Characteristics, management and outcome of stroke: Observations from the Sri Lanka Stroke Clinical Registry.

BACKGROUND: Stroke registries are pivotal to the monitoring and improvement of the quality of stroke care. We report data from the initial phase of a nationally representative hospital-based stroke registry in Sri Lanka. METHODS: Based on an observational cohort design, all consecutive patients aged ≥18 years with a diagnosis of stroke or transient ischemic attack (TIA) presenting to six tertiary-care hospitals in the Western, Eastern, Southern, Northern and Central provinces of Sri Lanka within 14 days of onset were recruited. RESULTS: During a period of 14 months, 5893 patients with a stroke/TIA (58.8% men; mean age 65.22 years, SD=13.28) were entered into the database; 69.8% (n=4111) had an ischaemic stroke (IS); 20.9% (n=1233) had a haemorrhagic stroke (HS); 7.2% (424) had a TIA; and 2.1% (125) had a venous stroke. While IS were more common among women (71.7% vs 68.4%; p=0.006), HS were more common among men (22.3% vs 19.0%; p=0.003). Hemiparesis (86.2% vs 83.2%; p=0.011), headache (29% vs 11.6%; p<0.001), seizures (5.9% vs 4.2%; p=0.013), sphincter dysfunction (11.8% vs 7.7%; p<0.001) and hypertension (72% vs 67.3%, p=0.002) were more common in HS while dysphasia (63.2% vs 50.0%; p<0.001), ataxia (9.6% vs 7.3%; p=0.014), sensory disturbances (10.8% vs 6.0%; p<0.001) and diabetes mellitus (37.9% vs 28.1%; p<0.001) were more common in IS. Thrombolysis was administered in only 2.1% while only 14.6% had access to stroke units. The mean door-to-needle time was 100.2 (SD=46.0) minutes. The hospital mortality rate was 8.3%. Recurrent strokes within three months were more common in HS than IS (3.2% vs 1.6%; p=0.007). CONCLUSIONS: While stroke characteristics in Sri Lanka are similar to that of other populations, the rate of thrombolysis and access to stroke units are inadequate. The stroke registry provides useful data for the appraisal and improvement of stroke services.

Validation of the Sri Lankan Health-Related Quality-of-Life Index for pre-schoolers (SLHQL-P) and school age (SLHQL-S) children with epilepsy.

INTRODUCTION: Health-related quality of life (HRQL) in children and adolescents remains an underappreciated problem in Asian region, due to lack of culturally sound HRQL measures. This paper describes the validation process of two age-specific, proxy-rated HRQL indexes namely Sri Lankan Health-Related Quality-of-Life Index for preschoolers (SLHQL-P) and school age children (SLHQL-S) with epilepsy. METHODS: Primary caregivers of children and adolescents with epilepsy aged 1-18 years from three districts in Sri Lanka were invited to fill the SLHQL-P (for 1-5 years) and SLHQLS (for 6-18 years). It was re-administered to a subset of consenting primary caregivers after an interval of two weeks. Scientific soundness of SLHQL-P and SLHQL-S were established based on causal indicator model. RESULTS: Total of 98 and 169 primary caregivers responded to SLHQL-P, SLHQL-S respectively. Final questionnaires of SLHQL-P and SLHQL-S consists of 26, 57 items respectively in three multi-item domains measuring the child's physical functioning (6, 9 items), psychological functioning (6, 31 items) and social functioning (14, 17 items) with higher scores reflecting better HRQL. Construct validity was established by several methods including strong relationship with seizure severity. Good test-retest reliability was also demonstrated for both SLHQL-P and SLHQL-S (r = 0.77, 0.938) CONCLUSIONS: Both SLHQL-P and SLHQL-S are feasible, reliable and valid instruments to measure HRQL in children and adolescents with epilepsy in clinical as well as research settings in Sri Lanka.

Determinants of quality of life among people with dementia: evidence from a South Asian population.

BACKGROUND: Dementia has become a public health priority along with population aging worldwide. Owing to its chronic progressive nature in the absence of a cure, maintaining the best possible quality of life (QOL) has become the desired outcome for people with dementia (PWD). AIM: The current study aimed to determine the factors associated with 'good QOL' in people with dementia in the Sri Lankan setting. METHODS: An unmatched case-control study was conducted to identify the factors associated with 'good QoL. Cases in the study included dementia patients having 'good' QOL, whereas controls were those having 'poor' or 'average' QOL. Both cases and controls were selected from the same patient base at a premier tertiary care state hospital in Colombo District, Sri Lanka. They were identified using the validated DEMQOL (Dementia Specific Quality of Life) tool, adhering to strict eligibility criteria. An interviewer-administered questionnaire was used to assess the associated factors. Bivariate analysis followed by logistic regression modelling determined the associated factors for 'good QOL' adjusted for confounders using odds ratio (OR) and 95% confidence interval (CI). RESULTS: The study sample consisted of 64 cases and 208 controls. After adjusting for confounders, education up to GCE O/Level and above (OR = 4.02; 95% CI = 2.97, 12.0), ever employed (OR = 3.21; 95% CI = 1.59, 11.06), good social functioning (OR = 4.14; 95% CI = 3.39, 16.46), mild functional impairment (OR = 1.77; 95% CI = 1.13, 9.67), little or no caregiver burden (OR = 2.96; 95% CI = 1.86, 10.94), absence of apathy (OR = 2.22; 95% CI = 1.27, 12.48) and absence of irritability (OR = 2.17; 95% CI = 1.72, 10.34) were found to be significantly associated with 'good QOL'. 60% of the variance of 'good' QOL among PWD was explained by the factors in the final model. CONCLUSIONS AND RECOMMENDATIONS: The identified determinants of 'good QOL' clearly show how the QOL improvement interventions need to be planned. Accordingly, such programmes should be primarily focused on strategies to improve PWDs' ADL (Activities of Daily living), reduce and manage neuropsychiatric symptoms effectively and to promote activities enhancing social functioning, and plan programmes to address caregiver burden.

Assessment of resilience levels among Sri Lankan nurses: Is there room for improvement?

BACKGROUND: Developing resilience at work is an effective primary preventive measure for occupational stress. The study aimed to adopt a tool and measure current resilience levels and determine the association of work-related characteristics on resilience among Sri Lankan nurses. METHODS: Translated, culturally adapted and validated Resilience at Work Scale- Sinhala version (RAW-S) was used to measure resilience levels in a sample of 855 government nurses from a health district. The mean RAW-S scores were calculated and appropriate cut off points were used to determine the prevalence of 'high', 'moderate' and 'low' resilience. Chi square test was used to determine the associations. RESULTS: The overall mean RAW-S score was 69.6 (95% CI = 68.9-70.3) and the scores ranged from 28.5 to 90.3. Only 28.4% (95% CI = 25.4-31.6) of nurses showed 'high' level of resilience at work, while 55.6% (95% CI = 52.1-58.9) & 16.0% (95% CI = 13.7-18.7) had shown 'moderate' and 'low' levels of resilience respectively. The resilience levels differed significantly (p < 0.05) by type of ward that they work and by work experience. CONCLUSIONS: This was the first study that examined the resilience levels in any health care worker category in Sri Lanka. The need of targeted, well-designed resilience building programme for ever burdened government sector nurses is clearly shown from the results, as more than two thirds of nurses had 'moderate' or 'low' level of resilience, which may not be good enough to combat the constant work stress they face on daily basis.

Baseline iron and low-grade inflammation modulate the effectiveness of iron supplementation: evidence from follow-up of pregnant Sri Lankan women.

PURPOSE: We evaluated the effectiveness of iron supplementation in relation to baseline iron and inflammatory status of pregnant women and their offspring in Sri Lanka. METHODS: Apparently healthy women aged 18-36 years at < 12 weeks of gestation prior to receiving any supplementation were randomly recruited at the antenatal clinics. They received 60 mg of elemental iron in combined iron-folic acid pills from 12 weeks of gestation until delivery via the National Maternal Supplementation Programme. Serum ferritins (SF), hemoglobin and high-sensitive C-reactive protein (hs-CRP) were assessed. The women were grouped as iron sufficient-inflammation (+), iron sufficient-inflammation (-), iron deficient-inflammation (+) and iron deficient-inflammation (-) based on their baseline iron stores and low-grade inflammation (hs-CRP > 5 < 10 mg/L) at baseline and late pregnancy. RESULTS: Despite supplementation, SF in the iron sufficient-inflammation (+) women reduced significantly (p = 0.037) to deficiency state (SF < 30 µg/L) at mid-pregnancy. Whereas no significant changes were noted in the SF in iron sufficient-inflammation (-) women (p > 0.05). They maintained their stores at sufficient state until delivery. The cord SF was higher (p < 0.001) in iron sufficient-inflammation (-) than the inflammation (+) women. 96.4% of the iron deficient women remained deficient until delivery regardless of their inflammatory state. Low-grade inflammation was higher (p < 0.001) in women with baseline BMI > 25 kg/m2. Whereas inflammation at late pregnancy was higher (p < 0.001) in women who gained weight in excess of the recommended, regardless of their baseline BMI. CONCLUSION: Iron status prior to supplementation and low-grade inflammation associated with BMI > 25 kg/m2 and excess weight gain during pregnancy appear to modulate the effectiveness of iron supplementation.

Quality of life at 6 years in children treated for West syndrome with hormonal therapy.

INTRODUCTION: West syndrome is a severe epileptic encephalopathy occurring in infancy. Majority of affected children suffer from poor epilepsy control in later life and are dependent on care-givers for daily living. There is no previous study evaluating the Quality of Life (QOL) in children suffered from WS. METHOD: A prospective cohort study was performed at six years in a group of children with West syndrome, followed up in the Sri Lanka Infantile Spasm Study (SLISS). The quality of life was evaluated using Sri Lankan Health-Related Quality-of-Life Index for school children (SLHRQ-S), an age-specific, primary caregiver proxy-rated, validated questionnaire for Sri Lankan children with epilepsy. Information on epilepsy, medication, and daily activities was obtained from the parents. RESULTS: Fifty parents of initial 97 children treated for WS participated. The majority had no ongoing epilepsy (56%) at time of evaluation. The mean QOL was 67.22 (SD 15.68). Mean QOL scores for individual domains showed that physical domain was the worst affected (58.51 (SD = 22.11)). Psychological and social function domains were 68.73 (SD = 17.74) and 75.2 (SD = 14.87), respectively. Male sex (0.02), using multiple anti-seizure medications (0.00) and lower ILAE epilepsy control scale (0.02) were significantly associated with a poor quality of life. Age at onset, delay in treatment, and early spasm control were among the factors that did not influence quality of life. CONCLUSION: Despite having control of their epilepsy in the majority, these children suffered from poor quality of life. The greater impact on the physical domain possibly is related to the effect of underlying pathologies.

The understanding, acceptability, and relevance of personalised multidimensional physical activity feedback among urban adults: evidence from a qualitative feasibility study in Sri Lanka.

BACKGROUND: Wearable technologies are being used to provide personalised feedback across multiple physical activity dimensions in countries such as the UK, but their feasibility has not been tested in South Asia, where physical inactivity is increasing. This study assessed the understanding, acceptability, and relevance of personalised multidimensional physical activity feedback in urban dwellers in Colombo, Sri Lanka. METHODS: A qualitative feasibility study was conducted among 35 adults to assess a community-based approach to provide multidimensional physical activity feedback. Healthy adults, adults at risk of non-communicable diseases and community-based primary healthcare professionals wore a physical activity monitor for 7 days and were then guided through their personalised multidimensional physical activity feedback. One-to-one interviews were conducted, transcribed verbatim and analysed using framework analysis. RESULTS: Four themes were generated: understanding of personalised physical activity feedback, perceived novelty of the feedback, motivation, and consideration of the multidimensional nature of physical activity. A majority of participants required guidance initially to understand the feedback, following which most were quickly able to interpret the data shown, and were willing to use the feedback as a basis for identifying goals to improve physical activity. Participants perceived the feedback and its delivery as novel because it provided new knowledge about physical activity guidelines and awareness on their own behaviour through graphics. Comparisons of personal performance against recommended physical activity levels and information on sedentary time were the most commonly motivating aspects of the feedback, prompting talk about behaviour change. All three groups showed poor planning on goal achievement, with some noticeable differences between those with and without health risk of non-communicable diseases. Following the feedback, most participants understood that physical activity is composed of several dimensions, while around half could recognise more suitable options to change behaviour. Of the physical activity dimensions, calorie burn received more attention than others. CONCLUSIONS: Multidimensional physical activity feedback was considered understandable and acceptable and has the potential to support behaviour change among urban Sri Lankans with or without identified health risk. These findings highlight the feasibility of this technology-enabled approach as a personalised intervention to improve knowledge and motivation for physical activity behaviour.

Knowledge and attitudes about end-of-life decisions, good death and principles of medical ethics among doctors in tertiary care hospitals in Sri Lanka: a cross-sectional study.

BACKGROUND: Competent end-of-life care is an essential component of total health care provision, but evidence suggests that it is often deficient. This study aimed to evaluate the knowledge and attitudes about key end-of-life issues and principles of good death among doctors in clinical settings. METHODS: A cross-sectional study was conducted among allopathic medical doctors working in in-ward clinical settings of tertiary care hospitals in Sri Lanka using a self-administered questionnaire with open- and close-ended questions as well as hypothetical clinical scenarios. Univariate and logistic regression analysis were used to identify the independent factors associated with knowledge and attitudes. RESULTS: Of the responders who had not been a caregiver for a terminally ill relative (n = 390), 57.9% were men with a mean age of 36.5 years (SD = 8.2). Compared to undergraduate (65.6%; n = 256), only 27.4% (n = 107) had received end-of-life care training at postgraduate level. Only 65.9% of doctors favoured disclosing terminal prognosis to patients; 27.7% of doctors were aware of advance directives; 14.6% were aware of the correct time of death when certifying brain death; 70.3% felt more comfortable in withholding than withdrawing life-sustaining treatment; 61.3% were aware of do-not-attempt cardiopulmonary resuscitation (DNACPR) decisions while 26.7% felt reluctant to administer it; 15.1% thought that all life-sustaining therapy should be withdrawn with a DNACPR decision; and only17.9% were able to name the four principles of medical ethics while 57.9% could not name a single. Participants scored a mean of 9.2 (SD = 3.9) of a maximum 14 points when tested on principles of a 'good death'. Doctors who had pursued postgraduate studies were more likely to be aware of breaking bad news (adjusted-Odds-Ratio:1.99; 95%CI = 1.19-3.32), advance directives (adjusted-OR: 4.15; 95%CI = 2.49-6.94), aware of certifying the correct time of death (adjusted-OR:2.37; 95%CI = 1.33-4.2) and less reluctant to make DNACPR decisions (adjusted-OR:1.74; 95%CI = 1.13-2.68). Doctors who had worked in ICU were more comfortable withholding than withdrawing treatment (adjusted-OR:1.99; 95%CI = 1.2-3.31). CONCLUSIONS: Knowledge and attitudes about end-of-life care, good death and principles of medical ethics among doctors in Sri Lanka were suboptimal. Structured training of end-of-life care needs to be integrated within curricula and in-service training.

In depth analysis of the association of FTO SNP (rs9939609) with the expression of classical phenotype of PCOS: a Sri Lankan study.

BACKGROUND: PCOS is a common disorder of women due to genetic, endocrine and environmental effects that manifests from puberty. The rs9939609 variant of fat mass and obesity associated (FTO) gene is linked to metabolic derangement in PCOS. We previously identified FTO (rs9939609) as a susceptibility locus for PCOS among Sri Lankan women and also explored the role of kisspeptin. Associated factors of the FTO candidate gene among South Asians with PCOS are unknown. METHODS: This study aimed to determine the association between FTO (rs9939609) polymorphism with clinical (BMI, acanthosis nigricans, hirsutism) and biochemical (serum kisspeptin and testosterone levels) characteristics of PCOS in a cohort of Sri Lankan women. Genetic and clinical data including serum kisspeptin and testosterone concentrations of our previously reported cases (n = 55) and controls (n = 110) were re-analyzed, specifically for an association with rs9939609 variant of FTO gene. RESULTS: Logistic regression analysis (AA - OR = 5.7, 95% CI = 2.41-13.63, p < 0.05) and genetic inheritance analysis (AA - OR = 5.49, 95%CI = 2.34-12.88, p < 0.05) showed that FTO (rs9939609) polymorphism is significantly associated with PCOS and its metabolic manifestations. Serum testosterone was significantly higher in affected women with mutant genotypes (AA+AT) than with the normal allele (TT) (p < 0.05). Although serum kisspeptin was higher in subjects with PCOS and mutant alleles than controls, this difference was not significant (p > 0.05). CONCLUSION: FTO gene variant rs9939609 is associated with hyperandrogenemia and metabolic manifestations of PCOS among women of Sri Lankan descent with the well-characterized phenotype. Serum kisspeptin and the FTO genotypes lack a significant association when adjusted for confounders.

Quality of life and its determinants among community re-integrated soldiers with permanent disabilities following traumatic limb injuries.

PURPOSE: To assess health-related-quality of life (HRQOL) after the end of war and its associated factors among soldiers with permanent limb disabilities in Sri Lanka METHODS: A cross-sectional study was conducted among 500 rehabilitated and socially re-integrated Army soldiers having permanent disability following traumatic limb injuries during the last year of ethnic conflict of Sri Lanka. Females, soldiers with no updated data, and soldiers having permanent deafness/total blindness/total brain or spinal cord injury were excluded. The sample was randomly selected from updated 'Disabled Category Registries'. Personal and injury data were collected through postal questionnaire. HRQOL was assessed using SF-36 tool validated for Sri Lankan soldiers. RESULTS: SF-36 scores obtained on HRQOL related to overall physical health (mean = 57.1; SD = 19) and mental health (mean = 58.8; SD = 17.2) were comparable. HRQOL was best in social functioning (mean = 73.4; SD = 24) and worst in vitality (mean = 48.4; SD = 15.5). Factors significantly associated with better HRQOL related to the overall physical and mental health were aged over 35 years, being married, being assigned duties, having only upper/lower limbs affected and absence of co-disability. Having duties assigned demonstrated better QOL in almost all domains. None were associated with income or education. CONCLUSIONS: Physical and mental health components contribute equally to the HRQOL of rehabilitated soldiers with permanent limb disabilty. Their poorer HRQOL was determined by certain person- and injury-related factors. These need to be addressed during re-integration and post-rehabilitation services.

Knowledge of Stroke, Its Warning Symptoms, Risk Factors and Treatment among the General Public and General Practitioners in a South Asian Population.

BACKGROUND: An adequate stroke literacy among the general public and first-contact physicians is an essential prerequisite to ensure timely treatment and prevention of stroke. Knowledge on stroke pathophysiology, warning symptoms, risk factors and treatment, and its determinants was assessed among general public and general practitioners (GPs) in a South Asian population. METHODS: A cross-sectional study was conducted among relatives of nonstroke patients admitted to the apex tertiary-care hospital in Sri Lanka. Trained doctors administered pretested, structured, open- and close-ended questionnaires. A postal survey using self-administered questionnaires was conducted among all registered GPs in Sri Lanka. RESULTS: The sample of general public (51.7% males; mean age = 40.7 years) from 21 of 25 districts of Sri Lanka was 840 (response-rate = 97.4%) while the sample of GPs (77.6% males; mean age = 59.63 years) was 98 (response-rate = 30%). Of the general public, 83.2% were aware of a vascular aetiology of stroke, but only 46.8% were aware that the affected organ was the brain while 67.5% believed that either the heart or limb muscles die as sequalae of stroke. Over 50% correctly identified stroke warning symptoms while 84.7% would seek immediate Western medical treatment. Approximately, 32%-46% were not aware of the major stroke risk factors. Lower education (adj. OR = 1.7; 95% CI = 1.3-2.3), absence of stroke risk factors (2.6; 1.9-3.7) and nonutility of information sources (1.5; 1.0-2.0) determined poor knowledge on risk factors. Only about 1 in 8 GPs accurately defined stroke and TIA while only 43.9% correctly classified stroke subtypes. Only 1 in 10 GPs were aware of the recommended therapeutic window for thrombolysis. Older age (P = 0.01) and longer service (P = 0.04) of GPs were associated with not requesting brain imaging in stroke. CONCLUSIONS: Strategies to educate both the public and first-contact physicians to improve stroke literacy need to be an integral part of programmes that aim to reduce the burden of stroke in any population.

High resilience leads to better work performance in nurses: Evidence from South Asia.

AIM: To find out how resilience level is related to work performance of nurses. BACKGROUND: Resilience is a developable and teachable skill which helps to recover from adversities and continue functioning above the norm. Though combating negative effects at work such as burnout is widely researched, harnessing positive organisational effects such as work performance through resilience is yet to be well-established. METHODS: Cross-sectional study enrolled 230 nurses from Sri Lanka. The level of resilience at work and performance were assessed using culturally adapted and validated tools. How each resilience subscale predicted the nursing performance was assessed using bivariate correlation and linear regression analysis using ordinary least squares method. RESULTS: The total resilience scale score demonstrated significant and strong positive correlations with all subdomains of nursing performance, as well as with overall performance (p < .05). In linear regression model, six out of seven subscales in resilience scale predicted 70.5% of variance of work performance. CONCLUSION: Higher resilience level at work is associated with better working performance among nurses. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing profession is well-known to be of highly stressful and fostering resilience would be extremely useful as an investment to combat such negative effects, while yielding positive organisational benefits such as better work performance.

Developmental profile at initial presentation in children with infantile spasms.

AIM: To describe the baseline developmental profile and influence of clinical and demographic factors on the developmental skills of infants diagnosed with infantile spasms. METHOD: Ninety-five infants (55 males, 40 females) newly diagnosed with infantile spasms were recruited for a cross-sectional, longitudinal study. All infants underwent Bayley Scales of Infant and Toddler Development assessments in the cognitive, receptive communication, expressive communication, and fine and gross motor developmental domains; they also underwent visual, auditory, and social behaviour assessments. Infants were categorized as 'early' (<6mo) or 'late' (≥6mo) presenters; if presented within 28 days, this was considered as 'early presentation', whereas a delay greater than 28 days was considered as a 'delay in presentation'. Antenatal, perinatal, and postnatal risk factors were identified. RESULTS: Over 90% of infants showed impairment in all domains, with the majority having severe delay; 99% showed cognitive impairment. Delayed presentation was significantly associated with receptive communication delay (odds ratio [OR]=5.35; 95% confidence interval [CI]=1.05-27.32). Onset at 6 months or less influenced auditory (OR=2.8; 95% CI=1.16-6.8) and visual (OR=3.03; 95% CI=1.22-7.57) behaviours. Neonatal infections impacted both receptive (OR=1.12; 95% CI=1.04-1.2) and expressive communication (OR=1.08; 95% CI=1.02-1.14) delay. Neonatal seizures significantly influenced visual, auditory, and social impairments. Expressive communication and gross motor development shared common perinatal risk factors. INTERPRETATION: Adverse developmental status at presentation, associated with delayed presentation and neonatal risk factors should alert clinicians to the surveillance of at-risk infants and seek out timely interventions. WHAT THIS PAPER ADDS: Ninety per cent of infants showed impaired cognitive, communication, and motor skills at presentation. Visual, auditory, and social behaviour impairments were significantly associated with perinatal risks. Visual, auditory, and social behaviour impairments were significantly associated with neonatal seizures.

PERFIL DE DESARROLLO DURANTE LA PRESENTACIÓN INICIAL DE LOS ESPASMOS INFANTILES EN NIÑOS: OBJETIVO: Describir el perfil de desarrollo basal y la influencia de factores clínicos y demográficos sobre las habilidades de desarrollo en niños diagnosticados con espasmos infantiles. METODO: Se reclutaron 95 niños recientemente diagnosticados con espasmos infantiles en una corte transversal, de un estudio longitudinal. Se realizaron Escalas de Bayley (Bayley Scales of Infant and Toddler Development) para el desarrollo de lactantes y preescolares a todos los niños, evaluando cognición, comunicación receptiva, comunicación expresiva, y los dominios del desarrollo motor, grueso y fino; también se sometieron a evaluaciones visuales, auditivas y de comportamiento social. Los niños fueron clasificados como presentación Temprana'(< 6 meses) o Tardía (≥ 6 meses); si los espasmos se presentaron dentro de los primeros 28 días, se consideró como presentación temprana, mientras que un retraso mayor de 28 días fue considerado como un retraso en la presentación. Se identificaron los factores de riesgo prenatales, perinatales y postnatales. RESULTADOS: Más del 90% de los lactantes mostró discapacidad en todos los dominios, la mayoría con retraso severo; 99% mostró deterioro cognitivo. El retraso en la presentación está significativamente asociado con retraso en la comunicación receptiva (razón de probabilidades [OR]= 5,35; 95% intervalo de confianza [CI]= 1,05-27,32). El inicio a los 6 meses o menos influenció en el comportamiento auditivo (OR = 2,8; 95% CI = 1,16-6,8) y visual (OR = 3,03; 95% CI = 1,22-7,57). Las infecciones neonatales impactaron tanto en el retraso de la comunicación receptiva (OR = 1,12; 95% CI=1,04-1,2) como en la expresiva (OR =1,08; 95% CI = 1,02-1,14). Las convulsiones neonatales influenciaron significativamente en discapacidades visuales, auditivas, y sociales. La comunicación expresiva y el desarrollo motor grueso tuvieron factores de riesgo perinatales comunes. INTERPRETACIÓN: Un estado de desarrollo adverso al momento de la presentación de espasmos infantiles, asociado con un retraso en la presentación y los factores de riesgo neonatal deben alertar a los clínicos a la vigilancia de niños en riesgo y buscar intervenciones oportunas.

PERFIL DE DESENVOLVIMENTO NA APRESENTAÇÃO INICIAL EM CRIANÇAS COM ESPASMOS INFANTIS: Xxx. OBJETIVO: Descrever o perfil de desenvolvimento inicial e a influência de fatores clínicos e demográficos nas habilidades do desenvolvimento de crianças diagnosticadas com espasmos infantis. MÉTODO: Noventa e cinco lactentes diagnosticados com espasmos infantis foram recrutados para um estudo transversal longitudinal. Todas as crianças foram submetidas a avaliações pela Escala Bayley de Desenvolvimento para bebes e crianças nos domínios Cognitivo, comunicação receptiva e expressiva, e desenvolvimento motor fino e grosso; eles também foram submetidos a avaliações: visual, auditivo e comportamento social. Os bebês foram categorizados como "precoces" (<6 m) ou "atrasados" (≥6 m); se apresentada no prazo de 28 dias, foi considerado como "precoces", enquanto que superior a 28 dias foi considerado como "atrasados". Fatores de risco pré-natais, perinatais e pós-natais foram identificados. RESULTADOS: Mais de 90% dos lactentes apresentaram comprometimento em todos os domínios, sendo a maioria com atraso grave; 99% apresentaram comprometimento cognitivo. A apresentação tardia foi significativamente associada ao atraso na comunicação receptiva (odds ratio [OR] = 5,35; intervalo de confiança de 95% [IC] = 1,05-27,32). O início aos 6 meses ou menos influenciou os comportamentos auditivos (OR = 2,8; 95% IC = 1,16-6,8) e visuais (OR = 3,03; IC95% = 1,22-7,57). As infecções neonatais impactaram no atraso na comunicação receptiva (OR = 1,12; 95% IC = 1,04-1,2) e expressiva (OR = 1,08; 95% IC = 1,02-1,14). As convulsões neonatais comprometeram significativamente as áreas: visual, auditiva e social. Comunicação expressiva e desenvolvimento motor grosso ambos demostraram fatores de risco perinatais comuns. INTERPRETAÇÃO: O estado de desenvolvimento adverso, associado à atraso na apresentação e fatores de risco neonatais devem alertar os clínicos para a vigilância de bebês de risco e buscar intervenções oportunas.

Changes in quality of life following initial treatment of oesophageal carcinoma: a cohort study from Sri Lanka.

BACKGROUND: Oesophageal carcinoma is one of the leading cancers in Sri Lanka. Recent advances in treatment modalities have drastically improved the survival of these patients. However, the quality of life (QoL) among the survivors needs to be reviewed in order to recognise the need for advocating more focussed rehabilitation for oesophageal carcinoma in Sri Lanka. METHODS: A prospective cohort study was conducted among 51 incident cases of oesophageal carcinoma recruited consecutively from the National Cancer Institute, Maharagama. Data were collected on their QoL using EORTC QLQ-C30 and EORTC-OES18 questionnaires validated for Sri Lankan oesophageal carcinoma patients, before and one month after the completion of initial treatment. Scoring was based on the EORTC manual. Comparison of baseline and follow-up scores was done using paired t test at significance level of 0.05. RESULTS: Response rate was 80%. The majority consisted of squamous cell carcinoma of stage IV. On a scale of 0-100, the overall QoL (mean score = 49.8; SD = 22); and role (42.2; SD = 34), physical (53.1; SD = 29), emotional (53.4; SD = 26) and social (57.2; SD = 23) functioning were relatively low at diagnosis. The scores of functioning scales further deteriorated (difference > 5 points) following the initial treatment (p < 0.05). Dysphagia (mean = 54; SD = 27) was the main symptom at diagnosis, which improved significantly (p < 0.05) in contrast to dry mouth (mean = 39.2; SD = 34) that worsened (p < 0.05) following initial treatment. Family support and financial difficulties were adversely affected (p < 0.05) during the initial treatment. CONCLUSIONS: The deterioration of several dimensions of QoL of oesophageal carcinoma patients following the initial treatment highlights the need for more targeted tertiary preventive strategies that address the issues identified.

Novel risk factors for primary prevention of oesophageal carcinoma: a case-control study from Sri Lanka.

BACKGROUND: Oesophageal carcinoma (OC) is one of the leading cancers in Sri Lanka. Its increasing incidence despite the implementation of various preventive activities addressing the conventional risk factors indicates the possibility of the existence of novel, country-specific risk factors. Thus, the identification of novel risk factors of OC specific to Sri Lanka is crucial for implementation of primary prevention activities. METHODS: A case-control study was conducted among 49 incident cases of OC recruited from the National Cancer Institute, Maharagama using a non-probability sampling method, and unmatched hospital controls (n = 196) excluded of having OC recruited from the endoscopy unit of the National Hospital of Sri Lanka. Data were collected using an interviewer administered questionnaire. Risk factors for OC were assessed by odds ratio (OR) with 95% confidence interval (CI). The risk factors were adjusted for possible confounding by logistic regression analysis. RESULTS: Of the study population, OC was common among males (69%) and the majority presented with squamous cell carcinoma (65%) at late stages (Stage IV: 45%; Stage III: 37%). Following adjusting for confounders, the risk factor profile for OC included; age > 65 years (OR = 4.0; 95% CI: 1.2-14.2); family history of cancer (OR = 5.04; 95% CI: 1.3-19.0); sub-optimal consumption of dietary fibre (OR = 3.58; 95% CI: 1.1-12.3); sub-optimal consumption of anti-oxidants (OR = 7.0; 95% CI: 2.2-22.5); over-consumption of deep fried food (OR = 6.68; 95% CI:2.0-22.6); 'high risk' alcohol drinking (OR = 11.7; 95% CI: 2.8-49.4); betel quid chewing (OR = 6.1; 95% CI: 2.0, 20.0); 'low' lifetime total sports and exercise activities (MET hours/week/year) (OR = 5.83; 95% CI: 1.5-23.0); agrochemicals exposure (OR = 6.57; 95% CI: 1.4-30.3); pipe-borne drinking water (OR = 5.62; 95% CI:1.7-18.9) and radiation exposure (OR = 4.64; 95% CI: 1.4-15.5). Significant effect modifications were seen between betel quid chewing and male sex (p = 0.01) and between ever exposure to radiation and age over 65 years (p = 0.04). CONCLUSIONS: Risk profile for OC includes novel yet modifiable risk factors in relation to diet, occupation, environment and health. Primary prevention should target these to combat OC in Sri Lanka.

Development of outcome criteria to measure effectiveness of antiepileptic therapy in children.

PURPOSE: Clinical trials of antiepileptic drugs frequently measure outcomes of seizure control, which demonstrate efficacy. Yet, functional status, quality of life, and long-term treatment effects reflecting effectiveness are scarcely assessed. We sought to use a consensus method to help identify which outcome criteria key stakeholders consider should be used to measure effectiveness in trials of antiepileptic treatments for children. METHOD: A two-round Delphi survey was used; parents of children with epilepsy and local, international experts comprising academics and clinicians participated in the survey. In the first round, 32 experts, 50 parents, and 15 children with epilepsy aged >13years suggested outcomes that they considered important in determining effectiveness of antiepileptic therapy in children, separately for preschool and school age. In the second round, 29 experts and 42 parents scored the importance of outcomes from the list suggested by at least 10% of round 1 respondents and also proposed five most important outcomes. RESULTS: Complete seizure freedom (67%), seizure frequency (48%), ability to perform normal day-to-day activities (45%), and quality of life (40%) were identified as the most important outcomes of antiepileptic therapy in children of both age groups. Additionally, effect on developmental milestones (47%) and child's compliance to treatment regimen (39%) were identified as most important in preschool age group and school performance (49%); adverse effects (39%) were identified as most important in school age group. CONCLUSION: For the first time, this study has identified outcome priorities regarding antiepileptic treatment in children based on the key stakeholders' perspectives. It could be used as a provisional list of outcomes for inclusion in a core outcome set for children with epilepsy.

Viral aetiologies of acute encephalitis in a hospital-based South Asian population.

BACKGROUND: The aetiological spectrum of acute encephalitis shows inter- and intra-geographical variations. We aimed to identify the viruses that cause infectious encephalitis in Sri Lanka, which represents a South Asian population. METHODS: A cross-sectional study was conducted among 99 patients with encephalitis/meningoencephalitis admitted to two tertiary-care hospitals in Colombo. Cerebrospinal fluid and serum were tested for conventional and emerging encephalitogenic viruses. Specific nucleic acid amplification and antibody assays were used to identify viruses. Plaque reduction neutralization test was done to confirm the diagnosis of West Nile virus (WNV). RESULTS: Patients' age ranged from 1 month to 73 years (mean = 24.91; SD = 21.33) with a male:female ratio of 1.75:1. A viral aetiology was identified in only 27.3%. These included dengue virus (40.7%), Japanese encephalitis virus (25.9%), varicella zoster virus, WNV and probable Epstein Barr virus (11.1% each). None were positive for herpes simplex viruses or cytomegalovirus. Screening for bacterial aetiologies was negative for all patients. There were no distinguishable clinical or laboratory findings between the different viral aetiologies. The case fatality rate was 7%, which was higher among patients with an identified viral aetiology. CONCLUSIONS: A viral aetiology was identified in only about a quarter of patients with encephalitis. Dengue virus accounted for the majority.

Risk of unsafe abortion associated with long-term contraception behaviour: a case control study from Sri Lanka.

BACKGROUND: When faced with an unintended pregnancy, some women choose to undergo an unsafe abortion, while others do not. This choice may depend on long-term contraception that shapes the fertility goals of women, along with many other risk factors. We assessed the risk for unsafe abortion associated with contraceptive practices based on women's long-term behaviour, and its likely modification by the use of different types of contraceptives among women in Sri Lanka. METHODS: An unmatched case-control study was conducted in nine hospitals among 171 women admitted for care following an unsafe abortion (Cases) and 600 women admitted to same hospitals for delivery of an unintended term pregnancy (Controls). Interviewer-administered-questionnaires assessed their socio-economic, reproductive and fertility (decisions on family size, family completion) characteristics, contraceptive method last used (traditional, modern), reasons for discontinuation/never-use, and contraceptive practices assessed at different time points. Using several regression models, the risk of abortion was assessed for 'non-use' of contraception against 'ineffective use' at conception; for non-use further categorised as 'never-use', 'early-discontinuation' (discontinued before last birth interval) and 'late-discontinuation' (discontinued during last birth interval); and for any interaction between the contraceptive practice and contraceptive method last used among the ever-users of contraception. RESULTS: At conception, 'non-use' of contraception imparted a two-fold risk for abortion against ineffective use (adjusted-OR = 2.0; 95% CI: 1.2-3.2). The abortion risk on 'non-use' varied further according to 'early' (adjusted-OR = 1.7; 95% CI: 1.1-3.1) and 'late' (adjusted-OR = 2.3; 95% CI: 1.5-3.6) discontinuation of contraception, but not with 'never-use' (crude-OR = 1.1; 95% CI: 0.6-2.3). Among the ever-users, the risk of abortion varied within each contraceptive practice by their last used contraceptive method and reasons for discontinuation. A significant interaction between modern contraceptives and early discontinuation (adjusted-OR = 1.4; 95% CI = 1.1-3.1) demonstrated a seven-fold abortion risk for early discontinuation of modern methods against its ineffective use. In particular, hormonal methods seemed to be responsible for this risk (51.1% cases versus 42.5% controls). CONCLUSIONS: Long-term contraceptive practices showed varying risk for abortion, and was further modified by early discontinuation of modern contraceptives. This knowledge should be applied during postnatal visits by public-health staff.

Use of food labels by adolescents to make healthier choices on snacks: a cross-sectional study from Sri Lanka.

BACKGROUND: Unhealthy snacking is commonly seen among adolescents. Therefore, use of food labels is promoted for making healthier choices on packaged snacks. This study was conducted to assess the use of food labels in making choices on packaged snack and its associated factors among adolescents. METHODS: A cross-sectional study was conducted in 2012 among 542 Grade 12 students in Sri Lanka. Eight classes were selected as 'clusters' for the study (two classes each from two schools that were selected randomly from each list of 'Girls only' and 'Boys only' schools in Colombo district). A self-administered questionnaire assessed their socio-demography, snacking behaviour, attitudes and nutrition knowledge related to food labels. Adolescents' use of labels was assessed by three practices (label reading frequency, attention paid to label contents and correct interpretation of six hypothetical labels of snacks). Based on total scores obtained for the three practices, 'satisfactory' (score ≥75(th) percentile mark) and 'unsatisfactory' (score <75(th) percentile mark) label users were identified. Using SPSS, associations were assessed at 0.05 significance level using Chi-square-test. RESULTS: Of the participants, 51 % were males; 61 % spent their pocket money at least once/week on packaged snacks; predominantly on biscuits (85 %) and cola-drinks (77 %) and 88 % selected snacks on their own. The majority (74.5 %) was frequent ('always' or 'most often') label readers with female predominance (p < 0.05). Over 74 % paid attention frequently to the brand name (75 %), price (85 %) and nutrition panel (81 %). Over 64 % were able to select the better food label when given a choice between two snacks, although some did it for reasons such as attractive label (63 %). The majority (84 %) had good knowledge (obtaining more than the 75(th) percentile mark) on interpreting labels. Although not statistically significant, 'unsatisfactory' label use was higher among males (73 %), purchasing power (70.4 %) and unhealthy snacking behaviour (73 %). In contrast, among the marketing strategies, identifying known brands (73.2 %) and imported products (75.8 %) as 'good' products were significantly associated with 'unsatisfactory' label use (p < 0.05). CONCLUSIONS: Despite having good knowledge and positive attitudes, food label use is unsatisfactory among adolescents. Skills in reading labels should be addressed in the 'School canteen policy' in Sri Lanka.

Relationship of family formation characteristics with unsafe abortion: is it confounded by women's socio-economic status? - A case-control study from Sri Lanka.

BACKGROUND: Literature shows that choice for unsafe abortion is often driven by poverty. However, factors related to the family formation behaviour of women are also implied as determinants of this decision. This study assessed which family formation characteristics of women are associated with the risk of unsafe abortion, without being confounded by their low socio-economic status among Sri Lankan women admitted to hospital following post-abortion complications. METHODS: An unmatched case-control study was conducted in nine hospitals in eight districts in Sri Lanka among 171 women with post-abortion complications following unsafe abortion (Cases) and 600 postpartum mothers admitted to same hospitals during the same period for delivery of term unintended pregnancies (Controls). Interviewer-administered-questionnaires obtained demographic, socio-economic and family formation related characteristics. Risk factors of abortion were assessed by odds-ratio (OR), adjusted for their socio-economic status in logistic regression analysis. RESULTS: Low socio-economic status, characterised by low-education (adjusted OR = 1.5; 95 % CI = 1.1-2.4) and less/unskilled occupations (2.3; 1.4-3.6) was a significant risk factor for unsafe abortion. Independent of this risk, being unmarried (9.3; 4.0-21.6), failure in informed decisions about desired family size (2.2; 1.4-3.5), not having a girl-child (2.2; 1.4-3.4) and longer average birth intervals (0.7 years; 0.6-0.8) signified the vulnerability of women for unsafe abortion. Cases were as fast as the controls in their family completion (4.3 versus 4.5 years; p = 0.4), but were at increased risk for abortion, if their average birth intervals (including the last one) were longer. Previous contraceptive use, age at reproductive events or partners' characteristics did not impart any risk for abortion. CONCLUSIONS: Low socio-economic status is not the most influencing risk factor for unsafe abortions leading to complications, but many other factors in relation to their family formation characteristics that are independent of their low socio-economic status.