SPOTlight

Transcription

SPOTlight

www.hkmacme.org July 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
Management
of Menstrual
Disorders
by Dr. CHAN Ying Tze, Viola
Dr. CHAN Kit Sheung
Continuous Renal
Replacement
Therapy (CRRT)
from ground zero
by Dr. HO Chung Ping, MH, JP
Dr. Ms. WONG Sui Lan
Surgical
Treatment
of Trigeminal
Neuralgia
by Dr. CHAN Ping Hon, Johnny
HKMA CME Bulletin
持續醫學進修專訊
Contents
Editorial 1
Spotlight 1 2
Surgical Treatment of
Trigeminal Neuralgia
Spotlight 2 7
Management of
Menstrual Disorders
Spotlight 3 17
Continuous Renal
Replacement Therapy (CRRT)
from ground zero
Spotlight 1
Surgical Treatment
of Trigeminal
Neuralgia
Cardiology 21
Spotlight 2
A Young Man with Shortness of Breath
Dermatology 23
Management of
Menstrual Disorders
A Teenager with Rough Skin
Complaints & Ethics 24
Answer Sheet 27
CME Notifications 29
Advertorial 35
Meeting Highlights 36
CME Calendar 40
Spotlight 3
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 August 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 8 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
Continuous Renal
Replacement Therapy
(CRRT) from ground zero
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。
Advertising Enquiry: 2527 8452
Fax: 2865 0943 / Email: [email protected]
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
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 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
陳家發醫生
陳業輝醫生
Family Medicine
Dr. LAM King Hei, Stanley
Dr. LI Kwok Tung, Donald, SBS, JP
林敬熹醫生
李國棟醫生
Gastroenterologist
Dr. NG Fook Hong
吳福康醫生
Radiology
Dr. CHAN Ka Fat, John
Dr. CHAN Yip Fai, Ivan
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, Reny
謝卓華醫生
顏令朱醫生
Medical Oncology
Dr. TSANG Wing Hang, Janice
曾詠恆醫生
Nephrology
Dr. CHAN Man Kam
Dr. HO Kai Leung, Kelvin
陳文岩醫生
何仲平醫生
何繼良醫生
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
NOTICE
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and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary
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contraindications. It is the responsibility of the practitioner, relying on experience and knowledge of the patient, to
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manufacturer.
The Proposals on the Method for Selecting the Chief Executive
by Universal Suffrage (the Pocket-First-Proposals) had
been voted down upon with a majority of 28 to 8 votes. Our
Legislative Councillor was among the 28 majority votes and
did not have to cry before media. But then I guessed he did
not receive the thank-you-phone-call for staying behind to
vote either. Government officials, self-claimed-politicians and
big guns stressed that Hong Kong people should then move
on and concentrate on other important, if not more important,
matters such as working hard to improve the economic status of
themselves and that of Hong Kong.
If such case was true, I would like to say proudly that doctors
were different. We had not been distracted by the Proposals
and related matters to the extent of neglecting our duties to look
after our patients, and of course to attend and to attempt CME
activities to keep ourselves updated, and to gain enough CME
points. I was not aware that the Medical Council would give
allowance, or plan to give allowance, to doctors fighting hard
for or against the Proposals in the past 20 months. Doctors are
used to multitasking. We are better than some smart-phones
and some officials. General practitioners and family doctors are
particularly trained to do so as the scope of need-to-knows and
must-knows are hard-to-believably wide. So, please proceed to
the content and wish everyone happy learning.
(Well, it is summer holiday for the kids. Do multitask again and
enjoy the holiday with your kids, or spare some leisure time in
the hot summer. Time management and striking balance are
also essential skills of general practitioners.)
Dr. CHENG Chi Man
Co-Chairman, CME Committee
SPOTlight -1
Surgical Treatment of
Trigeminal Neuralgia
Dr. CHAN Ping Hon, Johnny
MBBS(HK), FRCSEd, MMedSc(HK), FCSHK,
FHKAM(Surgery)
Specialist in Neurosurgery
INTRODUCTION
Trigeminal neuralgia is a severe facial pain in the
distribution of the trigeminal nerve. It usually affects
one side of the face. It is lightning in nature and has a
sensory trigger point on the face or in the mouth. The
patient usually enjoy pain free period in between attacks.
It is commonly occurring in the second branch (maxillary
branch) and the third branch (zygomatic branch) of the
trigeminal nerve. Medical therapy can be started when
the presentation is typical.
If the trigeminal neuralgia is not responding to the
medical therapy, the patient cannot tolerate the
medication either the side effects or intoxicated from
the medication, associate with neurological deficit or the
presentation is not typical, investigation is justified.
The early trigeminal neuralgia surgery can be dated back
in 1900; Cushing performed the Gasserian ganglion
removal.
1900
Cushing
Gasserian ganglion removal
1934
Dandy
Vascular compression as the
cause
1966
Jannetta
Transtentorial retrogasserian
microvascular decompression
1974
Sweet
Percutaneous radiofrequency
trigeminal rhizotomy
1981
Sweet
Glycerol injection rhizotomy
1983
Mullan
Balloon Catheter rhizotomy
1993
Rand
Gamma Knife treatment
Table 1. History of trigeminal neuralgia surgery
Choice of surgery
The choice of investigation is MRI examination. MRI
may show up intracranial tumour in the trigeminal area,
acoustic neuroma, cerebral multiple sclerosis or other
pathology affecting the trigeminal nerve. If a tumour
is found, it should be treated accordingly. Vessel loop
can be found in close approximation to the root entry
zone of the trigeminal nerve. The affected nerve may be
atrophic.(1) The problematic vessel should be visualized
from proximal to distal. So that a clear orientation
between the vessel and the trigeminal nerve is
established, it facilitates surgery. Multiple sclerosis can
produce trigeminal neuralgia; it may show up as multiple
sclerosis plaque in the trigeminal nerve.
There is evolution of the trigeminal neuralgia surgery in
the past century. It is related to the understanding of
the pathophysiology and the anatomy of the trigeminal
nerve.
2
HKMA CME Bulletin 持續醫學進修專訊 July 2015
These surgical treatments can be divided into nonablative and ablative treatment. The non-ablative
treatment is Microvascular Decompression. The
ablative treatments are Radiosurgery and Percutaneous
Radiofrequency Trigeminal Rhizotomy.
Microvascular Decompression (MVD)
Dandy discovered the vascular compression to the
trigeminal nerve causing trigeminal neuralgia in 1934.
It is believed that there is severe neurovascular contact
of a vessel at the root entry zone of the trigeminal
nerve. It may be arterial or venous in nature. It causes
displacement or atrophy of the trigeminal nerve. The
most common vessel involved is the superior cerebellar
artery, anterior inferior cerebellar artery and posterior
inferior cerebellar artery.(2)
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SPOTlight -1
The cause of the compression is not well known; it may
due to degeneration of the vessel, so the tortuous vessel
compresses the nerve. The direct compression and the
transmitted pulsation irritating the nerve may result in
secondary demyelination of the trigeminal nerve, which
exacerbated the neuralgia.(3)
With the advancement of microsurgery technique,
Jannetta introduced Microvascular Decompression in
1966. The idea of the Microvascular Decompression is
to dissect the vessel from the trigeminal nerve, secured
the vessel away from the trigeminal nerve. Placement
of cushioning material in between and protected the
trigeminal nerve from further contact to the vessel.
This operation is a major neurosurgical procedure, which
required general anaesthesia. Incision was made at the
post-auricular area at the junction of the transverse sinus
and the sigmoid sinus of the affected side. The dura was
opened; cerebrospinal fluid was drained to have brain
relaxation. The operative microscope magnified the
surgical view. With the advancement of the Endoscopic
instrument, it could be used alone or could be used
as adjuvants to the microscope. (4) The approach was
supracerebellar approach toward the trigeminal nerve
and the brainstem. The trigeminal nerve was inspected
from the brainstem. Arachnoid bands and adhesions
were freed in the trigeminal area. The offending vessel
at the root entry zone was identified and was carefully
dissected off from the trigeminal nerve.
Different materials are used for the cushioning purpose.
Polytetrafluoroethylene (Teflon ® ), Polyvinyl alcohol
sponge (Ivaron ® ), Polyurethane sponge, Silicone
sponge, Vascular tape, Fibrin glue, Collagen sheet
(Surgicel®, TachoComb®), Cyanoacrylate (Aron Alpha®),
Aneurysm clip, Titanium plate, Thread, Dura, tentorial
sling, Arachnoid sling are the choices for the cushion. (21)
The cushioning material was inserted between the
vessel and the trigeminal nerve; it absorbed the
transmitted vascular pulsation to the trigeminal nerve.
At the end of the operation, the dura, the bone and the
scalp were closed in layers.
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Fig. 1 Vascular compression in left trigeminal neuralgia, N-trigeminal
nerve, V-vessel
Fig. 2 Microvascular decompression, T-Teflon
Vascular compression can be identified in 84% of
patient during the operation.(5) For those patients with
no vascular compression identified during the operation,
local ablative procedures to the trigeminal nerve will be
performed. The local ablative procedures are trigeminal
root compression and intradural retrogasserian
trigeminal nerve section.(6) Cushioning material will be
placed surrounding the trigeminal nerve for further
protection. Those local ablative procedures are also
suggested when the operation is for recurrence and the
patient had a long history of trigeminal neuralgia.
The risk of the surgery is general anaesthesia,
cerebrospinal fluid leakage (1.6%), hearing deficit
(1.9%), facial numbness (9.1%), meningitis; the mortality
is around 0.1%.(2)
3
SPOTlight -1
Radiosurgery (RS)
It is an ablative procedure to the trigeminal nerve; Rand
reported the first series of Gamma Knife Radiosurgery
for trigeminal neuralgia in 1993 in Leksell Gamma Knife
Centre in Los Angeles.(7)
Radiosurgery is a day procedure. Head frame was fixed
to the skull under sedation. MRI was performed to define
the target. A single 4-mm isocenter was positioned in
the cisternal portion of the trigeminal nerve at a median
distance of 7.6 mm (range 4-14 mm) anterior to the
emergence of the nerve (retrogasserian target). A
median maximum dose of 90 Gy (range 70-90 Gy) was
delivered.(8)
Percutaneous Radiofrequency
Trigeminal rhizotomy (PRT)
This is an ablative procedure, the objective is to destroy
the A-delta and C fibers (nociceptive) while preserve
the A-alpha and beta fiber (touch). Radiofrequency
thermocoagulation is commonly used for the ablation. It
is performed under sedation. It required the cooperation
of the patient during the operation.
It is suitable for the trigeminal neuralgia arising from the
maxillary branch and the zygomatic branch.
A radiofrequency needle is inserted percutaneously
to the face. The entry point is 2.5cm lateral to the oral
commissure, aiming toward a plane 3cm anterior to
external auditory meatus and medial aspect of the
ipsilateral pupil.
The advancement of the radiofrequency needle is
guided by anatomical landmark, fluoroscopic guidance
and CT-navigation.(10, 11)
Fig. 4 Radiofrequency needle
insertion
Fig. 3 Radiosurgery planning for right trigeminal neuralgia
The success of the Radiosurgery is determined by
the target location. Pain relief is more effective when
it is close to the brainstem. However, the proximal
Radiosurgery target was associated with an increased
risk of mild to moderate facial numbness.(9)
Fig. 5 Lateral X-ray
The energy source of the radiosurgery can be x-ray
or gamma-ray. It is related to the local setting of the
institute. The efficacy and effectiveness of different
radiosurgery source haven’t been evaluated.
Fig. 6 AP X-ray
4
When the needle entered
the trigeminal foramen in the
skull base, it was advanced
further until the tip is at the
retrogasserian ganglion area.
Stimulation of the trigeminal
branch will induce trigeminal
pain. The reproduction
of the distribution of pain
confirmed the lesion target.
Thermo-coagulation will be
commenced. Most of the
patients have immediate pain
relief after the surgery. (12)
Radiofrequency allows
somatotopic nerve mapping
and selective division
lesioning. The advantage
of PRT is that it can be
performed again when there
is recurrence. It is suitable
for those patients with high
surgical risk or those not
consent for microvascular
decompression surgery.
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SPOTlight -1
Effectiveness of surgery
In a systematic review of twenty-six papers with 6,847
patients, the successful rate of MVD in controlling the
neuralgia was 83.5% (79.6-89.1) the average followup duration was 35.8 months (26.2-56.6). Most of the
patient had immediate relief of the neuralgia.(2,14)
For MVD operation with no vessel compression,
trigeminal root compression was performed. It provided
initial pain relief in 71.4%; 46.6% of patients were pain
free at follow-up of 46 months (8-60 months). 35.7%
developed facial numbness. (4) The result is slightly
inferior to those with vascular compression.
RS for trigeminal neuralgia do not produce immediate
pain relief. Pain cessation started at 6.5days after the
operation. Pain control can be achieved in 75% of patient
in 1 year. The rate of hyperesthesia was 33.3% in 6 months
and 50% in 1 year(8). For repeat radiosurgery in recurrent
trigeminal neuralgia, a systematic review of 20 studies with
a total of 626 patients showed that the median rate for
initial pain cessation was 88% (60%-100%) and the new
hypaesthesia was 33% (11%-80%).(8)
PRT provided pain relief in up to 97% of patients initially
and 58% at 5 years. (12) The complications included
diminished corneal reflex (5.7%), masseter weakness
and paralysis (4.1%), dysesthesia (1%), anesthesia
dolorosa (0.8%), keratitis (0.6%), and transient paralysis
of Cranial Nerves III and VI in 0.8%.(13)
In a medical claim analysis of trigeminal neuralgia
surgery, 51.1% have the MVD, 41.5% have the RS,
and 7.4% have the PRT. (15) There is a rising trend in
performing the MVD and RS while the PRT is in the
decreasing trend. It may be related to the effectiveness
of long-term pain control in MVD and RS.
When the trigeminal neuralgia recurs, medical therapy
should come first. MRI brain scan has to be repeated.
For those have the MVD before, re-do MVD is
possible.(16) 66% showed arachnoid adhesion around the
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Teflon felt and new vascular compression in 25%. The pain
control rate reported to be 93% with mean follow up period
of 38 months.(17) For those patient had previous ablative
procedures, it did not influence success rates.(18)
RS for recurrence after RS is possible, the success
rate is similar to the first treatment, but the toxicity is
higher than the first treatment. There are three difficult
questions for re-treat radiosurgery to be answered,
which patients to retreat, which target is optimal, and
which dose to use.(8)
Higher failure rate is observed for multiple sclerosis,
no matter which surgery is used. There is no best
treatment for trigeminal neuralgia related to multiple
sclerosis.(15, 19, 20)
Conclusions
When trigeminal neuralgia is refractory to medical
treatment, surgical treatment is indicated. Microvascular
decompression, radiosurgery and percutaneous
radiofrequency trigeminal rhizotomy are the common
options for trigeminal neuralgia surgery.
Microvascular Decompression and Percutaneous
Radiofrequency Trigeminal Rhizotomy have the advantage
of immediate pain relief after the operation. However,
there will be a delay in pain relief in Radiosurgery.
The effectiveness of pain control in Microvascular
Decompression is 83.4% in 3 year, Radiosurgery is 75%
in 1 year and percutaneous radiofrequency trigeminal
rhizotomy is 58% in 5 years. Re-treatment is possible when
the trigeminal neuralgia recurred.
Although the follow-up periods are different in these
three options, Microvascular Decompression seems to
be more effective in long-term pain control.
Key lessons
1.
2.
3.
4.
5.
Surgery is indicated when medical treatment failed.
MRI brain scan is mandatory for pre-operative evaluation.
MVD, RS and PRT are the common surgical procedures.
MVD, RS and PRT can be performed again for recurrence.
MVD have a better long-term pain control.
5
SPOTlight -1
References
(1) Leal PR, Barbier C, Hermier M, Souza MA, Cristino-Filho G, Sindou M.
Atrophic changes in the trigeminal nerves of patients with trigeminal
neuralgia due to neurovascular compression and their association with the
severity of compression and clinical outcomes. J Neurosurg. 2014 Jun;
120(6): 1484-95.
(2) Xia L, Zhong J, Zhu J, Wang YN, Dou NN, Liu MX, Visocchi M, Li ST.
Effectiveness and safety of microvascular decompression surgery for
treatment of trigeminal neuralgia: a systematic review. J Craniofac Surg.
2014 Jul; 25(4):1413-7.
(3) Stine Maarbjerg, Frauke Wolfram, Aydin Gozalov, Jes Olesen and Lars
Bendtsen. Significance of neurovascular contact in classical trigeminal
neuralgia. BRAIN 2015: 138; 311–319.
(4) Bohman, Leif-Erik. Fully endoscopic microvascular decompression for
trigeminal neuralgia: technique review and early outcomes. Neurosurgical
focus [1092-0684] yr: 2014 vol: 37 iss: 4 pg: E18.
(5) Ko AL, Ozpinar A, Lee A, Raslan AM, McCartney S, Burchiel KJ. Longterm efficacy and safety of internal neurolysis for trigeminal neuralgia
without neurovascular compression. J Neurosurg. 2015 May; 122(5):
1048-57.
(6) Jian Cheng, Ding Lei, Heng Zhang, Ke Mao. Trigeminal root compression
for trigeminal neuralgia in patients with no vascular compression. Acta
Neurochir (2015) 157:323–327.
(7) Rand R.W. Jacques D.B. Melbye R.W. Copcutt B.G. Levenick M.N. Fisher
M.R. Leksell Gamma Knife Treatment of Tic Douloureux. Stereotact Funct
Neurosurg 1993; 61:93-102.
(8) Tuleasca C, Carron R, Resseguier N, Donnet A, Roussel P, Gaudart J,
Levivier M, Régis J. Repeat Gamma Knife surgery for recurrent trigeminal
neuralgia: long-term outcomes and systematic review. J Neurosurg. 2014
Dec; 121 Suppl: 210-21.
(9) Xu Z, Schlesinger D, Moldovan K, Przybylowski C, Sun X, Lee CC, Yen
CP, Sheehan J. Impact of target location on the response of trigeminal
neuralgia to stereotactic radiosurgery. J Neurosurg. 2014 Mar; 120(3):
716-24.
(10) Gusmão S, Oliveira M, Tazinaffo U, Honey CR. Percutaneous trigeminal
nerve radiofrequency rhizotomy guided by computerized tomography
fluoroscopy. Technical note. J Neurosurg. 2003; 99(4): 785–786.
(11) Xu SJ, Zhang WH, Chen T, Wu CY, Zhou MD. Neuronavigator-guided
percutaneous radiofrequency thermocoagulation in the treatment of
intractable trigeminal neuralgia. Chin Med J (Engl) 2006; 119(18): 1528–
1535.
(12) Cheng JS, Lim DA, Chang EF, Barbaro NM. A review of percutaneous
treatments for trigeminal neuralgia. Neurosurgery. 2014 Mar; 10 Suppl
1:25-33; discussion 33.
(13) Kanpolat Y(1), Savas A, Bekar A, Berk C. Percutaneous controlled
radiofrequency trigeminal rhizotomy for the treatment of idiopathic
trigeminal neuralgia: 25-year experience with 1,600 patients.
Neurosurgery. 2001 Mar; 48(3):524-32; discussion 532-4.
(14) Nanda A, Javalkar V, Zhang S, Ahmed O. Long term efficacy and
patient satisfaction of microvascular decompression and gamma
knife radiosurgery for trigeminal neuralgia. J Clin Neurosci. 2015 May;
22(5):818-22.
(15) Sivakanthan S, Van Gompel JJ, Alikhani P, van Loveren H, Chen R,
Agazzi S. Surgical management of trigeminal neuralgia: use and costeffectiveness from an analysis of the Medicare Claims Database.
Neurosurgery. 2014 Sep; 75(3):220-6; discussion 225-6.
(16) Gu W, Zhao W. Microvascular decompression for recurrent trigeminal
neuralgia. J Clin Neurosci. 2014 Sep; 21(9):1549-53.
(17) Yang DB, Jiang DY, Chen HC, Wang ZM. Second microvascular
decompression for trigeminal neuralgia in recurrent cases after
microvascular decompression. J Craniofac Surg. 2015 Mar; 26(2):491-4.
6
(18) Bakker NA, Van Dijk JM, Immenga S, Wagemakers M, Metzemaekers JD.
Repeat microvascular decompression for recurrent idiopathic trigeminal
neuralgia. J Neurosurg. 2014 Oct; 121(4):936-9.
(19) Montano N, Papacci F, Cioni B, Di Bonaventura R, Meglio M. What is the
best treatment of drug-resistant trigeminal neuralgia in patients affected by
multiple sclerosis? A literature analysis of surgical procedures. Clin Neurol
Neurosurg. 2013 May; 115(5):567-72.
(20) Mohammad-Mohammadi A, Recinos PF, Lee JH, Elson P, Barnett
GH. Surgical outcomes of trigeminal neuralgia in patients with multiple
sclerosis. Neurosurgery. 2013 Dec; 73(6):941-50; discussion 950.
(21) Toda H, Goto M, Iwasaki K. Patterns and variations in microvascular
decompression for trigeminal neuralgia. Neurol Med Chir (Tokyo). 2015
May 15; 55(5):432-41.
Q&A Self-assessment
questions
Complete this
course and earn
1 CME Point
Answer these on page 27 or make an online submission at: www.hkmacme.org
Please indicate whether the following statements are true or false.
1
2
3
4
5
6
7
8
9
10
Surgery is the only treatment for trigeminal
neuralgia.
Radiosurgery for trigeminal neuralgia requires
general anaesthesia.
Uncooperative patient is contraindicated
to percutaneous radiofrequency trigeminal
rhizotomy.
MRI brain scan is mandatory for the surgical
planning for trigeminal neuralgia surgery.
MVD is not the surgical option for recurrence of
trigeminal neuralgia.
Radiosurgery for trigeminal neuralgia can only be
performed once.
Nothing can be done, if there is no vascular
compression found in the proposed
microvascular decompression operation.
Multiple sclerosis can cause trigeminal neuralgia.
Microvascular decompression is an effective
treatment for multiple sclerosis.
Gamma Knife is the only way to deliver
radiosurgery in Trigeminal neuralgia.
Answers to June 2015
Management of Epilepsy: Antiepileptic Drug
1.T 2.T 3.F 4.T 5.T 6.F 7.F 8.T
9.F
10.T
Laparoscopic Surgery for Colorectal Cancer
1.F 2.T 3.T 4.T 5.F 6.T 7.F 8.T
9.F
10.T
Putting the Better Back in Beta-blocker:
Expert Opinion on the Role of Vasodilating Beta-blockers in
Hypertension Management (for the Hong Kong Advisory Council on
Antihypertensives)
1.T 2.T 3.F 4.F 5.T 6.T 7.F 8.F 9.T 10.T
www.hkmacme.org
SPOTlight -2
Management of
Menstrual Disorders
Dr. CHAN Ying Tze, Viola
MBBS (HK), MRCOG, FHKAM (O&G)
Resident Specialist, Department of O&G,
Kwong Wah Hospital
Dr. CHAN Kit Sheung
BM (Jinan); FHKAM (Obstetrics & Gynaecology);
FHKCOG; FRCOG
Consultant, Department of O&G, Kwong Wah Hospital
INTRODUCTION
Normal menstrual cycle refers to the cyclical change of
the endometrium in women of reproductive age. This
is controlled by the hypothalamo-pituitary-ovarian axis.
Gonadotrophin-releasing hormone (GnRH) is released
by the hypothalamus in pulsatile fashion and travels
through the small blood vessels of the pituitary portal
system to the anterior pituitary, where it stimulates the
production of follicule-stimulating hormone (FSH) and
luteinizing hormone (LH). FSH and LH act on the ovary
to facilitate growth of ovarian follicles and ovulation
respectively. A normal menstrual cycle refers to regular
cycle length of 21-35 days,1 with moderate menstrual
flow lasting 3-7 days.2
Menstrual disorders include abnormal cycle length,
duration of menstrual flow, amount of menstrual flow,
or discomfort experienced during menstrual cycle. The
most common complaints on menstruation encountered
in general practice are heavy menstrual bleeding
(Menorrhagia), painful periods (Dysmenorrhoea),
infrequent menses (oligomenorrhoea), amenorrhoea,
intermenstural bleeding and prolonged menstrual flow.
HEAVY MENSTRUAL BLEEDING
Heavy menstrual bleeding or menorrahgia is defined as
excessive menstrual blood loss which interferes with
a woman’s physical, social, emotional and/or material
quality of life. 3 In research setting, menorrhagia is
defined as total menstrual blood loss of more than 80ml,
but this is not used clinically as menstrual blood loss is
not measured.4 Heavy menstrual bleeding is a symptom
but not a diagnosis. A detailed history and physical
examination should be performed to look for its cause.
www.hkmacme.org
CAUSES
In most women, a cause could not be found. In this
case, the diagnosis is by exclusion and is termed
dysfunctional uterine bleeding (DUB). Other common
causes include uterine factors, such as uterine fibroids,
adenomyosis, endometrial polyps, endometrial
hyperplasia or uterine cancer.
UTERINE FIBROIDS
Uterine fibroids are benign overgrowths of the
myometrium. They are common, occurring in 3 in
10 women of Chinese ethnicity. 5 Uterine fibroids are
classified according to their location in the uterus into (1)
subserosal (on the outer surface of uterus); (2) intramural
(within the uterine wall); and (3) submucosal (protruding
into the uterine cavity). Sometimes a submucosal fibroid
may present as a fibroid polyp with a stalk, resembling a
large grape. Not all uterine fibroids cause menorrhagia,
especially subserosal fibroids or small intramural fibroids
which do not interfere with the uterine cavity. Uterine
fibroids can cause other symptoms such as urinary or
bowel frequency (pressure symptoms) by increasing the
pressure onto adjacent organs, or presence of pelvic
mass due to an enlarged uterus.
ADENOMYOSIS
Adenomyosis is a benign condition in which there is
ectopic endometrial tissue within the myometrium,
causing thickening of the uterine wall and a globularly
enlarged uterus. Due to the presence of ectopic
endometrial tissue in the myometrium, the woman
usually complains of severe dysmenorrhoea apart
from menorrhagia. Otherwise, it can cause pressure
symptoms and presence of pelvic mass similar to uterine
fibroids.
7
SPOTlight -2
ENDOMETRIAL POLYP
Endometrial polyp is an overgrowth of the endometrium
and is usually benign. By increasing the surface area
of the endometrium, it can cause menorrhagia. In
some women, it may cause intermenstrual bleeding or
asymptomatic at all. Endometrial polyp is sometimes
picked up by ultrasound with the presence of thickened
endometrium or intracavity shadow, but the diagnosis
must be confirmed by a hysteroscopy.
ENDOMETRIAL HYPERPLASIA
Endometrial hyperplasia refers to abnormal overgrowth
of the endometrium and is diagnosed by histology.
It is more common in women ≥ 40 years old, obese,
nulliparous or with hypertension or diabetes. 6,7 The
World Health Organization (WHO) classified endometrial
hyperplasia according to (1) the glandular/stromal
architectural pattern of the endometrium, which
is described as either simple or complex; (2) The
presence or absence of nuclear atypia. 8 In patients
with endometrial hyperplasia with atypia, the risk of
concurrent endometrial cancer is 50%.9-14
UTERINE CANCER
Uterine cancer is divided into that of uterine corpus (CA
Corpus) and cervix uteri (CA Cervix). The most common
type of CA corpus is endometrial adenocarcinoma. 15
It can present as abnormal menstrual bleeding such
as menorrhagia or inetermesntrual bleeding, or
postmenopausal bleeding. Leiomyosarcoma is less
common cancer of the myometrium, usually presented
as rapidly enlarging fibroid with or without abnormal
vaginal bleeding. CA Cervix usually presents with
postcoital/intermenstrual bleeding, but it can also cause
menorrhagia if the tumour is vascular. However, CA
cervix, but is getting less common with the introduction
of cervical cancer screening program.
HISTORY AND PHYSICAL EXAMINATION
A detailed history should be obtained, including
past medical history of any medical disorders such
as thyroid disease, thrombocytopenia or clotting
disorders; drug history including any use of antiplatelet/anticoagulants such as aspirin or warfarin,
hormones, and in our locality, the use of traditional
Chinese medicine especially 阿膠，當歸，白鳳丸，
8
which are commonly used for menstrual problems. A
full menstrual history should be taken, including age at
menarche, previous menstrual pattern, duration of heavy
menstrual bleeding and any other abnormal vaginal
bleeding such as intermenstrual bleeding or postcoital
bleeding. Previous history of abnormal menstruation
and the investigation results should be asked. Anemic
symptoms such as dizziness and malaise should be
routinely asked. Symptoms of thyroid disorders such
recent weight change and hand tremor should be asked.
Any recent emotional stressor should be looked for.
Her contraceptive, obstetric and cervical smear history
should also be taken.
Pallor and goiter should be specifically looked for in
physical examination. Abdominal examination should
be performed to look for any pelvic mass. An enlarged
uterus of 12 weeks gravid size is usually just palpable
on abdominal palpation. Vaginal examination should
be done to look for any vaginal or cervical lesion, size,
regularity and mobility of uterus, and presence of any
adnexal mass. For women who are never sexually
active, a per-rectal examination should be done for
assessment of uterine size and presence of any adnexal
mass. Cervical smear needs not to be taken if her
cervical smear is updated according to the HKCOG
guidelines.16
INVESTIGATIONS
If the woman is 40 years old or more, endometrial
aspiration should be taken to rule out endometrial
pathology such as endometrial hyperplasia or cancer.
This is a simple office procedure. A thin plastic
tubing (Pipelle) is inserted into the uterine cavity and
endometrium is aspirated. The sensitivity is 83+/- 5%.17
Complete blood count (CBC) should be taken to
document any anaemia. Clotting profile and thyroid
function tests should be taken if clinical suspicion of
clotting disorders or thyroid disease.
A pelvic ultrasound is not always necessary in the
management of menorrhagia, unless the uterus is
palpable abdominally, or there is no response to
empirical treatment.
www.hkmacme.org
SPOTlight -2
REFERRAL TO SPECIALIST
Most women with heavy menstrual bleeding can be
managed in primary care setting. Below is a list of
conditions in which the women should be referred to
specialist for assessment:
•
•
•
•
a)
Oral Progestogen
Oral progestogen is usually given for 3-4 cycles
and is particularly useful for older women with
relative contraindication for OC pills.
b)
Depo Provera
Depo Provera is a medroxyprogesterone acetate
contraceptive injection which is given every 3
months. It may cause irregular bleeding and
bloating discomfort. Women should be warned
that ovulation may be delayed for 9 months after
stopping depo provera.
c)
Levonorgesterol-releasing intrauterine system
(LNG-IUS)
The NICE guidelines recommended
levonorgesterol-releasing intrauterine system
(LNG-IUS) as the first-line treatment for women
with menorrhagia. 3 The commercially available
LNG-IUS commonly used in Hong Kong is Mirena.
The LNG-IUS is similar to the traditional copper
intrauterine contraceptive device (IUCD), except
that Levonorgesterol is released at 20microgram
daily. 18 The levonorgesterol is a progestin which
acts on the endoemtrium to induce progressive
atrophy. 15 The insertion of LNG-IUS is simple
and can be carried out in the outpatient clinic.
A pelvic ultrasound is not a pre-requisite before
insertion, but some units prefer to scan for any
endometrial polyp or submucosal fibroids before
insertion to reduce the risk of expulsion. The LNGIUS is contraindicated in women with known or
suspected pregnancy, congenital or acquired
uterine anomaly including fibroids if they distort
the uterine cavity; known or suspected breast
cancer or other progestin-sensitive cancer, now
or in the past; known or suspected uterine or
cervical neoplasia; liver disease, including tumours,
untreated acute cervicitis or vaginitis until infection
is controlled; postpartum endometritis or infected
abortion in the past 3 months; unexplained uterine
bleeding; acute pelvic inflammatory disease
(PID) or history of PID; conditions increasing
susceptibility to pelvic infection or hypersensitivity
to any component of the LNG-IUS. The LNGIUS can last for 5 years and therefore can also
offer long-acting reversible contraception. It is
very effective in treating menorrhagia, but at the
same time it commonly causes irregular spotting,
and up to 80% of women became amenorrhoic
Pelvic mass palpable on abdominal examination
(Uterus ≥ 12 weeks gravid size)
Failed treatment in primary care
Pressure symptoms (urinary or bowel symptoms)
Suspected or confirmed malignancy
TREATMENT: FIRST LINE (Primary care)
First line treatment includes medical and hormonal
treatment.
MEDICAL TREATMENT
Anti-fibronolytic agents & non-steroidal antiinflammatory drugs (NSAIDS) are commonly used as
first- line treatment for menorrhagia. Anti-fibrinolytic
agents commonly used is tranexamic acid which is given
orally and is effective in 50% of reduction of menstrual
flow.3 NSAIDS are usually given if patient has associated
dysmenorrhoea, with 30% reduction of menstrual flow.3
HORMONAL TREATMENT
Combined oral contraceptive pills
Combined oral contraceptive pills are usually given
to women with additional need for contraception and
should not be used as a short term treatment. They are
usually given for at least 6 months and can be continued
until menopause if no contraindication arises.
Cyclical Progestogen
Progestogen can be administered for menstrual
regulation. The most commonly used forms include
oral progestogen (Norcolut or Primolut N), Depo
Provera injection and Levonorgesterol-releasing
intrauterine system (LNG-IUS). The latter two forms offer
contraception apart from treatment for menorrhagia.
www.hkmacme.org
9
SPOTlight -2
at 1 year after LNG-IUS insertion.19 This has to be
counseled specifically, as some women might not
tolerate the irregular spotting or amenorrhoea and
request premature removal of the device. Although
this is recommended as the first-line treatment for
menorrhagia in the UK, LNG-IUS is not popular
among Hong Kong population because of the
above. The woman should be given follow-up 1-2
months later to check the IUCD thread and her
symptoms.
SECOND LINE TREATMENT
(Specialist care)
Second line treatment is usually given in specialist
settings. It includes surgical treatment and non-surgical
treatment.
SURGICAL TREATMENT
Hysteroscopy & Curettage (H&C) is warranted for
women who are never sexually active to obtain
endometrial tissue to exclude endometrial pathology, or
to confirm diagnosis if there is suspected endometrial
polyps or submucosal fibroids. Hysteroscopic
polypectomy or resection of submucosal fibroids
can then be planned. Transcerivcal resection of
endometrium (TCRE) is a procedure during which
endometrium is resected hysteroscopically. There
is risk of uterine perforation and surgically induced
menopause if large amount of endometrium is resected.
Endometrium ablation can also be performed using heat
(Fluid-filled thermal balloon endometrial ablation (TBEA)
or Free fluid thermal endometrial ablation), microwave
(Microwave endometrial ablation (MEA)), Impedancecontrolled bipolar radiofrequency, 3 but they are not
commonly performed due to cost and availability.
For women with fibroids, myomectomy or hysterectomy
could be performed. Myomectomy has the advantage
of preserving the uterus but there is a small risk of
scar rupture in future pregnancy. Fibroids may also
recur. Hysterectomy is the definitive treatment for
menorrhagia. Ovaries and tubes are not removed unless
there is co-existing pathology or on request due to
strong family history of breast cancer or ovarian cancer.
These women would be surgically menopause and
fertility will be lost. Both myomectomy and hysterectomy
could be performed vaginally, laparoscopically or by
10
open surgery depending on the size of uterus, coexisting pathology and level of expertise available.
Other non-surgical treatment for fibroids include uterine
artery embolisation, Magnetic resonance (MI) imageguided percutaneous laser ablation of uterine fibroids;3
Magnetic resonance (MI) Guided Focused ultrasound
treatment, but they are less commonly used limited by
availability and cost. The use of danazol or GnRHa are
associated with significant side effects and are seldom
used.3
For patients with endometrial hyperplasia, a 6-month
cause of progestogen therapy either in oral form or
LNG-IUS is given, followed by repeated endometrial
aspiration to ascertain successful cure. Hysterectomy is
indicated for patients with endometrial hyperplasia with
atypia, or confirmed cancer.
DYSMENORRHOEA
Dysmenorrhoea refers to excessive menstrual
pain. It may radiate to the back or associated with
gastrointestinal symptoms. It is classified into primary
dysmenorrhoea which is usually associated with
anovulatory cycles in the first 2 years after menarche.
No pathological cause can be found. Secondary
dysmenorrhoea refers to dysmenorrhoea associated
with pelvic pathology, most commonly endometriosis,
adenomyosis or fibroids.20 It usually happens in women
without history of dysmenorrhoea.
History and Physical Examination are similar to that of
menorrhagia. Urinary and bowel symptoms should be
specificially looked for if the pelvic pain is not solely
related to menstruation, as this may suggest other
diagnoses such as interstitial cystitis or irritable bowel
syndrome. Particular attention should be paid to look
for any adnexal mass as some women may have
endometriotic cysts. Occasionally tender nodules may
be palpated at the rectovaginal septum in patients with
endometriosis.
INVESTIGATIONS
Blood tests are not routinely taken. Mid-stream urine
for culture is indicated if there is presence of urinary
symptoms. Pelvic ultrasound is indicated if there is
suspected adnexal mass.
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SPOTlight -2
TREATMENT
Majority of women with dysmenorrhoea are treated
in the primary care with simple analgesics including
paracetamol and NSAIDS. NSAIDS work by inhibiting
prostaglandin F2α which normally increases uterine
contractility during menstrual period. The preferred
NSAIDS are ponstan and ibuprofen because of good
efficacy and safety profile.
Hormonal treatment such as combined oral
contraceptive pills or LNG-IUS are also commonly used
for treatment of dysmenorrhoea, especially if the woman
also requires contraception.
WHEN TO REFER TO SPECIALIST?
Women should be referred to specialist if
•
failed first line treatment
•
pelvic mass
•
adnexal mass
•
abdominal pain outside menstruation
For women with suspected endometriotic cyst, ovarian
cystectomy or pelvic clearance will be discussed
depending on the size of the cyst, her fertility wish and
clinical picture.
OLIGOMENORRHOEA/AMENORRHOEA
Oligomenorrhoea refers to menstrual cycle length
>35 days. Primary amenorrhoea refers to absent of
menstruation by the age of 14 without secondary sexual
characteristics; or by the age of 16 with secondary
sexual characteristics. This is more commonly
presented to paediatricians or picked up during health
check for school children. Secondary amenorrhoea
refers to absent of menstruation for 6 months or 3
menstrual cycles. Oligomenorrhoea and secondary
amenorrhoea are common complaints to general
practitioner and these would be discussed in details in
this section.
www.hkmacme.org
CAUSES
Pregnancy must be first be ruled out. Common causes
for oligomenorrhoea include polycystic ovary syndrome
(PCOS), hyperprolactinaemia, thyroid dysfunction.
Dysfunctional uterine bleeding (DUB) is diagnosed when
the above are ruled out. For secondary amenorrhoea,
causes are classified into hypothalamic, pituitary or
ovarian origin. Hypothalamic causes include trauma,
physical or emotional stress, infection (encephalitis/
meningitis), tumour or significant weight loss. Pituitary
causes include tumour, trauma, or Sheehan syndrome
which classically follows major postpartum haemorrhage
in the preceding delivery. Ovarian causes include trauma
(after radiotherapy/chemotherapy/surgery), severe
genital tuberculosis, ovarian tumour, PCOS, mosaic
Turner’s syndrome and premature ovarian failure.
A detailed menstrual history should be taken. Symptoms
of hyperprolactinaemia such as galatorrhoea, headache
and visual disturbance should be particularly enquired.
Any recent life events or stress should be identified.
Any climacteric symptoms such as hot flushes should
be asked if premature ovarian failure is suspected.
Past medical history of any previous brain disease
should be noted. If the patient has psychiatric illness,
it is also important to ask for the medication as some
psychotic medication causes hyperprolactinaemia.
During physical examination, one should look for any
goiter, galactorrhoea, visual disturbance and hirsutism
(excessive facial hair). The body mass index should
be calculated. Abdominal examination and pelvic
examination should be performed to look for any pelvic
mass.
INVESTIGATIONS
If PCOS is suspected, a pelvic examination is of value to
look for any polycystic ovaries or adnexal mass. PCOS is
diagnosed if 2 out of 3 of the Rotterdam criteria 201321
is satisfied: (1) oligo/amenorrhoea (2) biochemical or
clinical hyperandrogenism (3) ultrasound showing 12
or more small ovarian follicles 2-9mm each or ovarian
volume >10ml in either ovary. Blood for testosterone
can be taken if PCOS is suspected but ultrasound was
inconclusive and no overt hirsutism. Blood for FSH and
LH are not routinely ordered as they have no value in
establishing the diagnoses.
11
SPOTlight -2
Thyroid function tests and prolactin are routinely taken
during investigation for oligo/amenorrhoea. If prolactin
level is raised, it should be double checked again as
stress or nipple stimulation can cause a false positive
results. If the prolactin level is markedly raised or the
woman has additional symptoms such as headache or
visual disturbance, a magnetic resonance imaging of
the brain is of value to look for any pituitary adenoma
(microadenoma or macroadenoma).
For women with hyperprolactinaemia with or without
pituitary microadenoma, dopamine agonist is
commonly used to lower the prolactin level. Surgery
is reserved for those with pituitary macroadenoma
which usually presented with prolactin level >1000ng/
mL. For psychiatric drug-induced hyperprolactinaemia,
a review of the drug regime could be made by the
psychiatrist. If medication adjustment is not possible,
hyperprolactinaemia could be treated with medication.
For women with secondary amenorrhoea, a course of
progestogen could be given to look for any withdrawal
bleeding. If there is no withdrawal bleeding, blood for
follicle-stimulating hormones (FSH) should be taken. A
low FSH signifies hypothalamic cause while a high FSH
(>40) may suggest premature ovarian failure. If history
is suggestive of Sheehan syndrome, blood for other
pituitary hormones should be taken and she should be
referred to the endocrinologist for further management.
For women with premature ovarian failure, psychological
support should be offered. Hormonal replacement
therapy (HRT) should be given to reduce the vasomotor
symptoms, risk of osteoporosis, and cardiac problems.
It can be given in oral form, transdermal form or as a
vaginal local application. Women should be reassured
that there is no evidence of additional breast disease if
HRT is given before the mean age of nature menopause
51.22
If Turner’s syndrome is suspected, blood should be sent
to genetics laboratory for karyotyping.
INTERMENSTRUAL BLEEDING/
PROLONGED MENSTRUAL BLEEDING
WHEN TO REFER TO SPECIALIST
•
•
•
•
PCOS with subfertility issues
Premature ovarian failure
Chromosomal/congenital diseases are suspected
Brain tumour
TREATMENT
For women with PCOS or DUB, progestogen every
3-4 months could be given if there is no spontaneous
menstruation and pregnancy is excluded. Alternatively,
combined oral contraceptive pills can be prescribed
for monthly withdrawal bleeding and contraception (if
needed). The women should also be advised to maintain
a normal BMI as obesity is associated with increased
menstrual irregularity. They should be counseled
that they have an increased risk of diabetes mellitus,
endometrial hyperplasia or cancer, infertility due to
anovulation, and should be referred to the respective
specialist should these occur.
12
Intermenstrual bleeding is common complaint and
is defined as vaginal bleeding outside menstruation.
Sometimes ovulation can cause mid cycle bleeding
which lasts 1-2 days and patients could be reassured.
Otherwise a detailed history and physical examination
are warranted to look for any cervical ectropion/polyp.
Cervical polyps can be easily avulsed with a ring forceps
at bedside. Women should be referred to specialist for
further assessment if in doubt. Other causes include
submucosal fibroid/endometrial polyp/endometrial
cancer. It can also be idiopathic.
Prolonged menstrual bleeding occurs when menstrual
bleeding last for more than 1 week. Common causes
such as cervical ectropion/polyp should be looked for.
Usually, no cause can be found. Less common causes
include cervical cancer/endometrial hyperplasia/cancer/
endometrial polyps and when the above are suspected,
women should be referred to specialist for assessment.
www.hkmacme.org
SPOTlight -2
Reduce
blood loss
Reduce
pain
√
(by 40%-50%)
X
Only needs to be taken during the period
itself, but some may have indigestion,
headache, diarrhoea
Uncommon; indigestion, diarrhoea,
headache
Non-steroidal antiinflammatory drugs
√
(by 30-50%)
√
Relieves both menorrhagia and
dysmenorrhoea
Common: indigestion; diarrhoea
May cause peptic ulcer, therefore should
give famotidine/antacids together
Levonorgestrelreleasing intrauterine
system
√
(by up to 90%)
√
Long-acting reversible contraception
Cost-effective Minimal systemic
side-effects
Common: irregular bleeding that may last
for over 6 months; minor and transient
hormone-related problems such as breast
tenderness, acne or headaches
Less common: amenorrhoea
Rare: uterine perforation at the time of
insertion
Combined oral
contraceptives
√ (by 50%)
√
Provides contraception, regulate
menstruation
Common: mood changes; headaches;
nausea; fluid retention; breast tenderness
Very rare: deep vein thrombosis; stroke;
heart attacks
Oral progestogen
(norethisterone)
√ (by 30%)
Regulate menstruation
Common (minor& transient): weight gain;
bloating; breast tenderness; headaches;
acne
Rare: depression
Irregular bleeding
Similar to oral progestogen
Less common: small loss of bone mineral
density, largely recovered when treatment
discontinued
Suitable for women who are
perimenopausal/to shrink fibroid before
surgery/UAE
Common: menopausal-like symptoms
Less common: osteoporosis, particularly
trabecular bone with longer than
6-months’ use
Tranexamic acid
Benefits
Side-effects
Injected progestogen
√
Gonadotrophinreleasing hormone
analogue
√
Endometrial ablation
√
Suitable for women with no fertility wish
and up to 10 week size uterus (with small
fibroids <3cm)
Common: vaginal discharge; increased
period pain or cramping (even if no further
bleeding); need for additional surgery
Less common: infection
Rare: perforation (but very rare with
second generation techniques)
Uterine artery
embolisation (UAE)
√
Enable conservation of uterus
Common: persistent vaginal discharge;
post-embolisation syndrome – pain,
nausea, vomiting and fever (not involving
hospitalisation)
Less common: need for additional
surgery; premature ovarian failure
particularly in women over 45 years old;
haematoma
Rare: haemorrhage; non-target
embolisation causing tissue necrosis;
infection causing septicaemia
Myomectomy
√
Enable conservation of uterus
Less common: adhesions (which may lead
to pain and/or impaired fertility); need for
additional surgery; recurrence of fibroids;
perforation (hysteroscopic route); infection
Rare: haemorrhage
Hysterectomy
√
Definitive treatment for menorrhagia;
the role of prophylactic bilateral
salpingo-oophorectomy is controversial
Common: infection
Less common: intraoperative
haemorrhage; damage to other abdominal
organs, such as the urinary tract or bowel;
urinary dysfunction – frequent passing of
urine and incontinence
www.hkmacme.org
√
√
13
SPOTlight -2
Urine pregnancy test
Infrequent menstruation
>35 days but <6 months
≥ 6 months or for equivalent to
3 menstrual cycles
Amenorrhoea
Oligomenorrhoea
History: Associated
symptoms/past health/
Drugs/hormones/Chinese Herbs
Physical Exam/PV:
Check Body Mass Index
Look for galactorrhoea/visual field/signs of Hirsutism
Blood test: Prolactin, thyroid function test +/- testosterone
Pelvic ultrasound: Look for polycystic ovaries
+/ - MRI Brain if suspect pituitary macroadenoma
Progesterone Withdrawal Test
(Medroxyprogesterone Acetate 10mg Daily x 1 week)
Negative
Positive
Blood test: LH, FSH
Prolactin
Dopamine
agonist or
surgery if
pituitary
macroaden
oma
14
Testosterone/
polycystic ovary
on USG
Normal
A course of
progesterone for
withdrawal
bleeding every 3
months or
combined oral
contraceptive pills
Abnormal
thyroid
function
Anti -thyroid
medication/
refer to medical
FSH, LH
Hypothalamicpituitary
cause
Normal
FSH/LH
Ovarian
dysfunction
/DUB
FSH,LH
Ovarian failure
Refer to specialist
Refer to A course of progesterone +/ - HRT
specialist for withdrawal bleeding
every 3 months or
combined oral
contraceptive pills
www.hkmacme.org
SPOTlight -2
Heavy Menstrual Bleeding
History: Associated symptoms/
past health/Drugs/hormones/
Chinese Herbs
Physical Exam/PV:
Pallor/Goitre/Uterine size
Blood x Complete Blood Count
+/- Thyroid function test if signs/symptoms of thyroid disease
Cervical smear if due
Endometrial aspirate if Age ≥40
Pelvic ultrasound if palpable uterus
Start Empirical treatment in primary care
if no alarming symptoms
Medical treatment:
- Tranexamic acid 500mg
QID po prn
And/Or Non-steroidal anti inflammatory drugs esp if
associated dysmenorrheoa
Hormonal treatment
- Combined oral contraceptive pills if no
contradications
-
Levonorgestrel - releasing intrauterine
system
-
Norethisterone (15mg) daily from days
5 to 26 ofthe menstrual cycle x 3-4
cycles
Injected long-acting progestogens.
-
Refer to Specialist if
- Failed first line treatment
- Palpable uterus/ Uterus >12
cm in length on ultrasound
- Suspected/ confirmed
endometrial
hyperplasia/cancer
Second line treatment (specialist)
- Gonadotrophin- releasing hormone analogue
- Endometrial ablation
- Uterine artery embolisation
- Myomectomy/Hysterectomy
- Others: Magnetic resonance (MI) image-guided percutaneous
laser ablation of uterine fibroids; Magnetic resonance (MI)
Guided Focused ultrasound treatment
www.hkmacme.org
15
SPOTlight -2
References
1. Widmaier, Eric P.; Raff, Hershel; Strang, Kewin T. (2010).
Vander’s Human Physiology: The Mechanism of Body
Function (12th ed.). New York, NY: McGrawHill. Pp 555-631.
ISBN 0-077-35001-4.
2. Womenshealth.gov. Menstruation and the Menstrual Cycle.
December 2014.
3. National Institute for Clinical Excellence (NICE). CG44 Heavy
Menstrual Bleeding. London: NICE, 2007
4. Warner PE, Critchley HO, Lumsden MA, Campbell-Brown M,
Douglas A, Murray GD. Menorrhagia II: is the 80-mL blood loss
criterion useful in management of complaint of menorrhagia?.
Am J Obstet Gynecol. 2004;190:1224-9.
5. US Census Bureau, International Data Base, 2004
6. Kurman RJ, Kaminiski PF, Norris HJ. The behaviour of
endometrial hyperplasia. A long-term study of ‘untreated’
hyperplasia in 170 women. Cancer 1985;56:403–12.
doi:10.1002/1097-0142(19850715)56:2 403:: AIDCNCR2820560233 3.0.CO;2-X
7. Fu YS, Gambone JC, Berek JS. Pathophysiology and
management of endometrial hyperplasia and carcinoma. West
J Med 1990;153:50–61.
8. Scully RE, Bonfiglio TA, Kurman, et al. Uterine corpus. In:
Histological Typing of Female Genital Tract Tumours, 2nd ed.,
Springer-Verlag, New York 1994. P. 13
9. Widra EA, Dunton CJ, McHugh M, Palazzo JP. Endometrial
hyperplasia and the risk of carcinoma. Int J Gynecol Cancer
1995;5:233–5. doi:10.1046/j.1525-1438.1995.05030233.x
10. 17 Trimble CL, Kauderer J, Zaino RJ, Silverburg S, Lim PC,
Burke JJ 2nd, et al. Concurrent endometrial carcinoma
in women with a biopsy diagnosis of atypical endometrial
hyperplasia. A Gynecologic Oncology Group study. Cancer
2006;106:812–9. doi:10.1002/cncr.21650
11. 18 Janicek MF, Rosenshein NB. Invasive endometrial cancer
in uteri resected for atypical endometrial hyperplasia. Gynecol
Oncol 1994;52:373–8. doi:10.1006/gyno.1994.1064
12. 19 Zaino RJ, Kauderer J, Trimble CL, Silverburg SG, Curtin
JP, Lim PC, et al. Reproducibility of the diagnosis of atypical
endometrial hyperplasia. A Gynecologic Oncology Group
study. Cancer 2006;106:804–11. doi:10.1002/cncr.21649
13. Shutter J, Wright TC Jr. Prevalence of underlying
adenocarcinoma in women with atypical endometrial
hyperplasia. Int J Gynecol Pathol 2005;24:313–8.
doi:10.1097/01.pgp.0000164598.26969.c3
14. Gücer F, Reich O, Tamussino K, Bader AA, Pieber D, Schöll
W, et al. Concomitant endometrial hyperplasia in patients
with endometrial carcinoma. Gynecol Oncol 1998;69:64–8.
doi:10.1006/gyno.1997.4911
15. Endometrial Cancer. Obstetrics and Gynaecology. An
evidence-based text for MRCOG. Luesley DM, Baker PN (ed).
2010. 2nd ed. London
16. Guidelines on the Management of Abnormal Cervical Cytology.
The Hong Kong College of Obstetricans and Gynaecologists.
2008
17. Guido RS, Kanbour-Shakir A, Rulin MC, Christopherson WA.
Pipelle endometrial sampling. Sensitivity in the detection of
endometrial cancer. J Reprod Med. 1995 Aug; 40(8):553-5
16
18. French, R.S., et al. Levonorgestrel-releasing (20ug/day)
intrauterine systems (Mirena) compared with other methods
of reversible contraceptive. BJOG: An international Journal of
Obstetrics & Gynaecology, 2000, 107, 10:1218-1225.
19. Stewart A, Cummins C, Gold L et al. The effectiveness of the
levonorgestrel-releasing intrauterine system in menorrhagia: a
systematic review. Br J Obstet Gynaecol 2001; 108:74-86
20. Dysmenorrhoea. Obstetrics and Gynaecology. An evidencebased text for MRCOG. Luesley DM, Baker PN (ed). 2010. 2nd
ed. London
21. Rotterdam ESHRE/ASRE-Sponsored PCOS consensus
workshop group. Revised 2003 consensus on diagnostic
criteria and long-term health risks related to polycystic ovary
syndrome (PCOS). Hum Reprod 2004; 10: 41-7
22. When does menopause usually take place? Family Health
Service. Department of Health, The Government of the Hong
Kong Special Administrative Region. www.fhs.gov.hk/english/
health_info/faq/women_health/WH2_5_5.html
Questions:
Q&A Self-assessment
Complete this
course and earn
1 CME Point
1.
Pelvic ultrasound is a routine investigation in
women with menorrhagia.
2.
Cervical smear should be routinely taken during
assessment for menorrhagia.
3.
Endometrial sampling should be performed
in women ≥ 40 years of age or with other risk
factors.
4.
Levonorgestrel-releasing Intrauterine System
(LNG-IUS) is commonly used to treat
menorrhagia in Hong Kong.
5.
Non-steroidal anti-inflammatory drugs (NSAIDS)
should not be prescribed to women with
menorrhagia alone.
6.
Endometrial ablation should be offered to women
who wants to retain their uterus for future fertility.
7.
Serum testosterone is mandatory in diagnosis of
polycystic ovary syndrome.
8.
All women with oligomenorrhoea/Amenorrhoea
should be referred to specialist.
9.
Progestogen should not be given on the first
presentation of oligomenorrhoea/amenorrhoea.
10. All women with MRI evidence of pituitary
microadenoma should be referred to
neurosurgeons for assessment.
www.hkmacme.org
SPOTlight -3
Continuous Renal
Replacement Therapy (CRRT)
from ground zero
Continuous renal replacement therapy (CRRT) is a familiar
term in the intensive care units (ICU). It is a commonly
used procedure to provide renal support to critically
ill patients such as those with multi-organ failure. For
patients with unstable cardiovascular status, conventional
haemodialysis may pose a significant risk. CRRT is
mainly a haemofiltration process which can provide
renal support with less stress on the body. It is getting
increasingly popular in the last 20 years.
The operation of the CRRT machine might look
complicated and intimidating. Contrary to its appearance,
its underlying principle is simple. The author was involved in
its evolution from the beginning (‘ground zero’) and tracing
its developmental history would be interesting and would
help the understanding of the procedure.
Problems of the early haemodialysis and the ‘dry
dialysis’
The development of haemofiltration stemmed from the
limitations of haemodialysis in its early days. It was not
uncommon to see patients developing hypovolemic
shock during haemodialysis. This was related to
the hypovolaemia due to removal of accumulated
fluid from the patient. Fluid removal was effected by
applying a negative pressure on the dialysate side of
Figure 1 The ‘dry
dialysis’ setup. Note the
haemodialysis machine
was the old batch tank
machine
www.hkmacme.org
Figure 2 The ‘dry
dialysis’. Note that the
dialysate outlet port was
clamped
Ms. WONG Sui Lan
M.B.B.S.(H.K.), MRCP (UK),
FRCP (Edin), FRCP (Glasg),
FHKAM (Medicine), FHKCP,
Specialist in Nephrology
Senior Registered
Nurse
the dialyser and the water was ‘sucked’ across the
membrane from the blood to the dialysate side down
the pressure gradient. The process is technically known
as ‘ultrafiltration’ and the water so removed was called
the ‘ultrafiltrate’. Normally, as the fluid is removed from
the blood compartment, water from the interstitial
compartment move into the blood compartment to
compensate for the reduced blood volume (‘refilling’). If
the rate of fluid removal was too fast, the rate of refilling
might not be fast enough to compensate and there
would be circulating volume depletion with resulting
hypotension.
Another difficulty was that haemodialysis has limited
ability to remove fluid from the patient over a short
period of time. For patients presenting to the renal unit
with huge fluid gain, say 4 litres of fluid, removal of
such volume in the dialysis span of a few hours can be
problematic. One would need to use a large negative
pressure to achieve the desired ultrafiltration and this
may occasionally cause membrane rupture in the early
parallel plate dialysers.
One ‘trick’ that nephrologists could do in those early
days was to clamp the dialysate inlet and connect the
outlet to a suction pump with no dialysate flow. The
negative pressure so created drew the fluid from the
blood to the empty dialysate compartment across the
membrane. The fluid in the dialysate compartment and
was then drained. After about a litre of fluid extraction,
the dialysate flow was reconnected and the normal
dialysis resumed (Figures 1 to 3).
Figure 3 ‘Dry dialysis’. Water was
removed by a negative pressure
pump (left in the picture)
It was found that with such
modification, patients could
tolerate fluid removal much better.
One explanation is that since
there was no dialysate, there was
no urea removal by diffusion and
hence the serum osmolarity was
maintained and this maintained the
17
SPOTlight -3
plasma oncotic pressure to facilitate the refilling from the
interstitial space.
This procedure was called ‘dry dialysis’ because there
was no dialysate in the dialyser. The term was not
logical because without dialysate, the process cannot
be called dialysis. The proper technical term was
‘isolated ultrafiltration’ but nephrologist loved term ‘dry
dialysis’ anyway. The author had done this a number
of times for patients with large fluid retention. It was
virtually abandoned (and forgotten) when more efficient
dialysis techniques such as bicarbonate dialysis and
biocompatible dialysers were available. Moreover, newer
generation haemodialysis machines had the capacity to
perform isolated ultrafiltration with the touch of a button.
This was also called ‘haemofiltration’ because blood
was purified by filtering and it paved the way for the
development of haemofiltration, haemofiltration-dialysis
and CRRT.
Early haemofiltration-the CAVH (continuous
arterio-venous haemofiltration) and CVVH
(continuous veno-venous haemofiltration)
The discovery that the ‘isolated ultrafiltration’ (removal of
water by a pressure gradient without dialysis) was better
tolerated generated much interest in the nephrology
circle, for patient tolerance was a very important
consideration. In the early isolated ultrafiltration, one
would need to use a suction pump. This was because
the membrane in the early dialyser was made of
cuprophane derived from plant cellulose cell walls. The
natural pore size would allow small molecules like urea,
potassium, water etc to pass through but not the larger
molecules like plasma proteins. Due to the limited size
of the pores, the rate of water removal was not high and
for patients with large volume of fluid to be removed,
a large negative pressure was necessary. This could
pose a problem because early dialysers, being made
of flat membrane, could not stand high transmembrane
pressure.
With the improvement in polymer technology in the
plastic industry, synthetic membrane was available. The
pore size could be made larger and hence the rate of
water removal can be increased. Such membrane can
be used to replace the cuprophane membrane of a usual
dialyser. It was found that water could be removed with
relatively low transmembrane pressure and it was said
to have a high ‘ultra-filtration coefficient’. It was called a
‘haemofilter’ to distinguish it from the usual dialysers.
Such ‘haemofilters’ became available in 1980’s in Hong
Kong. Its overall size was small and can be held with the
palm of a hand (Figure 4). Its synthetic membrane has
large pores to allow easy passage of the fluid. Because
of the high ultra-filtration coefficient, the pressure of the
blood flowing inside the hollow fibres would be sufficient
to drive water from the blood across the membrane
without the aid of negative pressure. The set-up was
simple that no machine was needed. In its simplest
form, a catheter was inserted into the femoral artery and
the blood was returned through another catheter into
the femoral vein. The patient’s blood was driven by the
pressure from the femoral artery to the haemofilter and
back to the body by the femoral vein (Figure 5 and 6, the
CAVH setup). The water (ultrafiltrate) was drained into
‘urine meter’ and the volume measured and recorded.
Uraemic toxins such as urea and acids were removed
along with the ultrafiltrate and the fluid removed could
be partially replaced with substitution fluid. The process
of toxin removal was slow but was better tolerated by
the critically ill patients. Since the efficiency was low, the
process had to be continued for several days.
In this procedure, no external power
was needed and it was known
as continuous arterio-venous
haemofiltration CAVH (Figures 5 and
6). It was especially useful in those
ICUs with no haemodialysis facility
to treat acute renal failure. CAVH
kits were available in which all the
necessary materials (haemofilter,
blood line, catheters, fluid collection
box etc.) were packed into a kit. In
Figure 4 A small size
haemofilter
18
Figure 5 CAVH setup
Figure 6 CAVH closeup
www.hkmacme.org
SPOTlight -3
available in 2 litre bags. The author has used this method
with the dialysate running at the rate of 999 ml/hour, the
maximum rate of the infusion pump. The dialysate flow
rate of one litre per hour was slow in comparison with 30
l/hour in standard haemodialysis. It would augment the
efficiency but it added to the complexity of the procedure.
(Figure 10 the CVVHD, note that dialysate was delivered
to the haemofilter with an infusion pump, the right one in
the picture.)
Machine controlled haemofiltration and CRRT
Figure 7 A CAVH kit
the 1980’s, the author used to have one such kit in the
boot of his car in case he was called to treat patient in a
hospital with no dialysis facilities (Figure 7). (1)
Since puncture of the femoral artery was somewhat
traumatic and posed some risks, attempts were made to
obtain the blood flow from one femoral vein and return
through another one. Later double lumen catheters were
available and only one venous puncture was needed.
Since the pressure in the femoral vein was low, a blood
pump was needed and the modified procedure was then
called continuous veno-venous haemofiltration (CVVH)
(Figures 8 and 9).
The CVVH with dialysis-the CVVHD
The CVVH provide a safe form of renal support in critically
ill patients. It was good for fluid removal (such as the
treatment of acute pulmonary oedema) but the rate of
removal of uraemic toxin was slow. One way to augment
the rate of toxin removal was to run dialysate in the
dialysate compartment with an infusion pump so that
some uraemic toxins can be removed by diffusion across
the membrane to the dialysate. A convenient source of
the dialysate was the dialysis fluid used in continuous
ambulatory peritoneal dialysis because it was widely
Figure 8 The blood pump used in CVVH
www.hkmacme.org
The advantage of CVVH and CVVHD was that they were
(relatively) well-tolerated even in critically ill patients and
no special equipment was needed. However, it was very
labour intensive as the attending nurses have to measure
the ultrafiltration output, the urine output and then calculate
the rate of the substitution fluid every hour. In addition,
they had to take care of the extra-corporeal circulation,
monitor the pressure in the arterial and venous chambers,
the anticoagulation and the dialysate flow etc. (in CVVHD).
These were in addition to the already heavy ICU routines.
Since the procedures involved in CVVHD were straight
forward and mechanical (though tedious), there were
attempts to perform them with a computer. A machine
was built in which the weight of the fluid removed (ultrafiltrate) was continuously monitored, the data was fed into
a microprocessor (the heart of a computer) which would
calculate the substitution fluid rate and then control the
built-in fluid pump to replace the fluid. There were also
blood warmers, dialysate pumps, replacement pumps
in addition to the blood pumps and heparin pumps
to monitor the extra-corporeal circulation parameters
like a haemodialysis machine. It was found that such
machines could reduce the workload of the nursing staff
considerably. Since it is not exactly a dialysis process
and it needs to be carried on for a few days, it was called
continuous renal replacement therapy.
Figure 9 CVVH setup. Note the complexity
Figure 10 CVVHD. Note the infusion
pump (right) delivering dialysate to the
haemofilter
19
SPOTlight -3
Disadvantages of CRRT
The introduction of the CRRT greatly reduced the
amount of work by the attending staff. However, the
setting up of the machine was a bit complicated and
the staff needed special training. The machines and
the consumables are expensive. It had to be done
continuously for a few days and ICU stay was needed.
There were also problems associated with prolonged
anticoagulation. As a result, the cost of CRRT is high.
Another alternative is to perform slow low efficacy
dialysis (SLED) daily instead of continuously. The
efficiency of the dialysis set low so as to reduce the
stress to the patient. It is also well-tolerated but the cost
is much lower than CRRT. There may be no need for
ICU stay and the cost would be further reduced. Initial
data showed that both methods yielded similar result
but more trials are needed for a definitively comparison
of the pros and cons (Figure 12, SLED).
Conclusion
The ‘dry dialysis’ was the humble starting point of
the present day CRRT which was made possible by
modern industrial technology. Hemofiltration was
made possible with the development of the polymer
membrane technology and CRRT was facilitated by the
microprocessor technology. However, the feedback of
the clinicians was essential in its success.
CRRT is mainly for the short term management of acute
unstable renal failure patients using haemofiltration.
Another application of the technique was to prevent long
term dialysis complications in chronic stable renal failure
patients. This is another advance in the renal replacement
technology and it is not covered in this short article.
Q&A questions
Self-assessment
Complete this
course and earn
1 CME Point
1.
Continuous renal replacement therapy is a
commonly used procedure to provide renal
support to critically ill patients with multi-organ
failure in ICU.
2. Patients could develop hypovolemic shock easily
in early haemodialysis.
3. ‘Dry dialysis’ provides a stable environment in
which water from the interstitial compartment
can easily move into blood compartment for
refilling since serum osmolarity was maintained.
4. A suction pump was needed in early CAVH
to create a negative pressure in the dialysate
compartment in order to draw the fluid from the
blood.
5. The availability of double lumen catheters
facilitated the procedure from CAVH to CVVH.
6. The membrane in the early dialyser was made of
cuprophane which derived from cell membranes.
7. The natural pore size of cuprophane is big
enough to allow large volume of water to be
removed in the process.
8. Polymer technology in haemofilter enabled
uremic toxins to be removed efficiently with
relatively low transmembrane pressure.
9. CVVHD is the augmentation of uremic toxin
removal by running dialysate in the dialysate
compartment at a slow speed with an infusion
pump.
10. The introduction of the CRRT machine made the
process less labour intensive since some of the
decision is made by the microprocessor.
Figure 12 The patient on SLED, only intermittent dialysis was needed
References:
Figure 11 The CRRT setup. Note the patient has multi-organ
failure requiring a ventilator
20
1. CP Ho. Continuous Arterio-venous haemofiltration (CAVH) – a new tool in
critical care therapy. Journal of the HKMA, vol 38, 4, 1986.
www.hkmacme.org
Cardiology
The content of the July Cardiology Series is provided by:
Dr. CHEUNG Ling Ling MBBS(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in Cardiology
七月臨床心臟科個案研究之內容承蒙張玲玲醫生提供。
Complete BOTH Cardiology and
Dermatology courses and earn
0.5 CME POINT
A Young Man with Shortness of Breath
Mr. F is a 36-year-old gentleman. He is a nonsmoker and non-drinker. He had no history of
any illicit drug use and enjoyed good past health.
He was admitted for shortness of breath for 2
weeks associated with chest discomfort and mild
cough. He has travelled to Australia for a business
trip two weeks ago. Physical examination was
unremarkable and he was haemodynamically stable
but was mildly tachypneic in room air. The ECG
Figure 1
2.
3.
Blood was taken for complete blood picture, liver
and renal function which were all normal. However,
the troponin T was raised to 117 pg/ml. D dimer was
over 7000. Chest X-ray was normal. Urgent spiral
computerized tomography was shown in Figure 2.
Figure 2
Q&A
1.
at emergency department was shown in Figure 1.
Echocardiography showed D shaped LV, dilated
RA/RV with prominent pulmonary trunk.
Please indicate one answer to each question
What did the ECG show?
A.
Sinus tachycardia
B.
Right axis deviation
C.
S1Q3T3
4.
What would be the appropriate initial treatment?
A. Low molecular weight heparin (LMWH) plus
warfarin
B. Low molecular weight heparin (LMWH) plus
warfarin or new oral anticoagulant (NOAC)
C. Aspirin plus warfarin
D. Warfarin alone
5.
Which risk group did the patient belong to?
A. Low
B. Intermediate
C. High
6.
What is the recommended minimum duration of
anticoagulation in patients with provoked PE?
A. 3 months
B. 6 months
C. 12 months
What did the Spiral CT show?
A.
Acute pulmonary embolism
B.
Acute myocardial infarction
C.
Acute aortic dissection
What other tests would you order?
A.
Urgent USG Doppler bilateral calf
B.
Thrombophilia screen
C.
Cardiac catheterization
www.hkmacme.org
21
Cardiology
June Answers
A Lady with Abdominal Distension and Ovarian Mass
Answers:
1. E
2. D
3. C
This lady presented with predominant right heart
failure symptoms. The differential diagnosis include
concomitant left sided heart failure, chronic lung
disease, ischaemic heart disease, right sided valvular
disease, pericardial disease, pulmonary hypertension
or thromboembolic disease involving the pulmonary
circulation. A wide range of clinical signs therefore
could be observed depending on the underlying
causes.
The ovarian tumour of this lady was confirmed to be
a carcinoid tumour. This rare neuroendocrine tumour
is most commonly found in gastrointestinal tract and
bronchus. Clinical presentation of carcinoid syndrome
is related to the release of vasoactive substances
including serotonin, 5-hydroxytrytophan, histamine,
bradykinin, tachykinin and prostaglandin, which are
usually metabolized and inactivated by liver and lung.
Symptoms (e.g. flushing, bronchospasm or diarrhea)
typically occur in patients with hepatic metastasis.
However, in ovarian and bronchial carcinoid, hepatic
metastasis is not necessary to produce symptoms
due to their direct drainage of vasoactive substances
into systemic circulation.
The 2D echo images showed classical appearance
of carcinoid heart disease, which is characterized by
pathognomonic plaque like deposit of fibrous tissue
on the endocardium of valve cusps and leaflets, the
cardiac chambers or the intima of the pulmonary
artery or aorta. The right sided valves (both tricuspid
and pulmonary) are most often affected since
inactivation of vasoactive substances in lung protects
the left sided valves. Yet left sided valve involvement
can occur (in less than 10% patients of carcinoid heart
disease) if there is atrial right to left shunt (as with a
patent foramen ovale) or in cases of primary bronchial
carcinoid. Echocardiographic features of advanced
disease include thickening and retraction of immobile
tricuspid leaflets with failed coaptation, leading to
significant tricuspid regurgitation (and less commonly
stenosis). Right atrial and ventricular enlargement is a
common end result of chronic volume overload.
The diagnosis of carcinoid syndrome is usually
confirmed by identification of the primary and
metastatic tumor, and detection of increased urinary
22
excretion of the by-product of serotonin metabolism,
5-hydroxyindoleacetic acid (5-HIAA). N-terminal proBrain Natriuretic Peptide (NT-proBNP) could be
elevated but it is a non-specific marker of heart failure
of various etiologies. Echocardiogram is a simple,
non-invasive method for definitive diagnosis of cardiac
involvement.
Treatment of tumour itself usually does not lead to
regression of valvular disease. Medical treatment
options of right heart failure are limited. Diuretics
temporarily improve symptoms related to edema
but result in a further reduction in left-sided cardiac
output. Surgical treatment by valvular replacement is
the only effective treatment for carcinoid heart disease
and should be considered for symptomatic patients
whose metastatic carcinoid disease and symptoms of
carcinoid syndrome are well controlled.
References:
1.
2.
3.
4.
5.
6.
Lundin L, Norheim I, Landelius J, et al. Carcinoid heart disease:
relationship of circulating vasoactive substances to ultrasounddetectable cardiac abnormalities. Circulation 1988; 77:264.
Pandya UH, Pellikka PA, Enriquez-Sarano M, et al. Metastatic
carcinoid tumor to the heart: echocardiographic-pathologic study
of 11 patients. J Am Coll Cardiol 2002; 40:1328.
Denney WD, Kemp WE Jr, Anthony LB, et al. Echocardiographic
and biochemical evaluation of the development and progression of
carcinoid heart disease. J Am Coll Cardiol 1998; 32:1017.
Møller JE, Connolly HM, Rubin J, et al. Factors associated with
progression of carcinoid heart disease. N Engl J Med 2003;
348:1005.
Wilkowske MA, Hartmann LC, Mullany CJ, et al. Progressive
carcinoid heart disease after resection of primary ovarian
carcinoid. Cancer 1994; 73:1889.
Chaowalit N, Connolly HM, Schaff HV, et al. Carcinoid heart
disease associated with primary ovarian carcinoid tumor. Am J
Cardiol 2004; 93:1314.
The content of the June Cardiology Series is provided by:
Dr. WONG Chi Yuen MBBS, MRCP, FHKCP, FHKAM, Specialist in Cardiology
六月臨床心臟科個案研究之內容承蒙黃志遠醫生提供。
www.hkmacme.org
Dermatology
Complete BOTH Cardiology and
Dermatology courses and earn
The content of the July 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
七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。
0.5 CME POINT
A Teenager with Rough Skin
A 14-year-old teenager boy with previously good past health complained of roughness over bilateral upper
limbs for few months which were increasing in size. Physical examination showed numerous tiny rough
papules over bilateral upper limbs. These lesions were clinically asymptomatic.
Q&A
1.
2.
3.
4.
5.
Please answer ALL questions
What are the diagnosis and the differential
diagnoses?
What other skin diseases may be associated with
this skin disorder?
What is the cause for this type of skin disorder?
How to diagnose this skin disease?
What are the management options for this disease?
June Answers
Whitish Patch in Mouth
Answers:
1. The diagnosis is oral lichen planus (LP).
2. The differential diagnoses include mucous
membrane pemphigoid, pemphigus vulgaris,
liner IgA dermatosis, oral Crohn disease, hairy
leukoplakia and squamous cell carcinoma
(SCC) or lichenoid drug reaction such as
NSAIDs, anti-malarials or beta-blockers.
3. Other mucosal lesions especially genitalia
may also be involved or vice versa. Although
oral lichen planus is reported less frequently
associated with cutaneous LP when compared
to genital involvement, other common sites for
cutaneous LP such as limbs, nails and even
scalp should also look for any involvement.
Some authors proposed that oral lichen planus
is associated with Hepatitis C infection (HCV) so
blood test for HCV may be considered.
5. Oral LP may be more resistant to treatment
than cutaneous LP. Provocative factors such
as tobacco, dental plaque and calculus should
be avoided and controlled. The mainstay of
treatment is topical or systemic corticosteroids.
Immunosuppressions agents such as
azathioprine, mycophenolate mofetil (MMF) can
be considered for difficult cases.
4. The diagnosis is made clinically. However, if
it is in doubt, biopsy should be considered
to rule out especially the malignant lesions. If
symptoms suggest oesophageal involvement,
endoscopy is needed for further investigation.
The content of the June 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
六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。
www.hkmacme.org
23
Complaints & Ethics
Complaint cases on
the Rise: A question
of incompetency or
vulnerability?
Dr. CHOI Kin
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 in the Mega-Conference 2015)
I would like to thank Dr. Samuel Kwok’s invitation to give this
presentation in the Mega-conference.
Professor Lau has just presented that there is a rise in
number of complaints from 400+ to 600+ over the last two
years. I shall endeavor to explain why this is the case and
whether it is related to a deterioration in skill or standard of
the doctors or whether it is due to other reasons.
Every year, a dozen or more cases that went to the inquiry
were related to doctors complaining against other doctors
in an attempt to protect one’s turf. These complaints have
their basis on Section 7.2 of the code that ‘doctors who
are not on the Specialist Register cannot claim to be or
hold themselves out as specialists. A non-specialist is not
allowed to use any misleading description or title implying
specialization in a particular area (irrespective of whether it is
a recognized specialty)’. Calling oneself as ‘skin doctor’ or
‘cosmetic medicine doctor’ would not be allowed and are
common causes for complaints. Doctors should scrutinize
the article of the interview they give before they go to the
press. Without looking at the article first and allowing it to
go to the press on the pretext that the reporter refuses the
preliminary review is not acceptable to the Medical Council.
Professional jealousy is extended to the universities. Staff
from University A complains that staff from University B
announced to the reporters that they were first in Asia to do
a certain operation when it is not true and the operation has
been done elsewhere in Asia.
Doctor C publicized on his website that his firm has the
lowest incidence of side effects and failure and is the
only firm in Hong Kong to do a certain procedure. These
contravene Section 5.2 of the Code on information
dissemination which stated that such information must not:
(a)
be exaggerated or misleading
(b)
be comparative with or claim superiority over other
doctors
(c)
claim uniqueness without proper justifications for such
claim
(d)
aim to solicit or canvass for patients
(e)
be used for commercial promotion of medical and
health related products and services
(f)
be sensational or unduly persuasive
(g)
arouse unjustified public concern or distress
(h)
generate unrealistic expectations
(i)
disparage other doctors
A doctor was reported to have the DCH (Ireland) displayed
on his name card and signboard when in fact he had
failed the examination. The complainant bombarded the
fax machine of the Royal College of Surgeons of Ireland
to the extent that the College could not function properly.
The College had to send a secretary to Hong Kong to act
as a witness for the Medical Council Inquiry. If you have a
certificate attesting a certain skill, and it is not quotable, do
not change it into a quotable diploma which you do not
have. You are bound to be disclosed by your colleagues.
The format of the Dangerous Drug Register has been laid
out in Appendix F of the Code for many years. In the last
24
www.hkmacme.org
Complaints & Ethics
decade, under Note 7 of the Appendix F, it is clear that ‘a
register stored electronically in a computer will not fulfill the
requirement’. Nonetheless, every year, doctors including
specialist psychiatrists are found guilty of misconduct
and guilty in a criminal court for not properly filling in the
Dangerous Drug Register.
unjustified public concern or distress’ and ‘must not be used
for commercial promotion of medical and health related
products and services’. A doctor announcing to the public
about the use of a vaccine should not over-exaggerate
the prevalence and infectivity of the virus the vaccine is
supposed to be protecting.
The Code has grown more than triple its size over the
last three decades. In addition to the more serious issues
the Council needs to attend to, minor restrictions prevail
which may bring a doctor to the inquiry. Such triviality
includes quoting MB, BS (Hons) on the name card, not
quoting the LMCHK before the primary qualification gained
outside of Hong Kong (e.g. MD Chicago or MB Oxon),
or putting the specialist qualification (FHKAM) before the
registrable qualification (MB, BS HK). Since the Council
has taken up the role of looking at quotable appointments,
those specialist radiologists who quote themselves as
Consultant Radiologists of a private laboratory who have
not got endorsement from the Medical Council may also be
breaching the Code.
One of reasons for the rise in complaints is political agenda.
Many (or actually there may be only a few who were using
the same template on the internet) complaint about a doctor
refusing to see law enforcement officer confronting the
crowd during the recent demonstration. However, 3.1 of the
code stipulated that ‘there may be situations where it is in the
best interest of the patient for medical care to be provided by
another doctor’. Sometimes the patient fell in love with the
doctor. If the doctor avoids seeing such a patient who has
a crush on him, can the charge of ‘patient abandonment’
stand?
In the last decade, there seems to be a surge of complaints
of a sexual nature. There have been complaints of
relationship with patient’s spouse, underskirt photography,
breast grabbing in the wards, touching and exposure,
flirtatious remarks to patients etc. etc. etc. Section 25.1 of
the Code stipulates that ‘any form of sexual advance to a
person with whom the doctor has a professional relationship
is professional misconduct’. Proper explanation before
examining a patient and having a chaperone close by is
a MUST in all situations of contact with a patient of the
opposite sex.
We complain when ParknShop sells expired meat or
vegetables. Understandably, patients will complain if we
provide them with expired medicine and injections. The
Good Dispensing Practice Manual issued by the Hong Kong
Medicine Association and section 9.4 of the Code require
on the medicine bag the full name of the patient, the date
of dispensing, the name of the medicine, the method of
administration, the dosage to be administered, the strength
of the medicine and the precautions when applicable.
Relying only on your clinic assistants to check the drug labels
will surely bring you in front of an Inquiry.
Section 5.2.1.2 puts down that dissemination of information
must not ‘be sensational or unduly persuasive’, ‘arouse
www.hkmacme.org
Using one identical template, over one hundred e-mail
complaints flooded the Secretariat identifying a public health
official for assuring the public that there was no need for the
use of face mask during the middle of an influenza epidemic.
The Medical Council accepts e-submissions of complaints.
One individual can duplicate 100 different names and send
in the same complaint over and over and it would take
enormous man-power to vet the complaints and decide
whether an inquiry is needed. Complaints to the Medical
Council are free of charge and the Medical Council is
required to solicit expert opinion to consider the validity of
the complaint. This saves the complainant thousands of
dollars in seeking expert opinion when he/she goes to the
civil court for litigation after the preliminary work-up by the
Medical Council.
Failure of treatment when the expectations of the patient
and his family members are recovery or cure is the
commonest cause of complaint. As doctors, we know
that no treatment is 100% guaranteed and we should
emphasize that in our discussion with our patients before
starting therapy. Unfortunately, in an attempt to secure
‘business’, such is not the case and informed consent after
proper information of risks and benefits in an unhurried
manner is not always obtained. Proper documentation of
the explanation and discussion are lacking in many cases.
Just getting the patient to agree and sign a consent form
is not informed consent. Just having the patient sign on a
25
Complaints & Ethics
form for a colonoscopy 3 minutes before the procedure and
attended to by a clinic nurse only is not informed consent.
Without properly explaining the risk of haemorrhage and
perforation that can result from the procedure even though
the education pamphlets contain such warning may not
be enough when the patient sues after colon perforation
occurs. The Montgomery case has made it clear that even
remote risks must be disclosed.
Nothing replaces empathy and time spent explaining to
patients. A radiologist who thrust the ultrasound probe
into a patient’s vagina without proper explanation of what
he is about to do may face a charge of criminal assault
and a Medical Council inquiry. A public doctor who calls
himself ‘son of crab’ ( 蟹仔 ) and declares that he cannot
make decision because he is a neurosurgeon and not a
neurologist when asked by the relatives of a stroke patient is
not showing sympathy or empathy.
When I encounter difficulty with my patients, I remember
what my geriatric teacher from Whittington Hospital,
London, taught me – ‘treat your patients as you would your
parents’. Unfortunately, nowadays, we may even sue our
parents.
I do not think the increased number of cases in the
Inquiries is due to incompetence. As discussed, the
ease of complaint and allowing e-submission resulted
in the increase. With the type of specialist training that
we have, there should not be too many incompetent
doctors. However, many ended up in an inquiry because
of carelessness, lack of concern when patients or relatives
voiced out their concerns, and a could-not-care-less
attitude. Doctors are more vulnerable than ever because of
the over-supply and the transparency in the Medical Council
Inquiries. Any specialist can be pulled down from his/her
high horse. It is time to re-think your practice.
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。
26
www.hkmacme.org
Name 姓名
Signature 簽名：
Answer Sheet
HKMA Membership No. or HKMA CME No.
香港醫學會會員編號或持續進修號碼：
Contact Tel No. 聯絡電話：
HKID No. 香港身份証號碼：
-
xxx(x)
July 2015
ANSWER SHEET
Please answer ALL questions and write the answers in the space provided.
SPOTlight - 1
Complete Spotlight and earn 1 CME point
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
7
7
8
8
9
9
10
10
7
7
8
8
9
9
10
10
SPOTlight - 2
1
1
2
2
3
3
4
4
5
5
6
6
SPOTlight - 3
1
1
2
2
3
3
4
4
5
5
答題紙
6
6
Please return the
completed answer sheet
to the HKMA Secretariat
(Fax: 2865 0943) on or
before 15 August 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 8 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。
Complete BOTH Cardiology & Dermatology cases and earn 0.5 CME point
Cardiology
1
2
3
4
5
6
Dermatology
1
2
3
4
5
www.hkmacme.org
27
CMEnotifications
HKMA CME Programme
香港醫學會持續進修計劃
香港醫學會
CME Lecture – August 2015 進修講課 – 二零一五年八月
THE HONG KONG
MEDICAL ASSOCIATION
HKMA Structured CME Programme with HKS&H Session
VllI: Diagnosis and Treatment of Early Liver Cancer
香港醫學會分科持續醫學進修計劃第八節：早期肝
癌的診斷與治療
講者：范上達醫生
Dr. FAN Sheung Tat
MBBS (HK), MS (HK), MD (HK), PhD (HK),DSc (HK), FRCS RCPS (Glasg),
FRCSEd, FCSHK, FHKAM (Surgery), Specialist in General Surgery Director,
Liver Surgery Centre, HKS&H
香港大學內外全科醫學士、香港大學外科碩士、香港大學醫學博
士、香港大學哲學博士、香港大學科學博士、英國格拉斯哥皇家
醫學院外科院士、英國愛丁堡皇家外科醫學院院士、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、養和醫
院肝臟外科中心主任
Date: 13 August 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：二零一五年八月十三日（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 請填妥表格連同支票寄交香港灣仔軒尼詩道十五號溫莎公爵社會服務大廈五樓，支票抬頭
Hong Kong Medical Association” to 5/F Duke of Windsor Social Service Building, 15 Hennessy Road, Hong 請書明支付「香港醫學會」
。參加者可獲醫務委員會 / 香港醫學會持續醫學進修計劃積分一分
Kong. Each lecture will carry 1 CME point under the MCHK/HKMA CME Programme (unless otherwise stated). （除特別註明外）
。其他專科學院之學分尚在申請中。( 秘書處傳真號碼 : 2865 0943)
Accreditation from other colleges is pending. (The Secretariat fax no.: 2865 0943)
To be more eco-friendly and avoid postal delay, notification to registrants will no longer be made through 為響應環保及為免郵遞延誤，秘書處將以手機短訊通知講課報名結果。因此，請準確填上
sending confirmation letters but via SMS. Please fill in your updated mobile number so that you can be notified 閣下之手機號碼以便接收通知，倘若閣下沒有手提電話，秘書處仍會以郵寄方式把講課確
of your application. If you do not have a mobile phone number, the Secretariat will issue a confirmation letter to 認通知書寄上。參加者如沒有收到任何通知，請致電 2527 8452 查詢。
you. If you have not received any replies, please do not hesitate to contact us at 2527 8452.
Please register for participation. First come, first served.
名額有限請早登記
TYPHOON/BLACK RAINSTORM POLICY
When Tropical Storm Warning Signal No. 8 (or above) or the Black Rainstorm Warning Signal is hoisted When Tropical Storm Warning Signal No. 8 (or above) or the Black Rainstorm Warning Signal is hoisted
within 3 hours of the commencement time, the relevant CME function will be cancelled. (i.e. CME starting after CME commencement, announcement will be made depending on the conditions as to whether the
at 2:00 pm will be cancelled if the warning signal is hoisted or in force any time between 11:00 am and CME will be terminated earlier or be conducted until the end of the session.
2:00 pm).
The above are general guidelines only. Individuals should decide on their CME attendance according to
The function will proceed as scheduled if the signal is lowered three hours before the commencement their own transportation and work/home location considerations to ensure personal safety.
time. (i.e. 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 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
CME Participants
HK$80
HKMA Structured CME Programme with HKS&H
13 August 2015
(Thursday)
HKMA Structured CME Programme with HKS&H Year
2015 Session VllI: Diagnosis and Treatment of Early
Liver Cancer
I enclose herewith a cheque of
現隨表格付上支票一張作為講課之報名費用：
HK$ 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。
www.hkmacme.org
29
CMEnotifications
CME Lectures in August 2015
THE HONG KONG
MEDICAL ASSOCIATION
Organized by
Date
: Tuesday, 4 August 2015
Tuesday, 18 August 2015
Topic and Speaker
: Management of Dyslipidemia: Strategies for
An Insulin-Independent Approach to Manage
Patients with Type 2 Diabetes Mellitus
Dr. CHEUNG Fu Keung
Specialist in Endocrinology, Diabetes & Metabolism
Long-Term Success
Dr. TSANG Kin Keung
Specialist in Cardiology
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
: Crystal Room I-III, 30/F., Panda Hotel, 3 Tsuen Wah Street, Tsuen Wan, N.T.
Moderator
: Dr. CHAN Ching Pong
Committee Member,
HKMA Kowloon West Community Network
Dr. WONG Wai Hong, Bruce
Hon. Secretary,
Deadline
: Monday, 27 July 2015
Fee
: Free-of-charge
Capacity
: 50. Registration is strictly required on a first come, first served basis. Priority will be given to
Friday, 7 August 2015
doctors practising in Kowloon West district.
Enquiry
: Miss Hana YEUNG, Tel: 2527 8285
*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
I would like to register for the following lecture(s):
4 August 2015
Please “✓” as appropriate
18 August 2015
HKMA No.:
Fax No.:
Name:
Mobile 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 you a confirmation letter.
Practising location:
In Kowloon West (Please specify *:
)
Others (Please specify:
)
* Null entry will be treated as non-Kowloon West member registration.
Signature:
Date:
Data collected will be used and processed for the purposes related to these events only.
30
www.hkmacme.org
CMEnotifications
Organized by
THE HONG KONG
MEDICAL ASSOCIATION
Date
: Wednesday, 5 August 2015
Thursday, 27 August 2015
Topic and Speaker
: Update in Stroke Prevention in Atrial
Fibrillation Patients
Dr. TSE Tak Sun
Postmenopausal Osteoporosis Continuum:
Why Do We Start So Early?
Dr. WOO Yu Cho
Consultant Cardiologist,
Head, Department of Cardiology,
St. Paul’s Hospital
Associate Consultant, Dept. of Medicine,
Queen Mary Hospital,
Honorary Clinical Assistant Professor,
Dept. of Medicine, Li Ka Shing Faculty of Medicine, HKU
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
Moderator
: Dr. TSANG Chun Au
Dr. YIK Ping Yin
Committee member,
HKMA CW&S Community Network
Chairman,
HKMA CW&S Community Network
Deadline
: Monday, 27 July 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
*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
5 August 2015
27 August 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.
In Central, Western & Southern districts (Please specify *:
)
)
* Null entry will be treated as non-Hong Kong Central, Western & Southern member registration.
Signature:
Date:
www.hkmacme.org
31
CMEnotifications
THE HONG KONG
MEDICAL ASSOCIATION
Organizer
Date
Topic and Speaker
:
HKMA Yau Tsim Mong Community Network
HKMA Kowloon East Community Network
:
Tuesday, 11 August 2015
:
Treatment of Female Stress Urinary
Incontinence
(1) Dr. CHEON Willy Cecilia
Specialist in Obstetrics & Gynaecology
(2) Ms. Anny TONG
Registered Nurse
Latest COPD Management
Dr. CHAN Chung Yan, Anthony
Specialist in Respiratory Medicine
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
:
Pearl Ballroom, Level 2,
Eaton, Hong Kong,
380 Nathan Road, Kowloon
Moderator
:
Dr. WONG Kam Ho
Committee Member,
HKMA YTM Community Network
Deadline
Fee
Capacity
:
Friday, 24 July 2015
:
Free-of-charge
:
80
V Cuisine, 6/F.,
Holiday Inn Express Hong Kong Kowloon East,
3 Tong Tak Street, Tseung Kwan O
（將軍澳唐德街3號香港九龍東智選假日酒店6樓彩雲軒）
Dr. MA Ping Kwan, Danny
Vice-chairman,
48
Registration is strictly required on a first come, first served basis. Priority will be given to doctors practising
in YTM districts (for the lecture on 11 Aug)/Kowloon East districts (for the lecture on 27 Aug).
Enquiry
:
Ms. Candice TONG, Tel: 2527 8285
Miss Hana YEUNG, Tel: 2527 8285
*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 YTM & KE Community Networks
11 August 2015 (YTM)
27 August 2015 (KE)
HKMA No.:
Fax No.:
Name:
Mobile No.*:
the Secretariat will still issue you a confirmation letter.
In YTM (Please specify *:
)
In Kowloon East (Please specify *:
)
)
* Null entry will be treated as non-Yau Tsim Mong or non-Kowloon East member registration.
Signature:
Date:
32
www.hkmacme.org
CMEnotifications
Reference Framework for Preventive Care
for Older Adults in Primary Care Settings
THE HONG KONG
MEDICAL ASSOCIATION
Co-organized by
The HKMA Kowloon East Community Network
and Primary Care Office of the Department of Health
Date
:
Speaker
:
Dr. SIN Ka Ling, Cecilia
Specialist (Primary Care), Primary Care Office, Department of Health
Time
:
2:00 – 2:45 p.m. Lecture
2:45 – 3:00 p.m. Q & A Session
Venue
:
Lei Garden Restaurant ( 利苑酒家 ),
Shop no. L5-8, apm, Kwun Tong,
No. 418 Kwun Tong Road, Kwun Tong, Kowloon
Moderator
:
Dr. AU Ka Kui, Gary
Chairman, HKMA Kowloon East Community Network
Deadline
:
Friday, 31 July 2015
Fee
:
Free-of-charge
Capacity
:
48. Registration is strictly required on a first come, first served basis.
Priority will be given to doctors practising in Kowloon East district.
Enquiry
:
Miss Hana YEUNG, Tel: 2527 8285
CME Accreditation
:
Pending
REPLY SLIP
Reference Framework for Preventive Care for Older Adults in Primary Care Settings
I would like to register for the above event.
Fax: 2865 0943
HKMA No.:
Fax No.:
Name:
Mobile No.*:
In Kowloon East (Please specify *:
)
)
* Null entry will be treated as non-Kowloon East member registration.
Signature:
Date:
Data collected will be used and processed for the purposes related to this event only.
www.hkmacme.org
33
CMEnotifications
Psoriatic Arthritis: Is it a Skin or Joint Disease?
Co-organized by
The HKMA Yau Tsim Mong Community Network
and Hong Kong Society of Rheumatology
Date
:
Speaker
:
Dr. YU Ka Lung, Carrel
Specialist in Rheumatology
Time
:
2:00 – 2:45 p.m. Lecture
2:45 – 3:00 p.m. Q&A Session
Venue
:
Jade Ballroom, Level 2, Eaton, Hong Kong,
380 Nathan Road, Kowloon
Moderator
:
Dr. HO Hok Ming
Committee Member, HKMA YTM Community Network
Deadline
:
Monday, 17 August 2015
Fee
:
Free-of-charge
Capacity
:
60. Registration is strictly required on a first come, first served basis. Priority will be given to
doctors practising in YTM district.
Enquiry
:
Ms. Candice TONG, Tel: 2527 8285
CME Accreditation
:
Pending
This lecture is sponsored by
AbbVie Ltd.
REPLY SLIP
Fax: 2865 0943
HKMA Yau Tsim Mong Community Network
Psoriatic Arthritis: Is it a Skin or Joint Disease?
I would like to register for the above lecture.
HKMA No.:
Fax:
Name:
Mobile No.*:
In Yau Tsim Mong (Please specify *:
)
)
* Null entry will be treated as non-Yau Tsim Mong member registration.
Signature:
Date:
Data collected will be used and processed for the purposes related to this event only.
34
www.hkmacme.org
Meeting Highlights
The HKMA Central, Western and Southern Community Network (CW&SCN) ~ Dr. YIK
Ping Yin
Dr. TSE Tak Sun, Consultant Cardiologist and Head of the Department of Cardiology of St. Paul’s Hospital, will give a talk
on “Update in Stroke Prevention in Atrial Fibrillation Patients” on Wednesday, 5 August 2015. Dr. WOO Yu Cho, Associate
Consultant of the Department of Medicine of Queen Mary Hospital and Honorary Clinical Assistant Professor of the
Department of Medicine of Li Ka Shing Faculty of Medicine of the University of Hong Kong, will present on “Postmenopausal
Osteoporosis Continuum: Why Do We Start So Early?” on Thursday, 27 August 2015. Interested members please refer to
the announcement on p.31 for details and enrolment.
The HKMA Hong Kong East Community Network
(HKECN) ~ Dr. CHAN Nim Tak, Douglas
The lecture on “Reference Framework for Preventive Care for Older
Adults in Primary Care Settings”, co-organized with Primary Care
Office of the Department of Health, was delivered by Dr. LUK Kam
Hung, Deputy Consultant in-charge (Primary Care) of Primary Care
Office of Department of Health, on Thursday, 11 June 2015.
Dr. Joseph LAM (left, moderator) presenting a certificate of
appreciation to Dr. LUK Kam Hung (speaker) during the lecture on
11 June 2015
The HKMA Yau Tsim Mong Community Network (YTMCN) ~ Dr. LAM Tzit Yuen, David
Dr. KO Wai Chin, Specialist in Cardiology, gave a lecture on “Diet and Chest Pain” on Tuesday, 9 June 2015.
The first session of the “Certificate Course on Sports Medicine” began on Tuesday, 16 June 2015. Dr. CHAN Wai Kwong,
Specialist in Cardiology, delivered a lecture on “Can We Prevent Sudden Cardiac Death during Sports Event?” and Dr. HO Hok
Ming, Specialist in Orthopaedics & Traumatology, delivered a lecture on “Common Sports Lower Limbs Injuries” respectively.
A lecture on “Treatment of Female Stress Urinary Incontinence” will be given by Dr. CHEON Willy Cecilia, Specialist in
Obstetrics & Gynaecology, and Ms. Anny TONG, Registered Nurse, on Tuesday, 11 August 2015. Interested members please
refer to the announcement on p.32 for details and enrolment.
Dr. YU Ka Lung, Carrel, Specialist in Rheumatology, will present on “Psoriatic Arthritis: Is it a Skin or Joint Disease?” on Friday,
28 August 2015. Interested members please refer to the announcement on p.34 for details and enrolment.
Dr. KO Wai Chin (speaker) delivering his talk during the
lecture on 9 June 2015
36
Dr. David LAM (left, moderator) presenting a souvenir to
Dr. Andy CHAN (speaker) during the lecture on 16 June
2015
Dr. David LAM presenting a souvenir to Dr. HO Hok Ming
(speaker) during the lecture on 16 June 2015
www.hkmacme.org
Meeting Highlights
The HKMA Kowloon East Community Network (KECN) ~ Dr. AU Ka Kui, Gary
A CME lecture on “New Treatment Option for the
Management of Facial Redness in Rosacea” was given by
Dr. CHAN Yung, Specialist in Dermatology & Venereology,
on Thursday, 11 June 2015. Another CME lecture on “Tips
and Tricks for Heel Pain Management” was presented by Dr.
YEUNG Yeung, Specialist in Orthopaedics & Traumatology,
on Friday, 19 June 2015.
The Network and the Primary Care Office (PCO) of the
Department of Health (DH) will co-organize a lecture on
“Reference Framework for Preventive Care for Older Adults
in Primary Care Settings” on Thursday, 13 August 2015. Dr.
SIN Ka Ling, Cecilia, Specialist (Primary Care) of PCO of DH,
is invited to be the speaker. Interested members please refer
to the announcement on p.33 for details and enrolment.
Dr. Gary AU (right, moderator)
presenting a souvenir to Dr. CHAN
Yung (speaker) during the lecture
on 11 June 2015
Dr. Gary AU (left, moderator) presenting a
souvenir to Dr. YEUNG Yeung (speaker)
during the lecture on 19 June 2015
Dr. CHAN Chung Yan, Anthony, Specialist in Respiratory Medicine, will deliver a lecture on “Latest COPD Management” on
Thursday, 27 August 2015. Interested members please refer to the announcement on p.32 for details and enrolment.
The HKMA Shatin Doctors Network (SDN) ~ Dr. FUNG Yee Leung, Wilson and Dr. MAK
Wing Kin
Dr. FONG Chun Yan, Julian, Specialist in Radiology, will present on “Advancement in Breast Imaging – Practical Use of
Tomosynthesis and Minimally Invasive Breast Procedures” on Wednesday, 26 August 2015. Interested members please
contact Ms. Agnes FUNG at 9702 5251 for enquiry and registration.
The HKMA Kowloon West Community Network (KWCN) ~ Dr. TONG Kai Sing
There were three lectures held in June. A CME lecture
“Novel Management of Pneumonia from Prevention to
Treatment” was given by Dr. WONG Ka Chun, Specialist in
Respiratory Medicine, on Tuesday, 9 June 2015. Another
lecture on “Psoriatic Arthritis: Does Early Diagnosis Make a
Difference?” co-organized by the Network and Hong Kong
Society of Rheumatology was presented by Dr. LEE Tsz
Yan, Samson, Specialist in Rheumatology, on Friday, 19
June 2015. Dr. MOK Chun Keung, Francis, Chief of Service
of the Department of Medicine and Geriatrics of Tuen Mun
Hospital, delivered a lecture on “Reference Framework for
Preventive Care for Older Adults in Primary Care Settings”
co-organized by the Network and the Primary Care Office of
DH on Tuesday, 23 June 2015.
Dr. TSANG Kin Keung, Specialist in Cardiology, will give
a talk on “Management of Dyslipidemia: Strategies for
Long-Term Success” on Tuesday, 4 August 2015. Dr.
CHEUNG Fu Keung, Specialist in Endocrinology, Diabetes
& Metabolism, will present on “An Insulin-Independent
Approach to Manage Patients with Type 2 Diabetes
Mellitus” on Tuesday, 18 August 2015. Interested members
please refer to the announcement on p.30 for details and
enrolment.
38
Group photo taken during the lecture on 9 June 2015
From left: Dr. Bernard CHAN, Dr. TONG Kai Sing, Dr. WONG Ka Chun (speaker),
Dr. LEUNG Gin Pang (moderator), Dr. Bruce WONG and Dr. CHAN Ching Pong
Dr. TONG Kai Sing (left, moderator)
presenting a souvenir to
Dr. Samson LEE (speaker) during
the lecture on 19 June 2015
Dr. Bruce WONG (right, moderator)
presenting the Certificate of
Appreciation to Dr. Francis MOK
(speaker) during the lecture on 23
June 2015
www.hkmacme.org
Meeting Highlights
The HKMA New Territories West Community Network (NTWCN) ~ Dr. CHEUNG Kwok
Wai, Alvin
The third and final sessions of the “Certificate Course on Pain” were held in June 2015. On Thursday, 11 June 2015, Dr. LO
Man Wai, Specialist in Neurology, gave a talk on “A New Approach for Treating Elderly Patients Suffering from Postherpetic
Neuralgia (PHN)”. Dr. TONG Ka Fai, Henry, Specialist in Anaesthesiology and Pain Physician, presented on “Herpes Zoster
and Post Herpetic Neuralgia – Are They Related?” on Thursday, 18 June 2015. There were 40 doctors awarded the
Certificate of Attendance.
HKMA Structured CME Programme with
Hong Kong Sanatorium & Hospital 2015
Dr. WONG Kim Ping, Rex,
Specialist in Radiology,
delivered a luncheon
lecture on “Ultrasound for
Head & Neck Disease”
on Thursday, 11 June
2015 at the HKMA Central
Premises. Dr. NG Wai
Man, Raymond, kindly
acted as the moderator for
the event.
Dr. NG Wai Man, Raymond (right)
presenting a souvenir to the speaker,
Dr. WONG Kim Ping, Rex (left).
Dr. LO Man Wai (right, speaker)
receiving a souvenir from
Dr. Matthew MOK (moderator)
during the lecture on 11 June 2015
Dr. LEE Huen (left, moderator)
presenting a souvenir to Dr. Henry
TONG (speaker) during the lecture on
18 June 2015
HKMA CME Bulletin
Monthly Self-Study Series
Call for Articles
Since its publication, the HKMA CME Bulletin has become one of the most popular CME readings for doctors. This monthly publication
has been serving more than 9,500 readers each month through practical case studies and picture quizzes. To enrich its content, we are
inviting articles from experts of different specialties. Interested contributors may refer to the General Guidance below. Other formats are
also welcome.
For further information, please contact Miss Sophia Lau at 2527 8452 or by email at [email protected].
General Guidance for Authors
Intended Readers :
Length of Article :
Review Questions :
Language
Highlights
Key Lessons
Others
:
:
:
:
Deadline
:
General Practitioners
Approximately 8-10 A-4 pages in 12-pt fonts in single line spacing, or around 1,500-3,000 words (excluding
references).
Include 10 self-assessment questions in true-or-false format.
(It is recommended that analysis and answers to most questions be covered in the article.)
English
It is preferable that key messages in each paragraph/section be highlighted in bold types.
Recommended to include, if possible, a key message in point-from at the end of the article.
List of full name(s) of author(s), with qualifications and current appointment quoted, plus a digital photograph of
each author.
All manuscripts for publication of the month should reach the Editor before the 1st of the previous month.
All articles submitted for publication are subject to review and editing by the Editorial Board.
www.hkmacme.org
39
CMECalendar
July 2015
16 Jul 2015
(Thu)
1:00 – 3:00 pm
16 Jul 2015
(Thu)
4:00 – 5:33 pm
16 Jul 2015
(Thu)
6:30 – 9:30 pm
17 Jul 2015
(Fri)
4:30 – 6:00 pm
18 Jul 2015
(Sat)
8:30 – 4:30 pm
18 Jul 2015
(Sat)
2:00 – 4:00 pm
18 Jul 2015
(Sat)
2:30 – 5:00 pm
18 Jul 2015
(Sat)
2:30 – 5:30 pm
19 Jul 2015
(Sun)
1:00 – 4:00 pm
19 Jul 2015
(Sun)
3:30 – 5:30 pm
20 Jul 2015
(Mon)
8:30 – 9:30 am
20 Jul 2015
(Mon)
1:00 – 2:00 pm
21 Jul 2015
(Tue)
1:00 – 2:00 pm
#
40
Hospital Authority – United Christian Hospital
Hong Kong College of Family Physicians
Hong Kong Medical Association – Kowloon East Community Network
Certificate Course for GPs 2015 – Acute Confusional State in Older Adults:
Avoidable Causes
V Cuisine, 6/F, Holiday Inn Express Hong Kong Kowloon East, 3 Tong Tak
Street, Tseung Kwan O
Ms. Polly Tai – Tel: 3513 3430
Hong Kong College of Psychiatrists
Hospital Authority – Kowloon Hospital
Academic Systematic Review
Conference Room 1, 2/F, KHMB
Ms. Lucita Chan – Tel: 2871 8777
Hong Kong Medical Association
Medical Protection Society
Mastering Difficult Interactions with Patients
HKMA Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese Club
Building, 21-22 Connaught Road, Central, H.K.
HKMA CME Dept. – Tel: 2527 8452
Kwai Chung Hospital – Psychotherapy Committee
Case based discussion group
Conference Room, Kwai Chung Hospital
Hong Kong College of Anaesthesiologists
Enhancing Safety in Sedation Workshop (Identical)
NTE Simulation & Training Centre 3E Ward, North District Hospital
Mr. Thomas Tam – Tel: 2683 8343
Certificate Course on Bringing Better Health to Our Community 2015
Lecture Theatre, G/F, Block M, Queen Elizabeth Hospital
Ms. Teresa Liu – Tel: 2528 6618
Hong Kong Paediatric Society
Hong Kong College of Paediatricians
Hong Kong Paediatrics Nurse Association
Update Series on Child Health 2015
Session II) Lecture 1: Sports Medicine & Pre-participation Sports Screening
for Adolescents; Lecture 2: Use of Cord Blood in Paediatric Practice
Jordan Valley St. Josephen's Catholic Primary School, 80 Choi Ha Road,
Kowloon
Mr. Peter Law – Tel: 5588 2520
Assessment Enhancement Course 2015
8/F, Duke of Windsor Social Service Building, Wanchai, H.K.
Mr. John Lee – Tel: 2528 6618
Hong Kong Doctors Union
The 306th HKDU Sunday Afternoon Symposium
Lecture Hall, 8th Floor, Block G, Princess Margaret Hospital, Kwai Chung,
N.T.
Miss Tsang – Tel: 2388 2728
Hong Kong Doctors Union
The 307th HKDU Sunday Afternoon Symposium
Lecture Hall, 8th Floor, Block G, Princess Margaret Hospital, Kwai Chung,
N.T.
Miss Tsang – Tel: 2388 2728
Union Hospital – Department of Paediatrics
Paediatrics Departmental Round
New Seminar Room 2, 2/F, Hospital Building, Union Hospital
Ms. Kay Ho – Tel: 2608 3800
Hospital Authority – Kwai Chung Hospital
Monthly Seminar – Topic: Delirium
Lecture Theatre, Block J, Kwai Chung Hospital
Hospital Authority – United Christian Hospital-training centre
Balint Group
Conference Room, United Christian Hospital; Conference Room, Yung
Fung Shee Psychiatric Centre
1
1
2.5
2
5
2
2.5
3
1.5
1.5
1
1
1
Hong Kong Medical Association – Kowloon West Community Network
The Journey to Optimize Type 2 Diabetes Therapy
Crystal Room I-III, 30/F, Panda Hotel, 3 Tsuen Wah Street, Tsuen Wan, N.T.
Miss Hana Yeung – Tel: 2527 8285
Hong Kong Community Psychological Medicine Association
21 Jul 2015
Application of Pharmacogenetic Test in Choosing The Right Psychiatric
(Tue)
1:45 – 3:00 pm Medications
CCC Club Causeway Bay, H.K.
Mr. Allen Sun – Tel: 9017 3694
Hong Kong Medical Association – Central, Western & Southern
22 Jul 2015
Community Network
(Wed)
1:00 – 3:00 pm An Insulin-Independent Approach to Manage Patients with Type 2 Diabetes
Mellitus
HKMA Central Premises, Dr. Li Shu Pui Professional Education Centre, 2/F,
Chinese Club Building, 21-22 Connaught Road, Central, H. K.
Hong Kong Academy of Medicine
22 Jul 2015
Recent Advances in Gastric Cancer and Gastrointestinal Stromal Tumour
(Wed)
2:00 – 4:00 pm Seminar Room 3, LG1, Ruttonjee Hospital, Wanchai, H.K.
Ms. Joanne Ho – Tel: 2871 8747
HKU – Department of Obstetrics & Gynaecology
22 Jul 2015
Tumour Board Meeting – clinical-pathological conference on gynaecological
(Wed)
4:15 – 5:15 pm oncology cases
Room 215, 2/F, Seminar Room, Clinical Pathology Building, Queen Mary
Hospital
Ms. Phyllis Kwok – Tel: 2255 4518
Hong Kong Sanatorium & Hospital – Orthopaedic & Sports Medicine
23 Jul 2015
Centre
(Thu)
8:30 – 10:30 am 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
23 Jul 2015
Dyslipidemia Management with Combination Therapy – Improve Outcomes
(Thu)
1:00 – 3:00 pm Further?
V Cuisine, 6/F, Holiday Inn Express Hong Kong Kowloon East, 3 Tong Tak
Street, Tseung Kwan O
Hong Kong Medical Association – Hong Kong East Community
23 Jul 2015
Network
(Thu)
1:00 – 3:00 pm Management of Dyslipidemia: Do it Better in High Risk Patients!
5/F, Duke of Windsor Social Service Building, 15 Hennessy Road, Wanchai,
H.K.
Ms. Candice Tong – Tel: 2527 8285
Hong Kong Medical Association – New Territories West Community
23 Jul 2015
Network
(Thu)
1:00 – 3:00 pm The Journey to Optimize Type 2 Diabetes Therapy
Pearl Ocean, 1/F, Gold Coast Yacht and Country Club, 1 Castle Peak Road,
Castle Peak Bay, H.K.
Queen Mary Hospital – Department of Neurosurgery
23 Jul 2015
Neuroscience Working Group Meeting (4th Thursday of every month)
(Thu)
6:00 – 7:00 pm Lecture Theatre, 5th Professorial Block, Queen Mary Hospital
Ms. Sherla Yu – Tel: 2255 3368
23 – 24 Jul 2015 Hong Kong College of Emergency Medicine
American Heart Association (AHA) Advanced Cardiovascular Life Support
(Thu-Fri)
(ACLS)
HKEC Training Centre for Healthcare Management & Clinical Technology,
Pamela Youde Nethersole Eastern Hospital
Ms. Cherry Kwok – Tel: 2871 8877
24 Jul 2015
(Fri)
4:45 – 6:00 pm Readers' Club (Topic: Therapeutic relationship in CBT for psychosis)
Hospital Authority
25 Jul 2015
Hong Kong College of Community Medicine
(Sat)
9:30 – 11:30 am 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
21 Jul 2015
(Tue)
1:00 – 3:00 pm
1
1
1
2
1
2
1
1
1
1
10
1
2
for whole function
www.hkmacme.org
CMECalendar
27 Jul 2015
(Mon)
1:00 – 2:00 pm
28 Jul 2015
(Tue)
8:30 – 9:30 am
28-29 Jul 2015
(Tue-Wed)
29 Jul 2015
(Wed)
2:00 – 4:00 pm
29 Jul 2015
(Wed)
4:15 – 5:15 pm
31 Jul 2015
(Fri)
1:00 – 3:00 pm
31 Jul 2015
(Fri)
4:45 – 6:00 pm
1 Aug 2015
(Sat)
2:30 – 5:00 pm
4 Aug 2015
(Tue)
1:00 – 3:00 pm
5 Aug 2015
(Wed)
1:00 – 3:00 pm
5 Aug 2015
(Wed)
4:15 – 5:15 pm
5 Aug 2015
(Wed)
5:00 – 7:30 pm
Hospital Authority – Kwai Chung Hospital
Monthly Academic Meeting – Part III Presentation
Lecture Theatre, Block J, Kwai Chung Hospital
Hong Kong Sanatorium & Hospital – Respiratory Medicine Centre &
Clinical Oncology Centre
Lung Cancer Tumour Board Meeting
Rm1103, 11/F, Li Shu Pui Block, Hong Kong Sanatorium & Hospital
Ms. Wong – Tel: 2835 8673
Hong Kong College of Emergency Medicine
American Heart Association (AHA) Advanced Cardiovascular Life Support
(ACLS)
HKEC Training Centre for Healthcare Management & Clinical Technology,
Pamela Youde Nethersole Eastern Hospital
Hong Kong Academy of Medicine
1) Updates on Renal Replacement Therapy
2) Minimally Invasive Surgery for Colorectal Cancer
Seminar Room 3, LG1, Ruttonjee Hospital, Wanchai, H.K.
Ms. Joanne Ho – Tel: 2871 8747
oncology cases
Hospital
Hong Kong Medical Association – Yau Tsim Mong Community
Network
1) Use of 3D Mammogram in Symptomatic Patients and Breast Cancer
Screening – Principles and Scientific Evidence;
2) Management of Common Breast Symptoms
Pearl Ballroom, Level 2, Eaton, Hong Kong, 380 Nathan Road, Kowloon
Case based discussion group
Hong Kong Paediatric Society
Hong Kong College of Paediatricians
Hong Kong Paediatrics Nurse Association
Update Series on Child Health 2015
Session III) Lecture 1: Orthodontic Problems and Dental Development in
Children; Lecture 2: New Advances of Management of Paediatric Arrhythmia
Jordan Valley St. Joseph's Catholic Primary School, 80 Choi Ha Road,
Kowloon
Mr. Peter Law – Tel: 5588 2520
Hong Kong Medical Association – Kowloon West Community Network
Management of Dyslipidemia: Strategies for Long-Term Success
Crystal Room I-III, 30/F, Panda Hotel, 3 Tsuen Wah Street, Tsuen Wan, N.T.
Hong Kong Medical Association – Central, Western & Southern
Community Network
Update in Stroke Prevention in Atrial Fibrillation Patients
HKMA Central Premises, Dr. Li Shu Pui Professional Education Centre, 2/F,
Chinese Club Building, 21-22 Connaught Road, Central, H.K.
Tumour Board Meeting-clinical-pathological conference on gynaecological
oncology cases
Hospital
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
www.hkmacme.org
1
1
10
2
1
1
1
2.5
1
1
1
2
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
Hong Kong Medical Association – New Territories West Community
6 Aug 2015
Network
(Thu)
1:00 – 3:00 pm Primary Prevention of Infancy Allergy and Latest International Guidelines
Plentiful Delight Banquet, 1/F, Ho Shun Tai Building, 10 Sai Ching Street,
Yuen Long
Hong Kong College of Anaesthesiologists
8 Aug 2015
Enhancing Safety in Sedation Workshop (Identical)
(Sat)
8:30 – 4:30 pm NTE Simulation & Training Centre 3E Ward, North District Hospital
Mr. Thomas Tam – Tel: 2683 8343
Hong Kong Medical Association – Yau Tsim Mong Community
11 Aug 2015
Network
(Tue)
1:00 – 3:00 pm Treatment of Female Stress Urinary Incontinence
Pearl Ballroom, Level 2, Eaton, Hong Kong, 380 Nathan Road, Kowloon
Union Hospital
12 Aug 2015
Clinical Pathologic Conference (Regular Meeting 2015)
(Wed)
8:30 – 9:30 am Training Room, MIC, 8/F, Hospital Building, Union Hospital
Ms. Penny Fok – Tel: 2608 3287
12 Aug 2015
(Wed)
4:15 – 5:15 pm oncology cases
Hospital
Hong Kong Poison Information Centre
12 Aug 2015
(Wed)
5:00 – 7:00 pm 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
Union Hospital
13 Aug 2015
Association of Private Orthopaedic Surgeons
(Thu)
8:30 – 10:30 pm 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
13 Aug 2015
Department of Health – Primary Care Office
(Thu)
1:00 – 3:00 pm Reference Framework for Preventive Care for Older Adults in Primary Care
Settings
Lei Garden Restaurant, Shop No. L5-8, apm, Kwun Tong, No. 418 Kwun
Tong Road, Kowloon
Hong Kong Medical Association
13 Aug 2015
Hong Kong Sanatorium & Hospital
(Thu)
1:15 – 3:00 pm HKMA Structured CME Programme with HKS&H Session 6: Diagnosis and
Treatment of Early Liver Cancer
Function Room A, HKMA Dr. Li Shu Pui Professional Education Centre, 2/
F, Chinese Club Building, 21-22 Connaught Road Central, H.K.
HKMA CME Dept. – Tel: 2527 8452
15 Aug 2015
(Sat)
1:30 – 3:45 pm Hong Kong Medical Association – Kowloon East Community Network
CME Course for Health Personnel 2015 – Adolescent Mental Health Issues
Lecture Theatre, G/F, Block P, United Christian Hospital, 130 Hip Wo
Street, Kwun Tong, Kowloon
Ms. Polly TAI – Tel: 3513 3430
15 Aug 2015
Assessment Enhancement Course 2015
(Sat)
2:30 – 5:30 pm 8/F, Duke of Windsor Social Service Building, Wanchai, H.K.
Mr. John Lee – Tel: 2528 6618
6 Aug 2015
(Thu)
8:30 – 9:30 am
1
1
5
1
1
1
2
2
1
1
1.5
3
41

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Transcription

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