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CONTENTS Page No.
Cover Story Joint Regional Meeting
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THE OFFICIAL NEWSLETTER OF THE SRI LANKA MEDICAL ASSOCIATION
March 2015, Volume 8, issue 03 02, 03, 04
SLMA News Editorial Committee-2015
News President's message Joint Regional Meeting...
Editor-In-Chief: Prof. Sharmini Gunawardena
02 02, 03, 04
Committee: Dr. Amaya Ellawala Dr. Iyanthi Abeyewickreme Prof. Deepika Fernando Dr. Sarath Gamini De Silva
Q & A On Malaria in Sri Lanka...
04, 07, 08
The doctor as a leader.
10
Procedures of the SLMA...
12
Carcinoma of the cervix...
14, 16
Guidelines for Physical...
16, 18, 19, 20
Avoidant / restrictive food...
20, 21, 22
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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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March 2015
PRESIDENT'S MESSAGE
Dear Members
W
e have concluded an extremely busy month at the SLMA. We had the traditional History of Medicine lecture on the 26th of February 2015 titled "Providing care for people with lunacy to promotion of mental health“. It was delivered by Professor Nalaka Mendis, Emeritus Professor of the University of Colombo, who gave us a very informative and interesting account of the evolution and development of psychiatry services in Sri Lanka spanning back to the time of British governance. Several guest lectures were delivered by overseas as well as local speakers who are eminent specialists in their respective fields. The Monthly Clinical Lecture in February was delivered by the Sri Lanka College of Paediatricians. The Joint Regional Meeting was conducted in collaboration with the Homagama Clinical Society on the 16th of February 2015 with over 100 doctors participating and this activity was sponsored by the State Pharmaceuticals Corporation. Most of these activities were conducted at venues outside the SLMA as the roof of Wijerama House is being replaced, which was long overdue. As the repair work will continue for over two months, please take special note of the venues mentioned in posters and bulletin notices so as to avoid facing any difficulties. The Expert Committees are busy getting ready their plans for the year in line with the SLMA strategic plan. The SLMA committee met this month to revisit the corporate / strategic plan
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with a view to determining the purpose of the association. During this meeting it transpired that patients were to be our main stakeholders while doctors were considered as the means by which better patient and health outcomes could be achieved. Currently, the corporate plan committee is in the process of identifying the vision 2020 for the SLMA with a view to determining implementation strategies and we hope to keep you updated on this new development.
SLMA. My best wishes are with you.
Preparations for the 128th Annual Scientific Congress and Annual National Health Walk and Run are being made at an accelerated pace. I would like to sincerely thank the colleagues who have taken up the responsibility in organizing these events. The Ministry of Health, the industry and other partners have responded positively to our requests for sponsorships and financial assistance and I am hopeful that we can host a high quality programme of events. It is no secret that the success of these events depend on the degree of participation of doctors and I extend a warm invitation to all of you to be part of this exciting programme organized from the 28th of June to 8th of July 2015.
19th February 2015 at the Pathology Lecture Hall, Faculty of Medicine, University of Colombo - “Implementation of next generation sequencing in Clinical Medicine” by Dr. Michael Paumen, PhD - Senior Director, Medical Sciences Asia Pacific & Japan, Thermo Fisher Scientific Life Sciences Solutions Group
I wish to conclude this message with an appeal to all medical professionals who are not SLMA members, to become life members of the SLMA and help strengthen the role of the SLMA by becoming partners in its various activities. We are in the process of preparing special benefit packages and organising social events to enhance the attractiveness of having membership of the
Professor Jennifer Perera SERIES OF GUEST LECTURES HELD DURING THE PAST MONTH
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8th February 2015 at the Board Room, Faculty of Medicine, University of Colombo - “Keeping our humanity in an age of technological medicine” by Prof. John Stephen Wyatt, Consultant Neonatologist
19th February 2015 at the Pathology Lecture Hall, Faculty of Medicine, University of Colombo - “Metagenomics - increasing the speed and accuracy of diagnosing infectious diseases with NGS” by Dr. Anupama Gaur, Ph. D - Business Development Lead - NGS and Clinical Applications, Thermo Fisher Scientific Life Sciences Solutions (Life Technologies) 6th March 2015 at the LRH New Lecture Theatre - “Writing and publishing journal articles: ways to decrease stress and increase success” by Prof. Barbara Gastel, BA (Yale), MD, MPH (John Hopkins), Professor of Integrative Biosciences and Humanities in Medicine and Biotechnology at Texas A & M University.
JOINT REGIONAL MEETING OF THE HOMAGAMA CLINICAL SOCIETY AND THE SLMA By Dr. Shamini Prathapan (Asst. Secretary, SLMA)
T
he joint regional meeting of the SLMA in collaboration with the Homagama Clinical Society was held on the 16th of February 2015
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at the Homagama Base Hospital. The President of the Homagama Clinical Society, Dr. Anoma Abeygunawardena, delivered the welcome speech. Prof. Jennifer Perera, Presi-
dent of the SLMA also addressed the gathering. It was well attended by around 100 medical officers from the hospital and the Homagama area. Contd. on page 03
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Contd. from page 02
Joint Regional.. The first session was chaired by Dr. Nandana Dickmadugoda and Dr. Asiri Rodrigo. The panel of speakers were Dr. Sanjeewa Wijekoon (Consultant Physician, Colombo South Teaching Hospital), Dr. Chandimani Undugodage (Respiratory Physician/Senior Lecturer, University of Sri Jayawardenepura), Dr. Nalin Kithulwatta, (Consultant Paediatric Intensivist, Lady Ridgeway Hospital) and Dr. Ranthilaka Ranawaka (Consultant Dermatologist, Base Hospital Homagama). Dr. Sanjeewa Wijekoon started off the session with his lecture on “Management of hypertension; an evidence based approach”. He stressed that hypertension is a major reversible risk factor for several NCDs and that landmark clinical trials have proved that treatment is beneficial. However, he emphasised that there is conflicting evidence regarding the treatment threshold (when to treat), treatment goals (how much to reduce) and how to treat when there are other risk factors. The 2014 evidence based guideline for management of hypertension by the 8th Joint National Committee (JNC 8) was the basis of his lecture, which has reviewed all good quality evidence and come up with simple recommendations such as; the threshold and goals of treatment for the general population >60 years being 150/90mmHg, and for the general population <60 years being a BP of 140/90mmHg and for CKD/DM patients the target BP being 140/90mmHg. He also stressed that thiazide diuretics, CCB, ACEI and ARB are the first line drugs. The next speaker, Dr. Chandimani Undugodage, spoke on the topic “COPD - for the Primary Care Physician”. She specified that COPD is one of the leading causes of morbidity and mortality worldwide and the number of exacerbations and the co-morbidities significantly affected a patients' out-
come.
diagnosing Leprosy.
The combined assessment of COPD, a GOLD initiative, takes into consideration the symptoms, Spirometry, post bronchodilator FEV1 and the number of exacerbations in deciding the therapies in COPD. Cessation of smoking, pulmonary rehabilitation, vaccination, pharmacotherapy and treatment of co-morbidities are the key areas in the management of COPD.
The second session was chaired by Dr. Tissa Perera and Dr. Shamini Prathapan. The speakers were Dr. Neelamani S Rajapaksa Hewageegana (Director, Health Education Bureau), Dr. Ranil Jayawardena (Clinical Nutritionist, Nawaloka Hospital) and Dr. Malik Fernando, (Past President, SLMA).
Dr. Nalin Kitulwatte, a Consultant Paediatric Intensivist from LRH, spoke on “Challenges in treating paediatric dengue patients”. He emphasised on the many challenges in treating paediatric dengue patients including proper diagnosis, fluid management, decision taking and facing criticism by others. He also stressed that even though NS1 antigen is widely used for the diagnosis, the detection rate is 50% - 70% in secondary dengue. Furthermore, he emphasised that the fluid management of DHF should be to maintain haemodynamics of the patient with minimum amount of fluids and if the patient is not improving to also think about ABCS (Acidosis, Bleeding, Calcium and other electrolytes, and Sugar - RBS). Dr. Ranthilaka Ranawaka addressed the gathering with case presentations and photographic images which highlighted the challenges in
The second session began with the lecture on “Health promotion hospital and effective communication” delivered by Dr. Neelamani S Rajapaksa Hewageegana. She indicated that health promotion is the process of enabling people to increase control over the major determinants of health and that if we promote our hospitals as health promotion institutes, we will see behaviour changes in the staff, patients and the community at large. She also voiced that one key component in this endeavour is “effective communication” which is to understand the communication process and to overcome its barriers together with effective communication skills being imperative for its success. It was also emphasised that by following simple guidelines, you can improve your communication skills greatly, promote better understanding in your relationships, and enhance not only your quality of life but the quality of life of people around you.
Contd. on page 04
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March 2015 Contd. from page 03
Joint Regional... This lecture was followed by Dr. Ranil Jayawardena’s lecture on “Controversies in diabetic diet”. He started off by saying that diabetes has now reached epidemic proportions in Sri Lanka. Published data show that one in five adults suffer from dysglycaemia. Although published data on dietary habits and association of diabetes is limited, it is believed that dietary habits play an important role in the epidemic of diabetes among Sri Lankans. In this lecture, controversies in dietary practices in diabetes were reviewed. In Sri Lanka, several dietary misconceptions have been reported: high intake of red rice, kurakkan products, atta flour, and brown bread are considered favourable. On the other hand, bread and food products from wheat flour are considered as harmful. Fruit and vegetable contains several nutrients, which may be responsible for health benefits in patients with diabetes. The effect is beyond the cumulative effects of individual nutrients such as dietary fibre, vitamins and antioxidants. Fruit and vegetable intake is inversely associated with diabetes incidence. Although several herbal products are highly popular among diabetes patients, daily consumption of vegetables is very low. Meat and
fish provides high quality proteins and reduces hunger as well. However, animal proteins are considered as detrimental among many diabetes patients. The last lecture was by Dr. Malik Fernando on “Decompression sickness (DCS)”, commonly referred to as bends, which is an occupational disease of underwater divers. In Sri Lanka the population at risk are ornamental fish collectors—including those divers who collect sea cucumbers and chanks for the export trade. They dive deep and spend excessive hours underwater breathing air at increased pressure resulting in increased nitrogen absorption by the tissues. Upon returning to atmospheric pressure without adequate time given for the elimination of the body’s burden of nitrogen, this gas leaves the dissolved state as bubbles that block the blood flow, as well as in other ways, causing tissue damage. The symptoms range from mild (urticarial rashes and joint pains) to severe (neurological symptoms including paraesthesia, paresis and retention of urine) and even unconsciousness. The definitive treatment is hyperbaric oxygen therapy in a chamber—the only such chamber being available at the Sri Lanka Naval Base in Trincomalee. The Management Guide produced by the SLMA
and the Directorate of Health Services of the SL Navy (available from the SLMA office free of charge) gives details of management, references to literature and useful telephone numbers. The joint meeting concluded with the vote of thanks given by the Secretary of the Homagama Clinical Society, Dr. Dhammika Wijethunga. This meeting was sponsored by the State Pharmaceuticals Corporation and CCL Pharmaceuticals.
Q & A On Malaria in Sri Lanka: What the clinician needs to know Prepared by: Dr. K. N. Mendis, MD, DSc Independent Consultant and former WHO Malariologist, 141 Jawatta Road, Colombo 5.
Dr. Risintha Premaratne, MBBS, MSc, MD (Community Medicine), MPH (Biosecurity) Director, Anti Malaria Campaign, Ministry of Health.
Prof. A. R. Wickremasinghe, MBBS, MPH, PhD Professor of Public Health, Faculty of Medicine, University of Kelaniya.
Prof. Deepika Fernando, MBBS, MD Professor in Parasitology, (Medical Parasitology), PhD Faculty of Medicine, University of Colombo.
Q. Has malaria been eliminated from Sri Lanka?
A. Yes, there has been no malaria transmission in the country since October 2012 - for over 2 years now, and so malaria has been eliminated from Sri Lanka. Contd. on page 07
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077 395 1513 /
Rs 6,800,000/=
+94773510383
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Contd. from page 04
Malaria in Sri Lanka... However, in order to be officially certified by the World Health Organisation (WHO) as a “Malaria-Free” country there needs to be 3 consecutive years without a single reported case of locally acquired (indigenous) malaria. Sri Lanka will apply to the WHO for certification of malaria elimination, if zero transmission is maintained for another year. Certification will only be granted by the WHO after a rigorous evaluation to make certain that there is no transmission in the country, and if there is a reasonable assurance that Sri Lanka will be able to maintain a malaria-free status in the future.
Q. If there is no malaria transmission in Sri Lanka, why should I be concerned about malaria as a disease in my patients? A: For two important reasons.
1) Although there is no malaria transmission occurring in the country, there continue to be “imported” malaria cases in Sri Lanka. For example, in 2012, 2013 and 2014 there were 70, 95, and 49 malaria patients respectively, detected and treated in Sri Lanka. All of these patients had contracted the disease overseas but they developed clinical symptoms while they were in Sri Lanka and therefore had to be diagnosed and treated by clinicians in Sri Lanka. 2) If we do not detect early and treat effectively, such “imported” malaria cases in Sri Lanka, the disease could progress to a severe and complicated form, which is associated with a high case fatality rate. Besides, the untreated patient could spread the infection to others and this could lead to malaria becoming endemic again in Sri Lanka.
Q. Can indigenous malaria return to Sri Lanka? A. Yes, indeed.
The mosquito that transmits malaria is still prevalent in the country. Parasites from a malaria-infected person who is not treated could be transmit-
ted to another person by the mosquito vector, thus beginning a cycle of local transmission. If, due to a delay in diagnosis and treatment, malaria parasites spread onwards from a patient, it could lead to an outbreak of malaria in the country. This could eventually result in the disease being re-introduced to Sri Lanka and the country would thus become endemic for malaria again. Such a situation did, in fact, occur once before in the 1960’s when Sri Lanka nearly eliminated malaria from the country, but due to lack of necessary surveillance, an outbreak occurred and from there malaria spread to other parts of the country. This eventually led to the country becoming endemic for malaria again and remaining so for several decades, during which period Sri Lanka incurred enormous losses to healthcare and the economy. The scale of the disease was such that there were: • 80,000 reported malaria deaths during the 1934/35 epidemic • Over 1.5 million reported cases of malaria over three years (1967-70) after malaria resurged following the success in 1963 • Over 400,000 cases of malaria in the country as recently as 1991 Being malaria-free is an enormous achievement for health and human development in Sri Lanka, and the role of the clinician is extremely important if Sri Lanka is to maintain being free of malaria.
Q. What is the critical role of the clinician in keeping Sri Lanka malaria-free? A. The clinicians’ role is two-fold
071-2841767 (24 hr on-call). This is because the AMC has to take several immediate steps when a case is detected including to: a) ensure, by working with the clinician, that the patient is treated effectively (the latest medicines are available with the AMC); b) ensure that the patient’s infection has not, and does not spread to others through a rigorous surveillance and response operation; and c) document in detail every malaria case, which is a necessity to maintain the “malaria-free” status of the country with respect to WHO.
Q. In what kind of patients should I suspect malaria?
A. Patients seeking care (in any part of the country) with any of the following presentations, • a history of fever • a history of travel overseas during the past 1 year • a history of undiagnosed chronic low grade symptoms such as tiredness, backache, headache, myalgia, loss of weight, with or without low-grade fever and anaemia • severe illness with cerebral symptoms or multiple organ dysfunction Particularly if the patient is from one of the categories below: • Sri Lankan businessmen/traders who travel frequently to India and other neighbouring countries • Sri Lankan military personnel returning from service in peace-keeping missions abroad • Sri Lankan fishermen who return after several weeks of fishing in the waters around Africa • Sri Lankan pilgrims returning from India and Myanmar • Sri Lankans returning from leisure trips abroad – mainly from Africa and East and South Asia • Western tourists who have arrived here traveling through other countries in Asia or Africa
1) Diagnose a malaria patient without delay, and treat the patient effectively – if not treated early and effectively, malaria could have two devastating consequences – death of the patient, and/or re-introduction of malaria to Sri Lanka.
• Migrant workers/labourers who are from neighbouring countries who are working here on industrial and development projects – dockyard, ports.
2) Report every case of malaria immediately to the Ministry of Health – Anti Malaria Campaign (AMC) – telephone numbers: 011-7626626;
• Refugees including those from Pakistan, Afghanistan and Myanmar who are housed here under the care of agencies such as UNHCR
• Immigrants from neighbouring countries – basically any foreign national, noting that some may be illegal immigrants and may not provide accurate information about their origin or resident status in this country
Contd. on page 08
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Malaria in Sri Lanka... Q. How can I diagnose malaria in a patient? • Seek a laboratory diagnosis of malaria – either by the microscopic examination of a blood film or A rapid diagnostic test (RDT) for malaria Both tests are widely available in any government or private hospital or laboratory • A single negative test may not be sufficient to rule out malaria.
deficiency prior to administration of a 14-day primaquine course as recommended, the patient should be closely monitored and advised to watch out for symptoms of haemolysis. If symptoms of haemolysis are detected, the patient should be advised to discontinue the drug immediately and to report to a health facility. There is a dangerous type of multi-drug resistant falciparum malaria in East Asian countries, which does not respond to standard medicines. Therefore, the therapeutic response to the antimalarial drug regimen prescribed needs to be monitored in every patient, and it is best to contact the AMC for advice before antimalaria treatment is administered to any patient.
Q. From where could I seek help on laboratory diagnosis of malaria, and obtain antimalarial medicines to treat a patient? Q. What advice should I provide to Advice and assistance can be ob- persons who are traveling abroad tained from: about prophylactic treatment, 1) the Anti Malaria Campaign, Nara- personal protection from malaria, henpita, Colombo 5, which has access and what to do if they get fever on to highly sensitive tests to diagnose their return? malaria, even at low parasitaemias. The AMC will also provide antimalarial medicines for treatment.
A. When individuals or families seek your advice on health prior to traveling abroad,
The AMC can be contacted on a hotline at 011-7626626, 071-2841767 24 hours of the day.
• Inform them of the risks of malaria in the country they are traveling to, and
2) The Regional Malaria Officer (RMO) of the district whose office is under the Regional Directorate of Health Services.
Q. What is the state-of–the art treatment for malaria?
A. Treatment must be in accordance with the National Treatment Guidelines for Malaria, and depends on the species of the malaria parasite. The Anti Malaria Campaign will provide guidance on diagnosis and treatment and the necessary medicines to a medical practitioner in the public or private sector in any part of the country. • Plasmodium falciparum malaria must be treated with an artemisinin-based combination therapy (ACT) for three days, plus a single dose of primaquine • Plasmodium vivax malaria must be treated with chloroquine for 3 days plus, primaquine for 14 days to prevent relapses. As we do not test all patients for G6PD
• Advice them on taking preventive measures against contracting malaria - a) chemoprophylaxis to prevent malaria and b) use of personal protection against mosquito bites (http://www.who.int/ith/ITH_chapter_7. pdf?ua=1). • Refer them to the AMC for further advice and to obtain malaria preventive medicines free-of-charge. • Advice them on seeking medical care if they develop fever on their return and inform the clinician of their overseas travel in the recent past.
Q. What are the main challenges of keeping Sri Lanka malaria-free?
A. Since there are so few malaria patients seen in Sri Lanka, it has become a “forgotten disease” among clinicians who often fail to include malaria in the differential diagnosis of fever. Consequently, during the past 3 years, most “imported” malaria patients have been diagnosed very late and some progressed to a life-threatening form of severe and complicated malaria due to a delay in diagnosis.
It is extremely important that a malaria diagnosis is not missed because, if detected in the early stages, malaria is easily treatable. If, however, treatment is delayed malaria could progress to a severe form, which may be fatal.
Q. What were the main reasons why there was a delay in diagnosing malaria in the past 3 years?
A. The most frequent lapses in clinical practice and, failures to diagnose malaria have been due to the: 1. Clinician being unaware of the risk of malaria 2. Failure to take a history of travel in fever patients 3. Continuing to investigate fever patients for dengue and other viral infections and failing to request a simple, inexpensive and easily accessible malaria diagnostic test 4. The disease being misdiagnosed as dengue or another viral infection because haematological findings accompanying malaria such as thrombocytopaenia, and leucopenia are also features of viral infections
Q. What is the global malaria situation that I should know of?
Malaria is prevalent in most tropical and sub-tropical countries in the world in all continents. It is highly endemic in Africa, Asia, and in some South American countries. In East Asia – in the Mekong countries, is prevalent a type of multi-drug resistant falciparum malaria which does not respond to standard medicines. Our neighbouring countries in South Asia – India, Bangladesh, Bhutan, Pakistan, Nepal, Myanmar, and Indonesia are also endemic for malaria.
In the past few years too many malaria diagnoses have been missed by clinicians, leading to life-threatening illness and risking the re-introduction of malaria to Sri Lanka. The clinicians’ role is extremely important in sustaining a malaria-free Sri Lanka.
ANTI MALARIA CAMPAIGN HOTLINE 071-284-1767 8
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THE DOCTOR AS A LEADER Prof. Samudra T. Kathriarachchi President Sri Lanka College of Psychiatrists
D
octors have long held a unique position in the world and Sri Lankan society is not an exemption. In addition to clinical responsibilities, doctors are expected to serve as experts and opinion leaders whose voice is heard by many. At organizational, community, and societal levels they are respected and are expected to function as members and leaders of different bodies. These roles in addition to their traditional role as clinicians, draws on much energy when one has to prioritize his/her work to meet with competing demands. In society at large and in the context of the organization one works for, the expectations are varied, ranging from looking up to leadership in managing day to day affairs of the ward to developing national policies. Doctors also have a legal duty broader than any other health care professional and therefore have an inherent leadership role embedded in their work. In this context, it may be difficult for a young doctor to balance different roles in life, especially when these issues are not addressed and even thought of, before commencing ‘real work’. The question we have to answer today is ‘Are the medical professionals in the 21st century in Sri Lanka equipped with enough resources to deal with these challenges? Are the young doctors ready to face ‘real life challenges’ in the work context?’ It is observed that an increasing number of young doctors who are of high intelligence, good motivation and possessing good qualities fail in real work situations, simply because they are not prepared to face work stress, team dynamics and other unseen challenges. Considerable numbers suffer in silence, while those who are spotted, receive help to overcome challenges.
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There is no formal setup to look in to grievances of post graduate trainees although this issue is somewhat better addressed in undergraduate training in many medical schools. Doctors are traditionally observed to behave in a manner advising people rather than inspiring them, behave reactively and tactically rather than strategically and strictly adhering to hierarchies than collaborating with stake holders. Often these observations are the only sources of leadership training that budding doctors receive during their training. However lately leadership has been identified as an integral part of a doctor’s role by medical regulatory bodies in various countries such as UK, Australia and Canada and therefore teaching of leadership skills is an essential component of medical curricula of those countries. In Sri Lanka, some medical schools have given considerable emphasis to personal and professional development of students though not necessarily well received by the students as it is not perceived as an essential component of the medical curriculum. The increasing complexities of the health care landscape and related societal changes in Sri Lanka should serve as a wake-up call to medical educators and postgraduate trainers to educate the next generation of doctors and specialists in leadership skills. Doctors essentially work in teams. While their effectiveness is largely determined by the efficiency of their teams, job satisfaction is dependent on harmony within the team. Working in a team and managing team dynamics is as important as guiding them. Developing personal qualities to work effectively with others and learning to work within teams are vital leadership skills for a doctor. Working within a team invariably involves conflict resolution, as team members being independent individuals will have differences of opinion. If the team leader is able to ensure that due respect is
given to each opinion even if the personal opinion of the leader may differ, the team will learn to respect each other, including the most junior colleague. Conflict resolution skills to arrive at a win-win situation need to be taught at undergraduate level and more importantly incorporated into postgraduate training with as equal importance as clinical knowledge. Working in multi-disciplinary teams should receive considerable attention as many find this move as challenging to traditional hierarchical setting. Unpreparedness to face challenges associated with team dynamics may lead to frustration of team members, ultimately leading to poor quality of work. The doctor as a team leader should be able to think beyond limitations and obstacles to overcome not only clinical issues but also administrative and social issues of patients and team members. He / she should be a visionary with innovative ideas and plans and this creativity should be nurtured from undergraduate days. Doctors have a responsibility to take the initiative to advance the services provided and actively engage in policy planning rather than waiting for and blaming bureaucrats and politicians. The future of the medical profession in Sri Lanka will be the product of leadership qualities of today’s doctors.
“
Doctors essentially work in teams. While their effectiveness is largely determined by the efficiency of their teams, job satisfaction is dependent
on
harmony
within the team. Working in a team and managing team dynamics is as important as guiding them.
”
March 2015
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March 2015
CARCINOMA OF THE CERVIX – A SRI LANKAN PERSPECTIVE Dr. Bimalka Seneviratne Consultant Pathologist & Senior Lecturer, Department of Pathology, Faculty of Medical Sciences, University of Sri Jayewardenepura On behalf of the SLMA Expert Committee on Women's Health
C
arcinoma of the cervix is the most common female genital tract malignancy in Sri Lanka. In terms of incidence cervical carcinoma shows a wide geographic variation, which is partially explained by differences in the healthcare systems, intensity of screening programmes and exposure to major risk factors. Pre-invasive carcinoma of the cervix In cervical pre-cancer, epithelial abnormalities form a continuous spectrum of dysplastic changes. In the 1970s and 1980s several “terms” were suggested to describe the dysplastic changes of cervical pre-cancer. The most widely accepted term was cervical intraepithelial neoplasia (CIN). CIN includes squamous lesions (squamous intraepithelial neoplasia) and glandular lesions (cervical glandular intraepithelial neoplasia / CGIN). CIN (squamous) is divided into 3 categories CIN 1- mild dysplasia
Fig 1: Keratinizing squamous cell carcinoma of the cervix
junction in early reproductive life - age at first intercourse - long term use of OCP - non use of barrier protection • Smoking • Immunosuppression
Large loop excision (LLETZ) Conization Cryocautery Electrocautery Laser cautery
Evolution of CIN
Invasive carcinoma of the cervix
Majority of CIN 1 lesions regress. Progression to invasive cancer occurs in 1% of CIN 1, 5% of CIN 2 and >12% of CIN 3 lesions. Progression to invasive malignancy typically takes 15 (3-40) years. Invasive carcinoma can develop without progressing through the pre-invasive stage.
Squamous cell carcinoma of the cervix is the most common primary invasive malignant tumour of the cervix (80-90%). Gross features depend on the pattern of growth which may be exophytic or endophytic.
CIN 2- moderate dysplasia
Management
CIN 3 – severe dysplasia & carci noma in situ
• CIN 1 (Low SIL) - Follow- up
CGIN is divided into 2 categories Low-grade CGIN & high-grade CGIN
of the following methods
(70% of CIN 1 lesions will regress in 1 year, 90% in 2 years) • CIN 2 & CIN 3 (High SIL) - will be treated by one
Histological types of squamous cell carcinoma 1. Large cell non-keratinizing 2. Keratinizing squamous cell carcinoma 3. Small cell, non-keratinizing carcinoma Histological grade (modified Broder system)
Pre-invasive (pre-cancer) stage which is asymptomatic is detected by screening methods (pap smear).
Risk factors of cervical carcinoma • Persistent infection of high risk HPV (HPV 16,18,31,33,35…) • Multiple sexual partners • Vulnerability of the squamocolumnar
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Contd. on page 16
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March 2015 Contd. from page 14
Carcinoma... •
Fig 2: Invasive adenocarcinoma of the cervix
The mean age of patients is about 55 years. • Risk factors – HPV 18 is the most common form associated with adenocarcinoma.
of poorly-differentiated cells) Prognostic factors Stage of the disease (FIGO/ International Federation of Gynaecology & Obstetrics) is the single most important determinant of the outcome. FIGO stage and 5 year survival 1. Well-differentiated – Grade I (mature squamous cells with abundant keratin pearl formation) 2. Moderately-differentiated – Grade II (greater pleo morphism of cells, more mitoses) 3. Poorly-differentiated – Grade III (nests & masses
Adenocarcinoma of the cervix • Invasive carcinoma of glandular origin
• Prognosis is slightly worse than for squamous cell carcinoma. • Histological types – Mucinous, intestinal, endometrioid types……….. Management of invasive cervical carcinoma The standard treatment is radical hysterectomy with the removal of pelvic nodes. Surgery will be combined with radiotherapy and / or chemotherapy, based on the stage of the disease.
• Accounts for about 10 -20% of all cervical carcinomas.
Guidelines for Physical Exercise and Prevention of Musculoskeletal Injuries during Sport and Exercise Dr. Aranjan Lionel Karunanayake MBBS, DM, DOH&S, Dip.Tox, Dipin.Coun, D.Sp.Med, DSEM, FSS Senior Lecturer, Department of Anatomy, Faculty of Medicine, University of Kelaniya & Member National Olympic Medical Committee
P
hysical exercise implies intentional physical activity for improving health and fitness (1). Being physically active can prevent numerous chronic diseases including coronary heart disease, obesity, hypertension and improve muscle
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strength, endurance and mental health . It has been shown that people, who are inactive, can lower the risk of early death, depression, coronary heart disease, stroke, type 2 diabetes, obesity and high blood pressure by increasing their physical activity level (3) . Middle-aged and older people who take part in regular physical activity programmes are more positive about their appearance, physical functioning and physical health (4). Various modalities of vigorous training, including aerobic training, resistant training, and sprint interval training done five times (2)
per week have helped in the control of diabetes and obesity (5). Physical inactivity has been identified as a serious global public health problem which is associated with numerous preventable diseases and has been classified as the fourth leading risk factor for global mortality (6). The World Health Organization estimates that globally the prevalence of physical inactivity among adults is 17%, ranging from 11% to 24% across different regions of the world (6). Contd. on page 18
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Guidelines for... The following factors need to be avoided during physical exercises to prevent the development of musculo skeletal injuries and to reap the necessary benefits. Sudden increases in the training load with regard to the intensity, frequency and duration, using incorrect technique, incorrect surface, incorrect equipment, not adequately rehabilitating previous injuries, exercising in extremes of weather, muscle imbalances, nutritional errors and fluid intake errors (7). Physical training programmes tend to target improving the aerobic power, body composition strength, flexibility, proprioception, pliometrics and sport specific skills. Aerobic training - It is done to improve the aerobic power and the body composition. Aerobic power is the maximum capacity to transport and utilize oxygen (8). Aerobic training generally involves large muscle groups. Swimming, running and cycling are some examples for aerobic exercises. This type of training provides several benefits such as enhanced oxygen exchange in lungs, increased cardiac output, increased arteriovenous oxygen difference, improved blood flow to skeletal muscles, increased concentration of capillaries, mitochondria, myoglobin and oxidative enzymes of skeletal muscles (9). To get such benefits these exercises need to be done for 3-5 days per week at an intensity of 60% - 90% of maximum heart rate for 20 – 60 minutes (8). There are many types of endurance training programmes. Some of them are interval training and Fartlek training.
comfortable speed is combined with short sprints. It trains the body for more intense training and reduces the boredom associated with training (9). Anaerobic training - This type of training enhances the anaerobic enzyme activity, increases the glycogen and phosphogen energy stores, improves speed, strength and power. Relies on ATP –PC system and the glycolytic system. Activities like strength training and sprint work outs are good examples (9). Strength training refers to exercises that are designed to increase the maximum force a muscle or muscle group can generate voluntarily (10). Following are basic recommendations for strength training. A safe training environment and qualified instructors are important. Warm up activities need to be done prior to strength training. A training frequency of at least 2-3 times per week needs to be done. Performing multi joint exercises using multiple sets (ex 10-15 repetitions into three sets) and strengthening of core muscles (Fig.1) are important (9).
Fig 1. Core strengthening exercises. Available from: http://www.mightyfighter.com/top-8-simple-corestrengthening-exercises/ [Accessed 25 February 2015]
Types of strength training exercises – Isometric - there is generation of muscular force with minimal change in the joint movement (10) (Fig. 2).
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Fig 3. Isotonic exercises. – Available from: http:// manbir-online.com/cardiac/exercise_6.htm [Accessed 25 February 2015]
Isokinetic - there is generation of muscular force with visible joint movement at a constant speed with a variable external resistance. A variable external resistance is applied by a machine (10) (Fig.4).
Fig 4. Isokinetic exercises. Available from: http://www. biodex.com/physical-medicine/products/dynamometers/system-4-pro [Accessed 25 February 2015]
Open chain Exercises - Force applied by the body is greater than the resistance that needs to be overcome. Ex – bench press, leg press (10) (Fig.5). Fig 5. Open chain exercises. Available from: http:// www.cpsc.gov/en/Recalls/2013/Cybex-InternationalRecalls-Leg-Press-Due-to-Risk-of-Injury/ [Accessed 25 February 2015]
Interval training - involves intense workout bouts for 30 seconds to 5 minutes followed by a rest interval. Work to rest interval is about 1:1. Fartlek training - the training is done at different intensities. Running at a
Isotonic - there is generation of muscular force with visible joint movement at a variable speed using a constant external resistance (10) (Fig. 3).
Fig 2. Isometric exercises. Available from: http:// www.healthcentral.com/diet-exercise/000395.html Accessed 25 February 2015]
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Guidelines for... Closed chain exercises - force applied by the body is not greater than the resistance that needs to be overcome. Ex – pull ups and pushups (10) (Fig.6).
Fig 6. Closed chain exercises. Available from: http:// breakingmuscle.com/strength-conditioning/pull-upvs-chin-up-a-comparison-and-analysis [Accessed 25 February 2015]
Lifting weights, pushups and pullups are some common types of strength training exercises (10). The following training protocols are used in strength training. Circuit training - ten types of exercises performed for 10-15 repetitions with loads approximately 40% to 60% 1 RM (1 repetitive maximum) with 1530 second rest period in between the different type of exercises (9). Pyramid training - exercise progress from light to heavier load while decreasing the number of repetitions (9).
fore and after the practice session. Various types of stretches are done to improve flexibility (9). Dynamic stretching - This is done as part of a warm up programme. The movements must be appropriate to what is experienced in sport. The joint is moved through controlled repetitive movement and with Fig 7. Dynamic stretcheach repetition ing exercises. Available from: http://www.bloomthe joint range of tofit.com/5-killer-dynammovement is in- ic-stretching-exercises 25 February creased. Prepares [Accessed 2015] the joint for full range of movement and muscles for optimal activation (9) (Fig. 7). Static stretching - This form of stretching is used as a part of a cool down programme. The joint is stretched to a minimally challenging position and held in that position for 20 - 30 seconds. Need to breathe comfortably while stretching (9) (Fig. 8).
Super set training – this method involves several sets of two exercises for agonist and antagonist muscles with minimal rest between sets (9).
after 30 seconds with the help of the trainer (7) (Fig. 9). Proprioceptive training - This type of training trains the muscles and joints to judge the position. Proprioception is compromised in soft tissue injuries and lack of proprioception can lead to injuries. In proprioception training the stress to the joint is applied very mildly and then increased gradually. Single leg stance, uniaxial balance boards and multi axial balance boards are used in proprioceptive training (7) (Fig. 10).
Fig 10. Proprioceptive exercises. Available from: https://www.healthtap.com/topics/proprioception-ankle-exercises [Accessed 25 February 2015]
Plyometrics - This form of training trains the muscles to produce a strong and lengthened contraction as quickly as possible (9) (Fig. 11).
Flexibility training – Flexibility refers to the ability to move a joint of the body through the range of movement for which it is intended for (11). Ideal flexibility is the range of movement at a joint that will allow a maximal performance of a defined activity while protecting the joint from acute and chronic injury (11). Flexibility training reduces muscle tension, body stiffness and improves performance. Following guidelines need to be followed to gain the benefits and prevent injuries during flexibility training. Warming up (ex brisk walking or slow jogging) for 5 – 10 minutes before stretching. Generally needs to perform 8-12 stretches be-
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Fig 8. Static stretching exercises. – Available from: http://www.projectswole.com/flexibility/what-is-staticstretching/ [Accessed 25 February 2015]
Facilitated stretching - This type of stretching is done with the help of a trainer. Stretch the muscle and then contract isometrically against resistance. Thereafter stretch it again to a new range of motion Fig 9. Facilitated stretching exercises. Available from: http://www.stretching-exercises-guide.com/passivestretches.html [Accessed 25 February 2015]
Fig 11. Pliometric exercises. Available from: http:// injuryfix.com/archives/plyometrics.php [Accessed 25 February 2015]
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Guidelines for... Sports specific skills - Sports specific movements have to be trained at the proper speed and strength prior to taking part in sports (7) (Fig. 12).
disturbances, chronic fatigue, psychological staleness, flu like symptoms and decreased performance (9). To improve a person’s physical performance a physical training programme must take into consideration the specific goals, needs, medical concerns, motivation and stress tolerance of a person. References 1. Kirk-Sanchez NJ, L McGough E. .Physical exercise and cognitive performance in the elderly: current perspectives. Clin Interv Aging 2014; 9: 51–62.
Fig 12. Sports specific exercises. Available from: http://www.myoquip.com.au/ScrumTrukExercises.htm [Accessed 25 February 2015]
Over training - This can occur due to inappropriate rate of training progression, prolonged monotonous training, inadequate periods of rest and failure to taper training before the competition. Effects of over training can last for few days to six months. Features of over training include increased or decreased resting heart rate, decreased body mass, loss of appetite, muscle tenderness, sleep
2.Sutherland R,Campbell E, Lubans DR,Morgan PJ, D Okely A,Nathan N, Wolfenden L, Jones J, Davies L, Gillham K, and Wiggers J. A cluster randomised trial of a school-based intervention to prevent decline in adolescent physical activity levels: study protocol for the ‘Physical Activity 4 Everyone’ trial. BMC Public Health 2013;13: 57. 3.Lowry R, ,Lee SM,Fulton JE,Demissie Z,Kann L. Obesity and Other Correlates of Physical Activity and Sedentary Behaviors among US High School Students. J Obesity volume 2013; article ID 276318: 1-10. 4. Taylor AH, Fox KR. Effectiveness of a Primary Care Exercise Referral Intervention for Changing Physi-
cal Self-Perceptions Over 9 Months. Health Psychology2005;24: 11–21. 5. Roberts KC, Hevener AL, Barnard RJ.. Metabolic Syndrome and Insulin Resistance: Underlying Causes and Modification by Exercise Training. Compr Physiol 2013; 3: 1–58. 6. Frantz JM, Ngambare R.Physical activity and health promotion strategies among physiotherapists in Rwanda. Afr Health Sci;2013;13: 17–23. 7. Brukner P, Khan K, Bahr WR. Principles of injury prevention. Clinical sports Medicine. 3rd edn. New South Wales. McGraw-Hill Professional; 2007: 78 -101. 8. Latin RW. Building Aerobic power In: Mellion MB ed. Sports medicine Secrets. New Delhi, Jaypee Brothers Medical Publishers (P) LTD. 2nd edition 2002: 57 -60. 9. Bachl N, faigenbaum A D. Principles of exercise Physiology. In Micheli LJ, Smith AD, Bachl N, Rolf CG, Chan K. eds. F.I.M.S. Team Physician Manual. Hong Kong, Lippincott Williams & Wilkins Asia Ltd. 2007; 49 -77 10. Thigpen LK. Building Strength. In: Mellion MB ed. Sports medicine Secrets. New Delhi, Jaypee Brothers Medical Publishers (P) LTD 2nd edition 2002: 61 -66. 11. Blanke D. Flexibility. In: Mellion MB ed. Sports medicine Secrets. New Delhi, Jaypee Brothers Medical Publishers (P) LTD. 2nd edition 2002: 70- 76.
AVOIDANT / RESTRICTIVE FOOD INTAKE DISORDER SLCPsych Presentation at the SLMA monthly clinical meeting January 2015 Case: Eating disorder in a 14 year old girl Ms. N was a 14 year old schoolgirl who was studying in grade 9. She was the younger of two siblings. She presented to the child and adolescent services with a headache and severe weight loss of nine months duration. There were no associated neurological signs or symptoms nor a history of fever or loss of appetite. Multiple medical investigations including a MRI of the brain were done with negative results. All possible medical diagnoses were excluded with these investigations. The headache gradually progressed and her daily routines and education was disrupted. At
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around this time, she started to refuse food, saying food was distasteful even though her appetite was normal. No obvious family stressors were elicited. She did not harbour any depressive cognition such as helplessness, worthlessness, hopelessness or suicidal ideas. There was preserved interest in her daily activities even though she did not have the physical strength to perform them. There were no obvious body image issues nor was she found to have behaviours for reducing weight such as excessive exercising, purging or vomiting. There were no associated features such as excessive mirror gazing or other health consulting behaviours to change the per-
ceived mishaps in the body. She denied any intrusive, distressing and repugnant thoughts of food being contaminated or getting stuck in the throat or about distaste. She did not have any accompanying compulsions or any phobias about swallowing or choking and neither did she have any psychotic features. Physical examination and investigations
Her physical examination revealed a body mass index of 10.7 which was significantly low with height-164 cm and weight-28.8 kg. There were Lanugo hair on her face and back with evident carotinaemia. Contd. on page 21
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Avoidant... There were no specific signs such as Russel’s sign (defined as calluses on the knuckles or back of the hand due to repeated self-induced vomiting over long periods of time) or evidence of perimylolysis. Her muscle mass was thin, with evidence of cold intolerance and dehydration. The biochemical, radiological, hormonal and metabolic parameters were normal. Differential Diagnosis At the initial presentation with headache and severe weight loss the possible differential diagnoses would include organic causes as the main category. The considered causes would be infective conditions such as tuberculosis or infective endocarditis, inflammatory conditions such as systemic lupus erythematosus, autoimmune conditions such as diabetes mellitus or thyrotoxicosis, other neoplastic conditions such as intracranial tumours, namely craniopharyngiomas or hypothalamic tumours. The psychiatric diagnoses to be considered would be a depressive disorder, obsessive compulsive disorder, body dysmorphic disorder, eating disorders and other anxiety spectrum disorders such as specific phobias with a rare possibility of a psychotic illness. Following thorough examination and investigation, medical diagnoses were eliminated and the possibility of a psychiatric disorder was made prominent. The possibility of a depressive disorder was excluded since she did not have depressive cognitions such as helplessness, worthlessness, hopelessness or suicidal ideas. She preserved interest in her daily activities even though she did not have the physical strength to perform them. The possibility of a body image disorder was considered to be less likely since there were no preoccupations with a particular body part nor was there a body image distortion. There
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was no evidence for an obsessive compulsive disorder or a phobic anxiety disorder. According to DSM 5, a classical eating disorder such as anorexia nervosa can be diagnosed with a restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory and physical health with intense fear of gaining weight or becoming fat. In contrast to the above Ms. N denied body image distortion with desire to be thin. Behaviours such as frequent mirror checking or frequent weighing at home was absent. Her initial food refusals were mainly at times where she wanted to demand certain things from her parents. She did not attempt any weight reducing strategies such as binging, purging or exercising. At this point with a review of the past assessments, investigations and observations, a diagnosis of avoidant/ restrictive food intake disorder according to DSM 5 was made. DSM 5 criteria for diagnosis of avoidant / restrictive food intake disorder 1. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following: • Significant weight loss (or failure to achieve expected weight gain or faltering growth in children). • Significant nutritional deficiency. • Dependence on enteral feeding or oral nutritional supplements. • Marked interference with psychosocial functioning. 2. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice. 3. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced [body image].
4. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that which is routinely associated with the condition or disorder and warrants additional clinical attention. Treatment There have been many guidelines published regarding treatment of eating disorders. The following account is based on the Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders published in 2014. There are some general principles applicable in the treatment of all eating disorders. Firstly, all decisions should be person-centred and informed. Secondly, family and significant others should be involved unless there are contraindications or the individual is opposing. Thirdly, care must be based on recovery-oriented practice and treated in the least restrictive setting, ideally as an outpatient unless there are specific indications. However, at times involuntary admissions may be needed for assessment or treatment if a person has impaired decision- making capacity, and is unable or unwilling to consent to interventions required to preserve life. Furthermore, the patient should be treated with the help of a multidisciplinary team incorporating, a medical team, a psychiatric team, as well as dieticians. Moreover, the care should be transferred in a stepped and seamless manner between the various teams involved as well as in the many treatment settings (general practice, emergency departments, medical wards, mental health settings, private clinicians and specialist services, outpatient, intensive outpatient with meal support, day programme, and inpatient treatment). Finally, a dimensional and culturally informed approach to diagnosis and treatment is a must.
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Avoidant... Apart from the above mentioned general principles, prior to starting treatment a comprehensive assessment of the individual and their circumstances should be undertaken to confirm the diagnosis of the eating disorder, to evaluate any co-morbid psychiatric or medical diagnoses, to evaluate medical and psychiatric risks, and to develop a biopsychosocial formulation. Depending on the assessment, the treatment setting will have to be decided upon. According to the individual disorder the management differs to some extent.
Anorexia nervosa If the patient is having anorexia nervosa, hospitalization may be needed for acute medical stabilization, especially if the BMI is less than 12 or if the person is at imminent risk of serious medical complications, or if outpatient treatment is not working. Restoring weight is a main goal in the management. However, there is debate about rates of weight gain in inpatient settings with recommended rates ranging from 500–1,400g/week (1-2). This should be carefully balanced, so that a refeeding syndrome does not occur or that the patient is not underfed. Once medically stabilized, psychiatric co-morbidities such as anxiety, depression, substance misuse, suicidality, personality disorders, anxiety disorders and deliberate self harm should be assessed. However, recent systematic reviews of RCTs and meta-analyses of the pharmacological treatment of anorexia nervosa suggest weak evidence for the use of any psychotropic agents and prescribing for co-morbid conditions is best left until it is clear that such symptoms are not simply secondary to starvation (3-6). Furthermore, physical problems secondary to anorexia nervosa may place individuals at greater risk of adverse side effects but low doses of antipsychotics such as olanzapine may be helpful when patients are severely anxious and demonstrate obsessive
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eating-related ruminations (5). Providing psychoeducation, support and building a therapeutic relationship are all crucial activities at all stages of treatment. The more intense structured psychological therapies should generally be initiated only after the individual is sufficiently stabilized and cognitively improved from the acute effects of starvation. For children, family based therapy or an alternate family therapy is the treatment of choice. Cognitive behavioural therapy (CBT) and its many forms, for example CBTEnhanced (7), are frequently recommended approaches for anorexia nervosa especially for adults. Nutritional therapy should be continued after achievement of healthy weight and discharge, moreover regular monitoring is needed as rates of relapse are considerable. In patients with severe and long standing anorexia nervosa the goal of treatment is to maintain realistic hope, expectations for improvement and harm minimization.
Bulimia nervosa and binge eating disorder Though a majority are treated as outpatients, inward treatment may be needed if there is increased risk of non-response to outpatient care. First-line treatment for bulimia nervosa and binge eating disorder in adults is an individual psychological therapy and the best evidence for such therapy is for CBT (1). Unlike in anorexia nervosa, pharmacotherapy has more evidence. High dose fluoxetine has the strongest evidence base, while other SSRI antidepressants are also effective (8). Pharmacotherapy can be considered as an adjunctive treatment, since an additive benefit has been shown for combined psychological and pharmacological therapy (5).
Avoidant/restrictive food intake italicise (ARFID) To date there have been no published studies to guide appropriate treatment interventions or inform prognosis for this group.
Prognosis of eating disorders In patients with anorexia nervosa the outcome for young onset eating disorders are better than for older adolescent and adult onset eating disorders. Most people with bulimia nervosa, binge eating disorder or other specified feeding or eating disorders experience a good outcome in longterm follow-up studies, with 50% or more free of symptoms at five years or more (9). In both categories a significant proportion may cross over to other categories. There is also an increase in mortality, especially in patients with anorexia nervosa. References 1. NICE (National Institute for Clinical Excellence) (2004b) Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. In: NICE (ed). National Clinical Practice Guideline CG9. London: British Psyhcological Society and Gaskell.Available at: http://www.nice. org. uk/guidance/cg9 (accessed 7 October 2014). 2. Yager J, Devlin M, Halmi K, et al. (2006) American Psychiatric Association practice guideline for the treatment of patients with eating disorders. American Journal of Psychiatry 163(7 Suppl): 4–54. 3. Aigner M, Treasure J, Kaye W, et al. (2011) World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of eating disorders. World Journal of Biological Psychiatry 12: 400–443. 4. Flament MF, Bissada H and Spettigue W (2012) Evidence-based pharmacotherapy of eating disorders. International Journal of Neuro- Psychopharmacology 15: 189–207 5. Hay PJ and Claudino AM (2012) Clinical psychopharmacology of eating disorders: A research update. International Journal of NeuroPsychopharmacology 15: 209–222. 6. Kishi T, Kafantaris V, Sunday S, et al. (2012) Are antipsychotics effective for the treatment of anorexia nervosa? Results from a systematic review and meta-analysis. The Journal of Clinical Psychiatry 73: e757–e766. 7. Fairburn CG (2008) Cognitive Behavior Therapy and Eating Disorders. New York: Guilford Press 8. Cowen P, Harrison P, Burns T. Shorter Oxford Textbook of Psychiatry. Sixth edition. Oxford university press, 444- 463 9. Fairburn CG, Cooper Z, Doll HA, et al. (2000) The natural course of bulimia nervosa and binge eating disorder in young women. Archives of General Psychiatry 57: 659–665.
SLMANEWS 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