SPOTlight
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SPOTlight
www.hkmacme.org March 2015 香港醫學會 THE HONG KONG MEDICAL ASSOCIATION B U L L E T I N 持 續 醫 學 進 修 專 訊 Myeloma as a chronic disease by Dr. AU Wing Yan Male infertility - the often forgotten significant other by Dr. HO Kwan Lun HKMA CME Bulletin 持續醫學進修專訊 Contents Editorial 1 Spotlight 1 2-6 Myeloma as a chronic disease Spotlight 2 7-11 Male infertility – the often forgotten significant other Cardiology 12-13 Doctor, should I stop my anti-platelet agents? Spotlight 1 Myeloma as a chronic disease Dermatology 14 A 53-year-old man presented with generalized rash Complaints & Ethics 15-18 Answer Sheet 19 CME Notifications 20-21 Learning Centre article 22-24 Meeting Highlights 26-27 CME Calendar 28-29 Spotlight 2 Male infertility – the often forgotten significant other Cardiology Doctor, should I stop my anti-platelet agents? Dermatology HKMA CME Bulletin – MONTHLY SELF-STUDY SERIES to help you grow! Please read the following articles and answer the questions. Participants in the HKMA CME Programme will be awarded credit points under the Programme for returning the completed answer sheet via fax (2865 0943) or by mail to the HKMA Secretariat on or before 15 April 2015. Answers to questions will be provided in the next issue of the HKMA CME Bulletin. (Questions may also be answered online at www.hkmacme.org) 請 細 閱 本 期 文 章, 並 利 用 答 題 紙 完 成 自 我 評 估 測 驗, 於 2015 年 4 月 15 日 前, 將 已 填 妥 之 答 題 紙 傳 真 (號碼:2865 0943)或寄回本會秘書處,您將可獲持續 醫學進修的積分點 ; 至於是期自我評估測驗之答案,將 刊於下一期《持續醫學進修專訊》之中。(您亦可透過網 站 www.hkmacme.org 完成自我評估測驗) HKMA CME Enquiry Hotline Tel: 2527 8452 / 2861 1979 A 53-year-old man presented with generalized rash The Hong Kong Medical Association is dedicated to providing a coordinated CME programme for all members of the medical profession. Under the HKMA CME Programme, a CME registration process has been created to document the CME efforts of doctors and to provide special CME avenues. The Association strives to foster a vibrant environment of CME throughout the medical profession. Both members as well as non-members of the Association are welcome to join us. You may contact the HKMA Secretariat for details of the programme. 香港醫學會體察到業界有必要設立完善的持續進修計劃,致力推動持續醫學進修,為 同僚建立有系統的進修記錄機制,以及為全科醫生提供適切的進修課程。藉著這個計 劃,我們期望將優良的進修傳統推展至醫學界中每一角落,同時為業界締造一個充滿 活力的進修文化。我們誠意邀請您參與醫學會持續進修計劃,不論您是否醫學會的會 員,均歡迎您同來與我們一起學習,以及享用醫學會為所有醫生設立的進修記錄機 制。如欲了解香港醫學會持續醫學進修計劃的詳情,請聯絡本會秘書處查詢。 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 Dr. WONG Bun Lap, Bernard 陳以誠醫生 鄭志文醫生 張漢明醫生 蔡 堅醫生 周伯展醫生 何仲平醫生 何鴻光醫生 林哲玄醫生 李深和醫生 史泰祖醫生 謝鴻興醫生 黃品立醫生 Cardiology Dr. CHEN Wai Hong Dr. HO Hung Kwong, Duncan Dr. LEE Pui Yin Dr. LI Siu Lung, Steven Dr. WONG Bun Lap, Bernard Dr. WONG Shou Pang, Alexander 陳偉康醫生 何鴻光醫生 李沛然醫生 李少隆醫生 黃品立醫生 王壽鵬醫生 Neurology Dr. FONG Chung Yan, Gardian Dr. TSANG Kin Lun, Alan 方頌恩醫生 曾建倫醫生 Neurosurgery Dr. CHAN Ping Hon, Johnny 陳秉漢醫生 Obstetrics and Gynaecology Dr. CHAN Kit Sheung 陳潔霜醫生 Ophthalmology Dr. CHOW Pak Chin, JP Dr. LIANG Chan Chung, Benedict Dr. PONG Chiu Fai, Jeffrey 周伯展醫生 梁展聰醫生 龐朝輝醫生 Cardiothoracic Surgery Dr. CHENG Lik Cheung Dr. CHIU Shui Wah, Clement Dr. CHUI Wing Hung Dr. LEUNG Siu Man, John 鄭力翔醫生 趙瑞華醫生 崔永雄醫生 梁兆文醫生 Colorectal Surgery Dr. CHAN Cheung Wah Dr. CHU Kin Wah Dr. LEE Yee Man Dr. TSE Tak Yin, Cyrus 陳長華醫生 朱建華醫生 李綺雯醫生 謝得言醫生 Orthopaedics and Traumatology Dr. IP Wing Yuk, Josephine Dr. KONG Kam Fu Dr. POON Tak Lun Dr. TANG Yiu Kai 葉永玉醫生 江金富醫生 潘德鄰醫生 鄧耀楷醫生 Dermatology Dr. CHAN Hau Ngai, Kingsley Dr. HAU Kwun Cheung Dr. SHIH Tai Cho, Louis 陳厚毅醫生 侯鈞翔醫生 史泰祖醫生 Endocrinology Dr. LEE Ka Kui Dr. LO Kwok Wing, Matthew Paediatrics Dr. CHAN Yee Shing, Alvin Dr. FUNG Yee Leung, Wilson Dr. TSE Hung Hing, JP Dr. YEUNG Chiu Fat, Henry 陳以誠醫生 馮宜亮醫生 謝鴻興醫生 楊超發醫生 李家駒醫生 盧國榮醫生 Plastic Surgeon Dr. NG Wai Man, Raymond 吳偉民醫生 ENT Dr. CHOW Chun Kuen 周振權醫生 Psychiatry Dr. LAI Tai Sum, Tony Dr. LEUNG Wai Ching Dr. WONG Yee Him, John 黎大森醫生 梁偉正醫生 黃以謙醫生 吳福康醫生 Radiology Dr. CHAN Ka Fat, John Dr. CHAN Yip Fai, Ivan 陳家發醫生 陳業輝醫生 General Surgery Dr. LAM Tzit Yuen, David Dr. Hon. LEUNG Ka Lau 林哲玄醫生 梁家騮醫生 Respiratory Medicine Dr. LEUNG Chi Chiu Dr. YUNG Wai Ming, Miranda 梁子超醫生 容慧明醫生 Geriatric Medicine Dr. KONG Ming Hei, Bernard Dr. SHEA Tat Ming, Paul 江明熙醫生 佘達明醫生 Rheumatology Dr. CHAN Tak Hin Dr. CHEUNG Tak Cheong 陳德顯醫生 張德昌醫生 Haematology Dr. AU Wing Yan Dr. MAK Yiu Kwong, Vincent 區永仁醫生 麥耀光醫生 Urology Dr. CHEUNG Man Chiu Dr. KWOK Ka Ki Dr. KWOK Tin Fook 張文釗醫生 郭家麒醫生 郭天福醫生 Hepatobiliary Surgery Dr. CHIK Hsia Ying, Barbara Dr. LIU Chi Leung 戚夏穎醫生 廖子良醫生 Vascular Surgery Dr. TSE Cheuk Wa, Chad Dr. YIEN Ling Chu, Renny 謝卓華醫生 顏令朱醫生 Medical Oncology Dr. TSANG Wing Hang, Janice 曾詠恆醫生 HKMA Secretariat Ms. Jovi LAM Miss Sophia LAU Miss Irene GOT 林偉珊女士 劉思妃小姐 葛樂詩小姐 Family Medicine Dr. LAM King Hei, Stanley Dr. LI Kwok Tung, Donald, SBS, JP Gastroenterologist Dr. NG Fook Hong Nephrology Dr. CHAN Man Kam Dr. HO Chung Ping, MH, JP Dr. HO Kai Leung, Kelvin 林敬熹醫生 李國棟醫生 陳文岩醫生 何仲平醫生 何繼良醫生 NOTICE Medical knowledge is constantly changing. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on experience and knowledge of the patient, to determine dosages and best treatment for each individual patient. Neither the Publisher nor the Authors assume any liability for any injury and/or damage to persons or property arising from this publication. Although all advertising material is expected to conform to ethical (medical) standards, inclusion in this publication does not constitute a guarantee or endorsement of the quality or value of such product or of the claims made of it by its manufacturer. CME Bulletin Editorial – March 2015 Dear HKMA Fellow Members, When you are reading this editorial, the long winter was gone and we are now enjoying the adorable season of spring. I am truthfully hoping that our political and economic turmoil has passed away with the winter season altogether. While enjoying our beautiful spring, I am going to share with you some positive quotes of wisdom for this lovely season. “No winter lasts forever; no spring skips its turn.” Hal Borland (1900-1978), American author and journalist “We cannot stop the winter or the summer from coming. We cannot stop the spring or the fall or make them other than they are. They are gifts from the universe that we cannot refuse. But we can choose what we will contribute to life when each arrives.” Gary Zukav (1942-), American writer, public speaker “I believe in process. I believe in four seasons. I believe that winter’s tough, but spring’s coming. I believe that there’s a growing season. And I think that you realize that in life, you grow. You get better.” Steve Southerland (1965-), Florida politician “In winter, I plot and plan. In spring, I move.” Henry Rollins (1980-), American performer, writer, journalist, publisher “If Winter comes, can Spring be far behind?” Percy Bysshe Shelley (1792-1822), Kingdom of Sardinia, poet, dramatist, essayist, novelist “It is only the farmer who faithfully plants seeds in the Spring, who reaps a harvest in the Autumn.” B.C. Forbes (1880-1954), American journalist, author, publisher The HKMA CME Bulletin Editorial Board wishes you and your family a Happy Spring time. Dr. WONG Bun Lap, Bernard Chief Editor SPOTlight -1 Dr. AU Wing Yan Myeloma as a chronic disease Update on myeloma epidemiology MBBS (HK), MD (HK), FRCP (London/ Edin), FHKCP FHKAM Specialist in Hematology Incidence of plasma cell myeloma in HK 1983-2012 (HK Cancer Registry) 250 Myeloma is a hematological malignancy originating from the abnormal growth of plasma cells. Plasma cells are the terminally differentiated B cells, usually residing in the marrow, that produce specific antibodies to immunological challenge. The World Health Organization has replaced the old term of multiple myeloma (MM) with the nomenclature as plasma cell myeloma (PCM). It is usually a malignancy in the elderly. Data from the Hong Kong Cancer Registry (http://www3.ha.org. hk/cancereg/) showed a steadily increasing annual incidence from less than 100 cases per year in 1980 approaching 250 cases per year in 2011 (Figure 1). The peak age of occurrence is between 70 to 75 years and it is more common in men than in women (Figure 1). Epidemiological data for PCM is interesting the following ways. Although the case load in Hong Kong is increasing, this is mainly due to population growth and ageing rather than a real increase in risk. Indeed, when corrected for gender and age, the incidence is static (Figure 1). Hence there is no environmental change in Hong Kong that increased the risk. Secondly, the disease is indolent and hardly ever seen below age 40. This is because of the long time it takes for the abnormal plasma cells to accumulate enough pathogenic mutations. Indeed, the first clonal myeloma cells may occur 10 to 20 years before clinical onset. Myeloma risk increases sharply after age 60 to beyond 80 years. Thirdly, myeloma is 60% less common in Chinese than in Caucasians. The ethnic difference is genetically based since the lower incidence is maintained in Chinese migrants to the West. (Chan, Song et al. 2011) Finally, although the annual incidence of death due to myeloma is also increasing, the rise is less steep from that of increasing incidence and the lag time between the two curves appears to be increasing, suggesting that myeloma patients in Hong Kong are surviving for increasingly longer periods of time (Figure 1). 2 HKMA CME Bulletin 持續醫學進修專訊 March 2015 Case load increasingg 200 Less sharp p rise in mortality 150 all men women death WASR case per 10000 100 More men than women 50 Stable when corrected for age 0 1980 1985 1990 1995 2000 2005 2010 2015 Figure 1: Data from 1983 to 2011 showing increasing case load of myeloma (blue line) with higher rates in male (green line) than females (red line). Myeloma deaths (black line) also increases but at lower pace than case incidence. Corrected for population size and age, the world age standardized rate (WASR) remained constant (purple line) Update on diagnosis and presentation of myeloma The diagnostic workup of myeloma has advanced dramatically for the past 10 years. (Engelhardt, Terpos et al. 2014; Rajkumar, Dimopoulos et al. 2014) However, all the tests fall into three groups. Classically there are three hallmarks of PCM, namely the triad of bone pain, plasma cells damaging marrow and abnormal blood monoclonal immunoglobulins (Ig, which may be IgG or IgA). Onset can be insidious and a high index of suspicion should be maintained when taking care of elderly patients with unexplained systemic symptoms. Myeloma cells reside in the bone marrow and form an autocrine loop with osteoclasts to cause bone erosion. The marrow rich tissue of the vertebral column www.hkmacme.org SPOTlight -1 is often involved and back pain with bone collapse is common. Since there is little bone healing, alkaline phosphatase level is normal, unlike osteoporotic or metastatic fractures. In the past skeletal survey X-rays are used to look for punched out or moth eaten lesions in the skull and long bones. Nowadays, this is superseded by magnetic resonance imaging (MRI) bone scan or acetate positron emission tomogram (PET) scans that are far more sensitive in detecting bone lesions (Figure 2A). However, if the patient has frank PCM, MRI and PET are not required to start treatment. Screening blood tests are usually suggestive and nomochromic normocytic anemia with low platelet counts, a raised globulin level associated with elevated erythrocyte sedimentation rate (ESR) are classical. The anemia is due to marrow replacement by PCM cells plus autocrine suppression of erythropoietic activity, while the increased globulin is due to the clonal abnormal immunoglobulin (M protein) secreted. Its quantification reflects the total volume of PCM cells and is useful for monitoring. The total disappearance of blood M protein by immunofixation is termed complete remission (CRi). Bence Jones protein testing in urine is obsolete. A more sensitive test than M protein level or total IgG/IgA level is the use of serum free light chains (FLC). (Figure 2B) This can pick up light chain myeloma, IgD myeloma, amyloidosis or so-called non-secreting myelomas, but is not needed in every case. Finally, a bone marrow (BM) biopsy will reveal the clonal myeloma cells, which are stained CD138 positive and show κ/ λ expression. PCM is defined by over 10% plasma cells, but distribution can be patchy and sampling error may occur. The marrow specimen is also increasingly important for genetic studies looking for specimen chromosomal abnormalities (e.g. t(6:14), 17p-) which give poorer prognosis (Figure 2C). In addition, two blood tests albumin level and the beta-2 microglobulin level (b2m, reflects PCM mass and renal function), with low albumin <3.5g/dl and raised b2m >5.5mg/l reflecting poor prognosis (Rajkumar, Dimopoulos et al. 2014). www.hkmacme.org X ray punch lesions PET Figure2A MRI Monoclonal (M) Protein Serum Free light chain Figure2B Marrow Plasma Cells FISH genecs Figure2C Figure 2: Advance in diagnostic workup of myeloma from 20th (upper row) to 21 st century (lower row), with X ray lesions better detected by PET or MRI (panel A); clonal gamma-immunoglobulin detection and quantification by immunoelectrophoresis (γ peak abnormal) superseded by serum free light chain quantification (abnormal black and blue cases outside the parallel normal lines indicating either κ or λ disease) (Panel B) and bone marrow morphological and numerical assessment of plasma cells (100% abnormal cells in this view) supplemented by fluorescent in situ hybridization (FISH) DNA technique looking for specific genetic lesions (red green fusion signals abnormal for t(4;14) fusion in this case) (Panel C) Natural history of myeloma Myeloma is characterized by long latency and the first clonal plasma cells may occur up to decades before symptomatic disease. Indeed 0.8% of normal blood donors in Hong Kong above age of 50 shows trace levels of detectable M band (Wu, Minter et al. 2013). The incidence increase with age and is 3 times higher in Caucasians. This is called monoclonal gammopathy of unknown significance (MGUS). Although the M band level may increase slowly with time, most people never progress to PCM in their lifetime. MGUS forms a continuous spectrum with PCM and the crossover is arbitrary: when the M band is above 20g/l or plasma cells are over 10%. This may or may not be symptomatic. Symptomatic PCM warrants treatment and the classical quartet of symptoms are calcium increase, renal impairment, anemia and bone erosion (acronymed CRAB). Some would also include infections (due to hypogammaglobulinemia), neuropathy (due to light chain) and malaise (multifactorial) as symptomatic. The traditional wisdom is that treatment of PCM is based on symptoms, and asymptomatic PCM HKMA CME Bulletin 持續醫學進修專訊 March 2015 3 SPOTlight -1 Drugs for the treatment of PCM For over 30 years, the basic treatment of PCM was a combination of alkylator chemotherapy and steroids, with a combination of melphalan and prednisolone (MP) being the most common. The median survival was on 2 to 3 years and complete remissions (CR) are not seen. The side of effects of long term steroids included infections, muscle wasting, hypertension, weight and fluid gain, hyperglycemia, bone loss and hepatitis viral reactivation. Long terms steroids is poorly tolerated especially in elderly with multiple medical problems. Oral alkylators do not cause nausea and aloplecia but can cause marrow suppression, infection, bleeding and leukemia. The use of more intensive chemotherapy including cyclophosphamide, vincristine and doxorubicin gives CR rates of 5-10% and allow some younger patients (cut-off age <65 (representing 17% of all PCM) in Hong Kong) to proceed to autologous transplantation (ABMT). These treatments are in-patient and intensive. They carry full chemotherapy side effects and a mortality rate. Understandably, they are irrelevant to most PCM patients who are elderly. Furthermore, the added benefit of ABMT is only one year extra survival on average. Hence, there was very little improvement in the survival curve of overall myeloma patients until 2000 (Kumar, Rajkumar et al. 2008) (Figure 3). 4 HKMA CME Bulletin 持續醫學進修專訊 March 2015 Median survival from 3 years (1971 (1971-2000) 2000) to 5 years (2001 (2001-2006) 2006) 100 1971-1976 1977-1982 1983-1988 1983 1988 1989-1994 1994-2000 2001-2006 80 Alive (%)) A (termed smouldering multiple myeloma SMM) may still be observed. This is because it is difficult to prove that earlier chemotherapy gives survival benefit and it carries side effects. This concept is recently challenged. Firstly, the appearance of symptoms may be abrupt and catastrophic. Secondly, with high disease burden, symptom emergence is projectable and inevitable and an artificial cutoff is not logical. Thirdly, the emergence of target therapy has curtailed the immediate and longterm risks of treatment and even allowed long duration maintenance so that benefits increasingly outweigh the risk. Finally, recent trials actually proved that treatment of high disease load SMM with target agents provide longer survival over a waiting approach (Mateos, Hernandez et al. 2013). Marrow genetics, MRI bone and serum free light chain levels would be useful in selecting such SMM cases. 60 Target therapy 40 20 0 Auto BMT (age<65) ( 6 ) Chemo Steroids 0 20 40 60 80 Mos 100 120 140 Kumar SK, et al. Blood. 2008;111:2516-2520. . Figure 3: Minimal progress in survival from 1971 to 2000 despite improved chemotherapy and supportive care and BMT, with dramatic improvement after 2000 due to target therapy Two classes of medication changed the outlook of myeloma patients (Figure 4). The first group is immunomodulators (IMID), the first one being thalidomide. This oral drug was used in 1970 for pregnancy related dizziness and was banned for 30 years since it cause limb deformities in babies. However, it was found to have profound suppressive effects on PCM. Studies adding thalidomide (T) to MP can give CR and delay progression from 14.5 to 24.8 months (Palumbo, Bringhen et al. 2008). Side effects of thalidomide are mild, including numbness, sleepiness and constipation, none of which are life-threatening. The dose can be titrated for individual elderly patients. The drug can be used for maintenance for up to 3 years, and is relative inexpensive since its patent is long over. A non-chemo combination of thalidomide and dexamethasone (TD) give CR rates comparable to that of chemotherapy regimens. Pharmaceutical companies tested numerous thalidomide analogues with extensive list of side chain modifications and produced lenalidomide (R) and pomalidomide (P) as second and third generation IMIDs, with more powerful antimyeloma properties. Both are oral drugs with few side effects except mildly reduced platelets and diarrhea www.hkmacme.org SPOTlight -1 in some patients. Uses of lenalidomide in upfront (up to 60% CR), salvage after thalidomide relapse, or maintenance settings are well established. Maintenance lenalidomide can improve median progression from 13 to 31 months (Palumbo, Hajek et al. 2012). Immunomodulators (IMID) Protesome Inhibitors (PI) CC-5013 Figure 4: Chemical structure of the families of proteasome inhibitor (PI: left) and immunomodulator (IMID, right) and their purported mechanism of action. For IMID, thalidomide is taken as example and the multiple mechanisms of action are not fully characterized. A second class of medicine that showed remarkable activity against PCM is the proteasome inhibitor (PI) groups. The parent compound mafilzomib was discovered in toxic seabed bacteria from San Diego beaches. The medicine works by a novel mechanism of blocking protein metabolism. Plasma cells, which are extremely active in producing immunoglobulins proteins, are highly susceptible. The first generation drug was bortezomib or velcade (V) which can be given as weekly subcutaneous injections. Feet numbness is the commonest side effect with high cumulative doses. The addition of bortezomib to MP (MPV) delays progression to 17.8 months and biweekly maintenance extended it to 31.5 months (Palumbo, Bringhen et al. 2010). The second generation drug, calfizomib showed increased potency and reduced side effect profile. It is effective in over half of patients already resistant to both velcade and lenalidomide. www.hkmacme.org These revolutionary medicines changed the landscape of PCM treatment for ever and all patients regardless of age are now treated with target therapy backbone upfront, either a doublet or a triplet of agents choosing from IMID and/or PI plus either steroids and/or alkylator (Engelhardt, Terpos et al. 2014). The CR rates can now reach up to 60%. There are a number of distinct features about the PCM target agents. Firstly, all well tolerated out-patient therapy for elderly. Secondly, they out-perform all chemotherapy agents. Thirdly, the response improves with time with prolonged administration. Fourthly, long term maintenance treatment is possible. Finally, they are synergistic in action and results in rapid tumor depletion. This may be useful in situations such as impending renal failure or severe bone damage. The problematic issue is their cost which, except thalidomide, can be substantial in the long run. Myeloma as a chronic disease Life expectancy is increasing in Hong Kong and the caseload of myeloma is likely to increase. The treatment goals of PCM in elderly may be different from that in the younger generation. Some centers in the USA specialize in treating young myeloma cases as an acute disease. Their total therapy approach aim to eradicate the PCM clone for up to 10 years using six cycles of intensive therapy with 4 cytotoxic drugs, 3 target agents and 2 BMT all completed within six months (Barlogie, Mitchell et al. 2014). This is obviously not feasible for elderly. Even in young patients, it is not chosen or tolerated by most patients. Moreover, in elderly there are competing causes of death (Figure 5). This means that the background survival curve will decline irrespective of the patient having myeloma or not. This has to be compared against the decay curve of myeloma patients (Figure 4 and 5). Before 2000, the myeloma survival curve was steeper than the population decay curve resulting in premature death, due to treatment intolerance or inadequacy. After 2000, each new therapy pushes the survival curves to the right and closer and closer to the population decay curve. Myeloma is not a curable disease. All patients will relapse with infinite follow-up. HKMA CME Bulletin 持續醫學進修專訊 March 2015 5 SPOTlight -1 However, this problem may not be relevant for elderly patients. Upfront use of target agents means they can be free from symptoms and side effects using outpatient continuous therapy, for a median of 5 years and often beyond. It is therefore very relevant to look out for suspected myeloma cases in the elderly and start treatment early. This avoids irreversible organ damage, improves disease control and returns the survival curve back towards the baseline elderly population. Background populaon overall survival at 70 2013 HK life-table data ((courtesyy Prof Dennis KM Ip) p) Key Message: Myeloma cases will increase with ageing population. Early detection by blood test is easy. Target therapy has replaced chemotherapy. It is now an outpatient chronic disease which may not be lifethreatening within the life-span of some elderly patients. References: Barlogie, B., A. Mitchell, et al. (2014). "Curing myeloma at last: defining criteria and providing the evidence." Blood 124(20): 3043-3051. Chan, V., Au, W.Y, K. Song, et al. (2011). "Lower incidence of plasma cell neoplasm is maintained in migrant Chinese to British Columbia: findings from a 30-year survey." Leuk Lymphoma 52(12): 2316-2320. Engelhardt, M., E. Terpos, et al. (2014). "European Myeloma Network recommendations on the evaluation and treatment of newly diagnosed patients with multiple myeloma." Haematologica 99(2): 232-242. Kumar, S. K., S. V. Rajkumar, et al. (2008). "Improved survival in multiple myeloma and the impact of novel therapies." Blood 111(5): 2516-2520. Mateos, M. V., M. T. Hernandez, et al. (2013). "Lenalidomide plus dexamethasone for high-risk smoldering multiple myeloma." N Engl J Med 369(5): 438-447. Palumbo, A., S. Bringhen, et al. (2008). "Oral melphalan, prednisone, and thalidomide in elderly patients with multiple myeloma: updated results of a randomized controlled trial." Blood 112(8): 3107-3114. Palumbo, A., S. Bringhen, et al. (2010). "Bortezomib-melphalan-prednisonethalidomide followed by maintenance with bortezomib-thalidomide compared with bortezomib-melphalan-prednisone for initial treatment of multiple myeloma: a randomized controlled trial." J Clin Oncol 28(34): 5101-5109. Move curve to right Myeloma prolong survival Palumbo, A., R. Hajek, et al. (2012). "Continuous lenalidomide treatment for newly diagnosed multiple myeloma." N Engl J Med 366(19): 1759-1769. Figure 5: Concept of myeloma as a chronic disease as the hypothetical survival curve of myeloma (red) is continually pushed to the right (green dotted) so that it approaches the life-table natural decay curves for elderly females and males (70-year old starting curves used in this example, the older the age at diagnosis, the steeper the natural decay curve). Questions: Q&A Self-assessment Complete this course and earn 1 CME Point Answer these on page 19 or make an online submission at: www.hkmacme.org Please indicate whether the following statements are true of false. Rajkumar, S. V., M. A. Dimopoulos, et al. (2014). "International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma." Lancet Oncol 15(12): e538-e548. Wu, S. P., Au, W. Y., A. Minter, et al. (2013). "MGUS prevalence in an ethnically Chinese population in Hong Kong." Blood 121(12): 2363-2364. Answers to February 2015 Polypharmacy in elderly patients 1.F 2.T 3.T 4.F 5.F 6.T 7.F 8.F 9.T 10.T Advances in the Treatment of Rheumatoid Arthritis 1. True. Rheumatology referral is mandatory not only for diagnosis, but also risk stratification, disease activity assessment, formulate plan of pharmacological and non-pharmacological treatment. 2. False, as in the criteria, although large joints only involvement is less classical of RA, it is not an uncommon clinical manifestation. 1. Myeloma is a disease of elderly and peaks at 70-75 years old. 2. Myeloma is a curable disease using chemotherapy. 3. Bone pain and anemia are present features. 4. PET-CT should be done for all myeloma cases. 4. True. 5. Target therapy should be considered for all myeloma cases. 5. True. 6. The survival of myeloma patients had improved little from 1970 to 2000. 7. IMID (e.g. thalidomide) and PI (e.g. velcade) are two target agents. 8. Complete remission can now occur in ½ of myeloma cases. 9. Most target agents are inexpensive. 10. The myeloma survival curve can overlap that of background elderly population. 3. True. Seronegative RA is not uncommon, as high as in 30% of RA patients. 6. False. All biological DMARD show better response rate when combined with methotrexate. 7. False. A composite score is needed to assess for remission. 8. False. 9. False. 10. False. 6 HKMA CME Bulletin 持續醫學進修專訊 March 2015 www.hkmacme.org SPOTlight -2 Male infertility – the often forgotten significant other Introduction Infertility is defined by the inability to conceive after one year of regular unprotected sexual intercourse. The condition affects 15% of couples and is a worldwide phenomenon1. In addition to the well-known factor of ever-increasing advanced maternal age in developed countries, multiple genetic and environmental factors have been implicated as possible etiologies. With the development of assisted reproductive technology (ART) and in-vitro fertilization procedures pioneered by British scientist Sir Robert Edwards, more than five million “test-tube” babies have been born since the birth of Louise Brown in 1978. Sir Robert Edwards was awarded the Nobel prize for medicine, honoring his contribution to the field. Since the birth of the first “test-tube baby”, infertility treatment had been focusing on the female for decades. The male factor had been overlooked if not neglected, until the development of intracytoplasmic sperm injection technology which brought new hopes to couples with severe male factor infertility. In the report of Council on Human Reproductive Technology in 2012, male factors were involved in 50% of couples receiving ART treatment2. The disease spectrum and treatment patterns in a local male infertility clinic were reported recently3. 36% of patients attending the male infertility clinic were diagnosed with azoospermia and a further 48% of them had various abnormalities in semen parameters. Dr. HO Kwan Lun MBBS (HK), FRCSEd (Urol), FCSHK, FHKAM (Surgery) Specialist in Urology Table 1. Role of Urologist in Male Infertility 1. Find out the causes of male infertility 2. Identify potential life-threatening disorders e.g. ca testis 3. Counselling on treatment options (a) Varicocelectomy (b) Reconstructive surgery for obstructive azoospermia (c) Sperm retrieval and assisted reproduction Reproductive history Most physicians are aware of the definition of infertility. However, it is also important to ask specifically about the frequency of sexual intercourse and whether there are any difficulty of intravaginal ejaculation e.g. erectile or ejaculatory dysfunction. The author had encountered patients who lived apart from their female partners residing in Mainland China and could only manage to have sexual intercourse one to two times a month, which significantly decreased the chance of natural conception. There are also misconceptions about fertility window and timed sexual intercourse. Most experts in reproductive medicine advocate either timed sexual intercourse after the LH surge (commercially available urine test kit) or regular sexual intercourse every two to three days starting from Day 10 after the last menstrual period. These two methods are more reliable than calculations based on basal body temperature or estimated ovulation day from last menstrual period. General practitioners and family physicians are usually the first tiers who assess couples with fertility issues. Pre-marital or at least pre-pregnancy check-up can identify potential patients with infertility conditions. A simple semen analysis is cost-effective and can identify male clients who may benefit from referral to further urology assessment (Table 1). www.hkmacme.org HKMA CME Bulletin 持續醫學進修專訊 March 2015 7 SPOTlight -2 There are some key questions related to male infertility (Table 2). The history of genital tract infection is associated with potential obstruction in epididymal tubules or vas deferens. Prior inguinal hernia surgery may cause vasal obstruction in the inguinal region. For patients who have previous infertility treatment, it is of utmost importance to inquire about the nature and timing of procedures involved. For example, prior epididymal sperm retrieval will jeopardize the potential of future reconstructive surgery in obstructive azoospermic patients. Azoospermia affects 13% of patients with unilateral undescended testis, 46% with bilateral treated and 89% with bilateral untreated undescended testes 4. Contemporary literature has postulated that the pathophysiology of undescended testes involves the abnormal transformation of primitive germ cells (gonocytes) to spermatogonia, which happens at the age of three to six months. While alkylating chemotherapeutic agents are well-known spermicidal agents, the use of exogenous testosterone or anabolic steroid is also detrimental to spermatogenesis. Mumps after puberty is associated with mumps orchitis in 40% of patients affected, of which 13% may suffer from subsequent subfertility5. Table 2. Key questions related to male infertility Genital tract infection e.g. urethritis, epididymo-orchitis Inguino-scrotal surgery e.g. hernia, vasectomy, prior sperm retrieval or varicocelectomy History of undescended testis or orchidopexy Chemotherapy or radiotherapy Drugs e.g. immunosuppresants, exogenous testosterone or anabolic steroids Clinical examination A focused physical examination is cost-effective. The underdevelopment of secondary sexual characteristics and gynecomastia lead to suspicion of Klinefelter’s syndrome, which is associated with testicular failure. Testis size and consistency are evaluated. Any abnormal testicular mass or hardness should lead to prompt urology assessment, since testicular cancer is associated with testicular failure. Epididymal and vasal assessment may be difficult to those less experienced. Distended epididymes or nodules signify previous inflammation and obstruction. Congenital absence of vas is a clinical diagnosis and is usually associated with a decrease in semen volume with acidic pH. Varicocele examination should be performed with the patient in standing posture. Investigations Semen analysis according to the WHO 2010 criteria6 is central to the male infertility assessment. Specimen collection should be done after two to five days of abstinence from ejaculation and should be promptly sent for laboratory processing within one hour of collection, in preferably close to body temperature. The important semen parameters include volume, pH, sperm concentration, motility and morphology. Azoospermia should be confirmed after specimen centrifugation and microscopic examination of the pellet. Small number of sperms can still be found in 20 per cent of “azoospermic” patients after the above processing. Mump after puberty Erectile or ejaculatory dysfunction Smoking Last but not least, it is crucial to include the concomitant female factors into consideration. Advanced maternal age of greater than 35 is associated with rapidly declining chance of natural pregnancy. History of prior pregnancy, endometriosis, polycystic ovarian disease, pelvic inflammatory disease, fertility assessment in terms of ovarian reserve and tubal status are all contributing to the comprehensive assessment of the couple facing infertility. 8 HKMA CME Bulletin 持續醫學進修專訊 March 2015 T h e r e a r e t w o m a i n t y p e s o f a z o o s p e r m i a 7-9, obstructive and non-obstructive (Table 3). Common causes of obstruction involve either the vas deferens or epididymal tubules. These patients usually have normal sized testes and hormonal profiles. Non-obstructive causes involve severe impairment of spermatogenesis or testicular failure. The testes are usually small with low serum testosterone and reactionary high serum FSH. Genetic causes contribute to 10 to 15% of nonobstructive azoospermia and these patients should be offered karyotyping and Y chromosome microdeletion analysis. www.hkmacme.org SPOTlight -2 Table 3. Azoospermia Obstructive Normal sized testes Normal FSH and testosterone Common causes Congenital absence of vas Genital tract infection Vasectomy Inguinal hernia surgery Idiopathic Varicocele Non-obstructive Small testes High FSH and low testosterone Idiopathic Genetic History of mumps Cryptorchidism Drug For patients with abnormalities in either sperm concentration, motility, morphology or all of the above, it is important to look for clinically significant varicocele which is the commonest surgically reversible cause of male infertility. Genito-urinary infection with leuokospermia is another common reversible cause of sperm quality impairment. Transrectal ultrasound may be employed in patients with low volume ejaculate, to differentiate between congenital absence of vas (absent seminal vesicles) and ejaculatory duct obstruction (distended seminal vesicles). In case of suspected retrograde ejaculation, post-ejaculation urine should be examined for presence of sperms. Ultrasound of scrotum is reserved for testicular asymmetry or masses. Sub-clinical varicocele detected by ultrasound is not clinically detrimental to sperm quality and is not an indication of routine ultrasound of scrotum. Management The role of an urologist in male infertility10 includes finding out the causes, identifying potentially lifethreatening disorders and counselling on various treatment options (Table 1). The couple should be counselled together and various options ranging from conservative treatment, adoption, donor sperms, surgical correction to sperm retrieval and assisted reproduction are thoroughly discussed. Factors considered include the female age, ovarian reserve, tubal status, sperm quality, surgical expertise, individual ART centre’s success rates and after all patient choices. www.hkmacme.org This is the commonest surgically reversible c o n d i t i o n o f m a l e i n f e r t i l i t y 11. 1 5 % o f m e n i n general population and 40% of subfertile men have varicoceles. The pathophysiology of varicocelerelated infertility is controversial. Recent literatures have focused on the effect of impaired testicular microcirculation, increased accumulation of reactive oxygen species and sperm DNA damage, leading to impairment of all semen parameters. It is even more controversial whether varicocele treatment improves pregnancy outcomes. Recent meta-analyses and limited randomized controlled trial seem to support the benefit of varicocelectomy in improving pregnancy outcomes12-13. Common approaches of varicocelectomy are high retroperitoneal (Palomo’s operation), laparoscopic and microsurgical subinguinal ligation. High retroperitoneal approach is familiar to most surgeons but cannot tackle the gubernaculum and external spermatic tributaries, leading to high recurrence rate. Failure to preserve lymphatics also leads to increased risks of hydrocele. Laparoscopic approach tackles bilateral pathologies but has the same pitfalls of high incidence of recurrence and hydrocele. Besides there is a small but non-negligible risk of bowel or great vessel injury because of the intraperitoneal approach. Microsurgical subinguinal approach is the contemporary preferred approach 14 because it can tackle internal spermatic, external spermatic and gubernaculum tributaries leading to low recurrence rate. With preservation of testicular artery and lymphatics, incidence of testis atrophy and hydrocele is extremely low. However, this approach requires sub-specialized microsurgical training and is more time consuming than traditional approaches. HKMA CME Bulletin 持續醫學進修專訊 March 2015 9 SPOTlight -2 Azoospermia About one per cent of men in general population and 10 to 15 percent of subfertile men have azoospermia, which have obstructive or nonobstructive causes 7-9 (Table 3). For patients with irreversible obstructive lesions e.g. congenital absence of vas or multiple obstructions of the genital tract which cannot be reconstructed, sperm retrieval and assisted reproduction is the only hope of childbearing. Congenital absence of vas is associated with cystic fibrosis transmembrane conductance regulator (CFTR) gene mutations in Caucaseans. Recent literature has shown that Chinese men with congenital absence of vas carry different CFTR gene mutations, which may give rise to a mild genital form of cystic fibrosis15. Besides, cystic fibrosis is very rare in Chinese patients and CFTR gene mutation analysis is not a routine in local Chinese patients with congenital absence of vas3. Huge number of possible CFTR gene mutations also makes targeted examination in local patients extremely difficult. Conclusion Male factor contributes to 50% of couples suffering from infertility. A brief reproductive history coupled with focused clinical examination and semen analysis will help to identify potential patients with male infertility. The role of an urologist is to find out the causes, identify lifethreatening disorders and counsel the couple on the optimal treatment strategies. Key lessons • Male Infertility is not uncommon and contributes to 50% of couples suffering from infertility • Pre-marital or pre-pregnancy check-up is crucial for timely identification of potential patients with male infertility • Various treatment strategies can be offered to infertile men after comprehensive assessment and counselling of the couples References: For patients with reversible obstructive lesions e.g. post-vasectomy or epididmal obstruction, there is a choice between surgical reconstruction and assisted reproduction 16 . Vasectomy reversal and vasoepididymostomy are routinely performed by urologists specialized in microsurgical reconstruction 17 . The procedures are technically demanding but rewarded with reasonable success rates. On the other hand, epididymal or testicular sperm retrieval and assisted reproduction is a viable alternative. Surgical expertise and female factors are thoroughly considered before the couple arrive at a well informed choice. In a significant proportion of patients with nonobstructive azoospermia (Table 3), no causes can be identified despite extensive investigations. Testicular sperm extraction has an overall 50% success rate in these patients with poor spermatogenesis18. About 10 to 15% of these patients have abnormal karyotyping e.g. Klinefelter’s syndrome or Y chromosome microdeletion8. In those patients with certain types of Y chromosome microdeletion e.g. complete absence of AZFa or AZFb, the chance of testicular sperm extraction is minimal and the couple should be counselled about donor sperm issues. 10 HKMA CME Bulletin 持續醫學進修專訊 March 2015 1. Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Stevens GA. National, regional, and global trends in infertility prevalence since 1990: a systematic analysis of 277 health surveys. PLoS Med 2012;9:e1001356. 2. Infertility diagnosis by age of patients receiving RT procedures (other than DI and AIH) in 2012. Council on Human Reproductive Technology. Available from: http://www.chrt.org.hk/english/ publications/files/table17_2012.pdf. Accessed December 2014. 3. Ho KL, Tsu JH, Tam PC, Yiu MK. Disease spectrum and treatment patterns in a local male infertility clinic. Hong Kong Med J. 2015 Jan 2. doi: 10.12809/hkmj144376. Epub ahead of print 4. Chung E, Brock GB. Cryptorchidism and its impact on male fertility: a state of art review of current literature. Can Urol Assoc J. 2011 Jun;5(3):210-4. 5. Davis NF, McGuire BB, Mahon JA, Smyth AE, O’Malley KJ, Fitzpatrick JM. The increasing incidence of mumps orchitis: a comprehensive review. BJU Int. 2010 Apr;105(8):1060-5. 6. Cooper TG, Noonan E, von Eckardstein S, et al. World Health Organization reference values for human semen characteristics. Hum Reprod Update. 2010 May-Jun;16(3):231-45. 7. Wosnitzer M, Goldstein M, Hardy MP. Review of Azoospermia. Spermatogenesis 2014;4:e28218. 8. Berookhim BM, Schlegel PN. Azoospermia due to spermatogenic failure. Urol Clin North Am 2014;41:97-113. 9. Wosnitzer MS, Goldstein M. Obstructive azoospermia. Urol Clin North Am 2014;41:83-95. 10. Male Infertility Best Practice Policy Committee of the American Urological Association; Practice Committee of the American Society for Reproductive Medicine. Report on optimal evaluation of the infertile male. Fertil Steril 2006;86(5 Suppl 1):S202-9. www.hkmacme.org SPOTlight -2 11. Practice Committee of American Society for Reproductive Medicine. Report on varicocele and infertility. Fertil Steril 2008;90(5 Suppl):S247-9. 12. Marmar JL, Agarwal A, Prabakaran S, et al. Reassessing the value of varicocelectomy as a treatment for male subfertility with a new metaanalysis. Fertil Steril 2007;88:639-48. 13. Abdel-Meguid TA, Al-Sayyad A, Tayib A, Farsi HM. Does varicocele repair improve male infertility? An evidence-based perspective from a randomized, controlled trial. Eur Urol 2011;59:455-61. Q&A Questions Self-assessment Complete this course and earn 1 CME Point Answer these on page 19 or make an online submission at: www. hkmacme.org Please indicate whether the following statements are true of false. 1. Infertility affects 30% of couples worldwide. 2. Male factor contributes to 50% of couples with infertility. 14. Leung L, Ho KL, Tam PC, Yiu MK. Subinguinal microsurgical varicocelectomy for male factor subfertility: ten-year experience. Hong Kong Med J 2013;19:334-40. 3. Azoospermia affects 10% of men in general population. 4. Congenital absence of vas is reversible by reconstructive surgery. 15. Lu S, Yang X, Cui Y, et al. Different cystic fibrosis transmembrane conductance regulator mutations in Chinese men with congenital bilateral absence of vas deferens and other acquired obstructive azoospermia. Urology. 2013 Oct;82(4):824-8. 5. Genital tract infection is a cause of obstructive azoospermia. 6. Exogenous testosterone improves spermatogenesis in men with testicular failure. 7. Undescended testis is associated with male factor infertility. 8. Patients with non-obstructive azoospermia have normal FSH. 9. All patients with male infertility should have routine ultrasound examination of scrotum. 16. Lee R, Li PS, Schlegel PN, Goldstein M. Reassessing reconstruction in the management of obstructive azoospermia: reconstruction or sperm acquisition? Urol Clin North Am 2008;35:289-301. 17. Ho KL, Wong MH, Tam PC. Microsurgical vasoepididymostomy for obstructive azoospermia. Hong Kong Med J 2009;15:452-7. 18. Esteves SC, Miyaoka R, Agarwal A. Sperm retrieval techniques for assisted reproduction. Int Braz J Urol 2011;37:570-83. 10. Subinguinal microsurgical approach of varicocelectomy has the lowest risk of recurrence. 香港醫生網 The Hong Kong Doctors Homepage www.hkdoctors.org This web site is developed and maintained by the Hong Kong Medical Association for all registered Hong Kong doctors to house their Internet practice homepage. The format complies with the Internet Guidelines which was proposed by the Hong Kong Medical Association and adopted by the Medical Council of Hong Kong. We consider a practice homepage as a signboard or an entry in the telephone directory. It contains essential information about the doctor including his specialty and how to get to him. This facilitates members of the public to communicate with their doctors. This website is open to all registered doctors in Hong Kong. For practice page design and upload, please contact the Hong Kong Medical Association Secretariat. 由香港醫學會成立並管理的《香港醫生網》,是一個收錄本港註冊西醫執業網頁的 網站。內容是根據由香港醫學會擬訂並獲香港醫務委員會批准使用的互聯網指引內 的規定格式刊載。 醫生的「執業網頁」性質與電話索引內刊載的資料相近。目的是提供與醫生執業有 關的基本資料,例如註冊專科及聯絡方法等,方便市民接觸個別醫生。 任何香港註冊西醫都可以參加《香港醫生網》。關於網頁版面安排及上載之詳情, 請與香港醫學會秘書處聯絡為荷。 www.hkmacme.org HKMA CME Bulletin 持續醫學進修專訊 March 2015 11 Cardiology The content of the March Cardiology Series is provided by: Dr. WONG Chi Yuen MBBS, MRCP, FHKCP, FHKAM, Specialist in Cardiology Dr. TSANG Chun Fung, Sunny MBChB, MRCP (UK) 三月臨床心臟科個案研究之內容承蒙黃志遠醫生及曾振峯醫生提供。 Complete BOTH Cardiology and Dermatology courses and earn 0.5 CME POINT Doctor, should I stop my anti-platelet agents? For each of the scenario below, please choose the most appropriate peri-procedure management of anti-platelet agents. Q&A Please indicate one answer to each question Answer these on page 19 or make an online submission at: www.hkmacme.org Q1. A 57-year-old gentleman is taking aspirin 160 mg daily for prior history of minor ischaemic stroke with good recovery. He is planning to have tooth extraction. A. B. Stop aspirin 5 days before procedure, and resume as soon as haemostasis is acheived Continue aspirin during peri-procedure period Q2. A 62-year-old lady is taking aspirin 160 mg daily for asymptomatic mild coronary artery stenosis documented by cardiac CT scan. She also has diabetes and hypertension. She is planning to have colonoscopy (with anticipated biopsy or therapeutic procedures) for per rectal bleeding. A. B. Stop aspirin 5 days before procedure, and resume as soon as haemostasis is acheived Continue aspirin during peri-procedure period Q3. An 80-year-old gentleman is taking aspirin 160 mg daily, clopidogrel 75 mg daily for prior acute coronary syndrome 2 months ago and he refuses invasive coronary intervention. He is planning to have surgery for colorectal cancer. A. B. C. D. Stop aspirin at least 5 days before procedure, and resume as soon as haemostasis is achieved. Continue clopidogrel during peri-procedure period Stop clopidogrel at least 5 days before procedure, and resume as soon as haemostasis is achieved. Continue aspirin during peri-procedure period Stop both aspirin and clopidogrel at least 5 days before procedure, and resume both as soon as haemostasis is achieved. Use low molecular weight heparin as bridging therapy during peri-operative period Continue both aspirin and clopidogrel during peri-operative period Q4. A 55-year-old lady is taking aspirin 160 mg daily, clopidogrel 75 mg daily for coronary artery disease with drug eluting stents (DES) implanted in left anterior descending artery 7 months ago. She is diagnosed to have breast cancer after coronary stenting. Surgeon advises mastectomy as soon as possible. A. B. C. D. E. 12 Stop aspirin at least 5 days before procedure, and resume as soon as haemostasis is achieved. Continue clopidogrel during peri-procedure period Stop clopidogrel at least 5 days before procedure, and resume as soon as haemostasis is achieved. Continue aspirin during peri-procedure period Stop both aspirin and clopidogrel at least 5 days before procedure, and resume both as soon as haemostasis is achieved. Use low molecular weight heparin as bridging therapy during peri-operative period Continue both aspirin and clopidogrel during peri-operative period Liaise with the treating cardiologist for appropriate management strategy HKMA CME Bulletin 持續醫學進修專訊 March 2015 www.hkmacme.org Cardiology February Answers A Pregnant Woman Presented with Acute Chest Pain Answers: 1.A 2.A 3.A Chest pain in a pregnant woman may be the result of various conditions, ranging from benign to life-threatening diagnosis. The main important differential diagnosis of acute retrosternal chest pain in pregnancy are acute coronary syndrome (ACS), acute pulmonary embolism, pre-eclampsia and acute aortic dissection. With the rise in maternal age and the increasing number of high-risk women who become pregnant, pregnancy related ACS is expected to increase. For the pathophysiology, as in non-pregnant women, the occurrence of atherosclerotic changes in the coronary artery remains the primary cause of pregnancy-related myocardial infarction. However, coronary artery dissection should be considered especially in pregnant patients presenting during the peripartum and post-partum period. Spontaneous coronary artery dissection, a rare cause of myocardial infarction in the non-pregnant population, is being responsible for 50% of myocardial infarction during peripartum period. The high incidence of coronary dissection during pregnancy may be related to high progesterone levels with subsequent structural changes in the collagen of the vessel wall. For treatment, in patients presenting with acute ST elevation myocardial infarction (STEMI), coronary angiography with the possibility of primary percutaneous coronary intervention (PCI) is preferred to intravenous fibrinolysis, as it will also diagnose coronary artery dissection. The risk of potential radiation exposure to the fetus should be kept in mind, especially in the first trimester. Nonetheless, the risk of radiation from coronary angiography is deemed negligible when the abdomen is properly shielded unless the procedure is exceptionally challenging. Although several studies have demonstrated that placental transfer of thrombolytic therapy like streptokinase and tPA is too low to cause fibrinolytic effects in the fetus, it may induce maternal and fetal complications like maternal haemorrhage, preterm delivery, fetal loss, spontaneous abortion, subchorionic haematomas and abruption placenta. Moreover, the safety and efficacy of thrombolytic therapy in the treatment of myocardial infarction secondary to coronary dissection have not been clearly established, and such therapy may increase the risk of haemorrhage and further progression of the dissection. Therefore, thrombolytic therapy should be reserved for life-threatening STEMI when there is no access to PCI. The European Society Cardiology guidelines on the management of cardiovascular diseases during pregnancy suggest coronary angioplasty as the preferred reperfusion therapy for STEMI during pregnancy (Class 1 recommendation). References: 1. 2. 3. Regitz-Zagrosek V, Lundqvist CB, Borghi C, et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy. EHJ 2011; (32) 3147-97. Elkayam U, Jalnapurkar S, Barakkat MN, et al. Pregnancy-associated acute myocardial infarction: A review of contemporary experience in 150 cases between 2006 and 2011. Circulation 2014; 129:1695-1702. Poh CL, Lee CH. Acute myocardial infarction in pregnant women. Ann Acad Med Singapore 2010; 39:247-53. The content of the February Cardiology Series is provided by: Dr. CHEUNG Ling Ling MBBS(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in Cardiology Dr. LO Ka Yip, David MbChB(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in Cardiology Dr. CHUNG Tak Shun MBBS(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in Cardiology 二月臨床心臟科個案研究之內容承蒙張玲玲醫生、盧家業醫生及鍾德惇醫生提供。 www.hkmacme.org HKMA CME Bulletin 持續醫學進修專訊 March 2015 13 Dermatology The content of the March Dermatology Series is provided by: Dr. CHAN Hau Ngai, Kingsley, Dr. TANG Yuk Ming, William, Dr. KWAN Chi Keung and Dr. LEUNG Wai Yiu Specialists in Dermatology & Venereology 三月皮膚科個案研究之內容承蒙陳厚毅醫生、鄧旭明醫生、關志強醫生及梁偉耀醫生提供。 Complete BOTH Cardiology and Dermatology courses and earn 0.5 CME POINT A 53-year-old man presented with generalized rash A 53-year-old man first presented with rash over anus. Two weeks later, rash started to develop over generalized body and the mouth. The rash was painful but non itchy. There was no fever. He enjoyed good past health and he had no long term medication. Physical examination showed erosions over the month, trunk, back, limbs and anal region. There was no ocular involvement. Q&A Please answer ALL questions Answer these on page 19 or make an online submission at: www.hkmacme.org Q1. What is the diagnosis and the possible differential diagnoses? Q2. What is the cause of the disease? Q3. How is it diagnosed? Q4. Apart from skin, where are the other possible areas of involvement? Q5. How should the disease be managed? February Answers Asymptomatic lower limbs rash Answers: 1. The clinical diagnosis is capillaritis or pigmented purpuric dermatosis (PPD). 2. The differential diagnoses include eczema, small vessel vasculitis, scurvy and drug eruption. 3. The diagnosis can be made by clinical. Classical presentation is dusky brown, sprinkled cayenne pepper discolouration over bilateral shins. Complete blood picture may be require to rule out thrombocytopenia and clotting profit may also be needed to rule out other possibility of purpura. If other causes suspect, skin biopsy may help to differentiate from other possibilities. 4. The underlying etiology is unknown. Venous hypertension, vigorous exercise, gravitational dependency may be related to PPD and appear to influence the presentation. The histology reveals perivascular lymphocytic infiltration on capillaries of superficial skin associated with endothelial cell swelling and narrowing the lumen of these capillaries which signifies capillaritis. Extravasation of red blood cells with haemosiderin deposition in macrophages is also found. 5. There is no specific treatment for PPD. Removal of risk factors such as avoidance of prolonged leg dependency and pressure socking for venous stasis can help. Emollient and topical steroid may be used to relieve the itchiness. Phototherapy such as narrowband UVB and PUVA has been reported anecdotally in treatment of PPD. The content of the February Dermatology Series is provided by: Dr. KWAN Chi Keung, Dr. TANG Yuk Ming, William, Dr. CHAN Hau Ngai, Kingsley and Dr. LEUNG Wai Yiu Specialists in Dermatology & Venereology 二月皮膚科個案研究之內容承蒙關志強醫生、鄧旭明醫生、陳厚毅醫生及梁偉耀醫生提供。 14 HKMA CME Bulletin 持續醫學進修專訊 March 2015 www.hkmacme.org Complaints & Ethics Therapeutic Misadventures in Pediatric Practice MBBS (HK), MFM (Clin)(Monash), LRCP (Lond), MRCS (Eng), MRCP (UK), FRCP (Irel), FHKCP, FRACGP, FHKCFP, DFM (CUHK), FHKAM (Medicine), FHKAM (Family Medicine), DCH (Lond), DOM (CUHK), DPD (Cardiff), PDipID (HK), PDipComPsychMed (HK), PDipCommunityGeriatrics (HK), Dip Ger Med RCPS (Glasg) Specialist in Nephrology based on a lecture to DCH (Sydney) graduates 2015 Dr. CHOI Kin It is an honor to give this talk to a group of doctors who are keen to better themselves when they see children in their practice. You have been taught that prescribing to young children is not simply halving the dose. The following examples from Medical Council inquiries illustrate common mistakes encounter in prescribing for children. Dispensing Practice Manual issued by the Hong Kong Medical Association. Case 1 On 26 May 2011, a child presented to a general practitioner for presumed diagnosis of pharyngitis. He was prescribed 4 types of medications including Cefaclor. After taking 8 doses of Cefaclor in the following two days, the parents found that the expiry date of the prescribed Cefaclor was October 2009, thus the consumption of the Cefaclor by the patient was 19 months beyond the expiry date. The child was brought to the Emergency Department of a public hospital for consultation and subsequently admitted into pediatric ward for observation and investigation. All the investigations were normal except for an incidental finding of iron deficiency anemia. The Medical Council had ruled on an earlier case that since doctors are given the authority to prescribe and dispense medicines, there is the corresponding responsibility to ensure that only proper medicine is dispensed to the patients. It is the personal responsibility of every doctor who chooses to dispense medicines to patients to ensure that the medicine is proper in all aspects, including that it has not expired. This is a personal responsibility which cannot be delegated to other persons such as clinic assistants. Section 9.2 of the Code of Professional Conduct provides that a doctor who dispenses medicine to patients should establish suitable procedures for ensuring that drugs are properly labeled and dispensed, and should observe the provisions of the Good www.hkmacme.org The significance of an expiry date lies in that beyond the expiry date the efficacy of the medicine is not guaranteed, and the expired medicine may have undesirable effects. A dispensing doctor has the professional responsibility to ensure that all dispensed medicine have not expired. By dispensing an expired medicine with no guarantee of the intended therapeutic effect, the doctor may delay the proper treatment of the patient’s illness, let alone the potential of causing undesirable effects to the patient if the medicine has deteriorated. It is improper and unacceptable conduct for a doctor to dispense a medicine without ensuring that it has not expired. Remedial measures taken up by defendant doctors included sending the clinic assistant for training in basic pharmacology and dispensing practice, personally making weekly stock check on all medications, maintaining a record of the expiry dates of the stocked medicines, and reviewing the Good Dispensing Practice Manual issued by the HKMA. A computerized dispensing system with automatic monitoring of expiration of medications was also used to improve the dispensing system. Case 2 The patient was 18 months old when his mother took him to the Defendant’s clinic for vaccination. The vaccination was a booster dose of the 5-in-1 vaccine called Infanrix and previous doses had been given on 3 occasions by another doctor in the same clinic. The vaccine consists of a liquid element which contains 4 of the 5 vaccines, and a powder element which contains the 5th vaccine. The liquid and powder elements should be mixed together before administering to HKMA CME Bulletin 持續醫學進修專訊 March 2015 15 Complaints & Ethics the patient by intramuscular injection. The Defendant mistakenly administered only the liquid element to the patient without mixing it with the powder element. Shortly after the injection, he discovered that he had made a mistake. He then explained to the mother that he had injected only the solvent but not the chemical of the vaccine. He recommended a second injection of the properly reconstituted vaccine be given to the patient, and the mother agreed. A second injection of the properly reconstituted vaccine was then given to the patient. The Inquiry found that the Defendant failed to follow the instruction for administering the vaccine by injecting the liquid element but not the powder element of the vaccine. This is conduct below the standard expected amongst registered medical practitioners and constituted professional misconduct. The Inquiry also found that there was no urgency to give the 2nd injection on the same day. In the absence of immediately available information from authoritative sources, the Defendant should have ascertained the risks and effect of the double dose of the 4 injected vaccines from authoritative sources before advising the patient’s mother to accept a second injection. There was no reason to rush into a second injection without ascertaining the potential risks. This constituted professional misconduct. Case 3 On 20/9/11, defendant doctor injected or caused to be injected pneumococcal vaccine into the patient when the patient’s parent requested for an injection of Hepatitis A vaccine for the patient. He also failed to advice and/or to properly address the concern of the patient’s parent about the repeated administration of pneumococcal vaccine on the patient. After the injection, the immunization record of the patient was returned to the complainant. When the complainant found out that the patient was given a different vaccination, she immediately voiced her concern about the repeat of a booster pneumococcal vaccine with the clinic staff. The defendant’s wife told her that the additional dose of pneumococcal vaccine would not cause the patient any harm. When the Customer Service Division of the medical group did not respond after she 16 HKMA CME Bulletin 持續醫學進修專訊 March 2015 e-mailed them, she complaint to the Medical Council of Hong Kong. The Medical Council ruled that had the defendant taken the simple step of explaining to the complainant what kind of vaccination that he was going to administer, the patient would not have been given a pneumococcal vaccination instead of a Hepatitis vaccination. It was evident from the immunization record that the patient received a booster dose of pneumococcal vaccination some 3 months ago. The defendant obviously had not read the record before giving him a pneumococcal vaccination again. The expert suggested that the defendant should take the proactive approach by asking the clinic staff to keep the patient and the complainant in his clinic so that he could personally explain to the complainant after he had finished the consultation of another patient. It was certainly not good enough for the defendant to let a nonmedically qualified person to tell the complainant that there was nothing to worry. Case 4 Father of a 9 months old daughter weighing 6.5 Kg complaint that the dosage of Polaramine prescribed may be too high. The drug label put the dosage as 2 ml three times daily for running nose. The drug name was not put on the label. Micromedex and AHGS Drug Information 2011 have no recommendation for children below 2 years of age. From 2-6 years old, the dosage is 0.5 mg every 4-6 hours, if taken 6 times daily, the total dose will add up to 3 mg/day. Assuming the concentration of polaramine syrup is 2 mg/5 ml, 2 ml tds correspond to 0.8 mg tds and 2.4 mg/day. The individual dose may be higher than recommended but the total daily dose is about right for children 2-6 years old. Patient’s name was missing from the drug label. Case 5 An 8-years-3-months-old boy weighing 30 Kg sought consultation and was diagnosed to have pharyngitis, fever and flu. He was prescribed Panadol 300 mg qid, Piriton 4 mg qid, Zinnat 250 mg bd, Lysozyme 60 mg qid, Voren 25 mg qid, and Tagamet 200 mg qid. 2 days later, the boy started to vomit. He was brought www.hkmacme.org Complaints & Ethics to another doctor who told the parent that Voren is for treatment for arthritis and should not be given to children and renal damage may be a side effect. The mother brought in a complaint. The expert commented on the use of Voren: ‘Though the total daily dose of diclofenac is within recommendation, there appeared to be no strong justification for its use from the information supplied by the complainant and the second doctor. Diclofenac has been used for its antipyretic effect in febrile illness, but it should not be routinely used as an antipyretic because of its potential adverse effects. Adverse reactions to oral diclofenac are usually mild and transient and mainly involve the upper gastrointestinal tract. Nausea, diarrhea, constipation, abdominal pain or cramps, flatulence, vomiting and dyspepsia occur in up to 10% of patients receiving oral diclofenac. More severe adverse effects necessitating discontinuation of the drug occur in 1.5-2% of patients. Diclofenac has been reported to cause impairment in renal function but its incidence is not known.’ Case 6 The patient was 4 years old when she was taken by her aunt to see the defendant on 7 August 2008. He had a fever 38.7 degrees C and diagnosed as upper respiratory tract infection. The defendant doctor prescribed and dispensed Paracetamol and Biogesic 250 Paracetamol. The medications were not properly labeled, either as to the name or strength including the strength of Cephalexin and name and strength of Chlorpheniramine, amongst other poorly legible drug names. After taking the medications, the father noticed the girl vomited and lost her appetite. She was taken to the Emergency Department and investigated for suspected Paracetamol overdose. Laboratory examination confirmed that the Biogesic suspension contained 240 mg/5ml paracetamol and not 125 mg/5 ml as claimed by the Defendant. According to the BNF for children 2007, the maximum daily dosage of paracetamol for a child of age 1 to 5 is 1000 mg and in case of severe symptoms 90 mg/kg of the patient’s body weight. The dosage of paracetamol being prescribed and dispensed to the girl was 2250 www.hkmacme.org mg/day, more than two times the maximum dosage of 1000 mg/day. Even if the patient had severe symptoms, the dosage was still in excess of the maximum dosage of 1530 mg/day. Whether it is necessary to label the strength of the medication depends on the nature of the medication. While it is not necessary in respect of medications (such as commercially marketed capsules and tablets with standardized strength), the strength of which is readily ascertainable, this is essential in respect of medications (such as medications prepared or reconstituted by the doctor) where the strength cannot be readily ascertained. Without information on the strength, it is not possible to know the dosage of the medication dispensed. This is particularly important where the medication has potentially serious consequences if taken excessively. To label a medication in an illegible manner defeats the very purpose of drug labeling. Case 7 A 27 month old boy weighing 13.2 Kg ran a fever of 38.3 degrees C and was brought to see the defendant doctor. She diagnosed fever and prescribed indomethacin suppository 100 mg q8h. Three doses were prescribed which were to be given over one day, amounting to 300 mg per day. In a telephone call by the father to the Defendant following the consultation on 13 November 2007, the father told the defendant doctor that the dosage she prescribed was excessive and inappropriate. On 15 November 2007, the defendant telephoned the father and told him that the dosage of indomethacin prescribed was excessive and inappropriate. The father checked the dosage from the BNF and Lexi-comp Drug Information Handbook, and found that the daily dosage of Indomethacin prescribed was over 5 times the recommended dosage of up to 4 mg/kg/day. The expert witness opined that Indomethacin is indicated in children for the relief of pain and inflammation in rheumatic disease and closure of patent ductus arteriosus in premature infants. Because of the higher risk of side effects and the availability of other antipyretics with fewer side effects, e.g. paracetamol, it is generally not recommended as a first line treatment for fever in young children in the HKMA CME Bulletin 持續醫學進修專訊 March 2015 17 Complaints & Ethics absence of a systemic disease like rheumatic arthritis or other autoimmune disorder. The prescription of indomethacin as a first line drug for the relief of fever in a young child of 27 months without an obvious identified focus is considered inappropriate. The appropriate dosage, even if indicated, for the minor patient who weighed 13.2 kg should be a maximum of 15 mg two times per day, a total of 30 mg per day at a maximum. Hence the dosage of 300 mg for a day was ten times the recommended dosage. Excessive dosage of indomethacin can lead to shutdown of the kidneys, accumulation of fluid and rectal irritation and bleeding when given as a suppository. The Inquiry concluded that all medical practitioners owe patients a duty of care. The exercise of that duty includes prescribing the appropriate medications which are specifically indicated. The dosage of such medication must be accurate. This is especially important in the treatment of children where the dosage varies markedly with body weight. Mitigations include enrollment in DCH for which she was granted suspension of a removal order. Case 8 The defendant doctor was charged with prescribing in one consultation 5 drugs, namely Hexine syrup; synbetamine; a mixture of Cocillana and Coclean syrup; a mixture of Paracetamol suspension and Mefanamic acid; and Paracetamol suppository 250 mg. He was charged with failing to indicate on the drug label the strength of Hexine and Synbetamine, and the strength of the mixture of Cocillana and Coclean. Patient was one year old and suffering from high fever of 39.3 degree C. The baby did not have severe coughing at the time of consultation. The defendant claimed that there was blocked nose, nasal discharge, sticky phlegm, dermatitis over the face and neck. The defendant doctor prescribed Bromhexine 4 mg/5ml, Synbetamine containing Dexchlorpheniramine (2mg/5ml) and Betamethasone (0.25 mg/5ml), Cocillana and Coclean syrup with Coclean syrup containing Codeine phosphate (9mg/5ml), Ephedrine hydrochloride (8mg/5ml) and Promethazine hydrochloride (4mg/5ml). Paracetamol and Mefanmic acid mixture with Paracetamol being 250 mg/5ml and Mefanamic acid being 50 mg/5ml 18 HKMA CME Bulletin 持續醫學進修專訊 March 2015 before mixing. All drugs were labeled with instruction to be taken 3 times a day and 1 gradation each time. In the judgment, the inquiry stressed that ‘medical practitioners in Hong Kong are in a unique position that they can both prescribe and dispense medicine to their patient. Consequently, the defendant might prescribe medicine to the patient only if drug treatment was necessary and appropriate. As a doctor who dispenses medicine to patients, the defendant also had the personal responsibility to ensure medication safety. Just looking at the number of different ingredients, no less than 12, contained in the relevant medicines, it would be an obvious case of polypharmacy. The patient was barely one year old and the defendant ought to consider carefully the indication and justification for each ingredient. The defendant frankly admitted that he was not even aware that Promethazine was a form of antihistamine. The combined sedation effect and respiratory suppression effect of Dexchlorpheniramine, Promethazine and Codeine on such a young child was clearly overlooked by the defendant.’ More important, the inquiry found no indication for the prescription of Synbetamine. The use of cough suppressants containing Codeine is not generally recommended in children and should be avoided altogether in those under one year old. Although the Hong Kong College of Pediatricians did recommend that such medicine could still be used in special cases with justifications and explanations to parents, any doctor who prescribed it to a child ought to be careful in ensuring medication safety. The inquiry found no indication for the use of oral steroid. It pointed out that the indiscriminate use of Synbetamine on a young child with high fever from upper respiratory infection would suppress the normal immunological reaction and might result in spreading the infection. I hope that the case illustrations can shed some light on how to prescribe when attending to children in your daily practice. You should also familiarize yourselves with The HKMA Good Dispensing Practice Manual which is used as a yardstick in Medical Council Inquiries. Please note that compounding of liquid medicines and diluting of liquid medicines should be avoided in pediatric practice. Stability data are not generally available. I hope that the Faculty of DCH (Sydney) will assist you with the dosage of pediatric formulations through the internet as I discussed with them prior. www.hkmacme.org Name 姓名 Signature 簽名: HKMA Membership No. or HKMA CME No. 香港醫學會會員編號或持續進修號碼: Answer Sheet Contact Tel No. 聯絡電話: HKID No. 香港身份証號碼: - xxx(x) March 2015 ANSWER SHEET Please answer ALL questions and write the answers in the space provided. SPOTlight - 1 Complete Spotlight and earn 1 CME point 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 SPOTlight - 2 Complete Spotlight and earn 1 CME point 1 1 2 2 3 3 4 4 5 5 6 6 Complete BOTH Cardiology & Dermatology cases and earn 0.5 CME point Cardiology 1 2 3 4 Dermatology 答題紙 Please return the completed answer sheet to the HKMA Secretariat (Fax: 2865 0943) on or before 15 April 2015 for documentation. If you complete the exercise online, you are NOT required to return the answer sheet by fax. 請回答所有問題, 並於 2015 年 4 月 15 日前 將答題紙傳真或寄回 香港醫學會 ( 傳真號碼:2865 0943)。 如果選擇在網上完成練習, 便無需將答題紙傳真到 秘書處。 1 2 3 4 5 HKMA CME Bulletin 持續醫學進修專訊 www.hkmacme.org www.hkmacme.org HKMA CME Bulletin 持續醫學進修專訊 March 2015 19 CMEnotifications HKMA CME Programme 香港醫學會持續進修計劃 香港醫學會 CME Lecture – March & April 2015 進修講課 - 二零一五年三月及四月 THE HONG KONG MEDICAL ASSOCIATION Advances in the Prevention and Management of Herpes Zoster Speaker: Dr. David WEBER Professor of Medicine, Pediatrics, and Epidemiology Associate Chief Medical Officer, UNC Health Care Medical Director, Hospital Epidemiology & Occupational Health Schools of Medicine and Public Health The University of North Carolina Date: 24 March 2015 (Tuesday) Time: Venue: Expected Attendance: 19:00 – 22:00 Shanghai Room I & II, Level 8, Langham Place Hotel, 555 Shanghai Street, Kowloon 80 – 100 persons This symposium is sponsored by Merck Sharp & Dohme (Asia) Limited HKMA Structured CME Programme with HKS&H Session IV: What does a General Surgeon Do Nowadays? 香港醫學會分科持續醫學進修計劃第四節:現今外科 醫生的職責是什麼 ? Dr. SIU Wing Tai 講者:蕭永泰醫生 MBChB (CUHK), FRCSEd, FRCSEd (Gen), FCSHK, FHKAM (Surgery), Specialist in General Surgery 香 港 中 文 大 學 內 外 全 科 醫 學 士、 英 國 愛 丁 堡 皇 家 外 科 醫 學 院 院 士、 英 國 愛 丁 堡 皇 家 外 科 醫 學 院 院 士( 外 科 )、 香 港 外 科 醫 學 院 院 士、 香港醫學專科學院院士(外科)、外科專科醫生 Date: 9 April 2015 (Thursday) Time: 2:00–3:00 p.m. Light lunch starts at 1:15 pm Venue: The HKMA Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese Club Building, 21–22 Connaught Road Central, HK 日期:二零一五年四月九日(星期四) 時間:下午二時至三時正輕膳於下午一時十五分開始 地點:香港中環干諾道中二十一至二十二號華商會所大廈二樓香港醫學會 李樹培醫生專業教育中心 This symposium is co-organized with Hong Kong Sanatorium & Hospital. 講課與養和醫院合辦 Registration: 報名方法: Please fill in and return the Registration Form together with a cheque of adequate amount made payable to “The Hong Kong Medical Association” to 5/F Duke of Windsor Social Service Building, 15 Hennessy Road, Hong Kong. Each lecture will carry 1 CME point under the MCHK/HKMA CME Programme (unless otherwise stated). Accreditation from other colleges is pending. (The Secretariat fax no.: 2865 0943) 請填妥表格連同支票寄交香港灣仔軒尼詩道十五號溫莎公爵社會服務大廈五樓,支票抬頭請 書明支付「香港醫學會」 。參加者可獲醫務委員會╱香港醫學會持續醫學進修計劃積分一分(除 特別註明外) 。其他專科學院之學分尚在申請中。 (秘書處傳真號碼:2865 0943) To be more eco-friendly and avoid postal delay, notification to registrants will no longer be made through sending confirmation letters but via SMS. Please fill in your updated mobile number so that you can be notified of your application. If you do not have a mobile phone number, the Secretariat will issue a confirmation letter to you. If you have not received any replies, please do not hesitate to contact us at 2527 8452. 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 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。 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 within 3 When Tropical Storm Warning Signal No. 8 (or above) or the Black Rainstorm Warning Signal is hoisted after hours of the commencement time, the relevant CME function will be cancelled. (i.e. CME starting at 2:00 pm will CME commencement, announcement will be made depending on the conditions as to whether the CME will be terminated earlier or be conducted until the end of the session. be cancelled if the warning signal is hoisted or in force any time between 11:00 am and 2:00 pm). The function will proceed as scheduled if the signal is lowered three hours before the commencement time. (i.e. The above are general guidelines only. Individuals should decide on their CME attendance according to their own CME starting at 2:00 pm will proceed if the warning signal is lowered at 11:00 am, but will be cancelled even if it transportation and work/home location considerations to ensure personal safety. is lowered at 11:01 am). Reply Slip 回條 I would like to register for the following CME lecture(s): 本人欲報名參加以下講課: Please “✓” as appropriate. 請在適用處加上 ✓ 號 HKMA Member HK$50 24 March 2015 (Tuesday) 9 April 2015 (Thursday) Advances in the Prevention and Management of Herpes Zoster CME Participants HK$80 Free-of-charge HKMA Structured CME Programme with HKS&H Year 2015 Session IV: What does a General Surgeon Do Nowadays? I enclose herewith a cheque of 現隨表格付上支票一張作為講課之報名費用 HK$ 港幣 Name 姓名 : HKMA Membership No. or HKMA CME No. 會員編號或進修號碼: Mobile No. 手機號碼 : Signature 簽名 : (Mandatory for emergency contact or SMS 必須填寫用以緊急聯絡或接收短訊) Fax No. 傳真 : Date 日期: Data collected will be used and processed for the purposes related to the MCHK/HKMA CME Programme only. All registration fees are not refundable or transferable. 個人資料將用於有關香港醫學會持續醫學進修計劃之事宜。所有報名費用將不給予退還或轉授予其他會員。 20 HKMA CME Bulletin 持續醫學進修專訊 March 2015 www.hkmacme.org CMEnotifications CME Lectures in April 2015 香港醫學會 Organized by THE HONG KONG MEDICAL ASSOCIATION Date : Wednesday,15 April 2015 Wednesday, 29 April 2015 Topic and Speaker : Management of Erectile Dysfunction in Primary Practice – An Urologist’s Perspective Dr. HO Kwan Lun Malnutrient Management for Oncology Patients Dr. LUI Siu Fai, MH, JP Specialist in Urology Moderator Clinical Professional Consultant, Division of Health System, Policy and Management, JCSPHPC, Faculty of Medicine, CUHK Dr. TSANG Chun Au : Dr. YIK Ping Yin Committee member, HKMA CW&S Community Network Chairman, HKMA CW&S Community Network Time : 1:00 – 2:00 p.m. Registration & Lunch 2:00 – 2:45 p.m. Lecture 2:45 – 3:00 p.m. Q&A Session Venue : The Hong Kong Medical Association Central Premises, Dr. Li Shu Pui Professional Education Centre, 2/F., Chinese Club Building, 21-22 Connaught Road Central, Hong Kong Deadline : Monday, 30 March 2015 Fee : Free-of-charge Capacity : 80. Registration is strictly required on a first-come, first-served basis. Priority will be given to doctors practising in the Hong Kong Central, Western and Southern districts. Enquiry : Miss Hana YEUNG, Tel: 2527 8285 Friday, 17 April 2015 *Please call and confirm that your facsimile has been successfully transmitted to the HKMA Secretariat if you do not receive confirmation 14 days before the event. Sponsor : CME Accreditation : Pending REPLY SLIP Fax: 2865 0943 HKMA Central, Western & Southern Community Network CME Lectures in April 2015 I would like to register for the following lecture(s): 15 April 2015 Please “✓” as appropriate 29 April 2015 Name: Mobile No.*: HKMA No.: Fax No.: *Please fill in your updated mobile number so that you can be notified of your application via SMS. If you do not have a mobile phone, the Secretariat will still issue a confirmation letter to you. Practising location: In Central, Western & Southern districts (Please specify *: ) Others (Please specify: ) * Null entry will be treated as non-Hong Kong Central, Western & Southern member registration. Signature: Date: Data collected will be used and processed for the purposes related to these events only. www.hkmacme.org HKMA CME Bulletin 持續醫學進修專訊 March 2015 21 Learning Centre article Doctor, how can I help to improve my mother’s nutrition? Introduction Nutrition is one of the most important factors affecting the survival of patients on renal dialysis but unfortunately 40-70% of dialysis patients are malnourished (1) . Emaciated renal patients have a high mortality rate despite adequate dialysis. Causes of the malnutrition include poor intake due to uraemia, inflammation, vascular access infection and other concomitant conditions. Correction of the underlying factors and increasing the oral intake are essential in improving patient survival. The following case may serve to illustrate the principles in renal nutrition. Case history A 94-year-old patient with diabetic nephropathy had been on haemodialysis (HD) for 4 years. Her cardiac condition deteriorated in the past few months. Physical examination showed that she had raised jugular venous pressure, the liver was grossly enlarged and there was pedal oedema up to the thighs. Her body weight (BW) after dialysis was 46.6 Kg and she complained of anorexia and orthopnoea. There was wasting of the body muscles. In view of the fluid retention, water removal (‘ultrafiltration’) was increased during succeeding HD and her post dialysis BW was reduced to 42 Kg after two weeks. Her jugular venous pressure returned to normal, there was no hepatomegaly and the orthopnoea subsided. There was no pedal oedema but the muscle wasting became more prominent. Her appetite has improved. Dr. HO Chung Ping, MH, JP M.B.B.S.(H.K.), MRCP (UK), FRCP (Edin), FRCP (Glasg), FHKAM (Medicine), FHKCP, Specialist in Nephrology Ms. WONG Sui Lan, Senior Registered Nurse Nutrition in renal dialysis patients This patient has poor dietary intake due to the heart failure and fluid retention. The signs of malnutrition hard been partially masked by the oedema. In this case, her appetite improved after correction of the heart failure and fluid overload. Knowledge of renal nutrition management would be needed to correct her malnutrition. The most important aspect is to maintain adequate protein and caloric intake. The protein intake in HD patients should be around 1.2 g/kg/day and in this case, the protein intake should be 50 gram per day, at least half of which should be of high biological value proteins such as meat and eggs. Protein intake can be measured by ‘exchanges’ and each exchange is around 7 gram protein. One ounce of meat or poultry or one whole egg constitutes one exchange. White meat such as chicken is preferred to pork or beef. For this patient, she would need to take some 5 exchanges of high biological value protein per day. The actual protein can be estimated from the dietary history but it is inaccurate. Since dietary protein is turned into urea and excreted in the urine, the protein intake can be calculated from the 24 hour urine urea excretion (2) . This patient is on HD and the protein intake cannot be calculated in such manner because the urea was removed during HD. However, it can be calculated from the ‘urea generation rate’ which in turn was calculated from the blood urea levels between HDs and the rate is proportional to the protein intake. Other methods of nutrition assessment had been described elsewhere (1). Her relatives were pleased at the symptomatic improvement but they were shocked by the degree of muscle wasting which became more prominent after the subsidence of oedema. Her mid-calf circumference was 22 cm. Their question was ‘doctor, how can I help to improve my mother’s nutrition?’ 22 HKMA CME Bulletin 持續醫學進修專訊 March 2015 www.hkmacme.org Learning Centre article From kinetic calculations, her urea generation rate was 0.094 mmol/minute and the dietary protein intake was calculated to be 30 g/day only. Her serum phosphate was low at 0.58 mmol/l (reference range: 0.87 to 1.45 mmol/l) compatible with low protein intake (Figure 1). This patient has low serum phosphate due to poor protein intake. After normalization of the intake, the phosphate is expected to be elevated. To prevent hyperphosphataemia, one would need to avoid the food items with very high phosphate content such as animal internal organs like liver etc. (Figure 2). Egg white does not contain phosphate and the egg protein is of high biological value. It might not be practical to ask the patient to eat 2 eggs every days but some dietary ‘tricks’ like adding egg white to congee or steamed egg whites can make dishes attractive to the patients. Figure 1: Low serum phosphate in ESRD patients may indicate malnutrition Despite the fact that she had diabetes mellitus, adequate calorie intake must be maintained while the blood sugar should be controlled to within normal limits. At the age of 94, the life expectancy is expected to be less than 5 years and the blood sugar control could be ‘relaxed’ a bit. The patient’s appetite has improved due to the correction of the pulmonary congestion and it improved further on the correction of anemia with erythropoietin. The greatest barrier is that the patient may not have the appetite to take in all the ‘prescribed’ food to fulfill the protein and calories requirements. The best remedy is to encourage small and frequent meals. Variation in the food and cooking methods would also be useful. The importance of serum phosphate Patients with advanced renal failure have reduced capacity to excrete phosphate and it is common to find dialysis patients with high serum phosphate. Studies consistently showed that high serum phosphate is associated with a high mortality. Unfortunately, phosphate is present in most food items, especially in meat and beans, which are the sources of protein. As a rule of the thumb, one gram of meat (protein) contains 15 mg of phosphate and hence a 60 gram protein diet would incur a phosphate intake of 900 mg. It is estimated that about 75% of the phosphate would be absorbed and may contribute to the hyperphosphataemia. www.hkmacme.org Figure 2: High phosphate food to avoid Despite all these dietary measures, the serum phosphate may still be elevated. In that case phosphate binders would be necessary. They bind the phosphate in the food and were excreted in the stool. Phosphate binders can be aluminum based such aluminum hydroxide or calcium based such as calcium carbonate or calcium acetate. One gram of elemental calcium can bind about 150 mg of phosphate. They are cheap and would correct hypocalcaemia as well, but hypercalcemia is one of the side effects. New drugs like sevelemar or lanthanium carbonate are effective but they are much more expensive. It should be noted that cola drinks contains phosphoric acid and is the cause of its brown colour. Phosphoric acid is metabolized to phosphate in the body. One litre of Coco-cola contains 520 mg phosphoric acid and thus Coca-Cola is not advised in renal patients. HKMA CME Bulletin 持續醫學進修專訊 March 2015 23 Learning Centre article Dietary supplement There are many dietary supplements for boosting nutrition in the market. It ranges from simple milk powder to those ‘renal formula’. They are milk based and broadly speaking, they can be divided into the ‘renal’ formula and ‘non-renal’ formula. The ‘renal’ formula has low electrolytes (including sodium and phosphate) content and high in protein (2 g/ml), taking care of the protein need of the renal patients. Such formulae include the ‘Nephro’ and the ‘Renilon’). Some formula such as the Supplena has lower protein content (1 g/ml) and is suitable for the pre-dialysis patients. Some are available in powder form and some as readymade liquid form and some as both. The fluid preparation is more convenient but more expensive and takes up storage space. If the patient is using those products as supplement and not as the sole nutritional source, there may be no need to use the ‘renal formula’ because the electrolyte load may not be high. The diet for the patient should be assessed individually, taken into account of his requirement and his usual diet. Intravenous nutrition For those emaciated patients whose oral intake is insufficient to meet the need, sometimes parenteral nutritional supplement is necessary. In general, enteral nutrition is preferable to parenteral nutrition because it is much cheaper, more physiological and safer. The main problem with parenteral nutrition solutions is that they have a high osmolality and it is damaging to the peripheral veins. Although there are preparations for peripheral veins administration, a central venous access is preferable. For those pre-dialysis patients or those with on continuous ambulatory peritoneal dialysis, a Hickman’s catheter is usually used but there are risks associated with central vein cannulation such as pneumothorax or sepsis (Figure 3). For some emaciated HD patients, it might be necessary to give the nutritional supplement through the intravenous route during the dialysis. Since there is a vascular access in HD patients, the nutrient can be administered during HD (Figure 4). The nutrition solution comes in one litre bags and there was a limit to the rate of the infusion. Since the usual dialysis is around 5 hours, the solution could not be administered in full and some of it would have to be discarded. Figure 4: Parenteral nutrition during HD Conclusion Nutrition in renal patients is receiving increasing attention. To improve the nutrition state, it is necessary to correct the underlying causes such as inflammation, heart failure and anaemia. Oral feeding is to be preferred to parenteral feeding. The limiting factor may be the patient’s appetite and small and frequent meals are useful. A caring family member with time and patience is the key to the success. Declaration of interest Dr. HO Chung Ping is the director of the Integrated Dialysis Facilities (HK) Ltd. There is no conflict of interest to be declared. References (1) Ho Chung Ping, Wong Sui Lan, Wah Sai Ling, Louise. Nutrition screening and assessment in Renal Dialysis Patients. HKMA CME Bulletin December 2014. (2) Ho Chung Ping, Yuen Hing Wah, Wah Sai Ling, Louise. Rehabilitation in patients with chronic kidney disease. HKMA CME Bulletin January 2013. Figure 3: A Hickman’s catheter 24 HKMA CME Bulletin 持續醫學進修專訊 March 2015 www.hkmacme.org Stay in touch… Update your contact to obtain the most up-to-date information on medical advances and development, continued education, medical and health care policies, leisure and fun, etc. Fill in the form below and email to [email protected] or fax to 2865 0943. Change of Contact and Status Update Name: Membership No.: New Contact Office Tel.: Fax: Home Tel.: Fax: Mobile Tel.: Pager: Email: Correspondence Address (Please delete as appropriate.) Office / Home: Type of Practice: (Please tick as appropriate.) □ Private □ University □ Government □ Hospital Authority □ Subvented Organization □ Others (Please specify) I would also like to update my information on Doctors Homepage: □ Office Add, Tel. & Fax □ Email □ Mobile Tel. & Pager □ Type of Practice (For amendment of other information on Doctors Homepage, Please contact the HKMA at 2527 8285.) Please note the above changes effective from Email Redirection Service Application Please assign the following address for my access to the HKMA Email Re-direct Service: Doctors’ Teahouse Password Request Please assign the following login name and password for my access to the Doctors’ Teahouse: @hkma.org (Alphabets & numeric figures only, no symbol except underscore”_” is allowed) Login Name: (8 to 12 characters with no space in between) Intended Destination Email Address: Password: (6 to 8 characters or numbers with no space in between and the first one being character only) (i.e. your own email address, e.g. [email protected]) Signature: Date: Meeting Highlights HKMA Structured CME Programme with Hong Kong Sanatorium & Hospital 2015 Dr. TANG Wai Man, Specialist in Orthopaedics and Traumatology, delivered a luncheon lecture on “Joint Replacement with Robot” on Thursday, 12 February 2015 at the HKMA Central Premises. Dr. CHAN Tak Hin kindly acted as the moderator for the event. Dr. CHAN Tak Hin (right) presenting a souvenir to the speaker, Dr. TANG Wai Man (left). The HKMA Central, Western and Southern Community Network (CW&SCN) ~ Dr. YIK Ping Yin Prof. LAM Tai Pong, Professor and Chief of Postgraduate Education of the Department of Family Medicine & Primary Care of the University of Hong Kong, gave a talk on “Reference Framework for Preventive Care for Older Adults in Primary Care Settings” on Wednesday, 11 February 2015. Dr. HO Kwan Lun, Specialist in Urology, will deliver a lecture on “Management of Erectile Dysfunction in Primary Practice – An Urologist’s Perspective” on Wednesday, 15 April 2015. Dr. LUI Siu Fai, MH, JP, Clinical Professional Consultant of the Division of Health System, Policy and Management of the JC School of Public Health and Primary Care of Faculty of Medicine of the Chinese University of Hong Kong, will present on “Malnutrient Management for Oncology Patients” on Wednesday, 29 April 2015. Interested members please refer to the announcement on p.21 for details and enrolment. Prof. LAM Tai Pong (right, speaker) receiving the Certificate of Appreciation from Dr. LAW Yim Kwai (moderator) during the lecture on 11 February 2015 The HKMA Hong Kong East Community Network (HKECN) ~ Dr. CHAN Nim Tak, Douglas Dr. YIP Wai Man (left, speaker) receiving a souvenir from Dr. TSANG Kin Lun (moderator) during the lecture on 5 February 2015 Dr. TSANG Man Wo (left, speaker) receiving a souvenir from Dr. Kenneth YIP (moderator) during the lecture on 12 February 2015 香港房屋委員會轄下診所單位 Dr. YIP Wai Man, Specialist in Geriatric Medicine, delivered a lecture on “Sarcopenia in Elderly” on Thursday, 5 February 2015. Moreover, Dr. TSANG Man Wo, Specialist in Endocrinology, Diabetes & Metabolism, delivered a lecture on “Role of GTSN in the Management of Prediabetes and Diabetes” on Thursday, 12 February 2015. NOTICE 香港房屋委員會將於二零一五年三月以競出租金方式招租的西醫診所單位如下: 九龍深水埗澤安邨富澤樓13A號舖位 新界元朗洪福邨洪福商場13號舖位 26 HKMA CME Bulletin 持續醫學進修專訊 March 2015 24 51 暫定在2015年3月 暫定在2015年3月 www.hkmacme.org Meeting Highlights The HKMA Kowloon West Community Network (KWCN) ~ Dr. TONG Kai Sing Dr. TSANG Man Wo, Specialist in Endocrinology, Diabetes & Metabolism, presented on “Emerging Role of DPP4i and TZD Combination in the Management of T2DM” on Tuesday, 3 February 2015. Dr. YIP Wai Chun, Andrew, Specialist in Urology, delivered a lecture on “HPV Vaccination – The Urologist’s Perspective” on Tuesday, 10 February 2015. Group photo taken during the lecture on 3 February 2015 From left: Dr. Raymond LAM, Dr. CHAN Ching Pong, Dr. TSANG Man Wo (speaker), Dr. Kenneth LEUNG (moderator) and Dr. Bernard CHAN Group photo taken during the lecture on 10 February 2015 From left: Dr. Raymond LAM, Dr. CHAN Ching Pong (moderator), Dr. Andrew YIP (speaker), representative from sponsor and Dr. Bernard CHAN The HKMA New Territories West Community Network (NTWCN) ~ Dr. CHEUNG Kwok Wai, Alvin Dr. MA Pui Shan, Specialist in Endocrinology, Diabetes & Metabolism, gave a talk on “The Practical Issues in Diabetes Mellitus Management” on Thursday, 5 February 2015. Dr. MA Pui Shan (right, speaker) receiving a souvenir from Dr. LEE Huen (moderator) during the lecture on 5 February 2015 The HKMA Shatin Doctors Network (SDN) ~ Dr. FUNG Yee Leung, Wilson and Dr. MAK Wing Kin The following lectures will be held in late March and April: Date Wednesday, 25 March 2015 Wednesday, 15 April 2015 Wednesday, 29 April 2015 Topic Update in the Management of Haemorrhoidal Disease Update in Management of Acne Vulgaris Nutrition Intervention for Prevention of Eczema Speaker Dr. LAM Ching Wa, Steve Dr. HO Ka Keung Dr. CHOW Chung Mo Registration/Enquiry Ms. Cherie LI T: 2909 4802 Ms. Wendy CHENG T: 2824 0333 Ms. Cathy LAU T: 2859 6324 The HKMA Yau Tsim Mong Community Network (YTMCN) ~ Dr. LAM Tzit Yuen, David A talk on “Optimizing Glycemic Control to Improve Renal Outcomes: Findings from ADVANCE-ON” was presented by Dr. LAM Man Fai, Specialist in Nephrology, on Tuesday, 10 February 2015. Dr. CHAN Wai Kwong (left, moderator) presenting a souvenir to Dr. LAM Man Fai (speaker) during the lecture on 10 February 2015 www.hkmacme.org HKMA CME Bulletin 持續醫學進修專訊 March 2015 27 CMECalendar March 2015 16 Mar 2015 (Mon) 8:30 – 9:30 am Union Hospital – Department of Paediatrics Paediatrics Departmental Round New Seminar Room 2, 2/F, Hospital Building, Union Hospital Ms. Kay Ho - Tel: 2608 3800 17 Mar 2015 (Tue) 1:00 – 3:00 pm Hong Kong Medical Association – Kowloon West Community Network 1) Understanding on Acid Pocket 2) Update on Pharyngitis Management Crystal Room I-III, 30/F, Panda Hotel, 3 Tsuen Wah Street, Tsuen Wan, NT Miss Hana Yeung - Tel: 2527 8285 17 Mar 2015 (Tue) 1:45 – 3:00 pm Hong Kong Medical Association – Tai Po Community Network Use of Dydrogesterone in DUB 潮江春-新界大埔新達廣場1樓001-003號 Ms. Nuu Tsang - Tel: 8100 9403 17 Mar 2015 (Tue) 3:30 – 5:30 pm Hong Kong College of Psychiatrists Kwai Chung Hospital Level 1 Topic 15: General Adult Psychiatry – Explain treatment to a pregnant patient Meeting Room, 1/F, Admin Block, Kwai Chung Hospital Ms. Kaman Chan - Tel: 2871 8717 17 Mar 2015 (Tue) 3:30 – 5:30 pm 17 Mar 2015 (Tue) 3:30 – 5:30 pm 17 Mar 2015 (Tue) 3:30 – 5:30 pm 17 Mar 2015 (Tue) 3:30 – 5:30 pm # 28 Hong Kong College of Psychiatrists Kwai Chung Hospital Level 2 Topic 15: Old Age Psychiatry – Discussion with the Consultant on management of dementia Seminar Room, 1/F, Admin Block, Kwai Chung Hospital Ms. Kaman Chan - Tel: 2871 8717 Hong Kong College of Psychiatrists Pamela Youde Nethersole Eastern Hospital Queen Mary Hospital Level 1 Topic 15: General Adult Psychiatry – Explain treatment to a pregnant patient Room 36, 1/F, East Block, Pamela Youde Nethersole Eastern Hospital Ms. Kaman Chan - Tel: 2871 8717 Hong Kong College of Psychiatrists Kowloon Hospital United Christian Hospital Level 1 Topic 15: General Adult Psychiatry – Explain treatment to a pregnant patient Conference Room, Room 2080, 2/F, PYPC Ms. Kaman Chan- Tel: 2871 8717 Hong Kong College of Psychiatrists Kowloon Hospital United Christian Hospital Level 2 Topic 15: Old Age Psychiatry – Discussion with the Consultant on management of dementia Conference Room 2, Kowloon Hospital Ms. Kaman Chan - Tel: 2871 8717 17 Mar 2015 (Tue) 3:30 – 5:30 pm Hong Kong College of Psychiatrists Pamela Youde Nethersole Eastern Hospital Queen Mary Hospital Level 2 Topic 15: Old Age Psychiatry – Discussion with the Consultant on management of dementia J2 Seminar Room, Queen Mary Hospital Ms. Kaman Chan - Tel: 2871 8717 17 Mar 2015 (Tue) 3:30 – 5:30 pm Hong Kong College of Psychiatrists HA – New Territories East Cluster Level 1 Topic 15: General Adult Psychiatry – Explain treatment to a pregnant patient Multicentre Seminar Room, Tai Po Hospital Ms. Kaman Chan - Tel: 2871 8717 17 Mar 2015 (Tue) 3:30 – 5:30 pm Hong Kong College of Psychiatrists HA – New Territories East Cluster Level 2 Topic 15: Old Age Psychiatry – Discussion with the Consultant on management of dementia Multicentre Seminar Room, Tai Po Hospital Ms. Kaman Chan - Tel: 2871 8717 17 Mar 2015 (Tue) 3:30 – 5:30 pm Hong Kong College of Psychiatrists Castle Peak Hospital Level 1 Topic 15: General Adult Psychiatry – Explain treatment to a pregnant patient Kaizen Room, Block D, Castle Peak Hospital Ms. Kaman Chan - Tel: 2871 8717 17 Mar 2015 (Tue) 3:30 – 5:30 pm Hong Kong College of Psychiatrists Castle Peak Hospital Level 2 Topic 15: Old Age Psychiatry – Discussion with the Consultant on management of dementia Seminar Room 4, Block F, Castle Peak Hospital Ms. Kaman Chan - Tel: 2871 8717 18 Mar 2015 (Wed) 12:45 – 2:00 pm Hospital Authority – Our Lady of Maryknoll Hospital Grand Round/Journal Club (Wednesday Educational Meeting January-March 2015) Conference Room D, 1/F, OPD Block, Our Lady of Maryknoll Hospital Ms. Clara Tsang - Tel: 2354 2440 18 Mar 2015 (Wed) 4:15 – 5:15 pm Hong Kong University – Department of Obstetrics & Gynaecology Tumour Board Meeting – clinical-pathological conference on gynaecological oncology cases Rm 215, 2/F, Seminar Room, Clinical Pathology Building, Queen Mary Hospital Ms. Phyllis Kwok - Tel: 2255 4518 19 Mar 2015 (Thu) 1:00 – 3:00 pm Hong Kong Medical Association – Hong Kong East Community Network Practical Tips for GERD Management 5/F, Duke of Windsor Social Service Building, 15 Hennessy Road, Wanchai, Hong Kong Ms. Candice Tong - Tel: 2527 8285 19 Mar 2015 (Thu) 1:00 – 3:00 pm Hong Kong Medical Association – New Territories West Community Network Emerging Role of DPP4i and TZD Combination in the Management of T2DM Plentiful Delight Banquet, 1/F, Ho Shun Tai Building, 10 Sai Ching Street, Yuen Long Miss Hana Yeung - Tel: 2527 8285 1 1 19 Mar 2015 (Thu) 1:00 – 3:00 pm Hospital Authority – United Christian Hospital Hong Kong College of Family Physicians Hong Kong Medical Association – Kowloon East Community Network Certificate Course for GPs 2015 – Management of Chronic Hepatitis B V Cuisine, 6/F, Holiday Inn Express Hong Kong Kowloon East, 3 Tong Tak Street, Tseung Kwan O Ms. Polly Tai - Tel: 3513 3430 19 Mar 2015 (Thu) 6:30 – 9:30 pm Hong Kong Medical Association Medical Protection Society Mastering Shared Decision Making HKMA Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese Club Building, 21-22 Connaught Road, Central, Hong Kong HKMA CME Dept. - Tel: 2527 8452 20 Mar 2015 (Fri) 1:00 – 2:00 pm Tuen Mun Hospital – Department of Obstetrics & Gynaecology CME Programme for January-June 2015 Room SB1034 A&B, Conference Room, 1/F, Special Block, Tuen Mun Hospital Ms. Angela Cheung - Tel: 2468 5404 20 Mar 2015 (Fri) 7:00 – 8:30 pm Federation of Medical Societies of HK Hong Kong Association of Speech Therapists Certificate Course on Development and Disorders of Speech and Language in Children 2015 Lecture Hall, 4/F, Duke of Windsor Social Service Building, 15 Hennessy Road, Wanchai, Hong Kong Ms. Erica Hung - Tel: 2527 8898 21 Mar 2015 (Sat) 2:30 – 5:30 pm Hong Kong Medical Association Medical Protection Society Mastering Professional Interactions HKMA Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese Club Building, 21-22 Connaught Road, Central, Hong Kong HKMA CME Dept. - Tel: 2527 8452 22 Mar 2015 (Sun) 9:00 – 6:00 pm Hong Kong Thoracic Society American College of Chest Physicians (HK & Macau Chapter) Annual Scientific Meeting 2015 Hong Kong Convention & Exhibition Centre Ms. Agnes Ku - Tel: 2155 8557 22 Mar 2015 (Sun) 1:00 – 4:00 pm Association of Licentiates of Medical Council of Hong Kong 1) What is Mediation? And the application in medical dispute 2) Common Foot and Ankle Orthopedics Problems: – Rupture Tendon Achilles; – Hallus Valgus 九龍亞皆老街147B號醫院管理局大樓M/F研討室 ALMCHK - Tel: 2327 2869 1 2 2 2 2 2 23 – 24 Mar 2015 Hong Kong College of Emergency Medicine (Mon-Tue) American Heart Association (AHA) Advanced Cardiovascular Life Support (ACLS) HKEC Training Centre for Healthcare Management & Clinical Technology, Pamela Youde Nethersole Eastern Hospital Ms. Cherry Kwok - Tel: 2871 8877 2 2 2 2 24 Mar 2015 (Tue) 3:30 – 5:30 pm Hong Kong College of Psychiatrists Kwai Chung Hospital Level 1 Topic 16: General Adult Psychiatry – Taking collateral information from a mother whose son/daughter was admitted to ward Meeting Room, 1/F, Admin Block, Kwai Chung Hospital Ms. Kaman Chan - Tel: 2871 8717 24 Mar 2015 (Tue) 3:30 – 5:30 pm Hong Kong College of Psychiatrists Kwai Chung Hospital Level 2 Topic 16: Rehabilitation & Social Psychiatry – Discussion with the Consultant on management of treatment-resistant psychiatric conditions Seminar Room, 1/F, Admin Block, Kwai Chung Hospital Ms. Kaman Chan - Tel: 2871 8717 24 Mar 2015 (Tue) 3:30 – 5:30 pm Hong Kong College of Psychiatrists Pamela Youde Nethersole Eastern Hospital Queen Mary Hospital Level 1 Topic 16: General Adult Psychiatry – Taking collateral information from a mother whose son/daughter was admitted to ward J2 Seminar Room, Queen Mary Hospital Ms. Kaman Chan - Tel: 2871 8717 24 Mar 2015 (Tue) 3:30 – 5:30 pm Hong Kong College of Psychiatrists Kowloon Hospital United Christian Hospital Level 1 Topic 16: General Adult Psychiatry – Taking collateral information from a mother whose son/daughter was admitted to ward Room 7, 1/F, Block P (P-1C), United Christian Hospital Ms. Kaman Chan - Tel: 2871 8717 24 Mar 2015 (Tue) 3:30 – 5:30 pm Hong Kong College of Psychiatrists Pamela Youde Nethersole Eastern Hospital Queen Mary Hospital Level 2 Topic 16: Rehabilitation & Social Psychiatry – Discussion with the Consultant on management of treatment-resistant psychiatric conditions Room 36, 1/F, East Block, Pamela Youde Nethersole Eastern Hospital Ms. Kaman Chan - Tel: 2871 8717 24 Mar 2015 (Tue) 3:30 – 5:30 pm Hong Kong College of Psychiatrists Kowloon Hospital United Christian Hospital Level 2 Topic 16: Rehabilitation & Social Psychiatry – Discussion with the Consultant on management of treatment-resistant psychiatric conditions Conference Room 2, Kowloon Hospital Ms. Kaman Chan - Tel: 2871 8717 24 Mar 2015 (Tue) 3:30 – 5:30 pm Hong Kong College of Psychiatrists HA – NT East Cluster Level 1 Topic 16: General Adult Psychiatry – Taking collateral information from a mother whose son/daughter was admitted to ward Multicentre Seminar Room, Tai Po Hospital Ms. Kaman Chan - Tel: 2871 8717 2 1 1 1 1 1 2.5 1 10# 2.5 5 3 10 2 2 2 2 2 2 2 for whole function HKMA CME Bulletin 持續醫學進修專訊 March 2015 www.hkmacme.org CMECalendar 24 Mar 2015 (Tue) 3:30 – 5:30 pm 24 Mar 2015 (Tue) 3:30 – 5:30 pm Hong Kong College of Psychiatrists HA-NT East Cluster Level 2 Topic 16: Rehabilitation & Social Psychiatry – Discussion with the Consultant on management of treatment-resistant psychiatric conditions Multicentre Seminar Room, Tai Po Hospital Ms. Kaman Chan - Tel: 2871 8717 Hong Kong College of Psychiatrists Castle Peak Hospital Level 1 Topic 16: General Adult Psychiatry – Taking collateral information from a mother whose son/daughter was admitted to ward Kaizen Room, Block D, Castle Peak Hospital Ms. Kaman Chan - Tel: 2871 8717 24 Mar 2015 (Tue) 3:30 – 5:30 pm Hong Kong College of Psychiatrists Castle Peak Hospital Level 2 Topic 16: Rehabilitation & Social Psychiatry – Discussion with the Consultant on management of treatment-resistant psychiatric conditions Seminar Room 4, Block F, Castle Peak Hospital Ms. Kaman Chan - Tel: 2871 8717 24 Mar 2015 (Tue) 7:00 – 10:00 pm Hong Kong Medical Association Advances in the Prevention and Management of Herpes Zoster Shanghai Room I & II, Level 8, Langham Place Hotel, 555 Shanghai Street, Mongkok, Kowloon HKMA CME Dept. - Tel: 2527 8452 25 Mar 2015 (Wed) 12:45 – 2:00 pm Hospital Authority – Our Lady of Maryknoll Hospital Grand Round/Journal Club (Wednesday Educational Meeting January-March 2015) Conference Room D, 1/F, OPD Block, Our Lady of Maryknoll Hospital Ms. Clara Tsang - Tel: 2354 2440 25 Mar 2015 (Wed) 1:00 – 3:00 pm Hong Kong Medical Association – Shatin Doctors Network Update in the Management of Haemorrhoidal Disease Jasmine Room, Level 2, Royal Park Hotel, Shatin Ms. Cherie Li - Tel: 2909 4802 25 Mar 2015 (Wed) 1:30 – 3:30 pm Hong Kong Medical Association Medical Protection Society Mastering Adverse Outcomes – 2 hours Eaton, Hong Kong, 380 Nathan Road, Kowloon HKMA CME Dept. - Tel: 2527 8452 25 Mar 2015 (Wed) 4:15 – 5:15 pm Hong Kong University – Department of Obstetrics & Gynaecology Tumour Board Meeting – clinical-pathological conference on gynaecological oncology cases Rm 215, 2/F, Seminar Room, Clinical Pathology Building, Queen Mary Hospital Ms. Phyllis Kwok - Tel: 2255 4518 26 Mar 2015 (Thu) 8:30 – 10:30 am Hong Kong Sanatorium & Hospital – Orthopaedic & Sports Medicine Centre Academic Professional Development Meeting 2015 of OSMC HKSH (Every Fourth Thursday of the Month) Hong Kong Sanatorium & Hospital Ms. Cheng Hoi Yan - Tel: 2835 7890 27 Mar 2015 (Fri) 1:00 – 2:00 pm Tuen Mun Hospital – Department of Obstetrics & Gynaecology CME Programme for January-June 2015 Room SB1034 A&B, Conference Room, 1/F, Special Block, Tuen Mun Hospital Ms. Angela Cheung - Tel: 2468 5404 27 Mar 2015 (Fri) 1:00 – 3:00 pm Hong Kong Medical Association – Yau Tsim Mong Community Network Updated Diagnosis and Management of Male Pattern Hair Loss Pearl Ballroom, Level 2, Eaton, Hong Kong, 380 Nathan Road, Kowloon Ms. Candice Tong - Tel: 2527 8285 27 Mar 2015 (Fri) 7:00 – 8:30 pm Federation of Medical Societies of Hong Kong Hong Kong Association of Speech Therapists Certificate Course on Development and Disorders of Speech and Language in Children 2015 Lecture Hall, 4/F, Duke of Windsor Social Service Building, 15 Hennessy Road, Wanchai, Hong Kong Ms. Erica Hung - Tel: 2527 8898 28 March 2015 (Sat) 9:30 – 11:30 am Hospital Authority Hong Kong College of Community Medicine Case presentations and Journal presentations in areas related to Administrative Medicine Room 524N, 5/F, Hospital Authority Building, 147B Argyle Street, Kowloon Ms. Yandy Ho - Tel: 2871 8745 30 – 31 Mar 2015 Hong Kong College of Emergency Medicine American Heart Association (AHA) Pediatric Advanced Life Support (PALS) Courses (Mon-Tue) HKEC Training Centre for Healthcare Management & Clinical Technology, Pamela Youde Nethersole Eastern Hospital Ms. Cherry Kwok - Tel: 2871 8877 31 Mar 2015 (Tue) 1:00 – 3:00 pm Hong Kong Medical Association – Kowloon West Community Network Management of Post Herpetic Neuralgia in an Era of Aging Population Crystal Room I-III, 30/F, Panda Hotel, 3 Tsuen Wah Street, Tsuen Wan, NT Miss Hana Yeung - Tel: 2527 8285 1 Apr 2015 (Wed) 4:15 – 5:15 pm Hong Kong University – Department of Obstetrics & Gynaecology Tumour Board Meeting – clinical-pathological conference on gynaecological oncology cases Rm 215, 2/F, Seminar Room, Clinical Pathology Building, Queen Mary Hospital Ms. Phyllis Kwok - Tel: 2255 4518 1 Apr 2015 (Wed) 5:00 – 7:30 pm Hong Kong College of Emergency Medicine Joint Clinical Meeting & Didactic Lecture (JCM) Lecture Theatre, G/F, Block M; Multi-Function Room, G/F, Block D; Seminar Room, G/ F, Block A, 12/F, Block R, Lecture Theatre, Queen Elizabeth Hospital Ms. Cherry Kwok - Tel: 2871 8877 www.hkmacme.org 2 2 Apr 2015 (Thu) 8:30 – 9:30 am Hong Kong Sanatorium & Hospital – Neurology Centre Joint neurology – neurosurgery clinical meeting 4/F, Function Room, Hong Kong Sanatorium & Hospital Ms. Linda Chan - Tel: 2835 7287 8 Apr 2015 (Wed) 8:30 – 9:30 am Union Hospital Clinical Pathologic Conference (Regular Meeting 2015) Training Room, MIC, 8/F, Hospital Building, Union Hospital Ms. Penny Fok - Tel: 2608 3287 8 Apr 2015 (Wed) 4:15 – 5:15 pm Hong Kong University – Department of Obstetrics & Gynaecology Tumour Board Meeting – clinical-pathological conference on gynaecological oncology cases Rm 215, 2/F, Seminar Room, Clinical Pathology Building, Queen Mary Hospital Ms. Phyllis Kwok - Tel: 2255 4518 8 Apr 2015 (Wed) 5:00 – 7:00 pm Hong Kong Poison Information Centre Hospital Authority – United Christian Hospital Monthly Meeting of HKPIC (Presentation and discussion on interesting cases of the month) Lecture Theatre, Block F, United Christian Hospital Ms. Winnie Cheung - Tel: 3949 5096 9 Apr 2015 (Thu) 8:30 – 10:30 pm Union Hospital Association of Private Orthopaedic Surgeons Hong Kong Sanatorium & Hospital – Orthopaedic & Sports Medicine Centre Orthopaedic Clinical Meeting – Teleconference (Every Second Thursday of the Month) Hong Kong Sanatorium & Hospital/Union Hospital Ms. Cheng Hoi Yan - Tel: 2835 7890 9 Apr 2015 (Thu) 1:15 – 3:00 pm Hong Kong Medical Association Hong Kong Sanatorium & Hospital HKMA Structured CME Programme with HKS&H Session 4: What does a General Surgeon Do Nowadays? Function Room A, HKMA Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese Club Building, 21-22 Connaught Road Central, Hong Kong HKMA CME Dept. - Tel: 2527 8452 10 April 2015 (Fri) 1:00 – 2:00 pm Tuen Mun Hospital-Department of Obstetrics & Gynaecology CME Programme for January-June 2015 Room SB1034 A&B, Conference Room, 1/F, Special Block, Tuen Mun Hospital Ms. Angela Cheung - Tel: 2468 5404 10 Apr 2015 (Fri) 7:00 – 8:30 pm Federation of Medical Societies of HK Hong Kong Association of Speech Therapists Certificate Course on Development and Disorders of Speech and Language in Children 2015 Lecture Hall, 4/F, Duke of Windsor Social Service Building, 15 Hennessy Road, Wanchai, Hong Kong Ms. Erica Hung - Tel: 2527 8898 11 Apr 2015 (Sat) 9:00 – 4:30 pm Hong Kong University-Department of Surgery Hong Kong Surgical Forum Lecture Theatre, Cheung Kung Hai Conference Centre, Li Ka Shing Faculty of Medicine Forum Secretary - Tel: 3917 9691 11 Apr 2015 (Sat) 2:15 – 4:15 pm Hong Kong Medical Association HK College of Family Physicians HA – Our Lady of Maryknoll Hospital Refresher Course for Health Care Providers 2014/2015– Musculoskeletal assessments and rehabilitation Training Room II, 1/F, OPD Block, Our Lady of Maryknoll Hospital, 118 Shatin Pass Road, Wong Tai Sin, Kowloon Ms. Clara Tsang - Tel: 2354 2440 14 Apr 2015 (Tue) 1:00 – 3:00 pm Hong Kong Medical Association – Yau Tsim Mong Community Network Treating Patient Present with Joint Pain Pearl Ballroom, Level 2, Eaton, Hong Kong, 380 Nathan Road, Kowloon Ms. Candice Tong - Tel: 2527 8285 14 Apr 2015 (Tue) 3:00 – 6:00 pm Hong Kong College of Psychiatrists CAC Lecture Module (Jan-May 2015) – B) Major disorders in general adult psychiatry; Bipolar affective disorder I: concept, aetiology and phenomenology; Bipolar affective disorder II: pharmacological treatment Seminar Room, 2/F, Block J, Queen Mary Hospital Ms. Kaman Chan - Tel: 2871 8717 14 April 2015 (Tue) 6:00 – 8:00 pm Hong Kong College of Physicians Palliative Medicine Grand Round Seminar Room 2, LG1, Ruttonjee Hospital Ms. Kathy Wong - Tel: 2991 1348 15 Apr 2015 (Wed) 1:00 – 3:00 pm Hong Kong Medical Association – Central, Western & Southern Community Network Management of Erectile Dysfunction in Primary Practice – An Urologist’s Perspective Hong Kong Medical Association Central Premises, Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese Club Building, 21-22 Connaught Road, Central, Hong Kong Miss Hana Yeung - Tel: 2527 8285 15 Apr 2015 (Wed) 4:15 – 5:15 pm Hong Kong University – Department of Obstetrics & Gynaecology Tumour Board Meeting – clinical-pathological conference on gynaecological oncology cases Rm 215, 2/F, Seminar Room, Clinical Pathology Building, Queen Mary Hospital Ms. Phyllis Kwok - Tel: 2255 4518 15 Apr 2015 (Wed) 6:30 – 9:30 pm Hong Kong Medical Association Medical Protection Society Mastering Difficult Interactions with Patients Eaton, Hong Kong, 380 Nathan Road, Kowloon HKMA CME Dept. - Tel: 2527 8452 2 2 1 1 1 2 1 2 1 1 10# 2 10# 1 1 2 1 1 1 2 2 1 1 10# 5 2 1 3 2 1 1 2.5 HKMA CME Bulletin 持續醫學進修專訊 March 2015 29