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Wijeramahouse

BEHIND THE PALMYRA CURTAIN

3rd Palliative Medicine Course

In collaboration with the Jaffna Medical Association the third course in Palliative Medicine, organized by the College was held on 22nd and 23rd February, in the

auditorium of the Nurses Training School, Jaffna. The team from the Institute of Palliative Medicine, Kerala, India comprising Drs. Suresh Kumar, Sandya P Muthumana and Messers Muhammed Saif and Gopinath conducted the course. Darrel Mathew - who played the key role, B Karunaratne, Eugene Corea and Pushpa Weerasinghe of the Palliative Care Committee, Shreen Willathgamuwa and Nalin Ashubodha from the Council comprised the College team that attended to the organization and administration of the course. The sponsors were Dr. Soma Panch, Professor Sir. S Arulkumaran, Dr. V Manoharan, Dr. K Nandhabalan, Dr. P Wignaraja who are expats from Jaffna, Mrs. Gowrie Ponniah, Dr. Darrel Mathew (Blue Cross Medical Centre (Pvt) Ltd) and Prof. Dennis J Aloysius.

NEWSLETTER OF THE COLLEGE OF GENERAL PRACTITIONERS OF SRI LANKA No.6, “Wijerama House”, Wijerama Mawatha, Colombo 7. MARCH 2014

Tele: 2698894 / 2688775 E-mail: cgpsl@sltnet.lk / genprac@sltnet.lk Website: www.cgpsl.org

CGPSL

In This Issue

Behind the Palmyra Curtain – P1, 2 Jaffna Diary – P2, 3 A Man for All Seasons – P4, 5 Important Council Decisions – P5 Tumour Markers – P6, 7, 8 New Primary Health Care Model – P9, 10 “GP & Eye” – Hands on experience – P10 Desk top reference to management of Hypertension-P11, 13 Up coming events – P14

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–MARCH 2014 BEHIND THE PALMYRA CURTAIN PALLIATIVE CARE COURSE Regular pharmaceutical sponsors of our College Swiss Biogenics, Emar Pharma, Ranbaxy, Halcyon and Novartis were afforded the opportunity of promoting their products to the participants free of charge. Twenty six doctors including our own President K Chandrasekher and Past President Preethi Wijegoonewardene participated in this course. Pushpa Weerasinghe JAFFNA DIARY

@ Nallur Kovil

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–MARCH 2014 JAFFNA DIARY

@ Nagadeepa

Group @ Family Health Center, Kondavil @ the dinner hosted by the Faculty of Medicine, Jaffna

In front of Jaffna Fort By the Jaffna Lagoon

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–MARCH 2014 TRANSITION BY SEKHER

A MAN FOR ALL SEASONS

WALTER ROLAND GOONERATNE

Dr Walter Gooneratne, distinguished Past President and icon of the college, passed away recently. He was a man of rare distinction who made a colossal contribution as a Council Member, Vice President, and three term President. He was the beloved General Practitioner of several generations of patients at Thimbirigasyaya. Walter an old boy of St. Thomas’ College, Mount Lavinia, excelled in studies and demonstrated his prowess in swimming, athletics and cricket. He was a member of the Thomian first eleven cricket team.

He graduated from the Colombo Medical College in 1949. Friends at the faculty fondly remember him as a superb baila dancer, a composer and singer of naughty baila songs. He served in many hospitals across the country before leaving to United Kingdom to obtain his Diploma in Thoracic Diseases. He worked as the Medical Superintendent of Ragama Chest Hospital in 1956 after returning from the United Kingdom.

In 1963 Dr. Walter Gooneratne commenced general practice at Thimbirigasyaya. A brilliant general practitioner, he was in practice for over 40 years. Due to his wide ranging interests, Walter was referred to by his friends and admirers as “Renaissance Man”. While excelling in the field of Family Medicine, he retained his interest in the study of wild life, photography, and water sports including swimming, skin diving, speedboat racing and surfing. He played an important role in undergraduate and postgraduate medical education and in continuing medical education programmes of the College. He was in the three-man implementation committee which created the North Colombo Medical College and also on it’s Board of Governors since it’s inception in 1980. I accompanied Walter as member of the College team that went to Pothuvil on a post tsunami project. Walter entertained us with interesting stories of yesteryear and having him on that team was real fun. I realized how much College meant to him when I met him again at his residence in 2009. He had the College Desktop Aide, past newsletters of the College and some past issues of the Sri Lanka Family Physician Journal, along with other books by his bedside, to which he referred as his dear friends who kept him company in his solitude.

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–MARCH 2014 TRANSITION FROM SEKHER Nirmalene, his wife passed away in 1988. He had promised her to treat patients free of charge in his last years before retirement. He kept that promise until health problems made it difficult for him to practice. In 2012, he published an autobiography entitled, “Golden Memories and Silver Tears” and made arrangements for the proceeds from the sale of this book to go to charity. Walter leaves behind his four children, Dr Ravi, Neomal, Dr Romesh and Sharmali. Those of us who knew Walter Gooneratne will remember him as a man with a superb intellect, great compassion, an unfailingly positive attitude, and a focused mind. Sir, although we will miss your reassuring physical presence you will live in our hearts. K Chandrasekher President CGPSL COUNCIL AND COMMITTEE NEWS FROM MAITHRI

IMPORTANT COUNCIL DECISIONS

November 2013

1. Council approved the entry criteria for the MCGP course. 2. Council decided to validate the articles to be included in website before uploading to the website. A

committee was appointed to scrutinize this process. M K Muruganandan, K Chandrasekher, Eugene Corea, Preethi Wijegoonewardene, D G A Abeygoonewardene, D J Aloysius, Pushpa Weerasinghe, Ariyasena U Gamage and Nalin Ashubodha were appointed as committee members.

3. An Advisory committee was appointed to advise regarding requests from external bodies. Preethi Wijegoonewardene was appointed as Chairman. Eugene Corea, Thivanka Munasinghe, Antoinette Perera, M R Haniffa, K Chandrasekher, Maithri Rupasinghe, B Karunaratne, D J Aloysius, Joel Fernando were appointed as members.

December 2013

1. Decided to write a request to UDA to obtain a plot of land for our College building. 2. Decided to start a building fund at 3.3 million. 3. Decided to set up an Ethical Review committee. Jayantha Jayatissa was requested to prepare guidelines

for the setting up of this committee and to report back to Council. 4. Concept paper on Palliative care was approved. 5. Decided to recruit a pre intern to carryout MCGP quality assurance work.

Maithri Rupasinghe Hony. Secretary CGPSL

Editor – Pushpa Weerasinghe Editorial Board – Eugene Corea & Preethi Wijegoonewardene Type setting, page setting & formatting – Dimuthu C Weerasekera

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–MARCH 2014 THE INVESTIGATIONS CONTINUE FROM PUSHPA

TUMOUR MARKERS

Tumour markers are substances which are produced by malignant or normal cells of the body in response to malignant and certain benign conditions. These substances are produced in increased amounts in malignancy and can be found in blood, urine, stools, tumour tissues and body fluids of some patients with malignancies. They are mostly glycoproteins. Some tumour markers are associated with only one type of cancer, whereas others are associated with two or more. There is no ‘universal’ tumour marker that can detect all types of malignancies. Tumour markers are commonly used in: 1. Screening – For detection of malignancy in high risk individuals before symptoms develop. 2. To confirm the diagnosis. ie. to confirm the results of other tests and procedures. The presence of tumour markers alone even in increased amounts is not diagnostic of malignancy. 3. To stage the cancer – In certain types of cancers the presence of tumour markers reflects the stage of disease. 4. To evaluate prognosis and monitor treatment –A decrease in the level of a tumour marker or a return to the normal level may indicate that the cancer is responding to treatment, whereas no change or an increase may indicate that the cancer is not responding. Looking for quantitative change may

be part of the follow up and may help to detect recurrences sooner than other procedures. Chemotheraphy treatment can cause malignant cells to die quickly and release large amounts of a tumour marker which can cause levels to rise. But this increase is temporary. Slight increase may not be significant. Need to look at trends in increase over time. 6. Predict or monitor the recurrences Limitations in the use of tumour markers and the interpretation of results:

• Not for general screening • Sometimes non malignant conditions can cause the

levels of certain tumour markers to increase. • Not every patient with a particular type of cancer

will have a higher level of a tumour marker associated with that cancer.

• Tumour markers have not been identified for every type of cancer.

• Other tests in addition to tumour markers such as X-ray, scans and biopsies are required to determine the presence of malignancy.

• None of the tumour markers currently in use are adequately sensitive or specific to pin point a particular type of cancer. Egs - PSA levels can be caused by benign prostrate conditions - CA 125 can also be elevated in women with benign conditions

INVITATION

Authorship of this column is open to members and associates who are interested in writing about investigations. Please send us your contributions. “My College” will be happy to publish your article after review by the editorial board.

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–MARCH 2014 THE INVESTIGATIONS CONTINUE FROM PUSHPA

Tumour Markers currently used in Sri Lanka

Tumour Marker Cancer Tissue Analyzed Alpha Feto protein (AFP)

Liver Malignancy

Blood

Germ cell tumours * Blood

Beta-Human Chorionic Gonadotropin (Beta- HCG)

Choriocarcinoma and testicular tumour

Urine or Blood

CA 15 - 3 Breast cancer Blood

CA 19 - 9 Pancreatic cancer Gallbladder cancer Bile duct cancer Gastric cancer

Blood

CA 125 Ovarian cancer Blood

HE 4 (Much more sensitive test than CA 125)

Ovarian cancer Blood

Calcitanion Medullary thyroid Cancer

Blood

Carcinoembryonic Antigen (CEA)

Colorectal cancer Blood

Breast cancer

Blood

CD 20 Non-Hodgkin Lymphoma

Blood

Lactate dehydrogenase (LDH)

Germ cell tumours Blood

Thyroglobulin Thyroid cancer

Blood

Prostate specific Antigen (PSA)

Prostate cancer Blood

PSA – Free (done when the PSA value is more than 4 ng/dl) PS – Not free of charge

Prostate cancer Blood

Bladder Cancer test

Bladder Urine

Cyfra 21-1

Lung Carcinoma Blood

* Neoplasms (benign and malignant) derived from cells that develop in to sperm and ova

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–MARCH 2014 THE INVESTIGATIONS CONTINUE FROM PUSHPA In addition to these commonly used tests, facilities are available in certain laboratories in Sri Lanka to look for changes in genetic material in patient’s samples for certain types of malignancies Recent developments Researchers are turning to proteomics (the study of protein structure, function and the patterns of all the proteins in the blood instead of looking at individual protein levels) and Genomics (the study of patterns of DNA mutations in blood, urine and stool) in hope of developing new biomarkers. Acknowledgements: I thank Wickrama, Padmali, Roshan de Silva, Roshan Palihawadana and Ruwan for their support to gather information about tumour markers used in Sri Lanka. Excerpted from:

• American Society of Clinical Oncology – Understanding Tumour Markers updated 3/ 18/ 2013

• Lee P, Pincus MR, Mc Pherson RA. Diagnosis and Management of cancer using serologic tuour markers.

• Cancer Net. (Oncologist approved cancer information from the American Society of Clinical Oncology)

• National Cancer Institute. Tumour Markers. Updated 25/10/13

• Tumour Markers, American Association for Clinical Chemistry (2010, Nov 24)

• American Cancer Society (2009, 12/21) tumour marker Atlanta: American Cancer Society

• www.cancer.gov/cancertopics/factsheet/detection/tumourmarkers

• www.cancer.org/treatment/../tumormarkers/index?sitearea

• www.cancernet>....>DiagnosisCancer> Tests and Procedures

Pushpa Weerasinghe

READER’S VIEWS FROM LIONEL The Editor My College Let me thank you for publishing some valuable facts about CRP. Likewise please get somebody to elaborate on, S. Creatinine/ eGFR in the next issue of My College. Thanking You Lionel Dissanayake Mathugama Thank you for your feedback and useful suggestion. The next issue of My College will deal with that subject. Editor

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

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–MARCH 2014 FAMILY HEALTH CENTRE FROM KUMARAN

NEW PRIMARY HEALTH CARE MODEL FACULTY OF MEDICINE, JAFFNA

The Department of Community and Family medicine, Faculty of medicine, university of Jaffna established a primary health care center in 2010.It was named as Family health center. The Family health center is located in the premises of the Divisional hospital Kondavil, one kilometer away from the Faculty of medicine Jaffna. The center was started with two major objectives; 1. To provide primary health care education to both undergraduate and post graduate medical and allied health professionals.

2. To improve the health coverage of the population (Nallur MOH area). The family health center collaborates with various institutions to achieve these objectives. It collaborate with the following; Divisional hospital Kondavil, Nallur MOH, Divisional secretariat Nallur, Pradesh Shaba Nallur and the Institution of Medical Sciences Jaffna. It has started the following activities in order to achieve the main objectives

1. Outpatient services and emergency services 2. Appointment based chronic illness management twice a week. 3. Accepting referrals from the secondary ,tertiary hospitals, MOH

Nallur and from some rehabilitation institution 4. Referring patients to the rehabilitation institution and social

institutions. 5. Basic laboratory services - Once a week 6. Home visits – Once a week 7. Basic Vaccination and family planning clinics - Once a week 8. Counseling services according to the requirement 9. Address the intellectual development of children by creating a child

friendly environment 10. Medical education to the undergraduate medical students 11. Training paramedical personals - health assistances, Midwives 12. Conducting community mobilizing programs for the purpose of

addressing social problems 13. Preparing health education material 14. Conducting research related to primary health care 15. Maintaining medical records and registers in a paper based format 16. Conducting continuing medical education programs

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–MARCH 2014 FAMILY HEALTH CENTRE FROM KUMARAN The services of the medical centre are provided free of charge to the people in the Nallur MOH area. It is hoped to conduct the following activities in near future

1. Establish an electronic based medical record system 2. Establish a body to produce primary health care guide lines and protocol to tackle the health problem in

the local community 3. Establish a primary health care physician forum for the purpose of Continuing medical education and

other future needs 4. Promote the center as a post graduate training institution

S Kumaran MBBS, DFM, Lecture Family Medicine Jaffna, Registar in Family medicine

“Hands on experience- GP series programme” GP and the Eye

Venue: Vasan Eye Care Hospital Premises. No. 423, Galle Road, Colombo 3

Number of Participants: 20 - 25 only per programme

Day: 20th of April 2014, 11th of May 2014, 15th of June 2014

Time: 6.00 pm to 8.00 pm

Resource person: Dr. Ayasmantha Peiris MBBS, MD, FRCS (Glasgow) -consultant eye surgeon

Content area: “Use of Fundoscopy in GP Practice and other vital areas of importance in family practice” The programme will be followed by cocktails and short eats

Please call the College office (2698894/ 2688775) early and book your slot (on first come first serve basis) for

any of the above dates – inform Dimuthu, Angelo or Hassen

Please remember to bring your opthalmoscopes

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–MARCH 2014 MANAGEMENT OF HYPERTENSION FROM CPD COMMITTEE

Your Desk Top reference to management of hypertension Possible combinations of anti­hypertensive drugs 

  Green continuous line: preferred combination Green dashed line: useful combination Black dashed line: possible but less well tested combination Red line: not recommended combination

Management of Hypertension 

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–MARCH 2014 MANAGEMENT OF HYPERTENSION FROM CPD COMMITTEE  Definition and classification 

All guidelines define the first stage of hypertension as Systolic blood pressure of 140 mmHg and Diastolic blood  pressure  of  90 mmHg.  Therefore  an Office  BP  of  140/90  is  required  to  start  a  pharmacological treatment.   Assess total cardiovascular risk  The following table shows the stratification of total CV risk in categories of low, moderate, high and very high risk according to SBP and DBP and prevalence of risk factors 

Category  Systolic    Diastolic Optimal   <120   and   <80  Normal   120 –129   and/or   80 –84  High normal   130 –139   and/or   85–89  Grade 1 hypertension   140 –159   and/or   90 –99  Grade 2 hypertension   160 –179   and/or   100 –109  Grade 3 hypertension   ≥180   and/or   ≥110  Isolated systolic hypertension   ≥140   and   <90  

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–MARCH 2014 CPD FROM CPD COMMITTEE

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

Up Coming Events

20th April 2014 : “Hands on experience - GP series programme” 11th May 2014 : “Hands on experience - GP series programme” May 2014 : Health camp @ Iththepana, Mathugama June 2014 : Annual General Meeting 15th June 2014 : “Hands on experience - GP series programme” 21st June 2014 : MCGP Examination - Morning Session MCQ

- Afternoon Session SEQ 22nd June 2014 : MCGP Examination - OSCE/ OSPE - Group 1 morning 20 candidates

- Group 2 afternoon 20 candidates

28th June 2014 : MCGP Examination - Portfolio assessment 29th June 2014 : MCGP Examination - Portfolio assessment