Hyperhomocysteinaemia in Sri Lankan patients with coronary artery disease

OBJECTIVE: To determine the association between hyperhomocysteinaemia and coronary artery disease (CAD) in a sample of Sri Lankans. DESIGN: A case control study. SETTING: Asiri Hospital, Kirula Road, Colombo 5, Sri Lanka. SUBJECTS: 105 patients with coronary artery disease and 112 controls. METHOD: Fasting serum homocysteine levels were measured in 105 patients diagnosed as having CAD and in 112 unmatched controls. All patients admitted with clinical, electrocardiographical, biochemical or echocardiographical evidence of CAD were included in the study. Controls were selected from subjects admitted for health screening. RESULTS: 105 patients with CAD and 112 controls (unmatched for age and sex) were studied. A serum homocysteine level in excess of 18.2 mumol/l was considered high. Confounding effects of other conventional risk factors for CAD were controlled using multivariate logical regression analysis. CONCLUSION: Hyperhomocysteinaemia is significantly associated with CAD. Multivariate logistic regression analysis indicated that the association between hyperhomocysteinaemia and CAD was confounded by other risk factors. However, statistical analysis revealed a significant independent association between hyperhomocysteinaemia and CAD (adjusted odds ratio = 2.881).     

Clinical features,risk factors and efficacy of cryotherapy in cutaneous leishmaniasis in Sri Lanka

INTRODUCTION: The first autochthonus case of cutaneous leishmaniasis in Sri Lanka was reported in 1992. Several case reports from different parts of the island have been documented. The case incidence has increased in the recent past. OBJECTIVES: To determine the clinical patterns, risk factors and efficacy of cryotherapy for cutaneous leishmaniasis in Sri Lanka. PATIENTS: Sixty-five patients with cutaneous leishmaniasis. DESIGN: Prospective study. SETTING: Department of Parasitology, Faculty of Medicine, Colombo. METHODS: Direct smears prepared from lesion aspirates or punch biopsies were stained and examined for Leishmania sp. All patients with positive smears were included in the study. A pre-designed questionnaire was completed based on clinical evaluation, and the patients were treated and followed up regularly. Investigations were repeated on day 14 and day 90 depending on the response to treatment. RESULTS: Lesions were non-tender, non-itchy papules (early lesions), scaling single nodules or dry crust forming single or multiple ulcers. Young adult males with outdoor behavioural characteristics were mostly affected. Other risk factors were close proximity to jungles, potential reservoir hosts in the environment, lack of awareness and inadequate knowledge and use of preventive measures. Compliance rate for cryotherapy was 40%. The need for frequent hospital visits, the long course of treatment, limited availability and undesirable side effects were identified as reasons for poor compliance. Smear positive rate on day 14 after treatment was 89%. CONCLUSIONS: Cutaneous leishmaniasis is now an established disease in Sri Lanka. Raising public awareness, early diagnosis, definite species identification, availability of proper treatment methods and vector studies are important for its effective control.     

Reducing tobacco use in Sri Lanka.

Tobacco use is steadily declining in wealthy countries, whereas it is increasing in poor countries. Approaches found successful in wealthy countries should be applied vigorously in Sri Lanka too. This requires sustained and active lobbying, especially by doctors. Some promising strategies are already being used in Sri Lanka which indicate that countries such as ours could develop appropriate local approaches in addition to those found useful in rich countries. These have evolved with little active support from the medical profession. If doctors actively complement these efforts, Sri Lanka could provide a model in successful smoking control for poor nations.     

Sri Lankan health care provision and medical education: a discussion

My elective was spent at a teaching hospital in Galle, in Sri Lanka. My time was spent shadowing final year students in the specialties of general medicine and paediatrics. This period provided me with much food for thought in comparing and contrasting the health service in Sri Lanka with that of the UK and also considering the differences in the style of medical education. In addition, during my stay, I was able to gain some appreciation of the political and organisational problems faced by a country in the midst of a civil war.In this report, I have attempted to integrate an account of my observations with a discussion of the thoughts and emotions that I experienced while working in a developing country. Studying in Sri Lanka facilitated my appreciation of facets of British health care and medical education that I had not previously considered. However, fewer resources do not necessarily mean poorer patient care: could Britain have something to learn from the Sri Lankan Health Service?     

Validity and reliability of Tamil version of Strengths and Difficulties Questionnaire self-report

BACKGROUND: Child and adolescent mental health services are scarce in Sri Lanka. Moreover there are no validated instruments to measure the mental health problems of Tamil speaking adolescents in Sri Lanka. Hence, strengths and difficulties questionnaire (SDQ) self-report was translated into Tamil and validated in the District of Jaffna, Sri Lanka. SDQ self-report was translated from English to Tamil using standard translation and back translation method. The Tamil version of the SDQ self-report was validated against a gold standard (ie. diagnosis made by a consultant psychiatrist). Both clinic and community samples were included in the validation study. Thirty-five adolescents (11-16 years) attending a psychiatric clinic and 91 adolescents from the community were included. The consultant psychiatrist made the diagnosis independent of the SDQ responses. Receiver operating characteristics (ROC) curve was used to measure the validity of SDQ. Reliability was measured using internal consistency. RESULTS: The ROC curve indicated high validity for the identification of adolescents with mental health problems: area under the curve 0.87 (95% - CI = 0.79-0.93). International cut-off point of 15 gave a sensitivity of 69.4% and specificity of 92.2%. Cronbach's alpha values (0.67-0.78) were good in all subscales and total difficulties scale. CONCLUSION: The SDQ self-report Tamil version can be used effectively for screening of adolescents to identify mental health problems as well as for research purposes.     

An attempt to measure burden of disease using disability adjusted life years for Sri Lanka

INTRODUCTION: Disability adjusted life years (DALY) is a measure of burden of disease (BOD) that assesses the years of healthy life lost due to disease or illness. OBJECTIVE: The main objective of the study was to develop a draft measure of the BOD in Sri Lanka, using DALY. METHODS: Computation was done for 100 disease categories identified to reflect the disease pattern in Sri Lanka. Factors that were considered for the calculation of DALY were incidence, degree of disability, duration of the illness and age of onset. RESULTS: Injuries, ischaemic heart disease, asthma, disease of the pulmonary circulation and burns contribute to 55% of BOD in Sri Lanka. CONCLUSION: The highest burden was due to non-communicable diseases, as their duration and degree of disability are high. Diseases such as malaria, which are short term illnesses with low disability, although affecting large numbers, did not give a high value for DALY.     

Prevention of coronary heart disease among Indians: focus on primary prevention

Epidemiological transition with increasing life expectancy and demographic shifts in population age-profile combined with lifestyle related increases in the levels of cardiovascular risk factors is accelerating coronary heart disease (CHD) epidemic in India. As prospective cohort studies for evaluation of coronary risk factors do not exist, urban-rural differences in prevalence of coronary risk factors and case-control studies provide important information regarding coronary risk factors that need prevention to control the CHD epidemic. The risk factors more in urban Indians or associated with increased risk in case-control studies are: Sedentary lifestyle, smoking, truncal obesity, hypertension, hypercholesterolaemia, impaired glucose tolerance, insulin resistance and diabetes. Primordial prevention ie, prevention of risk factors can be achieved by encouragement of positive health behaviour and promotion of the concept of health as a social value. Special target groups are children, adolescents, family unit, under-privileged and high-risk groups. Behavioural and environmental changes relevant to primordial prevention are changes in eating patterns, drinking, smoking, physical activity and stress management. Primary prevention focuses on population and on high-risk groups. Specific high-risk subjects are those with family history of CHD, hypertension or diabetes or those having sedentary lifestyle, obesity, truncal obesity and biochemical coronary risk factors. The interventions are smoking cessation, increased physical activity, weight regulation, blood pressure control, lipid regulation and diabetes management.     

Genetic testing for single gene disorders

Genetic testing for single gene disorders is becoming available in Sri Lanka. While it offers many benefits, there are concerns about psychological and social problems that can be a consequence of such tests. This article aims to review the potential benefits and disadvantages of genetic testing, and recommends mechanisms that would help minimise problems associated with the inappropriate use of genetic tests.     

Preventable acute organophosphate poisoning deaths

Poisoning with cholinesterase inhibiting insecticides such as organophosphates (OP) is a major health problem in Sri Lanka, with over 10,000 hospital admissions and over 1,000 hospital deaths annually. Atropine and pralidoxime are the most useful antidotes in the treatment of OP poisoning. Three cases of fatal OP poisoning are described where although the initial diagnosis and therapy were correct, patients did not survive due to inadequate atropine therapy. The need for continuous monitoring and administering adequate doses of atropine in OP poisoning for several days is stressed.     

Impaired glucose tolerance and diabetes mellitus in a suburban Sri Lankan community.

The prevalence of impaired glucose tolerance and diabetes mellitus was studied in a suburban Sri Lankan community using 1985 WHO criteria. Oral 75 g glucose tolerance tests were performed on 633 subjects aged 30-64 years. The age-standardized prevalence rates for diabetes mellitus were 5.02 (95% CI 3.59-6.43) and impaired glucose tolerance 5.27 (95% CI 3.74-6.78). A total of 21% of diabetic patients were not known to have diabetes and were diagnosed for the first time during the survey. Obesity was more common (P < 0.05) in diabetic patients (21%) when compared to non-diabetic subjects (10.5%). Diabetes mellitus is a common health problem in Sri Lanka, and there is a need for developing national policies for its prevention and control.     

Health in the Huxleyan tropical island of Pala

Huxley's Island: a novel (1962) is a parable on "realistic idealism"--set in an imaginary island situated in the Indian ocean between Sri Lanka and Sumatra, called Pala. The characters in the story include a doctor, a nurse and several patients. The general importance of health as a basic human need is well recognised. Vis medicatrix naturae, the natural healing powers of the body, are taken account of, along with psychotherapy and drugs. Prevention of illness is emphasised and doctors get paid for keeping people well. Since health and illness are influenced by a multitude of factors, "we attack on all the fronts at once ... from diet to auto-suggestion, from negative ions to medication".     

Chronic pain syndrome should be recognized as a separate clinical entity.

Chronic pain is a relatively new concept in our understanding of pain. It is rarely recognised or diagnosed as a separate clinical entity in Sri Lanka. Thus the extent of this problem is not known. The case histories of two patients with the chronic pain syndrome are presented, with a brief review of the theoretical aspects of chronic pain. Trends in the management of chronic pain are summarized. Unfortunately, organized treatment programmes for chronic pain are unavailable in Sri Lanka.     

Anti-tuberculosis drug inducd hepatitis - a Sri Lankan experience

OBJECTIVE: To assess the incidence of anti-tuberculosis (TB) drug induced hepatitis (AIH) in Sri Lankan patients, determine risk factors of AIH, and to address management options in AIH. DESIGN: A prospective study. SETTING: Chest Hospital, Welisara, Sri Lanka, from April 2001 to April 2002. PATIENTS: Seven hundred and eighty three patients with a confirmed diagnosis of TB and resident in the Colombo and Gampaha districts who presented to Chest Hospital, Welisara, Sri Lanka. METHODS: WHO recommended treatment was commenced in all cases. AIH was diagnosed when patients complained of decreased appetite with nausea or vomiting and elevated serum bilirubin (SB; >1.1 mg/dL) or elevated serum alanine transferase (ALT; > 3 times upper limit of normal). RESULTS: Of 783 enrolled patients, 74 (9.5%) developed AIH, the majority (58%) developing AIH within the first 2 weeks of the intensive phase of treatment. AIH was more common among patients over 60 years (p = 0.018), who developed pulmonary TB (p = 0.028), and in patients weighing 33-55 kg (p = 0.004). Age, weight and rifampicin overdosage were significant predictors of AIH. Of the 74 AIH patients, standard treatment was restarted in 60, treatment modified in six, two defaulted and six died. CONCLUSIONS: The incidence of AIH in Sri Lanka is 9.5% in treated patients. AIH was associated with age, low body weight and rifampicin overdosage.     

Coconut fats

In many areas of Sri Lanka the coconut tree and its products have for centuries been an integral part of life, and it has come to be called the "Tree of life". However, in the last few decades, the relationship between coconut fats and health has been the subject of much debate and misinformation. Coconut fats account for 80% of the fat intake among Sri Lankans. Around 92% of these fats are saturated fats. This has lead to the belief that coconut fats are 'bad for health', particularly in relation to ischaemic heart disease. Yet most of the saturated fats in coconut are medium chain fatty acids whose properties and metabolism are different to those of animal origin. Medium chain fatty acids do not undergo degradation and re-esterification processes and are directly used in the body to produce energy. They are not as 'bad for health' as saturated fats. There is the need to clarify issues relating to intake of coconut fats and health, more particularly for populations that still depend on coconut fats for much of their fat intake. This paper describes the metabolism of coconut fats and its potential benefits, and attempts to highlight its benefits to remove certain misconceptions regarding its use.     

An observational study of staghorn calculi in south Sri Lanka

OBJECTIVES: To ascertain patient characteristics, management strategies and outcome of patients with staghorn calculi in southern Sri Lanka. METHODS: All patients with staghorn calculi seen at the urology unit in a teaching hospital during a period of eighteen months were included in this prospective study. Data in relation to patient demography, investigations, treatment and postoperative complications were collected. RESULTS: There were 60 patients with a mean age of 54 years. Eight (13%) of them were female. Urine pH was less than 7.0 in 52 (87%) patients. Urine culture was positive for bacteria in four (7%) patients. 58 patients underwent open surgery, and two patients were managed non-operatively. Seven (12%) patients developed postoperative complications. CONCLUSIONS: Staghorn calculi elsewhere are usually commoner in females and associated with alkaline urine. But in our study there was a clear male preponderance (M:F = 6.5:1), and urine pH was alkaline in 8 (13%) patients only. Hence the aetiological factors for staghorn calculi in Sri Lanka appear to be different. Although open surgical procedures which form the mainstay of treatment of staghom calculi in Sri Lanka can be performed safely and effectively, there is a necessity to provide minimal access surgical facilities.     

Loa loa in a Sri Lankan expatriate from Nigeria

A worm was extracted from the subconjunctival space of the left eye in a 14-year old Sri Lankan girl, who returned to Sri Lanka in 1983 after spending six years in Nigeria. It was identified as a male Loa loa. A history of evanescent (Calabar) swellings was obtained. She also had significant eosinophilia. Microfilariae were not detected in the blood. This is the first case of Loa loa infection reported from Sri Lanka.     

Attitudes of doctors to the Alma Ata recommendations in Sri Lanka

A detailed postal questionnaire was sent to 400 general practitioners, hospital doctors, and Ayurvedic practitioners in Sri Lanka as part of a wider study to investigate the delivery of primary medical care. The responses to questions that were related to the Alma Ata recommendations, which aim at providing "health for all by the year 2000," and the perceived health needs of the population are reported. Basic sanitation, clean water, adequate nutrition, and improved health education were considered to be the most important needs. When asked to suggest one change in health care 30% of the doctors recommended the integration of primary and secondary care services.