illnesses.

Prevalence of knee osteoarthritis in a suburban, Srilankan, adult female population: a population-based study.

INTRODUCTION: Prevalence of knee osteoarthritis (KOA) has not been assessed in Sri Lanka, since 2006. This study aimed to determine the prevalence of clinical KOA and radiographic KOA and to assess the severity of it, among adult females of a suburban setting in Sri Lanka. METHODS: A cross-sectional survey was conducted among a representative sample of 666 females aged 50 years or more resident in Pita Kotte Medical Officer of Health area. Four physiotherapy graduates applied American College of Rheumatology (ACR) criteria by performing the clinical assessment in the households. Participants with clinical knee osteoarthritis were referred for radiography to identify radiographic osteoarthritis and to assess severity. Age standardized prevalence of clinical KOA for Sri Lanka was estimated based on population statistics of 2001 Census. RESULTS: Study included 666 adult females with a response rate of 99.4%. The mean age was 63.3 years (±9.29 years). A total of 134 were found to satisfy ACR criteria resulting in a crude prevalence of clinical KOA of 20.1% (95% CI 17.0%-23.2%). Estimated age standardized prevalence of clinical KOA for Sri Lanka was 21.8% (95% CI 21.7-21.9). Among those with clinical KOA 58.9% showed radiographic KOA and the prevalence of moderate/severe KOA among those with clinical KOA was 29.9%. CONCLUSION AND RECOMMENDATIONS: Prevalence of clinical KOA among the adult females over 50 years was high with considerable proportion of them being moderate /severe KOA. These findings should be used to advice the health authorities regarding improving preventive and curative services for KOA.

Healthy Lifestyle Centres: a service for screening noncommunicable diseases through primary health-care institutions in Sri Lanka.

The Ministry of Health in Sri Lanka initiated the Healthy Lifestyle Centres (HLCs) in 2011, to address the lack of a structured noncommunicable disease (NCD) screening service through the lowest level of primary health-care institutions. The main service objective of the HLCs is to reduce the risk of NCDs of 40-65 year olds by detecting risk factors early and improving access to specialized care for those with a higher risk of cardiovascular disease (CVD). The screened clients are managed at HLCs, based on the total-risk approach to assess their 10-year CVD risk, using the World Health Organization/International Society of Hypertension risk-prediction chart. Those with a 10-year CVD risk of more than 30% are referred to the specialized medical clinics, while others are managed with lifestyle modification and are requested to visit the HLC for rescreening, based on the levels of CVD risk and intermediate risk factors. Identified challenges to date include: underutilization of services, especially by men; weak staff adherence to protocols; lack of integration into pre-existing NCD-screening services; non-inclusion of screening for all the major NCDs; and human resources. The government plans to address these challenges as a priority, within the context of the National multisectoral action plan for the prevention and control of NCDs in Sri Lanka 2016-2020. Key interventions include: extended opening hours for HLCs, outreach activities in workplaces, and integration with "well woman clinics". Costs related to actions have been realistically estimated. Some actions have already been initiated, while others are being designed with identified funds.

Tobacco-promotional activities in rural Sri Lanka: a cross-sectional study of knowledge, exposure and responses among adolescent schoolchildren.

BACKGROUND: Tobacco promotions are linked to tobacco consumption in adolescents. The aim of this study was to determine knowledge of and exposure and responses to tobacco-promotional activities and factors associated with knowledge among adolescents in a rural setting in Sri Lanka. METHODS: Seven schools in Polonnaruwa district were randomly selected for this cross-sectional study. Adolescents (n = 500) aged 14-15 years in grade 10 were selected using convenience sampling and studied by using a self-administered questionnaire during June-October 2014. The questions on exposure to tobacco-promotional activities were based on the validated questionnaire of the Global Youth Tobacco Survey. Adolescents were categorized into two levels of knowledge, exposure and responses to tobacco promotions, based on the scores obtained. Selected factors associated with knowledge of tobacco promotions were assessed using univarate and multivariate analyses. RESULTS: The response rate was 99.6% (498/500). The mean age of the adolescents was 14.9 years (standard deviation ±0.37) and the proportion of females was slightly higher (n = 280, 56.2%) than for males. The prevalence of current smoking was 3.2% (n = 16). Half (48.6%, n = 242) of the adolescents had a good level of knowledge of tobacco-promotional activities. Most (64.9%, n = 323) had experienced a low level of exposure to tobacco-promotional activities, while 85.7% (n = 427) indicated that they had responded/would respond assertively to exposure to tobacco promotion. In the univariate analysis, having a mother with a high level of education (odds ratio [OR] 1.742), having a father with a high level of education (OR 1.997) and the student attending a type 1AB school (OR 1.310) were significant factors associated with a good level of knowledge of tobacco-promotional activities. A father with a high level of education (adjusted OR 1.772) and the student attending a type 1AB school (adjusted OR 1.455) were the factors associated with a good level of knowledge for tobacco-promotional activities, when confounding effects of the variables were taken into consideration. CONCLUSION: Knowledge of tobacco-promotional activities was poor among the adolescents in the rural setting in Sri Lanka. Nevertheless, most of the adolescents in the study population indicated that their responses to such exposures were/ would be assertive.

Personal and family attributes of pregnant teenagers: findings from a community-based study in Sri Lanka.

BACKGROUND: Teenage pregnancies are associated with negative outcomes. Prevention requires understanding them and their families. OBJECTIVES: This study aimed to describe personal and family attributes of pregnant teenagers in Sri Lanka. METHODS: This was a community-based study in Sri Lanka among 510 pregnant teenagers. RESULTS: Half (50%) of the subjects were 19 years of age at the time of pregnancy. A majority (79.8%) had studied up to grades 6-11. Confidence in decision-making (80.7%) and in refusing unnecessary requests (88.3%) was "excellent" in a majority. Mean age of marriage/co-habiting was 17.6 years. For 31%, marriage/cohabiting was a sudden decision taken jointly with their partner (81.6%) and 83% reported being "legally" married. Substantial proportions of mothers (17.6%) and fathers (13.9%) had not attended school, and 33.1% mothers had worked abroad. Teenagers reported the death of a parent (14.1%), parental separation (10.9%) and being brought up by relatives (20%). Only a few rated strictness of rules/regulations (32.4%), freedom to discuss problems regarding puberty (25.5%), love affairs (12.7%) and sexuality (26.7%) as excellent/good. Of the spouses, 12.9% were <20 years, 71.9% had low education and 98.8% were employed. A majority had "planned" the pregnancy, and for 79.8%, the reason was "husband's wish to have a baby". CONCLUSIONS: Pregnant teenagers were mostly in their late teens, from poor families and with low formal education. Though teenagers showed confidence in decision-making, the decision to have a pregnancy had mostly been their spouses. Parents and spouses of the teenagers were also young, less educated and poor. There was evidence of poor parenting practices.

Students' perception of school environment and life satisfaction at Sinhala-medium secondary schools in the Colombo District, Sri Lanka.

The objective of this study was to examine the associations between students' perception of physical and psychosocial school environment and satisfaction with life among secondary school students in Colombo District, Sri Lanka. Data were collected from 20 Sinhala-medium secondary schools between January and February in 2010. A questionnaire-based survey was conducted with students in grade seven (n = 342) and grade ten (n = 446). Multivariate logistic regression analysis, adjusted for confounding variables, was used to assess the associations between students'satisfaction with life measured by Cantril ladders, and scores of perceived physical and psychosocial school environment that focused on school cleanliness and attractiveness, relations with teachers and peers, satisfaction with school and bullying. Students in the highest quartile of school environment score were significantly more likely to have high life satisfaction, compared to those in the lowest quartile (adjusted odds ratio 2.32; 95% confidence interval 1.35-3.99). Odds ratio of high life satisfaction increased with increasing school environment scores (p for trend<0.001). In conclusion, students who perceived positive school environment were significantly more likely to have high life satisfaction. Positive changes in the focused areas of school environment have the potential to lead to improved life satisfaction of students.

Premenstrual syndrome: the experience from a sample of Sri Lankan adolescents.

SETTING: Government schools of Colombo. MAIN OUTCOME MEASURES: Premenstrual symptomatology (PMS) was determined by a modified version of Premenstrual Symptom screening tool and American College of Obstetricians and Gynecologists (ACOG) diagnostic criteria were used in categorizing study units as having PMS. Other outcome measures were demographic and reproductive factors thought to be correlates of PMS, health seeking behavior for premenstrual symptoms, and how premenstrual symptoms impact their daily life. RESULTS: Individual premenstrual symptoms were experienced by 65.7% of the population. The most common somatic symptom was fatigue (29.9%) and affective symptom was feeling sad/hopeless (29.6%). Prevalence of PMS was 8.75% (95%CI: 6.43-11.07). Multivariate analysis revealed the presence of: chronic physical illness (P = 0.001); dysmenorrhea (P < 0.0001), and regular menstrual cycles (P = 0.006) as correlates of PMS. Presence of PMS significantly disturbed "in school" activities, relationships and daily routines (P < 0.005) indicating a high negative influence on adolescents' daily life. Only 9.7% sought help from (western) medical practitioners for their premenstrual symptoms and a majority has not perceived it as a condition to report. CONCLUSION: Premenstrual syndrome is a common condition among adolescent schoolgirls with a high negative influence on their daily life. The health care seeking behavior is poor, indicating the necessity to address the subject at adolescent reproductive health programs.

Development of an instrument to measure patient perception of the quality of nursing care and related hospital services at the national hospital of sri lanka.

PURPOSE: This study aimed to develop and validate an instrument to measure patient perception of quality of nursing care and related hospital services in a tertiary care setting. METHODS: We compiled an instrument with 72 items that patients may perceive as quality of nursing care and related hospital services, following an extensive literature search, discussions with patients and care pro-I viders and a brainstorming session with an expert panel. A cross-sectional study was conducted at the National Hospital of Sri Lanka. A sample (n = 120) of patients stayed in general surgical or medical units responded to the interviewer administered instrument upon discharge. Item analysis and principal component factor analysis were performed to assess validity, and internal consistency was calculated to measure reliability. RESULTS: Of the 72 items, 18 had greater than 20% of responses as 'not relevant'. A further 11 items were eliminated since item-total correlations were less than .2. Factor analysis was performed on remaining 43 items which resulted in 36 items classifying into eight factors accounting for 71% of the variation. Factor loadings in the final solution after Varimax rotation were interpersonal aspects (.68-.85), efficiency (.62-.79), competency (.66-.68), comfort (.60-.84), physical environment (.65-.82), cleanliness (.81-.85), personalized information (.76-.83), and general instructions (.61-.78). The instrument had high Internal consistency (Cronbach's alpha = .91). CONCLUSION: We developed a comprehensive, reliable and valid, 36-item instrument that may be used to measure patient perception of quality of nursing care in tertiary care settings.