Quality of life and its associated factors among home-dwelling older people residing in the District of Colombo, Sri Lanka: a community-based cross-sectional study

INTRODUCTION

This community-based cross-sectional study explored the factors affecting overall and domain-specific (physical health, psychological health, social relationships and environmental) quality of life (QOL) of home-dwelling older residents of the District of Colombo, Sri Lanka.

METHODS

A representative sample (n=723) of older adults aged >65 years was obtained by the multistage cluster sampling technique. QOL was assessed using the validated Sinhala version of WHOQOL BREF Questionnaire. Data analysis was done using SPSS V.20.

RESULTS

The mean±SD age was 72.23±6.3 years with the overall QOL score being (mean±SD) 56.73±12.57/100. The mean±SD QOL score of physical health, psychological health, social relationships and environmental domains were 55.81±15.80, 59.25±14.68, 46.36±20.08 and 64.61±11.96, respectively. The overall QOL in the adjusted model showed a significant positive association with the educational status, living conditions (with spouse, with spouse and children), participation in religious activities, being visited by friends or relatives and financial independence. The overall QOL was negatively associated with limitations in activities of daily living and instrumental activities of daily living, chronic arthritis and heart disease in the adjusted model. Living with the spouse was positively associated with the psychological domain of QOL. Osteoporosis and chronic arthritis affected the physical health domain, while cancer and disabling stroke affected the psychological domain of QOL negatively. All statistical significances were considered at p<0.05.

CONCLUSION

The overall QOL of home-dwelling elders of the Colombo District is moderate, with the lowest score being in social relationships and the highest in the environmental domain. Educational status, engaging in religious activities and financial independence are key factors associated with a better QOL. Limitations in physical activity and chronic diseases are associated with a reduced QOL. Living with the spouse is a key factor associated with the psychological health domain.

The impact of peer-led support groups on health-related quality of life, coping skills and depressive symptomatology for women with PCOS

Support groups can be a powerful medium in providing psychological support to women with Polycystic Ovary Syndrome (PCOS). The study evaluated the impact of peer support group on Health-Related Quality of Life (HRQoL), depressive symptomatology and coping strategies among women with PCOS. The pre- and post-test experimental design was used. Women with PCOS not receiving psychiatric medication and attending clinics of a teaching hospital in Colombo were recruited. They were randomly allocated based on clinic days to the experimental (n = 20) and control (n = 22) groups. The Intervention group participated in the specific peer support program for 10 weeks, while the control group received general health reading material for 10 weeks through the post. The Modified Polycystic Ovary Syndrome Questionnaire (M-PCOSQ), Centre for Epidemiologic Studies Depression Scale (CES-D) and Brief COPE inventory were administered to both groups before and 1 month after completing the intervention. Before the intervention, there was no significant difference between the two groups regarding the scores of HRQoL, depressive symptomatology and coping skills. One month after the intervention, the support group exhibited improvement in HRQoL, depressive symptomatology and coping skills (p < 0.01) compared to the control group. The peer support group is an effective intervention to uplift the psycho-social wellbeing of women with PCOS through receiving emotional support from those similarly afflicted.

Experiences of family caregivers of the older people with limitations in activities: A qualitative study

Functional disabilities increase with ageing and limitations in daily living activities (ADLs) occurred as a consequence. Older people living at home may therefore become dependent on family members in managing activities in daily living. As the informal caregivers' role is known to be challenging, their experiences need to be explored to strengthen their new roles as family caregivers. This study aimed at exploring family caregivers' experiences of providing care for older people living at home with limited ADLs in Sri Lanka. Caregivers caring for older people with limitations in activities at home were purposively selected. Limitations in ADL were determined using the Sinhala-validated Barthel Index. Data were collected through in-depth interviews with 20 caregivers who cared for older people with several basic self-care limitations. Data were analysed using thematic analysis. The results consist of three themes related to caring for older people with limited ADLs: committed to providing compassionate care for the activity-limited older person, trapped in one's own home by caring for the activity-limited older person and in need of respite and support in caring for older persons with limitations of activity. Motivated to care, adapting to care-giving challenges, changed life pattern, neglecting one's own health, emotional suffering, lack of knowledge and skills and wanting assistance in care-giving and with financial support were resultant subthemes. Family caregivers of older people with limited activities living at home, face many challenges to their own health. Supporting interventions will therefore be necessary. An introduction of educational training programmes for informal caregivers would promote the health and well-being of functionally disabled older people and their caregivers. Developing home-based care will be a future solution since the availability of informal caregivers will be at risk due to a rapid increase in older people and social changes related to the family structure.

Sporadic miscarriage: evidence to provide effective care

The physical and psychological effect of miscarriage is commonly underappreciated. The journey from diagnosis of miscarriage, through clinical management, to supportive aftercare can be challenging for women, their partners, and caregivers. Diagnostic challenges can lead to delayed or ineffective care and increased anxiety. Inaccurate diagnosis of a miscarriage can result in the unintended termination of a wanted pregnancy. Uncertainty about the therapeutic effects of interventions can lead to suboptimal care, with variations across facilities and countries. For this Series paper, we have developed recommendations for practice from a literature review, appraisal of guidelines, and expert group discussions. The recommendations are grouped into three categories: (1) diagnosis of miscarriage, (2) prevention of miscarriage in women with early pregnancy bleeding, and (3) management of miscarriage. We recommend that every country reports annual aggregate miscarriage data, similarly to the reporting of stillbirth. Early pregnancy services need to focus on providing an effective ultrasound service, as it is central to the diagnosis of miscarriage, and be able to provide expectant management of miscarriage, medical management with mifepristone and misoprostol, and surgical management with manual vacuum aspiration. Women with the dual risk factors of early pregnancy bleeding and a history of previous miscarriage can be recommended vaginal micronised progesterone to improve the prospects of livebirth. We urge health-care funders and providers to invest in early pregnancy care, with specific focus on training for clinical nurse specialists and doctors to provide comprehensive miscarriage care within the setting of dedicated early pregnancy units.

Recurrent miscarriage: evidence to accelerate action

Women who have had repeated miscarriages often have uncertainties about the cause, the likelihood of recurrence, the investigations they need, and the treatments that might help. Health-care policy makers and providers have uncertainties about the optimal ways to organise and provide care. For this Series paper, we have developed recommendations for practice from literature reviews, appraisal of guidelines, and a UK-wide consensus conference that was held in December, 2019. Caregivers should individualise care according to the clinical needs and preferences of women and their partners. We define a minimum set of investigations and treatments to be offered to couples who have had recurrent miscarriages, and urge health-care policy makers and providers to make them universally available. The essential investigations include measurements of lupus anticoagulant, anticardiolipin antibodies, thyroid function, and a transvaginal pelvic ultrasound scan. The key treatments to consider are first trimester progesterone administration, levothyroxine in women with subclinical hypothyroidism, and the combination of aspirin and heparin in women with antiphospholipid antibodies. Appropriate screening and care for mental health issues and future obstetric risks, particularly preterm birth, fetal growth restriction, and stillbirth, will need to be incorporated into the care pathway for couples with a history of recurrent miscarriage. We suggest health-care services structure care using a graded model in which women are offered online health-care advice and support, care in a nurse or midwifery-led clinic, and care in a medical consultant-led clinic, according to clinical needs.

Effectiveness of Low-dose Ethinylestradiol/Cyproterone Acetate and Ethinylestradiol/Desogestrel with and without Metformin on Hirsutism in Polycystic Ovary Syndrome: A Randomized, Double-blind, Triple-dummy Study

BACKGROUND: The effectiveness of different combined oral contraceptive pills and metformin in reducing hirsutism in patients with polycystic ovary syndrome (PCOS) remains unclear. OBJECTIVE: We sought to determine the effects of ethinylestradiol (35μg)/cyproterone acetate (2mg) (EE/CPA) and ethinylestradiol (20μg)/desogestrel (0.15mg) (EE/DES), alone or with metformin, on hirsutism in PCOS. METHODS: A randomized, double-blind, triple-dummy study was conducted on women with PCOS and hirsutism (N=107) who received one of four drug combinations (Arm A: EE/CPA; Arm B: EE/DES; Arm C: EE/CPA plus metformin; or Arm D: EE/DES plus metformin). Hirsutism was assessed at baseline, six months, and 12 months by using five outcomes variables. RESULTS: No outcomes variable showed a significant difference between the four arms at 12 months. There was a significant reduction in both hair density and modified Ferriman-Gallwey score (mFGS) in Arm A, mFGS in Arm B, hair density in Arm C, and diameter of sideburn hair in Arm D, respectively. Separately, there was a significant increase noted in the hair growth rate of chin and an improvement in patients' perceptions of hirsutism in all four study arms. CONCLUSION: EE/CPA and EE/DES were equally effective in improving hirsutism in PCOS, with no added benefit from low-dose metformin. Sri Lanka Clinical Trials Registry (http://www.slctr.lk) registration no. SLCTR/2015/007.

Polycystic ovary syndrome (PCOS) and kisspeptin - A Sri Lankan study

Context

Polycystic ovary syndrome (PCOS) is the commonest endocrine disorder affecting young women. Kisspeptins are a family of closely related peptides encoded by Kiss1 gene that controls the hypothalamic-pituitary-gonadal axis by binding to its receptor (GPR54) expressed in gonadotropin-releasing hormone (GnRH) neurons and releases GnRH. Since GnRH secretion is deregulated in PCOS, we hypothesized that dysregulated gonadotropin secretion in PCOS is reflected by kisspeptin levels.

Aim

We aimed to measure serum kisspeptin levels of subjects with well-characterized PCOS versus controls and explore any correlation between kisspeptin and PCOS-related reproductive and metabolic disturbances.

Materials and Methods

: Consecutive women with PCOS manifesting from adolescence (n = 55) and adult controls (n = 110) were recruited. Pre-treatment baseline clinical, anthropometry, and biochemical parameters were measured in all. Serum kisspeptin and testosterone levels were determined by enzyme-linked immunosorbent assay method.

Results

: Serum kisspeptin and testosterone concentrations were significantly higher in women with PCOS (kisspeptin 4.873 nmol/L; testosterone 4.713 nmol/L) than controls (kisspeptin 4.127 nmol/L; testosterone 3.415 nmol/L; P < 0.05). Serum kisspeptin levels were positively associated with PCOS (odds ratio: 1.853; 95% confidence interval: 1.246-2.755; P = 0.002) in our studied population.

Conclusion

Serum kisspeptin levels are higher in Sri Lankan women with PCOS manifesting from adolescence compared with controls regardless of body mass index. We propose serum kisspeptin concentration as a useful marker to recognize PCOS that manifests from adolescence.

Increased risk of obstructive sleep apnoea in women with polycystic ovary syndrome: a population-based cohort study

OBJECTIVE

Obesity is very common in patients with obstructive sleep apnoea (OSA) and polycystic ovary syndrome (PCOS). Longitudinal studies assessing OSA risk in PCOS and examining the role of obesity are lacking. Our objective was to assess the risk of OSA in women with vs without PCOS and to examine the role of obesity in the observed findings.

DESIGN

Population-based retrospective cohort study utilizing The Health Improvement Network (THIN), UK.

METHODS

76 978 women with PCOS and 143 077 age-, BMI- and location-matched women without PCOS between January 2000 and May 2017 were identified. Hazard ratio (HR) for OSA among women with and without PCOS were calculated after controlling for confounding variables using multivariate Cox models.

RESULTS

Median patient age was 30 (IQR: 25-35) years; median follow-up was 3.5 (IQR: 1.4-7.1) years. We found 298 OSA cases in PCOS women vs 222 in controls, with incidence rates for OSA of 8.1 and 3.3 per 10 000 person years, respectively. Women with PCOS were at increased risk of developing OSA (adjusted HR = 2.26, 95% CI: 1.89-2.69, P < 0.001), with similar HRs for normal weight, overweight and obese PCOS women.

CONCLUSIONS

Women with PCOS are at increased risk of developing OSA compared to control women irrespective of obesity. Considering the significant metabolic morbidity associated with OSA, clinicians should have a low threshold to test for OSA in women with PCOS. Whether OSA treatment has an impact on PCOS symptoms and outcomes needs to be examined.

Long and short-term outcomes of Gestational Diabetes Mellitus (GDM) among South Asian women - A community-based study

AIMS

To quantify short and long-term outcomes of Gestational Diabetes Mellitus (GDM) among South Asians.

METHODS

Prospective cohort-study in Gampaha District, Sri Lanka following a community-prevalence study (WHO 1999 criteria). All women with GDM (exposed) and within sample non-GDM (non-exposed) were recruited. Data was gathered at selected intervals until one-year post-partum by interviewer-administered questionnaire, anthropometry, blood pressure, post-partum 75gOGTT and cholesterol. Two groups were compared for pregnancy outcomes; and age, parity, first-trimester BMI adjusted odds ratios (aOR) calculated.

RESULTS

GDM and non-GDM (n = 194 each) had 169 (87.1%) and 178 (91.8%) responders respectively. Significant differences in outcomes: Antenatal/Perinatal - obstetric and/or medical complications (aOR = 1.8; 95% CI = 1.1-2.7), pregnancy induced hypertension (aOR = 3.1; 95% CI = 1.5-6.5), birth-weight ≥ 3.5 kg (aOR = 2.8; 95% CI = 1.4-5.5), special baby-care for prematurity (aOR = 4.1; 95% CI = 1.1-15.1), low mean POA at delivery (p = 0.005), vaginal moniliasis (aOR = 4.9; 95% CI = 1.4-17.4) and breast-engorgement (aOR = 2.6; 95% CI = 1.02-6.4). Two months postpartum: impaired glucose tolerance (IGT) (aOR = 6.1; 95% CI = 2.7-13.8) and abnormal glucose tolerance [AGT = diabetes, impaired fasting glucose (IFG) and IGT collectively] (aOR = 9.1; 95% CI = 4.3-19.1). One-year postpartum (participation rate = 39.7%): exclusive breastfeeding for six months (aOR = 0.3; 95% CI = 0.1-0.7), diabetes mellitus (aOR = 4.1; 95% CI = 1.1-15.7), IGT (aOR = 5.8; 95% CI = 1.5-21.8), AGT (aOR = 7.7; 95% CI = 2.9-20.6).

CONCLUSIONS

Hyperglycaemia in Pregnancy detected and followed up in a sub-urban community setting in Sri Lanka, had significantly worse pregnancy outcomes with a high risk of maternal pre-diabetes/diabetes in first post-partum year.

Hyperglycemia in pregnancy among South Asian women: A single tertiary care center experience from Colombo, Sri Lanka

AIM

To study case mix, risk factors, adverse outcomes and associations of hyperglycemia in pregnancy in a cohort of Sri Lankans.

METHODS

Prospective observational study, from April 2011-October 2015 at a tertiary care referral center, Colombo, Sri Lanka. Data from first trimester to delivery of HIP was analyzed. Three subgroups were defined: Diabetes in pregnancy (DIP), Hyperglycemia in early Pregnancy (HIEP) [<24 weeks] and Gestational diabetes (GDM) [>24 weeks].

RESULTS

Of 782 patients 572 (73.1%) had complete data. Case-mix: 137(24.0%) DIP, 331(57.9%) GDM and 104 (18.2%) HIEP. Primigravidae commoner in GDM (<0.05). DIP older - mean 33.3 ± 5.5 years (<0.01). Previous GDM commoner and pharmacological interventions needed in DIP and HIEP. Majority GDM (66.8%) required Medical Nutrition Therapy (MNT) alone. There was no difference in pregnancy outcomes between the 3 subgroups. Macrosomia significantly greater in HIEP (33.7%); neonatal cardiac defects more in DIP and HIEP.

CONCLUSIONS

Increasing maternal age is a significant risk for DIP, while previous GDM is a risk for DIP and HIEP and neonatal congenital cardiac defects in subsequent pregnancies of South Asian women. We recommend preconception screening for glucose intolerance and achieving normoglycaemia among South Asian women with advanced maternal age and previous GDM.

Obstetric outcomes and effects on babies born to women treated for epilepsy during pregnancy in a resource limited setting: a comparative cohort study

BACKGROUND

Management of epilepsy during pregnancy in a resource-limited setting (RLS) is challenging. This study aimed to assess obstetric outcomes and effects on babies of women with epilepsy (WWE) exposed to Anti-epileptic drugs (AEDs) compared to non-exposed controls in a RLS.

METHODS

Pregnant WWE were recruited from antenatal and neurology clinics of a tertiary care hospitals in Sri Lanka. Patients were reviewed in each trimester and post-partum. Medication adherence, adverse effects, seizure control and carbamazepine blood levels were monitored. Post-partum, measurements for anthropometric and dysmorphic features of the babies and congenital abnormalities were recorded. Age and sex matched babies not exposed to AED recruited as controls were also examined.

RESULTS

Ninety-six pregnant WWE were recruited (mean period of gestation 22.9 weeks). Mean age was 28 years and 48(50%) were primigravidae. Fifty percent (48) were on monotherapy, while 23.8, 15.9 and 4.1% were on two, three and four AEDs respectively. AEDs in first trimester (TM1) were carbamazepine (71%), valproate (25.8%) clobazam (29.5%), lamotrigine (7%) topiramate (5%) and others (3.4%). Sodium valproate use reduced significantly from T1 to T2(p < 0.05). Sub-therapeutic carbamazepine levels correlated positively (r = 0.547) with poor medication adherence (p = 0.009) and negatively (r = 0.306) with adverse effects (p = 0.002). Seventy-six WWE completed follow-up reporting w 75 (98.6%) live births and one T1 miscarriage (1.3%). Three (4.3%) were preterm. Majority (73.33%) were normal vaginal deliveries. Cesarean sections were not increased in WWE. Fifty-nine (61.45%) babies were examined. For those examined during infancy, 53 age and sex matched controls were recruited and examined.. Congenital abnormalities occurred in 5 (9.43%) babies of WWE [atrio-ventricular septal defect (2), renal hypoplasia (1), cryptorchidism (1), microcephaly (1)] compared to 2 (3.77%) in controls (2 microcephaly; p = 0.24). Fetal exposure to AEDs increased a risk of low birth weight (RR 2.8; p = 0.049). Anthropometric parameters of AED exposed babies were lower at birth but not statistically significant between the two groups (weight p = 0.263, length p = 0.363, occipito-frontal circumference (OFC) p = 0.307). However, weight (p = 0.009), length (p = 0.016) and OFC (p = 0.002) were significantly lower compared to controls at an average of 3.52 months.

CONCLUSION

Most pregnancies are unplanned in the RLS studied, and AEDs were altered during pregnancy. Congenital anomalies occurred at rates comparable to previous reports. Fetal exposure to AED had growth retardation in infancy compared to non-exposed babies.

Polycystic ovary syndrome, androgen excess, and the risk of nonalcoholic fatty liver disease in women: A longitudinal study based on a United Kingdom primary care database

BACKGROUND

Androgen excess is a defining feature of polycystic ovary syndrome (PCOS), which affects 10% of women and represents a lifelong metabolic disorder, with increased risk of type 2 diabetes, hypertension, and cardiovascular events. Previous studies have suggested an increased risk of nonalcoholic fatty liver disease (NAFLD) in individuals with PCOS and implicated androgen excess as a potential driver.

METHODS AND FINDINGS

We carried out a retrospective longitudinal cohort study utilizing a large primary care database in the United Kingdom, evaluating NAFLD rates in 63,120 women with PCOS and 121,064 age-, body mass index (BMI)-, and location-matched control women registered from January 2000 to May 2016. In 2 independent cohorts, we also determined the rate of NAFLD in women with a measurement of serum testosterone (n = 71,061) and sex hormone-binding globulin (SHBG; n = 49,625). We used multivariate Cox models to estimate the hazard ratio (HR) for NAFLD and found that women with PCOS had an increased rate of NAFLD (HR = 2.23, 95% CI 1.86-2.66, p < 0.001), also after adjusting for BMI or dysglycemia. Serum testosterone >3.0 nmol/L was associated with an increase in NAFLD (HR = 2.30, 95% CI 1.16-4.53, p = 0.017 for 3-3.49 nmol/L and HR = 2.40, 95% CI 1.24-4.66, p = 0.009 for >3.5 nmol/L). Mirroring this finding, SHBG <30 nmol/L was associated with increased NAFLD hazard (HR = 4.75, 95% CI 2.44-9.25, p < 0.001 for 20-29.99 nmol/L and HR = 4.98, 95% CI 2.45-10.11, p < 0.001 for <20 nmol/L). Limitations of this study include its retrospective nature, absence of detailed information on criteria used to diagnosis PCOS and NAFLD, and absence of data on laboratory assays used to measure serum androgens.

CONCLUSIONS

We found that women with PCOS have an increased rate of NAFLD. In addition to increased BMI and dysglycemia, androgen excess contributes to the development of NAFLD in women with PCOS. In women with PCOS-related androgen excess, systematic NAFLD screening should be considered.

Management, characteristics and outcomes of patients with acute coronary syndrome in Sri Lanka

Background

Ischaemic heart disease is the leading cause of in-hospital mortality in Sri Lanka. Acute Coronary Syndrome Sri Lanka Audit Project (ACSSLAP) is the first national clinical-audit project that evaluated patient characteristics, clinical outcomes and care provided by state-sector hospitals.

Methods

ACSSLAP prospectively evaluated acute care, in-hospital care and discharge plans provided by all state-sector hospitals managing patients with ACS. Data were collected from 30 consecutive patients from each hospital during 2–4 weeks window. Local and international recommendations were used as audit standards.

Results

Data from 87/98 (88.7%) hospitals recruited 2177 patients, with 2116 confirmed as having ACS. Mean age was 61.4±11.8 years (range 20–95) and 58.7% (n=1242) were males. There were 813 (38.4%) patients with unstable angina, 695 (32.8%) with non-ST-elevation myocardial infarction (NSTEMI) and 608 (28.7%) with ST-elevation myocardial infarction (STEMI). Both STEMI (69.9%) and NSTEMI (61.4%) were more in males (P<0.001). Aspirin, clopidogrel and statins were given to over 90% in acute setting and on discharge. In STEMI, 407 (66.9%) were reperfused; 384 (63.2%) were given fibrinolytics and only 23 (3.8%) underwent primary percutaneous coronary intervention (PCI). Only 42.3 % had thrombolysis in <30 min and 62.5% had PCI in <90 min. On discharge, beta-blockers and ACE inhibitors/angiotensin II receptor blockers were given to only 50.7% and 69.2%, respectively and only 17.6% had coronary interventions planned.

Conclusions

In patients with ACS, aspirin, clopidogrel and statin use met audit standards in acute setting and on discharge. Vast majority of patients with STEMI underwent fibrinolyisis than PCI, due to limited resources. Primary PCI, planned coronary interventions and timely thrombolysis need improvement in Sri Lanka.

Perceived Importance of Information Needs on Breast Cancer among Adults: a Population-Based Survey in the District of Colombo, Sri Lanka

Background: Information needs of Breast Cancer (BC) and its perceived importance has not been adequately assessed in Sri Lanka. The present study aimed to assess cognitive information needs of BC among the adults. Methods: A household survey was conducted among a representative sample (n=1500) of over 18 years of age resident in the district of Colombo not having BC patients in the families. A validated interviewer-administered questionnaire collected information on general and cognitive information needs. Exploratory factor analysis assessed whether any of the aspects of informational needs are redundant and to group the needs. Results: Mean age of the participants was 37.21 (SD = ±9.7) years. Proportion of females was 51.7%, 82.9% were married and 44.1% had been educated up to General Certificate of Education (GCE) Ordinary Level. Exploratory factor analysis revealed all items of the questionnaire to form two groups that were named as “Factual information on BC prevention and early detection (screening and early diagnosis)” and “Factual information on BC diagnosis and treatment”. Results indicated that both groups of information needs were considered as highly important and the group “Factual information on BC diagnosis and treatment” (mean score 4.20 ± 0.75) was perceived as more important than the other group. The perceived importance of information needs was shown to be significantly different based on the sex of the adults, marital status, level of education and the employment status of the participants. Conclusion: This study demonstrates that cognitive information needs on BC are viewed as highly important by the general public. The study identified specific informational needs that are perceived as more important and some socio-demographic characteristics that are associated with higher perceived needs. The study recommends taking into account the findings of the study in designing the content and target groups for education on BC.

The management of anovulatory infertility in women with polycystic ovary syndrome: an analysis of the evidence to support the development of global WHO guidance

BACKGROUND

Here we describe the consensus guideline methodology, summarise the evidence-based recommendations we provided to the World Health Organisation (WHO) for their consideration in the development of global guidance and present a narrative review on the management of anovulatory infertility in women with polycystic ovary syndrome (PCOS).

OBJECTIVE AND RATIONALE

The aim of this paper was to present an evidence base for the management of anovulatory PCOS.

SEARCH METHODS

The evidence to support providing recommendations involved a collaborative process for: (i) identification of priority questions and critical outcomes, (ii) retrieval of up-to-date evidence and exiting guidelines, (iii) assessment and synthesis of the evidence and (iv) the formulation of draft recommendations to be used for reaching consensus with a wide range of global stakeholders. For each draft recommendation, the methodologist evaluated the quality of the supporting evidence that was then graded as very low, low, moderate or high for consideration during consensus.

OUTCOMES

Evidence was synthesized and we made recommendations across the definition of PCOS including hyperandrogenism, menstrual cycle regulation and ovarian assessment. Metabolic features and the impact of ethnicity were covered. Management includes lifestyle changes, bariatric surgery, pharmacotherapy (including clomiphene citrate (CC), aromatase inhibitors, metformin and gonadotropins), as well as laparoscopic surgery. In-vitro fertilization (IVF) was considered as were the risks of ovulation induction and of pregnancy in PCOS. Approximately 80% of women who suffer from anovulatory infertility have PCOS. Lifestyle intervention is recommended first in women who are obese largely on the basis of general health benefits. Bariatric surgery can be considered where the body mass index (BMI) is ≥35 kg/m2 and lifestyle therapy has failed. Carefully conducted and monitored pharmacological ovulation induction can achieve good cumulative pregnancy rates and multiple pregnancy rates can be minimized with adherence to recommended protocols. CC should be first-line pharmacotherapy for ovulation induction and letrozole can also be used as first-line therapy. Metformin alone has limited benefits in improving live birth rates. Gonadotropins and laparoscopic surgery can be used as second-line treatment. There is no clear evidence for efficacy of acupuncture or herbal mixtures in women with PCOS. For women with PCOS who fail lifestyle and ovulation induction therapy or have additional infertility factors, IVF can be used with the safer gonadotropin releasing hormone (GnRH) antagonist protocol. If a GnRH-agonist protocol is used, metformin as an adjunct may reduce the risk of ovarian hyperstimulation syndrome. Patients should be informed of the potential side effects of ovulation induction agents and of IVF on the foetus, and of the risks of multiple pregnancy. Increased risks for the mother during pregnancy and for the child, including the exacerbating impact of obesity on adverse outcomes, should also be discussed.

WIDER IMPLICATIONS

This guidance generation and evidence-synthesis analysis has been conducted in a manner to be considered for global applicability for the safe administration of ovulation induction for anovulatory women with PCOS.

Pregnancy outcomes of antiphospholipid syndrome: In a low resource South Asian setting

PROBLEM

Antiphospholipid syndrome is associated with recurrent pregnancy loss, and specific treatment improves pregnancy outcome. Laboratory diagnosis is limited in South Asia. We assessed management outcomes of definite/probable antiphospholipid syndrome treated at a tertiary centre in Sri Lanka.

METHOD

Descriptive cross-sectional study of pregnancy outcomes with heparin and aspirin therapy.

OUTCOME MEASURES

miscarriage, intrauterine death and live birth when compared to previous untreated pregnancies.

RESULTS

Of 646 gestations in 145 women, 146 (22.6%) received specific treatment. In the preceding pregnancies without specific treatment, the rates of miscarriage, late fetal loss, stillbirth and live birth were 60%, 26%, 8% and 7%, respectively. Following specific treatment with low-dose aspirin ± low-molecular weight heparin in 146 pregnancies (145 women), the rates of miscarriage, late fetal loss, stillbirth and live birth were 14%, 10%, 3% and 74%, respectively. Mean birth weight was 2.54 ± 0.62 kg, preterm births complicated 32 (29.6%) with a mean gestational age at delivery 33.7 ± 2.6 weeks, with three neonatal deaths. Maternal complications were: pre-eclampsia 16 (10.9%), gestational diabetes 28 (19.2%), antepartum haemorrhage in 1 patient. Only 73/145 (50.3%) women had laboratory confirmation of antiphospholipid syndrome, while others were treated empirically. Live births in diagnosed vs. empiric treatment - 80.8% vs. 67.1%.

CONCLUSION

Pregnant women with clinical antiphospholipid syndrome when treated with low-dose aspirin and heparin, the live birth rate of 7% in the previous pregnancy resulted in live births of 74% in a resource limited South Asian setting.

Ethnic-specific polycystic ovary syndrome: epidemiology, significance and implications

Being the most common endocrinopathy of young women, polycystic ovary syndrome has much variation in its clinical expression based on ancestry. Ethnic differences of the phenotype are closely linked to its complex pathophysiology. This paper reviews data of the past three decades ensuring a precise diagnosis and taking into account underlying factors, effects of migration including heterogeneity, and diversity within each identified ethnic group. Differing expressions of hyperandrogenism, obesity, insulin resistance and metabolic manifestations of polycystic ovary syndrome occur among women from distinct geographic locations and ancestry. These ethnic phenotypes correlate with their inherent metabolic risks, skin sensitivity to androgens and social outlook that particularly affects their quality of life and health-seeking behavior. It is recommended that such ethnic variations are recognized in routine clinical practice and longitudinal data be maintained to study the true impact of such differences on disease outcomes.

Epidemiology, diagnosis and management of hirsutism: a consensus statement by the Androgen Excess and Polycystic Ovary Syndrome Society

BACKGROUND

Hirsutism, defined by the presence of excessive terminal hair in androgen-sensitive areas of the female body, is one of the most common disorders in women during reproductive age.

METHODS

We conducted a systematic review and critical assessment of the available evidence pertaining to the epidemiology, pathophysiology, diagnosis and management of hirsutism.

RESULTS

The prevalence of hirsutism is ~10% in most populations, with the important exception of Far-East Asian women who present hirsutism less frequently. Although usually caused by relatively benign functional conditions, with the polycystic ovary syndrome leading the list of the most frequent etiologies, hirsutism may be the presenting symptom of a life-threatening tumor requiring immediate intervention.

CONCLUSIONS

Following evidence-based diagnostic and treatment strategies that address not only the amelioration of hirsutism but also the treatment of the underlying etiology is essential for the proper management of affected women, especially considering that hirsutism is, in most cases, a chronic disorder needing long-term follow-up. Accordingly, we provide evidence-based guidelines for the etiological diagnosis and for the management of this frequent medical complaint.

Acute acalculous cholecystitis due to dengue hemorrhagic fever during pregnancy

A 29-year-old pregnant woman presented with fever, right hypochondrial pain and fatigability at 29 weeks of gestation. Dengue hemorrhagic fever was diagnosed based on clinical, hematological and serological features. However, ultrasound scanning was suggestive of acute acalculous cholecystitis. The patient was managed symptomatically and made a good recovery 8 days following onset of fever. This is the first case of acute acalculous cholecystitis coinciding with dengue hemorrhagic fever reported during pregnancy from an endemic country in Asia. The possible viral and host factors for the development of such a severe form of disease and preventive measures are discussed.

Phenotype and metabolic profile of South Asian women with polycystic ovary syndrome (PCOS): results of a large database from a specialist Endocrine Clinic

BACKGROUND

Compared with other populations, South Asians have a greater propensity to insulin resistance and the metabolic syndrome (MetS). This is the first study to determine the distribution of phenotypes of polycystic ovary syndrome (PCOS) and their relationship to the MetS among indigenous South Asians.

METHOD

An evaluation of the phenotype and metabolic characteristics of PCOS was conducted by recruiting consecutive women diagnosed by Rotterdam consensus criteria from an Endocrine clinic in Colombo, Sri Lanka. Prevalence of MetS was determined, in relation to the phenotypic subgroup of PCOS and compared with ethnically matched, BMI- and age-adjusted controls (n =231).

RESULTS

Acanthosis nigricans (AN) occurred in 64.6% of women with PCOS (n= 469). MetS occurred in 30.6% of the PCOS group compared with 6.34% of controls (P = 0.0001). Those with PCOS and MetS had significantly higher median BMI, blood pressure (BP), fasting plasma glucose, insulin and triglycerides and lower high-density lipoprotein and sex hormone-binding globulin (SHBG), but similar testosterone concentrations compared with those with PCOS alone. Prevalence of MetS was similar in the four PCOS phenotypes, although oligomenorrhoeic women were more obese compared with the normal cycling hyperandrogenic group. Multivariate logistic regression confirmed age ≥35 years, BMI ≥25 kg/m(2) and AN as significant predictors of MetS in PCOS. Case-control comparisons showed that the presence of PCOS results in higher odds of having the MetS, a high waist circumference, elevated diastolic BP, abnormal fasting lipids and high fasting insulin and plasma testosterone concentrations.

CONCLUSIONS

Young indigenous South Asians with PCOS have greater odds of being centrally obese, with a third having the MetS that bears no relationship to the androgenic phenotype. Significant predictors for MetS within the PCOS cohort are advancing age, obesity determined by the Asian cut off (BMI >25 kg/m(2)) and AN, while family history of diabetes, hyperandrogenism and elevated SHBG have no predictive value.

Screening for gestational diabetes mellitus: the Sri Lankan experience

OBJECTIVE

To evaluate tests used for screening and confirmation of gestational diabetes mellitus (GDM) in Sri Lanka.

METHODS FIELD BASED

Consecutive pregnant women in Homagama DDHS area (n = 853), were assessed for risk factors and subjected to random and postprandial urinary Benedict's and Dipstick tests, fasting and 2 hour post 75 g glucose capillary blood glucose (FBG and 2hBG) which were validated against 75 g oral glucose tolerance test (OGTT) performed at 24-28 weeks (WHO criteria).

HOSPITAL BASED

Retrospective analysis of consecutive high-risk women (n = 999) and prospective study of randomly selected GDM women (n = 66) to assess predictive value of the OGTT.

RESULTS FIELD BASED

Sensitivity and specificity respectively of random urine Benedict's, 10%, 99.2%; postprandial urine Benedict's, 52.2%, 94.5%; postprandial urine Dipstick, 68.7%, 90%; capillary FBG threshold 4.1 mmol/l, 62.6%, 73%; capillary 2hBG threshold 7.2 mmol/l, 98.5%, 95.2%; risk factors, 93.1%, 22.2%.

HOSPITAL BASED

OGTT-11.6% lag curves, 16.3% abnormal, FPG accuracy at 4.7mmol/l; predictive value of 2 hPG > or = 8.9 mmol/l for insulin treatment-sensitivity 97.2%, specificity 71.4%.

CONCLUSIONS

Current practice of random urine testing in community screening for gestational diabetes is unreliable, and glucose specific postprandial urine test improves sensitivity. FPG is unsuitable for screening, the 2 hour post 75 g blood glucose at a threshold of > 7.2 mmol/l is sensitive and specific. In laboratory confirmation using 75 g OGTT the fasting plasma glucose has low predictive value, 2 hour test performed alone is liable to false positives and 2 hour glucose > 8.9 mmol/l following a peak at 1 hour suggests the need for insulin treatment.

Restricted thyroglobulin antibody epitope specificities in subjects with type 1 diabetes mellitus

OBJECTIVES

Following iodisation in Sri Lanka we observed a high prevalence of thyroglobulin antibodies (TgAbs) in type 1 diabetic (T1DM) patients. The clinical significance of these TgAbs is uncertain. We sought to obtain a detailed epitope analysis of TgAbs in T1DM patients recruited from diabetes clinics and to compare these with TgAb epitope specificities in patients with autoimmune thyroid disease (AITD) and healthy individuals in that country.

DESIGN AND METHODS

We used a panel of 10 Tg-MAbs in competitive ELISA reactions in a prospective study of subjects recruited from Colombo, to determine the epitopes recognised by TgAb-positive patients with T1DM (n=58, 34F:24M, median age 16 years), AITD patients (n=42, 33F:9M, median age 37 years) and healthy subjects (n=50, 39F:11M, median age 27 years). The outcomes were a comparison of reactivity with six Tg clusters (I-VI) in these subjects, and the relation of epitope specificity patterns with free thyroxine and TSH.

RESULTS

Patients with T1DM and AITD but not healthy control subjects preferentially recognised the immunodominant clusters, I, III and IV. Patients with these narrow epitope specificities had higher median TSH levels (1.60 vs 1.06; P=0.01), and were more frequently positive for antibodies to thyroid peroxidase than those with broad specificities (52.3 vs 7.1%; P=0.004).

CONCLUSIONS

The TgAb epitope specificities in euthyroid Sri Lankans with T1DM are similar to AITD patients. TgAb epitope studies may potentially identify T1DM patients at risk of thyroid dysfunction.

A simple screening approach for assessing community prevalence and phenotype of polycystic ovary syndrome in a semi-urban population in Sri Lanka

In most of South Asia, prevalences and phenotypes of polycystic ovary syndrome (PCOS) among women in the community are unknown. The authors aimed to estimate prevalence and phenotype in a community setting in Sri Lanka and to test a valid, feasible screening approach to early diagnosis. A community-based, cross-sectional study was carried out in 2005-2006. A random sample of 3,030 women aged 15-39 years was selected by cluster sampling proportionate to population size. An interviewer-administered questionnaire was utilized to screen for "probable cases" of PCOS based on menstrual history and clinical manifestations of hyperandrogenism. Selected "probable cases" underwent clinical, biochemical, and ovarian ultrasound assessment. The response rate was 96.2% (n = 2,915). A total of 220 (7.5%) "probable cases" were identified: 209 women with oligo/amenorrhea (95%) and 11 women with hirsutism (5%). Further evaluation of the 220 probable cases confirmed 164 newly diagnosed cases of PCOS based on the 2003 Rotterdam diagnostic criteria. With 19 previously diagnosed cases already present, total prevalence was 6.3% (95% confidence interval: 5.9, 6.8). Of the women with "oligo/amenorrhea and/or hirsutism," 91.1% were confirmed to have PCOS; 99.4% of women with "regular cycles in the absence of clinical hyperandrogenism" were confirmed as normal. The most common phenotypes of PCOS were oligo/amenorrhea and polycystic ovaries (91.4%) and oligo/amenorrhea and hirsutism (48.3%).

An outbreak of Aspergillus meningitis following spinal anaesthesia for caesarean section in Sri Lanka: a post-tsunami effect?

An outbreak of Aspergillus fumigatus meningitis occurred in 5 women following spinal anaesthesia, performed between 21 June and 17 July 2005 for caesarean section, in Colombo, Sri Lanka. The patients' median age was 27 years. Different teams in 2 maternity hospitals gave spinal anaesthesia. Mean incubation period was 11.2 days. Fever, headache and nuchal rigidity were common presentations. Remittent fever continued despite broad-spectrum intravenous antibiotics. Papilloedema, lateral rectus palsy, cerebral infarction and haemorrhage developed later. Three patients died. Cerebrospinal fluid pleocytosis with low glucose yielded negative PCR for fungi. Fungal cultures subsequently grew Aspergillus fumigatus. A post-mortem of the first patient confirmed Aspergillus meningitis, followed by treatment with amphotericin B and voriconazole, that saved the lives of others. Visual and hearing impairment in one and complete recovery in the other were observed a year after treatment. Examination of unused plastic syringes, needles, cannulae, and ampoules of anaesthetic agents confirmed that 43 syringes from three different manufactures were contaminated with Aspergillus fumigatus. The stores for drugs and devices of the Ministry of Health were examined and found to be full of tsunami donations, while regular procurements of the Ministry were kept in a poorly maintained humid warehouse. Inadequate space for tsunami donations was identified as the most plausible explanation for sub-optimal storage. Withdrawal and incineration of all unused syringes controlled the outbreak. The survival of those aggressively treated for Aspergillus meningitis suggests in hindsight that the availability of diagnostic tests and specific treatment, and early recognition of the outbreak could have saved the lives of victims who died. Early life-threatening side-effects and permanent long term sequelae of antifungal medication stress the need to be cautious with empirical treatment in immuno-competent low-risk individuals.

Islet cell, thyroid, adrenal and celiac disease related autoantibodies in patients with Type 1 diabetes from Sri Lanka

AIMS

The prevalence of islet cell, thyroid, adrenal and celiac disease related autoantibodies in patients with Type 1 diabetes mellitus (Type 1 DM) from Sri Lanka is described.

DESIGN AND METHODS

Autoantibodies to glutamic acid decarboxylase 65 (GAD65Ab), protein tyrosine phosphatase IA-2 (IA-2Ab), insulin (IAAb), thyroglobulin (TgAb), thyroid peroxidase (TPOAb), TSH receptor (TRAb), 21-hydroxylase (21-OHAb) and tissue transglutaminase (tTGAb) were measured in 122 Type 1 DM patients who had low C-peptide activity or were >20 yr old at the time of diagnosis and in 100 non-diabetic blood donors.

RESULTS

GAD65Ab and/or IA-2Ab were present in 74/122 (60.7%) Type 1 DM subjects with a significantly higher prevalence compared to non-diabetic controls (no. 100) (GAD65Ab-59 vs 4%; IA-2Ab-14 vs 0%; respectively) (p<0.001). The median (inter-quartile range) Type 1 DM duration in antibody positive subjects was 3.3 (0.99-6.9) vs 4.9 (1.7-7.5) yr in antibody negative subjects (p=0.23). IA-2Ab prevalence decreased with disease duration > or =5 yr (19 vs 4%) (p<0.001). There was no difference in the prevalence of TgAb (25 vs 33%)(p=0.21) and TPOAb (22 vs 18%) (p=0.48) in Type 1 DM and non-diabetic subjects. Also, there was no difference in TgAb and TPOAb prevalence in antibody positive Type 1 DM (34.7%) compared to antibody negative Type 1 DM (24.4%) subjects (p=0.24). tTGAb (3/119) and TRAb (1/119) were found in low prevalence and 21-OHAb were not detected.

CONCLUSIONS

Diabetes associated autoantibodies were detected in the majority of Type 1 DM subjects, suggesting a major role for autoimmunity in the pathogenesis of Type 1 DM in Sri Lankans. The prevalence of TgAb and TPOAb in Type 1 DM subjects and non-diabetic controls was relatively high and similar in both groups.

Metabolic and polycystic ovary syndromes in indigenous South Asian women with previous gestational diabetes mellitus

OBJECTIVE

To determine the risk of metabolic syndrome (MS) and polycystic ovary syndrome (PCOS) in a cohort of indigenous South Asian women with a recent history of gestational diabetes mellitus (GDM).

DESIGN

Case-control study.

SETTING

Department of Obstetrics & Gynaecology, University of Colombo, Sri Lanka.

SAMPLE

Two hundred and seventy-four indigenous Sri Lankan women with previous GDM and 168 ethnically matched controls. Of these, 147 with previous GDM and 67 controls not taking hormonal contraception participated in an in-depth endocrine study.

METHODS

Assessing the prevalence of MS and PCOS based on clinical features, biochemistry and ovarian ultrasound examination at 3 years postpartum.

MAIN OUTCOME MEASURES

Prevalence of MS and PCOS.

RESULTS

Women with previous GDM and controls were studied at a mean (range) of 34.6 (13.4-84.1) and 46.5 (17.5-78) months postpartum, respectively. Those with previous GDM had a larger mean +/- 95% confidence interval waist circumference (90.9 +/- 1.3 versus 81.2 +/- 2.8 cm, P = 0.0004) and were more likely to have hypertension (17.6 versus 7.4%, P = 0.001), glucose intolerance (51.7 versus 10.4%, P = 0.00001), hypertriglyceridaemia (16.3 versus 5.9%, P = 0.02) and a lower level of high-density lipoprotein (70 versus 56.7%, P = 0.04) than the controls. Of the women who had GDM, 72 (49%) had MS, 86 (58.5%) had polycystic ovaries and 59 (40%) had PCOS, significantly more than the control women-4 (6%), 9 (13%) and 2 (3%), respectively (P = 0.00001).

CONCLUSIONS

The prevalence of MS and PCOS in indigenous Sri Lankan women 3 years postpartum is significantly higher in those with previous GDM compared with ethnically matched controls. This confirms an association between GDM and subsequent PCOS and MS.

Dengue infections during pregnancy: A case series from Sri Lanka and review of the literature

BACKGROUND

Dengue is a major public health problem in several countries. Few reports document presentations and outcomes of dengue during pregnancy. In many endemic countries as the average age of getting dengue infections is shifting upwards, dengue in pregnancy is likely to be encountered more frequently. Patterns of dengue in patients from different regions are needed if we are to draft evidence based management guidelines.

OBJECTIVES

To document clinical and laboratory findings in a cohort of hospitalised patients with dengue during pregnancy in Sri Lanka and compare their presentation and outcomes with previously published cases.

STUDY DESIGN

Clinical, laboratory, maternal and fetal outcomes and demographic information were collected from patients with confirmed dengue infections during pregnancy treated in a Maternity Hospital in Sri Lanka from 1 January 2000 to 30 June 2004. The Medline database was searched to identify reports relating to dengue infection during pregnancy since 1965.

RESULTS

Twenty-six patients [mean (S.D.) age: 29 (4.2) years] were studied. One (3.8%), 2 (7.7%) and 20 (77%) presented in the first, second and third trimesters of pregnancy, and 3 (11.5%) in the immediate post-partum period. Seventeen (65.3%) had primary and nine (34.7%) secondary dengue infections. Ten (38.5%) had DF, 6 (23.1%): DHF grade I and 10 (38.5%): DHF grade II. Five (19.2%) and three (11.5%) patients who first presented with cough/breathlessness or vaginal bleeding, were initially managed as having a pulmonary embolism or a primary obstetric cause for their vaginal bleeding. Bradycardia was noted in three of the four patients who had a cardiac arrhythmia. Seven (26.9%) needed admission to an ICU. Raised AST and ALT levels were seen in 81.2% and 43.7% of 16 patients in whom liver function tests results were available. No fetal malformations were seen in any of the babies born. The single patient who developed DHF in the first trimester had an abortion while having acute symptoms of dengue.

CONCLUSIONS

Awareness of clinical and laboratory manifestations of dengue in pregnancy should allow its early recognition and institution of appropriate treatment. Reports on dengue in pregnancy from different regions should allow more evidence-based guidelines to be formulated for optimum evaluation and care of such patients. Our data contributes towards this goal.

Sequential studies on thyroid antibodies during pregnancy

Thyroid antibodies were measured sequentially in 25 pregnant women from a Sri Lankan population. A high prevalence of antithyroid antibodies, particularly antithyroglobulin antibodies (TgAb) had previously been demonstrated in female schoolchildren drawn from this population. In the present study TgAb were detected in 36.8% of nonpregnant controls while thyroid peroxidase antibody (TPOAb) positivity was present in 26.3%. The prevalence of both antibodies in the pregnancy study group showed a progressive decline compared to nonpregnant controls throughout gestation becoming undetectable in the third trimester. The results are consistent with an immunosuppressive effect of pregnancy in a population in whom high thyroid autoantibody titers may have resulted from a recent salt iodization program.

Plasma homocysteine in polycystic ovary syndrome: does it correlate with insulin resistance and ethnicity?

BACKGROUND

Polycystic ovary syndrome (PCOS) is associated with insulin resistance and premature coronary artery disease (CAD). Hyperhomocysteinaemia is a recognized risk factor for atherosclerosis, particularly among migrant South Asians, and has recently been shown to be correlated positively with the degree of insulin resistance/hyperinsulinaemia.

OBJECTIVES

To compare total plasma homocysteine (Hcy) in PCOS with controls from ethnic groups at high and low risk of insulin resistance.

METHODS

Case control study of three ethnic groups, Sri Lankans (SL), British Asians (BA) and white Europeans (C), with and without PCOS at specialist centres in Sri Lanka and Yorkshire, UK. Fasting total plasma Hcy concentration was analysed by fluorescence polarization immunoassay and examined for any correlation with age, body mass index (BMI), central obesity, fasting insulin and insulin sensitivity [calculated by the Quantitative Insulin Sensitivity Check Index (QUICKI) method], lipids and testosterone in each ethnic group.

RESULTS

Eighty SL with PCOS and 45 controls, 47 BA with PCOS and 11 controls, and 40 C with PCOS and 22 controls were studied. Both Asian groups with PCOS were younger than affected Europeans (P = 0.008). Sri Lankans with PCOS had significantly lower BMI values than other affected groups: mean +/- SEM (SL) 26.3 +/- 0.95; (BA) 30.59 +/- 7.54; (C) 32.1 +/- 5.95 kg/m2 (P = 0.006). However, waist : hip ratios (WHR) of Sri Lankans with PCOS were similar to others: mean +/- SEM (SL) 0.97 +/- 0.01 (BA) 1.04 +/- 0.02 (C) 0.92 +/- 0.01, P = 0.33. Mean plasma Hcy was significantly higher in all PCOS groups than in their ethnically matched controls (Student's t-test): (SL) 10.2 +/- 1.9 vs 9.0 +/- 3.8, P = 0.01; (BA) 7.9 +/- 1.9 vs 6.8 +/- 2.5, P < 0.0001; (C) 8.3 +/- 2.3 vs 6.8 +/- 1.5, P = 0.0007 micromol/l. Sri Lankans with PCOS had significantly greater Hcy concentrations than British Asians and Europeans with PCOS [P = 0.001; single-factor analysis of variance (anova)] and also significantly greater fasting insulin concentrations [(SL) 242.9 +/- 38.9; (BA) 89.4 +/- 8.9; (C) 48.6 +/- 4.8 pmol/l (P = 0.0003)] and significantly lower QUICKI [(SL) 0.308 +/- 0.004; (BA) 0.335 +/- 0.005; (C) 0.375 +/- 0.002 (P = 0.0007)]. Fasting plasma Hcy correlated best with fasting insulin (r = 0.56, P = 0.0001) and QUICKI (r =-0.53, P < 0.0001) in Sri Lankans with PCOS. Hcy in PCOS subjects from all three ethnic groups correlated significantly with fasting insulin following adjustment for age, BMI and WHR (r = 0.45, P = 0.0001), but this was not evident in the controls (r =-0.32, P = 0.1).

CONCLUSIONS

Elevation of fasting plasma homocysteine in PCOS varies with ethnicity and correlates significantly with fasting insulin. High homocysteine in young Sri Lankans with PCOS has major implications for their long-term risk for atherosclerosis.

Evolution of thyroid autoimmunity during iodine prophylaxis--the Sri Lankan experience

OBJECTIVE

To study the evolution of thyroid autoimmunity, in relation to the change in goitre prevalence, during 3 Years of iodine prophylaxis in Sri Lanka.

METHODS

Two groups of Sri Lankan schoolgirls between the ages of 10.8 and 17.5 Years were studied in 1998 (401 girls) and 2001 (282 girls). A prospective study was performed in 42 schoolgirls who were thyroid autoantibody (Ab)-positive (+ve) in 1998. Anthropometric measures, urinary iodine excretion (UIE), thyroid Volume, free thyroxine, free tri-iodothyronine, TSH, and thyroglobulin (Tg) and thyroid peroxidase (TPO) Ab were evaluated in all 683 girls.

RESULTS

Goitre prevalence was significantly lower in 2001 compared with 1998 related to age (2.9% compared with 20.2%) and body surface area (11.6% compared with 40.8%), although UIE was unchanged. Prevalence of thyroid Ab in 2001 was also lower (23.4% compared with 49.9%); among those with the Ab, 34.8% had TgAb alone and 46.9% had a combination of TgAb+TPOAb, compared with 82.0% TgAb alone in 1998. In 2001, subclinical hypothyroidism was more frequent in Ab+ve (6.3%) than Ab-negative girls (1.0%). A cohort of 42 Ab+ve schoolgirls in 1998 (34 with TgAb alone, eight with TgAb+TPOAb) were evaluated again in 2001. Only 10 of them (23.8%) remained Ab+ve (mostly TPOAb+/-TgAb) in 2001.

CONCLUSIONS

This study demonstrates that: (1) in 2001, goitre prevalence and thyroid autoimmunity rates were significantly lower than in 1998; (2) the pattern of thyroid Ab was different in the two surveys; (3) in 2001 alone, the occurrence of hypothyroidism was correlated with the presence of thyroid autoimmunity. These results indicate an evolution of thyroid autoimmune markers during the course of iodine prophylaxis, which has not been described before.

Clinical manifestations and insulin resistance (IR) in polycystic ovary syndrome (PCOS) among South Asians and Caucasians: is there a difference?

OBJECTIVE

Polycystic ovary syndrome (PCOS) is more prevalent in South Asian women residing in the UK than in Caucasians. Insulin resistance (IR) is central to the pathogenesis of PCOS, while type 2 diabetes is commoner in South Asians. We aimed to determine a possible ethnic difference in the clinical and biochemical characteristics of South Asian vs. Caucasian women with PCOS.

PATIENTS AND DESIGN

A case-control cross-sectional observational study of consecutive women with anovular PCOS (47 South Asians, 40 Caucasians) and their age-matched controls (11 South Asians and 22 Caucasians).

MEASUREMENTS

Index subjects: a questionnaire-based interview on clinical symptoms and family history; anthropometric measurements, clinical observations of the presence and degree of acne, hirsutism and acanthosis nigricans; transvaginal pelvic ultrasound; biochemical analyses of fasting blood sugar, fasting plasma insulin, fasting lipids, testosterone, and SHBG concentrations.

CONTROL GROUP

age- and weight-matched unrelated women from the same ethnic backgrounds without PCOS seeking treatment for male infertility were studied by similar methods to those used with the index subjects.

RESULTS

South Asians with PCOS presented at a younger age (age 26 +/- 4 vs. 30.1 +/- 5 years, P = 0.005). Body mass index (BMI) and waist : hip ratios were similar in the two affected cohorts. More South Asians had oligomenorrhoea commencing at a younger age. Hirsutism (Ferriman Gallwey score 18 vs. 7.5, P = 0.0001), acne, acanthosis nigricans and secondary infertility were significantly more prevalent in South Asians. The fasting glucose was similar (4.52 +/- 0.08 vs. 4.62 +/- 0.09 mmol/l, P = 0.25), the fasting insulin higher (89.4 +/- 8.9 vs. 48.6 +/- 4.8 pmol/l, P = 0.0001) and insulin sensitivity (IS) lower (0.335 +/- 0.005 vs. 0.357 +/- 0.002, P = 0.0001) among South Asians. Serum SHBG was significantly less in South Asians (35 +/- 3.3 vs. 55 +/- 9.4 nmol/l, P = 0.02), while serum testosterone was similar (2.69 +/- 0.11 vs. 2.64 +/- 0.13 nmol/l, P = 0.37).

CONCLUSIONS

We conclude that South Asians with anovular PCOS seek treatment at a younger age, have more severe symptoms, and have higher fasting insulin concentrations and lower insulin sensitivity than Caucasians.

Pregnancy following renal transplantation in Sri Lanka

OBJECTIVE

To assess the outcome and complications of pregnancy following renal transplantation in Sri Lanka.

METHODS

Ten pregnancies following transplantation managed between January 1993 and July 1999 by the University Obstetrics and Gynaecology Unit, De Soysa Hospital for Women, Colombo were reviewed.

RESULTS

Five women had planned pregnancy with an average duration from transplantation to conception of 2.3 (+/- 0.2) years; five had an unplanned pregnancy within 12 months of transplantation. All were treated with immunosuppressives, with none developing rejection. In the planned pregnancy group, 3 developed pregnancy induced hypertension and 3 impaired glucose tolerance. All delivered mature healthy babies with an average birth weight of 2.6 (+/- 0.3) kg. In the unplanned group, 1 developed cholestatic jaundice and delivered a growth retarded baby at 36 weeks. Another developed severe pulmonary oedema at 34 weeks (due to a past myocardial infarction) resulting in a fresh stillbirth. Two others has mid-trimester foetal deaths complicating severe diabetes mellitus. The conception at 3 months after transplantation developed diabetes mellitus and pregnancy induced hypertension, and delivered a live growth retarded baby. None had deterioration of renal function.

CONCLUSION

Although a successful outcome is possible with stringent pre-pregnancy selection, maternal morbidity and foetal wastage can be high in those without.

Increased prevalence of thyroglobulin antibodies in Sri Lankan schoolgirls--is iodine the cause?

OBJECTIVE

Iodine deficiency was the likely cause of a high prevalence of goitre previously in Sri Lankan schoolchildren. Salt iodination was made compulsory in 1993 but there has been no recent study, using modern techniques, of its benefits or harmful effects.

METHODS

Three hundred and sixty-seven schoolgirls between the ages of 11 and 16 years had ultrasound thyroid volume, free thyroxine (T4), free tri-iodothyronine (T3), thyrotrophin (TSH), anti-thyroglobulin (TgAb) and thyroid peroxidase (TPOAb) antibodies, and urine iodine concentrations measured.

RESULTS

Median ultrasound thyroid volume ranged from 4.8 ml (11-year-old girls) to 8.6 ml (16-year-old girls) with an age-related increase. Median urine iodine concentrations ranged from 105 to 152 microg/l. Free T4 and free T3 were normal in all, but TSH was elevated in four subjects (5. 53-41.29 mU/l). However, the prevalence of TgAb was markedly raised, ranging between 14.3% (11-year-old girls) and 69.7% (16-year-old girls) (P<0.03). In contrast, the prevalence of TPOAb was 10% or less in all age groups.

CONCLUSIONS

Normal median thyroid volumes, iodine concentrations and thyroid function would indicate that iodine deficiency is not a major problem in this group. The high prevalence of TgAb, hitherto unreported, most likely reflects excessive iodination of Tg resulting in increased immunogenicity. There is an urgent need to continuously monitor the adequacy and risks of iodination in this population.

The effect of alpha human atrial natriuretic peptide on plasma volume and vascular permeability in normotensive subjects

Low dose infusion of alpha human atrial natriuretic peptide (ANP) has been shown to cause a shift of intravascular fluid to the interstitial space. No studies have been reported on the effect of ANP on capillary permeability to plasma proteins. We studied the effect of low dose ANP (2.5 pmol/kg.min) or equal volume of saline control when infused over 90 min, on plasma volume, transcapillary escape rate of intravascular albumin, and the rate of reentry of albumin to the vascular space in eight normal subjects. Intravenous injection of 125I-human serum albumin was used for measurement of plasma volume and intravascular albumin escape rate. A significant ANP-induced fall in plasma volume (P < 0.01) was observed. Transcapillary escape rate of intravascular albumin when corrected for concurrent plasma volume changes showed a significantly greater escape during ANP infusion than during saline control (P < 0.05). The mean +/- SEM changes in plasma albumin concentration were +0.36 +/- 0.22 g/L.h during ANP infusion and -0.46 +/- 0.50 g/L.h during placebo. Plasma sodium, red cell volume, and urinary albumin and radioactivity remained unchanged. The mass of albumin reentering the circulation per hour showed no significant difference between the 2 days. In summary, low dose ANP infusion in healthy subjects caused a shift of plasma water and electrolytes from the circulation, with albumin escape as a secondary phenomenon.