Anuradhapura Medical Journal 2012 by Anuradhapura Clinical Society

Anuradhapura Medical Journal Established 2002 Volume 6, No 1, 2012 Concept Paper

Seeking patient's consent for examination and treatment: Introducing a consent form to be used in government hospitals in Sri Lanka. Dhananjaya L. Waidyaratne

Original Article

Late presentation of breast carcinoma at North Central Province of Sri Lanka. WAK Weerawardena, PDJ Edirisooriya, IJ Piyadasa, TDB Illangasingha, GAL Niroshana, SM Rathnayaka, WTDUPT Subaweera.

Case Reports

Endovascular management of multiple aneurysms in pulmonary artery in a patient with Bechet's disease â&#x20AC;&#x201C; Case presentation

L P Paranahewa, AN Wijewardena

ICU Management of a patient with Anaphylaxis Kudavidanage BP

Review Article

Aetiology for gastro intestinal reflux disease Weeerawardena WAK

Abstracts

An analysis of psychiatric referrals In a multidisciplinary General hospital in Sri Lanka Dharmawardene V.

Infant feeding behaviors in Nuwaragam-Palatha-Central (NPC) Medical Officer of Health (MOH) area; a qualitative study. Agampodi TC, Chathurani HKJU, Agampodi SB

Habits of the players during the competition day Rajasinghe SV , Thurairaja C

Bacteriological profile with their antibiograms in neonatal septicaemia in a Teaching Hospital in Srilanka Fernando R, Samarawickrama B.

Percutaneous Biliary Stenting For Malignant Biliary Obstruction â&#x20AC;&#x201C; Retrospective Single Center Case Series L P Paranahewa

Pre competition anxiety among athletes Sumudu V. Rajasinghe , Dilini V. Vipulaguna

Anuradhapura Medical Journal 2012 Concept Paper

Seeking patient's consent for examination and treatment: Introducing a consent form to be used in government hospitals in Sri Lanka. Dhananjaya L. Waidyaratne Department of Forensic Medicine, Teaching Hospital Anutradhapura Background

Main Objective

Respect of the patient's right to self determination (autonomy), through informed consent is considered the foundation of doctor – patient relationship.

The main objective was to design a suitable format to obtain informed consent of patients for various surgical, investigative and therapeutic procedures in clinical practice.

Despite the considerable development in health infrastructure and human resources, a regular practice of modern ethical standards has not yet been appropriately established. So far the country has failed even to reach a consensus regarding informed consent. Frequently the “consent for medical examination and treatment” was looked from a paternalistic view point, often only as a tool of defense against litigation. Obtaining consent was merely limited to getting any person, accompanying the patient to hospital, to sign on bed head ticket (BHT), next to a “stereotype” phrase: “No property, consent for operation”. Usually no doctors were involved in this process, a nurse, receiving patient to the ward, write the phrase. Patient information about the nature and consequences of procedures or available treatment options were often ignored.

Specific objectives 1. Identify the quantity and the quality of

information, that patients should be given in order for the consent to be valid 2. Design a widely acceptable format to

obtain informed consent of patients for various surgical, investigative and therapeutic procedures in clinical practice Ethical principles concerning the informed consent Patient consent is required on occasions where the doctor wishes to initiate an examination or treatment or any other intervention, except in emergencies or where the law prescribes otherwise (such as where compulsory treatment is authorized by mental health legislation). Consent may be explicit or implied. Explicit (or expressed) consent is when a person actively agrees, either orally or in writing. Implied consent is when signaled by the behavior of an informed patient. Implied consent is not considered a lesser form of consent but it only has validity if the patient genuinely knows and understands what is being proposed

The situation is being changed to the better. Many doctors are exploring ways of obtaining consent; formats are being designed by individual clinicians. Incompleteness in view of legal validity and unsuitability for use in different situations were among many shortfalls noted in those consent forms. The purpose of this paper is to focus on practical medico legal issues concerning consent and clinical ethics and to propose a format which may be appropriate and applicable in many of the clinical scenarios for obtaining consent.

Failure to follow the recommended protocols for obtaining meaningful, lawful consent is unethical and can harm patients both physically and psychologically.

Seeking patient's consent for examination and treatment: Introducing a consent form to be used in government hospitals in Sri Lanka.

Interventions without obtaining consent can end in either civil litigation or in rare cases, criminal prosecution. A quality health care demands more than mere technical proficiency, and wherever possible it needs to allow for active patient participation. This cannot be achieved in an atmosphere of mistrust, or if patients feel that what they think and say is of no real consequence.

Extent of patient information required for a valid consent The information that patients should be provided with, includes, • Purpose of the investigation or treatment, details and uncertainties of the diagnosis, • Options for treatment, including the option not to treat, explanation of the likely benefits and probabilities of success for each option the risks such as known possible side effects, • Complications and adverse outcomes including where intervention and/or treatment may fail to improve the condition, • The name of the doctor who will have overall responsibility, • A reminder that the patient can change his or her mind at any time.

Consent is a process, not a one-off event, and it is important that there is continuing discussion to reflect the evolving nature of treatment. A consent form simply documents that some discussion about the procedure or investigation has taken place. It is only an evidence of a process, not the process itself. The provision of sufficient accurate information is an essential part of seeking consent. Competent adult patients are entitled to refuse consent to treatment, even when doing so may result in permanent physical injury or death. Compliance when a patient does not know what the intervention entails, or is unaware that he or she can refuse, is not 'consent'. Doctors must respect a refusal of treatment if the patient is an adult who is competent, properly informed and is not being coerced.

A careful balance needs to be struck between what patients want to know and ought to know (i.e. listening to what the patient wants and providing enough information) in order that the patient's decisions are informed Introducing the proposed consent form The proposed consent form is believed to be appropriate for obtaining written consent from patients for examination and treatment in government hospitals in Sri Lanka. The development of this format took more than 03 years of consultation and discussion with different medical/surgical specialists attached to Matale and Anuradhapura hospitals during the period between 2008 and 2010.

The doctor who recommends that the patient should undergo the intervention should have responsibility for providing an explanation to the patient and obtaining his or her consent. In a hospital setting this will normally be the senior clinician. In exceptional circumstances the task of reaffirming consent can be delegated to a doctor who is suitably trained and qualified, is sufficiently familiar with the procedure and possesses the appropriate communication skills.

Efforts had been made to make the form to be complete and comprehensive while being concise to be user-friendly. · Important information referring to identity of the patient and nature of the proposed intervention is included in the given format.

Any discussion, however, should be recorded in the patient's medical notes. Generally there is no legal requirement to obtain written consent but in some cases it may be advisable.

Seeking patient's consent for examination and treatment: Introducing a consent form to be used in government hospitals in Sri Lanka.

路

Further it elaborates the areas of most valuable concern in the discussion leading to informed consent, though it does not contain the concrete constituent facts. The document guides both clinicians and patients into their rights and responsibilities.

(Singhalese/English and Tamil/English versions of proposed consent form are given below.) Since the amount of information which, doctors should provide to each patient will vary according to factors such as the nature and severity of the condition, the complexity of and the risks associated with the treatment or procedure and the patient's own wishes, it is simply impossible to design a universal consent form carrying all necessary information. As such this consent form needs to be supplemented with provision of information applicable to respective areas of medical practice or disciplines, clinical scenarios, individual interventions and procedures. Good quality information leaflets that patients can take away with them can be a useful way of improving information provision but these should not be seen as an alternative to discussion. Separate Sinhalese/English and Tamil/English versions were thought to be justifiably appropriate to use for any patient.

Seeking patient's consent for examination and treatment: Introducing a consent form to be used in government hospitals in Sri Lanka.

frday, khtl;l nghJ Hospital Y,H l¾uhla fyda úfYaIs; mÍCIKhla fyda m%;sldr l%uhla i|yd tlÕ;djh m%ldY lsÍu' eclaration of Consent for Surgical or Special Investigative or Therapeutic Procedure. 1' frda.shdf.a ku ^iïmQ¾Kfhka& ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' Name of Patient (in full) '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

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2. jhi Age '''''''''''''''

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ia;%S mqreI Male Female

4' we| bym;a wxlh ''''''''''''''' BHT No.

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5. jdÜgqj Ward

} '''''''''''''''

6' wjYHjk Y,Hl¾ufha $ úfYaIs; mÍCIKfha $ m%;sldr l%ufha iajNdjh' Investigative / Therapeutic intervention required fõ kï úfYaIfhka i|yka lrkak $ is to be performed & Nature of the Surgical ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 6'1 wjhjhla fyda fldgila bj;a ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 6'2 wjYHjk ks¾úkaokfha iajNdjh $ ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 7' by; ku i|yka lrk ,o Y,Hl¾ufha $ úfYaIs; mÍCIKfha $ m%;sldr l%ufha wjYH;dj;a" udf.a frda.hg m%;sldr lsÍu i|yd tys jeo.;alu fukau" tjekakl yd ks¾úkaokfha os isÿùug bvwe;s w;=re wdndO yd ixl+,;d ms<sn|j;a ffjoH ks<OdÍ Dr. ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''meyeos,s lr fok ,os' Explained me about the necessity, and importance of the above mentioned procedure in treating my illness and possible risks and complications of such a procedure and anaesthesia. 8' hï úfYaIs; ffjoHjrfhla úiska fuu Y,Hl¾uh $ úfYaIs; mÍCIKh $ m%;sldr l%uh lrk njg fmdfrdkaÿjla oS fkdue;' flfia jQjo tu lghq;a; i|yd iqÿiqlï ,o" m%ùk;djla we;s ffjoHjrhl= ld¾hh lrkq ,nk nj uu oksñ' I have never been promised that a particular doctor would do this procedure. However, I understand that a doctor with necessary qualification, skill and proficiency would be attending to the procedure. 9. wdid;ñ a l;d yd úIùï $ Allergies and toxicity ^wod, fkdjk fþoh lmd oukk a ' Delete inappropriate section& 9.1 udf.a oekqfï yeáhg óg fmr lsisÿ wjia:djl hï fnfy;la fyda wdydrhla ksid wdid;añl;djla fyda úIùula udyg we;sù ke;' To the best of my knowledge I have never had any allergy or toxicity after taking any drug or food 9.2 ………………………………………………………………………… T!IOh $ wdydr j¾.h ksid wdid;añl;djla $ úIùula udyg we;s úh' I have experienced an allergic / a toxic reaction to following drug / food item …………………………………………………………………………………………………………………………………………… 10 fuu Y,Hl¾uh $ úfYaIs; mÍCIKh $ m%;sldr l%uh i|yd fmr iQodkï ùfïoS ffjoHjrhd $ fyo ks<Odß úiska ,ndfok Wmfoia wkq.ukh l,hq;= nj;a" tfia fkdùfuka ixl+,;djka we;súh yels nj;a uu oksñ' hï Wmfoila lvjQ wjia:djla fõ kï ta nj Y,Hl¾uh $ úfYaIs; mÍCIKh $ m%;sldr l%uh wdrïN lsÍug fmr oekqï oSug tlÕ fjñ' I understand that I must strictly follow the instructions given by the Doctor / Nurse while preparing for the procedure and I understand that any breach would result in complications. I undertake the responsibility of informing of such breach if any before commencement of the procedure.

Seeking patient's consent for examination and treatment: Introducing a consent form to be used in government hospitals in Sri Lanka.

11 by; lreKq ish,a, ud yg b;d fyd|ska meyeos,s lr ÿka nj;a" ug we;s .eg¨ iy.; ;eka ms<sn|j m%Yak lsÍug wjia:djla ,enqkq nj;a" udf.a .eg¿ j,g iEySulg m;aúh yels ms<s;=re ,o nj;a iy;sl lrñ' ta wkqj by; i|yka Y,Hl¾uh $ úfYaIs; mÍCIKh $ m%;sldr l%uh i|yd uu wjfndaOfhka hq;=j ksoyfia yd iajdëkj tlÕ;dj m<lrñ ' I certify that everything mentioned above was explained to me carefully and I was given the opportunity to question and clarify all my queries to my satisfaction. Accordingly, I express my free and voluntary informed consent for the above mentioned procedure.

frda.shdf.a w;aik Signature of Patient idCIs/Attestation

} ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

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frda.shdg we;s iïnkaOh Relationship to the Patient

ffjoH ks<OdÍ Medical . Officer

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w;aik$Signature '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' ku$Name

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oskh Date ''''''''''''''''''''''''''''''''''''''''

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Seeking patient's consent for examination and treatment: Introducing a consent form to be used in government hospitals in Sri Lanka.

frday, khtl;l;l nghJ Hospital rj;jpurpfpr;ir my;yJ tpnrl gupnrhjid my;yJ rpfpr;irf;fhf ,zf;fk; bjuptpj;jy; Declaration of Consent for Surgical or Special Investigative or Therapeutic Procedure. 1. nehahspapd; bgau; (KGikahf) Name of Patient (in full) 2.taJ Age

} ''''''''''''''''''''''

} '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

bgz; Mz; Female Male

4. fl;oy; ,yf;fk; BHT No.

} '''''''''''''''

5. thl;L Ward

} '''''''''''''''

6. mtrpag;gLk; rj;jpurpfpr;irapd; / tpnrl gupnrhjidapd; / rpfpr;irapd; jd;ik Nature of the Surgical / Investigative / Therapeutic intervention required. (VjhtJ mitat';fis; my;yJ gFjpia mfw;wy; my;yJ bghUj;Jjy; gw;wp tpnrlkhff; Fwpg;gplt[k;) $ please specifically state if removal of any organ or part or any grafts is to be performed& '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 6.1 mtat';fs; my;yJ gFjpia mfw;wy; my;yJ ,izj;jy; /Removals or grafts '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 6.2 njitahd kaf;ftpaypd; jd;ik $ Nature of anaesthesia required. '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 7. nkny bgau; Fwpg;gplg;gl;l rj;jpurpfpr;irapd; Æ tpnrl gupnrhjidapd; Ærpfpr;ir Kiwapd; mtrpaKk;; Kf;fpaj;JtKk; kw;Wk; kaf;ftpaypdhy; Vw;glf;Toa ,lu;ghLfs; gw;wpa[k; jPikfs;; gw;wpa[k;; itj;jpa mjpfhup Dr. ''''''''''''''''''''''''''''''''''''''''''''''''''''''''' mtu; f shy; vdf; F tpsf; f kspf; f g; g l; L s; s J. explained me about the necessity, and importance of the above mentioned procedure in treating my illness and possible risks and complications of such a procedure and anaesthesia. 8. ahuhtJ bgah; Fwpg;gpl;l tpnrl itj;jpauhy; ,e;j rj;jpurpfpr;ir Æ tpnrl gupnrhjidÆ rpfpr;ir Kiw bra;ag;gLtjhf cj;juthjk; mspf;fg;gltpy;iy. vt;thwhapDk; me;j tplaj;jpid jifik bgw;w epg[zj;Jtk; [bgw;w itj;jpauhy; mt;tplak; epiwntw;wg;gLk; vd;gij ehd; mwpntd; I have never been promised that a particular doctor would do this procedure. However, I u n d e r s t a n d that a doctor with necessary qualification, skill and proficiency would be attending to the procedure. 9. xt;thik my;yJ tprkhjy; $ Allergies and toxicity (njitaw;w tplaj;ij btl;otplt[k;.)' Delete inappropriate section& 9.1

vdJ mwpt[f;F vl;oa tpjj;jp;y; ,jw;F Kd; ve;jbthU re;ju;g;gj;jpYk; VjhtJ kUe;J my;yJ czt[ tifahy; xt;thik my;yJ tprj;jd;ik Vw;gltpy;iy. To the best of my knowledge I have never had any allergy or toxicity after taking any drug or food.

9.2

…………………………………………………………………… rhg;gpl;lhy; xt;thikj; jd;ik / tprkhFjy;

vdf;F Vw;gLtJ cz;L. I have experienced an allergic / a toxic reaction to following drug / food item '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 06

Seeking patient's consent for examination and treatment: Introducing a consent form to be used in government hospitals in Sri Lanka.

10. ,e;j rj;jpurpfpr;ir / tpnrl gupnrhjid / rpfpr;ir Kiwf;F Kd;dhaj;jkhFk; nghJ itj;j pau/ jhjpau;fshy; tH';fg;gl;l Mnyhridfs; fl;lhakhf gpd;gw;wg;gl ntz;oajd; mtrpaj ;ija[k; mt;thW ,y;yhj re;ju;g;gj;jpy; ghjpg;g[f;fs; Vw;gLk ; vd;Wk; ehd; mwpntd;.VjhtJ Mnyhridfs; kPwg;gLkhdhy; mjid rj;jpurpfpr;ir / tpnrl gupnrhjid Kiw Muk;gpg;gjw;F Kd; mtw;iwr; brhy;tjw;F ehd; cld;gLfpd;nwd;. I understand that I must strictly follow the instructions given by the Doctor / Nurse while preparing for the procedure and I understand that any breach would result in complications. I undertake the responsibility of informing of such breach if any before commencement of the procedure. 11 nkw;Fwpg;gplg;gl;l vy;yh tpla';fisa[k; kpf ed;whf vdf;F tpsf;fpa[s;snjhL vdf;F cs;s Ia';fs; rk;ge;jkhf ehd; nfs;tp nfl;gjw;F re;ju;g;gk; tH';fg;gLs;snjhL vdJ nfs;tpfSf;F jpUg;jp milaf;ToathW tpilfs; bgwg;gl;Ls;sjhft[k; cWjp TWfpd;nwd;. mjdog;gilapy; nkw;Fwpg;gpl;l rj;jpurpfpr;ir Æ tpnrl gupnrhjid Æ gupnrhjid Kiwf;fhf vdJ mwpt[f;F vl;oa tifapy; Rje;jpukhft[k; kw;Wk; RahjPdkhft[k; cld;gLfpd;nwd;. I certify that everything mentioned above was explained to me carefully and I was given the opportunity to question and clarify all my queries to my satisfaction. Accordingly, I express my free and voluntary informed consent for the above mentioned procedure.

nehahspapd; ngau; Signature of Patient

} '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' ifbahg;gk; $Signature ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

}

rhl;rp$Attestation

bgau; / Name tpyhrk; / Address

nehahspa[ldhd cwt[Kiw Relationship to the Patient

}

itj;jpa mjpfhup Medical Officer .

}

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Seeking patient's consent for examination and treatment: Introducing a consent form to be used in government hospitals in Sri Lanka.

Acknowledgment Many of the Consultants attached to District General Hospital, Matale and Teaching Hospital, Anuradhapura, during the period between 2008 and 2010 contributed with their ideas to the development of this consent form. Tamil translation of the consent form was done by Mr. N.P.A. Rahuman, Teacher attached to Zahira College, Anuradhapura and Dr. U. Mayorathan. Services of all of them should be highly commended.

Reference 1. Mason J.K., McCall Smith R.A.

, Laurie G.T. Law and Medical Ethics. 5th edn. London: Butterworths. (1999). pp 244-288 Plueckhahn Vernon D. Cordner Stephen M. Ethics Legal Medicine and Forensic Pathology. 2 n d edn. Melbourne University Press (1991). pp 1-5 Wilks M., Kinght M. The Practitioner's Obligations in Clinical Forensic Medicine. McLay WDS 2nd edn. London, Greenwich Medical Media, 1996, Chap. 3 pp 43-45. Worthington R. (2002) Clinical issues on consent: Some philosophical concerns J. Medical Ethics; 28: 377-380 Consent tool kit, British Medical Association downloaded from the website www.bma.org.uk/ethics

Anuradhapura Medical Journal 2012 Original Article

Late presentation of breast carcinoma at North Central Province of Sri Lanka. WAK Weerawardena, PDJ Edirisooriya, IJ Piyadasa, TDB Illangasingha, GAL Niroshana, SM Rathnayaka, WTDUPT Subaweera. Surgical Unit - Teaching Hospital Anuradhapura Abstract Introduction Breast carcinoma is the main cancer among female. Delay in presentation causes high morbidity and mortality world wide. Our aim was to analyze female breast carcinoma at North Central Province in relation to delay in seeking t r e a t m e n t .

It is necessary to overcome the barriers of disclosing the symptoms to another and barriers to approach the health care institutions considering socioeconomic status of patients. Introduction

Objective Analyze presentation of patients with breast carcinoma to surgical wards in Anuradhapura and Polonnaruwa Hospital. Materials and methods We analyzed all the patients who underwent mastectomy for carcinoma in surgical unit B at General Hospital Polonnaruwa (from July 2007 to September 2009) and at Teaching Hospital Anuradhapura (from September 2009 to June 2012). Results We studied 44 patients. Duration of delay in presentations was with a range of 1 month to 3 years (mean 8 months). Only 11(25%) presented within 3 months of first detecting symptoms. Seventeen (45%) cases were detected accidentally, pain has given the attention in 18(47%) cases while only 3(8%) cases were detected during self breast examination(SBE) out of 38 cases. Conclusion We need to broaden the knowledge of people in the community about symptoms of carcinoma including non lump symptoms and consequences. People should be encouraged to perform SBE and present early.

Breast carcinoma is the commonest cancer in women worldwide. This cancer is the main cause of death from cancer among women with approximately 1.3 million new cases and an estimated 458000 deaths reported in 2008 in the world. In the United States a woman has a 1 in 8 chance of having invasive breast carcinoma during her lifetime. The breast carcinoma risk increases with age. Tumour stage is the main determinant of breast carcinoma outcome of women. Among female nonmetastatic breast carcinoma, there is a strong correlation between tumour size and the extent of axillary spread. The risk of distant metastasis is most closely correlated with the number of axillary lymph nodes involvement, followed by tumour size. This means that the ideal screening regimen for breast cancer would be one that could detect a tumour before it was large enough to be palpable. Since 1990, mortality from breast carcinoma in the United States and other industrialized countries has been decreasing at the rate of approximately 2.2% per year. In the United States, this decline has been attributed both to advances in adjuvant therapy and to increasing use of screening mammography, in approximately equal measure1. We have analyzed the data of patients presented with breast carcinoma to detect the time of presentation for intervention.

Late presentation of breast carcinoma at North Central Province of Sri Lanka.

Materials and methods.

Age distribution of 25 patients from Anuradhapura.

We have analyzed 44 patients who underwent mastectomy for breast carcinoma from July 2007 to September 2009 at surgical unit B at General Hospital Polonnaruwa and from September 2009 to June 2012 at Teaching Hospital Anuradhapura. The age, sex, site and size of the breast lump at presentation, detection method, delay in presentation and outcome of the patients were analyzed. During the search we have analyzed about the possible aetiological factors for the breast carcinoma such as use of oral contraceptive pills, Depo Provera, the age at menarche, menopausal age, age at first child birth and breast feeding. All the patients with suspected breast lumps were investigated with triple assessment (clinical examination, ultrasound examination and fine needle aspiration cytology (FNAC). We did not perform mammogram in any of those patients. If FNAC report is inconclusive we proceeded to perform incisional biopsy. Although we offered breast reconstruction procedures to the patients, they were not willing for such surgeries. If the cancer is at advanced stage we offered neoadjuvent chemotherapy. We performed Patey mastectomy with level 3 axillary clearance in those studied patients. All the patients were discharged at 5th day with the removal of draitube. Results There were 44 patients (19 patients at GH Polonnaruwa and 25 patients at TH Anuradhapura). All the patients were females with age distribution of 31-74 years (mean 51.4). Maximum lengths of the lesions were with a range from 2 cm to 8 cm (mean 4.0 cm). Twenty six were right side and 18 were left sided. Duration of delay in presentations was with a range of 1 month to 3 years (mean 8 months). Only 11 (25%) presented within 3 months of first detecting a lump.

Age group

Number of patients

31-40

41-50

51-60

61-70

71-80

Analyzing the possible aetiological factors showed only 13 (31%) used hormonal contraceptive method. They attained menarche at 12-16 years of age. Mean menopausal age was 46.8 years (range 37 -54 years). Mean age at first child birth was 23.5 years (range 13-39) of 19 cases. Thirty three of 36 (91%) have breast fed and 24(56%) of 43 patients have more than 2 children . Seventeen (45%) patients detected lump accidentally. Pain has given the attention in 18(47%) cases while only 3(8%) cases were detected during self breast examination out of 38 cases. One patient has died shortly with metastasis. All the other patients are following oncology clinics . Discussion Delayed patient presentation refers to a prolonged interval between discovery of initial symptoms to presentation to a provider and is typically defined as greater than 12 weeks. Delayed presentation of breast cancer (â&#x2030;Ľ 3 months) is associated with poorer survival at all ages The intervention builds on evidence about risk factors for delayed presentation of breast cancer. The ultimate aim of the intervention is to reduce the proportion of older women with breast cancer who delay their presentation, and thereby save lives. 2,3

Late presentation of breast carcinoma at North Central Province of Sri Lanka.

Self breast examination (SBE) is helpful for early detection of breast carcinoma. In one study done in Iran, significant proportion of people studied performed SBE .Proportion of those patients did not perform self breast examination because of lack of knowledge about the technique of examination. Some patients did not perform SBE because of fear of becoming positive for carcinoma or did not care about them. A large proportion of patients who perform SBE do it incorrectly. Those who performed SBE learned it from medical personals, their relatives, television, radio, books, journals and pamphlets. In our study sample only 8% of patients did SBE .

These factors need to be considered for targe ting a population in planning of education pro grams of breast carcinoma. However the asso ciation of high breast carcinoma risk with lower duration of education may be a barrier for pro per communication with health workers. Women need further information about the different types of breast cancer symptoms to assist symptom recognition, as well as encouragement to seek medical advice if a symptom is ambiguous. In addition, women may benefit from greater awareness of the benefits of early detection and reassurance about the improvements in quality of breast cancer care . Those non lump symptoms are known factors to delay in presentation. It is necessary to broaden the knowledge of patients about the symptoms of breast carcinoma. Those patients who present late due to fear of consequences of carcinoma usually gathered the information from their friends and relatives. People should be educated that if detect early, lesser degree of surgeries are available in cancer treatment. If presentation is late extensive surgeries with radio/chemotherapy methods are needed for therapeutic purpose.

5,6,7

Community disease preventive teams should teach of Self Breast Examination [SBE] to patients, Clinical Breast Examination [CBE] to health workers. All efforts should be made to break the vicious cycle of late presentation, poor treatment outcome and reluctance of patients to present to health facilities because of poor outcome. Significant delays in presentation still abound with only 12% presenting within 1 month of noticing symptoms in one study in 8 Nigeria. This late presentation is universal among patients in the third world including Asian and Arab countries. The reasons for delayed presentation included long distances to hospital, lack of awareness, fear of the consequences, strong belief in traditional medicine, religious charlatans, poverty, poor education, fear, denial, and negligence by patients or their family 8,9 members and general practitioners. This knowledge can be used to launch a program to motivate the patients to present early in North Central Province in Sri Lanka.

11,12

Some of the patients do not attend to seek treatment because they failed to prioritize the health ov e r their other activities. So education of breast cancer awareness programs should extent to educate the consequence of not attending for treatment 11

Symptoms that could be a warning sign of breast cancer included a painless lump, swelling, breast skin changes, pain, discharge from the nipples, nipple retraction . Fever, pruritus, cold, weight loss and presence of a wound have been recognized as presentation symptoms of women. In a study in Nigeria only few people knew that BSE should be performed 2–3 days after menstruation monthly and less number knew that women who have reached menopause were expected to choose a specific day of the month to perform BSE.

In one study Breast cancer risk was found to be increased in women with age (≥ 50), induced abortion, age at first birth (≥35 years), body mass index (BMI ≥ 25), and a positive family history. However, decreased breast cancer risk was associated with the duration of education (≥ 13 years), presence of spontaneous abortion, breast feeding . . 10

13,14

Late presentation of breast carcinoma at North Central Province of Sri Lanka.

6) G Ertem, A Kocer. Breast self-examination among nurses and midwives in Odemis health district in Turkey. Indian journal of cancer 2009 ; 46( 3 ): 208-213.

One review article shows poverty to be the most common and strongest barrier for early presentation. Traveling away from home, family and work responsibilities, and high cost of diagnosis and treatment constitute particularly burdensome problems facing the poor. Future interventions should primarily attempt to enhance access for affordable healthcare close to their home (3).

7) TT Fancher, J A Palesty, JJ Paszkowiak, RP Kiran, AD Malkan, SJ Dudrick . Can Breast Self-Examination Continue to Be Touted Justifiably as an Optional Practice? International Journal of Surgical Oncology 2011;2011:1-5.

Conclusion It is necessary to design programs to increase women's knowledge about breast symptoms and risk , to promote disclosure of symptoms to someone, to reduce the barriers to approach therapy. There are many barriers to overcome to achieve these targets. However all these are feasible with the available facilities in North Central Province.

8) Stanley NC Anyanwu . Temporal trends in breast cancer presentation in the third world. Journal of Experimental & Clinical Cancer Research 2008;27:17. 9) Talpur AA, Surahio AR, Ansari A, Ghumro AA Late presentation of breast cancer: a dilemma. JPMA, The Journal of the Pakistan Medical Association 2011;61(7):662-666.

References

10) Vahit Ozmen, Beyza Ozcinar, Hasan Karanlik, Neslihan Cabioglu, Mustafa Tukenmez, Rian Disci, Tolga Ozmen, Abdullah Igci, Mahmut Muslumanoglu, Mustafa Kecer, Atilla Soran. Breast cancer risk factors in Turkish women – a University Hospital based nested case control study World Journal of Surgical Oncology 2009;7:37.

1 ) Ellen Warner. Cancer Screening. N Engl J Med 2011; 365:1025-1032. 2) AJ Ramirez, AM Westcombe, CC Burgess, S Sutton, P Littlejohns, MA Richards. “Factors predicting delayed presentation of symptomatic breast cancer: a systematic review,” The Lancet 1999;353(9159):1127–1131.

11) C Burgess, MS Hunter, AJ Ramirez. A qualitative study of delay among women reporting symptoms of breast cancer. Br J Gen Pract 2001 December; 51(473): 967–971.

3) Ketan Sharma, Ainhoa Costas, Lawrence N. Shulman, John G. Meara. Review Article. A

12) Al-Kahiry W, Omer HH, Saeed NM, Hamid GA. Late presentation of breast cancer in aden, yemen. Gulf J Oncolog 2011 Jan; 1(9):7-11.

Systematic Review of Barriers to Breast Cancer Care in Developing Countries Resulting in Delayed Patient Presentation. Journal of Oncology Volume 2012 ;2012: 8 pages.

13 ) Abimbola Oluwatosin, Oladimeji Oladepo. Knowledge of breast cancer and its early detection measures among rural women in Akinyele Local Government Area, Ibadan, Nigeria. BMC Cancer 2006; 6:271.

4) A Ramirez. Promoting early breast cancer presentation in women after their final routine breast screening mammogram Breast Cancer Research 2006;8(Suppl 1):15.

14) Bachok Norsa'adah, Krishna G Rampal, Mohd A Rahmah, Nyi N Naing , Biswa M Biswal. Diagnosis delay of breast cancer and its associated factors in Malaysian women . BMC Cancer 2011; 11:141.

5) A Simi, M Yadollahie, F Habibzadeh. Knowledge and attitudes of breast self examination in a group of women in Shiraz, southern Iran . Postgrad Med J 2009;85:283287. 12

Anuradhapura Medical Journal 2012 Case Reports

Endovascular management of multiple aneurysms in pulmonary artery in a patient with Bechet's disease â&#x20AC;&#x201C; Case presentation . L P Paranahewa, AN Wijewardena Division of Interventional Radiology, National Hospital of Sri Lanka Introduction Pulmonary artery aneurysms are rare which could be congenital or acquired in origin. The primary symptom is haemoptysis which is often massive. Bechet's disease is a chronic systemic collagen vascular disease of unknown origin mainly affecting young men. Pulmonary aneurysms associated with Bechet's disease are pseudoaneurysms and arise as complications of vasculitis and transmural necrosis and suggests poor prognosis with massive haemoptysis associated with a high mortality rate. In most patients these aneurysms are saccular, multiple, bilateral with partial or complete thrombosis of the aneurysm as well as the distal pulmonary artery.

Fig. 1 â&#x20AC;&#x201C; chest ray PA view showing a large soft tissue opacity in the lower R/ hemithorax. Diagnostic angiogram under local anaesthesia via jugular venous access (due to the presence of B/L lower limb deep venous thrombosis extending up to the IVC) using a 5F sheath and an angle pig tail catheter confirmed the presence of the two previouly diagnosed aneurysms in the Right lung. The larger aneurysm in the lower lobe was supplied by the R/ posterior basal artery (Fig. 2) and the smaller aneurysm in the mid zone filling via right lateral artery (middle lobe)( Fig.3). Both vessels did not demonstrate any distal blood flow.

Diagnosis of the aneurysms are by contrast enhanced CT scan and pulmonary artery angiogram. Medical treatment of these patients include cytostatic and corticosteroids which may cause regression of pseudoaneurysms. Recurrent hemoptysis or progression in size of the pseudoaneurysms is common, where endovascular embolisation is a valuble alternative to surgery. Case report 28 year old male with a past history of recurrent deep vein thrombosis, recurrent oral and genital ulcers, one episode of transient blurring of vision presented to the local hospital with massive haemoptysis and progressive dyspneoa. Chest X ray (fig. 1) revealed a large soft tissue mass occupying the lower zone of the R/ lung. CT scan demonstratedtwo aneurysms in relation to the right pulmonary artery and a thrombus within the apex of the right ventricle. The patient was transferred to the national hospital for specialized management. After initial evaluation a repeat CT scan was done which revealed significant increase of size of the aneurysm to 10 x 12 cm. Due to the rapid increase in size of the aneurysm and the multiplicity of lesions the patient was referred for endovascular management.

Fig. 2

Fig. 3

Fig. 2 - Pre embolisation angiogram showing the large aneurysm in the lower lobe supplied by the by the R/ posterior basal artery and a smaller aneurysm overlapping the R/ pulmonary artery Fig.3- Angiogram (oblique view) showing the smaller aneurysm in the mid zone filling via right lateral artery (middle lobe). The larger aneurysm does not show any further filling in this film.

Endovascular management of multiple aneurysms in pulmonary artery in a patient with Bechet's disease

Pre and post contrast enhanced CT scan done 3 days after the procedure demonstrated complete thrombosis of the aneurismal sacs (Fig. 7). The patient was referred for further medical management of Bechet's disease and followup.

Embolisation was planned at a different sitting after optimizing the patient with cardiothoracic surgical back up under local anaesthesia where the right main pulmonary artery was selectively catheterized via jugular access and a Amplatzer PDA delivery system was positioned proximal to it's bifurcation. Super selective catheterisaton of the feeding vessels was then performed separately with a6 F, 064” “Guider” guiding catheter (Boston) and successful occlusion of each vessel was achieved immideately proximal to the origin of the aneurysm with 6mm x 7 mm and 8 mm x 7mm vascular plugs (Amplatzer) (Fig. 4, Fig 5)

Fig. 8.CT scan of the chest showing the thrombosed aneurysm with no further filling of contrast. The vascular plug is seen in this section at the region of the neck of the aneurysm.

Fig. 4.

Discussion: Our patient who presented with pulmonary artery aneurysms had recurrent oral and genital ulceration (Fig. 8) several episodes of probable eye involvement recurrent deep vein thrombosis, thrombus within the Right ventricle and multiple pulmonary artery aneurysms which satisfies the practical clinical diagnostic criteria for Bechet's disease which was diagnosed retrospectively.

Fig. 5.

Fig. 4.Angiogram following embolisation of the larger aneurysm showing complete cessation of blood flow. Fig. 5.Successfully deployed vascular plugs insitu.

Complete occlusion of the vessels with cessation of blood flow in to the aneurismal sac was demonstrated by post procedure angiogram (Fig. 6). Patient tolerated the procedure well and had an immediate reduction of his symptoms.

Fig.8. Genital Ulcers in the same patient.

The rapidly enlarging large pulmonary artery aneurysm involving the apical and posterior segments of the R/ lung was impending rupture with a risk of life threatening haemoptysis. Due to the large size of the aneurysm and as there was already thrombosis of the distal vessels, after discussing with the cardiothoracic surgeon and the chest physician it was decided to occlude both feeding branch vessels as distal as possible using Amplatzervascular plugs. Due to the retrievable nature of these plugs prior to release, .

Fig. 6. Post procedure angiogram demonstrating complete occlusion of the embolised vessels with cessation of flow in to both aneurismal sacs.

Endovascular management of multiple aneurysms in pulmonary artery in a patient with Bechet's disease

it was possible to position the plugs immediately proximal to the origin of the aneurysms thereby salvaging the maximum length of the proximal pulmonary artery. Immediate post procedure angiogram showed complete cessation of blood flow in to both aneurismal sacs indicating successful occlusion of the vessels using a single occlusive devise. Thereby it was possible to treat this patient by endovascular means safely enabling rapid recovery under local anaesthesia avoiding major thoracic surgery under general anaesthesia.

Conclusion Large and multiple pulmonary artery aneurysms leading to life threatening haemospysis can be successfully managed by endovascular means avoiding major surgery as described by this patient with Bechet's disease.

Anuradhapura Medical Journal 2012 Case Reports

Intrathyroid Abscess Formation with Multiple Necrotizing Cervical Lymphadenitis due to Meticillin Resistant Staphylococcus aureus (MRSA); A Case Report with Literature Review Senanayake KJ, Pitigalaarachchi PR Department of Surgery, Faculty of Medicine and Allied Health Sciences, Rajarata University of Sri Lanka1, Department of General Surgery, Teaching Hospital Kandy, Sri Lanka2,

Abstract

The patient

Introduction Intrathyorid abscess formation due to MRSA is rare. It needs high index of suspicion to diagnose early. Early diagnosis and treatment improves the outcome.

A seventy seven year old Sri Lankan female patient presented to the emergency surgical department of Teaching Hospital Kandy, Sri Lanka with high fever and neck swelling for 2 days. She did not have difficulty in breathing. The onset of fever was gradual and associated with chills. Relatives noticed that the patient was confused and disoriented. On examination, the patient was dehydrated and drowsy. There was a large right sided tender, warm swelling in the thyroid region with multiple cervical lymphadenopathy.

The Patient A 77 year old Sri Lankan female, presented to the emergency surgical department with a tender swelling in the anterior neck. On examination there was an enlarged thyroid gland with multiple cervical lymphadenopathy. Ultrasound scan revealed an abscess within the right lobe of the thyroid. Ultrasound guided aspiration of the puss and culture ABST done and the MRSA was isolated after 24 hour incubation. Incision and drainage of the abscess was done. Intravenous antibiotics were started according to the culture ABST.

An urgent white cell count showed a very high leucocyte count with neutrophilia. The ultrasound scan revealed an abscess in the right lobe of the thyroid gland with multiple cervical lymphadenopathy. A CT scan (figure 1.) of the neck with reconstruction was performed to assess the extension. Ultrasound guided aspiration of the abscess was done and pus was sent for culture and antibiotic sensitivity (table 1). The gram stain showed few gram negative bacilli and few gram positive bacilli. Pus grew Methicillin Resistant Staphylococcus aureus (MRSA) after 24 hours of incubation. The patient was also screened for tuberculosis and it was negative. The Biopsy of cervical lymph node showed necrosis with secondary deposit from a sqamous cell carcinoma of which the primary was not found. She was a known patient with diabetic mellitus and had poor control of blood sugar. The patent was rehydrated with intravenous normal saline and adequate urine output was maintained. After taking the puss for culture ABST by USS guided aspiration the patient was empirically treated with cefuroxime 750mg

Conclusion It needs high index of suspicion to diagnose the thyroid abscess early. Ultrasound guided aspiration, Incision and drainage and early administration of sensitive antibiotic would improve the outcome. Introduction Abscess formation within the thyroid gland is rare (1). Because of its rarity, it is often not suspected and hence the diagnosis would be delayed. Possibility of thyroid abscess formation should be suspected in any patient who presented with tender neck swelling in thyroid area.

Intrathyroid Abscess Formation with Multiple Necrotizing Cervical Lymphadenitis due to Meticillin Resistant Staphylococcus aureus (MRSA)

eight hourly and the patient was treated with oral fucidic acid and intravenous vancomycin after the culture report. Incision and drainage was performed under general anesthesia. Patent had a good recovery from the sepsis after post operative day 3. Informed written consent was taken from the patient for photography and publishing the case report.

reported secondary to biliary sepsis (8).The bacteraemia cause by the MRSA is reported in immunologically compromised patients (9).The thyroid abscess formation commonly reported among the immunocompromised (1). In the present case the patient is immunologically compromised due to the presence of diabetes mellitus and the underling malignancy of which the primary is unknown.

Table 1. Sensitivity pattern of MRSA from the pus culture Antibibiotic Cefuroxime Clindamycin Cloxacillin Co-trimoxazole Erythromycin Fusidic acid Vancomycin

The rarity of abscess formation in thyroid leads to delay in the diagnosis due to the fact that it is not included in the differential diagnosis list in many physicians. The thyroid gland is highly resistant to be infected. The resistance of thyroid gland to form abscess is multifactorial. Presence of a capsule, high concentration of iodine, very high vascularity, and presence of high lymphatic drainage was postulated (1).

Sensitivity Resistant Resistant Resistant Resistant Resistant Sensitive Sensitive

The commonest organism of thyroid abscess formation reported is staphylococci aurius (3). Butthe reported cases of thyroid abscess due to MRSA are minimal. The other organisms that have been isolated and responsible for abscess formation in the thyroid are tuberculosis, norcadia, E.coli, Salmonella, Eikenella corrodens, Actinomycosis Rhodoccus equi, and fugal infections suchas Cryptococcus and aspergillous etc.

Discussion Abscess formation within the thyroid gland is rare (1). The intrathyroid abscess formation with MRSA may be rarer. The oldest case of thyroid abscess reported in the Pub Med was in 1894 by Ransohoff J (2). There are 319 cases reported in English in the literature from 1900 to 2000, et al and Jacobs et al (3).Possible causes of infection of thyroid gland are either direct inoculation or hematological spread. The commonest route of infection is probably hematological (3). Other possible causes reported are the direct trauma such as, FNAC, esophageal perforation due to fish bone injury and in children's it is commonly due toanatomical anomalies such as piriform sinus fistula (1,4,5).The acute suppurative thyroiditis now rarely progress to thyroid abscess formation due to widespread use of antibiotics (6). The hemorrhage in to a thyroid cyst leading to secondary infection is a possible cause for the intrathyroid abscess formation. Rarely the post anginal sepsis (Lemierre's Syndrome) could present with thyroid abscess (7) and further it has been

Cases of thyoiditis with thyrotoxicosis cause bybacteria are reported (10). Therefore the altered thyroid function must be anticipated and suspected in a patient with thyroid abscess.However the current case the patient is euthyroid.

The diagnosis of the thyroid abscess is straightforward if it is suspected and examine. Clinically the enlarged, tender thyroid with the evidence of inflammation of overlying skin, multiple cervical lymphadinopathy gives a clue to the diagnosis. Ultrasonogrphy gives details a b o u t t h e a b s c e s s c a v i t y, c e r v i c a l lyphadenophathy and the diagnosis can be confirmed by ultrasoundguided aspiration.

Intrathyroid Abscess Formation with Multiple Necrotizing Cervical Lymphadenitis due to Meticillin Resistant Staphylococcus aureus (MRSA)

References 1. Herndon MD, Christie DB, Ayoub MM,

2. Figure 1. Non contrast, Axial CT Scan of the neck at the level of the thyroid abscess

Contrast enhanced CT scan also delineates the anatomical extension of the thyroid abscess and may be helpful to plan the management. In the current case a plain CT scan (figure 1.) was donedue topresence of multiple allergies. Barium swallow can be used to assess theanatomical abnormalities after inflammatory process is resolved (11, 12).

The usual treatment includes intervention of the ENT service with incision and drainage of theabscess or partial thyroidectomy, depending upon the presence or absence of underlying thyroid pathologies, together with intravenous antibiotics (5).In the current case the treatment was a high dose ofsensitive intravenous antibiotics and ultrasound guided aspiration together with incision anddrainage. The most frequently recommended treatment in the literature is surgery either excisionor incision and drainage (3). However the role of more extensive surgery such as total or neartotal thyroidectomy in the management of intrathyroid abscess is not widely discussed. Non surgical management with ultrasound guided aspiration is suggested (13).However there is a possibility of recollection.

Duggan AD. Thyroid abscess: case report andreview of the literature. Am Surg. 2007 Jul;73(7):725-8. R a n s o h o ff J . T h y r o i d A b s c e s s ; Thyroidectomy; Recovery. Ann Surg. 1894 Oct;20(4):406-13. Jacobs A. Gros DC, Gradon JD. Thyroid abscess due to Acinetobacter cakoaceticus: Casereport and review of the causes of and current management strategies of thyroidabscesses. South Med J 2(X) 3:96:300-7. Lin ZH, Teng YS, Lin M. Acute thyroid abscess secondary to esophageal perforation. JInt Med Res. 2008 JulAug;36(4):860-4. Stavreas NP, Amanatidou CD, Hatzimanolis EG, Legakis I, Naoum G,Lakka-Papadodima E, Georgoulias G, Morfou P, Tsiodras S. Thyroid abscess due to a mixedanaerobic infection with Fusobacterium mortiferum. J Clin Microbiol. 2005Dec;43(12):6202-4. Menegaux, F., G. Biro, C. Schatz, and J. P. Chigot. 1991. Thyroid abscess. Apropos of 5cases. Ann. Med. Interne (Paris). 142:99-102

7. Kara E, Sakarya A, KeleĂ&#x2026;Ĺ¸ C, Borand H et

al. Case of Lemierre's syndrome presentingwith thyroid abscess. Eur J Clin Microbiol Infect Dis. 2004 Jul;23(7):570-2. 8. Mathew J, Goodfellow P, Chadwick DR. Thyroid abscess: an unusual case secondary tobiliary sepsis. Hosp Med. 2003 Oct;64(10):622-3. 9. Mitchell DH, Howden BP. Diagnosis and management of Staphylococcus aureusbacteraemia. Intern Med J. 2005 Dec;35 Suppl 2:S17-24.

Conclusion Abscess formation due to MRSA within the thyroid gland is rare. Thyroid abscess should besuspected in immunocompromised patients presenting with neck pain and swelling. Thiswould enable early diagnosis and treatment

Intrathyroid Abscess Formation with Multiple Necrotizing Cervical Lymphadenitis due to Meticillin Resistant Staphylococcus aureus (MRSA)

10. Al-Kordi RS, Alenizi E, Elgazzar AH.

Acute suppurative thyroiditis with abscess, gasformation, and thyrotoxic crisis. Nuklearmedizin. 2008;47(4):N446. 11. Houghton DJ, Gray HW, MacKenzie K. The tender neck:Thyroiditis or thyroid abscess?Clin Endocrinol (Oxf) 1995:48:521 4.32. 12. Takai SI. Miyauchi A, Matsuzuka F. et al. Intemal fistula as a route of infection in acutesuppurative thyroiditis. Lancet 1979:1:751-2. 13. Ilyin A, Zhelonkina N, Severskaya N, Romanko S. Nonsurgical management of thyroidabscess with sonographically guided fine needle aspiration. J ClinUltrasound. 2007 JulAug;35(6):333-7..

Anuradhapura Medical Journal 2012 Case Reports

ICU Management of a patient with Anaphylaxis Kudavidanage BP Department of Anaesthesia - Teaching Hospital Anuradhapura But most of these cases have been reported to occur in middle-aged and elderly people. We experienced a case of anaphylaxis occurring due to rocuronium during anaesthesia in a patient who is coming for a nephrectomy.

Abstract Hypersensitivity reactions might occur during anaesthesia. Muscle relaxants have the highest frequency of inducing anaphylaxis. Rocuronium is the most common out of all muscle relaxants. We experienced a case of anaphylaxis occurring due to rocuronium during anaesthesia in a patient who is coming for a nephrectomy at Queens Hospital, London, UK. We managed the episode of anaphylaxis according to guidelines established by Association of Anaesthetists of Great Britain and Ireland.

Case History Preoperative assessment Our patient was a 69 year old female Caucasian coming for an elective radical laparoscopic nephrectomy for multi locular renal cell carcinoma at Queens Hospital, London. She gave a history of well controlled hypertension without any end organ damage. She did not have any other medical problems. She had good exercise tolerance. She was on regular antihypertensives, namely Ramipril 2.5mg once daily, Bendroflumethiazole 2.5mg once daily and anti depression Citalopram 20mg nocte. She had undergone general anaesthesia for repair of detached retina in 1990. She received Thiopentone, Atracurium and Fentanyl for general anaesthesia and there were no reported complications. She didn't give any history of allergy to any of the medications or food.

Introduction Hypersensitivity reactions that might occur during anaesthesia, i.e., anaphylaxis and anaphylactoid reaction have been reported to have a variable degree of incidence. But it has been reported to be approximately1/3,00020,000 [1] and its mortality has been reported to be 3-6% [1]. Of the drugs which are used for anaesthesia, muscle relaxants have the highest frequency of inducing anaphylaxis. In addition, substances such as latex or antibiotics can also induce the occurrence of anaphylaxis. On the other hand, the occurrence of anaphylaxis due to anaesthetic agents has been frequently reported in men in their fifties and women in their forties. In paediatric patients aged ten years or younger, it occurs to such a rare extent as <4% of total cases of anaphylaxis [3]. In the mid-1990s, rocuronium bromide (one of the non depolarizing aminosteroid muscle relaxants with a short action time) has been introduced in a clinical setting. As described here, according to the increased use of rocuronium, although not yet available in Sri Lanka, the occurrence of Rocuronium anaphylaxis has been reported to rise [1].

On examination she was an averagely built lady. She was not pale. On assessment of her air way, she didn't present with a difficult airway. On cardiovascular assessment pulse rate was 65 beats per minute and blood Pressure was 170/85. Heart was in dual rhythm and no murmurs detected. Respiratory and central nervous systems were normal. Blood investigations were all normal except for haemoglobin which is 12.5. Consent was taken for surgery after explaining the risks of general anaesthesia and laparoscopic nephrectomy. 20

ICU Management of a patient with Anaphylaxis

Anaesthetic procedure

Post op management

After establishing 16G intravenous access on the dorsum of the right hand and stating 0.9% intravenous infusion, routine monitoring was established. Initial pulse rate was 70bpm, blood pressure 180/90mmHg and saturation was 96% on induction. Patient was induced intravenously using Propofol 130mg, Fentanyl 100Âľg and muscle relaxant was induced with Rocuronium 40 mg intravenously. Patient was intubated with size 8 end tracheal tube and tube was secured after checking the position. As soon as the patient was induced, saturation in the pulse oxymeter dropped to 60% and air way pressure increased to 40 cmH2O. Blood pressure also dropped to 60/30 and severe bradycardia was noticed. Patient was clinically flushed on examination.

Patent was admitted to intensive care for further management with intermittent positive pressure ventilation and infusions of Ephenephrene, Remifentanyl and Midazolam. On admission she was on 50% oxygen maintaining 100% saturation with PaO2 of 54 kPa and PaCO2 of 7.15 kPa. Chest X ray was clear without any evidence of pulmonary oedema. She was tachycardic with blood pressure maintained by adrenalin infusion. She was on Midazolam and Remifentanyl infusion for sedation with pupils reacting equally to light. Initial investigations were within normal range except for the serum potassium which was 3.2 mmol/l, glucose of 8.4 mmol/l with normal clotting profile. In addition serum tryptase was taken immediately after admission to the ICU, 6 hours after and 24 hours after the admission to ICU. Routine observation was carried out in the ICU with close monitoring for further evidence of anaphylaxis.

The initial differential diagnosis was a drop in blood pressure due to overdose of induction agents and anaphylactic reaction to induction agents or muscle relaxants.

Once haemodynamically stable she was gradually weaned off from adrenaline infusion and ventilatory support was reduced. Potassium was replaced intravenously. Advice for further management was taken from the regional allergic centre at the allergic clinic at the Guy's Hospital in London.

Intravenous fluids especially 500ml of colloids were transfused as a bolus, followed by injection of ephedrine and Metaraminol boluses to improve blood pressure. Epheneprene boluses were required to maintain blood pressure as blood pressure was low in spite of previous treatment. This was followed by Epheneprine infusion which was titrated according to the response to maintain the blood pressure.

She was referred to the allergic clinic at Guy's Hospital for further investigations, where she underwent skin testing and RAST testing. Skin testing was strongly positive for Rocuronium and Suxamethonium, while mildly positive for Vecuronium, Mivacurium and borderline positive for Atracurium. Investigations established that Cisatracurium, Pancuronium and Propofol are negative for the reaction and were safe to use. Therefore it was confirmed that the anaphylactic reaction was due to the Rocuronium which was used at the induction.

Management of the patient was done by following the guidelines for anaphylaxis management by the Association of Anaesthetists in Great Britain and Ireland. Accordingly Hydrocortisone 100mg and Ranitidine 50mg was given and Chlopheniramine 10mg also given intravenously.

She subsequently successfully underwent the surgery with Propofol, Pancuronium and fentanyl. 21

ICU Management of a patient with Anaphylaxis

On the other hand, Propofol may also cause the occurrence of anaphylaxis rarely. In the previous anaesthetic exposure, Propofol and rocuronium were not used. In this occasion, propofol, rocuronium was used along with Fentanyl. Based on these findings, in the current case, the possibility for anaphylaxis due to Propofol could not be ruled out.

Discussion We experienced a case in which anaphylaxis was strongly suspected based on hypotension, tachycardia and hypoxia due to the use of Rocuronium which was used for general anaesthesia. Two types of immediate hypersensitivity reactions including anaphylaxis and anaphylactoid reaction are classified according to the involvement of such antibodies as immuoglobulin E (IgE). But it is not easy to make a differential diagnosis of these two reactions based on the clinical symptoms. Instead, they can be classified according to skin test or biologic test. In association with this, it would be desirable to use such terms as anaphylactoid reaction in cases in which a diagnosis of immunological mechanisms was not made through an allergic test.

Anaphylaxis occurring during anaesthesia occurs at a frequency which is approximately four times higher in men than women [5]. In regard to the age, it occurs most frequently in people in their forties. Muscle relaxants are the most common drugs that cause the occurrence of anaphylaxis to a life-threatening extent during anaesthesia, accounting for approximately 50-70% of cases [6,7]. Anaphylaxis occurring due to muscle relaxants occurred the most frequently in people aged ten years or younger. Besides, it also occurred the most frequently in women aged in their thirties. Clinical characteristics due to rocuronium are mainly classified into two types: cardiovascular collapse and bronchospasm [2]. Generally in cases in which bronchospasm occurred due to anaphylaxis, due to the actions of alpha-1 elevating the blood pressure and those of beta-2 relaxing the bronchial smooth muscles, the immediate administration of epinephrine is important. Besides, in cases of cardiovascular collapse due to anaphylaxis, fluid supply is generally done and Epinephrine and Phenylephrine are administered. In cases which are refractory to these treatments, the administration of vasopressin could be of help [5].

In regard to most cases of the allergy occurring during anesthesia, i.e., acute hypersensitivity reaction, grade-2 responses (non-life-threatening skin reaction, hypotension accompanying tachycardia, coughing or the difficulty of mechanical respiration) or grade-3 responses (life-threatening cardiovascular collapse, bradycardia or tachycardia and severe bronchospasm) account for approximately 85% of total cases [4] The current case is the one that is suspected to be grade-2 or grade-3 anaphylaxis occurring due to rocuronium. To make an accurate diagnosis of anaphylaxis or anaphylactoid reaction, in addition to clinical symptoms, the concentrations of tryptase or IgE which are present in the blood should be measured. After several weeks following the occurrence of allergic reactions, skin prick test or intradermal test should be performed [5]. Skin reactions occurring during the allergic responses due to drugs may be manifested as urticaria, edema, pruritis, thermal sensation and red spots.

Due to the increased permeability of capillary during the occurrence of anaphylaxis, the plasma volume is abruptly increased. A massive amount of fluid therapy might also be essential in this case. Owing to this, the oedema might occur in the lung or respiratory tract. This might be due to the increased permeability of pulmonary capillary vessels because of anaphylaxis. 22

ICU Management of a patient with Anaphylaxis

However in the case discussed here clinical or radiological evidence of pulmonary oedema did not occur. We assumed the possibility that pulmonary oedema occurred due to anaphylaxis or might have originated from the negative pressure of the respiratory tract

References 1. Mertes PM, Aimone-Gastin I, GueantRodriguez RM, Mouton- Faivre C, Audibert G, O'Brien J, et al. Hypersensitivity reactions to neuromuscular blocking agents. Curr Pharm Des 2008; 14: 2809-25. 2. Heier T, Guttormsen AB. Anaphylactic reactions during induction of anaesthesia using rocuronium for muscle relaxation: a report including 3 cases. Acta Anaesthesiol Scand 2000; 44: 775-81. 3. Laxenaire MC, Mertes PM; Groupe d'Etudes des Reactions Anaphylactoides Peranesthesiques. Anaphylaxis during anaesthesia: results of a two-year survey in France. Br J Anaesth 2001; 87: 549-58. 4. Laxenaire MC, Mertes PM; Groupe d'Etudes des Reactions Anaphylactoides Peranesthesiques. Anaphylaxis during anaesthesia: results of a two-year survey in France. Br J Anaesth 2001; 87: 549-58. 5. Rose M, Fisher M. Rocuronium: high risk for anaphylaxis? Br J Anaesth 2001; 86: 678-82. 6. Mertes PM, Laxenaire MC. Allergy and anaphylaxis in anaesthesia. Minerva Anestesiol 2004; 70: 285-91. 7. Watkins J. Adverse reaction to neuromuscular blockers: frequency, investigation, and epidemiology. Acta Anaesthesiol Scand Suppl.1994; 102: 6-10. 8. Lee HM, Song SO. Anaphylaxis after injection of rocuronium: a case report. Korean J Anesthesiol 2006; 51: 101-4. 9. Laxenaire MC, Gastin I, MoneretVautrin DA, Widmer S, Gueant JL. Cross-reactivity of rocuronium with other neuromuscular blocking agents. Eur J Anaesthesiol Suppl 1995; 11: 5564. 10.Matthey P, Wang P, Finegan BA, Donnelly M. Rocuronium anaphylaxis and multiple neuromuscular blocking drug sensitivities. Can J Anaesth 2000; 47: 890-3.

On the other hand, Rocuronium is an amino-steroid nondepolarizing muscle relaxant whose pharmacological characteristics are similar to those of Vecuronium. In cases of allergic reactions due to Rocuronium, there might be cross reactions with other types of steroid non-depolarizing muscle relaxants. In particular, aminosteroid muscle relaxants have a higher prevalence of the cross-reactions as compared with benzilisoquinoline-derived muscle relaxants [9]. These muscle relaxants commonly have tetra-positively charged ammonium ion (NH4+) as an antigenic determinant. Due to this chemical structure, cross-reactions can occur. This should therefore be confirmed by further investigating the patient once stabilized [10]. The occurrence of Rocuronium induced anaphylaxis has been reported more frequently than that due to Vecuronium or Pancuronium and less frequently than that due to Succinylcholine [8]. There is a tendency that the use of Succinylcholine has recently been decreased and that of Rocuronium has been increased. Owing to this, the occurrence of rocuronium-induced anaphylaxis may be on the rise in western countries.

Conclusion Muscle relaxants are the most commonly recognized cause for allergic reactions due to anaesthesia. Rocuronium is the number one cause for allergy among the muscle relaxants in western countries. Prompt identification and appropriate treatment according to established guidelines is important for immediate management of anaphylaxis. Follow up and further investigations for confirmation of anaphylactic reactions and identification of causative agent is important for prevention of further anaphylactic reactions during future anaesthesia. 23

Anuradhapura Medical Journal 2012 Review Article

Aetiology for gastro intestinal reflux disease Weeerawardena WAK Department of Surgery - Teaching Hospital Anuradhapura

Abstract

alcohol, high salt intake, fibre intake, physical exercise are some of the association factors. People have capacity to alter those factors with view to reduce the incidence of GORD . Introduction

Introduction Gastro intestinal reflux disease(GORD) is common. The incidence is rising in the world and in Sri Lanka. Food habits, behavioural pattern are considered to be of concerned about aetiology.

GORD is common. The incidence is rising in the world and in Sri Lanka. Food habits, behavioural pattern are considered to be of concerned about aetiology. The therapeutic options are wide. However treatment may include long term PPI and laparotomy or thoracotomy with variable results. It is the time to investigate for the cause GORD. Adherent to preventive steps will abolish

Objective To identify the risk factors for GORD to make a plan for reducing the incidence o0f symptoms. Materials and methods Reviewed 23 journal articles published during last 15 years of duration. Key words of GORD, aetiology, risk factors were used. Different possible aetiological factors were identified and their relationship to GORD was assessed.

the complications of long term medication and extensive surgeries and the expenses involved. I have reviewed index journal literature published during last 15 years duration.

Results

Gastro-oesophageal reflux disease is a condition with the reflux of gastric contents into the oesophagus. This reflux provokes symptoms or complications and impairs quality of life. Typical symptoms of gastro-oesophageal reflux disease are ,

Gastric acid, tobacco smocking, table salt use, dietary factors, alcohol, physical activity, Body mass index, obesity, ethnicity, gender, posture, genetic contribution, medication effect, role of Helicobactor pylori, effect of naso gastric tubes, hiatus hernia, pregnancy, other cardiac diseases were identified for considering as aetiology. Special variety of infantile GORD was also selected.

1. heartburn 2. regurgitation However gastro-oesophageal reflux disease has also been related to extra-oesophageal manifestations, such as asthma, chronic cough and laryngitis. The pathogenesis of gastrooesophageal reflux disease is multifactorial. This involve transient lower oesophageal sphincter relaxations and other lower oesophageal sphincter pressure abnormalities. Reflux of acid, bile, pepsin and pancreatic enzymes cause oesophageal mucosal injury(1).

Discusion and conclusion Exact aetiology of GORD is largely unknown. However this review has detected several significant associations with GORD. Knowledge of those association factors are useful in the management of the symptoms. Overweight, obesity, tobacco smocking, 24

Aetiology for gastro intestinal reflux disease

Other factors contributing to the

1.Gastric acid

pathophysiology of gastro-oesophageal reflux The main diseases associated with dyspepsia are peptic ulcer disease, gastro-oesophageal reflux disease and non-ulcer dyspepsia. Increased gastric acid secretion is a characteristic of most duodenal ulcer patients and of a small minority of non-ulcer dyspepsia and GORD patients. Although acid secretion is normal in most GORD patients, the condition is mainly the result of excess exposure of the distal oesophagus to acid refluxing from the stomach. Increased mucosal sensitivity to acid is the aetiology of dyspeptic symptoms in the majority of patients with peptic ulcer disease and GORD, and in a minority of nonulcer dyspepsia subjects. Gastric acid, therefore, plays an important role in both the aetiology of dyspeptic diseases and in the aetiology of dyspeptic symptoms (3)

disease include, 1.hiatal hernia, 2. impaired oesophageal clearance, 3.delayed gastric emptying 4. impaired mucosal defensive factors. Hiatal hernia contributes to gastro-oesophageal reflux disease by promoting lower oesophageal sphincter dysfunction. Impaired oesophageal clearance is responsible for prolonged acid exposure of the mucosa. Delayed gastric emptying, resulting in gastric distension, can significantly increase the rate of transient lower oesophageal sphincter relaxations, contributing to postprandial gastro-oesophageal reflux disease(1,2).

2. Tobacco smocking , alcohol and table salt

Method

The aetiology of gastro-oesophageal reflux is largely unknown. In Norway, a case control study within the two public health surveys, including 3153 individuals reported severe heartburn or regurgitation during the last 12 months were defined as case. They included 40 210 people without reflux symptoms to constitut the control group. There was a significant dose response association between tobacco smoking and reflux symptoms. Among people who had smoked daily for more than 20 years the odds ratio was 1.7 (95% confidence interval 1.5 to 1.9) compared with non-smokers. (4, 5)Another large, population based study provides that tobacco smoking causes symptomatic GORD.(11)

Pubmed search were carried out to find out the aetiological factors for GORD. 22 journal articles were reviewed published during last 15 years. Key words of GORD, aetiology, risk factors were used. Different aetiological factors were identified and their relationship to GORD was assessed. Results Gastric acid, tobacco smocking, table salt use, dietary factors, alcohol, physical activity, Body mass index, obesity, ethnicity, gender, posture, genetic contribution, medication effect, role of Helicobactor pylori, effect of naso gastric tubes, hiatus hernia, pregnancy, other cardiac diseases were identified for considering as aetiology. Special variety of infantile GORD was also selected.

In two large population base studies , alcohol was not identified as a risk factor(4)(11) . However total of 7124 subjects were interviewed as part of the German National Health Interview and Examination Survey, a representative sample of the general adult population. They found that smoking and the frequent consumption of spirits are risk factors for GORD.(5)GORD shows a positive association with table salt intake. The odds ratio for reflux was 1.7 (95% CI 25

Aetiology for gastro intestinal reflux disease

1.4 to 2.0) among those who always used extra table salt compared with those who never did so.(4) Another large, population based study shows that table salt intake seem to be risk fa c t o r s fo r g a s t ro - o e s o p h a g e a l re f l u x symptoms(11).

A large population based study provides firm evidence that dietary fibres may protect against reflux.(11)(4).Coffee, and tea do not seem to be risk factors for reflux(4)(11). 4. Overweight and obesity.

3. Dietary factors A team used PubMed and Ovid to perform a search of the literature published between 1975 and 2004 using the key words heartburn, GERD(Gastro esophageal reflux disease), smoking, alcohol, obesity, weight loss, caffeine or coffee, citrus, chocolate, spicy food, head of bed elevation, and late-evening meal. Although there was physiologic evidence that exposure to tobacco, alcohol, chocolate, and high-fat meals decreases lower esophageal sphincter pressure, there was no published evidence of the efficacy of dietary measures. Neither tobacco nor alcohol cessation was associated with improvement in esophageal pH profiles or symptoms (9). In two large population base studies, alcohol was not identified as a risk factor (4, 11). However total of 7124 subjects were interviewed as part of the German National Health Interview and Examination Survey, a representative sample of the general adult population. They found that smoking and the frequent consumption of spirits are risk factors for GORD.(5)

A total of 7124 subjects were interviewed as part of the German National Health Interview and Examination Survey, a representative sample of the general adult population. They found an association among those with reflux symptoms who were overweight and obese (odds ratio: 1.8, 95% confidence interval: 1.5-2.2; odds ratio: 2.6, 95% confidence interval: 2.2-3.2), respectively. A study demonstrated a clear and dosedependent association between increasing degrees of overweight and gastro-oesophageal reflux. The mechanisms by which obesity causes reflux are unknown though there is some limited data to suggest that hiatal hernia may be the causal link between obesity and reflux. There are some evidence that obesity is clearly a stronger risk factor among women than among men, and that the relation between overweight and reflux is substantially augmented by postmenopausal hormone therapy(6). Weight-reduction seems to reduce the risk of symptomatic GORD , indicating that such strategy might be a useful tool in the treatment of reflux. (6)(9). In 2000, a team used a supplemental questionnaire to determine the frequency, severity, and duration of symptoms of gastroesophageal reflux disease among randomly selected participants in a Study. Of 10,545 women who completed the questionnaire (response rate, 86 percent), 2310 (22 percent) reported having symptoms at least once a week, and 3419 (55 percent of those who had any symptoms) described their symptoms as moderate in severity.(7) Body mass index (BMI) is associated with symptoms of gastroesophageal reflux disease in both normal-weight and overweight women. Even moderate weight gain among persons of normal weight may cause or exacerbate symptoms of reflux (7).

A team systematically reviewed the pathogenetic link between overweight/obesity, dietary habits, physical activity and GERD, and the beneficial effect of specific recommended changes, by means of the available literature from the 1999 to 2009.(10) . The role of dietary behavior, mainly in terms of specific dietary components, remains controversial. Mild routine physical activity in association with diet modifications, i.e. a diet rich in fiber and low in fat, is advisable in preventing reflux symptoms (10,4). Physical activity and the consumption of fruits seemed to have some protective effect and sweets, or white bread are risk factors for GORD (5) .

Aetiology for gastro intestinal reflux disease

A study was done to systematically review the pathogenetic link between overweight/obesity, dietary habits, physical activity and GORD, and the beneficial effect of specific recommended changes, by means of the available literature from the 1999 to 2009(10).This team concluded that, being obese/overweight and GORD-specific symptoms and endoscopic features are related, and weight loss significantly improves GORD clinical-endoscopic manifestations (10)

esophagus. Due to the associated risk of postoperative pulmonary complications, they recommend that nasogastric intubation be performed on a selective rather than routine basis.(12). 9. Gastro oesophageal reflux in infants According to epidemiological data, the role of gastro-oesophageal reflux in the aetiology of this life threatening events is unclear.The incident of sudden infant death is decreased in the supine versus the prone sleeping position. On the contrary, gastro-oesophageal reflux is more pronounced in the supine than in the prone position, both in infants and in older children, both in infants with physiological and with pathological reflux. In the supine position, infants do sleep shorter, have more rapid-eye-movement sleep and have more arousals than in the prone position. It is thought that in the majority of infants, gastro-oesophageal reflux stimulates arousals and thus may well be considered as "protective" for rather than "provoking" sudden infant death. However the authors concluded that this hypothesis needs to be validated.(13).

5. Physical activity A large, population based study provides firm evidence that physical exercise may protect against reflux(11, 4,5). 6. Ethnicity and gender. There was a consistent association between abdominal diameter (independent of BMI) and reflux-type symptoms in the white population, but no consistent associations in the black population or Asians. The BMI association was also strongest among the white population. These findings, combined with the increased prevalence of abdominal obesity in male subjects, suggest that an increased obesity may disproportionately increase GORD-type symptoms in the white population and in male subjects. (8)

10. Genetic contribution A total of 4480 unselected twin pairs, identified from a national volunteer twin register, were asked to complete a validated symptom questionnaire about GORD in Glagow ,United Kingdom. GORD was defined as symptoms of heartburn or acid regurgitation at least weekly during the past year (14). They detected that there is a substantial genetic contribution to the aetiology of GORD.

7. Posture Head of bed elevation and left lateral decubitus position improved the overall time that the esophageal pH was less than 4.0. Weight loss and head of bed elevation are effective lifestyle interventions for GERD(9)

11. Relation to Helicobactor pylori 8. Nasogastric tubes Epidemiological studies demonstrate a negative association between Helicobacter pylori infection and gastro-oesophageal reflux disease and its complications. This might represent a protective effect for GORD as the tendency for H. pylori infection lower the gastric acid secretion with advancing age.

A prospective randomized case-control study with 15 consenting patients demonstrated that patients undergoing elective laparotomy with routine nasogastric tube placement have significant gastroesophageal reflux in the perioperative period and shows reduced ability to clear refluxed acid from the distal 27

Aetiology for gastro intestinal reflux disease

However, studies of the effect of H. pylori eradication on GORD have failed to show any worsening of GORD symptoms. Helicobacter pylori infection improves the control of gastric acidity by proton-pump inhibitors and this produces a small advantage in clinical control of reflux disease. The infection prevents rebound acid hypersecretion occurring when protonpump inhibitor therapy is discontinued. However, concerns have been expressed that the body gastritis induced by proton-pump inhibitor therapy in H. pylori-infected subjects might increase the risk of gastric cancer. At present, it is unclear whether H. pylori should be eradicated in gastro-oesophageal reflux disease patients.(15)

People experiencing frequent GOR D symptoms have markedly increased risks of oesophageal adenocarcinoma and gastro oesophageal junctional adeno carcinoma , and this effect may be greater amongst smokers. Use of aspirin and NSAIDs, but not acid suppressants, significantly reduced the risks of oesophageal cancers associated with GORD(22) Naproxen did not induce reflux in normal subjects, although reflux did increase in some subjects (23) Individuals with long-standing GERD are at increased risk of esophageal adenocarcinoma, whether or not the symptoms are treated with H2 blockers or antacids(16)

12. Hiatus hernia Hiatal hernia, in combination with other reflux conditions and symptoms, was associated s t ro n gly w i t h t h e r i s k o f e s o p h a g e a l adenocarcinoma. These associations were more modest for gastric cardia adenocarcinomas. A significant and positive association between body size and history of hiatal hernia/reflux symptoms also was observed.(17)

14. Other diseases A multicenter questionnaire survey demonstra ted that among traditional cardiovascular risk factors, AF was an independent risk factor for GERD. A large cohort study to assess the pote ntial relationship between GERD and AF is warranted. (19)

13. Medications

15. Pregnancy

A multicenter questionnaire survey concluded that though larger cohort is required for further study, the combination of calcium channel blo ckers and warfarin is an independent risk factor for GORD(18).

Heartburn is a common symptom in pregnancy, affecting about two-thirds of pregnant women. The aetiology of GORD in pregnancy is multifactorial. Reduced lower basal gastrooesophageal sphi ncter pressure, increased intragastric pressure, delayed intestinal transit time and duodenogastric reflux have been found in pregnant women with heartburn, all factors which dispose to increased gastro-oesophageal reflux. Gastric emptying is apparently normal during pregnancy, but delayed during delivery. Therapy involves lifestyle modification and nonsystemic medication as the initial choices. H2-antagonists should only be used in severe and refractory cases(20)

Oral bronchodilators are known to worsen GORD and may lead to vicious cycle when gastr oeso pha geal reflux causes bronchospasm. The effect of in haled bronchodilators on gastroeso phageal refl ux is unknown. Patients with gast roeso pha geal reflux disease, who require bron chodilator ther apy for obstructive lung disease, have less re flux with inhaled albuterol (22) )

Aetiology for gastro intestinal reflux disease

Discussion

Conclusion

Exact aetiology of GORD is largely unknown. However this review has detected several significant association factors with GORD. Knowledge of those association factors is useful in the management of the symptoms. Overweight, obesity, tobacco smocking, alcohol, high salt intake, fibre intake, physical exercise are some of the association factors. People have capacity to alter those factors with view to reduce the incidence of GORD. It was also useful to review the association of the symptoms with tea and coffee. The relationship with the medications is valuable for the clinicians in their practice. The association of GORD with the nasogastric tube and posture need to be considered during inpatient management. The association of GORD with genetic changes, ethnicity and gender are useful in future research(4,5,11).

With the available data a preventive program can be arranged to reduce the incidence of GORD at North Central Province of Sri Lanka. Simple heath education may prevent sinister complications of GORD. References 1) F De Giorgi, M Palmiero, I Esposito, F Mosca, R Cuomo. Pathophysiology of gastro-oesophageal reflux disease . Acta Otorhinolaryngol Ital. 2006 26(5): 241â&#x20AC;&#x201C;246. 2)John Bancewicz. The oesophagus. In Baily and Love s Short Text Book of Surgery. RCG Russell, NS W illiams, CJK Bulstrode . 23 rd Edition , Arnold 2000 .863-871. 3)McColl KE. Role of gastric acid in the aetiology of dyspeptic disease and dyspepsia. Baillieres Clin Gastroenterol. 1998 ;12(3):489502.

Transient loosening of the lower oesophageal sphincter tone is suspected to be the mechanism of reflux. The angle between stomach and oesophagus, intra abdominal pressure over the intra peritoneal part of oesophagus are also play a role in preventing reflux. Those associated triggering factors for reflux are expected to alter the defense mechanism of anti reflux process. The anti reflux medication and surgical procedures are aiming at strengthening of those lower oesophageal sphincter tone and normalizing the angle between stomach and oesophagus. There is a failure rate Of those surgical procedures and medical therapy and the t h e ra p e u t i c c o s t i s ve r y h i g h t o t h e community(2). Once the symptoms star, the investigation with upper gastro intestinal endoscopy, Ba swallow, 24 hours ambulant lower oesophageal pH measurement with calculation of DeMeester score are useful. Considering about the cost of those investigations it is necessary to adhere to a preventing steps of the disease. Simple change of diet and behaviour will reduce the symptoms and consequences. Patient education and induction of exercise based weight reduction programs are expected to be favourable.

4)Nilsson M, Johnsen R, Ye W, Hveem K, Lagergren J.Lifestyle related risk factors in the aetiology of gastro-oesophageal reflux.Gut. 2004 ;53(12):1730-5. 5)Nocon M, Labenz J, Willich SN. Lifestyle factors and symptoms of gastro-oesophageal reflux -- a population-based study.Aliment Pharmacol Ther. 2006 1;23(1):169-74. 6)Nilsson M, Lagergren J. The relation between body mass and gastro-oesophageal reflux.Best Pract Res Clin Gastroenterol. 2004 Dec;18(6):1117-23. 7)Jacobson BC, Somers SC, Fuchs CS, Kelly CP, Camargo CA Jr. Body-mass index and symptoms of gastroesophageal reflux in women.N Engl J Med. 2006 1;354(22):2340-8. 8) Corley DA, Kubo A, Zhao W.Gut.Abdominal obesity, ethnicity and gastro-oesophageal reflux symptoms 2007 ;56(6):756-62. Epub 2006 Oct 17. 29

Aetiology for gastro intestinal reflux disease

(9)Review Kaltenbach T, Crockett S, Gerson LB.Arch Intern Med. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach.2006 ;166(9):965-71.

17) Wu AH, Tseng CC, Bernstein L. Hiatal hernia, reflux symptoms, body size, and risk of esophageal and gastric adenocarcinoma. . Cancer. 2003 1;98(5):940-8. 18)Nakaji G, Fujihara M, Fukata M, Yasuda S, Odashiro K, Maruyama T, Akashi K. Influence of common cardiac drugs on gastroesophageal reflux disease: multicenter questionnaire survey. Int J Clin Pharmacol Ther. 2011;49(9):555-62.

10) Festi D, Scaioli E, Baldi F, Vestito A, Pasqui F, Di Biase AR, Colecchia A Body weight, lifestyle, dietary habits and gastroesophageal reflux disease World J Gastroenterol. 2009 14;15(14):1690-701. 11)M Nilsson,R Johnsen,W Ye,K Hveem,J Lagergren . Lifestyle related risk factors in the aetiology of gastro-oesophageal reflux Gut. 2004; 53(12): 1730â&#x20AC;&#x201C;1735. 12)Manning BJ, Winter DC, McGreal G, Kirwan WO, Redmond HPNasogastric intubation causes gastroesophageal reflux in patients undergoing elective laparotomy. Surgery. 2001;130(5):78891.

19) Shimazu H, Nakaji G, Fukata M, Odashiro K, Maruyama T, Akashi K; Fukuoka F-Scale Trial Group Relationship between atrial fibrillation and gastroesophageal reflux disease: a multicenter questionnaire survey. Cardiology. 2011;119(4):217-23 20)Okholm M, Jensen SM. [Gatroesophageal reflux in pregnant women] [Article in Danish] . Ugeskr Laeger. 1995 27;157(13):1835-8.

13)Vandenplas Y, Hauser B. Gastro-oesophageal reflux, sleep pattern, apparent life threatening event and sudden infant death. The point of view of a gastro-enterologist. Eur J Pediatr. 2000;159(10):726-9.

21)Ruzkowski CJ, Sanowski RA, Austin J, Rohwedder JJ, Waring JP. The effects of inhaled albuterol and oral theophylline on gastroesophageal reflux in patients with gastroesophageal reflux disease and obstructive lung disease. Arch Intern Med. 1992;152(4):783-5.

14) Mohammed I, Cherkas LF, Riley SA, Spector TD, Trudgill NJ. Genetic influences in gastrooesophageal reflux disease: a twin study. Gut. 2003;52(8):1085-9.

22)Pandeya N, Webb PM, Sadeghi S, Green AC, Whiteman DC; Australian Cancer Study.Gastrooesophageal reflux symptoms and the risks of oesophageal cancer: are the effects modified by smoking, NSAIDs or acid suppressants? Gut. 2010;59(1):31-8.

15) Delaney B, McColl K.Review article: Helicobacter pylori and gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2005 Aug;22 Suppl 1:32-40. 16) Farrow DC, Vaughan TL, Sweeney C, Gammon MD, Chow WH, Risch HA, Stanford JL, Hansten PD, Mayne ST, Schoenberg JB, Rotterdam H, Ahsan H, West AB, Dubrow R, Fraumeni JF Jr, Blot WJ. Gastroesophageal reflux disease, use of H2 receptor antagonists, and risk of esophageal and gastric cancer. Cancer Causes Control. 2000 Mar;11(3):231-8.

(23) Scheiman JM, Patel PM, Henson EK, Nostrant TT. Effect of naproxen on gastroesophageal reflux and esophageal function: a randomized, double-blind, placebocontrolled study. Am J Gastroenterol. 1995;90(5):754-7.

Anuradhapura Medical Journal 2012 Abstracts

An analysis of psychiatric referrals In a multidisciplinary General hospital in Sri Lanka Dharmawardene V. Department of Psychiatry Teaching Hospital Anuradhapura

Introduction Psychiatric morbidity significantly affects the outcome of physical illness. Rate of psychiatric morbidity is 20-50% of the inpatient population in global studies. There is limited published data on the subject from a Sri Lanka. Objective To describe the patterns of psychiatric morbidity in referrals from the inpatient population received at the psychiatric unit of teaching hospital Anuradhapura, a multidisciplinary hospital. Methods and design A Retrospective file review was carried out into all the ward referrals received between 01 May 2012 and 31 July 2012. All the assessments during the period had been conducted by one consultant psychiatrist. Results: There were 213 Referrals received during the study period comprising 0.58 % of the admissions. 59% were females. Highest number was received from the general medical wards (47%) followed by cardiology (18%) and surgery (12%). 30% did not have any diagnosable psychiatric illness. Commonest psychiatric diagnosis was depressive disorder (19%). 24% of the referrals were for patients who have attempted self harm (DSH). Oleander seed ingestion was the commonest method (44%) followed by medication overdose (22%) with only 18% seen with ingestion of agrochemicals. 11% patients who have attempted self harm had depressive illness. The rate was 06 % for oleander seed ingestion. Conclusions: Though Depressive illness appears to be the commonest diagnosis, it is relatively less common among the DSH patients. DSH by agrochemicals are represented less in this sample.

Anuradhapura Medical Journal 2012 Abstracts

Awareness of well woman clinic services among attendees to Anuradhapura on Poson poya day: are the socially deprived at a disadvantage? Warnasekara YPJN, Gamakumbura MK, Koonthota SD, Liyanage LSK, Maduwantha KDNK, Pemasiri WRAM, Lakpriya BAD, Hendawitharana KJ, Gunathilaka JAMTN, Athukorala APN , Agampodi SB Faculty of Medicine and Allied Sciences (FMAS), Rajarata University of Sri Lanka (RUSL) Department of Community Medicine, FMAS, RUSL Background Though the Well Woman Clinic (WWC) in Sri Lanka has been designed as the primary strategy for secondary prevention of breast and cervical cancers, whether we have yielded the utmost public health outcome from it is questionable. Objective To assess the awareness and the use of WWC for screening for these two malignant conditions among women aging more than 35 years (target group of WWC). Methods A rapid spot survey was conducted in the sacred city of Anuradhapura on 4th, June 2012 (Poson poya day). (Statistics show that this is the largest gathering of people representing a majority of areas in Sri Lanka on a single day.) The study sample included women aged 35 and above, who came to the premises on the day and those who consented to participate. This was done as a part of health promotion program conducted by MSU, FMAS. Results A total of 3116 females from 22 districts were interviewed. Mean age of the study sample was 52.6 years (SD 10.3 years). Risk of breast and cervical cancers in their age group was known only to 1150 (36.9%) and 1011 (32.4%) women respectively. Awareness on availability of WWC was 60.8%. However, only 578 (18.5%) have attended the WWC. Of the women reported as professionals or associate professionals (n=217), awareness on WWC was 87.6% compared to 58.8% among other occupation categories and housewives. Clinic attendance was also significantly higher (40.1% compared to 16.9%) among this group. Younger (<60years) women had a significantly higher awareness on WWC (64.7% compared to 48.2%) and a higher number of them (20.3% compared to 13.1%) have attended the WWC. Conclusion A gross social disparity was observed on WWC awareness and attendance. Health promotional programs should focus more on socially disadvantaged groups.

Anuradhapura Medical Journal 2012 Abstracts

Infant feeding behaviors in Nuwaragam-Palatha-Central (NPC) Medical Officer of Health (MOH) area; a qualitative study. Agampodi TC, Chathurani HKJU, Agampodi SB Department of Community Medicine, Rajarata University of Sri Lanka

Background Although Sri Lanka has achieved exemplary progress in many maternal and child health services, indicators related to childhood nutrition have been disappointing and stagnating for the past few decades. Locally prevalent behavioral factors may play an important role in determining child nutrition. Objective To explore the infant and youngchild feeding behaviors of mothers in NPC- MOH area. Methods We used a qualitative approach using two key informant interviews with public health midwives and six focus group discussions (FGDs) with mothers of children less than 2 years of age to identify the locally prevalent food practices, behaviours, belief and myths. Participants for these FGDs were selected from child welfare clinics. Around 8-12 participants were selected for each FGDs and Family Health International guidelines were be followed in conducting the discussions. Interviews were tape recorded; transcribed and thematic analysis was performed. Results Optimal and suboptimal behavioural factors were identified in mothers having children with normal and inadequate weight gain respectively. Mothers having children with normal growth were appropriately informed by the service providers to practice infant feeding guidelines given by the national child health programme. Suboptimal behaviours identified among the group of mothers who had children with inadequate weight gain were mainly related to; exclusive breast feeding, selection and preparation of complementary foods, complimentary feeding patterns and adaptation to adult foods. Healthcare providers and mothers of small children had different views and perceptions on causes for growth problems. Service providers were not having an in-depth understanding of sub optimal practices in this community. Discussion Identification of locally prevalent behavioural factors should be used in local programme planning for infant feeding. Qualitative techniques are useful for in-depth exploration of these behaviours.

Anuradhapura Medical Journal 2012 Abstracts

Habits of the players during the competition day Rajasinghe SV1 , Thurairaja C 2 1

Sports Medicine Unit, T.H. Anuradhapura. Oasis Hospital, Colombo.

Introduction Every player should need proper training, skills and several other factors for his success, but optimal performance will depend on his behavior on the day of competition. Objectives To assess the habits and practices which are negatively affect the performance of the players during the competition. Method 50 players aged 16-40 years were assessed by an interviewer administered questionnaire during the North central provincial meet 2011. Results Sixteen players (32%) were between 21-25 years of age and 60% (n=30) have not had their breakfast. 19 (38%) players consumed simple carbohydrate like glucose before the event. Twenty two players (44%) reported to the venue before 15-30 minutes and 72% (n=36) of the players didn't do proper warm-up before their event. 29 (58%) players sustained an injury during the event and 94% of the players did not do any type of cooling down. 60% have not had post-event meal and only 10% had it within 1 hour. 88% players consumed fluids after the event but pre-event fluid consumption was only 40%. 54% of players experienced sleep disturbances day before the night. Discussion Majority of players paid less attention to essential factors like pre-event meal, warm-up and cooling down during the competition day, though they have done those during their training. Players, coaches as well as parents should be educated regarding this in order to gain better outcome.

Anuradhapura Medical Journal 2012 Abstracts

Bacteriological profile with their antibiograms in neonatal septicaemia in a Teaching Hospital in Srilanka Fernando R, Samarawickrama B. Microbiology Department District General Hospital Chilaw Introduction Neonatal septicemia continues to be a major problem in Neonatal ICU. The gold standard for diagnosis of septicemia is the isolation of the microorganism from the blood culture which takes 48 hrs to 7 days. Therefore empirical treatment is crucial & it should be based on the local sensitivity data. Objectives To determine the Bacteriological profile with their antibiogram and to provide sensitivity data to make local treatment protocols Materials and Methods Total blood culture samples received in Brain Heart Infusion broth from clinically suspected cases of neonates from neonatal ICU from 1st January, to 31st December 2010 included for the study. Standard isolation procedures were done using blood, chocolate and MacConkey agar. All the organisms were identified by standard methods. However most Enterobactereciae were further identified using API 20E. Stokes disc diffusion method was used for susceptibility testing and ESBL detection was done using clavulanic acid . Materials and Methods Total blood culture samples received in Brain Heart Infusion broth from clinically suspected cases of st neonates from neonatal ICU from 1st January, to 31 December 2010 included for the study. Standard isolation procedures were done using blood, chocolate and MacConkey agar. All the organisms were identified by standard methods. However most Enterobactereciae were further identified using API 20E. Stokes disc diffusion method was used for susceptibility testing and ESBL detection was done using clavulanic acid .

Bacteriological profile with their antibiograms in neonatal septicaemia in a Teaching Hospital in Srilanka

Results: During the study period 838 blood cultures were requested and 121 non repetitive specimens were positive (14.4%). Gram negative bacilli (59.5%) were more frequently isolated than Gram positive cocci (GPC) (40.5%). API 20E identification method was able to identify Klebsiella spp (30.4%), Enterobacter spp (20.2%), Escherichia coli (13%) as the common pathogens. 15.9% were unclassified with API and 20.2% of Enterobactereciae were unidentified. Coagulase negative staphylococcus (CNS) (63%), and Staphylococcus aureus(18%) were the major GPC . Other pathogens were Grp D streptococcus (4), Group B streptococci (3), Methicillin resistant Staphylococcus aureus (2), pseudomonas spp (2) and Acinetobacter spp(1). Majority of Enterobactereciae were ESBL producers and sensitive to ciprofloxacin meropenam and amikacin . Coagulase negative stayhlococcus resistance to penicillin and cloxacillin was 100% and 83% respectively. Penicillin resistance in staphylococcus aureus was 78%. However, only 18% of Staphylococcus aureus were found to be MRSA. All Gram positive organisms were sensitive to vancomycin. Enterobactereciae antibiotic susceptibility

Amp

Cefu Co amox Cefotax

8.3 13.3

20.6

38.4

Genta Cipro

74.1

95.3

Merop Amikac

93.3

100

Conclusion ESBL producing Enterobactereciae were the main pathogens in neonatal sepsis in our NICU. Empirical antibiotic choice of neonatal septicaemia in most NICUs is penicillin and cefotaxime. But High ESBL prevalence among Enterobactereciae makes cefotaxime resistant. Therefore Amikacin can be recommended as a replacement for cefotaxime for empirical treatment of sepsis to prevent mortality. This situation is serious therefore we should focus on preventive measures such as strict asepsis during labour and correct hand hygiene to prevent transmission of resistant pathogens.

Anuradhapura Medical Journal 2012 Abstracts

Percutaneous Biliary Stenting For Malignant Biliary Obstruction â&#x20AC;&#x201C; Retrospective Single Center Case Series L P Paranahewa Asiri Surgical Hospital Objective To assess the effectiveness of percutaneous, retrograde biliary stenting as palliative management for malignant biliary obstruction. Method Retrospective analysis done of the patients referred for percutaneous biliary stenting to Asiri Surgical hospital from Nov 2011 to May 2012. The procedure was done under ultrasound / fluoroscopic guidance. The duct system was accessed on the right side with left sided access only with difficult catheter navigation. 035 'angled guide wire was used to bypass the stricture. Stenting was done following balloon dilatation. Type of stent selected according to the clinical situation and the affordability. Results During the period of 7 months 12 patients were referred for antegrade biliary stenting. 7 patients were referred following failed retrograde access of which one was done as a combined Randouz approach and 2 patients were post surgical with unsuitable anatomy for retrograde approach. 5 patients had obstruction distal to the biliary confluence and in 7 patients the obstruction was in the CBD distal to the confluence. In 8 patients the obstruction was complete. Procedure was successful in 11 patients, 2 patients having the procedure in 2 stages. The procedure failed in one patient due to tight stricture involving the confluence which could not be bypassed. Conclusion Percutaneous antegrade approach is successful in crossing a malignant stricture for palliative biliary stenting especially useful in failed retrograde approach or in patients with post surgical anatomy unsuitable for retrograde approach.

Anuradhapura Medical Journal 2012 Abstracts

Pre competition anxiety among athletes Sumudu V. Rajasinghe 1, Dilini V. Vipulaguna 2 1 Sports Medicine Unit, T.H. Anuradhapura. 2 Faculty of Medicine, Colombo. Introduction Mental preparation is one of the most important part of an individual's sports performance. Anxiety caused by impending competition will lead to problems in sleep and reduction in performance. Most players do not realize this and they blame for other factors for their poor performance. Objectives To assess the level of anxiety and psychological factors that can negatively affect the performance of the players during the competition. Method 50 players aged 16-40 years were assessed by an interviewer administered questionnaire including SCAT (Sport competition anxiety test) during the North central provincial sports meet 2011. Results Most players (54%, n=27) were athletes and 34 (68%) were involved in individual events. Sixteen players were (32%) between 21-25 years of age and 74% (n=37) were males. Majority (72%, n=36) had average SCAT score but 26% (n=13) had high score. 52% (n=26) players had problems related to sleep before their competition and players involved in individual events experienced more sleep problems and high SCAT score.64% (n=32) were not aware about the coping strategies like relaxation and 96% (n=48) of players never used it. Discussion Pre competition anxiety will adversely affect performance. Identification of anxiety among players is utmost important and coping strategies like relaxation should be taught to players as well as coaches to control pre competition anxiety.

Anuradhapura Medical Journal 2012 Abstracts

Predictive validity of Post Prandial Blood Sugar (PPBS) at booking visit and routine urine dip stick test (UDST) in detecting Gestational Diabetes Mellitus (GDM) Ranasinghe ORJC1, Dahanayaka NJ2, Agampodi SB2 1 Taeching Hospital Anuradhapura and 2Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka

Background Prevalence of GDM in Sri Lanka is estimated to be around 5-10%. Recommended screening methods for detection of GDM include risk based PPBS and routine urine dip stick test. Objective To determine the predictive validity of PPBS at booking visit and the validity of UDST to detect GDM among pregnant women in Anuradhapura district. Methods Pregnant women at 24-28 week POA, residing in Anuradhapura district and who had undergone PPBS during the first trimester were selected for the present study. GDM was defined using International Association of Diabetes and Pregnancy Study Group (IADPSG) criteria using 75g Oral Glucose Tolerance Test (OGTT). Screening results were extracted from the ante natal records. Ethical clearance was obtained from the ethics review committee of Faculty of Medicine & Allied Sciences, Rajarata University of Sri Lanka. Results Of the 405 women screened for the study, only 113 (27.9%) had PPBS either at booking visit or during the first trimester. Out of them, 19 (6.8%) were confirmed as having GDM. Sensitivity, specificity, positive and negative and predictive values of PPBS was 10.5%, 100.0%, 100.0% and 84.6% respectively. Regular UDST was done for 389 (96.0%) pregnant women and of them, 43 (10.9%) were confirmed as having GDM. Out of them, only 3 had abnormal dipstick results. There were 7 false positive urine dipstick results at least once during the pregnancy showing a sensitivity of 6.8%. Conclusion Validity of the present recommended screening practice is highly doubtful. Alternative methods for screening should be employed to control the effects of GDM.

Anuradhapura Clinical Society Office bearers 2012 President Dr. Darshana Sirisena President Elect Dr. Damith Chandradasa Immediate Past President Dr.W.A.K. Weerawardana Joint Secretaries Dr.Niranjala Meegoda Widanage Dr. Rohan Dissanayake Treasurer Dr.Deeptha Wickramarathna Editorial Advisor Professor Sisira Siribaddana Editors Dr. Akalanka Jayasinghe, Dr. Wishva Panagoda

Commite Members Dr Rajeewa Dasanayake, Dr Priyantha Dissanayake, Dr Sanjeewa Hulangamuwa,Dr Senaka pilipitiya, Dr Sujeewa Thalgaspitiya, Dr Thamara Illangasinghe, Dr Sidath Yawasinghe, Dr Lasantha Bandara. Dr Kelum Dehigaspitiya,Dr Chamila Herath, Dr Charitha Herath, Dr Darshana Chandrakumara, Dr Thushara Bandara