Presentation, Diagnosis and Treatment Delays in Breast Cancer Care and Their Associations in Sri Lanka, a Low-resourced Country.

AIMS: Delays in breast cancer care, one important attributable factor for breast cancer being diagnosed at advanced stages, are not systematically studied in many countries. This study assessed the magnitude and factors associated with delays in breast cancer care in Sri Lanka, from symptom detection to treatment initiation. MATERIALS AND METHODS: We interviewed 800 consecutively sampled female breast cancer patients, diagnosed within the last 12 months, using context-specific questionnaires and medical records. We defined the cut-off times for delays using international guidelines and features of the national health system and care-seeking patterns in the country. Delays were estimated as proportions with 95% confidence intervals and presented for: (i) presentation delay; (ii) diagnosis delay and (iii) treatment delay. We looked at how sociodemographic and healthcare availability and accessibility at the individual level were associated with delays using multivariate logistic regression, with a P value of 0.05 to define statistical significance. RESULTS: Nearly two-thirds of patients reported a presentation delay (63.3%, 95% confidence interval 59.9-66.6%). A diagnosis delay (36.7%, 95% confidence interval 33.4-40.0%) was also seen among one-third, whereas treatment delays (13.2%, 95% confidence interval 10.8-15.5%) were less common. Low family monthly income (odds ratio 6.3; 95% confidence interval 4.2-9.3) and poor knowledge on breast cancer (odds ratio 2.7; 95% confidence interval 1.8-3.8) were associated with presentation delay. Poor health literacy (odds ratio 1.7; 95% confidence interval 1.1-2.7) and the need to make more than two visits to the first contact health provider prior to diagnosis (odds ratio 7.2; 95% confidence interval 4.6-11.1) were associated with diagnosis delays, whereas directly contacting an appropriate specialised health provider once the lump was detected reduced diagnosis delay (odds ratio 0.3; 95% confidence interval 0.2-0.4). Having undergone a core biopsy (odds ratio 0.5; 95% confidence interval 0.3-0.8) and having a mammogram (odds ratio 0.6; 95% confidence interval 4.7-32.7) reduced the likelihood of treatment delays. CONCLUSIONS: Our study findings show that delays in breast cancer care in Sri Lanka are much lower than those in other lower-middle income countries. However, there is significant room for improvement, especially in relation to the excellence in quality of care, such as improving access to mammography services. Periodical estimation of breast cancer delays enabling temporal comparisons will probably provide useful information to policy makers in improving care delivery for breast cancer patients and, hence, is recommended. Such future assessments designed for comparisons between different treatment modalities would provide more information to assist policy decisions in care improvement.

'Why are you not dead yet?' - dimensions and the main driving forces of stigma and discrimination among COVID-19 patients in Sri Lanka.

OBJECTIVES: To explore the experiences, and main driving forces of stigma and discrimination among COVID-19 patients, following hospital discharge, in Sri Lanka. STUDY DESIGN: A qualitative study was used in order to gain insight and explore the depth and complexity of COVID-19 patients' experiences. METHODS: Semi-structured interviews were conducted via telephone in a purposively selected sample of 139 COVID-19 patients. Participants were interviewed during the first 3 weeks following discharge from four main state hospitals that were treating COVID-19 patients during the early phase of the pandemic. Questions on stigma and discrimination were open-ended, enabling patients to provide responses about their different experiences and settings; results were analysed using thematic analysis. RESULTS: The majority of participants were men (n = 80; 57.6%), with a mean age of 43 years (SD = 11.2). In total, up to one-third of the study participants experienced stigma related to COVID-19 and were discriminated against by the community, co-workers and healthcare workers in Sri Lanka. Social discrimination included barriers in accessing basic needs, insulting, blaming, defaming, spreading rumours and receiving no support during emergencies. Workplace discrimination included loss of jobs, not allowing re-entry and loss of earnings due to self-employment. Discrimination by healthcare workers included breaching of confidentiality, lack of respect, not providing health services and communication barriers. Discrimination has led to social isolation, not seeking help and severe psychosocial issues impacting their family relationships. Irresponsible media reporting and sensationalism of news coverage leading to breaching of privacy and confidentiality, defaming, false allegations and reporting household details without consent were perceived as the main factors underlying the views and opinions of the general public. CONCLUSIONS: Stigma and discrimination experienced by COVID-19 patients in society, workplaces and healthcare facilities have serious negative consequences at the individual and family level. Regulations on responsible media reporting, including an effective risk communication strategy to counteract its effects, are strongly recommended.

The correlation between bowel complications and cardiac surgery.

Although advances in knowledge and technology have improved outcomes in surgical cardiac patients over the last decade, complications following cardiac operations still remain to be potentially fatal. Gastrointestinal complications, in particular, tend to have high rates of reintervention and mortality following cardiac surgery, with ischemia and hemorrhage being two of the commonest underlying causes. The intention of this review is to identify which risk factors play important roles in predisposing patients to such complications and to gain better insight into the pathogenesis of the sequelae. Furthermore, strategies for prevention have been discussed to educate and increase awareness of how adverse cardiac surgical outcomes can be minimized.

Barriers for Cataract Treatment among Elderly in Sri Lanka.

Cataract is still the leading cause of blindness. Many government institutes and voluntary organizations in Sri Lanka are providing free treatment services to patients with cataract. Still people are not patronizing the available free services; thus they have to live with impaired vision or blindness. This paper describes the barriers for cataract treatment among the population over 60 years of age. Out of 470 elders, 379 were found to have some kind of cataract. This study demonstrated lack of awareness and knowledge, socioeconomic factors, and misconceptions as the main barriers for cataract treatment which has led to a lower cataract surgery rate irrespective of the high cataract prevalence reported. Findings of this study highlight the importance of cataract as a common health problem in elderly and need for removal of the barriers for its treatment which should be given due prominence in the formulation of public health policy in Sri Lanka at the earliest.

Unconfirmed death as a predictor of psychological morbidity in family members of disappeared persons.

BACKGROUND: The 2004 tsunami, the civil conflict until 2009 and the youth insurrection in the late 1980s in Sri Lanka resulted in many persons being classified as 'missing' as they disappeared and were unaccounted for. Our aim was to compare the prevalence of major depressive disorder (MDD) and prolonged grief disorder (PGD) in families of disappeared individuals, who eventually received the mortal remains and those who did not. METHOD: An ethically approved cross sectional study was conducted in a purposively selected sample after informed consent. Information on the circumstances of the family member going missing was gathered. Culturally adapted versions of the General Health Questionnaire and the Beck Depression Scale were administered. Those who screened positive were assessed by a psychiatrist on Diagnostic and Statistical Manual of Mental Disorders-5 criteria to arrive at a diagnosis. RESULTS: Of 391 cases of disappearances studied, MDD (17.5% v. 6%) and PGD (22% v. 7%) were significantly higher in those who did not eventually receive the mortal remains of the disappeared person. Among those who did not receive the mortal remains, being unsure whether the disappeared person was dead or alive was highly predictive of MDD and PGD. Mothers and wives, older family members and those with a family history of mental illness were more vulnerable. CONCLUSIONS: Family members of missing individuals unsure whether their loved one was alive or dead have higher psychological morbidity in the form of MDD and PGD.

Photoprotective Effect of Carpomitra costata Extract against Ultraviolet B-Induced Oxidative Damage in Human Keratinocytes.

Natural marine products show various biological properties such as antiphotoaging, antioxidant, anticancer, and anti-inflammation. This study evaluated the protective effects of the brown alga Carpomitra costata (Stackhouse) Batters (Sporochnaceae) against ultraviolet B (UVB)-provoked damage in human HaCaT keratinocytes. C. costata extract (CCE) effectively reduced superoxide anion, hydroxyl radical, and UVB-stimulated intracellular reactive oxygen species (ROS) levels. CCE also restored the expression and activity of UVB-suppressed antioxidant enzymes. Furthermore, CCE decreased UVB-triggered oxidative damage to cellular components including DNA, protein, and lipid and defended the cells against mitochondrial membrane depolarization-medicated apoptosis. The results of this study indicate that CCE can safeguard human keratinocytes against UVB-induced cellular damage via a potent antioxidant mechanism. CCE may find utility as part of a therapeutic arsenal against the damaging effects of UVB radiation on the skin.

Mental health research trends in Sri Lanka.

OBJECTIVE: To review the number of research publications in the field of mental health in Sri Lanka from 1900 to 2009. METHODS: A search of all publications in psychiatry and mental health from Sri Lanka was conducted using Pubmed, all medical journals published in Sri Lanka and researchers. The identified papers were reviewed for their content and categorised as research in psychiatry and mental health, based on strict inclusion and exclusion criteria. RESULTS: A total of 207 papers were identified. The first mental health research publication from Sri Lanka is in 1964. The last decade (2000-2009) accounted for 62% of the publications with the majority of the papers being published in indexed journals. The Ceylon Medical Journal carried the most number of papers and the topic on which most of the research was conducted was suicide and deliberate self harm. CONCLUSIONS: There is an increasing trend towards research in to psychiatry and mental health in Sri Lanka.

Selection of medical students in Sri Lanka: time to re-think criteria?

OBJECTIVE: To examine the validity of selected entry level characteristics in relation to the GCE A/L examination as independent predictors of performance of students in medical school. METHODS: A retrospective, analytical study was done at the Faculty of Medicine, University of Kelaniya. Student characteristics at entry were described by sex, the average z-score, General English grade and attempt at GCE A/L examination, and average mark obtained at the English placement test on registration to medical school. Average marks at three summative examinations were used as indicators of performance in medical school. Multivariate analysis using multiple linear regression was carried out using these three outcome measures in relation to four entry point variables as predictors of performance in medical school. Causal path diagrams were constructed using standardised regression coefficients for the whole group and for male and female students separately. RESULTS: The A/L z-score, A/L attempt and English placement test marks were all significant predictors of outcome at the First Examination. Of the variables relating to the A/L examination, the attempt had a much higher path coefficient with performance at the First Examination than the A/L z-score, as did the English marks. Separate path analyses for male and female students showed that while the significance of the relationships remained the same, the magnitude of the correlation was different. CONCLUSIONS: Students who gain admission on their 3rd attempt at the AL examination fare much worse than those admitted to medical school on their 1st attempt. Differences between sexes in examination performance are probably linked to both A/L attempt and English language proficiency.

GDP referrals for orthodontic treatment.

OBJECTIVE: To assess the accuracy of the information provided by General Dental Practitioners (GDPs) in referral letters for orthodontic treatment. DESIGN: An audit. SETTING: Orthodontic Department, Royal Aberdeen Children's Hospital, Aberdeen. METHOD (SUBJECTS): Prospective assessment of GDP referrals over a two month period. Information provided by referrals compared with British Orthodontic Society guidelines. RESULTS: A total of 103 new referrals were assessed. Only 25 (24%) patients knew why they were referred. Nineteen (18%) patients were keen on treatment before being explained what treatment was indicated. Nine (8%) patients declined treatment after being explained the risk/benefit of the treatment. Approximately one third of the patients examined had inadequate oral hygiene. Five (4%) patients had more than two active carious lesions. Forty two (41%) referrals provided no information or missed important malocclusion features. None of the letters provided details of patient's general medical practitioner. CONCLUSIONS: The present audit has highlighted a number of recurring problems with GDP referrals to a hospital orthodontic department. It has indicated a need to inform referring GDPs about the minimum information required in their referral letters. It is suggested that referring dentists should follow the recommendations of the British Orthodontic Society.

Creation of a chimaeric periodontium in the rat by isotopic tooth germ transplantation.

The purpose of this work was to develop and test a chimaeric periodontium in which it would be possible to distinguish between connective tissue cells of odontogenic and oral mucosal origin. The recombinant periodontium was created by transplanting first maxillary molar tooth germs with their follicles from 1-3-day-old hooded Lister rats into the corresponding evacuated crypts of 6-9-day-old histocompatible recipients of the same strain. Of 71 transplants, 22 had formed erupted teeth 3 weeks later, with dentogingival junctions and periodontal ligaments histologically similar to those of control teeth. The recombinant nature of the graft periodontium was confirmed by incubating tooth germs in vitro with tritiated thymidine before grafting them, and then demonstrating radiolabelled nuclei in the dentogingival junctions formed by the transplants. Labelled cells were randomly distributed within the periodontal ligament and predominantly near to the basement membrane of junctional epithelium.

A clinical trial of a light activated bonding material over an 18 month period.

Heliosit-orthodontic, a visible light cured adhesive, has been compared with Right-on, a chemically activated adhesive, on 122 patients for a mean period of 12 months with a range 3-18 months. The overall bond failure rate was 20 per cent. Heliosit-orthodontic had a 23 per cent failure rate compared with a 16 per cent failure rate for Right-on. Heliosit-orthodontic performed less well on the posterior teeth particularly lower second premolars (P less than 0.01). Both materials performed equally well in the labial segment.