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Anuradhapura Medical Journal (AMJ) Volume 6,No 1 ,2012
Citation preview
Seeking patient's consent for examination and treatment: Introducing a consent form to be used in government hospitals in Sri Lanka.
Dhananjaya L. Waidyaratne
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Anuradhapura Medical Journal Established 2002
Volume 6, No 1, 2012
Concept Paper
Review Article
Original Article
Case Reports
Abstracts
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Percutaneous Biliary Stenting For Malignant Biliary Obstruction – Retrospective Single Center Case Series
Seeking patient's consent for examination and treatment: Introducing a consent form to be used in government hospitals in Sri Lanka.
Dhananjaya L. Waidyaratne Department of Forensic Medicine, Teaching Hospital Anutradhapura
Background
Respect of the patient's right to self determination (autonomy), through informed consent is considered the foundation of doctor – patient relationship.
Despite the considerable development in health infrastructure and human resources, a regular practice of modern ethical standards has not yet been appropriately established. So far the country has failed even to reach a consensus regarding informed consent. Frequently the “consent for medical examination and treatment” was looked from a paternalistic view point, often only as a tool of defense against litigation. Obtaining consent was merely limited to getting any person, accompanying the patient to hospital, to sign on bed head ticket (BHT), next to a “stereotype” phrase: “No property, consent for operation”. Usually no doctors were involved in this process, a nurse, receiving patient to the ward, write the phrase. Patient information about the nature and consequences of procedures or available treatment options were often ignored.
The situation is being changed to the better. Many doctors are exploring ways of obtaining consent; formats are being designed by individual clinicians. Incompleteness in view of legal validity and unsuitability for use in different situations were among many shortfalls noted in those consent forms.
The purpose of this paper is to focus on practical medico legal issues concerning consent and clinical ethics and to propose a format which may be appropriate and applicable in many of the clinical scenarios for obtaining consent.
Main Objective
The main objective was to design a suitable format to obtain informed consent of patients for various surgical, investigative and therapeutic procedures in clinical practice.
Specific objectives
1. Identify the quantity and the quality of information, that patients should be given in order for the consent to be valid
2. Design a widely acceptable format to obtain informed consent of patients for various surgical, investigative and therapeutic procedures in clinical practice
Ethical principles concerning the informed consent
Patient consent is required on occasions where the doctor wishes to initiate an examination or treatment or any other intervention, except in emergencies or where the law prescribes otherwise (such as where compulsory treatment is authorized by mental health legislation). Consent may be explicit or implied. Explicit (or expressed) consent is when a person actively agrees, either orally or in writing. Implied consent is when signaled by the behavior of an informed patient. Implied consent is not considered a lesser form of consent but it only has validity if the patient genuinely knows and understands what is being proposed
Failure to follow the recommended protocols for obtaining meaningful, lawful consent is unethical and can harm patients both physically and psychologically.
Anuradhapura Medical Journal 2012Concept Paper
01
Interventions without obtaining consent can end in either civil litigation or in rare cases, criminal prosecution. A quality health care demands more than mere technical proficiency, and wherever possible it needs to allow for active patient participation. This cannot be achieved in an atmosphere of mistrust, or if patients feel that what they think and say is of no real consequence.
Consent is a process, not a one-off event, and it is important that there is continuing discussion to reflect the evolving nature of treatment. A consent form simply documents that some discussion about the procedure or investigation has taken place. It is only an evidence of a process, not the process itself.
The provision of sufficient accurate information is an essential part of seeking consent. Competent adult patients are entitled to refuse consent to treatment, even when doing so may result in permanent physical injury or death. Compliance when a patient does not know what the intervention entails, or is unaware that he or she can refuse, is not 'consent'. Doctors must respect a refusal of treatment if the patient is an adult who is competent, properly informed and is not being coerced.
The doctor who recommends that the patient should undergo the intervention should have responsibility for providing an explanation to the patient and obtaining his or her consent. In a hospital setting this will normally be the senior clinician. In exceptional circumstances the task of reaffirming consent can be delegated to a doctor who is suitably trained and qualified, is sufficiently familiar with the procedure and possesses the appropriate communication skills.
Any discussion, however, should be recorded in the patient's medical notes.
Generally there is no legal requirement to obtain written consent but in some cases it may be advisable.
Extent of patient information required for a valid consent
The information that patients should be provided with, includes,
• Purpose of the invest igat ion or treatment, details and uncertainties of the diagnosis,
• Options for treatment, including the option not to treat, explanation of the likely benefits and probabilities of success for each option the risks such as known possible side effects,
• Complications and adverse outcomes including where intervention and/or treatment may fail to improve the condition,
• The name of the doctor who will have overall responsibility,
• A reminder that the patient can change his or her mind at any time.
A careful balance needs to be struck between what patients want to know and ought to know (i.e. listening to what the patient wants and providing enough information) in order that the patient's decisions are informed
Introducing the proposed consent form
The proposed consent form is believed to be appropriate for obtaining written consent from patients for examination and treatment in government hospitals in Sri Lanka. The development of this format took more than 03 years of consultation and discussion with different medical/surgical specialists attached to Matale and Anuradhapura hospitals during the period between 2008 and 2010.
Efforts had been made to make the form to be complete and comprehensive while being concise to be user-friendly.
· Important information referring to identity of the patient and nature of the proposed intervention is included in the given format.
Seeking patient's consent for examination and treatment: Introducing a consent form to be used in government hospitals in Sri Lanka.
02
· Further it elaborates the areas of most valuable concern in the discussion leading to informed consent, though it does not contain the concrete constituent facts.
· The document guides both clinicians and patients into their rights and responsibilities.
(Singhalese/English and Tamil/English versions of proposed consent form are given below.)
Since the amount of information which, doctors should provide to each patient will vary according to factors such as the nature and severity of the condition, the complexity of and the risks associated with the treatment or procedure and the patient's own wishes, it is simply impossible to design a universal consent form carrying all necessary information. As such this consent form needs to be supplemented with provision of information applicable to respective areas of medical practice or disciplines, clinical scenarios, individual interventions and procedures. Good quality information leaflets that patients can take away with them can be a useful way of improving information provision but these should not be seen as an alternative to discussion.
Separate Sinhalese/English and Tamil/English versions were thought to be justifiably appropriate to use for any patient.
Seeking patient's consent for examination and treatment: Introducing a consent form to be used in government hospitals in Sri Lanka.
03
frday,khtl;l nghJ
Hospital
Y,H l¾uhla fyda úfYaIs; mÍCIKhla fyda m%;sldr l%uhla i|yd tlÕ;djh m%ldY lsÍu'
eclaration of Consent for Surgical or Special Investigative or Therapeutic Procedure.
1' frda.shdf.a ku ^iïmQ¾Kfhka&
Name of Patient (in full)
2. jhi
Age
5. jdÜgqj
Ward
4' we| bym;a wxlh
BHT No.
ia;%SFemale
mqreIMale
6' wjYHjk Y,Hl¾ufha $ úfYaIs; mÍCIKfha $ m%;sldr l%ufha iajNdjh' Investigative / Therapeutic intervention required fõ kï úfYaIfhka i|yka lrkak $ is to be performed & Nature of the Surgical'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
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'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
6'1 wjhjhla fyda fldgila bj;a
6'2 wjYHjk ks¾úkaokfha iajNdjh $
7' by; ku i|yka lrk ,o Y,Hl¾ufha $ úfYaIs; mÍCIKfha $ m%;sldr l%ufha wjYH;dj;a" udf.a frda.hg m%;sldr lsÍu i|yd tys jeo.;alu fukau" tjekakl yd ks¾úkaokfha os isÿùug bvwe;s w;=re wdndO yd ixl+,;d
ms<sn|j;a ffjoH ks<OdÍ Dr. ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''meyeos,s lr fok ,os'
Explained me about the necessity, and importance of the above mentioned procedure in treating my
illness and possible risks and complications of such a procedure and anaesthesia. 8' hï úfYaIs; ffjoHjrfhla úiska fuu Y,Hl¾uh $ úfYaIs; mÍCIKh $ m%;sldr l%uh lrk njg fmdfrdkaÿjla oS fkdue;' flfia jQjo tu lghq;a; i|yd iqÿiqlï ,o" m%ùk;djla we;s ffjoHjrhl= ld¾hh lrkq ,nk nj uu
oksñ' I have never been promised that a particular doctor would do this procedure. However, I underst-
and that a doctor with necessary qualification, skill and proficiency would be attending to the procedure.
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
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9. wdid;ña l;d yd úIùï $ Allergies and toxicity ^wod, fkdjk fþoh lmd oukka ' Delete inappropriate section&
9.1 udf.a oekqfï yeáhg óg fmr lsisÿ wjia:djl hï fnfy;la fyda wdydrhla ksid wdid;añl;djla fyda úIùula
udyg we;sù ke;' To the best of my knowledge I have never had any allergy or toxicity after taking
any drug or food
9.2 ………………………………………………………………………… T!IOh $ wdydr j¾.h ksid wdid;añl;djla $
úIùula udyg we;s úh' I have experienced an allergic / a toxic reaction to following drug / food item
……………………………………………………………………………………………………………………………………………
10 fuu Y,Hl¾uh $ úfYaIs; mÍCIKh $ m%;sldr l%uh i|yd fmr iQodkï ùfïoS ffjoHjrhd $ fyo ks<Odß úiska
,ndfok Wmfoia wkq.ukh l,hq;= nj;a" tfia fkdùfuka ixl+,;djka we;súh yels nj;a uu oksñ' hï Wmfoila
lvjQ wjia:djla fõ kï ta nj Y,Hl¾uh $ úfYaIs; mÍCIKh $ m%;sldr l%uh wdrïN lsÍug fmr oekqï oSug
tlÕ fjñ' I understand that I must strictly follow the instructions given by the Doctor / Nurse while
preparing for the procedure and I understand that any breach would result in complications. I undert-
ake the responsibility of informing of such breach if any before commencement of the procedure.
Seeking patient's consent for examination and treatment: Introducing a consent form to be used in government hospitals in Sri Lanka.
04
11 by; lreKq ish,a, ud yg b;d fyd|ska meyeos,s lr ÿka nj;a" ug we;s .eg¨ iy.; ;eka ms<sn|j m%Yak lsÍug wjia:djla ,enqkq nj;a" udf.a .eg¿ j,g iEySulg m;aúh yels ms<s;=re ,o nj;a iy;sl lrñ' ta wkqj by; i|yka Y,Hl¾uh $ úfYaIs; mÍCIKh $ m%;sldr l%uh i|yd uu wjfndaOfhka hq;=j ksoyfia yd iajdëkj tlÕ;dj m<lrñ '
I certify that everything mentioned above was explained to me carefully and I was given the opportunity
to question and clarify all my queries to my satisfaction. Accordingly, I express my free and voluntary
informed consent for the above mentioned procedure.
frda.shdf.a w;aik
Signature of Patient
idCIs/Attestation w;aik$Signature
ku$Name
,smskh$Address
frda.shdg we;s iïnkaOh
Relationship to the Patient
ffjoH ks<OdÍ
Medical Officer .
oskh
Date
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
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''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
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''''''''''''''''''''''''''''''''''''''''
}
}
}
}
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}
Seeking patient's consent for examination and treatment: Introducing a consent form to be used in government hospitals in Sri Lanka.
05
frday,khtl;l;l nghJ
Hospitalrj;jpurpfpr;ir my;yJ tpnrl gupnrhjid my;yJ rpfpr;irf;fhf ,zf;fk; bjuptpj;jy;
Declaration of Consent for Surgical or Special Investigative or Therapeutic Procedure.
1. nehahspapd; bgau; (KGikahf)
Name of Patient (in full)
2.taJ
Age
}
} } }bgz;
Female
Mz;
Male
'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
'''''''''''''''''''''' ''''''''''''''' '''''''''''''''
4. fl;oy; ,yf;fk;
BHT No.
5. thl;L
Ward
6. mtrpag;gLk; rj;jpurpfpr;irapd; / tpnrl gupnrhjidapd; / rpfpr;irapd; jd;ik Nature of the Surgical /
Investigative / Therapeutic intervention required. (VjhtJ mitat';fis; my;yJ gFjpia mfw;wy;
my;yJ bghUj;Jjy; gw;wp tpnrlkhff; Fwpg;gplt[k;) $ please specifically state if removal of any organ
or part or any grafts is to be performed&
6.1 mtat';fs; my;yJ gFjpia mfw;wy; my;yJ ,izj;jy; /Removals or grafts
6.2 njitahd kaf;ftpaypd; jd;ik $ Nature of anaesthesia required.
7. nkny bgau; Fwpg;gplg;gl;l rj;jpurpfpr;irapd; Æ tpnrl gupnrhjidapd; Ærpfpr;ir Kiwapd; mtrpaKk;;
Kf;fpaj;JtKk; kw;Wk; kaf;ftpaypdhy; Vw;glf;Toa ,lu;ghLfs; gw;wpa[k; jPikfs;; gw;wpa[k;; itj;jpa
mjpfhup Dr. ''''''''''''''''''''''''''''''''''''''''''''''''''''''''' mtu;fshy; vdf;F tpsf;fkspf;fg;gl;Ls;sJ.
explained me about the necessity, and importance of the above mentioned procedure in treating my illness and possible risks and complications of such a procedure and anaesthesia.
8. ahuhtJ bgah; Fwpg;gpl;l tpnrl itj;jpauhy; ,e;j rj;jpurpfpr;ir Æ tpnrl gupnrhjidÆ rpfpr;ir Kiw
bra;ag;gLtjhf cj;juthjk; mspf;fg;gltpy;iy. vt;thwhapDk; me;j tplaj;jpid jifik bgw;w
epg[zj;Jtk; [bgw;w itj;jpauhy; mt;tplak; epiwntw;wg;gLk; vd;gij ehd; mwpntd;
I have never been promised that a particular doctor would do this procedure. However, I understand
that a doctor with necessary qualification, skill and proficiency would be attending to the procedure.
9. xt;thik my;yJ tprkhjy; $ Allergies and toxicity (njitaw;w tplaj;ij btl;otplt[k;.)'
Delete inappropriate section&
9.1 vdJ mwpt[f;F vl;oa tpjj;jp;y; ,jw;F Kd; ve;jbthU re;ju;g;gj;jpYk; VjhtJ kUe;J my;yJ
czt[ tifahy; xt;thik my;yJ tprj;jd;ik Vw;gltpy;iy. To the best of my knowledge
I have never had any allergy or toxicity after taking any drug or food.
9.2 …………………………………………………………………… rhg;gpl;lhy; xt;thikj; jd;ik / tprkhFjy;
vdf;F Vw;gLtJ cz;L. I have experienced an allergic / a toxic reaction to following drug / food item
Seeking patient's consent for examination and treatment: Introducing a consent form to be used in government hospitals in Sri Lanka.
06
10. ,e;j rj;jpurpfpr;ir / tpnrl gupnrhjid / rpfpr;ir Kiwf;F Kd;dhaj;jkhFk; nghJ itj;j pau/ jhjpau;fshy; tH';fg;gl;l Mnyhridfs; fl;lhakhf gpd;gw;wg;gl ntz;oajd; mtrpaj ;ija[k; mt;thW ,y;yhj re;ju;g;gj;jpy; ghjpg;g[f;fs; Vw;gLk ; vd;Wk; ehd; mwpntd;.VjhtJ Mnyhridfs; kPwg;gLkhdhy;
mjid rj;jpurpfpr;ir / tpnrl gupnrhjid Kiw Muk;gpg;gjw;F Kd; mtw;iwr; brhy;tjw;F ehd; cld;gLfpd;nwd;.
I understand that I must strictly follow the instructions given by the Doctor / Nurse while preparing for the
procedure and I understand that any breach would result in complications. I undertake the responsibility
of informing of such breach if any before commencement of the procedure.
.
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
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nehahspapd; ngau;
Signature of Patient
bgau; / Name
tpyhrk; / Address
jpfjp /Date
itj;jpa mjpfhup Medical Officer
nehahspa[ldhd cwt[Kiw Relationship to the Patient
rhl;rp$Attestation ifbahg;gk; $Signature
11 nkw;Fwpg;gplg;gl;l vy;yh tpla';fisa[k; kpf ed;whf vdf;F tpsf;fpa[s;snjhL vdf;F cs;s
Ia';fs; rk;ge;jkhf ehd; nfs;tp nfl;gjw;F re;ju;g;gk; tH';fg;gLs;snjhL vdJ nfs;tpfSf;F jpUg;jp
milaf;ToathW tpilfs; bgwg;gl;Ls;sjhft[k; cWjp TWfpd;nwd;. mjdog;gilapy; nkw;Fwpg;gpl;l
rj;jpurpfpr;ir Æ tpnrl gupnrhjid Æ gupnrhjid Kiwf;fhf vdJ mwpt[f;F vl;oa tifapy;
Rje;jpukhft[k; kw;Wk; RahjPdkhft[k; cld;gLfpd;nwd;. I certify that everything mentioned above was explained to me carefully and I was given the opportunity to question and clarify all my queries to my satisfaction. Accordingly, I express my free and voluntary informed consent for the above mentioned procedure.
Seeking patient's consent for examination and treatment: Introducing a consent form to be used in government hospitals in Sri Lanka.
07
Acknowledgment
Many of the Consultants attached to District General Hospital, Matale and Teaching Hospital, Anuradhapura, during the period between 2008 and 2010 contributed with their ideas to the development of this consent form. Tamil translation of the consent form was done by Mr. N.P.A. Rahuman, Teacher attached to Zahira College, Anuradhapura and Dr. U. Mayorathan. Services of all of them should be highly commended.
Reference
1. Mason J.K., McCall Smith R.A. , thLaurie G.T. Law and Medical Ethics. 5
edn. London: Butterworths. (1999). pp 244-288
2. Plueckhahn Vernon D. Cordner Stephen M. Ethics Legal Medicine and Forensic
n dPathology . 2 edn. Melbourne University Press (1991). pp 1-5
3. Wilks M., Kinght M. The Practitioner's Obligations in Clinical Forensic
ndMedicine. McLay WDS 2 edn. London, Greenwich Medical Media, 1996, Chap. 3 pp 43-45.
4. Worthington R. (2002) Clinical issues on consent: Some philosophical concerns J. Medical Ethics; 28: 377-380
5. Consent tool kit, British Medical Association downloaded from the website www.bma.org.uk/ethics
Seeking patient's consent for examination and treatment: Introducing a consent form to be used in government hospitals in Sri Lanka.
08
Abstract
Introduction
Breast carcinoma is the main cancer among
female. Delay in presentation causes high
morbidity and mortality world wide. Our aim was
to analyze female breast carcinoma at North
Central Province in relation to delay in seeking
t r e a t m e n t .
Objective
Analyze presentation of patients with breast
carcinoma to surgical wards in Anuradhapura
and Polonnaruwa Hospital.
Materials and methods
We analyzed all the patients who underwent
mastectomy for carcinoma in surgical unit B at
General Hospital Polonnaruwa (from July 2007 to
September 2009) and at Teaching Hospital
Anuradhapura (from September 2009 to June
2012).
Results
We studied 44 patients. Duration of delay in
presentations was with a range of 1 month to 3
years (mean 8 months). Only 11(25%) presented
within 3 months of first detecting symptoms.
Seventeen (45%) cases were detected
accidentally, pain has given the attention in
18(47%) cases while only 3(8%) cases were
detected during self breast examination(SBE) out
of 38 cases.
Conclusion
We need to broaden the knowledge of people in
the community about symptoms of carcinoma
i n c l u d i n g n o n l u m p s y m p t o m s a n d
consequences. People should be encouraged to
perform SBE and present early.
It is necessary to overcome the barriers of
disclosing the symptoms to another and barriers
to approach the health care institutions
considering socioeconomic status of patients.
Introduction
Breast carcinoma is the commonest cancer in
women worldwide. This cancer is the main cause
of death from cancer among women with
approximately 1.3 million new cases and an
estimated 458000 deaths reported in 2008 in the
world. In the United States a woman has a 1 in 8
chance of having invasive breast carcinoma
during her lifetime. The breast carcinoma risk
increases with age. Tumour stage is the main
determinant of breast carcinoma outcome of
women. Among female nonmetastatic breast
carcinoma, there is a strong correlation between
tumour size and the extent of axillary spread. The
risk of distant metastasis is most closely
correlated with the number of axillary lymph
nodes involvement, followed by tumour size. This
means that the ideal screening regimen for breast
cancer would be one that could detect a tumour
before it was large enough to be palpable. Since
1990, mortality from breast carcinoma in the
United States and other industrialized countries
has been decreasing at the rate of approximately
2.2% per year. In the United States, this decline
has been attributed both to advances in adjuvant
therapy and to increasing use of screening
mammography, in approximately equal measure .
We have analyzed the data of patients presented
with breast carcinoma to detect the time of
presentation for intervention.
Late presentation of breast carcinoma at North Central Province of Sri Lanka.
WAK Weerawardena, PDJ Edirisooriya, IJ Piyadasa, TDB Illangasingha, GAL Niroshana, SM Rathnayaka, WTDUPT Subaweera.Surgical Unit - Teaching Hospital Anuradhapura
1
Anuradhapura Medical Journal 2012Original Article
09
Materials and methods.
We have analyzed 44 patients who underwent
mastectomy for breast carcinoma from July 2007
to September 2009 at surgical unit B at General
Hospital Polonnaruwa and from September 2009
to June 2012 at Teaching Hospital Anuradhapura.
The age, sex, site and size of the breast lump at
presentation, detection method, delay in
presentation and outcome of the patients were
analyzed. During the search we have analyzed
about the possible aetiological factors for the
breast carcinoma such as use of oral
contraceptive pills, Depo Provera, the age at
menarche, menopausal age, age at first child birth
and breast feeding. All the patients with
suspected breast lumps were investigated with
triple assessment (clinical examination,
ultrasound examination and fine needle
aspiration cytology (FNAC). We did not perform
mammogram in any of those patients. If FNAC
report is inconclusive we proceeded to perform
incisional biopsy. Although we offered breast
reconstruction procedures to the patients, they
were not willing for such surgeries. If the cancer
is at advanced stage we offered neoadjuvent
chemotherapy. We performed Patey mastectomy
with level 3 axillary clearance in those studied thpatients. All the patients were discharged at 5
day with the removal of draitube.
Results
There were 44 patients (19 patients at GH
Po l o n n a r uwa a n d 2 5 p a t i e n t s a t T H
Anuradhapura). All the patients were females
with age distribution of 31-74 years (mean 51.4).
Maximum lengths of the lesions were with a
range from 2 cm to 8 cm (mean 4.0 cm). Twenty
six were right side and 18 were left sided.
Duration of delay in presentations was with a
range of 1 month to 3 years (mean 8 months).
Only 11 (25%) presented within 3 months of first
detecting a lump.
Age distribution of 25 patients from
Anuradhapura.
Analyzing the possible aetiological factors
showed only 13 (31%) used hormonal
contraceptive method. They attained menarche
at 12-16 years of age. Mean menopausal age was
46.8 years (range 37 -54 years). Mean age at first
child birth was 23.5 years (range 13-39) of 19
cases. Thirty three of 36 (91%) have breast fed
and 24(56%) of 43 patients have more than 2
children .
Seventeen (45%) patients detected lump
accidentally. Pain has given the attention in
18(47%) cases while only 3(8%) cases were
detected during self breast examination out of 38
cases. One patient has died shortly with
metastasis. All the other patients are following
oncology clinics .
Discussion
Delayed patient presentation refers to a
prolonged interval between discovery of initial
symptoms to presentation to a provider and is
typically defined as greater than 12 weeks.
Delayed presentation of breast cancer (≥ 3
months) is associated with poorer survival at all
ages The intervention builds on evidence about
risk factors for delayed presentation of breast
cancer. The ultimate aim of the intervention is to
reduce the proportion of older women with
breast cancer who delay their presentation, and
thereby save lives.
Age group Number of patients
31-40
41-50
51-60
61-70
71-80
05
10
06
01
03
2,3
4
Late presentation of breast carcinoma at North Central Province of Sri Lanka.
10
Self breast examination (SBE) is helpful for early
detection of breast carcinoma. In one study done
in Iran, significant proportion of people studied
performed SBE .Proportion of those patients did
not perform self breast examination because of
lack of knowledge about the technique of
examination. Some patients did not perform SBE
because of fear of becoming positive for
carcinoma or did not care about them. A large
proportion of patients who perform SBE do it
incorrectly. Those who performed SBE learned it
from medical personals, their relatives,
television, radio, books, journals and pamphlets.
In our study sample only 8% of patients did SBE .
Community disease preventive teams should
teach of Self Breast Examination [SBE] to
patients, Clinical Breast Examination [CBE] to
health workers. All efforts should be made to
break the vicious cycle of late presentation, poor
treatment outcome and reluctance of patients to
present to health facilities because of poor
outcome. Significant delays in presentation still
abound with only 12% presenting within 1
month of noticing symptoms in one study in
Nigeria. This late presentation is universal among
patients in the third world including Asian and
Arab countries. The reasons for delayed
presentation included long distances to hospital,
lack of awareness, fear of the consequences,
strong belief in traditional medicine, religious
charlatans, poverty, poor education, fear, denial,
and negligence by patients or their family
members and general practitioners. This
knowledge can be used to launch a program to
motivate the patients to present early in North
Central Province in Sri Lanka.
In one study Breast cancer risk was found to be
increased in women with age (≥ 50), induced
abortion, age at first birth (≥35 years), body mass
index (BMI ≥ 25), and a positive family history.
However, decreased breast cancer risk was
associated with the duration of education (≥ 13
years), presence of spontaneous abortion, breast
feeding .
.
These factors need to be considered for targe ting
a population in planning of education pro grams
of breast carcinoma. However the asso ciation of
high breast carcinoma risk with lower duration of
education may be a barrier for pro per
communication with health workers.
Women need further information about the
different types of breast cancer symptoms to
assist symptom recognition, as well as
encouragement to seek medical advice if a
symptom is ambiguous. In addition, women may
benefit from greater awareness of the benefits of
early detection and reassurance about the
improvements in quality of breast cancer care .
Those non lump symptoms are known factors to
delay in presentation. It is necessary to broaden
the knowledge of patients about the symptoms of
breast carcinoma. Those patients who present
late due to fear of consequences of carcinoma
usually gathered the information from their
friends and relatives. People should be educated
that if detect early, lesser degree of surgeries are
available in cancer treatment. If presentation is
l a t e e x t e n s i v e s u r g e r i e s w i t h
radio/chemotherapy methods are needed for
therapeutic purpose.
Some of the patients do not attend to seek
treatment because they failed to prioritize the
health ov e r their other activities. So education of
breast cancer awareness programs should extent
to educate the consequence of not attending for
treatment
Symptoms that could be a warning sign of breast
cancer included a painless lump, swelling, breast
skin changes, pain, discharge from the nipples,
nipple retraction . Fever, pruritus, cold, weight
loss and presence of a wound have been
recognized as presentation symptoms of women.
In a study in Nigeria only few people knew that
BSE should be performed 2–3 days after
menstruation monthly and less number knew
that women who have reached menopause were
expected to choose a specific day of the month to
perform BSE.
5,6,7
8
8,9
10
13,14
11
11,12
11
11
Late presentation of breast carcinoma at North Central Province of Sri Lanka.
11
One review article shows poverty to be the most common and strongest barrier for early presentation. Traveling away from home, family and work responsibilities, and high cost of diagnosis and treatment constitute particularly burdensome problems facing the poor. Future interventions should primarily attempt to enhance access for affordable healthcare close to their home (3).
Conclusion
It is necessary to design programs to increase women's knowledge about breast symptoms and risk , to promote disclosure of symptoms to someone, to reduce the barriers to approach therapy. There are many barriers to overcome to achieve these targets. However all these are feasible with the available facilities in North Central Province.
References
1 ) Ellen Warner. Cancer Screening. N Engl J Med 2011; 365:1025-1032.
2) AJ Ramirez, AM Westcombe, CC Burgess, S Sutton, P Littlejohns, MA Richards. “Factors predicting delayed presentation of symptomatic breast cancer: a systematic review,” The Lancet 1999;353(9159):1127–1131.
3) Ketan Sharma, Ainhoa Costas, Lawrence N. Shulman, John G. Meara. Review Article. A
Systematic Review of Barriers to Breast Cancer Care in Developing Countries Resulting in Delayed Patient Presentation. Journal of Oncology Volume 2012 ;2012: 8 pages.
4) A Ramirez. Promoting early breast cancer presentation in women after their final routine breast screening mammogram Breast Cancer Research 2006;8(Suppl 1):15.
5) A Simi, M Yadollahie, F Habibzadeh. Knowledge and attitudes of breast self examination in a group of women in Shiraz, southern Iran . Postgrad Med J 2009;85:283-287.
6) G Ertem, A Kocer. Breast self-examination among nurses and midwives in Odemis health district in Turkey. Indian journal of cancer 2009 ; 46( 3 ): 208-213.
7) TT Fancher, J A Palesty, JJ Paszkowiak, RP Kiran, AD Malkan, SJ Dudrick . Can Breast Self-Examination Continue to Be Touted Justifiably as an Optional Practice? International Journal of Surgical Oncology 2011;2011:1-5.
8) Stanley NC Anyanwu . Temporal trends in breast cancer presentation in the third world.Journal of Experimental & Clinical Cancer Research 2008;27:17.
9) Talpur AA, Surahio AR, Ansari A, Ghumro AA Late presentation of breast cancer: a dilemma. JPMA, The Journal of the Pakistan Medical Association 2011;61(7):662-666.
10) Vahit Ozmen, Beyza Ozcinar, Hasan Karanlik, Neslihan Cabioglu, Mustafa Tukenmez, Rian Disci, Tolga Ozmen, Abdullah Igci, Mahmut Muslumanoglu, Mustafa Kecer, Atilla Soran. Breast cancer risk factors in Turkish women – a University Hospital based nested case control study World Journal of Surgical Oncology 2009;7:37.
11) C Burgess, MS Hunter, AJ Ramirez. A qualitative study of delay among women reporting symptoms of breast cancer. Br J Gen Pract 2001 December; 51(473): 967–971.
12) Al-Kahiry W, Omer HH, Saeed NM, Hamid GA. Late presentation of breast cancer in aden, yemen. Gulf J Oncolog 2011 Jan; 1(9):7-11.
13 ) Abimbola Oluwatosin, Oladimeji Oladepo.Knowledge of breast cancer and its
early detection measures among rural women in Akinyele Local Government Area, Ibadan, Nigeria. BMC Cancer 2006; 6:271.
14) Bachok Norsa'adah, Krishna G Rampal, Mohd A Rahmah, Nyi N Naing , Biswa M
Biswal. Diagnosis delay of breast cancer and its associated factors in Malaysian women . BMC Cancer 2011; 11:141.
Late presentation of breast carcinoma at North Central Province of Sri Lanka.
12
Introduction
Pulmonary artery aneurysms are rare which could be
congenital or acquired in origin. The primary
symptom is haemoptysis which is often massive.
Bechet's disease is a chronic systemic collagen
vascular disease of unknown origin mainly affecting
young men. Pulmonary aneurysms associated with
Bechet's disease are pseudoaneurysms and arise as
complications of vasculitis and transmural necrosis
and suggests
poor prognosis with massive haemoptysis associated
with a high mortality rate. In most patients these
aneurysms are saccular, multiple, bilateral with
partial or complete thrombosis of the aneurysm as
well as the distal pulmonary artery.
Diagnosis of the aneurysms are by contrast enhanced
CT scan and pulmonary artery angiogram. Medical
treatment of these patients include cytostatic and
corticosteroids which may cause regression of
pseudoaneurysms. Recurrent hemoptysis or
progression in size of the pseudoaneurysms is
common, where endovascular embolisation is a
valuble alternative to surgery.
Case report
28 year old male with a past history of recurrent deep
vein thrombosis, recurrent oral and genital ulcers,
one episode of transient blurring of vision presented
to the local hospital with massive haemoptysis and
progressive dyspneoa. Chest X ray (fig. 1) revealed a
large soft tissue mass occupying the lower zone of
the R/ lung. CT scan demonstratedtwo aneurysms in
relation to the right pulmonary artery and a thrombus
within the apex of the right ventricle. The patient
was transferred to the national hospital for
specialized management. After initial evaluation a
repeat CT scan was done which revealed significant
increase of size of the aneurysm to 10 x 12 cm. Due
to the rapid increase in size of the aneurysm and the
multiplicity of lesions the patient was referred for
endovascular management.
Fig. 1 – chest ray PA view showing a large soft
tissue opacity in the lower R/ hemithorax.
Diagnostic angiogram under local anaesthesia via
jugular venous access (due to the presence of B/L
lower limb deep venous thrombosis extending up to
the IVC) using a 5F sheath and an angle pig tail
catheter confirmed the presence of the two previouly
diagnosed aneurysms in the Right lung. The larger
aneurysm in the lower lobe was supplied by the R/
posterior basal artery (Fig. 2) and the smaller
aneurysm in the mid zone filling via right lateral
artery (middle lobe)( Fig.3). Both vessels did not
demonstrate any distal blood flow.
Fig. 2 - Pre embolisation angiogram showing the large aneurysm in the lower lobe
supplied by the by the R/ posterior basal artery and a smaller aneurysm overlapping
the R/ pulmonary artery
Fig.3- Angiogram (oblique view) showing the smaller aneurysm in the mid zone
filling via right lateral artery (middle lobe). The larger aneurysm does not show any
further filling in this film.
Endovascular management of multiple aneurysms in pulmonary artery in a patient with Bechet's disease – Case presentation .
L P Paranahewa, AN Wijewardena Division of Interventional Radiology, National Hospital of Sri Lanka
Fig. 2 Fig. 3
Anuradhapura Medical Journal 2012Case Reports
13
Embolisation was planned at a different sitting after
optimizing the patient with cardiothoracic surgical
back up under local anaesthesia where the right main
pulmonary artery was selectively catheterized via
jugular access and a Amplatzer PDA delivery
system was positioned proximal to it's bifurcation.
Super selective catheterisaton of the feeding vessels
was then performed separately with a6 F, 064”
“Guider” guiding catheter (Boston) and successful
occlusion of each vessel was achieved immideately
proximal to the origin of the aneurysm with 6mm x 7
mm and 8 mm x 7mm vascular plugs (Amplatzer)
(Fig. 4, Fig 5)
Fig. 4.Angiogram following embolisation of the larger aneurysm showing complete cessation of blood flow.
Fig. 5.Successfully deployed vascular plugs insitu.
Complete occlusion of the vessels with cessation of
blood flow in to the aneurismal sac was
demonstrated by post procedure angiogram (Fig. 6).
Patient tolerated the procedure well and had an
immediate reduction of his symptoms.
Fig. 6. Post procedure angiogram demonstrating complete occlusion of the
embolised vessels with cessation of flow in to both aneurismal sacs.
Pre and post contrast enhanced CT scan done 3 days after the procedure demonstrated complete thrombosis of the aneurismal sacs (Fig. 7). The patient was referred for further medical management of Bechet's disease and followup.
Fig. 8.CT scan of the chest showing the thrombosed aneurysm with no further filling of contrast. The vascular plug is seen in this section at the region of the neck of the aneurysm.
Discussion:
Our patient who presented with pulmonary artery
aneurysms had recurrent oral and genital ulceration
(Fig. 8) several episodes of probable eye
involvement recurrent deep vein thrombosis,
thrombus within the Right ventricle and multiple
pulmonary artery aneurysms which satisfies the
practical clinical diagnostic criteria for Bechet's
disease which was diagnosed retrospectively.
Fig.8. Genital Ulcers in the same patient.
The rapidly enlarging large pulmonary artery aneurysm involving the apical and posterior segments of the R/ lung was impending rupture with a risk of life threatening haemoptysis. Due to the large size of the aneurysm and as there was already thrombosis of the distal vessels, after discussing with the cardiothoracic surgeon and the chest physician it was decided to occlude both feeding branch vessels as distal as possible using Amplatzervascular plugs. Due to the retrievable nature of these plugs prior to release, .
Fig. 4. Fig. 5.
Endovascular management of multiple aneurysms in pulmonary artery in a patient with Bechet's disease
14
it was possible to position the plugs immediately proximal to the origin of the aneurysms thereby salvaging the maximum length of the proximal pulmonary artery. Immediate post procedure angiogram showed complete cessation of blood flow in to both aneurismal sacs indicating successful occlusion of the vessels using a single occlusive devise.
Thereby it was possible to treat this patient by
endovascular means safely enabling rapid recovery
under local anaesthesia avoiding major thoracic
surgery under general anaesthesia.
Conclusion
Large and multiple pulmonary artery aneurysms
leading to life threatening haemospysis can be
successfully managed by endovascular means
avoiding major surgery as described by this patient
with Bechet's disease.
Endovascular management of multiple aneurysms in pulmonary artery in a patient with Bechet's disease
15
Abstract
IntroductionIntrathyorid abscess formation due to MRSA is rare. It needs high index of suspicion to diagnose early. Early diagnosis and treatment improves the outcome.
The Patient
A 77 year old Sri Lankan female, presented to the emergency surgical department with a tender swelling in the anterior neck. On examination there was an enlarged thyroid gland with multiple cervical lymphadenopathy. Ultrasound scan revealed an abscess within the right lobe of the thyroid. Ultrasound guided aspiration of the puss and culture ABST done and the MRSA was isolated after 24 hour incubation. Incision and drainage of the abscess was done. Intravenous antibiotics were started according to the culture ABST.
ConclusionIt needs high index of suspicion to diagnose the thyroid abscess early. Ultrasound guided aspiration, Incision and drainage and early administration of sensitive antibiotic would improve the outcome.
Introduction
Abscess formation within the thyroid gland is rare (1). Because of its rarity, it is often not suspected and hence the diagnosis would be delayed. Possibility of thyroid abscess formation should be suspected in any patient who presented with tender neck swelling in thyroid area.
The patient
A seventy seven year old Sri Lankan female patient presented to the emergency surgical department of Teaching Hospital Kandy, Sri Lanka with high fever and neck swelling for 2 days. She did not have difficulty in breathing. The onset of fever was gradual and associated with chills. Relatives noticed that the patient was confused and disoriented. On examination, the patient was dehydrated and drowsy. There was a large right sided tender, warm swelling in the thyroid region with multiple cervical lymphadenopathy.
An urgent white cell count showed a very high leucocyte count with neutrophilia. The ultrasound scan revealed an abscess in the right lobe of the thyroid gland with multiple cervical lymphadenopathy. A CT scan (figure 1.) of the neck with reconstruction was performed to assess the extension. Ultrasound guided aspiration of the abscess was done and pus was sent for culture and antibiotic sensitivity (table 1). The gram stain showed few gram negative bacilli and few gram positive bacilli. Pus grew Methicillin Resistant Staphylococcus aureus (MRSA) after 24 hours of incubation. The patient was also screened for tuberculosis and it was negative. The Biopsy of cervical lymph node showed necrosis with secondary deposit from a sqamous cell carcinoma of which the primary was not found. She was a known patient with diabetic mellitus and had poor control of blood sugar. The patent was rehydrated with intravenous normal saline and adequate urine output was maintained. After taking the puss for culture ABST by USS guided aspiration the patient was empirically treated with cefuroxime 750mg
Intrathyroid Abscess Formation with Multiple Necrotizing Cervical Lymphadenitis due to Meticillin Resistant Staphylococcus aureus (MRSA); A Case Report with Literature ReviewSenanayake KJ, Pitigalaarachchi PR
Department of Surgery, Faculty of Medicine and Allied Health Sciences, Rajarata University of 1 2Sri Lanka , Department of General Surgery, Teaching Hospital Kandy, Sri Lanka ,
Anuradhapura Medical Journal 2012Case Reports
16
eight hourly and the patient was treated with oral fucidic acid and intravenous vancomycin after the culture report. Incision and drainage was performed under general anesthesia. Patent had a good recovery from the sepsis after post operative day 3. Informed written consent was taken from the patient for photography and publishing the case report.
Table 1. Sensitivity pattern of MRSA from the pus culture
Discussion
Abscess formation within the thyroid gland is rare (1). The intrathyroid abscess formation with MRSA may be rarer. The oldest case of thyroid abscess reported in the Pub Med was in 1894 by Ransohoff J (2). There are 319 cases reported in English in the literature from 1900 to 2000, et al and Jacobs et al (3).Possible causes of infection of thyroid gland are either direct inoculation or hematological spread. The commonest route of infection is probably hematological (3). Other possible causes reported are the direct trauma such as, FNAC, esophageal perforation due to fish bone injury and in children's it is commonly due toanatomical anomalies such as piriform sinus fistula (1,4,5).The acute suppurative thyroiditis now rarely progress to thyroid abscess formation due to widespread use of antibiotics (6). The hemorrhage in to a thyroid cyst leading to secondary infection is a possible cause for the intrathyroid abscess formation. Rarely the post anginal sepsis (Lemierre's Syndrome) could present with thyroid abscess (7) and further it has been
reported secondary to biliary sepsis (8).The bacteraemia cause by the MRSA is reported in immunologically compromised patients (9).The thyroid abscess formation commonly reported among the immunocompromised (1). In the present case the patient is immunologically compromised due to the presence of diabetes mellitus and the underling malignancy of which the primary is unknown.
The rarity of abscess formation in thyroid leads to delay in the diagnosis due to the fact that it is not included in the differential diagnosis list in many physicians. The thyroid gland is highly resistant to be infected. The resistance of thyroid gland to form abscess is multifactorial. Presence of a capsule, high concentration of iodine, very high vascularity, and presence of high lymphatic drainage was postulated (1).
The commonest organism of thyroid abscess formation reported is staphylococci aurius (3). Butthe reported cases of thyroid abscess due to MRSA are minimal. The other organisms that have been isolated and responsible for abscess formation in the thyroid are tuberculosis, norcadia, E.coli, Salmonella, Eikenella corrodens, Actinomycosis Rhodoccus equi, and fugal infections suchas Cryptococcus and aspergillous etc.
Cases of thyoiditis with thyrotoxicosis cause bybacteria are reported (10). Therefore the altered thyroid function must be anticipated and suspected in a patient with thyroid abscess.However the current case the patient is euthyroid.
The diagnosis of the thyroid abscess is straightforward if it is suspected and examine. Clinically the enlarged, tender thyroid with the evidence of inflammation of overlying skin, multiple cervical lymphadinopathy gives a clue to the diagnosis. Ultrasonogrphy gives details a b o u t t h e a b s c e s s c av i t y, c e r v i c a l lyphadenophathy and the diagnosis can be confirmed by ultrasoundguided aspiration.
Antibibiotic
CefuroximeClindamycin
Cloxacillin
Co-trimoxazole
Erythromycin
Fusidic acid
Vancomycin
Sensitivity
Resistant
Resistant
Resistant
Resistant
Resistant
Sensitive
Sensitive
Intrathyroid Abscess Formation with Multiple Necrotizing Cervical Lymphadenitis due to Meticillin Resistant Staphylococcus aureus (MRSA)
17
Figure 1. Non contrast, Axial CT Scan of the neck at the level of the thyroid abscess
Contrast enhanced CT scan also delineates the anatomical extension of the thyroid abscess and may be helpful to plan the management. In the current case a plain CT scan (figure 1.) was donedue topresence of multiple allergies. Barium swallow can be used to assess t h e a n a t o m i c a l a b n o r m a l i t i e s a f t e r inflammatory process is resolved (11, 12).
The usual treatment includes intervention of the ENT service with incision and drainage of theabscess or partial thyroidectomy, depending upon the presence or absence of underlying thyroid pathologies, together with intravenous antibiotics (5).In the current case the treatment was a high dose ofsensitive intravenous antibiotics and ultrasound guided aspiration together with incision anddrainage. The most frequently recommended treatment in the literature is surgery either excisionor incision and drainage (3). However the role of more extensive surgery such as total or neartotal thyroidectomy in the management of intrathyroid abscess is not widely discussed. Non surgical management with ultrasound guided aspiration is suggested (13).However there is a possibility of recollection.
Conclusion
Abscess formation due to MRSA within the thyroid gland is rare. Thyroid abscess should besuspected in immunocompromised patients presenting with neck pain and swelling. Thiswould enable early diagnosis and treatment
References
1. Herndon MD, Christie DB, Ayoub MM, Duggan AD. Thyroid abscess: case report andreview of the literature. Am Surg. 2007 Jul;73(7):725-8.
2. Ransohoff J .Thyro id Abscess ; Thyroidectomy; Recovery. Ann Surg. 1894 Oct;20(4):406-13.
3. Jacobs A. Gros DC, Gradon JD. Thyroid abscess due to Ac ine tobac te r cakoaceticus: Casereport and review of the causes of and current management strategies of thyroidabscesses. South Med J 2(X) 3:96:300-7.
4. Lin ZH, Teng YS, Lin M. Acute thyroid abscess secondary to esophageal perforation. JInt Med Res. 2008 Jul-Aug;36(4):860-4.
5. Stavreas NP, Amanatidou CD, Hatzimanolis EG, Legakis I, Naoum G,Lakka-Papadodima E, Georgoulias G, Morfou P, Tsiodras S. Thyroid abscess due to a mixedanaerobic i n f ec t i on w i th Fusobac t e r i um mort i ferum. J Clin Microbiol . 2005Dec;43(12):6202-4.
6. Menegaux, F., G. Biro, C. Schatz, and J. P. Chigot. 1991. Thyroid abscess. Apropos of 5cases. Ann. Med. Interne (Paris). 142:99-102
7. Kara E, Sakarya A, KeleÅŸ C, Borand H et al. Case of Lemierre's syndrome presentingwith thyroid abscess. Eur J Clin Microbiol Infect Dis. 2004 Jul;23(7):570-2.
8. Mathew J, Goodfellow P, Chadwick DR. Thyroid abscess: an unusual case secondary tobiliary sepsis. Hosp Med. 2003 Oct;64(10):622-3.
9. Mitchell DH, Howden BP. Diagnosis and management of Staphylococcus aureusbacteraemia. Intern Med J. 2005 Dec;35 Suppl 2:S17-24.
Intrathyroid Abscess Formation with Multiple Necrotizing Cervical Lymphadenitis due to Meticillin Resistant Staphylococcus aureus (MRSA)
18
10. Al-Kordi RS, Alenizi E, Elgazzar AH. Acute suppurative thyroiditis with abscess, gasformation, and thyrotoxic crisis. Nuklearmedizin. 2008;47(4):N44-6.
11. Houghton DJ, Gray HW, MacKenzie K. The tender neck:Thyroiditis or thyroid a b s c e s s ? C l i n E n d o c r i n o l ( O x f ) 1995:48:521 4.32.
12. Takai SI. Miyauchi A, Matsuzuka F. et al. Intemal fistula as a route of infection in acutesuppurative thyroiditis. Lancet 1979:1:751-2.
13. Ilyin A, Zhelonkina N, Severskaya N, Romanko S. Nonsurgical management of thyroidabscess with sonographically guided fine needle aspiration. J C l i n U l t r a s o u n d . 2 0 0 7 J u l -Aug;35(6):333-7..
Intrathyroid Abscess Formation with Multiple Necrotizing Cervical Lymphadenitis due to Meticillin Resistant Staphylococcus aureus (MRSA)
19
ICU Management of a patient with Anaphylaxis
Kudavidanage Department of - Teaching Hospital Anuradhapura
BPAnaesthesia
AbstractHypersensitivity reactions might occur
during anaesthesia. Muscle relaxants have the highest frequency of inducing anaphylaxis. Rocuronium is the most common out of all muscle relaxants. We experienced a case of anaphylaxis occurring due to rocuronium during anaesthesia in a patient who is coming for a nephrectomy at Queens Hospital, London, UK. We managed the episode of anaphylaxis according to guidelines established by Association of Anaesthetists of Great Britain and Ireland.
Introduction
Hypersensitivity reactions that might occur during anaesthesia, i.e., anaphylaxis and anaphylactoid reaction have been reported to have a variable degree of incidence. But it has been reported to be approximately1/3,000-20,000 [1] and its mortality has been reported to be 3-6% [1]. Of the drugs which are used for anaesthesia, muscle relaxants have the highest frequency of inducing anaphylaxis. In addition, substances such as latex or antibiotics can also induce the occurrence of anaphylaxis.
On the other hand, the occurrence of anaphylaxis due to anaesthetic agents has been frequently reported in men in their fifties and women in their forties. In paediatric patients aged ten years or younger, it occurs to such a rare extent as <4% of total cases of anaphylaxis [3]. In the mid-1990s, rocuronium bromide (one of the non depolarizing aminosteroid muscle relaxants with a short action time) has been introduced in a clinical setting. As described here, according to the increased use of rocuronium, although not yet available in Sri Lanka, the occurrence of Rocuronium anaphylaxis has been reported to rise [1].
But most of these cases have been reported to occur in middle-aged and elderly people. We experienced a case of anaphylaxis occurring due to rocuronium during anaesthesia in a patient who is coming for a nephrectomy.
Case HistoryPreoperative assessment
Our patient was a 69 year old female Caucasian coming for an elective radical laparoscopic nephrectomy for multi locular renal cell carcinoma at Queens Hospital, London. She gave a history of well controlled hypertension without any end organ damage. She did not have any other medical problems. She had good exercise tolerance. She was on regular antihypertensives, namely Ramipril 2.5mg once daily, Bendroflumethiazole 2.5mg once daily and anti depression Citalopram 20mg nocte.She had undergone general anaesthesia for repair of detached retina in 1990. She received Thiopentone, Atracurium and Fentanyl for general anaesthesia and there were no reported complications. She didn't give any history of allergy to any of the medications or food.
On examination she was an averagely built lady. She was not pale. On assessment of her air way, she didn't present with a difficult airway. On cardiovascular assessment pulse rate was 65 beats per minute and blood Pressure was 170/85. Heart was in dual rhythm and no murmurs detected. Respiratory and central nervous systems were normal.
Blood investigations were all normal except for haemoglobin which is 12.5. Consent was taken for surgery after explaining the risks of general anaesthesia and laparoscopic nephrectomy.
Anuradhapura Medical Journal 2012Case Reports
20
Anaesthetic procedure
After establishing 16G intravenous access on the dorsum of the right hand and stating 0.9% intravenous infusion, routine monitoring was established. Initial pulse rate was 70bpm, blood pressure 180/90mmHg and saturation was 96% on induction. Patient was induced intravenously using Propofol 130mg, Fentanyl 100µg and muscle relaxant was induced with Rocuronium 40 mg intravenously. Patient was intubated with size 8 end tracheal tube and tube was secured after checking the position. As soon as the patient was induced, saturation in the pulse oxymeter dropped to 60% and air way pressure increased to 40 cmH O. 2
Blood pressure also dropped to 60/30 and severe bradycardia was noticed. Patient was clinically flushed on examination.
The initial differential diagnosis was a drop in blood pressure due to overdose of induction agents and anaphylactic reaction to induction agents or muscle relaxants.
Intravenous fluids especially 500ml of colloids were transfused as a bolus, followed by injection of ephedrine and Metaraminol boluses to improve blood pressure. Epheneprene boluses were required to maintain blood pressure as blood pressure was low in spite of previous treatment. This was followed by Epheneprine infusion which was titrated according to the response to maintain the blood pressure.
Management of the patient was done by following the guidelines for anaphylaxis management by the Association of Anaesthetists in Great Britain and Ireland. Accordingly Hydrocortisone 100mg and Ranitidine 50mg was given and Chlopheniramine 10mg also given intravenously.
Post op management
Patent was admitted to intensive care for further management with intermittent positive pressure ventilation and infusions of Ephenephrene, Remifentanyl and Midazolam. On admission she was on 50% oxygen maintaining 100% saturation with PaO of 54 2
kPa and PaCO of 7.15 kPa. Chest X ray was 2
clear without any evidence of pulmonary oedema. She was tachycardic with blood pressure maintained by adrenalin infusion. She was on Midazolam and Remifentanyl infusion for sedation with pupils reacting equally to light. Initial investigations were within normal range except for the serum potassium which was 3.2 mmol/l, glucose of 8.4 mmol/l with normal clotting profile. In addition serum tryptase was taken immediately after admission to the ICU, 6 hours after and 24 hours after the admission to ICU. Routine observation was carried out in the ICU with close monitoring for further evidence of anaphylaxis.
Once haemodynamically stable she was gradually weaned off from adrenaline infusion and ventilatory support was reduced. Potassium was replaced intravenously. Advice for further management was taken from the regional allergic centre at the allergic clinic at the Guy's Hospital in London.
She was referred to the allergic clinic at Guy's Hospital for further investigations, where she underwent skin testing and RAST testing. Skin testing was strongly positive for Rocuronium and Suxamethonium, while mildly positive for Vecuronium, Mivacurium and border l ine pos i t ive for Atracur ium. Investigations established that Cisatracurium, Pancuronium and Propofol are negative for the reaction and were safe to use. Therefore it was confirmed that the anaphylactic reaction was due to the Rocuronium which was used at the induction.
She subsequent ly successful ly underwent the surgery with Propofol, Pancuronium and fentanyl.
ICU Management of a patient with Anaphylaxis
21
Discussion
We experienced a case in which anaphylaxis was strongly suspected based on hypotension, tachycardia and hypoxia due to the use of Rocuronium which was used for general anaesthesia.
Two types of immediate
hypersensitivity reactions including anaphyl- axis and anaphylactoid reaction are classified according to the involvement of such antibodies as immuoglobulin E (IgE). But it is not easy to make a differential diagnosis of these two reactions based on the clinical symptoms. Instead, they can be classified according to skin test or biologic test. In association with this, it would be desirable to use such terms as anaphylactoid reaction in cases in which a diagnosis of immunological mechanisms was not made through an allergic test.
In regard to most cases of the allergy occurring during anesthesia, i.e., acute hypersensitivity reaction, grade-2 responses (non-life-threatening skin reaction, hypotension accompanying tachycardia, coughing or the difficulty of mechanical respiration) or grade-3 responses (life-threatening cardiovascular collapse, bradycardia or tachycardia and severe bronchospasm) account for approximately 85% of total cases [4]
The current case is the one that is suspected to be grade-2 or grade-3 anaphylaxis occurring due to rocuronium. To make an accurate diagnosis of anaphylaxis or anaphylactoid reaction, in add i t ion to c l in ica l symptoms , the concentrations of tryptase or IgE which are present in the blood should be measured. After several weeks following the occurrence of allergic reactions, skin prick test or intradermal test should be performed [5]. Skin reactions occurring during the allergic responses due to drugs may be manifested as urticaria, edema, pruritis, thermal sensation and red spots.
On the other hand, Propofol may also cause the occurrence of anaphylaxis rarely. In the previous anaesthetic exposure, Propofol and rocuronium were not used. In this occasion, propofol, rocuronium was used along with Fentanyl. Based on these findings, in the current case, the possibility for anaphylaxis due to Propofol could not be ruled out.
Anaphylax i s occur r ing dur ing anaesthesia occurs at a frequency which is approximately four times higher in men than women [5]. In regard to the age, it occurs most frequently in people in their forties.
Muscle relaxants are the most common drugs that cause the occurrence of anaphylaxis to a life-threatening extent during anaesthesia, accounting for approximately 50-70% of cases [6,7].
Anaphylaxis occurring due to muscle relaxants occurred the most frequently in people aged ten years or younger. Besides, it also occurred the most frequently in women aged in their thirties. Clinical characteristics due to rocuronium are mainly classified into two types: cardiovascular collapse and bronchospasm [2]. Generally in cases in which bronchospasm occurred due to anaphylaxis, due to the actions of alpha-1 elevating the blood pressure and those of beta-2 relaxing the bronchial smooth muscles, the immediate administration of epinephrine is important. Besides, in cases of cardiovascular collapse due to anaphylaxis, fluid supply is generally done and Epinephrine and Phenylephrine are administered. In cases which are refractory to these treatments, the administration of vasopressin could be of help [5].
Due to the increased permeability of capillary during the occurrence of anaphylaxis, the plasma volume is abruptly increased. A massive amount of fluid therapy might also be essential in this case. Owing to this, the oedema might occur in the lung or respiratory tract. This might be due to the increased permeability of pulmonary capillary vessels because of anaphylaxis.
ICU Management of a patient with Anaphylaxis
22
However in the case discussed here clinical or radiological evidence of pulmonary oedema did not occur. We assumed the possibility that pulmonary oedema occurred due to anaphylaxis or might have originated from the negative pressure of the respiratory tract
On the other hand, Rocuronium is an amino-steroid nondepolarizing muscle relaxant whose pharmacological characteristics are similar to those of Vecuronium. In cases of allergic reactions due to Rocuronium, there might be cross reactions with other types of steroid non-depolarizing muscle relaxants. In particular, aminosteroid muscle relaxants have a higher prevalence of the cross-reactions as compared with benzilisoquinoline-derived muscle relaxants [9]. These muscle relaxants commonly have tetra-positively charged ammonium ion (NH4+) as an antigenic determinant. Due to this chemical structure, cross-reactions can occur. This should therefore be confirmed by further investigating the patient once stabilized [10].
The occurrence of Rocuronium induced anaphylaxis has been reported more frequently than that due to Vecuronium or Pancuronium and less frequently than that due to Succinylcholine [8]. There is a tendency that the use of Succinylcholine has recently been decreased and that of Rocuronium has been increased. Owing to this, the occurrence of rocuronium-induced anaphylaxis may be on the rise in western countries.
Conclusion
Muscle relaxants are the most commonly recognized cause for allergic reactions due to anaesthesia. Rocuronium is the number one cause for allergy among the muscle relaxants in western countries. Prompt identification and appropriate treatment according to established guidelines is important for immediate management of anaphylaxis. Follow up and further investigations for confirmation of anaphylactic reactions and identification of causative agent is important for prevention of further anaphylactic reactions during future anaesthesia.
References1. Mertes PM, Aimone-Gastin I, Gueant-
Rodriguez RM, Mouton- Faivre C, Audibert G, O'Brien J, et al. Hyper sens i t iv i ty r eac t ions to neuromuscular blocking agents. Curr Pharm Des 2008; 14: 2809-25.
2. Heier T, Guttormsen AB. Anaphylactic react ions during induct ion of anaesthesia using rocuronium for muscle relaxation: a report including 3 cases. Acta Anaesthesiol Scand 2000; 44: 775-81.
3. Laxenaire MC, Mertes PM; Groupe d ' E t u d e s d e s R e a c t i o n s Anaphylactoides Peranesthesiques. Anaphylaxis during anaesthesia: results of a two-year survey in France. Br J Anaesth 2001; 87: 549-58.
4. Laxenaire MC, Mertes PM; Groupe d ' E t u d e s d e s R e a c t i o n s Anaphylactoides Peranesthesiques. Anaphylaxis during anaesthesia: results of a two-year survey in France. Br J Anaesth 2001; 87: 549-58.
5. Rose M, Fisher M. Rocuronium: high risk for anaphylaxis? Br J Anaesth 2001; 86: 678-82.
6. Mertes PM, Laxenaire MC. Allergy and anaphylaxis in anaesthesia. Minerva Anestesiol 2004; 70: 285-91.
7. Watkins J. Adverse reaction to neuromuscular blockers: frequency, investigation, and epidemiology. Acta Anaesthesiol Scand Suppl.1994; 102: 6-10.
8. Lee HM, Song SO. Anaphylaxis after injection of rocuronium: a case report. Korean J Anesthesiol 2006; 51: 101-4.
9. Laxenaire MC, Gastin I, Moneret-Vautrin DA, Widmer S, Gueant JL. Cross-reactivity of rocuronium with other neuromuscular blocking agents. Eur J Anaesthesiol Suppl 1995; 11: 55-64.
10.Matthey P, Wang P, Finegan BA, Donnelly M. Rocuronium anaphylaxis and multiple neuromuscular blocking drug sensitivities. Can J Anaesth 2000; 47: 890-3.
ICU Management of a patient with Anaphylaxis
23
Aetiology for gastro intestinal reflux disease
Weeerawardena WAK
Department of Surgery - Teaching Hospital Anuradhapura
Abstract
Introduction
Gastro intestinal reflux disease(GORD) is
common. The incidence is rising in the world and
in Sri Lanka. Food habits, behavioural pattern are
considered to be of concerned about aetiology.
Objective
To identify the risk factors for GORD to make a
plan for reducing the incidence o0f symptoms.
Materials and methods
Reviewed 23 journal articles published during
last 15 years of duration. Key words of GORD,
aetiology, risk factors were used. Different
possible aetiological factors were identified and
their relationship to GORD was assessed.
Results
Gastric acid, tobacco smocking, table salt use,
dietary factors, alcohol, physical activity, Body
mass index, obesity, ethnicity, gender, posture,
genetic contribution, medication effect, role of
Helicobactor pylori, effect of naso gastric tubes,
hiatus hernia, pregnancy, other cardiac diseases
were identified for considering as aetiology.
Special variety of infantile GORD was also
selected.
Discusion and conclusion
Exact aetiology of GORD is largely unknown.
However this review has detected several
significant associations with GORD. Knowledge
of those association factors are useful in the
management of the symptoms. Overweight,
obesity, tobacco smocking,
alcohol, high salt intake, fibre intake, physical
exercise are some of the association factors.
People have capacity to alter those factors with
view to reduce the incidence of GORD
.
Introduction
GORD is common. The incidence is rising in the
world and in Sri Lanka. Food habits, behavioural
pattern are considered to be of concerned about
aetiology. The therapeutic options are wide.
However treatment may include long term PPI
and laparotomy or thoracotomy with variable
results. It is the time to investigate for the cause
GORD. Adherent to preventive steps will abolish
the complications of long term medication and
extensive surgeries and the expenses involved. I
have reviewed index journal literature
published during last 15 years duration.
Gastro-oesophageal reflux disease is a condition
with the reflux of gastric contents into the
oesophagus. This reflux provokes symptoms or
complications and impairs quality of life.
Typical symptoms of gastro-oesophageal reflux
disease are ,
1. heartburn
2. regurgitation
However gastro-oesophageal reflux disease has
also been related to extra-oesophageal
manifestations, such as asthma, chronic cough
and laryngitis. The pathogenesis of gastro-
oesophageal reflux disease is multifactorial. This
involve transient lower oesophageal sphincter
relaxations and other lower oesophageal
sphincter pressure abnormalities. Reflux of acid,
bile, pepsin and pancreatic enzymes cause
oesophageal mucosal injury(1).
Anuradhapura Medical Journal 2012Review Article
24
Other factors contributing to the
pathophysiology of gastro-oesophageal reflux
disease include,
1.hiatal hernia,
2. impaired oesophageal clearance,
3.delayed gastric emptying
4. impaired mucosal defensive factors.
Hiatal hernia contributes to gastro-oesophageal
reflux disease by promoting lower oesophageal
sphincter dysfunction. Impaired oesophageal
clearance is responsible for prolonged acid
exposure of the mucosa. Delayed gastric
emptying, resulting in gastric distension, can
significantly increase the rate of transient lower
oesophageal sphincter relaxations, contributing
to postprandial gastro-oesophageal reflux
disease(1,2).
Method
Pubmed search were carried out to find out the
aetiological factors for GORD. 22 journal articles
were reviewed published during last 15 years.
Key words of GORD, aetiology, risk factors were
used. Different aetiological factors were
identified and their relationship to GORD was
assessed.
Results
Gastric acid, tobacco smocking, table salt use,
dietary factors, alcohol, physical activity, Body
mass index, obesity, ethnicity, gender, posture,
genetic contribution, medication effect, role of
Helicobactor pylori, effect of naso gastric tubes,
hiatus hernia, pregnancy, other cardiac diseases
were identified for considering as aetiology.
Special variety of infantile GORD was also
selected.
1.Gastric acid
The main diseases associated with dyspepsia are
peptic ulcer disease, gastro-oesophageal reflux
disease and non-ulcer dyspepsia. Increased
gastric acid secretion is a characteristic of most
duodenal ulcer patients and of a small minority of
non-ulcer dyspepsia and GORD patients.
Although acid secretion is normal in most GORD
patients, the condition is mainly the result of
excess exposure of the distal oesophagus to acid
refluxing from the stomach. Increased mucosal
sensitivity to acid is the aetiology of dyspeptic
symptoms in the majority of patients with peptic
ulcer disease and GORD, and in a minority of non-
ulcer dyspepsia subjects. Gastric acid, therefore,
plays an important role in both the aetiology of
dyspeptic diseases and in the aetiology of
dyspeptic symptoms (3)
2. Tobacco smocking , alcohol and table salt
The aetiology of gastro-oesophageal reflux is
largely unknown. In Norway, a case control study
within the two public health surveys, including
3153 individuals reported severe heartburn or
regurgitation during the last 12 months were
defined as case. They included 40 210 people
without reflux symptoms to constitut the control
group. There was a significant dose response
association between tobacco smoking and reflux
symptoms. Among people who had smoked daily
for more than 20 years the odds ratio was 1.7
(95% confidence interval 1.5 to 1.9) compared
with non-smokers. (4, 5)Another large,
population based study provides that tobacco
smoking causes symptomatic GORD.(11)
In two large population base studies , alcohol was
not identified as a risk factor(4)(11) . However
total of 7124 subjects were interviewed as part of
the German National Health Interview and
Examination Survey, a representative sample of
the general adult population. They found that
smoking and the frequent consumption of spirits
are risk factors for GORD.(5)GORD shows a
positive association with table salt intake. The
odds ratio for reflux was 1.7 (95% CI
Aetiology for gastro intestinal reflux disease
25
1.4 to 2.0) among those who always used extra
table salt compared with those who never did
so.(4) Another large, population based study
shows that table salt intake seem to be risk
fa c tors for ga st ro- oesop ha g ea l re f lu x
symptoms(11).
3. Dietary factors
A team used PubMed and Ovid to perform a
search of the literature published between 1975
and 2004 using the key words heartburn,
GERD(Gastro esophageal reflux disease),
smoking, alcohol, obesity, weight loss, caffeine or
coffee, citrus, chocolate, spicy food, head of bed
elevation, and late-evening meal. Although there
was physiologic evidence that exposure to
tobacco, alcohol, chocolate, and high-fat meals
decreases lower esophageal sphincter pressure,
there was no published evidence of the efficacy of
dietary measures. Neither tobacco nor alcohol
cessation was associated with improvement in
esophageal pH profiles or symptoms (9).
In two large population base studies, alcohol was
not identified as a risk factor (4, 11). However
total of 7124 subjects were interviewed as part of
the German National Health Interview and
Examination Survey, a representative sample of
the general adult population. They found that
smoking and the frequent consumption of spirits
are risk factors for GORD.(5)
A team systematically reviewed the pathogenetic
link between overweight/obesity, dietary habits,
physical activity and GERD, and the beneficial
effect of specific recommended changes, by
means of the available literature from the 1999 to
2009.(10) . The role of dietary behavior, mainly in
terms of specific dietary components, remains
controversial. Mild routine physical activity in
association with diet modifications, i.e. a diet rich
in fiber and low in fat, is advisable in preventing
reflux symptoms (10,4). Physical activity and the
consumption of fruits seemed to have some
protective effect and sweets, or white bread are
risk factors for GORD (5) .
A large population based study provides firm
evidence that dietary fibres may protect against
reflux.(11)(4).Coffee, and tea do not seem to be
risk factors for reflux(4)(11).
4. Overweight and obesity.
A total of 7124 subjects were interviewed as part
of the German National Health Interview and
Examination Survey, a representative sample of
the general adult population. They found an
association among those with reflux symptoms
who were overweight and obese (odds ratio: 1.8,
95% confidence interval: 1.5-2.2; odds ratio: 2.6,
95% confidence interval: 2.2-3.2), respectively.
A study demonstrated a clear and dose-
dependent association between increasing
degrees of overweight and gastro-oesophageal
reflux. The mechanisms by which obesity causes
reflux are unknown though there is some limited
data to suggest that hiatal hernia may be the
causal link between obesity and reflux. There are
some evidence that obesity is clearly a stronger
risk factor among women than among men, and
that the relation between overweight and reflux
is substantially augmented by postmenopausal
hormone therapy(6). Weight-reduction seems to
reduce the risk of symptomatic GORD , indicating
that such strategy might be a useful tool in the
treatment of reflux. (6)(9).
In 2000, a team used a supplemental
questionnaire to determine the frequency,
severity, and duration of symptoms of
gastroesophageal reflux disease among
randomly selected participants in a Study. Of
10,545 women who completed the questionnaire
(response rate, 86 percent), 2310 (22 percent)
reported having symptoms at least once a week,
and 3419 (55 percent of those who had any
symptoms) described their symptoms as
moderate in severity.(7) Body mass index (BMI)
is associated with symptoms of gastroesophageal
reflux disease in both normal-weight and
overweight women. Even moderate weight gain
among persons of normal weight may cause or
exacerbate symptoms of reflux (7).
Aetiology for gastro intestinal reflux disease
26
A study was done to systematically review the
pathogenetic link between overweight/obesity,
dietary habits, physical activity and GORD, and
the beneficial effect of specific recommended
changes, by means of the available literature from
the 1999 to 2009(10).This team concluded that,
being obese/overweight and GORD-specific
symptoms and endoscopic features are related,
and weight loss significantly improves GORD
clinical-endoscopic manifestations (10)
5. Physical activity
A large, population based study provides firm
evidence that physical exercise may protect
against reflux(11, 4,5).
6. Ethnicity and gender.
There was a consistent association between
abdominal diameter (independent of BMI) and
reflux-type symptoms in the white population,
but no consistent associations in the black
population or Asians. The BMI association was
also strongest among the white population.
These findings, combined with the increased
prevalence of abdominal obesity in male
subjects, suggest that an increased obesity may
disproportionately increase GORD-type
symptoms in the white population and in male
subjects. (8)
7. Posture
Head of bed elevation and left lateral decubitus
position improved the overall time that the
esophageal pH was less than 4.0. Weight loss and
head of bed elevation are effective lifestyle
interventions for GERD(9)
8. Nasogastric tubes
A prospective randomized case-control study
with 15 consenting patients demonstrated that
patients undergoing elective laparotomy with
routine nasogastric tube placement have
significant gastroesophageal reflux in the
perioperative period and shows reduced ability
to clear refluxed acid from the distal
esophagus. Due to the associated risk of
postoperative pulmonary complications, they
recommend that nasogastric intubation be
performed on a selective rather than routine
basis.(12).
9. Gastro oesophageal reflux in infants
According to epidemiological data, the role of
gastro-oesophageal reflux in the aetiology of this
life threatening events is unclear.The incident of
sudden infant death is decreased in the supine
versus the prone sleeping position. On the
contrary, gastro-oesophageal reflux is more
pronounced in the supine than in the prone
position, both in infants and in older children,
both in infants with physiological and with
pathological reflux. In the supine position, infants
do sleep shorter, have more rapid-eye-movement
sleep and have more arousals than in the prone
position. It is thought that in the majority of
infants, gastro-oesophageal reflux stimulates
arousals and thus may well be considered as
"protective" for rather than "provoking" sudden
infant death. However the authors concluded that
this hypothesis needs to be validated.(13).
10. Genetic contribution
A total of 4480 unselected twin pairs, identified
from a national volunteer twin register, were
asked to complete a validated symptom
questionnaire about GORD in Glagow ,United
Kingdom. GORD was defined as symptoms of
heartburn or acid regurgitation at least weekly
during the past year (14). They detected that
there is a substantial genetic contribution to the
aetiology of GORD.
11. Relation to Helicobactor pylori
Epidemiological studies demonstrate a negative
association between Helicobacter pylori
infection and gastro-oesophageal reflux disease
and its complications. This might represent a
protective effect for GORD as the tendency for H.
pylori infection lower the gastric acid secretion
with advancing age.
Aetiology for gastro intestinal reflux disease
27
However, studies of the effect of H. pylori
eradication on GORD have failed to show any
worsening of GORD symptoms. Helicobacter
pylori infection improves the control of gastric
acidity by proton-pump inhibitors and this
produces a small advantage in clinical control of
reflux disease. The infection prevents rebound
acid hypersecretion occurring when proton-
pump inhibitor therapy is discontinued.
However, concerns have been expressed that the
body gastritis induced by proton-pump inhibitor
therapy in H. pylori-infected subjects might
increase the risk of gastric cancer. At present, it is
unclear whether H. pylori should be eradicated in
gastro-oesophageal reflux disease patients.(15)
12. Hiatus hernia
Hiatal hernia, in combination with other reflux
conditions and symptoms, was associated
strongly with the r isk of esophageal
adenocarcinoma. These associations were more
modest for gastric cardia adenocarcinomas. A
significant and positive association between
body size and history of hiatal hernia/reflux
symptoms also was observed.(17)
13. Medications
A multicenter questionnaire survey concluded
that though larger cohort is required for further
study, the combination of calcium channel blo
ckers and warfarin is an independent risk factor
for GORD(18).
Oral bronchodilators are known to worsen GORD
and may lead to vicious cycle when gastr oeso pha
geal reflux causes bronchospasm. The effect of in
haled bronchodilators on gastroeso phageal refl
ux is unknown. Patients with gast roeso pha geal
reflux disease, who require bron chodilator ther
apy for obstructive lung disease, have less re flux
with inhaled albuterol (22) )
People experiencing frequent GOR D symptoms
have markedly increased risks of oesophageal
adenocarcinoma and gastro oesophageal
junctional adeno carcinoma , and this effect may
be greater amongst smokers. Use of aspirin and
NSAIDs, but not acid suppressants, significantly
reduced the risks of oesophageal cancers
associated with GORD(22)
Naproxen did not induce reflux in normal
subjects, although reflux did increase in some
subjects
(23)
Individuals with long-standing GERD are at
increased risk of esophageal adenocarcinoma,
whether or not the symptoms are treated with H2
blockers or antacids(16)
14. Other diseases
A multicenter questionnaire survey demonstra
ted that among traditional cardiovascular risk
factors, AF was an independent risk factor for
GERD. A large cohort study to assess the pote ntial
relationship between GERD and AF is warranted.
(19)
15. Pregnancy
Heartburn is a common symptom in pregnancy,
affecting about two-thirds of pregnant women.
The aetiology of GORD in pregnancy is
multifactorial. Reduced lower basal gastro-
oesophageal sphi ncter pressure, increased
intragastric pressure, delayed intestinal transit
time and duodenogastric reflux have been found
in pregnant women with heartburn, all factors
which dispose to increased gastro-oesophageal
reflux. Gastric emptying is apparently normal
during pregnancy, but delayed during delivery.
Therapy involves lifestyle modification and
nonsystemic medication as the initial choices. H-
2-antagonists should only be used in severe and
refractory cases(20)
Aetiology for gastro intestinal reflux disease
28
Discussion
Exact aetiology of GORD is largely unknown.
However this review has detected several
significant association factors with GORD.
Knowledge of those association factors is useful
in the management of the symptoms.
Overweight, obesity, tobacco smocking, alcohol,
high salt intake, fibre intake, physical exercise are
some of the association factors. People have
capacity to alter those factors with view to reduce
the incidence of GORD. It was also useful to
review the association of the symptoms with tea
and coffee. The relationship with the
medications is valuable for the clinicians in their
practice. The association of GORD with the
nasogastric tube and posture need to be
considered during inpatient management. The
association of GORD with genetic changes,
ethnicity and gender are useful in future
research(4,5,11).
Transient loosening of the lower oesophageal
sphincter tone is suspected to be the mechanism
of reflux. The angle between stomach and
oesophagus, intra abdominal pressure over the
intra peritoneal part of oesophagus are also play
a role in preventing reflux. Those associated
triggering factors for reflux are expected to alter
the defense mechanism of anti reflux process.
The anti reflux medication and surgical
procedures are aiming at strengthening of those
lower oesophageal sphincter tone and
normalizing the angle between stomach and
oesophagus. There is a failure rate Of those
surgical procedures and medical therapy and the
t h e ra p e u t i c c o s t i s ve r y h i gh to t h e
community(2).
Once the symptoms star, the investigation with
upper gastro intestinal endoscopy, Ba swallow,
24 hours ambulant lower oesophageal pH
measurement with calculation of DeMeester
score are useful. Considering about the cost of
those investigations it is necessary to adhere to a
preventing steps of the disease. Simple change of
diet and behaviour will reduce the symptoms and
consequences. Patient education and induction
of exercise based weight reduction programs are
expected to be favourable.
Conclusion
With the available data a preventive program can
be arranged to reduce the incidence of GORD at
North Central Province of Sri Lanka. Simple heath
education may prevent sinister complications of
GORD.
References
1) F De Giorgi, M Palmiero, I Esposito, F Mosca, R
Cuomo. Pathophysiology of gastro-oesophageal
reflux disease . Acta Otorhinolaryngol Ital. 2006
26(5): 241–246.
2)John Bancewicz. The oesophagus. In Baily and
Love s Short Text Book of Surgery. RCG Russell,
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Aetiology for gastro intestinal reflux disease
30
An analysis of psychiatric referrals In a multidisciplinary General hospital in Sri Lanka
Dharmawardene V. Department of Psychiatry Teaching Hospital Anuradhapura
Introduction
Psychiatric morbidity significantly affects the outcome of physical illness. Rate of psychiatric morbidity is 20-50% of the inpatient population in global studies. There is limited published data on the subject from a Sri Lanka.
Objective
To describe the patterns of psychiatric morbidity in referrals from the inpatient population received at the psychiatric unit of teaching hospital Anuradhapura, a multidisciplinary hospital.
Methods and design
A Retrospective file review was carried out into all the ward referrals received between 01 May 2012 and 31 July 2012. All the assessments during the period had been conducted by one consultant psychiatrist.
Results:
There were 213 Referrals received during the study period comprising 0.58 % of the admissions. 59% were females. Highest number was received from the general medical wards (47%) followed by cardiology (18%) and surgery (12%). 30% did not have any diagnosable psychiatric illness. Commonest psychiatric diagnosis was depressive disorder (19%). 24% of the referrals were for patients who have attempted self harm (DSH). Oleander seed ingestion was the commonest method (44%) followed by medication overdose (22%) with only 18% seen with ingestion of agrochemicals. 11% patients who have attempted self harm had depressive illness. The rate was 06 % for oleander seed ingestion.
Conclusions:
Though Depressive illness appears to be the commonest diagnosis, it is relatively less common among the DSH patients. DSH by agrochemicals are represented less in this sample.
Anuradhapura Medical Journal 2012Abstracts
31
Awareness of well woman clinic services among attendees to Anuradhapura on Poson poya day:
are the socially deprived at a disadvantage?
Warnasekara YPJN, Gamakumbura MK, Koonthota SD, Liyanage LSK,
,
Agampodi SB
Faculty of Medicine and Allied Sciences (FMAS), Rajarata University of Sri Lanka (RUSL)
Department of Community Medicine, FMAS, RUSL
Maduwantha KDNK,
Pemasiri WRAM, Lakpriya BAD, Hendawitharana KJ, Gunathilaka JAMTN, Athukorala APN
Background
Objective
Methods
Results
Mean
Conclusion
Though the Well Woman Clinic (WWC) in Sri Lanka has been designed as the primary strategy for secondary
prevention of breast and cervical cancers, whether we have yielded the utmost public health outcome from it
is questionable.
To assess the awareness and the use of WWC for screening for these two malignant conditions among women
aging more than 35 years (target group of WWC).
A rapid spot survey was conducted in the sacred city of Anuradhapura on 4th, June 2012 (Poson poya day).
(Statistics show that this is the largest gathering of people representing a majority of areas in Sri Lanka on a
single day.) The study sample included women aged 35 and above, who came to the premises on the day and
those who consented to participate. This was done as a part of health promotion program conducted by MSU,
FMAS.
A total of 3116 females from 22 districts were interviewed. age of the study sample was 52.6 years (SD
10.3 years). Risk of breast and cervical cancers in their age group was known only to 1150 (36.9%) and 1011
(32.4%) women respectively. Awareness on availability of WWC was 60.8%. However, only 578 (18.5%)
have attended the WWC. Of the women reported as professionals or associate professionals (n=217),
awareness on WWC was 87.6% compared to 58.8% among other occupation categories and housewives.
Clinic attendance was also significantly higher (40.1% compared to 16.9%) among this group. Younger
(<60years) women had a significantly higher awareness on WWC (64.7% compared to 48.2%) and a higher
number of them (20.3% compared to 13.1%) have attended the WWC.
A gross social disparity was observed on WWC awareness and attendance. Health promotional programs
should focus more on socially disadvantaged groups.
Anuradhapura Medical Journal 2012Abstracts
32
Infant feeding behaviors in Nuwaragam-Palatha-Central (NPC) Medical Officer of Health (MOH) area; a qualitative study.
Agampodi TC, Chathurani HKJU, Agampodi SB
Department of Community Medicine, Rajarata University of Sri Lanka
Background
Although Sri Lanka has achieved exemplary progress in many maternal and child health services, indicators related to childhood nutrition have been disappointing and stagnating for the past few decades. Locally prevalent behavioral factors may play an important role in determining child nutrition.
Objective
To explore the infant and youngchild feeding behaviors of mothers in NPC- MOH area.
Methods
We used a qualitative approach using two key informant interviews with public health midwives and six focus group discussions (FGDs) with mothers of children less than 2 years of age to identify the locally prevalent food practices, behaviours, belief and myths. Participants for these FGDs were selected from child welfare clinics. Around 8-12 participants were selected for each FGDs and Family Health International guidelines were be followed in conducting the discussions. Interviews were tape recorded; transcribed and thematic analysis was performed.
Results
Optimal and suboptimal behavioural factors were identified in mothers having children with normal and inadequate weight gain respectively. Mothers having children with normal growth were appropriately informed by the service providers to practice infant feeding guidelines given by the national child health programme. Suboptimal behaviours identified among the group of mothers who had children with inadequate weight gain were mainly related to; exclusive breast feeding, selection and preparation of complementary foods, complimentary feeding patterns and adaptation to adult foods. Healthcare providers and mothers of small children had different views and perceptions on causes for growth problems. Service providers were not having an in-depth understanding of sub optimal practices in this community.
Discussion
Identification of locally prevalent behavioural factors should be used in local programme planning for infant feeding. Qualitative techniques are useful for in-depth exploration of these behaviours.
Anuradhapura Medical Journal 2012Abstracts
33
Habits of the players during the competition day
1 2Rajasinghe SV , Thurairaja C
1Sports Medicine Unit, T.H. Anuradhapura.2Oasis Hospital, Colombo.
Introduction
Every player should need proper training, skills and several other factors for his success, but optimal performance will depend on his behavior on the day of competition.
Objectives
To assess the habits and practices which are negatively affect the performance of the players during the competition.
Method
50 players aged 16-40 years were assessed by an interviewer administered questionnaire during the North central provincial meet 2011.
Results
Sixteen players (32%) were between 21-25 years of age and 60% (n=30) have not had their breakfast. 19 (38%) players consumed simple carbohydrate like glucose before the event. Twenty two players (44%) reported to the venue before 15-30 minutes and 72% (n=36) of the players didn't do proper warm-up before their event. 29 (58%) players sustained an injury during the event and 94% of the players did not do any type of cooling down. 60% have not had post-event meal and only 10% had it within 1 hour. 88% players consumed fluids after the event but pre-event fluid consumption was only 40%. 54% of players experienced sleep disturbances day before the night.
Discussion
Majority of players paid less attention to essential factors like pre-event meal, warm-up and cooling down during the competition day, though they have done those during their training. Players, coaches as well as parents should be educated regarding this in order to gain better outcome.
Anuradhapura Medical Journal 2012Abstracts
34
Bacteriological profile with their antibiograms in neonatal septicaemia in a Teaching Hospital in Srilanka
Fernando R, Samarawickrama B.
Microbiology Department District General Hospital Chilaw
Introduction
Neonatal septicemia continues to be a major problem in Neonatal ICU. The gold standard for diagnosis of septicemia is the isolation of the microorganism from the blood culture which takes 48 hrs to 7 days. Therefore empirical treatment is crucial & it should be based on the local sensitivity data.
Objectives
To determine the Bacteriological profile with their antibiogram and to provide sensitivity data to make local treatment protocols
Materials and Methods
Total blood culture samples received in Brain Heart Infusion broth from clinically suspected cases of stneonates from neonatal ICU from 1st January, to 31 December 2010 included for the study.
Standard isolation procedures were done using blood, chocolate and MacConkey agar. All the organisms were identified by standard methods. However most Enterobactereciae were further identified using API 20E. Stokes disc diffusion method was used for susceptibility testing and ESBL detection was done using clavulanic acid .
Materials and Methods
Total blood culture samples received in Brain Heart Infusion broth from clinically suspected cases of st
neonates from neonatal ICU from 1st January, to 31 December 2010 included for the study. Standard isolation procedures were done using blood, chocolate and MacConkey agar. All the organisms were identified by standard methods.
However most Enterobactereciae were further identified using API 20E. Stokes disc diffusion method was used for susceptibility testing and ESBL detection was done using clavulanic acid .
Anuradhapura Medical Journal 2012Abstracts
35
Results:
During the study period 838 blood cultures were requested and 121 non repetitive specimens were positive (14.4%). Gram negative bacilli (59.5%) were more frequently isolated than Gram positive cocci (GPC) (40.5%). API 20E identification method was able to identify Klebsiella spp (30.4%), Enterobacter spp (20.2%), Escherichia coli (13%) as the common pathogens. 15.9% were unclassified with API and 20.2% of Enterobactereciae were unidentified.
Coagulase negative staphylococcus (CNS) (63%), and Staphylococcus aureus(18%) were the major GPC . Other pathogens were Grp D streptococcus (4), Group B streptococci
(3), Methicillin resistant Staphylococcus aureus (2), pseudomonas spp (2) and Acinetobacter spp(1).
Majority of Enterobactereciae were ESBL producers and sensitive to ciprofloxacin meropenam and amikacin Coagulase negative stayhlococcus resistance to penicillin and cloxacillin was 100% and 83% respectively. Penicillin resistance in staphylococcus aureus was 78%. However, only 18% of Staphylococcus aureus were found to be MRSA. All Gram positive organisms were sensitive to vancomycin.
Enterobactereciae antibiotic susceptibility
Conclusion
ESBL producing Enterobactereciae were the main pathogens in neonatal sepsis in our NICU. Empirical antibiotic choice of neonatal septicaemia in most NICUs is penicillin and cefotaxime. But High ESBL prevalence among Enterobactereciae makes cefotaxime resistant. Therefore Amikacin can be recommended as a replacement for cefotaxime for empirical treatment of sepsis to prevent mortality. This situation is serious therefore we should focus on preventive measures such as strict asepsis during labour and correct hand hygiene to prevent transmission of resistant pathogens.
.
Amp Cefu Co amox Cefotax Genta Cipro Merop Amikac
8.3 13.3 20.6 38.4 74.1 95.3 93.3 100
Bacteriological profile with their antibiograms in neonatal septicaemia in a Teaching Hospital in Srilanka
36
Percutaneous Biliary Stenting For Malignant Biliary Obstruction – Retrospective Single
Center Case Series
L P ParanahewaAsiri Surgical Hospital
Objective
To assess the effectiveness of percutaneous, retrograde biliary stenting as palliative management for malignant biliary obstruction.
Method
Retrospective analysis done of the patients referred for percutaneous biliary stenting to Asiri Surgical hospital from Nov 2011 to May 2012. The procedure was done under ultrasound / fluoroscopic guidance. The duct system was accessed on the right side with left sided access only with difficult catheter navigation. 035 'angled guide wire was used to bypass the stricture. Stenting was done following balloon dilatation. Type of stent selected according to the clinical situation and the affordability.
Results
During the period of 7 months 12 patients were referred for antegrade biliary stenting. 7 patients were referred following failed retrograde access of which one was done as a combined Randouz approach and 2 patients were post surgical with unsuitable anatomy for retrograde approach. 5 patients had obstruction distal to the biliary confluence and in 7 patients the obstruction was in the CBD distal to the confluence. In 8 patients the obstruction was complete. Procedure was successful in 11 patients, 2 patients having the procedure in 2 stages. The procedure failed in one patient due to tight stricture involving the confluence which could not be bypassed.
Conclusion
Percutaneous antegrade approach is successful in crossing a malignant stricture for palliative biliary stenting especially useful in failed retrograde approach or in patients with post surgical anatomy unsuitable for retrograde approach.
Anuradhapura Medical Journal 2012Abstracts
37
Pre competition anxiety among athletes
1 2Sumudu V. Rajasinghe , Dilini V. Vipulaguna
1Sports Medicine Unit, T.H. Anuradhapura.2Faculty of Medicine, Colombo.
Introduction
Mental preparation is one of the most important part of an individual's sports performance. Anxiety caused by impending competition will lead to problems in sleep and reduction in performance. Most players do not realize this and they blame for other factors for their poor performance.
Objectives
To assess the level of anxiety and psychological factors that can negatively affect the performance of the players during the competition.
Method
50 players aged 16-40 years were assessed by an interviewer administered questionnaire including SCAT (Sport competition anxiety test) during the North central provincial sports meet 2011.
Results
Most players (54%, n=27) were athletes and 34 (68%) were involved in individual events. Sixteen players were (32%) between 21-25 years of age and 74% (n=37) were males. Majority (72%, n=36) had average SCAT score but 26% (n=13) had high score. 52% (n=26) players had problems related to sleep before their competition and players involved in individual events experienced more sleep problems and high SCAT score.64% (n=32) were not aware about the coping strategies like relaxation and 96% (n=48) of players never used it.
Discussion
Pre competition anxiety will adversely affect performance. Identification of anxiety among players is utmost important and coping strategies like relaxation should be taught to players as well as coaches to control pre competition anxiety.
Anuradhapura Medical Journal 2012Abstracts
38
Predictive validity of Post Prandial Blood Sugar (PPBS) at booking visit and routine urine dip stick test
(UDST) in detecting Gestational Diabetes Mellitus (GDM)
1 2 2Ranasinghe ORJC , Dahanayaka NJ , Agampodi SB1 2Taeching Hospital Anuradhapura and Faculty of Medicine and Allied Sciences,
Rajarata University of Sri Lanka
Background
Prevalence of GDM in Sri Lanka is estimated to be around 5-10%. Recommended screening methods for
detection of GDM include risk based PPBS and routine urine dip stick test.
Objective
To determine the predictive validity of PPBS at booking visit and the validity of UDST to detect GDM among
pregnant women in Anuradhapura district.
Methods
Pregnant women at 24-28 week POA, residing in Anuradhapura district and who had undergone PPBS
during the first trimester were selected for the present study. GDM was defined using International
Association of Diabetes and Pregnancy Study Group (IADPSG) criteria using 75g Oral Glucose Tolerance Test
(OGTT). Screening results were extracted from the ante natal records. Ethical clearance was obtained from
the ethics review committee of Faculty of Medicine & Allied Sciences, Rajarata University of Sri Lanka.
Results
Of the 405 women screened for the study, only 113 (27.9%) had PPBS either at booking visit or during the
first trimester. Out of them, 19 (6.8%) were confirmed as having GDM. Sensitivity, specificity, positive and
negative and predictive values of PPBS was 10.5%, 100.0%, 100.0% and 84.6% respectively. Regular UDST
was done for 389 (96.0%) pregnant women and of them, 43 (10.9%) were confirmed as having GDM. Out of
them, only 3 had abnormal dipstick results. There were 7 false positive urine dipstick results at least once
during the pregnancy showing a sensitivity of 6.8%.
Conclusion
Validity of the present recommended screening practice is highly doubtful. Alternative methods for
screening should be employed to control the effects of GDM.
Anuradhapura Medical Journal 2012Abstracts
39
PresidentDr. Darshana Sirisena
President ElectDr. Damith Chandradasa
Immediate Past PresidentDr.W.A.K. Weerawardana
Joint SecretariesDr.Niranjala Meegoda Widanage
Dr. Rohan Dissanayake
TreasurerDr.Deeptha Wickramarathna
Editorial AdvisorProfessor Sisira Siribaddana
EditorsDr. Akalanka Jayasinghe,
Dr. Wishva Panagoda
Anuradhapura Clinical Society
Office bearers 2012
Dr Rajeewa Dasanayake, Dr Priyantha Dissanayake,
Dr Sanjeewa Hulangamuwa,Dr Senaka pilipitiya, Dr Sujeewa Thalgaspitiya,
Dr Thamara Illangasinghe, Dr Sidath Yawasinghe, Dr Lasantha Bandara.
Dr Kelum Dehigaspitiya,Dr Chamila Herath, Dr Charitha Herath,
Dr Darshana Chandrakumara, Dr Thushara Bandara
Commite Members
40