'Modified STOPP-START criteria for Sri Lanka'; translating to a resource limited healthcare setting by Delphi consensus.

BACKGROUND: 'Screening tool of older people's prescriptions (STOPP) and screening tool to alert to right treatment (START)' criteria is a useful tool to assess the appropriateness of medicines among older adults. However, the original STOPP/START criteria developed in the West, may not be directly applicable to resource limited healthcare settings like Sri Lanka. Hence, we aimed to modify STOPP/START criteria (Version 2) to suit Sri Lanka. METHOD: Two investigators (a clinical pharmacologist and a pharmacist) reviewed and flagged criteria that were unfeasible to Sri Lanka based on their previous research experiences on using STOPP/START version 1. A Delphi consensus methodology was conducted among six experts, including geriatricians, clinical pharmacologists, physicians and a pharmacist, to review and assess each criterion (including the ones flagged by the researchers) for suitability to Sri Lanka. RESULTS: Two Delphi validation rounds were conducted. A final meeting was held with the participation of all experts to resolve disagreements and to establish 100% consensus. The expert panel agreed on a list of 105 criteria, including 70 STOPP and 35 START criteria, indicating an 8% reduction in criteria compared to the original version. Modifications included complete removal (n = 11), re-wording (n = 25), splitting (n = 1) of original criteria and adding a new criterion (n = 1). Main reasons for modifications were unavailability of some medicines in the country, unavailability or inaccessibility of specific clinical information required for assessment of criteria, and adherence to treatment guidelines commonly used in the country. CONCLUSION: A list of 'Modified STOPP/START criteria for Sri Lanka' was developed. These criteria are currently being validated through a multi-centre study.

Utility of glycosylated haemoglobin in diagnosing diabetes in an urban Sri Lankan community

Introduction: American Diabetes Association (ADA) has officially endorsed glycosylated haemoglobin (HbA1c) as a diagnostic tool. The recommended cut-off for diagnosing diabetes is  6.5%. Objectives: To compare use of HbA1c and fasting plasma glucose (FPG) to diagnose diabetes in an urban Sri Lankan community. Methods: This cross-sectional study is based on baseline data from a prospective study on non-communicable diseases in randomly selected individuals aged 35-64 years in a selected community. HbA1c was measured by National Glycohaemoglobin Standardization Program certified Bio Rad Variant HbA1c HPLC method. Diagnostic performance of HbA1c was evaluated in those without previous diabetes. Receiver Operating Characteristic Curve was used to identify optimum HbA1c threshold. Results: We studied 2516 individuals with no previous history of diabetes. Of these 53.8% were women. Mean age was 52 ± 7.9 years. FPG was 7mmol/l in 245 (9.7%). HbA1c was  6.5% in 173 (6.9%). Concordance between FPG and HbA1c was 95% (both criteria positive: 5.8%; both criteria negative: 89.2%). Compared to FPG, HbA1c cut-off of 6.5% had specificity of 98.9% (95% CI 98.3-99.3) and sensitivity of 60% (95% CI 53.6-66.2). Positive and negative predictive values were 85% (95% CI 78.8-89.9) and 95.8% (95% CI 94.9-96.6), respectively. Compared to FPG, optimum HbA1c threshold for diagnosing diabetes was 5.9% (sensitivity: 84%; specificity: 88.8%; area under the curve: 0.91). Conclusions: In the study population, detection of diabetes with ADA recommended HbA1ccriterion was 29% less than with FPG criterion. Compared to FPG, HbA1c had high specificity but sensitivity was low. Further research is needed to refine the optimum HbA1c threshold in Sri Lankans.

Risk estimates of cardiovascular diseases in a Sri Lankan community.

OBJECTIVES: Quantifying the risk of cardiovascular disease (CVD) in a community is important in planning preventive strategies, but such data are limited from developing countries, especially South Asia. We aimed to estimate the risks of coronary heart disease (CHD), total CVD, and CVD mortality in a Sri Lankan community. METHODS: A community survey was conducted in an urban health administrative area among individuals aged 35-64 years, selected by stratified random sampling. Their 10-year CHD, total CVD, and CVD mortality risks were estimated using three risk prediction tools: National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III), Systematic Coronary Risk Evaluation (SCORE), and World Health Organisation/ International Society of Hypertension (WHO/ISH) charts. RESULTS: Among study participants (n=2985), 54.5% were females, and mean age (SD) was 52.4 (7.8) years. According to NCEP-ATP III ('hard' CHD risk), WHO/ISH (total CVD risk), and SCORE (CVD mortality risk) criteria, 25.4% (95% CI 23.6-27.2), 8.2% (95% CI 7.3-9.2), and 11.8 (95% CI 10.5-13.1) respectively were classified as at 'high risk'. The proportion of high risk participants increased with age. 'High risk' was commoner among males (30.3% vs 20.6%, p<0.001) according to NCEPATP III criteria, but among females (9.7% vs. 6.7%, p<0.001) according to WHO/ISH criteria. No significant gender difference was noted in SCORE risk categories. CONCLUSIONS: A large proportion of individuals in this community are at risk of developing cardiovascular diseases, especially in older age groups. Risk estimates varied with the different prediction tools, and were comparatively higher with NCEP-ATP III charts.

A Comparison between Revised NCEP ATP III and IDF Definitions in Diagnosing Metabolic Syndrome in an Urban Sri Lankan Population: The Ragama Health Study.

Background. The prevalence of metabolic syndrome (MetS) within individual cohorts varies with the definition used. The aim of this study was to compare the prevalence of MetS between IDF and revised NCEP ATP III criteria in an urban Sri Lankan population and to investigate the characteristics of discrepant cases. Methods. 2985 individuals, aged 35-65 years, were recruited to the study. Anthropometric and blood pressure measurements and laboratory investigations were carried out following standard protocols. Results. Age and sex-adjusted prevalences of MetS were 46.1% and 38.9% by revised NCEP and IDF definitions, respectively. IDF criteria failed to identify 21% of men and 7% of women identified by the revised NCEP criteria. The discrepant group had more adverse metabolic profiles despite having a lower waist circumference than those diagnosed by both criteria. Conclusion. MetS is common in this urban Sri Lankan cohort regardless of the definition used. The revised NCEP definition was more appropriate in identifying the metabolically abnormal but nonobese individuals, especially among the males predisposed to type 2 diabetes or cardiovascular disease. Further research is needed to determine the suitability of the currently accepted Asian-specific cut-offs for waist circumference in Sri Lankan adults.

Dengue hemorrhagic fever presenting with acute pancreatitis.

Acute pancreatitis is an uncommon manifestation of dengue fever. Here we present a 47 year old male with dengue hemorrhagic fever who presented with acute pancreatitis and associated hyperglycemia. To our knowledge, this is the first reported case of dengue complicated with acute pancreatitis from South Asia.