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June 2015, VOLUME 08, ISSUE 06
THE OFFICIAL NEWSLETTER OF THE SRI LANKA MEDICAL ASSOCIATION
Cover Story...
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Food Safety
Approach to Thrombocytopenia
Diabetic Foot Ulcer
Joint Regional Meeting - Matara
Joint Regional Meeting - Nuwara Eliya
Child Injury Prevention
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CONTENTS Page No.
Cover Story Food Safety
SLMANEWS
THE OFFICIAL NEWSLETTER OF THE SRI LANKA MEDICAL ASSOCIATION
June 2015, Volume 8, issue 06
02, 03, 04, 06, 08
SLMA News Editorial Committee-2015 Editor-In-Chief: Prof. Sharmini Gunawardena
News
Committee:
President's message Food Safety
02
02, 03, 04, 06, 08
Approach to Thrombocytopenia Dilemmas and Limitations
07, 08, 09
Dr. Amaya Ellawala Dr. Iyanthi Abeyewickreme Prof. Deepika Fernando Dr. Sarath Gamini De Silva
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Diabetic Foot Ulcer: Musculoskeletal Perspective
09, 10, 12
Joint Regional Meeting of the Ruhuna Clinical Society and the SLMA
12, 13, 14
Joint Regional Meeting of the Hill Country Clinical Society and the SLMA
14,15
Glaxosmithkline Pharmaceuticals Ltd. Tokyo Cement Company (Lanka) Plc. Durdans Hospital. The Central Hospital George Steuart Health. Emerchemie NB (Ceylon) Ltd.
Child Injury Prevention through Maternal and Child Health (MCH) Networks in Sri Lanka
16
Official Newsletter of The Sri Lanka Medical Association. Tele: +94 112 693324 E mail: office@slma.lk Professor Jennifer Perera MBBS, MD (Col), MBA(Wales), PgDip MedEd (Dundee), PgDip Women’s Studies(Col). President, Sri Lanka Medical Association, No 6, Wijerama Mawatha, Colombo 7, Sri Lanka.
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1
June 2015
PRESIDENT'S MESSAGE
SLMANEWS
Dear Colleagues,
T
he first six months of 2015 have passed by at an amazing speed. By the time you receive this newsletter the 128th Anniversary Congress would most likely be over. The SLMA office is very busy and everybody is working hard to make this event a success. The Scientific Committee chair, Dr. Padma Gunaratne with her energetic team, is navigating very efficiently to make the congress a very successful event with many current topics of interest being included in the scientific programme. There are over 35 overseas guest speakers who have confirmed their attendance as resource persons. The sponsors have been very receptive to our needs as usual. At the same time the logistics committee headed by Dr. Kalyani Guruge and Dr. Navoda Atapattu are preparing the stage for making the event a pleasurable academic experience to all con-
gress participants Early this week the SLMA actively participated as a chief collaborator at the launch of the child injury prevention posters and the media seminar conducted by the Ergonomics Committee of the SLMA in collaboration with the Health Education Bureau of the Ministry of Health and UNICEF. Dr. Kapila Jayaratne, the Chairman of the Ergonomics Committee was responsible for this initiative. This is a significant health problem in Sri Lanka as 600 children die every year and another 270,000 are hospitalized due to injury-related causes. Many are either permanently or temporarily disabled. Child injuries occur irrespective of social status and independent of the level of education achieved by parents. All strata of the society are affected. During this month the president of the World Diabetic Federation (WDF)
and his project team visited Sri Lanka. The Nirogi Lanka, the flagship project of the SLMA, is funded by the WDF and the Nirogi team had a busy time during this period. The WDF team held several meetings with stakeholders and the Ministry of Health in particular. Field visits were made to different action stations by the WDF team in order to review the progress of work. Discussions were held regarding the proposed strategic plans for control of diabetes in Sri Lanka. SLMA is hopeful that new funding will be provided to continue the proposed activities for curbing the rising epidemic of diabetes. I take this opportunity to invite all members to participate in the numerous activities organized by the SLMA to enable all of us to contribute to the change that is needed in making Sri Lanka a better place to live. Prof. Jennifer Perera
FOOD SAFETY
“From Farm to Plate, Make Food Safe”
E
xcerpts of the symposium
organized
by the SLMA Expert
Dr. Sujatha Pathirage
Committee on Communi-
Consultant Microbiologist
cable Diseases to mark
Medical Research Institute, Ministry of Health
World Health Day on 30th April 2015 from 8.45am – 12.45 pm, at the New Building Lecture Hall, Faculty of Medicine, University of Colombo in collaboration with the WHO. 2
Microbial contamination of food and testing of food for pathogens
Food borne microorganisms include bacteria, viruses, fungi, parasites and prions. Clinical presentations vary from gastroenteritis, enteric fever, bacteraemia, meningitis, endocarditis, Guillain Barre Syndrome (GBS) and haemolytic uraemic syndrome.
Contd. on page 03
SLMANEWS
June 2015
Contd. from page 02
Food Safety... to high protein diet, higher proportion of immunologically compromised populations, changing farming practices and climate change. In USA, it is shown that there was 43% and 32% increase of food borne disease due to Vibrio in 2012 and 2013 respectively. Different laboratory methods are used to detect microorganisms from food. Culture is the gold standard, but ELISA, molecular biology methods and some new technologies are also in use.
tation of control measures for food borne diseases.
However identification of the exact cause for a food borne outbreak depends on various factors. Testing food samples microbiologically has its own limitations. The cost of testing and the cost of food lost to testing increases proportionately. Mass food testing would be extremely expensive.
Research Scientist, Food Technology Section
Finally, as there is a changing trend in food borne diseases, it is important to collect data and find out the possible causative agents. This will in turn facilitate the planning and implemenContamination of food can occur during production, harvesting, processing, distribution and storage. Prevention of food contamination is a shared responsibility. It should be practiced all along the food chain with a structured approach for food safety. Food safety management system based on Hazard Analysis Critical Control Point principles (HACCP), Good Manufacturing Practices and Good Agriculture Practices are all important in prevention of food contamination. There is a changing trend in food borne diseases due to rapid population growth and demographic changes towards an aging population, global market for vegetables, fruits, meat and farm animals, increase in travel, changing eating habits, shift from low
Chemical contamination of food & their testing Mr. Nisala Gunasekara
Industrial Technology Institute, Colombo Chemical contaminants are substances that have not been intentionally added to food. These substances could enter in to the food supply chain at various stages from cultivation, animal farming, processing, packaging, storage, transport and even at the point of consumption. Toxins of natural origin are also considered as food contaminants. Contamination generally has a negative impact on the quality of food and may imply a risk to human health. Most common food chemical contaminants include pesticide residues, persistent organic pollutants – POPs (dioxins, furans, polychlorinated biphenyls-PCBs), polycyclic aromatic hydrocarbons (PAHs), acryl amides, natural toxins (mycotoxins), heavy metals (Mercury, Cadmium, Lead, Arsenic, Tin, Chromium), veterinary drug residues and other chemicals such as perchlorates , melamine, etc.. Sources of chemical contaminants include but are not limited to the widespread use of chemicals such as fertilizers, pesticides, ripening/antiripening agents & veterinary drugs; industrial pollutants from the environment; food processing aids such as high temperature cooking, leaching from food packaging materials. Contd. on page 04
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SLMANEWS
June 2015 Contd. from page 03
Food Safety... Mycotoxins on the other hand are the secondary metabolites produced by food contaminated with certain types of fungi. Due to toxicity and potential prevalence of these contaminants their associated risks legislations (Sri Lanka: FOOD ACT, NO. 26 OF 1980, EFSA, FDA) and standards (Sri Lanka: SLS, WHO: Codex) have been introduced worldwide as a measure of control. Various analytical techniques such as Chromatography Mass Spectrometry (LC-MS, GC-MS), Plasma Spectrometry (ICP-MS, ICPOES), Spectroscopy (UV-Vis, AAS) and Bio assay (ELISA) techniques are available for the detection, identification and quantification of these contaminants. Educating the consumer: How to handle, store and prepare food safely Dr. Ranjani Amarakoon Senior Lecturer Department of Microbiology University of Kelaniya Safe food is a key factor to protect the public from health risks. Statistics reveal that food-borne illnesses increase each year globally. World Health Organisation has recognised this and determined Five Keys for Food Safety, namely, keep clean, separate raw and cooked food, cook thoroughly, store food at safe temperatures, use safe water and raw materials. Safety measures are not lim-
ited to the above. In some instances food must be specially handled and examples are raw chicken, cassava and vegetables / green leaves that are eaten as fresh. Overcooking leads to formation of toxic compounds. Information on food labels is important with respect to safety measures to be adopted such as storage temperatures and expiry dates. The message of good personal hygiene and safety practices of handling food from farm to plate must reach others in your community and make safe food a top priority to prevent foodborne diseases, protect the health of your family and community, and be confident about the safety of the food you eat. Standards for food safety Ms. W Nayana N Satharasinghe Deputy Director-General, Sri Lanka Standards Institution, Colombo The Sri Lanka Standards Institution (SLSI) established under an Act of Parliament in 1964, is the national standards body of the country, having the primary function of formulating national standards to be used by all sectors of the economy. It is a semi government organization, presently functioning under the Ministry of Trade and Commerce. In line with the vision of the Institution to be the premier national organization providing leadership to uplift the quality of life of the nation through standardization and quality improvement in all sectors of the economy, SLSI also carries out various other ac-
tivities. The Product Certification (the SLS Marks Scheme), Systems Certification such as ISO 9001, ISO 14001, GMP, ISO 22000 etc., providing training, laboratory services and information services, calibration of equipment and checking quality of certain identified products are some of the services thus provided. SLSI acts as a facilitator for quality but it is not a regulatory body. A Standard, as defined by the International Organization for Standardization (ISO), is a document established by consensus and approved by a recognized body, that provides for common or repeated use, rules, guidelines or characteristics, for activities or their results, aimed at the achievement of optimum degree of order, in a given context. Different types of standards are available such as specifications which define characteristics for a product (e.g. SLS 729:2010 Ready-to-serve fruit drinks), Code of practices which give recommended practices for a given activity/industry (e.g. SLS 872:2009 Code of hygienic practice for dairy industry), test methods which define how a particular test is to be carried out so that tests done at different laboratories are comparable (e.g. SLS 516 Microbiological test methods), Glossary of terms which help to have common understanding of words used in a particular industry/activity (e.g. SLS 71:1981 Glossary of tea terms), Symbols which facilitate communication (e.g. SLS 809:1988 Recommended shipping marks for goods) etc. Contd. on page 05
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SLMANEWS
June 2015
Contd. from page 04
Food Safety... Though use of standards is not mandatory when compared with technical regulations, the adherence to which is compulsory, use of standards helps ensure safety, reliability and environmental care. Further it also facilitates interchangeability and variety reduction providing economic benefits. As a result, users perceive standardized products and services as more dependable – this in turn raises user confidence, increasing sales and the take-up of new technologies. However, standards are frequently referenced by regulatory bodies for protecting user and business interests, and to support government policies. National standards on food products have been adopted under the Food Act [Food (Adoption of Standards) Regulations 2008 revised in 2013] whenever separate regulations have not been published under the Food Act. The national standards are developed following the internationally accepted procedures. While SLSI as the national standards body coordinates and provides the technical secretariat support for development of national standards, these standards are de-
veloped by experts in the fields representing different stake holders. A two month period is given to the public to comment at the draft standards level. In product specifications, the characteristics of the product are defined in terms of physical, chemical and microbiological parameters. It may be a minimum, maximum or a range, as relevant to the product and the characteristic concerned.
In order to ensure safety in food, suitable controls need to be exercised throughout the food chain from farm to fork. Good manufacturing practices form the foundation of an effective Food Safety Management system. The Sri Lanka Standard Code of Practice for general principles of food hygiene, SLS 143, gives general guidelines on the necessary hygienic conditions for producing food which is safe and suitable for consumption throughout the food chain, from the primary production to the final consumer. In addition, there are a number of industry specific guideline standards such as for the dairy industry, bottling of water industry etc. Guidelines with respect to providing suitable facilities including construction and layout of buildings, associated utilities, premises, workspace and employee facilities, providing supporting utilities including air, water and energy, providing supporting services including waste and sewage disposal, cleaning and maintenance, management and control of purchased materials, prevention of cross contamination, pest control, personal health and hygiene, chemical control, product trace and recall and complaint investigation are defined in SLS 143. Contd. on page 06
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SLMANEWS
June 2015 Contd. from page 05
Food Safety... A Food Safety Management System that can be applied to any organization in the food chain, from farm to fork, is specified in the International Standard ISO 22000 which has been adopted as a Sri Lanka Standard. Applying the principles of Hazard Analysis and Critical Control Point (HACCP) system for reducing the risk of safety hazards in food is an important aspect of this system. A HACCP System requires that potential biological, chemical and physical hazards are identified and controlled at specific points in the process. The standard also addresses other important aspects of the management system to ensure food safety. Standards can thus be effectively used to ensure food safety. Good Agricultural Practices (GAP) for Food Safety Mrs. Priyanjani Madana Bandara BSc (Agri) Hons. SL /MSc (Sustainable Agri) The Netherlands Additional Director – Agribusiness Counseling Department of Agriculture, Peradeniya, Sri Lanka Food is safe if it is free from pathogenic micro organisms, chemical and physical contaminants. Food safety begins at the farm. Therefore, Good Agricultural Practices (GAP) must be implemented to ensure food safety. The definition of GAP as given by United Nations Food & Agriculture Organization (FAO) is the practices to ensure environmental, economical and social sustainability of on-farm and post production practices resulting in safe and quality food. GAP includes practices in primary production to ensure safety and quality of food products and to minimize the negative impact on the environment as well as workers’ health. Identifying causes of food hazards and taking preventive and control measures are two major components in implementation of GAP. Types of hazards in primary
6
production are the environment, inputs, cultivation practices, harvesting and transporting, facilities, equipment, machines and utensils. Chemical and faecal contamination of water, soil and crops are the main hazards associated with the environment. Safe use of agro chemicals is a very important factor in GAP to avoid these hazards. Some of the other important practices to be implemented are the use of quality inputs such as seeds, water, and fertilizers etc., control of workers’ behaviour, use of Integrated Pest and Crop Management (IPM, ICM) where ever possible, use of appropriate harvesting, packing and transporting
techniques and provision of facilities in primary and post production.
The following lecture was also delivered at the above symposium: The role of veterinary public health in food safety Dr. Vipula Dharmawardana, Chief Municipal Veterinary Surgeon, Colombo
SLMANEWS
June 2015
APPROACH TO THROMBOCYTOPENIA DILEMMAS AND LIMITATIONS Dr. Dammika Gunawardena, Senior Lecturer, Consultant Haematologist, Department of Pathology, Faculty of Medical Sciences, University of Sri Jayawardenapura &
4. Liver disease
Dr. Thanusha Wijegunaratne, Registrar, Diploma in Clinical Haematology
History taking becomes a very important tool in the diagnostic work up. This will be helpful in excluding causes involved in pancytopenia such as, Large platelets in ITP bone marrow infiltrations, primary and agnostic tests’’ to confirm ITP3. secondary malignancies, or infection associated causes1. History should What is the place for bone marrow include age, gender, severity and du- examination and anti-platelet ration of the bleeding episodes, other antibodies in ITP? sites of bleeding, previous bleeding Examination of the bone marrow episodes, past history of infections has limited value in a case of isolatand drug history2. ed thrombocytopenia where the hisExamination findings will be im- tory and examination findings strongly portant to exclude secondary causes suggest a diagnosis of ITP. In fact it is of immune thrombocytopenia. One justifiable to proceed with a diagnosis must look for lymphadenopathy, hepa- of ITP without a bone marrow which to-splenomegaly, and features of SLE is often done in current practice, given or evidence of primary malignancy. A the typical history, examination finding 3 negative finding would favour a diag- and investigations of ITP . However, it is warranted in any patient with atypinosis of ITP3. cal features in the history, examination or investigations. There is insufficient How will you investigate a patient evidence to support the routine use of with thrombocytopenia? Full Blood Count and blood picture anti-platelet antibodies in the diagnowill confirm the thrombocytopenia, sis of immune thrombocytopenia3. give information about other counts and detect other morphological ab- What is “Isolated” normalities such as immature white thrombocytopenia? It is defined as a low platelet count cells (blasts), dysplastic neutrophils in the absence of abnormalities of or reactive lymphocytes. ITP will show red blood cells and white blood cell no other abnormality other than large platelets. Finding large platelets with lineages and no clinical features of a no other abnormality in the blood systemic illness. The most prevalent film is more supportive of a case of conditions leading to isolated thromITP rather than bone marrow failure. bocytopenia are ITP and drug induced 2 Therefore, examination of the blood thrombocytopenia . film is a basic key investigation in ITP - one of the commonest thrombocytopenia.
On behalf of the Sri Lanka College of Haematologists
T
hrombocytopenia has become one of the most common haematological problems in the clinical set up today. Hence the proper understanding of a diagnostic work up and a plan of management is warranted. With the current burden of dengue infection in the country, detection of thrombocytopenia due to infection has become a common laboratory finding, although this could happen with any viral infection which may have gone undetected previously. Since there is marked diversity amongst the pathogenesis of thrombocytopenia, proper management needs careful review and a multi-disciplinary approach with the correct input from the laboratory.
What are the causes of thrombocytopenia? 1. Bone marrow failure - due to primary or secondary infiltration of bone marrow. E.g. Acute Leukaemia, Lymphoma, Myelodysplastic syndrome, secondary infiltration by primary malignancy elsewhere (breast cancer) etc. 2. Increased consumption - due to destruction of platelets in spite of normal production of normal platelets by the bone marrow. a) Immune – Idiopathic - ITP (commonest cause of isolated thrombocytopenia in a healthy individual.) Secondary - due to infection (viral, malaria), drugs, connective tissue disorders (SLE), antiphospholipid antibody syndrome. b) Non immune - Microangiopathic haemolytic anaemia (DIC, TTP, HUS) 3. Hypersplenism
5. Massive transfusion
What is the general approach to a patient with thrombocytopenia?
Exclude secondary causes of immune thrombocytopenia such as SLE, lymphoma and infections (HIV, Hepatitis C) by doing relevant investigations. The diagnosis of ITP is made on the exclusion of secondary causes of thrombocytopenia as there are no “di-
causes of isolated thrombocytopenia - How do we manage them?
• Idiopathic thrombocytopenia (ITP) is an autoimmune disorder where antibody mediated destruction of platelets occur in response to an unknown stimulus, leading to a platelet count of <100x109/L1. Contd. on page 8
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SLMANEWS
June 2015 Contd. from page 7
Approach to... • An International Working Group (IWG) consensus panel recently provided guidelines for both adult and paediatric aspects in ITP3. However, management of ITP still remains difficult in spite of the plethora of new drugs in the market.
Are we over treating ITP patients?
• Unlike ITP in childhood, where the majority go in to spontaneous remission without any treatment, adults with ITP tend to relapse even though the majority undergo remission with corticosteroids initially, which is the first line therapy.
2. Incidence of life threatening bleeding (ICH) is only <1%
• Steroids should not be continued if the patient doesn’t respond to the standard dose of prednisolone (1mg/kg) by 3 weeks. Further steroids will only increase the side effects3. • It is justifiable to treat patients who have episodes of bleeding with platelet counts <30x109/L, where the decision is made mainly on the bleeding episodes and not on the platelet count. • Splenectomy is considered as the second line of therapy if the patient relapses after steroid therapy3. Unfortunately only 60% will show a response and there is no method to check the response prior to splenectomy. • Majority of the ITP patients end up as ‘steroid dependent’ in routine hematology clinics where steroids are needed either to maintain a platelet count of >30x109/L or to prevent bleeding. • Many patients and clinicians prefer to go for other options such as dapsone, danazole, immunosuppressive therapy or Monoclonal anti CD20 antibody (Rituximab) failing which splenectomy will be considered. • The latest treatment option of thrombopoietin receptor agonists are given for patients at risk of bleeding who relapse after splenectomy or who have a contraindication to splenectomy and who have failed at least one other therapy4. Unfortunately this option is not available for many patients due to the cost and lack of availability. • Is there a place for platelet transfusions in ITP? In emergency management of ITP when there is impending intra cranial haemorrhage (ICH) or life threatening bleeding with a platelet count of <10x109/L, intravenous immunoglobulin is the therapy of choice with or without a high dose of platelets. A platelet rise could be seen within 6-12hr. Other than this, platelet transfusions have a very small role to play in routine practice. The transfused platelets will be subjected to immune mediated destruction themselves and therefore provide little benefit.
8
YES WE ARE!! 1. ITP patients rarely bleed even with counts less than 20x109/L as their platelets are functionally superior.
3. Steroids are the therapy of choice and often used on a long term basis by some clinicians. This will cause deleterious side effects (diabetes mellitus; drug induced Cushings, osteoporosis and gastritis) without any benefit to the patient. 4. Watch and wait policy may be safer for some patients who rarely bleed with low counts rather than trying a plethora of drugs which are often ineffective. Since ITP is often seen in middle aged females, it is important to make them understand the chronic nature of the illness and the need for minimal therapeutic interventions provided that they identify bleeding episodes and seek medical advice on time. Simple measures like maintaining oral hygiene to prevent gum disease and bleeding, treating menorrhagia and iron deficiency and using antifibrinolytic therapy to prevent mucosal bleeding will all help in the management.
Drug induced thrombocytopenia Even though drugs are a common cause of acute immune mediated thrombocytopenia, due to its sudden onset and severity, drug aetiology is not recognized by most of the clinicians. Thus inappropriate management is instituted where the management may simply involve stopping the drug and avoiding its usage in future. The list of drugs associated with thrombocytopenia is an ever increasing one. A comprehensive database of drugs which may cause thrombocytopenia is available at www.ouhsc.edu/ platelets5.
Thrombocytopenia in pregnancy The most common causes of thrombocytopenia in pregnancy are gestational thrombocytopenia (GT), preeclampsia and ITP. GT is a diagnosis of exclusion and it is not associated
with adverse outcomes to either the mother or foetus. Even though there is no clearly defined lower limit of normal value for the platelet count in GT, counts < 70 X 109/L should raise a suspicion of an alternative diagnosis. Thrombocytopenia occurs in up to 50% of women with preeclampsia, and its severity generally correlates with the underlying preeclampsia. Of all cases of pregnancy associated ITP, approximately one third of them are first diagnosed during the pregnancy and the remaining two third are in patients with preexisting disease. It is important to differentiate ITP from GT as the former may cause thrombocytopenia in the neonate which can lead to neonatal intracranial haemorrhage6.
Thrombocytopenia in Dengue fever - Viral induced thrombocytopenia Thrombocytopenia is a common laboratory finding in Dengue Haemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS). The mechanisms identified for thrombocytopenia in dengue infection include maturational arrest of megakaryocyte production in the bone marrow and platelet destruction by antibody mediated mechanisms and the virus itself or due to disseminated intravascular coagulation. Since the pathogenesis of bleeding manifestations and thrombocytopenia is poorly understood, there are no guidelines about the use of platelet transfusions in DHF/DSS. According to The World Health Organization (WHO) manual 2009 there is little evidence to support the practice of transfusing platelet concentrates and/or fresh-frozen plasma for severe bleeding. But it is being practiced when massive bleeding cannot be managed with just fresh whole blood/ fresh-packed cells; however it may exacerbate the fluid overload in a patient with DSS7. Contd. on page 9
SLMANEWS
June 2015
Contd. from page 8
Approach to... Thrombocytopenia is a common complication in chronic liver disease accounting for about 76% of patients which is associated with significant morbidity. There are several mechanisms involved which include hypersplenism due to portal hypertension, reduced thrombopoietin production and immune mediated destruction8.
When and how to transfuse platelets? Transfusions are not without any hazards, the risk of bacterial contamination being 1:10,000, and if it does not improve the situation, it is best not given unless it is lifesaving9. Platelets have a limited shelf life of 5 days and are stored at 20째C-24째C. Due to the short shelf life, they are often in short supply and many laboratories do not store platelets. Thrombocytopenia due to bone marrow failure is managed by platelet transfusions. In fact, platelet transfusions are mainly indicated in thrombocytopenia associated with malignancies. The cut off level of platelets for transfusions is
mainly determined by clinical bleeding. Bleeding due to thrombocytopenia is rare unless the platelet count is below 30x109/L, and when there is an associated platelet functional disorder where they bleed at a higher platelet count. Therefore it may be a healthy practice to transfuse patients if they have a platelet count below 30x109/L with clinical bleeding or if the count is below 10x109/L if there is no bleeding. Many surgical procedures can be managed without platelet transfusions if the platelet count is >50x109/L. Random donor platelet units are given in a dose of one (01) random donor unit/10kg to a maximum of five random donor platelet units. However single donor apheresis units are becoming popular due to their many advantages of reduced donor exposure and a better platelet yield9.
2
Provan, d. & Newland, A.. (2011). Primary immune thrombocytopenia. In: Hoffbrand, AV. Catovsky D. Tuddenham EGD & Anthony, RG. Postgraduate Haematology. 6th ed. United Kingdom: Blackwell Publishing Ltd. p928- 939.
3
Neunert C, Lim W, Crowther M, Cohen A, Solberg L Jr, Crowther MA. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood. 2011; 117(16):4190-4207.
4
Rodeghiero F, Stasi R, Gernsheimer T, et al. Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood. 2009; 113(11):2386-2393.
5
George JN, Aster RH. Drug-induced thrombocytopenia: pathogenesis, evaluation, and management. Hematology Am Soc Hematol Educ Program. 2009; 2009:153-158.
6
McCrae KR. Thrombocytopenia in pregnancy. Hematology Am Soc Hematol Educ Program. 2010; 2010:397402.
7
World Health Organization (2009). Dengue guidelines for diagnosis, treatment, prevention and control. Geneva: World Health Organization. P23-p44.
8
Hancox S.H, Smith B.C, Liver diseases as a cause of thrombocytopenia.QJM.2013
9
Yulia Lin, Lynda M, Foltz. Proposed guidelines for platelet transfuaion:BCMJ.2005:245-248
References 1
British Society of Haematology. Guidelines for the investigation and management of idiopathic thrombocytopenic purpura in adults, children and in pregnancy. B J Haematol. 2003; 120(4):574- 596.
DIABETIC FOOT ULCER: MUSCULOSKELETAL PERSPECTIVE Dr. Duminda Munidasa MBBS (Colombo), MD (Medicine) Consultant in Rheumatology & Rehabilitation Rheumatology & Rehabilitation Hospital - Ragama
Introduction Ulceration of the foot in a diabetic is one of the most distressing complications causing enormous financial burden to the patient and the health care system. Its' management is difficult and the outcome is poor. The life time risk of a foot ulcer in a patient with diabetes is calculated to be 15%. Eighty per cent of amputations in diabetics are due to foot ulcers1. Prevention through proper assessment of risk factors during follow-up of diabetic
patients is known to be the best form of management. Biomechanical changes due to foot deformities and increased vulnerability and loss of protection due to sensory neuropathy and angiopathy result in ulcer formation. When a care-giver assesses the patient with a view to preventing ulcers, attention needs to be given to all three (musculoskeletal changes, neuropathy and angiopathy) risk factors2. This article describes the musculoskeletal changes that occur in a diabetic foot with emphasis on areas that need to be focused on by the care-giver in order to prevent the occurrence of foot ulcers.
Patho-physiology of a diabetic ulcer
Foot Deformities in Diabetics3,4 A typical diabetic foot will consist of the following features: high arched, rigid foot, retracted and clawed digits, tightening of the Achilles tendon, callus formation on weight-bearing areas, particularly under the 1st and 5th metatarsal heads and atrophied fibrofatty pad. Contd. on page 10
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SLMANEWS
June 2015 Contd. from page 9
Diabetic Foot... These changes occur due to several pathological entities described in diabetes.
external forces. Change in its position or composition removes this protection. In a diabetic, the following may occur due to changes in the fibro-fatty pad:
• Limited joint mobility syndrome • Diabetic osteoarthropathy (Charcot joint)
• anterior displacement of the fat pad leading to deformities such as clawing and hammer toe
• Deformity due to motor neuropathy
• degeneration of the fat pad due to vasculopathy
Limited Joint Mobility Syndrome This is seen in 50% of diabetics. It has been found to correlate with the duration of diabetes. The pathogenesis is due to increased non-enzymatic glycosylation of collagen in skin and peri-articular tissue, decreased degradation of collagen, micro-angiopathy and neuropathy. This leads to thick, tight, waxy skin, tendon sheath sclerosis, decreased range of movement of joints, shortening of Achilles' tendon and plantar fascia contributing to the limitation of joint mobility especially in hands and feet. In the hand this is demonstrated by the "prayers' sign". Changes in the foot cause changes in the gait, plantar pressure and increased pressure on metatarsal heads. All these biomechanical changes contribute to the formation of an ulcer.
Diabetic Osteoarthropathy This is a condition involving painless, progressive destruction of bone and soft tissues of weight bearing joints re-
• breaking down and weakening of the fat pad due to glycsosylation of collagen in septae.
Fibro-fatty pad
sulting in dislocations, fractures and deformities in different joint areas of the foot. Charcot first described this in syphilis. It is seen in 0.1 – 0.4% of diabetic patients. Unperceived trauma to the insensate foot due to sensory neuropathy and increased blood flow due to autonomic neuropathy leading to disruption of bone turn over are thought to play a significant role in the pathogenesis of the Charcot joint.
Diabetic Motor Neuropathy Motor neuropathy contributes to loss of muscle fibres resulting in atrophy of small muscles in the foot. The imbalance that develops between flexor and extensor muscles causes clawing of the toes / hammer toes, prominent metatarsal heads and anterior displacement of metatarsal fibro fatty pad. The end result is a change in biomechanics and creation of abnormal pressure points on the sole.
Foot deformities and conditions unrelated to diabetes Deformities of foot already existing or caused by trauma or surgery in a diabetic patient will also increase the risk of ulcer formation due to changes in biomechanics. Conditions such as malposition of the big toe (hallux vulgus, hallux rigidus), malposition of foot (lack of pronation, laterally displaced calcaneus, flat feet) need to be assessed during the examination of the patient to identify these risks. Trauma or surgery, especially amputations, will change the plantar pressure distribution. Callus formation causes areas with increased pressure hence it is important to regularly shave them off. Obesity itself contributes to ulcer formation by collapse of the medial longitudinal arch, laxity of ligaments, increased tendency for fissuring of the heels and fungal infections.
Changes in the fibro- fatty pad Conclusion Foot ulceration is a rising health under metatarproblem among diabetics. Diabetes sal heads may affect the musculo skeletal sysThe subcutaneous fibro-fatty pad under the metatarsal heads serves as a source of cushioning to protect the skin and deep seated bone and soft tissue structures from
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tem in a wide variety of ways. Many factors contribute to the disruption of the normal biomechanics of the foot, leading to few areas of high pressure on walking. This will result in the formation of foot ulcers, contributed to by the loss of protection and increased vulnerability due to angiopathy and sensory neuropathy. Contd. on page 12
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Diabetic Foot... Managing a diabetic foot ulcer is difficult. It will result in amputation. Increased mortality is associated with ulcers. The ideal situation is prevention of ulcer formation. This can be achieved by regular assessment of diabetic feet with above risk factors in mind, giving good foot care advice and
use of correct footwear and orthosis. References 1
2
Jeffcoate WJ, Harding KG. Diabetic foot ulcers: Lancet, http://image.thelancet.com/extras /02art6190web. pdf, Published online February 25, 2003. Kim RP, Edelman SV, Kim DD. Musculoskeletal Complications of Diabetes Mellitus Clinical Diabetes:
2001;19(3):132-135. 3
Arkkila PE, Gautier JF. Musculoskeletal disorders in diabetes mellitus: an update. Best Pract Res Clin Rheumatol 2003;17(6):945-70.
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Whitt BC, Steel G, Rajbhandari SM. Foot Biomechanics for the treatment and prevention of diabetic foot ulcers: Int J Diabetes & Metab (2010) 18:1-4.
JOINT REGIONAL MEETING OF THE RUHUNA CLINICAL SOCIETY AND THE SLMA Dr. Shamini Prathapan (Asst. Secretary, SLMA)
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he joint regional meeting of the SLMA in collaboration with the Ruhuna Clinical Society was held on the 20th of May 2015 at the Matara District General Hospital. The theme of the meeting was ‘Infections Revisited’. The President of the Ruhuna Clinical Society, Dr. V. T. Rajendiran, delivered the welcome speech. Prof. Jennifer Perera, President of the SLMA also addressed the gathering and described the goals of the SLMA, stressing on the need for all doctors to attend the annual sessions and to be life members of the SLMA. The meeting was well attended by around 100 Consultants and Medical Officers from hospitals in the region. Dr. S. Senevirathne Epa represented the SLMA on behalf of the
Southern Province. The first session was chaired by Dr. V. T. Rajendiran and Prof. Jennifer Perera. The panel of speakers were Dr. Ruwanthi Perera, Senior Lecturer from the Faculty of Medical Sciences, University of Sri Jayewardenepura, Dr. Hemantha Gamage, Consultant ENT Surgeon, from the District General Hospital Matara, and Dr. Z. M. Ruhullah, Con-
sultant Anaesthetist from the District General Hospital Matara. Dr. Ruwanthi Perera commenced the session with a lecture on ‘Atypical pneumonia in children’. She described the aetiology of atypical pneumonias and made special reference to Mycoplasma pneumonia. She further discussed the extra pulmonary manifestations and stressed that all doctors should be aware of them as the respiratory symptoms may go unnoticed. Ocular and neurological symptoms and signs were discussed and this was followed by investigations, with special mention that even a bed side test of cold agglutinin could be performed in low resource settings. She said the treatment of choice is macrolides. Other atypical pneumonias such as Legionella and Chlamydia were discussed. She finally highlighted the need for alleviating the disease burden of atypical pneumonias in Sri Lanka. Contd. on page 13
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Joint Regional Meeting... The next speaker, Dr. Hemantha Gamage, spoke on ‘Complications of sinusitis’. He said that the prevalence of sinusitis is high in Sri Lanka. He further stated that the symptoms and signs of sinusitis were not specific and with no definite diagnostic test, other than CT scans and endoscopy, the prevalence of complications too was high. He further divided these complications into acute local manifestations such as orbital, boney and chronic complications such as orbital cellulitis and cavernous sinus thrombosis, all of which need immediate treatment to prevent loss of vision and intra cranial complications. He stressed on the need for a careful history and examination with CT scan if possible, all with the urgency on initiating treatment as soon as possible. Dr. Ruhullah, spoke on ‘Basics of CPR’. He stressed that the aim was to maintain oxygenation to the brain and the vital organs by supporting the respiratory and cardiovascular systems since the brain can sustain hypoxic damage for only 2 minutes while the heart can sustain damage for about 5 minutes. He then spelled out the causes of cardiac arrest and continued to highlight the steps for basic and advanced life support measures. He also stressed that before life support is initiated its best to shout for help as an individual cannot continue life support by himself for more than two minutes. He also mentioned that if the life support was not working, the causes for it should be thought of, which can be remembered as the 5H; Hypoxia, Hypovolemia, Hypo or Hyperkalemia, Hyper/Hypothermia and High hydrogens which is acidosis and the 5T; Tamponade, Tension pneumothorax, Toxic disturbances, Thromboembolism and Trauma. He also stressed that CPR does not stop with reviving the heart and respiration but to also look after the post cardiac arrest management. The second session on Paediatrics
was chaired by Dr. R.P. Jayasinghe and Dr. Shantha Kumara. The speakers were Dr. Susil Herath, Consultant Respiratory Physician from the District General Hospital Matara, Dr. Harindra Karunathilake, Consultant Physician from the District General Hospital Matara, Dr. M. G. A. Dinusha, Dermatologist from the District General Hospital Matara and Dr. Kapila Piyasena, Senior Registrar in Community Medicine from the Health Education Bureau. The second session began with Dr. Susil Herath’s lecture on ‘Drug resistant tuberculosis’. He outlined the global situation of resistance stating that 50% of cases were resistant to one type of drug in the former USSR, which has the highest incidence of resistance. Worldwide, 32,000 children become sick each year and in Sri Lanka in 2014, eleven patients were diagnosed with multidrug resistant tuberculosis (MDR-TB). MDR was defined as resistance against at least Isoniazid and Rifampicin. The main causes for MDR were indicated as being prescribing incorrect chemotherapy, irregular drug supply and poor case management. The side effects of anti TB drugs were a major cause for patients to not take the medication and a patient diagnosed with MDR must
be quarantined with close monitoring. He traced the history of TB, highlighting that before 1990 there was drug susceptible TB and MDR-TB was recognised in 1990. Sixteen years later, extreme drug resistant tuberculosis (XDR-TB) was diagnosed. Dr. Herath stressed the need for action before resistance develops to all available drugs which will lead to increased morbidity and mortality that will be worse than for cancer. Dr. Harindra Karunathilake, the next speaker discussed case reports on ‘Leptospirosis’, mentioning the symptoms, signs, investigations and available treatment options. Each of the cases presented had complications with ICU admissions and even mortality. All had multi organ failure were confirmed as leptospirosis. Dr. Karunathilake had done a literature review on the high mortality of leptospirosis. The case fatality rate for leptospirosis was higher than for dengue being 1.3 vs 0.63 respectively. He further stated that antibiotics will not reduce the mortality but will only reduce the duration of the illness. Doxycycline and penicillin are proven to be effective in reducing the duration of the illness. All regimes are therapeutically effective. Contd. on page 14
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Joint Regional Meeting... In severely ill patients doxycycline and cefotaxime are the drugs of choice. Current research shows that even if late, in order to restore renal function, antibiotics need to be started. Steroids may be useful in pulmonary leptospirosis. Dr. M. G. A. Dinusha delivered her lecture on ‘Leishmaniasis’ and enlightened the audience on the burden of leishmaniasis. 12 million patients have been diagnosed in 88 countries with more than 50,000 deaths in the world. She mentioned that although cutaneous leishmaniasis is the commonest form in Sri Lanka, visceral leishmaniasis was also reported. Since January 2006 to 2008, 382 patients were diagnosed from Matara and 265 patients were diagnosed from Hambantota, among which the Dickwella MOH area was the most endemic. However, she stressed that in Galle, Matara and Hambantota, 2, 107 and 372 cases were diagnosed respectively in 2013 and this has increased to 3, 96 and 375 respectively in 2014. The life cycle with the morphological forms were described, following which, the clinical features of cutaneous leishmaniasis were detailed at length, with the types of lesions which may vary in size from a few millimeters to several centimeters. The associated features such
as a photosensitive rash, satellite lesions, hypo or hyper pigmentation were described supported with photographic images. She stressed that visceral leishmaniasis must be considered in pyrexia of unknown origin if the patient is from an endemic area. She concluded her lecture with grey areas in research such as the doubt on the reservoir, genetic susceptibility for the type of disease, endemicity and most importantly that drug resistance has increased, all of which makes Sri Lanka at risk for becoming an endemic country. Dr. Kapila Piyasena’s lecture on
‘Health promotion hospital and effective communication’ highlighted many aspects of hospitals as health promotion institutes and on communication skills. He stated that many hospitals have incorporated this programme as a policy to improve the hospitals’ development not only in patient and nursing care, but also for health promotion activities in communicable and non-communicable diseases control. The session concluded with a discussion and the vote of thanks delivered by Dr. Hemantha Gamage, Secretary of the Ruhuna Clinical Society. The sole sponsor of the event was the State Pharmaceuticals Corporation.
JOINT REGIONAL MEETING OF THE HILL COUNTRY CLINICAL SOCIETY AND THE SLMA Dr. Asiri Rodrigo
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he joint regional meeting of the SLMA in collaboration with the Hill Country Clinical Society was held on the 9th of March 2015 at the Nuwara Eliya District General Hospital. The theme of the meeting was ‘Infections’. The President of the Hill Country Clinical Society, Dr. Neranjan Dissanayake, welcomed the audience. Prof. Jennifer Perera, President of the
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SLMA addressed the gathering and highlighted the role SLMA plays in a wide range of issues, emphasising the necessity for all doctors to participate in SLMA activities. The meeting was attended by more than 100 medical officers, both senior and junior, from the hospital and the region. The first session was chaired by Dr. Asiri Rodrigo and Dr. Ajith Gurusinghe. Contd. on page 15
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Joint Regional Meeting of the Hill Country... ka, Acting Consultant Anaesthetist, Dr Indika Hewage, Consultant Paediatrician, Dr. Neranjan Dissanayake, Consultant Respiratory Physician of the District General Hospital, Nuwara Eliya and Dr. Malik Fernando, Past President, SLMA.
The panel of speakers were Dr. Hasini Banneheke, Senior Lecturer, Faculty of Medical Sciences, University of Sri Jayewardenepura, Prof. Deepika Fernando, Professor in Parasitology, University of Colombo, Dr. Madhumanee Abeywardena, Consultant Microbiologist and Dr. Sandeepa Ekanayake, Consultant Dermatologist of the Nuwara Eliya Hospital. Dr. Madhumanee Abeywardena discussed the reasons for and deleterious effects of irrational antibiotic use and therefore the necessity for rational antibiotic use. She reiterated the importance of antibiotic sensitivity awareness and commencement of simple yet effective antibiotic monotherapy. Dr. Hasini Banneheke provided a comprehensive and succinct account on emerging infections in the region and in Sri Lanka. She discussed the surveillance of infectious diseases and the control measures of same. Dr. Sandeepa Ekanayake elaborated on the various presentations of leprosy and how each could be detected and treated. Prof. Deepika Fernando described the monumental achievements towards eradication of malaria in Sri Lanka. She stressed the importance of consolidating the gains that have been achieved and the dangers of complacency.
Dr. Duminda Gunawardane outlined indications, methods, advantages and potential problems of antibiotic prophylaxis in surgery. He reiterated the importance of collaboration between the microbiologist and the clinicians. Dr. Pandula Jayathilaka described the pathophysiology, clinical presentation and management of sepsis. He summarised the clinical burden of sepsis and the importance of early detection and assertive management. Dr. Indika Hewage enlightened the audience on demographics, varying presentations, treatment and possible long-term sequelae of childhood meningitis. She also talked about the use of vaccines for prevention of this condition. Dr. Neranjan Dissanayake discussed respiratory infections occuring during
pregnancy. He outlined the responsible pathogens, clinical features, management and adverse effects if not treated adequately. Finally, Dr. Malik Fernando’s lecture on ‘Advertising by doctors and institutions: the SLMC Guide’, highlighted many ethical dilemmas and possible solutions. The session concluded with a lively discussion followed by the vote of thanks by Dr. Muditha Priyankara, Secretary, Hill Country Clinical Society. The event was sponsored by the State Pharmaceuticals Corporation.
The second session was chaired by Prof. Jennifer Perera and Prof. Vasanthi Thevanesam. The speakers were Dr. Duminda Gunawardane, Consultant Surgeon, Dr. Pandula Jayathila-
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CHILD INJURY PREVENTION THROUGH MATERNAL AND CHILD HEALTH (MCH) NETWORKS IN SRI LANKA
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media seminar and the launching of ‘Child Injury Prevention’ posters were held on 11th June 2015 under the patronage of Dr. Palitha Mahipala, Director General of Health Services, at the Health Education Bureau. The posters show injury prevention options categorized in each age group for children under five years in all three languages - Sinhala, Tamil and English. They will be distributed through MCH networks to all field level healthcare workers, health institutions and general practitioners. Dr. Kapila Jayaratne, Chairperson of the SLMA Expert Committee on Ergonomics, handed the posters to Dr. Palitha Mahipala and the UNICEF Child Protection Chief Ms. Caroline Bakker. Dr. Hemantha Beneragama (Director – MCH), Prof. Jennifer Perera (President – SLMA) and Prof. Sujeewa Amarasena (President – SLCP) were also present at the launching ceremony. This was a collaborative project of the Family Health Bureau, SLMA Expert Committee on Ergonomics, Health Education Bureau and the UNICEF.
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THE OFFICIAL NEWSLETTER OF THE SRI LANKA MEDICAL ASSOCIATION
If undelivered return to : Sri Lanka Medical Association. No. 6, Wijerama Mawatha, Colombo 7 Registered at the Department of Post Under No: QD/27/NEWS/2015