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Contents

THE OFFICIAL NEWSPAPER OF THE SRI LANKA MEDICAL ASSOCIATION

October 2012 Volume 05 Issue 10

President’s Note Dear SLMA members, colleagues, friends As we approach the last quarter of the year, the SLMA is busy as ever with more activities. The month of October saw two regional meetings, one in Wathupitiwela in collaboration with the Wathupitiwela Clinical Society (WCS) and the other in Anuradhapura in collaboration with the Anuradhapura Clinical Society (ACS). Both meetings were grand successes. They were attended by hundreds of young doctors from the regions, showing their enthusiasm for continuing professional development. This augurs well for the future. I wish to express my gratitude to the WCS and ACS for their untiring efforts to make these events successful. The month of November is going to be a busy month for the SLMA. The Foundation Sessions and the FERCAP International Congress makes it another month of conferencing. We hope that all of you will be able to join us at these events as well as the grand finale of the year – the Medical Dance on 8 December 2012.

Thank you. On behalf of the council of the SLMA,

Prof. Vajira H.W. Dissanayake President, Sri Lanka Medical Assosiation, No.06, Wijerama Mawatha, Colombo 07, Sri Lanka Publisher and Printer

This Source (Pvt.) Ltd.,

236/14-2, Vijaya Kumaranathunga Mawatha, Kirillapone, Colombo 05, Sri Lanka Tele: +94-112-854954 info@thissource.com

Page No. Sri Lanka Navy Invents a Low-cost Infusion Pump for Thalassemia Patients

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Towards an Efficient and Effective Workforce

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Preventing Physician Burnout

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Nirogi Lanka Project

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Early Detection of Oral Cancer

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Symposium on Osteoporosis

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Otorhinolaryngology in Sri Lanka

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Reducing Morbidity and Mortality from Road Traffic Accidents

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You and Your Doctor

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Psychiatry in Sri Lanka

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October, 2012

Sri Lanka Navy Invents a Low-cost Infusion Pump for Thalassemia Patients

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he Sri Lanka Navy launched a ‘Social Responsibility Program’ to assist the destitute and needy people in the society. As the maiden project, the Research and Development Unit of the Sri Lanka Navy, developed an affordable medical infusion pump, required for the treatment of thalassemia patients. Sri Lanka currently has about 2000 thalassemia patients and annually another 60 – 80 patients are added to the disease burden. Having observed

As a Naval Social Responsibility project, a total of 400 units were distributed free of charge to selected hospitals and among the people in need in two phases.

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The First Lady, Shiranthi Wickramasinghe Rajapaksa handing over a low-cost thalassemia drug infusion system to one of the thalassemia patients in need.

that the majority of the patients affected by the disease cannot afford a commercially available infusion pump, which is essential to the treatment process, Research and Development Unit of the Sri Lanka Navy developed the low-cost Thalassemia infusion pump costing only Rs. 4500/- compared to imported pumps costing over Rs. 50,000/-. Each unit has been carefully designed to deliver accuracy, electromechanical safety, user friendly nature, minimal or no repairs, ruggedness, compactness and power saving with extended battery life in administrating subcutaneous iron

The low cost Thalassemia infusion pump

chelation drug, Desferrioxamine. As a Naval Social Responsibility project, a total of 400 units were distributed free of charge to selected hospitals and among the people in need in two phases. The users who have received

the machines in the first phase have given positive feedback about the product. Moreover the thalassemia infusion pump was recommended by the Ministry of Health as one of the best innovations in Sri Lanka medical field in the recent history.


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October, 2012

Towards an Efficient and Effective Workforce The NCD committee, NIROGI Lanka project of the SLMA and the NCD Unit of the Ministry of Health organized a symposium ‘Towards an efficient and effective workforce’ on 5th July 2012 from 8.45 am to 3.45 pm at the BMICH during the 125th Anniversary International Medical Congress.

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he NCD committee and NIROGI Lanka project of the SLMA and the NCD Unit of the Ministry of Health organized a symposium titled ‘Towards an efficient and effective workforce’ on 5 July 2012 from 8.45 am to 3.45 pm at the BMICH during the 125th Anniversary International Medical Congress. The symposium was well-attended by more than 200 doctors and nursing officers from all regions of the country. Each district other than Jaffna, Killinochchi, Trincomalee and Mullaitivu was represented by the Regional Director of Health Services, 1 hospital administrator, 1 Medical Officer of Health, 2 Medical Officers attached to the newly established lifestyle clinics in hospitals, 1 Medical Officer/NCD and 1 Nurse administrator. In addition, 20 General Practitioners representing the Ceylon College of

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General Practitioners were invited. All were present by the invitation of the Secretary/ Ministry of Health and sponsored by the NIROGI Lanka project. Each participant was provided with a package containing publications of the NIROGI Lanka project including books, booklets, posters and leaflets on prevention of diabetes and CVD. The morning session named ‘Ground Reality - Who is Responsible?’ was chaired by DDG MS-I Dr Ananda Gunasekera and NCD unit Director Dr Thalatha Liyanage. The symposium commenced with a lecture on ‘Rationale for prevention and control of NCDs’ delivered by University of Colombo Faculty of Medicine, Senior Lecturer and Consultant Diabetologist and Endocrinologist Dr Prasad Katulanda, that focused on the current situation and extent of the problem of NCD in Sri Lanka. It was followed

by a lecture on ‘Role of health services in NCD prevention’ by Ministry of Health, NCD Unit, Consultant Community Physician Dr Virginie Mallawarachchi with special emphasis on the NCD policy and on-going programmes, including the newly established lifestyle hospital clinics and another lecture on ‘Total risk approach in NCD at primary health care level’ by NHSL, Consultant Neurologist Dr Padma Gunaratne focusing on the practical aspects of multiple risk factor approach utilized in the management of NCD at primary health care level. Lecture on “Dream team approach - local evidence

Some Participants

Some Participants

from NIROGI Lanka” was delivered by NIROGI Lanka project Chairperson Prof. Chandrika Wijeyaratne that highlighted the NIROGI Lanka project as a model to be adopted in empowering communities, for developing primary-tertiary partnerships in the management of diabetes and training of Diabetes Educator Nursing Officers (DENO). Contd. on page 30

SLMA Non Communicable Diseases Committee Chairperson Prof. Chandrika Wijeyarathne addressing the symposium.


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Preventing Physician Burnout Dr. Vajira Lakamwasam

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he chief guest, Dr. Nanda Amarasekara and Dr. Esther Amarasekera, Dr. Channa Yahatugoda, orator of GMA 2012 oration, past presidents, council members, DeanFaculty of Medicine, Karapitiya, Directors of both Karapitiya and Mahamodera hospitals, academics of the Faculty of Medicine, Karapitiya, invited guests, ladies and gentlemen. On behalf of the council of the GMA, I welcome you to the 71st Annual academic sessions of our association. Special welcome to Dr Nanda Amarasekara, the chief guest of this evening. Apart from the long years of clinical experience, Dr Nanda Amarasekara has a vast experience in both

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undergraduate and postgraduate training in this country. Still an active member in many organizations including the Ceylon College of Physicians, senate nominee of many university councils, he contributes to the medical fraternity in this country in many different ways. Among medical associations GMA has a long history. Considering the period of service, GMA is only second to the SLMA and GMA has been the major organizer of CME activities in the Southern province for 71 years. Although most of you are aware, those who are new to Galle would like to hear that GMA was started as the Galle Clinical Society and was transformed to GMA in 1993 to get both clinicians and academics attached to the medical faculty under its fold.

Current membership of GMA is about 500 and we conduct regular academic activities, join hands with other professional organizations in CME activities and publish the Galle Medical Journal biannually. The number of specialties and hence the number of doctors in Karapitiya hospital has increased sharply during the last few years. According to hospital sources, currently we have 77 specialists and 391 grade medical officers in the hospital. The corresponding figures were 48 and 326, in 2010. The increasing number of doctors places a considerable demand on the services provided by the GMA. Doctors, however, are the primary focus of GMA and cornerstone of its survival. Contd. on page 08

Quality of patient care is the major concern of any health care system. Health care systems are committed to provide the safest and highest quality care to patients. The major components in quality of care include superior care and outcome, outstanding patient safety, care delivered in timely manner and fair and unbiased access to health care.


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October, 2012 Contd.from page 06

Preventing Physician... Although we have a limited involvement with medical undergraduates, we are firmly connected with the postgraduate training in Galle. We take maximum efforts to stock our library with the latest versions of textbooks. In undergraduate and postgraduate training, apart from the factual knowledge, we insist on professional skills of doctors. In addition to their ability to reason out, analyze situations, we assess their ability to perform tasks such as lumbar puncture and liver biopsy. However, less attention is paid to the working environment of doctors in the current setup. It is essential that a doctor should be in his optimal physical and mental wellbeing to make rational decisions and to display various professional skills. Therefore it is worth briefly looking at the factors that influence the physical and mental integrity of a doctor. Quality of patient care is the major concern of any health care system. Health care systems are committed to provide the safest and highest quality care to patients. The major components in quality of care include superior care and outcome, outstanding patient safety, care delivered in timely manner and fair and unbiased access to health care. Causes of failure to deliver quality patient care are multifaceted. Although doctors work hard and stay

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President GMA Dr Vajira Lekamwasam making her Presidential Address

committed, we have no control over other elements that determine quality of care. These include medical complexities and system failures, which are not uncommon to us. Furthermore, we have other problems locally such as limited infrastructure facilities, limited man power and financial constraints. We try to sustain our services in the background of these uncertainties. Although our aim is to do well in all four domains, research and surveys show a different story. Even though one can achieve superior care with unlimited resources such as in the USA, the achieving of targets in other components of quality of care is doubtful. For an instance, unlimited resources can provide a superior care and achieve better patient outcomes but whether you can eliminate accidental

injuries to patients is questionable or whether you can guarantee timely care is also doubtful. Millennia ago, Hippocrates recognized the potential danger of accidental injuries to patients and drafted the Hippocrates orth. It says “prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone”. Since then the directive “first do no harm” has become the main focus of modern medicine. The concept of Patient Safety has a history. In the USA, in 1982, TV program by the ABC television entitled “Deep Sleep” revealed that every year 6000 Americans die or suffer brain damage due to anesthetic mishaps. In 1983, the British Royal Society of Medicine and

the Harvard Medical School jointly organized a symposium on anesthesia related deaths and injuries. In 1984, the American Society of Anesthesiologists established the Patient Safety Foundation where the term “patient safety” was first introduced. The Department of Health Expert Group in 2000 estimated that 850,000 incidents harm NHS patients each year. In 2004, Canadians found adverse events in 7 per cent of admissions. Prof Bill Runciman one of the original Australian study author and the President of the Australian Patient Safety Foundation reported himself a victim of a medical dosing error. Now let us briefly look at the causes of adverse incidents or health care errors. Contd. on page 10


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October, 2012 Contd.from page 08

Preventing Physician... These errors can be attributed to 1. human errors: variations in training, experience, fatigue, depression and burnout 2. medical complexities: complicated technologies and powerful drugs 3. system failures: poor communication, lack of resources, drug names (look-alike and soundalike), cost cutting efforts This evening I have chosen one aspect of human errors that is not very well addressed in our set up. It is a condition that can harm the doctor as well as the patient. Let’s look at this example reported from the USA. A middle aged restaurant worker had awakened one morning with a tight pain in his shoulder and travelled down his right arm. “My fingers were so weak” he recalled. “I could not get a good grip around a glass of water”. A senior doctor at the local clinic diagnosed a cervical spondylosis and gave him pain killers and muscle relaxants. Two weeks later, only more incapacitated, the patient went to another clinic where another doctor made the right diagnosis of Pancoast tumor. “The first doctor couldn’t be bothered by what I was trying to say” the patient said. “He acted like he just didn’t want to be there with me or with any patient”. Mistakes of this

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nature are not confined only to the USA or for that matter for doctors. Although, both conditions, i.e. Cervical spondylosis and Pancoast tumor were clear possibilities of the given clinical scenario, the first doctor was too tired or mentally exhausted to consider both and considered only the easy option. A study from the USA involving 7288 physicians showed that 46 per cent of them had at least one symptom of burnout. Prof Shanafelt who conducted this study on behalf of the Mayo clinic stated that “the rates are higher than expected” and “we expected may be one out of three”. Symptoms of burnout include emotional fatigue, depersonalization, lost enthusiasm, and a failed sense of personal accomplishments. On long term burnout can lead to decline in quality of care, increased risk of errors, early retirement, disruption of social and family life and suicide. Burnt out doctor has a tendency to treat people as objects. One of the most useful models to understand physician burnout is a bank account. In this bank there is a store of your energy and that energy comes in three forms. • Physical Energy – your basic physical strength

• Emotional Energy – your ability to be emotionally available and compassionate • Spiritual Energy – your connection to your purpose in your work Every single day you work, there is a withdrawal from this Physical / Emotional / Spiritual Energetic bank accounts. The amount of the withdrawal is different from person to person and day to day. You need to maintain your bank account in a positive balance. Your life outside of medicine, your health and your relationships depend on it. These bank accounts are different than the common symbol of “your batteries”. When your batteries run out, the machine stops. When it comes to physician burnout, you can operate for a very long time on a negative balance in the accounts. Physician burnout is just another name for a negative balance in these accounts. Work has drained you beyond your energetic, emotional and spiritual reserves. You have been unable, for whatever reason, to recharge your account. You are in an overdrawn and it hurts. You can feel it and your colleagues and family can see and feel it as well. In many cases you are a last person to recognize your own physician burnout. Contd. on page 12


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Contd.from page 10

Preventing Physician... Being burnt out means feeling empty, devoid of motivation and beyond caring. People experiencing burnout often do not see any hope of positive change in their situations. If excessive stress is like drowning in responsibilities, burnout is being all dried up. Symptoms of burnout have three distinct patterns. Phase 1: Physician burnout and stress vary from day to day and you never become symptomatic Phase 2(a): Symptoms are only intermittent and you are feeling fine more often than not. Phase 2(b): You notice the symptoms more often than not. You only occasionally feel at full strength. Phase 2(c): It has been a long time since you felt at full strength and yet, you are “hanging in there” and “doing the best you can”, trying to convince yourself this is how all doctors feel. Phase 3(a): Your baseline is chronic symptomatic physician burnout and you dip occasionally into the danger zone. You never recover to the “doing OK” level of energy and compassion. Phase 3(b): You are constantly in the danger zone. Burnout may be the result of unrelenting stress, but it isn’t the same as too much stress. Stress, by and large, involves too much:

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The audience at the Inauguration of the GMA 72nd Annual Scientific Sessions

too many pressures that demand too much of you physically and psychologically. Stressed people can still imagine, though, that if they can just get everything under control, they will feel better. Burnout, on the other hand, is about not enough. Being burnt out means feeling empty, devoid of motivation and beyond caring. People experiencing burnout often do not see any hope of positive change in their situations. If excessive stress is like drowning in responsibilities, burnout is being all dried up. One other difference between stress and burnout: while you are usually aware of being under a lot of stress, you do not always notice burnout when it happens. Burnout generally differs from depression. Depression is a more general form of mood impairment that affects all aspects of a person’s life both at home and workplace. Burnout, by contrast, applies mainly to the working environment. The prevalence of burnout varies accord to the specialty; emer-

gency medicine, internal medicine, neurology and family medicine reported the highest prevalence. Least prevalence was seen among dermatologists, pathologists and general pediatricians. Previous studies have shown that burnout can lead to decline in quality of care, increased risk of errors and push doctors in to early retirement. Also highlighted in the report was that physicians were more likely to complain than other specialists or US workers. (37.8 per cent among physicians vs. 27.8 per cent among other workers) The negative effects of burnout spill over into every area of life including your domestic and social life. Burnout can also cause long-term changes to your body that make you vulnerable to illnesses like colds and flu. Burnout may occur in a range of occupations but more frequently in the caring professions. Burnout is not only applicable to practicing doctors. Many analyses have shown that it is sizable problem among medical students as well.

This study done in Brazil by Costa et al. using the Maslach Burnout Inventory found that 10 per cent medical students have symptoms of burnout. Prevalence was higher among those who did not have confidence on their clinical skills, those who felt uncomfortable with course activities, and those who did not see the coursework as a source of pleasure. Burnout is not limited to doctors and medical students. Nurses too are vulnerable to this condition. Study by Raftopoulos and others in Cyprus reported a prevalence of 12.8 per cent among nurses in Cyprus. There was no difference of prevalence based on their working environment or marital status. Factors that contribute or are associated with burnout include excessive workloads, patients pressure, lack of control, interference from managers, insecurity, reorganization, poor support, front-line practice, perceived threats of complains or violence and dysfunctional workplaces. Contd. on page 14


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Contd.from page 12

Preventing Physician... A genetic predisposition and susceptible personality traits also have been recognized. BMA published the Oldenburg Burnout Inventory in its website as a guide to the doctors to screen themselves for the symptoms of burnout. This questionnaire consisting 16 questions related to the current work can signal impending burn-

out. Here you find a series of statements, with which you may agree or disagree. Select the button under the column the best matched your agreement with each sentence and calculate the score. Dealing with burnout: The "Three R" Approach • Recognize; Watch for the warning signs of burnout.

• Reverse; Undo the damage by managing stress and seeking support. • Resilience; Build your resilience to stress by taking care of your physical and emotional health. Personal strategies

1. Identify personal and professional values. Do some soul searching. What brings joy to your life both inside and outside of work? Focus on how to find more of these things and weave them into your daily routines. 2. Engage in religious or other spiritual activities 3. Pay attention to your personal life. Find things that give meaning to life outside of work. Strive for a calmness and sense of well-being. Schedule time off. 4. Spend time with family, friends and engage a supportive partner or spouse. 5. Exercise regularly. Make time to care for your own physical health. Professional strategies

1. Analyze your practice situation and attempt to restructure things in a way that makes you feel empowered and ready for success. 2. Find meaning in your work and set limits. 3. Identify and routinely spend time with a mentor. 4. Develop adequate administrative support systems. In addition to working to identify and prevent burnout in our own lives, we have a responsibility to ensure that our trainees do not suffer burnout.Early mentorship programs in medical schools and training programs are essential. I believe that the concept of burn-

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out should be discussed regularly with trainees so that all can be proactive in prevention. There are many remedial actions to safeguard doctors from burnout. First and foremost is the early recognition. Reversal of burnout can be achieved by legislative changes, readjusting working environment and adjustments in life. Shared care and multidiscipline approach would reduce the burden of clinical care at individual level. Also studies have shown that various trainings such as Ricki, and Yoga can help the affected individuals. I would like to end my speech adding that time has come for us to assess ourselves and those around us to see that we maintain the maximum physical strength and mental integrity required to discharge our duties effectively and efficiently. We need to recognize factors that affect these components and eliminate them early. Quality of patient care is our primary objective and we should be ready in every ways to meet that objective.

About the writer This article was produced comprising the address by the Galle Medical Association, President Dr Vajira Lakamwasam at the Inauguration of the Gall Medical Association Sessions 2012


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SLMA

October, 2012

Early Detection Oral Potentially Malignant Disorders Dr Hemantha Amarasinghe

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n Sri Lanka oral cancer is the most common cancer among males and ranks sixth among women, reported to account for 12.9 per cent of total malignancies in the country. The incidence of cancer of the oral cavity and oro-pharynx in Sri Lanka, standardized to the world standard population, in the year 2006, was 16 per 1000 and four per 100,000 in males and females respectively. Oral cancer is often preceded by oral potentially malignant disorders (OPMD), the term recommended by a recent workshop from the WHO Collaborating Centre for Oral Cancer/Precancer to entail what were earlier referred to as “precancer” or “premalignant lesions and conditions”. The global prevalence of OPMD has been reported at 1-5 per cent, but higher prevalences are described from South and South East Asia, with male preponderance, e.g. Taiwan (12.7 per cent), and in some Western Pacific countries, e.g. Papua New Guinea 11.7 per cent. Such wide geographical variations are due to life styles specific to the country or region. In Sri Lanka, the prevalence of oral leukoplakia and of Oral Sub mucous Fibrosis (OSF) is reported as 26.2 and 4.0 per

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Fig. 1 - Homogenious leukoplakia

Fig. 2 - Nodular leukoplakia

Fig. 4 - Oral submucous fibrosis. Note the blanching on Fig. 5 - OSF. Note the diffuse the lower labial mucosa buccal mucosa, with severe area. Note betel stains on th 1000 respectively. Studies in central Sri Lanka estimated the prevalence of all OPMD at 4.2 per cent, that among tea estate workers at 6.7 per cent. Recent study conducted in the Sabaragamuwa

province reported prevalence of OPMD as 11 per cent in the rural and estate sector. The following lesions and conditions are usually described under OPMD: leukoplakia, erythroplakia,

submucous fibrosis, lichen planus, palatal lesions of reverse smoking, discoid lupus erythematosus, and hereditary disorders such as dyskeratosis congenita and epidermolysis bullosa. Of


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n of Oral Cancer

on the right buccal mucosa. Fig. 3 - Erythroplakia. Note the red patch on the right buccal mucosa with white areas posteriorly.

e blanching on the right blanching in the retromolar he tongue and teeth these, leukoplakia, submucous fibrosis and lichen planus are the commonly found disorders in OPMD. However the health system of the country has failed so far to carry out systematic

Fig. 6 - Lichen planus

interventions to detect those with OPMD and to manage them, with a view to preventing oral cancers. The early detection and appropriate management of OPMD with habit intervention is one of

the main strategies to reduce the burden of oral cancer in Sri Lanka.

Oral Leukoplakia According to the new definition proposed by WHO in 2005, ‘The term leukoplakia

should be used to recognize white plaques of questionable risk having excluded other known diseases or disorders that carry no increased risk of cancer’. There are two main clinical types of leukoplakia homogeneous and non-homogeneous. The distinction of these is purely clinical, based on surface colour and the morphological characteristics, which do have bearing on the outcome or prognosis. Homogeneous lesions are uniformly flat, thin and exhibit shallow cracks on the keratin surface. The risk of malignant transformation of this variety is relatively low. Non-homogeneous lesions carry a much higher risk of malignant transformation and are classified as follows. Speckled: Mixed, white and red, but retaining predominantly white character. Nodular: Small polyploidy outgrowths, rounded red or white excrescences. Verrucous: Wrinkled or corrugated surface appearance. Proliferative verrucous leukoplakia presents with multiple, simultaneous leukoplakia, as the disease is visibly multimodal and frequently covers a wide area. However, those with mixed white and red plaques should be recognized as having a higher risk status, and these are to be denoted as ‘erythroleukoplakia’. Contd. on page 22

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October, 2012 Contd.from page 21

Early detection... Approximately 70 per cent of the oral leukoplakia lesions are found on the buccal mucosa and commisures and they are less common on the palate, maxillary mucosa, retromolar area, floor of the mouth, and tongue. Lesions of the tongue and the floor of the mouth account for more than 90 per cent of cases that show dysplasia or carcinoma. The causative factors for leukoplakia are identified by number of locally acting etiological agents, such as tobacco, alcohol, arecanut, eletrogalvanic reactions, ultraviolet radiation and by micro-organisms such as (possibly) candida albicans, herpes simplex and papillomaviruses. Ultraviolet radiation is a well-known for the formation of leukoplakia of the vermilion border of the lower lip. The most important and conclusive method of diagnosing leukoplakia lesions is microscopic examination of an adequate biopsy specimen. Benign forms of leukoplakia are characterized by variable patterns of hyperkeratosis and chronic inflammation. Epithelial dysplasia is a collective term for various epithelial changes seen by light microscopy, which indicate an increased likelihood of malignant transformation. An estimate is made of the degree of dysplastic change in the epithelium, usually expressed as mild, moderate or severe, the latter being essentially in

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carcinoma in situ. Prevention is the key to manage oral leukoplakia; therefore, patients must understand the risk of tobacco, areca nut and alcohol use. Management of leukoplakia depends on the histological report and the site of the lesion. If no dysplasia is noted on a buccal mucosal biopsy, routine observation of the lesion is recommended. Patients with leukoplakial lesions of the floor of the mouth, lateral and ventral tongue, soft palate, and oropharynx should have these lesions removed completely whether microscopic examination reveals dysplasia or not. Long term monitoring of the site of the lesions after surgical removal, is important since recurrence is frequent and additional leukoplakia may develop. Smaller benign lesions that do not demonstrate dysplasia, the chances of malignant transformation is four to six per cent.

Erythroplakia Erythroplakia is defined by WHO as ‘any lesion of the oral mucosa that presents as bright red velvety plaques which cannot be characterized clinically or pathologically as any other definable disease’. Such lesions are less common than leukoplakia but very careful observation reveal an association of erythroplakia with early invasive oral carcinomas. Erytroplakia may also be associated with leukoplakia, as mixed

red and white lesions. However, it is the red portion that is more worrisome than the white. It has been reported that 80 to 90 per cent of cases of erythroplakia are histopathologically severe epithelial dysplasia, carcinoma in situ, or invasive carcinoma. By analysis of malignant transformation of erythroplakia, Waldron and Shafer (1975) reported that none of the erythroplakia lesion represented benign keratosis. Management of erythroplakia, follows the same principles of management of leukoplakia, according to its histopathological features.

Oral Submucous Fibrosis (OSF) OSF is an important form of a potentially malignant oral condition that appears in the oral cavity. Among this special recognition was made for OSF because of its high prevalence, relatively high rate of malignant transformation than leukoplakia and possible avenues for prevention. Worldwide estimates indicate that 2.5 million people are affected; most cases are concentrated on the Indian subcontinent. The prevalence varies from 0.2 per cent- 2.3 per cent in males and 1.2 per cent- 4.5 per cent in females in Indian communities. Contd. on page 24

Oral cancer is often preceded by oral potentially malignant disorders (OPMD), the term recommended by a recent workshop from the WHO Collaborating Centre for Oral Cancer/Precancer to entail what were earlier referred to as “precancer” or “premalignant lsions and conditions”. The global prevalence of OPMD has been reported at 1-5 per cent, but higher prevalences are described from South and South East Asia, with male preponderance, e.g. Taiwan (12.7 per cent), and in some Western Pacific countries, e.g. Papua New Guinea 11.7 per cent.


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October, 2012 Contd.from page 22

Early detection... Prevention is the key to manage oral leukoplakia; therefore, patients must understand the risk of tobacco, areca nut and alcohol use. Management of leukoplakia depends on the histological report and the site of the lesion. If no dysplasia is noted on a buccal mucosal biopsy, routine observation of the lesion is recommended.

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A sharp spurt in the incidence of OSF was noted after packets of areca nut came onto the market and the incidence is increasing. OSF also occurs in other parts of Asia and the Pacific islands. High prevalence of OSF (1.7 per cent) was reported in the Sabaragamuwa province of Sri Lanka in 2008. OSF presents with burning sensation, blanching of the oral mucosa together with stiffness of oral mucosa and symptoms leading to restricted mouth opening, inability to protrude the tongue, altered pronunciation, and intolerance to spicy-hot foods. In severe cases; firm sub mucosal bands may be palpable. OSF is often misdiagnosed by general practitioners as iron deficiency anaemia, due to its pale white blanching appearance of the oral mucosa. Etiological hypotheses on OSF are abundant which includes use of areca nut, iron deficiency, autoimmunity and genetic preponderance but recent studies favour areca nut use as the major cause of OSF. OSF is often resistant to treatment regimes that are proposed to alleviate the signs and symptoms, however without much success. Submucosal injected steroids and hyaluronidase, oral iron preparations, and topical vitamin A with steroids are some of the agents that are used. All these therapies are essentially palliative. In severe cases, surgical interven-

tion is the only treatment, but the fibrous bands and other symptoms often recur within a few months to a few years. The potentially malignant nature of sub mucous fibrosis has been well documented. A malignant transformation rate of 7.6 per cent for OSF over a period of 10 years was described in an Indian cohort and the relative risk for malignant transformation may be as high as 397.3.

Oral lichen planus Oral lichen planus is a common chronic immunologic inflammatory mucocutaneous disorder that varies in appearance on clinical presentations and is described to include both white and red components. The white forms include papular, reticular, and plaque likes lesions. The most common is the reticular form, which typically presents as a non-elevated keratotic patch with fine, lace like striations (Wickham’s striae). Red forms are less common and include atropic, ulcerative and bullous forms. Lichen planus lesions are sometimes painful, particularly the ulcerative type. They may appear in almost any oral site but are most common on the buccal mucosa. About 28 per cent of patients who have oral lichen planus also have skin lesions. The aetiology of oral lichen planus involves a cell-mediated immunologically induced degeneration of the basal cell layer of

the epithelium. There are broader ranges of disorders of an immunologically induced lichenoid lesions, lichen planus is one. Speculated cofactors in its cause, such as stress, diabetes, hepatitis-C, trauma, and hypersensitivity to drugs and metals, have varying degrees of support for development of lichen planus but a specific causative factor has not been identified. Treatment is usually palliative and a small percentage of cases may predispose to the development of oral cancer. The occurrence of squamous cell carcinoma in most series ranged from 0.4 to 2.0 per cent for a 5 year observation period.

Further reading:

National Cancer Control Programme Sri Lanka, Cancer Incidence data: Sri Lanka year 2006, NCCP: Colombo 8th Publication. 2012. Ministry of Health Sri Lanka, National Oral Health Survey, Sri Lanka (2002/2003). Colombo, 3rd publication, 2009.

About the writer Dr Hemantha Amarasinghe is a Consultant in Community Dentistry of National Cancer Control Programme, No 555, Public Health Complex, Narahenpita, Colombo 05. Email: hemanthaamarasinghe@yahoo.com


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Symposium on Osteoporosis The Women’s Health Committee of the Sri Lanka Medical Association organized a symposium in collaboration with the Ceylon College of Physicians titled postmenopausal osteoporosis. It was held at the Lionel Memorial Auditorium at Wijerama House on the 27th of July 2012. It was well received with more than 150 participants attending it.

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he panel of speakers included University of Ruhuna Department of Physiology, Senior Lecturer Dr R S Janaka Lenora, the Ceylon College of Physicians President and University of Ruhuna Faculty of Medicine Professor in Medicine Prof, Sarath Lekamwasam and University of Colombo Department of Clinical Medicine Consultant Rheumatologist Dr Inoshi Atukorale. Prof.Vajira Dissanayake welcomed the audience with an inspirational

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speech. Dr R S. J. Lenora started the symposium with a comprehensive presentation on pathophysiology of osteoporosis. Dr Lenora’s lecture was followed by Professor Sarath Lekamwasam’s presentation on “diagnosis and management of postmenopausal osteoporosis” (PMO). Professor Lekamwasam pointed out that PMO and fragility fractures are the major health issues causing considerable health care cost and recognition of those with high fracture probability and treating them with drugs with proven anti-fracture efficacy are the main ways of mitigating the fracture burden. He also spoke about the FRAX model introduced by the World Health Organization to assess the probability of osteoporotic fracture, which is used widely to identify those with high fracture risk. Professor Lekamwasam enlightened the audience about country-specific FRAX models that have been developed to accommodate the geographical differences in fracture incidence and mortality rates. In Sri Lanka, the FRAX model has been introduced in December 2011. Going on to speak about the therapeutic options he emphasized that bisphosphonates remain the main stay of osteoporosis therapy due to their efficacy and cost. The third speaker, Dr Inoshi Athukorale, concluded the symposium with an informative presentation

Ceylon College of Physicians President Prof. Sarath Lakamwasam chairing the symposium.

on glucocorticoid (GC)- induced osteoporosis. She said that GC is the commonest cause of secondary osteoporosis and epidemiological studies have revealed that up to 4.6 per cent of postmenopausal females are on GC. Explaining about the diagnosis and treatment of the condition, she pointed out that patients aged more than 70 years, those with previous fragility fractures or patients on high dosage of steroids for more than 3 months should be considered for treatment. Dr Athukorale reiterated that all high risk patients must be commenced on pharmacological bone protective measures at the onset of GC treatment, if the duration of treatment is anticipated to last more than 3 months. Moreover, bone protective treatment may be stopped when GC are stopped unless patient was on long term steroids and continues be at increased fracture risk. Bisphosphonates are the first line treatment in these patients. She stressed on the importance of assessment of falls- risk and falls prevention. The symposium concluded with a discussion.


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SLMANEWS

October, 2012

Otorhinolaryngology in Sri Lanka Celebrating the Past and Looking into the Future Dr Chandra Jayasuriya

History Otorhinolaryngology was first merit as a separate subspecialty in 1898. But it was 1928 when higher education in Otorhinolaryngology was first obtained by Sir Nicolas Attygalle (DLO). ENT unit was not established in the General Hospital premises until 1938 and Dr Kadiragamathamby was the first ENT surgeon appointed for practice. Dr B. M. Fonseka obtained the first MS in ENT and in 1955 Dr R. C. J. Rustomjee passed the fellowship of the Royal College of Surgeons of England. ENT Unit in general hospital was transferred to current location in 1958. Dr Ananda Soysa was the founder President of Association of Otolaryngologist of Sri Lanka (1970 onwards). Dr Ranjit Abeywickrama was the first president of College of Otorhinolaryngologists and

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Head and Neck Surgeons in Sri Lanka.

Current achievements Current state of ENT Units in Sri Lanka has remarkably improved during last few years. In addition to ENT wards and new theatre complexes with state of the art instruments, Speech therapy units, Audiology units were supplemented to deliver quality care to the patients. Latest investigations are available for diagnosis; i. e. Plysomnography. The range of surgeries done by the ENT surgeons has expanded during last few years, which include Head and Neck surgery, Skull Base Surgery, Endoscopic Sinus Surgery in addition to ENT surgery. Newer treatment options have also evolved throughout the past and currently more sophisticated instruments are available for patients; i. e. Cochlear implants, Bone Anchored Hearing Aids.

Training post graduate candidates in Otorhinplaryngology is done to meet the international standards. Specializing in Otorhinolaryngology commence after passing MS part-l and 3 years of through training in General surgery, Neurosurgery and cancer surgery is given to post graduate candidates prior to MD. Following MD, one year local and one year abroad training is given. Forty seven consultant surgeons had passed up to date and out of them Forty are still practicing in Sri Lanka and seven are abroad. College of Otorhinolaryngologists and Head and Neck surgeons was formed in 2002 with the intention of promoting research, post graduate training in the field and to endorse communication and fellowship among ENT surgeons and improve standards of this sub-specialty. It also had the privilege of hosting international events like

SARCC congress-2004 and will be facilitating Sound Hearing 2030 that is scheduled to be held in September 2012 in Sri Lanka.

Future Sri Lankan health system is in need of more sophisticated ENT super centres, at least one centre per province with 24 hour care. ENT units lack investigations for vertigo patients, which is often neglected without much evaluation yet need more attention at least at tertiary care level. Professional voice clinic is another facility that should be integrated to ENT units. Universal screening of new-borns for hearing is another major goal that is to be achieved at national level. About the writer Dr Chandra Jayasuriya is the President of the College of Otorhinolaryngologists and Head and Neck Surgeons


SLMANEWS

October, 2012

Reducing Morbidity and Mortality from Road Traffic Accidents Dr C M Asela Anthony

R

oad Traffic accident Prevention Committee conducted a symposium under the theme “Reducing Morbidity and Mortality from Road Traffic Accidents” The chairperson of the committee, Prof. Sheriffdeen gave an overview of the problem faced by all of us on our roads.

SLMA Road Traffic Accident Prevention Committee Chairman Prof. A. H. Sheriffdeen addressing the participants.

In his presentation he stated that many accidents take place due to driver fatigue, disrespect of road rules by drives as well as all other road uses, negligent driving and road conditions as main causes. He also stated that as a result of these accidents, there is loss of lives, injury to persons, loss of earning capacity as well as damage to property. This colossal sum of money, which is wasted, can be saved by reducing the number of accidents by active intervention. Consultant surgeon, Dr Ranjith Ellawala explained how proper Preliminary Trauma Care can save lives and help in the fast

recovery of the patients. The initial assessment of the patient by the doctor is the most important step in the management followed by correct treatment, which should be instituted quickly. Training and re-training of the doctors and other medical staff at the accident service in the protocols of preliminary trauma care was emphasised. Consultant to the Department of Motor Traffic, A W Dissanayake, spoke on “Improving Driver Behaviour”. All these years, the faulty drivers were punished by asking them to pay a fine, depending on the offence. With the new system, a driver will start

with an X number of points, and at each offence, some points will be deducted. When the driver loses all the points, he will have to undergo training and obtain a new licence. This system will place us in par with developed countries, but still a lot of ground work has to be done on this project before implementation.

and process to be followed in initiating workplaces free of NCD. These were followed by an interactive session chaired by Prof. Samarasinghe on a pragmatic approach to reducing risk factors for NCD. Each participant was requested to identify and suggest amendments based on feasibility and NCD priorities. During the lunch time, there were two interactive sessions by Dr Thureirajah and by Dr Ranjuka Ubayasiri themed “Doctors as role models”, which encouraged participants to follow healthy lifestyles. Soon after lunch, participants engaged in group work for

planning activities for creating their own work place free of NCD. In the final session, groups presented their work while identifying the barriers for action. Prof. Samarasinghe and Dr Manoj Fernando facilitated this session and comments were given to modify their activities. Participants were motivated to initiate activities at small scale in their work places and were invited to link-up with the resource persons for further work and expertise via email. All the participants were given a certificate proving their participation to the symposium at the end.

About the writer Dr C M Asela Anthony is the Secretary of Road Traffic Accident Prevention Committee of the Sri Lanka Medical Association.

Contd.from page 04

Towards an Efficient... Finally, University of Colombo, Faculty of Medicine, Consultant Psychiatrist Dr Mahesh Rajasuriya concluded the symposium with his lecture on ‘Health at workplace: the unseen narrative’ that motivated the audience to appreciate the strengths and barriers existing in workplaces for NCD prevention. Following tea, the second half of the workshop named “Creating workplaces free of NCD” was conducted by University of Colombo, Faculty of Medicine, Professor in Psychiatry Prof. Diyanath Samarasinghe , University

30

of Colombo, Faculty of Medicine, Senior Lecturer in Community Medicine Dr Carukshi Arambepola, University of Rajarata, Lecturer in Health Promotion, Dr Manoj Fernando and Postgraduate trainee in Community Medicine Dr Nadeeka Chandraratne. The workshop commenced with a plenary on ‘What works well in the prevention of NCD’ by Dr Arambepola that demonstrated the evidence for interventions that have shown to be effective in preventing NCD. It was followed by a plenary on the ‘Principles of workplace health promotion’ that described the principles


October, 2012

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SLMANEWS


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SLMANEWS

October, 2012

Psychiatry in Sri Lanka Past, Present and Future By Dr Usha Gunawardena

The past

The Mental Hospital at Angoda has undergone a phase of redevelopment and is now the National Institute of Mental Health (NIMH), a tertiary care centre for the mentally ill providing specialised services, post-graduate training and treatment for mentally ill offenders. 36

Formal mental health services commenced in Sri Lanka during British rule and came under the purview of the Lunacy Ordinance of 1873, which was based mostly on British laws existing at that time. Although there were several hospitals that treated mentally ill patients, it was not until over fifty years later that a major hospital was dedicated to the care of the mentally ill. That was with the commissioning of the hospital at Angoda, which catered to the ‘asylum’ concept of treating the mentally ill, which prevailed at the time. Although the hospital provided a centrally located treatment facility that catered exclusively to the mentally ill and offered in-patient treatment, it had many drawbacks. Standards of care were less than ideal and there was significant overcrowding after only a few years. While the central location was convenient it also led to much stigma being attached to the hospital with ‘Angoda’ becoming synonymous with mental illness, a phenomenon that exists to this day. There was also a tendency to refer most patients to this hospital and the development of regional centres of treatment was not a priority. As the hospital was built on the ‘asylum’ model, there was also no provision for community based care. The Lunacy Ordinance, enacted nearly a hundred and forty

years ago has been amended on several occasions, most recently in 1956, over fifty years ago. As such, a comprehensive overhaul of this archaic legislation is now overdue.

The present Despite the lack of progress in mental health legislation, service provision in mental health care in Sri Lanka has kept pace and has seen remarkable developments over the past few decades. The Mental Hospital at Angoda has undergone a phase of redevelopment and is now the National Institute of Mental Health (NIMH), a tertiary care centre for the mentally ill providing specialised services, postgraduate training and treatment for mentally ill offenders. Its capacity for service provision has been enhanced considerably, being better resourced with designated physicians and dental surgeons as well as over eighty medical officers. As its services expanded it has attracted staff from overseas as well, with the Voluntary Services Overseas (VSO) organisation regularly sending its volunteers to work at the Institute Its specialised services include a peri-natal unit, a psychogeriatric unit, a psychiatric intensive care unit, learning disability unit and a gender based violence unit, some of these services not being available elsewhere in Sri Lanka. In more recent years, regional services in Sri Lanka have also made noteworthy progress. At


SLMANEWS present, in-patient units have been set up in sixteen hospitals and include six professorial units in teaching hospitals as well as units in distant regional centres such as Anuradhapura, Badulla and Batticaloa. Other recent developments include the provision of services in child psychiatry in Colombo and Galle and the setting up of mental health clinics in rural and remote areas, utilising existing infrastructure. Although a significant percentage of psychiatrists trained in the country continue to migrate overseas in response to offers of better remuneration, at present there are 48 board certified psychiatrists in Sri Lanka. They work in conjunction with Diplomats in Psychiatry and Medical Officers in Mental Health, two categories of doctors trained in Psychiatry to counter the dearth of specialists in remote areas. With the increase in the number of psychiatrists in the country, research and professional development in the discipline have become a priority. A recently developed research tool has been the ‘Peradeniya Depression Scale’ at the

October, 2012

University of Peradeniya while another research instrument for neuropsychological testing in the elderly is being developed at the University of Ruhuna in Karapitiya. Meanwhile, the Sri Lanka Association of Psychiatrists, which was incorporated as the Sri Lanka College of Psychiatrists in 2003 has become a focal institution for all aspects related to the specialty. The College faced one of its toughest challenges in the aftermath of the 2004 Tsunami disaster when it was tasked with co-ordinating psychological supports to hundreds of thousands of victims of the disaster. This it did with remarkable success, working together with the World Health Organisation, other overseas institutions and state agencies. The College has also been responsible for an academic renaissance in the specialty, mostly through well attended annual academic sessions, which are held in collaboration with the Sri Lanka Psychiatric Association of the United Kingdom. It is also the publisher of the Sri Lanka Journal of Psychiatry, a publication aimed at fostering research and

academic interest within the specialty.

The future While there has been an almost exponential increase in the provision of mental health care services, more remains to be done for the improvement of mental health services in the country. It has been estimated that a total of 200 diplomats in Psychiatry and MOMH would be required to provide satisfactory medical coverage of the entire island in mental health. Ongoing training programmes are working towards this target. A complete revision of current mental health legislation has been undertaken for some years now but the draft legislation has yet to be passed into law. This has serious implications for

the development of services and is arguably the top priority in mental health at present. The development of a community based mental health care model is also a target. This remains an ambitious objective because of the costs involved but training of community psychiatric nurses have already commenced. When implemented, this will signal a landmark change in the provision of mental health services in the county and will bring it on par with the community care model used in developed countries. About the writer Dr Usha Gunawardena is the President of the College of Psychiatrists of Sri Lanka

Other recent developments include the provision of services in child psychiatry in Colombo and Galle and the setting up of mental health clinics in rural and remote areas, utilising existing infrastructure. 37



SLMAnews-2012-10