SLMAnews-2013-05 by Sri Lanka Medical Association

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Contents

THE OFFICIAL NEWSPAPER OF THE SRI LANKA MEDICAL ASSOCIATION

May 2013 Volume 06 Issue 05

President's Column Dear members and colleagues, I bring you greetings from the SLMA. We are forging ahead with our academic activities with gusto. In conformity with our expressed desire to take some of our activities to the underprivileged areas, we had a very successful Collaborative Programme with Moneragala Hospital on the 2nd of May 2013. There was a CPD Programme for doctors incorporating topics requested by the doctors of the Moneragala region, a programme on immunisation for the nurses and a separate event on “Personal Hygiene & Hand Washing”, sponsored by Reckitt Benkisser for a heterogeneous group of nurses, attendants and labourers. We have also been involved in several other activities chronicles elsewhere in this Newsletter. Arrangements for the 126th Anniversary International Medical Congress are in full swing. A Preliminary Programme is given in this Newsletter. In compliance with our theme of “Towards continuing enhancement of quality and safety in healthcare”, I believe that we have tried to present a programme of superlative quality. Even though I say so myself, it covers a wide range of subjects coming under the umbrella of this apex medical institution of Sri Lanka. We would love to have all of you joining us for the 126th Anniversary International Medical Congress. The forerunner for the venture will be the ‘SLMA Run & Walk’ on Sunday the 7th of July 2013. We are expecting a very large crowd of participants, perhaps numbering several thousand, for this event. It will be followed by the congress proper replete with Pre-Congress Workshops on the 9th and 10th of July 2013 and the Main Congress from the 10th evening to the night of the 13th of July 2013. The topics covered have been selected to titillate the academic palate of all types and all grades of doctors in the country. The event will conclude with the Banquet on the night of the 13th of July 2013. Please do block these dates in your personal calendar to be with us for this grand event.

Page No.  Notice board

 Assessment of performance: the Workplace-Based Assessments

 Letter to the Editor

 SLMA Snakebite Hotline

 Japanese Encephalitis (JE) and the recent outbreak at Rathnapura

 Stung by a jellyfish? Some do’s and don’ts

14-15

 126th Anniversary International Medical Congress - Programme

 Cancer in Women: Current concepts, practices and strategies

Our Advertisers Glaxowelcome Ceylon Ltd. Hyundai Lanka (Pvt) Ltd. JLanka Technologies (Pvt) Ltd. Seylan Bank PLC. Prestige Automobile (Pvt) Ltd. Astron Ltd. Central finance Company PLC Kent Tower. George Steuart Health. Tokyo Cement Group. Asiri Surgical Hospital. A.Baurs & Co. (Pvt.)Ltd. Emerchemie NB (Ceylon) Ltd. GlaxoSmithKline Pharmaceuticals.

Official Newsletter of The Sri Lanka Medical Association. Tele : 0094 - 112 -693324 E mail - slma@eureka.lk Publishing and printing assistance by

This Source (Pvt.) Ltd etc., Dr B J C Perera President, Sri Lanka Medical Association, No.06, Wijerama Mawatha, Colombo 07, Sri Lanka

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May, 2013

Notice Board

Research Promotion Committee workshops Workshop on Biostatistics for Clinicians

The second research training workshop organized by the Research Promotion Committee of the SLMA this year was aimed at enhancing the statistical skills of postgraduate clinical trainees. It was successfully conducted by Prof. Chrishantha Abeysena and Dr. B. Kumarendran on 7th May 2013. The workshop drew a large audience with over 50 participants. The workshop focused on data types in research and interpretation of their key characteristics, tests of statistical significance, and sampling. Participants engaged in several hands-on activities including interpretation of findings in a published article.

SLMANEWS

SLMA 126th ANNIVERSARY RUN & WALK SLMA 126th Anniversary Run and Walk will be held on 7th of July 2013, 6.00 a.m. onwards starting from the BMICH. This time a parallel Yoga/ Aerobic session will also be conducted. Free T shirt and a cap will be given to all participants. Stalls providing free healthy food and drinks will be available at the BMICH premises. All runners need a health clearance before participation and details about the pre-race check-up and registration process will be communicated soon.

Workshops on Geographical Information Science.

The next two workshops will be on Geographical Information Science and will be conducted by Prof. Kithsiri Gunawardena on the 2nd and 29th of June. Those interested in participating can contact the SLMA office on 0112693324 for details. We invite suggestions from our readership on future workshops. Please email the Convenor, SLMA Research Promotion Committee (asela_o@yahoo.com) for suggestions on areas of interest and/ or for expressions of interest in contributing as resource persons.

SLMA Research Grants SLMA wishes to congratulate the following recipients of the SLMA Research Grants for the year 2013: FAIRMED Foundation Research Grant 2013

Benefits of walking Do you know ? • Walking 30 minutes a day cuts the rate of people becoming diabetic by more than half and it cuts the risk of people over 60 becoming diabetic by almost 70 %. • Walking cuts the risk of stroke by more than 25 %. • Walking strengthens the heart, bones & improves the circulatory system. • Women with breast cancer who walk regularly can reduce their recurrence rate and their mortality rate by over 50 %. • Men who walk regularly have a 60 % lower risk of colon cancer. • For men with prostate cancer, studies have shown that walkers have a 46 % lower mortality rate.

SLMA Research Grant 2013

• Walking also helps prevent depression, people who walk regularly are more likely to see improvements in their depression. • Walking generates positive neurochemicals.

Glaxo Wellcome SLMA Research Grant 2013 – not awarded

Many of the applications were of a high standard and the Research Promotion Committee wishes to thank all applicants for their efforts. The committee would like to note that unprofessional behaviour such as plagiarism is viewed extremely unfavourably. The committee wishes to thank the scientific reviewers for their contribution.

• Walking is a good boost of high density cholesterol and people with high levels of HDL are less likely to have heart attacks and stroke. (These benefits were extracted from a communique by the NIROGI Lanka Project)

SLMANEWS

May, 2013

Offer of a dedicated, affiliated and SLMA branded Hatton National Bank (HNB) Credit/Debit Card to SLMA members Hatton National Bank Credit/Debit Card is offering several attractive facilities to the SLMA members. These are: at HNB partner establishments

 No joining fee  Free supplementary cards for spouse and children (linked to the SLMA Card holder)

 Free Overseas Travel Insurance and Health Insurance cover

 50% off the first year Annual Fee

 No fuel surcharge on the use of the card to purchase petrol/ diesel anywhere in Sri Lanka.

 Free SMS alerts on transactions

 Cash-in-a-hurry : Cash advances through ATMs

 Free credit, up to a maximum of 55 days

 Loyalty Programmes such as FlySmiles from Sri Lankan Air ways

 Free e-Banking and SMS-Banking facilities  Attractive rates for several types of loans including housing and car loans  Educational loans for children etc.

 Easy-payment plans for purchases at certain designated establishments

 Local surgical and Hospitalisation Insurance Cover, starting from Rs 2000/- plus VAT per year.

 Year-round discounts, Special Offers and Seasonal Discounts

For existing members:Please come to the SLMA Office and fill up the forms and provide the necessary documents.

For new members-: Please come to the SLMA Office and join the SLMA, using the Credit Card facility and pay your Life Membership fee of Rs 10,000/- in nine monthly interest-free instalments.

Documents needed for either category:•

Salary particulars, certified by the Head of the Institution

•

Certified copy of the National Identity Card

New and existing members are hereby cordially invited to join the SLMA Credit Card Scheme. Dr. B.J.C.Perera President, Sri Lanka Medical Association

Dr. Thistle Jayawardena Research Grant for Intensive and Critical Care - 2013 Applications are invited from researchers in Sri Lanka for grant funding for a research project in Intensive and Critical Care (maximum possible of the grant offered is SLR 100,000). This grant is offered through the Thistle Jayawardena Trust Fund. Dr. Thistle Jayawardena was a pioneer Anaesthesiologist in Sri Lanka and a former president of SLMA. Following submission of completed proposals by the deadline below, one project will be selected by a SLMA expert panel. The selection criteria include the technical soundness of the proposal and relevance to the advancement of Intensive and Critical Care in Sri Lanka. Applications can be obtained from

http://www.slmaonline.info/images/pdf/applicationb.pdf3

Application Deadline: 30th June 2013

SLMANEWS

May, 2013

Assessment of performance: the Workplace-Based Assessments Dr Madawa Chandratilake MBBS, MMEd, PhD Medical Education Centre, Faculty of Medicine, University of Kelaniya.

Introduction

ssessment is a vital component of medical education. Its importance as a determinant of fitness-to-practice medicine and a tool for facilitating feedback has been repeatedly emphasised (Epstein 2007). In addition, assessments hold a high educational impact; what we assess and how we assess drive student learning (Epstein 2007; Chandratilake et al 2010). Therefore, assessments should always be relevant, practical and fair, and should reflect the desired educational outcome (van de Vleuten 1996). â&#x20AC;&#x2DC;Students can, with difficulty, escape from the effects of poor teaching, they cannot (by definition, if they want to graduate) escape from the effects of poor assessment.â&#x20AC;&#x2122; (Boud 1995) The assessments in medical education focus on different levels of professional ability from knowledge to performance. In 1990, Miller introduced a pyramidal framework which helped medical educators immensely to identify the different aspects, settings and tools for various assessment purposes (Miller 1990) (Figure 1). According to the Millerâ&#x20AC;&#x2122;s pyramid, the lower three levels of assessments focus on assessing the preparedness of students / trainees for practice. The top level of assessments actually assesses their practice. It is very important to assess the lower levels to ensure the progress of students / trainees toward the intended direction. However, the assessment of performance in actual practice (the top level) should be the ultimate choice of every assessor.

Workplace-Based Assessment tools The assessments of performance are collectively called WorkplaceBased Assessments (WBA), as those assessments take place together with day-to-day practice. There is a myriad of WBA tools which were developed for use in undergraduate, postgraduate and continuing medical education. They can be used to assess a wide range of attributes related to the practice of medicine. Some WBA tools demonstrate stronger potential than others in assessing certain attributes. However, the literature has not established the utility (e.g. validity, reliability and practicality) of all tools with the same rigor. Therefore, it is advisable to use WBA tools with at least some evidence of effectiveness, e.g. Mini Clinical Evaluation Exercise (Mini-CEX) (Norcini 1997), Direct Observation of Procedural Skills (DOPS), Multi-Source Feedback (MSF) and Patient Satisfaction Questionnaire (PSQ). The focus of this account, therefore, will be focused primarily on these tools. Table 1 (on page 05) provides an overview of the selected assessment tools and the attributes which

can be assessed using these tools. Assessment process The attributes to be assessed have already been identified for many WBA assessment tools. However, they need to be appropriately adapted to suite local needs and intended outcomes before using them in the local contexts. All WBA tools use either a checklist (which expects a yes/no answer for each of a series of attributes included) or a rating scale (which expects a rating, e.g. from 1 to 5, for each of a series of attributes included). Checklists are more appropriate in early stages of training of a given task, e.g. to assess history taking and physical examination of third year medical students who have just started their clinical rotations, as the primary focus of the assessment is the methodical / stepwise approach to the task. However, in final stages of training, e.g. in the final year of undergraduate training, a rating scale may be more appropriate as both the methodical approach as well as the quality of completing each element of the task should be included in the assessment. Contd. on page 05

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May, 2013

Contd. from page 05

Assessment ... Table 1 – An overview of commonly used Workplace-Based Assessment tools Norcini and Burch 2007; RCGP n.d.)

Tool Mini Clinical Evaluation Exercise (Mini-CEX)

Nature of assessment A faculty member observes and assessors a student / trainee as he/she interacts with a patient around a selected clinical task.

Direct Observation of Procedures (DOPS)

Procedural skills, Professionalism, A trainer observes and assesses a Communication skills trainee conducting a procedure as a part of his/her routine practice against a set of criteria.

Multi-Source Feedback (MSF) (Also referred to as 360-degree assessment).

This is a systematic collection of feedback for an individual student / trainee using structured questionnaires. They are completed by a number of members of the healthcare delivery team. MSF is different from the methods mentioned above, as MSF reflects routine performance and not the performance during a specific patient encounter.

Interpersonal relationships, Communication skills, Humanistic qualities

Patient Satisfaction Questionnaire (PSQ)

The assessment is given to patients before the doctor-patient encounter with a request to complete it after the consultation.

Communication skills, Humanistic qualities, Patient-centred practice, Holistic approach

The key element of WBA is a structured observation which focuses on a particular task or a part of it (Norcini and Burch 2007). The observer is required to be an expert and well-experienced in the task concerned (Norcini and Burch 2007). The level of training of the assessee and the complexity of the task need to be taken into consideration in the assessment. Like for all assessments, the goal of WBA should be the facilitation of further learning, i.e. the assessment should highlight the strengths and the areas which need improvement (Norcini & Burch 2007). The most effective way of achieving this goal is the provision of a constructive feedback to the assesse after the assessment. Therefore, a feedback session is an integral component of each WPA which has made the process and the outcome of the assessment more meaningful. In Mini-CEX and DOPS, the feedback

Attributes for assessment Medical interviewing, Physical examination, Humanistic qualities, Clinical judgement, Counselling skills, Organisation / eﬃciency, Overall clinical ability

session should be immediately after the assessment. In MSF and PSQ, the feedback received from different stakeholders is collated by the educational supervisor and a cumulative feedback is communicated to the assessee. Opportunities and challenges There are several characteristics of WBA which facilitate learning (Nocini and Burch 2007). The WPA makes the alignment between goals, content and assessment practices clear, as it takes place in an authentic environment. Therefore, the assesees see the relevance of assessments. WPA provides opportunities for the assessor to provide feedback to the assessee based on the actual performance. Assessee is benefitted by the receiving feedback based on his /her actual performance. WBA can be used more strategically than other assessment methods

to guide a student / trainee towards the intended outcomes of the educational programme. WBA tools such as MSF helps obtained holistic view of the assessee which is paramount in team-based work environment like healthcare setting; this may not be achievable with other assessment methods. However, there can be several challenges of using WPA. As several assessment encounters are necessary to achieve high level of reliability, especially for high-stake summative assessments, WBA warrants a substantial amount of time commitments from clinicians. However, the reliability can be compromised to certain extent by reducing the number of assessments and the assessment time if the WBA is used only for the provision of feedback, ( i.e formative purposes). Either the purpose of assessment is formative or summative, the provision of feedback is an integral component of WBA. Therefore, assessors need to be both competent and confident to provide constructive feedback to assessees. This can be challenging for some assessors (Norcini and Burch 2007). They should to be supported through staff development programmes to enhance their skills of providing constructive feedback. The key features of WBA are direct observation and timely feedback. If the assessment forms are completed without direct observation of the selected task the validity, reliability and the educational impact of the assessment become questionable. Conducting all WBAs towards the end of the training programme, e.g. in the final few months of a three year postgraduate training, contradicts the purpose (performance feedback improvement) of WBA. Both these factors defeat the goals of WBA and make it just a tick-box exercise. Contd. on page 06

SLMANEWS

May, 2013 Contd. from page 05

Assessment ... In assessment tools like MSF and PSQ, other healthcare workers, e.g. nurses, pharmacists, medical laboratory technologist, and patients play a role. Although openness to constructive feedback is an important professional attribute of doctors (Chandratilake et al 2012) the source of feedback may be a matter of concern for some doctors. On the other hand, other healthcare workers need to be trained to take a ‘professional’ approach in an event of providing feedback on the performance of doctors (Epstein 2007). Conclusion Although the assessment of preparedness to practice is important the assessment of actual performance and the provision of feedback should be the ultimate goal of assessments in medical education. WBA can be

used effectively to achieve this goal. There is a wide range of WBA tools which focus on different aspects of the practice of medicine. The choice of assessment tool depends on the purpose. The benefits of using WBA are many. However, certain challenges need to be overcome for the successful implementation of WBA in Sri Lankan context. References: Boud D (1995) Assessment and learning: contradictory or complementary? In Knight P. (Ed.) Assessment for Learning in Higher Education. London: Kogan, 35-48. Chandratilake M, McAleer S & Gibson J (2012) Cultural similarities and differences in medical professionalism: a multi-region study. Medical Education, 46:257-266. Chandratilake MN, Ponnamperuma G & Davis MH (2010) Evaluating and design-

ing assessments for medical education: the utility formula. Internet Journal of Medical Education, 1 (1) Epstein RM (2007) Assessment in medical education. New England Journal of Medicine 356:387-96. Norcini J & Burch V. (2007) Workplacebased assessment as an educational tool: AMEE Guide No. 31. Medical Teacher, 29: 855–871. RCGP n.d. PSQ for Workplace Based Assessment. Available from: <http://www. rcgp.org.uk/gp-training-and-exams/mrcgp-workplace-based-assessment-wpba/ psq-for-workplace-based-assessment. aspx> [14 May 2013] van der Vleuten C. (1996) The assessment of professional competence: developments, research and practical implications. Advances in Health Science Education, 1: 41 - 67.

SLMANEWS

Letter to the Editor

May, 2013

14 May 2013 Editor SLMA NEWS Dear Sir / Madam,

VIOLENCE AS SHOWN IN THE MEDIA AND THE ROLE OF THE MEDICAL PROFESSION Have you watched TV News recently, or cared to reflect on some of the headlines in newspapers? Do you notice that we are being bombarded with graphic pictures of violence? Are we seeing a progressive increase in the number violence reported by the media in Sri Lanka?

Violence in any form is a concern to all citizens of the country. However, this does not justify the consistent depiction of explicit and graphic visuals or descriptions in newspapers, television channels and in the internet, often without any warning given to the viewer. Some of the daily television news items have almost become a glory list of deaths, accidents, and social discord.

As a result even children in their formative years are exposed to these reports. Anecdotal reports of children ‘running away’ in fear of television news are not uncommon. Persistent psychological distress in viewers is yet another problem. This could take the form of anxiety, features of post-traumatic stress disorder, sleeplessness, and nightmares, to name a few. Some of these symptoms are self-limiting, and a few may require treatment or counseling. A more dangerous effect of violence in the media is on aggressive behaviour. At an individual level ‘copycat’ crimes based on violence in the media are well recognized, especially among juvenile delinquents. An example cited in the literature is the film ‘Natural Born Killers’ in 1990s that led to several random killings of strangers in the US by gun-toting teens, who had watched the film prior to the crime!

There is also a serious concern whether exposure to repeated violent scenes (either in the media or in video games) could also lead to more aggressive behavior in vulnerable persons. The emerging consensus is that violence depicted in the media and by the entertainment industry contributes to more aggressive behavior and therefore promotes violence in society, some of it is supported by advanced neurophysiolgical imaging studies such as functional imaging studies (e.g. functional MRIs). If this is correct, we are then facing a spiraling situation where violence in society breeds more explicit depiction of it (by the media or entertainment industry), which in turn fans the flames of further violence in society. This is simply not acceptable to Sri Lanka, a country struggling to come out of a devastating conflict that almost tore the social fabric to pieces.

The medical profession has the responsibility to improve awareness and education of media, public and regulatory authorities on the above situation and the detrimental effects of viewing violence on social cohesion and on psychological status of vulnerable groups. The SLMA members should take a lead in this process by networking with stakeholders and increasing their awareness. The SLMA as an organization has begun to contact media leaders in order to organize a series of activities to increase awareness and educate on the health impacts of violence. We need to act NOW.

Saroj Jayasinghe Council Member SLMA Chairperson Health Equity Committee SLMA

SLMANEWS

May, 2013

Japanese Encephalitis (JE) and the recent outbreak at Rathnapura From the Symposium on JE held on 20th March 2013 compiled by Prof Jennifer Perera, Chairperson Communicable Diseases Committee SLMA. Summary of the presentations on “Recent outbreak of Japanese Encephalitis at Ratnapura” and “Epidemiology of Japanese Encephalitis in Sri Lanka & recent changes” were published in the SLMA News Aril 2013 issue. 3.Laboratory Diagnosis of Japanese encephalitis Dr Geethani Galagoda, Consultant Virologist, Medical Research Institute, Colombo

Japanese encephalitis is a zoonotic, flavivirus. The virion is a spherical, enveloped, single stranded, RNA virus. There are 5 genotypes GI – GV and a single serotype. The genotype found in Sri Lanka is genotype 111. The JE complex comprises Japanese encephalitis (JE), West Nile encephalitis

(WEE), St. Louis encephalitis (SLE), Murray Valley encephalitis (MVE). Related flavi viruses are dengue, yellow fever, tick borne encephalitis. The mosquito vectors are culex species (C. tritaeniorhynchus, C. gelidus, C. vishnuii complex, C. fuscocephala). The virus also has been isolated from other mosquito species such as Aedes, Anopheles and Mansonia. The methods of laboratory diagnosis are serology, virus isolation, RT-PCR and antigen detection. Serology tests are commonly used in the diagnosis of JE. JE specific IgM antibody (single sample), JE specific IgG antibody (rising titer) and plaque reduction neutralization test are available.The specimens for diagnosis are, CSF, serum and brain tissue (post mortem). CSF is the best specimen to diagnose encephalitis because antibody levels rise higher and earlier than with serum. In addition, a positive serum can be a coincidental finding in a patient with encephalitis due do the high incidence of asymptomatic infection, especially in areas with high endemicity and serum IgM antibody could remain positive for a short period after vaccination. The most sensitive type of JE specific IgM test is a Capture IgM Enzyme immunoassay (EIA) which is 70 - 75% positive by the 4th day of illness and

100% positive by 7-10th day. Only a single CSF (0.5ml) or serum sample is required and antibodies persist for about 3 months after infection. The sensitivity and specificity are more than 95% for CNS infection. JE specific IgG test is done by Haemagglutination inhibition test (HAI) which is technically demanding. Two serum samples 10-14 days apart and a four fold rise of antibody titer is required for accurate interpretation of results. Confirmatory tests are required if there is circulating dengue virus infection at the same time, a high level of vaccine coverage and if a case occurs without any epidemiological evidence of JE transmission. Virus isolation can be conducted only in a research laboratory. JE virus is a risk group 3 pathogen and needs BSL-3 facility for virus isolation. RTPCR although a very specific test, is not recommended for routine diagnosis due to low sensitivity. It is generally negative in patients with clinical encephalitis as JE virus titer in blood is low and the duration of viraemia is short. The PCR can be demonstrated in brain specimens in fatal cases and provides information regarding molecular epidemiology. The methods of laboratory diagnosis in animals include RT-PCR, virus culture of brain tissue in mosquitoes, and serology tests such as neutralization, EIA and HAI methods could be used. The other investigations are cell count, protein, sugar and bacterial culture. For virological investigations, the sample should be refrigerated if there’s a delay of more than 1-2 hours. The sample should be stored at 4O C for 48 hours and at -200C for longer periods of storage. The sample should be transported in ice to the laboratory.

Figure 2: Serological profile of JE

Contd. on page 13

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May, 2013

Contd. from page 12

Japanese... Outbreak investigation

laboratory reagents.

Laboratory confirmation of 5-10 samples is sufficient to establish the presence of an outbreak. Once the outbreak has been established, 5-10% of samples have to be tested.

The laboratory data are sent as monthly returns to WHO and Epidemiology unit. All AES cases are followed up by the Epidemiological Unit and given an Epidemiology number similar to AFP cases (eg AES-SRLWPCOL13001). Laboratory accreditation is conducted by the WHO with annual testing using proficiency panels with renewal of annual accreditation of the laboratory.

Even in large outbreaks only 30% samples are positive in acute enephalitic syndrome (AES).

Laboratory surveillance of AES at MRI Laboratory surveillance in Sri Lanka is a program conducted by the WHO. CSF and serum samples are received at MRI with a history of AES. Laboratory tests are done by WHO approved test kits and a report is sent back to the clinician. The data request form should be filled including the duration of illness, JE vaccination etc. Samples should be collected 7 days after onset of illness. The CSF sample (0.5 ml) and the serum sample (2 ml) should be stored and transported at 40C if there is a delay. If the first sample was collected early in the disease, a second serum sample should be sent. The drawbacks and challenges faced in providing laboratory diagnosis are inadequate or absent clinical history (duration), samples collected too early in the illness, not receiving convalescent serum samples, samples being stored for long periods at the hospital and irregular supply of

4.Japanese Encephalitis Vaccine Dr Omala Wimalaratne, Consultant Virologist and Vaccinologist, Medical Research Institute. Colombo

Vaccination is the most effective method to control the disease. Types of JE vaccines are Purified inactivated mouse brain vaccine (Nakayama & Beijing strains), cell culture based inactivated vaccine Beijing P3 strain used in China, live attenuated SA-1414-2 vaccine from China, live recombinant vaccine: SA-14-14-2 strain inserted to the genome of 17D YF strain grown in Vero cell culture. In 1988 JE Nakayama strain vaccine was first introduced in Sri Lanka in a phased manner and in 1992 the Beijing strain was introduced. The Live SA-14-14-2 introduced at one year of

age in 2009 and later at nine months of age in 2011. Inactivated Japanese encephalitis vaccine contains inactivated Japanese Encephalitis virus prepared in mouse brain and only one strain is available at present in Sri Lanka(Nakayama strain).This vaccine is recommended after 1 year of age, and the primary immunization consists of 2 doses each given 2 weeks apart. A booster is given one year after the 2nd dose. In the government sector, the primary immunization is given with the live vaccine at 9 months of age. No boosters are recommended at present. The dosage is 0.5ml which is reconstituted and administered subcutaneously. The contraindications for JE vaccination are fever more than 38.3째 C, progressive neurological illness, pregnancy, persons who are allergic to the constituents of the vaccine, history of convulsions during the past one year, leukemia, lymphoma and other malignancies. The live vaccine is available only at state run vaccination clinics and this was thought to be a problem in achieving universal coverage in the relevant age groups. In outbreak situations, the need to extend immunization to adults was discussed as most amounts of morbidity and mortality occurred in the unimmunized adults, during the current outbreak.

From one great to another Charlie Chaplin meets Albert Einstein "What I admire most about your art", Albert Einstein said, "is its universality. You do not say a word, and yet ... the world understands you." "It's true", replies Chaplin. "But your fame is even greater: the world admires you, even when nobody understands you. Courtesy Dr. Dennis Aloysius Past President, SLMA

April, 2013

Stung by a jellyfish?

SLMAN

Some do’s and don’ts Malik Fernando ex-SCUBA diver, Marine Naturalist (Part time doctor)

ellyfish are not fish: they are primitive invertebrates that belong to the larger group (Phylum Cnidaria, formerly Coelenterata) that includes corals, sea fans and sea anemones—all capturing their prey by shooting venompacked darts from structures called nematocysts (or cnidocysts). These are microscopic in size, most too small to penetrate the human skin. But some jellyfish do possess nematocysts with penetrating threads long enough and containing venom with sufficient punch to hurt humans. But the venom of local animals is of low potency and do not cause problems—unless someone were unfortunate enough to have an allergic reaction, which are very much in the “rare” category. Jellyfish venoms were first studied in the Australian box jellyfish (Chironex

fleckeri) and were shown to be labile proteins with fractions that were haemolytic (not clinically significant), dermatonecrotic and cardiotoxic (that impedes relaxation of myocardium leading to arrest in systole). There are a number of possible sequelae following jellyfish stings:

Recurrent dermatitis is said to be a well known phenomenon occurring predominantly in females. The induction of a granulomatous inflammation by jellyfish toxins is rare. More typically, acute toxic and urticarial reactions are seen.

1. Immediate a)Pain (local), wheals, erythema, blistering, skin necrosis; b)Pain spreading through limb involving regional lymph nodes (Physalia); c)Agitation, distress – tachycardia, tachypnoea, sweating.

2. Late a)Dermal pigmentation (box jellyfish); b)Irukandje syndrome (Northern Australia); c)Recurrent dermatitis; d)Granulomatous dermatitis.

First Aid and Management—Do's & Don’ts • Prevent drowning;

A plate of jellyfish and cucumber appetizer in a local Chinese restaurant

• Reassure, ensure rest; • Remove adherent tentacles without touching; • First aid using nematocyst arresting solutions is variable and species specific; • Apply ice for pain relief (lignocaine ointment, or gel, effective); • Pain usually settles within 2hrs except following Physalia sting; • Generally no specific treatment is necessary; • Anaphylaxis following JF sting is said to be rare. Allergic reactions may occur and need antihistamines and corticosteroids. Not indicated routinely.

Details of stings by the four jellyfish stingers on the West coast are in the boxes with their photographs. These have been identified and studied personally. A number of nonstingers are also seen; but none in swarms since the El Niño of 1998. Swarms of jellyfish are seen off the East coast – but these have not been studied by the author. One edible species was collected some years ago for export till stopped by the authorities. The literature reports that some of these edible species cause cutaneous eruptions and pruritus in those harvesting them; in some parts of the world even systemic symptoms. They do not cause symptoms when eaten.

April, 2013

NEWS Jellyfish stingers of the West coast of Sri Lanka—off Colombo Each entity is a colony consisting of a gas filled float with a cluster of short and long tentacles attached to the underside, all coloured blue. They float at the surface and are driven by wind and currents, being washed up on beaches during stormy weather (photo right). The local species has one long “fishing” tentacle covered with clusters of nematocysts that give a potent sting. Recent experience suggests that these jellyfish deliver more potent stings than they did in the nineteen-seventies and eighties. The pain of the sting develops slowly to reach its maximum in 10-15 minutes; or is instantaneous and severe. It fluctuates in intensity and begins to wane in 1 hour, resolving completely at the end of 2 hours; or persists for 24 hours.

Chrysaora quiquecirra

“Nuisance jellyfish” One to three centimetres across, these small transparent jellyfish (Hydromedusae) occur in large shoals. Unseen by the swimmer or diver they give a mild sting wherever they touch causing much discomfort. They leave no mark and result in no symptoms following contact. The coloured masses are the gonads. Bell diameter 1-3 cm. The drawing at left is of an animal referred to by spear fishermen as needle jellies. Invisible in the water they give sharp pricks where they touch. The bell <1 cm.

Cyanea purpurea (Lion’s mane jellyfish) Bell diameter 20-45 cm, often appearing in swarms. Possibly another solitary species have bells 60-75 cm in diameter. Stings cause instantaneous pain with rapid development of erythema and wheals—such as rows of erythematous papules 2 mm across spaced 6 mm apart. The pain subsides over the next 30 to 60 minutes but may persist for a few hours if sensitive areas such as lips are stung. Erythema subsides over about 3 hours, the wheals taking a few days to resolve completely during which time they are mildly pruritic. As with stings of other Sri Lanka jellyfish no specific treatment is indicated. Pain caused by this jellyfish is usually mild, hardly necessitating even the application of ice.

Erythema and wheals in the form of linear streaks or characteristically beaded lines develop. Pain can be quite sePhysalia utricularis vere and distressing, radiating (Portuguese man-o'-war, blue bottle) to the regional lymph nodes; above and below. axillary pain following a sting Float length 2-4 cm. on the arm can radiate on to the chest wall and cause further worry to the victim (and ignorant practitioner). In any event, all symptoms and signs resolve in 24 hours with no specific treatment

(Compass jellyfish). Bell diameter 10 cm. A potent stinger. The thread-like tentacles the main stinging structures; contact with the ribbon-like mouthparts, that can extend up to 1 to 2 metres, causes an irritating pricking sensation. An erythematous weal forms within 10 minutes,

reaching its maximum size after 30 minutes and fading thereafter. The pain subsides in about 30 minutes of onset. If multiple stings from many tentacles have occurred ice may be used locally for pain relief. No specific treatment is necessary. Used to be very common off Colombo at the start of the S-W monsoon in the first week of May. But have disappeared following the El Niño ocean warming event in 1998.

Chiropsalmus buitendijki (Indian Ocean box jellyfish) Bell box-shaped with sides 10 cm. The 1 mm wide ribbon-like tentacles are borne in clusters at the four corners. Stings are painful, the pain developing slowly, being less severe than those caused by Physalia and Chrysaora. Erythematous wheals appear rapidly; they can be confluent and cover a large area if caused by multiple tentacles. Within 30 minutes the pain is replaced by pruritus and both wheals and pruritus start waning at one hour. It takes 36 to 48 hours for both to resolve. However, some stings can be more severe and take longer to resolve. Stings result in skin pigmentation that resolve over four months. Ice is usually adequate for pain control. No specific treatment is needed.

If stung by a jellyfish relax, keep calm, get someone to carefully remove any adherent tentacles, apply ice if pain is a problem. If you must apply something, use lignocaine gel if conveniently available. Avoid the various alcoholic and other liquids (including body fluids) as well as various macerated plants that will be recommended by helpful onlookers for local application.

Physalia utricularis

References: Fernando Malik. Some Hazards of Diving. (Presidential Address) CMJ 1992; 37, 72-80 First Aid for jellyfish stings. (Letter) C M J 1994; 39, 58 Hunting jellyfish. C M J 2001; 46 (4), 139-140 Consortium of Jellyfish Stings: Recent Publications, Jellyfish Sting Newsletter. Web based. University of Maryland, School of Medicine, Department of Dermatology

May, 2013

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126th Anniversary International Medical Congress - Programme

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May, 2013

“Cancer in Women: Current concepts, practices and strategies” A regional symposium at Trincomalee organized by the Women’s Health Committee of the SLMA

Dr. Shamini Prathapan MBBS, MSc, MD (Community Medicine) Secretary, Women’s Health Committee

he Expert Committee on Women’s Health of the Sri Lanka Medical Association organized a symposium titled “Cancer in Women: Current concepts, practices and strategies”. It was held in the auditorium of the District General Hospital (DGH) of Trincomalee on the 10th April 2013. It was well attended by medical officers from the region. The panel of speakers were from the Eastern Province

other than for Dr.Varuni Bandara, Senior Registrar in Community Medicine, National Cancer Control Programme. The speakers from the region included Dr.P.A Denagama (Consultant Obstetrician & Gynaecologist, DGH Trincomalee), Dr.R.Prathapan (Consultant Obstetrician & Gynaecologist, DGH Trincomalee), Dr.G.M.K. Bogammana (Consultant Surgeon, DGH Trincomalee), Dr. Prabath Wickrama (Acting Consultant Psychiatrist, Cancer Institute, Maharagama and DGH Trincomalee) and Dr. W.D.I.Shama Goonatillake (Consultant Clinical Oncologist, Teaching Hospital Batticaloa) The secretary of the Women’s Health Committee, Dr.Shamini Prathapan, welcomed the gathering and chaired the symposium. The gathering began with the Director of the District General Hospital Trincomalee, Dr.E.G.Gnanagunalan. He thanked the Women’s Health Committee for giving the medical officers an opportunity for continuous medical education and stressing the importance of such programmes in the region.

Dr. Varuni Bandara

Dr.P.A Denagama

Dr. Varuni Bandara then initiated the symposium with a comprehensive presentation on epidemiology of cancer in women. She highlighted the fact that worldwide cancer incidence and age-standardized rates are increasing. It was not only worldwide but in Sri Lanka too, among all cancers, taking into account the age standardized rates, breast cancer was the commonest. In Sri Lanka breast cancer is about 22% of all cancers diagnosed among women in 2006. The second common cancer was cervical cancer in cancers in women. Contd. on page 25

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May, 2013

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Cancer... Dr.Varuni Bandara also described the role of National Cancer Control Programme and its programmes in cancer prevention in the country. She stressed the fact that the programme was currently addressing the three most common cancers in lieu of prevention – Oral, breast and cervical cancers. The National Cancer Control programme practices six major strategies which are primary prevention, early detection, diagnosis and treatment, surveillance, palliative care and research. This was followed a presentation by Dr.P.A Denagama on Malignancies of the vulva and cervix. He mentioned the fact that suffering from cervical cancers are decreasing because women are undergoing Pap smear. He also pointed out that although the causative factor was multi-factorial, Human Papilloma Virus was responsible for over 90% of the cervical cancers against which the immunization is now available. Multiple sexual partners of the women as well as multiple sexual partners of the partners were important risk factors. One of the positive points that he pointed out was that vulval carcinomas could be completely treated with proper treatment if diagnosed early. This followed Dr.Prathapan’s presentation that mainly focused on the

Dr.Prathapan

issues and challenges in Cancer of the ovary and endometrium. His concern was of the ovarian cancer as it is a challenge to diagnose it, because of the non-specific nature of symptoms and signs and because currently there aren’t any screening programmes established so far in Sri Lanka. He stressed that estimation of the risk of malignancy is essential in the assessment of an ovarian mass once diagnosed. Concerning endometrial cancer, the main issue was that 75% occur in postmenopausal women and one in 10 women presenting with postmenopausal bleeding will be diagnosed of endometrial cancer in Sri Lanka. Dr. Bogammana enlightened the gathering with his presentation on “Breast Cancer”. He clearly pointed out the challenge in Breast Cancer was that one in eight women in the world will have breast cancer at some stage of their life which justifies the need to reinforce the screening programme in Sri Lanka. The advantage of early detection of breast cancer is that it could lead to cure which further substantiates the challenge of educating the public. The consultant oncologist for all three districts, Dr. Shama Goonathilake, introduced the novel concepts in Cancer management. Going on to speak about the therapeutic options, he emphasized that the main stay of each cancer therapy be justified to its efficacy and cost. Taking into account all what has been said in the above presentations, he stressed that the provincial cancer centres should be improved, and at-least one mammogram should be made available to a district general hospital. It was further discussed at the symposium that based on current evidence, national guidelines for cancer management should be made available and proper palliative care should be established in all districts.

Dr. Bogammana

Dr. Shama Goonathilake

Dr. Prabath Wickrama

Finally, the symposium concluded with Dr. Prabath Wickrama, speaking on “Psychological aspects of women diagnosed with cancer”. The key points that pointed out were that cancer causes a severe threat to the psychological wellbeing, and the psychological problems range from anticipatory anxiety, adjustment problems to post treatment. It evokes fear of death, grief, disfigurement, treatment and stigma. The positive point that was pointed out was that significant proportion of cancer related mental problems and iatrogenic and are thus preventable.

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The Bo-path Ella...

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