Journal/Magazine Articles
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This collection contains original research articles, review articles and case reports published in local and international peer reviewed journals by the staff members of the Faculty of Medicine
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Item Environmental pollution by traffic noise in the city of Colombo, Sri Lanka(IOS Press, 2016) Nagodawithana, N.S.; Pathmeswaran, A.; Pannila, A.S.; Wickremasinghe, A.R.; Sathiakumar, N.Traffic noise levels in most cities of the world are higher than the recommended levels. Exposure to high levels of noise may cause adverse health effects such as ischemic heart diseases and noise induced hearing loss. We conducted a cross-sectional study to determine road traffic noise levels at 60 selected locations in the city of Colombo, Sri Lanka. On randomly selected days we measured equivalent continuous sound pressure level (LAeq) for six hours during the day. From these measurements LAeq for eight hours were calculated and used as the average noise level of a particular location. LAeq (8 hrs) within Colombo ranged 76.6 to 84.0 dB; well above the Sri Lankan recommendation of 63.0 dB (an increase of 13.3 to 21.0 dB), and the WHO recommendation of 55.0 dB (an increase of 21.6 to 29.0 dB). These levels translate into increase of sound pressure level by 21.4 to 794.3 times above the recommendations on the logarithmic scale of dB. Thirty-eight of 60 locations recorded levels more than 80.0 dB. Road traffic noise levels in Colombo were well above the recommended levels. Though the increase in measured decibels might not appear to be too high, in reality this translates into an increase manifold times in the sound pressure level that reaches the earItem Non-resolution of non-alcoholic fatty liver disease (NAFLD) among urban, adult Sri Lankans in the general population: A prospective, cohort follow-up study.(Public Library of Science, 2019) Niriella, M.A.; Kasturiratne, A.; Beddage, T.; Ediriweera, D.S.; de Silva, S.T.; Perera, K.R.; Subasinghe, C.E.; Kodisinghe, S.K.; Piyaratna, T.C.; Rishikesawan, V.; Dassanayake, A.S.; de Silva, A.P.; Pathmeswaran, A.; Wickremasinghe, A.R.; Kato, N.; de Silva, H.J.BACKGROUND: There are few studies investigating the natural course of non-alcoholic fatty liver disease (NAFLD) in the community. We assessed resolution of NAFLD in a general population cohort of urban Sri Lankans adults. METHODS: Participants were selected by age-stratified random sampling from electoral lists. They were initially screened in 2007 and re-evaluated in 2014. On both occasions structured interview, anthropometric-measurements, liver ultrasonography, and biochemical/serological tests were performed. NAFLD was diagnosed on ultrasound criteria for fatty liver, safe-alcohol consumption (<14-units/week for men, <7-units/week for women) and absence of hepatitis B/C markers. Non-NAFLD was diagnosed on absence of any ultrasound criteria for fatty liver and safe-alcohol consumption. Resolution of NAFLD was defined as absence of ultrasound criteria for fatty liver. Changes in anthropometric indices [Weight, Body-Mass-Index (BMI), waist-circumference (WC), waist-hip ratio (WHR)], clinical [systolic blood pressure (SBP), diastolic blood pressure (DBP)] and biochemical measurements [Triglycerides (TG), High Density Lipoprotein (HDL), Total Cholesterol (TC), HbA1c%] at baseline and follow-up were compared. RESULTS: Of the 2985 original study participants, 2148 (71.9%) attended follow-up after 7 years. This included 705 who had NAFLD in 2007 and 834 who did not have NAFLD in 2007. Out of 705 who had NAFLD in 2007, 11(1.6%) changed their NAFLD status due to excess alcohol consumption. After controlling for baseline values, NAFLD patients showed significant reduction in BMI, weight, WHR, HDL and TC levels and increase in HbA1c levels compared to non-NAFLD people. Despite this, none of them had complete resolution of NAFLD. CONCLUSION: We did not find resolution of NAFLD in this general population cohort. The observed improvements in anthropometric, clinical and biochemical measurements were inadequate for resolution of NAFLD.nal Center for Global Health and Medicine, Toyama, Shinjuku-ku, Tokyo, Japan.Item Adjusting for spatial variation when assessing individual-level risk: A case-study in the epidemiology of snake-bite in Sri Lanka(Public Library of Science, 2019) Ediriweera, D.S.; Kasturiratne, A.; Pathmeswaran, A.; Gunawardena, N.K.; Jayamanne, S.F.; Murray, K.; Iwamura, T.; Lalloo, D.G.; de Silva, H.J.; Diggle, P.J.BACKGROUND:Health outcomes and causality are usually assessed with individual level sociodemographic variables. Studies that consider only individual-level variables can suffer from residual confounding. This can result in individual variables that are unrelated to risk behaving as proxies for uncaptured information. There is a scarcity of literature on risk factors for snakebite. In this study, we evaluate the individual-level risk factors of snakebite in Sri Lanka and highlight the impact of spatial confounding on determining the individual-level risk effects.METHODS:Data was obtained from the National Snakebite Survey of Sri Lanka. This was an Island-wide community-based survey. The survey sampled 165,665 individuals from all 25 districts of the country. We used generalized linear models to identify individual-level factors that contribute to an individual's risk of experiencing a snakebite event. We fitted separate models to assess risk factors with and without considering spatial variation in snakebite incidence in the country.RESULTS:Both spatially adjusted and non-adjusted models revealed that middle-aged people, males, field workers and individuals with low level of education have high risk of snakebites. The model without spatial adjustment showed an interaction between ethnicity and income levels. When the model included a spatial adjustment for the overall snakebite incidence, this interaction disappeared and income level appeared as an independent risk factor. Both models showed similar effect sizes for gender and age. HEmployment and education showed lower effect sizes in the spatially adjusted model.CONCLUSIONS:Both individual-level characteristics and local snakebite incidence are important to determine snakebite risk at a given location. Individual level variables could act as proxies for underling residual spatial variation when environmental information is not considered. This can lead to misinterpretation of risk factors and biased estimates of effect sizes. Both individual-level and environmental variables are important in assessing causality in epidemiological studies.Item Fetal Doppler reference values in women with a normal body mass index(Sri Lanka Medical Association, 2019) Dias, T.; Abeykoon, S.; Mendis, P.; Gunawardena, C.; Pragasan, G.; Padeniya, T.; Pathmeswaran, A.; Kumarasiri, S.OBJECTIVES:To construct gestation specific reference limits for fetal umbilical (UA), middle cerebral artery (MCA) pulsatility indices (PI) and the cerebroplacental ratio (CPR) in singleton pregnancies with normal BMI between 16 and 40 weeks of gestation.METHODS:We ultrasonographically examined 596 fetuses from women with normal nutritional and health status and minimal environmental constraints on fetal growth. Each mother was considered only once for measurement of fetal Doppler indices, at gestations between 16 and 40 weeks in a prospective cross-sectional study. Gestational age was confirmed by fetal crown-rump length measurement between 11 and 14 weeks. Pulsatility indices of umbilical and middle cerebral arteries were measured by real time and Doppler ultrasonography. CPR ratio was calculated by dividing MCA PI by UA PI. The fetal Doppler measurements obtained from the current study were compared with commonly used reference charts. For each parameter separate polynomial regression models were fitted to estimate the gestation specific means and standard deviations, assuming that the measurements have a normal distribution at each gestational age.RESULTS:A significant difference of fetal Doppler indices was observed between our study and previously published reference charts for most gestational weeks. The fitted 10th, 50th and 90th centiles at 40 weeks of gestation were 0.65, 0.87 and 1.08 for UA PI; 0.93, 1.32 and 1.71 MCA PI; 1.02, 1.58 and 2.13 for CPR.CONCLUSIONS: These charts can be used for better defining the normal range of fetal arterial Doppler indices. This will be useful in the diagnosis and management of fetuses with abnormal fetal growthItem Incidence and risk factors for metabolic syndrome among urban, adult Sri Lankans: a prospective, 7-year community cohort, follow-up study.(BioMed Central, 2019) de Silva, S.T.; Niriella, M.A.; Ediriweera, D.S.; Kottahachchi, D.; Kasturiratne, A.; de Silva, A.P.; Dassanayake, A.S.; Pathmeswaran, A.; Wickremasinghe, A.R.; Kato, N.; de Silva, H.J.BACKGROUND:The metabolic syndrome (MetS) is a clustering of abdominal obesity, diabetes and prediabetes, high cholesterol and high blood pressure, that confers an increased risk of cardiovascular disease. There is limited data on incidence of MetS from South Asia. This study investigated incidence and risk factors for new onset MetS in an urban adult Sri Lankan population.METHODS:Subjects (selected by age-stratified random sampling from the Ragama Medical Officer of Health area) were screened initially in 2007 (35-64 years) and re-evaluated in 2014 (42-71 years). On both occasions they were assessed by structured interview, anthropometric measurements, liver ultrasound, and biochemical/serological tests. MetS was diagnosed on International Diabetes Federation (IDF-2006) criteria. Total body fat (TBF) and visceral fat percentage (VFP) were measured in 2014, using body impedance method. Incidence and factors at baseline, associated with new onset MetS, were investigated among those who presented for re-evaluation.RESULTS:2985 (99.1%) [1636 (54.8%) women (54.8%); median age (IQR) 53 (47-59) years] from the initial cohort in 2007 had complete data. 2148 (71.9%) [1237 (57.6%) women; median age (IQR) 60 (54-66) years] attended follow-up. 949 of them [701 (73.9%) women; median age (IQR) 60 (54-65) years] had MetS (prevalence 47.2%, 95% CI 45.0-49.4%). Of 1246 who did not have MetS in 2007, 265 [178 (67.1%) women, median age (IQR) 57 (51-64) years] had developed MetS after 7 years (annual incidence 3.5% (95% CI 2.4-4.5%). Females (OR = 4.9, 95% CI 3.4-7.4), BMI > 23 kg/m2 in 2007 (OR = 1.6 per unit increase, 95% CI 1.5-1.7), weight gain (by 2-5% OR = 2.0, 95% CI 1.1-3.5; by > 5% OR = 2.2, 95% CI 1.4-3.4), and increase in waist circumference (by 2-5% OR = 7.0, 95% CI 4.0-12.2; by > 5% OR = 13.4, 95% CI 8.3-22.4) from baseline and presence of non-alcoholic fatty liver disease (NAFLD) in 2007 (OR = 1.70, 95% CI 1.04-2.76) were associated new onset MetS. Those with MetS had abnormal VFP and TBF in 2014 [P < 0.001].CONCLUSION:In this study, annual incidence of MetS was 3.5%. Female gender, BMI > 23 kg/m2 and NAFLD in 2007 and increase in weight and waist circumference from baseline were significantly associated with new onset MetS. Obesity was the best predictor of future MetSItem Reassessment of the prevalence of soil-transmitted helminth infections in Sri Lanka to enable a more focused control programme: a cross-sectional national school survey with spatial modelling(Elsevier, 2019) Ediriweera, D.S.; Gunawardena, S.; Gunawardena, N.K.; Iddawela, D.; Kannathasan, S.; Murugananthan, A.; Yahathugoda, C.; Pathmeswaran, A.; Diggle, P. J.; de Silva, N.BACKGROUND:In Sri Lanka, deworming programmes for soil-transmitted helminth infections became an integral part of school health in the 1960s, whereas routine antenatal deworming with mebendazole started in the 1980s. A 2003 national soil-transmitted helminth survey done among schoolchildren found an overall prevalence of 6·9%. In our study, we aimed to reassess the national prevalence of soil-transmitted helminth infections to enable implementation of a more focused control programme that targets smaller administrative areas at risk of continued transmission.METHODS:We did a cross-sectional, school-based, national survey using multistage stratified cluster sampling, covering all nine provinces as well as populations at high risk of soil-transmitted helminth infections living in urban slums and in plantation-sector communities. Our study population was children aged 5-7 years attending state schools. Faecal samples were collected and analysed with duplicate modified Kato-Katz smears. We modelled the risk of soil-transmitted helminth infection using generalised linear mixed-effects models, and we developed prevalence maps to enable informed decision making at the smallest health administrative level in the country.FINDINGS:Between Jan 23 and May 9, 2017, we recruited 5946 children from 130 schools; 4276 (71·9%) children provided a faecal sample for examination. National prevalence of soil-transmitted helminth infection was 0·97% (95% CI 0·63-1·48) among primary schoolchildren. Prevalence in the high-risk communities surveyed was higher than national prevalence: 2·73% (0·75-6·87) in urban slum communities and 9·02% (4·29-18·0) in plantation sector communities. Our prevalence maps showed that the lowest-level health administrative regions could be categorised into low risk (prevalence <1%), high risk (prevalence >10%), or intermediate risk (1-10%) areas.INTERPRETATION:Our survey findings indicate that the national prevalence of soil-transmitted helminth infection has continued to decline in Sri Lanka. On the basis of WHO guidelines, we recommend discontinuation of routine deworming in low-risk areas, continuation of annual deworming in high-risk areas, and deworming once every 2 years in intermediate-risk areas, for at least 4 years.FUNDING:Task Force for Global Health and WHO.Item Percentage of small platelets on peripheral blood smear and Child-Turcott-Pugh class can predict the presence of oesophageal varices in newly diagnosed patients with cirrhosis: development of a prediction model for resource limited settings(BioMed Central, 2019) Perera, K.; Kodisinghe, S.K.; Ediriweera, D.S.; Moratuwagama, D.; Williams, S.; Pathmeswaran, A.; Niriella, M.A.; de Silva, H.J.BACKGROUND:In cirrhosis upper-gastrointestinal-endoscopy (UGIE) identifies oesophageal varices (OV). UGIE is unavailable in most resource-limited settings. Therefore, we assessed prediction of presence of OV using hematological parameters (HP) and Child-Turcott-Pugh (CTP) class.METHODS:A prospective study was carried out on consecutive, consenting, newly-diagnosed patients with cirrhosis, in the University Medical Unit, Colombo North Teaching Hospital, Ragama, Sri Lanka from April 2014-April 2016. All patients had UGIE to evaluate presence and degree of OV, prior to appropriate therapy. HP (full blood count with indices using automated analyzer and peripheral blood smear using Leishmann stain) and CTP class were assessed on admission. Linear logistic regression model was developed to predict OV using HP and CTP class.RESULTS:54-patients with cirrhosis were included [14(26%), 24(44%) and 16(30%) belonged to CTP class A, B and C respectively]. 37 had varices [CTP-A 4/14(26.6%), CTP-B 19/24(79.2%), CTP-C 14/16(87.5%)] on UGIE. Generalized linear model fitting showed decreasing percentage of small platelets (%SP) (P = 0.002), CTP-B (P = 0.003) and CTP-C (P = 0.003) compared to CTP-A had higher probability of having OV. The model predicts the log odds for having OV = - 0.189 - (0.046*%SP) + 2.9 [if CTP-B] + 3.7 [if CTP-C]. Based on receiver operating characteristic (ROC) analysis, a model value > - 0.19 was selected as the cutoff point to predict OV with 89%-sensitivity, 76%-specificity, 89%-positive predictive value and 76%-negative predictive value.CONCLUSIONS:We constructed a model using %SP on peripheral blood smear and CTP class. This model may be used to predict the presence of OV, in newly diagnosed patients with cirrhosis, with acceptable sensitivity and specificity, to prioritize the patients who deserve early UGIE in limited resource settingsItem Prescribing, dispensing and administration indicators to describe rational use of oral dosage forms of medicines given to children(Mumbai : Wolters Kluwer Health, Medknow, 2019) Nadeshkumar, A.; Sathiadas, G.; Pathmeswaran, A.; Ranganathan, S. S.BACKGROUND:Owing to lack of indicators, researchers are compelled to use non-specific indicators to assess rational use of medicines in children. Thus, paediatric-specific issues are poorly described. This study aims to develop a set of indicators to describe rational use of oral dosage forms of medicines given to children. METHODS: A modified RAND/UCLA Appropriateness Method was used. A comprehensive draft list of 40 indicators was compiled, based on the results of a literature review. Twelve experts rated these indicators in two rounds, using a nine-point Likert scale, first in an online survey, for clarity, necessity and scientific merit, and secondly in a face-to-face meeting, for necessity, feasibility and predictive value. An overall panel median score of ≥7 and agreement within the experts were used in indicators. The indicators were ranked independently by the research team and a final list of indicators was prepared. These indicators were pilot-tested for acceptability and interrater reliability. RESULTS: Nine prescribing indicators, such as weight, appropriate dose and age-appropriate dosage form; five dispensing indicators, such as adequacy of labelling and inappropriate manipulation by pharmacists; and five administration indicators, such as inappropriate manipulation by parents and full completion of dose, were finalized in the second round. CONCLUSION:This novel approach has provided a set of indicators to describe the use of oral dosage forms of medicines given to children, which can be used by researchers as a supplement to the World Health Organization's drug use indicators when investigating rational use of medicines in children.Item Socioeconomic inequality and determinants of postnatal home visits made by public health midwives: An analysis of the Sri Lanka Demographic and Health Survey.(Public Library of Science, 2019) Siriwardhana, D.D.; Pathmeswaran, A.; Wickremasinghe, A.R.INTRODUCTION:The impact of socioeconomic inequalities on health outcomes and service delivery is increasingly researched globally. This study assessed the overall and sector-wise socioeconomic inequality in postnatal home visits made by Public Health Midwives (PHMs) in Sri Lanka and decomposed the observed socioeconomic inequality into potential determinants. METHODS: Data from the Sri Lanka Demographic and Health Survey (SLDHS) 2006-07 were used. Data were collected from ever-married women who gave birth to their last child in 2001 or later (up to 2007). Whether the PHM visited the home to provide postnatal care within one month of the delivery was the health outcome of interest. Sri Lanka is divided into three sectors (areas) as urban, rural, and estate (plantation) based on the geographical location and the availability of infrastructure facilities. Concentration indices were calculated and concentration curves were plotted to quantify the overall and sector-wise socioeconomic inequality. Decomposition analysis using probit regression was performed to estimate the contribution of potential determinants to the observed socioeconomic inequality. RESULTS:Overall, 83.0% of women were visited by a PHM within one month of the delivery. The highest number of home visits was reported in the rural sector (84.5%) and lowest was reported from the estate sector (72.4%). A pro-poor, pro-rich, and no inequality were observed across urban, rural, and estate sectors respectively. Wealth had a small contribution to the estimated inequality. Province of residence and the education level of women were the main determinants of the observed socioeconomic inequality. CONCLUSION: Addressing the socioeconomic inequality of postnatal home visits made by PHMs should not be seen as a health system issue alone. The associated social determinants of health should be addressed through a multi-sectoral approach encompassing the principles of primary health care.Item Challenges of costing a surgical procedure in a lower-middle-income country(Springer-Verlag, 2019) Ekanayake, C.; Pathmeswaran, A.; Kularatna, S.; Herath, R.; Wijesinghe, P.BACKGROUND: It is vital to enquire into cost of health care to ensure that maximum value for money is obtained with available resources; however, there is a dearth of information on cost of health care in lower-middle-income countries (LMICs). Our aim was to develop a reproducible costing method for three routes of hysterectomy in benign uterine conditions: total abdominal (TAH), non-descent vaginal (NDVH) and total laparoscopic hysterectomy (TLH). METHODS: A societal perspective with a micro-costing approach was applied to find out direct and indirect costs. A total of 147 patients were recruited from a district general hospital (Mannar) and a tertiary care hospital (Ragama). Costs incurred from preoperative period to convalescence included direct costs of labour, equipment, investigations, medications and utilities, and indirect costs of out-of-pocket expenses, productivity losses, carer costs and travelling. Time-driven activity-based costing was used for labour, and top-down micro-costing was used for utilities. RESULTS: The total cost [(interquartile range), number] of TAH was USD 339 [(308-397), n = 24] versus USD 338 [(312-422), n = 25], NDVH was USD 315 [(316-541), n = 23] versus USD 357 [(282-739), n = 26] and TLH was USD 393 [(338-446), n = 24] versus USD 429 [(390-504), n = 25] at Mannar and Ragama, respectively. The direct cost of TAH, NDVH and TLH was similar between the two centres, whilst indirect cost was related to the setting rather than the route of hysterectomy. CONCLUSIONS: The costing method used in this study overcomes logistical difficulties in a LMIC and can serve as a guide for clinicians and policy makers in similar settings.