Adoptability of New Technology in the Small-Holdings Tea Sector

The degree of adoption of recommended technology is a crucial factor in the tea smallholdings sector of the low country Sri Lanka as far as the yield is concerned. An empirical study was carried out to ascertain the present situation. Almost all the recommendations were grouped into 11 packages (selection of clones, fertilizer application, soil and moisture conservation, field establishment, training, infilling, weed control, pruning, shading, pest and disease control and plucking). A package consisted of sub indicators to reveal farmers’ adoption level. High, middle, low and non-adopters were given justified scores (according to their importance to the yield). The total of marks given to sub indicators was the adoption index of farmers. Though the mean adoption level was 71%, some packages such as pest and disease control, and weed control were marginally adopted. Highest adopted packages included plucking, clone selection, field establishment, and fertilizer application (above 75% level). Adoption level was positively correlated to education, number of dependents, labour use pattern, and subsidies and further, it was negatively correlated to land extent

Delayed Psychological Morbidity Associated with Snakebite Envenoming

Introduction The psychological impact of snakebite on its victims, especially possible late effects, has not been systematically studied. Objectives To assess delayed somatic symptoms, depressive disorder, post-traumatic stress disorder (PTSD), and impairment in functioning, among snakebite victims. Methods The study had qualitative and quantitative arms. In the quantitative arm, 88 persons who had systemic envenoming following snakebite from the North Central Province of Sri Lanka were randomly identified from an established research database and interviewed 12 to 48 months (mean 30) after the incident. Persons with no history of snakebite, matched for age, sex, geograpical location and occupation, acted as controls. A modified version of the Beck Depression Inventory, Post-Traumatic Stress Symptom Scale, Hopkins Somatic Symptoms Checklist, Sheehan Disability Inventory and a structured questionnaire were administered. In the qualitative arm, focus group discussions among snakebite victims explored common somatic symptoms attributed to envenoming. Results Previous snakebite victims (cases) had more symptoms than controls as measured by the modified Beck Depression Scale (mean 19.1 Vs 14.4; p<0.001) and Hopkins Symptoms Checklist (38.9 vs. 28.2; p<0.001). 48 (54%) cases met criteria for depressive disorder compared to 13 (15%) controls. 19 (21.6%) cases also met criteria for PTSD. 24 (27%) claimed that the snakebite caused a negative change in their employment; nine (10.2%) had stopped working and 15 (17%) claimed residual physical disability. The themes identified in the qualitative arm included blindness, tooth decay, body aches, headaches, tiredness and weakness. Conclusions Snakebite causes significant ongoing psychological morbidity, a complication not previously documented. The economic and social impacts of this problem need further investigation

High lethality and minimal variation after acute self-poisoning with carbamate insecticides in Sri Lanka – implications for global suicide prevention

Highly hazardous organophosphorus (OP) insecticides are responsible for most pesticide poisoning deaths. As they are removed from agricultural practice, they are often replaced by carbamate insecticides of perceived lower toxicity. However, relatively little is known about poisoning with these insecticides. METHODS: We prospectively studied 1288 patients self-poisoned with carbamate insecticides admitted to six Sri Lankan hospitals. Clinical outcomes were recorded for each patient and plasma carbamate concentration measured in a sample to confirm the carbamate ingested. FINDINGS: Patients had ingested 3% carbofuran powder (719), carbosulfan EC25 liquid (25% w/v, 389), or fenobucarb EC50 liquid (50% w/v, 127) formulations, carbamate insecticides of WHO Toxicity Classes Ib, II, and II, respectively. Intubation and ventilation was required for 183 (14.2%) patients while 71 (5.5%) died. Compared with carbofuran, poisoning with carbosulfan or fenobucarb was associated with significantly higher risk of death [carbofuran 2.2%; carbosulfan 11.1%, OR 5.5 (95% CI 3.0-9.8); fenobucarb 6.3%, OR 3.0 (1.2-7.1)] and intubation [carbofuran 6.1%; carbosulfan 27.0%, OR 5.7 (3.9-8.3); fenobucarb 18.9%, OR 3.6 (2.1-6.1)]. The clinical presentation and cause of death did not differ markedly between carbamates. Median time to death was similar: carbofuran 42.3 h (IQR 5.5-67.3), carbosulfan 21.3 h (11.5-71.3), and fenobucarb 25.3 h (17.3-72.1) (p = 0.99); no patients showed delayed onset of toxicity akin to the intermediate syndrome seen after OP insecticide poisoning. For survivors, median duration of intubation was 67.8 h (IQR 27.5-118.8) with no difference in duration between carbamates. Reduced GCS at presentation was associated with worse outcome although some patients with carbosulfan died after presentation with normal GCS. CONCLUSIONS: We did not find carbamate insecticide self-poisoning to vary markedly according to the carbamate ingested although the case fatality varied according to the concentration and formulation of the insecticide. Carbamate poisoning did not appear to be much less toxic than poisoning with some liquid OP insecticide formulations, e.g., chlorpyrifos EC40, that we have previously noted in these same hospitals (Lancet 2005, 366:1452-1459; QJM 2006, 99:513-522). Replacement of WHO Class II Toxicity OP insecticides in agriculture with high-strength liquid carbamate formulations may not substantially reduce case fatality after pesticide poisoning and, therefore, global suicide rates.NHMRC Grant 07166

Doctors and nurses perceptions towards the introduction of clinical pharmacy service to the Sri Lankan healthcare system- Experience from a tertiary care hospital

Objectives: To evaluate the rate of acceptance of the clinical pharmacist’s (CP’s) recommendations regarding Drug Related Problems (DRPs) by healthcare team, to determine the quality and quantity of drug information queries directed to the CP and to assess the level of acceptance of clinical pharmacy service (CPS) by other members of the ward staff.Methods: This was a controlled trial conducted in a tertiary care hospital. The control group received standard care. The intervention group received a CPS in addition to the standard care. DRPs were classified according to the adapted PCNE classification system V5.01. The CP discussed the identified potential DRPs with healthcare team. All the drug related questions directed to the CP by healthcare staff were recorded. A staff survey was carried out before and after the study.Results: A total of 270 drug related recommendations were directed to the healthcare team. 83% (P < 0.001) of the recommendations were accepted by doctors and 74% (P < 0.001) were acted upon. 17 medication-related questions were directed to the CP from the team. The perceptions of doctors regarding ward-based CPS were satisfactory at baseline period. At end of study, the majority of doctors were happy to welcome a service from a competent CP. Nurses were resistant to this collaboration.Conclusions: There was high acceptance of CP’s recommendations regarding DRPs by the medical team. Doctors were satisfied with the inclusion of a ward-based pharmacist to the healthcare team. However there is a need to improve liaisons between CP and nursing staff

Benefits of having a clinical pharmacist in an out-patient renal clinic in Sri Lanka

Introduction: Laboratory investigations are an essential tool for health care professionals. Clinicalpharmacists (CP) are well placed to contribute to pharmacotherapy optimization using laboratorymonitoring in their armamentarium. Three examples describe CP associated laboratory monitoring fortherapy improvements in an out-patient renal clinic in Sri Lanka.Case Report:Case 1: Spiranolactone 12.5mg was commenced in a patient with stage IV chronic kidney disease(CKD) when a low serum potassium level of 2.9mmol/L was detected. This continued to be prescribedeven after serum potassium level became high (5.6mmol/L). The CP informed the clinic doctor, whoordered a repeat serum electrolyte level. Serum potassium remained elevated and spironolactone wasdiscontinued.Case 2: A CKD stage V patient with anemia (hemoglobin 8.62g/dL) had self-discontinued weeklysubcutaneous erythropoietin injection two months previously. Since he remained anemic, the CPinformed the clinic doctor that the patient had defaulted treatment. The doctor prescribed weeklyerythropoietin and a full blood count for the next clinic visit.Case 3: In a patient with CKD Stage IV and hypercholesterolemia, atorvastatin had been unintentionallyomitted from the prescription. No recent lipid profile was available. The CP communicated this to thedoctor, who requested a lipid profile. Total cholesterol level was 293mg/dL. Atorvastatin was restartedat 20mg at night.Discussion: These cases illustrate the opportunities for CP to optimize pharmacotherapy in response tolaboratory monitoring to improve patients’ therapeutic outcomes. Collaboration of skills and knowledgeof healthcare professionals will result in improved patient management in busy renal clinics

High lethality and minimal variation after acute self-poisoning with carbamate insecticides in Sri Lanka - implications for global suicide prevention

Highly hazardous organophosphorus (OP) insecticides are responsible for most pesticide poisoning deaths. As they are removed from agricultural practice, they are often replaced by carbamate insecticides of perceived lower toxicity. However, relatively little is known about poisoning with these insecticides. METHODS: We prospectively studied 1288 patients self-poisoned with carbamate insecticides admitted to six Sri Lankan hospitals. Clinical outcomes were recorded for each patient and plasma carbamate concentration measured in a sample to confirm the carbamate ingested. FINDINGS: Patients had ingested 3% carbofuran powder (719), carbosulfan EC25 liquid (25% w/v, 389), or fenobucarb EC50 liquid (50% w/v, 127) formulations, carbamate insecticides of WHO Toxicity Classes Ib, II, and II, respectively. Intubation and ventilation was required for 183 (14.2%) patients while 71 (5.5%) died. Compared with carbofuran, poisoning with carbosulfan or fenobucarb was associated with significantly higher risk of death [carbofuran 2.2%; carbosulfan 11.1%, OR 5.5 (95% CI 3.0-9.8); fenobucarb 6.3%, OR 3.0 (1.2-7.1)] and intubation [carbofuran 6.1%; carbosulfan 27.0%, OR 5.7 (3.9-8.3); fenobucarb 18.9%, OR 3.6 (2.1-6.1)]. The clinical presentation and cause of death did not differ markedly between carbamates. Median time to death was similar: carbofuran 42.3 h (IQR 5.5-67.3), carbosulfan 21.3 h (11.5-71.3), and fenobucarb 25.3 h (17.3-72.1) (p = 0.99); no patients showed delayed onset of toxicity akin to the intermediate syndrome seen after OP insecticide poisoning. For survivors, median duration of intubation was 67.8 h (IQR 27.5-118.8) with no difference in duration between carbamates. Reduced GCS at presentation was associated with worse outcome although some patients with carbosulfan died after presentation with normal GCS. CONCLUSIONS: We did not find carbamate insecticide self-poisoning to vary markedly according to the carbamate ingested although the case fatality varied according to the concentration and formulation of the insecticide. Carbamate poisoning did not appear to be much less toxic than poisoning with some liquid OP insecticide formulations, e.g., chlorpyrifos EC40, that we have previously noted in these same hospitals (Lancet 2005, 366:1452-1459; QJM 2006, 99:513-522). Replacement of WHO Class II Toxicity OP insecticides in agriculture with high-strength liquid carbamate formulations may not substantially reduce case fatality after pesticide poisoning and, therefore, global suicide rates.NHMRC Grant 07166

Impact of a ward based clinical pharmacy service on drug-related hospital re-admissions - Evidence from a controlled clinical trial in a tertiary care hospital in Sri Lanka

Objective: To determine the impact of a ward-based clinical pharmacy service on drug related hospital re-admissions.Methods: This was a part of a controlled trial conducted in a tertiary care hospital in Sri Lanka to evaluate the clinical pharmacy service. The control group received the standard care whereas the intervention group received a ward-based pharmacist’s service in addition to the standard care. The pharmacist performed a prospective medications review of patients with chronic non-communicable diseases during their hospital stay and made recommendations to the health care team when appropriate. At discharge reconciliation of discharge prescription was done. Patients were educated about discharge medicines to improve knowledge and compliance. Both groups were followed up monthly for six months to identify drug-related hospital re-admissions.Results: Of 137 drug-related re-admissions, 93 (involving 87/356 patients) were from the control group, and 44 (involving 42/361 patients) were from the intervention group (P < 0.001). Non-compliance was the main reason for re-admissions in the control group and it was significantly higher in the control group (control vs. intervention: 53.8% vs. 34.1%; P = 0.013). Adverse drug reactions were the most common reason for re-admission in the intervention group (23/44; 52.3%). There was a significantly larger percentage of re-admissions in the control group due to unintentional omission of drugs on discharge prescription (control vs. intervention: 17.2% vs. 2.3%; P = 0.012).Conclusion: Ward based clinical pharmacy service was useful to reduce drug related hospital re-admissions in patients with chronic non-communicable diseases. Establishing a ward based clinical pharmacy service is recommended

Food environment and diabetes mellitus in South Asia: A geospatial analysis of health outcome data

BACKGROUND: The global epidemic of type 2 diabetes mellitus (T2DM) renders its prevention a major public health priority. A key risk factor of diabetes is obesity and poor diets. Food environments have been found to influence people's diets and obesity, positing they may play a role in the prevalence of diabetes. Yet, there is scant evidence on the role they may play in the context of low- and middle-income countries (LMICs). We examined the associations of food environments on T2DM among adults and its heterogeneity by income and sex. METHODS AND FINDINGS: We linked individual health outcome data of 12,167 individuals from a network of health surveillance sites (the South Asia Biobank) to the density and proximity of food outlets geolocated around their homes from environment mapping survey data collected between 2018 and 2020 in Bangladesh and Sri Lanka. Density was defined as share of food outlets within 300 m from study participant's home, and proximity was defined as having at least 1 outlet within 100 m from home. The outcome variables include fasting blood glucose level, high blood glucose, and self-reported diagnosed diabetes. Control variables included demographics, socioeconomic status (SES), health status, healthcare utilization, and physical activities. Data were analyzed in ArcMap 10.3 and STATA 15.1. A higher share of fast-food restaurants (FFR) was associated with a 9.21 mg/dl blood glucose increase (95% CI: 0.17, 18.24; p < 0.05). Having at least 1 FFR in the proximity was associated with 2.14 mg/dl blood glucose increase (CI: 0.55, 3.72; p < 0.01). A 1% increase in the share of FFR near an individual's home was associated with 8% increase in the probability of being clinically diagnosed as a diabetic (average marginal effects (AMEs): 0.08; CI: 0.02, 0.14; p < 0.05). Having at least 1 FFR near home was associated with 16% (odds ratio [OR]: 1.16; CI: 1.01, 1.33; p < 0.05) and 19% (OR: 1.19; CI: 1.03, 1.38; p < 0.05) increases in the odds of higher blood glucose levels and diagnosed diabetes, respectively. The positive association between FFR density and blood glucose level was stronger among women than men, but the association between FFR proximity and blood glucose level was stronger among men as well as among those with higher incomes. One of the study's key limitations is that we measured exposure to food environments around residency geolocation; however, participants may source their meals elsewhere. CONCLUSIONS: Our results suggest that the exposure to fast-food outlets may have a detrimental impact on the risk of T2DM, especially among females and higher-income earners. Policies should target changes in the food environments to promote better diets and prevent T2DM

Food environments and obesity: a geospatial analysis of the South Asia Biobank, income and sex inequalities.

Introduction: In low-middle income countries (LMICs) the role of food environments on obesity has been understudied. We address this gap by 1) examining the effect of food environments on adults' body size (BMI, waist circumference) and obesity; 2) measuring the heterogeneity of such effects by income and sex. Methods: This cross-sectional study analysed South Asia Biobank surveillance and environment mapping data for 12,167 adults collected between 2018 and 2020 from 33 surveillance sites in Bangladesh and Sri Lanka. Individual-level data (demographic, socio-economic, and health characteristics) were combined with exposure to healthy and unhealthy food environments measured with geolocations of food outlets (obtained through ground-truth surveys) within 300 m buffer zones around participants' homes. Multivariate regression models were used to assess association of exposure to healthy and unhealthy food environments on waist circumference, BMI, and probability of obesity for the total sample and stratified by sex and income. Findings: The presence of a higher share of supermarkets in the neighbourhood was associated with a reduction in body size (BMI, β = - 3∙23; p < 0∙0001, and waist circumference, β = -5∙99; p = 0∙0212) and obesity (Average Marginal Effect (AME): -0∙18; p = 0∙0009). High share of fast-food restaurants in the neighbourhood was not significantly associated with body size, but it significantly increased the probability of obesity measured by BMI (AME: 0∙09; p = 0∙0234) and waist circumference (AME: 0∙21; p = 0∙0021). These effects were stronger among females and low-income individuals. Interpretation: The results suggest the availability of fast-food outlets influences obesity, especially among female and lower-income groups. The availability of supermarkets is associated with reduced body size and obesity, but their effects do not outweigh the role of fast-food outlets. Policies should target food environments to promote better diets and reduce obesity

Pralidoxime in Acute Organophosphorus Insecticide Poisoning-A Randomised Controlled Trial

Background: Poisoning with organophosphorus (OP) insecticides is a major global public health problem, causing an estimated 200,000 deaths each year. Although the World Health Organization recommends use of pralidoxime, this antidote's effectiveness remains unclear. We aimed to determine whether the addition of pralidoxime chloride to atropine and supportive care offers benefit. Methods and Findings: We performed a double-blind randomised placebo-controlled trial of pralidoxime chloride (2 g loading dose over 20 min, followed by a constant infusion of 0.5 g/h for up to 7 d) versus saline in patients with organophosphorus insecticide self-poisoning. Mortality was the primary outcome; secondary outcomes included intubation, duration of intubation, and time to death. We measured baseline markers of exposure and pharmacodynamic markers of response to aid interpretation of clinical outcomes. Two hundred thirty-five patients were randomised to receive pralidoxime (121) or saline placebo (114). Pralidoxime produced substantial and moderate red cell acetylcholinesterase reactivation in patients poisoned by diethyl and dimethyl compounds, respectively. Mortality was nonsignificantly higher in patients receiving pralidoxime: 30/121 (24.8%) receiving pralidoxime died, compared with 18/114 (15.8%) receiving placebo (adjusted hazard ratio HR] 1.69, 95% confidence interval CI] 0.88-3.26, p = 0.12). Incorporating the baseline amount of acetylcholinesterase already aged and plasma OP concentration into the analysis increased the HR for patients receiving pralidoxime compared to placebo, further decreasing the likelihood that pralidoxime is beneficial. The need for intubation was similar in both groups (pralidoxime 26/121 21.5%], placebo 24/114 21.1%], adjusted HR 1.27 95% CI 0.71-2.29]). To reduce confounding due to ingestion of different insecticides, we further analysed patients with confirmed chlorpyrifos or dimethoate poisoning alone, finding no evidence of benefit. Conclusions: Despite clear reactivation of red cell acetylcholinesterase in diethyl organophosphorus pesticide poisoned patients, we found no evidence that this regimen improves survival or reduces need for intubation in patients with organophosphorus insecticide poisoning. The reason for this failure to benefit patients was not apparent. Further studies of different dose regimens or different oximes are required