Medicine
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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
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Item Policy implementation and recommended actions to create healthy food environments using the healthy food environment policy index (Food-EPI): a comparative analysis in South Asia(Elsevier Ltd, 2024) Pineda, E.; Atanasova, P.; Wellappuli, N.T.; Kusuma, D.; Herath, H.; Segal, A.B.; Vandevijvere, S.; Anjana, R.M.; Shamim, A.A.; Afzal, S.; Akter, F.; Aziz, F.; Gupta, A.; Hanif, A.A.; Hasan, M.; Jayatissa, R.; Jha, S.; Jha, V.; Katulanda, P.; Khawaja, K.I.; Kumarendran, B.; Loomba, M.; Mahmood, S.; Mridha, M.K.; Pradeepa, R.; Aarthi, G.R.; Tyagi, A.; Kasturiratne, A.; Sassi, F.; Miraldo, M.BACKGROUND The increasing prevalence of diet-related non-communicable diseases (NCDs) in South Asia is concerning, with type 2 diabetes projected to rise to 68%, compared to the global increase of 44%. Encouraging healthy diets requires stronger policies for healthier food environments.METHODS This study reviewed and assessed food environment policies in Bangladesh, India, Pakistan, and Sri Lanka from 2020 to 2022 using the Healthy Food Environment Policy Index (Food-EPI) and compared them with global best practices. Seven policy domains and six infrastructure support domains were considered, employing 47 good practice indicators to prevent NCDs. Stakeholders from government and non-governmental sectors in South Asia (n = 148) were invited to assess policy and infrastructure support implementation using the Delphi method.FINDINGS Implementation of food environment policies and infrastructure support in these countries was predominantly weak. Labelling, monitoring, and leadership policies received a moderate rating, with a focus on food safety, hygiene, and quality rather than obesity prevention. Key policy gaps prioritized for attention included front-of-pack labelling, healthy food subsidies, unhealthy food taxation, restrictions on unhealthy food promotion, and improvements in school nutrition standards to combat NCDs.INTERPRETATION Urgent action is required to expand food policies beyond hygiene and food security measures. Comprehensive strategies targeting NCD prevention are crucial to combat the escalating burden of NCDs in the region.Item Food environment and diabetes mellitus in South Asia: A geospatial analysis of health outcome data(Public Library of Science,San Francisco, 2022) Kusuma, D.; Atanasova, P.; Pineda, E.; Anjana, R.M.; de Silva, L.; Hanif, A.A.; Hasan, M.; Hossain, M.M.; Indrawansa, S.; Jayamanne, D.; Jha, S.; Kasturiratne, A.; Katulanda, P.; Khawaja, K.I.; Kumarendran, B.; Mridha, M.K.; Rajakaruna, V.; Chambers, J.C.; Frost, G.; Sassi, F.; Miraldo, M.Background: The global epidemic of type 2 diabetes mellitus (T2DM) renders its prevention a major public health priority. A key risk factor of diabetes is obesity and poor diets. Food environments have been found to influence people's diets and obesity, positing they may play a role in the prevalence of diabetes. Yet, there is scant evidence on the role they may play in the context of low- and middle-income countries (LMICs). We examined the associations of food environments on T2DM among adults and its heterogeneity by income and sex. Methods and findings: We linked individual health outcome data of 12,167 individuals from a network of health surveillance sites (the South Asia Biobank) to the density and proximity of food outlets geolocated around their homes from environment mapping survey data collected between 2018 and 2020 in Bangladesh and Sri Lanka. Density was defined as share of food outlets within 300 m from study participant's home, and proximity was defined as having at least 1 outlet within 100 m from home. The outcome variables include fasting blood glucose level, high blood glucose, and self-reported diagnosed diabetes. Control variables included demographics, socioeconomic status (SES), health status, healthcare utilization, and physical activities. Data were analyzed in ArcMap 10.3 and STATA 15.1. A higher share of fast-food restaurants (FFR) was associated with a 9.21 mg/dl blood glucose increase (95% CI: 0.17, 18.24; p < 0.05). Having at least 1 FFR in the proximity was associated with 2.14 mg/dl blood glucose increase (CI: 0.55, 3.72; p < 0.01). A 1% increase in the share of FFR near an individual's home was associated with 8% increase in the probability of being clinically diagnosed as a diabetic (average marginal effects (AMEs): 0.08; CI: 0.02, 0.14; p < 0.05). Having at least 1 FFR near home was associated with 16% (odds ratio [OR]: 1.16; CI: 1.01, 1.33; p < 0.05) and 19% (OR: 1.19; CI: 1.03, 1.38; p < 0.05) increases in the odds of higher blood glucose levels and diagnosed diabetes, respectively. The positive association between FFR density and blood glucose level was stronger among women than men, but the association between FFR proximity and blood glucose level was stronger among men as well as among those with higher incomes. One of the study's key limitations is that we measured exposure to food environments around residency geolocation; however, participants may source their meals elsewhere. Conclusions: Our results suggest that the exposure to fast-food outlets may have a detrimental impact on the risk of T2DM, especially among females and higher-income earners. Policies should target changes in the food environments to promote better diets and prevent T2DM.Item Food environments and obesity: A geospatial analysis of the South Asia Biobank, income and sex inequalities(Elsevier Ltd, 2022) Atanasova, P.; Kusuma, D.; Pineda, E.; Anjana, R.M.; de Silva, L.; Hanif, A.A.M.; Hasan, M.; Hossain, M.M.; Indrawansa, S.; Jayamanne, D.; Jha, S.; Kasturiratne, A.; Katulanda, P.; Khawaja, K.I.; Kumarendran, B.; Mrida, M.K.; Rajakaruna, V.; Chambers, J.C.; Frost, G.; Sassi, F.; Miraldo, M.Introduction: In low-middle income countries (LMICs) the role of food environments on obesity has been understudied. We address this gap by 1) examining the effect of food environments on adults' body size (BMI, waist circumference) and obesity; 2) measuring the heterogeneity of such effects by income and sex.Methods: This cross-sectional study analysed South Asia Biobank surveillance and environment mapping data for 12,167 adults collected between 2018 and 2020 from 33 surveillance sites in Bangladesh and Sri Lanka. Individual-level data (demographic, socio-economic, and health characteristics) were combined with exposure to healthy and unhealthy food environments measured with geolocations of food outlets (obtained through ground-truth surveys) within 300 m buffer zones around participants' homes. Multivariate regression models were used to assess association of exposure to healthy and unhealthy food environments on waist circumference, BMI, and probability of obesity for the total sample and stratified by sex and income.Findings: The presence of a higher share of supermarkets in the neighbourhood was associated with a reduction in body size (BMI, β = - 3∙23; p < 0∙0001, and waist circumference, β = -5∙99; p = 0∙0212) and obesity (Average Marginal Effect (AME): -0∙18; p = 0∙0009). High share of fast-food restaurants in the neighbourhood was not significantly associated with body size, but it significantly increased the probability of obesity measured by BMI (AME: 0∙09; p = 0∙0234) and waist circumference (AME: 0∙21; p = 0∙0021). These effects were stronger among females and low-income individuals.Interpretation: The results suggest the availability of fast-food outlets influences obesity, especially among female and lower-income groups. The availability of supermarkets is associated with reduced body size and obesity, but their effects do not outweigh the role of fast-food outlets. Policies should target food environments to promote better diets and reduce obesity.Item Formative research to design an implementation strategy for a postpartum hemorrhage initial response treatment bundle (E-MOTIVE): study protocol(BioMed Central, 2021) Bohren, M.A.; Lorencatto, F.; Coomarasamy, A.; Althabe, F.; Devall, A.J.; Evans, C.; Oladapo, O.T.; Lissauer, D.; Akter, S.; Forbes, G.; Thomas, E.; Galadanci, H.; Qureshi, Z.; Fawcus, S.; Hofmeyr, G.J.; Al-Beity, F.A.; Kasturiratne, A.; Kumarendran, B.; Mammoliti, K.M.; Vogel, J.P.; Gallos, I.; Miller, S.BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. When PPH occurs, early identification of bleeding and prompt management using evidence-based guidelines, can avert most PPH-related severe morbidities and deaths. However, adherence to the World Health Organization recommended practices remains a critical challenge. A potential solution to inefficient and inconsistent implementation of evidence-based practices is the application of a 'clinical care bundle' for PPH management. A clinical care bundle is a set of discrete, evidence-based interventions, administered concurrently, or in rapid succession, to every eligible person, along with teamwork, communication, and cooperation. Once triggered, all bundle components must be delivered. The E-MOTIVE project aims to improve the detection and first response management of PPH through the implementation of the "E-MOTIVE" bundle, which consists of (1) Early PPH detection using a calibrated drape, (2) uterine Massage, (3) Oxytocic drugs, (4) Tranexamic acid, (5) Intra Venous fluids, and (6) genital tract Examination and escalation when necessary. The objective of this paper is to describe the protocol for the formative phase of the E-MOTIVE project, which aims to design an implementation strategy to support the uptake of this bundle into practice. METHODS: We will use behavior change and implementation science frameworks [e.g. capability, opportunity, motivation and behavior (COM-B) and theoretical domains framework (TDF)] to guide data collection and analysis, in Kenya, Nigeria, South Africa, Sri Lanka, and Tanzania. There are four methodological components: qualitative interviews; surveys; systematic reviews; and design workshops. We will triangulate findings across data sources, participant groups, and countries to explore factors influencing current PPH detection and management, and potentially influencing E-MOTIVE bundle implementation. We will use these findings to develop potential strategies to improve implementation, which will be discussed and agreed with key stakeholders from each country in intervention design workshops. DISCUSSION: This formative protocol outlines our strategy for the systematic development of the E-MOTIVE implementation strategy. This focus on implementation considers what it would take to support roll-out and implementation of the E-MOTIVE bundle. Our approach therefore aims to maximize internal validity in the trial alongside future scalability, and implementation of the E-MOTIVE bundle in routine practice, if proven to be effective. KEYWORDS: Behavior change; Care bundle; Formative research; Implementation; Intervention development; Maternal health; Maternal mortality; Obstetric hemorrhage; Postpartum hemorrhage.Item Low uptake of COVID-19 prevention behaviours and high socioeconomic impact of lockdown measures in South Asia: Evidence from a large-scale multi-country surveillance programme(Elsevier Science, 2021) Kusuma, D.; Pradeepa, R.; Khawaja, K.I.; Hasan, M.; Siddiqui, S.; Mahmood, S.; Ali Shah, S.M.; de Silva, C.K.; de Silva, L.; Gamage, M.; Loomba, M.; Rajakaruna, V.P.; Hanif, A.A.; Kamalesh, R.B.; Kumarendran, B.; Loh, M.; Misra, A.; Tassawar, A.; Tyagi, A.; Waghdhare, S.; Burney, S.; Ahmad, S.; Mohan, V.; Sarker, M.; Goon, I.Y.; Kasturiratne, A.; Kooner, J.S.; Katulanda, P.; Jha, S.; Anjana, R.M.; Mridha, M.K.; Sassi, F.; Chambers, J.C.; NIHR Global Health Research Unit for diabetes and cardiovascular disease in South Asia.BACKGROUND: South Asia has become a major epicentre of the COVID-19 pandemic. Understanding South Asians' awareness, attitudes and experiences of early measures for the prevention of COVID-19 is key to improving the effectiveness and mitigating the social and economic impacts of pandemic responses at a critical time for the Region. METHODS: We assessed the knowledge, behaviours, health and socio-economic circumstances of 29,809 adult men and women, at 93 locations across four South Asian countries. Data were collected during the national lockdowns implemented from March to July 2020, and compared with data collected prior to the pandemic as part of an ongoing prospective surveillance initiative. RESULTS: Participants were 61% female, mean age 45.1 years. Almost half had one or more chronic disease, including diabetes (16%), hypertension (23%) or obesity (16%). Knowledge of the primary COVID-19 symptoms and transmission routes was high, but access to hygiene and personal protection resources was low (running water 63%, hand sanitisers 53%, paper tissues 48%). Key preventive measures were not widely adopted. Knowledge, access to, and uptake of COVID-19 prevention measures were low amongst people from disadvantaged socio-economic groups. Fifteen percent of people receiving treatment for chronic diseases reported loss of access to long-term medications; 40% reported symptoms suggestive of anxiety or depression. The prevalence of unemployment rose from 9.3% to 39.4% (P < 0.001), and household income fell by 52% (P < 0.001) during the lockdown. Younger people and those from less affluent socio-economic groups were most severely impacted. Sedentary time increased by 32% and inadequate fruit and vegetable intake increased by 10% (P < 0.001 for both), while tobacco and alcohol consumption dropped by 41% and 80%, respectively (P < 0.001), during the lockdown. CONCLUSIONS: Our results identified important knowledge, access and uptake barriers to the prevention of COVID-19 in South Asia, and demonstrated major adverse impacts of the pandemic on chronic disease treatment, mental health, health-related behaviours, employment and household finances. We found important sociodemographic differences for impact, suggesting a widening of existing inequalities. Our findings underscore the need for immediate large-scale action to close gaps in knowledge and access to essential resources for prevention, along with measures to safeguard economic production and mitigate socio-economic impacts on the young and the poor. KEYWORDS: COVID-19; Preventative measures; Socioeconomic impact; South Asia; Surveillance system.Item Serum testosterone, sex hormone-binding globulin and sex-specific risk of incident type 2 diabetes in a retrospective primary care cohort(Blackwell Scientific Publications, 2019) O'Reilly, M. W.; Glisic, M.; Kumarendran, B.; Subramanian, A.; Manolopoulos, K. N.; Tahrani, A. A.; Keerthy, D.; Muka, T.; Toulis, K. A.; Hanif, W.; Thomas, G. N.; Franco, O. H.; Arlt, W.; Nirantharakumar, K.OBJECTIVE: Previous studies suggest that androgens have a sexually dimorphic impact on metabolic dysfunction. However, the sex-specific link between circulating androgens and risk of type 2 diabetes mellitus (T2DM) has not been examined in a large scale, longitudinal cohort, a task we undertook in this study. DESIGN: A retrospective cohort study in a UK primary care database. PATIENTS: We included men and women with available serum testosterone and sex hormone-binding globulin (SHBG) results. MEASUREMENTS: We categorized serum concentrations according to clinically relevant cut-off points and calculated crude and adjusted T2DM Incidence Rate Ratios (IRRs and aIRRs). RESULTS: Serum testosterone concentrations were available in 70 541 men and 81 889 women; serum SHBG was available in 15 907 men and 42 034 women. In comparison to a reference cohort with serum testosterone ≥20 nmol/L, men with lower serum testosterone had a significantly increased risk of T2DM, with the highest risk in those with serum testosterone <7 nmol/L (aIRR 2.71, 95% CI 2.34-3.14, P < 0.001). In women, the risk of T2DM started to increase significantly when serum testosterone concentrations exceeded 1.5 nmol/L, with the highest risk in women with serum testosterone ≥3.5 nmol/L (aIRR 1.98, 95% CI 1.55-2.52, P < 0.001). These observations were verified in a continuous rather than categorized analysis. The risk of T2DM increased in men and women with serum SHBG <40 and <50 nmol/L, respectively. CONCLUSIONS/INTERPRETATION: In this longitudinal study, we found sexually dimorphic associations between serum testosterone and risk of incident T2DM. Androgen deficiency and excess should be considered important risk factors for diabetes in men and women, respectively.Item 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(Public Library of Science, 2018) Kumarendran, B.; O'Reilly, M.W.; Manolopoulos, K.N.; Toulis, K.A.; Gokhale, K.M.; Sitch, A.J.; Wijeyaratne, C.N.; Coomarasamy, A.; Arlt, W.; Nirantharakumar, K.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.Item Do newspapers fulfil the demand for adolescent reproductive health?(Faculty of Medicine, University of Kelaniya & Plan International, 2008) Kumarendran, B.; Nandasena, Y.L.S.; Abeysena, C.OBJECTIVE: To describe the expectations of adolescent school children, perceptions of editorial staff and coverage of topics of articles published by selected Sinhala newspapers regarding reproductive health. METHOD: Data were extracted from three national and three tabloid newspapers published during the period May to October 2007. Thematic analysis was done to analyse in-depth interviews of eleven editorial staff. One hundred and thirty four 17-18 year old school children were sampled using stratified (based on stream, sex and urban/rural) purposive sampling from the Gampaha district. Content analysis of 14 Focus Group Discussions (FGD) was done. RESULTS: Ninety two and 58 articles on reproductive health were published in national and tabloid papers respectively during the study period. Pregnancy related issues were the commonest topic addressed followed by reproductive system, commercial sex and sexually transmitted infections (STIs). Most of the published articles included photographs. The majority was written with the guidance of professionally qualified doctors. Although journalists knew the spectrum of reproductive health issues, they were more prone to write on STIs and less on homosexuality, virginity and family planning. The opportunities given for selecting a topic by the press authorities were not satisfactory. Adolescent girls were interested to read about puberty, menstruation, contraception, commercial sex, virginity and STIs and boys were interested to read about homosexuality, heterosexuality, masturbation, STIs, contraception and abortion. Most of the students claimed that they were not provided with adequate RH related knowledge by the newspapers. The way of presenting the articles was not, satisfactory. Most of the adolescents preferred information in simple language (than scientific jargon) in question and answer form without seductive photographs. CONCLUSIONS: Reproductive health coverage by newspapers are not satisfactory. Publishing articles to fulfil the expectations of adolescents would make newspapers a successful mode of RH education.Item Admission patterns and completeness of documentation of clinical features of head injuries in Accident and Emergency Unit of a Sri Lankan hospital for children(College of Community Physicians of Sri Lanka, 2009) Kumarendran, B.; Kumanan, T.INTRODUCTION: Accident and Emergency unit (AEU) of Lady Ridgeway Hospital for Children (LRH) provides outpatient care (OPD) and in-patient care (admissions). OBJECTIVE: To describe the pattern of admissions and completeness of documentation of clinical features of head injury cases admitted to AEU of LRH. METHODS: This was a clinical audit. Data on daily attendance at OPD and admissions from January 2003 - April 2009 were collected using bed head tickets, admission registers and monthly epidemiological reports at LRH. Pattern of admissions from 2003 to 2008 were described on a monthly and those from January to April 2009 on a daily basis. Completeness of documentation of clinical features of head injury was assessed using a check list developed for the purpose for 243 head injury cases admitted during March 2009. RESULTS: During 2003 to 2008, monthly attendance to OPD showed an increasing trend, while a reducing trend was observed in monthly admissions. During January to April 2009, median OPD attendance in morning (8am-2pm), evening (2pm-8 pm) and night (8pm-8am) shifts were 53(IQR:45,59), 35(IQR:32,40) and 15(IQR:12,17) respectively. Median admissions during these shifts was 9(IQR:7,11), 8(IQR:7,10) and 4(IQR:3,6) respectively. Number of medical officers listed for these shifts was 9, 7 and 2 respectively. Most admissions were for males (63.5%; n=445) and commonest age group was 2 to 3 years (26.2%, n=184). Proportion of head injury admissions for March 2009 was 34.7% (243/701). Date, time and signature were documented by, medical officers only in 30.9% (n =75), 10.3% (n=25) and11.1% (n=27) of BHTs. Documentation of presence/absence of selected symptoms on head injury included, nausea or vomiting (80.2%; n=195), unconsciousness (76.1%; n=185), headache (49.4%; n=120), fits (24.7%, n=60) and drowsiness (14.4%, n=35). Documentation of presence/absence of selected signs included site and side of injury in 41.6% (n = 101), diagram on site of injury in 8.6% (n=21), Glasgow Coma Scale (GCS) in 53.1% (n=123), clinical evidence of fracture in 63.8% (n=155) and ENT bleeding in 69.2% (n=178). CONCLUSION: Trend shows a rise in OPD attendance with a decline in IPC admissions. Documentation of clinical features of head injuries needs improvement.Item Sleep patterns among medical undergraduates in Faculty of Medicine, Ragama(College of the Community Physicians of Sri Lanka, 2013) Rajapaksha, R.M.D.S.S.; Ranathunga, R.M.D.C.; Ranaweera, R.K.M.D.S.P.; Randika, J.M.T.; Rathnayake, R.M.N.P.; Rathnayaka, K.M.S.P.; Kumarendran, B.; Pinidiyapathirage, J.M.INTRODUCTION: Sleep pattern has a proven role in the academic performances. OBJECTIVES: To assess sleep patterns and associated factors for different sleep patterns among medical undergraduates in Faculty of Medicine, University of Kelaniya (FMUK). METHODS: This descriptive cross sectional study was conducted among 311 medical undergraduates from second (n= 57), third (n=94), fourth (n=128) and final (n=32) years of FMUK. Data was collected by a group of six fourth year medical students during September 2011. Data were collected using a self-ad ministered questionnaire and analysed using Epi info and SPSS software. RESULTS: Of the 311 respondents, 65% were females. Majority (54.7%) of them stayed in university hostels while 34.1% were in private boarding places and 11.3% in their own houses. Median duration of reported sleep during the weekday was 6.5 hours (Inter Quartile Rage -IQR : 6 to 7) and 8.5 hours [IQR : 7.5 to 9.5) during weekends. Reported quality of sleep varied from good quality (58.5%), trouble in falling asleep (13.8%), nightmares (13.5%), snoring (8.4%) and talking in sleep (5.5%). A single student reported walking in sleep. At least one nap per day was reported among 60%. The most common sleep habit among participants was falling to sleep without knowledge (40.8%) followed by dozing on table while studying (36.3%), studying/reading on bed (33.8%) and drinking alcohol or smoking prior to be (0.6%). However the majority of study participants (44.7%) reported to wake up without difficulty. Decreased sleep was reported prior to examinations among 54% and increased sleep among 23.2%. Nearly half of the participants (46.6%), reported feeling sleepy during most of the lectures. Sleep during lecture was reported to be associated with the topic of lecture (n= 96), presentation skills (n= 249), voice (n= 158), and the appearance (n-35) of lecturer. Good quality of sleep was associated with female sex (p -0.04), students resides at their homes (p = 0.04) and not dozing on the table (p = 0.02). CONCLUSION: Students identified the factors associated with sleep during lectures. Good quality sleep was associated with female sex. residence at home and not dozing on table. Lecturers should consider the factors which are associated with sleep during lectures.