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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Prevalence and correlates of cardiometabolic multimorbidity among hypertensive individuals: a cross-sectional study in rural South Asia-Bangladesh, Pakistan and Sri Lanka.(BMJ Publishing Group Ltd, 2019) Feng, L.; Jehan, I.; de Silva, H.A.; Naheed, A.; Farazdaq, H.; Hirani, S.; Kasturiratne, A.; Ranasinha, C.D.; Islam, M.T.; Siddiquee, A.T.; Jafar, T.H.OBJECTIVE: To determinate the prevalence and correlates of cardiometabolic multimorbidity (CMM), and their cross-country variation among individuals with hypertension residing in rural communities in South Asia. DESIGN: A cross-sectional study. SETTING: Rural communities in Bangladesh, Pakistan and Sri Lanka. PARTICIPANTS: A total of 2288 individuals with hypertension aged ≥40 years from the ongoing Control of Blood Pressure and Risk Attenuation- Bangladesh, Pakistan and Sri Lanka clinical trial. MAIN OUTCOME MEASURES: CMM was defined as the presence of ≥2 of the conditions: diabetes, chronic kidney disease, heart disease and stroke. Logistic regression was done to evaluate the correlates of CMM. RESULTS: About 25.4% (95% CI 23.6% to 27.2%) of the hypertensive individuals had CMM. Factors positively associated with CMM included residing in Bangladesh (OR 3.42, 95% CI 2.52 to 4.65) or Sri Lankan (3.73, 95% CI 2.48 to 5.61) versus in Pakistan, advancing age (2.33, 95% CI 1.59 to 3.40 for 70 years and over vs 40-49 years), higher waist circumference (2.15, 95% CI 1.42 to 3.25) for Q2-Q3 and 2.14, 95% CI 1.50 to 3.06 for Q3 and above), statin use (2.43, 95% CI 1.84 to 3.22), and higher levels of triglyceride (1.01, 95% CI 1.01 to 1.02 per 5 mg/dL increase). A lower odds of CMM was associated with being physically active (0.75, 95% CI 0.57 to 0.97). A weak inverted J-shaped association between International Wealth Index and CMM was found (p for non-linear=0.058), suggesting higher risk in the middle than higher or lower socioeconomic strata. CONCLUSIONS: CMM is highly prevalent in rural South Asians affecting one in four individuals with hypertension. There is an urgent need for strategies to concomitantly manage hypertension, cardiometabolic comorbid conditions and associated determinants in South Asia.Item Patient perspectives on hypertension management in health system of Sri Lanka: a qualitative study.(BMJ Publishing Group Ltd, 2019) Perera, M.; de Silva, C.K.; Tavajoh, S.; Kasturiratne, A.; Luke, N. V.; Ediriweera, D.S.; Ranasinha, C.D.; Legido-Quigley, H.; de Silva, H.A.; Jafar, T.H.INTRODUCTION:Uncontrolled hypertension is the leading risk factor for mortality globally, including low-income and middle-income countries (LMICs). However, pathways for seeking hypertension care and patients' experience with the utilisation of health services for hypertension in LMICs are not well understood.OBJECTIVES:This study aimed to explore patients' perspectives on different dimensions of accessibility and availability of healthcare for the management of uncontrolled hypertension in Sri Lanka.SETTING:Primary care in rural areas in Sri Lanka.PARTICIPANTS:20 patients with hypertension were purposively sampled from an ongoing study of Control of Blood Pressure and Risk Attenuation in rural Bangladesh, Pakistan, Sri Lanka.METHOD:We conducted in-depth interviews with patients. Interviews were audio-recorded and transcribed into local language (Sinhala) and translated to English. Thematic analysis was used and patient pathways on their experiences accessing care from government and private clinics are mapped out.RESULTS:Overall, most patients alluded to the fact that their hypertension was diagnosed accidentally in an unrelated visit to a healthcare provider and revealed lack of adherence and consuming alternatives as barriers to control hypertension. Referring to the theme 'Accessibility and availability of hypertension care', patients complained of distance to the hospitals, long waiting time and shortage of medicine supplies at government clinics as the main barriers to accessing health services. They often resorted to private physicians and paid out of pocket when they experienced acute symptoms attributable to hypertension. Considering the theme 'Approachability and ability to perceive', the majority of patients mentioned increasing public awareness, training healthcare professionals for effective communication as areas of improvement. Under the theme 'Appropriateness and ability to engage', few patients were aware of the names or purpose of their medications and reportedly missed doses frequently. Reminders from family members were considered a major facilitator to adherence to antihypertensive medications. Patients welcomed the idea of outreach services for hypertension and health education closer to home in the theme 'Things the patients reported to improve the system'.CONCLUSION:Patients identified several barriers to accessing hypertension care in Sri Lanka. Measures recommended improving hypertension management in Sri Lanka including public education on hypertension, better communication between healthcare professionals and patients, and efforts to improve access and understanding of antihypertensive medications.TRIAL REGISTRATION NUMBER:NCT02657746.Item A Composite symptom score using frequency and severity correlates better to an objective measure of Gastro-Oesophageal Reflux Disease (GERD) than one scoring frequency of symptoms alone(American Gastroenterological Association(AGA) Institute, Published by Elsevier Inc., 2008) Amarasiri, L.; Pathmeswaran, A.; Ranasinha, C.D.; de Silva, H.J.INTRODUCTION: The prevalence of GERD is increasing. Community prevalence in Sri Lanka is unknown. There is lack of a practical screening instrument to use in an epidemiological setting. OBJECTIVE : To develop a practical clinical score to screen for GERD in the community and assess whether a score using both symptom frequency and severity correlated better with an objective measure of GERD than one using only symptom frequency. METHODOLOGY: A cross-sectional validity study was performed in 100 GERD patients and 150 healthy controls comparable in age and gender. Ethical clearance was granted. GERD was diagnosed by upper gastro-intestinal endoscopy, including patients with all grades of oesophagitis. All subjects faced a GERD-specific interviewer-administered questionnaire with seven upper gastro-intestinal symptoms (heartburn, acid regurgitation, chest/abdominal pain, abdominal distension, dysphagia, cough, belching). Each symptom was graded using a 5-item Likert scale for frequency (never, monthly, 2-4 times per week, weekly, daily) and a 4-item scale for severity (no effect, mild, moderate, severe) and two scores generated. Score 1 being the sum of frequency of symptoms while score 2 was the sum of products of frequency and severity of each symptom. All GERD patients underwent 24h ambulatory pH monitoring. Face and content validity were assessed by expert consultation and literature review, internal consistency by Cronbach alpha statistics, reliability by intra class correlation coefficient estimation and concurrent validity by comparison of scores with 24 hour pH monitoring values as the gold standard. Cut-off values were determined by constructing receiver-operating characteristic curves. RESULTS: For both scores, mean scores of cases were significantly higher than controls (p<0.001) Cut-off score for score 1 was ≥ 10.50 (sensitivity 92.0%; specificity 78.7%; area under the curve 0.937 respectively). Cut-off score for score 2 was ≥ 12.50 (sensitivity 90.0%; specificity 78.0%; area under the curve 0.929 respectively). Intra class correlation coefficient for score 1 and 2 were 0.94 and 0.82 respectively. There was good correlation between both symptom scores and 24-h pH metry parameters (Spearman rank correlation, p=0.01), but score 2 showed a significantly better correlation (correlation of Total reflux time pH<4 with score 1 and score 2 was 0.491 and 0.651; p=0.001, and of Demeester score with score 1 and score 1 was 0.590 and 0.747; p<0.001). CONCLUSION: Our GERD questionnaire is valid, reliable and showed better correlation with an objective test when both severity and frequency of symptoms were scored rather than frequency of symptoms alone.Item The Prevalence of reflux oesophagitis in adult asthmatics(Wiley- Blackwell, 2009) Amarasiri, L.; Ranasinha, C.D.; de Silva, H.J.BACKGROUND/PURPOSE: Asthma and gastro-oesophageal reflux disease are known to be associated. The severity of asthma is related to the degree of reflux. This relationship has been little studied in South Asia. METHODS: Thirty asthmatics underwent a reflux symptom assessment using a validated questionnaire assessing 7 upper gastro-intestinal (UGI) symptoms graded on a 5-point Likert scale (Amarasiri LD 2009). They further underwent UGI endoscopy. RESULTS: All asthmatics had mild stable asthma. 20 of the 30 asthmatics had apositive GORD symptom score. 27 asthmatics consented to UGI endoscopy. The grade of oesophagitis was classified using Savary Miller criteria. 10 of the 27 asthmatics had evidence of mucosal damage (see Table 1). There was no correlation between the grade of oesophagitis and the GORD score (r = 0.025; P = 0.896, Spearman Rank correlation). CONCLUSIONS: The prevalence of reflux oesophagitis in asthmatics was 37%. There was no association of severity of oesophagitis with symptoms. Both these findings are consistent with the global data, but have not previously been described in a South Asian population.Item Management of yellow oleander poisoning (YOP) with multiple-dose activated charcoal: a randomized placebo controlled trial(Sri Lanka Medical Association, 2003) de Silva, H.A.; Fonseka, M.M.D.; Pathmeswaran, A.; Alahakone, D.G.S.; Ratnatilake, G.A.; Gunatilake, S.B.; Ranasinha, C.D.; Lalloo, D.G.; Aronson, J.K.; de Silva, H.J.Abstract AvailableItem Alcohol consumption and tobacco smoking in an urban adult Sri Lankan population(Sri Lanka Medical Association, 2008) Kasturiratne, A.; Pinidiyapathirage, M.J.; Perera, H.K.K.; Fernando, E.D.P.S.; Ranasinha, C.D.; Edirisinghe, P.A.S.; Makaya, M.; Kato, N.BACKGROUND: Data on the prevalence and patterns of alcohol consumption and smoking in the general population in Sri Lanka are scarce. Objective: To describe patterns of alcohol use and smoking in an urban adult population in Sri Lanka. DESIGN, SETTING AND METHODS: A random sample of the general population aged between 35-65 years, resident in the Ragama Medical Officer of Health area was interviewed to obtain drinking and smoking habits. RESULTS: Among 2985 subjects [males 45.5%; mean age 52.7 years (SD7.8)], 1156(39.7%) reported ever use of alcohol, and 892(29.7%) reported current use. 58.8% of males and 5.7% of females were current drinkers. 190(14%) males and 12(0.7%) females consumed alcohol above the weekly safe limit (>14 units for males, >7 units for females). The median duration of alcohol use among ever users was 18 years (interquartile range 10-25), and current users was 20 years (interquartile range 1,0-25). The commonest type of alcohol consumed was arrack (n=492), followed by beer (n=217). 60.2% of males and 2.1% of females reported ever smoking, 483(16.2%) were current smokers. 35.1% of males and 0.5% of females were current smokers. The median duration of smoking was 20 years among both ever smokers (interquartile range 10-27.3), and current smokers (interquartile range 15-30). Most (55.3%) smoked cigarettes, only 36(4.2%) smoked beedi. The median pack years of current smokers was 4,5 (interquartile range 2-10). CONCLUSION: Lifetime and current use of alcohol and smoking are high among males. Focused interventions are required to reduce current rates among males and to maintain low rates reported by females.Item Peristaltic dysfunction in asthma is secondary to increased Gastro-Oesophageal Reflux(American Gastroenterological Association(AGA) Institute, Published by Elsevier Inc., 2010) Amarasiri, L.; Pathmeswaran, A.; Ranasinha, C.D.; de Silva, A.P.; Dassanayake, A.S.; de Silva, H.J.BACKGROUND: Vagal dysfunction and prolonged intra-oesophageal acidification cause oesophageal hypomotility. Asthmatics have ineffective oesophageal motility, but demonstrate increased vagal activity. Whether oesophageal hypomotility in asthmatics is a primary abnormality or secondary to pathological gastro-oesophageal reflux is unclear. Our aim was to investigate the relationship of oesophageal motility and gastro-oesophageal reflux (GOR)to vagal function in asthmatics. METHODS: Thirty consecutive mild, stable asthmatics (ATS criteria) and 30 healthy volunteers underwent 24-hour ambulatory dual-sensor oesophageal monitoring, stationary oesophageal manometry and autonomic function testing. They also underwent gastro-oesophageal reflux disease (GORD) symptom assessment. Twenty seven of the thirty asthmatics underwent gastroscopy. A parasympathetic autonomic function score was calculated from vagal function tests (valsalva manouvre, heart rate variation to deep breathing, heart rate and blood pressure response to standing from a supine position) and correlated with gastro-oesophageal function parameters. RESULTS: Age and sex of asthmatics (mean age(SD), 34.8 years (8.4); 60% female) and controls (mean age(SD), 30.9 years (7.7); 50% female) were comparable. Asthmatics had a higher frequency and severity of GORD symptoms and 10/27 (39%) had oesophageal mucosal damage. Twenty two (69%) asthmatics showed a hypervagal response and none had a hyperadrenergic response. Manometrically, LOS and UOS parameters were similar in the two groups, but 14 asthmatics had ineffective oesophageal motility. Asthmatics with higher GORD symptom scores had a significantly lower percentage of peristaltic contractions and a higher percentage of simultaneous contractions than controls. They also had higher total and upright oesophageal acid contact times in the proximal oesophagus than those with low symptom scores. All reflux parameters were significantly higher in asthmatics. Twenty (66.7%) asthmatics had abnormal distal acid reflux and 22 (73.3%) had abnormal proximal acid reflux. Asthmatics also had significantly prolonged proximal and distal acid clearance times than controls. There was no association between parasympathetic function and either oesophageal motility or reflux parameters. CONCLUSIONS: Asthmatics with mild, stable asthma have abnormal oesophageal motility and pathological GOR. The asthmatics did not show any evidence of vagal dysfunction nor did the vagal function score correlate with oesophageal motility parameters. It seems likely that the peristaltic dysfunction is secondary to damage due to GOR and not primary vagal dysfunction.Item Gastric motility following ingestion of a solid meal in a cohort of adult asthmatics(The Korean Society of Neurogastroenterology and Motility, 2013) Amarasiri, W.A.D.L.; Pathmeswaran, A.; de Silva, A.P.; Dassanayake, A.S.; Ranasinha, C.D.; de Silva, H.J.BACKGROUND/AIMS: Asthmatics have abnormal esophageal motility and increased prevalence of gastroesophageal reflux disease (GERD). The contribution of gastric motility is less studied. We studied gastric myoelectrical activity, gastric emptying (GE) and their association with GERD symptoms and vagal function in adult asthmatics. METHODS: Thirty mild, stable asthmatics and 30 healthy controls underwent real-time ultrasonography and 1 hour pre- and post-prandial cutaneous electrogastrography, following a test meal (480 kcal, 60% carbohydrate, 20% protein, 20% fat and 200 mL water). The percentage of normal slow waves and arrhythmias, dominant frequency and power, frequency of antral contractions, gastric emptying rate (GER) and antralmotility index (MI) was calculated. Twenty-seven asthmatics underwent gastroscopy and in all subjects GERD symptoms were assessed by a validated questionnaire. Vagal function parameters were correlated with gastric motility parameters. RESULTS: The asthmatics (37% male; 34.8 ± 8.4 years) and controls (50% male; 30.9 ± 7.7 years) were comparable. None had endoscopicgastric pathological changes. Twenty asthmatics described GERD symptoms. Twenty-two (73.3%) asthmatics showed a hypervagal response. Compared to controls, asthmatics had delayed GER and lower MI, lower percentage of normal gastric slow waves, more gastric dysrythmias and failed to increase the post-prandial dominant power. There was no correlation of GE and cutaneous electrogastrography parameters with presence of GERD symptoms or with vagal function. CONCLUSIONS: Asthmatics showed abnormal gastric myoelectrical activity, delayed GE and antral hypomotility in response to a solid mealcompared to controls. There was no association with vagal function or GERD symptom statusItem Response of the airways and autonomic nervous system to acid perfusion of the esophagus in patients with asthma: a laboratory study(BioMed Central, 2013) Amarasiri, D.L.; Pathmeswaran, A.; de Silva, H.J.; Ranasinha, C.D.BACKGROUND: Gastro-esophageal reflux disease (GERD) predisposes to airway disease through a vagally-mediated esophago-bronchial reflex. This study investigates this vagal response to esophageal acid perfusion. METHODS: 40 asthmatics with mild stable asthma participated. Each subject underwent spirometry and autonomic function testing (valsalva maneuver, heart rate response to deep breathing and to standing from supine position) four times: a) before intubation, b) after intubation, and then immediately after perfusion with, in random order, c) concentrated lime juice solution (pH 2--3) and d) 0.9% saline. Subjects were blinded to the solution perfused. RESULTS: Asthmatics were of mean (SD) age 34.3 years (1.3), and 67.5% of them were females. pH monitoring demonstrated that 20 subjects had abnormal reflux and 20 did not. In each group 10 subjects had a positive GERD symptom score. Following perfusion with acidcompared to saline, all subjects showed significant decreases in FEV1 and PEFR and significant increases in the mean valsalva ratio and heart rate difference on deep breathing from baseline values, but no changes in FVC or heart rate ratio on standing. There were no significant differences in any of the parameters between subjects with and without reflux. CONCLUSIONS: Acid stimulation of the distal esophagus results in increased parasympathetic activity and concomitant broncho-constriction in asthmatics irrespective of their reflux state. This strengthens the hypothesis that GER triggers asthma-like symptoms through a vagally mediated esophago-bronchial reflex and encourages a possible role for anti-cholinergic drugs in the treatment of reflux-associated asthmaItem Esophageal motility, vagal function and gastroesophageal reflux in a cohort of adult asthmatics(BioMed Central, 2012) Amarasiri, D.L.; Pathmeswaran, A.; Dassanayake, A.S.; de Silva, A.P.; Ranasinha, C.D.; de Silva, H.J.BACKGROUND: Asthmatics are known to have esophageal hypomotility. Vagal hypofunction and prolonged intra-esophageal acidification cause esophageal hypomotility. The contribution of gastroesophageal reflux (GER) and vagal function to esophageal motility in asthmatics is unclear. We studied the relationship between esophageal motility, GER and vagal function in a cohort of adult asthmatics. METHODS: Thirty mild, stable asthmatics (ATS criteria) and 30 healthy volunteers underwent 24-hour ambulatory esophageal monitoring, manometry, autonomic function testing and GER symptom assessment. 27 asthmatics underwent gastroscopy. A vagal function score calculated from 3 tests (valsalva maneuver, heart rate response to deep breathing and to standing from supine position) was correlated with esophageal function parameters. RESULTS: Asthmatics (mean age 34.8 (SD 8.4), 60% female) had more frequent GERD symptoms than controls (mean age 30.9 (SD 7.7), 50% female). 10/27 asthmatics had esophageal mucosal damage, 22 showed hypervagal response, none had a hyperadrenergic response. 14 asthmatics had ineffective esophageal motility. Higher GERD-score asthmatics had significantly fewer peristaltic and more simultaneous contractions than controls, and higher esophageal acid contact times than those with lower scores. All reflux parameters were significantly higher and acid clearance time prolonged in asthmatics than controls (p < 0.001, Mann-Whitney U test). There was no correlation between vagal function score and esophageal function parameters. CONCLUSIONS: A cohort of adult asthmatics was found to have peristaltic dysfunction and pathological GER, but otherwise normal esophageal motility. The peristaltic dysfunction seems to be associated with vagal hyperreactivity rather than vagal hypofunction