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www.hkmacme.org March 2015
香港醫學會
THE HONG KONG
MEDICAL ASSOCIATION
B
U
L
L
E
T
I
N
持 續 醫 學 進 修 專 訊
Myeloma
as a
chronic
disease
by Dr. AU Wing Yan
Male infertility
- the often
forgotten
significant
other
by Dr. HO Kwan Lun
HKMA CME Bulletin
持續醫學進修專訊
Contents
Editorial 1
Spotlight 1 2-6
Myeloma as a chronic disease
Spotlight 2 7-11
Male infertility – the often
forgotten significant other
Cardiology 12-13
Doctor, should I stop my anti-platelet
agents?
Spotlight 1
Myeloma as a
chronic disease
Dermatology 14
A 53-year-old man presented with
generalized rash
Complaints & Ethics 15-18
Answer Sheet 19
CME Notifications 20-21
Learning Centre article 22-24
Meeting Highlights 26-27
CME Calendar 28-29
Spotlight 2
Male infertility – the often
forgotten significant
other
Cardiology
Doctor, should I stop my anti-platelet
agents?
Dermatology
HKMA CME Bulletin – MONTHLY SELF-STUDY
SERIES to help you grow!
Please read the following articles and answer the
questions. Participants in the HKMA CME Programme
will be awarded credit points under the Programme
for returning the completed answer sheet via fax
(2865 0943) or by mail to the HKMA Secretariat on
or before 15 April 2015. Answers to questions will
be provided in the next issue of the HKMA CME
Bulletin. (Questions may also be answered online at
www.hkmacme.org)
請 細 閱 本 期 文 章， 並 利 用 答 題 紙 完 成 自 我 評 估 測
驗， 於 2015 年 4 月 15 日 前， 將 已 填 妥 之 答 題 紙 傳 真
（號碼：2865 0943）或寄回本會秘書處，您將可獲持續
醫學進修的積分點 ; 至於是期自我評估測驗之答案，將
刊於下一期《持續醫學進修專訊》之中。（您亦可透過網
站 www.hkmacme.org 完成自我評估測驗）
HKMA CME Enquiry Hotline
Tel: 2527 8452 / 2861 1979
A 53-year-old man presented with
generalized rash
The Hong Kong Medical Association is dedicated to providing a coordinated CME
programme for all members of the medical profession. Under the HKMA CME
Programme, a CME registration process has been created to document the CME
efforts of doctors and to provide special CME avenues. The Association strives to
foster a vibrant environment of CME throughout the medical profession. Both members
as well as non-members of the Association are welcome to join us. You may contact
the HKMA Secretariat for details of the programme.
香港醫學會體察到業界有必要設立完善的持續進修計劃，致力推動持續醫學進修，為
同僚建立有系統的進修記錄機制，以及為全科醫生提供適切的進修課程。藉著這個計
劃，我們期望將優良的進修傳統推展至醫學界中每一角落，同時為業界締造一個充滿
活力的進修文化。我們誠意邀請您參與醫學會持續進修計劃，不論您是否醫學會的會
員，均歡迎您同來與我們一起學習，以及享用醫學會為所有醫生設立的進修記錄機
制。如欲了解香港醫學會持續醫學進修計劃的詳情，請聯絡本會秘書處查詢。
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CME Bulletin & Online Editorial Board
EDITORIAL
Chief Editor
Dr. WONG Bun Lap, Bernard
黃品立醫生
Executive Committee
Dr. CHAN Yee Shing, Alvin
Dr. CHENG Chi Man
Dr. CHEUNG Hon Ming
Dr. CHOI Kin
Dr. CHOW Pak Chin, JP
Dr. HO Chung Ping, MH, JP
Dr. HO Hung Kwong, Duncan
Dr. LAM Tzit Yuen, David
Dr. LI Sum Wo, MH
Dr. SHIH Tai Cho, Louis
Dr. TSE Hung Hing, JP
Dr. WONG Bun Lap, Bernard
陳以誠醫生
鄭志文醫生
張漢明醫生
蔡 堅醫生
周伯展醫生
何仲平醫生
何鴻光醫生
林哲玄醫生
李深和醫生
史泰祖醫生
謝鴻興醫生
黃品立醫生
Cardiology
Dr. CHEN Wai Hong
Dr. HO Hung Kwong, Duncan
Dr. LEE Pui Yin
Dr. LI Siu Lung, Steven
Dr. WONG Bun Lap, Bernard
Dr. WONG Shou Pang, Alexander
陳偉康醫生
何鴻光醫生
李沛然醫生
李少隆醫生
黃品立醫生
王壽鵬醫生
Neurology
Dr. FONG Chung Yan, Gardian
Dr. TSANG Kin Lun, Alan
方頌恩醫生
曾建倫醫生
Neurosurgery
Dr. CHAN Ping Hon, Johnny
陳秉漢醫生
Obstetrics and Gynaecology
Dr. CHAN Kit Sheung
陳潔霜醫生
Ophthalmology
Dr. CHOW Pak Chin, JP
Dr. LIANG Chan Chung, Benedict
Dr. PONG Chiu Fai, Jeffrey
周伯展醫生
梁展聰醫生
龐朝輝醫生
Cardiothoracic Surgery
Dr. CHENG Lik Cheung
Dr. CHIU Shui Wah, Clement
Dr. CHUI Wing Hung
Dr. LEUNG Siu Man, John
鄭力翔醫生
趙瑞華醫生
崔永雄醫生
梁兆文醫生
Colorectal Surgery
Dr. CHAN Cheung Wah
Dr. CHU Kin Wah
Dr. LEE Yee Man
Dr. TSE Tak Yin, Cyrus
陳長華醫生
朱建華醫生
李綺雯醫生
謝得言醫生
Orthopaedics and Traumatology
Dr. IP Wing Yuk, Josephine
Dr. KONG Kam Fu
Dr. POON Tak Lun
Dr. TANG Yiu Kai
葉永玉醫生
江金富醫生
潘德鄰醫生
鄧耀楷醫生
Dermatology
Dr. CHAN Hau Ngai, Kingsley
Dr. HAU Kwun Cheung
Dr. SHIH Tai Cho, Louis
陳厚毅醫生
侯鈞翔醫生
史泰祖醫生
Endocrinology
Dr. LEE Ka Kui
Dr. LO Kwok Wing, Matthew
Paediatrics
Dr. CHAN Yee Shing, Alvin
Dr. FUNG Yee Leung, Wilson
Dr. TSE Hung Hing, JP
Dr. YEUNG Chiu Fat, Henry
陳以誠醫生
馮宜亮醫生
謝鴻興醫生
楊超發醫生
李家駒醫生
盧國榮醫生
Plastic Surgeon
Dr. NG Wai Man, Raymond
吳偉民醫生
ENT
Dr. CHOW Chun Kuen
周振權醫生
Psychiatry
Dr. LAI Tai Sum, Tony
Dr. LEUNG Wai Ching
Dr. WONG Yee Him, John
黎大森醫生
梁偉正醫生
黃以謙醫生
吳福康醫生
Radiology
Dr. CHAN Ka Fat, John
Dr. CHAN Yip Fai, Ivan
陳家發醫生
陳業輝醫生
General Surgery
Dr. LAM Tzit Yuen, David
Dr. Hon. LEUNG Ka Lau
林哲玄醫生
梁家騮醫生
Respiratory Medicine
Dr. LEUNG Chi Chiu
Dr. YUNG Wai Ming, Miranda
梁子超醫生
容慧明醫生
Geriatric Medicine
Dr. KONG Ming Hei, Bernard
Dr. SHEA Tat Ming, Paul
江明熙醫生
佘達明醫生
Rheumatology
Dr. CHAN Tak Hin
Dr. CHEUNG Tak Cheong
陳德顯醫生
張德昌醫生
Haematology
Dr. AU Wing Yan
Dr. MAK Yiu Kwong, Vincent
區永仁醫生
麥耀光醫生
Urology
Dr. CHEUNG Man Chiu
Dr. KWOK Ka Ki
Dr. KWOK Tin Fook
張文釗醫生
郭家麒醫生
郭天福醫生
Hepatobiliary Surgery
Dr. CHIK Hsia Ying, Barbara
Dr. LIU Chi Leung
戚夏穎醫生
廖子良醫生
Vascular Surgery
Dr. TSE Cheuk Wa, Chad
Dr. YIEN Ling Chu, Renny
謝卓華醫生
顏令朱醫生
Medical Oncology
Dr. TSANG Wing Hang, Janice
曾詠恆醫生
HKMA Secretariat
Ms. Jovi LAM
Miss Sophia LAU
Miss Irene GOT
林偉珊女士
劉思妃小姐
葛樂詩小姐
Family Medicine
Dr. LAM King Hei, Stanley
Dr. LI Kwok Tung, Donald, SBS, JP
Gastroenterologist
Dr. NG Fook Hong
Nephrology
Dr. CHAN Man Kam
Dr. HO Chung Ping, MH, JP
Dr. HO Kai Leung, Kelvin
林敬熹醫生
李國棟醫生
陳文岩醫生
何仲平醫生
何繼良醫生
NOTICE
Medical knowledge is constantly changing. Standard safety precautions must be followed, but as new research
and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary
or appropriate. Readers are advised to check the most current product information provided by the manufacturer
of each drug to be administered to verify the recommended dose, the method and duration of administration, and
contraindications. It is the responsibility of the practitioner, relying on experience and knowledge of the patient, to
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liability for any injury and/or damage to persons or property arising from this publication.
Although all advertising material is expected to conform to ethical (medical) standards, inclusion in this publication does
not constitute a guarantee or endorsement of the quality or value of such product or of the claims made of it by its
manufacturer.
CME Bulletin Editorial – March 2015
Dear HKMA Fellow Members,
When you are reading this editorial, the long winter was gone
and we are now enjoying the adorable season of spring. I am
truthfully hoping that our political and economic turmoil has
passed away with the winter season altogether.
While enjoying our beautiful spring, I am going to share with you
some positive quotes of wisdom for this lovely season.
“No winter lasts forever; no spring skips its turn.”
Hal Borland (1900-1978), American author and journalist
“We cannot stop the winter or the summer from coming. We
cannot stop the spring or the fall or make them other than they
are. They are gifts from the universe that we cannot refuse.
But we can choose what we will contribute to life when each
arrives.”
Gary Zukav (1942-), American writer, public speaker
“I believe in process. I believe in four seasons. I believe that
winter’s tough, but spring’s coming. I believe that there’s a
growing season. And I think that you realize that in life, you grow.
You get better.”
Steve Southerland (1965-), Florida politician
“In winter, I plot and plan. In spring, I move.”
Henry Rollins (1980-), American performer, writer, journalist,
publisher
“If Winter comes, can Spring be far behind?”
Percy Bysshe Shelley (1792-1822), Kingdom of Sardinia, poet,
dramatist, essayist, novelist
“It is only the farmer who faithfully plants seeds in the Spring,
who reaps a harvest in the Autumn.”
B.C. Forbes (1880-1954), American journalist, author, publisher
The HKMA CME Bulletin Editorial Board wishes you and your
family a Happy Spring time.
Dr. WONG Bun Lap, Bernard
Chief Editor
SPOTlight -1
Dr. AU Wing Yan
Myeloma as a chronic
disease
Update on myeloma epidemiology
MBBS (HK), MD (HK), FRCP (London/
Edin), FHKCP FHKAM
Specialist in Hematology
Incidence of plasma cell myeloma in HK 1983-2012 (HK Cancer Registry)
250
Myeloma is a hematological malignancy originating
from the abnormal growth of plasma cells. Plasma cells
are the terminally differentiated B cells, usually residing
in the marrow, that produce specific antibodies to
immunological challenge. The World Health Organization
has replaced the old term of multiple myeloma (MM)
with the nomenclature as plasma cell myeloma (PCM).
It is usually a malignancy in the elderly. Data from the
Hong Kong Cancer Registry (http://www3.ha.org.
hk/cancereg/) showed a steadily increasing annual
incidence from less than 100 cases per year in 1980
approaching 250 cases per year in 2011 (Figure 1).
The peak age of occurrence is between 70 to 75 years
and it is more common in men than in women (Figure
1). Epidemiological data for PCM is interesting the
following ways. Although the case load in Hong Kong is
increasing, this is mainly due to population growth and
ageing rather than a real increase in risk. Indeed, when
corrected for gender and age, the incidence is static
(Figure 1). Hence there is no environmental change
in Hong Kong that increased the risk. Secondly, the
disease is indolent and hardly ever seen below age 40.
This is because of the long time it takes for the abnormal
plasma cells to accumulate enough pathogenic
mutations. Indeed, the first clonal myeloma cells may
occur 10 to 20 years before clinical onset. Myeloma
risk increases sharply after age 60 to beyond 80 years.
Thirdly, myeloma is 60% less common in Chinese
than in Caucasians. The ethnic difference is genetically
based since the lower incidence is maintained in
Chinese migrants to the West. (Chan, Song et al. 2011)
Finally, although the annual incidence of death due to
myeloma is also increasing, the rise is less steep from
that of increasing incidence and the lag time between
the two curves appears to be increasing, suggesting
that myeloma patients in Hong Kong are surviving for
increasingly longer periods of time (Figure 1).
2
HKMA CME Bulletin 持續醫學進修專訊 March 2015
Case load
increasingg
200
Less sharp
p rise in
mortality
150
all
men
women
death
WASR case per 10000
100
More men than
women
50
Stable when
corrected for age
0
1980
1985
1990
1995
2000
2005
2010
2015
Figure 1: Data from 1983 to 2011 showing increasing case load of
myeloma (blue line) with higher rates in male (green line) than females
(red line). Myeloma deaths (black line) also increases but at lower
pace than case incidence. Corrected for population size and age, the
world age standardized rate (WASR) remained constant (purple line)
Update on diagnosis and presentation
of myeloma
The diagnostic workup of myeloma has advanced
dramatically for the past 10 years. (Engelhardt, Terpos
et al. 2014; Rajkumar, Dimopoulos et al. 2014) However,
all the tests fall into three groups. Classically there are
three hallmarks of PCM, namely the triad of bone
pain, plasma cells damaging marrow and abnormal
blood monoclonal immunoglobulins (Ig, which may
be IgG or IgA). Onset can be insidious and a high index
of suspicion should be maintained when taking care of
elderly patients with unexplained systemic symptoms.
Myeloma cells reside in the bone marrow and form
an autocrine loop with osteoclasts to cause bone
erosion. The marrow rich tissue of the vertebral column
www.hkmacme.org
SPOTlight -1
is often involved and back pain with bone collapse
is common. Since there is little bone healing, alkaline
phosphatase level is normal, unlike osteoporotic
or metastatic fractures. In the past skeletal survey
X-rays are used to look for punched out or moth eaten
lesions in the skull and long bones. Nowadays, this
is superseded by magnetic resonance imaging (MRI)
bone scan or acetate positron emission tomogram
(PET) scans that are far more sensitive in detecting
bone lesions (Figure 2A). However, if the patient has
frank PCM, MRI and PET are not required to start
treatment. Screening blood tests are usually suggestive
and nomochromic normocytic anemia with low
platelet counts, a raised globulin level associated with
elevated erythrocyte sedimentation rate (ESR) are
classical. The anemia is due to marrow replacement by
PCM cells plus autocrine suppression of erythropoietic
activity, while the increased globulin is due to the clonal
abnormal immunoglobulin (M protein) secreted. Its
quantification reflects the total volume of PCM cells
and is useful for monitoring. The total disappearance of
blood M protein by immunofixation is termed complete
remission (CRi). Bence Jones protein testing in urine is
obsolete. A more sensitive test than M protein level or
total IgG/IgA level is the use of serum free light chains
(FLC). (Figure 2B) This can pick up light chain myeloma,
IgD myeloma, amyloidosis or so-called non-secreting
myelomas, but is not needed in every case. Finally, a
bone marrow (BM) biopsy will reveal the clonal myeloma
cells, which are stained CD138 positive and show κ/
λ expression. PCM is defined by over 10% plasma
cells, but distribution can be patchy and sampling error
may occur. The marrow specimen is also increasingly
important for genetic studies looking for specimen
chromosomal abnormalities (e.g. t(6:14), 17p-) which
give poorer prognosis (Figure 2C). In addition, two blood
tests albumin level and the beta-2 microglobulin
level (b2m, reflects PCM mass and renal function), with
low albumin <3.5g/dl and raised b2m >5.5mg/l reflecting
poor prognosis (Rajkumar, Dimopoulos et al. 2014).
www.hkmacme.org
X ray punch lesions
PET
Figure2A
MRI
Monoclonal (M) Protein
Serum Free light chain
Figure2B
Marrow Plasma Cells
FISH genecs
Figure2C
Figure 2: Advance in diagnostic workup of myeloma from 20th (upper
row) to 21 st century (lower row), with X ray lesions better detected
by PET or MRI (panel A); clonal gamma-immunoglobulin detection
and quantification by immunoelectrophoresis (γ peak abnormal)
superseded by serum free light chain quantification (abnormal black
and blue cases outside the parallel normal lines indicating either
κ or λ disease) (Panel B) and bone marrow morphological and
numerical assessment of plasma cells (100% abnormal cells in this
view) supplemented by fluorescent in situ hybridization (FISH) DNA
technique looking for specific genetic lesions (red green fusion signals
abnormal for t(4;14) fusion in this case) (Panel C)
Natural history of myeloma
Myeloma is characterized by long latency and the first
clonal plasma cells may occur up to decades before
symptomatic disease. Indeed 0.8% of normal blood
donors in Hong Kong above age of 50 shows trace
levels of detectable M band (Wu, Minter et al. 2013).
The incidence increase with age and is 3 times higher in
Caucasians. This is called monoclonal gammopathy
of unknown significance (MGUS). Although the M
band level may increase slowly with time, most people
never progress to PCM in their lifetime. MGUS forms
a continuous spectrum with PCM and the crossover
is arbitrary: when the M band is above 20g/l or
plasma cells are over 10%. This may or may not be
symptomatic. Symptomatic PCM warrants treatment
and the classical quartet of symptoms are calcium
increase, renal impairment, anemia and bone
erosion (acronymed CRAB). Some would also include
infections (due to hypogammaglobulinemia), neuropathy
(due to light chain) and malaise (multifactorial) as
symptomatic. The traditional wisdom is that treatment of
PCM is based on symptoms, and asymptomatic PCM
HKMA CME Bulletin 持續醫學進修專訊
March 2015
3
SPOTlight -1
Drugs for the treatment of PCM
For over 30 years, the basic treatment of PCM was a
combination of alkylator chemotherapy and steroids,
with a combination of melphalan and prednisolone (MP)
being the most common. The median survival was on
2 to 3 years and complete remissions (CR) are not
seen. The side of effects of long term steroids included
infections, muscle wasting, hypertension, weight and
fluid gain, hyperglycemia, bone loss and hepatitis viral
reactivation. Long terms steroids is poorly tolerated
especially in elderly with multiple medical problems.
Oral alkylators do not cause nausea and aloplecia but
can cause marrow suppression, infection, bleeding
and leukemia. The use of more intensive chemotherapy
including cyclophosphamide, vincristine and
doxorubicin gives CR rates of 5-10% and allow some
younger patients (cut-off age <65 (representing 17%
of all PCM) in Hong Kong) to proceed to autologous
transplantation (ABMT). These treatments are in-patient
and intensive. They carry full chemotherapy side effects
and a mortality rate. Understandably, they are irrelevant
to most PCM patients who are elderly. Furthermore, the
added benefit of ABMT is only one year extra survival
on average. Hence, there was very little improvement in
the survival curve of overall myeloma patients until 2000
(Kumar, Rajkumar et al. 2008) (Figure 3).
4
HKMA CME Bulletin 持續醫學進修專訊 March 2015
Median survival from 3 years (1971
(1971-2000)
2000) to 5 years (2001
(2001-2006)
2006)
100
1971-1976
1977-1982
1983-1988
1983
1988
1989-1994
1994-2000
2001-2006
80
Alive (%))
A
(termed smouldering multiple myeloma SMM) may
still be observed. This is because it is difficult to prove
that earlier chemotherapy gives survival benefit and it
carries side effects. This concept is recently challenged.
Firstly, the appearance of symptoms may be abrupt
and catastrophic. Secondly, with high disease burden,
symptom emergence is projectable and inevitable and
an artificial cutoff is not logical. Thirdly, the emergence
of target therapy has curtailed the immediate and longterm risks of treatment and even allowed long duration
maintenance so that benefits increasingly outweigh the
risk. Finally, recent trials actually proved that treatment
of high disease load SMM with target agents provide
longer survival over a waiting approach (Mateos,
Hernandez et al. 2013). Marrow genetics, MRI bone and
serum free light chain levels would be useful in selecting
such SMM cases.
60
Target therapy
40
20
0
Auto BMT (age<65)
(
6 )
Chemo Steroids
0
20
40
60
80
Mos
100
120 140
Kumar SK, et al. Blood. 2008;111:2516-2520. .
Figure 3: Minimal progress in survival from 1971 to 2000 despite
improved chemotherapy and supportive care and BMT, with dramatic
improvement after 2000 due to target therapy
Two classes of medication changed the outlook
of myeloma patients (Figure 4). The first group is
immunomodulators (IMID), the first one being
thalidomide. This oral drug was used in 1970 for
pregnancy related dizziness and was banned for
30 years since it cause limb deformities in babies.
However, it was found to have profound suppressive
effects on PCM. Studies adding thalidomide (T) to MP
can give CR and delay progression from 14.5 to 24.8
months (Palumbo, Bringhen et al. 2008). Side effects of
thalidomide are mild, including numbness, sleepiness
and constipation, none of which are life-threatening.
The dose can be titrated for individual elderly patients.
The drug can be used for maintenance for up to 3
years, and is relative inexpensive since its patent is
long over. A non-chemo combination of thalidomide
and dexamethasone (TD) give CR rates comparable
to that of chemotherapy regimens. Pharmaceutical
companies tested numerous thalidomide analogues with
extensive list of side chain modifications and produced
lenalidomide (R) and pomalidomide (P) as second
and third generation IMIDs, with more powerful antimyeloma properties. Both are oral drugs with few side
effects except mildly reduced platelets and diarrhea
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SPOTlight -1
in some patients. Uses of lenalidomide in upfront (up
to 60% CR), salvage after thalidomide relapse, or
maintenance settings are well established. Maintenance
lenalidomide can improve median progression from 13
to 31 months (Palumbo, Hajek et al. 2012).
Immunomodulators (IMID)
Protesome Inhibitors (PI)
CC-5013
Figure 4: Chemical structure of the families of proteasome inhibitor
(PI: left) and immunomodulator (IMID, right) and their purported
mechanism of action. For IMID, thalidomide is taken as example and
the multiple mechanisms of action are not fully characterized.
A second class of medicine that showed remarkable
activity against PCM is the proteasome inhibitor
(PI) groups. The parent compound mafilzomib was
discovered in toxic seabed bacteria from San Diego
beaches. The medicine works by a novel mechanism of
blocking protein metabolism. Plasma cells, which are
extremely active in producing immunoglobulins proteins,
are highly susceptible. The first generation drug was
bortezomib or velcade (V) which can be given as
weekly subcutaneous injections. Feet numbness
is the commonest side effect with high cumulative
doses. The addition of bortezomib to MP (MPV) delays
progression to 17.8 months and biweekly maintenance
extended it to 31.5 months (Palumbo, Bringhen et al.
2010). The second generation drug, calfizomib showed
increased potency and reduced side effect profile. It is
effective in over half of patients already resistant to both
velcade and lenalidomide.
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These revolutionary medicines changed the landscape
of PCM treatment for ever and all patients regardless
of age are now treated with target therapy backbone
upfront, either a doublet or a triplet of agents choosing
from IMID and/or PI plus either steroids and/or alkylator
(Engelhardt, Terpos et al. 2014). The CR rates can
now reach up to 60%. There are a number of distinct
features about the PCM target agents. Firstly, all well
tolerated out-patient therapy for elderly. Secondly,
they out-perform all chemotherapy agents. Thirdly,
the response improves with time with prolonged
administration. Fourthly, long term maintenance
treatment is possible. Finally, they are synergistic in
action and results in rapid tumor depletion. This may be
useful in situations such as impending renal failure or
severe bone damage. The problematic issue is their cost
which, except thalidomide, can be substantial in the long
run.
Myeloma as a chronic disease
Life expectancy is increasing in Hong Kong and the
caseload of myeloma is likely to increase. The treatment
goals of PCM in elderly may be different from that in the
younger generation. Some centers in the USA specialize
in treating young myeloma cases as an acute disease.
Their total therapy approach aim to eradicate the PCM
clone for up to 10 years using six cycles of intensive
therapy with 4 cytotoxic drugs, 3 target agents and 2
BMT all completed within six months (Barlogie, Mitchell
et al. 2014). This is obviously not feasible for elderly.
Even in young patients, it is not chosen or tolerated by
most patients. Moreover, in elderly there are competing
causes of death (Figure 5). This means that the
background survival curve will decline irrespective of the
patient having myeloma or not. This has to be compared
against the decay curve of myeloma patients (Figure
4 and 5). Before 2000, the myeloma survival curve
was steeper than the population decay curve resulting
in premature death, due to treatment intolerance or
inadequacy. After 2000, each new therapy pushes the
survival curves to the right and closer and closer to
the population decay curve. Myeloma is not a curable
disease. All patients will relapse with infinite follow-up.
HKMA CME Bulletin 持續醫學進修專訊
March 2015
5
SPOTlight -1
However, this problem may not be relevant for elderly
patients. Upfront use of target agents means they can
be free from symptoms and side effects using outpatient continuous therapy, for a median of 5 years and
often beyond. It is therefore very relevant to look out
for suspected myeloma cases in the elderly and start
treatment early. This avoids irreversible organ damage,
improves disease control and returns the survival curve
back towards the baseline elderly population.
Background populaon overall survival at 70
2013 HK life-table data ((courtesyy Prof Dennis KM Ip)
p)
Key Message: Myeloma cases will increase with
ageing population. Early detection by blood test is easy.
Target therapy has replaced chemotherapy. It is now
an outpatient chronic disease which may not be lifethreatening within the life-span of some elderly patients.
References:
Barlogie, B., A. Mitchell, et al. (2014). "Curing myeloma at last: defining criteria
and providing the evidence." Blood 124(20): 3043-3051.
Chan, V., Au, W.Y, K. Song, et al. (2011). "Lower incidence of plasma cell
neoplasm is maintained in migrant Chinese to British Columbia: findings from
a 30-year survey." Leuk Lymphoma 52(12): 2316-2320.
Engelhardt, M., E. Terpos, et al. (2014). "European Myeloma Network
recommendations on the evaluation and treatment of newly diagnosed
patients with multiple myeloma." Haematologica 99(2): 232-242.
Kumar, S. K., S. V. Rajkumar, et al. (2008). "Improved survival in multiple
myeloma and the impact of novel therapies." Blood 111(5): 2516-2520.
Mateos, M. V., M. T. Hernandez, et al. (2013). "Lenalidomide plus
dexamethasone for high-risk smoldering multiple myeloma." N Engl J Med
369(5): 438-447.
Palumbo, A., S. Bringhen, et al. (2008). "Oral melphalan, prednisone, and
thalidomide in elderly patients with multiple myeloma: updated results of a
randomized controlled trial." Blood 112(8): 3107-3114.
Palumbo, A., S. Bringhen, et al. (2010). "Bortezomib-melphalan-prednisonethalidomide followed by maintenance with bortezomib-thalidomide compared
with bortezomib-melphalan-prednisone for initial treatment of multiple
myeloma: a randomized controlled trial." J Clin Oncol 28(34): 5101-5109.
Move curve to right
Myeloma prolong survival
Palumbo, A., R. Hajek, et al. (2012). "Continuous lenalidomide treatment for
newly diagnosed multiple myeloma." N Engl J Med 366(19): 1759-1769.
Figure 5: Concept of myeloma as a chronic disease as the hypothetical
survival curve of myeloma (red) is continually pushed to the right (green
dotted) so that it approaches the life-table natural decay curves for
elderly females and males (70-year old starting curves used in this
example, the older the age at diagnosis, the steeper the natural decay
curve).
Questions:
Q&A Self-assessment
Complete this
course and earn
1 CME Point
Answer these on page 19 or make an online submission at: www.hkmacme.org
Please indicate whether the following statements are true of false.
Rajkumar, S. V., M. A. Dimopoulos, et al. (2014). "International Myeloma
Working Group updated criteria for the diagnosis of multiple myeloma." Lancet
Oncol 15(12): e538-e548.
Wu, S. P., Au, W. Y., A. Minter, et al. (2013). "MGUS prevalence in an ethnically
Chinese population in Hong Kong." Blood 121(12): 2363-2364.
Answers to February 2015
Polypharmacy in elderly patients
1.F
2.T
3.T
4.F
5.F
6.T
7.F
8.F
9.T
10.T
Advances in the Treatment of Rheumatoid Arthritis
1. True. Rheumatology referral is mandatory not only for diagnosis, but
also risk stratification, disease activity assessment, formulate plan of
pharmacological and non-pharmacological treatment.
2. False, as in the criteria, although large joints only involvement is less
classical of RA, it is not an uncommon clinical manifestation.
1.
Myeloma is a disease of elderly and peaks at 70-75 years old.
2.
Myeloma is a curable disease using chemotherapy.
3.
Bone pain and anemia are present features.
4.
PET-CT should be done for all myeloma cases.
4. True.
5.
Target therapy should be considered for all myeloma cases.
5. True.
6.
The survival of myeloma patients had improved little from 1970 to 2000.
7.
IMID (e.g. thalidomide) and PI (e.g. velcade) are two target agents.
8.
Complete remission can now occur in ½ of myeloma cases.
9.
Most target agents are inexpensive.
10.
The myeloma survival curve can overlap that of background elderly
population.
3. True. Seronegative RA is not uncommon, as high as in 30% of RA
patients.
6. False. All biological DMARD show better response rate when combined
with methotrexate.
7. False. A composite score is needed to assess for remission.
8. False.
9. False.
10. False.
6
HKMA CME Bulletin 持續醫學進修專訊 March 2015
www.hkmacme.org
SPOTlight -2
Male infertility –
the often forgotten
significant other
Introduction
Infertility is defined by the inability to conceive after one
year of regular unprotected sexual intercourse. The
condition affects 15% of couples and is a worldwide
phenomenon1. In addition to the well-known factor of
ever-increasing advanced maternal age in developed
countries, multiple genetic and environmental factors
have been implicated as possible etiologies. With the
development of assisted reproductive technology (ART)
and in-vitro fertilization procedures pioneered by British
scientist Sir Robert Edwards, more than five million
“test-tube” babies have been born since the birth of
Louise Brown in 1978. Sir Robert Edwards was awarded
the Nobel prize for medicine, honoring his contribution
to the field.
Since the birth of the first “test-tube baby”, infertility
treatment had been focusing on the female for decades.
The male factor had been overlooked if not neglected,
until the development of intracytoplasmic sperm
injection technology which brought new hopes to
couples with severe male factor infertility. In the report
of Council on Human Reproductive Technology in
2012, male factors were involved in 50% of couples
receiving ART treatment2. The disease spectrum and
treatment patterns in a local male infertility clinic were
reported recently3. 36% of patients attending the male
infertility clinic were diagnosed with azoospermia and a
further 48% of them had various abnormalities in semen
parameters.
Dr. HO Kwan Lun
MBBS (HK), FRCSEd (Urol), FCSHK, FHKAM (Surgery)
Specialist in Urology
Table 1.
Role of Urologist in Male Infertility
1. Find out the causes of male infertility
2. Identify potential life-threatening disorders e.g. ca testis
3. Counselling on treatment options
(a) Varicocelectomy
(b) Reconstructive surgery for obstructive azoospermia
(c) Sperm retrieval and assisted reproduction
Reproductive history
Most physicians are aware of the definition of infertility.
However, it is also important to ask specifically about
the frequency of sexual intercourse and whether
there are any difficulty of intravaginal ejaculation e.g.
erectile or ejaculatory dysfunction. The author had
encountered patients who lived apart from their female
partners residing in Mainland China and could only
manage to have sexual intercourse one to two times
a month, which significantly decreased the chance of
natural conception. There are also misconceptions
about fertility window and timed sexual intercourse.
Most experts in reproductive medicine advocate
either timed sexual intercourse after the LH surge
(commercially available urine test kit) or regular sexual
intercourse every two to three days starting from Day
10 after the last menstrual period. These two methods
are more reliable than calculations based on basal
body temperature or estimated ovulation day from last
menstrual period.
General practitioners and family physicians are usually
the first tiers who assess couples with fertility issues.
Pre-marital or at least pre-pregnancy check-up can
identify potential patients with infertility conditions. A
simple semen analysis is cost-effective and can identify
male clients who may benefit from referral to further
urology assessment (Table 1).
www.hkmacme.org
HKMA CME Bulletin 持續醫學進修專訊 March 2015
7
SPOTlight -2
There are some key questions related to male
infertility (Table 2). The history of genital tract infection
is associated with potential obstruction in epididymal
tubules or vas deferens. Prior inguinal hernia surgery
may cause vasal obstruction in the inguinal region.
For patients who have previous infertility treatment,
it is of utmost importance to inquire about the nature
and timing of procedures involved. For example, prior
epididymal sperm retrieval will jeopardize the potential of
future reconstructive surgery in obstructive azoospermic
patients. Azoospermia affects 13% of patients with
unilateral undescended testis, 46% with bilateral
treated and 89% with bilateral untreated undescended
testes 4. Contemporary literature has postulated that
the pathophysiology of undescended testes involves
the abnormal transformation of primitive germ cells
(gonocytes) to spermatogonia, which happens at
the age of three to six months. While alkylating
chemotherapeutic agents are well-known spermicidal
agents, the use of exogenous testosterone or anabolic
steroid is also detrimental to spermatogenesis. Mumps
after puberty is associated with mumps orchitis in 40%
of patients affected, of which 13% may suffer from
subsequent subfertility5.
Table 2.
Key questions related to male infertility
Genital tract infection e.g. urethritis, epididymo-orchitis
Inguino-scrotal surgery e.g. hernia, vasectomy, prior sperm
retrieval or varicocelectomy
History of undescended testis or orchidopexy
Chemotherapy or radiotherapy
Drugs e.g. immunosuppresants, exogenous testosterone
or anabolic steroids
Clinical examination
A focused physical examination is cost-effective. The
underdevelopment of secondary sexual characteristics
and gynecomastia lead to suspicion of Klinefelter’s
syndrome, which is associated with testicular failure.
Testis size and consistency are evaluated. Any
abnormal testicular mass or hardness should lead to
prompt urology assessment, since testicular cancer is
associated with testicular failure. Epididymal and vasal
assessment may be difficult to those less experienced.
Distended epididymes or nodules signify previous
inflammation and obstruction. Congenital absence of
vas is a clinical diagnosis and is usually associated with
a decrease in semen volume with acidic pH. Varicocele
examination should be performed with the patient in
standing posture.
Investigations
Semen analysis according to the WHO 2010 criteria6
is central to the male infertility assessment. Specimen
collection should be done after two to five days of
abstinence from ejaculation and should be promptly
sent for laboratory processing within one hour of
collection, in preferably close to body temperature. The
important semen parameters include volume, pH, sperm
concentration, motility and morphology. Azoospermia
should be confirmed after specimen centrifugation
and microscopic examination of the pellet. Small
number of sperms can still be found in 20 per cent of
“azoospermic” patients after the above processing.
Mump after puberty
Erectile or ejaculatory dysfunction
Smoking
Last but not least, it is crucial to include the
concomitant female factors into consideration.
Advanced maternal age of greater than 35 is associated
with rapidly declining chance of natural pregnancy.
History of prior pregnancy, endometriosis, polycystic
ovarian disease, pelvic inflammatory disease, fertility
assessment in terms of ovarian reserve and tubal status
are all contributing to the comprehensive assessment of
the couple facing infertility.
8
HKMA CME Bulletin 持續醫學進修專訊 March 2015
T h e r e a r e t w o m a i n t y p e s o f a z o o s p e r m i a 7-9,
obstructive and non-obstructive (Table 3). Common
causes of obstruction involve either the vas deferens or
epididymal tubules. These patients usually have normal
sized testes and hormonal profiles. Non-obstructive
causes involve severe impairment of spermatogenesis
or testicular failure. The testes are usually small with low
serum testosterone and reactionary high serum FSH.
Genetic causes contribute to 10 to 15% of nonobstructive azoospermia and these patients should be
offered karyotyping and Y chromosome microdeletion
analysis.
www.hkmacme.org
SPOTlight -2
Table 3.
Azoospermia
Obstructive
Normal sized testes
Normal FSH and testosterone
Common causes
Congenital absence of vas
Genital tract infection
Vasectomy
Inguinal hernia surgery
Idiopathic
Varicocele
Non-obstructive
Small testes
High FSH and low testosterone
Idiopathic
Genetic
History of mumps
Cryptorchidism
Drug
For patients with abnormalities in either sperm
concentration, motility, morphology or all of the
above, it is important to look for clinically significant
varicocele which is the commonest surgically reversible
cause of male infertility. Genito-urinary infection with
leuokospermia is another common reversible cause of
sperm quality impairment.
Transrectal ultrasound may be employed in patients with
low volume ejaculate, to differentiate between congenital
absence of vas (absent seminal vesicles) and ejaculatory
duct obstruction (distended seminal vesicles). In case of
suspected retrograde ejaculation, post-ejaculation urine
should be examined for presence of sperms. Ultrasound
of scrotum is reserved for testicular asymmetry or
masses. Sub-clinical varicocele detected by ultrasound
is not clinically detrimental to sperm quality and is not an
indication of routine ultrasound of scrotum.
Management
The role of an urologist in male infertility10 includes
finding out the causes, identifying potentially lifethreatening disorders and counselling on various
treatment options (Table 1). The couple should be
counselled together and various options ranging from
conservative treatment, adoption, donor sperms,
surgical correction to sperm retrieval and assisted
reproduction are thoroughly discussed. Factors
considered include the female age, ovarian reserve,
tubal status, sperm quality, surgical expertise, individual
ART centre’s success rates and after all patient choices.
www.hkmacme.org
This is the commonest surgically reversible
c o n d i t i o n o f m a l e i n f e r t i l i t y 11. 1 5 % o f m e n i n
general population and 40% of subfertile men have
varicoceles. The pathophysiology of varicocelerelated infertility is controversial. Recent literatures
have focused on the effect of impaired testicular
microcirculation, increased accumulation of reactive
oxygen species and sperm DNA damage, leading to
impairment of all semen parameters. It is even more
controversial whether varicocele treatment improves
pregnancy outcomes. Recent meta-analyses and
limited randomized controlled trial seem to support the
benefit of varicocelectomy in improving pregnancy
outcomes12-13.
Common approaches of varicocelectomy are high
retroperitoneal (Palomo’s operation), laparoscopic and
microsurgical subinguinal ligation. High retroperitoneal
approach is familiar to most surgeons but cannot tackle
the gubernaculum and external spermatic tributaries,
leading to high recurrence rate. Failure to preserve
lymphatics also leads to increased risks of hydrocele.
Laparoscopic approach tackles bilateral pathologies but
has the same pitfalls of high incidence of recurrence and
hydrocele. Besides there is a small but non-negligible
risk of bowel or great vessel injury because of the
intraperitoneal approach.
Microsurgical subinguinal approach is the
contemporary preferred approach 14 because it
can tackle internal spermatic, external spermatic and
gubernaculum tributaries leading to low recurrence rate.
With preservation of testicular artery and lymphatics,
incidence of testis atrophy and hydrocele is extremely
low. However, this approach requires sub-specialized
microsurgical training and is more time consuming than
traditional approaches.
HKMA CME Bulletin 持續醫學進修專訊 March 2015
9
SPOTlight -2
Azoospermia
About one per cent of men in general population
and 10 to 15 percent of subfertile men have
azoospermia, which have obstructive or nonobstructive causes 7-9 (Table 3). For patients with
irreversible obstructive lesions e.g. congenital absence
of vas or multiple obstructions of the genital tract
which cannot be reconstructed, sperm retrieval and
assisted reproduction is the only hope of childbearing.
Congenital absence of vas is associated with cystic
fibrosis transmembrane conductance regulator (CFTR)
gene mutations in Caucaseans. Recent literature has
shown that Chinese men with congenital absence of
vas carry different CFTR gene mutations, which may
give rise to a mild genital form of cystic fibrosis15.
Besides, cystic fibrosis is very rare in Chinese patients
and CFTR gene mutation analysis is not a routine in local
Chinese patients with congenital absence of vas3. Huge
number of possible CFTR gene mutations also makes
targeted examination in local patients extremely difficult.
Conclusion
Male factor contributes to 50% of couples suffering
from infertility. A brief reproductive history coupled with
focused clinical examination and semen analysis will
help to identify potential patients with male infertility. The
role of an urologist is to find out the causes, identify lifethreatening disorders and counsel the couple on the
optimal treatment strategies.
Key lessons
• Male Infertility is not uncommon and contributes to
50% of couples suffering from infertility
• Pre-marital or pre-pregnancy check-up is crucial for
timely identification of potential patients with male
infertility
• Various treatment strategies can be offered to
infertile men after comprehensive assessment and
counselling of the couples
References:
For patients with reversible obstructive lesions e.g.
post-vasectomy or epididmal obstruction, there is a
choice between surgical reconstruction and assisted
reproduction 16 . Vasectomy reversal and vasoepididymostomy are routinely performed by urologists
specialized in microsurgical reconstruction 17 . The
procedures are technically demanding but rewarded
with reasonable success rates. On the other hand,
epididymal or testicular sperm retrieval and assisted
reproduction is a viable alternative. Surgical expertise
and female factors are thoroughly considered before the
couple arrive at a well informed choice.
In a significant proportion of patients with nonobstructive azoospermia (Table 3), no causes can be
identified despite extensive investigations. Testicular
sperm extraction has an overall 50% success rate in
these patients with poor spermatogenesis18. About
10 to 15% of these patients have abnormal karyotyping
e.g. Klinefelter’s syndrome or Y chromosome
microdeletion8. In those patients with certain types of Y
chromosome microdeletion e.g. complete absence of
AZFa or AZFb, the chance of testicular sperm extraction
is minimal and the couple should be counselled about
donor sperm issues.
10
HKMA CME Bulletin 持續醫學進修專訊 March 2015
1.
Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Stevens
GA. National, regional, and global trends in infertility prevalence
since 1990: a systematic analysis of 277 health surveys. PLoS Med
2012;9:e1001356.
2.
Infertility diagnosis by age of patients receiving RT procedures
(other than DI and AIH) in 2012. Council on Human Reproductive
Technology. Available from: http://www.chrt.org.hk/english/
publications/files/table17_2012.pdf. Accessed December 2014.
3.
Ho KL, Tsu JH, Tam PC, Yiu MK. Disease spectrum and treatment
patterns in a local male infertility clinic. Hong Kong Med J. 2015 Jan 2.
doi: 10.12809/hkmj144376. Epub ahead of print
4.
Chung E, Brock GB. Cryptorchidism and its impact on male fertility:
a state of art review of current literature. Can Urol Assoc J. 2011
Jun;5(3):210-4.
5.
Davis NF, McGuire BB, Mahon JA, Smyth AE, O’Malley KJ, Fitzpatrick
JM. The increasing incidence of mumps orchitis: a comprehensive
review. BJU Int. 2010 Apr;105(8):1060-5.
6.
Cooper TG, Noonan E, von Eckardstein S, et al. World Health
Organization reference values for human semen characteristics. Hum
Reprod Update. 2010 May-Jun;16(3):231-45.
7.
Wosnitzer M, Goldstein M, Hardy MP. Review of Azoospermia.
Spermatogenesis 2014;4:e28218.
8.
Berookhim BM, Schlegel PN. Azoospermia due to spermatogenic
failure. Urol Clin North Am 2014;41:97-113.
9.
Wosnitzer MS, Goldstein M. Obstructive azoospermia. Urol Clin North
Am 2014;41:83-95.
10. Male Infertility Best Practice Policy Committee of the American
Urological Association; Practice Committee of the American Society
for Reproductive Medicine. Report on optimal evaluation of the infertile
male. Fertil Steril 2006;86(5 Suppl 1):S202-9.
www.hkmacme.org
SPOTlight -2
11. Practice Committee of American Society for Reproductive
Medicine. Report on varicocele and infertility. Fertil Steril 2008;90(5
Suppl):S247-9.
12. Marmar JL, Agarwal A, Prabakaran S, et al. Reassessing the value of
varicocelectomy as a treatment for male subfertility with a new metaanalysis. Fertil Steril 2007;88:639-48.
13. Abdel-Meguid TA, Al-Sayyad A, Tayib A, Farsi HM. Does varicocele
repair improve male infertility? An evidence-based perspective from a
randomized, controlled trial. Eur Urol 2011;59:455-61.
Q&A Questions
Self-assessment
Complete this
course and earn
1 CME Point
Answer these on page 19 or make an online submission at: www.
hkmacme.org Please indicate whether the following statements are true of
false.
1.
Infertility affects 30% of couples worldwide.
2.
Male factor contributes to 50% of couples with infertility.
14. Leung L, Ho KL, Tam PC, Yiu MK. Subinguinal microsurgical
varicocelectomy for male factor subfertility: ten-year experience. Hong
Kong Med J 2013;19:334-40.
3.
Azoospermia affects 10% of men in general population.
4.
Congenital absence of vas is reversible by reconstructive surgery.
15. Lu S, Yang X, Cui Y, et al. Different cystic fibrosis transmembrane
conductance regulator mutations in Chinese men with congenital
bilateral absence of vas deferens and other acquired obstructive
azoospermia. Urology. 2013 Oct;82(4):824-8.
5.
Genital tract infection is a cause of obstructive azoospermia.
6.
Exogenous testosterone improves spermatogenesis in men with
testicular failure.
7.
Undescended testis is associated with male factor infertility.
8.
Patients with non-obstructive azoospermia have normal FSH.
9.
All patients with male infertility should have routine ultrasound
examination of scrotum.
16. Lee R, Li PS, Schlegel PN, Goldstein M. Reassessing reconstruction in
the management of obstructive azoospermia: reconstruction or sperm
acquisition? Urol Clin North Am 2008;35:289-301.
17. Ho KL, Wong MH, Tam PC. Microsurgical vasoepididymostomy for
obstructive azoospermia. Hong Kong Med J 2009;15:452-7.
18. Esteves SC, Miyaoka R, Agarwal A. Sperm retrieval techniques for
assisted reproduction. Int Braz J Urol 2011;37:570-83.
10. Subinguinal microsurgical approach of varicocelectomy has the lowest
risk of recurrence.
香港醫生網
The Hong Kong Doctors Homepage
www.hkdoctors.org
This web site is developed and maintained by the Hong Kong Medical Association
for all registered Hong Kong doctors to house their Internet practice homepage. The
format complies with the Internet Guidelines which was proposed by the Hong Kong
Medical Association and adopted by the Medical Council of Hong Kong.
We consider a practice homepage as a signboard or an entry in the telephone
directory. It contains essential information about the doctor including his specialty and
how to get to him. This facilitates members of the public to communicate with their
doctors.
This website is open to all registered doctors in Hong Kong. For practice page design
and upload, please contact the Hong Kong Medical Association Secretariat.
由香港醫學會成立並管理的《香港醫生網》，是一個收錄本港註冊西醫執業網頁的
網站。內容是根據由香港醫學會擬訂並獲香港醫務委員會批准使用的互聯網指引內
的規定格式刊載。
醫生的「執業網頁」性質與電話索引內刊載的資料相近。目的是提供與醫生執業有
關的基本資料，例如註冊專科及聯絡方法等，方便市民接觸個別醫生。
任何香港註冊西醫都可以參加《香港醫生網》。關於網頁版面安排及上載之詳情，
請與香港醫學會秘書處聯絡為荷。
www.hkmacme.org
HKMA CME Bulletin 持續醫學進修專訊 March 2015
11
Cardiology
The content of the March Cardiology Series is provided by:
Dr. WONG Chi Yuen MBBS, MRCP, FHKCP, FHKAM, Specialist in Cardiology
Dr. TSANG Chun Fung, Sunny MBChB, MRCP (UK)
三月臨床心臟科個案研究之內容承蒙黃志遠醫生及曾振峯醫生提供。
Complete BOTH Cardiology and
Dermatology courses and earn
0.5 CME POINT
Doctor, should I stop my anti-platelet agents?
For each of the scenario below, please choose the most appropriate peri-procedure management of anti-platelet
agents.
Q&A
Please indicate one answer to each question
Answer these on page 19 or make an online submission at: www.hkmacme.org
Q1. A 57-year-old gentleman is taking aspirin 160 mg daily for prior history of minor ischaemic stroke with good
recovery. He is planning to have tooth extraction.
A.
B.
Stop aspirin 5 days before procedure, and resume as soon as haemostasis is acheived
Continue aspirin during peri-procedure period
Q2. A 62-year-old lady is taking aspirin 160 mg daily for asymptomatic mild coronary artery stenosis
documented by cardiac CT scan. She also has diabetes and hypertension. She is planning to have
colonoscopy (with anticipated biopsy or therapeutic procedures) for per rectal bleeding.
A.
B.
Stop aspirin 5 days before procedure, and resume as soon as haemostasis is acheived
Continue aspirin during peri-procedure period
Q3. An 80-year-old gentleman is taking aspirin 160 mg daily, clopidogrel 75 mg daily for prior acute coronary
syndrome 2 months ago and he refuses invasive coronary intervention. He is planning to have surgery for
colorectal cancer.
A.
B.
C.
D.
Stop aspirin at least 5 days before procedure, and resume as soon as haemostasis is achieved. Continue
clopidogrel during peri-procedure period
Stop clopidogrel at least 5 days before procedure, and resume as soon as haemostasis is achieved.
Continue aspirin during peri-procedure period
Stop both aspirin and clopidogrel at least 5 days before procedure, and resume both as soon as
haemostasis is achieved. Use low molecular weight heparin as bridging therapy during peri-operative period
Continue both aspirin and clopidogrel during peri-operative period
Q4. A 55-year-old lady is taking aspirin 160 mg daily, clopidogrel 75 mg daily for coronary artery disease with
drug eluting stents (DES) implanted in left anterior descending artery 7 months ago. She is diagnosed to
have breast cancer after coronary stenting. Surgeon advises mastectomy as soon as possible.
A.
B.
C.
D.
E.
12
Stop aspirin at least 5 days before procedure, and resume as soon as haemostasis is achieved. Continue
clopidogrel during peri-procedure period
Stop clopidogrel at least 5 days before procedure, and resume as soon as haemostasis is achieved.
Continue aspirin during peri-procedure period
Stop both aspirin and clopidogrel at least 5 days before procedure, and resume both as soon as
haemostasis is achieved. Use low molecular weight heparin as bridging therapy during peri-operative period
Continue both aspirin and clopidogrel during peri-operative period
Liaise with the treating cardiologist for appropriate management strategy
HKMA CME Bulletin 持續醫學進修專訊 March 2015
www.hkmacme.org
Cardiology
February Answers
A Pregnant Woman Presented with Acute Chest Pain
Answers:
1.A
2.A
3.A
Chest pain in a pregnant woman may be the result of various
conditions, ranging from benign to life-threatening diagnosis.
The main important differential diagnosis of acute retrosternal
chest pain in pregnancy are acute coronary syndrome (ACS),
acute pulmonary embolism, pre-eclampsia and acute aortic
dissection. With the rise in maternal age and the increasing
number of high-risk women who become pregnant,
pregnancy related ACS is expected to increase.
For the pathophysiology, as in non-pregnant women, the
occurrence of atherosclerotic changes in the coronary
artery remains the primary cause of pregnancy-related
myocardial infarction. However, coronary artery dissection
should be considered especially in pregnant patients
presenting during the peripartum and post-partum period.
Spontaneous coronary artery dissection, a rare cause of
myocardial infarction in the non-pregnant population, is
being responsible for 50% of myocardial infarction during
peripartum period. The high incidence of coronary dissection
during pregnancy may be related to high progesterone levels
with subsequent structural changes in the collagen of the
vessel wall.
For treatment, in patients presenting with acute ST elevation
myocardial infarction (STEMI), coronary angiography with
the possibility of primary percutaneous coronary intervention
(PCI) is preferred to intravenous fibrinolysis, as it will also
diagnose coronary artery dissection. The risk of potential
radiation exposure to the fetus should be kept in mind,
especially in the first trimester. Nonetheless, the risk of
radiation from coronary angiography is deemed negligible
when the abdomen is properly shielded unless the procedure
is exceptionally challenging.
Although several studies have demonstrated that placental
transfer of thrombolytic therapy like streptokinase and
tPA is too low to cause fibrinolytic effects in the fetus, it
may induce maternal and fetal complications like maternal
haemorrhage, preterm delivery, fetal loss, spontaneous
abortion, subchorionic haematomas and abruption placenta.
Moreover, the safety and efficacy of thrombolytic therapy
in the treatment of myocardial infarction secondary to
coronary dissection have not been clearly established, and
such therapy may increase the risk of haemorrhage and
further progression of the dissection. Therefore, thrombolytic
therapy should be reserved for life-threatening STEMI when
there is no access to PCI. The European Society Cardiology
guidelines on the management of cardiovascular diseases
during pregnancy suggest coronary angioplasty as the
preferred reperfusion therapy for STEMI during pregnancy
(Class 1 recommendation).
References:
1.
2.
3.
Regitz-Zagrosek V, Lundqvist CB, Borghi C, et al. ESC Guidelines on the
management of cardiovascular diseases during pregnancy. EHJ 2011; (32)
3147-97.
Elkayam U, Jalnapurkar S, Barakkat MN, et al. Pregnancy-associated acute
myocardial infarction: A review of contemporary experience in 150 cases
between 2006 and 2011. Circulation 2014; 129:1695-1702.
Poh CL, Lee CH. Acute myocardial infarction in pregnant women. Ann Acad
Med Singapore 2010; 39:247-53.
The content of the February Cardiology Series is provided by:
Dr. CHEUNG Ling Ling MBBS(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in Cardiology
Dr. LO Ka Yip, David MbChB(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in Cardiology
Dr. CHUNG Tak Shun MBBS(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in Cardiology
二月臨床心臟科個案研究之內容承蒙張玲玲醫生、盧家業醫生及鍾德惇醫生提供。
www.hkmacme.org
HKMA CME Bulletin 持續醫學進修專訊 March 2015
13
Dermatology
The content of the March Dermatology Series is provided by:
Dr. CHAN Hau Ngai, Kingsley, Dr. TANG Yuk Ming, William, Dr. KWAN Chi Keung and Dr. LEUNG Wai Yiu
Specialists in Dermatology & Venereology
三月皮膚科個案研究之內容承蒙陳厚毅醫生、鄧旭明醫生、關志強醫生及梁偉耀醫生提供。
Complete BOTH Cardiology and
Dermatology courses and earn
0.5 CME POINT
A 53-year-old man presented with generalized rash
A 53-year-old man first presented with rash over anus. Two weeks
later, rash started to develop over generalized body and the mouth.
The rash was painful but non itchy. There was no fever. He enjoyed
good past health and he had no long term medication. Physical
examination showed erosions over the month, trunk, back, limbs
and anal region. There was no ocular involvement.
Q&A
Please answer ALL questions
Answer these on page 19 or make an online submission at: www.hkmacme.org
Q1. What is the diagnosis and the possible differential
diagnoses?
Q2. What is the cause of the disease?
Q3. How is it diagnosed?
Q4. Apart from skin, where are the other possible areas of
involvement?
Q5. How should the disease be managed?
February Answers
Asymptomatic lower limbs rash
Answers:
1. The clinical diagnosis is capillaritis or pigmented
purpuric dermatosis (PPD).
2. The differential diagnoses include eczema,
small vessel vasculitis, scurvy and drug
eruption.
3. The diagnosis can be made by clinical. Classical
presentation is dusky brown, sprinkled cayenne
pepper discolouration over bilateral shins.
Complete blood picture may be require to rule
out thrombocytopenia and clotting profit may
also be needed to rule out other possibility of
purpura. If other causes suspect, skin biopsy
may help to differentiate from other possibilities.
4. The underlying etiology is unknown. Venous
hypertension, vigorous exercise, gravitational
dependency may be related to PPD and appear
to influence the presentation. The histology
reveals perivascular lymphocytic infiltration
on capillaries of superficial skin associated
with endothelial cell swelling and narrowing
the lumen of these capillaries which signifies
capillaritis. Extravasation of red blood cells with
haemosiderin deposition in macrophages is also
found.
5. There is no specific treatment for PPD. Removal
of risk factors such as avoidance of prolonged
leg dependency and pressure socking for
venous stasis can help. Emollient and topical
steroid may be
used to relieve
the itchiness.
Phototherapy such
as narrowband
UVB and PUVA
has been reported
anecdotally in
treatment of PPD.
The content of the February Dermatology Series is provided by:
Dr. KWAN Chi Keung, Dr. TANG Yuk Ming, William, Dr. CHAN Hau Ngai, Kingsley and Dr. LEUNG Wai Yiu
Specialists in Dermatology & Venereology
二月皮膚科個案研究之內容承蒙關志強醫生、鄧旭明醫生、陳厚毅醫生及梁偉耀醫生提供。
14
HKMA CME Bulletin 持續醫學進修專訊 March 2015
www.hkmacme.org
Complaints & Ethics
Therapeutic
Misadventures in
Pediatric Practice
MBBS (HK), MFM (Clin)(Monash), LRCP (Lond),
MRCS (Eng), MRCP (UK), FRCP (Irel), FHKCP,
FRACGP, FHKCFP, DFM (CUHK),
FHKAM (Medicine), FHKAM (Family Medicine),
DCH (Lond), DOM (CUHK), DPD (Cardiff),
PDipID (HK), PDipComPsychMed (HK),
PDipCommunityGeriatrics (HK),
Dip Ger Med RCPS (Glasg)
Specialist in Nephrology
based on a lecture to DCH (Sydney) graduates 2015
Dr. CHOI Kin
It is an honor to give this talk to a group of doctors who
are keen to better themselves when they see children
in their practice. You have been taught that prescribing
to young children is not simply halving the dose. The
following examples from Medical Council inquiries
illustrate common mistakes encounter in prescribing for
children.
Dispensing Practice Manual issued by the Hong Kong
Medical Association.
Case 1
On 26 May 2011, a child presented to a general
practitioner for presumed diagnosis of pharyngitis.
He was prescribed 4 types of medications including
Cefaclor. After taking 8 doses of Cefaclor in the
following two days, the parents found that the expiry
date of the prescribed Cefaclor was October 2009,
thus the consumption of the Cefaclor by the patient
was 19 months beyond the expiry date. The child was
brought to the Emergency Department of a public
hospital for consultation and subsequently admitted
into pediatric ward for observation and investigation. All
the investigations were normal except for an incidental
finding of iron deficiency anemia.
The Medical Council had ruled on an earlier case that
since doctors are given the authority to prescribe
and dispense medicines, there is the corresponding
responsibility to ensure that only proper medicine is
dispensed to the patients. It is the personal responsibility
of every doctor who chooses to dispense medicines
to patients to ensure that the medicine is proper in
all aspects, including that it has not expired. This is a
personal responsibility which cannot be delegated to
other persons such as clinic assistants.
Section 9.2 of the Code of Professional Conduct
provides that a doctor who dispenses medicine to
patients should establish suitable procedures for
ensuring that drugs are properly labeled and dispensed,
and should observe the provisions of the Good
www.hkmacme.org
The significance of an expiry date lies in that beyond
the expiry date the efficacy of the medicine is not
guaranteed, and the expired medicine may have
undesirable effects. A dispensing doctor has the
professional responsibility to ensure that all dispensed
medicine have not expired. By dispensing an expired
medicine with no guarantee of the intended therapeutic
effect, the doctor may delay the proper treatment of
the patient’s illness, let alone the potential of causing
undesirable effects to the patient if the medicine has
deteriorated. It is improper and unacceptable conduct
for a doctor to dispense a medicine without ensuring
that it has not expired.
Remedial measures taken up by defendant doctors
included sending the clinic assistant for training in basic
pharmacology and dispensing practice, personally
making weekly stock check on all medications,
maintaining a record of the expiry dates of the stocked
medicines, and reviewing the Good Dispensing
Practice Manual issued by the HKMA. A computerized
dispensing system with automatic monitoring of
expiration of medications was also used to improve the
dispensing system.
Case 2
The patient was 18 months old when his mother took
him to the Defendant’s clinic for vaccination. The
vaccination was a booster dose of the 5-in-1 vaccine
called Infanrix and previous doses had been given on
3 occasions by another doctor in the same clinic. The
vaccine consists of a liquid element which contains 4 of
the 5 vaccines, and a powder element which contains
the 5th vaccine. The liquid and powder elements
should be mixed together before administering to
HKMA CME Bulletin 持續醫學進修專訊 March 2015
15
Complaints & Ethics
the patient by intramuscular injection. The Defendant
mistakenly administered only the liquid element to the
patient without mixing it with the powder element.
Shortly after the injection, he discovered that he had
made a mistake. He then explained to the mother that
he had injected only the solvent but not the chemical
of the vaccine. He recommended a second injection
of the properly reconstituted vaccine be given to the
patient, and the mother agreed. A second injection
of the properly reconstituted vaccine was then given
to the patient. The Inquiry found that the Defendant
failed to follow the instruction for administering the
vaccine by injecting the liquid element but not the
powder element of the vaccine. This is conduct below
the standard expected amongst registered medical
practitioners and constituted professional misconduct.
The Inquiry also found that there was no urgency to
give the 2nd injection on the same day. In the absence
of immediately available information from authoritative
sources, the Defendant should have ascertained the
risks and effect of the double dose of the 4 injected
vaccines from authoritative sources before advising
the patient’s mother to accept a second injection.
There was no reason to rush into a second injection
without ascertaining the potential risks. This constituted
professional misconduct.
Case 3
On 20/9/11, defendant doctor injected or caused to
be injected pneumococcal vaccine into the patient
when the patient’s parent requested for an injection
of Hepatitis A vaccine for the patient. He also failed
to advice and/or to properly address the concern of
the patient’s parent about the repeated administration
of pneumococcal vaccine on the patient. After the
injection, the immunization record of the patient was
returned to the complainant. When the complainant
found out that the patient was given a different
vaccination, she immediately voiced her concern about
the repeat of a booster pneumococcal vaccine with
the clinic staff. The defendant’s wife told her that the
additional dose of pneumococcal vaccine would not
cause the patient any harm. When the Customer Service
Division of the medical group did not respond after she
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HKMA CME Bulletin 持續醫學進修專訊 March 2015
e-mailed them, she complaint to the Medical Council
of Hong Kong. The Medical Council ruled that had the
defendant taken the simple step of explaining to the
complainant what kind of vaccination that he was going
to administer, the patient would not have been given
a pneumococcal vaccination instead of a Hepatitis
vaccination. It was evident from the immunization
record that the patient received a booster dose of
pneumococcal vaccination some 3 months ago. The
defendant obviously had not read the record before
giving him a pneumococcal vaccination again. The
expert suggested that the defendant should take the
proactive approach by asking the clinic staff to keep
the patient and the complainant in his clinic so that he
could personally explain to the complainant after he
had finished the consultation of another patient. It was
certainly not good enough for the defendant to let a nonmedically qualified person to tell the complainant that
there was nothing to worry.
Case 4
Father of a 9 months old daughter weighing 6.5 Kg
complaint that the dosage of Polaramine prescribed may
be too high. The drug label put the dosage as 2 ml three
times daily for running nose. The drug name was not put
on the label. Micromedex and AHGS Drug Information
2011 have no recommendation for children below 2
years of age. From 2-6 years old, the dosage is 0.5 mg
every 4-6 hours, if taken 6 times daily, the total dose
will add up to 3 mg/day. Assuming the concentration
of polaramine syrup is 2 mg/5 ml, 2 ml tds correspond
to 0.8 mg tds and 2.4 mg/day. The individual dose may
be higher than recommended but the total daily dose
is about right for children 2-6 years old. Patient’s name
was missing from the drug label.
Case 5
An 8-years-3-months-old boy weighing 30 Kg sought
consultation and was diagnosed to have pharyngitis,
fever and flu. He was prescribed Panadol 300 mg qid,
Piriton 4 mg qid, Zinnat 250 mg bd, Lysozyme 60 mg
qid, Voren 25 mg qid, and Tagamet 200 mg qid. 2
days later, the boy started to vomit. He was brought
www.hkmacme.org
Complaints & Ethics
to another doctor who told the parent that Voren is for
treatment for arthritis and should not be given to children
and renal damage may be a side effect. The mother
brought in a complaint. The expert commented on the
use of Voren:
‘Though the total daily dose of diclofenac is within
recommendation, there appeared to be no strong
justification for its use from the information supplied by
the complainant and the second doctor. Diclofenac has
been used for its antipyretic effect in febrile illness, but it
should not be routinely used as an antipyretic because
of its potential adverse effects. Adverse reactions
to oral diclofenac are usually mild and transient and
mainly involve the upper gastrointestinal tract. Nausea,
diarrhea, constipation, abdominal pain or cramps,
flatulence, vomiting and dyspepsia occur in up to 10% of
patients receiving oral diclofenac. More severe adverse
effects necessitating discontinuation of the drug occur
in 1.5-2% of patients. Diclofenac has been reported to
cause impairment in renal function but its incidence is
not known.’
Case 6
The patient was 4 years old when she was taken by
her aunt to see the defendant on 7 August 2008. He
had a fever 38.7 degrees C and diagnosed as upper
respiratory tract infection. The defendant doctor
prescribed and dispensed Paracetamol and Biogesic
250 Paracetamol. The medications were not properly
labeled, either as to the name or strength including
the strength of Cephalexin and name and strength
of Chlorpheniramine, amongst other poorly legible
drug names. After taking the medications, the father
noticed the girl vomited and lost her appetite. She was
taken to the Emergency Department and investigated
for suspected Paracetamol overdose. Laboratory
examination confirmed that the Biogesic suspension
contained 240 mg/5ml paracetamol and not 125
mg/5 ml as claimed by the Defendant. According to
the BNF for children 2007, the maximum daily dosage
of paracetamol for a child of age 1 to 5 is 1000 mg
and in case of severe symptoms 90 mg/kg of the
patient’s body weight. The dosage of paracetamol
being prescribed and dispensed to the girl was 2250
www.hkmacme.org
mg/day, more than two times the maximum dosage of
1000 mg/day. Even if the patient had severe symptoms,
the dosage was still in excess of the maximum dosage
of 1530 mg/day. Whether it is necessary to label the
strength of the medication depends on the nature of
the medication. While it is not necessary in respect of
medications (such as commercially marketed capsules
and tablets with standardized strength), the strength
of which is readily ascertainable, this is essential in
respect of medications (such as medications prepared
or reconstituted by the doctor) where the strength
cannot be readily ascertained. Without information
on the strength, it is not possible to know the dosage
of the medication dispensed. This is particularly
important where the medication has potentially
serious consequences if taken excessively. To label
a medication in an illegible manner defeats the very
purpose of drug labeling.
Case 7
A 27 month old boy weighing 13.2 Kg ran a fever
of 38.3 degrees C and was brought to see the
defendant doctor. She diagnosed fever and prescribed
indomethacin suppository 100 mg q8h. Three doses
were prescribed which were to be given over one day,
amounting to 300 mg per day. In a telephone call by
the father to the Defendant following the consultation
on 13 November 2007, the father told the defendant
doctor that the dosage she prescribed was excessive
and inappropriate. On 15 November 2007, the
defendant telephoned the father and told him that the
dosage of indomethacin prescribed was excessive and
inappropriate. The father checked the dosage from
the BNF and Lexi-comp Drug Information Handbook,
and found that the daily dosage of Indomethacin
prescribed was over 5 times the recommended dosage
of up to 4 mg/kg/day. The expert witness opined that
Indomethacin is indicated in children for the relief of
pain and inflammation in rheumatic disease and closure
of patent ductus arteriosus in premature infants.
Because of the higher risk of side effects and the
availability of other antipyretics with fewer side effects,
e.g. paracetamol, it is generally not recommended as
a first line treatment for fever in young children in the
HKMA CME Bulletin 持續醫學進修專訊 March 2015
17
Complaints & Ethics
absence of a systemic disease like rheumatic arthritis
or other autoimmune disorder. The prescription of
indomethacin as a first line drug for the relief of fever in
a young child of 27 months without an obvious identified
focus is considered inappropriate. The appropriate
dosage, even if indicated, for the minor patient who
weighed 13.2 kg should be a maximum of 15 mg two
times per day, a total of 30 mg per day at a maximum.
Hence the dosage of 300 mg for a day was ten times
the recommended dosage. Excessive dosage of
indomethacin can lead to shutdown of the kidneys,
accumulation of fluid and rectal irritation and bleeding
when given as a suppository. The Inquiry concluded
that all medical practitioners owe patients a duty of
care. The exercise of that duty includes prescribing the
appropriate medications which are specifically indicated.
The dosage of such medication must be accurate.
This is especially important in the treatment of children
where the dosage varies markedly with body weight.
Mitigations include enrollment in DCH for which she was
granted suspension of a removal order.
Case 8
The defendant doctor was charged with prescribing
in one consultation 5 drugs, namely Hexine syrup;
synbetamine; a mixture of Cocillana and Coclean syrup;
a mixture of Paracetamol suspension and Mefanamic
acid; and Paracetamol suppository 250 mg. He was
charged with failing to indicate on the drug label the
strength of Hexine and Synbetamine, and the strength
of the mixture of Cocillana and Coclean. Patient was
one year old and suffering from high fever of 39.3
degree C. The baby did not have severe coughing at
the time of consultation. The defendant claimed that
there was blocked nose, nasal discharge, sticky phlegm,
dermatitis over the face and neck. The defendant
doctor prescribed Bromhexine 4 mg/5ml, Synbetamine
containing Dexchlorpheniramine (2mg/5ml) and
Betamethasone (0.25 mg/5ml), Cocillana and Coclean
syrup with Coclean syrup containing Codeine phosphate
(9mg/5ml), Ephedrine hydrochloride (8mg/5ml) and
Promethazine hydrochloride (4mg/5ml). Paracetamol
and Mefanmic acid mixture with Paracetamol being
250 mg/5ml and Mefanamic acid being 50 mg/5ml
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HKMA CME Bulletin 持續醫學進修專訊 March 2015
before mixing. All drugs were labeled with instruction
to be taken 3 times a day and 1 gradation each time.
In the judgment, the inquiry stressed that ‘medical
practitioners in Hong Kong are in a unique position
that they can both prescribe and dispense medicine
to their patient. Consequently, the defendant might
prescribe medicine to the patient only if drug treatment
was necessary and appropriate. As a doctor who
dispenses medicine to patients, the defendant also had
the personal responsibility to ensure medication safety.
Just looking at the number of different ingredients, no
less than 12, contained in the relevant medicines, it
would be an obvious case of polypharmacy. The patient
was barely one year old and the defendant ought to
consider carefully the indication and justification for
each ingredient. The defendant frankly admitted that
he was not even aware that Promethazine was a form
of antihistamine. The combined sedation effect and
respiratory suppression effect of Dexchlorpheniramine,
Promethazine and Codeine on such a young child was
clearly overlooked by the defendant.’ More important,
the inquiry found no indication for the prescription
of Synbetamine. The use of cough suppressants
containing Codeine is not generally recommended in
children and should be avoided altogether in those
under one year old. Although the Hong Kong College
of Pediatricians did recommend that such medicine
could still be used in special cases with justifications and
explanations to parents, any doctor who prescribed it to
a child ought to be careful in ensuring medication safety.
The inquiry found no indication for the use of oral steroid.
It pointed out that the indiscriminate use of Synbetamine
on a young child with high fever from upper respiratory
infection would suppress the normal immunological
reaction and might result in spreading the infection.
I hope that the case illustrations can shed some light on how
to prescribe when attending to children in your daily practice.
You should also familiarize yourselves with The HKMA Good
Dispensing Practice Manual which is used as a yardstick in
Medical Council Inquiries. Please note that compounding of
liquid medicines and diluting of liquid medicines should be
avoided in pediatric practice. Stability data are not generally
available. I hope that the Faculty of DCH (Sydney) will assist
you with the dosage of pediatric formulations through the
internet as I discussed with them prior.
www.hkmacme.org
Name 姓名
Signature 簽名：
HKMA Membership No. or HKMA CME No.
香港醫學會會員編號或持續進修號碼：
Answer Sheet
Contact Tel No. 聯絡電話：
HKID No. 香港身份証號碼：
-
xxx(x)
March 2015
ANSWER SHEET
Please answer ALL questions and write the answers in the space provided.
SPOTlight - 1
Complete Spotlight and earn 1 CME point
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SPOTlight - 2
Complete Spotlight and earn 1 CME point
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Complete BOTH Cardiology & Dermatology cases and earn 0.5 CME point
Cardiology
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4
Dermatology
答題紙
Please return the
completed answer sheet
to the HKMA Secretariat
(Fax: 2865 0943) on or
before 15 April 2015
for documentation.
If you complete
the exercise online,
you are NOT required to
return the answer sheet by
fax.
請回答所有問題，
並於 2015 年 4 月 15 日前
將答題紙傳真或寄回
香港醫學會
( 傳真號碼：2865 0943)。
如果選擇在網上完成練習，
便無需將答題紙傳真到
秘書處。
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HKMA CME Bulletin 持續醫學進修專訊
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HKMA CME Bulletin 持續醫學進修專訊 March 2015
19
CMEnotifications
HKMA CME Programme
香港醫學會持續進修計劃
香港醫學會
CME Lecture – March & April 2015 進修講課 － 二零一五年三月及四月
THE HONG KONG
MEDICAL ASSOCIATION
Advances in the Prevention and Management of Herpes Zoster
Speaker:
Dr. David WEBER
Professor of Medicine, Pediatrics, and Epidemiology
Associate Chief Medical Officer, UNC Health Care
Medical Director, Hospital Epidemiology & Occupational Health
Schools of Medicine and Public Health
The University of North Carolina
Date:
24 March 2015 (Tuesday)
Time:
Venue:
Expected Attendance:
19:00 – 22:00
Shanghai Room I & II, Level 8,
Langham Place Hotel,
555 Shanghai Street, Kowloon
80 – 100 persons
This symposium is sponsored by Merck Sharp & Dohme (Asia) Limited
HKMA Structured CME Programme with HKS&H Session
IV: What does a General Surgeon Do Nowadays?
香港醫學會分科持續醫學進修計劃第四節：現今外科
醫生的職責是什麼 ?
Dr. SIU Wing Tai
講者：蕭永泰醫生
MBChB (CUHK), FRCSEd, FRCSEd (Gen), FCSHK, FHKAM (Surgery), Specialist in General
Surgery
香 港 中 文 大 學 內 外 全 科 醫 學 士、 英 國 愛 丁 堡 皇 家 外 科 醫 學 院 院 士、
英 國 愛 丁 堡 皇 家 外 科 醫 學 院 院 士（ 外 科 ）、 香 港 外 科 醫 學 院 院 士、
香港醫學專科學院院士（外科）、外科專科醫生
Date: 9 April 2015 (Thursday)
Time: 2:00–3:00 p.m. Light lunch starts at 1:15 pm
Venue: The HKMA Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese Club Building,
21–22 Connaught Road Central, HK
日期：二零一五年四月九日（星期四）
時間：下午二時至三時正輕膳於下午一時十五分開始
地點：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
This symposium is co-organized with Hong Kong Sanatorium & Hospital.
講課與養和醫院合辦
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)
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。其他專科學院之學分尚在申請中。
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When Tropical Storm Warning Signal No. 8 (or above) or the Black Rainstorm Warning Signal is hoisted within 3 When Tropical Storm Warning Signal No. 8 (or above) or the Black Rainstorm Warning Signal is hoisted after
hours of the commencement time, the relevant CME function will be cancelled. (i.e. CME starting at 2:00 pm will CME commencement, announcement will be made depending on the conditions as to whether the CME will be
terminated earlier or be conducted until the end of the session.
be cancelled if the warning signal is hoisted or in force any time between 11:00 am and 2:00 pm).
The function will proceed as scheduled if the signal is lowered three hours before the commencement time. (i.e. The above are general guidelines only. Individuals should decide on their CME attendance according to their own
CME starting at 2:00 pm will proceed if the warning signal is lowered at 11:00 am, but will be cancelled even if it transportation and work/home location considerations to ensure personal safety.
is lowered at 11:01 am).
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：
Please “✓” as appropriate. 請在適用處加上 ✓ 號
HKMA Member
HK$50
24 March 2015
(Tuesday)
9 April 2015
(Thursday)
Advances in the Prevention and Management of Herpes Zoster
CME Participants
HK$80
Free-of-charge
HKMA Structured CME Programme with HKS&H Year 2015
Session IV: What does a General Surgeon Do Nowadays?
I enclose herewith a cheque of
現隨表格付上支票一張作為講課之報名費用
HK$ 港幣
Name 姓名 :
HKMA Membership No. or HKMA CME No. 會員編號或進修號碼：
Mobile No. 手機號碼 :
Signature 簽名 :
（Mandatory for emergency contact or SMS 必須填寫用以緊急聯絡或接收短訊）
Fax No. 傳真 :
Date 日期：
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。
20
HKMA CME Bulletin 持續醫學進修專訊 March 2015
www.hkmacme.org
CMEnotifications
CME Lectures in April 2015
香港醫學會
Organized by
THE HONG KONG
MEDICAL ASSOCIATION
Date
: Wednesday,15 April 2015
Wednesday, 29 April 2015
Topic and Speaker
: Management of Erectile Dysfunction
in Primary Practice – An Urologist’s
Perspective
Dr. HO Kwan Lun
Malnutrient Management for Oncology
Patients
Dr. LUI Siu Fai, MH, JP
Specialist in Urology
Moderator
Clinical Professional Consultant, Division of Health
System, Policy and Management, JCSPHPC,
Faculty of Medicine, CUHK
Dr. TSANG Chun Au
: Dr. YIK Ping Yin
Committee member,
HKMA CW&S Community Network
Chairman,
HKMA CW&S Community Network
Time
: 1:00 – 2:00 p.m. Registration & Lunch
2:00 – 2:45 p.m. Lecture
2:45 – 3:00 p.m. Q&A Session
Venue
: The Hong Kong Medical Association Central Premises,
Dr. Li Shu Pui Professional Education Centre,
2/F., Chinese Club Building, 21-22 Connaught Road Central, Hong Kong
Deadline
: Monday, 30 March 2015
Fee
: Free-of-charge
Capacity
: 80. Registration is strictly required on a first-come, first-served basis. Priority will be given to
doctors practising in the Hong Kong Central, Western and Southern districts.
Enquiry
: Miss Hana YEUNG, Tel: 2527 8285
Friday, 17 April 2015
*Please call and confirm that your facsimile has been successfully transmitted to the HKMA Secretariat if you
do not receive confirmation 14 days before the event.
Sponsor
:
CME Accreditation
: Pending
REPLY SLIP
Fax: 2865 0943
HKMA Central, Western & Southern Community Network
CME Lectures in April 2015
I would like to register for the following lecture(s):
15 April 2015
Please “✓” as appropriate
29 April 2015
Name:
Mobile No.*:
HKMA No.:
Fax No.:
*Please fill in your updated mobile number so that you can be notified of your application via SMS. If you do not have a mobile phone,
the Secretariat will still issue a confirmation letter to you.
Practising location:
In Central, Western & Southern districts (Please specify *:
)
Others (Please specify:
)
* Null entry will be treated as non-Hong Kong Central, Western & Southern member registration.
Signature:
Date:
Data collected will be used and processed for the purposes related to these events only.
www.hkmacme.org
HKMA CME Bulletin 持續醫學進修專訊 March 2015
21
Learning Centre article
Doctor, how can I
help to improve my
mother’s nutrition?
Introduction
Nutrition is one of the most important factors affecting
the survival of patients on renal dialysis but unfortunately
40-70% of dialysis patients are malnourished (1) .
Emaciated renal patients have a high mortality rate
despite adequate dialysis. Causes of the malnutrition
include poor intake due to uraemia, inflammation,
vascular access infection and other concomitant
conditions. Correction of the underlying factors and
increasing the oral intake are essential in improving
patient survival. The following case may serve to
illustrate the principles in renal nutrition.
Case history
A 94-year-old patient with diabetic nephropathy had
been on haemodialysis (HD) for 4 years. Her cardiac
condition deteriorated in the past few months. Physical
examination showed that she had raised jugular venous
pressure, the liver was grossly enlarged and there
was pedal oedema up to the thighs. Her body weight
(BW) after dialysis was 46.6 Kg and she complained
of anorexia and orthopnoea. There was wasting of the
body muscles.
In view of the fluid retention, water removal
(‘ultrafiltration’) was increased during succeeding HD
and her post dialysis BW was reduced to 42 Kg after
two weeks. Her jugular venous pressure returned to
normal, there was no hepatomegaly and the orthopnoea
subsided. There was no pedal oedema but the muscle
wasting became more prominent. Her appetite has
improved.
Dr. HO Chung Ping, MH, JP
M.B.B.S.(H.K.), MRCP (UK),
FRCP (Edin), FRCP (Glasg),
FHKAM (Medicine), FHKCP,
Specialist in Nephrology
Ms. WONG Sui Lan,
Senior Registered Nurse
Nutrition in renal dialysis patients
This patient has poor dietary intake due to the heart
failure and fluid retention. The signs of malnutrition
hard been partially masked by the oedema. In this
case, her appetite improved after correction of the
heart failure and fluid overload. Knowledge of renal
nutrition management would be needed to correct her
malnutrition.
The most important aspect is to maintain adequate
protein and caloric intake. The protein intake in HD
patients should be around 1.2 g/kg/day and in this case,
the protein intake should be 50 gram per day, at least
half of which should be of high biological value proteins
such as meat and eggs. Protein intake can be measured
by ‘exchanges’ and each exchange is around 7 gram
protein. One ounce of meat or poultry or one whole egg
constitutes one exchange. White meat such as chicken
is preferred to pork or beef. For this patient, she would
need to take some 5 exchanges of high biological value
protein per day.
The actual protein can be estimated from the dietary
history but it is inaccurate. Since dietary protein is
turned into urea and excreted in the urine, the protein
intake can be calculated from the 24 hour urine urea
excretion (2) . This patient is on HD and the protein
intake cannot be calculated in such manner because
the urea was removed during HD. However, it can be
calculated from the ‘urea generation rate’ which in turn
was calculated from the blood urea levels between HDs
and the rate is proportional to the protein intake. Other
methods of nutrition assessment had been described
elsewhere (1).
Her relatives were pleased at the symptomatic
improvement but they were shocked by the degree of
muscle wasting which became more prominent after the
subsidence of oedema. Her mid-calf circumference was
22 cm. Their question was ‘doctor, how can I help to
improve my mother’s nutrition?’
22
HKMA CME Bulletin 持續醫學進修專訊 March 2015
www.hkmacme.org
Learning Centre article
From kinetic calculations, her urea generation rate was
0.094 mmol/minute and the dietary protein intake was
calculated to be 30 g/day only. Her serum phosphate
was low at 0.58 mmol/l (reference range: 0.87 to 1.45
mmol/l) compatible with low protein intake (Figure 1).
This patient has low serum phosphate due to poor
protein intake. After normalization of the intake, the
phosphate is expected to be elevated.
To prevent hyperphosphataemia, one would need to
avoid the food items with very high phosphate content
such as animal internal organs like liver etc. (Figure
2). Egg white does not contain phosphate and the
egg protein is of high biological value. It might not be
practical to ask the patient to eat 2 eggs every days but
some dietary ‘tricks’ like adding egg white to congee or
steamed egg whites can make dishes attractive to the
patients.
Figure 1: Low serum phosphate in ESRD patients may indicate malnutrition
Despite the fact that she had diabetes mellitus,
adequate calorie intake must be maintained while the
blood sugar should be controlled to within normal limits.
At the age of 94, the life expectancy is expected to be
less than 5 years and the blood sugar control could be
‘relaxed’ a bit.
The patient’s appetite has improved due to the
correction of the pulmonary congestion and it improved
further on the correction of anemia with erythropoietin.
The greatest barrier is that the patient may not have the
appetite to take in all the ‘prescribed’ food to fulfill the
protein and calories requirements. The best remedy is
to encourage small and frequent meals. Variation in the
food and cooking methods would also be useful.
The importance of serum phosphate
Patients with advanced renal failure have reduced
capacity to excrete phosphate and it is common to find
dialysis patients with high serum phosphate. Studies
consistently showed that high serum phosphate
is associated with a high mortality. Unfortunately,
phosphate is present in most food items, especially
in meat and beans, which are the sources of protein.
As a rule of the thumb, one gram of meat (protein)
contains 15 mg of phosphate and hence a 60 gram
protein diet would incur a phosphate intake of 900
mg. It is estimated that about 75% of the phosphate
would be absorbed and may contribute to the
hyperphosphataemia.
www.hkmacme.org
Figure 2: High phosphate food to avoid
Despite all these dietary measures, the serum
phosphate may still be elevated. In that case phosphate
binders would be necessary. They bind the phosphate
in the food and were excreted in the stool. Phosphate
binders can be aluminum based such aluminum
hydroxide or calcium based such as calcium carbonate
or calcium acetate. One gram of elemental calcium can
bind about 150 mg of phosphate. They are cheap and
would correct hypocalcaemia as well, but hypercalcemia
is one of the side effects. New drugs like sevelemar or
lanthanium carbonate are effective but they are much
more expensive.
It should be noted that cola drinks contains phosphoric
acid and is the cause of its brown colour. Phosphoric
acid is metabolized to phosphate in the body. One litre
of Coco-cola contains 520 mg phosphoric acid and thus
Coca-Cola is not advised in renal patients.
HKMA CME Bulletin 持續醫學進修專訊 March 2015
23
Learning Centre article
Dietary supplement
There are many dietary supplements for boosting
nutrition in the market. It ranges from simple milk
powder to those ‘renal formula’. They are milk based
and broadly speaking, they can be divided into the
‘renal’ formula and ‘non-renal’ formula. The ‘renal’
formula has low electrolytes (including sodium and
phosphate) content and high in protein (2 g/ml), taking
care of the protein need of the renal patients. Such
formulae include the ‘Nephro’ and the ‘Renilon’).
Some formula such as the Supplena has lower protein
content (1 g/ml) and is suitable for the pre-dialysis
patients. Some are available in powder form and some
as readymade liquid form and some as both. The fluid
preparation is more convenient but more expensive and
takes up storage space.
If the patient is using those products as supplement
and not as the sole nutritional source, there may be no
need to use the ‘renal formula’ because the electrolyte
load may not be high. The diet for the patient should
be assessed individually, taken into account of his
requirement and his usual diet.
Intravenous nutrition
For those emaciated patients whose oral intake is
insufficient to meet the need, sometimes parenteral
nutritional supplement is necessary. In general, enteral
nutrition is preferable to parenteral nutrition because
it is much cheaper, more physiological and safer. The
main problem with parenteral nutrition solutions is that
they have a high osmolality and it is damaging to the
peripheral veins. Although there are preparations for
peripheral veins administration, a central venous access
is preferable. For those pre-dialysis patients or those
with on continuous ambulatory peritoneal dialysis,
a Hickman’s catheter is usually used but there are
risks associated with central vein cannulation such as
pneumothorax or sepsis (Figure 3).
For some emaciated HD patients, it might be necessary
to give the nutritional supplement through the
intravenous route during the dialysis. Since there is a
vascular access in HD patients, the nutrient can be
administered during HD (Figure 4). The nutrition solution
comes in one litre bags and there was a limit to the
rate of the infusion. Since the usual dialysis is around 5
hours, the solution could not be administered in full and
some of it would have to be discarded.
Figure 4: Parenteral nutrition during HD
Conclusion
Nutrition in renal patients is receiving increasing
attention. To improve the nutrition state, it is necessary
to correct the underlying causes such as inflammation,
heart failure and anaemia. Oral feeding is to be preferred
to parenteral feeding. The limiting factor may be the
patient’s appetite and small and frequent meals are
useful. A caring family member with time and patience is
the key to the success.
Declaration of interest
Dr. HO Chung Ping is the director of the Integrated
Dialysis Facilities (HK) Ltd. There is no conflict of interest
to be declared.
References
(1) Ho Chung Ping, Wong Sui Lan, Wah Sai Ling, Louise. Nutrition screening and
assessment in Renal Dialysis Patients. HKMA CME Bulletin December 2014.
(2) Ho Chung Ping, Yuen Hing Wah, Wah Sai Ling, Louise. Rehabilitation in patients
with chronic kidney disease. HKMA CME Bulletin January 2013.
Figure 3: A Hickman’s catheter
24
HKMA CME Bulletin 持續醫學進修專訊 March 2015
www.hkmacme.org
Stay in touch…
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development, continued education, medical and health care policies, leisure and fun, etc.
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Meeting Highlights
HKMA Structured CME Programme with Hong Kong
Sanatorium & Hospital 2015
Dr. TANG Wai Man, Specialist in Orthopaedics and Traumatology, delivered a luncheon
lecture on “Joint Replacement with Robot” on Thursday, 12 February 2015 at the
HKMA Central Premises. Dr. CHAN Tak Hin kindly acted as the moderator for the
event.
Dr. CHAN Tak Hin (right) presenting a
souvenir to the speaker, Dr. TANG Wai Man
(left).
The HKMA Central, Western and Southern Community
Network (CW&SCN) ~ Dr. YIK Ping Yin
Prof. LAM Tai Pong, Professor and Chief of Postgraduate Education of the Department
of Family Medicine & Primary Care of the University of Hong Kong, gave a talk on
“Reference Framework for Preventive Care for Older Adults in Primary Care Settings”
on Wednesday, 11 February 2015.
Dr. HO Kwan Lun, Specialist in Urology, will deliver a lecture on “Management of Erectile
Dysfunction in Primary Practice – An Urologist’s Perspective” on Wednesday, 15 April
2015. Dr. LUI Siu Fai, MH, JP, Clinical Professional Consultant of the Division of Health
System, Policy and Management of the JC School of Public Health and Primary Care of
Faculty of Medicine of the Chinese University of Hong Kong, will present on “Malnutrient
Management for Oncology Patients” on Wednesday, 29 April 2015. Interested members
please refer to the announcement on p.21 for details and enrolment.
Prof. LAM Tai Pong (right, speaker) receiving
the Certificate of Appreciation from Dr. LAW
Yim Kwai (moderator) during the lecture on
11 February 2015
The HKMA Hong Kong East
Community Network (HKECN) ~
Dr. CHAN Nim Tak, Douglas
Dr. YIP Wai Man (left, speaker) receiving
a souvenir from Dr. TSANG Kin Lun
(moderator) during the lecture on
5 February 2015
Dr. TSANG Man Wo (left, speaker)
receiving a souvenir from Dr. Kenneth YIP
(moderator) during the lecture on
12 February 2015
香港房屋委員會轄下診所單位
Dr. YIP Wai Man, Specialist in Geriatric
Medicine, delivered a lecture on “Sarcopenia
in Elderly” on Thursday, 5 February 2015.
Moreover, Dr. TSANG Man Wo, Specialist
in Endocrinology, Diabetes & Metabolism,
delivered a lecture on “Role of GTSN in the
Management of Prediabetes and Diabetes” on
Thursday, 12 February 2015.
NOTICE
香港房屋委員會將於二零一五年三月以競出租金方式招租的西醫診所單位如下：
九龍深水埗澤安邨富澤樓13A號舖位
新界元朗洪福邨洪福商場13號舖位
26
HKMA CME Bulletin 持續醫學進修專訊 March 2015
24
51
暫定在2015年3月
暫定在2015年3月
www.hkmacme.org
Meeting Highlights
The HKMA Kowloon West Community
Network (KWCN) ~ Dr. TONG Kai Sing
Dr. TSANG Man Wo, Specialist in Endocrinology,
Diabetes & Metabolism, presented on “Emerging Role
of DPP4i and TZD Combination in the Management
of T2DM” on Tuesday, 3 February 2015. Dr. YIP Wai
Chun, Andrew, Specialist in Urology, delivered a lecture
on “HPV Vaccination – The Urologist’s Perspective” on
Tuesday, 10 February 2015.
Group photo taken during the lecture on
3 February 2015
From left: Dr. Raymond LAM, Dr. CHAN
Ching Pong, Dr. TSANG Man Wo
(speaker), Dr. Kenneth LEUNG (moderator)
and Dr. Bernard CHAN
Group photo taken during the lecture on
10 February 2015
From left: Dr. Raymond LAM, Dr. CHAN
Ching Pong (moderator), Dr. Andrew YIP
(speaker), representative from sponsor
and Dr. Bernard CHAN
The HKMA New Territories West Community Network
(NTWCN) ~ Dr. CHEUNG Kwok Wai, Alvin
Dr. MA Pui Shan, Specialist in Endocrinology, Diabetes & Metabolism, gave a talk on “The
Practical Issues in Diabetes Mellitus Management” on Thursday, 5 February 2015.
Dr. MA Pui Shan (right, speaker) receiving
a souvenir from Dr. LEE Huen (moderator)
during the lecture on 5 February 2015
The HKMA Shatin Doctors Network (SDN) ~ Dr. FUNG Yee Leung, Wilson and Dr. MAK
Wing Kin
The following lectures will be held in late March and April:
Date
Wednesday, 25 March 2015
Wednesday, 15 April 2015
Wednesday, 29 April 2015
Topic
Update in the Management
of Haemorrhoidal Disease
Update in Management of
Acne Vulgaris
Nutrition Intervention for
Prevention of Eczema
Speaker
Dr. LAM Ching Wa, Steve
Dr. HO Ka Keung
Dr. CHOW Chung Mo
Registration/Enquiry
Ms. Cherie LI
T: 2909 4802
Ms. Wendy CHENG
T: 2824 0333
Ms. Cathy LAU
T: 2859 6324
The HKMA Yau Tsim Mong Community Network (YTMCN) ~
Dr. LAM Tzit Yuen, David
A talk on “Optimizing Glycemic Control to Improve Renal Outcomes: Findings from
ADVANCE-ON” was presented by Dr. LAM Man Fai, Specialist in Nephrology, on
Tuesday, 10 February 2015.
Dr. CHAN Wai Kwong (left, moderator)
presenting a souvenir to Dr. LAM Man Fai
(speaker) during the lecture on 10 February
2015
www.hkmacme.org
HKMA CME Bulletin 持續醫學進修專訊 March 2015
27
CMECalendar
March 2015
16 Mar 2015
(Mon)
8:30 – 9:30 am
Union Hospital – Department of Paediatrics
Paediatrics Departmental Round
New Seminar Room 2, 2/F, Hospital Building, Union Hospital
Ms. Kay Ho - Tel: 2608 3800
17 Mar 2015
(Tue)
1:00 – 3:00 pm
Hong Kong Medical Association – Kowloon West Community Network
1) Understanding on Acid Pocket
2) Update on Pharyngitis Management
Crystal Room I-III, 30/F, Panda Hotel, 3 Tsuen Wah Street, Tsuen Wan, NT
Miss Hana Yeung - Tel: 2527 8285
17 Mar 2015
(Tue)
1:45 – 3:00 pm
Hong Kong Medical Association – Tai Po Community Network
Use of Dydrogesterone in DUB
潮江春－新界大埔新達廣場1樓001-003號
Ms. Nuu Tsang - Tel: 8100 9403
17 Mar 2015
(Tue)
3:30 – 5:30 pm
Hong Kong College of Psychiatrists
Kwai Chung Hospital
Level 1 Topic 15: General Adult Psychiatry – Explain treatment to a pregnant patient
Meeting Room, 1/F, Admin Block, Kwai Chung Hospital
Ms. Kaman Chan - Tel: 2871 8717
17 Mar 2015
(Tue)
3:30 – 5:30 pm
17 Mar 2015
(Tue)
3:30 – 5:30 pm
17 Mar 2015
(Tue)
3:30 – 5:30 pm
17 Mar 2015
(Tue)
3:30 – 5:30 pm
#
28
Hong Kong College of Psychiatrists
Kwai Chung Hospital
Level 2 Topic 15: Old Age Psychiatry – Discussion with the Consultant on management
of dementia
Seminar Room, 1/F, Admin Block, Kwai Chung Hospital
Ms. Kaman Chan - Tel: 2871 8717
Hong Kong College of Psychiatrists
Pamela Youde Nethersole Eastern Hospital
Queen Mary Hospital
Level 1 Topic 15: General Adult Psychiatry – Explain treatment to a pregnant patient
Room 36, 1/F, East Block, Pamela Youde Nethersole Eastern Hospital
Ms. Kaman Chan - Tel: 2871 8717
Hong Kong College of Psychiatrists
Kowloon Hospital
United Christian Hospital
Level 1 Topic 15: General Adult Psychiatry – Explain treatment to a pregnant patient
Conference Room, Room 2080, 2/F, PYPC
Ms. Kaman Chan- Tel: 2871 8717
Hong Kong College of Psychiatrists
Kowloon Hospital
United Christian Hospital
Level 2 Topic 15: Old Age Psychiatry – Discussion with the Consultant on management
of dementia
Conference Room 2, Kowloon Hospital
Ms. Kaman Chan - Tel: 2871 8717
17 Mar 2015
(Tue)
3:30 – 5:30 pm
Hong Kong College of Psychiatrists
Pamela Youde Nethersole Eastern Hospital
Queen Mary Hospital
Level 2 Topic 15: Old Age Psychiatry – Discussion with the Consultant on management
of dementia
J2 Seminar Room, Queen Mary Hospital
Ms. Kaman Chan - Tel: 2871 8717
17 Mar 2015
(Tue)
3:30 – 5:30 pm
Hong Kong College of Psychiatrists
HA – New Territories East Cluster
Level 1 Topic 15: General Adult Psychiatry – Explain treatment to a pregnant patient
Multicentre Seminar Room, Tai Po Hospital
Ms. Kaman Chan - Tel: 2871 8717
17 Mar 2015
(Tue)
3:30 – 5:30 pm
Hong Kong College of Psychiatrists
HA – New Territories East Cluster
Level 2 Topic 15: Old Age Psychiatry – Discussion with the Consultant on management of
dementia
Multicentre Seminar Room, Tai Po Hospital
Ms. Kaman Chan - Tel: 2871 8717
17 Mar 2015
(Tue)
3:30 – 5:30 pm
Hong Kong College of Psychiatrists
Castle Peak Hospital
Level 1 Topic 15: General Adult Psychiatry – Explain treatment to a pregnant patient
Kaizen Room, Block D, Castle Peak Hospital
Ms. Kaman Chan - Tel: 2871 8717
17 Mar 2015
(Tue)
3:30 – 5:30 pm
Hong Kong College of Psychiatrists
Castle Peak Hospital
Level 2 Topic 15: Old Age Psychiatry – Discussion with the Consultant on management
of dementia
Seminar Room 4, Block F, Castle Peak Hospital
Ms. Kaman Chan - Tel: 2871 8717
18 Mar 2015
(Wed)
12:45 – 2:00 pm
Hospital Authority – Our Lady of Maryknoll Hospital
Grand Round/Journal Club (Wednesday Educational Meeting January-March 2015)
Conference Room D, 1/F, OPD Block, Our Lady of Maryknoll Hospital
Ms. Clara Tsang - Tel: 2354 2440
18 Mar 2015
(Wed)
4:15 – 5:15 pm
Hong Kong University – Department of Obstetrics & Gynaecology
Tumour Board Meeting – clinical-pathological conference on gynaecological oncology
cases
Rm 215, 2/F, Seminar Room, Clinical Pathology Building, Queen Mary Hospital
Ms. Phyllis Kwok - Tel: 2255 4518
19 Mar 2015
(Thu)
1:00 – 3:00 pm
Hong Kong Medical Association – Hong Kong East Community Network
Practical Tips for GERD Management
5/F, Duke of Windsor Social Service Building, 15 Hennessy Road, Wanchai, Hong Kong
Ms. Candice Tong - Tel: 2527 8285
19 Mar 2015
(Thu)
1:00 – 3:00 pm
Hong Kong Medical Association – New Territories West Community Network
Emerging Role of DPP4i and TZD Combination in the Management of T2DM
Plentiful Delight Banquet, 1/F, Ho Shun Tai Building, 10 Sai Ching Street, Yuen Long
Miss Hana Yeung - Tel: 2527 8285
1
1
19 Mar 2015
(Thu)
1:00 – 3:00 pm
Hospital Authority – United Christian Hospital
Hong Kong College of Family Physicians
Hong Kong Medical Association – Kowloon East Community Network
Certificate Course for GPs 2015 – Management of Chronic Hepatitis B
V Cuisine, 6/F, Holiday Inn Express Hong Kong Kowloon East, 3 Tong Tak Street,
Tseung Kwan O
Ms. Polly Tai - Tel: 3513 3430
19 Mar 2015
(Thu)
6:30 – 9:30 pm
Hong Kong Medical Association
Medical Protection Society
Mastering Shared Decision Making
HKMA Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese Club Building, 21-22
Connaught Road, Central, Hong Kong
HKMA CME Dept. - Tel: 2527 8452
20 Mar 2015
(Fri)
1:00 – 2:00 pm
Tuen Mun Hospital – Department of Obstetrics & Gynaecology
CME Programme for January-June 2015
Room SB1034 A&B, Conference Room, 1/F, Special Block, Tuen Mun Hospital
Ms. Angela Cheung - Tel: 2468 5404
20 Mar 2015
(Fri)
7:00 – 8:30 pm
Federation of Medical Societies of HK
Hong Kong Association of Speech Therapists
Certificate Course on Development and Disorders of Speech and Language in Children
2015
Lecture Hall, 4/F, Duke of Windsor Social Service Building, 15 Hennessy Road,
Wanchai, Hong Kong
Ms. Erica Hung - Tel: 2527 8898
21 Mar 2015
(Sat)
2:30 – 5:30 pm
Hong Kong Medical Association
Medical Protection Society
Mastering Professional Interactions
HKMA Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese Club Building, 21-22
Connaught Road, Central, Hong Kong
HKMA CME Dept. - Tel: 2527 8452
22 Mar 2015
(Sun)
9:00 – 6:00 pm
Hong Kong Thoracic Society
American College of Chest Physicians (HK & Macau Chapter)
Annual Scientific Meeting 2015
Hong Kong Convention & Exhibition Centre
Ms. Agnes Ku - Tel: 2155 8557
22 Mar 2015
(Sun)
1:00 – 4:00 pm
Association of Licentiates of Medical Council of Hong Kong
1) What is Mediation? And the application in medical dispute
2) Common Foot and Ankle Orthopedics Problems: – Rupture Tendon
Achilles; – Hallus Valgus
九龍亞皆老街147B號醫院管理局大樓M/F研討室
ALMCHK - Tel: 2327 2869
1
2
2
2
2
2
23 – 24 Mar 2015 Hong Kong College of Emergency Medicine
(Mon-Tue)
American Heart Association (AHA) Advanced Cardiovascular Life Support (ACLS)
HKEC Training Centre for Healthcare Management & Clinical Technology, Pamela
Youde Nethersole Eastern Hospital
Ms. Cherry Kwok - Tel: 2871 8877
2
2
2
2
24 Mar 2015
(Tue)
3:30 – 5:30 pm
Hong Kong College of Psychiatrists
Kwai Chung Hospital
Level 1 Topic 16: General Adult Psychiatry – Taking collateral information from a mother
whose son/daughter was admitted to ward
Meeting Room, 1/F, Admin Block, Kwai Chung Hospital
Ms. Kaman Chan - Tel: 2871 8717
24 Mar 2015
(Tue)
3:30 – 5:30 pm
Hong Kong College of Psychiatrists
Kwai Chung Hospital
Level 2 Topic 16: Rehabilitation & Social Psychiatry – Discussion with the Consultant on
management of treatment-resistant psychiatric conditions
Seminar Room, 1/F, Admin Block, Kwai Chung Hospital
Ms. Kaman Chan - Tel: 2871 8717
24 Mar 2015
(Tue)
3:30 – 5:30 pm
Hong Kong College of Psychiatrists
Pamela Youde Nethersole Eastern Hospital
Queen Mary Hospital
Level 1 Topic 16: General Adult Psychiatry – Taking collateral information from a mother
whose son/daughter was admitted to ward
J2 Seminar Room, Queen Mary Hospital
Ms. Kaman Chan - Tel: 2871 8717
24 Mar 2015
(Tue)
3:30 – 5:30 pm
Hong Kong College of Psychiatrists
Kowloon Hospital
United Christian Hospital
Level 1 Topic 16: General Adult Psychiatry – Taking collateral information from a mother
whose son/daughter was admitted to ward
Room 7, 1/F, Block P (P-1C), United Christian Hospital
Ms. Kaman Chan - Tel: 2871 8717
24 Mar 2015
(Tue)
3:30 – 5:30 pm
Hong Kong College of Psychiatrists
Pamela Youde Nethersole Eastern Hospital
Queen Mary Hospital
Level 2 Topic 16: Rehabilitation & Social Psychiatry – Discussion with the Consultant on
management of treatment-resistant psychiatric conditions
Room 36, 1/F, East Block, Pamela Youde Nethersole Eastern Hospital
Ms. Kaman Chan - Tel: 2871 8717
24 Mar 2015
(Tue)
3:30 – 5:30 pm
Hong Kong College of Psychiatrists
Kowloon Hospital
United Christian Hospital
Level 2 Topic 16: Rehabilitation & Social Psychiatry – Discussion with the Consultant on
management of treatment-resistant psychiatric conditions
Conference Room 2, Kowloon Hospital
Ms. Kaman Chan - Tel: 2871 8717
24 Mar 2015
(Tue)
3:30 – 5:30 pm
Hong Kong College of Psychiatrists
HA – NT East Cluster
Level 1 Topic 16: General Adult Psychiatry – Taking collateral information from a mother
whose son/daughter was admitted to ward
Multicentre Seminar Room, Tai Po Hospital
Ms. Kaman Chan - Tel: 2871 8717
2
1
1
1
1
1
2.5
1
10#
2.5
5
3
10
2
2
2
2
2
2
2
for whole function
HKMA CME Bulletin 持續醫學進修專訊 March 2015
www.hkmacme.org
CMECalendar
24 Mar 2015
(Tue)
3:30 – 5:30 pm
24 Mar 2015
(Tue)
3:30 – 5:30 pm
Hong Kong College of Psychiatrists
HA-NT East Cluster
Level 2 Topic 16: Rehabilitation & Social Psychiatry – Discussion with the Consultant on
management of treatment-resistant psychiatric conditions
Multicentre Seminar Room, Tai Po Hospital
Ms. Kaman Chan - Tel: 2871 8717
Hong Kong College of Psychiatrists
Castle Peak Hospital
Level 1 Topic 16: General Adult Psychiatry – Taking collateral information from a mother
whose son/daughter was admitted to ward
Kaizen Room, Block D, Castle Peak Hospital
Ms. Kaman Chan - Tel: 2871 8717
24 Mar 2015
(Tue)
3:30 – 5:30 pm
Hong Kong College of Psychiatrists
Castle Peak Hospital
Level 2 Topic 16: Rehabilitation & Social Psychiatry – Discussion with the Consultant on
management of treatment-resistant psychiatric conditions
Seminar Room 4, Block F, Castle Peak Hospital
Ms. Kaman Chan - Tel: 2871 8717
24 Mar 2015
(Tue)
7:00 – 10:00 pm
Hong Kong Medical Association
Advances in the Prevention and Management of Herpes Zoster
Shanghai Room I & II, Level 8, Langham Place Hotel, 555 Shanghai Street, Mongkok,
Kowloon
HKMA CME Dept. - Tel: 2527 8452
25 Mar 2015
(Wed)
12:45 – 2:00 pm
Hospital Authority – Our Lady of Maryknoll Hospital
Grand Round/Journal Club (Wednesday Educational Meeting January-March 2015)
Conference Room D, 1/F, OPD Block, Our Lady of Maryknoll Hospital
Ms. Clara Tsang - Tel: 2354 2440
25 Mar 2015
(Wed)
1:00 – 3:00 pm
Hong Kong Medical Association – Shatin Doctors Network
Update in the Management of Haemorrhoidal Disease
Jasmine Room, Level 2, Royal Park Hotel, Shatin
Ms. Cherie Li - Tel: 2909 4802
25 Mar 2015
(Wed)
1:30 – 3:30 pm
Hong Kong Medical Association
Medical Protection Society
Mastering Adverse Outcomes – 2 hours
Eaton, Hong Kong, 380 Nathan Road, Kowloon
HKMA CME Dept. - Tel: 2527 8452
25 Mar 2015
(Wed)
4:15 – 5:15 pm
Hong Kong University – Department of Obstetrics & Gynaecology
Tumour Board Meeting – clinical-pathological conference on gynaecological oncology
cases
Rm 215, 2/F, Seminar Room, Clinical Pathology Building, Queen Mary Hospital
Ms. Phyllis Kwok - Tel: 2255 4518
26 Mar 2015
(Thu)
8:30 – 10:30 am
Hong Kong Sanatorium & Hospital – Orthopaedic & Sports Medicine Centre
Academic Professional Development Meeting 2015 of OSMC HKSH (Every Fourth Thursday
of the Month)
Hong Kong Sanatorium & Hospital
Ms. Cheng Hoi Yan - Tel: 2835 7890
27 Mar 2015
(Fri)
1:00 – 2:00 pm
Tuen Mun Hospital – Department of Obstetrics & Gynaecology
CME Programme for January-June 2015
Room SB1034 A&B, Conference Room, 1/F, Special Block, Tuen Mun Hospital
Ms. Angela Cheung - Tel: 2468 5404
27 Mar 2015
(Fri)
1:00 – 3:00 pm
Hong Kong Medical Association – Yau Tsim Mong Community Network
Updated Diagnosis and Management of Male Pattern Hair Loss
Pearl Ballroom, Level 2, Eaton, Hong Kong, 380 Nathan Road, Kowloon
Ms. Candice Tong - Tel: 2527 8285
27 Mar 2015
(Fri)
7:00 – 8:30 pm
Federation of Medical Societies of Hong Kong
Hong Kong Association of Speech Therapists
Certificate Course on Development and Disorders of Speech and Language in Children
2015
Lecture Hall, 4/F, Duke of Windsor Social Service Building, 15 Hennessy Road,
Wanchai, Hong Kong
Ms. Erica Hung - Tel: 2527 8898
28 March 2015
(Sat)
9:30 – 11:30 am
Hospital Authority
Hong Kong College of Community Medicine
Case presentations and Journal presentations in areas related to Administrative
Medicine
Room 524N, 5/F, Hospital Authority Building, 147B Argyle Street, Kowloon
Ms. Yandy Ho - Tel: 2871 8745
30 – 31 Mar 2015 Hong Kong College of Emergency Medicine
American Heart Association (AHA) Pediatric Advanced Life Support (PALS) Courses
(Mon-Tue)
HKEC Training Centre for Healthcare Management & Clinical Technology, Pamela
Youde Nethersole Eastern Hospital
Ms. Cherry Kwok - Tel: 2871 8877
31 Mar 2015
(Tue)
1:00 – 3:00 pm
Hong Kong Medical Association – Kowloon West Community Network
Management of Post Herpetic Neuralgia in an Era of Aging Population
Crystal Room I-III, 30/F, Panda Hotel, 3 Tsuen Wah Street, Tsuen Wan, NT
Miss Hana Yeung - Tel: 2527 8285
1 Apr 2015
(Wed)
4:15 – 5:15 pm
Hong Kong University – Department of Obstetrics & Gynaecology
Tumour Board Meeting – clinical-pathological conference on gynaecological oncology
cases
Rm 215, 2/F, Seminar Room, Clinical Pathology Building, Queen Mary Hospital
Ms. Phyllis Kwok - Tel: 2255 4518
1 Apr 2015
(Wed)
5:00 – 7:30 pm
Hong Kong College of Emergency Medicine
Joint Clinical Meeting & Didactic Lecture (JCM)
Lecture Theatre, G/F, Block M; Multi-Function Room, G/F, Block D; Seminar Room, G/
F, Block A, 12/F, Block R, Lecture Theatre, Queen Elizabeth Hospital
Ms. Cherry Kwok - Tel: 2871 8877
www.hkmacme.org
2
2 Apr 2015
(Thu)
8:30 – 9:30 am
Hong Kong Sanatorium & Hospital – Neurology Centre
Joint neurology – neurosurgery clinical meeting
4/F, Function Room, Hong Kong Sanatorium & Hospital
Ms. Linda Chan - Tel: 2835 7287
8 Apr 2015
(Wed)
8:30 – 9:30 am
Union Hospital
Clinical Pathologic Conference (Regular Meeting 2015)
Training Room, MIC, 8/F, Hospital Building, Union Hospital
Ms. Penny Fok - Tel: 2608 3287
8 Apr 2015
(Wed)
4:15 – 5:15 pm
Hong Kong University – Department of Obstetrics & Gynaecology
Tumour Board Meeting – clinical-pathological conference on gynaecological oncology
cases
Rm 215, 2/F, Seminar Room, Clinical Pathology Building, Queen Mary Hospital
Ms. Phyllis Kwok - Tel: 2255 4518
8 Apr 2015
(Wed)
5:00 – 7:00 pm
Hong Kong Poison Information Centre
Hospital Authority – United Christian Hospital
Monthly Meeting of HKPIC (Presentation and discussion on interesting cases of the
month)
Lecture Theatre, Block F, United Christian Hospital
Ms. Winnie Cheung - Tel: 3949 5096
9 Apr 2015
(Thu)
8:30 – 10:30 pm
Union Hospital
Association of Private Orthopaedic Surgeons
Hong Kong Sanatorium & Hospital – Orthopaedic & Sports Medicine Centre
Orthopaedic Clinical Meeting – Teleconference (Every Second Thursday of the Month)
Hong Kong Sanatorium & Hospital/Union Hospital
Ms. Cheng Hoi Yan - Tel: 2835 7890
9 Apr 2015
(Thu)
1:15 – 3:00 pm
Hong Kong Medical Association
Hong Kong Sanatorium & Hospital
HKMA Structured CME Programme with HKS&H Session 4: What does a General
Surgeon Do Nowadays?
Function Room A, HKMA Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese
Club Building, 21-22 Connaught Road Central, Hong Kong
HKMA CME Dept. - Tel: 2527 8452
10 April 2015
(Fri)
1:00 – 2:00 pm
Tuen Mun Hospital-Department of Obstetrics & Gynaecology
CME Programme for January-June 2015
Room SB1034 A&B, Conference Room, 1/F, Special Block, Tuen Mun Hospital
Ms. Angela Cheung - Tel: 2468 5404
10 Apr 2015
(Fri)
7:00 – 8:30 pm
Federation of Medical Societies of HK
Hong Kong Association of Speech Therapists
Certificate Course on Development and Disorders of Speech and Language in Children
2015
Lecture Hall, 4/F, Duke of Windsor Social Service Building, 15 Hennessy Road,
Wanchai, Hong Kong
Ms. Erica Hung - Tel: 2527 8898
11 Apr 2015
(Sat)
9:00 – 4:30 pm
Hong Kong University-Department of Surgery
Hong Kong Surgical Forum
Lecture Theatre, Cheung Kung Hai Conference Centre, Li Ka Shing Faculty of Medicine
Forum Secretary - Tel: 3917 9691
11 Apr 2015
(Sat)
2:15 – 4:15 pm
Hong Kong Medical Association
HK College of Family Physicians
HA – Our Lady of Maryknoll Hospital
Refresher Course for Health Care Providers 2014/2015–
Musculoskeletal assessments and rehabilitation
Training Room II, 1/F, OPD Block, Our Lady of Maryknoll Hospital, 118 Shatin Pass
Road, Wong Tai Sin, Kowloon
Ms. Clara Tsang - Tel: 2354 2440
14 Apr 2015
(Tue)
1:00 – 3:00 pm
Hong Kong Medical Association – Yau Tsim Mong Community Network
Treating Patient Present with Joint Pain
Pearl Ballroom, Level 2, Eaton, Hong Kong, 380 Nathan Road, Kowloon
Ms. Candice Tong - Tel: 2527 8285
14 Apr 2015
(Tue)
3:00 – 6:00 pm
Hong Kong College of Psychiatrists
CAC Lecture Module (Jan-May 2015) – B) Major disorders in general adult psychiatry;
Bipolar affective disorder I: concept, aetiology and phenomenology; Bipolar affective
disorder II: pharmacological treatment
Seminar Room, 2/F, Block J, Queen Mary Hospital
Ms. Kaman Chan - Tel: 2871 8717
14 April 2015
(Tue)
6:00 – 8:00 pm
Hong Kong College of Physicians
Palliative Medicine Grand Round
Seminar Room 2, LG1, Ruttonjee Hospital
Ms. Kathy Wong - Tel: 2991 1348
15 Apr 2015
(Wed)
1:00 – 3:00 pm
Hong Kong Medical Association – Central, Western & Southern Community
Network
Management of Erectile Dysfunction in Primary Practice – An Urologist’s Perspective
Hong Kong Medical Association Central Premises, Dr. Li Shu Pui Professional Education
Centre, 2/F, Chinese Club Building, 21-22 Connaught Road, Central, Hong Kong
Miss Hana Yeung - Tel: 2527 8285
15 Apr 2015
(Wed)
4:15 – 5:15 pm
Hong Kong University – Department of Obstetrics & Gynaecology
Tumour Board Meeting – clinical-pathological conference on gynaecological oncology
cases
Rm 215, 2/F, Seminar Room, Clinical Pathology Building, Queen Mary Hospital
Ms. Phyllis Kwok - Tel: 2255 4518
15 Apr 2015
(Wed)
6:30 – 9:30 pm
Hong Kong Medical Association
Medical Protection Society
Mastering Difficult Interactions with Patients
Eaton, Hong Kong, 380 Nathan Road, Kowloon
HKMA CME Dept. - Tel: 2527 8452
2
2
1
1
1
2
1
2
1
1
10#
2
10#
1
1
2
1
1
1
2
2
1
1
10#
5
2
1
3
2
1
1
2.5
HKMA CME Bulletin 持續醫學進修專訊 March 2015
29