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SLMA News Editorial Committee-2015Editor-In-Chief: Prof. Sharmini Gunawardena

Committee:

Dr. Amaya EllawalaDr. Iyanthi AbeyewickremeProf. Deepika FernandoDr. Sarath Gamini De Silva

1

March 2015, Volume 8, issue 03

SLMANEWSTHE OFFICIAL NEWSLETTER OF THE SRI LANKA MEDICAL ASSOCIATION

Page No.

CONTENTS

Cover StoryJoint Regional Meeting 02, 03, 04

NewsPresident's message 02

Joint Regional Meeting... 02, 03, 04

Q & A On

Malaria in Sri Lanka... 04, 07, 08

The doctor as a leader. 10

Procedures of the SLMA... 12

Carcinoma of the cervix... 14, 16

Guidelines for Physical... 16, 18, 19, 20

Avoidant / restrictive food... 20, 21, 22

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Official Newsletter of The Sri Lanka Medical Association.Tele: +94 112 693324 E mail: office@slma.lk

Professor Jennifer Perera MBBS, MD (Col), MBA(Wales), PgDip MedEd (Dundee), PgDip Women’s Studies(Col).

President, Sri Lanka Medical Association, No 6, Wijerama Mawatha, Colombo 7, Sri Lanka.

March 2015 SLMANEWSPRESIDENT'S MESSAGE

2

JOINT REGIONAL MEETING OF THE HOMAGAMA CLINICAL SOCIETY AND THE SLMA

By Dr. Shamini Prathapan (Asst. Secretary, SLMA)

The joint regional meeting of the SLMA in collaboration with the Homagama Clinical Society

was held on the 16th of February 2015

at the Homagama Base Hospital.

The President of the Homagama Clinical Society, Dr. Anoma Abeygu-nawardena, delivered the welcome speech. Prof. Jennifer Perera, Presi-

dent of the SLMA also addressed the gathering.

It was well attended by around 100 medical officers from the hospital and the Homagama area.

Dear Members

We have concluded an ex-tremely busy month at the SLMA. We had the tradi-

tional History of Medicine lecture on the 26th of February 2015 titled "Pro-viding care for people with lunacy to promotion of mental health“. It was delivered by Professor Nalaka Men-dis, Emeritus Professor of the Univer-sity of Colombo, who gave us a very informative and interesting account of the evolution and development of psy-chiatry services in Sri Lanka spanning back to the time of British governance.

Several guest lectures were de-livered by overseas as well as local speakers who are eminent specialists in their respective fields. The Monthly Clinical Lecture in February was de-livered by the Sri Lanka College of Paediatricians. The Joint Regional Meeting was conducted in collabora-tion with the Homagama Clinical Soci-ety on the 16th of February 2015 with over 100 doctors participating and this activity was sponsored by the State Pharmaceuticals Corporation.

Most of these activities were con-ducted at venues outside the SLMA as the roof of Wijerama House is being replaced, which was long overdue. As the repair work will continue for over two months, please take special note of the venues mentioned in posters and bulletin notices so as to avoid fac-ing any difficulties.

The Expert Committees are busy getting ready their plans for the year in line with the SLMA strategic plan. The SLMA committee met this month to revisit the corporate / strategic plan

with a view to determining the purpose of the association. During this meet-ing it transpired that patients were to be our main stakeholders while doc-tors were considered as the means by which better patient and health out-comes could be achieved. Currently, the corporate plan committee is in the process of identifying the vision 2020 for the SLMA with a view to determin-ing implementation strategies and we hope to keep you updated on this new development.

Preparations for the 128th Annual Scientific Congress and Annual Na-tional Health Walk and Run are being made at an accelerated pace. I would like to sincerely thank the colleagues who have taken up the responsibility in organizing these events. The Ministry of Health, the industry and other part-ners have responded positively to our requests for sponsorships and finan-cial assistance and I am hopeful that we can host a high quality programme of events. It is no secret that the suc-cess of these events depend on the degree of participation of doctors and I extend a warm invitation to all of you to be part of this exciting programme organized from the 28th of June to 8th of July 2015.

I wish to conclude this message with an appeal to all medical profes-sionals who are not SLMA mem-bers, to become life members of the SLMA and help strengthen the role of the SLMA by becoming partners in its various activities. We are in the process of preparing special ben-efit packages and organising social events to enhance the attractive-ness of having membership of the

SLMA. My best wishes are with you.

Professor Jennifer Perera

18th February 2015 at the Board Room, Faculty of Medi-cine, University of Colombo

- “Keeping our humanity in an age of technological medicine” by Prof. John Stephen Wyatt, Consultant Neonatologist

19th February 2015 at the Patholo-gy Lecture Hall, Faculty of Medicine, University of Colombo - “Implemen-tation of next generation sequencing in Clinical Medicine” by Dr. Michael Paumen, PhD - Senior Director, Medical Sciences Asia Pacific & Ja-pan, Thermo Fisher Scientific Life Sciences Solutions Group

19th February 2015 at the Patholo-gy Lecture Hall, Faculty of Medicine, University of Colombo - “Metage-nomics - increasing the speed and accuracy of diagnosing infectious diseases with NGS” by Dr. Anupama Gaur, Ph. D - Business Development Lead - NGS and Clinical Applica-tions, Thermo Fisher Scientific Life Sciences Solutions (Life Technolo-gies)

6th March 2015 at the LRH New Lecture Theatre - “Writing and pub-lishing journal articles: ways to de-crease stress and increase success” by Prof. Barbara Gastel, BA (Yale), MD, MPH (John Hopkins), Professor of Integrative Biosciences and Hu-manities in Medicine and Biotechnol-ogy at Texas A & M University.

SERIES OF GUEST LECTURES HELD

DURING THE PAST MONTH

Contd. on page 03

SLMANEWS March 2015

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Joint Regional..Contd. from page 02

Contd. on page 04

The first session was chaired by Dr. Nandana Dickmadugoda and Dr. Asiri Rodrigo.

The panel of speakers were Dr. Sanjeewa Wijekoon (Consultant Phy-sician, Colombo South Teaching Hos-pital), Dr. Chandimani Undugodage (Respiratory Physician/Senior Lectur-er, University of Sri Jayawardenepu-ra), Dr. Nalin Kithulwatta, (Consultant Paediatric Intensivist, Lady Ridgeway Hospital) and Dr. Ranthilaka Ranawa-ka (Consultant Dermatologist, Base Hospital Homagama).

Dr. Sanjeewa Wijekoon started off the session with his lecture on “Man-agement of hypertension; an evidence based approach”. He stressed that hypertension is a major reversible risk factor for several NCDs and that landmark clinical trials have proved that treatment is beneficial. However, he emphasised that there is conflict-ing evidence regarding the treatment threshold (when to treat), treatment goals (how much to reduce) and how to treat when there are other risk factors. The 2014 evidence based guideline for management of hy-pertension by the 8th Joint National Committee (JNC 8) was the basis of his lecture, which has reviewed all good quality evidence and come up with simple recommendations such as; the threshold and goals of treat-ment for the general population >60 years being 150/90mmHg, and for the general population <60 years being a BP of 140/90mmHg and for CKD/DM patients the target BP be-ing 140/90mmHg. He also stressed that thiazide diuretics, CCB, ACEI and ARB are the first line drugs.

The next speaker, Dr. Chandimani Undugodage, spoke on the topic “COPD - for the Primary Care Physi-cian”. She specified that COPD is one of the leading causes of morbidity and mortality worldwide and the number of exacerbations and the co-morbidities significantly affected a patients' out-

come.

The combined assessment of COPD, a GOLD initiative, takes into consideration the symptoms, Spirom-etry, post bronchodilator FEV1 and the number of exacerbations in decid-ing the therapies in COPD. Cessa-tion of smoking, pulmonary rehabili-tation, vaccination, pharmacotherapy and treatment of co-morbidities are the key areas in the management of COPD.

Dr. Nalin Kitulwatte, a Consultant Paediatric Intensivist from LRH, spoke on “Challenges in treating paediat-ric dengue patients”. He emphasised on the many challenges in treating paediatric dengue patients including proper diagnosis, fluid management, decision taking and facing criticism by others. He also stressed that even though NS1 antigen is widely used for the diagnosis, the detection rate is 50% - 70% in secondary dengue. Furthermore, he emphasised that the fluid management of DHF should be to maintain haemodynamics of the patient with minimum amount of flu-ids and if the patient is not improving to also think about ABCS (Acidosis, Bleeding, Calcium and other electro-lytes, and Sugar - RBS).

Dr. Ranthilaka Ranawaka ad-dressed the gathering with case pre-sentations and photographic images which highlighted the challenges in

diagnosing Leprosy.

The second session was chaired by Dr. Tissa Perera and Dr. Shamini Prathapan. The speakers were Dr. Neelamani S Rajapaksa Hewageega-na (Director, Health Education Bu-reau), Dr. Ranil Jayawardena (Clinical Nutritionist, Nawaloka Hospital) and Dr. Malik Fernando, (Past President, SLMA).

The second session began with the lecture on “Health promotion hospital and effective communication” deliv-ered by Dr. Neelamani S Rajapaksa Hewageegana. She indicated that health promotion is the process of enabling people to increase control over the major determinants of health and that if we promote our hospitals as health promotion institutes, we will see behaviour changes in the staff, patients and the community at large. She also voiced that one key com-ponent in this endeavour is “effective communication” which is to under-stand the communication process and to overcome its barriers together with effective communication skills being imperative for its success. It was also emphasised that by following simple guidelines, you can improve your communication skills greatly, promote better understanding in your relation-ships, and enhance not only your quality of life but the quality of life of people around you.

March 2015 SLMANEWS

This lecture was followed by Dr. Ranil Jayawardena’s lecture on “Con-troversies in diabetic diet”. He started off by saying that diabetes has now reached epidemic proportions in Sri Lanka. Published data show that one in five adults suffer from dysgly-caemia. Although published data on dietary habits and association of dia-betes is limited, it is believed that di-etary habits play an important role in the epidemic of diabetes among Sri Lankans.

In this lecture, controversies in di-etary practices in diabetes were re-viewed.

In Sri Lanka, several dietary mis-conceptions have been reported: high intake of red rice, kurakkan prod-ucts, atta flour, and brown bread are considered favourable. On the other hand, bread and food products from wheat flour are considered as harm-ful. Fruit and vegetable contains sev-eral nutrients, which may be responsi-ble for health benefits in patients with diabetes. The effect is beyond the cu-mulative effects of individual nutrients such as dietary fibre, vitamins and an-tioxidants. Fruit and vegetable intake is inversely associated with diabetes incidence. Although several herbal products are highly popular among diabetes patients, daily consumption of vegetables is very low. Meat and

fish provides high quality proteins and reduces hunger as well. How-ever, animal proteins are considered as detrimental among many diabetes patients.

The last lecture was by Dr. Malik Fernando on “Decompression sick-ness (DCS)”, commonly referred to as bends, which is an occupational dis-ease of underwater divers. In Sri Lan-ka the population at risk are ornamen-tal fish collectors—including those divers who collect sea cucumbers and chanks for the export trade. They dive deep and spend excessive hours underwater breathing air at increased pressure resulting in increased nitro-gen absorption by the tissues. Upon returning to atmospheric pressure without adequate time given for the elimination of the body’s burden of ni-trogen, this gas leaves the dissolved state as bubbles that block the blood flow, as well as in other ways, causing tissue damage. The symptoms range from mild (urticarial rashes and joint pains) to severe (neurological symp-toms including paraesthesia, paresis and retention of urine) and even un-consciousness. The definitive treat-ment is hyperbaric oxygen therapy in a chamber—the only such chamber being available at the Sri Lanka Naval Base in Trincomalee. The Manage-ment Guide produced by the SLMA

and the Directorate of Health Ser-vices of the SL Navy (available from the SLMA office free of charge) gives details of management, references to literature and useful telephone num-bers.

The joint meeting concluded with the vote of thanks given by the Sec-retary of the Homagama Clinical So-ciety, Dr. Dhammika Wijethunga. This meeting was sponsored by the State Pharmaceuticals Corporation and CCL Pharmaceuticals.

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Joint Regional...Contd. from page 03

Contd. on page 07

Prepared by:

Dr. K. N. Mendis, MD, DSc Independent Consultant and former WHO Malariologist, 141 Jawatta Road, Colombo 5.

Prof. A. R. Wickremasinghe, MBBS, MPH, PhD Professor of Public Health, Faculty of Medicine, University of Kelaniya.

Dr. Risintha Premaratne, MBBS, MSc, MD (Community Medicine), MPH (Biosecurity) Director, Anti Malaria Campaign, Ministry of Health.

Prof. Deepika Fernando, MBBS, MD Professor in Parasitology, (Medical Parasitology), PhD Faculty of Medicine, University of Colombo.

Q. Has malaria been eliminated from Sri Lanka?

A. Yes, there has been no malaria transmission in the country since Oc-tober 2012 - for over 2 years now, and so malaria has been eliminated from Sri Lanka.

Q & A OnMalaria in Sri Lanka: What the clinician needs to know

077 395 1513 /

11

Rs 6,800,000/=

+94773510383

SLMANEWS March 2015

7

However, in order to be officially cer-tified by the World Health Organisation (WHO) as a “Malaria-Free” country there needs to be 3 consecutive years without a single reported case of lo-cally acquired (indigenous) malaria.

Sri Lanka will apply to the WHO for certification of malaria elimination, if zero transmission is maintained for another year.

Certification will only be granted by the WHO after a rigorous evaluation to make certain that there is no trans-mission in the country, and if there is a reasonable assurance that Sri Lanka will be able to maintain a malaria-free status in the future.

Q. If there is no malaria transmission in Sri Lanka, why should I be concerned about malaria as a disease in my patients?A: For two important reasons.

1) Although there is no malaria transmission occurring in the country, there continue to be “imported” ma-laria cases in Sri Lanka. For example, in 2012, 2013 and 2014 there were 70, 95, and 49 malaria patients re-spectively, detected and treated in Sri Lanka. All of these patients had con-tracted the disease overseas but they developed clinical symptoms while they were in Sri Lanka and therefore had to be diagnosed and treated by clinicians in Sri Lanka.

2) If we do not detect early and treat effectively, such “imported” ma-laria cases in Sri Lanka, the disease could progress to a severe and com-plicated form, which is associated with a high case fatality rate. Besides, the untreated patient could spread the in-fection to others and this could lead to malaria becoming endemic again in Sri Lanka.

Q. Can indigenous malaria return to Sri Lanka?A. Yes, indeed.

The mosquito that transmits malaria is still prevalent in the country. Para-sites from a malaria-infected person who is not treated could be transmit-

ted to another person by the mosquito vector, thus beginning a cycle of local transmission. If, due to a delay in diag-nosis and treatment, malaria parasites spread onwards from a patient, it could lead to an outbreak of malaria in the country. This could eventually result in the disease being re-introduced to Sri Lanka and the country would thus be-come endemic for malaria again.

Such a situation did, in fact, occur once before in the 1960’s when Sri Lanka nearly eliminated malaria from the country, but due to lack of neces-sary surveillance, an outbreak oc-curred and from there malaria spread to other parts of the country. This eventually led to the country becom-ing endemic for malaria again and re-maining so for several decades, dur-ing which period Sri Lanka incurred enormous losses to healthcare and the economy.

The scale of the disease was such that there were:• 80,000 reportedmalariadeathsduring the1934/35

epidemic

• Over1.5 million reported cases of malaria over three years(1967-70)aftermalariaresurgedfollowingthesuccessin1963

• Over400,000casesofmalaria in thecountryasre-centlyas1991

Being malaria-free is an enormous achievement for health and human development in Sri Lanka, and the role of the clinician is extremely impor-tant if Sri Lanka is to maintain being free of malaria.

Q. What is the critical role of the clinician in keeping Sri Lanka malaria-free?A. The clinicians’ role is two-fold

1) Diagnose a malaria patient without delay, and treat the patient effectively – if not treated early and effectively, malaria could have two devastating consequences – death of the patient, and/or re-introduction of malaria to Sri Lanka.

2) Report every case of malaria im-mediately to the Ministry of Health – Anti Malaria Campaign (AMC) – telephone numbers: 011-7626626;

071-2841767 (24 hr on-call).

This is because the AMC has to take several immediate steps when a case is detected including to: a) ensure, by working with the clinician, that the patient is treated effectively (the lat-est medicines are available with the AMC); b) ensure that the patient’s in-fection has not, and does not spread to others through a rigorous surveil-lance and response operation; and c) document in detail every malaria case, which is a necessity to maintain the “malaria-free” status of the country with respect to WHO.

Q. In what kind of patients should I suspect malaria?A. Patients seeking care (in any part of the country) with any of the follow-ing presentations,• ahistoryoffever

• ahistoryoftraveloverseasduringthepast1year

• ahistoryofundiagnosedchroniclowgradesymptomssuch as tiredness, backache, headache, myalgia, loss of weight,withorwithoutlow-gradefeverandanaemia

• severeillnesswithcerebralsymptomsormultipleor-gan dysfunction

Particularly if the patient is from one of the categories below:• SriLankanbusinessmen/traderswhotravelfrequently

to India and other neighbouring countries

• SriLankanmilitarypersonnelreturningfromserviceinpeace-keepingmissionsabroad

• SriLankanfishermenwhoreturnafterseveralweeksoffishinginthewatersaroundAfrica

• SriLankanpilgrimsreturningfromIndiaandMyan-mar

• Sri Lankans returning from leisure trips abroad –mainly from Africa and East and South Asia

• Western tourists who have arrived here travelingthrough other countries in Asia or Africa

• Migrantworkers/labourerswho are fromneighbour-ing countries who are working here on industrial and developmentprojects–dockyard,ports.

• Immigrants from neighbouring countries – basicallyany foreign national, noting that some may be illegal immigrants and may not provide accurate information about their origin or resident status in this country

• Refugees includingthosefromPakistan,Afghanistanand Myanmar who are housed here under the care of agencies such as UNHCR

Malaria in Sri Lanka...Contd. from page 04

Contd. on page 08

March 2015 SLMANEWS

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Malaria in Sri Lanka...Contd. from page 07

Q. How can I diagnose malaria in a patient?• Seekalaboratorydiagnosisofmalaria–eitherbythe

microscopicexaminationofabloodfilmor A rapid di-agnostic test (RDT) for malaria

Both tests are widely available in any government or pri-vate hospital or laboratory

• Asinglenegativetestmaynotbesufficienttoruleoutmalaria.

Q. From where could I seek help on laboratory diagnosis of malaria, and obtain antimalarial medicines to treat a patient?

Advice and assistance can be ob-tained from:

1) the Anti Malaria Campaign, Nara-henpita, Colombo 5, which has access to highly sensitive tests to diagnose malaria, even at low parasitaemias. The AMC will also provide antimalarial medicines for treatment.

The AMC can be contacted on a ho-tline at 011-7626626, 071-2841767 24 hours of the day.

2) The Regional Malaria Officer (RMO) of the district whose office is under the Regional Directorate of Health Ser-vices.

Q. What is the state-of–the art treatment for malaria?A. Treatment must be in accordance with the National Treatment Guide-lines for Malaria, and depends on the species of the malaria parasite. The Anti Malaria Campaign will provide guidance on diagnosis and treatment and the necessary medicines to a medical practitioner in the public or private sector in any part of the coun-try.

• Plasmodium falciparum malaria must be treated with an artemisinin-based combination therapy (ACT) forthreedays,plusasingledoseofprimaquine

• Plasmodium vivax malaria must be treated with chlo-roquinefor3daysplus,primaquinefor14daystopre-ventrelapses.AswedonottestallpatientsforG6PD

deficiencypriortoadministrationofa14-dayprima-quinecourseas recommended, thepatient shouldbeclosely monitored and advised to watch out for symp-toms of haemolysis. If symptoms of haemolysis are detected, the patient should be advised to discontinue the drug immediately and to report to a health facil-ity.Thereisadangeroustypeofmulti-drugresistantfalciparum malaria in East Asian countries, which does not respond to standard medicines. Therefore, the therapeutic response to the antimalarial drug regimen prescribed needs to be monitored in every patient, and it isbest tocontact theAMCforadvicebeforeanti-malaria treatment is administered to any patient.

Q. What advice should I provide to persons who are traveling abroad about prophylactic treatment, personal protection from malaria, and what to do if they get fever on their return?A. When individuals or families seek your advice on health prior to traveling abroad,

• Inform them of the risks of malaria in the country they are traveling to, and

• Advice them on taking preventive measures against contractingmalaria-a)chemoprophylaxistopreventmalaria and b) use of personal protection against mos-quito bites (http://www.who.int/ith/ITH_chapter_7.pdf?ua=1).

• Refer them to the AMC for further advice and to ob-tainmalariapreventivemedicinesfree-of-charge.

• Advicethemon seeking medical care if they develop fever on their return and inform the clinician of their overseas travel in the recent past.

Q. What are the main challenges of keeping Sri Lanka malaria-free?A. Since there are so few malaria pa-tients seen in Sri Lanka, it has become a “forgotten disease” among clinicians who often fail to include malaria in the differential diagnosis of fever. Conse-quently, during the past 3 years, most “imported” malaria patients have been diagnosed very late and some pro-gressed to a life-threatening form of severe and complicated malaria due to a delay in diagnosis.

It is extremely important that a ma-laria diagnosis is not missed because, if detected in the early stages, malaria is easily treatable. If, however, treat-ment is delayed malaria could prog-ress to a severe form, which may be fatal.

Q. What were the main reasons why there was a delay in diagnosing malaria in the past 3 years?A. The most frequent lapses in clini-cal practice and, failures to diagnose malaria have been due to the:

1. Clinician being unaware of the risk of malaria

2. Failure to take a history of travel in fever patients

3. Continuing to investigate fever pa-tients for dengue and other viral infec-tions and failing to request a simple, inexpensive and easily accessible malaria diagnostic test

4. The disease being misdiagnosed as dengue or another viral infection because haematological findings ac-companying malaria such as thrombo-cytopaenia, and leucopenia are also features of viral infections

Q. What is the global malaria situation that I should know of?

Malaria is prevalent in most tropical and sub-tropical countries in the world in all continents. It is highly endemic in Africa, Asia, and in some South Ameri-can countries.

In East Asia – in the Mekong coun-tries, is prevalent a type of multi-drug resistant falciparum malaria which does not respond to standard medi-cines.

Our neighbouring countries in South Asia – India, Bangladesh, Bhutan, Pakistan, Nepal, Myanmar, and Indo-nesia are also endemic for malaria.

In the past few years too many malaria diagnoses have been missed by clinicians, leading to life-threat-ening illness and risking the re-introduction of malaria to Sri Lanka. The clinicians’ role is extremely important in sustaining a malaria-free Sri Lanka.

ANTI MALARIA CAMPAIGN HOTLINE 071-284-1767

March 2015 SLMANEWS

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Prof. Samudra T. Kathriarachchi President Sri Lanka College of Psychiatrists

Doctors have long held a unique position in the world and Sri Lankan society is not

an exemption. In addition to clinical responsibilities, doctors are expected to serve as experts and opinion lead-ers whose voice is heard by many. At organizational, community, and so-cietal levels they are respected and are expected to function as members and leaders of different bodies. These roles in addition to their traditional role as clinicians, draws on much energy when one has to prioritize his/her work to meet with competing demands. In society at large and in the context of the organization one works for, the expectations are varied, ranging from looking up to leadership in managing day to day affairs of the ward to devel-oping national policies.

Doctors also have a legal duty broader than any other health care professional and therefore have an inherent leadership role embedded in their work. In this context, it may be difficult for a young doctor to balance different roles in life, especially when these issues are not addressed and even thought of, before commencing ‘real work’.

The question we have to answer today is ‘Are the medical profession-als in the 21st century in Sri Lanka equipped with enough resources to deal with these challenges? Are the young doctors ready to face ‘real life challenges’ in the work context?’ It is observed that an increasing number of young doctors who are of high in-telligence, good motivation and pos-sessing good qualities fail in real work situations, simply because they are not prepared to face work stress, team dynamics and other unseen challeng-es. Considerable numbers suffer in silence, while those who are spotted, receive help to overcome challenges.

There is no formal setup to look in to grievances of post graduate trainees although this issue is somewhat better addressed in undergraduate training in many medical schools.

Doctors are traditionally observed to behave in a manner advising people rather than inspiring them, behave re-actively and tactically rather than stra-tegically and strictly adhering to hier-archies than collaborating with stake holders. Often these observations are the only sources of leadership training that budding doctors receive during their training. However lately leader-ship has been identified as an integral part of a doctor’s role by medical regu-latory bodies in various countries such as UK, Australia and Canada and therefore teaching of leadership skills is an essential component of medi-cal curricula of those countries. In Sri Lanka, some medical schools have given considerable emphasis to per-sonal and professional development of students though not necessarily well received by the students as it is not perceived as an essential compo-nent of the medical curriculum. The increasing complexities of the health care landscape and related societal changes in Sri Lanka should serve as a wake-up call to medical educators and postgraduate trainers to educate the next generation of doctors and specialists in leadership skills.

Doctors essentially work in teams. While their effectiveness is largely determined by the efficiency of their teams, job satisfaction is dependent on harmony within the team. Working in a team and managing team dynam-ics is as important as guiding them. Developing personal qualities to work effectively with others and learning to work within teams are vital leader-ship skills for a doctor. Working within a team invariably involves conflict resolution, as team members being independent individuals will have dif-ferences of opinion. If the team leader is able to ensure that due respect is

given to each opinion even if the per-sonal opinion of the leader may differ, the team will learn to respect each oth-er, including the most junior colleague. Conflict resolution skills to arrive at a win-win situation need to be taught at undergraduate level and more impor-tantly incorporated into postgraduate training with as equal importance as clinical knowledge.

Working in multi-disciplinary teams should receive considerable attention as many find this move as challeng-ing to traditional hierarchical setting. Unpreparedness to face challenges associated with team dynamics may lead to frustration of team members, ultimately leading to poor quality of work. The doctor as a team leader should be able to think beyond limita-tions and obstacles to overcome not only clinical issues but also adminis-trative and social issues of patients and team members. He / she should be a visionary with innovative ideas and plans and this creativity should be nurtured from undergraduate days. Doctors have a responsibility to take the initiative to advance the services provided and actively engage in policy planning rather than waiting for and blaming bureaucrats and politicians.

The future of the medical profes-sion in Sri Lanka will be the product of leadership qualities of today’s doctors.

THE DOCTOR AS A LEADER

Doctors essentially work in teams. While their effective-ness is largely determined by the efficiency of their teams, job satisfaction is dependent on harmony within the team. Working in a team and managing team dynamics is as important as guiding them.

“

”

March 2015 SLMANEWS

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March 2015 SLMANEWS

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Dr. Bimalka Seneviratne

Consultant Pathologist & Senior Lecturer, Department of Pathology, Faculty of Medical Sciences, University of Sri Jayewardenepura

On behalf of the SLMA Expert Committee on Women's Health

Carcinoma of the cervix is the most common female genital tract malignancy in Sri Lanka.

In terms of incidence cervical carci-noma shows a wide geographic varia-tion, which is partially explained by differences in the healthcare systems, intensity of screening programmes and exposure to major risk factors.

Pre-invasive carcinoma of the cervix

In cervical pre-cancer, epithe-lial abnormalities form a continuous spectrum of dysplastic changes. In the 1970s and 1980s several “terms” were suggested to describe the dys-plastic changes of cervical pre-can-cer. The most widely accepted term was cervical intraepithelial neoplasia (CIN). CIN includes squamous lesions (squamous intraepithelial neoplasia) and glandular lesions (cervical glan-dular intraepithelial neoplasia / CGIN).

CIN (squamous) is divided into 3 cat-egories -

CIN 1- mild dysplasia

CIN 2- moderate dysplasia

CIN 3 – severe dysplasia & carci noma in situ

CGIN is divided into 2 categories - Low-grade CGIN & high-grade CGIN

Pre-invasive (pre-cancer) stage which is asymptom-atic is detected by screening methods (pap smear).

Risk factors of cervical

carcinoma • Persistent infection of high risk HPV

(HPV16,18,31,33,35…)• Multiplesexualpartners

• Vulnerability of the squamocolumnar

junction in early reproductive life-ageatfirstintercourse-longtermuseofOCP-nonuseofbarrierprotection• Smoking• Immunosuppression

Evolution of CIN

Majority of CIN 1 lesions regress. Progression to invasive cancer oc-curs in 1% of CIN 1, 5% of CIN 2 and >12% of CIN 3 lesions. Progression to invasive malignancy typically takes 15 (3-40) years. Invasive carcinoma can develop without progressing through the pre-invasive stage.

Management

• CIN1(LowSIL)-Follow-up

(70% of CIN 1 lesions will regress in 1 year, 90%in2years)

• CIN2&CIN3(HighSIL)-willbetreatedbyone

of the following methods

Large loop excision (LLETZ) Conization Cryocautery Electrocautery Laser cautery

Invasive carcinoma of the cervix

Squamous cell carcinoma of the cervix is the most common primary in-vasive malignant tumour of the cervix (80-90%). Gross features depend on the pattern of growth which may be exophytic or endophytic.

Histological types of squamous

cell carcinoma

1.Largecellnon-keratinizing 2.Keratinizingsquamouscellcarcinoma 3.Smallcell,non-keratinizingcarcinoma

Histological grade (modified Broder system)

CARCINOMA OF THE CERVIX – A SRI LANKAN PERSPECTIVE

Contd. on page 16

Fig 1: Keratinizing squamous cell carcinoma of the cervix

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1.Well-differentiated –Grade I (mature squamous cells with abundant keratin pearl formation)

2.Moderately-differentiated–GradeII(greaterpleo morphism of cells, more mitoses)

3.Poorly-differentiated–GradeIII(nests&masses

ofpoorly-differentiatedcells)

Prognostic factors

Stage of the disease (FIGO/ Inter-national Federation of Gynaecology & Obstetrics) is the single most impor-tant determinant of the outcome.

FIGO stage and 5 year survival

Adenocarcinoma of the cervix

• Invasivecarcinomaofglandularorigin

• Accountsforabout10-20%ofallcervicalcarcino-mas.

•

The mean age of patients is about 55 years.

• Riskfactors–HPV18isthemostcommonformas-sociated with adenocarcinoma.

• Prognosisisslightlyworsethanforsquamouscellcar-cinoma.

• Histologicaltypes–Mucinous,intestinal,endometri-oidtypes………..

Management of invasive cervical carcinoma

The standard treatment is radical hysterectomy with the removal of pel-vic nodes. Surgery will be combined with radiotherapy and / or chemo-therapy, based on the stage of the disease.

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Contd. on page 18

Dr. Aranjan Lionel Karunanayake

MBBS, DM, DOH&S, Dip.Tox, Dipin.Coun, D.Sp.Med, DSEM, FSS

Senior Lecturer, Department of Anatomy, Faculty of Medicine, University of Kelaniya & Member National Olympic Medical Committee

Physical exercise implies inten-tional physical activity for im-proving health and fitness (1).

Being physically active can prevent numerous chronic diseases includ-ing coronary heart disease, obesity, hypertension and improve muscle

strength, endurance and mental health (2). It has been shown that people, who are inactive, can lower the risk of early death, depression, coronary heart disease, stroke, type 2 diabetes, obesity and high blood pressure by increasing their physical activity level (3). Middle-aged and older people who take part in regular physical activity programmes are more positive about their appearance, physical functioning and physical health (4). Various mo-dalities of vigorous training, including aerobic training, resistant training, and sprint interval training done five times

per week have helped in the control of diabetes and obesity (5).

Physical inactivity has been identi-fied as a serious global public health problem which is associated with nu-merous preventable diseases and has been classified as the fourth leading risk factor for global mortality (6). The World Health Organization estimates that globally the prevalence of physi-cal inactivity among adults is 17%, ranging from 11% to 24% across dif-ferent regions of the world (6).

Guidelines for Physical Exercise and Prevention of Musculoskeletal Injuries during Sport and Exercise

Carcinoma...Contd. from page 14

Fig 2: Invasive adenocarcinoma of the cervix

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Guidelines for...Contd. from page 16

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The following factors need to be avoided during physical exercises to prevent the development of musculo skeletal injuries and to reap the nec-essary benefits.

Sudden increases in the training load with regard to the intensity, fre-quency and duration, using incorrect technique, incorrect surface, incorrect equipment, not adequately rehabili-tating previous injuries, exercising in extremes of weather, muscle imbal-ances, nutritional errors and fluid in-take errors (7).

Physical training programmes tend to target improving the aerobic power, body composition strength, flexibility, proprioception, pliometrics and sport specific skills.

Aerobic training - It is done to im-prove the aerobic power and the body composition. Aerobic power is the maximum capacity to transport and utilize oxygen (8). Aerobic training gen-erally involves large muscle groups. Swimming, running and cycling are some examples for aerobic exercises. This type of training provides several benefits such as enhanced oxygen exchange in lungs, increased cardiac output, increased arteriovenous oxy-gen difference, improved blood flow to skeletal muscles, increased con-centration of capillaries, mitochondria, myoglobin and oxidative enzymes of skeletal muscles (9). To get such ben-efits these exercises need to be done for 3-5 days per week at an intensity of 60% - 90% of maximum heart rate for 20 – 60 minutes (8).

There are many types of endurance training programmes. Some of them are interval training and Fartlek train-ing.

Interval training - involves intense workout bouts for 30 seconds to 5 minutes followed by a rest interval. Work to rest interval is about 1:1.

Fartlek training - the training is done at different intensities. Running at a

comfortable speed is combined with short sprints. It trains the body for more intense training and reduces the boredom associated with training (9).

Anaerobic training - This type of training enhances the anaerobic en-zyme activity, increases the glyco-gen and phosphogen energy stores, improves speed, strength and pow-er. Relies on ATP –PC system and the glycolytic system. Activities like strength training and sprint work outs are good examples (9).

Strength training refers to exercises that are designed to increase the max-imum force a muscle or muscle group can generate voluntarily (10). Follow-ing are basic recommendations for strength training. A safe training envi-ronment and qualified instructors are important. Warm up activities need to be done prior to strength training. A training frequency of at least 2-3 times per week needs to be done. Perform-ing multi joint exercises using multiple sets (ex 10-15 repetitions into three sets) and strengthening of core mus-cles (Fig.1) are important (9).

Types of strength training exercis-es –

Isometric - there is generation of muscular force with minimal change in the joint movement (10) (Fig. 2).

Isotonic - there is generation of muscular force with visible joint move-ment at a variable speed using a con-stant external resistance (10) (Fig. 3).

Isokinetic - there is generation of muscular force with visible joint move-ment at a constant speed with a vari-able external resistance. A variable external resistance is applied by a machine (10) (Fig.4).

Open chain Exercises - Force ap-plied by the body is greater than the resistance that needs to be overcome. Ex – bench press, leg press (10) (Fig.5).

Fig 1. Core strengthening exercises. Available from: http://www.mightyfighter.com/top-8-simple-core-strengthening-exercises/ [Accessed 25 February 2015]

Fig 3. Isotonic exercises. – Available from: http://manbir-online.com/cardiac/exercise_6.htm [Accessed 25 February 2015]

Fig 2. Isometric exercises. Available from: http://www.healthcentral.com/diet-exercise/000395.html Accessed 25 February 2015]

Fig 4. Isokinetic exercises. Available from: http://www.biodex.com/physical-medicine/products/dynamom-eters/system-4-pro [Accessed 25 February 2015]

Contd. on page 19

Fig 5. Open chain exercises. Available from: http://www.cpsc.gov/en/Recalls/2013/Cybex-International-Recalls-Leg-Press-Due-to-Risk-of-Injury/ [Accessed 25 February 2015]

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Closed chain exercises - force ap-plied by the body is not greater than the resistance that needs to be over-come. Ex – pull ups and pushups (10) (Fig.6).

Lifting weights, pushups and pull-ups are some common types of strength training exercises (10).

The following training protocols are used in strength training.

Circuit training - ten types of exer-cises performed for 10-15 repetitions with loads approximately 40% to 60% 1 RM (1 repetitive maximum) with 15-30 second rest period in between the different type of exercises (9).

Pyramid training - exercise progress from light to heavier load while de-creasing the number of repetitions (9).

Super set training – this method in-volves several sets of two exercises for agonist and antagonist muscles with minimal rest between sets (9).

Flexibility training –

Flexibility refers to the ability to move a joint of the body through the range of movement for which it is in-tended for (11). Ideal flexibility is the range of movement at a joint that will allow a maximal performance of a de-fined activity while protecting the joint from acute and chronic injury (11).

Flexibility training reduces muscle tension, body stiffness and improves performance. Following guidelines need to be followed to gain the ben-efits and prevent injuries during flex-ibility training. Warming up (ex brisk walking or slow jogging) for 5 – 10 minutes before stretching. Generally needs to perform 8-12 stretches be-

fore and after the practice session. Various types of stretches are done to improve flexibility (9).

Dynamic stretch-ing - This is done as part of a warm up programme. The movements must be appropri-ate to what is ex-perienced in sport. The joint is moved through controlled repetitive move-ment and with each repetition the joint range of movement is in-creased. Prepares the joint for full range of movement and muscles for optimal activation (9) (Fig. 7).

Static stretching - This form of stretching is used as a part of a cool down programme. The joint is stretched to a minimally challeng-ing position and held in that position for 20 - 30 seconds. Need to breathe comfortably while stretching (9) (Fig. 8).

Facilitated stretching - This type of stretching is done with the help of a trainer. Stretch the muscle and then contract isometrically against resis-tance. Thereafter stretch it again to a new range of motion

after 30 seconds with the help of the trainer (7) (Fig. 9).

Proprioceptive training - This type of training trains the muscles and joints to judge the position. Proprioception is compromised in soft tissue injuries and lack of proprioception can lead to injuries. In proprioception training the stress to the joint is applied very mildly and then increased gradually. Single leg stance, uniaxial balance boards and multi axial balance boards are used in proprioceptive training (7) (Fig. 10).

Plyometrics - This form of training trains the muscles to produce a strong and lengthened contraction as quickly as possible (9) (Fig. 11).

Guidelines for...Contd. from page 18

Fig 6. Closed chain exercises. Available from: http://breakingmuscle.com/strength-conditioning/pull-up-vs-chin-up-a-comparison-and-analysis [Accessed 25 February 2015]

Fig 7. Dynamic stretch-ing exercises. Available from: http://www.bloom-tofit.com/5-killer-dynam-ic-stretching-exercises [Accessed 25 February 2015]

Fig 8. Static stretching exercises. – Available from: http://www.projectswole.com/flexibility/what-is-static-stretching/ [Accessed 25 February 2015]

Fig 9. Facilitated stretching exercises. Available from: http://www.stretching-exer-cises-guide.com/passive-stretches.html [Accessed 25 February 2015]

Fig 10. Proprioceptive exercises. Available from: https://www.healthtap.com/topics/proprioception-an-kle-exercises [Accessed 25 February 2015]

Contd. on page 20

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Fig 11. Pliometric exercises. Available from: http://injuryfix.com/archives/plyometrics.php [Accessed 25 February 2015]

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Sports specific skills - Sports spe-cific movements have to be trained at the proper speed and strength prior to taking part in sports (7) (Fig. 12).

Over training - This can occur due to inappropriate rate of training progression, prolonged monotonous training, inadequate periods of rest and failure to taper training before the competition. Effects of over training can last for few days to six months. Features of over training include in-creased or decreased resting heart rate, decreased body mass, loss of appetite, muscle tenderness, sleep

disturbances, chronic fatigue, psycho-logical staleness, flu like symptoms and decreased performance (9).

To improve a person’s physical performance a physical training pro-gramme must take into consideration the specific goals, needs, medical concerns, motivation and stress toler-ance of a person.

References

1.Kirk-SanchezNJ,LMcGoughE. .Physical exerciseandcognitiveperformanceintheelderly:currentper-spectives.ClinIntervAging2014;9:51–62.

2.Sutherland R,Campbell E, Lubans DR,Morgan PJ, DOkely A,Nathan N, Wolfenden L, Jones J, Davies L, Gillham K, and Wiggers J. A cluster randomised trial of a school-based intervention to prevent decline inadolescentphysicalactivity levels: studyprotocol forthe ‘Physical Activity 4 Everyone’ trial. BMC Public Health2013;13:57.

3.LowryR,,LeeSM,FultonJE,DemissieZ,KannL.Obe-sity and Other Correlates of Physical Activity and Sed-entary Behaviors among US High School Students. J Obesityvolume2013;articleID276318:1-10.

4. Taylor AH, Fox KR. Effectiveness of a Primary Care Exercise Referral Intervention for Changing Physi-

calSelf-PerceptionsOver9Months.HealthPsychol-ogy2005;24:11–21.

5. Roberts KC, Hevener AL, Barnard RJ.. Metabolic SyndromeandInsulinResistance:UnderlyingCausesandModificationbyExerciseTraining.ComprPhysiol2013;3:1–58.

6.FrantzJM,NgambareR.Physicalactivityandhealthpromotion strategies among physiotherapists in Rwan-da.AfrHealthSci;2013;13:17–23.

7.BruknerP,KhanK,BahrWR.Principlesofinjurypre-vention.ClinicalsportsMedicine.3rdedn.NewSouthWales.McGraw-HillProfessional;2007:78-101.

8.LatinRW.BuildingAerobicpowerIn:MellionMBed.Sports medicine Secrets. New Delhi, Jaypee Broth-ersMedical Publishers (P) LTD. 2nd edition 2002:57-60.

9.BachlN,faigenbaumAD.PrinciplesofexercisePhysi-ology. In Micheli LJ, Smith AD, Bachl N, Rolf CG, Chan K. eds. F.I.M.S. Team Physician Manual. Hong Kong, LippincottWilliams&WilkinsAsiaLtd.2007;49-77

10.ThigpenLK.BuildingStrength.In:MellionMBed.Sports medicine Secrets. New Delhi, Jaypee Brothers MedicalPublishers(P)LTD2ndedition2002:61-66.

11. Blanke D. Flexibility. In:MellionMB ed. Sportsmedicine Secrets. New Delhi, Jaypee Brothers Medi-calPublishers(P)LTD.2ndedition2002:70-76.

Fig 12. Sports specific exercises. Available from: http://www.myoquip.com.au/ScrumTrukExercises.htm [Accessed 25 February 2015]

Guidelines for...Contd. from page 19

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Case: Eating disorder in a 14 year old girl

Ms. N was a 14 year old schoolgirl who was studying in grade 9. She was the younger of two siblings. She presented to the child and adoles-cent services with a headache and severe weight loss of nine months duration. There were no associated neurological signs or symptoms nor a history of fever or loss of appetite. Multiple medical investigations includ-ing a MRI of the brain were done with negative results. All possible medical diagnoses were excluded with these investigations. The headache gradu-ally progressed and her daily rou-tines and education was disrupted. At

around this time, she started to refuse food, saying food was distasteful even though her appetite was normal. No obvious family stressors were elicited.

She did not harbour any depressive cognition such as helplessness, worth-lessness, hopelessness or suicidal ideas. There was preserved interest in her daily activities even though she did not have the physical strength to perform them. There were no obvi-ous body image issues nor was she found to have behaviours for reducing weight such as excessive exercising, purging or vomiting. There were no associated features such as exces-sive mirror gazing or other health con-sulting behaviours to change the per-

ceived mishaps in the body.

She denied any intrusive, distress-ing and repugnant thoughts of food being contaminated or getting stuck in the throat or about distaste. She did not have any accompanying compul-sions or any phobias about swallow-ing or choking and neither did she have any psychotic features.

Physical examination and investigations

Her physical examination revealed a body mass index of 10.7 which was significantly low with height-164 cm and weight-28.8 kg. There were La-nugo hair on her face and back with evident carotinaemia.

AVOIDANT / RESTRICTIVE FOOD INTAKE DISORDERSLCPsych Presentation at the SLMA monthly clinical meeting January 2015

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Avoidant...Contd. from page 20

There were no specific signs such as Russel’s sign (defined as calluses on the knuckles or back of the hand due to repeated self-induced vomiting over long periods of time) or evidence of perimylolysis. Her muscle mass was thin, with evidence of cold intoler-ance and dehydration. The biochemi-cal, radiological, hormonal and meta-bolic parameters were normal.

Differential Diagnosis

At the initial presentation with head-ache and severe weight loss the pos-sible differential diagnoses would include organic causes as the main category. The considered causes would be infective conditions such as tuberculosis or infective endocardi-tis, inflammatory conditions such as systemic lupus erythematosus, auto-immune conditions such as diabetes mellitus or thyrotoxicosis, other neo-plastic conditions such as intracranial tumours, namely craniopharyngiomas or hypothalamic tumours.

The psychiatric diagnoses to be considered would be a depressive disorder, obsessive compulsive disor-der, body dysmorphic disorder, eating disorders and other anxiety spectrum disorders such as specific phobias with a rare possibility of a psychotic illness.

Following thorough examination and investigation, medical diagnoses were eliminated and the possibility of a psy-chiatric disorder was made prominent.

The possibility of a depressive dis-order was excluded since she did not have depressive cognitions such as helplessness, worthlessness, hope-lessness or suicidal ideas. She pre-served interest in her daily activities even though she did not have the physical strength to perform them.

The possibility of a body image dis-order was considered to be less likely since there were no preoccupations with a particular body part nor was there a body image distortion. There

was no evidence for an obsessive compulsive disorder or a phobic anxi-ety disorder.

According to DSM 5, a classical eat-ing disorder such as anorexia nervosa can be diagnosed with a restriction of energy intake relative to require-ments leading to a significantly low body weight in the context of age, sex, developmental trajectory and physi-cal health with intense fear of gaining weight or becoming fat.

In contrast to the above Ms. N de-nied body image distortion with de-sire to be thin. Behaviours such as frequent mirror checking or frequent weighing at home was absent. Her ini-tial food refusals were mainly at times where she wanted to demand certain things from her parents. She did not attempt any weight reducing strate-gies such as binging, purging or ex-ercising.

At this point with a review of the past assessments, investigations and ob-servations, a diagnosis of avoidant/restrictive food intake disorder accord-ing to DSM 5 was made.

DSM 5 criteria for diagnosis of avoidant / restrictive food intake disorder1. An eating or feeding disturbance (e.g., apparent lack

of interest ineatingorfood;avoidancebasedonthesensorycharacteristicsoffood;concernaboutaversiveconsequences of eating) asmanifested by persistentfailuretomeetappropriatenutritionaland/orenergyneedsassociatedwithone(ormore)ofthefollowing:

• Significantweightloss(orfailuretoachieveexpectedweight gain or faltering growth in children).

• Significantnutritionaldeficiency.

• Dependence on enteral feeding or oral nutritionalsupplements.

• Markedinterferencewithpsychosocialfunctioning.

2.Thedisturbanceisnotbetterexplainedbylackofavail-able food or by an associated culturally sanctioned practice.

3.Theeatingdisturbancedoesnotoccurexclusivelydur-ing the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced [body image].

4. The eating disturbance is not attributable to a con-current medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that which is routinely associated with the condition or dis-order and warrants additional clinical attention.

Treatment

There have been many guidelines published regarding treatment of eat-ing disorders. The following account is based on the Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders pub-lished in 2014.

There are some general principles applicable in the treatment of all eating disorders. Firstly, all decisions should be person-centred and informed. Secondly, family and significant others should be involved unless there are contraindications or the individual is opposing. Thirdly, care must be based on recovery-oriented practice and treated in the least restrictive setting, ideally as an outpatient unless there are specific indications. However, at times involuntary admissions may be needed for assessment or treatment if a person has impaired decision- mak-ing capacity, and is unable or unwilling to consent to interventions required to preserve life. Furthermore, the patient should be treated with the help of a multidisciplinary team incorporating, a medical team, a psychiatric team, as well as dieticians. Moreover, the care should be transferred in a stepped and seamless manner between the various teams involved as well as in the many treatment settings (general practice, emergency departments, medical wards, mental health settings, private clinicians and specialist ser-vices, outpatient, intensive outpatient with meal support, day programme, and inpatient treatment). Finally, a di-mensional and culturally informed ap-proach to diagnosis and treatment is a must.

Contd. on page 22

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March 2015 SLMANEWS

Apart from the above mentioned general principles, prior to starting treatment a comprehensive assess-ment of the individual and their cir-cumstances should be undertaken to confirm the diagnosis of the eating disorder, to evaluate any co-morbid psychiatric or medical diagnoses, to evaluate medical and psychiatric risks, and to develop a biopsychoso-cial formulation. Depending on the assessment, the treatment setting will have to be decided upon. According to the individual disorder the manage-ment differs to some extent.

Anorexia nervosa

If the patient is having anorexia ner-vosa, hospitalization may be needed for acute medical stabilization, espe-cially if the BMI is less than 12 or if the person is at imminent risk of serious medical complications, or if outpatient treatment is not working. Restoring weight is a main goal in the manage-ment. However, there is debate about rates of weight gain in inpatient set-tings with recommended rates rang-ing from 500–1,400g/week (1-2). This should be carefully balanced, so that a refeeding syndrome does not oc-cur or that the patient is not underfed. Once medically stabilized, psychiatric co-morbidities such as anxiety, de-pression, substance misuse, suicid-ality, personality disorders, anxiety disorders and deliberate self harm should be assessed. However, re-cent systematic reviews of RCTs and meta-analyses of the pharmacological treatment of anorexia nervosa sug-gest weak evidence for the use of any psychotropic agents and prescribing for co-morbid conditions is best left until it is clear that such symptoms are not simply secondary to starvation (3-6). Furthermore, physical problems secondary to anorexia nervosa may place individuals at greater risk of ad-verse side effects but low doses of an-tipsychotics such as olanzapine may be helpful when patients are severely anxious and demonstrate obsessive

eating-related ruminations (5).

Providing psychoeducation, support and building a therapeutic relationship are all crucial activities at all stages of treatment. The more intense struc-tured psychological therapies should generally be initiated only after the individual is sufficiently stabilized and cognitively improved from the acute effects of starvation. For children, fam-ily based therapy or an alternate fam-ily therapy is the treatment of choice. Cognitive behavioural therapy (CBT) and its many forms, for example CBT-Enhanced (7), are frequently recom-mended approaches for anorexia ner-vosa especially for adults.

Nutritional therapy should be con-tinued after achievement of healthy weight and discharge, moreover regu-lar monitoring is needed as rates of relapse are considerable.

In patients with severe and long standing anorexia nervosa the goal of treatment is to maintain realistic hope, expectations for improvement and harm minimization.

Bulimia nervosa and binge eating disorder

Though a majority are treated as outpatients, inward treatment may be needed if there is increased risk of non-response to outpatient care.

First-line treatment for bulimia ner-vosa and binge eating disorder in adults is an individual psychological therapy and the best evidence for such therapy is for CBT (1).

Unlike in anorexia nervosa, phar-macotherapy has more evidence. High dose fluoxetine has the stron-gest evidence base, while other SSRI antidepressants are also effective (8). Pharmacotherapy can be considered as an adjunctive treatment, since an additive benefit has been shown for combined psychological and pharma-cological therapy (5).

Avoidant/restrictive food intake italicise (ARFID)

To date there have been no pub-lished studies to guide appropriate treatment interventions or inform prognosis for this group.

Prognosis of eating disorders

In patients with anorexia nervosa the outcome for young onset eating disorders are better than for older adolescent and adult onset eating dis-orders. Most people with bulimia ner-vosa, binge eating disorder or other specified feeding or eating disorders experience a good outcome in long-term follow-up studies, with 50% or more free of symptoms at five years or more (9). In both categories a sig-nificant proportion may cross over to other categories. There is also an in-crease in mortality, especially in pa-tients with anorexia nervosa.

References1. NICE (National Institute for Clinical Excellence) (2004b) Eating

disorders:Coreinterventionsinthetreatmentandmanagementofanorexianervosa,bulimianervosaandrelatedeatingdisorders.In:NICE(ed).NationalClinicalPracticeGuidelineCG9.London:Brit-ishPsyhcologicalSocietyandGaskell.Availableat:http://www.nice.org.uk/guidance/cg9(accessed7October2014).

2.YagerJ,DevlinM,HalmiK,etal.(2006)AmericanPsychiatricAs-sociation practice guideline for the treatment of patients with eat-ingdisorders.AmericanJournalofPsychiatry163(7Suppl):4–54.

3.AignerM,TreasureJ,KayeW,etal.(2011)WorldFederationofSoci-eties of Biological Psychiatry (WFSBP) guidelines for the pharma-cological treatment of eating disorders. World Journal of Biological Psychiatry12:400–443.

4. FlamentMF, Bissada H and SpettigueW (2012) Evidence-basedpharmacotherapy of eating disorders. International Journal of Neuro-Psychopharmacology15:189–207

5. HayPJandClaudinoAM(2012)Clinical psychopharmacologyofeatingdisorders:Aresearchupdate.InternationalJournalofNeuro-Psychopharmacology15:209–222.

6.KishiT,KafantarisV,SundayS,etal.(2012)Areantipsychoticseffec-tive for the treatment of anorexia nervosa? Results from a system-atic review andmeta-analysis.The Journal of ClinicalPsychiatry73:e757–e766.

7.FairburnCG(2008)CognitiveBehaviorTherapyandEatingDisor-ders.NewYork:GuilfordPress

8.CowenP,HarrisonP,BurnsT.ShorterOxfordTextbookofPsychia-try.Sixthedition.Oxforduniversitypress,444-463

9.FairburnCG,CooperZ,DollHA,etal.(2000)Thenaturalcourseofbulimia nervosa and binge eating disorder in young women. Archives ofGeneralPsychiatry57:659–665.

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