Download Advances in SSRI Treatment

持續醫學進修專訊
May 2007
二零零七年五月
Advances in SSRI
Treatment
Dr. LAM Tat Chung Paul
Private Specialist; Hon Clinical Assistant Professor,
University of Hong Kong
FRCP, FHKAM (Medicine), FHKAM (Psychiatry)
Selective Serotonin Reuptake Inhibitors is
one of the most frequently prescribed classes of
drugs in Psychiatry and Family Practice nowadays.
Its use in the treatment of depression has largely
replaced that of tricyclic antidepressants, the side
effects of which are well known (Plate 1). TCAs
are problematic because they have a multitude
of actions, some of which are unwanted. These
include antihistaminic, anticholinergic and
adrenergic activity. (Plate 2) Other unwanted
side effects include membrane stabilizing activity
which may induce cardiac conduction defects and
arrhythmia, and the lowering of seizure threshold.
They are fatal when taken in overdose.
Currently there are six
SSRIs available on the
market (Plate 3). In
general, these drugs are equal in efficacy to TCAs,
have a better side effect profile, and are safe in
overdose. They are better tolerated by patients and
have a more diverse therapeutic spectrum.
Plate 3
Plate 1
Plate 2
In the treatment of depression, the serotonin
pathway involved is from the midbrain Raphe
nucleus to the prefrontal cortex (Plate 4). Usually
the standard recommended dose of the drug is
used. Onset of antidepressant action is delayed for
2-4 weeks and the patient should be encouraged
to expect this delay in therapeutic effect, and
to accept the initial side effects which may be
experienced immediately. For anti-obsessive
compulsive action, the pathway involved is from
the Raphe nucleus to the basal ganglia (Plate 5).
Usually a higher dose of medication is required
and the improvement in symptoms takes months.
For anti-panic action, the pathway involved is from
the Raphe nucleus to the hippocampus and limbic
cortex. (Plate 6) Medication should start at half
the usual dosage, and dose escalation be carried
out very gradually, for example every four weeks.
Otherwise the symptoms may worsen and the
patient may refuse to continue with treatment.
However, medication may eventually be increased
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Advances in
SSRI Treatment
Advances
in SSRI
Treatment
to two or three times the usual dosage to achieve good
symptom relief. For anti-bulimia action, the pathway
involved is from the Raphe nucleus to the hypothalamus
(Plate 7). A high dose of medication, e.g. 3-4 times
normal dosage is required from the start of treatment
for good results. Other indications for SSRIs include posttraumatic stress disorder, drug addiction, premenstrual
syndrome, impulse control disorder and Gilles de la Tourette
syndrome1.
have been postulated for the causation of sexual
dysfunction:
(1)
Serotonergic stimulation of 5HT2C and 5HT3 receptors
(2)
Decreased doperminergic activity
(3)
Anticholinergic effect
(4)
Inhibition of nitric oxide synthetase
(5)
Prolactinaemia.
Plate 4
Plate 6
Plate 5
Plate 7
SSRIs as a group exhibit certain side effects. Doctors should
be vigilant when prescribing these medications to their
patients and review the patients from time to time.
Sexual dysfunction:
Patients may not give this information voluntarily and
doctors need to enquire about this symptom. It may
take the form of loss of desire or libido, impotence or
ejaculatory delay. The problem is dose dependant and may
improve with tolerance of the drug. Several mechanisms
Some patients may improve with dose reduction and
drug holidays, for example asking the patient to take the
drug for five days per week, omitting the days prior to
sexual activity. Drug treatment includes adding Sidenafil,
Cyproheptadine, Trazodone, Mianserin or Mirtazapine.
Bupropion may also be useful. However if the symptoms
persist, it may be necessary to change to another class of
medication.2
HKMA CME BULLETIN • MAY 2007
P. 3
Advances in
SSRI Treatment
Advances
in SSRI
Treatment
The syndrome of inappropriate anti-diuretic hormone
secretion (SIADH) may develop in 1 in 200 cases. Patients
present with confusion, drowsiness, convulsion or coma.
The median onset is 13 days after starting treatment
and 80% of cases develop in 3 weeks. It tends to occur
in patients with low body weight taking high doses, in
females and in the elderly. Diagnosis is confirmed by a low
serum sodium of <120 mmol/l and a plasma osmolality
of <268 m Osmol/l, and a normal or high urine sodium
concentration. Treatment by water restriction is indicated3.
Plate 9
Bleeding tendency may occur in some patients due
to platelet inhibition. This usually takes the form of
gastrointestinal bleeding, but there is no increase in
cerebral haemorrhage. Post-operative bleeding may occur
and patients on concomitant treatment with Asprin and
NSAID are at special risk.4
Abuse of SSRI is relatively uncommon. Fluoxetine and
Sertraline have been reported to prolong the high periods
of Methylenedioxymethamphatamine (NMDA, Ecstacy) for
2-4 hours due to inhibition of the liver enzyme P450 2D6.
The stimulant effect of Amphatamine, Coccaine and LSD
is also augmented. A drug abuser ingested 200 tablets
of Sertraline 50 mg daily for six months and developed
euphoria, excitement, visual and auditory hallucination.5,6,7
SSRI discontinuation Syndromes are usually mild, but
occasionally may become quite alarming. It usually starts 1
to 10 days after discontinuation, and lasts about 10 days.
It occurs most frequently with Paroxetine, in about 5% of
cases and least frequently with Fluoxetine, in about 1%.
Treatment is to reinstate the drug and withdraw gradually
at about 25% per week. The somatic and psychological
symptoms of SSRI discontinuation are listed in Plates 8 and 9.
Drug interaction can be a problem with some SSRI
since the metabolizing enzyme cytochrome P450 is also
involved in the degradation of many other drugs. In
this respect, the greatest vigilance need to be kept for
Fluvoxamine and Fluoxetine, followed by Paroxetine and
Sertraline (Plates 10,11,12). Citalopram and Escitalopram
are safe and should be chosen for patients taking multiple
drugs for treatment of other medical conditions. Genetic
polymorphism occurs in the cytochrome P450 enzymes.
7-10% of Caucasians lack the enzyme 2D6 and should
avoid Fluoxetine and Paroxetine. 5-10% lack 1A2 and
should avoid Fluvoxamine, 20% of Asians lack 2C19 and
care should be exercised when prescribing Fluvoxamine,
Fluoxetine and Sertraline8. Commonly used medications
that inhibit the cytochrome P450 enzymes are shown in
Plates 11 and 12.
Plate 10
Plate 8
HKMA CME BULLETIN • MAY 2007
P. 5
Advances in
SSRI Treatment
Advances
in SSRI
Treatment
Plate 11
Plate 12
Hezardous Drug interactions occur with Warfarin,
causing haemorrhagic tendency because of CYP2C9
inhibition. Cardiac arrhythmias can be a problem when
used with Tricyclics, Terfenadine(Teldane), Theophylline and
Thioridazine (Melleril).
Dangerous drug interactions triggering a serotionin
syndrome may occur with monoamine oxidase inhibitors,
reversible inhibitor of monoamine oxidase A, Tryptophan,
Fenfluramine, Selegiline, Sibutramine, and St John's Wort.
The patient may be very distressed with restlessness,
tremor, rigidity, fever, hyperreflexia, myoclonic jerks, cardiac
arrhythmia, terminating in collapse and death. Treatment is
by Chlorpromazine (Largactil) or Cyproheptadine (Periactin)
and general supportive care.9
SSRI may induce suicidal thoughts and behaviour,
especially in children and adolescents10,11. This has led the
FDA to issue a warning in Oct 2004 that “Antidepressants
increase the risk of suicidal thinking and behaviour
(suicidality) in short-term studies in children and
adolescents with major depressive disorder and other
psychiatric disorders.” The National Institute for Clinical
Excellence (NICE) in UK also responded to these findings by
issuing the guideline that “Children and young people with
moderate to severe depression should be offered, as a first
line treatment, a specific, brief (up to 15 sessions, over at
least 15 weeks) psychological intervention.”
SSRIs need to be used with caution in pregnant women.
Up until lately, this group of drugs is thought to be
relatively safe, however, recent observations and research
have called for caution. As in other antidepressants, SSRI
may increase the rate of spontaneous abortion (SSRI
13.5%, TCA 10.7%, control 7-8%), cause low birth weight
and preterm birth. However, some of these ailments may
be due to maternal depression itself. When taken towards
the end of pregnancy, a poor adaptation syndrome in the
newborn has been reported (Plate 13)12. Fortunately most
of the cases are mild and self limiting, not requiring specific
treatment except supportive care and observation. There is
greater worry from the study that SSRI use after the 20th
week of pregnancy is associated with a six-fold increased
risk of developing persistent pulmonary hypertension in the
newborn13, a severe and sometimes fatal condition. There
are also several unpublished reports, including materials
taken from birth register analysis, that Paroxetine doubles
the risk of cardiac malformation in neonates, mostly
ventricular septal defect. In a case-control study based on
an American register of birth defects, the estimated relative
risk of omphalocele was 3.0 with all SSRIs (Paroxetine 6)
and the estimated relative risk of craniosynostosis was
1.814. All such reports need further validation and study but
are certainly adequate to raise an alarm that one should
be vigilant when using this group of drugs in pregnant
women. The present consensus seems to be that while
avoiding Paroxetine, SSRIs can be used judiciously when it
is definitely indicated15,16, otherwise we may be faced with
a case of maternal suicide or infanticide. Fluoxetine may
be a suitable choice under the situation as we have more
experience and data.
HKMA CME BULLETIN • MAY 2007
P. 7
Advances in SSRI Treatment
Plate 13
Use of SSRI in breastfeeding is relatively safe. SSRIs
are excreted into mother's milk. The majority of studies
show reassuring results although a minority show mild
unwanted reactions. Fluvoxamine and Paroxetine, followed
by Sertraline are detected in low levels in the infant, hence
these are the drugs of choice for the nursing mother.17
The individual SSRI has its specific properties. Fluoxetine
(Prozac) is the drug that has been used for the longest
time and gives the best post-marketing data. Together
with an active metabolite Norfluoxetine, it has a very long
elimination half life. Several weeks are required for the
drug to reach a steady state in the body, hence the onset
of action is delayed. It also takes about 5 weeks for the
drug to be eliminated, hence it may have a disadvantage
if switching to another drug or starting of incompatible
drugs are required. It can cause significant agitation and
anxiety with insomnia in some patients. Up to 4% of
patients may develop a skin rash, some with associated
allergic symptoms resulting in withdrawal of the drug.
Fluvoxamine (Faverin) may cause more nausea, vomiting
and drowsiness than others in the group.
Plate 14
P. 8
HKMA CME BULLETIN • MAY 2007
For Paroxetine (Seroxat), weight gain seems to be more
pronounced. It causes some sedation, which may be
beneficial for treatment of patients with anxiety and panic
attacks. Doctors need to be vigilant about a discontinuation
syndrome and gradual tapering of the drug is advised.
The risk of cardiac teratogenicity has been mentioned.
Sertraline (Zoloft) is generally well tolerated. It tends
to cause a greater frequency of diarrhea and tremor.
Escitalopram (Lexapro) is the purified active isomer of
Citalopram (Cipram) (Plate 14). It is the most specific of
all the SSRIs. Removal of the inactive isomer results in more
rapid onset of action with greater and more sustained
potency, and reduced side effects. It is the only dual action
SSRI in that it binds to the primary binding site and an
allosteric binding site on the serotonin transporter, making
the binding more secure with consequent enhanced clinical
efficacy. Due to its lack of inhibition on the cytochrome
P450 enzyme system, it is the drug of choice for patients
with polypharmacy.
The choice of a particular SSRI depends on the clinical
situation. For the average adult patient, Escitalopram is a
good choice for its relative lack of side effects, rapid onset
of action and infrequent drug interaction. For patients
with anxiety and agitation, Paroxetine seems to be a
reasonable first consideration. For patients who exhibit
retardation, Fluoxetine with its stimulant effect is indicated,
so is for patients who are overweight as the drug may
induce some weight loss. Due to its prolonged action and
relatively lack of withdrawal syndrome, it may be used
in patients who are irregular with taking medications.
Patients who are non-compliant with taking drugs should
avoid Paroxetine, because a discontinuation syndrome may
be troublesome. It is preferred in patients with poor liver
function, but should be avoided in patients with poor renal
function. Fluoxetine is the drug of choice for children and
adolescents, as more data are available in its use in this
population18. For use of SSRI in pregnancy and lactation,
please refer to the previous section.
Conclusion:
The SSRIs is one of the mostly frequently prescribed classes
of drugs in medical practice. It has a wide spectrum of
indications, is relatively safe and effective. We have learned
a lot since its debut in the l980s. We are still continuing to
making discoveries. Currently, the most pressing question
seems to be its safety in pregnancy and we await with
interest further research in this most important area.
Advances in
SSRI Treatment
Advances
in SSRI
Treatment
4.
Appendix
Choice of SSRI
Clinical situation
Prefer
Avoid
New patient
Fast onset required
Anxiety / agitation
Retardation
Over weight
Poor compliance
Drug interaction
TCA / antipsychotic
Possible switch
Asian
Poor liver function
Poor renal function
Children & adolescent
Pregnancy
Lactation
Lexapro (Zoloft*)
Lexapro
Seroxat
Prozac
Prozac
Prozac
Lexapro
Lexapro
Lexapro, Zoloft
Lexapro, Seroxat
Seroxat
–
Prozac
Prozac
Faverin, Seroxat, Zoloft
Faverin / Prozac
Prozac
Prozac
Seroxat / Faverin
Seroxat
Seroxat
Prozac, Faverin, Seroxat
Prozac, Faverin, Seroxat
Prozac
Prozac, Faverin, Zoloft
–
Seroxat / Prozac
All others
Seroxat
Cipram, Prozac
*
Zoloft is a good second choice. However it inhibits P450 2C19. Also
20% of Asians are deficient in this enzyme.
Self-Assessment Questions
Looper K. Potential medical and surgical complications of
serotonergic antidepressant medications. Psychosomatics JanFeb 2007; 48:1.
5. Singh A. Estasy and Prozac. New Scientist Oct 1995; 51.
6. Singh A.N., Catalan J. The misuse potential of antidepressants.
J Psychopharmacology 1996; 10(suppl): abstract 122.
7. D'Urso. Abuse of Sertraline. J Clin Pharm Ther 1996.
8. Serretti A., Artioli P. The pharmacogenomics of selective
serotonin reuptake inhibitors. The Pharmacogenomics Journal
2004; 4:233-244.
9. Sternbach H. The serotonin syndrome. Am J of Psychiatry 1991;
148:705-713.
10. Gibbons R., Kwan Hur, Bhaumik D., Mann J. The relationship
between antidepressant medication use and rate of suicide.
Arch Gen Psychiatry Feb 2005; 62.
11. Fergusson D., Docuette S., Glass K., Shapiro S. et al.
Association between suicide attempts and SSRI: systemic
review of randomised controlled trials. BMJ 19 Feb 2005; 330.
12. Oberlander T. Neonatal outcomes after prenatal exposure
to SSRI antidepressants and maternal depression using
population based linked health data. Arch Gen Psych 2006.
13. SSRI and the risk of persistent pulmonary hypertension in the
newborn New England Journal of Medicine. C. Chambers 2006.
14. SSRI antidepressants and birth defects. Prescrire International
Dec 2006; 15(86).
15. Hallberg P. and Sjoblom V. The use of SSRI during pregnancy
and breast feeding: A review and clinical aspects. Journal of
Clinical Psychopharmacology Feb 2005; 25(1).
16. Gentile S. The safety of newer antidepressants in pregnancy
and breastfeeding. Drug Safety 2005; 28(2):137-152.
17. Gentile S. Use of contemporary antidepressants during
breastfeeding. Drug Safety 2007; 30(2):107-121.
18. Anderson I., Edwards J. Guidelines for choice of SSRI in
depressive illness. Advances in psychiatric treatment 2001;
7:170-180.
(Please indicate true or false to the following questions.)
1. All SSRIs are the same and can be use interchangeably.
2. The starting dose of SSRI should be high for panic
disorder and low for obsessive compulsive disorder.
3. SSRI discontinuation syndrome is more likely in patients
taking Fluoxetine.
4. Asians have a higher rate of deficiency in cytochrome
P450 2C19 and hence Fluvoxamine, Fluoxetine and
Sertraline should be used with caution.
5. SSRI use in the first trimester of pregnancy is associated
with a six-fold increased risk of persistent pulmonary
hypertension in the newborn.
6. Paroxetine is linked to development of ventricular septal
defect in the foetus.
7. Fluvoxamine, Paroxetine and Sertraline are the drugs of
choice for the nursing mother.
8. Escitalopram is the active isomer of Citalopram.
9. SSRIs may augment the effect of Warfarin.
10. Escitalopram is the drug of choice in polypharmacy.
References:
1.
2.
3.
Stahl S. M. Mechanism of action of SSRI, Serotonin receptors
and pathways mediate therapeutic effects and side effects.
Journal of Affective Disorders 1998; 51:215-235.
Rosen R., Lane R., Menza M. Effect of SSRI on sexual function,
A critical review. Journal of Clinical Psychopharmacology 1999;
19(1):67-85.
Wilkinsom T., Begg E., Winter W., Sainsbury R. Incidence and
risk factors for hyponatraemia following treatment with fluoxetine
or paroxetine in elderly people. British Journal of Clinical
Pharmacology 1999; 47:211-217.
The Hong Kong Medical Association
What is the VYTAL Option to
Manage Dyslipidemia Today?
Speaker
: Dr. CHEN Wai Hong
Specialist in Cardiology
Date
: 12 June 2007 (Tuesday)
Venue
: Ballroom A, 2/F., Langham Hotel,
8 Peking Road, Tsim Sha Tsui
Time
: 1:00 - 2:00pm Luncheon
2:00 – 3:00pm Lecture & Q/A
Capacity
: 48
Please register for participation. First come, first served.
MCHK/HKMA CME Accreditation: 1 point
Please make reservation on or before 8 June 2007 by
sending a fax with your name, telephone number and
EVENT NAME and EVENT DATE to 2834 0756 or contact
Ms. Christine SHEK on 7202 4155 for enquiries.
Sponsored by : Merck Sharp & Dohme (Asia) Ltd.
HKMA CME BULLETIN • MAY 2007
P. 11
Advances in
SSRI Treatment
Advances
in SSRI
Treatment
4.
Appendix
Choice of SSRI
Clinical situation
Prefer
Avoid
New patient
Fast onset required
Anxiety / agitation
Retardation
Over weight
Poor compliance
Drug interaction
TCA / antipsychotic
Possible switch
Asian
Poor liver function
Poor renal function
Children & adolescent
Pregnancy
Lactation
Lexapro (Zoloft*)
Lexapro
Seroxat
Prozac
Prozac
Prozac
Lexapro
Lexapro
Lexapro, Zoloft
Lexapro, Seroxat
Seroxat
–
Prozac
Prozac
Faverin, Seroxat, Zoloft
Faverin / Prozac
Prozac
Prozac
Seroxat / Faverin
Seroxat
Seroxat
Prozac, Faverin, Seroxat
Prozac, Faverin, Seroxat
Prozac
Prozac, Faverin, Zoloft
–
Seroxat / Prozac
All others
Seroxat
Cipram, Prozac
*
Zoloft is a good second choice. However it inhibits P450 2C19. Also
20% of Asians are deficient in this enzyme.
Self-Assessment Questions
Looper K. Potential medical and surgical complications of
serotonergic antidepressant medications. Psychosomatics JanFeb 2007; 48:1.
5. Singh A. Estasy and Prozac. New Scientist Oct 1995; 51.
6. Singh A.N., Catalan J. The misuse potential of antidepressants.
J Psychopharmacology 1996; 10(suppl): abstract 122.
7. D'Urso. Abuse of Sertraline. J Clin Pharm Ther 1996.
8. Serretti A., Artioli P. The pharmacogenomics of selective
serotonin reuptake inhibitors. The Pharmacogenomics Journal
2004; 4:233-244.
9. Sternbach H. The serotonin syndrome. Am J of Psychiatry 1991;
148:705-713.
10. Gibbons R., Kwan Hur, Bhaumik D., Mann J. The relationship
between antidepressant medication use and rate of suicide.
Arch Gen Psychiatry Feb 2005; 62.
11. Fergusson D., Docuette S., Glass K., Shapiro S. et al.
Association between suicide attempts and SSRI: systemic
review of randomised controlled trials. BMJ 19 Feb 2005; 330.
12. Oberlander T. Neonatal outcomes after prenatal exposure
to SSRI antidepressants and maternal depression using
population based linked health data. Arch Gen Psych 2006.
13. SSRI and the risk of persistent pulmonary hypertension in the
newborn New England Journal of Medicine. C. Chambers 2006.
14. SSRI antidepressants and birth defects. Prescrire International
Dec 2006; 15(86).
15. Hallberg P. and Sjoblom V. The use of SSRI during pregnancy
and breast feeding: A review and clinical aspects. Journal of
Clinical Psychopharmacology Feb 2005; 25(1).
16. Gentile S. The safety of newer antidepressants in pregnancy
and breastfeeding. Drug Safety 2005; 28(2):137-152.
17. Gentile S. Use of contemporary antidepressants during
breastfeeding. Drug Safety 2007; 30(2):107-121.
18. Anderson I., Edwards J. Guidelines for choice of SSRI in
depressive illness. Advances in psychiatric treatment 2001;
7:170-180.
(Please indicate true or false to the following questions.)
1. All SSRIs are the same and can be use interchangeably.
2. The starting dose of SSRI should be high for panic
disorder and low for obsessive compulsive disorder.
3. SSRI discontinuation syndrome is more likely in patients
taking Fluoxetine.
4. Asians have a higher rate of deficiency in cytochrome
P450 2C19 and hence Fluvoxamine, Fluoxetine and
Sertraline should be used with caution.
5. SSRI use in the first trimester of pregnancy is associated
with a six-fold increased risk of persistent pulmonary
hypertension in the newborn.
6. Paroxetine is linked to development of ventricular septal
defect in the foetus.
7. Fluvoxamine, Paroxetine and Sertraline are the drugs of
choice for the nursing mother.
8. Escitalopram is the active isomer of Citalopram.
9. SSRIs may augment the effect of Warfarin.
10. Escitalopram is the drug of choice in polypharmacy.
References:
1.
2.
3.
Stahl S. M. Mechanism of action of SSRI, Serotonin receptors
and pathways mediate therapeutic effects and side effects.
Journal of Affective Disorders 1998; 51:215-235.
Rosen R., Lane R., Menza M. Effect of SSRI on sexual function,
A critical review. Journal of Clinical Psychopharmacology 1999;
19(1):67-85.
Wilkinsom T., Begg E., Winter W., Sainsbury R. Incidence and
risk factors for hyponatraemia following treatment with fluoxetine
or paroxetine in elderly people. British Journal of Clinical
Pharmacology 1999; 47:211-217.
The Hong Kong Medical Association
What is the VYTAL Option to
Manage Dyslipidemia Today?
Speaker
: Dr. CHEN Wai Hong
Specialist in Cardiology
Date
: 12 June 2007 (Tuesday)
Venue
: Ballroom A, 2/F., Langham Hotel,
8 Peking Road, Tsim Sha Tsui
Time
: 1:00 - 2:00pm Luncheon
2:00 – 3:00pm Lecture & Q/A
Capacity
: 48
Please register for participation. First come, first served.
MCHK/HKMA CME Accreditation: 1 point
Please make reservation on or before 8 June 2007 by
sending a fax with your name, telephone number and
EVENT NAME and EVENT DATE to 2834 0756 or contact
Ms. Christine SHEK on 7202 4155 for enquiries.
Sponsored by : Merck Sharp & Dohme (Asia) Ltd.
HKMA CME BULLETIN • MAY 2007
P. 11
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Multiple Cardiometabolic Risk Factors
Ching Room, 4/F., Sheraton Hong Kong Hotel & Towers,
Tsimshatsui, Kowloon
1
6:30-9:30 pm Fax: 2506 2537
1
THURSDAY
16
HKU – Dept of Surgery
Pre-Hospital Trauma Life Support (PHTLS) Provider Course – Day 2
Hong Kong St. John Ambulance Association, 2 Mcdonnell Road
9:00-6:50 pm Tel: 2530 8015
5
HKDU Shatin Study Group
First-in-class CB1-blocker – A Breakthrough Management of Multiple
Cardiometabolic Risk Factors
Royal Park Chinese Restaurant, Level 2, Royal Park Hostel, 8 Pak Hok Ting
Street, Shatin NT
1:00-3:00 pm Tel: 2388 2728
1
FRIDAY
17
HKDU Tsuen Wan Study Group and HA-Yan Chai Hospital
Upper GI Tumours
Lecture Theatre, 3/F., Block A, Yan Chai Hospital, Tsuen Wan NT
Ms. Catherine Cheng
1:00-3:00 pm Tel: 2417 8347
1
Hong Kong College of Community Medicine
Review Meeting in areas related to Public Health Medicine
Centre for Health Protection in Argyle Street/Wu Chung House
Ms. Fanny Kwong
6:00-8:00 pm Tel: 2871 8745
2
Hong Kong Academy of Medicine
1) Degenerative Arthritis Lower Limb; 2) Common Entrapment
Neuroplasty; 3) Prevention of Progression of Chronic Kidney Diseases
Lecture Theatre, Block M, G/F., Queen Elizabeth Hospital
Ms. Joanne Ho
2:00-4:00 pm Tel: 2871 8888
2
SATURDAY
18
19
HKU-Dept of Obstetrics & Gynaecology
Joint Scientific Meeting of The Nuffield Visiting Society and
The Department of Obstetrics & Gynaecology,
The University of Hong Kong
Cheung Kung Hai Lecture Theatre IV, William MW Mong
Block, 21 Sassoon Road, Pokfulam
Ms. Li
5
9:00-5:10 pm Tel: 2855 4647
HA – Caritas Medical Centre
American Heart Association Basic Life Support for
Healthcare Provider Course (BLS-P)
Resuscitation Training Centre, Caritas Medical Centre
(CMCRTC), Room 303, Wai Oi Block, 111 Wing Hong
Street, Shumshuipo, Kowloon
Ms. Irene Shiu
3
8:30-1:00 pm Tel: 3408 7444
Hong Kong Medical Association
HKMA CME Lecture Series in Dermatology (IV): Acne
Vulgaris and Other Acneiform Eruptions
Shantung Room II, Level 8, Langham Place Hotel,
Mongkok, Kowloon
1
1:30-3:00 pm Fax: 2827 7760
HA – Tseung Kwan O Hospital, Department of
Anaesthesiology
Postoperative Visual Loss
Conference Room, 2/F., A&OT Department, Tseung Kwan
O Hospital
Ms. Ivy Yeung
2
9:00-10:30 am Tel: 2208 0630
Hong Kong Sanatorium & Hospital
Boston Hong Kong/Guangzhou International Cardiology
Teleconference
Auditorium, 4/F., Hong Kong Sanatorium & Hospital
Emily
2
7:00-9:00 pm Tel: 2835 7899
Hong Kong Doctors Union
Video Cassette Session: Optimizing Control of Chronic Obstructive Pulmonary
Disease
Room 901, Hang Shing Building, 363-373, Nathan Road, Kowloon
1
2:15-3:15 pm Tel: 2388 2728
CME Calendar
HKU – Department of Medicine
Grand Round
Room 403, Professorial Block, Queen Mary Hospital
Executive Officer
11:00-12:00 noon Tel: 2855 4607
1
See More Activities ›››
20
Hong Kong Sanatorium & Hospital
2nd Certificate Course in Recent Medical Advances for
General Practitioners
Session 10 – Endocrinology
Auditorium, 4/F, Hong Kong Sanatorium & Hospital, 2
Village Road, Happy Valley, Hong Kong
Ms. Angie Fung
3
1:00-5:00 pm Tel: 2835 8800
Hong Kong Doctors Union
The 116th HKDU Sunday Afternoon Symposium
Lecture Hall, 8/F., Block G, Princess Margaret Hospital
1.5
1:00-4:00 pm Tel: 2388 2728
Hong Kong Doctors Union
The 117th HKDU Sunday Afternoon Symposium
Lecture Hall, 8/F., Block G, Princess Margaret Hospital
3:30-6:00 pm Tel: 2388 2728
2
27
Hong Kong Medical Association and Kwong Wah
Hospital
HKMA Structured CME Programme at KWH 07/08 (II) –
O&G
Lecture Theatre, 10/F., Yu Chun Keung Memorial Medical
Centre, Kwong Wah Hospital
3
2:00-5:00 pm Tel: 2861 1979
03
Hong Kong College of Emergency Medicine
American Heart Association Basic Life Support (BLS)
Course for Healthcare Providers 2007
3/F, A&E Training Centre, Tang Shiu Kin Hospital
Ms. Juana Ng
3
8:30-1:05 pm Tel: 2871 8877
St. Teresa’s Hospital; College of Surgeon of Hong Kong
The Role of Radio Frequency Ablation in Liver, Kidney,
Bone and Abrenal Tumours
St. Teresa’s Hospital
Dr. Lawrence Chan
2
10:00-11:30 am Tel: 2771 2312
Hong Kong Medical Association and Queen Elizabeth
Hospital
HKMA Structured CME Programme at QEH Year 07/08
(III)-Surgery
Lecture Theatre, G/F., Block M,Queen Elizabeth
Hospital
3
2:00-5:00 pm Tel: 2861 1979
HKU Department of Medicine
HKW Geriatrics Grand Round
6/F, KTSH Centre, Grantham Hospital
Ms Joanne Hui
12:00-1:00 pm Tel: 2855 3315
HKU Department of Medicine
HKW Geriatric Academic Meeting
6/F, KTSH Centre, Grantham Hospital
Ms Joanne Hui
1:00-2:00 pm Tel: 2855 3315
21
1
1
HKU Family Institute
Certificate Course in Family Therapy (Level 1) – X
Lecture Hall, HKU Family Institute, 5/F., Tsan Yuk Hospital,
30 Hospital Road, Sai Ying Pun, Hong Kong
Miss Daisy KW Lai
3
6:40-9:40 pm Tel: 2859 5300
HKU Department of Medicine
HKW Geriatrics Grand Round
5/F, Fung Yiu King Hospital
Ms Joanne Hui
12:00-1:00 pm Tel: 2855 3315
HKU Department of Medicine
HKW Geriatric Academic Meeting
5/F, Fung Yiu King Hospital
Ms Joanne Hui
1:00-2:00 pm Tel: 2855 3315
HKU Department of Medicine
HKW Geriatrics Grand Round
K2, Queen Mary Hospital
Ms Joanne Hui
12:00-1:00 pm Tel: 2855 3315
HKU Department of Medicine
HKW Geriatric Academic Meeting
K2, Queen Mary Hospital
Ms Joanne Hui
1:00-2:00 pm Tel: 2855 3315
28
1
1
04
1
1
22
HA-PWH-Dept of Obstetrics & Gynaecology
HK College of Obstetricians & Gynaecologists
Tumour Board Meeting-Clinical Pathological Conference
of Colposcopy & Gynae-Oncology Cases
Room 34053A, 1/F, Department of Anatomical & Cellular
Pathology, PWH
Ms. Alice Lai
1
9:00-10:00 am Tel: 2632 1528
HKDU Tuen Mun Study Group
Management of Arthritis
新界屯門青山公路 19 咪地下容龍海鮮酒家
1:00-3:00 pm Tel: 2388 2728
1
HKMA Tai Po Community Network
香港醫學會大埔社區網絡－持續進修證書課程:
Management of Trigeminal Neualgia, CRPS, Post-stroke Pain
新界大埔安慈路昌運中心商場一樓京都海鮮酒家
Ms. Wong
2
1:30-4:00 pm Fax: 2807 2496
29
HKMA Tai Po Community Network
香港醫學會大埔社區網絡－持續進修證書課程 :
Management of Pain in the Elderly
新界大埔安慈路昌運中心商場一樓京都海鮮酒家
Ms. Wong
1:30-4:00 pm Fax: 2807 2496
2
HA – New Territories West Private Practitioners’ Network
Community Medical Program – Common Poisoning Presents to
Your Clinic
Room D1002, 1/F., Main Block, Tuen Mun Hospital
Ms. Leung Ho Yan
1
2:00-3:00 pm Tel: 2468 6249
05
HK College of Radiologists
HA-PWH-Dept of Clinical Oncology
Combined Head and Neck Meeting
AKC Surgical Library, 4/F., Clinical Sciences Building,
Prince of Wales Hospital
Ms. Diane Lee
1
10:00-11:00 am Tel: 2871 8830
HKMA Tai Po Community Network
香港醫學會大埔社區網絡 － 持續進修證書課程 :
Management of Neck & Back Pain
新界大埔安慈路昌運中心商場一樓京都海鮮酒家
Ms. Wong
2
1:30-4:00 pm Fax: 2807 2496
HK College of Psychiatrists
CAC Term IV – Neuro-Pathology
Room 11, G/F, Block A, Prince of Wales Hospital
Karen
3
2:30-5:45 pm Tel: 2871 8777
23
24
Hong Kong Academy of Medicine
Travel and Infection
Lecture Theatre, Block M, G/F., Queen Elizabeth Hospital
Ms. Joanne Ho
2
2:00-3:30 pm Tel: 2871 8888
HKU – Department of Medicine, Family Medicine Unit
Certificate Course in Clinical Dermatology – VI
HKMA Dr. Li Shu Pui Professional Education Centre
Ms. Magdalene Tang
2
2:00-4:00 pm Tel: 2518 5656
HK College of Radiologists
HA-PWH-Dept of Clinical Oncology
Topic Review
Lecture Room, Department of Clinical Oncology, Prince of Wales Hospital
Ms. Diane Lee
1
2:30-3:30 pm Tel: 2871 8830
HKU-Dept of Obstetrics & Gynaecology
HK College of Obstetricians & Gynaecologists
Tumour Board Meeting – Clinical – Pathological
Conference On Gynaecological Oncology Cases
Room 215, 2/F, Seminar Room, Clinical Pathology Building,
Queen Mary Hospital
4:30-5:30 pm Tel: 2855 3111
10
5
HKU Department of Medicine
HKW Geriatrics Grand Round
C9, Tung Wah Hospital
Ms Joanne Hui
12:00-1:00 pm Tel: 2855 3315
HKU Department of Medicine
HKW Geriatric Academic Meeting
C9, Tung Wah Hospital
Ms Joanne Hui
1:00-2:00 pm Tel: 2855 3315
11
1
1
12
HK College of Radiologists
HA-PWH-Dept of Clinical Oncology
Combined Head and Neck Meeting
AKC Surgical Library, 4/F., Clinical Sciences Building,
Prince of Wales Hospital
Ms. Diane Lee
1
10:00-11:00 am Tel: 2871 8830
HKMA Tai Po Community Network
香港醫學會大埔社區網絡－持續進修證書課程 : 灰甲治療方法
新界大埔安慈路昌運中心商場一樓京都海鮮酒家
Mr. Leung
1
1:15-2:45 pm Tel: 8203 0369
HK College of Psychiatrists
CAC Term IV – Epidmiology
Room 56, Conference Room, 1/F, East Block, Pamela
Youde Nethersole Eastern Hospital
Karen
3
2:30-5:15 pm Tel: 2871 8777
See More Activities ›››
1
HKU – Department of Community Medicine
CMED 6401 Advanced Clinical Epidemiology and Decision
Analysis – I
William MW Mong Block, 21 Sassoon Road, Pokfulam HK
Ms. Cecilia Sie
2
2:00-4:00 pm Tel: 2819 9911
MAY 15 - JUNE 14
››› More Activities
19 May 2007
HA – Kwong Wah Hospital, Department of Family
Medicine co-joint with Kowloon West Cluster
Department of Family medicine & Primary Health Care
Refresher Course: How to Deal with and Ways to Avoid
Medical Malpractices and Medical Litigation in Primary
Care Setting?
Seminar Room, 1/F., Nurses Quarter, Kwong Wah Hospital,
25 Waterloo Road, Kowloon
Ms. Clara Hung
2
1:30-3:30 pm Tel: 3517 5499
HA – United Christian Hospital
Refresher Course for Health Personnel 2007
Lecture Theatre, G/F., Block P, United Christian Hospital
Ms. Marina Pun
2:15-3:45 pm Tel: 3513 4888
2
20-24 May 2007
HA – Castle Peak Hospital
Training Course for Cognitive-behavioural Therapy
Castle Peak Hospital
Ms. Amy Chow Tel: 2456 7838
10
6 June 2007
HA – Infectious Disease Control Centre & Infection Control
Branch
23rd Clinical Infection and Public Health Forum
Lecture Theatre Centre for Health Protection, 147C Argyle
Street, Kowloon
Ivan Wong
1
6:00-7:00 pm Tel: 2125 2930 Fax: 3523 0752
7-8 June 2007
HKU – Dept of Surgery
Head & Neck Course 2007 – “Surgery for Nasopharyngeal
Carcinoma and Anterior Skull Base Pathology”
Underground Lecture Theatre, New Clinical Building, Queen
Mary Hospital
10
Mr. Lobo Yau Tel: 2855 4885
9 June 2007
30
31
HKDU Hong Kong East Study Group
Optimal Lifestyle & Therapeutic Options in Lipid Management
Cheers Restaurant – Tao Heung 88,
Heng Fa Chuen Commercial Block, Chai Wan Hong Kong
1
1:00-3:00 pm Tel: 2495 6268
Hong Kong Society of Endocrinology, Metabolism & Reproduction
Protection of β-cell function: At the Heart of Type 2 Diabetes Treatment
Ballroom, Level 2, Langham Hotel Hong Kong, 8 Peking Road, Tsimshatsui
Kowloon
1.5
1:00-3:30 pm Tel: 2909 4662
Hong Kong College of Community Medicine
Review Meeting in areas related to Public Health Medicine
Centre for Health Protection in Argyle Street/Wu Chung House
Ms. Fanny Kwong
2
6:00-8:00 pm Tel: 2871 8745
Hong Kong Academy of Medicine
1) Management of Back Pain;
2) Physical Examination of Hand
Lecture Theatre, Block M, G/F., Queen Elizabeth Hospital
Ms. Joanne Ho
2
2:00-4:00 pm Tel: 2871 8888
HKU – Department of Medicine, Family Medicine Unit
Certificate Course in Clinical Dermatology – VIII
HKMA Dr. Li Shu Pui Professional Education Centre
Ms. Magdalene Tang
2
2:00-4:00 pm Tel: 2518 5656
HK College of Radiologists
HA-PWH-Dept of Clinical Oncology
Topic Review
Lecture Room, Department of Clinical Oncology, Prince of Wales Hospital
Ms. Diane Lee
1
2:30-3:30 pm Tel: 2871 8830
06
HKDU-Central Study Group
Role of DPP-IV Inhibitor (incretin enhancer) in the Management of
Type 2 Diabetes
DB City Centre, Pier 3, Upper Level, 11 Man Kwong Street, Central, Hong
Kong
Miss Lam
1
1:00-3:00 pm Tel: 2388 2728
Hong Kong Doctors Union
Video Cassette Session: Clinical Case Reviews: Significant Advances in the
Treatment of Obesity
Room 901, Hang Shing Building, 363-373, Nathan Road, Kowloon
1
2:15-3:15 pm Tel: 2388 2728
Hong Kong College of Community Medicine
Review Meeting in areas related to Public Health Medicine
Centre for Health Protection in Argyle Street/Wu Chung House
Ms. Fanny Kwong
2
6:00-8:00 pm Tel: 2871 8745
HA – Castle Peak Hospital
Seminar – ADHD In Adult
Lecture Theatre, Blk D, CPH
Ms. Fion LING
11:30-1:00 pm Tel: 2456 7843
HA – Tuen Mun Hospital, Family Medicine Dept
Occupational Medicine/Injury-on-duty case sharing
3/F, Yan Oi GOPC Tuen Mun
Cowin TANG
5:30-6:45 pm Tel: 2468 6601
Hong Kong Academy of Medicine
1) Immunology Test in General Practice;
2) Making Sense Out of Obstetric Ultrasonography
Lecture Theatre, Block M, G/F., Queen Elizabeth Hospital
Ms. Joanne Ho
2:00-4:00 pm Tel: 2871 8888
HKU – Department of Medicine, Family Medicine Unit
Certificate Course in Clinical Dermatology – IX
HKMA Dr. Li Shu Pui Professional Education Centre
Ms. Magdalene Tang
2:00-4:00 pm Tel: 2518 5656
Hong Kong Poison Information Centre;
Hong Kong College of Emergency Medicine
Monthly Clinical Meeting
Block F, Lecture Theatre, United Christian Hospital
Ms. Bejyork Wong
4:30-6:30 pm Tel: 3513 5089
26
1
2
07
01
Hong Kong Baptist Hospital
Laparoscopic hernia operating in children
The Chapel, 9/F Hong Kong Baptist Hospital
Connie
8:00-9:30 am Tel: 2339 8872
1.5
08
02
HKU – Dept of Surgery
Pre-Hospital Trauma Life Support (PHTLS) Provider Course
– Day 1
Hong Kong St. John Ambulance Association,
2 Mcdonnell Road
5
8:45-6:40 pm Tel: 2530 8015
HKU – Department of Medicine
Grand Round
Room 403, Professorial Block, Queen Mary Hospital
Executive Officer
1
11:00-12:00 noon Tel: 2855 4607
HKU – Department of Community Medicine
CMED 6401 Advanced Clinical Epidemiology and Decision
Analysis – II
William MW Mong Block, 21 Sassoon Road, Pokfulam HK
Ms. Cecilia Sie
2
2:00-4:00 pm Tel: 2819 9911
HKU – Sau Po Centre on Ageing
Counselling Older Adults in Family Context – Clinical
Supervision & Live Case Demonstration – IV
The Hong Kong Chinese Women’s Club Madam Wong Chan
Sook Ying Memorial Care & attention Home
Ms. Carmen Yiu
2
2:30-5:30 pm Tel: 2241 5524
12 June 2007
HK College of Psychiatrists
Central Academic Course Term I – Psychiatric Services & Other
Services
1) Psychosocial Aspect and Service-related Issues
2) Family Intervention; Papers on Life Events & Psychosocial
Interventions
Lecture Theatre, G073-074, Block D, Castle Peak Hospital, 15
Tsing Chung Koon Road, Tuen Mun, NT
Karen
3
2:30-5:45 pm Tel: 2871 8777
13 June 2007
Hong Kong Society of Clinical Toxicology and Hong Kong
College of Emergency Medicine
Conjoint Toxicology Round
F1 Lecture Theatre, Block F, United Christian Hospital
Ms. Bejyork Wong
1
6:30-7:30 pm Tel: 3513 5089
09
HKU – Department of Medicine
Grand Round
Room 403, Professorial Block,
Queen Mary Hospital
Executive Officer
1
11:00-12:00 noon Tel: 2855 4607
HKU – Department of Community Medicine
CMED 6401 Advanced Clinical Epidemiology and Decision
Analysis – III
William MW Mong Block, 21 Sassoon Road, Pokfulam HK
Ms. Cecilia Sie
2
2:00-4:00 pm Tel: 2819 9911
The Hong Kong Medical Association; The Hong Kong
College of Family Physicians; Our Lady of Maryknoll
Hospital
Refresher Course for Health Care Providers 2006/2007 –
Sexually Transmitted Diseases in the Community
Training Room II, 1/F, OPD Block, Our Lady of Maryknoll
Hospital, 118 Shatin Pass Road, Wong Tai Sin, Kowloon
Ms. Clara Tsang
2
2:30-4:30 pm Tel: 2354 2440
1
See More Activities ›››
HKU – Dept of Surgery
Pre-Hospital Trauma Life Support (PHTLS)
Provider Course – Day 2
Hong Kong St. John Ambulance Association,
2 Mcdonnell Road
9:00-6:50 pm Tel: 2530 8015
HKU – Department of Medicine
Grand Round
Room 403, Professorial Block,
Queen Mary Hospital
Executive Officer
11:00-12:00 noon Tel: 2855 4607
HKU – Sau Po Centre on Ageing
Counselling Older Adults in Family Context – Clinical
Supervision & Live Case Demonstration – III
The Hong Kong Chinese Women’s Club Madam Wong
Chan Sook Ying Memorial Care & attention Home
Ms. Carmen Yiu
3
2:30-5:30 pm Tel: 2241 5524
Hong Kong Academy of Medicine
Practical Tips on the Utilization and Interpretation of Common
Laboratory Tests
Lecture Theatre, Block M, G/F., Queen Elizabeth Hospital
Ms. Joanne Ho
2
2:00-4:00 pm Tel: 2871 8888
HKU – Department of Medicine, Family Medicine Unit
Certificate Course in Clinical Dermatology – VII
HKMA Dr. Li Shu Pui Professional Education Centre
Ms. Magdalene Tang
2
2:00-4:00 pm Tel: 2518 5656
HK College of Radiologists
HA-PWH-Dept of Clinical Oncology
Topic Review
Lecture Room, Department of Clinical Oncology, Prince of Wales Hospital
Ms. Diane Lee
1
2:30-3:30 pm Tel: 2871 8830
HKU-Dept of Obstetrics & Gynaecology
HK College of Obstetricians & Gynaecologists
Tumour Board Meeting-Clinical-Pathological Conference On
Gynaecological Oncology Cases
Room 215, 2/F, Seminar Room, Clinical Pathology Building,
Queen Mary Hospital
1
4:30-5:30 pm Tel: 2855 3111
Fax: 2455 9330
25
HKDU Sham Shui Po Study Group
What is New in Hepatitis B?
Lychee Garden Chinese Restaurant, 1/F, Metropark Hotel
Mongkok, Mongkok, Kowloon
1
1:00-3:00 pm Tel: 2388 2728
Labour Department and HK College of Community
Medicine
Review Meeting on Occupational Health Service in 2007
25/F., Harbour Building, Central
Ms. Elke To
2
6:00-8:00 pm Tel: 2852 4052
持續進修日程
See More Activities ›››
11
13
2
2
2
The Hong Kong Society of Dermatology & Venereology
Clinico-pathological Meeting/Case Demonstration
YMT Dermatology Clinic – 12th Floor, Yaumatei Specialist Clinic Examination, 143
Battery Street, Kowloon
Ms. Rebecca Leung
3
5:30-8:00 pm Tel: 2116 4322
14
12
Hong Kong Sanatorium & Hospital – Orthopaedic and Sports Medicine
Centre
Orthopaedic Clinical Meeting (Every Second Thursday of the Month)
Room 1103, 11/F, Li Shu Pui Block, Hong Kong Sanatorium & Hospital
Ms. Eva Wong
1
8:30-9:30 am Tel: 2835 7890
Union Hospital
Clinical Pathologic Conference
Conference Room, 2/F., Medical Centre, Union Hospital, 18 Fu Kin Street,
Tai Wai NT
Marketing Department
1
8:30-9:30 am Tel: 2608 3180
HKMA, HK Sanatorium & Hospital
HKMA Structured CME Programme with HKS&H 2007 –
Persistent Knee Pain. What Else Can We Offer?
HKMA Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese Club
Building, 21-22 Connaught Road Central, HK
1
1:15-3:00 pm Tel: 2861 1979
Hong Kong Doctors Union – Shatin Study Group
What is New in Hepatitis B?
Royal Park Chinese Restaurant, Level 2, Royal Park Hotel, 8 Pak Hok Ting
Street, Shatin, NT
Ms. Lam
1
1:00-3:00 pm Tel: 2388 2728
13
14
See More Activities ›››
Note: For each issue of the CME Bulletin, we shall try our best to include all the CME activities for the month, which are made known to the Association Secretariat. Members interested in any of these functions are encouraged to check with the individual Colleges for credit points awarded by the Colleges and with respective organizers for confirmation of the details.
Pharmaceutical advertisements are welcome. For advertising rates and placement details, please contact Ms. Sophia Lau, Executive Officer at Tel: 2527 8452, Fax: 2865 0943 or email: [email protected] Your comments to the HKMA CME Bulletin are most welcome. Please send your opinion to Dr. Wong Bun Lap, Bernard, Editor of HKMA CME Bulletin, by fax at 2865 0943 or via e-mail at [email protected].
Total CME points for entire course
Clinical Case Study
專科個案剖析
Please answer the questions for each quiz below by returning the completed answer sheet printed on page 23. This exercise will attract 0.5 CME point for participants completing
BOTH quizzes. Answers and explanations will be provided in the next issue.
請回答下列問題並填妥第二十三頁之答題紙交回本會秘書處，參加者將可獲持續醫學進修積分點零點五分，請注意，參加者必須同時回答兩個小測驗之問題。至於今期之答案
將刊於下一期《持續醫學進修專訊》之中。
Clinical Cardiology Series
臨床心臟科個案研究
1. What are the abnormalities?
2. What is the diagnosis?
A 35 year old lady complained of progressive
exertional shortness of breath in the past two years.
Physical examination revealed a loud first heart
sound, an opening snap and a mid diastolic rumbling
murmur with an irregularly irregular pulse.
3. What treatment is needed?
Answers:
1. What diagnosis do these findings suggest?
2. What is the underlying etiology?
3. What investigation is useful?
4. What treatment does she need?
The content of the Office Cardiology Series is provided by:
Dr. LI Siu Lung, Steven
F.H.K.A.M. (Med), F.R.C.P. (Glasg), F.R.C.P. (Edin), F.R.C.P. (Lond), Specialist in Cardiology
Dr. WONG Shou Pang, Alexander
F.R.C.P., F.H.K.A.M.(Med.), F.H.K.C.P., Specialist in Cardiology
臨床心臟科個案研究之內容誠蒙李少隆醫生及王壽鵬醫生
提供。
Answers to April 2007
二零零七年四月份答案
An 84 year old gentleman was admitted because of
recurrent dizziness and near syncope. This was his
ECG.
1. The ECG showed isolated ventricular premature
beat, first degree heart block, right bundle branch
block and left posterior hemiblock.
2. The ECG diagnosis is trifascicular block. The
conduction system consists of three fascicles:
right bundle branch and the left anterior and
posterior fascicles of the left bundle branch.
Tri-fascicular block is present when there is a
combination of bifascicular block and first degree
atrioventricular block. Bifascicular block, in turn,
refers to conduction disturbances affecting two
of the fascicles, most commonly right bundle
branch block plus left anterior fascicular block.
Left posterior hemiblock is much rarer than left
anterior hemiblock and its typical features include:
right axis deviation in the frontal plane (>+100
degrees), rS complex in lead I, qR complexes in
lead II, III, aVF, with R in lead III>lead II.
3. More than 5% of patients with trifascicular
block may progress to complete heart block.
The recurrent symptoms of this gentleman may
be related to intermittent complete heart block,
although it may sometimes be difficult to obtain
ECG documentation. To prevent the associated
hazard of complete heart block (e.g. bradycardia
related hypotension and fall/head injury),
prophylactic placement of permanent pacemaker
may be helpful if no other causes of recurrent
dizziness/syncope can be identified.
P. 14
HKMA CME BULLETIN • MAY 2007
Clinical Case Study
專科個案剖析
Dermatology Series
皮膚科病例研究
Answers to April 2007
二零零七年四月份答案
A 54 year old woman presented with a few years of
progressive hardening and pain of her lower legs. She had
a number of episodes of painful red swelling on her legs
treated as infection by her GP with antibiotics, but every
time it took a few weeks for the redness and swelling
to subside. Otherwise she has always enjoyed good
health except being overweight. Examination revealed
hyperpigmented indurated depression of the skin encircling
the lower third of both her legs. There was no ulceration.
No obvious varicose vein was seen.
1. What is the most likely clinical diagnosis?
2. What are the differential diagnoses?
3. What investigations will you perform for this lady?
4. How do you treat this lady?
5. What is the prognosis?
The content of the Dermatology Series is provided by:
Dr. CHOW Ka Yuen, Dr. TANG Yuk Ming, William,
Dr. CHAN Loi Yuen & Dr. MAK Kam Har
Specialists in Dermatology & Venereology
皮膚科病例研究之內容誠蒙周家源醫生、鄧旭明醫生、陳來源
醫生及麥錦霞醫生提供。
A 54 year old gentleman presented with papules on
scalp, chest and upper back for two months. The papules
turned into“ hard scales” later on. The lesions on scalp
were mildly pruritic but those on body were painful. There
was appearance of single blister of the oral cavity once
about a month after onset of the skin lesions. The blister
spontaneously ruptured and healed that day. There was
no systemic upset. He was diagnosed to have seborrheic
dermatitis by general practitioner but the treatment was not
effective. He enjoyed good health all along and there was
no history of intake of medication or herb prior to the onset
of skin lesions. On examination, there was large area of
thick crusting over the frontal scalp. Multiple erythematous
patches with crusting or scabbing were found scattering over
the chest and upper back. One small blister was detected on
his right scapular region. Oral mucosa was intact.
HKMA CME BULLETIN • MAY 2007
P. 15
Clinical Case Study
專科個案剖析
Answers:
3. Where is the more commonly affected site when this
disease begins?
1. What is the most likely diagnosis and what are the
differential diagnoses?
This patient suffered from pemphigus vulgaris. It is a
chronic immunobullous disorder of skin and mucous
membranes that histologically shows clefting between
the basal cell layer of the epidermis and the suprabasilar
epidermis. Other differential diagnoses include
erythema multiforme, impetigo, other immunobullous
disorders such as bullous pemphigoid and pemphigus
foliaceus.
More typically, pemphigus vulgaris starts as painful
erosions in the mouth and months may elapse before
skin lesions occur.
4. What is the mainstay of treatment for this skin disorder?
High dose of oral corticosteroids is required initially
to stop formation of new blisters. It is then tapered
slowly over months. Other immunosuppressants such
as azathioprine, cyclophosphamide are often given
concomitantly for their steroid-sparing effect.
2. How could one confirm the diagnosis?
5. What is the prognosis?
Diagnostic skin biopsy for histology with
immunofluoresence is mandatory for immunobullous
disorders. Circulating anti-skin antibody should also be
checked to confirm the diagnosis of pemphigus vulgaris
and to monitor the disease activity.
Before the introduction of corticosteroids, the mortality
was 99% by 5 years. Nowadays the mortality rate is
markedly reduced and death is almost invariably due to
complications of the immunosuppressive therapy.
HKMA CME Bulletin
Monthly Self-Study Series
Call for Articles
Since its publication, the HKMA CME Bulletin has become one of the most popular CME readings for doctors.
This monthly publication has been serving more than 6,800 readers each month through practical case studies
and picture quizzes. To enrich its content, we are inviting articles from experts of different specialties. Interested
contributors may refer to the General Guidance below. Other formats are also welcome. For further information,
please contact Miss Sophia Lau at 2527 8452 or by email at [email protected].
General Guidance for Authors
(1)
(2)
(3)
Intended readers :
Length of article :
Review questions :
(4)
(5)
Language
Key Lessons
:
:
(6)
Highlights
:
(7)
Others
:
(8)
Deadline
:
General practitioners
Approximately 8-10 A-4 pages in 12-pt fonts in single line spacing
Recommended to include 10 self-assessment questions in true-or-false format.
(It is recommended that analysis and answers to most questions be covered in the
article.)
English (preferably with an optional Chinese introduction of 200-300 words)
Recommended to include, if possible, a key message in point-form at the end of the
article
It is preferable that key messages in each paragraph/section be highlighted in bold
types
List of full name(s) of author(s), with qualifications and current appointment quoted,
plus a digital photo
All manuscripts for publication of the month should reach the Editor before the 15th
of the previous month
All articles submitted for publication are subject to review and editing by the Editorial Board.
P. 16
HKMA CME BULLETIN • MAY 2007
HKMA Structured CME Programme at Queen Elizabeth Hospital
香港醫學會─伊利沙伯醫院分科進修課程
The Hong Kong Medical Association
Lecture
Date
Topic
III
3 June 2007
Surgery
IV
Venue
Time
Fee
8 July 2007
:
:
:
Queen Elizabeth Hospital
1.
Modern Trends in Liver Surgery
Dr. CHIA Nam Hung
Senior Medical & Health Officer, Dept of Surgery,
Queen Elizabeth Hospital
2.
Goitre & Neck Masses
Dr. TONG Kar Lun
Senior Medical & Health Officer,
Dept of Surgery, Queen Elizabeth Hospital
3.
Endovascular Surgery
Dr. TSE Cheuk Wa
Associate Consultant, Dept of Surgery, Queen Elizabeth Hospital
4.
Colorectal Malignancy
Dr. KWOK Kam Hung
Senior Medical & Health Officer, Dept of Medicine,
Queen Elizabeth Hospital
5.
Common Urological Problems
Dr. LO Hak Keung
Associate Consultant, Dept of Surgery, Queen Elizabeth Hospital
6.
Minimally Invasive Paediatric Surgery
Dr. LEUNG Wai Yip, Michael
Associate Consultant, Dept of Surgery, Queen Elizabeth Hospital
ENT
1.
Management of Sleep Disordered Breathing in ENT Perspective
Dr. CHOW Chun Kuen, Lawrence
Director of ENT Centre, Hong Kong Baptist Hospital
2.
Rhinosinusitis
Dr. YIP Kim Kwong, Gary
Specialist in Otorhinolaryngology
3.
Advances in Management of Deafness and Vertigo
Dr. CHOW Chun Kuen, Lawrence
Director of ENT Centre, Hong Kong Baptist Hospital
Lecture Theatre, G/F, Block M, QEH
2:00 – 5:00 p.m.
HK$50 per lecture for HKMA Members
HK$80 per lecture for CME Participants
地點
時間
報名費用
:
:
:
伊利沙伯醫院 M 座地下演講廳
下午二時至五時
醫學會會員－每課堂港幣五十元正
持續進修參加者－每課堂港幣八十元正
Light snacks and lecture notes will be provided. 敬備茶點及講義
First come, first served. 名額有限 請早登記
Registration: Please fill in and return the Registration Form on p. 19 together with a cheque of adequate amount made
payable to “The Hong Kong Medical Association” to 5/F Duke of Windsor Social Service Building, 15 Hennessy
Road, Hong Kong. Each lecture will carry 3 CME points under the MCHK/HKMA CME Programme.
報名方法 :
P. 18
請填妥第十九頁之表格連同支票寄交香港灣仔軒尼詩道十五號溫莎公爵社會服務大廈五樓 , 支票抬頭請書明支付
「香港醫學會」。參加者可獲醫務委員會╱香港醫學會持續醫學進修計劃積分三分。
HKMA CME BULLETIN • MAY 2007
HKMA Structured CME Programme at Kwong Wah Hospital
香港醫學會─廣華醫院分科進修課程
S I N C E
The Hong Kong Medical Association
Lecture
II
III
Date
Topic
27 May 2007
Obstetrics & Gynaecology
24 June 2007
Venue
:
Time
Fee
:
:
1 8 7 0
Kwong Wah Hospital
1.
Update on Management of Infertility
Dr. WONG Yuen Kwan, Alice
Consultant, Department of O&G, KWH
2.
Screening and Prevention of Cervical Cancer
Dr. LAM Siu Keung
Consultant, Department of O&G, KWH
Paediatrics
3.
Paediatric Epilepsy
Dr. HO Che Shun
Chief of Service, Dept of Paediatrics, KWH
4.
Food Allergy in Childhood
Dr. CHOW Pok Yu
Medical Officer, Dept of Paediatrics, KWH
Lecture Theatre, 10/F, Yu Chun Keung
Memorial Medical Centre, KWH
2:00-5:00 p.m.
HK$50 per lecture for HKMA Members
HK$80 per lecture for CME Participants
地點
： 廣華醫院余振強紀念中心
十樓演講廳
時間
： 下午二時至五時
報名費用 ： 醫學會會員－每課堂港幣五十元正
持續進修參加者－每課堂港幣八十元正
Light snacks and lecture notes will be provided. 敬備茶點及講義
Reply Slip 回 條
HKMA Structured CME Programme at QEH/KWH – Registration Form
香港醫學會分科進修課程報名表格
HKMA Members
I would like to register for the following lecture(s):
本人欲參加下列講課：
香港醫學會會員
HK$50 港幣五十元正
KWH
27 May 2007
24 June 2007
Obstetrics & Gynaecology
Paediatrics
QEH
3 June 2007
8 July 2007
Surgery
ENT
CME Participan ts
(Non-HKMA members)
持續進修參加者
（非香港醫學會會員）
HK$80 港幣八十元正
Please “✓ ” as appropriate. 請在適用處加上「✓」 號
I enclose herewith a cheque of
現隨表格付上支票一張作為講課之報名費用： HK$ 港幣
Name 姓名 :
HKMA Membership No. 會員編號
or HKMA CME No. 或進修號碼：
Tel No. 電話 :
Fax No. 傳真 :
Signature 簽名 :
Data collected will be used and processed for the purposes related to the MCHK/HKMA CME Programme only. All registration fees are not refundable or transferable.
個人資料將用於有關香港醫學會持續醫學進修計劃之事宜。所有報名費用將不給予退還或轉授予其他會員。
HKMA CME BULLETIN • MAY 2007
P. 19
Snapshots
P. 20
Dr. CHEUNG Tse Ming presenting souvenir to Dr. CHAN Chi Wai,
Angus for the lecture on Diagnosis & Treatment of
Gastroesophageal Reflux Disease
Dr. CHAN Chi Wai, Angus giving his presentation on Diagnosis
& Treatment of Gastroesophageal Reflux Disease on 12 April
2007 at HKMA Central Premises
At the lecture on Achieving Glycemic Targets in Type 2
Diabetes on 19 April 2007 at Langham Place Hotel, Mongkok
Our speakers and moderator at the lecture on Achieving
Glycemic Targets in Type 2 Diabetes: (from left) Dr. Roger CHEN,
Dr. YAN Wing Tat, Victor and Dr. TSANG Man Wo
Dr. CHOI Kin presenting souvenir to Dr. Tim HEGAN for the
Medico-legal Seminar on “Doctors and the Law – Anything
Goes”
Dr. Tim HEGAN giving his presentation on Medico-legal Seminar
on “Doctors and the Law – Anything Goes” on 26 April 2007
at Langham Place Hotel, Mongkok
HKMA CME BULLETIN • MAY 2007
CME Lecture for June 2007
二零零七年六月之進修講課
CME Event 講課簡介
Venue & Time 地點及時間
14 June 2007 (Thursday)
HKMA Structured CME Programme with HKS&H Session VI:
Persistent Knee Pain. What Else Can We Offer?
The HKMA Dr. Li Shu Pui Professional
Education Centre
2/F, Chinese Club Building
21-22 Connaught Road Central, HK
Lecture: 2:00 - 3:00 p.m.
[Light lunch will be started at 1:15 p.m.]
Dr. WU Wing Cheung, Stephen
Director, Orthopaedic and Sports Medicine Centre, HKS&H
M.B.,B.S.(H.K.), F.R.C.S.(Edin.), F.R.A.C.S., F.H.K.C.O.S.,
F.H.K.A.M.(Orthopaedic Surgery),
Specialist in Orthopaedics and Traumatology
This symposium is co-organized with Hong Kong Sanatorium & Hospital.
香港中環干諾道中二十一至二十二號
華商會所大廈二樓
香港醫學會李樹培醫生專業教育中心
講課：下午二時至三時正
[ 茶點於下午一時十五分開始 ]
Please register for participation. First come, first served. 名額有限 請早登記
Registration:
報名方法：
Please fill in and return the Registration Form together
with a cheque of adequate amount made payable to
“The Hong Kong Medical Association” to 5/F Duke of
Windsor Social Service Building, 15 Hennessy Road,
Hong Kong. Each lecture will carry 1 CME point under
the MCHK/HKMA CME Programme (unless otherwise
stated). Accreditation from other colleges is pending. (The
Secretariat fax no.: 2865 0943)
請填妥表格連同支票寄交香港灣仔軒尼詩道十五號溫
莎公爵社會服務大廈五樓，支票抬頭請書明支付「香港
醫學會」。參加者可獲醫務委員會╱香港醫學會持續醫
學進修計劃積分一分（除特別註明外）
。其他專科學院
之學分尚在申請中。( 秘書處傳真號碼 :2865 0943)
Please be informed that Confirmation Letter of Registration is required. If you have not received any replies,
please do not hesitate to contact us at 2527 8452.
參加者需持有講課確認通知書出席持續醫學進修講課。假若你沒有收到任何通知 , 請致電 2527 8452 查詢。
Reply Slip 回 條
I would like to register for the following CME lecture(s):
本人欲報名參加以下講課：
HKMA Structured CME Programme with HKS&H
14 June 2007:
HKMA Structured CME Programme with HKS&H Year 2007 –
Persistent Knee Pain. What Else Can We Offer?
HKMA Members
HK$50
CME Participants
HK$80
❑
❑
Please “✓” as appropriate. 請在適用處加上「✓」號
I enclose herewith a cheque of
現隨表格付上支票一張作為講課之報名費用
Name 姓名 :
HKMA Membership No. 會員編號
or HKMA CME No. 或進修號碼 :
: HK$ 港幣
Tel No 電話 :
Fax No. 傳真 :
Signature 簽名 :
Data collected will be used and processed for the purposes related to the MCHK/HKMA CME Programme only. All registration fees are not refundable or transferable.
個人資料將用於有關香港醫學會持續醫學進修計劃之事宜。所有報名費用將不給予退還或轉授予其他會員。
HKMA CME BULLETIN • MAY 2007
P. 21
Answer Sheet for May 2007
二零零七年五月號答題紙
Please return completed answer sheet to the HKMA Secretariat (Fax: 2865 0943) on or before 15 June 2007 for documentation. 1 CME point will be awarded
for answering the Monthly Self-Study Series (I) and an extra 0.5 CME point for completing the Clinical Case Study (II). However, if you choose to do the exercises
online, you do not need to return this answer sheet by fax.
請回答所有問題，並於二零零七年六月十五日前將答題紙傳真或寄回至香港醫學會（傳真號碼 : 2865 0943）。參加者將可獲持續醫學進修積分點─每月自修系
列：一分；「專科個案剖析」系列：零點五分。但如果選擇在網上做練習，便不需要把答題紙傳真給秘書處。
Advances in SSRI Treatment
(Please indicate “T” or “F” in each box.)
1
2
3
4
5
ANSWERS TO APRIL 2007 ISSUE
香港醫學會持續醫學進修計劃
每月自修資料二零零七年四月號答案
T
T
T
T
F
6.
7.
8.
9.
10.
7
8
9
10
姓名
Name:
Inguinal Hernia Repair: Which Operation
for Your Patient?
1.
2.
3.
4.
5.
6
T
T
T
F
F
香港醫學會會員編號
或持續進修編號
HKMA Membership No.
or HKMA CME No.:
香港身份證號碼
HKID No.:
X X X ( X )
簽名
Signature:
聯絡電話
Contact Tel. No.:
(II) Clinical Case Study
(Please answer both quizzes and write down the answers in the space provided.)
(A) Clinical Cardiology Series
1.
2.
3.
4.
(B) Dermatology Series
1.
2.
3.
4.
5.
HKMA CME BULLETIN • MAY 2007
P. 23