President's Column

Contents

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Dear members and colleagues,

I bring you greetings from the SLMA.

We are forging ahead with our academic activities with gusto. In conformity with our expressed desire to take some of our activities to the underprivileged areas, we had a very successful Collaborative Programme with Moneragala Hospital on the 2nd of May 2013. There was a CPD Programme for doctors incorporat-ing topics requested by the doctors of the Moneragala region, a programme on immunisation for the nurses and a separate event on “Personal Hygiene & Hand Washing”, sponsored by Reckitt Benkisser for a het-erogeneous group of nurses, attendants and labourers. We have also been involved in several other activities chronicles elsewhere in this Newsletter.

Arrangements for the 126th Anniversary International Medical Congress are in full swing. A Preliminary Pro-gramme is given in this Newsletter. In compliance with our theme of “Towards continuing enhancement of quality and safety in healthcare”, I believe that we have tried to present a programme of superlative quality. Even though I say so myself, it covers a wide range of subjects coming under the umbrella of this apex medi-cal institution of Sri Lanka.

We would love to have all of you joining us for the 126th Anniversary International Medical Congress. The forerunner for the venture will be the ‘SLMA Run & Walk’ on Sunday the 7th of July 2013. We are expecting a very large crowd of participants, perhaps numbering several thousand, for this event. It will be followed by the congress proper replete with Pre-Congress Work-shops on the 9th and 10th of July 2013 and the Main Congress from the 10th evening to the night of the 13th of July 2013. The topics covered have been selected to titillate the academic palate of all types and all grades of doctors in the country. The event will conclude with the Banquet on the night of the 13th of July 2013.

Please do block these dates in your personal calen-dar to be with us for this grand event.

Page No.

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May 2013 Volume 06 Issue 05

SLMANEWSTHE OFFICIAL NEWSPAPER OF THE SRI LANKA MEDICAL ASSOCIATION

Notice board 02

Assessment of performance:

the Workplace-Based Assessments 04

Letter to the Editor 07

SLMA Snakebite Hotline 06

Japanese Encephalitis (JE) and the

recent outbreak at Rathnapura 12

Stung by a jellyfish? Some do’s and don’ts 14-15

126th Anniversary International Medical Congress - Programme 20

Cancer in Women: Current concepts, practices and strategies 24

Dr B J C PereraPresident,Sri Lanka Medical Association,No.06, Wijerama Mawatha,Colombo 07, Sri Lanka

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

May, 2013 SLMANEWS

SLMA Research Grant 2013

2

Notice Board

Benefits of walkingDo you know ?

•Walking30minutesadaycutstherateofpeoplebecomingdiabeticbymorethanhalfanditcutstheriskofpeopleover60becomingdiabeticbyalmost70%.

•Walkingcutstheriskofstrokebymorethan25%.

•Walkingstrengthenstheheart,bones&improvesthecirculatorysystem.

•Women with breast cancer who walk regularlycanreducetheirrecurrencerateandtheirmor-talityratebyover50%.

•Menwhowalkregularlyhavea60%lowerriskofcoloncancer.

•Formenwithprostatecancer,studieshaveshownthatwalkershavea46%lowermortalityrate.

•Walking also helps prevent depression, peoplewho walk regularly are more likely to see im-provementsintheirdepression.

•Walkinggeneratespositiveneurochemicals.

•Walking is a good boost of high density choles-terolandpeoplewithhighlevelsofHDLarelesslikelytohaveheartattacksandstroke.

(These benefits were extracted from a commu-nique by the NIROGI Lanka Project)

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

SLMA 126th ANNIVERSARY RUN & WALK

Research Promotion Committee workshops

Workshop on Biostatistics for Clinicians

The second research training workshop organized by the Re-searchPromotionCommitteeoftheSLMAthisyearwasaimedatenhancingthestatisticalskillsofpostgraduateclinicaltrain-ees.ItwassuccessfullyconductedbyProf.ChrishanthaAbeysenaandDr.B.Kumarendranon7thMay2013.Theworkshopdrewalargeaudiencewithover50participants.Theworkshopfocusedondatatypesinresearchandinterpretationoftheirkeycharac-teristics, tests of statistical significance, and sampling.Partici-pantsengagedinseveralhands-onactivitiesincludinginterpreta-tionoffindingsinapublishedarticle.

Workshops on Geographical Information Science.

Thenext twoworkshopswill be onGeographical InformationScienceandwillbeconductedbyProf.KithsiriGunawardenaonthe 2nd and 29th of June.Those interested in participating cancontacttheSLMAofficeon0112693324fordetails.Weinvitesuggestions from our readership on future workshops. Pleaseemail the Convenor, SLMA Research Promotion Committee(asela_o@yahoo.com) for suggestionsonareasof interestand/orforexpressionsofinterestincontributingasresourcepersons.

SLMA Research Grants

SLMA wishes to congratulate the following recipients of theSLMAResearchGrantsfortheyear2013:

FAIRMED Foundation Research Grant 2013

Glaxo Wellcome SLMA Research Grant 2013 – not awarded

Manyof theapplicationswereofahigh standardand theRe-searchPromotionCommitteewishestothankallapplicantsfortheirefforts.Thecommitteewouldliketonotethatunprofession-albehavioursuchasplagiarismisviewedextremelyunfavourably.Thecommitteewishestothankthescientificreviewersfortheircontribution.

SLMANEWS May, 2013

Offer of a dedicated, affiliated and SLMA branded Hatton National Bank (HNB) Credit/Debit Card to SLMA members

Hatton National Bank Credit/Debit Card is offering several attractive facilities to the SLMA members. These are:-

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

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

Documents needed for either category:-• Salary particulars, certified by the Head of the Institution

• Certified copy of the National Identity Card

New and existing members are hereby cordially invited to join the SLMA Credit Card Scheme. Dr. B.J.C.Perera

President, Sri Lanka Medical Association

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Dr. Thistle Jayawardena Research Grant for Intensive and Critical Care - 2013

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

Applications can be obtained from

Application Deadline: 30th June 2013

Nojoiningfee

Freesupplementarycardsforspouseandchildren(linkedtotheSLMACardholder)

50%offthefirstyearAnnualFee

FreeSMSalertsontransactions

Freecredit,uptoamaximumof55days

Freee-BankingandSMS-Bankingfacilities

Attractiveratesforseveraltypesofloansincludinghousingandcarloans

Educationalloansforchildrenetc.

Year-rounddiscounts,SpecialOffersandSeasonalDiscounts

atHNBpartnerestablishments

FreeOverseasTravelInsuranceandHealthInsurancecover

Nofuelsurchargeontheuseofthecardtopurchasepetrol/ dieselanywhereinSriLanka.

Cash-in-a-hurry:CashadvancesthroughATMs

LoyaltyProgrammessuchasFlySmilesfromSriLankanAirways

Easy-paymentplansforpurchasesatcertaindesignated establishments

LocalsurgicalandHospitalisationInsuranceCover,startingfromRs2000/-plusVATperyear.

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

May, 2013 SLMANEWS

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SLMANEWS

DrMadawaChandratilakeMBBS,MMEd,PhDMedicalEducationCentre,FacultyofMedicine,UniversityofKelaniya.

Introduction

Assessment is a vital compo-nent of medical education. Its importance as a determinant

of fitness-to-practice medicine and a tool for facilitating feedback has been repeatedly emphasised (Epstein 2007). In addition, assessments hold a high educational impact; what we as-sess and how we assess drive student learning (Epstein 2007; Chandratilake et al 2010). Therefore, assessments should always be relevant, practical and fair, and should reflect the desired educational outcome (van de Vleuten 1996).

‘Students can, with difficulty, escape from the effects of poor teaching, they cannot (by definition, if they want to graduate) escape from the effects of poor assessment.’ (Boud 1995)

The assessments in medical educa-tion focus on different levels of profes-sional ability from knowledge to per-formance. In 1990, Miller introduced a pyramidal framework which helped medical educators immensely to iden-tify the different aspects, settings and tools for various assessment purpos-es (Miller 1990) (Figure 1). According to the Miller’s pyramid, the lower three levels of assessments focus on as-sessing the preparedness of students / trainees for practice.

The top level of assessments actu-ally assesses their practice. It is very important to assess the lower levels to ensure the progress of students / trainees toward the intended direc-tion. However, the assessment of per-formance in actual practice (the top level) should be the ultimate choice of every assessor.

Workplace-Based Assessment tools

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

Table 1 (on page 05) provides an overview of the selected assess-ment tools and the attributes which

can be assessed using these tools. Assessment process

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

Assessment of performance: the Workplace-Based Assessments

Contd. on page 05

SLMANEWS May, 2013

Assessment ...Contd. from page 05

The key element of WBA is a struc-tured observation which focuses on a particular task or a part of it (Norcini and Burch 2007). The observer is re-quired to be an expert and well-expe-rienced in the task concerned (Norcini and Burch 2007). The level of training of the assessee and the complexity of the task need to be taken into consid-eration in the assessment.

Like for all assessments, the goal of WBA should be the facilitation of further learning, i.e. the assessment should highlight the strengths and the areas which need improvement (Nor-cini & Burch 2007). The most effective way of achieving this goal is the provi-sion of a constructive feedback to the assesse after the assessment. There-fore, a feedback session is an integral component of each WPA which has made the process and the outcome of the assessment more meaningful. In Mini-CEX and DOPS, the feedback

session should be immediately after the assessment. In MSF and PSQ, the feedback received from different stakeholders is collated by the edu-cational supervisor and a cumulative feedback is communicated to the as-sessee.

Opportunities and challenges

There are several characteristics of WBA which facilitate learning (Nocini and Burch 2007). The WPA makes the alignment between goals, content and assessment practices clear, as it takes place in an authentic environment. Therefore, the assesees see the rele-vance of assessments. WPA provides opportunities for the assessor to pro-vide feedback to the assessee based on the actual performance. Assessee is benefitted by the receiving feedback based on his /her actual performance.

WBA can be used more strategi-cally than other assessment methods

to guide a student / trainee towards the intended outcomes of the educa-tional programme. WBA tools such as MSF helps obtained holistic view of the assessee which is paramount in team-based work environment like healthcare setting; this may not be achievable with other assessment methods.

However, there can be several chal-lenges of using WPA. As several as-sessment encounters are necessary to achieve high level of reliability, es-pecially for high-stake summative as-sessments, WBA warrants a substan-tial amount of time commitments from clinicians. However, the reliability can be compromised to certain extent by reducing the number of assessments and the assessment time if the WBA is used only for the provision of feed-back, ( i.e formative purposes).

Either the purpose of assessment is formative or summative, the provision of feedback is an integral component of WBA. Therefore, assessors need to be both competent and confident to provide constructive feedback to assessees. This can be challeng-ing for some assessors (Norcini and Burch 2007). They should to be sup-ported through staff development pro-grammes to enhance their skills of providing constructive feedback. The key features of WBA are direct obser-vation and timely feedback.

If the assessment forms are com-pleted without direct observation of the selected task the validity, reliabil-ity and the educational impact of the assessment become questionable. Conducting all WBAs towards the end of the training programme, e.g. in the final few months of a three year postgraduate training, contradicts the purpose (performance feedback improvement) of WBA. Both these factors defeat the goals of WBA and make it just a tick-box exercise.

Tool Nature of assessment Attributes for assessment Mini Clinical Evaluation Exercise (Mini-CEX)

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

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

Direct Observation of Procedures (DOPS)

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

Procedural skills, Professionalism, Communication skills

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

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

Interpersonal relationships, Communication skills, Humanistic qualities

Patient Satisfaction Questionnaire (PSQ)

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

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

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

Contd. on page 06

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May, 2013 SLMANEWS

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In assessment tools like MSF and PSQ, other healthcare workers, e.g. nurses, pharmacists, medical labora-tory technologist, and patients play a role.

Although openness to constructive feedback is an important professional attribute of doctors (Chandratilake et al 2012) the source of feedback may be a matter of concern for some doc-tors. On the other hand, other health-care workers need to be trained to take a ‘professional’ approach in an event of providing feedback on the perfor-mance of doctors (Epstein 2007).

Conclusion

Although the assessment of pre-paredness to practice is important the assessment of actual performance and the provision of feedback should be the ultimate goal of assessments in medical education. WBA can be

used effectively to achieve this goal. There is a wide range of WBA tools which focus on different aspects of the practice of medicine. The choice of assessment tool depends on the purpose. The benefits of using WBA are many. However, certain challeng-es need to be overcome for the suc-cessful implementation of WBA in Sri Lankan context.

References:

Boud D (1995) Assessment and learn-ing: contradictory or complementary? In Knight P. (Ed.) Assessment for Learning in Higher Education. London: Kogan, 35-48.

Chandratilake M, McAleer S & Gibson J (2012) Cultural similarities and differences in medical professionalism: a multi-region study. Medical Education, 46:257-266.

Chandratilake MN, Ponnamperuma G & Davis MH (2010) Evaluating and design-

ing assessments for medical education: the utility formula. Internet Journal of Medical Education, 1 (1)

Epstein RM (2007) Assessment in medi-cal education. New England Journal of Medicine 356:387-96.

Norcini J & Burch V. (2007) Workplace-based assessment as an educational tool: AMEE Guide No. 31. Medical Teacher, 29: 855–871.

RCGP n.d. PSQ for Workplace Based Assessment. Available from: <http://www.rcgp.org.uk/gp-training-and-exams/mrc-gp-workplace-based-assessment-wpba/psq-for-workplace-based-assessment.aspx> [14 May 2013]

van der Vleuten C. (1996) The assess-ment of professional competence: de-velopments, research and practical im-plications. Advances in Health Science Education, 1: 41 - 67.

Contd. from page 05

Assessment ...

SLMANEWS May, 2013

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14 May 2013

Editor SLMA NEWS

Dear Sir / Madam,

VIOLENCE AS SHOWN IN THE MEDIA AND THE ROLE OF THE MEDICAL PROFESSION

Have you watched TV News recently, or cared to reflect on some of the headlines in newspapers? Do you notice that we are being bombarded with graphic pictures of violence? Are we seeing a progressive increase in the number violence reported by the media in Sri Lanka?

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

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

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

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

Saroj Jayasinghe

Council Member SLMA

Chairperson Health Equity Committee SLMA

Letter to the Editor

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May, 2013 SLMANEWS

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Contd. on page 13

3.Laboratory Diagnosis of

Japanese encephalitisDrGeethaniGalagoda,ConsultantVirologist,MedicalResearchInstitute,Colombo

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

(WEE), St. Louis encephalitis (SLE), Murray Valley encephalitis (MVE). Related flavi viruses are dengue, yel-low fever, tick borne encephalitis. The mosquito vectors are culex species (C. tritaeniorhynchus, C. gelidus, C. vishnuii complex, C. fuscocephala). The virus also has been isolated from other mosquito species such as Ae-des, Anopheles and Mansonia.

The methods of laboratory diagnosis are serology, virus isolation, RT-PCR and antigen detection. Serology tests are commonly used in the diagnosis of JE. JE specific IgM antibody (single sample), JE specific IgG antibody (ris-ing titer) and plaque reduction neutral-ization test are available.The speci-mens for diagnosis are, CSF, serum and brain tissue (post mortem). CSF is the best specimen to diagnose en-cephalitis because antibody levels rise higher and earlier than with serum. In addition, a positive serum can be a co-incidental finding in a patient with en-cephalitis due do the high incidence of asymptomatic infection, especially in areas with high endemicity and serum IgM antibody could remain positive for a short period after vaccination.

The most sensitive type of JE spe-cific IgM test is a Capture IgM Enzyme immunoassay (EIA) which is 70 - 75% positive by the 4th day of illness and

100% positive by 7-10th day. Only a single CSF (0.5ml) or serum sample is required and antibodies persist for about 3 months after infection. The sensitivity and specificity are more than 95% for CNS infection. JE spe-cific IgG test is done by Haemagglu-tination inhibition test (HAI) which is technically demanding.

Two serum samples 10-14 days apart and a four fold rise of antibody titer is required for accurate interpreta-tion of results. Confirmatory tests are required if there is circulating dengue virus infection at the same time, a high level of vaccine coverage and if a case occurs without any epidemiologi-cal evidence of JE transmission.

Virus isolation can be conducted only in a research laboratory. JE virus is a risk group 3 pathogen and needs BSL-3 facility for virus isolation. RT-PCR although a very specific test, is not recommended for routine diagno-sis due to low sensitivity. It is gener-ally negative in patients with clinical encephalitis as JE virus titer in blood is low and the duration of viraemia is short. The PCR can be demonstrated in brain specimens in fatal cases and provides information regarding molec-ular epidemiology.

The methods of laboratory diagno-sis in animals include RT-PCR, virus culture of brain tissue in mosquitoes, and serology tests such as neutraliza-tion, EIA and HAI methods could be used.

The other investigations are cell count, protein, sugar and bacterial culture. For virological investigations, the sample should be refrigerated if there’s a delay of more than 1-2 hours. The sample should be stored at 4O C for 48 hours and at -200C for longer periods of storage. The sample should be transported in ice to the laboratory.

Japanese Encephalitis (JE) and the recent outbreak at Rathnapura

Figure 2: Serological profile of JE

From the Symposium on JE held on 20th March 2013 compiled by Prof Jennifer Perera, Chairperson Com-municable Diseases Commit-tee SLMA. Summary of the presentations on “Recent outbreak of Japanese En-cephalitis at Ratnapura” and “Epidemiology of Japanese Encephalitis in Sri Lanka & recent changes” were pub-lished in the SLMA News Aril 2013 issue.

SLMANEWS May, 2013

Japanese...Contd. from page 12

Outbreak investigationLaboratory confirmation of 5-10

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

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

Laboratory surveillance of AES

at MRILaboratory surveillance in Sri Lanka

is a program conducted by the WHO. CSF and serum samples are received at MRI with a history of AES. Labora-tory tests are done by WHO approved test kits and a report is sent back to the clinician. The data request form should be filled including the duration of illness, JE vaccination etc. Samples should be collected 7 days after onset of illness. The CSF sample (0.5 ml) and the serum sample (2 ml) should be stored and transported at 40C if there is a delay. If the first sample was collected early in the disease, a sec-ond serum sample should be sent.

The drawbacks and challenges faced in providing laboratory diagno-sis are inadequate or absent clinical history (duration), samples collected too early in the illness, not receiving convalescent serum samples, sam-ples being stored for long periods at the hospital and irregular supply of

laboratory reagents. The laboratory data are sent as

monthly returns to WHO and Epidemi-ology unit. All AES cases are followed up by the Epidemiological Unit and given an Epidemiology number simi-lar to AFP cases (eg AES-SRLWP-COL13001). Laboratory accreditation is conducted by the WHO with annual testing using proficiency panels with renewal of annual accreditation of the laboratory.

4.Japanese Encephalitis

VaccineDrOmalaWimalaratne,ConsultantVirologistandVaccinologist,MedicalResearchInstitute.Colombo

Vaccination is the most effective method to control the disease. Types of JE vaccines are Purified inactivat-ed mouse brain vaccine (Nakayama & Beijing strains), cell culture based inactivated vaccine Beijing P3 strain used in China, live attenuated SA-14-14-2 vaccine from China, live recom-binant vaccine: SA-14-14-2 strain in-serted to the genome of 17D YF strain grown in Vero cell culture.

In 1988 JE Nakayama strain vaccine was first introduced in Sri Lanka in a phased manner and in 1992 the Bei-jing strain was introduced. The Live SA-14-14-2 introduced at one year of

age in 2009 and later at nine months of age in 2011.

Inactivated Japanese encephalitis vaccine contains inactivated Japanese Encephalitis virus prepared in mouse brain and only one strain is available at present in Sri Lanka(Nakayama strain).This vaccine is recommended after 1 year of age, and the primary immunization consists of 2 doses each given 2 weeks apart. A booster is given one year after the 2nd dose.

In the government sector, the prima-ry immunization is given with the live vaccine at 9 months of age. No boost-ers are recommended at present. The dosage is 0.5ml which is reconstituted and administered subcutaneously.

The contraindications for JE vacci-nation are fever more than 38.3° C, progressive neurological illness, preg-nancy, persons who are allergic to the constituents of the vaccine, history of convulsions during the past one year, leukemia, lymphoma and other malig-nancies.

The live vaccine is available only at state run vaccination clinics and this was thought to be a problem in achiev-ing universal coverage in the relevant age groups. In outbreak situations, the need to extend immunization to adults was discussed as most amounts of morbidity and mortality occurred in the unimmunized adults, during the cur-rent outbreak.

From one great to anotherCharlie Chaplin meets Albert Einstein

"What I admire most about your art", Albert Einstein said, "is its universality. You do not say a word, and yet ... the world understands you."

"It's true", replies Chaplin. "But your fame is even greater: the world admires you, even when nobody understands you.

Courtesy Dr. Dennis AloysiusPast President, SLMA

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April, 2013 SLMANEWS

Stung by a jellyfish? MalikFernandoex-SCUBAdiver,MarineNaturalist(Parttimedoctor)

Jellyfish are not fish: they are primi-tive invertebrates that belong to the larger group (Phylum Cnidar-

ia, formerly Coelenterata) that includes corals, sea fans and sea anemones—all capturing their prey by shooting venom-packed darts from structures called ne-matocysts (or cnidocysts). These are microscopic in size, most too small to penetrate the human skin. But some jellyfish do possess nematocysts with penetrating threads long enough and containing venom with sufficient punch to hurt humans. But the venom of lo-cal animals is of low potency and do not cause problems—unless someone were unfortunate enough to have an al-lergic reaction, which are very much in the “rare” category.

Jellyfish venoms were first studied in the Australian box jellyfish (Chironex

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

1. Immediate

a)Pain(local),wheals,erythema,blistering,skinnecrosis;

b)Painspreadingthroughlimbinvolvingre-gionallymphnodes(Physalia);

c)Agitation, distress – tachycardia, tachy-

pnoea,sweating.

2. Late

a)Dermalpigmentation(boxjellyfish);

b)Irukandjesyndrome(NorthernAustralia);

c)Recurrentdermatitis;

d)Granulomatousdermatitis.

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

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

Details of stings by the four jellyfish stingers on the West coast are in the boxes with their photographs. These have been identified and studied personally. A number of non-stingers are also seen; but none in swarms since the El Niño of 1998.

Swarms of jellyfish are seen off the East coast – but these have not been studied by the author. One edible species was collected some years ago for export till stopped by the authorities. The literature reports that some of these edible species cause cutaneous eruptions and pruritus in those harvesting them; in some parts of the world even systemic symptoms. They do not cause symptoms when eaten.

• Prevent drowning;

• Reassure, ensure rest;

• Remove adherent tentacles without touching;

• First aid using nematocyst arresting solutions is variable and species specific;

• Apply ice for pain relief (lignocaine ointment, or gel, effective);

• Pain usually settles within 2hrs except following Physalia sting;

• Generally no specific treatment is necessary;

• Anaphylaxis following JF sting is said to be rare. Allergic reactions may occur and need antihista-mines and corticosteroids. Not indicated routinely.

First Aid and Management—Do's & Don’ts

Some do’s and don’ts

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April, 2013SLMANEWS

“Nuisance jellyfish”

One to three centimetres across, these small transparent jellyfish (Hy-dromedusae) occur in large shoals. Unseen by the swimmer or diver they give a mild sting wherever they touch causing much discomfort. They leave no mark and result in no symptoms following contact. The coloured masses are the gonads. Bell diameter 1-3 cm.

The drawing at left is of an animal referred to by spear fishermen as needle jellies. Invisible in the water they give sharp pricks where they touch. The bell <1 cm.

Bell box-shaped with sides 10 cm. The 1 mm wide ribbon-like tentacles are

borne in clusters at the four corners. Stings are painful, the pain developing slowly, be-ing less severe than those caused by Phy-salia and Chrysaora. Erythematous wheals appear rapidly; they can be confluent and cover a large area if caused by multiple tentacles. Within 30 minutes the pain is replaced by pruritus and both wheals and pruritus start waning at one hour. It takes 36 to 48 hours for both to resolve. However, some stings can be more severe and take longer to resolve. Stings result in skin pig-mentation that resolve over four months. Ice is usually adequate for pain control. No specific treatment is needed.

Chiropsalmus buitendijki (Indian Ocean box jellyfish)

Bell diameter 20-45 cm, often appearing in swarms. Possibly another solitary species have bells 60-75 cm in diameter.

Stings cause instantaneous pain with rapid devel-opment of erythema and wheals—such as rows of erythematous papules 2 mm across spaced 6 mm apart. The pain subsides over the next 30 to 60 minutes but may persist for a few hours if sensitive areas such as lips are stung. Erythema subsides over about 3 hours, the wheals taking a few days to resolve completely during which time they are mildly pruritic.

As with stings of other Sri Lanka jellyfish no specific treatment is indicated. Pain caused by this jellyfish is usually mild, hardly necessitating even the application of ice.

Cyanea purpurea (Lion’s mane jellyfish)

Physalia utricularis (Portuguese man-o'-war, blue bottle)

above and below. Float length 2-4 cm.

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

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

Eachentityisacolonyconsistingofagasfilledfloatwithaclusterofshortandlongtentaclesattachedtotheunderside,allcolouredblue.Theyfloatatthesurfaceandaredrivenbywindandcurrents,beingwasheduponbeachesduringstormyweather(photoright).Thelocalspecieshasonelong“fishing”tentaclecoveredwithclustersofnematocyststhatgiveapotentsting.Recentexperiencesuggeststhatthesejellyfishdelivermorepotentstingsthantheydidinthenineteen-seventiesandeighties.Thepainofthestingdevelopsslowlytoreachitsmaximumin10-15minutes;orisinstantaneousandsevere.Itfluctuatesinintensityandbeginstowanein1hour,resolvingcompletelyattheendof2hours;orpersistsfor24hours.

Erythemaandwhealsintheformoflinearstreaksorcharacteristicallybeadedlinesdevelop.Paincanbequitese-vereanddistressing,radiatingtotheregionallymphnodes;axillarypainfollowingastingonthearmcanradiateontothechestwallandcausefurtherworrytothevictim(andignorantpractitioner).Inanyevent,allsymptomsandsignsresolvein24hourswithnospecifictreatment

Jellyfish stingers of the West coast of Sri Lanka—off Colombo

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

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

Chrysaora quiquecirra (Compass jellyfish).

Physalia utricularis

May, 2013 SLMANEWS

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126th Anniversary International Medical Congress - Programme

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Dr.ShaminiPrathapanMBBS,MSc,MD(CommunityMedicine)Secretary,Women’sHealthCommittee

The Expert Committee on Wom-en’s Health of the Sri Lanka Medical Association organized

a symposium titled “Cancer in Women: Current concepts, practices and strat-egies”. It was held in the auditorium of the District General Hospital (DGH) of Trincomalee on the 10th April 2013. It was well attended by medical officers from the region. The panel of speak-ers were from the Eastern Province

other than for Dr.Varuni Bandara, Se-nior Registrar in Community Medicine, National Cancer Control Programme. The speakers from the region in-cluded Dr.P.A Denagama (Consultant Obstetrician & Gynaecologist, DGH Trincomalee), Dr.R.Prathapan (Con-sultant Obstetrician & Gynaecologist, DGH Trincomalee), Dr.G.M.K. Bo-gammana (Consultant Surgeon, DGH Trincomalee), Dr. Prabath Wickrama (Acting Consultant Psychiatrist, Can-cer Institute, Maharagama and DGH Trincomalee) and Dr. W.D.I.Shama Goonatillake (Consultant Clinical On-cologist, Teaching Hospital Batticaloa) The secretary of the Women’s Health Committee, Dr.Shamini Prathapan, welcomed the gathering and chaired the symposium.

The gathering began with the Di-rector of the District General Hospital Trincomalee, Dr.E.G.Gnanagunalan. He thanked the Women’s Health Committee for giving the medical of-ficers an opportunity for continuous medical education and stressing the importance of such programmes in the region.

Dr. Varuni Bandara then initiated the symposium with a comprehensive presentation on epidemiology of can-cer in women. She highlighted the fact that worldwide cancer incidence and age-standardized rates are increas-ing. It was not only worldwide but in Sri Lanka too, among all cancers, tak-ing into account the age standardized rates, breast cancer was the com-monest. In Sri Lanka breast cancer is about 22% of all cancers diagnosed among women in 2006.

The second common cancer was cervical cancer in cancers in women.

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

Dr.P.A Denagama

Dr. Varuni Bandara

SLMANEWS May, 2013

Dr.Varuni Bandara also described the role of National Cancer Control Programme and its programmes in cancer prevention in the country. She stressed the fact that the programme was currently addressing the three most common cancers in lieu of pre-vention – Oral, breast and cervical cancers. The National Cancer Control programme practices six major strat-egies which are primary prevention, early detection, diagnosis and treat-ment, surveillance, palliative care and research.

This was followed a presentation by Dr.P.A Denagama on Malignancies of the vulva and cervix. He mentioned the fact that suffering from cervi-cal cancers are decreasing because women are undergoing Pap smear. He also pointed out that although the causative factor was multi-factorial, Human Papilloma Virus was respon-sible for over 90% of the cervical cancers against which the immuniza-tion is now available. Multiple sexual partners of the women as well as mul-tiple sexual partners of the partners were important risk factors. One of the positive points that he pointed out was that vulval carcinomas could be com-pletely treated with proper treatment if diagnosed early.

This followed Dr.Prathapan’s pre-sentation that mainly focused on the

issues and challenges in Cancer of the ovary and endometrium. His con-cern was of the ovarian cancer as it is a challenge to diagnose it, because of the non-specific nature of symptoms and signs and because currently there aren’t any screening programmes established so far in Sri Lanka. He stressed that estimation of the risk of malignancy is essential in the as-sessment of an ovarian mass once diagnosed. Concerning endometrial cancer, the main issue was that 75% occur in postmenopausal women and one in 10 women presenting with postmenopausal bleeding will be di-agnosed of endometrial cancer in Sri Lanka.

Dr. Bogammana enlightened the gathering with his presentation on “Breast Cancer”. He clearly pointed out the challenge in Breast Cancer was that one in eight women in the world will have breast cancer at some stage of their life which justifies the need to reinforce the screening pro-gramme in Sri Lanka. The advantage of early detection of breast cancer is that it could lead to cure which further substantiates the challenge of educat-ing the public.

The consultant oncologist for all three districts, Dr. Shama Goon-athilake, introduced the novel con-cepts in Cancer management. Going on to speak about the therapeutic op-tions, he emphasized that the main stay of each cancer therapy be justi-fied to its efficacy and cost. Taking into account all what has been said in the above presentations, he stressed that the provincial cancer centres should be improved, and at-least one mam-mogram should be made available to a district general hospital. It was further discussed at the symposium that based on current evidence, na-tional guidelines for cancer manage-ment should be made available and proper palliative care should be estab-lished in all districts.

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

Cancer...Contd. from page 24

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Dr.Prathapan

Dr. Bogammana

Dr. Shama Goonathilake

Dr. Prabath Wickrama

May, 2013 SLMANEWS

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The Bo-path Ella...Contd. from page 24