A discrete choice experiment to elicit preferences for a chronic disease screening programme in Queensland, Australia.

OBJECTIVE: Patient-centred care, increasingly highlighted in healthcare strategies, necessitates understanding public preferences for healthcare service attributes. We aimed to understand the preferences of the Australian population regarding the attributes of chronic disease screening programmes. STUDY DESIGN: The preferences were elicited using the discrete choice experiment (DCE) methodology. METHODS: A DCE was administered to a sample of the Australian general population. Respondents were asked to make choices, each offering two hypothetical screening scenarios defined by screening conduct, quality and accuracy of the test results, cost to the patient, wait time and source of information. Data were analysed using a panel mixed multinomial logit model. RESULTS: A strong preference for highly accurate screening tests and nurse-led screenings at local health clinics was evident. They expressed disutility for waiting time and out-of-pocket costs but were indifferent about the source of information. Their preference for a nurse-led programme was highlighted by the fact that they were willing to pay $81 and $88 to get a nurse-led programme when they were offered a general practitioner-led and a specialist-led programme, respectively. Furthermore, they were willing to pay $32 to reduce a week of waiting time and $205 for a 95% accurate test compared to a 75% accurate test. Preferences remained consistent irrespective of the respondent's place of residence. CONCLUSIONS: Our findings highlight the importance of diagnostic test accuracy and nurse-led service delivery in chronic disease screening programmes. These insights could guide the development of patient-centric services by enhancing test accuracy, reducing waiting times and promoting nurse-led care models.

Adaptation and Validation of a Sinhala version of the Radbound Oral Motor Inventory (ROMP) for Parkinson's disease.

Background: The Radboud Oral Motor Inventory for Parkinson's disease (ROMP) is a patient-rated assessment measuring patients' perceptions of speech, swallowing, and saliva control among patients with idiopathic Parkinson's disease (IPD). Objective: The present study was carried out to adapt and validate the Sinhala version of the ROMP questionnaire in a Sinhala-speaking patient cohort diagnosed with IPD. Materials and Methods: The study population consisted of patients diagnosed with IPD attending a tertiary care neurology clinic at the National Hospital of Sri Lanka. ROMP was translated from English to Sinhala, and an expert committee verified its content. Construct validity was assessed by correlating the Sinhala ROMP scores with the subscales in speech, salivation, and swallowing of the Unified Parkinson's Disease Rating Scale and with five-point Likert-type scale to assess dysarthria, dysphagia, and drooling by a speech and language therapist. Test-retest reproducibility was assessed by repeating the questionnaire in 2 weeks. Results: A cohort of 21 patients was evaluated (male to female ratio = 2.5:1, mean age was 58.8 [±8.3] years). The Spearman's correlations between ROMP and the Likert-type scale assessment, that is, speech r = 0.85 (P < 0.01), swallowing r = 0.86 (P < 0.01), and drooling r = 0.88 (P < 0.01), and subscales of the UPDRS were statistically significant, that is, speech r = 0.75 (P < 0.01), swallowing r = 0.96 (P < 0.01), and salivation r = 0.94 (P < 0.01). Reproducibility of the three domains and total intraclass correlation coefficients indicated a high level of agreement in test-retest reproducibility (range: 0.98-0.99). The three subdomains of the instrument also had excellent internal consistency (total Cronbach's α = 0.99). Conclusion: The Sinhala version of ROMP has proved to be a good assessment tool for dysphagia, dysarthria, and drooling in the early stage of IPD patients.

Emerging pesticides responsible for suicide in rural Sri Lanka following the 2008-2014 pesticide bans.

BACKGROUND: Sri Lanka has reduced its overall suicide rate by 70% over the last two decades through means restriction, through a series of government regulations and bans removing highly hazardous pesticides from agriculture. We aimed to identify the key pesticide(s) now responsible for suicides in rural Sri Lanka to provide data for further pesticide regulation. METHODS: We performed a secondary analysis of data collected prospectively during a cluster randomized controlled trial in the Anuradhapura district of Sri Lanka from 2011 to 16. The identity of pesticides responsible for suicides were sought from medical or judicial medical notes, coroners' records, and the person's family. Trend analysis was done using a regression analysis with curve estimation to identify relative importance of key pesticides. RESULTS: We identified 337 suicidal deaths. Among them, the majority 193 (57.3%) were due to ingestion of pesticides while 82 (24.3%) were due to hanging. A specific pesticide was identified in 105 (54.4%) of the pesticide suicides. Ingestion of carbosulfan or profenofos was responsible for 59 (56.2%) of the suicides with a known pesticide and 17.5% of all suicides. The increasing trend of suicides due to carbosulfan and profenofos over time was statistically significant (R square 0.846, F 16.541, p 0.027). CONCLUSION: Ingestion of pesticides remains the most important means of suicides in rural Sri Lanka. The pesticides that were once responsible for most pesticide suicides have now been replaced by carbosulfan and profenofos. Their regulation and replacement in agriculture with less hazardous pesticides will further reduce the incidence of both pesticide and overall suicides in rural Sri Lanka.

Construct validity and reliability of EQ-5D-3L for stroke survivors in a lower middle income setting

Introduction: Stroke is a leading disease accounting for burden of chronic NCDs especially in lower and lower-middle income (LMI) settings. Quality of Life (QOL) is considered as an important facet of determination of success of patient management. EQ-5D-3L is a generic QOL tool. It provides an index score amalgamating responses for five descriptive questions and a visual analogue scale (VAS) value. Objectives: To assess the validity and reliability of EQ-5D-3L for stroke patients in Sri Lanka, which is a LMI setting. Methods: A descriptive cross sectional study was done among 100 stroke survivors among whom 50 each were managed at an ambulatory setting and an in-ward setting. A second wave of data collection was done for reliability analysis among one half of participants. The validity of EQ-5D-3L was assesses with five a-priori hypotheses. Reliability was assessed with test-retest method and with internal consistency. Non parametric Mann Whitney U test and Spearman correlation coefficients were used in the analysis. Results: The EQ-5D index scores had significant positive correlation with SF-36 domain scores (p<0.001). The EQ-5D VAS scores had significant positive correlation with SF-36 domain scores (p<0.01). Index and VAS values of the EQ-5D were proved to be valid in known-group comparison (p<0.001). Participants reporting some kind of impairment for EQ-5D-3L dimensions had lower SF-36 domain scores. All the kappa values in the analysis of test-retest method were significant (p<0.001). For the VAS score, the Spearman correlation coefficient in test-reter analysis was 0.993 (p<0.001). Cronbach's alpha value was 0.928. Conclusions: and Recommendations EQ-5D-3L questionnaire demonstrates construct validity and a is a reliable toolin measuring QOL among stoke survivors in Sri Lanka.

Noncaseating suppurative granulomatous lymphadenitis in adult onset Still's disease - a diagnostic dilemma in a tuberculosis-endemic region: a case report.

BACKGROUND: Lymphadenopathy is not an uncommon presentation of adult onset Still's disease: it is present in up to two thirds of patients with adult onset Still's disease. The characteristic appearance of lymphadenopathy is described as intense, paracortical immunoblastic hyperplasia. Changes in light microscopy may resemble lymphoma, but immunohistochemistry reveals a benign polyclonal B cell hyperplasia. CASE PRESENTATION: We describe a 67-year-old Sri Lankan woman who manifested relapsing prolonged fever, raised inflammatory markers, arthralgia, myalgia, transient skin rash, and cervical lymphadenopathy histologically characterized by noncaseating granulomatous adenitis with central suppuration. Due to the fact of high prevalence of tuberculosis in the region, an extensive diagnostic evaluation was done to exclude the possibility of extrapulmonary tuberculosis; unsuccessful therapeutic trials of complete antituberculosis regime reliably excluded the possibility of tuberculosis and strengthened the diagnostic validity. Disease flares were characterized by systemic inflammatory response syndrome with immediate clinical and laboratory response to corticosteroids. After systematic diagnostic workup which ruled out possible malignant, rheumatic, or autoimmune diseases and infections previously described as causes of granulomatous adenitis, our patient was diagnosed as having adult onset Still's disease based on Yamaguchi criteria. She required a trial of indomethacin followed by methylprednisolone pulse therapy and long-term maintenance steroid therapy without steroid-sparing immunosuppressive agents or biological disease-modifying antirheumatic drugs. She achieved full disease remission in 3 months. Reevaluation after 6 months and 1 year did not reveal residual disease activity. CONCLUSIONS: To the best of our knowledge this is the first report of suppurative noncaseating granulomatous lymphadenitis attributed to adult onset Still's disease among Asian or South Asian ethnicities and it is also rarely reported among Europeans and North Americans. It is an extremely challenging situation to diagnose Still's disease with granulomatous lymphadenitis where tuberculosis is highly prevalent. This case highlights the importance of consideration of adult onset Still's disease as a potential diagnosis in a compatible clinical context in the presence of noncaseating granulomatous adenitis and indicates that one should not be misled into a diagnosis of tuberculosis by the fact of the high prevalence of tuberculosis, however, the exclusion of other diagnoses is a prerequisite.

Dermotropic Leishmania donovani in Sri Lanka: visceralizing potential in clinical and preclinical studies.

The visceralizing potential of apparently dermotropic Leishmania donovani in Sri Lanka (L. donovani-SL) was investigated through long-term follow-up of cutaneous leishmaniasis (CL) patients and in vivo and in vitro experimental infection models. CL patients (n = 250) treated effectively with intra-lesional antimony therapy were followed-up six monthly for 4 years. There was no clinical evidence of visceralization of infection (VL) during this period. Infection of BALB/c mice with L. donovani-SL (test) through intra-dermal route led to the development of cutaneous lesions at the site of inoculation with no signs of systemic dissemination, in contrast to the observations made in animals similarly infected with a visceralizing strain of L. donovani-1S (control). Cytokine (IL-10, IFN-γ) release patterns of splenocytes and lymph node cell cultures derived from mice primed with experimental infections (with either test or control parasites) revealed significantly high IFN-γ response associated with test mice with CL, while prominent IL-10 levels were observed in association with control mice with VL. Furthermore, diminished infection efficiency, intracellular growth and survival of L. donovani-SL parasites compared with L. donovani-1S were evident through in vitro macrophage infection experiments. These studies confirm, for the first time, the essential dermotropic nature of L. donovani-SL suggesting natural attenuation of virulence of local parasite strains.

Out-of-pocket expenditure in accessing healthcare services among Chronic Kidney Disease patients in Anuradhapura District

Introduction: Chronic Kidney Disease (CKD) has significant economic impact on both patients' households and the country. Objectives: To assess the out-of-pocket (OOP) expenditure of accessing health services among CKD patients in Anuradhapura District Methods: This community based cross-sectional study included a representative sample of 1174 registered CKD patients from all 19 Medical Officer of Health areas in the District of Anuradhapura. Trained para-medical staff visited the households and administered an interviewer administered questionnaire to gather information. Results: A total of 1118 CKD patients participated. Mean age was 58.3 (SD 10.8) years. Fifty nine (5.3%) patients had been hospitalized during the six months preceding data collection. The total OOP for a hospital admission for one patient was Rs. 3625 (IQR 1650-8760). Thirty eight (3.4%) patients were on dialysis. The median direct cost per patient for an episode of dialysis was Rs.595 (IQR 415-995) while the median direct cost for a dialysis patient per month was Rs.5490 (IQR 3950-10934). In the study population a total of 1095 (98.0%) had attended clinic at least once during the six months preceding the study. The OOP expenditure for a single clinic visit for one patient was Rs.434 (IQR 200- 860). Conclusions: CKD patients living in the Anuradhapura District spent significant amounts on accessing health care which can worsen their economic hardships. Planned interventions are warranted in order to improve their quality of life and financial situation.

Knowledge, attitudes and practices regarding handling mercury containing medical devices among nurses in a tertiary care paediatric hospital in Sri Lanka.

BACKGROUND: Mercury is a highly toxic heavy metal used in many medical devices in the healthcare sector, making nurses one of the vulnerable occupational groups. OBJECTIVE: To assess knowledge, attitudes and practices regarding handling mercury containing devices and factors associated with knowledge among nurses in a paediatric hospital in Sri Lanka. METHODS: A descriptive cross-sectional study was conducted among nurses (n = 538) working in Lady Ridgeway Hospital, Sri Lanka. Information on the use of mercury containing medical devices, accidental exposure, management of spillage and disposal was gathered using a self-administered questionnaire. RESULTS: A total of 472 nurses responded with a response rate of 87.7%. Of the 347 mercury thermometer users, 67.1% had experienced breakages while among 405 mercury sphygmomanometer users, 20.0% had experienced mercury spillages, during a three months period prior to the study. A majority (56.8%) had 'good' overall knowledge regarding mercury and its adverse effects while 94.1% had favorable attitudes towards protecting themselves/others from mercury. Practices related to managing a mercury spill were poor. Work experience >10 years (p = 0.032) and favorable attitude (p = 0.007) were associated with good knowledge while having a training on managing a mercury spillage was not (p = 0.850). CONCLUSIONS: Gaps in practices on managing a mercury spillage were evident. Current training programmes were not found to be effective.

CHARACTERISTICS OF PHLEBOTOMINE SANDFLIES IN SELECTED AREAS OF SRI LANKA.

Cutaneous leishmaniasis (CL) is an endemic disease in Sri Lanka. Studies on vector aspects, although important for better understanding of disease transmission dynamics, are still limited. The present study describes the species distribution and behavioral patterns of sandflies within selected disease-prevalent zones in the country. Adult sandflies were collected from several field sites over a two-year duration in Sri Lanka using cattle-baited net traps, CDC light traps and manual methods. Species identification was performed using standard keys. Leishmania donovani and source of blood meal in blood-fed female sandflies DNA were identified using PCR-based methods. Aggregation period of adult sandflies during overnight collections was also noted. The collected sandflies were identified as Phlebotomus argentipes glaucus (previously known as morphospecies A) and a non-vector species, Sergentomyia zeylanica. Presence of L. donovani DNA was found in 2/634 female sandflies. The parasite ITS1 region of SSU rDNA had 99% sequence similarity with L. donovani from Bangladesh and India. The peak aggregation period of sandflies within cattle-traps was between 8:00 PM to 11:00 PM, indicating that vector control strategies could be conducted during this time period. As Sergentomyia zeylanica is likely to be merely a biting nuisance and showed more of an anthropophilic behavior, whereas the probable vector of CL in Sri Lanka (P. argentipes glaucus) demonstrated zoophilic behavior, has implications for the planning of future vector control strategies.

An intelligent recovery progress evaluation system for ACL reconstructed subjects using integrated 3-D kinematics and EMG features.

An intelligent recovery evaluation system is presented for objective assessment and performance monitoring of anterior cruciate ligament reconstructed (ACL-R) subjects. The system acquires 3-D kinematics of tibiofemoral joint and electromyography (EMG) data from surrounding muscles during various ambulatory and balance testing activities through wireless body-mounted inertial and EMG sensors, respectively. An integrated feature set is generated based on different features extracted from data collected for each activity. The fuzzy clustering and adaptive neuro-fuzzy inference techniques are applied to these integrated feature sets in order to provide different recovery progress assessment indicators (e.g., current stage of recovery, percentage of recovery progress as compared to healthy group, etc.) for ACL-R subjects. The system was trained and tested on data collected from a group of healthy and ACL-R subjects. For recovery stage identification, the average testing accuracy of the system was found above 95% (95-99%) for ambulatory activities and above 80% (80-84%) for balance testing activities. The overall recovery evaluation performed by the proposed system was found consistent with the assessment made by the physiotherapists using standard subjective/objective scores. The validated system can potentially be used as a decision supporting tool by physiatrists, physiotherapists, and clinicians for quantitative rehabilitation analysis of ACL-R subjects in conjunction with the existing recovery monitoring systems.

Thiopurine withdrawal during sustained clinical remission in inflammatory bowel disease: relapse and recapture rates, with predictive factors in 237 patients.

BACKGROUND: Thiopurines (azathioprine and mercaptopurine) remain integral to most medical strategies for maintaining remission in Crohn's disease (CD) and ulcerative colitis (UC). Indefinite use of these drugs is tempered by long-term risks. While clinical relapse is noted frequently following drug withdrawal, there are few published data on predictive factors. AIM: To investigate the success of planned thiopurine withdrawal in patients in sustained clinical remission to identify rates and predictors of relapse. METHODS: This was a multicentre retrospective cohort study from 11 centres across the UK. Patients included had a definitive diagnosis of IBD, continuous thiopurine use ≥3 years and withdrawal when in sustained clinical remission. All patients had a minimum of 12 months follow-up post drug withdrawal. Primary and secondary end points were relapse at 12 and 24 months respectively. RESULTS: 237 patients were included in the study (129 CD; 108 UC). Median duration of thiopurine use prior to withdrawal was 6.0 years (interquartile range 4.4-8.4). At follow-up, moderate/severe relapse was observed in 23% CD and 12% UC patients at 12 months, 39% CD and 26% UC at 24 months. Relapse rate at 12 months was significantly higher in CD than UC (P = 0.035). Elevated CRP at withdrawal was associated with higher relapse rates at 12 months for CD (P = 0.005), while an elevated white cell count was predictive at 12 months for UC (P = 0.007). CONCLUSION: Thiopurine withdrawal in the context of sustained remission is associated with a 1-year moderate-to-severe relapse rate of 23% in Crohn's disease and 12% in ulcerative colitis.

Morphological effects of the nanostructured ceria support on the activity and stability of CuO/CeO2 catalysts for the water-gas shift reaction.

Three CuO/CeO2 catalyst with different morphologies of ceria, namely nanospheres, nanorods and nanocubes, were synthesized and used to catalyze the water-gas shift (WGS) reaction. The reactivity tests showed that the Cu supported on the ceria nanospheres exhibited both the highest activity and superior stability when compared with the nanocube and nanorod ceria catalysts. Operando X-ray diffraction (XRD), X-ray absorption fine structure (XAFS) and diffuse reflectance Fourier transform infrared spectroscopy (DRIFTS) methods were used to characterize these catalysts in their working state. High resolution electron microscopy (HRTEM, STEM) was used to look at the local atomic structure and nano-scale morphology. Our results show that the morphology of the ceria support, which can involve different crystal faces and concentrations of defects and imperfections, has a critical impact on the catalytic properties and influences: (1) the dispersion of CuO in the as-synthesized catalyst; (2) the particle size of metallic Cu upon reduction during the WGS reaction, (3) the stability of the metallic Cu upon variations of temperature, and (4) the dissociation of water on the ceria support. The nanosphere ceria catalyst showed an excellent water dissociation capability, the best dispersion of Cu and a strong Cu-Ce interaction, therefore delivering the best performance among the three WGS catalysts. The metallic Cu, which is the active species during the WGS reaction, was more stabilized on the nanospheres than on the nanorods and nanocubes and thus led to a better stability of the nanosphere catalyst than the other two architectures. Each catalyst exhibited a distinctive line-shape in the 800-1600 cm(-1) region of the DRIFTS spectra, pointing to the existence of different types of carbonate or carboxylate species as surface intermediates for the WGS.

Assessing post-anterior cruciate ligament reconstruction ambulation using wireless wearable integrated sensors.

Abstract A hardware/software co-design for assessing post-Anterior Cruciate Ligament (ACL) reconstruction ambulation is presented. The knee kinematics and neuromuscular data during walking (2-6 km h(-1)) have been acquired using wireless wearable motion and electromyography (EMG) sensors, respectively. These signals were integrated by superimposition and mixed signals processing techniques in order to provide visual analyses of bio-signals and identification of the recovery progress of subjects. Monitoring overlapped signals simultaneously helps in detecting variability and correlation of knee joint dynamics and muscles activities for an individual subject as well as for a group. The recovery stages of subjects have been identified based on combined features (knee flexion/extension and EMG signals) using an adaptive neuro-fuzzy inference system (ANFIS). The proposed system has been validated for 28 test subjects (healthy and ACL-reconstructed). Results of ANFIS showed that the ambulation data can be used to distinguish subjects at different levels of recuperation after ACL reconstruction.

3-D kinematics and neuromuscular signals' integration for post ACL reconstruction recovery assessment.

An intelligent recovery classification and monitoring system (IRCMS) for post Anterior Cruciate Ligament (ACL) reconstruction has been developed in this study. This system provides an objective assessment and monitoring of the rehabilitation progress by integrating 3-D kinematics and neuromuscular signals recorded through wearable motion and electromyography sensors, respectively. The data from a group of healthy and ACL reconstructed subjects were collected for normal/brisk walking (4-6km/h) and single leg balance (eyes open and eyes closed) testing activities. Fuzzy clustering and fuzzy nearest neighbor methods have been used to classify the collected data into different groups for each activity. The classification accuracy of the system is found to be 94.49% for 4 km/h walking speed, 95.41% for 5 km/h walking speed, 96.00% for 6 km/h walking speed, 94.44% for single leg balance testing with eyes open and 95.83% for single leg balance testing with eyes closed. The recovery status of a subject is evaluated based on different activities assessed and the overall assessment is done using Choquet integral fusion technique. Further, biofeedback mechanism has been developed using a visual monitoring system which provides the variations in strength/activation of knee flexors/extensors and 3-D joint kinematics. This integrated system can be used as an assistive tool by sports trainers, coaches and clinicians for monitoring overall progress of athletes' rehabilitation and classifying their recovery stage for multiple activities.

Growth mode and oxidation state analysis of individual cerium oxide islands on Ru(0001).

The growth of cerium oxide on Ru(0001) by reactive molecular beam epitaxy has been investigated using low-energy electron microscopy (LEEM) and diffraction as well as local valence band photoemission. The oxide islands are found to adopt a carpet-like growth mode, which depending on the local substrate morphology and misorientation leads to deviations from the otherwise almost perfect equilateral shape at a growth temperature of 850 °C. Furthermore, although even at this high growth temperature the micron-sized CeO2(111) islands are found to exhibit different lattice registries with respect to the hexagonal substrate, the combination of dark-field LEEM and local intensity-voltage analysis reveals that the oxidation state of the islands is homogeneous down to the 10 nm scale.

Validation of the Sinhala version of the Chronic Liver Disease Questionnaire (CLDQ) for assessment of health related quality of life among Sri Lankan cirrhotics.

OBJECTIVES: The Chronic Liver Disease Questionnaire (CLDQ) is a validated tool measuring Health Related Quality of Life among patients with cirrhosis. The aim of this study was to validate a Sinhala version of the CLDQ (sCLDQ) and to test its correlation with the degree of liver dysfunction in a cohort of Sri Lankan patients with cirrhosis. METHODS: A standard translation method was used. Pilot testing was done with relevant cultural and language adaptations. The final version and the WHO Quality of Life-BREF (WHOQOL-BREF) validated Sinhala version were administered to patients with chronic lever disease (CLD). sCLDQ was re-administered 4 weeks later to test internal consistency and reliability. The validaty and reliability were assessed by Cronabach's alpha, intraclass correlation coefficient (ICC) and Pearson's correlation coefficient. ANOVA and Pearson's correlation were used to assess correlation with the degree of liver dysfunction. RESULTS: Validation was done with 214 participants [mean age 55.6 years (SD 10.4) male 77.6%]. Cronabach's alpha was 0.926. Intra-class correlations varied from 0.431 to 0.912 and all were significant (p< 0.001). Retesting was done on a sub-sample of 18 participants. Test-retest correlation was 0.695 (p = 0.008). WHO-BREF was administered to a sub-sample of 48 subjects. There was a significant correlation (Pearson's r=0.391; p=0.004) between sCLDQ and WHOQOL BREF. sCLDQ was significantly associated with MELD (r=-0.13; p=0.038), MELD sodium (r=-0.223; p=0.002), serum bilirubin (r=-0.124; p=0.036), serum sodium (r=0.172; p=0.009), serum albumin (r=0.201; p=0.003) and Child grade (f=3.687; p=0.027). CONCLUSIONS: CLDQ is a reliable and valid tool to assess quality of life of Sri Lankan patients with cirrhosis and correlates well with known indices of disease severity.