SLMAnews-2013-03 by Sri Lanka Medical Association

SLMANEWS

Contents

THE OFFICIAL NEWSPAPER OF THE SRI LANKA MEDICAL ASSOCIATION

March 2013 Volume 06 Issue 03

President's Column Greetings from the SLMA. There are several activities that we are engaged in at the present time to carry on with the programmes of the SLMA to provide services to the membership in particular and to the medical fraternity in general. The Speech Craft Programme is in full swing. By all reports, the participants are quite happy with the progress of events and feel that it is a most useful exercise. We will be going to Nuwara Eliya on the 19th of March 2013 for a collaborative activity with the Hill Country Clinical Society. In addition to the Academic Programme for doctors, we will also be doing a session on “Safety in the Workplace”, for other grades of staff, in collaboration with Unilever Ltd. This is a gesture on our part towards taking our activities to all stakeholders in healthcare delivery. The Expert Committee of the SLMA on CPD has had a

Page No.  Notice board

 Personal health record system: a Sri Lankan model

 E M Wijerama endowment lecture 2010 – part 2

 Clinical guidelines on "Diabetes Mellitus : Glucose Control"

 Introducing Quality Improvement Programme in RDHS Division Jaffna

14 -15

 Bladder Outlet Obstruction (BOO)

 Factor Analysis Workshop : The First in a series of workshops  Quality and Safety Directorate

16 18

 Discover Sri Lanka a visit to Ridi Viharaya and Rambodagala

 Public speaking – fear it not!

very fruitful dialogue with The Secretary – Health, Dr. Nihal Jayathilleke in late February. Further developments are awaited. CPD points are now a mandatory requirement for registration with the General Medical Council, UK. We are in the process of negotiating a dedicated Credit/

Our Advertisers Glaxowelcome Ceylon Ltd. Atlantis Developments (Pvt.) Ltd. (110 Parliament Road)

Debit Card with a leading bank. It will provide some valu-

DFCC Vardhana Bank

able concessions to members of SLMA. We will inform

Seylan Bank PLC

the membership of the full details once the formalities are

Guardian Acuity Asset Management Ltd.

finalised. Initial sorting out of the details and other logistics for the

Tokyo Cement Group Astron Ltd. A. Baurs & Co. (Pvt.) Ltd.

126th Anniversary International Medical Congress of the

Asiri Surgical Hospital

SLMA are in full swing. Professor Sir Sabaratnam Arulku-

Emerchemie NB (Ceylon) Ltd.

maran, President, British Medical Association will be the

GlaxoSmithKline Pharmaceuticals

Chief Guest. Please await further details in the very near future. The Anniversary Congress will be preceded by the Health Walk & Run on the 7th of July 2013. Our Council and the Committees are working hard to enhance further the activities of the SLMA. I am most grateful for all their efforts. With the very best of wishes.

Official Newsletter of The Sri Lanka Medical Association. Publishing and printing assistance by

This Source (Pvt.) Ltd etc., Dr B J C Perera President, Sri Lanka Medical Association, No.06, Wijerama Mawatha, Colombo 07, Sri Lanka

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

SLMANEWS

March, 2013

Notice Board Sri Lanka Medical Association

MONTHLY CLINICAL MEETING

Joint Clinical Meeting with the

Adrenal Disorders in Children

Hill Country Medical Society

Case presentation

Date :

19th March 2013

Dr. Nimasari Ginige

Time :

8.30 am – 2.15 pm

MBBS DCH MD

Venue :

District General Hospital

Nuwara Eliya

Senior Registrar, Paediatric Endocrinology Lady Ridgeway Hospital

Review Lecture & MCQs

Topics: - Quality and safety in healthcare

Dr. Navoda Atapattu

- Childhood nutrition

MBBS DCH MD MRCPCH

Senior Registrar in Paediatric Endocrinology Lady Ridgeway Hospital

- Nutrition assessment and supplementation of the Hospitalized patient - Management of the acutely wheezing child - Wound care: General guidelines

- Non accidental injuries in children

19th March 2013

- Management of Burns – When to refer

During

- Strokes: Modern management strategies

12 noon to 1.30 pm

- Paediatric Emergencies (Electronic interactive session) - Early identification of developmental delay in children

Lionel Memorial Auditorium, SLMA

- Workplace safety

Transport will leave SLMA premises at 3.00 am on 19-03-2013 & will be back by 9.00 pm on the same day.

ALL ARE WELCOME

Those who are interested, please contact the SLMA office

The 126th Anniversary International Medical Congress of the SLMA “Towards continuing enhancement of quality and safety in healthcare” Inauguration and SLMA Oration : 10th July 2013 Full Registration for the Main Congress SLMA member

: Rs 3000/-

Non-member doctors

: Rs 3500/-

Non-doctors & medical students

: Rs: 1500/-

126th Anniversary International Medical Congress :11th to 13th July 2013 Day Registration (any doctor) : Rs 1500/- per day Workshop registration (any doctor) : Rs 1000/- per work shop Day registration (non-doctors)

: Rs. 1000/- per day

Sports Medicine Workshop

: Rs 2000/-

(for Doctors, Physiotherapists, Coaches and Trainers)

SLMANEWS

March, 2013

DISCOUNTED AIRLINE TICKETS FOR THE 126th ANNIVERSARY INTERNATIONAL MEDICAL CONGRESS OF THE SLMA 10th – 13th JULY 2013 Sri Lankan Airlines, the official airline for the 126th Anniversary International Medical Congress of the SLMA, has kindly offered all participants and accompanying persons a 15 percent discount on economy class airfare and a 10 percent discount on business class airfare, on the prevailing market fare at the time of ticketing, for purchase of tickets for registered delegates travelling to Sri Lanka from their online stations. The online code for special discount is operational now. All the participants need to do is to send an e-mail to either mice@srilankan.com or thiwanka.dharmapala@srilankan.com and the airline will make arrangements to provide the discount.

Women’s Health Committee of the SLMA

DOCTORS CONCERT 2013 By doctors and their families

In Collaboration with

11th JULY 2013 at 7.00 PM at the Water’s Edge

Zonta Club 1 of Colombo commemorates International Women's Day 2013 Guest Lecture

If you like to participate please contact the Social Secretaries and the SLMA Office by 31st May 2013 Dr. Suriyakanthie Amarasekara (suri.amarasekera@gmail.com) Dr. Gamini Walagampaya ( nbwalgampaya@ymail.com ) SLMA Office (slma@eureka.lk) Update your organizer!

By Professor Nandani de Silva MBBS(Cey.), DCH(Col.), DFM(Col.), MD(Col.), FCGP(SL) Emeritus Professor of Family Medicine University of Kelaniya

On Stress and Women at the SLMA Auditorium on Monday 18th March 2013 from 3.00pm to 4.00pm ALL ARE WELCOME 2 CPD points will be awarded

15 - 17 March 2013 : 20th Annual Scientific Sessions of College of Medical Administrators

19th April 2013 : Deadline for submission of abstracts for 4th Academic Sessions of PGIM

30th April 2013 : Closing date for the applications for orations Ceylon College of Physicians

7th July, 2013 : Deadline for submission of abstracts for Annual Academic Sessions of Menopause Society of Sri Lanka

17 to 19 July 2013 : PGIM 4th Academic Sessions

Encourage your colleagues to join SLMA Life membership

: Rs. 10, 000

Ordinary membership

: Rs. 2, 500 (valid for one year)

Overseas Life membership : USD 250

(for those residing overseas)

Membership application could be obtained from http://www.slmaonline.info/index.php/membership.html

SLMANEWS

March, 2013

SLMANEWS

March, 2013

Personal Health Record System: A Sri Lankan model Dr. Deepal Wijesooriya, MBBS, MBA-HCS, MSc in Biomedical Informatics, Dip in Psychology

personal health record (PHR) is typically a health record that is initiated and maintained by an individual of his own health. It would necessarily provide a complete and accurate summary of the health and medical history of the individual. These details are gathered from many sources and the information is accessible online to anyone who is given the necessary electronic credentials to view the information by the individual concern. PHR is a rapidly developing concept globally. Because PHR shows promising feasibility for emerging health issues like ageing population, high prevalence of non- communicable diseases etc., it would be most useful for a country like Sri Lanka. However, there is very little work of this nature that is undertaken in Sri Lanka. Since, the e-government policy in Sri Lanka attempts to address some IT power to the health sector,this is a good time to work on a PHR system. “PHR version 1.0” is an electronic web based system which is a tailor made unique product designed to cater to Sri Lankan health needs. This PHR version 1.0 was developed through a project called “A Client Friendly and Physician Accepted PHR System Relevant to Sri Lanka”. Requirement analysis of Sri Lankan population was gathered as a part of a thesis in MSc in Biomedical Informatics in the Postgraduate Institute of Medicine (PGIM).Any Sri Lankan who has email address and internet accessibility, can use this system to keep their health records online.

Rationale for the use of PHR It is common knowledge that patients and clinicians experience problems due to lack of transfer of clear information during their encounters. Much of the information may have to be repeated during these sessions that can raise questions on the accuracy of data transferred between the two groups. This problem may adversely affect the health care institution and decision makers too. A Personal Health Record System will be helpful to solve most of the problems arising in handling of data and information between patients, clinicians and health institutions.

What are the benefits of this PHR? There are many benefits of this PHR. • The profile owner can keep his/her health related events and medical records in a secure place. This is so because, PHR version 1.0 is password protected and can only be accessed by authenticated individuals authorized by the owner.

• It helps to reduce unnecessary investigations, exposure to drugs and unnecessary expenses. • Drug interactions and allergic reactions to the drugs can be reduced. It enhances the safety of the profile owner.

During emergencies, an emergency card can be used to get life saving information to the health care providers. Sustainably of the project Sustainability is mainly dependent on external and internal factors. Success of implementation mainly depends on the availability of suitable hardware, distribution of the internet and mobile services, awareness of PHR among the stakeholders, affordability of the client and attitude of the community. This system is a free service for any client in Sri Lanka. Maintenance cost and further development cost could be reimbursed by commercial advertisements and donations.

• The profile owner can access his/her records anytime at anyplace if an internet connected device is available. • The profile owner can share his/her records with health professionals at anytime. Those data could be tabulated as required by the physician. It is also easily sorted by various parameters as and when needed. If EMR, HIS systems are available, this system is cable to datashare with other systems with security and accuracy. • The profile owner is more aware of the current health conditions. It helps in preventing mistakes which would happen during health interventions.

A screen shot of New Registration Page in Sri Lankan PHR version 1.0. Contd. on page 8

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Contd. from page 6

Personal Health Record... How to register with the system? A screen shot of New Registration Page in Sri Lankan PHR version 1.0. New Registration(Sub Head2) A video demonstration of this is available via (http://sriphr.familycarehospital.com/index.php?option=com_ content&view=article&id=53&Item id=61) 1. Log into www.sharedcarevault.info site. This is a community portal of PHR version 1.0. or you can directly log into http://www.maximlogics.net/phr/ 2. When shared care vault web page is loaded, click upper right hand corner in header “Login/Register” button and you will be directed to Login/Registration form. 3. Select “Register Now” button. Fill required information and submit. 4. If submission is successful, you will be asked to activate account after proper authentication.

User Login i. Continue steps 1,2,3 in New Registration procedure ii. Log with your user name (email) and PHR password.

Dashboard • You will be directed to the main dashboard. Click “My Profile” tab -------then

“My Details” tab. Then you will direct to the interface where you can update your profile details. You can upload profile photo by browsing from your local PC. The entire fields are self-explanatory. Then put “Save” button to update profile details. • You can print Emergency Card by clicking “print” button on “My Details” interface. This card would be helpful in emergency to get life saving details from card itself and My Details interface as a read only logger. But your other data are completely secure. No one read those other details without your permission.

Additional demonstration on the use of PHR can be accessed via http://www.sharedcarevault.info/ or from the author via deepal.wijesooriya@gmail.com.

A Press conference on SLPHR A press conference was organized on the 1st of March 2013 at 2.00 pm at the Lionel Memorial Auditorium at Wijerama House, 6 Wijerama Mawatha, Colombo 07 with a view to raise awareness about this new innovation, the Sri Lankan PHR. Leading media organizations were invited to participate in the media conference and was successfully completed with the participation of around thirty media organizations. The SLPHR received a certificate of appreciation under the Health and Environment category at the E-Swabhimani 2012 awards ceremony held recently.

This event was addressed by Dr B J C Perera, the President of the SLMA, Prof Vajira Dissanayake President of the Health Informatics Society of Sri Lanka and Immediate Past President of SLMA and Dr Deepal Wijesooriya, the Inventor of Sri Lankan PHR System. This media conference focused on the introduction to Personal Health Record (PHR) system, advantages of the PHR system and its impact on future health challenges, PHR systems in other countries, implementation of PHR, the role of media in the sustainability of the “Sri Lankan PHR” and the potential impact of the Sri Lankan PHR on the health system in the future.

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March, 2013

E M Wijerama Endowment Lecture 2010 – Part 2 This article is the continuation from SLMA News February 2013 issue

Vidyajyothi Prof. Colvin Goonaratna MBBS, FRCP (Lond), FRCP (Edin), FCCP, PhD (Dundee), FNAS, Hon DSc (Colombo), Hony Fellow of the College of Surgeons of Sri Lanka; Hony Fellow of the College of General Practitioners of Sri Lanka

ow for some stories. About my schooling at Royal College Colombo Dr. Narada Warnasuriya has told you all there is to tell. As for medical school, the Colombo Medical Faculty was the only one in existence then, and medical students were a greatly admired and respected species. I recall being appalled by the vulgarity and the obscenity of the so-called ragging that we were subjected to during the first few days of our medical student life – hardly the ideal initiation to a noble profession. I went through the ordeal without much personal hurt, but when I saw two of my colleagues in tears, I realised that I was witnessing a cowardly assault on human dignity.

I hated the dissecting rooms in the Anatomy Department, and avoided it as much as possible. I loved the game of contract bridge. And I spent most of my scheduled dissection time in the students’ common room playing this card game, usually for small stakes. The small stakes were to prevent reckless bidding and play, that would otherwise have ruined the intellectual content of the game. I think that it is fair to say that overall, I won more money than I lost at the bridge tables. So how did I learn anatomy then? My method was simple. I would visit the dissection rooms at about 3.30 pm each day, and ask the smelly but dedicated dissectors to “show me some structures”. They were more than happy to oblige, proud as they were of their beautiful displays of rotting human flesh. Having got a 3dimensional perspective of the thing, I would go to my room in the boarding house and read the anatomy textbook – not dissection manuals, mind you. And I regularly scored well in the fortnightly and term end assessments, much to the surprise of my more assiduous colleagues. We were fortunate to have a galaxy of professional giants as our teachers, you see on this panel I can tell you some wonderful stories about all of them and mimic all of them, but time will not permit me to demonstrate my entire repertoire. I will confine myself to mimicking one, Professor Gerald H Cooray – and telling you 2 anecdotes about two other professors.

Professor G H Cooray

I reproduce verbatim the first few sentences of Professor Gerald Cooray’s first lecture in path to us. Please note that I do so with great respect and affection, without a trace of rancour. Here it is.

Prof. Senaka Bibile

“Good morning, Ladies and Gentlemen, I am Professor Gerald Cooray, Professor of Pathology and Head of the Department. In this Department I am the Chief and you are students. I shall give the first 8 lectures that will lay the foundation for your knowledge of pathology, and in the final term, I shall do 8 tutorials on the essence of systemic pathology to give the finishing touches. My assistants here will do the rest. If you have any concerns or problems, you must see me by prior appointment, and I will do my best to help you”. The last sentence was not taken seriously by anyone, because no student was likely ever to seek a meeting with that daunting personality. Now for the first anecdote, I thought I had done fairly well in the 3rd MB examination in all the subjects, except that, in the Pharmacy practicals, which carried 10% of the marks in Pharmacology, the mixture I had to make had a royal purple colour, whereas my colleagues’ endproducts were beige or milky white. At the Pharmacology viva voce that followed, conducted by Professor Senaka Bibile and Dr. Wickreme Wijenaike, the Professor asked me, “I say, what did you do at your Pharmacy practicals?”. I replied, innocent as a baby, “Sir, I made the powder and a mixture that we were asked to make”. For you young guys’ information, powders and mixtures were very much a part of a doctor’s armamentarium in those days.

Contd. on page 12

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Contd. from page 10

E M Wijerama... Says Professor Bibile, “Well, well, you have got nought out of ten for your efforts”. But he saw my discomfiture and hastened to add, “Don’t worry, son. You have secured 65 out of the balance 90 marks” in Pharmacology .

lunch or tea. I returned to the professorial ward by 7.30 am the following day, only to be quizzed by Professor Rajasuriya on a few tests. I knew the answers and he permitted me to rejoin the batch.

The second anecdote is about Professor K Rajasuriya, who was a strict task-master. On the first day of our first professorial appointment, which was with Rajasuriya, after the preliminaries of appointing a “monitor” for the 15-strong batch and allocating patients to each one of us, he started the ward round. At the first bed, a nurse was taking venous blood for some test. Professor Rajasuirya indicated this scene with a nod in my direction, and the following drama ensued.

I was then asked to present the patient alotted to me within 5 days. He was a 18-year old boy with Hodgkin disease. After intense preparation I made a trembling presentation, the climax of which came when I said that, although the boy was being treated (with radiotherapy) for Hodgkin, neither bone marrow examination nor a cervical lymph node biopsy had revealed Reed-Sternberg cells, the multinucleated large cells supposed to be the hallmark of the disease. This statement evoked a brisk response from Professor Rajasuriya.

Professor Rajasuriya:“What is that nurse doing?” Colvin Goonaratna: “Sir, she is performing a venepuncture to obtain blood for a test” Prof R “What is the test?” CG: now trembling. “ I have to ask her, Sir” Prof R: “Ask her” (I turn on what I think is my most courteous demeanour and ask the nurse) CG: “Sir, she is taking blood for ESR”. Prof R: “How do you take blood for ESR?” CG: “ I don’t know, Sir, may I ask the nurse?” Prof R: “No you may not, although I think nurses are quite appropriate teachers for people like you. But I have a better idea. You will leave this class immediately. And do not come this way until you have learnt all the tests in Hutchisons’s Clinical Methods”.

I went to the library and learnt by heart all the tests in that marvellous book from 8.30 am till the library closed at 6.00 pm, without a break for

“So you think our diagnosis is wrong?” To which I replied, respectfully, “No Sir, I did not say that. I only made a factually correct observation” After a few agonising moments Professor Rajasuriya smiled, and uttered one word that mattered so much to me then, and that I hear over and over again in my brain whenever I reminisce, as I am doing now. The word was , “ Good”. His Registrars praised me for getting an apparently rare “Good” from their Chief, and my batchmates seized the opportunity to set me back by over 40 Rupees at the College canteen. Forty Rupees in 1959 is equivalent to at least 2500 Rupees today. For comparison, I am telling you that my monthly boarding fee for a single room at a private residence close to the Faculty, with all meals, was only 120 Rupees. I mopped up knowledge and skills such as lumbar puncture, low forceps delivery of both vertex and breech presentations, manual removal of placentae. dilation and curettage and so on, but noted that we were not taught or demonstrated appropriate

attitudes.

Prof. K Rajasuriya

Let me relate two instances to illustrate my plight as an intern. The first was the death of a 30-year old young sturdy male, of monocytic leukemia, just 3 days after admission to our medical ward, transferred rather pointlessly from another General Hospital. It was not his death that caused me anguish. Death was expected. We had no treatments then for acute leukemias and no oncologists. It was the arrival of his young wife and 10-year old son during the noon visiting hour, having waited outside the gate for over one hour, only to see his dead body. Their weeping was heart-wrenching. I could not handle the situation. Indeed I knew that I was about to break down. I took the coward’s way out, ran to my room in the quarters, locked myself into it, and burst into tears. I know I would have handled that situation much better if I knew at the time, a few basic principles in the art of communicating bad news. The second incident was about a primigravid woman in labour , admitted by me to the professorial unit of Obstetrics under Professor D A Ranasinghe. She was transferred to De Soysa Maternity Hospital as a “no progress of labour”, from a District Contd. on page 13

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Contd. from page 12

E M Wijerama... 100/70 mm Hg. The presentation seemed to be vertex, occipito-posterior. I set up a dextrose-saline drip, with an intravenons multivitamin vial added to the drip, and a bolus of 25 percent dextrose. I had just walked down again to the admissions room when a call came through from the staff nurse in the labour room to say that the woman’s pulse rate had shot up to 115 bpm.

Prof. D A Ranasinghe

Hospital notorious at the time for sending bad patients after preposterous delays. In fact, she had been in labour for nearly 10 hours, she was dehydrated, and looked exhausted. But her pulse was 80 bpm and BP

I called in the Senior Registrar. He arrived in 15 minutes, did a vaginal examination, and told me gently that it was not a vertex but a face presentation .He made me do another vaginal, and explained my error, which was mistaking an eye socket of the face for the fontanelle. An emergency caesarian section was performed under general anaesthesia.

Her uterus had just started to rupture anteriorly. A beautiful 3kg baby boy was delivered and the uterus and abdominal wall were sutured routinely. However, the anaesthetist announced that she did not regain consciouness. She remained unconscious and died at about noon the following day. No diagnosis was made then, and to this day I am unable to give a plausible explanation for her death. After her death I decided to give up doing medicine, and remained in my room for two days. My colleagues and my boss persuaded me to return to work, arguing that I could always give up medicine after completing my internship year. That never happened, of course. (This article will be continued in next issue)

Clinical guidelines on “Diabetes Mellitus: Glucose control”

ndocrine Society of Sri Lanka released clinical guidelines on “Diabetes Mellitus: Glucose control” on the 18th of January at the Foundation Institute of Sri Lanka 2013. Guidelines were developed by a local panel of experts. This guideline includes chapters on “Treatment of Type 2 Diabetes”, “Diabetes in Children”, “Diabetes in Older Adults”, “Diabetes in Pregnancy”, “Diabetes in Chronic Kidney Disease”, “Diabetes Management in Hospital Setting” and “Definitions”. The appendix includes “Sample menu” and “I.V. insulin protocol for ICU patients”. These guidelines will help to improve the quality of care of patients with diabetes in Sri Lanka. The full text of this booklet on guidelines is available at

http://endocrinesociety.files.wordpress.com/2012/09/diabetes-mellitus-glucose-control.pdf

SLMAN

March, 2013

Introducing Quality Improvement Pr A challenging experience Dr.A.Ketheswaran MD, M.Sc (Community Medicine) Regional Director of Health Services, Jaffna.

here was a wide spread misbelieve in our country that Quality Improvement Programme (QIP) can be implemented only in private hospitals. Castle Street Hospital for Women broke this misbelieve first in Sri Lanka and proved that QIP can be successfully implemented in state hospitals too. Then several state hospitals considered the Castle Street Hospital for Women as their role model and started implementing QIP to improve the quality of health services. In short, Castle Street Hospital for Women is the pioneer among the state health sector in quality improvement programme and revolutionized the health service delivery in our country. We visited Castle Street Hospital for Women on several occasions and admired with its success. We had a dream to implement QIP in our hospitals too. In 2009, when the conflict situation came to an end, we started the process of re-building the health institutions in Jaffna District, which were badly affected by the 30 years prolonged conflict situation. We thought that it was high time to introduce QIP as well in Jaffna District. We decided to implement QIP in three health institutions in Jaffna District as pilot project namely RDHS office, Jaffna; Base Hospital, Point Pedro and MOH Office Chavakachcheri. We invited Mr. M. Thilakasri, a senior consultant from Sri Lanka Institute for Development Administration (SLIDA) as our resource person to introduce QIP. He personally visited these health institutions, advised us how to move forward and he conducted an introductory training programme on QIP for the staff from these three institutions. Then we took 50 staff in two batches to SLIDA for three days residential

Divisional Hospital, Chankanai

training. During this training, we visited Castle Street Hospital for Women, Motor Traffic Department and other few institutions, which had successfully implemented QIP. These trainings highly motivated our staff and guided us to move forward. As soon as we returned from Colombo, the Work Improvement Teams (WITs) were established in each unit of these institutions and the teams actively started to implement the QIP. There was a constructive competition among the WIT teams. Fortunately we had the Health Sector Development Programme to support some activities for QIP. The staff personally extended their own contributions too to improve their units and raised funds from the local donors. The staff from Base Hospital, Point Pedro conducted bicycle and motor bike parks in a temple festival and organized a football tournament to raise funds for QIP. After seeing the sudden change in this institution people in the area, schools and business organiza-

tions came forward to render financial and manual support. School children, Bank officers came and did cleaning of premises and painting of building. We were able to allocate some more funds for infrastructure development as our higher authorities were also impressed with these improvements. These health institutions became clean, beautiful and well organized. The staff were highly motivated and proud to work there. They have recognized their own capabilities and started to think creatively. They have worked beyond their duty hours to achieve a better recognition in the community. These three institutions participated in the National Health Excellence Award Competition 2009 - 2010 conducted by the Ministry of Health. The BH Point Pedro won the silver award in the Medium Scales Hospitals category. The RDHS office, Jaffna won the bronze award in the Management Units category. First time in the history, the efforts of our staff were recognized in front of large gatherings. Our institu-

March, 2013

NEWS

rogramme in RDHS Division Jaffna : tions became popular at National level for our efforts and achievements. It was a big appreciation and motivation for our staff to move further. These institutions have become pioneers for QIP in Northern Province. Now we train other department staff in our institutions. Our staff feel proud to be the trainers for other department staff. We have started to expand the QIP to other health institutions in Jaffna District. We trained all staff from all other three Base Hospitals namely, BH Tellippalai, BH Chavakachcheri and BH Kayts and Divisional Hospital, Chankanai. We plan to train staff from MOH Offices, Divisional Hospitals and Primary Medical Care Units also.

community support. Lot of people predicted that QIP cannot be implemented in Jaffna. It will be a miracle for us. But our dedicated staff, who served our people in very difficult circumstances during the past 30 years of conflict period, made a history by implementing QIP in Jaffna successfully and by winning National awards for Health excellence.

We hope to complete the training on QIP for entire health staff in RDHS Division, Jaffna in near future. Recently, the Divisional Hospital, Chankanai implemented the QIP successfully. The staff personally contributed and raised support from the local community. It has become as a role model for smaller health institutions to implement the QIP.Maintaining clean, beautiful and well organized health institutions is not enough. We have to show improvements in the service delivery. We focus to analyze the improvements in our performance indicators. Staff were trained for developing positive attitudes. Customer satisfaction surveys were conducted to review the service delivery and lot of improvements were made based on these findings. As the quality improvement is a continuous effort, the mechanisms to monitor and evaluate the progress and give feedback were established in each institution. Finally, I would like to highlight the key factors behind the success of QIP in Jaffna District which include dedicated leadership at senior, middle and junior levels, hard work and team work of dedicated health staff and excellent

Base Hospital, Point Pedro - Entrance

Divisional Hospital, Chankanai

RDHS Office Jaffna â&#x20AC;&#x201C; Planning Unit Divisional Hospital, Chankanai

Medical Ward - Base Hospital ,Point Pedro

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March, 2013

BLADDER OUTLET OBSTRUCTION (BOO) Prof. Neville D. Perera1 MS(Col), FRCS(Eng), FRCS(Ed), DUrol(Lon),FCS(SL)

Dr. Sohan Perera2 MD (Surg)(Col) Dr A .A Manoj Lankapura Wickramaratne2, MD(Surg)(Col), MRCS(Eng), 1 Consultant Urological Surgeon, 2 Senior Registrar in Urology, Department of Urology, NHSL.

distention. Dilatation and lengthening can be seen in the ureters. Pelvicaliceal changes are hyperactivity and hypertrophy and leading to dilatation and rounding of the fornices, followed by flattening of the papillae and finally clubbing of the minor calyces. Renal parenchymal changes are compression and ischemic atrophy.

Principles of management Introduction Bladder Outlet Obstruction (BOO) is an urological condition where the urine flow from the urinary bladder through the urethra is impeded. Consequences of BOO depend on the level of obstruction (infra vesical or intra vesical), degree of obstruction (complete or partial), nature of obstruction (structural or functional) and the duration of obstruction.(acute or chronic) There are many structural causes for bladder outlet obstruction. Congenital causes, mainly found during childhood are tight phimosis ,meatal stenosis and posterior urethral valves . Acquired causes are Benign Prostatic Hyperplasia (BPH) and carcinoma of prostate, inflammatory or traumatic urethral strictures, vesical tumours, stones, extrinsic urethral distortion (loaded bowel).Functional obstruction which is mainly die to disturbance of the micturition reflex following upper motor or lower motor neurone injury at the S2,3,4 spinal cord level(spinal cord injury,peripheral neuropathy due to pelvic surgery ) neurogenic bladder. Uncorrected BOO will result in urinary stasis, infection, loss of renal function, hydronephrosis, detrusor failure and stone formation. The changes in the various segments in the urinary tract due to BOO will depend on severity and duration of obstruction. Urethral changes are dilatation, diverticulae and fistulae formation. Bladder changes are trabeculation, residual urine, diverticula and

BOO present with lower urinary tract symptoms(LUTS)which are mostly obstructive (Hesitancy, slow stream and over flow incontinence) and also irritative (frequency, urgency nocturia and urge incontinence) when the bladder become unstable due to prolonged obstruction.Clinical examination should be directed to find external urethral disease(Phimosis,balanitis xeortica with meatal stenosis ,palpable penile urethral stricture, percussable or palpable bladder and ballotable enlarged kidneys(chronic retention) nature of the prostatic enlargement and signs of chronic renal failure. Laboratory findings of the BOO include evidence of infection(in urine deposits, FBC and CRP), and impaired renal functions. Imaging is important in localizing the site of obstruction, to assess anatomical and functional changes and to demonstrate the extent of the obstruction. Ultrasound scan of the KUB with pre and post voidal residual volume and the uroflowmetry are the most informatory. Contrast studies IVU/CTurogram(upper tract dilatation), urethrography(urethra stricture), isotope renography(non-functioning or refluxing kidney) are added depending on the suspected pathology or complications. Presence of haematuria or elevated PSA(prostatic cancer) need special investigations to exclude urological malignancy(prostatic biopsy,cystoscopy)

Indications for urgent intervention in BOO with immediate decompression are active infection with systemic effects(septicaemia), acute retention (BPH, spinal shock), upper tract dilatation with renal impairment , intractable incontinence (overflow) and large residual volumes(over 300cc). Prognosis depends on the cause, site, duration, degree of parenchymal renal injury the nature of the definitive management.Immediate decompression should be done by sterile catheterization of the bladder by urethral or supra-pubic route. Persistant hydro uretro nephrosis would need decompression by indwelling double J ureteric stenting or image guided percutaneous nephrostomy for renal preservation. Acute Urethral injury and massive post decompression diuresis are complications which should be kept in mind Management of two important and commonly encountered examples of structural (BPH) and functional(spinal cord injury) BOO are discussed below

Benign prostatic hyperplasia(BPH) The prostate will show microscopic changes of BPH from the age of 35-40 years .Yet only Half of all men over the age of 60 will develop Benign Prostatic Hyperplasia (BPH). All men with BPH about 50% will develop BPH and 50% of them develop LUTS/ BOO .By the time men reach their 70â&#x20AC;&#x2122;s or 80â&#x20AC;&#x2122;s, 80% will experience some urinary symptoms. Main etiological factor for BPH is the age. Other possible factors are androgen status, race (Japanese), Smoking, body mass, cirrhosis, alcohol, family history . Patients with BPH can present with various Lower Urinary Tract Symptoms (LUTS). Contd. on page 20

SLMANEWS

March, 2013

Factor Analysis Workshop : The First in a series of workshops in 2013

he Research Promotion Committee of the SLMA will be organizing a series of workshops on research related topics throughout the year. These workshops are aimed at postgraduate trainees in health professions, but researchers from other disciplines are welcome. As one of the first of these workshops, a workshop on Factor Analysis was successfully conducted by Prof. Chrishantha Abeysena on 7th March 2013. The workshop drew a large audience with over 70 participants. Factor Analysis is a statistical method used to describe variability among observed variables (e.g. items in a survey) in terms of a potentially lower number of unobserved variables called factors. This method is used in behavioral sciences, social sciences, marketing, and other applied sciences. It has many uses including data reduction and scale validation. The workshop focused on exploratory factor analysis. Key terms and definitions, the procedure of analysis using SPSS, and interpretation of results was discussed at the workshop. Participants engaged in several hands-on activities including practice on dummy data sets and interpretation of findings in a published article.

include writing for publication and making scientific presentations, qualitative research methods, statistical methods of analysis and questionnaire development, and facilities and opportunities for research in Sri Lanka. We invite suggestions from our readership on future workshops. Please email your suggestions to Dr. Asela Olupeliyawa (asela_o@yahoo.com ). Resource persons who wish to contribute to future workshops are also invited to contact Dr. Asela Olupeliyawa (asela_o@yahoo.com ).

Participant feedback was positive and several areas for future workshops have been suggested. These

Vacancies in SLMA Committees The SLMA has around 25 committees which comprise the functional unit of the SLMA. Joining as new members to the committees would enable doctors from different levels to get involved with the work of the SLMA, commence their linkage with SLMA activities and also enable the Committees to utilise their potential. The applications are called for varying numbers of vacancies in the following committees.

• Communicable Diseases Committee

• Research Promotion Committee

• Road Traffic Crashes Prevention Committee

• Working Group on Healthcare Quality and Safety

• Herbal Medicine Committee

The application can be downloaded from http://www.slmaonline.info/ . Separate application should be used for each committee you wish to join. Perfected applications should be sent via the e mail address given in the application. The applications received will be forwarded to the respective committees for their opinion and then submitted to the Council of the SLMA for approval. The members who both failed to attend three consecutive meetings and did not contribute to any of the activities of the committee for three months would be removed from the committee. We encourage you to join these committees.

SLMANEWS

March, 2013

SLMANEWS

March, 2013

Contd. from page 16

Bladder Outlet... They are either obstructive and/or irritative It is essential to evaluate the symptoms with International prostate symptom score(IPSS ), information regarding compounding illnesses (Prior surgery/DM/neuropathy/drugs), physical examination (DRE, voiding diary, urinalysis, basic renal function tests, PSA (If life expectancy is more than 10 yrs). Essential investigations are Ultra songraphy of KUB with post void residual volume(PVR) combined with uroflowmetry. There is no place for routine X ray,advanced urodynamics or urethrography. However if the patient has other concomitant symptoms, imaging such as IVU, CT IVU or endoscopy would be added. (European guide lines 2012) After catheterization for acute retention, uncomplicated patients (without infection, hydronephrosis or obstructive renal impairment) are subjected to a trial without catheter (TWOC) while on alpha blockers(see below) for 24-48 hours .Failure would necessitate long term catheterisation or surgical interventions. Definitive management modalities of BPH are watchful waiting (with life style adjustments), pharmacotherapy, phyto-therapy(doubtful value) and a range of surgical procedures. Patients with minimal symptoms, old and the feeble with serious co morbidities should be offered watchful waiting. They should be regularly evaluated (once or twice a year) to assess the progression of symptoms or complications. Pharmacotherapy is the mainstay of treatment which is based on two principles. They are relaxing the bladder neck (Alpha blockers -prazosin, terazosin, tamsulosin,doxasoin and Silodosin) and shrinking the prostatic adenoma (5-alpha reductase Inhibitors to reduce intra prostatin di hydro testosterone- finesteride, dutesteride)

Alpha blockers are indicated for men presenting with uncomplicated LUTS. Patients will have symptomatic improvement within 1-2 weeks. They enhance urine flow by 3-5 ml/ sec and it may require dose titration. Main side side-effects are related to peripheral vasodilatation, postural hypotension, dizziness and headache, nasal congestion) and bladder neck dilatation(Retrograde ejaculation). Cost, uncertain duration, recurrence of symptoms, over treatment are the main disadvantages of alpha blockers. 5 Alpha reductase have two sub types - 1 and 2. Finesteride a Type 1 inhibitor and dutasteride inhibit both Type 1 and 2). They are indicated in patients with prostates volume more than 40cc. It takes 3 – 6 months for onset of action. They significantly reduces incidence of long-term complications of BPH (Retention and surgery) and also reduces haematuria associated with BPH. Side effects include reversible impotence, reduced libido in 3-5% of patients. Main disadvantages are cost, uncertain duration of therapy, masking prostatic cancer as they cause false eduction in PSA by approximately 50% .. Phytotherapy is popular in Europe. These are plant extracts and are commonly known as prostate pills or men’s health pills. (Saw palmetto). Over 15 ingredients are identified in these pills (Phytosteroles, Luphenone, Lectines,Flavanoids, phytooestrogens, Genistein, Zinc, Vitamin E, Aminoacids). However recent clinical trials have proven that they are mostly ineffective. In case of 20-30 % of patient in whom the drug therapy fail (retention or increase of symptom score)in the past open enucleation of the prostatic adenoma was the mainstay of surgical treatment. Still this gives the best way to remove large adenomas and it has the best urodynamic outcome. However It is associated with all the

complications of open surgery and has faded off with the emergence of endoscopic resections and now a days practiced only when expertise or equipment are lacking. Trans Urethral Resection of Prostate (TURP) is the “Gold standard” of surgery for BPH since 1935. With TURP, 80~90% obstructive symptoms and 30% irritative symptoms(caused by the bladder) can be improved. 80-90%of people will have improvement of all symptoms at 1 year but the rate decrease to 60-75% at 5 years due to aging bladder and regrowth of the adenoma. Hence 5% of patients will require repeat TURP. It has low mortality rate (0-0.2%) and 18% morbidity. Complications are mainly associated with larger prostates and less experienced surgeons. TURP syndrome is the most dreaded complication caused by absorption and over loading of hypo-osmolar irrigation fluid during resection. It is featured by dilutional hyponatraemia, haemolysis, renal failure and cardiac failure .Transurethral resection of prostate in saline (TURiS) is a new modification of TURP and Other new procedures such as transurethral Laser vaporization and resection and bipolar endo enucleation of prostate could minimize these complications.

Neuropathic (neurogenic) bladder obstruction For practical purposes classified mainly in two types. Upper Motor Neuron lesions (above sacral 2,3,4 level) causing spastic neurogenic bladder (High pressure ,low volume, bladder with detrusor –sphincter disharmony) and Lower Motor Neuron lesion(at or below S234 level) causing an atonic bladder (Floppy .low pressure non contractile bladder.) Sometimes there can be a mixed picture. Contd. on page 23

SLMANEWS

March, 2013

Healthcare Quality and Safety Directorate trains overseas participants Dr S Sridharan MD (USSR), M.Sc (Med. Admn.), MD (Col.), Director / Healthcare Quality & Safety, Ministry of Health, Sri Lanka

What are SSC, TCTP, 5 S, CQI and TQM? We will get an understanding of some terms used in the quality and safety arena such as SSC, TCTP, 5 S, CQI and TQM. South–South Cooperation (SSC) is a term historically used by policymakers and academics to describe the exchange of resources, technology, and knowledge between developing countries, also known as countries of the global South. Japan is to promote SSC actively in collaboration with those developing countries, not only in Asia but also in other regions of the world that show more advanced path in their development. Third Country Training Program (TCTP) is one of scheme of SSC. This scheme is one whereby with the assistance of JICA, developing countries accept trainees from other developing countries for the purpose of technology transfer or dissemination. Continuous Quality Management (CQI) is an approach to improving and maintaining quality that emphasizes regular, internally driven assessments of potential causes of quality defects, followed by action aimed at either avoiding a reduction in quality or correcting the quality defect at an early stage. Total Quality Management (TQM), which is a process for creating organization-wide participation in planning and implementing continuous improvements in quality. This system of TQM was originally developed in the Japanese manufacturing industry, comprising of the 5S’s organizational method (seiri (sort), seiton (set), seiso (shine), seiketsu (standardize) and shitsuke (sustain) and kaizen (continuous

quality improvement).

Sri Lanka providing training on SSC, TCTP, 5 S, CQI and TQM The low cost approach to quality improvement in Sri Lankan health sector has been given due recognition by Japanese International Cooperation Agency (JICA). Therefore Sri Lanka was selected for the TCTP and so far nearly 24 countries were trained in Sri Lanka to understand this 5S-CQI-TQM approach to quality improvement programme for hospitals. As one of the successful cases of South-South cooperation, JICA will present its triangular program for health services improvement along with the experts of Sri Lanka and Tanzania on 21st November 2013. The program has helped improve Sri Lanka’s healthcare management system with the use of Japanesestyle quality management methods called 5S*, CQI and TQM. Sri Lanka’s experience of applying the Japanese methods has been further utilized to improve the healthcare system and health services quality of 15 African states including Tanzania. The Program of Quality Improvement of Health Services by 5S-KAIZEN-TQM, which received the Solution Award this year, is Triangular Cooperation based on the innovative experience of hospital management in Sri Lanka. The innovation was the use of the Total Quality Management (TQM) method in hospitals, and it has contributed to reducing neonatal infections despite limited human, physical and financial resources. JICA has helped systematize Sri Lanka’s successful experience into an approach that can be applied in

other countries. In the case of Tanzania, it has led to the reduction in waiting time for patients and an increase of hospital incomes due to improved accounting operations. When JICA promotes South-South Cooperation and implements Triangular Cooperation, it creates many benefits beyond transferring useful knowledge to developing countries. It also helps developing countries (including emerging countries) build their capacity as aid providers. Due to these factors, JICA will continue to be a stronger supporter of South-South Cooperation. Contd. on page 26

Appreciation by UNDP to Ministry of Health for South-South Cooperation

DGHS discussing with Bangladesh participants

Address by DDG (MS) 1 to Cambodian participants

SLMANEWS

March, 2013

DISCOVER SRI LANKA A visit to Ridi Viharaya and Rambodagala – the old and the new

his one day trip from Colombo will take you to ‘Ridi Viharaya’ a Buddhist temple dating from the 2nd Century BC. Once you have finished seeing the sights there you will proceed to Rambodagalla Vihare a few Kilometers further on. A massive statue of Lord Buddha is being carved out of solid rock by traditional artisans from South India. It will give you an idea of how these massive structures were carved out of granite. The road from Colombo past Alawwa, Kurunegala takes you to Ibbagamuwa on the road to Dambulla. Ibbagamuwa is 106 Kms away from Colombo and should take about two hours drive. You turn to the right after leaving Ibbagamuwa on the road to Ridi Viharaya which is about 11 Kms from Ibbagamuwa. Ridivihare has its origins attributed to spiritually advanced Buddhist monks (arahaths) who were contemporaries of the Rev Mahindha Thero of the 2nd to the 3rd century BC. These arahaths had resided in about 25 caves scattered around this site and one of them being at Rambodagala.

merchant had gone inside the cave and found a mound of silver ore. The astonished merchant had taken a piece of the silver ore, and given it to King Dutugemunu (161 – 137 BC). The latter had sent one of his courtiers who had mined the ore and brought it to Anuradhapura the capital of that time. The silver was used to make the pinnacle (‘Kotha’) of the Ruwanweli Maha Sthupa. The grateful King had built a temple inside the cave which is called ‘Rajathe Lena’ meaning silver cave. The Vihare built near the cave was called ‘Ridi Vihare’ (Silver temple) and the village nearby ‘Ridigama’ (Silver village).

A stone water reservoir

An Arahat

The temple

Old stone stairway

A Moonston

A stairway

The story is told how a merchant travelling through this area to the hill country, had acquired a Jak fruit of exquisite taste. He had offered it to an Arahath residing in the area. The latter had shown a path to the hill country which the merchant took. While passing a cave on the way, the Contd. on page 24

SLMANEWS

March, 2013

Contd. from page 20

Bladder Outlet... It is most important to differentiate the bladders with high bladder pressures from low bladder pressures to prevent damage to kidneys. Apart from the neurological examination to determine the level of the spinal cord lesion ,advanced urodynamic studies to check the bladder pressures(Cystometrography) and urethral function(Urethral pressure profile) is the most informative investigation done by the urologists. As the urinary symptoms and basic investigations do not provide accurate information and often misleading in assessing the bladder function. urodynamics plays a pivotal role in managing all neuropathic bladder disorders. Mismanagement of neuropathic bladders is a major cause of renal failure, sepsis and death among patients with spinal cord lesions. There are 5 basic concepts of managing a neuropathic bladder. They are “keep it empty”, “keep it relaxed”, “keep it continent”, “keep it clean” and , “ detect and prevent injury to the kidney”. Time Voiding (by the clock), Double emptying, Clean Self Intermittent Catheterization, Indwelling catheterisation (Spinal shock, tetraplegic patients), drugs (alfa blockers),urethral sphincterotomy are the ways to keep the bladder empty. Patients should be advised against compression of lower abdomen (Credes maneuver) , Straining (Valsalva) to empty the bladder and applying external appliances in overflow incontinence( overlooking the destruction taking place inside the bladder!). It is important to note that when the bladder is stretched to more than 500cc infection or reflux is more likely. So try to

maintain intermittent catheterizations to maintain a capacity of 250cc-350cc/catheterisation Maintain bladder compliance/ capacity in hyper reflexic upper motor neurone bladders , with medications which paralyze bladder wall (anticholinergics and botox injections), bladder instillations (capsasin,, resinifera toxin) or in intractable cases ,surgery with augmentation cystoplasty using interpositioned bowel segments), or urinary diversion.

SLMA monthly Clinical meeting for the month of February was held on 19th February at the SLMA auditorium. The meeting was well attended with more than 60 participants. A summary of the review lecture is given above.

Regular emptying, external appliances (pads,penile clamps), increase capacity, drugs (Ancholinergics), Catheters, diversions, artificial urinary sphincters and neuromodulation are important in keeping the bladder continent to prevent social discomfort and skin complications. It is important to detect and treat infections promptly. Regular urinalysis has to be performed. While Upper tract infections with systemic effects need vigorous antibiotic treatment. Afebrile,asymptomatic bacteriuria with or without catheters should not be treated with antibiotics as it is a sure way of development of antibiotic resistance with a detrimental outcome. Resistant infections need investigations to exclude complications such as stones and urinary stagnation. Complications such as strictures, fistulae acquired hypospadias and balloon encrustation stones require prompt treatment. Regular follow up(twice a year) with Renal function tests, Ultrasongraphy, Uroflowmetry, Urodynamics and other imaging studies are needed for detection of upper tract obstructive uropathy and prompt intervention.

McConnell, J. D., R. Bruskewitz, et al. (1998). "The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. Finasteride Long-Term Efficacy and Safety Study Group." The New England journal of medicine 338(9): 557-563.

SLMANEWS

March, 2013 Contd. from page 22

A visit to Ridi Viharaya... Rambadagalla – Monaragala Vihara, near Ridigama, Kurunegala. Rambadagalla – Monaragala Vihara, near Ridigama, Kurunegala. You have to go back to Ridigama and travel a few more Kms to come to the Rambodagalla – Monaragala Vihare. It is a drive of about half an hour. Inquire from any passerby and they will direct you there. You might have to climb a rock but it is a steady incline of about a hundred meters. The news of the destruction of the ‘Bamiyan Buddha image’ in Afghanistan by the Taliban was the incentive to create this statue. Chief Shilpi Muththaiah Sthapathy, who had experience in this field, was approached through Mr. Easwaran of

Artisans at work

Easwaran Co., Colombo. After inspecting the rock Mr. Muththaiah suggested a statue of 67.5 feet. He had never done a massive statue in granite of Lord Budhdha but he came from a generation of Shilpis who had done massive statues in stone of Hindu deities. He did not want a fee. He wanted only food, lodging and pay for the artisans from Thamil Nadu from South India working on the statue. I visited this site while work was in progress. It will be instructive for you to see the workmen doing the construction of this massive statue. You may be able to tell your grand-children, that you witnessed its construction.

The statue of Lord Buddha under construction

The overall plan

Measurements of the statue

The Chief Priest with Chief Shilpi Muththaiah Sthapathy

The climb on the rock to reach the statue and looking down

The statue of King Raavana There is a statue dedicated to King Raavana of ancient Sri Lanka, about 100 meters away from the site of the Buddha statue. This is supposed to be the only statue dedicated to King Raavana in present Sri Lanka. There are some peculiar markings below the statue which are well worth studying.

It was published in CoMSAA NEWS 2012;1(2):34-38 Looking down into the valley

All contents were produced and provided by Dr. Philip G. Veerasingam This article is reproduced with permission from the author and Editor, CoMSAA

A statue of Raavana with some inscriptions

SLMANEWS

March, 2013

Public Speaking – Fear It Not!

or many of us, public speaking is the bane of our existence. The mere thought of it could make us nervous and nauseous. Public speaking skills and effective communication are essential for smooth progress in a successful career. The Toastmasters Speech Craft venture is an established, encouraging and entertaining programme that aims to train individuals to effectively and confidently converse, communicate and conquer the fear of public speaking. Being enrolled in the 10-week Speech Craft Programme of the SLMA, organised from mid February, held once a week on Wednesdays and run by Toastmasters, has already become one of the

highlights of my week. It provides a comfortable platform for meeting new people, excellent learning opportunities and receiving constructive feedback from experienced Toastmasters. Furthermore, even activities such as Ice Breaker Speeches and Table Topic Speeches are generally packed with good humour. Therefore, if you are thinking of polishing up your speaking skills, enrolling in Toastmasters Speech Craft Programme will be well worth your time and all the money you pay for it. Ms. Srisaiyini Kidnapillai Participant of the current Speech Craft Programme

Sri Lanka Medical Association Symposium on “Japanese Encephalitis and the recent outbreak at Rathnapura” Organized by the Communicable Diseases Committee of the SLMA

11.30 am

Clinical features and the current outbreak

11.50 am

Epidemiology of JE in Sri Lanka and recent changes

Dr. N. Sritharan Consultant Physician, General Hospital, Rathnapura

Dr Paba Palihawadana Chief Epidemiologist, Epidemiology Unit, Ministry of Health

12.10 pm

Laboratory diagnosis

12.30 pm

Vaccination: current recommendations

12.50 pm

Discussion

Date Time Venue

: : :

Dr Geethani Galagoda Consultant Virologist, Medical Research Institute, Colombo Dr Omala Wimalaratne, Consultant Virologist and Vaccinologist, Medical Research Institute, Colombo Wednesday 20th March 2013 11.30 am - 1.00 pm SLMA Auditorium All are welcome

Contd. from page 20

Healthcare... Under this programme, JICA in collaboration with Directorate of Healthcare Quality & Safety, Ministry of Health trained health managers from Cambodia (18th – 22nd Feb. 2013) and Bangladesh (25th Feb – 2nd March 2013). The training programme comprised of basic health care quality and safety, group discussion and study visits. The Cambodian team visited Castle Street Hospital foe Women, Colombo South Teaching Hospital and Lanka Hospitals. The Bangladesh Castle Street Hospital foe Women, Lanka Hospitals, Puttalam Base Hospital ( Since Puttalam BH initiated Quality Assurance programme 6 months ago, to understand the approach of 5S-CQITQM at the initial stage), District Hospital Polpitigama (to understand QA programme in Primary care Unit) and District Hospital Bingiriya (to understand QA programme in Primary care Unit).