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CCP News Newsletter of the Ceylon College of Physicians

June 2019

Contents

1. President’s message

2. YPF

3. Is it cryptogenic? A review of cryptogenic organising pneumonia

4. How to approach when all are connected but not in order – Undifferentiated Connective

Tissue Disease

5. Demyelinating Diseases of the Central Nervous System

6. Diagnosis of non motor seizures

7. Regional Meeting – Embilipitiya

8. Best Publication by a Physician – Call for Applications

9. Annual Academic Sessions 2019 at a Glance

10. Forthcoming events

Ceylon College of Physicians

341/1, Kotte Road

Rajagiriya, Sri Lanka

Phone: +94 (0)11 2888146 or 3094140

Fax: +94 (0)11 2888119 E-mail: office@ccp.lk

Compiled and edited by:

Dr Shehan Silva

Dr Kishara Gooneratne

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Dear Fellows and Members, As the first 6 months of the Council of the CCP for 2019 draw to a close, it is time for us to look back at what we have done and at what is in store for the next 6 months. The first 6 months saw the Council working tirelessly to set the pace and foundation for the activities of the year. We have successfully conducted the regular activities such as the guest lectures, specialty days, YPFs and College lectures and concluded two very successful regional meeting. The decision to take the regional meetings away from the main centres to District General Hospitals has paid off handsomely. The record attendance we have had for both the doctors’ meeting and the nurses’ training provided ample testimony of the need for such programmes in the periphery, in many instances there was only standing space for the attendees. Despite the ready availability of internet and other online facilities, these face-to-face interactions still remain as one of the preferred methods of acquiring new knowledge and clarifying doubts. What is important is to identify the needs of those in the periphery who need such educational activities and deliver it in the most effective manner. I would like to request our members in the periphery to contact the College with their educational needs to help us formulate quality outreach teaching-learning programmes. I would also like to draw your attention to a pressing problem that we face in our practices, namely that of quality failures in medicines/drugs we use. In many instances we are unaware that we can complain of quality failures to enable the authorities to investigate and take remedial action. I urge you to make use of this facility by complaining to the National Medicines Regulatory Authority (NMRA) through their website when you suspect quality failures of medicines you use. The website provides the option of making a complaint on line: <https://www.nmra.gov.lk/index.php?option=com_contact&view=contact&id=1&Itemid=182&lang=en>

and information about quality failures of products that were in use and withdrawn

<https://www.nmra.gov.lk/index.php?option=com_content&view=article&id=118:withholding-of-a-batch-due-to-quality-failure&catid=11&Itemid=167&lang=en>

Cont…...

President’s message

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In many instances we make random complaints among ourselves without taking appropriate actions and this is one way of doing so, it is always better to light a candle than to curse the darkness. The NMRA website also has information of available and registered medicines, devices, borderline products and cosmetics, and also the relevant details if you wish to conduct phase 2/3 clinical trials in Sri Lanka with investigational products or new indications for existing, registered products. It is up to us to make use of facilities and information available to provide the best service to that we are capable of our patients. The newsletter will carry information about the activities for the next few months. The highlight among them is the 52nd Anniversary Academic Sessions of the College which will be held from 12th to 14th September at the Galadari Hotel. We have had a few anxious moments with the travel bans imposed in the aftermath of Easter bombing, but I am happy to inform you that all our overseas speakers will be joining us as planned. So do keep the dates free and join us for a truly educational experience. With best wishes, Professor Chandanie Wanigatunge President

President’s message

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YPF

The YPF for this month was held on Tuesday, 4th June 2019 at the Galle Medical Association Auditorium, Teaching Hospital Karapitiya, Galle. There were 5 excellent speakers at this event which was well attended. The Senior Registrars in Medicine, Dr. D.P.G.S.P. Fernando and Dr. W.F.C. Nilanga presented the lectures ‘‘Is it Cryptogenic?’ A review of cryptogenic organising pneumonia’ and ‘Antibiotic Resistance’. Dr. H.S. Nilanka (Senior Registrar in Rheumatology and Rehabilitation) spoke on mixed connective tissue disease on the topic ‘How to approach when all are connected but not in order’. The Senior Registrar in Neurology Dr. W.C.S. Perera conducted a lecture on demyelinating diseases while the Senior Registrar in Neurophysiology, Dr. S.P. Mohotti presented a talk on diagnosis of non motor seizures. We would like to extend our deep gratitude to the Galle Medical Association for hosting this event. The program was sponsored by Cipla Pharmaceuticals.

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Dr. D P G S P Fernando, Senior Registrar in Medicine Two patients presenting with respiratory tract symptoms treated as viral and bacterial infection initially were presented in this talk. Persistiant symptoms of shortness of breath and cough opted the author’s team to further evaluate. This was found to be organizing pneumonia by high resolution CT (HRCT) of the lungs with the clinical correlation. Cryptogenic organising pneumonia (COP) has an incidence of 1.1 per 100,000 population as per published data. It is a disease predominant in the 6th decade of life and is equal in both sexes. Although histology is needed for a definitive diagnosis of organizing pneumonia, suspicion following four radiological features on HRCT gives 99.3% specificity to arrive at a diagnosis. These features are parenchymatous consolidation, patchy infiltration, absence of honey combing and absence of interlobular septal thickening. Mild cases of COP resolve spontaneously but steroids play a major role in the treatment with some promising results with macrolides in mild to moderate cases.

Dr H S Nilanka, Senior Registrar in Rheumatology and Rehabilitation Undifferentiated Connective Tissue Disease (UCTD) is a condition characterized by the presence of clinical and serological manifestations suggestive of systemic autoimmune diseases, but not fulfilling the classification criteria for defined connective tissue diseases. It is a vague clinical entity. Clinical manifestations include Raynaud phenomenon, arthralgia, arthritis mucocutaneous symptoms, fever and sicca symptoms. Routine laboratory investigations include full blood count, ESR, CRP, UFR, RF and ANA. Other investigations are needed to consider on a case-by-case basis. The main pharmaceutical agents used in UCTD are: NSAIDS, hydroxychloroquine and steroids. Immunosuppressive drugs such as azathioprine are used in specific conditions. UCTD may evolve into a defined Connective Tissue Disease in 20%-40%, while the rest remain undifferentiated. Early identification, regular monitoring and follow-up is paramount.

Is it cryptogenic? A review of cryptogenic organising

pneumonia

How to approach when all are connected but not in

order – Undifferentiated Connective Tissue Disease

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Demyelinating Diseases of the Central Nervous System

Dr W C S Perera, Senior Registrar in Neurology Demyelinating disease is any disease that leads to damage of the myelin cover of nerves. Basically it can manifest in the central nervous system (e.g. multiple sclerosis, neuro myelitis optica, central pontine myelinolysis, progressive multifocal leukoencephalopathy) or in the peripheral nervous system (e.g. Guillain Barre Syndrome (GBS), Chronic Inflammatory Demyelinating Polyneuropathy (CIDP), HSMN (Hereditary Sensory Motor Neuropathy) type 1 and 3. Multiple Sclerosis (MS) is the commonest immune mediated demyelinating disease of the central nervous system. Although comparatively rare compared to Western countries there are sporadic cases of MS in Sri Lanka. The aetiology remain unknown and immune mediated demyelination is thought to occur in a genetically predisposed person when exposed to environmental antigens. The most common clinical presentation is of a clinically isolated syndrome (optic neuritis, transverse myelitis, brain stem syndrome, cerebellar syndrome). MS still remains as a clinical diagnosis with the aid of characteristic imaging (MRI) findings and to a lesser extent with CSF findings. There are various clinical patterns of MS, where Relapsing Remitting MS is the most common pattern (90%) followed by Secondary Progressive MS pattern and Primary Progressive MS (10%). Many decades have followed from the first description in 1868. However, we still do not have a cure for MS. Disease modifying treatments to reduce the rate of relapses are widely used worldwide. (e.g. Interferon beta, Glatiramer acetate, Natalizumab, Fingolimod). Some of these drugs are now available for patients with MS, in Sri Lanka as well.

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A Simplified Approach to a Complex Lung Condition –

Interstitial Lung Disease

Dr S P Mohotti, Senior Registrar in Neurophysiology Patients with episodic transient neurological events are common presentations in the medical casualty. Epilepsy or seizure disorder should be considered as an important differential diagnosis in such presentations. Clinicians needs to inquire about the ictus in detail to look for features such as tonic-clonic movements, frothing, tongue bites etc. However, absence of theses do not rule out seizures completely as non motor manifestations are not assessed. ILEA 2017 seizure classification defines non motor seizures as, those predominantly associated with non motor manifestations. They can be either of focal onset or generalized onset. Focal onset non motor seizures includes, autonomic, cognitive, emotional, sensory and behaviour arrest seizures, whereas generalized onset non motor seizures are classified as typical absence, atypical absence, myoclonic absence and absence seizures with eye lid myoclonus. Because of the variety of clinical manifestations non motor seizures may end up with misdiagnosis or erroneous diagnosis of a functional or even as a psychiatric disorder. Since most of the clinical features of non motor seizures are subtle and brief, patients and relatives often tend to ignore them and patients may experience seizures for years without seeking medical attention. Such patients will have normal clinical examination findings and imaging, and routine EEG would be usually negative. Therefore, clinicians need to have a high degree of suspicion and inquire with direct and specific questions to identify these features and arrive at a diagnosis.

Diagnosis of non motor seizures

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Regional Meeting – Embilipitiya

The second regional meeting for the year 2019 was held at the Embilipitiya District General Hospital and at the office of the Medical Officer of Health, Embilipitiya on the 5th of June in collaboration with the Walawa Clinical Society. As in the past, the program consisted of 2 parts targeting doctors as well as nurses. This program was attended by 120 nurses and 80 doctors from the hospital and environs. The CCP team conducted the Acute Kidney Injury Module along with topics on management of Dengue and Leptospirosis for doctors, and CPR, monitoring of dengue, falls and frailty, and nutrition for nurses. The 2 consultant physicians of the hospital, Dr. R Lokugamage and Dr. A Adhikari delivered 2 excellent lectures on A&E model of care and Falls & frailty. The program was also contributed by the local faculty Dr. Amila Walawwatta, Dr. Wathsala Gunasinghe and Dr. Athula de Silva on Cardiac Arrhythmia, Oxygen Therapy and X-ray Interpretation. We are thankful to GSK pharmaceuticals for sponsoring this event.

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Best Publication by a Physician –

Call for Applications

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Annual Academic Sessions 2019 at a Glance

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Annual Academic Sessions 2019 at a Glance

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Annual Academic Sessions 2019 at a Glance

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Annual Academic Sessions 2019 at a Glance

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Annual Academic Sessions 2019 at a Glance

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Young Physicians’ Forum and College Lecture - 9th July at 11:30 am at

the ClinMARC Auditorium, NHSL

Council Meeting – 12th July at 12:00 pm

Specialty Update in Diabetes – 30th July 2019 at 8:45 am at the

ClinMARC Auditorium, NHSL

Forthcoming events

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