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SLMANEWS
Contents
THE OFFICIAL NEWSPAPER OF THE SRI LANKA MEDICAL ASSOCIATION
June 2013 Volume 06 Issue 06
President's Column Dear members and colleagues,
We are carrying on with the usual activities of the SLMA. All preparations are being made for the 126th Anniversary Scientific Medical Congress 2013. The programme will start with a Pre-Congress Symposium at Kalutara on the 4th of July 2013 and the “SLMA Health Run & Walk” will be on the 7th of July 2013. On the 9th and 10th of July there will be 7 Pre-Congress Workshops in Colombo. The Inauguration is on the 10th of July and the Main Congress will be from the 11th to the 13th of July. The complete Programme is given elsewhere in this Newsletter. The Steering Committee has tried very hard to include a plethora of different topics to the interests of a heterogeneous audience. I hasten to assure you that the proceedings and the fare provided will be fully worth the money you pay as the Registration Fee. Our continuing CPD activities are being carried out with the usual enthusiasm. In addition to the programmes for doctors, we have also had several activities for the nurses and other healthcare workers, in Colombo as well as in the out-station meetings. There was tremendous appreciation of these programmes and all the allied healthcare workers were unanimous in their assertion that this is the very first time that the SLMA has made a serious attempt to arrange CPD activities for them as well. We have organised further programmes for them, especially in view or the perceived crying need for them. The first Speech Craft Programme of the SLMA was successfully completed and we have started the second programme on the 12th of June 2013. I conclude with all good wishes to each and every one of you. With the very best of regards.
Page No. Notice board Run and Walk
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03
Another victory for the Department of Health Services, Southern Province
04
True compassion !
06
Abstract management Systems
10
Pre-congress workshops
13
Programme at a Glance
14-15
Evidence based approach for treatment of colorectal carcinoma Tips on good parenting
20 24
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Notice Board
June, 2013
SLMANEWS
Election of President Elect The SLMA elects a President-Elect at its Annual General Meeting every year in December to take over as President the following year. Any member may propose a candidate. It has been the practice however, that the Past Presidents receive nominations of suitable persons and make their recommendation to the Council for Council nomination. Any member who wishes to be considered for nomination, or any member who wishes to propose another (with that member’s consent), are invited to inform the undersigned or any other Past President, before the end of September. Malik Fernando Past Presidents’ Representative SLMA Council
Workshops on Geographic Information Systems (GIS) The third research training workshop organized by the Research Promotion Committee of the SLMA was aimed at introducing the use of Geographical Information Science/ Systems in health care. It was successfully conducted by Prof. Kithsiri Gunawardena on Sunday 02nd June 2013. The workshop drew an audience of over 30 participants from across the country, in spite of the adverse weather conditions. Theworkshop focused on introducing GIS including concepts and data types in GIS, basics of GPS technology and devices used, and GIS software. Participants engaged in several hands-on activities including data presentation using open-source GIS software. The next workshop on Geographical Information Science will be conducted by Prof. Kithsiri Gunawardena on 29th of June. The workshop will focus on practical application of GIS in research, including hands-on activities on use of GPS (data collection and entry, interpretation and error, etc…) and an introduction to Coordinate Reference Systems. Those interested in participating can contact the SLMA office on 2693324 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 CNAPT award The Ceylon National Association for the Prevention of Tuberculosis (CNAPT) award is awarded annually for publications related to medical research in Sri Lanka, and is valued at Rs. 50,000/-. The CNAPT award for the year 2013:Adikaram, C.P., Perera, J. & Wijesundera, S.S. (2012) The manual mycobacteria growth indicator tube and the nitrate reductase assay for the rapid detection of rifampicin resistance of M. Tuberculosis in low resource settings, BMC Infectious Diseases, 12:326. Available at http://www.biomedcentral.com/1471-2334/12/326 SLMA wishes to congratulate the authors of this publication for its scientific merit and relevance to Sri Lanka. All the submissions were of a high standard and the Research Promotion Committee wishes to thank all applicants for their efforts. The committee wishes to thank the scientific reviewers for their contribution.
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SLMA 126th ANNIVERSARY SCIENTIFIC MEDICAL CONGRESS -2013 Wednesday, 10th July 2013
Inauguration 5.45 pm Guests take their seats 6.00 pm Arrival of the Chief Guest 6.05 pm Introduction of Council Members to the Chief Guest 6.15 pm Ceremonial Procession 6.20 pm National Anthem 6.25 pm Lighting of the Oil Lamp 6.30 pm Welcome Address Dr. B. J. C. Perera President, SLMA 6.45 pm Address by the Guest of Honour Dr. Firdosi Rustom Mehta WHO Country Representative in Sri Lanka 7.00 pm Address by the Chief Guest Professor Sir Sabaratnam Arulkumaran MBBS (Cey) Hons,
DCH (Cey), LRCP & MRCS (UK), FRCOG, FRCS Ed, FAMS (Sing), MD, PhD; Hon. FSOGC, FACOG, FSCOG, FCPS, FSACOG, FSLCOG, FICOG, FDGG
7.20 pm Award of Research Grants 7.30 pm Vote of Thanks Dr. Samanmali Sumanasena Honorary Secretary, SLMA 7.40 pm The SLMA Oration 2013 “Epidemiology of snakebite: Investigating the burden” Vidyajyothi Professor H. Janaka de Silva
MBBS (Col), MD (Col), D Phil(Oxon), FRCP(Lond),FRCP,FNAS (SL), Hon. FRACP, Hon. FRCP (Thailand), Hon. FCGP (SL) Chair and Senior Professor of Medicine Faculty of Medicine, University of Kelaniya,
Ragama
8.25 pm
The Procession Leaves the Hall
8.30 pm Cultural Display and Reception (By invitation)
SLMANEWS
June, 2013
SRI LANKA MEDICAL ASSOCIATION 126th ANNIVERSARY CELEBRATIONS
HEALTH RUN & WALK 7th July 2013 at 6.00 am
Open to the public
Exercise for a healthier tomorrow Commencing from BMICH front lawn. ROUTE MAP
Programme 6.00 am onwards : Health Check 6.30 am—6.45 am : Warming up session 6.45 am—7.30 am : Run (in 3 groups) 7.45 am— 8.30 am : Walk 8.30am onwards : Yoga session
Free Lung Function Tests
Free medical check-up
Free Sports Physiotherapy
Free T-shirts, Caps and Gift Packs Valuable prizes to be won
Please Register Before the 30th of June 2013
Contact SLMA 2693324 (Nadeera)
E-mail: office@slma.lk slma@eureka.lk
COMPETE & WIN – Exciting Prizes PARTICIPATION IS FREE OF CHARGE In partnership with….
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SLMANEWS
June, 2013
Another victory for the Department of Health Services, Southern Province Ramya Mohotti Chest Clinic, Matara clinches a merit award in Taiki Akimoto Awards 2012
D
epartment of Health Services of the Southern Province, with the vision of “becoming the best Provincial Health Department in Sri Lanka by contributing towards the advancement of health, enriching Southern Province”, has achieved several prestigious awards in productivity, quality and safety including the first place in Taiki Akimoto Award 2011 and A Grade recognition in National Productivity 2012. Improving the quality and productivity of the institutions under the provincial department has been a priority of Dr. Hemachandra Edirimanne, the Provincial Director. As a result, twenty two health institutions under the Provincial Department of Health Services of Southern Province succeeded in getting C, D1 and D2 grades which clearly exceeded other provincial departments. The latest result is the achievement of a merit award in Taiki Akimoto Award 2013 by the Ramya Mohotti Chest Clinic, Matara. Taiki Akimoto 5S Awards are conducted annually by the Japan Sri Lanka Technical and Cultural Association (JASTECA). The Competition has a history of 17 years and it is recognized as the leading 5S competition of the country, and judged by a world renowned panel, including Prof. Seiichi Fujitha. The dedication, commitment and talents of Dr.(Mrs.) A T N Deepika Patabendige, Medical Officer in Charge, and her staff were responsible for the achievement. They have not only contributed their time, but also never hesitated to spend their money when needed in the preparation activities. This being the only chest clinic in the history to receive an award at the prestigious event, it sets an example for the government sector in implementing
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quality improvement programmes. Commenting on their success at this competition, Dr.(Mrs.) Patabendige, said that adhering to the 5S concept is the best tool for any organisation to improve quality of service and satisfaction of staff while implementing cost reduction and increased utilization of available resources. She conveyed special gratitude to the Provincial Director, Dr. Hemachandra Edirimanne, for his vision, guidance and commitment in achieving this success. Winning the award was a fitting recognition for the hard work and commitment of the team. She also stated that the award was a result of the collective efforts of the staff and further induced them to be
more creative, resulting in increased morale, enthusiasm and teamwork amongst them. We wish them success in their future endeavours to further increase the quality of the service they deliver to the care recipients of Matara District.
TAIKI Akimoto award trophy
Training session conducted by Provincial Director of Health Services – Southern Province Dr.Hemachandra Edirimanne
TAIKI Akimoto award Certificate
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SLMANEWS
June, 2013
A
True compassion !
t a fundraising dinner for a school that serves children with learning disabilities, the father of one of the students delivered a speech that would never be forgotten by all who attended. After extolling the school and its dedicated staff, he offered a question: ‘When not interfered with by outside influences, everything nature does, is done with perfection. Yet my son, Shay, cannot learn things as other children do. He cannot understand things as other children do.
Where is the natural order of things in my son?’ The audience was stilled by the query. The father continued. ‘I believe that when a child like Shay, who was mentally and physically disabled comes into the world, an opportunity to realize true human nature presents itself, and it comes in the way other people treat that child.’ Then he told the following story: Shay and I had walked past a park where some boys Shay knew were playing baseball. Shay asked, ‘Do you think they’ll let me play?’ I knew that most of the boys would not want someone like Shay on their team, but as a father I also understood that if my son were allowed to play, it would give him a much-needed sense of belonging and some confidence to be accepted by others in spite of his handicaps. I approached one of the boys on the field and asked (not expecting much) if Shay could play. The boy looked around for guidance and said, We're losing by six runs and the game is in the eighth inning. I guess he can be on our team and we'll try to put him in to bat in the ninth inning.' Shay struggled over to the team's bench and, with a broad smile, put on a team shirt. I watched with a small tear in my eye and warmth in my heart. The boys saw my joy at my son being accepted. In the bottom of the eighth inning, Shay's team scored a
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few runs but was still behind by three. In the top of the ninth inning, Shay put on a glove and played in the right field. Even though no hits came his way, he was obviously ecstatic just to be in the game and on the field, grinning from ear to ear as I waved to him from the stands. In the bottom of the ninth inning, Shay's team scored again. Now, with two outs and the bases loaded, the potential winning run was on base and Shay was scheduled to be next at bat.
At this juncture, do they let Shay bat and give away their chance to win the game?
Surprisingly, Shay was given the bat. Everyone knew that a hit was all but impossible because Shay didn't even know how to hold the bat properly, much less connect with the ball. However, as Shay stepped up to the plate, the pitcher, recognizing that the other team was putting winning aside for this moment in Shay's life, moved in a few steps to lob the ball in softly so Shay could at least make contact. The first pitch came and Shay swung clumsily and missed. The pitcher again took a few steps forward to toss the ball softly towards Shay. As the pitch came in, Shay swung at the ball and hit a slow ground ball right back to the pitcher. The game would now be over. The pitcher picked up the soft grounder and could have easily thrown the ball to the first baseman. Shay would have been out and that would have been the end of the game. Instead, the pitcher threw the ball right over the first baseman's head, out of reach of all team mates. Everyone from the stands and both teams started yelling, 'Shay, run to first! Run to first!'. Never in his life had Shay ever run that far, but he made it to first base. He scampered down the baseline, wide-eyed and startled. Everyone yelled, 'Run to second, run to second!'
Catching his breath, Shay awkwardly ran towards second, gleaming and struggling to make it to the base. By the time Shay rounded towards
second base, the right fielder had the ball, the smallest guy on their team who now had his first chance to be the hero for his team. He could have thrown the ball to the second-baseman for the tag, but he understood the pitcher's intentions so he, too, intentionally threw the ball high and far over the third-baseman's head. Shay ran toward third base deliriously as the runners ahead of him circled the bases toward home. All were screaming, 'Shay, Shay, Shay, all the Way Shay' Shay reached third base because the opposing shortstop ran to help him by turning him in the direction of third base, and shouted, 'Run to third! Shay, run to third!'. As Shay rounded third, the boys from both teams, and the spectators, were on their feet screaming, 'Shay, run home! Run home!'. Shay ran to home, stepped on the plate, and was cheered as the hero who hit the grand slam and won the game for his team. 'That day', said the father softly with tears now rolling down his face, 'the boys from both teams helped bring a piece of true love and humanity into this world'. Shay didn't make it to another summer. He died that winter, having never forgotten being the hero and making me so happy, and coming home and seeing his Mother tearfully embrace her little hero of the day! AND NOW A LITTLE FOOT NOTE TO THIS STORY: Public discussion about decency is too often suppressed in our schools and workplaces. We all have thousands of opportunities every single day to help realize the 'natural order of things.' So many seemingly trivial interactions between two people present us with a choice: Do we pass along a little spark of love and humanity or do we pass up those opportunities and leave the world a little bit colder in the process?. A wise man once said every society is judged by how it treats it's least fortunate amongst them.
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June, 2013
Abstract management Systems Dr. DeepalWijesooriya, MBBS, MBA-HCS, MSc in Biomedical Informatics, Dip in Psychology National Institute of Health Sciences, Kalutara.
Medical conference and abstract management systems in Sri Lanka SLMA is a leading conference organizer since it represents all category of medical professionals in Sri Lanka. Abstract management is the process which involves receipt of abstracts, distributing the abstracts for peer review, notification of selection or rejection status of the abstracts and preparation of abstract book in a scientific conference. In some cases submission of a full paper may be required before final acceptance is given. The abstract management process is closely tied up to the need to provide continuing education to professionals, especially Continuing Medical Education or CME. Many annual meetings hosted by specialty societies provide educational credit hours so that attendees may keep current in the field and maintain their professional certifications. This process has been mainly carried out manually until recent past. Increasingly, submissions take place online using various technologies nowadays.
Current situation of professional organizations in Sri Lanka Most of our professional organizations including SLMA are run by councils, which constitute annually elected honorary members. Apart from the contribution from few administrative staff, majority of the works is carried out by the council in a voluntary basis. Most of them are professionally qualified doctors from various specialities and are not the professional event organisers. Although the organisers of the conference in a particular year gain experience with trial and error, most often this gained experience is not passed on to the councils in the subsequent years. This leads to waste lot of time and effort
10
to collect information and management of event like abstract management. They have to learn and apply it from the beginning next time because council members are changed. Although, the councils include ex-officio members such as immediate past president, immediate past secretary and president elect, this system alone will not be enough to share the experiences.
So if there is an abstract management system with ability to make tailor made changes according to the specific conferences, it will reduce wastage of valuable time, money and reduce errors of the system.
Pros and cons of Manual to Electronic Abstract Submissions There are some drawbacks on manual abstract management system, although it was the common practice in the past. It needs manual processing, knowledgeable persons, more time and more chance to get clerical mistakes. It has various limitations to keep the standards, to prevent personal interest and keep full transparency. It is costly and need more manpower. Most of the above issues can be minimized with the use of electronic submission. But electronic submission has its own problems. Most of our medical doctors are not used to this sort of systems. External factors like internet service and internet devices are other critical factors. But it gives more transparency and reliability to the users. They can submit from their working station and no need to visit the office. It helps to increase the number of abstract submissions significantly. They can follow up the abstract process with the reference number.
What would be the ideal Abstract Management System? Ideal Abstract Management System should be arranged in a module basis which include Abstract Guideline, Principle Author Registration and abstract submission form in a Basic Module. It should cover complete process of Ab-
stract Management from Abstract Submission to Printing of Abstract Book. Those activities should be modularized namely Abstract Management Module, Referee Management Module, Abstract Evaluation Module and Abstract Publication Module.
Abstract management Module consists of Abstract Database with sorting options. It will help to arrange other module around the data captured from Basic Module. Referees Management Module is also a very important step. Referees should be registered with their basic demographic data, contact details, academic qualifications, experience and interesting areas. There should be a space for special remarks to enter additional information by the referees. Administrators should have facility to put their specific information under their profile which should not be seen by the referees. Administrators should have facility to grade the referees too. Abstract Evaluation Module consists of categorization of the abstract, allocating anonymous abstract to more than one referees, establish evaluation criteria and gridline, keep track of progress of each referees work, facilitate to write advice for authors, final evaluation of the abstract by the administrators of the system. Abstract Publication Module arranges all selected abstract into a common template. That template, font size, font type, logos and each branding can be customer zed.
Description of Basic Module Abstract submission guideline should be very simple and easy to understand. Guideline should be changed according to the corresponding abstract committee needs and wants. But, text size, font, spacing are not important. Those parameters can be easily changed with the abstract management system. But maximum number of words, grammar and language should be uniform and restricted by the guideline. Contd. on page 12
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June, 2013
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Abstract ... It should be included eligible criteria and time period of Abstract Submission and if it is not available now how to get it. It should be clearly mentioned how to get Back-office support to fulfil the eligible criteria. Corresponding Author registration is a very important step and it should be very simple and properly guided in Guideline Section. Contact information, institution information and user password should be collected at this stage. That information is important in Abstract Committee for further contacts. It also helps authors to get interactive contacts with the electronic system with user name and password. Author’s information is another important section. There can be more than one author. Among those presenting and principal authors are important. Author’s name, institution and email contacts should be gathered by the system. The Author’s name style, institution name style should be mentioned in Guideline Section with the example. Additional informations such as Presenting Author and Principle Author should be included in the Remarks Box. It should be clearly informed in Guideline with the example. Presentation Preference can be selected by the Author. (e.g.: Oral, Poser or One of them) But Ultimatum decision is by the abstract committee. Abstract title should be limited with the maximum number of words and acceptable case (Capital, simple or Capitalize Each Word etc.)
It should be included about right to change the title if needs by the Abstract Committee. Abstract body and it's contents should be decided by the Abstract Committee. It may vary from Conference to Conference. Usual format is Introduction, Objective or Aim, Methodology, Findings and Conclusions. Number of words should be decided by the Abstract Committee of the relevant conference. Any additional details should be included into the Remarks Box. Additional information should be decided by the Abstract Committee. It should be specifically mentioned in Abstract Guideline section with example. If abstract committee need any soft documents like Ethical Clearance Certificate, or supportive document, it should be uploaded by this facility. Exact document, file format and size of the document should be decided by the committee and clearly mentioned in the Abstract Guideline Section.
Current level of Electronic Abstract Management Systems in Sri Lanka National Institute of Health Sciences has used electronic submission abstract management system for ICPHI 2013 conference. It was developed by Dr Deepal Wijesooriya as a pilot project at the end of 2012. Abstract Guideline was developed by Dr Ruwan Ferdinando, Dr Sumal Nandasena . They have received 197 abstract submissions though this system within 45 days. This is a big number of abstract compared to last time manual submission to the
same conference. This system coved Basic Module and Abstract management Module of ideal Abstract Submission System. It is modified to the new requirement of SLMA conference and applied to this time online abstract submission. It gives 30 days to submit abstract. There are 231 abstract submissions through were system. But most of the abstract submissions were done within last 96 hours. It was about 220 submissions. This has created big rash at last moment leading to difficulties in submission. It was a new experience of the authors. Most of the inquiries through the phone and email were replied. Unfortunately all the inquiries were not addressed due to congestion of the system. If there were a separate help desk created at least in the last 4 days, it would have been helpful for lot of them. Online video guideline and help forum are other options for dedicated support. Some of them have difficulties to submit online, if there were other options like attachment with email, they also could have got submitted their abstracts. There was no literature found about user satisfaction survey for abstract submission system and no proper evaluation found to compare author’s point of view about this topic. So SLMA will do user satisfaction survey for abstract submission. It will help to identify user requirements to develop better systems in future.
SLMA events in May 2013 The Communicable Diseases Committee of the SLMA organized a symposium on “The Current Influenza Outbreak: Lessons that could be learnt” on 22nd May 2013. This symposium included presentations on ‘Current influenza outbreak: Global and local epidemiology’ by Dr. Paba Palihawadana, ‘Virological diagnosis and surveillance: Role of the National Influenza Centre’ by Dr Jude Jayamaha, ‘Management of patients at Castle Street Hospital & challenges’ by Dr Priyankara Jayawardene and ‘How prepared are we for an outbreak?’ by Dr Ananda Wijewickrama. Monthly Clinical Meeting of the SLMA for the May 2013 was held on 21st May 2013. Dr. Chandimani Undugodage presented a case on ‘Eosinophil and the Lung – “Beyond asthma”. This was followed by a review lecture on Pulmonary Eosinophilia by Dr. Ravini de Silva Karunatillake. Finally, Dr. Bodhika Samarasekara conducted MCQs and picture quiz.
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Pre Congress Workshops
SLMANEWS
June, 2013
SLMA 126th ANNIVERSARY
Sunday 07th July 2013 from the BMICH front lawn
All are welcome, Free participation
PRE CONGRESS WORKSHOPS 4th July 2013 BUILDING KEY COMPETENCIES OF FIELD HEALTH STAFF TO PROMOTE FAMILY WELLBEING Venue: NIHS - Kaluthara 9th July 2013 BUILDING EFFECTIVE TEAMS IN DIABETES CARE IN SRI : AN EVIDENC BASED APPROACH Venue: The Eagle Ball Room, Waters Edge, Battaramulla HEALTHCARE QUALITY & SAFETY Venue: Blood Transfusion Service Auditorium, Narahenpita OPTIMISING CARE FOR CHILDREN WITH DISABILITIES Venue: LRH auditorium
I0th July 2013 INCULCATING ERGONOMICS IN THE SRI LANKAN SETTINGS Venue: The kingsbury Hotel COMMUNICATION SKILLS FOR DOCTORS Venue: SLMA Auditorium IMPROVING THE QUALITY OF JOURNALS (INASP) Venue: At Albatross-Waters Edge SPORTS MEDICINE FOR COACHES & TRAINERS Venue: Sports Science Auditorium, Independence Square, Colombo 07 “CANCER GENETICS – DIAGNOSTICS, PROGNOSTICATION AND PHARMACOGENOMICS” Venue: Waters Edge, Battaramulla
11th July 2013 7.00 pm
Waters Edge, Battaramulla All are welcome, Free participation
13th July 2013 8.00 pm
Waters Edge, Battaramulla
Tickets : Rs 4500/= 13
June, 2013
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SLMAN
NEWS
June, 2013
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SLMANEWS
June, 2013
Evidence based approach for treatment of colorectal carcinoma not beneficial in MSI patients. A prospective Intergroup trial (E5202) is under way to assess whether patients with stage II disease can be stratified as low or high risk depending on retention of 18q alleles or MSI.
Dr. Prasad Abeysingha MD, Consultant Clinical Oncologist, National Cancer Institute, Sri Lanka
This article is a summary of the review lecture of the SLMA Monthly Clinical Meeting held on 23rd April 2013. This lecture was held in collaboration with the Sri Lanka College of Oncologists.
4. Management 4.1. Rectal Cancer
1. Introduction Colorectal carcinoma is the 4th commonest cancer in males in Sri Lanka. Due to lifestyle changes in our population we can expect the incidence to further rise in the coming years. Contemporarily, there are many treatment options available for treatment of this condition including the use of several novel drugs. However, careful examination of available clinical evidence is a must before deciding on treatment of individual cases.
2. Investigations Colonoscopy and biopsy is the gold standard for diagnosis of disease. In severely debilitated patients flexible sigmoidoscopy with biopsy (for low tumours) and a barium enema may suffice. Place of CT colonogram is still under investigation. MRI of the abdomen and pelvis with CT thorax and CEA levels are the minimum investigations needed for staging. In rectal cancers, endorectal ultra sound scan can be used to assess the intra mural spread. Although various staging methods are available the commonest used method is TNM staging. (See table below.)
3. Prognosis American College of Pathologists con-
20
sensus category 1 prognostic factors in colorectal cancers are TNM stage, blood vessel or lymphatic invasion, positive margins, and postoperative CEA elevation. It is also accepted that number of negative lymphnodes recovered from the surgical specimen is highly significant. Improvement of 5 year survival from 73% to 87% is seen when the number of negative lymphnodes increases from <10 to 20. It is important to note that this increase in survival is more than any increase by adjuvant chemotherapies. Molecular markers are playing an increasingly important role in prognosticating colorectal cancers. Loss of heterozygostiy in chromosome 18q equates the prognosis of a stage II cancer to a stage III cancer without the same genetic change. Micro Satellite Instability (MSI) is seen in cancers occurring proximal to the spleenic flexure. It is also seen commonly in patients with Hereditary Nonpolyposis Colorectal Cancers. Cancers with MSI is taught to have lesser tendency to metastasize and therefore carries a better prognosis compared to Micro satellite stable cancers. However florouracil based chemotherapy maybe
Name
Country
Regiman
Maio
USA
De Gramont
France
Modified De Gramont
UK
Lokich AIO
UK Germany
Rosswell Park
USA
Blous Low-Does FA 20 mg/m2/day followed by 5FU 425 mg/ m2/days 1-5, every 28 days D-Folinic acid 200 mg/m2 -hour infusion, 5FU bolus 400 mg/m2 and 5FU 600 mg/m2 22-hours infusion, days 1 and 2, ever 14 days L-Folinic acid 175 mg(flat does) 2-Hour infusion, 5FU bolus 400 mg/m2 and 5FU 2,800 mg/m2 46-hours infusion,ever 14 days Continuous infusion 5FU 300 mg/m2/day FA 500 mg/m2 + 5FU 2,600 mg/m2/24-hour infusion, weekly ×6, every 8 weeks FU 500 mg/m2 2-hour infusion followed by 5FU 500 mg/m2 bolus 1h after the start of FA infusion, weekly ×6, every 8 weeks
Initial treatment has to be decided on stage of the cancer and the risk of local recurrence. Metastatic disease management is same as colon cancer and discussed below. In localized disease, the risk of local recurrence is considered high if threatened (< 1 mm) or breached resection margin is seen, low tumours encroaching onto the inter-sphinctericplane or with levator involvement. The risk is moderate if clinical stage is T3b(15mm) or greater, in which the potential surgical margin is not threatened or any suspicious lymph node not threatening the surgical resection margin or the presence of extramural vascular invasion and low when stage is T1 or T2 or T3a (<1mm) and no lymph node involvement is seen. Low risk patients can have upfront surgery while patients in moderate risk group, short course radiotherapy (This is not widely practiced in Sri Lanka) immediately followed by surgery and high risk group, chemo-radiation followed by interval surgery is the treatment of choice. Adjuvant treatment is same as Colon cancer and is discussed below. It is important to note that according to NICE guidelines there is no place for preoperative chemo-radiotherapy solely to facilitate sphincter sparing surgery to patients with rectal cancer. 4.2. Colon Cancer Initial treatment of all localized colonic cancers is surgery. Further treatment would depend on the pathological staging as described above.
Stage I - No further treatment needed except for patients whose resection margins are involved. Stage II – No consensus regarding benefit of adjuvant chemotherapy but latest data suggest stage II high risk group might benefit from adjuvant chemotherapy (See below) Stage III – Definite benefit in adjuvant chemotherapy Stage IV – See management of metastatic disease. Contd. on page 25
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Contd. on page 24
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June, 2013
Tips on good parenting Dr Leenika Wijeratne MBBS, MD(Psych) Department of Psychiatry, Faculty of Medicine, University of Kelaniya
instructions may be given, but the child is unaware of it.
P
When asking a child to do something, it is important to make sure that you get the child’s attention before you do so. By following a few simple steps you can ensure that the child hears and understands what you have to say.
A few simple techniques though can be very effective in making the life of a parent much easier.
When you are telling them something, call them by their name or any other name that is used. Before giving your instruction make sure that the child stops what he is doing and gives you their full attention.
arenting, it has been said, is the most important job that a person will ever do. It is an irony though, that it is a job for which no training or qualification is required. It is a challenge to people of all walks of life and doctors are no exception.
Identifying desirable behaviours and reinforcing them Identifying desirable behaviours One of the first steps is to decide, what behaviours you expect from your child. In most families, even the two parents are not clear as to what they expect their child to do. It is therefore not surprising when the child is confused about what the parent expects from them. The two parents who come together to parent a child, come from different families with different experiences and different upbringings. Often they are in disagreement on what they want their child to do. The most important step in this situation is to discuss, compromise and come to an agreement about what they expect from the child. For example, a simple thing like whether or not it is alright for the child to have snacks in between meals might lead to conflicting opinions. Once a decision has been made it has to be communicated to the child clearly. In many instances, the child realizes he was expected to do something, only when his parents shout at him for not having done it or vice versa.
Communicating with the child Ineffective comunication between the parents and the child is a very common reason for behavioural problems in children. Sometimes
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Sometimes parents forget that the child is at a different developmental level and that they may not understand the complex language an adult may use. Use simple clear language that you know your child understands. Stick to one or two step instructions. Too many things said at once will confuse the child and will end up in the child not clearly understanding any of it. It is important to be specific about what you want done and mention when you want it done ( now / by 8 o’clock etc. ). Be firm but polite. Use an emotional neutral voice. Don’t yell. Don’t ask questions, but tell. Asking whether the child can do something conveys the message that he has the choice of saying no, whereas a statement tells him he has to do it. Eg. “Please do this” and not “Can you do this ? “ Talk to children as you would like to be spoken to by them because they will talk to you only as you talk to them. Example of an effective instruction : Menul, please go and brush your teeth now.
wasted getting angry and shouting at the child when he does not follow the instructions. Repeat instructions only once. If the child does not follow the instructions repeat it only one more time. And when you repeat tell the child clearly what the consequence will be if he doesn’t listen to you. Make sure the consequence is a realistic and practical one and make sure you follow through. If the child doesn’t listen the consequence has to follow immediately.
What consequences can be given for undesirable behaviours ? While many would say that sparing the rod will result in a spoilt child, this is not always the case. There are many effective consequences for negative behaviours that do not need the use of the rod. Taking away privileges is one effective form of negative consequence. Eg. No TV this afternoon if the homework is not finished by 5 o’clock. Time out is another form of negative consequence where the child has to sit somewhere without interacting with anyone for a specified period of time. This time is generally equivalent to the age in years ( 5 minutes for a 5 year old etc )
Reinforcing desirable behaviours Reinforcing desirable behaviours with positive rewards is even more important than negatively reinforcing undesirable behaviours. Desirable behaviours can be rewarded by a number of ways.
Amila, please put away your toys into the box when the clock turns to 8.
Praise Praise is a very powerful reward. However when you are giving praise you have to make sure you do it effectively.
Although it might be easier to shout the instruction across the hall or from another room , spending half a minute to give the instruction clearly will save a lot of time later which might be
For praise to be more effective it has to be given immediately after the action that prompted it. It is also
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Tips on good ...
important to label the praise, ( eg. I liked the way you put away your toys. It was very nice to see you share your toys with your brother). By mentioning what he did to deserve the praise, you emphasize the good behaviour and increase the chance of the child registering it in his mind. Time Spending special time with the child doing something the child likes doing. Make sure it is mentioned what he did to earn this special time. Tangible rewards It is best to stick to small inexpensive rewards. However this may not be effective if the child is getting similar gifts on a regular basis, irrespective of his behaviour. Physical affection Physical affection too can act as a powerful reinforcer of desirable behaviours.
Operant Conditioning
Positive or negative reinforcement
of behaviours uses the principal of operant conditioning. Operant conditioning is a type of learning in which an individualâ&#x20AC;&#x2122;s behavior is modified by its consequences. It involves the introduction of a positive event following a desirable behavior. This makes it more likely that the behavior will occur again in the future. This is positive reinforcement. When the rewards are immediate and consistent the chances of the behaviour happening again will increase further. Longer the time duration between the behaviour and the reward, weaker the association and lesser the chance of it affecting repetition of the behaviour. Although the use of positive reinforcement is a very effective tool in parenting it can also act in a negative way. Parents can inadvertently reinforce negative behaviours. Giving attention to a child by shouting or even pleading with him when he is having a tantrum will increase the chances of having tantrums in the future. Parents often say no to something and then give the same thing to the child when he starts crying or throwing a tantrum
demanding for it. This reinforces this negative behaviours and the child learns that crying is a way to get what he wants. The best way to handle negative behaviours is to minimize the chances of these behaviours getting rewarded. If the parent has said no to something it should not change however much the child cries and however difficult it is for the parents to watch him cry. Whereas if it is something that can be given to the child, make sure it is given to the child before he starts protesting or crying. Ignoring undesirable behaviours and noticing and praising desirable behaviours has shown to be an effective parenting strategy. Negative behaviours also need to be identified and addressed appropriately. Providing negative reinforcements for negative behaviours too can reduce the chances of these behaviours happening again while letting the child know that the behaviour is not accepted by the parent. Negative reinforcements just like positive reinforcements have to be consistent and immediate.
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Evidence based ... 4.3 Adjuvant chemotherapy
Since 1990s there was clear evidence to show adjuvant treatment has survival benefit for stage III colorectal cancer. Initially used chemotherapy regimen was Florouracil based regimens. and all other regimens was tested against these regimens subsequently. Capacetabine - A randomized phase III trial (X-ACT) showed capacetabine was atleast equivalent to florouracil(FU) plus leucovarine with significant reduction in side effects like neutropenia, stomatitis, nausea, alopecia and diarrhea. However Hand foot and mouth disease was more common. Irinotican â&#x20AC;&#x201C; Accor-2 trial investigated the benefit of addition of irrinotican to FU + leucoverine and it did not show any superiority of addition
of irrinotican. Therefore irrinotican currently has no place in adjuvant setting of colonic cancers. However irinotican can be used as second line treatment. Oxaloplatin - MOSAIC trial showed that there was a disease free survival but no survival advantage at 3 years by adding oxaloplatin to FU/ leucoverine. However at 6 years this disease free survival benefit translated into a survival benefit in stage III patients. A combined analysis of NSABP trial showed that addition of oxaloplatin may benefit stage II high risk patients as well. However, oxaloplatin based chemotherapy all caused significant peripheral neuropathy which can last up to one year. Therefore today standard of care in adjuvant treatment of colorectal cancer is Florouracil/Capacetabine +
Leucovarine + Oxaloplatin. 4.4 Metastatic disease
Here priority is to control symptoms. If both primary and metastatic disease are respectable neoadjuvant chemotherapy followed by surgery is the approach. Neoadjuvant chemotherapy can be Florouracil/Capacetabine + Leucovarine + Oxaloplatin. Second line chemotherapy would be irrinotican alone or in combination with Florouracil/Capacetabine and Leucovarine. For advanced colorectal cancer patients who are intolerant of FU, Raltitrexed (An inhibitor of thymidylate synthase) can be given. Addition of novel agents like cetuximab (monoclonal anto\ibody specific for EGFR) and bevacizumab (Monoclonal inhibitor specific for VEGF) are under investigation.
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The Bo-path Ella...
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