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Background - Gas station attendants are exposed to benzene, toluene and xylenes (BTX) from fuels. The aim was to study the association between this exposure and spirometry parameters in gas station attendants and office workers as controls.Method – In 44 male gas station attendants and 38 office workers in the Gampaha district of Sri Lanka spirometry was performed according to the guidelines of the American Thoracic Society (ATS). Pre- and post-shift end-exhaled air samples were collected from a subset of both study groups and analysed for BTX by gas chromatography-mass spectrometry.Results – Among gas station attendants (n = 20) median pre-/post-shift exhaled air concentrations (ng/L) were: benzene 11.23/21.05; toluene 10.39/22.19; m/p-xylene 1.62/2.45; o-xylene 1.01/1.45. For controls (n = 11) these values were (ng/L): 9.47/12.04, 3.13/4.00, 1.52/1.25 and 0.50/0.48, respectively. The peak expiratory flow rate (PEFR) and %-predicted PEFR were significantly lower among gas station attendants compared to controls (p 1/FVC ratio were not different but in gas station attendants benzene in post-shift samples was associated with %-predicted FVC (Spearman’s correlation coefficient of -0.469, p = 0.037). In addition, the %-predicted FVC was lower in gas station attendants working ≥ 5 years compared to those who worked

Background Data on alcoholic fatty liver (AFL) is limited. We investigated patterns of alcohol use and AFL, among urban, adult, Sri Lankans. Methods The study population (selected by age-stratified random sampling) was screened in 2007 (35–64 years) and re-evaluated in 2014. On both occasions they were assessed by structured-interview, anthropometric measurements, liver-ultrasound, biochemical and serological tests. AFL was diagnosed on ultrasound criteria, ‘unsafe’ alcohol consumption (Asian standards: males > 14units, females > 7units per-week) and absence of hepatitis B/C markers. Controls were unsafe alcohol consumers who had no fatty liver on ultrasound. Results 2985/3012 (99%) had complete data for analysis. 272/2985 (9.1%) were unsafe-drinkers in 2007 [males-270; mean-age-51.9, SD-8.0 years]. 86/272 (31.6%) had AFL [males-85; mean-age-50.2, SD-8.6 years]. Males [p 23kg/m2 [OR 3.5, p

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 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 MetS.

BackgroundThere is limited data on prevalence and outcome of prediabetes (PDM) and incidence of type 2 diabetes mellitus (T2DM) from South Asia. We investigated this in an urban, adult population in Sri Lanka that was followed-up for seven years. Methods The study population (selected by age-stratified random sampling from the community) was initially screened in 2007 and re-evaluated in 2014. On both occasions they were assessed by structured interview, anthropometric measurements, liver ultrasound, biochemical and serological tests. Results In the original cohort of 2985 recruited in 2007 [54.8% women, median age (IQR) 53 (47-59)], 737 had T2DM [baseline prevalence 24.7% (95% CI: 23.1–26.2)] and 525 (17.7%) had PDM [54.1% women, median age (IQR) 56 (50-60)]. 2148/2985 (71.6%) attended follow-up in 2014 [57.5% women; median (IQR) 60 (54–66) years], which included 1650 who did not have T2DM in 2007. By 2014, 436/1650 (27.6%) had developed new T2DM [annual incidence 3.9% (95% CI:3.0-4.9). On logistic regression, PDM, central obesity, dyslipidemia and non-alcoholic fatty liver disease (NAFLD) showed significant association with incident T2DM. Of 525 with PDM in 2007, 365 (69.5%) presented for follow up in 2014; 147 (40.3%) remained in PDM, 201 (55.1%) had progressed to T2DM and 17 (4.6%) had reverted to normal. Annual conversion rate of PDM to T2DM was 7.9%. Increase in waist circumference and decrease in HDL predicted progression to T2DM. ConclusionsPresence of components of the metabolic syndrome at baseline predicted new-onset T2DM and conversion of PDM to T2DM. Targeted lifestyle interventions are essential for individuals with metabolic risk to prevent incident T2DM.

Sri Lankans made over 100 million visits to public and private outpatient departments (OPD) during 2015, which is estimated to double in 2027. However, these visits have no records, either paper or electronic. Medical records are essential to provide continuity of care, and computer-based medical records were identified as essential technology in 1990 by the Institute of Medicine. The main initiative of the Ministry of Health addresses either OPD health information system or inward system, but it is limited to a few selected hospitals. There are no electronic health records (EHR) that can track patients as they crisscross between different primary care providers in public and private sectors, which is the normal behaviour of the majority of our patients. This paper gives a snapshot of the current healthcare system in Sri Lanka, notes the existing projects related to primary care health information systems, briefly reviews the current status of the global primary care EHR and describes our solution of a generic, cloud-based, open source EHR for use across public and private sectors focusing on a patient-centred electronic ‘personal health record’. We opted to modify a time-tested software solution OpenEMR - https://www.open-emr.org/ OpenEMR is a free and open source, ONC certified, electronic health records and medical practice management application featuring fully integrated electronic health records, practice management, scheduling, electronic billing, internationalization, and multi-lingual support. Sri Lanka OpenEMR (SLOEMR) is now used at the University Family Medicine Centre, Faculty of Medicine, University of Kelaniya at Ragama. Paper medical records of more than a decade were converted to the electronic format. We are in the planning process of piloting the SLOEMR in the Ragama Medical Officer of Health Area with a population of 70,000, with a single electronic record for each person across all private and public sector healthcare providers.

Introduction: A substantial population of never-smokers have Chronic Obstructive Pulmonary Disease (COPD). There is paucity of data on non-smoking related COPD in Sri Lanka. Aims and Objectives: To describe the prevalence, characteristics and associated risk factors of COPD in never-smokers in Sri Lanka. Methods: Adults, >18 years, randomly sampled from all provinces of the country, completed the Burden of Lung Disease (BOLD) survey. Pre- and post-bronchodilator spirometry was performed and COPD was classified according to GOLD criteria. Smoking status, education level, BMI, hospitalization due to childhood respiratory disease, doctor diagnosis of asthma, current asthma, resident area, exposure to domestic biomass, dust, and passive smoking was assessed. Results: Of 1987 participants (45.1% male), 144 (7.2% (95%CI: 6.1%-8.4%)) had COPD. Of 124 who responded to the question “have you ever smoked?”, 70 (56.5%) were never-smokers. 85.7% of them were >40 years, 62.8% were females, most had a normal BMI and >90% had a low educational level. Over 90% had mild-moderate COPD; more males had Stage II+ disease than females. 17.1%, 11.4%, 10% and 12.9% reported doctor-diagnosed asthma, current asthma, childhood hospitalization due to respiratory disease, and passive smoking, respectively. 58.6% of COPD never-smokers resided in urban areas, 32.9% reported dust exposure and 32.9% used firewood as cooking fuel. Majority of kitchens were inside houses and had chimneys. Conclusions: A significant proportion of Sri Lankan COPD patients were never-smokers. Exposure to dusty environment, firewood use, residing in urban areas, low education and being older or female increased the risk of COPD in never-smokers, but not significantly.

Introduction: Obstructive sleep apnoea (OSA) is the commonest sleep related breathing disorder worldwide, but there is only limited community level data on the risk of OSA from South Asian countries. Aims and objectives: This study assessed the community prevalence of persons at high-risk for OSA among Sri Lankan adults. Methods: A randomly selected sample of adults from 7 (out of 9) provinces of Sri Lanka was screened using the Berlin Questionnaire (BQ). BQ has 3 categories related to snoring severity (category 1), excessive day time somnolence (category 2) and history of hypertension or obesity (category 3). Individuals were classified as high or low risk according to the category score. Results: One thousand six hundred and eight adults (46.2% male) were screened, and 270 were classified as high risk for OSA {16.8%; 95% CI 14.9%-18.6% (15.1% in males; 18.3% in females, p >0.05)}. Of the high risk individuals, 239 (88.5%) were category 1 positive, 142 (52.6%) category 2 positive and 202 (74.8%) category 3 positive. 49/577 (8.5%) among persons = or 40 years were at high risk. 10.3% of the adults had a BMI=30 (5.7% of males, 14% of females p Conclusion: The prevalence of high risk for OSA in this Sri Lankan community survey is lower than that reported from Western countries and did not show a gender-related difference.

Background/Aim: Clinical observations indicate that asthma and atopic diseases is common in Sri Lankan children. The aim of this study is to study change in prevalence of wheezing, exercise wheezing, allergic rhinitis and eczema from 2001 to 2013 in Sri Lankan children. Methods: A cross-sectional survey using the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire was conducted in children aged 6-7 and 13–14 years from 9 provinces in Sri Lanka, in 2001 and in 2013. The change in prevalence of wheeze, allergic rhinitis, eczema and exercise-wheezing in the past 12 months was assessed. Results: In 2001, 3362 6-7 year olds (49.6% male) and 3140 13-14 year olds (46.1% male) participated in the survey. In 2013, 2848 6-7 year olds (44.7% male) and 3381 13-14 year olds (46.9% male) participated. In 6-7 year olds, the prevalence of current wheeze, declined from 27.5% to 18.1% from 2001 to 2013. Among the current wheezers, exercise-wheeze, rhinitis and eczema, in 2001 and 2013 were 53.9% and 35.6%, 82.5% and 75.2%, and 72.9% and 63.9%, respectively. In 13-14 year olds, the prevalence of current wheeze, declined from 23.0% in 2001 to 17.5% in 2013. Among the current wheezers, exercise-wheeze, rhinitis and eczema, in 2001 and 2013 were 72.3% and 70.2%, 78.9% and 77.7%, and 79.1% and 72.2%, respectively. Conclusion: The prevalence of current wheeze and associated atopic diseases show a decreasing trend from 2001 to 2013. Access to treatment may be a reason for the decline. It is important to further monitor this trend to assess whether it will continue or change direction.

Introduction: Chronic Obstructive Pulmonary Disease (COPD) is characterized by progressive airflow limitation not fully reversible, and is a major cause of morbidity and mortality worldwide. Global and South Asian estimated prevalences are 11.7% and 6-7% respectively. The prevalence of COPD in Sri Lanka has not been documented previously. Aims and objectives: This study assessed the prevalence of COPD, associated risk factors and co-morbidities in Sri Lankan adults >40 years of age. Methods: A randomly selected sample of Sri Lankan adults from 3 rural and 4 urban areas from 7 provinces completed the Burden of Lung Disease (BOLD) survey. Pre- and post-bronchodilator spirometry was used to diagnose and classify COPD according to GOLD criteria. The association of COPD with known risk factors: smoking, passive smoking, dusty job, use of firewood and comorbidities: diabetes mellitus, past history of tuberculosis, hypertension, heart disease, stroke and lung cancer was assessed. Results: A total of 1239 subjects (43.4% male) completed the study. The overall prevalance of COPD was 10.5% (95% CI 8.8%-12.2%) of whom the severity was stage 1 in 85.0%, stage 2 in 12%, stage 3 in 1.5% and stage 4 in 1.4%. The urban and rural prevalences were 6.4% and 4.1% respectively. The male prevalence was 16.4% [95% CI 13.2%-19.5%] compared to 6.0% [95% CI 4.2%-7.7%] in females. 57.1% of the COPD patients were non-smokers. In males, the presence of COPD was significantly associated with a history of smoking and a past history of tuberculosis. In females, COPD was not associated with any risk factor or any comorbidity. Conclusion: The prevalence of COPD in Sri Lankan adults is similar to global and regional prevalences.

Background This study investigated incidence and risk factors for NAFLD among an adult cohort with 7-years follow-up. Methods The study population (age-stratified random sampling, Ragama MOH area) was screened initially in 2007 (aged 35-64 years) and re-evaluated in 2014 (aged 42-71 years). On both occasions assessed by structured interview, anthropometric measurements, liver ultrasound, biochemical and serological tests. NAFLD was diagnosed on ultrasound criteria, safe alcohol consumption and absence of hepatitis B/C markers. Non-NAFLD controls did not have any ultrasound criteria for NAFLD. An updated case-control genetic association study for 10 selected genetic variants and NAFLD was also performed. Results Out of 2985 of the original cohort, 2148 (72.0%) attended follow-up [1238(57.6%) women; mean-age 59.2(SD-7.6) years] in 2014, when 1320 (61.5%) were deemed NAFLD subjects. Out of 778 who initially did not have NAFLD and were not heavy drinkers throughout follow up, 338(43.4%) [221(65.4%) women, mean-age 57.8(SD-8.0) years] had developed NAFLD after 7-years (annual incidence-6.2%). Central obesity [OR=3.82(95%-CI 2.09-6.99)], waist increase >5% [OR=2.46(95%-CI 1.20-5.05)] overweight [OR=3.26(95%-CI 1.90-5.60)], weight gain 5-10% [OR=5.70(95%-CI 2.61-12.47)], weight gain >10% [OR=16.94(95%- CI 6.88-41.73)], raised plasma triglycerides [OR=1.96(95%-CI 1.16-3.29)] and diabetes [OR=2.14(95%-CI 1.13-4.06)], independently predicted the development of incident NAFLD in multivariate analysis. The updated genetic association study (1362-cases, 392-controls) showed replicated association (p=0.045,1-tailed) with NAFLD at a candidate locus: PNPLA3(rs738409). Conclusion In this community cohort study, the annual incidence of NAFLD was 6.2%. Incident NAFLD was associated with general and central obesity, raised triglycerides and diabetes, and showed a tendency of association with PNPLA3 gene polymorphisms. This article is protected by copyright. All rights reserved.

Reform of the medical curriculum is occurring around the world. Two recurring themes are an emphasis on introducing a broader perspective on health and the need to impart knowledge and skills in new information technology. Groups of medical students from Canada, Sri Lanka, Norway, United Kingdom and Hungary took part in a 10-week 'electronic elective course' on the cultural and economic aspects of drugs and the pharmaceutical industry. The course involved a survey of local pharmacies to identify the most commonly prescribed drugs and their prices, study of selected readings on the cultural and economic aspects of pharmaceuticals, and discussion among participants of the issues raised. Communication was mainly by email discussion between participants. The drugs used and their prices varied substantially, especially between, but also within, the participating countries. The logistical and technical aspects of the course generally worked well. Student evaluation was generally positive, with participants part...

Background Perceived risks of road injury can reduce opportunities for social participation and physical activity among older people. These risks are particularly important in low and middle income countries undergoing rapid motorization. This study aimed to explore older peoples’ perceptions of opportunities and challenges for social participation, particularly including transport-related risks, in the Moneragala district of Sri Lanka. The Provincial Council of this region has initiated a process to make the district age and disability-friendly. Methods This qualitative study involved four focus group discussions (8–10 participants in each) with community-dwelling older people aged 60 years and older. The research sought to identify perceived physical and social environmental facilitators and challenges that influenced ease of access to the local and regional destinations that are most important to respondents. Results Places frequently visited by older people were the hospital, temple, Sunday fair, community hall and bank. The commonest modes of transportation used by respondents included the public bus, walking, and hired three-wheeled vehicles. Participants identified several challenges that increased their exposure to injuries and perceptions of safety including poor road conditions, lack of a disability-friendly transportation system, poor accessibility and negative attitudes of the wider community. Conclusions The perceptions and experiences reported by older Sri Lankans emphasise the need to develop and implement road designs, infrastructure and age- and disability- friendly transportation systems; public policies that enhance accessibility; and raise public awareness of the needs and aspirations of older people. These efforts would have the potential to promote resilient communities that enable vulnerable communities at risk of social exclusion, particularly older people, to live the lives they value.

Background The WHO recognises pesticide poisoning to be the single most important means of suicide globally. Pesticide self-poisoning is a major public health and clinical problem in rural Asia, where it has led to case fatality ratios 20-30 times higher than self-poisoning in the developed world. One approach to reducing access to pesticides is for households to store pesticides in lockable "safe-storage" containers. However, before this approach can be promoted, evidence is required on its effectiveness and safety. Methods/Design A community-based cluster randomised controlled trial has been set up in 44,000 households in the North Central Province, Sri Lanka. A census is being performed, collecting baseline demographic data, socio-economic status, pesticide usage, self-harm and alcohol. Participating villages are then randomised and eligible households in the intervention arm given a lockable safe storage container for agrochemicals. The primary outcome will be incidence of pesticide self-poisoning over three years amongst individuals aged 14 years and over. 217,944 person years of follow-up are required in each arm to detect a 33% reduction in pesticide self-poisoning with 80% power at the 5% significance level. Secondary outcomes will include the incidence of all pesticide poisoning and total self-harm. Discussion This paper describes a large effectiveness study of a community intervention to reduce the burden of intentional poisoning in rural Sri Lanka. The study builds on a strong partnership between provincial health services, local and international researchers, and local communities. We discuss issues in relation to randomisation and contamination, engaging control villages, the intervention, and strategies to improve adherence. Trial Registritation The trial is registered on ClinicalTrials.gov ref: NCT1146496 (http://clinicaltrialsfeeds.org/clinical-trials/show/NCT01146496).

Objective: To identify factors associated with early outcome after stroke in Sri Lankan patients. Background Majority of strokes and stroke-related deaths occur in the developing world, but little is known about the factors affecting stroke outcomes in developing countries. Design/Methods: We analyzed data from a prospective hospital-based Sri Lankan stroke registry (Ragama Stroke Registry). All patients with acute stroke admitted to the Colombo North Teaching Hospital (Ragama, Sri Lanka) over a one year period were studied. Factors associated with poor early outcome were identified by multivariate logistic regression. Poor early outcome was defined as severe disability at discharge [modified Barthel index (BI) of 0-12], severe handicap at discharge [modified Rankin score (mRS) of 3-5] or in-hospital death. Results: We studied 547 patients with stroke - 59.4% males; mean age (SD) 64(12.8) years. Of them, 460 patients (87.2%) had ischaemic strokes. 379 patients (69.3%) had severe disability at discharge [BI 0-12], and 435 (79.6%) had severe handicap at discharge [mRS 3-5]. There were 26 (4.7%) in-hospital deaths. Age ≥65 years, female sex and stroke severity (NIHSS score) were independent predictors of both disability [BI] and handicap [mRS] at discharge. Stroke severity was the only independent predictor of in-hospital mortality. High waist circumference (overweight/ obese) and a history of previous transient ischaemic attack were negatively associated with poor outcome. Type of stroke (ischaemic/ haemorrhagic), delay to hospital admission, previous stroke, systolic blood pressure on admission, prior antiplatelet therapy and presence of common stroke risk factors were not associated with functional outcome. Conclusions: Older age, female sex and stroke severity were the main predictors of poor early outcome after stroke in Sri Lankan patients with stroke. Supported by: University of Kelaniya, Sri Lanka and Japan International Cooperation Agency, Japan. Disclosure: Dr. Ranawaka has nothing to disclose. Dr. Alexander has nothing to disclose. Dr. Nawaratne has nothing to disclose. Dr. Liyanage has nothing to disclose. Dr. Kulatunga has nothing to disclose. Dr. Tissera has nothing to disclose. Dr. Cooray has nothing to disclose. Dr. Kasthuriratne has nothing to disclose. Dr. Wickramasinghe has nothing to disclose.