CGPSL

NEWSLETTER OF THE COLLEGE OF GENERAL PRACTITIONERS OF SRI LANKA No.6, “Wijerama House”, Wijerama Mawatha, Colombo 7. SEPTEMBER 2007 Tele: 2698894 Fax: 2695188 E-mail: [email protected] / [email protected] Website: www.cgp.lk

COME TO THE SESSIONS

Dear Colleagues, I thank the members of the steering committee I am sure you must be eagerly looking forward who are working very hard to ensure a successful to this year’s Annual Academic Sessions in scientific programme. The members are Titus October. You have been given an outline of what Fernando, Preethi Wijegoonewardene, K Sri it would be like in our last Newsletter but that Ranjan, K Chandrasekher, Jayantha Jayatissa, was only an appetizer. Please look within for the Eugene Corea, Antoinette Perera and A L P de S programme in detail and you will see the entire Seneviratne. menu. We would like to see large numbers registering at the sessions, so please hurry up and The Academic sessions will also be accredited register now. with the Central CPD Committee so you will be able to collect CPD credits with the certificate This year the scientific programme has been you receive at the end of the sessions. Make sure tailored to suit your learning needs. Your you sign the attendance sheet that will be passed educational needs were identified through a around during the sessions. Looking forward to questionnaire sent to those of you who attended your active participation at the academic sessions the sessions last year. The respondents to the on 6th and 7th of October. questionnaire will find the full list of topics suggested by you on page 4. You will be pleased Nandani de Silva to see that almost all the topics on offer are the President ones you had requested.

In this issue…..

∑ Come to the session – p1 ∑ 33rd A nnual A cadem ic S essions – p2,3 ∑ Your choice œ p3,4 ∑ A small sacrifice – p4 ∑ A Rock And Role Model? – p5 ∑ BioBombs – p5 ∑ Nice referrals – p6 ∑ No safe level œ p8 1 My College œ September 2007 COUNCIL & COMMITTEE NEWS FROM US

33RD ANNUAL ACADEMIC SESSIONS Theme: Enhancing Quality in Family Practice DAY 1: Saturday, 6th October 2007 Venue: Lionel Memorial Auditorium 9.00am – 12.00noon Joint Symposium with the National Stroke Association

A general practice perspective K P Piyasena, Family Physician Sanath Hettige, Family Physician

Acute stroke: what should you do? Padma Gunaratne, Consultant Neurologist

Rehabilitation of a stroke from hospital to community Lalith Wijeyaratne, President, National Stroke Association and the Rehabilitation Team

6.45pm – 8.30pm Inauguration Ceremony

DAY 2: Sunday, 7th October 2007 Venue: Lionel Memorial Auditorium, Colombo 7 8.00 am – 8.55 am Registration and Fellowship Breakfast

8.55 am – 9.00 am Welcome address by President Nandani de Silva

9.00 am – 9.30 am Guest Lecture - A role for the GP in medical management of thyroid diseases Noel Somasundaram, Consultant Endorinologist

9.30 am – 10.00 am Guest Lecture - Prodrome of Alzheimer’s Disease Asitha de Silva, Professor of Pharmacology

10.00 am – 11.15 am Gastro-enterology Symposium in association with the Gastro-intestinal and Digestive Endoscopy Society of Sri Lanka Moderator: K Chandrasekher • GORD Arjuna de Silva, Senior Lecturer in Medicine • Evaluation of asymptomatic patients with raised serum transaminases Janaka de Silva, Professor of Medicine • Rectal bleeding Kemal Deen, Professor of Surgery

11.15 am – 11.30 am Tea

11.30 am – 12.45 pm Free Papers (Parallel sessions)

12.45 pm – 1.30 pm Lunch

The College of General Practitioners of Sri Lanka sincerely thanks Nestle Lanka Limited for their educational grant, which has made the Newsletter a reality. 2 My College œ September 2007 COUNCIL & COMMITTEE NEWS FROM US

1.30 pm – 2.00 pm Guest Lecture - Evaluation of a patient with headache in family practice A T Alibhoy, Consultant Neurologist

2.00 pm – 3.15 pm Symposium on Health Care Waste Management in Practice Moderator: M R Haniffa

• Health Care Waste Management: A regional perspective D Gopinath, Professor of Community Medicine, M S Ramaiah Medical College, Bangalore • Waste management in a primary health care setting P Palihawadana, Epidemiologist • Situation analysis of Health Care Waste Management Ajith de Alwis, Professor, Dept. of Chemical & Process Engineering

3.15 pm – 3.45 pm Guest Lecture - NSAIDs – Use, Abuse and Iatrogenic Disease Priyadharshani Galappaththi, Senior Lecturer in Pharmacology

3.45 pm – 4.45 pm Symposium on Living with disaster Moderator: Eugene Corea

• Chemical Weapons of Mass Destruction Asiri Fernando • Role of the GP at site of disaster Narme Wickremasinghe, Family Physician

4.45 pm Tea

FROM YOU

YOUR CHOICE Topics requested by the membership for inclusion in the Academic Sessions programme

* Management of diabetes1 * Newer insulins and how it compares with older preparations1 * Cardiac injury markers * Management of newly diagnosed young hypertensive1 * Chest pain in family practice * Chronic eczema in family practice * Gastritis in Family practice√ * Common GI disease in children in Family Practice * UTI in adults and children * Current use of NSAIDs and gastric problems√ * Practical problems in Family Medicine5 * Genomic profiling in clinical oncology * Intra articular steroid injection6 * Recommendations on breast cancer screening3 * Current immunization procedures * Dermatological conditions in family practice * Stemcell transplant * Management of health care waste in practice√ * Management of obesity and diet control * Management of Fever * Febrile fits * Soft tissue swelling with or without pain or inflammation * Management of rheumectoid arthritis * Preventive oral health * Lipid lowering drugs and liver damage * Nebulization and use of inhalers in asthma in Family Practice2 * Minor surgical procedures * Emergencies in Primary care * Migraine in Family Practice√

Editor – Eugene Corea Type setting, page setting & formatting – Tharanga Sendanayake 3 My College œ September 2007 COUNCIL & COMMITTEE NEWS FROM YOU

* Management of contact dermatitis (allergic and irritant) in Family practice * Use of antibiotics in common diseases seen by General Practitioners4 * Management of hypothyrodism and hyperthyroidism in Family Practice√ * Use of Generics and GPs informing patient about the generics used * Sexology – Masturbation a) Moral health issues b) Would it relieve lonely beings of their urges and reduce violence in the form of rape and child abuse * Providing family practitioner service in Sri Lanka in health care system * How can CGPSL promote greater participation of younger members (below 50 years) in CGPSL activities both as decision makers and receivers of CPD * How can we promote better understanding of alternative systems of medicine practiced in Sri Lanka using the physicians providing primary care

1 has been dealt with in recent CME/CPD sessions 2 dealt with in pre-congress sessions last year 3 Article in previous issue of MY COLLEGE 4 covered in academic session 2006 5 Covered in CME/CPD session - September 2007 6 featured in wonca-mesar 2005 √ topics to be dealt with in October 2007 academic sessions

SOCIAL RESPONSIBILITY FROM US

A SMALL SACRIFICE Let us spend for our entertainment

Sociobiologists believe that the survival of the heartedly commends the council for taking these species Homo Sapiens, Sapiens (man) is closely measures. related to mans in-built capacity to give priority to the interests of others over his own (Altruism). The Let us take another step down this road. A step pioneers and icons of our College, some of whom are towards ensuring that sponsorship money will be still in active service have demonstrated this capacity used for educational purposes .It is time we seriously in no small measure. Their sacrifice has enabled the thought of reducing the burden on our sponsors and College to survive through turbulent times for over our patients from having to fund our entertainment. three decades. Times are hard for everyone in Sri Lanka. More so When speaking of survival of the College it must be for poor patients. Of all medical professionals, it is said that sponsorship extended by our friends in the the Family Doctors who can justifiably claim to be Pharmaceutical Industry is the only factor that stands the closest to the people. We deliver personalised between us and financial ruin. All of us (sponsors holistic care, and we are the advocates for our included) have to depend on profits for survival. It is constituencies-our patients. It is time for a sacrifice our patients who play the lead role, indeed the sole from all of us. A sacrifice that would indicate to role in ensuring the profitability of Family Doctors both, our sponsors and our patients that we will and the Industry. This is the sacrifice that is make requests for sponsorship only when mandated upon patients, if they are to obtain services absolutely necessary. in the private sector. The Values Committee appeals to you to make a In fact last year the College made two significant voluntary contribution towards meeting the cost decisions in this regard. The banquet after the of food and drink at the scientific sessions this academic sessions which was a heavily sponsored year. affair was discontinued and the small registration fee levied at monthly CPD meetings was utilised to fund Values Committee the fellowship. The values committee whole

4 My College œ September 2007 SOCIAL RESPONSIBILITY FROM YOU

A ROCK AND ROLE MODEL? by K.P.Piyasena The time was 3.30 PM on 30th Dec 1986. I should have started my evening Now this came like a torpedo and I session at 3PM. There I was, for the last 20 minutes at the railway crossing at was completely flabbergasted and Veyangoda waiting for the rail gate to be opened. There was no sign of a passing brought down to earth train. As far as I could see there were cars, busses and lorries on either side of the instantaneously. It didn’t take long crossing. I was imagining a long queue of patients at my clinic. I sounded the for me to realize what an ass I had horn several times. It was stupid as the signal system was controlled by the been. This sixteen year old school central signal room at Maradana. Few other motorists did the same after my lead boy {who is a doctor now} changed which made me very happy. my way of thinking for ever. I realized that there are people I was sure that the train was still at Maradana or at Polgahawela. Otherwise why watching you every step of the way. had we waited at the Veyangoda level crossing for such a long time (over 20 Your attitudes and behavior minutes)? Why had I wasted my valuable time at a level crossing? Then I made influence other people. The fact that one of those “smart” decisions. I swerved my car to the right lane of the road and you are a doctor means that you zig zaged to cross the level crossing from the wrong side. I heard the continuous can’t do things without attracting blasting of the approaching train. I was not bothered and anyway managed to pass the attention of the community in the approaching train just in the nick of time. I heard loud voices of people who which you live. You are public were stunned at my behaviour. Who was bothered? property. You have to respect yourself and your profession. You As I reached my clinic in one piece, surprisingly there were only few patients. So have to respect others and had it been worth all the trouble to have arrived in such a hurry and in the particularly the law of the country. process, missed creating headline news by a whisker? At the same time I was You are no longer just someone but elated that I had made my presence felt to everyone who was there. part of the wider society. You have

About half an hour later a retired school Principal walked in and gave a lengthy to respect the accepted social sermon about how people, particularly those who exert influence over others, norms. You should not make rash should behave in public. I told him politely to mind his own business and to see decisions within or outside your that the CGR runs a proper service. field.

The next patient who walked in was a sixteen year school boy. He said “SIR My sincere gratitude to that young YOU WERE MY HERO as well as the hero of my fellow school mates but NOT man who taught me the lesson of ANY MORE. (By the way there were very few doctors practicing in that area and my life. He is my HERO even there was nobody other than me, within a 5 mile radius}. He continued, “I too today. My dear readers, are you a wanted to be a doctor, to be someone like you. I am here today to get treatment role model? Remember there are for my illness, but if you don’t care for your own life how can I expect you to people watching you. But they may care for others lives?” With those words he walked away. not tell you, unlike my hero. That would be worse.

FROM US BIOBOMBS Health care waste management

In April this year a College CPD session on Health Care The expert resealing of used disposable syringes in India Waste Management was held. The resource persons were by unscrupulous individuals had led to the Pruthuvish and Gopinath – two medical professionals who recommendation for re-introduction of glass syringes and had pioneered a ground breaking waste management plan sterilizers. in Bangalore. P A C de Silva who was present at the meeting expressed According to them inadequate disposal of health care the view that untreated human excreta was used in the waste from a multitude of private and public sector paddy fields of China. In his opinion under the rubber rice facilities (including waste from GP practices) posed a pact (between Sri Lanka and China) we would have been serious potential health hazard to the community. supplied with rice that had been fortified in this manner! Untreated health care waste when added to the waste We need to deal with health care waste in a safe manner- disposal system could lead to a rapid and disastrous safe for our clients, our practices and the community. multiplication of pathogenic bacteria in the general waste This topic will be dealt with in detail at the academic dumps. sessions on the 7th of October. MY COLLEGE 5 My College œ September 2007 LITERATURE SCAN FROM YOU

NICE REFERRALS Guidelines in Practice, Vol.9, Issue 2, February 2006, Nice website www.nice.org.uk

Referral advice published by Nice and carried in the above journal are displayed here for the readers attention.

KEY: The starring system developed by NICE (National Institute for Health & Clinical Excellence UK) to identify referral priorities. Arrangements should be made so that the patient: ππππ is seen immediately1 1 within a day πππ is seen urgently2 2 health authorities, trusts and primary care organizations ππ is seen soon2 should work to local definitions of maximum waiting π has a routine appointment2 times in each of these categories. The multidisciplinary p is seen within an appropriate time depending advisory groups considered a maximum waiting time 2 on his or her clinical circumstances (discretionary) weeks to be appropriate for the urgent category.

MENORRHAGIA Many women with menorrhagia can be managed successfully in primary care. However, referral to a specialist service is advised if: πππ there is a suspicion of underlying cancer. For detailed advice on cancer referral see NICE Referral guidelines for suspected cancer (www.nice.org.uk) ππ they also have persistent intermenstrual or post-coital bleeding π despite 3 months of drug treatment, the heavy bleeding persists and is interfering with quality of life. Failure is best based upon the woman’s own assessment π they wish to explore the possibility of surgical intervention rather than persist with drug treatment p they have severe anaemia that has failed to respond to treatment

‘PROSTATISM’ Most men with evidence of urinary tract ‘outflow’ symptoms can be managed in primary care. However, referral to a specialist service is advised if: ππππ they develop acute urinary retention ππππ they have evidence of acute renal failure πππ they have visible haematuria πππ there is a suspicion of prostate cancer based on the finding of a nodular or firm prostate, and/or a raised PSA πππ they have culture-negative dysuria πππ they develop chronic urinary retention with overflow or night-time incontinence ππ they have a recurrent urinary tract infection ππ they develop microscopic haematuria p the symptoms have failed to respond to treatment in primary care and are severe enough to affect quality of life. This is best assessed by the patient using a symptom scoring system such as WHO’s International Prostate Symptom Score p they have evidence of chronic renal failure or renal damage

VARICOSE VEINS Most patients with varicose veins can be managed in primary care. In patients in whom varicosities are present or suspected, referral to a specialist service is advised if: ππππ they are bleeding from a varicosity that has eroded the skin πππ They have bled from a varicosity and are at risk of bleeding again ππ They have an ulcer which is progressive and/or painful despite treatment π They have an active or healed ulcer and/or progressive skin changes that may benefit from surgery π They have recurrent superficial thrombophlebitis π They have troublesome symptoms attributable to their varicose veins, and/or they and their GP feel that extent, site and size of the varicosities are having a severe impact on quality of life

Courtesy Farooq Sikkander

6 My College œ September 2007 LITERATURE SCAN FROM YOU NO SAFE LEVEL A new approach to PSA testing GP Review, Vol.33, March 2007 The role of prostate specific antigen (PSA) testing in the the blood is free and is generally produced by benign diagnosis of prostate cancer remains controversial. There prostate tissue. Other PSA is bound to proteins and is more is currently no evidence to suggest that screening for commonly made by prostate cancer tissue. Further prostate cancer will decrease mortality. Until results from investigation may be necessary if the free to total ratio is studies of the effectiveness of the PSA test become over 25 percent. If the ratio is very low (around 10 percent available, it is necessary to provide patients with informed for example), the risk of prostate cancer may be high, even choices and to take a shared decision making approach. with a normal total PSA level.

In the meantime, results from the Prostate Cancer It is important to discuss the pros and cons of PSA testing Prevention Trial recently conducted in the United States and the patient’s level of risk. If the patient wants to may herald a new approach in using the PSA test when proceed with testing, the GP should consider a prostate checking for prostate cancer.1 Every patient involved in the cancer risk management strategy involving the PSA trial had a biopsy whether they had a high PSA level or velocity and free to total PSA. A patient who chooses to not, to determine the true incidence of prostate cancer at have a PSA test must continue to have the test each year. normal PSA levels. The study found that even at very low levels of PSA, there is still a small risk of prostate cancer The Queensland Cancer Fund has developed an online and that no level of PSA is completely safe. education module on testing for prostate cancer reflecting these new changes in PSA testing. The module will be To assist in the accurate diagnosis of prostate cancer, GPs available in mid 2007 from the Andrology Australia should focus on the rate (velocity) at which the PSA level website at www.andrologyaustralia.org increases. If the PSA level doubles in 6 to 12 months, this would be seen as a significant cancer that is growing at a Andrology Australia is a community and professional reasonable rate, even if the PSA level was in the normal education programme providing information on male range. General practitioners should encourage their reproductive health. patients to be tested every 12 months to determine whether 1 PSA level is remaining stable or if it is increasing rapidly. Thompson IM, Chi C, Ankerst DP et at. Effect of finasteride on the sensitivity of PSA for detecting prostate The free to total PSA ratio is another blood test that can cancer. Urol Oncol 2007;25(1):89-90 assist in determining whether or not a PSA level may be a result of prostate cancer. Some of the PSA circulating in Courtesy Lukshmi Jayasekera

WRITE TO US. KEEP IN TOUCH. SHARE YOUR VIEWS. GIVE US YOUR ADVICE. BUT FOR GOD’S SAKE DON’T KEEP QUIET!

If undelivered please return to: COLLEGE OF GENERAL PRACTITIONERS OF SRI LANKA No.6, Wijerama Mawatha, Colombo 7. 7

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