Evaluation of the undergraduate family medicine programme of Faculty of Medicine, University of Kelaniya: quantitative and qualitative student feedback.

BACKGROUND: Worldwide there is an increasing emphasis on the importance of primary care. The ministry of health Sri Lanka issued a directive in 2016 that training of doctors in primary care should be strengthened. Medical students of the Faculty of Medicine, University of Kelaniya follow a 1 month long clinical appointment in family medicine in their fourth year of study. METHODS: Feedback is taken from students on completion of the appointment. Half the students from each group complete a pre tested structured feedback questionnaire that consists of answers to questions based on a likert scale with a space for free comments. The other half provide qualitative feedback. In this evaluation data were gathered from 185 (98%) students from all eight clinical groups throughout the year 2016. Quantitative data were analysed using SPSS version 22. Inductive thematic analysis was used to analyse the qualitative data from the Round Robin activity and free comments from the questionnaire. RESULTS: The qualitative feedback provided a richer indepth overview of student ideas on the appointment compared to the quantitative data. In reflection of a desire for learning to be of relevance students wanted clinically oriented teaching focused on management. They preferred active teaching learning methods such as the opportunity to conduct consultations and receive immediate feedback. Students had a high regard for the teaching sessions by general practitioners at their clinics. The appointment had created an interest in the discipline of family medicine which could have an impact on future choice of career. There were indications to suggest that student attitudes towards patients may have evolved to be more patient centred. Students appreciated the inclusive and low stress ambience of the learning environment. CONCLUSIONS AND RECOMMENDATIONS: Regular evaluation of teaching programmes helps maintain accountability of faculty and paves the way for more student centred teaching through the incorporation of students' views in devising teaching methods. This evaluation found that qualitative feedback provided more descriptive material to reflect on and therefore improve teaching on the programme. It is recommended that more use should be made of qualitative methodologies in programme evaluations.

Comprehensive case management of malaria: Operational research informing policy.

In 2013, the Odisha state Vector Borne Disease Control Programme led a five year operational research project, under programmatic conditions, in close collaboration with several partners. This Comprehensive Case Management Project covered a population of 900,000 across paired control and intervention blocks in four districts, each with different transmission intensities. Key gaps in access to malaria services were identified through household surveys and a detailed situation analysis. The interventions included ensuring adequate stocks of rapid diagnostic tests and antimalarial drugs at the village level, the capacity building of health workers and ASHAs, setting up microscopy centres at the primary health care level, and conducting mass screening and treatment in poorly accessible areas. The programme strengthened the routine health system, and improved malaria surveillance as well as the access to and quality of care. Initially, the programme led to increased case reporting due to improved detection, followed by a decline in malaria incidence. Lessons from the project were then scaled up statewide in the form of a new initiative-Durgama Anchalare Malaria Nirakaran (DAMaN).

Association of high plasma TNF-alpha levels and TNF-alpha/IL-10 ratios with TNF2 allele in severe P. falciparum malaria patients in Sri Lanka.

Plasma levels of pro- and anti-inflammatory cytokines of Plasmodium falciparum-infected patients with severe malaria (SM; n = 62) and uncomplicated malaria (UM; n = 69) from Sri Lanka were assessed. SM patients had significantly higher levels of TNF-alpha (P < 0·01), IL-6 (P < 0·01), and IL-10 (P < 0·05) compared to the UM patients. Plasma IL-2 levels of these patients were undetectable. TNF-alpha levels of a third group of patients with uncomplicated P. falciparum malaria, who were recruited during their fever episodes (UMF; n = 14) were significantly higher than those of the UM patients (P < 0·001) and comparable to SM patients. Plasma IFN-gamma levels of SM patients were higher compared to UM patients, but was not statistically significant. Body temperature in both SM and UMF groups were significantly higher compared to UM group, whereas percentages of parasitemia in all three groups were comparable. Analysis of plasma TNF-alpha levels and the ratio of TNF-alpha/IL-10 in UM (n = 34) and SM (n = 34) patients carrying TNF1 and TNF2 allelic types showed that SM patients carrying TNF2 had significantly higher TNF-alpha levels as well as TNF-alpha/IL-10 ratio compared to UM patients carrying TNF1, UM patients carrying TNF2 and SM patients carrying TNF1 (P < 0·05). These results suggest that the high circulating TNF-alpha levels and the inadequate IL-10 response in the SM patients carrying TNF2 allele could have contributed to the development of severe falciparum malarial disease.

Reporting observational studies of the use of information technology in the clinical consultation. A position statement from the IMIA Primary Health Care Informatics Working Group (IMIA PCI WG).

OBJECTIVES: To develop a classification system to improve the reporting of observational studies of the use of information technology (IT) in clinical consultations. METHODS: Literature review, workshops, and development of a position statement. We grouped the important aspects for consistent reporting into a "faceted classification"; the components relevant to a particular study to be used independently. RESULTS: The eight facets of our classification are: (1) Theoretical and methodological approach: e.g. dramaturgical, cognitive; (2) DATA COLLECTION: Type and method of observation; (3) Room layout and environment: How this affects interaction between clinician, patient and computer. (4) Initiation and Interaction: Who starts the consultation, and how the participants interact; (5) Information and knowledge utilisation: What sources of information or decision support are used or provided; (6) Timing and type of consultation variables: Standard descriptors that can be used to allow comparison of duration and description of continuous activities (e.g. speech, eye contact) and episodic ones, such as prescribing; (7) Post-consultation impact measures: Satisfaction surveys and health economic assessment based on the perceived quality of the clinician-patient interaction; and (8) Data capture, storage, and export formats: How to archive and curate data to facilitate further analysis. CONCLUSIONS: Adoption of this classification should make it easier to interpret research findings and facilitate the synthesis of evidence across studies. Those engaged in IT-consultation research shouldconsider adopting this reporting guide.

Key concepts to assess the readiness of data for international research: data quality, lineage and provenance, extraction and processing errors, traceability, and curation. Contribution of the IMIA Primary Health Care Informatics Working Group.

OBJECTIVE: To define the key concepts which inform whether a system for collecting, aggregating and processing routine clinical data for research is fit for purpose. METHODS: Literature review and shared experiential learning from research using routinely collected data. We excluded socio-cultural issues, and privacy and security issues as our focus was to explore linking clinical data. RESULTS: Six key concepts describe data: (1) DATA QUALITY: the core Overarching concept - Are these data fit for purpose? (2) Data provenance: defined as how data came to be; incorporating the concepts of lineage and pedigree. Mapping this process requires metadata. New variables derived during data analysis have their own provenance. (3) Data extraction errors and (4) Data processing errors, which are the responsibility of the investigator extracting the data but need quantifying. (5) Traceability: the capability to identify the origins of any data cell within the final analysis table essential for good governance, and almost impossible without a formal system of metadata; and (6) Curation: storing data and look-up tables in a way that allows future researchers to carry out further research or review earlier findings. CONCLUSION: There are common distinct steps in processing data; the quality of any metadata may be predictive of the quality of the process. Outputs based on routine data should include a review of the process from data origin to curation and publish information about their data provenance and processing method.

ABO-blood-group types and protection against severe, Plasmodium falciparum malaria.

Although the ABO blood group of the human host has been reported to influence malarial infection, there have been few clinical observations on this effect. A hospital-based, comparative study was therefore performed to investigate the relationship between blood-group type and severe disease i nPlasmodium falciparum malaria. Overall, 243 cases of malaria (163 uncomplicated and 80 severe) and 65 patients with severe, non-malarial infections were studied. In terms of ABO-blood-group composition, the patients with severe malaria were significantly different from the patients with the uncomplicated disease (P<0.001) and also from a population control described previously (P<0.0001). The patients with uncomplicated malaria or severe but non-malarial disease were, however, similar to the population control. The cases of severe malaria were significantly less likely to be of blood group O (P=0.0003), and significantly more likely to be of group AB (P<0.0001), than the patients with nonsevere malaria. It appears that individuals who are of blood-group O are relatively resistant to the severe disease caused by P. falciparum infection.

Cognitive performance at school entry of children living in malaria-endemic areas of Sri Lanka.

In a cross-sectional study, carried out in January 1997 at the beginning of the school year, the impact of repeated attacks of malarial infection on the cognitive performance of children at school entry in moderate malaria-endemic areas of Sri Lanka was investigated. The cognitive performance of 325 schoolchildren in grade 1 (mostly aged 5-6 years) in 2 districts of Sri Lanka which are endemic for malaria (Anuradhapura and Moneragala) was assessed by an entry performance test developed by the National Institute of Education, Sri Lanka. The indices assessed included writing, language and mathematical skills. There was no difference in any of the cognitive performance indices between children from Anuradhapura and Moneragala districts. The scores of most of the indices decreased as the number of malaria infections experienced by a child increased and the ability to identify letters was significantly impaired by the number of malaria infections a child had experienced after controlling for socio-economic and nutritional status. These findings suggests that repeated attacks of malaria in children can have an adverse impact on their development.

The impact of repeated malaria attacks on the school performance of children.

The impact of repeated malarial infections on the school performance of children was investigated in 571 school children 6-14 years of age in a malaria-endemic area in southern Sri Lanka where both Plasmodium falciparum and P. vivax infections are prevalent. Malaria infections confirmed by microscopy were monitored over a six-year period. School performance was assessed by two specially designed, school grade-specific, test papers for Sinhala language and mathematics. The scores for Sinhala language and mathematics for each school term test for the year 1997 were obtained. Malarial infections were a major predictor of children's performance in language and mathematics after controlling for parent's education, monthly family income, and house type. The education of the father predicted language scores but not mathematics scores. A child who experienced more than five attacks of malaria scored approximately 15% less than a child who experienced less than three attacks of malaria. The data suggest that repeated attacks of malaria have an adverse impact on the school performance of children.

The neglected burden of Plasmodium vivax malaria.

We estimate that the global burden of malaria due to Plasmodium vivax is approximately 70-80 million cases annually. Probably approximately 10-20% of the world's cases of P. vivax infection occur in Africa, south of the Sahara. In eastern and southern Africa, P. vivax represents around 10% of malaria cases but < 1% of cases in western and central Africa. Outside of African, P. vivax accounts for > 50% of all malaria cases. About 80-90% of P. vivax outside of Africa occurs in the Middle East, Asia, and the Western Pacific, mainly in the most tropical regions, and 10-15% in Central and South America. Because malaria transmission rates are low in most regions where P. vivax is prevalent, the human populations affected achieve little immunity to this parasite; as a result, in these regions, P. vivax infections affect people of all ages. Although the effects of repeated attacks of P. vivax through childhood and adult life are only rarely directly lethal, they can have major deleterious effects on personal well-being, growth, and development, and on the economic performance at the individual, family, community, and national levels. Features of the transmission biology of P. vivax give this species greater resilience than the less robust Plasmodiumfalciparum in the face of conditions adverse to the transmission of the parasites. Therefore, as control measures become more effective, the residual malaria burden is likely increasingly to become that of P. vivax.

Quantifying genetic and nongenetic contributions to malarial infection in a Sri Lankan population.

Explaining the causes of variation in the severity of malarial disease remains a major challenge in the treatment and control of malaria. Many factors are known to contribute to this variation, including parasite genetics, host genetics, acquired immunity, and exposure levels. However, the relative importance of each of these to the overall burden of malarial disease in human populations has not been assessed. Here, we have partitioned variation in the incidence of malarial infection and the clinical intensity of malarial disease in a rural population in Sri Lanka into its component causes by pedigree analysis of longitudinal data. We found that human genetics, housing, and predisposing systematic effects (e. g., sex, age, occupation, history of infections, village) each explained approximately 15% of the variation in the frequency of malarial infection. For clinical intensity of illness, 20% of the variation was explained by repeatable differences between patients, about half of which was attributable to host genetics. The other half was attributable to semipermanent differences among patients, most of which could be explained by known predisposing factors. Three percent of variation in clinical intensity was explained by housing, and an additional 7% was explained by current influences relating to infection status (e.g., parasitemia, parasite species). Genetic control of Plasmodium falciparum infections appeared to modulate the frequency and intensity of infections, whereas genetic control of Plasmodium vivax infections appeared to confer absolute susceptibility or refractoriness but not intensity of disease. Overall, the data show consistent, repeatable differences among hosts in their susceptibility to clinical disease, about half of which are attributable to host genes.

Spatial targeting of interventions against malaria.

Malaria transmission is strongly associated with location. This association has two main features. First, the disease is focused around specific mosquito breeding sites and can normally be transmitted only within certain distances from them: in Africa these are typically between a few hundred metres and a kilometre and rarely exceed 2-3 kilometres. Second, there is a marked clustering of persons with malaria parasites and clinical symptoms at particular sites, usually households. In localities of low endemicity the level of malaria risk or case incidence may vary widely between households because the specific characteristics of houses and their locations affect contact between humans and vectors. Where endemicity is high, differences in human/vector contact rates between different households may have less effect on malaria case incidences. This is because superinfection and exposure-acquired immunity blur the proportional relationship between inoculation rates and case incidences. Accurate information on the distribution of malaria on the ground permits interventions to be targeted towards the foci of transmission and the locations and households of high malaria risk within them. Such targeting greatly increases the effectiveness of control measures. On the other hand, the inadvertent exclusion of these locations causes potentially effective control measures to fail. The computerized mapping and management of location data in geographical information systems should greatly assist the targeting of interventions against malaria at the focal and household levels, leading to improved effectiveness and cost-effectiveness of control.

TNFalpha*2 marks high risk of severe disease during Plasmodium falciparum malaria and other infections in Sri Lankans.

We have investigated the association between alleles of the genes for tumour necrosis factor-alpha (TNF-alpha) and TNF-beta and severity of disease during malarial (Plasmodium falciparum) and other infections in the Sri Lankan population. Patients were categorized as having either (i) uncomplicated malaria, (ii) severe and complicated malaria, or (iii) severe and complicated infection in which a diagnosis of malaria had been excluded. For all the patients, as well as for a group of matched healthy controls, TNF-alpha and TNF-beta allelic types were identified using the polymerase chain reaction (PCR) and allele-specific oligonucleotide probes and restriction enzyme digestion. The odds in favour of carrying the TNFalpha*2 allele, mainly of the heterozygous genotype (TNFalpha*1,*2), were two to three times greater among individuals with severe disease, of either malarial or other infectious origin, relative to healthy controls or to those with uncomplicated malarial infections. No significant risk was associated with either of the alleles of TNF-beta.

Emergency cervical cerclage: A review of 15 cases.

BACKGROUND: This report describes our experience with 15 consecutive emergency cervical cerclages performed at Al Yamamah Hospital. PATIENTS AND METHODS: Between February 1994 and February 1997, 15 women with singleton pregnancies between 18 and 26 weeksâ gestation, with a cervical dilatation between 3 and 10 cm and with membrane prolapse, underwent emergency cerclage after excluding labor, placental abruption and intrauterine infection. The membranes were replaced using the technique of overfilling the urinary bladder and then performing McDonaldâs cerclage. All the patients received prophylactic antibiotics and tocolytics. RESULTS: Of the 15 pregnancies, two aborted and 13 ended in live births. Nine of the live births survived, giving a survival rate of 60%. The mean extension of pregnancy in the survivors was 11.5 weeks (range 7.6-15.2 weeks), and the gestational age at delivery ranged from 30-38+ weeks. In six of the patients, suture failed to prolong the pregnancy long enough to produce a âtake-home baby.â All the failures were due to subclinical intrauterine infection. There was no maternal morbidity. CONCLUSION: Emergency cerclage should be considered as a management option in women with painless cervical dilatation and membrane prolapse in the midtrimester.

Early oral intake after caesarean section performed under general anaesthesia.

This study assesses the outcome and benefits of initiation of oral intake 4 hours after caesarean section done under general anaesthesia. After uncomplicated sections, 207 healthy women were alternately assigned either to start oral intake 4 hours after operation, with concurrent stoppage of infusions (n = 106) or to receive 'standard'postoperative care (n = 101). Early oral intake was not associated with increase in gastrointestinal morbidity. Compared with the control group the early intake group had a shorter mean time to first flatus and to first bowel evacuation; initiated breast feeding earlier; ambulated more and were more satisfied. Both groups had similar urine output in the first 24 hours. The nurse's work load decreased when they looked after the early intake group. It is concluded that post-caesarean mothers could be adequately hydrated orally after discontinuing infusions in the early postoperative period without apparent harm and with benefit.