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President's Column

Contents

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Your Trusted Partner

EFFICACYThe golden poison dart frog from Columbia, considered the most poisonous creature on earth,

is a little less than 2 inches when fully grown. Indigenous Emberá, people of Colombia have used its powerful venom for centuries to tip their blowgun darts when hunting,

hence the species' name. The EFFICACY of its venom is such that it can kill as much as 10 grown men simply by coming into contact with their skin.

Knowing the importance of EFFICACY in the world of medicine,GSK, after years of research and development, developed Augmentin,

the antibiotic with a high EFFICACY rate in healing people.

Further information available on request from:

GlaxoWellcome Ceylon Ltd.

121, Galle Road, Kaldemulla, Moratuwa, Sri Lanka. Tel:2636 341 Fax:2622 574

Dear members and colleagues,

We are carrying on with the usual activities of the SLMA. All preparations are being made for the 126th Anniversary Scientific Medical Congress 2013. The programme will start with a Pre-Congress Sympo-sium at Kalutara on the 4th of July 2013 and the “SLMA Health Run & Walk” will be on the 7th of July 2013. On the 9th and 10th of July there will be 7 Pre-Congress Workshops in Colombo. The Inauguration is on the 10th of July and the Main Congress will be from the 11th to the 13th of July. The complete Programme is given else-where in this Newsletter. The Steering Committee has tried very hard to include a plethora of different topics to the interests of a heterogeneous audience. I has-ten to assure you that the proceedings and the fare provided will be fully worth the money you pay as the Registration Fee.

Our continuing CPD activities are being carried out with the usual enthusiasm. In addition to the pro-grammes for doctors, we have also had several ac-tivities for the nurses and other healthcare workers, in Colombo as well as in the out-station meetings. There was tremendous appreciation of these programmes and all the allied healthcare workers were unanimous in their assertion that this is the very first time that the SLMA has made a serious attempt to arrange CPD ac-tivities for them as well. We have organised further pro-grammes for them, especially in view or the perceived crying need for them.

The first Speech Craft Programme of the SLMA was successfully completed and we have started the sec-ond programme on the 12th of June 2013.

I conclude with all good wishes to each and every one of you.

With the very best of regards.

Page No.

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June 2013 Volume 06 Issue 06

SLMANEWSTHE OFFICIAL NEWSPAPER OF THE SRI LANKA MEDICAL ASSOCIATION

Notice board 02

Run and Walk 03 Another victory for the Department of

Health Services, Southern Province 04

True compassion ! 06

Abstract management Systems 10

Pre-congress workshops 13

Programme at a Glance 14-15

Evidence based approach for

treatment of colorectal carcinoma 20

Tips on good parenting 24

Dr B J C PereraPresident,Sri Lanka Medical Association,No.06, Wijerama Mawatha,Colombo 07, Sri Lanka

Official Newsletter of The Sri Lanka Medical Association.Tele : 0094 - 112 -693324 E mail - slma@eureka.lk

June, 2013 SLMANEWS

2

Notice Board

Workshops on Geographic Information Systems (GIS)

The third research training workshop organized by the Research Promotion Committee of the SLMA was aimed at introducing the use of Geographical Information Science/ Systems in health care. It was successfully conducted by Prof. Kithsiri Gunawardena on Sunday 02nd June 2013. The workshop drew an audience of over 30 participants from across the country, in spite of the adverse weather conditions. Theworkshop focused on introducing GIS including concepts and data types in GIS, basics of GPS technology and devices used, and GIS software. Partici-pants engaged in several hands-on activities including data presentation using open-source GIS software.

The next workshop on Geographical Information Sci-ence will be conducted by Prof. Kithsiri Gunawardena on 29th of June. The workshop will focus on practical applica-tion of GIS in research, including hands-on activities on use of GPS (data collection and entry, interpretation and error, etc…) and an introduction to Coordinate Reference Systems. Those interested in participating can contact the SLMA office on 2693324 for details. We invite suggestions from our readership on future workshops. Please email the Convenor, SLMA Research Promotion Committee (asela_o@yahoo.com) for suggestions on areas of inter-est and/ or for expressions of interest in contributing as resource persons.

SLMA CNAPT awardThe Ceylon National Association for the Prevention of

Tuberculosis (CNAPT) award is awarded annually for publications related to medical research in Sri Lanka, and is valued at Rs. 50,000/-. The CNAPT award for the year 2013:Adikaram, C.P., Perera, J. & Wijesundera, S.S. (2012) The manual mycobacteria growth indicator tube and the nitrate reductase assay for the rapid detection of rifampicin resistance of M. Tuberculosis in low resource settings, BMC Infectious Diseases, 12:326. Available at http://www.biomedcentral.com/1471-2334/12/326

SLMA wishes to congratulate the authors of this publica-tion for its scientific merit and relevance to Sri Lanka. All the submissions were of a high standard and the Research Promotion Committee wishes to thank all applicants for their efforts. The committee wishes to thank the scientific reviewers for their contribution.

Election of President Elect

The SLMA elects a President-Elect at its Annual General Meeting every year in December to take over as President the follow-ing year. Any member may propose a candidate. It has been the practice however, that the Past Presidents receive nominations of suitable persons and make their recommendation to the Council for Council nomination.

Any member who wishes to be considered for nomination, or any member who wishes to propose another (with that member’s consent), are invited to inform the undersigned or any other Past President, before the end of September.

Malik Fernando

Past Presidents’ Representative SLMA Council

5.45 pm Guests take their seats 6.00 pm Arrival of the Chief Guest 6.05 pm Introduction of Council Members to the Chief Guest 6.15 pm Ceremonial Procession 6.20 pm National Anthem 6.25 pm Lighting of the Oil Lamp 6.30 pm Welcome Address Dr. B. J. C. Perera President, SLMA 6.45 pm Address by the Guest of Honour Dr. Firdosi Rustom Mehta WHO Country Representative in Sri Lanka 7.00 pm Address by the Chief Guest Professor Sir Sabaratnam Arulkumaran MBBS (Cey) Hons, DCH (Cey), LRCP & MRCS (UK), FRCOG, FRCS Ed, FAMS (Sing), MD, PhD; Hon. FSOGC, FACOG, FSCOG, FCPS, FSACOG, FSLCOG, FICOG, FDGG 7.20 pm Award of Research Grants 7.30 pm Vote of Thanks Dr. Samanmali Sumanasena Honorary Secretary, SLMA 7.40 pm The SLMA Oration 2013 “Epidemiology of snakebite: Investigating the burden” Vidyajyothi Professor H. Janaka de Silva MBBS (Col), MD (Col), D Phil(Oxon), FRCP(Lond),FRCP,FNAS (SL), Hon. FRACP, Hon. FRCP (Thailand), Hon. FCGP (SL) Chair and Senior Professor of Medicine Faculty of Medicine, University of Kelaniya, Ragama

8.25 pm The Procession Leaves the Hall

8.30 pm Cultural Display and Reception (By invitation)

SLMA 126th ANNIVERSARY SCIENTIFIC MEDICAL CONGRESS -2013

Wednesday, 10th July 2013

Inauguration

SLMANEWS June, 2013

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SRI LANKA MEDICAL ASSOCIATION

126th ANNIVERSARY CELEBRATIONS

HEALTH RUN & WALK

7th July 2013 at 6.00 am

Open to the public

Exercise for a healthier tomorrow

Programme

6.00 am onwards : Health Check

6.30 am—6.45 am : Warming up session

6.45 am—7.30 am : Run (in 3 groups)

7.45 am— 8.30 am : Walk

8.30am onwards : Yoga session

Free Lung Function Tests

Free medical check-up

Free Sports Physiotherapy

Free T-shirts, Caps and Gift Packs Valuable prizes to be won

Please Register Before the 30th of June 2013

Contact SLMA 2693324 (Nadeera) E-mail: office@slma.lk slma@eureka.lk

COMPETE & WIN – Exciting Prizes

PARTICIPATION IS FREE OF CHARGE

ROUTE MAP

Commencing from BMICH front lawn.

In partnership with….

June, 2013 SLMANEWS

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SLMANEWS

Department of Health Services of the Southern Province, with the vision of “becoming the

best Provincial Health Department in Sri Lanka by contributing towards the advancement of health, enriching Southern Province”, has achieved several prestigious awards in pro-ductivity, quality and safety including the first place in Taiki Akimoto Award 2011 and A Grade recognition in National Productivity 2012. Improv-ing the quality and productivity of the institutions under the provincial department has been a priority of Dr. Hemachandra Edirimanne, the Provincial Director. As a result, twenty two health institutions under the Pro-vincial Department of Health Services of Southern Province succeeded in getting C, D1 and D2 grades which clearly exceeded other provincial departments. The latest result is the achievement of a merit award in Taiki Akimoto Award 2013 by the Ramya Mohotti Chest Clinic, Matara.

Taiki Akimoto 5S Awards are conducted annually by the Japan Sri Lanka Technical and Cultural Asso-ciation (JASTECA). The Competition has a history of 17 years and it is recognized as the leading 5S com-petition of the country, and judged by a world renowned panel, including Prof. Seiichi Fujitha.

The dedication, commitment and talents of Dr.(Mrs.) A T N Deepika Patabendige, Medical Officer in Charge, and her staff were respon-sible for the achievement. They have not only contributed their time, but also never hesitated to spend their money when needed in the preparation activities. This being the only chest clinic in the history to receive an award at the prestigious event, it sets an example for the government sector in implementing

quality improvement programmes.

Commenting on their success at this competition, Dr.(Mrs.) Pataben-dige, said that adhering to the 5S concept is the best tool for any organ-isation to improve quality of service and satisfaction of staff while imple-menting cost reduction and increased utilization of available resources. She conveyed special gratitude to the Provincial Director, Dr. Hemachandra Edirimanne, for his vision, guidance and commitment in achieving this success. Winning the award was a fitting recognition for the hard work and commitment of the team. She also stated that the award was a result of the collective efforts of the staff and further induced them to be

more creative, resulting in increased morale, enthusiasm and teamwork amongst them.

We wish them success in their future endeavours to further increase the quality of the service they de-liver to the care recipients of Matara District.

Another victory for the Department of Health Services, Southern Province Ramya Mohotti Chest Clinic, Matara clinches a merit award in Taiki Akimoto Awards 2012

Training session conducted by Provincial Director of Health Services – Southern Province Dr.Hemachandra Edirimanne

TAIKI Akimoto award trophy

TAIKI Akimoto award Certificate

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June, 2013 SLMANEWS

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At a fundraising dinner for a school that serves children with learning disabilities, the

father of one of the students delivered a speech that would never be forgot-ten by all who attended. After extol-ling the school and its dedicated staff, he offered a question:

‘When not interfered with by outside influences, everything nature does, is done with perfection.

Yet my son, Shay, cannot learn things as other children do. He cannot understand things as other children do.

Where is the natural order of things in my son?’ The audience was stilled by the query.

The father continued. ‘I believe that when a child like Shay, who was mentally and physically disabled comes into the world, an opportunity to realize true human nature presents itself, and it comes in the way other people treat that child.’

Then he told the following story:

Shay and I had walked past a park where some boys Shay knew were playing baseball. Shay asked, ‘Do you think they’ll let me play?’ I knew that most of the boys would not want someone like Shay on their team, but as a father I also understood that if my son were allowed to play, it would give him a much-needed sense of belonging and some confidence to be accepted by others in spite of his handicaps.

I approached one of the boys on the field and asked (not expecting much) if Shay could play. The boy looked around for guidance and said, We're losing by six runs and the game is in the eighth inning. I guess he can be on our team and we'll try to put him in to bat in the ninth inning.'

Shay struggled over to the team's bench and, with a broad smile, put on a team shirt. I watched with a small tear in my eye and warmth in my heart. The boys saw my joy at my son being accepted. In the bottom of the eighth inning, Shay's team scored a

few runs but was still behind by three.

In the top of the ninth inning, Shay put on a glove and played in the right field. Even though no hits came his way, he was obviously ecstatic just to be in the game and on the field, grinning from ear to ear as I waved to him from the stands. In the bot-tom of the ninth inning, Shay's team scored again. Now, with two outs and the bases loaded, the potential win-ning run was on base and Shay was scheduled to be next at bat.

At this juncture, do they let Shay bat and give away their chance to win the game?

Surprisingly, Shay was given the bat. Everyone knew that a hit was all but impossible because Shay didn't even know how to hold the bat prop-erly, much less connect with the ball. However, as Shay stepped up to the plate, the pitcher, recognizing that the other team was putting winning aside for this moment in Shay's life, moved in a few steps to lob the ball in softly so Shay could at least make contact.

The first pitch came and Shay swung clumsily and missed. The pitcher again took a few steps forward to toss the ball softly towards Shay. As the pitch came in, Shay swung at the ball and hit a slow ground ball right back to the pitcher. The game would now be over. The pitcher picked up the soft grounder and could have easily thrown the ball to the first baseman. Shay would have been out and that would have been the end of the game.

Instead, the pitcher threw the ball right over the first baseman's head, out of reach of all team mates. Every-one from the stands and both teams started yelling, 'Shay, run to first! Run to first!'. Never in his life had Shay ever run that far, but he made it to first base. He scampered down the baseline, wide-eyed and startled. Everyone yelled, 'Run to second, run to second!'

Catching his breath, Shay awk-wardly ran towards second, gleaming and struggling to make it to the base. By the time Shay rounded towards

second base, the right fielder had the ball, the smallest guy on their team who now had his first chance to be the hero for his team.

He could have thrown the ball to the second-baseman for the tag, but he understood the pitcher's intentions so he, too, intentionally threw the ball high and far over the third-baseman's head. Shay ran toward third base de-liriously as the runners ahead of him circled the bases toward home. All were screaming, 'Shay, Shay, Shay, all the Way Shay'

Shay reached third base because the opposing shortstop ran to help him by turning him in the direction of third base, and shouted, 'Run to third! Shay, run to third!'. As Shay rounded third, the boys from both teams, and the spectators, were on their feet screaming, 'Shay, run home! Run home!'.

Shay ran to home, stepped on the plate, and was cheered as the hero who hit the grand slam and won the game for his team. 'That day', said the father softly with tears now rolling down his face, 'the boys from both teams helped bring a piece of true love and humanity into this world'.

Shay didn't make it to another summer. He died that winter, having never forgotten being the hero and making me so happy, and coming home and seeing his Mother tearfully embrace her little hero of the day!

AND NOW A LITTLE FOOT NOTE TO THIS STORY:

Public discussion about decency is too often suppressed in our schools and workplaces. We all have thou-sands of opportunities every single day to help realize the 'natural order of things.' So many seemingly trivial interactions between two people present us with a choice: Do we pass along a little spark of love and humanity or do we pass up those opportunities and leave the world a little bit colder in the process?. A wise man once said every society is judged by how it treats it's least fortu-nate amongst them.

True compassion !

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June, 2013 SLMANEWS

Dr. DeepalWijesooriya, MBBS, MBA-HCS, MSc in Biomedical Informatics, Dip in Psychology National Institute of Health Sciences, Kalutara.

Medical conference and abstract management systems in Sri Lanka

SLMA is a leading conference orga-nizer since it represents all category of medical professionals in Sri Lanka. Abstract management is the process which involves receipt of abstracts, dis-tributing the abstracts for peer review, notification of selection or rejection status of the abstracts and preparation of abstract book in a scientific confer-ence. In some cases submission of a full paper may be required before final acceptance is given.

The abstract management process is closely tied up to the need to provide continuing education to professionals, especially Continuing Medical Educa-tion or CME. Many annual meetings hosted by specialty societies provide educational credit hours so that at-tendees may keep current in the field and maintain their professional certifi-cations. This process has been mainly carried out manually until recent past. Increasingly, submissions take place online using various technologies nowadays.

Current situation of professional organizations in Sri Lanka

Most of our professional organi-zations including SLMA are run by councils, which constitute annually elected honorary members. Apart from the contribution from few administrative staff, majority of the works is carried out by the council in a voluntary basis.

Most of them are professionally quali-fied doctors from various specialities and are not the professional event or-ganisers. Although the organisers of the conference in a particular year gain ex-perience with trial and error, most often this gained experience is not passed on to the councils in the subsequent years. This leads to waste lot of time and effort

to collect information and management of event like abstract management. They have to learn and apply it from the beginning next time because council members are changed. Although, the councils include ex-officio members such as immediate past president, im-mediate past secretary and president elect, this system alone will not be enough to share the experiences.

So if there is an abstract manage-ment system with ability to make tailor made changes according to the specific conferences, it will reduce wastage of valuable time, money and reduce errors of the system.

Pros and cons of Manual to Electronic Abstract Submissions

There are some drawbacks on manual abstract management system, although it was the common practice in the past. It needs manual processing, knowledgeable persons, more time and more chance to get clerical mistakes. It has various limitations to keep the standards, to prevent personal interest and keep full transparency. It is costly and need more manpower. Most of the above issues can be minimized with the use of electronic submission.

But electronic submission has its own problems. Most of our medical doctors are not used to this sort of systems. External factors like internet service and internet devices are other critical factors. But it gives more transparency and reliability to the users. They can submit from their working station and no need to visit the office. It helps to in-crease the number of abstract submis-sions significantly. They can follow up the abstract process with the reference number.

What would be the ideal Abstract Management System?

Ideal Abstract Management System should be arranged in a module basis which include Abstract Guideline, Prin-ciple Author Registration and abstract submission form in a Basic Module. It should cover complete process of Ab-

stract Management from Abstract Sub-mission to Printing of Abstract Book. Those activities should be modularized namely Abstract Management Module, Referee Management Module, Abstract Evaluation Module and Abstract Publi-cation Module.

Abstract management Module con-sists of Abstract Database with sorting options. It will help to arrange other module around the data captured from Basic Module. Referees Management Module is also a very important step. Referees should be registered with their basic demographic data, con-tact details, academic qualifications, experience and interesting areas. There should be a space for special remarks to enter additional information by the referees. Administrators should have facility to put their specific informa-tion under their profile which should not be seen by the referees. Admin-istrators should have facility to grade the referees too. Abstract Evaluation Module consists of categorization of the abstract, allocating anonymous abstract to more than one referees, es-tablish evaluation criteria and gridline, keep track of progress of each refer-ees work, facilitate to write advice for authors, final evaluation of the abstract by the administrators of the system. Abstract Publication Module arranges all selected abstract into a common template. That template, font size, font type, logos and each branding can be customer zed.

Description of Basic Module Abstract submission guideline should

be very simple and easy to understand. Guideline should be changed according to the corresponding abstract commit-tee needs and wants.

But, text size, font, spacing are not important. Those parameters can be easily changed with the abstract man-agement system. But maximum number of words, grammar and language should be uniform and restricted by the guideline.

Abstract management Systems

Contd. on page 12

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It should be included eligible criteria and time period of Abstract Submission and if it is not available now how to get it. It should be clearly mentioned how to get Back-office support to fulfil the eligible criteria.

Corresponding Author registration is a very important step and it should be very simple and properly guided in Guideline Section. Contact information, institution information and user pass-word should be collected at this stage. That information is important in Abstract Committee for further contacts. It also helps authors to get interactive contacts with the electronic system with user name and password. Author’s informa-tion is another important section. There can be more than one author. Among those presenting and principal authors are important. Author’s name, institution and email contacts should be gathered by the system. The Author’s name style, institution name style should be mentioned in Guideline Section with the example.

Additional informations such as Presenting Author and Principle Author should be included in the Remarks Box. It should be clearly informed in Guideline with the example. Presenta-tion Preference can be selected by the Author. (e.g.: Oral, Poser or One of them) But Ultimatum decision is by the abstract committee. Abstract title should be limited with the maximum number of words and acceptable case (Capital, simple or Capitalize Each Word etc.)

It should be included about right to change the title if needs by the Abstract Committee. Abstract body and it's con-tents should be decided by the Abstract Committee. It may vary from Confer-ence to Conference. Usual format is Introduction, Objective or Aim, Meth-odology, Findings and Conclusions. Number of words should be decided by the Abstract Committee of the relevant conference. Any additional details should be included into the Remarks Box. Additional information should be decided by the Abstract Committee. It should be specifically mentioned in Ab-stract Guideline section with example.

If abstract committee need any soft documents like Ethical Clearance Certificate, or supportive document, it should be uploaded by this facility. Exact document, file format and size of the document should be decided by the committee and clearly mentioned in the Abstract Guideline Section.

Current level of Electronic Abstract Management Systems in Sri Lanka

National Institute of Health Sci-ences has used electronic submission abstract management system for ICPHI 2013 conference. It was developed by Dr Deepal Wijesooriya as a pilot project at the end of 2012. Abstract Guideline was developed by Dr Ruwan Ferdinan-do, Dr Sumal Nandasena . They have received 197 abstract submissions though this system within 45 days. This is a big number of abstract compared to last time manual submission to the

same conference. This system coved Basic Module and Abstract manage-ment Module of ideal Abstract Submis-sion System.

It is modified to the new requirement of SLMA conference and applied to this time online abstract submission. It gives 30 days to submit abstract. There are 231 abstract submissions through were system. But most of the abstract submissions were done within last 96 hours. It was about 220 submissions. This has created big rash at last mo-ment leading to difficulties in submis-sion. It was a new experience of the authors.

Most of the inquiries through the phone and email were replied. Unfortu-nately all the inquiries were not ad-dressed due to congestion of the sys-tem. If there were a separate help desk created at least in the last 4 days, it would have been helpful for lot of them. Online video guideline and help forum are other options for dedicated support. Some of them have difficulties to submit online, if there were other options like attachment with email, they also could have got submitted their abstracts.

There was no literature found about user satisfaction survey for abstract submission system and no proper eval-uation found to compare author’s point of view about this topic. So SLMA will do user satisfaction survey for abstract submission. It will help to identify user requirements to develop better systems in future.

Abstract ...Contd. from page 10

SLMA events in May 2013The Communicable Diseases Committee of the SLMA organized a symposium on “The Current Influenza Out-

break: Lessons that could be learnt” on 22nd May 2013. This symposium included presentations on ‘Current influen-za outbreak: Global and local epidemiology’ by Dr. Paba Palihawadana, ‘Virological diagnosis and surveillance: Role of the National Influenza Centre’ by Dr Jude Jayamaha, ‘Management of patients at Castle Street Hospital & chal-lenges’ by Dr Priyankara Jayawardene and ‘How prepared are we for an outbreak?’ by Dr Ananda Wijewickrama.

Monthly Clinical Meeting of the SLMA for the May 2013 was held on 21st May 2013. Dr. Chandimani Undugodage presented a case on ‘Eosinophil and the Lung – “Beyond asthma”. This was followed by a review lecture on Pul-monary Eosinophilia by Dr. Ravini de Silva Karunatillake. Finally, Dr. Bodhika Samarasekara conducted MCQs and picture quiz.

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4th July 2013 BUILDING KEY COMPETENCIES OF FIELD HEALTH STAFF TO PROMOTE FAMILY WELLBEING

Venue: NIHS - Kaluthara

9th July 2013 BUILDING EFFECTIVE TEAMS IN DIABETES CARE IN SRI : AN EVIDENC BASED APPROACH

Venue: The Eagle Ball Room, Waters Edge, Battaramulla HEALTHCARE QUALITY & SAFETY

Venue: Blood Transfusion Service Auditorium, Narahenpita OPTIMISING CARE FOR CHILDREN WITH DISABILITIES

Venue: LRH auditorium

I0th July 2013 INCULCATING ERGONOMICS IN THE SRI LANKAN SETTINGS

Venue: The kingsbury Hotel COMMUNICATION SKILLS FOR DOCTORS

Venue: SLMA Auditorium IMPROVING THE QUALITY OF JOURNALS (INASP)

Venue: At Albatross-Waters Edge SPORTS MEDICINE FOR COACHES & TRAINERS

Venue: Sports Science Auditorium, Independence Square, Colombo 07 “CANCER GENETICS – DIAGNOSTICS, PROGNOSTICATION AND PHARMACOGENOMICS”

Venue: Waters Edge, Battaramulla

PRE CONGRESS WORKSHOPS

SLMA 126th ANNIVERSARY

Sunday 07th July 2013

from the BMICH front lawn

All are welcome, Free participation

11th July 2013 7.00 pm

Waters Edge, Battaramulla

All are welcome, Free participation

13th July 2013 8.00 pm

Waters Edge, Battaramulla

Tickets : Rs 4500/=

Pre Congress Workshops

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June, 2013 SLMANEWS

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June, 2013SLMANEWS

June, 2013 SLMANEWS

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Dr. Prasad Abeysingha MD, Consultant Clinical Oncologist, National Cancer Institute, Sri Lanka

This article is a summary of the review lecture of the SLMA Monthly Clinical Meeting held on 23rd April 2013. This lecture was held in collaboration with the Sri Lanka College of Oncologists.

1. IntroductionColorectal carcinoma is the 4th com-

monest cancer in males in Sri Lanka. Due to lifestyle changes in our population we can expect the incidence to further rise in the coming years. Contemporarily, there are many treatment options available for treatment of this condition including the use of several novel drugs. However, careful examination of available clinical evidence is a must before deciding on treatment of individual cases.

2. Investigations Colonoscopy and biopsy is the gold

standard for diagnosis of disease. In severely debilitated patients flexible sig-moidoscopy with biopsy (for low tumours) and a barium enema may suffice. Place of CT colonogram is still under investiga-tion. MRI of the abdomen and pelvis with CT thorax and CEA levels are the mini-mum investigations needed for staging. In rectal cancers, endorectal ultra sound scan can be used to assess the intra mural spread.

Although various staging methods are available the commonest used method is TNM staging. (See table below.)

3. Prognosis American College of Pathologists con-

sensus category 1 prognostic factors in colorectal cancers are TNM stage, blood vessel or lymphatic invasion, positive margins, and postoperative CEA eleva-tion. It is also accepted that number of negative lymphnodes recovered from the surgical specimen is highly significant. Im-provement of 5 year survival from 73% to 87% is seen when the number of negative lymphnodes increases from <10 to 20. It is important to note that this increase in survival is more than any increase by ad-juvant chemotherapies. Molecular mark-ers are playing an increasingly important role in prognosticating colorectal cancers. Loss of heterozygostiy in chromosome 18q equates the prognosis of a stage II cancer to a stage III cancer without the same genetic change. Micro Satellite Instability (MSI) is seen in cancers oc-curring proximal to the spleenic flexure. It is also seen commonly in patients with Hereditary Nonpolyposis Colorectal Can-cers. Cancers with MSI is taught to have lesser tendency to metastasize and there-fore carries a better prognosis compared to Micro satellite stable cancers. However florouracil based chemotherapy maybe

not beneficial in MSI patients. A prospec-tive Intergroup trial (E5202) is under way to assess whether patients with stage II disease can be stratified as low or high risk depending on retention of 18q alleles or MSI.

4. Management

4.1. Rectal Cancer

Initial treatment has to be decided on stage of the cancer and the risk of local recurrence. Metastatic disease man-agement is same as colon cancer and discussed below. In localized disease, the risk of local recurrence is considered high if threatened (< 1 mm) or breached resection margin is seen, low tumours encroaching onto the inter-sphincteric-plane or with levator involvement. The risk is moderate if clinical stage is T3b(1-5mm) or greater, in which the potential surgical margin is not threatened or any suspicious lymph node not threaten-ing the surgical resection margin or the presence of extramural vascular invasion and low when stage is T1 or T2 or T3a (<1mm) and no lymph node involve-ment is seen. Low risk patients can have upfront surgery while patients in moder-ate risk group, short course radiotherapy (This is not widely practiced in Sri Lanka) immediately followed by surgery and high risk group, chemo-radiation followed by interval surgery is the treatment of choice. Adjuvant treatment is same as Colon cancer and is discussed below. It is important to note that according to NICE guidelines there is no place for preopera-tive chemo-radiotherapy solely to facilitate sphincter sparing surgery to patients with rectal cancer.

4.2. Colon Cancer

Initial treatment of all localized colonic cancers is surgery. Further treatment would depend on the pathological staging as described above.

Stage I - No further treatment needed except for patients whose resection margins are involved.

Stage II – No consensus regarding benefit of adjuvant chemotherapy but latest data suggest stage II high risk group might benefit from adjuvant chemotherapy (See below)

Stage III – Definite benefit in adjuvant chemotherapy

Stage IV – See management of metastatic disease.

Evidence based approach for treatment of colorectal carcinoma

Contd. on page 25

Name Country Regiman

Maio USA Blous Low-Does FA 20 mg/m2/day followed by 5FU 425 mg/m2/days 1-5, every 28 days

De Gramont France D-Folinic acid 200 mg/m2 -hour infusion, 5FU bolus 400 mg/m2 and 5FU 600 mg/m2 22-hours infusion, days 1 and 2, ever 14 days

Modified De Gramont

UK L-Folinic acid 175 mg(flat does) 2-Hour infusion, 5FU bolus 400 mg/m2 and 5FU 2,800 mg/m2 46-hours infusion,ever14 days

Lokich UK Continuous infusion 5FU 300 mg/m2/dayAIO Germany FA 500 mg/m2 + 5FU 2,600 mg/m2/24-hour infusion, weekly

×6, every 8 weeksRosswell Park USA FU 500 mg/m2 2-hour infusion followed by 5FU 500 mg/m2

bolus 1h after the start of FA infusion, weekly ×6, every 8 weeks

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Contd. on page 25

Tips on good parentingDr Leenika Wijeratne MBBS, MD(Psych) Department of Psychiatry, Faculty of Medicine, University of Kelaniya

Parenting, it has been said, is the most important job that a person will ever do. It is an

irony though, that it is a job for which no training or qualification is required. It is a challenge to people of all walks of life and doctors are no exception.

A few simple techniques though can be very effective in making the life of a parent much easier.

Identifying desirable behaviours and reinforcing themIdentifying desirable behav-iours

One of the first steps is to decide, what behaviours you expect from your child. In most families, even the two parents are not clear as to what they expect their child to do. It is therefore not surprising when the child is confused about what the par-ent expects from them.

The two parents who come togeth-er to parent a child, come from differ-ent families with different experiences and different upbringings. Often they are in disagreement on what they want their child to do. The most important step in this situation is to discuss, compromise and come to an agreement about what they expect from the child. For example, a simple thing like whether or not it is alright for the child to have snacks in be-tween meals might lead to conflicting opinions. Once a decision has been made it has to be communicated to the child clearly. In many instances, the child realizes he was expected to do something, only when his parents shout at him for not having done it or vice versa.

Communicating with the child

Ineffective comunication between the parents and the child is a very common reason for behavioural problems in children. Sometimes

instructions may be given, but the child is unaware of it.

When asking a child to do some-thing, it is important to make sure that you get the child’s attention before you do so. By following a few simple steps you can ensure that the child hears and understands what you have to say.

When you are telling them some-thing, call them by their name or any other name that is used. Before giving your instruction make sure that the child stops what he is doing and gives you their full attention.

Sometimes parents forget that the child is at a different develop-mental level and that they may not understand the complex language an adult may use. Use simple clear language that you know your child understands. Stick to one or two step instructions. Too many things said at once will confuse the child and will end up in the child not clearly under-standing any of it. It is important to be specific about what you want done and mention when you want it done ( now / by 8 o’clock etc. ). Be firm but polite. Use an emotional neutral voice. Don’t yell. Don’t ask questions, but tell. Asking whether the child can do something conveys the message that he has the choice of saying no, whereas a statement tells him he has to do it.

Eg. “Please do this” and not “Can you do this ? “

Talk to children as you would like to be spoken to by them because they will talk to you only as you talk to them.

Example of an effective instruction : Menul, please go and brush your teeth now.

Amila, please put away your toys into the box when the clock turns to 8.

Although it might be easier to shout the instruction across the hall or from another room , spending half a min-ute to give the instruction clearly will save a lot of time later which might be

wasted getting angry and shouting at the child when he does not follow the instructions.

Repeat instructions only once. If the child does not follow the

instructions repeat it only one more time. And when you repeat tell the child clearly what the consequence will be if he doesn’t listen to you. Make sure the consequence is a realistic and practical one and make sure you follow through. If the child doesn’t listen the consequence has to follow immediately.

What consequences can be given for undesirable behaviours ? While many would say that sparing the rod will result in a spoilt child, this is not always the case. There are many effective consequences for negative behaviours that do not need the use of the rod.

Taking away privileges is one effec-tive form of negative consequence. Eg. No TV this afternoon if the home-work is not finished by 5 o’clock. Time out is another form of negative consequence where the child has to sit somewhere without interacting with anyone for a specified period of time. This time is generally equivalent to the age in years ( 5 minutes for a 5 year old etc )

Reinforcing desirable behav-iours

Reinforcing desirable behaviours with positive rewards is even more important than negatively reinforcing undesirable behaviours. Desirable behaviours can be rewarded by a number of ways.

PraisePraise is a very powerful reward.

However when you are giving praise you have to make sure you do it ef-fectively.

For praise to be more effective it has to be given immediately after the action that prompted it. It is also

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important to label the praise, ( eg. I liked the way you put away your toys. It was very nice to see you share your toys with your brother). By mention-ing what he did to deserve the praise, you emphasize the good behaviour and increase the chance of the child registering it in his mind.

TimeSpending special time with the child

doing something the child likes doing. Make sure it is mentioned what he did to earn this special time.

Tangible rewardsIt is best to stick to small inexpen-

sive rewards. However this may not be effective if the child is getting simi-lar gifts on a regular basis, irrespec-tive of his behaviour.

Physical affection Physical affection too can act as

a powerful reinforcer of desirable behaviours.

Operant ConditioningPositive or negative reinforcement

of behaviours uses the principal of operant conditioning. Operant condi-tioning is a type of learning in which an individual’s behavior is modified by its consequences. It involves the introduction of a positive event follow-ing a desirable behavior. This makes it more likely that the behavior will oc-cur again in the future. This is positive reinforcement. When the rewards are immediate and consistent the chanc-es of the behaviour happening again will increase further. Longer the time duration between the behaviour and the reward, weaker the association and lesser the chance of it affecting repetition of the behaviour.

Although the use of positive rein-forcement is a very effective tool in parenting it can also act in a negative way. Parents can inadvertently rein-force negative behaviours. Giving at-tention to a child by shouting or even pleading with him when he is having a tantrum will increase the chances of having tantrums in the future. Parents often say no to something and then give the same thing to the child when he starts crying or throwing a tantrum

demanding for it. This reinforces this negative behaviours and the child learns that crying is a way to get what he wants. The best way to handle negative behaviours is to minimize the chances of these behaviours get-ting rewarded. If the parent has said no to something it should not change however much the child cries and however difficult it is for the parents to watch him cry. Whereas if it is some-thing that can be given to the child, make sure it is given to the child before he starts protesting or crying.

Ignoring undesirable behaviours and noticing and praising desirable behaviours has shown to be an ef-fective parenting strategy. Negative behaviours also need to be identified and addressed appropriately. Provid-ing negative reinforcements for nega-tive behaviours too can reduce the chances of these behaviours happen-ing again while letting the child know that the behaviour is not accepted by the parent. Negative reinforcements just like positive reinforcements have to be consistent and immediate.

Tips on good ...Contd. from page 24

4.3 Adjuvant chemotherapy

Since 1990s there was clear evi-dence to show adjuvant treatment has survival benefit for stage III colorectal cancer. Initially used chemotherapy regimen was Floro-uracil based regimens. and all other regimens was tested against these regimens subsequently.

Capacetabine - A randomized phase III trial (X-ACT) showed ca-pacetabine was atleast equivalent to florouracil(FU) plus leucovarine with significant reduction in side effects like neutropenia, stomatitis, nausea, alopecia and diarrhea. However Hand foot and mouth disease was more common.

Irinotican – Accor-2 trial investigat-ed the benefit of addition of irrinoti-can to FU + leucoverine and it did not show any superiority of addition

of irrinotican. Therefore irrinotican currently has no place in adjuvant setting of colonic cancers. However irinotican can be used as second line treatment.

Oxaloplatin - MOSAIC trial showed that there was a disease free sur-vival but no survival advantage at 3 years by adding oxaloplatin to FU/leucoverine. However at 6 years this disease free survival benefit trans-lated into a survival benefit in stage III patients. A combined analysis of NSABP trial showed that addition of oxaloplatin may benefit stage II high risk patients as well. However, oxaloplatin based chemotherapy all caused significant peripheral neurop-athy which can last up to one year.

Therefore today standard of care in adjuvant treatment of colorectal cancer is Florouracil/Capacetabine +

Leucovarine + Oxaloplatin.

4.4 Metastatic disease

Here priority is to control symp-toms. If both primary and metastatic disease are respectable neoadjuvant chemotherapy followed by surgery is the approach. Neoadjuvant chemo-therapy can be Florouracil/Capac-etabine + Leucovarine + Oxaloplatin. Second line chemotherapy would be irrinotican alone or in combination with Florouracil/Capacetabine and Leucovarine. For advanced colorec-tal cancer patients who are intolerant of FU, Raltitrexed (An inhibitor of thymidylate synthase) can be given. Addition of novel agents like cetux-imab (monoclonal anto\ibody specific for EGFR) and bevacizumab (Mono-clonal inhibitor specific for VEGF) are under investigation.

Evidence based ...Contd. from page 20

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The Bo-path Ella...Contd. from page 24