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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Detection of human strongyloidiasis among patients with a high risk of complications attending selected tertiary care hospitals in Colombo, Sri Lanka using molecular and serological diagnostic tools(BioMed Central, 2024-10) Weerasekera, C.J.; Gunathilaka, N.; Menike, C.; Anpahalan, P.; Perera, N.; De Silva, N.R.; Wickremasinghe, R.BACKGROUND Strongyloidiasis a neglected tropical disease is known to cause severe disease among immunosuppressed and has not been studied extensively in Sri Lanka. Parasitological diagnostic approaches based on faecal microscopy and culture often fail to detect low-intensity infections. This study investigates the presence of strongyloidiasis among selected immunocompromised individuals using parasitological, molecular and serological techniques.METHODS Adult patients with immunocompromising conditions admitted to three tertiary care hospitals in Sri Lanka were recruited. A faecal sample and 2 ml of venous blood were collected. The faecal samples were subjected to direct faecal smear and cultures (agar plate, charcoal and Harada-Mori) and polymerase chain reaction (PCR) using species specific primers designed for Strongyloides stercoralis. The presence of Strongyloides IgG antibodies was tested in the collected serum samples using DRG Strongyloides IgG enzyme-linked immunosorbent assay (ELISA) kits. The PCR products of the positive samples were sequenced using Sanger sequencing method.RESULTS A total of 260 patients were recruited to this study, out of which 160 provided faecal samples and 122 provided blood samples. Out of the 160 faecal samples, none were positive for strongyloidiasis by direct smear, charcoal and Harada-Mori cultures. Only one sample (0.6%) was positive by agar plate culture. Out of the 123 samples subjected to PCR, 14 (11.4%), including the culture positive patient, were positive for S. stercoralis. Sequencing results of the PCR products indicated 100% similarity to S. stercoralis. Out of the 122 serum samples subjected to ELISA, 20 (16.4%), including the culture positive patient, were positive for Strongyloides IgG antibodies. However, sociodemographic, exposure factors, clinical features were not significantly associated with the presence of strongyloidiasis infection.CONCLUSIONS Strongyloidiasis is present among the immunocompromised population in Sri Lanka, even in the absence of a significant relationship with associated factors. It is advisable to screen such patients with highly sensitive tests such as PCR for early diagnosis and treatment.Item Content analysis of policy documents related to non-communicable diseases prevention and control in Sri Lanka: a developing country in the South-East Asia(F1000 Research, 2024) Talagala, I.; Abeysena, C.; Wickremasinghe, R.BACKGROUND: Health policies form the foundation for provisioning best level care and are important for all stakeholders including patients and healthcare providers. Health policy analysis and evaluation allows policy makers to improve an existing policy, terminate a non-effective policy and to successfully implement future policies. The objective was to assess the coherence between the two local policy documents on NCD prevention and control in Sri Lanka, the national NCD policy (NCD policy) and the multisectoral action plan (MSAP), and to assess the consistency of MSAP with the global action plan for NCDs. METHODS: The content analysis of the NCD policy and MSAP of Sri Lanka was conducted based on the modified criteria developed to the ‘Analysis of determinants of policy impact’ model, by two reviewers independently. Coherence between MSAP and the global NCD action plan were also assessed by two reviewers independently. Consensus for discrepancy was achieved through discussion. RESULTS: Accessibility was the strongest criteria for the NCD policy, while, resources and obligations were the weakest. Goals and monitoring and evaluation criteria were the strongest in the MSAP. Requirement for improvement were identified in policy background, goals, monitoring and evaluation, and public opportunities for the NCD policy. Accessibility, policy background, resources, public opportunities and obligations require further improvement in the MSAP. The MSAP is well coherent with the global road map for NCD prevention and control. CONCLUSION: Policy documents related to NCD prevention and control in Sri Lanka are coherent with the global action plan, while, there are areas within the local policy documents that need to be improved to enhance the coherence between the local documents. Lessons learnt by this activity need to be utilized by Sri Lanka and other countries to improve the uniformity between the NCD policy documents within the country as well as internationally.Item Initial response to SARS-CoV-2 (COVID-19) outbreak in Sri Lanka; views of public health specialists through an International Health Regulations lens(Public Library of Science, 2023) Caldera, A.; Wickremasinghe, R.; Newby, G.; Perera, R.; Mendis, K.; Fernando, D.The COVID-19 pandemic affected Sri Lanka despite having developed an International Health Regulations (IHR) steering committee in 2016 and a national action plan for health security following the Joint External Evaluation in 2018. Many steps were taken to improve the disaster management skills of healthcare workers even before the COVID-19 outbreak. We interviewed seven public health specialists to obtain their views on the country's response to the pandemic. A thematic analysis was conducted, leading to the emergence of three major themes and seven subthemes. The major themes included health security preparedness; COVID-19 management; and effects of COVID-19. The subthemes were; preparedness prior to pandemic and gaps in the preparedness (under health security preparedness); dual burden for the curative sector, strategies to reduce transmission and barriers to managing COVID-19 (under COVID-19 management) and negative and positive effects of COVID-19 (under effects of COVID-19). When COVID-19 reached Sri Lanka, healthcare workers, border control authorities and those involved with infectious disease control were overwhelmed by the magnitude of the pandemic. Healthcare workers' hesitation to work amidst the pandemic due to fear of infection and possible transmission of infection to their families was a major issue; the demand for personal protective equipment by health workers when stocks were low was also a contributory factor. Lockdowns with curfew and quarantine at government regulated centers were implemented as necessary. Perceptions of the public including permitting healthcare workers to perform field public health services, logistical barriers and lack of human resources were a few of the barriers that were expressed. Some persons did not declare their symptoms, fearing that they would have to be quarantined. The pandemic severely affected the economy and Sri Lanka relied on donations and loans to overcome the situation. Pandemic also brought about innovative methods to maintain and upgrade health service provision. Individuals with non-communicable diseases received their regular medications through the post which reduced their risk of being infected by visiting hospitals. Improvement of laboratory services and quarantine services, a reduction of acute respiratory infections and diarrhoeal diseases, improved intersectoral coordination and public philanthropic response were other positive effects.Item Measuring resilience among Sri Lankan healthcare workers: validation of the brief resilience scale in Sinhalese and Tamil languages(Sage Publishing, 2023) Baminiwatta, A.; Fernando, R.; Gadambanathan, T.; Jiyatha, F.; Sasala, R.; Kuruppuarachchi, L.; Wickremasinghe, R.; Hapangama, A.Resilience is the capacity for adaptation and “bouncing back” in the face of adversity.1,2 It protects against mental health problems such as depression, anxiety, and stress and improves well-being. 3 During the COVID-19 pandemic, there was a growing need for studies on protective factors in mental health, such as resilience, particularly among healthcare workers. 4 Psychometric assessment of resilience is a prerequisite for research in this area. A review of 19 resilience scales found a wide variation in their psychometric properties, with all of them posing some challenges. 5 However, the authors noted that the Resilience Scale for Adults, Brief Resilience Scale (BRS), and the Connor-Davidson Resilience Scale had the finest psychometric ratings. BRS may have an exceptional place in behavioral research because other resilience scales tend to assess resources that promote resilience rather than resilience itself. BRS is probably the only measure to assess resilience in its most basic meaning—the ability to “bounce back.” 2 Furthermore, among resilience scales, BRS is short and, therefore, would generate better response rates in research. As BRS was not available in local languages, its validation into Sinhalese and Tamil languages was needed to enable research on resilience in Sri Lanka. METHODS: Approval was obtained from the Ethics Review Committee. The procedure for questionnaire translation followed the recommendations of Beaton et al. (2000). 6 Firstly, BRS was translated into each local language (Sinhalese and Tamil) independently by two bilingual experts, and a consensus translation was prepared. The translated version was back-translated into English by two independent bilingual translators. They were compared with the original BRS for semantic, idiomatic, experiential, and conceptual equivalence by a group of experts comprising several Sinhalese- and Tamil-speaking psychiatrists, bilingual experts, and a methodologist. A few phrases in the original English version, such as “bounce back” and “snap back,” were replaced with conceptually equivalent phrases in the local languages. Face and content validity were discussed, and a consensus translation was prepared. After conducting a pre-test and cognitive debriefing with a purposive sample of 10 healthcare workers for each language, and further minor modifications, the translated scales were administered to 150 Sinhalese- and 110 Tamil-speaking healthcare workers (nurses, doctors, and other categories), after obtaining informed consent (see Table S1 for the sociodemographic profiles; the translated questionnaires are provided as supplementary files). Confirmatory factor analysis (CFA) was used to test the model fit for the one-factor structure of BRS, 2 using the following fit indices: comparative fit index (CFI), Tucker Lewis index (TLI), standardized root mean square residual (SRMR), and root mean square error of approximation (RMSEA). Depression, anxiety, and Stress Scale -21 (DASS-21) was administered to test expected inverse correlations with resilience. RESULTS: According to CFA, the six-item BRS formed a unitary construct, with satisfactory model fit for both the Sinhalese (CFI = 0.99, TLI = 0.99, RMSEA = 0.09, SRMR = 0.05) and Tamil versions (CFI = 0.98, TLI = 0.97, RMSEA = 0.14, SRMR = 0.07). Factor loadings of individual items ranged from 0.59 to 0.86 in the Sinhalese and 0.61 to 0.82 in the Tamil version (see Table S2 for item-level statistics). Cronbach alpha of the Sinhalese and Tamil BRS were 0.82 and 0.80, respectively, indicating good internal consistency. Removal of any single item did not significantly improve internal consistency. The Sinhalese BRS score had significant negative correlation with depression (r = –0.29, P = 0.002), anxiety (r = –0.27, P = 0.005), and stress (r = –0.20, P = 0.033), whereas the Tamil BRS score had significant negative correlation with anxiety (r = –0.18, P = 0.028) and stress (r = –0.25, P = 0.002) but not with depression. DISCUSSION: Our findings support the construct validity and internal reliability of the BRS as a measure of resilience. The one-factor structure proposed by the original developers 2 and replicated in subsequent studies 7 was observed in the present study. BRS has been previously translated and validated in several languages, including German, Polish, Spanish and Dutch.7–10 Similar to the observations in the original validation sample 2 and the Spanish validation, 7 resilience, as measured using BRS, showed significant inverse correlations with depression, anxiety, and stress in the present analysis. This provided further support for its construct validity through hypothesis testing. The absence of a significant inverse correlation of the Tamil BRS score with depression may be due to the comparatively small sample size available for the Tamil validation. Although our findings were based on healthcare workers, we expect the scale’s validity to extend to the general population. Thus, the Sinhalese and Tamil BRS can be used in future large-scale research on resilience in Sri Lanka. As high rates of mental health issues were reported among healthcare workers in Sri Lanka during the COVID-19 pandemic, 11 and the country is currently going through an unprecedented economic crisis, it is important to take measures to enhance resilience among Sri Lankan healthcare workers. The availability of a validated tool in both Sinhalese and Tamil languages would enable research on mental health and resilience among culturally-diverse populations in Sri Lanka, which would provide useful information to guide health policy development. Limitations of this study include the small sample sizes and the lack of test-retest reliability assessments to ascertain the temporal stability of the BRS scores.Item A malaria death due to an imported Plasmodium falciparum infection in Sri Lanka during the prevention of re-establishment phase of malaria(BioMed Central, 2023) Seneviratne, S.; Fernando, D.; Chulasiri, P.; Gunasekera, K.; Thenuwara, N.; Aluthweera, C.; Wijesundara, A.; Fernandopulle, R.; Mendis, K.; Wickremasinghe, R.BACKGROUND: Sri Lanka has maintained a rigorous programme to prevent the re-establishment of malaria ever since the disease was eliminated in October 2012. It includes efforts to sustain case surveillance to ensure early diagnosis and management of malaria. Yet, in April of 2023 the death occurred of an individual with imported malaria. CASE PRESENTATION: The deceased was a 37-year-old Sri Lankan male who returned to Sri Lanka on the 10th of April after a business trip to several countries including Tanzania. He was febrile on arrival and consulted three Allopathic Medical Practitioners in succession in his home town in the Western Province of Sri Lanka, over a period of 5 days starting from the very day that he arrived in the country. Malaria was not tested for at any of these consultations and his clinical condition deteriorated. On the evening of 14th of April he was admitted to the medical intensive care unit of a major private hospital in the capital city of Colombo with multiple organ failure. There, on a request by the treating physician blood was tested for malaria and reported early the next morning as Plasmodium falciparum malaria with a high parasitaemia (> 10%). The patient died shortly after on the 15th of April before any anti-malarial medication was administered. The deceased had been a frequent business traveller to Africa, but with no past history of malaria. He had not taken chemoprophylaxis for malaria on this or previous travels to Africa. DISCUSSION: The patient's P. falciparum infection progressed rapidly over 5 days of arriving in Sri Lanka leading to severe malaria without being diagnosed, despite him seeking healthcare from three different Medical Practitioners. Finally, a diagnosis of malaria was made on admission to an intensive care unit; the patient died before anti-malarial medicines were administered. CONCLUSIONS: This first death due to severe P. falciparum malaria reported in Sri Lanka after elimination of the disease was due to the delay in diagnosing malaria.Item Availability of rehabilitation services for communication disorders in Sri Lanka: a cross-sectional survey(BMJ Publishing Group Ltd, 2023) Caldera, A.V.; Wickremasinghe, R.; Munasinghe, T.U.; Perera, K.M.N.; Muttiah, N.; Tilakarathne, D.; Peiris, M.K.R.R.; Thamilchelvan, E.; Sooriyaarachchi, C.; Nasma, M.N.; Manamperige, R.M.; Ariyasena, A.D.K.; Sumanasena, S.P.OBJECTIVES: To describe the rehabilitation services available for communication disorders in Sri Lanka and to estimate the adequacy of the services in provinces and districts of the country. SETTING: The study considered government and private institutions, which provide rehabilitation services for communication disorders in Sri Lanka. PARTICIPANTS: Institutions providing services of speech-language pathologists, audiologists and audiology technicians in Sri Lanka. PRIMARY AND SECONDARY OUTCOME MEASURES: We investigated the number of government hospitals and private institutions, which provide speech-language pathology and audiology services in Sri Lanka as the primary outcome measure. A number of speech-language pathologists, audiologists and audiology technicians working in the institutions were obtained from records and institution-based inquiries to identify the adequacy of the services in the country as the secondary outcome measure. RESULTS: Of the 647 government hospitals that provide free healthcare services in the country, 45 and 33 hospitals had speech and language therapy and audiology units, respectively. Government hospitals do not have audiologists but only have audiology technicians. The number of speech and language therapists and audiology technicians in the government sector per 100 000 population in the country was 0.44 and 0.18, respectively. There were wide variations in specialist to population ratio between districts. 77 private centres provide speech therapy services in 15 out of the 25 districts; 36 private centres provide audiological evaluations in 9 districts. CONCLUSIONS: The number of specialist speech and language therapists and audiologists is not sufficient to provide adequate rehabilitation services for communications disorder for the Sri Lankan population. Not recruiting audiologists to the government sector affects the management of hearing impairment in the affected.Item Prediction equation for physical activity energy expenditure in 11-13-year-old Sri Lankan children(MDPI Publishing, 2023) Dabare, P.; Wickramasinghe, P.; Waidyatilaka, I.; Devi, S.; Kurpad, A.V.; Samaranayake, D.; de Lanerolle-Dias, M.; Wickremasinghe, R.; Hills, A.P.; Lanerolle, P.This study aimed to develop a regression equation to predict physical activity energy expenditure (PAEE) using accelerometry. Children aged 11-13 years were recruited and randomly assigned to validation (n = 54) and cross-validation (n = 25) groups. The doubly labelled water (DLW) technique was used to assess energy expenditure and accelerometers were worn by participants across the same period. A preliminary equation was developed using stepwise multiple regression analysis with sex, height, weight, body mass index, fat-free mass, fat mass and counts per minute (CPM) as independent variables. Goodness-of-fit statistics were used to select the best prediction variables. The PRESS (predicted residual error sum of squares) statistical method was used to validate the final prediction equation. The preliminary equation was cross-validated on an independent group and no significant (p > 0.05) difference was observed in the PAEE estimated from the two methods. Independent variables of the final prediction equation (PAEE = [0.001CPM] - 0.112) accounted for 70.6% of the variance. The new equation developed to predict PAEE from accelerometry was found to be valid for use in Sri Lankan children.Item Cross-cultural adaptation and validation of the Liebowitz Social Anxiety Scale (LSAS-SR) Tamil Version(The Sri Lanka Medical Association, 2022) Hapangama, A.; Premaratne, I.; Thilaxshan, T.; Gadambanathan, T.; Wickremasinghe, R.Background: Despite being the third most prevalent psychiatric disorder, social anxiety disorder remains under-diagnosed due to multiple reasons. Although many screening instruments are available in the English language, to date no instrument has been translated into Tamil. Objective: To translate and validate the Liebowitz Social Anxiety Scale (LSAS-SR) into Tamil among a group of Sri Lankan university students whose mother tongue is Tamil. Method: The process of translation and validation involved standard procedures. DSM- 5 was used as the gold standard to diagnose social anxiety disorder. As part of the psychometric study, test-retest reliability and analysis of items for internal consistency of the instrument were assessed. Results: A cut off of55.5had the optimum sensitivity and specificity for the Tamil version of the LSAS-SR. The Cronbach’s alpha between the avoidance subscaletotal and the fear subscale total was 0.860 while the figures for Cronbach’s alpha between the total score and fear subscale total score and the avoidance subscale total score were 0.880 and 0.855, respectively. The test- retest reliability correlation coefficients for the fear subscale, avoidance subscale and the total score were 0.890, 0.925 and 0.918, respectively (p<0.001 for all). Conclusions: The cut off score of 55.5had the optimum sensitivity and specificity for the LSAS-SR Tamil version. It had good internal consistency and test-retest reliability. Further studies will enable the assessment of the prevalence of social phobia and investigation of cultural and environmental factors associated with social phobia in Sri Lanka.Item Malaria elimination does not cost more than malaria control: Sri Lanka a case in point(BioMed Central, London, 2022) Mendis, K.; Wickremasinghe, R.; Premaratne, R.Background: Malaria was endemic in Sri Lanka for centuries and was eliminated in 2012. It is widely assumed that the costs of elimination are generally greater than that of control. The costs of malaria elimination in Sri Lanka with that of malaria control in the past using periods in which starting transmission dynamics were similar were compared. Methods: The expenditure of the Anti-Malaria Campaign (AMC), total and by budget category, during 2002-2010 is compared with that of malaria control during the period 1980-1989, using regression analyses and the Mann Whitney U statistic. Results: The expenditure on malaria control and malaria elimination was similar ranging from 21 to 45 million USD per year when adjusted for inflation. In both periods, external funding for the malaria progamme constituted around 24% of the total budget; during the control phase in the 1980s, external funds came from bilateral agencies and were disbursed in accordance with government budget guidelines. In the elimination phase in the 2000s, most of external funding was from the Global Fund and had flexibility of disbursement. In the 1980s, most funds were expended on commodities-insecticides, diagnostics and medicines and their delivery; in the elimination phase, they were spent on programme management, human resources, technical assistance and monitoring and evaluation; monitoring and evaluation was not a budget line in the 1980s. Although the cost per case of malaria was considerably higher during the elimination phase than in the control phase, expenditure was not on individual cases but on general systems strengthening. Conclusion: Malaria elimination in Southeast Asia may not require more funding than malaria control. But sustained funding for an agile programme with flexibility in fund utilization and improved efficiencies in programme management with stringent monitoring and evaluation appears to be critically important.Item Effects of indoor air pollution on the development of children under five years of age in Sri Lanka(MDPI, 2022) Ranathunga, N.; Perera, P.; Nandasena, S.; Sathiakumar, N.; Kasturiratne, A.; Wickremasinghe, R.Air pollution is a multifaceted environmental toxin affecting the Central Nervous System (CNS) through diverse pathways. The CNS of young children is particularly susceptible to the detrimental effects of toxins, as brain development continues postnatally with the formation of interneuronal connections, glial cell proliferation and myelination of axons. Indoor air pollution (IAP) from solid fuel combustion is more harmful than outdoor air pollution. Numerous air pollutants hazardous to health are released during the burning of unprocessed biomass. The primary source of fuel in Sri Lanka for cooking is biomass, mainly wood. In this study, we evaluated the influence of IAP resulting from biomass combustion on the neurodevelopment of children. In a cohort of children under five years living in a semi-urban area of Sri Lanka, neurodevelopment was assessed using Denver II developmental screening test. Air quality levels were measured (Carbon Monoxide (CO) and Particulate Matter 2.5 (PM2.5)) in a subsample. There were significantly high levels of CO and PM2.5 in the ambient air of households using biomass as the primary fuel for cooking. Children living in these households had a significantly higher number of children with ‘suspect’ developmental assessment scores in the language, social behavior and play and gross motor development domains.