Quality of life and its associated factors among home-dwelling older people residing in the District of Colombo, Sri Lanka: a community-based cross-sectional study.

INTRODUCTION: This community-based cross-sectional study explored the factors affecting overall and domain-specific (physical health, psychological health, social relationships and environmental) quality of life (QOL) of home-dwelling older residents of the District of Colombo, Sri Lanka. METHODS: A representative sample (n=723) of older adults aged >65 years was obtained by the multistage cluster sampling technique. QOL was assessed using the validated Sinhala version of WHOQOL BREF Questionnaire. Data analysis was done using SPSS V.20. RESULTS: The mean±SD age was 72.23±6.3 years with the overall QOL score being (mean±SD) 56.73±12.57/100. The mean±SD QOL score of physical health, psychological health, social relationships and environmental domains were 55.81±15.80, 59.25±14.68, 46.36±20.08 and 64.61±11.96, respectively. The overall QOL in the adjusted model showed a significant positive association with the educational status, living conditions (with spouse, with spouse and children), participation in religious activities, being visited by friends or relatives and financial independence. The overall QOL was negatively associated with limitations in activities of daily living and instrumental activities of daily living, chronic arthritis and heart disease in the adjusted model. Living with the spouse was positively associated with the psychological domain of QOL. Osteoporosis and chronic arthritis affected the physical health domain, while cancer and disabling stroke affected the psychological domain of QOL negatively. All statistical significances were considered at p<0.05. CONCLUSION: The overall QOL of home-dwelling elders of the Colombo District is moderate, with the lowest score being in social relationships and the highest in the environmental domain. Educational status, engaging in religious activities and financial independence are key factors associated with a better QOL. Limitations in physical activity and chronic diseases are associated with a reduced QOL. Living with the spouse is a key factor associated with the psychological health domain.

Sporadic miscarriage: evidence to provide effective care.

The physical and psychological effect of miscarriage is commonly underappreciated. The journey from diagnosis of miscarriage, through clinical management, to supportive aftercare can be challenging for women, their partners, and caregivers. Diagnostic challenges can lead to delayed or ineffective care and increased anxiety. Inaccurate diagnosis of a miscarriage can result in the unintended termination of a wanted pregnancy. Uncertainty about the therapeutic effects of interventions can lead to suboptimal care, with variations across facilities and countries. For this Series paper, we have developed recommendations for practice from a literature review, appraisal of guidelines, and expert group discussions. The recommendations are grouped into three categories: (1) diagnosis of miscarriage, (2) prevention of miscarriage in women with early pregnancy bleeding, and (3) management of miscarriage. We recommend that every country reports annual aggregate miscarriage data, similarly to the reporting of stillbirth. Early pregnancy services need to focus on providing an effective ultrasound service, as it is central to the diagnosis of miscarriage, and be able to provide expectant management of miscarriage, medical management with mifepristone and misoprostol, and surgical management with manual vacuum aspiration. Women with the dual risk factors of early pregnancy bleeding and a history of previous miscarriage can be recommended vaginal micronised progesterone to improve the prospects of livebirth. We urge health-care funders and providers to invest in early pregnancy care, with specific focus on training for clinical nurse specialists and doctors to provide comprehensive miscarriage care within the setting of dedicated early pregnancy units.

Recurrent miscarriage: evidence to accelerate action.

Women who have had repeated miscarriages often have uncertainties about the cause, the likelihood of recurrence, the investigations they need, and the treatments that might help. Health-care policy makers and providers have uncertainties about the optimal ways to organise and provide care. For this Series paper, we have developed recommendations for practice from literature reviews, appraisal of guidelines, and a UK-wide consensus conference that was held in December, 2019. Caregivers should individualise care according to the clinical needs and preferences of women and their partners. We define a minimum set of investigations and treatments to be offered to couples who have had recurrent miscarriages, and urge health-care policy makers and providers to make them universally available. The essential investigations include measurements of lupus anticoagulant, anticardiolipin antibodies, thyroid function, and a transvaginal pelvic ultrasound scan. The key treatments to consider are first trimester progesterone administration, levothyroxine in women with subclinical hypothyroidism, and the combination of aspirin and heparin in women with antiphospholipid antibodies. Appropriate screening and care for mental health issues and future obstetric risks, particularly preterm birth, fetal growth restriction, and stillbirth, will need to be incorporated into the care pathway for couples with a history of recurrent miscarriage. We suggest health-care services structure care using a graded model in which women are offered online health-care advice and support, care in a nurse or midwifery-led clinic, and care in a medical consultant-led clinic, according to clinical needs.

Effectiveness of Low-dose Ethinylestradiol/Cyproterone Acetate and Ethinylestradiol/Desogestrel with and without Metformin on Hirsutism in Polycystic Ovary Syndrome: A Randomized, Double-blind, Triple-dummy Study.

BACKGROUND: The effectiveness of different combined oral contraceptive pills and metformin in reducing hirsutism in patients with polycystic ovary syndrome (PCOS) remains unclear. OBJECTIVE: We sought to determine the effects of ethinylestradiol (35µg)/cyproterone acetate (2mg) (EE/CPA) and ethinylestradiol (20µg)/desogestrel (0.15mg) (EE/DES), alone or with metformin, on hirsutism in PCOS. METHODS: A randomized, double-blind, triple-dummy study was conducted on women with PCOS and hirsutism (N=107) who received one of four drug combinations (Arm A: EE/CPA; Arm B: EE/DES; Arm C: EE/CPA plus metformin; or Arm D: EE/DES plus metformin). Hirsutism was assessed at baseline, six months, and 12 months by using five outcomes variables. RESULTS: No outcomes variable showed a significant difference between the four arms at 12 months. There was a significant reduction in both hair density and modified Ferriman-Gallwey score (mFGS) in Arm A, mFGS in Arm B, hair density in Arm C, and diameter of sideburn hair in Arm D, respectively. Separately, there was a significant increase noted in the hair growth rate of chin and an improvement in patients' perceptions of hirsutism in all four study arms. CONCLUSION: EE/CPA and EE/DES were equally effective in improving hirsutism in PCOS, with no added benefit from low-dose metformin. Sri Lanka Clinical Trials Registry (http://www.slctr.lk) registration no. SLCTR/2015/007.

Association of Kiss1 and GPR54 Gene Polymorphisms with Polycystic Ovary Syndrome among Sri Lankan Women.

Polycystic ovary syndrome (PCOS) is the commonest endocrine disorder affecting women of reproductive age. Its aetiology, though yet unclear, is presumed to have an oligogenic basis interacting with environmental factors. Kisspeptins are peptide products of Kiss1 gene that control the hypothalamic pituitary (HPG) axis by acting via G protein-coupled receptor known as GPR54. There is paucity of data on the role of Kiss1 and GPR54 gene in PCOS. We aimed to identify the polymorphisms in Kiss1 and GPR54 genes and explore their association with serum kisspeptin levels among Sri Lankan women with well-characterized PCOS. Consecutive women with PCOS manifesting from adolescence (n=55) and adult controls (n=110) were recruited. Serum kisspeptin and testosterone levels were determined by ELISA method. Whole gene sequencing was performed to identify the polymorphisms in Kiss1 and GPR54 genes. Serum kisspeptin and testosterone concentrations were significantly higher in women with PCOS than controls: kisspeptin 4.873nmol/L versus 4.127nmol/L; testosterone 4.713nmol/L versus 3.415 nmol/L, p<0.05. Sequencing the GPR54 gene revealed 5 single nucleotide polymorphisms (SNPs), rs10407968, rs1250729403, rs350131, chr19:918686, and chr19:918735, with two novel SNPs (chr19:918686 and chr19:918735), while sequencing the Kiss1 gene revealed 2 SNPs, rs5780218 and rs4889. All identified SNPs showed no significant difference in frequency between patients and controls. GPR54 gene rs350131 polymorphism (G/T) was detected more frequently in our study population. The heterozygous allele (AG) of GPR54 gene novel polymorphism chr19:918686 showed a marginal association with serum kisspeptin levels (p=0.053). Genetic variations in GPR54 and Kiss1 genes are unlikely to be associated with PCOS among Sri Lankan women manifesting from adolescence. Meanwhile the heterozygous allele of chr19:918686 is probably associated with serum kisspeptin concentrations, which suggests a potential role in the aetiology of PCOS.

Increased risk of obstructive sleep apnoea in women with polycystic ovary syndrome: a population-based cohort study.

OBJECTIVE: Obesity is very common in patients with obstructive sleep apnoea (OSA) and polycystic ovary syndrome (PCOS). Longitudinal studies assessing OSA risk in PCOS and examining the role of obesity are lacking. Our objective was to assess the risk of OSA in women with vs without PCOS and to examine the role of obesity in the observed findings. DESIGN: Population-based retrospective cohort study utilizing The Health Improvement Network (THIN), UK. METHODS: 76 978 women with PCOS and 143 077 age-, BMI- and location-matched women without PCOS between January 2000 and May 2017 were identified. Hazard ratio (HR) for OSA among women with and without PCOS were calculated after controlling for confounding variables using multivariate Cox models. RESULTS: Median patient age was 30 (IQR: 25-35) years; median follow-up was 3.5 (IQR: 1.4-7.1) years. We found 298 OSA cases in PCOS women vs 222 in controls, with incidence rates for OSA of 8.1 and 3.3 per 10 000 person years, respectively. Women with PCOS were at increased risk of developing OSA (adjusted HR = 2.26, 95% CI: 1.89-2.69, P < 0.001), with similar HRs for normal weight, overweight and obese PCOS women. CONCLUSIONS: Women with PCOS are at increased risk of developing OSA compared to control women irrespective of obesity. Considering the significant metabolic morbidity associated with OSA, clinicians should have a low threshold to test for OSA in women with PCOS. Whether OSA treatment has an impact on PCOS symptoms and outcomes needs to be examined.

Association between visceral adiposity index, hirsutism and cardiometabolic risk factors in women with polycystic ovarian syndrome: A cross-sectional study

Introduction: Visceral adiposity index (VAI) is a mathematical index derived from the body mass index (BMI), waist circumference (WC), serum fasting triglyceride (TG) and high-density lipoprotein cholesterol (HDL-C). It reflects visceral adipocyte dysfunction (VAD) and is associated with cardiometabolic risk. Women with polycystic ovarian syndrome (PCOS) have adipocyte dysfunction, which is associated with metabolic disorders. Hirsutism in PCOS is considered to be due to high insulin levels which enhances androgen activity at the pilosebaceous unit. Objectives: To determine the association between VAI, hirsutism and cardiometabolic risk factors in patients with PCOS. Methods: A total of 99 patients aged 18-40 years with PCOS diagnosed by the Rotterdam consensus criteria-2003 and a hirsutism score of 8 or more according to the Ferriman-Gallway Score (FGS) were studied. BMI, WC, fasting lipid profile, serum leptin, insulin, sex hormone binding globulin (SHBG), free-androgen index (FAI), fasting blood glucose (FBG) and oral glucose tolerance test (OGTT) were determined. Homeostasis model assessment (HOMA)-beta, HOMA-insulin resistance (IR) and VAI were calculated. Diameter and rate of hair growth at sideburns and chin; density of hair at sideburns were measured. Data were analyzed by SPSS-22.0. Results: There was no significant association between parameters of hirsutism and VAI. There was a significant association between VAI and OGTT, FAI, systolic and diastolic blood pressure: but not between VAI and other metabolic parameters. Conclusion: Visceral adipocyte dysfunction is closely linked to glucose intolerance and blood pressure in women with PCOS. However, hirsutism is unlikely to be due to adipocyte dysfunction.

Integrated Model of Care for Polycystic Ovary Syndrome.

Polycystic ovary syndrome (PCOS) affects approximately one in seven women worldwide from early adulthood with heterogeneity in their healthcare needs through the life cycle. PCOS is challenging to diagnose and manage, with one-third of women reporting at least a 2-year delay in diagnosis. Current clinical services do not satisfactorily educate and support women with their diverse reproductive, metabolic, and psychological care needs with fragmentation of services across health providers. Women are dissatisfied with the care they received, while the first contact general practitioners often feel ill-equipped to diagnose and manage PCOS. Despite national evidence-based guidelines recommending integrated multidisciplinary services, guideline translation has been limited, with wide practice variation and no optimal models of care. Lifestyle management and psychological support are the cornerstones of care and health providers who most commonly manage PCOS (general practitioners, dermatologists, endocrinologists, and gynecologists) require appropriate resources and multidisciplinary support. An evidence-based patient-centered clinical model of care, codeveloped by consumers and health professionals that provides education and resources and offers multidisciplinary holistic care, is vital to support women with PCOS.

Obstetric outcomes and effects on babies born to women treated for epilepsy during pregnancy in a resource limited setting: a comparative cohort study.

BACKGROUND: Management of epilepsy during pregnancy in a resource-limited setting (RLS) is challenging. This study aimed to assess obstetric outcomes and effects on babies of women with epilepsy (WWE) exposed to Anti-epileptic drugs (AEDs) compared to non-exposed controls in a RLS. METHODS: Pregnant WWE were recruited from antenatal and neurology clinics of a tertiary care hospitals in Sri Lanka. Patients were reviewed in each trimester and post-partum. Medication adherence, adverse effects, seizure control and carbamazepine blood levels were monitored. Post-partum, measurements for anthropometric and dysmorphic features of the babies and congenital abnormalities were recorded. Age and sex matched babies not exposed to AED recruited as controls were also examined. RESULTS: Ninety-six pregnant WWE were recruited (mean period of gestation 22.9 weeks). Mean age was 28 years and 48(50%) were primigravidae. Fifty percent (48) were on monotherapy, while 23.8, 15.9 and 4.1% were on two, three and four AEDs respectively. AEDs in first trimester (TM1) were carbamazepine (71%), valproate (25.8%) clobazam (29.5%), lamotrigine (7%) topiramate (5%) and others (3.4%). Sodium valproate use reduced significantly from T1 to T2(p < 0.05). Sub-therapeutic carbamazepine levels correlated positively (r = 0.547) with poor medication adherence (p = 0.009) and negatively (r = 0.306) with adverse effects (p = 0.002). Seventy-six WWE completed follow-up reporting w 75 (98.6%) live births and one T1 miscarriage (1.3%). Three (4.3%) were preterm. Majority (73.33%) were normal vaginal deliveries. Cesarean sections were not increased in WWE. Fifty-nine (61.45%) babies were examined. For those examined during infancy, 53 age and sex matched controls were recruited and examined.. Congenital abnormalities occurred in 5 (9.43%) babies of WWE [atrio-ventricular septal defect (2), renal hypoplasia (1), cryptorchidism (1), microcephaly (1)] compared to 2 (3.77%) in controls (2 microcephaly; p = 0.24). Fetal exposure to AEDs increased a risk of low birth weight (RR 2.8; p = 0.049). Anthropometric parameters of AED exposed babies were lower at birth but not statistically significant between the two groups (weight p = 0.263, length p = 0.363, occipito-frontal circumference (OFC) p = 0.307). However, weight (p = 0.009), length (p = 0.016) and OFC (p = 0.002) were significantly lower compared to controls at an average of 3.52 months. CONCLUSION: Most pregnancies are unplanned in the RLS studied, and AEDs were altered during pregnancy. Congenital anomalies occurred at rates comparable to previous reports. Fetal exposure to AED had growth retardation in infancy compared to non-exposed babies.

Polycystic ovary syndrome, androgen excess, and the risk of nonalcoholic fatty liver disease in women: A longitudinal study based on a United Kingdom primary care database.

BACKGROUND: Androgen excess is a defining feature of polycystic ovary syndrome (PCOS), which affects 10% of women and represents a lifelong metabolic disorder, with increased risk of type 2 diabetes, hypertension, and cardiovascular events. Previous studies have suggested an increased risk of nonalcoholic fatty liver disease (NAFLD) in individuals with PCOS and implicated androgen excess as a potential driver. METHODS AND FINDINGS: We carried out a retrospective longitudinal cohort study utilizing a large primary care database in the United Kingdom, evaluating NAFLD rates in 63,120 women with PCOS and 121,064 age-, body mass index (BMI)-, and location-matched control women registered from January 2000 to May 2016. In 2 independent cohorts, we also determined the rate of NAFLD in women with a measurement of serum testosterone (n = 71,061) and sex hormone-binding globulin (SHBG; n = 49,625). We used multivariate Cox models to estimate the hazard ratio (HR) for NAFLD and found that women with PCOS had an increased rate of NAFLD (HR = 2.23, 95% CI 1.86-2.66, p < 0.001), also after adjusting for BMI or dysglycemia. Serum testosterone >3.0 nmol/L was associated with an increase in NAFLD (HR = 2.30, 95% CI 1.16-4.53, p = 0.017 for 3-3.49 nmol/L and HR = 2.40, 95% CI 1.24-4.66, p = 0.009 for >3.5 nmol/L). Mirroring this finding, SHBG <30 nmol/L was associated with increased NAFLD hazard (HR = 4.75, 95% CI 2.44-9.25, p < 0.001 for 20-29.99 nmol/L and HR = 4.98, 95% CI 2.45-10.11, p < 0.001 for <20 nmol/L). Limitations of this study include its retrospective nature, absence of detailed information on criteria used to diagnosis PCOS and NAFLD, and absence of data on laboratory assays used to measure serum androgens. CONCLUSIONS: We found that women with PCOS have an increased rate of NAFLD. In addition to increased BMI and dysglycemia, androgen excess contributes to the development of NAFLD in women with PCOS. In women with PCOS-related androgen excess, systematic NAFLD screening should be considered.

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.

The management of anovulatory infertility in women with polycystic ovary syndrome: an analysis of the evidence to support the development of global WHO guidance.

BACKGROUND: Here we describe the consensus guideline methodology, summarise the evidence-based recommendations we provided to the World Health Organisation (WHO) for their consideration in the development of global guidance and present a narrative review on the management of anovulatory infertility in women with polycystic ovary syndrome (PCOS). OBJECTIVE AND RATIONALE: The aim of this paper was to present an evidence base for the management of anovulatory PCOS. SEARCH METHODS: The evidence to support providing recommendations involved a collaborative process for: (i) identification of priority questions and critical outcomes, (ii) retrieval of up-to-date evidence and exiting guidelines, (iii) assessment and synthesis of the evidence and (iv) the formulation of draft recommendations to be used for reaching consensus with a wide range of global stakeholders. For each draft recommendation, the methodologist evaluated the quality of the supporting evidence that was then graded as very low, low, moderate or high for consideration during consensus. OUTCOMES: Evidence was synthesized and we made recommendations across the definition of PCOS including hyperandrogenism, menstrual cycle regulation and ovarian assessment. Metabolic features and the impact of ethnicity were covered. Management includes lifestyle changes, bariatric surgery, pharmacotherapy (including clomiphene citrate (CC), aromatase inhibitors, metformin and gonadotropins), as well as laparoscopic surgery. In-vitro fertilization (IVF) was considered as were the risks of ovulation induction and of pregnancy in PCOS. Approximately 80% of women who suffer from anovulatory infertility have PCOS. Lifestyle intervention is recommended first in women who are obese largely on the basis of general health benefits. Bariatric surgery can be considered where the body mass index (BMI) is ≥35 kg/m2 and lifestyle therapy has failed. Carefully conducted and monitored pharmacological ovulation induction can achieve good cumulative pregnancy rates and multiple pregnancy rates can be minimized with adherence to recommended protocols. CC should be first-line pharmacotherapy for ovulation induction and letrozole can also be used as first-line therapy. Metformin alone has limited benefits in improving live birth rates. Gonadotropins and laparoscopic surgery can be used as second-line treatment. There is no clear evidence for efficacy of acupuncture or herbal mixtures in women with PCOS. For women with PCOS who fail lifestyle and ovulation induction therapy or have additional infertility factors, IVF can be used with the safer gonadotropin releasing hormone (GnRH) antagonist protocol. If a GnRH-agonist protocol is used, metformin as an adjunct may reduce the risk of ovarian hyperstimulation syndrome. Patients should be informed of the potential side effects of ovulation induction agents and of IVF on the foetus, and of the risks of multiple pregnancy. Increased risks for the mother during pregnancy and for the child, including the exacerbating impact of obesity on adverse outcomes, should also be discussed. WIDER IMPLICATIONS: This guidance generation and evidence-synthesis analysis has been conducted in a manner to be considered for global applicability for the safe administration of ovulation induction for anovulatory women with PCOS.

Creating a pro-active health care system to combat chronic diseases in Sri Lanka: the central role of preventive medicine and healthy lifestyle behaviors.

INTRODUCTION: The current burden and future escalating threat of chronic diseases, constitutes the major global public health challenge. In Sri Lanka, cardiovascular diseases account for the majority of annual deaths. Data from Sri Lanka also indicate a high incidence and prevalence of pre-diabetes and diabetes; 1 in 5 adults have elevated blood sugar in Sri Lanka. It is well established that chronic diseases share four primary behavioral risk factors: 1) tobacco use; 2) unhealthy diet; 3) physical inactivity; and 4) harmful use of alcohol. AREAS COVERED: Evidence has convincingly shown that replacing these behavioral risk factors with the converse, healthy lifestyle characteristics, decrease the risk of poor outcomes associated with chronic disease by 60 to 80%. In essence, prevention or reversal of these behavioral risk factors with effective healthy lifestyle programing and interventions is the solution to the current chronic disease crisis. Expert commentary: Healthy lifestyle is medicine with global applicability, including Sri Lanka and the rest of the South Asia region. This policy statement will discuss the chronic disease crisis in Sri Lanka, its current policies and action implemented to promote healthy lifestyles, and further recommendations on preventive medicine and healthy lifestyle initiatives that are needed to move forward.

Ethnic-specific polycystic ovary syndrome: epidemiology, significance and implications.

Being the most common endocrinopathy of young women, polycystic ovary syndrome has much variation in its clinical expression based on ancestry. Ethnic differences of the phenotype are closely linked to its complex pathophysiology. This paper reviews data of the past three decades ensuring a precise diagnosis and taking into account underlying factors, effects of migration including heterogeneity, and diversity within each identified ethnic group. Differing expressions of hyperandrogenism, obesity, insulin resistance and metabolic manifestations of polycystic ovary syndrome occur among women from distinct geographic locations and ancestry. These ethnic phenotypes correlate with their inherent metabolic risks, skin sensitivity to androgens and social outlook that particularly affects their quality of life and health-seeking behavior. It is recommended that such ethnic variations are recognized in routine clinical practice and longitudinal data be maintained to study the true impact of such differences on disease outcomes.

Acute acalculous cholecystitis due to dengue hemorrhagic fever during pregnancy.

A 29-year-old pregnant woman presented with fever, right hypochondrial pain and fatigability at 29 weeks of gestation. Dengue hemorrhagic fever was diagnosed based on clinical, hematological and serological features. However, ultrasound scanning was suggestive of acute acalculous cholecystitis. The patient was managed symptomatically and made a good recovery 8 days following onset of fever. This is the first case of acute acalculous cholecystitis coinciding with dengue hemorrhagic fever reported during pregnancy from an endemic country in Asia. The possible viral and host factors for the development of such a severe form of disease and preventive measures are discussed.

Phenotype and metabolic profile of South Asian women with polycystic ovary syndrome (PCOS): results of a large database from a specialist Endocrine Clinic.

BACKGROUND: Compared with other populations, South Asians have a greater propensity to insulin resistance and the metabolic syndrome (MetS). This is the first study to determine the distribution of phenotypes of polycystic ovary syndrome (PCOS) and their relationship to the MetS among indigenous South Asians. METHOD: An evaluation of the phenotype and metabolic characteristics of PCOS was conducted by recruiting consecutive women diagnosed by Rotterdam consensus criteria from an Endocrine clinic in Colombo, Sri Lanka. Prevalence of MetS was determined, in relation to the phenotypic subgroup of PCOS and compared with ethnically matched, BMI- and age-adjusted controls (n =231). RESULTS: Acanthosis nigricans (AN) occurred in 64.6% of women with PCOS (n= 469). MetS occurred in 30.6% of the PCOS group compared with 6.34% of controls (P = 0.0001). Those with PCOS and MetS had significantly higher median BMI, blood pressure (BP), fasting plasma glucose, insulin and triglycerides and lower high-density lipoprotein and sex hormone-binding globulin (SHBG), but similar testosterone concentrations compared with those with PCOS alone. Prevalence of MetS was similar in the four PCOS phenotypes, although oligomenorrhoeic women were more obese compared with the normal cycling hyperandrogenic group. Multivariate logistic regression confirmed age ≥35 years, BMI ≥25 kg/m(2) and AN as significant predictors of MetS in PCOS. Case-control comparisons showed that the presence of PCOS results in higher odds of having the MetS, a high waist circumference, elevated diastolic BP, abnormal fasting lipids and high fasting insulin and plasma testosterone concentrations. CONCLUSIONS: Young indigenous South Asians with PCOS have greater odds of being centrally obese, with a third having the MetS that bears no relationship to the androgenic phenotype. Significant predictors for MetS within the PCOS cohort are advancing age, obesity determined by the Asian cut off (BMI >25 kg/m(2)) and AN, while family history of diabetes, hyperandrogenism and elevated SHBG have no predictive value.

Dengue infections during pregnancy: a case series from Sri Lanka and review of the literature.

BACKGROUND: Dengue is a major public health problem in several countries. Few reports document presentations and outcomes of dengue during pregnancy. In many endemic countries as the average age of getting dengue infections is shifting upwards, dengue in pregnancy is likely to be encountered more frequently. Patterns of dengue in patients from different regions are needed if we are to draft evidence based management guidelines. OBJECTIVES: To document clinical and laboratory findings in a cohort of hospitalised patients with dengue during pregnancy in Sri Lanka and compare their presentation and outcomes with previously published cases. STUDY DESIGN: Clinical, laboratory, maternal and fetal outcomes and demographic information were collected from patients with confirmed dengue infections during pregnancy treated in a Maternity Hospital in Sri Lanka from 1 January 2000 to 30 June 2004. The Medline database was searched to identify reports relating to dengue infection during pregnancy since 1965. RESULTS: Twenty-six patients [mean (S.D.) age: 29 (4.2) years] were studied. One (3.8%), 2 (7.7%) and 20 (77%) presented in the first, second and third trimesters of pregnancy, and 3 (11.5%) in the immediate post-partum period. Seventeen (65.3%) had primary and nine (34.7%) secondary dengue infections. Ten (38.5%) had DF, 6 (23.1%): DHF grade I and 10 (38.5%): DHF grade II. Five (19.2%) and three (11.5%) patients who first presented with cough/breathlessness or vaginal bleeding, were initially managed as having a pulmonary embolism or a primary obstetric cause for their vaginal bleeding. Bradycardia was noted in three of the four patients who had a cardiac arrhythmia. Seven (26.9%) needed admission to an ICU. Raised AST and ALT levels were seen in 81.2% and 43.7% of 16 patients in whom liver function tests results were available. No fetal malformations were seen in any of the babies born. The single patient who developed DHF in the first trimester had an abortion while having acute symptoms of dengue. CONCLUSIONS: Awareness of clinical and laboratory manifestations of dengue in pregnancy should allow its early recognition and institution of appropriate treatment. Reports on dengue in pregnancy from different regions should allow more evidence-based guidelines to be formulated for optimum evaluation and care of such patients. Our data contributes towards this goal.