SLM News 2016 02

February 2016, VOLUME 09, ISSUE 02

NEWS

REGISTERED AT THE DEPARTMENT OF POST QD/30/NEWS/2016

THE OFFICIAL NEWSLETTER OF THE SRI LANKA MEDICAL ASSOCIATION

Picture Story in Heamatology

Hippocrates - Medicine Becomes A Science

.........in page 3

First, Do No Harm

.........in page 4

Radiology Useful in General Practice

.........in page 8

Hard Work vs Smart Work

.........in page 18

.........in page 19

MALARIA COUNT

2016

07

SCAN THIS CODE TO READ ONLINE

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SLMA President Dr. Iyanthi Abeyewickreme

CONTENTS

MBBS (Ceylon), Diploma in Venereology (London), MSc, MD (Colombo),

President's Message

02

Monthly Clinical Meeting

02

Picture Stories in Haematology

03

First Do No Harm

04

Abstract Submission 2016

06

Appropriate use of Radiological Investigations in General Practice

08

Cover Story

13

List of Training Centres for Radiology Trainees

14

SLMA Joint Clinical Meeting

16

Emerchemie NB (Ceylon) Ltd.

Malaria Count

18

Official Newsletter of The Sri Lanka Medical Association

Hard Work Vs Smart Work

19

Tel: +94 112 693324 E mail: office@slma.lk

A Message from the Editor

20

Circular Letter on Still Birth Registration

22

FCVSL, Hon. Senior Fellow PGIM Consultant Venereologist

SLMA News Editorial Committee 2016 Editor-In-Chief: Dr. Hasini A. Banneheke Committee: Dr. Sarath Gamini De Silva Dr. Kalyani Guruge Dr. Ruvaiz Haniffa Dr. Amaya Ellawala

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1

PRESIDENT’S MESSAGE

S

ince the new Council for 2016 took office just a month ago, a number of issues of national importance related to health made headlines in the local media. The controversy on kidney transplantations carried out in Private Hospital in Sri Lanka on Indian nationals was discussed at length at an emergency council meeting and the council decided to issue a statement expressing SLMA’s concern. The statement was published in leading newspapers and called for strengthening current guidelines and procedures for organ transplant programmes including the implementation of the National Organ Programme for Deceased Donor Organ Transplants. It also highlighted the need to strengthen the capacity of ethics committees in hospitals to implement these guidelines and monitor such programmes.

The SLMA was deeply concerned about the recent media reports on the alleged administrative changes being made at the National Medicinal Drug Regulatory Authority (NMDRA). The NMDRA is a crucial arm of a rational drug policy for Sri Lanka and the SLMA has been a close partner in its evolution and establishment. The SLMA wrote to the Minister of Health seeking clarification regarding the media reports on changes being made to the NMDRA.

The Director General of Health Services (DGHS) has allocated three meetings for the SLMA for 2016 to discuss relevant issues and the first meeting was held on 12th January. The strategic plan for CKDU, the proposed agreement with India on trade in services, the new National Health Policy and the action taken to address pollution of water resources in Jaffna were discussed with the DGHS among other matters. As in the past, we hope to work in close collaboration with the Ministry of Health in its efforts to improve the health of our population.

The first monthly clinical meeting for 2016 was held in collaboration with the Sri Lanka College of Paediatricians on 19thJanuary where the approach to a child with hypocalcaemia was presented and discussed.

The first Regional clinical meeting for the year will be held in February with the Homagama Clinical Society and a very interesting and an educative programme has been planned. I thank Dr Kushlani Jayathileke who is in charge of organizing guest lectures and monthly clinical meetings and Dr Sumithra Tissera in charge of arranging Regional clinical meetings for their efforts in getting the academic programmes off the ground for this year.

Dr Anula Wijesundere and Dr G Weerasinghe who are heading the academic committee are busy put-

ting together a stimulating scientific programme for the annual academic congress. The 129th Annual Academic Congress will be held from 24th to 27th July. It will be preceded by several pre-congress symposia. In addition, a skills building workshop on emergency care is also being planned. Dr Samanthi De Silva and her team are busy organizing the annual SLMA Run and Walk to be held on 17th July and Dr Kalyani Guruge has already started work on the logistics for the annual congress.

The expert committees and working groups of the SLMA that provide technical expertise on health related matters are in the process of planning their programmes of work for the year.

I am confident that issues of importance to health and healthcare professionals will be addressed through these committees during this year.

I wish to conclude this month’s message by appealing to all medical professionals who are not members of the SLMA to obtain membership and become partners and contribute towards the many activities of the Association. It must be emphasised that the strength of the SLMA lies in its membership.

Thank you and best wishes to all.

Dr Iyanthi Abeyewickreme

MONTHLY CLINICAL MEETING Dr.Kushlani Jayatilleke Assistant secretary/SLMA

M

2

onthly clinical meeting of SLMA was held in collaboration with the Sri Lanka Col-

January 2016

lege of Haematologists on Tuesday 16th February 2016 from 12.00 noon to 01.30 pm at SLMA auditorium. It was a well attended symposium with case Presentation, picture quiz, MCQ

and discussion by Dr. D. Gunawardena, Consultant Haematologist/ Senior Lecturer, Department of Pathology, Faculty of Medical Sciences, University of Sri Jayawardenapura.

SLMANEWS

PICTURE STORIES IN HAEMATOLOGY Dammika Gunawardena, Senior Lecturer/Consultant Haematologist, Faculty of Medical Sciences, University of Sri Jayewardenepura

H

aematology shows a great diversity of presentations and it is where the laboratory and the morphologist of “blood” meet the patient. It varies from dealing with different types of anaemias, bleeding disorders and problems of clotting, transfusion related problems and haematological malignancies. The management of the patient in the ward and the routine haematology clinic needs a strong and a reliable support of the laboratory where quality control is assured by the haematologist.

The modern day analyzers are capable of providing several important parameters such as red cell indices, platelet volume and several other parameters which will aid the diagnosis.

A differential diagnosis of a hypochromic microcytic anaemia will be aided by the other investigations such as the red cell indices, blood picture and iron studies. Thalassaemia, iron deficiency anaemia and anaemia of chronic disorders should be diagnosed accurately as unnecessary iron treatment can be harmful to the body. It is not always easy to find a cause for the anaemia. Other causes such as autoimmune haemolysis, Myelodysplastic syndrome and underlying malignancy should be thought of in a patient with an unresolved anaemia.

the blood sample are given.

• Hb- 6.2g/dl

2. What is your diagnosis?

• WBC-3.1x109/L • Platelet count-110x109/L

Blood picture and bone marrow are given.

1. What is your diagnosis?

Blood picture

Blood picture

Blood sample

Quiz 2 85yr old male with marked pallor • Hb of 5g/dl • WBC of 1x109/L • PNL-0.5x109/L • Platelet count of 80x109/L

Blood picture and bone marrow are given.

1. Name the abnormalities of the blood film and the bone marrow.

2. What is your diagnosis?

67yr old patient with marked pallor • Red cell count- 1.2million/mm3 Blood picture

• MCV- 120fl • MCH-56pg • WBC- 10X109/L • Normal differential count • Platelet count- 230X109/L • Reticulocyte count-10%

The blood picture and a picture of

SLMANEWS

45yr old man with marked pallor

1. Explain the abnormalities of the analyzer report, blood film and the sample.

Quiz 1

• Hb-5g/dl

Quiz 3

Bone marroaw

Bone marrow

White cells are not always benign Clonal proliferation of while cells in bone marrow could give rise to lymphomas and leukaemias with high mortality and morbidity. Diagnosis is aided by the morphological findings, special tests such as flow cytometry of blood and bone marrow and immunohistochemistry of the tissue sections.

It is not always easy to find a cause for the anaemia. Other causes such as autoimmune haemolysis, Myelodysplastic syndrome and underlying malignancy should be thought of in a patient with an unresolved anaemia.

Contd. on page 20

January 2016

3

FIRST DO NO HARM Prof. Carlo Fonseka President Sri Lanka Medical Council

I

can lay my hand on my heart and say that during my student days in the Colombo Medical School (1955-1960) no teacher ever spoke to us on the subject of “Patient Safety” i.e. on saving patients from medical errors. The very concept was non-existent. (I must hasten to add that this is not an indictment of my beloved alma mater the Colombo Medical School or of my dedicated teachers. Truth to tell. Even the World Health Organization focused its serious attention on patient safety only in the 21st century.

To be specific, Resolution WHA55.1: Quality of care: patient safety, was adopted by the World Health Assembly in 2002. This resolution declared that the incidence of adverse events associated with medical treatment is a significant avoidable cause of human suffering and that improving patient safety is a matter of paramount importance.) But, as I was saying, when we were medical students everybody assumed that the doctor knows best what is good for a patient and what the doctor orders should be implemented to the letter in the best interests of the patient. By tradition the doctor was a patient’s friend, philosopher and guide in health and disease because he knew more about such matters than any layman. Therefore the idea of an “unsafe doctor” simply did not make sense. Conventional wisdom was that all doctors are safe, although some wise doctors may be safer than others because of their experience.

Safety of Drugs It was in the Department of Pharmacology that the concept of “safety” in the field of medicine surfaced for the first time in our undergraduate days.

The concept applied to drugs and never to doctors who prescribed the drugs. We were taught that the drugs used to treat patients must not only be “efficacious” (or effective) but also “safe”. The idea of safety of drugs

4

January 2016

was impressed on us by drawing our attention to a famous generalization attributed to Dr. William Withering, a famous British pharmacologist.

In 1789 he wrote: “Poisons in small doses are the best medicines; and useful medicines in too large doses are poisonous”. On this basis it was easy for us to understand how drugs had the potential of being unsafe or dangerous, especially if they were given in too large doses. So the absolutely important thing for doctors to do in order to practice medicine safely is to remember the doses of drugs accurately and precisely. In fact, the only time I was rebuked in a tutorial class by a teacher in the Colombo Medical School was when I grossly overstated the dose of atropine. The teacher who chastised me was Professor Senake Bibile. He asked the class for the dose of atropine that is used in anesthesia. The overly ambitious student that I was in the hope of impressing Prof. Bibile, I blurted out an unsolicited answer. It happened to be wrong by a thousand times. For once Prof. Bibile lost his cool. He said, “Fonseka, you are going to become a licensed killer one day”. I now realize that Prof.

Bibile’s remark implicitly encapsulates the problem of patient safety in relation to doctors. Errors made by doctors can kill patients but because we are licensed to practice medicine we are immune from the criminal charge of manslaughter, or womanslaughter and childslaughter for that matter. Prof. Bibile’s prophesy remains indelibly etched on my brain. To this day, I can’t write a prescription without a formulary at hand. After graduation I worked on the assumption that the only thing that was necessary to practise medicine safely is for doctors to remember unerringly the doses of important drugs. It did not take me long, however, to realize that patient safety depended a great deal on many more things than on doctors’ accurate memory of doses of drugs. We now know that fatal errors can occur during all stages of health care, namely prevention of disease, diagnosis, treat-

ment and after-care. The five fatal errors I had the occasion to report in the British Medical Journal in December 1996 had nothing to do with a faulty memory for doses of drugs.

Patient Safety as a Discipline It was in the 1990s that the marvelous advances in the theory of medicine notwithstanding, the dangerous nature of the practice of medicine came to be widely recognized. Evidence gradually accumulated that hospitals were not safe places for healing. On the contrary hospitals came to be regarded by knowledgeable people as places to be avoided like the plague. But medical education in general took no serious note of this reality. In our country to this day no Medical School teaches patient safety as a discipline. The truth is the reverse. I have said this before and I will repeat it ad nauseam: in February-March 2013 a question on “patient safety” was expunged from the MD Surgery Examination by the Postgraduate Institute of Medicine in order to make the results more “acceptable” to the medical establishment. Almost all the doctors who sat the examination had failed badly in that question. So the question was deleted from the paper. Just consider the implication of that decision by the authorities concerned: patient safety in our country can go to the dogs, but the careers of our budding surgeons must not be interrupted! The public knows this truth.

That is why all who can would rather go to Singapore for major surgery.

And one of the unmentionable perks of becoming a powerful politician in our country is entitlement to safe medicine at state expense in centers where medical science is scientifically practiced. No wonder politics has become so attractive to assorted people.

Concluding Remarks Coming to think of it, the first time I became sensitized to the hazards of medicine was after graduating MBBS. Contd. on page 06

SLMANEWS

Contd. from page 04

First do...

Prof. D.R. Laurance’s excellent textbook on Clinical Pharmacology came out in 1960. Reading its first chapter was a revelation to me.

I learnt the term “iatrogenic disease” from it. From its Greek etymology, iatrogenic means “physician caused”.

That is to say iatrogenic disease is a disease consequent on following medical advice. Even as a student I was aware of the Latin version of the dictum attributed to the Father of Western Medicine, Hippocrates of Cos. PRIMUM NON NOCERE which means FIRST, DO NO HARM. The wise Hippocrates knew that it was better to do nothing than to do well-intentioned harm. Perhaps because I first learnt this admonition in Latin, its full significance did not penetrate deeply into my consciousness. So I couldn’t

6

January 2016

believe my eyes when I read the following assertions in Laurance’s Clinical Pharmacology. “The most shameful act in therapeutics, apart from killing the patient is to cause disease in a patient who is but little disabled or who is suffering from a self-limiting disorder. Such iatrogenic disease induced by misguided treatment, is far from rare”. According to WHO estimates even in developed countries 10 out of every 100 patients are gravely harmed while receiving hospital care.

For example, according to the Institute of Medicine Report, in the USA it is estimated that upto 98,000 medial error deaths occur annually. Again in developed countries, Health Care Associated Infections (HAI) complicate anything upto 10% of admissions in acute care hospitals. The scale of patient safety problems in developing coun-

tries such as ours is perhaps best left unascertained. In fact, Patient Safety is now a fundamental element of health care extensively and intensively addressed by the WHO. Apart from errors committed by doctors, there are other causes of hospital deaths. According to the WHO publication titled Regional strategy for patient safety in the WHO South-East Asia Region (2016-2025) deaths may result from unsafe processes such as communication failures, ineffective team work, overwork by health care personnel and even poor patient hand overs! In the face of this appalling reality the Sri Lanka Medical Council and the Sri Lanka Medical Association should work together to make the Goal of Error Free Patient Care our crusade or Holy War.

SLMANEWS

APPROPRIATE USE OF RADIOLOGICAL INVESTIGATIONS IN GENERAL PRACTICE Dr. Thanuja Sumanasekara, Consultant radiologist, Base Hospital Wathupitiwala Dr. Anuja Ponnamperuma, Consultant radiologist, Hemas Capital Hospital, Thalawathugoda Dr. L.D.R.A.Perera, Consultant radiologist, Provincial General Hospital Badulla Dr. Uditha Kodithuwakkuarachchi, Consultant radiologist, Provincial General Hospital Rathnapura

Imaging is an important component in clinical diagnosis and management. With advancing technology, the field of imaging has reached new dimensions.

Introduction

Radiation exposure is a very important factor to be considered while choosing an investigation. Radiological investigations like computed tomography (CT) contribute significantly to radiation burden. Inappropriate requests for CT scans, especially in paediatric age-groups, increase lifetime radiation burden and risk of subsequent carcinogenesis. CT scans account for 9% of total radiological imaging but contribute to 47% of total medical radiation exposure in some studies. Other factors to consider in deciding appropriateness include local availability, economic resources and policies of a particular institution. Serious adverse effects caused by contrast media such as iodinated contrast-induced nephropathy in CT and gadolinium-induced nephrogenic systemic fibrosis in MRI also render these investigations inappropriate in patients who have deranged renal function. In such a scenario alternative modalities like ultrasound or noncontrast imaging may be considered.

agnostic test. It gives an overview of lungs, heart, pleura and thoracic cage with minimal radiation dose (Figure 1).

PA view is the preferred view, while anteroposterior (AP) and lateral decubitus views are done in supine patients to look for pleural effusion/pneumothorax. Lateral chest radiograph for localization of mediastinal masses has become obsolete as CT scans help in better characterization of mediastinal masses.

Figure 1: Cystic bronchiectasis with multiple cystic lucencies in both lung fields

As every good thing comes with its own price tag, imaging also has the risk of radiation (X-ray, DSA and CT scan) or high cost and is subject to availability (MRI). Inappropriate imaging pays this price without delivering the maximum benefit to the patient.

With the plethora of radiological investigations available, how does one really go about choosing the most appropriate radiological investigation?

In this article, we wish to discuss the approach to appropriate radiological investigations in general practice.

A radiological test is considered appropriate if it answers a particular clinical question with minimum expense and maximum benefit-risk ratio, significantly contributes to patient outcomes and improves net quality of life.

It also depends on the specific clinical scenario, the patient age and demography. For example, a test appropriate for adults may not be so for the paediatric population.

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January 2016

Table 1: Radiation Exposures Associated with Common Radiological Procedures

Chest

Chest radiography looks for respiratory and cardiovascular pathologies.

Symptoms such as cough, dyspnoea and chest pain are common for both systems. Because of this overlap, the chest radiograph-postero-anterior (PA) view remains the basic initial di-

Ultrasound of chest has a place in non-ambulatory and critically ill intensive care and trauma patients. Bedside ultrasound can demonstrate pleural and pericardial effusions, pneumothoraces and consolidation with reasonable sensitivity and specificity.

Contd. on page 10

SLMANEWS

Contd. from page 08

Appropriate use of...

Ultrasound is useful in paediatric patients for characterization of chest wall, diaphragmatic, thymic and mediastinal masses without radiation.

Chest ultrasound is also useful in interventions like tube placement and biopsies of peripheral lung and pleural based masses.

Vascular pathologies are evaluated with CT angiography. CT thoracic angiography is required for evaluation of thoracic aorta (aortic dissection/aneurysm) and bronchial arteries (haemoptysis) while pulmonary angiography is useful for evaluation in suspected pulmonary thromboembolism.

Similarly barium studies have limited use with advent of CT and presently are useful in evaluation of dysphagia (barium swallow) and as a low dose imaging alternative to CT for colon (double-contrast barium enema) in follow-up of inflammatory bowel disease.

Multi-detector CT (MDCT) is the mainstay for chest imaging as it acquires volumetric information. Various CT protocols are tailored to answer specific clinical questions. The contrast-enhanced CT (CECT) scan is the basic scan used for evaluation of infective, inflammatory and neoplastic thoracic pathologies.

Figure 2: CT chest sections in a patient with metastasis

The volumetric data obtained can be reconstructed at 8 mm to 10 mm intervals using bone algorithm to form high resolution CT (HRCT), useful for evaluation of interstitial lung disease (ILD) and bronchiectasis (Figures 3A to 3C). Low dose CT protocols have also been described for the paediatric population and interstitial lung disease.

Abdomen

Ultrasound is the major decision making modality in initial evaluation of abdominal symptoms. Abdominal radiographs in supine and erect positions are indicated in suspected intestinal obstruction, pneumoperitoneum, toxic megacolon and pneumatosis. Xray KUB is used in renal/ureteric colic.

Figure 3A, 3B & 3C: High resolution CT evaluates airways and pulmonary parenchyma. Sections show peripheral honeycombing (3A), suggestive of UIP pattern of ILD, ground-glassing with septal thickening (3B), suggestive of NSIP pattern of ILD and bilateral bronchiectasis (3C).

10 January 2016

Ultrasound of the abdomen is used as a fast scan, as it is an easily available, non-invasive, non-radiation technique used to demonstrate solid organs and to look for abdominal fluid/ collections. Transabdominal ultrasound is useful in patients with acute abdominal pain to look for appendicitis, cholecystitis, renal stones, ectopic pregnancy and intussusception (Figures 4A to 4E).Trans-vaginal ultrasound can demonstrate female pelvic pathologies and scrotal ultrasound is used for testicular evaluation. However, ultrasound is not useful in suspected peptic ulcer disease/gastritis and has a low-yield in cases of nonspecific abdominal pain.

Contd. on page 12

SLMANEWS

Contd. from page 10

Appropriate use of...

CECT abdomen is useful for the evaluation of abdomen in cases of fever, sepsis, lymphoma and metastatic staging. Multi-phase protocols comprising separate acquisitions in arterial, venous and delayed phases with one-time contrast administration are useful for characterization of hepatic or pancreatic masses. Similarly, renal masses and the excretory system can be evaluated by multi-phase and CT urography protocols respectively.

Inflammatory bowel disease can be evaluated with CT enterography/enteroclysis techniques where bowel lumen is distended with neutral contrast to optimise visualisation of mucosa as well as the bowel wall.

ability to get certain diagnostic information without the use of contrast by using various MR sequences. With its’ better tissue characterization ability, contrast-enhanced multiphase MRI is used to evaluate hepatic masses. MRI is also superior to CT for evaluation of pelvic organs for urologic and gynaecological imaging.

subarachnoid haemorrhage) (Figure 6) and to look for skull bone fractures.

Thus it is useful for initial evaluation of patients with stroke and trauma and used in follow-up for hydrocephalus.

Contrast-enhanced CT is required for suspected meningitis /abscesses, mass lesions and vascular pathologies (Figure 7).

Figure 5A, 5B & 5C: CT protocols include CT enterography (5A, 5B) in a patient with Crohn’s disease that show multiple areas of abnormal small bowel enhancement and narrowing suggestive of active disease and CT portography (5C) in patient with portal hypertension for selective evaluation of portovenous collaterals.

Central Nervous System

CNS evaluation is carried out by crosssectional imaging with CT and MRI. Skull radiographs are now obsolete and considered useful only in trauma as presence of fractures on skull radiograph in children with mild head trauma Figure 4A to 4E: Ultrasound images of abdomen show renal cal- is an indication for CT culi (4A), intussusception (4B), gallbladder calculi with posterior scan. CT brain is the shadowing (4C) and ruptured liver abscess (arrows 4D, 4E) major decision modality in CNS evaluation. Non-contrast CT is CT abdominal angiography is used done to look for suspected intracranial in evaluation of mesenteric ischaemia haemorrhage (epidural, subdural and and gastrointestinal bleeds while CT portography can be specifically used for splenoportal axis in cases of portal hypertension. Non-contrast low dose CT remains the most sensitive technique for evaluation of ureteric stones.

Thus the versatility of CT is extremely useful for evaluation of the abdomen (Figure 5A to 5C).

MRI of abdomen is useful for evaluation of the hepatobiliary system (MR cholangio-pancreaticography), excretory system (MR urography) and pancreas. An advantage of MRI is that it is free of radiation and has the

12 January 2016

Figure 6: Subarachnoid haemorrhage

Figure 7 : Aneurysm in a CT angiogram

MRI has an advantage in CNS imaging due to superior grey-white matter differentiation. Basic sequences include T1w and T2w. While T1w sequence (CSF black) is useful for anatomy, T2w sequence (CSF bright) is informative in detecting pathology. There are certain entities like fat, blood, proteinaceous contents, calcium and melanin/copper deposits which appear bright on T1 weighted images and thus can help in lesion characterization. Other sequences are FLAIR (CSF suppression sequence) which accentuate contrast between pathology and CSF and gradient imaging to detect haemorrhages (Figures 8).

Contd. on page 13

SLMANEWS

Contd. from page 12

Appropriate use of...

Newer techniques include diffusion weighted imaging (DWI), an extremely fast sequence which is crucial for detecting early infarcts.

MR spectroscopy is useful in tumours and tumour-like lesions and neurodegenerative pathologies while MR perfusion techniques are useful for characterisation and post-treatment follow-up of brain tumours. Similar to CT, contrast is required for infectious, inflammatory, vascular and neoplastic lesions.

spine are adequate initially.

Further imaging with MRI is required for treatment planning when radiographs are abnormal or inconclusive.

Doing an early MRI is also justified in the presence of one or more red flag signs even if the radiograph is normal.

CT of spine has limited use in evaluation of bony morphological abnormalities like fracture, spondylolisthesis and in post-operative evaluation of bone grafts, instrumentation and surgical fusion.

Figures 8 : Cerebellar hemorrhage in MRI

Spine

Imaging is not usually indicated in patients with acute onset low back pain without 4 to 6 weeks of symptomatic management and therapy.

Imaging is indicated in (a) failure of conservative therapy for 6 weeks (b) one or more red flag signs and (c) preoperative evaluation for discogenic pain/radiculopathy.

Red flag signs (a) Trauma (b) Unexplained, insidious weight loss (c) Age >50 years (d) Unexplained fever (e) Immunosuppression, diabetes, cancer

Figures 9 : Cervical spondylosis with myelomalacia

(f) History of intravenous drug use

Conclusion

(g) Cauda equina syndrome (h) Focal neurological deficit with progressive or disabling symptoms (i) History of prior surgery

When imaging is indicated, radiographs of cervical/thoracic or lumbar

14

SLMANEWS

Radiology plays an essential role in diagnosis. Appropriate ordering of radiological tests is essential to ensure optimum work-up while minimizing cost, exposure to radiation and contrast-related adverse effects. A wide variety of radiological tests are available, each with its own advantages and disadvantages. It is important to have a reasonable differential diagno-

sis based on which, radiological tests can be performed. Furthermore, discussion with the radiologist will help to select the most appropriate imaging modality.

COVER STORY Hippocrates Medicine Becomes A Science

“The ancient Greek physician Hippocrates of Cos, born around 460 B.C.E., is considered a founding father of medicine, and a key figure in medicine’s development as a profession and a systemic science separate from others. He is the namesake for the Hippocratic Oath, sworn by new physicians for centuries, and is considered a paragon of ancient physicians.

This painting illustrates him in both a metaphorically and literally fatherly role, reassuring the worried mother of a boy who has fallen ill, while reassuring the boy with a hand on his shoulder and simultaneously feeling the “hypochondrium”, or region near the spleen just below the ribs, where the ancient Greeks believed many illnesses began.”

Michigan artist Robert Thom had painted a series of 45 paintings in the 1950s. These are owned by the University of Michigan since 2007.

This is one of them quoted from the University of Michigan web site. (ref: http://www.med.umich.edu/ opm/newspage/2007/paintings. htm)

January 2016 13

LIST OF TRAINING CENTRES FOR RADIOLOGY TRAINEES (Please note that these are centres where Sri Lankan postgraduate trainees had been trained before. Collected from previous postgraduate trainees for the use of future trainees)

Australia 1.

The Queen Elizabeth hospital Campus, Woodwille South SA, Australia

2.

Royal Perth Hospital, Perth, Western Australia, Australia

3.

The Children's Hospital, Westmead NSW, Australia

4.

Regional Imaging Border, Medical Imaging, Albury NSW, Australia

5.

Barwon Medical Imaging, The Geelong Hospital, Australia

6.

The Royal Melbourne Hospital, Parkville, Australia

7.

Royal Brisbane and Women's Hospital, Brisbane , Australia

8.

The Alfred Hospital, Melbourne, Australia

9.

John Hunter Hospital, Lookout Road, New Lambton Heights

10.

Royal Prince Alfred Hospital, Camper Down, NSW, Sydney, Australia

11.

Diagnostic Imaging - Southern Health, Monash Medical Centre, Victoria, Australia

12.

Department of Radiology, Westmead Hospital, New South Wales, Australia

13.

Royal Adelaide Hospital, North Terrace, Adelaide, SA, Australia

14.

St Vincent's Hospital, NSW, Australia

15.

Lyell McEwin Hospital, Elizabeth Vale,SA, Australia

16.

Flinders Medical Centre, South Australia, Australia

17.

Fremantle Hospital, Fremantle, Western Australia

18.

Peter MacCallum Cancer Centre, St. Andrew Place, Australia

19.

Western Health, Sunshine Hospital, , St Albans VIC, Australia

20.

Dept. of Medical Injiry, Monash Medical Centre, Australia

21.

The Royal’s Children's Hospital, Melbourne, Australia

22.

Sir Charles Gairdner Hospital, Nedlands WA, Australia

23.

Royal Darwin Hospital, TiWi NT, Australia

24.

Westmead hospital, Wentworthville, NSW, Australia

25.

Medical Imaging Department, Townsville Hospital, Townsville QLD, Australia

India 26.

Dr. Balabhai Nanavati Hospitals, Mumbai, India.

27.

Sree Chitra Tirunal Institute for Medical Sciences & Technology, Kerala, India.

28.

Christian Medical College & Hospital, Vellore, Tamil Nadu, India

Malaysia 29.

Institute of Graduate Studies, University of Malaya, Kuala Lumpur, Malaysia

30.

Sarawak General Hospital, Sarawak, Malaysia

31.

Hospital Selayang, Lebuhraya Selayang-Kepong, 68100 Batu Caves, Selangor Darul Ehsan, Malaysia

32.

Tengku Ampuan Rahimah Hospital, Klang, Selangor, Malaysia

New Zealand 33.

Palmerston North Hospital, Midcentral District Health Board,Palmerston North, New Zealand

34.

Radiology department, Waikato Hospital, Waikato District Health Board, Hamilton, New Zealand Contd. on page 16

14 January 2016

SLMANEWS

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SLMA JOINT CLINICAL MEETING Dr.Sumithra Tissera Assistant secretary/SLMA

T

he first SLMA joint clinical meeting was held at Base Hospital Homagama on 18th of February 2016 with the attendance of over 100 participants. The programme commenced with the joint welcome given

by Dr.Iyanthi Abeyewickreme President of SLMA and Dr. Tissa Perera, Director of Base Hospital Homagama.

The first session was chaired by Dr.J.B. Peries, Consultant Neurologist. Lectures were given by Dr. Prasad Katulanda, Consultant Endo-

crinologists on Management of common Thyroid Disorders, Dr. G. Weerasinghe, Consultant Venereologist on New technologies in the diagnosis and management of STI/HIV and Dr. Manjula Dhanasuriya, Consultant Community physician, on Anti Malarila Campaign on Resurgence of Malaria.

The second session which was on Dengue Fever was chaired by Dr.Anula Wijesundara, Consultant Physician. Dr.Ananda Wijewickrama and Dr.Damayanthi Idampitiya both Consultant Physicians from Infectious Diseases Hospital, Angoda spoke on

Dengue Fever, DHF diagnosis and management through a series of case discussions. Dr.Jayantha Weeraman, Consultant Paediatrician at Epidemiology Unit spoke on management of complicated cases.

The meeting concluded with Dr. Dhammika Wijethunga, secretary of Clinical Society Base Hospital Homagama delivering the vote of thanks.

All participants were awarded a certificate of participation. The meeting was sponsored by The Dengue Control Unit, Ministry of Health and Family Planning Association of Sri Lanka.

Contd. from page 14

List of training...

Singapore 35.

Department of diagnostic imaging, National University Hospital, Singapore

36.

The National University of Singapore, Singapore

37.

Singapore General Hospital, Singapore

38.

Department of Clinical Radiology, Tan Tock Seng Hospital, Singapore

39.

KK Women's & Children's Hospital, Singapore

40.

Department of Diagnostic Radiology, Changi general Hospital, Singapore

Switzerland 41.

Department of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland

United Kingdom 42.

Portsmouth Hospitals NHS Trust,Queen Alexandra Hospital, Portsmouth, UK

43.

Oldchurch Hospital, London, UK

44.

Newham University Hospital, London, UK

45.

The John Radcliffe Hospital, Oxford, UK

46.

Institute of Neurological Sciences, Southern General Hospital,Glasgow, Scotland, Uk

47.

Queen Elizabeth Hospital, Imaging Department, London, UK

48.

East Surrey Hospital, Redhill, Uk

49.

Radiology Depatment, Saint Mary's Hospital, London, UK

50.

Lister Hospital,Hertfordshire, UK

16 January 2016

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15

077 395 1513 /

Contd. from page 14

List of training...

51.

Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, UK

52.

The Royal London Hospital,UK

53.

Nobles Hospital, Douglas, UK

54.

University Hospital of Wales,Cardiff, UK

55.

University Hospitals of Leicester, UK

56.

Kent & Canterbury Hospital,Kent, UK

57.

Rotherham General Hospital,The Rotherham NHS Foundation Trust,Rotherham, UK

58.

Royal Cornwall hospital, UK

59.

Luton & Dunstable University Hospital, UK

60.

King's College Hospital, UK

USA 61.

Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA.

62.

Department of Radiology, Abdominal Imaging, University of North Carolina, Chapel Hill, USA

63.

Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA

Just for a laugh !!

Medi.com.ic

Five doctors went on a duck hunt: a GP, a Physician, a Radiologist, a Surgeon & a Pathologist.

After a while a bird came winging overhead, the GP raised his shotgun but didn't shoot and said "I think it’s a duck, but needs a second opinion. So let the physician shoot."

The Physician also raised his gun and said. "It’s a duck but the other possibilities should be considered such as a hypertrophied sparrow or an atrophied ostrich."

Radiologist took the gun, quickly scanned the situation and mumbled. "It can be a duck, a sparrow or an ostrich or even a hen. However, please correlate clinically."

The Surgeon was the only one who shot. Boom!!!! He blew it away. Then he turned to the pathologist & said, "Go and confirm whether that’s a duck."

Ref: https://nhsreality.wordpress.com Montgomery v Lanarkshire Health Board – New rules of consent: the patient decides

MALARIA COUNT

2016

18 January 2016

The pathologist slowly carefully approached the bird and said………"Specimen inadequate…"

(Quoted from web)

07

Cases for 2016

All cases are imported !

Let’s keep Sri Lanka Malaria free

SLMANEWS

HARD WORK VS SMART WORK Sudeshini Fernando, Consultant Psychometrist, Cognadev Pty UK. sfernando@cognadev.com Office : 18B Balmoral Avenue, Sandton, South Africa

F

reud pointed out that work and love give meaning to our lives.

The average person spends the bulk of their waking hours working to achieve certain goals. But not everyone achieves their goals and not everyone experiences the sense of purpose that work is meant to provide us with. To some, work merely remains a burden.

What is the secret? Why are some people successful and happy in their work and others not? There are too many variables involved to answer this question, but there are some guidelines for working smart, which is likely to improve one’s chances of goal achievement.

Hard work One cannot get away from putting in effort. Hard work has been described as a method by which a person translates a vision and ideas into results.

This requires persistence and determination. As the inventor Thomas Edison said: “Success is one percent inspiration and ninety-nine percent perspiration”. Many people who give up on their goals werejust a step away from achieving success. But hard work by itself might not be enough. The key is to maximise the impact of that effort by working smart.

Smart work Smart work is about focusing on relevant issues, having a clear and flexible goal and going about it in a planned manner. It also involves a disciplined approach.

In order to cut through the usual clutter which obscures most problem solving situations, and to identify the key issues involved in any challenge, one needs knowledge and a thorough understanding of the situation. To obtain this, the situation needs to be

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explored without getting side-tracked or flooding one’s own mind with irrelevant detail. Proper understanding may also require analysis by pulling a situation apart to identify the factors involved and their interrelationships. It is important though, not to get knotted up in analysis paralysis. The information one obtains through analysis then needs to be ordered and structured in such a way as to be meaningful and coherent. The best way is to draw pictures to represent the information in terms of certain goals. Things that do not make sense, cannot be addressed properly. Once we have a proper understanding of what is involved, given both our personal goals and the contextual requirements, we can creatively come up with a smart and innovative way to achieve those goal.

“People who work hard and people who work smart, have different measures of success.”

Jacob Morgan.

Hard work and smart work go hand in hand. It is not a case of “either-or”, but a case of “and-but”. In our fast moving world, where many things compete for our time, smart work has become an imperative.

The key to smart work is awareness: of our goals, our thinking processes, our behaviour and our context. Inpsychology, this aspect is referred to as “metacognition”. It is about selfawarenessand self-monitoring, which involves asking ourselves critical questions, or by applying “metacognitive criteria”. Self-awareness and the use of the right questions, is bound to result in greater efficiency, focus, creativity, and appropriateness. This is important as creativity and innovation are critical prerequisites for a person to adapt to fast changing business environments. Over time it also results in optimising one’s intuitive insights, learning potential and an appreciation

of the big picture.

To find out more about how you capitalise on your metacognition, and whether you work smart, contact Cognadev to find out more about the Learning Orientation Index (LOI) designed for Millennials and Generation Y. Cognadev also offers the Cognitive Process Profile (CPP) to assess the cognitive effectiveness of adults in the work environment. Both these tools are computerised simulation exercises that measure information processing preferences and skills.

And don’t forget to work hard at working smart.

Psychometrics is a field of study concerned with the theory and technique of psychological measurement.

One part of the field is concerned with the objective measurement of skills and knowledge, abilities, attitudes, personality traits, and educational achievement. For example, some psychometric researchers have, thus far, concerned themselves with the construction and validation of assessment instruments such as questionnaires, tests, raters' judgments, and personality tests. Another part of the field is concerned with statistical research bearing on measurement theory (e.g., item response theory; intraclass correlation).

As a result of these focuses, psychometric research involves two major tasks: (i) the construction of instruments; and (ii) the development of procedures for measurement. Practitioners are described as psychometricians. Psychometricians usually possess a specific qualification, and most are psychologists with advanced graduate training. In addition to traditional academic institutions, many psychometricians work for the government or in human resources departments. Others specialize as learning and development professionals. https://en.wikipedia.org/wiki/Psychometrics January 2016 19

Contd. from page 03

Picture stories...

Blood picture findings of various lymphomas

Sri Lanka has an estimated population of 600-700 haemophilia patients from the registry completed so far.

normalities.

Once the diagnosis is established, it is important not to treat the patient with steroids unnecessarily as long term steroids can have deleterious side effects. The practice of treating a low platelet count rather than treating the symptoms of bleeding is therefore discouraged.

Answers to quizzes Quiz 1 The analyzer report shows a disproportionally low red cell count and a very high MCH, indicating that the machine has counted red cell clumps.

The tube shows clumps to the naked eye. Blood picture confirms the cell aggregates. This agglutination can be overcome by warming the sample.

The diagnosis is Cold autoimmune haemolytic anaemia

Resolving the problem of a bleeder The main types of bleeding disorders are coagulation factors’ defects such as haemophilia and platelet defects which are common. Bleeding disorders can be underdiagnosed if a proper history is not taken. The Bleeding Assessment Tool (BAT score) will be helpful in establishing a significant bleeding history in a mild bleeding disorder.

Some of the younger patients are put on regular prophylaxis and managing these patients with adequate factor replacement is a future challenge to the health sector due to its high cost.

Immune thrombocytopenic purpura is one the commonest causes of isolated thrombocytopenia in an otherwise healthy individual. There is no single investigation to diagnose ITP and it is made by excluding other causes of thrombocytopenia when the history, examination findings and other investigations show no other ab-

A positive DAT (Direct Antiglobulin Test) will confirm the diagnosis.

Quiz 2 1. Blood film- Macrocytes, dysplastic pelgar neutrophils, large platelets 2. Bone Marrow- Dysplastic cells of neutrophil lineage

Quiz 3 1. Blood film-Oval Macrocytes, hyper segmented neutrophils Bone marrow- Megaloblasts 2. Megaloblastic anaemia

A MESSAGE FROM THE EDITOR We would like to invite the membership of SLMA to contribute to the SLMA news letter.

Please feel free to send •

Articles on subject matter

•

Letters to the editor-matters related to the profession (Eg: ethics, soft skills)

•

Picture quizzes (with written consent from patients if photos are being used)

• •

Articles written on personnel who have done an exceptional service Poems/jokes/puzzles/cartoons etc

on matters related to medical profession.

All articles will go through the editorial committee and approved ones will be published in future issues. If you are good at drawing cartoons, please do write to us; we are looking for a ‘doctor cartoonist’. We would also like to hear your views regarding content of SLMA news letter. Please send them all to nleditor.slma@gmail.com

20 January 2016

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A CIRCULAR FOR YOUR ATTENTION Sent for publication by, Dr. Kapila Jayaratne Consultant Community Physician, National Programme Manager – Maternal & Child Morbidity & Mortality Surveillance, Ministry of Health

22 January 2016

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1344 Durdans Helpline

SLMANEWS

THE OFFICIAL NEWSLETTER OF THE SRI LANKA MEDICAL ASSOCIATION

If undelivered return to : Sri Lanka Medical Association. No. 6, Wijerama Mawatha, Colombo 7 Registered at the Department of Post Under No: QD/30/NEWS/2016