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www.hkmacme.

org November 2015

THE HONG KONG


MEDICAL ASSOCIATION

Recent advances
in cataract and
refractive surgery
by Dr.
b
D PONG Chiu
Chi F
Fai,
i J
Jeffrey
ff

Encephalitis and
Meningococcus
Vaccine
by Dr. CHAN Yee Shing, Alvin

HKMA CME Bulletin

Contents
Editorial 1
Spotlight 1 2
Encephalitis and Meningococcus
Vaccine

Spotlight 2 9
Recent advances in cataract
and refractive surgery

Cardiology 14
A lady presented with pulseless electrical
activity

Dermatology 16
A lady with itchy skin for three years

Spotlight 1
Encephalitis and
Meningococcus
Vaccine

Complaints & Ethics 17


Answer Sheet 19
CME Notifications 20
Meeting Highlights 26
CME Calendar 29

Spotlight 2
Recent advances in
cataract and refractive
surgery

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 December 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)

2015 12 15
2865 0943
;

www.hkmacme.org

HKMA CME Enquiry Hotline

Tel: 2527 8452 / 2861 1979

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.

Advertising Enquiry: 2527 8452

Fax: 2865 0943 / Email: sophia@hkma.org

CME Bulletin & Online Editorial Board

EDITORIAL

Chief Editor
Dr. WONG Bun Lap, Bernard

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

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
Dr. WONG Wai Lun, Warren

hardly deny the growing pessimism about the future

Neurosurgery
Dr. CHAN Ping Hon, Johnny

of Hong Kong & our profession. Political stability, fair

Obstetrics and Gynaecology


Dr. CHAN Kit Sheung

Colorectal Surgery
Dr. CHAN Cheung Wah
Dr. LEE Yee Man
Dr. TSE Tak Yin, Cyrus

Orthopaedics and Traumatology


Dr. IP Wing Yuk, Josephine
Dr. KONG Kam Fu
Dr. POON Tak Lun
Dr. TANG Yiu Kai

Dermatology
Dr. CHAN Hau Ngai, Kingsley
Dr. HAU Kwun Cheung
Dr. SHIH Tai Cho, Louis

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

Plastic Surgeon
Dr. NG Wai Man, Raymond

ENT
Dr. CHOW Chun Kuen

Psychiatry
Dr. LAI Tai Sum, Tony
Dr. LEUNG Wai Ching
Dr. WONG Yee Him, John

Radiology
Dr. CHAN Ka Fat, John
Dr. CHAN Yip Fai, Ivan

Respiratory Medicine
Dr. LEUNG Chi Chiu
Dr. WONG Ka Chun
Dr. YUNG Wai Ming, Miranda

Rheumatology
Dr. CHAN Tak Hin
Dr. CHEUNG Tak Cheong

Urology
Dr. CHEUNG Man Chiu
Dr. KWOK Ka Ki
Dr. KWOK Tin Fook

Vascular Surgery
Dr. TSE Cheuk Wa, Chad
Dr. YIEN Ling Chu, Reny

HKMA Secretariat
Ms. Jovi LAM
Miss Sophia LAU
Miss Irene GOT

General Practice
Dr. YAM Chun Yin

General Surgery
Dr. LAM Tzit Yuen, David
Dr. Hon. LEUNG Ka Lau

Geriatric Medicine
Dr. KONG Ming Hei, Bernard
Dr. SHEA Tat Ming, Paul

Haematology
Dr. AU Wing Yan
Dr. MAK Yiu Kwong, Vincent

Hepatobiliary Surgery
Dr. CHIK Hsia Ying, Barbara
Dr. LIU Chi Leung

Medical Oncology
Dr. TSANG Wing Hang, Janice

Nephrology
Dr. CHAN Man Kam
Dr. HO Chung Ping, MH, JP
Dr. HO Kai Leung, Kelvin

articles in our Bulletins and the CME lectures organized


by our community networks. However, one could

Ophthalmology
Dr. CHOW Pak Chin, JP
Dr. LIANG Chan Chung, Benedict
Dr. PONG Chiu Fai, Jeffrey

Gastroenterologist
Dr. NG Fook Hong

professionalism. I am sure most of us benefit from the

dedication of HKMA in maintaining our

Neurology
Dr. FONG Chung Yan, Gardian
Dr. TSANG Kin Lun, Alan

Cardiothoracic Surgery
Dr. CHENG Lik Cheung
Dr. CHIU Shui Wah, Clement
Dr. CHUI Wing Hung
Dr. LEUNG Siu Man, John

Family Medicine
Dr. LAM King Hei, Stanley
Dr. LI Kwok Tung, Donald, SBS, JP

There is no question about the

and open medico-legal system is the backbone for the


healthy development of our medical practice and more
importantly the ethical attitude towards our patients.

It is a pity to have silence demonstrations in QEH in 2000


and 2007, both complaining of the unfair remuneration
and promotion opportunities within HA. 8 years forward
from 2007, more than a thousand doctors gathered again
in QEH to express their anger towards the administration.
Delinking the HA staff from the Governments Master
Paid Scale is equivalent to disconnecting the immune
system from a body. By such divide and rule, how can
one maintain the homeostasis and healthy development
of Hong Kong? Irrational expansion of medical
school graduates upsets the normal apoptosis of our
professionals and jeopardizes the juniors training and
maturation.

Monopoly by HMO and insurance company are another


detrimental threat to our practice along with the growing

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.

interference towards our professional autonomy. HKMA


should welcome reports and gather evidence for future
action. Why dont we save Hong Kong ourselves rather
than relying on the others!

Dr. HO Hung Kwong, Duncan


Co-Chairman, CME Committee

SPOTlight -1

Dr. CHAN Yee Shing, Alvin


MBBS (HK), DCH (Glasgow),
MRCP (UK), FHKAM (Paed),
FHKCPaed, MRCPCH, FRCP (Edin),
Specialist in Paediatrics

Encephalitis and
Meningococcus
Vaccine
INTRODUCTION

during the evening and night time. There is no specific


therapy that cures Japanese Encephalitis.

Jenny came with her mother Mrs. CHAN in May to


enquire about the need of vaccination as she was
planning to leave for a charity summer vacation project
in Malaysia with the church. I advised her to have
vaccination against Japanese encephalitis and Hepatitis
A. Jenny and her mother said they were familiar with
Hepatitis A and in fact had received the vaccination. But
what about Japanese Encephalitis?

VIRAL
AMPLIFICATION
3

They live in the New Territories East, but not near


any pig farms or trenches with stagnant water, and
seldom go to mainland China. In the past, their family
physician had never advised them to have vaccination
against encephalitis vaccine. However, their church
pastor advised her to have vaccination before going to
Malaysia.
When Jenny was a child, encephalitis vaccines were
unavailable in most clinics. But the church pastor is right
to remind the teenager to consult doctor for this purpose
with these vaccines readily available in Hong Kong now.
So what is Japanese encephalitis? How should we
prescribe the relevant vaccine?

JAPANESE ENCEPHALITIS
Japanese encephalitis is caused by a virus, called the
Japanese Encephalitis Virus (JEV). It is the leading cause
of vaccine-preventable encephalitis in Asia and the
Western Pacific. JEV is maintained in an enzootic cycle
involving mosquitoes and amplifying vertebrate hosts,
mainly pigs and wild birds. The virus is transmitted to
humans primarily by Culicine mosquitoes, viz Culex
Tritaeniorhynchus which breed in flooded rice fields and
pools of stagnant water and most often feed outdoors

HKMA CME Bulletin November 2015

Uninfected mosquitoes bit pigs


and waterbirds infected by
Japanese Encephalitis virus

Infected
mosquitoes
transmit virus
to humans

Infected mosquitoes
reintroduce virus to
vertebrates

CLINICAL MANIFESTATION
Patients with Japanese encephalitis have a history
of mosquito exposure in an endemic area, with an
incubation period of 4-14 days. Most cases are
asymptomatic, subclinical or mild, presenting with
vague headache, diarrhoea, nausea, myalgia and
fever. Only 1 per 250 Japanese encephalitis virus (JEV)
infections results in symptomatic disease. In the severe
cases, symptoms could rapidly progress from ataxia,
weakness, and movement disorders to acute severe
headache, high fever, meningismus, delirium and
coma. Convulsions develop in 66% of infected persons,
most often children. Mutism has been reported as a
presenting symptoms. A syndrome of acute flaccid
paralysis has been described. Generalized weakness,
hypertonia and hyperreflexia are common. Papilledema
occurs, albeit in less than 10% of patients. Cranial
nerve findings (e.g. disconjugate gaze, cranial nerve
palsies) are found in 33% of patients. Fever disappears
by the second week, and extrapyramidal symptoms
develop as the other neurological symptoms disappear.
Extrapyramidal signs are common, including mask-like
faces, tremors, rigidity and choreoathetoid movements.

www.hkmacme.org

SPOTlight -1

In one study, central hyperpneic breathing and extra


pyramidal signs were the best clinical predictors of
infection. Other poor prognostic factors include the
following:

Age younger than 10 years


Low Glasgow coma scale score
Hyponatremia
Shock
Presence of immune complexes in CSF
Presence of increased amounts of antineurofilament antibodies
Increased levels of tumor necrosis factor
Coexisting neurocysticercosis

INVESTIGATIONS
Laboratory findings are mostly non-specific. 15% of
pediatric cases showed thrombocypenia. Inappropriate
Antidiuretic hormone secretions may occur with
hyponatremia. Viral isolation with JEV found in clinical
specimens, or even the identification of positive genetic
viral sequences in tissues, blood or cerebrospinal fluid
(CSF), is diagnostic. Immunoassay of immunoglobulin M
capture enzyme-linked immunoassay (ELISA) of serum
or CSF is the standard diagnostic test for Japanese
encephalitis.
MRI findings often show bilateral thalamic lesions with
hemorrhage. Hyper-intense lesions may be observed
in the thalamus, cerebrum or cerebellum in the T2weighted MRI scans. EEG often reveals diffuse slowing,
a diffuse delta pattern with spikes, theta waves and
burst suppression.

MANAGEMENT
No clearly effective antiviral agents exist for JEV. The
mainstay of management is supportive, often requiring

tube or parenteral feeding


airway management
anticonvulsants for seizure control
osmotic diuretic mannitol to decrease intracranial pressure
cerebral pressure maintenance in ICU settings

www.hkmacme.org

Even in advanced medical centres, the mortality rate is


about 25%. Among the survivors, almost half would be
left with disabilities like mental impairment, deafness,
epilepsy, aphasia, cognitive difficulties, dystonia and
movement disorders.
Since Japanese encephalitis is so severe, with no
definitive treatment but only supportive measures with
debilitating neurological sequelae, prevention by antimosquito measures and vaccination is of paramount
importance.

JAPANESE ENCEPHALITIS
VACCINATION
In comparison to another notorious deadly vector-borne
viral disease, dengue fever, vaccines are available for JE.
In the past, Hong Kong had very limited supply of the old
JEV vaccine, which was also notorious for its many side
effects. The demand for vaccination was really small.
Now it is different.
Firstly, many Chinese residents would come to Hong
Kong to be vaccinated for themselves and their children,
as they have confidence in our system. Japanese
encephalitis is endemic in many parts of China. Those
living in the northern part of the New Territories might
be worried especially if living near the pig farms
and trenches with stagnant water that breed Culex
Tritaenorhynchus which harbours JEV in Hong Kong.
Thirdly, JEV vaccine is indicated for people travelling
to regions which are endemic with JEV, for students
going to other regions for exchange and international
studies, for those living near pig farms or in mainland
for a month or more, and for those worried about Culex
Tritaenorhynchus which exists in many different districts
in Hong Kong.
In fact, JEV immunization is recommended for children
from infancy onward in regions like northern Australia,
China, Japan, Korea, Malaysia, Taiwan and Thailand.

HKMA CME Bulletin November 2015

SPOTlight -1

Therefore Jenny should take the JEV vaccine about a


month before leaving for Malaysia, to protect her while
travelling to foreign countries like those in South East
Asia where both JE and Hepatitis A are endemic.
The JEV vaccine had been unavailable in Hong Kong
until a couple of years ago. The new JEV vaccine
available is a live-attenuated recombinant vaccine with
very high efficacy, according to studies. Protective
levels of antibody against JEV develop effectively at 14
days after vaccination. In a clinical 3-stage research,
protection rate is still 100% 28 days after a dose of JEV
vaccine in children 12-24 months old, and protection
rate 85% 2 years afterwards.
In another research on children 36-42 months old,
protection rate is 100% 28 days after vaccination and
99.5% 2 years afterwards. In the same study, most
local and systemic reactions are mild to moderate
and transient, including injection site reaction, loss of
appetite and irritability. Fever was reported in 20% of
children in both this new vaccine group and the Hepatitis
A vaccine group. There were no serious adverse events
related to vaccination up to 6 months visit.

MENINGOCOCCAL MENINGITIS
I asked Jenny what she would do after the project. She
said she would then go to USA for university education
in California. She would be required to have certain
vaccines before going to the States. Jenny would most
likely have received most vaccines in the past except the
meningococcal vaccine.
In the past, when Jenny was a child, few would have
meningococcal vaccine in Hong Kong as it was not
commonly available in clinics. Though still not in the
standard childhood immunization scheme, it is now
readily available in private clinics.
Meningococcal A, C, Y and W-135 polysaccharide
vaccine is indicated for active immunization to prevent
invasive meningococcal disease caused by Neisseria
meningitides serogroups A, C, Y and W-135. A
commonly used form could safely be given to children
aged 2 years or older. In America it is now advised

HKMA CME Bulletin November 2015

to be given to adolescents above ten years of age


and indicated in children aged two to ten if they have
immune-suppression or defects in defense mechanism.
At least, 13 serogroups have been described.
Serogroups B and C have caused most cases of
Meningococcal meningitis in USA since the end of World
War II. Before that, Group A was more prevalent. More
than 90% of meningococcal infections was caused by
Serogroups A, B, C, 29-E or W-135.
Most patients infected by Neisseria Meningitidis suffer
from meningococcal meningitis, which would recover
only if appropriate antibiotic therapy is given promptly.
This is a very serious disease, associated with a high
mortality rate and persistent neurological deficit,
especially in infants and young children.

CLINICAL FEATURES
Meningococcal meningitis has an acute onset of high
fever, intense headache, nausea, vomiting, photophobia
and meningismus. Lethargy or drowsiness would often
progress to stupor. If coma is present, the prognosis
would be poor. Some patients have rash, which usually
points to disease progression.
A more serious form of meningococcal disease,
though less common, is meningococcal septicemia,
characterized by a hemorrhagic rash, and a rapid
circulatory collapse. If there are large petechial
hemorrhages in skin and mucosal membranes, fever,
septic shock as well as Disseminated Intravascular
Coagulation (DIC), it is called Waterhouse-Friderichsen
syndrome, and the prognosis is poor.
Sometimes, subacute infection with slower progression
in several days, could present in infants or young kids,
with irritability, projectile vomiting, focal or secondarily
generalized convulsions, and a bulging anterior
fontanelle if it is not yet closed. In children, the classical
signs and symptoms could be absent even when fever
and status epilepticus exist. We need to be very alert
with an index of suspicion always in mind not to miss the
diagnosis in time.

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SPOTlight -1

DIAGNOSIS
Laboratory findings of the CSF confirm the diagnosis,
with increased opening pressure (180 mm water),
neutrophilic pleocytosis (WBC counts 10-10,000/uL
mostly neutrophils), low CSF glucose (<45 mg/dL), high
CSF protein (>45 mg/dL).

Indeed, other pathogens also cause bacterial meningitis


preventable by vaccinations.

AVAILABLE VACCINES FOR BACTERIAL


MENINGITIS FOR INFANTS IN HONG KONG
Common pathogens of bacterial meningitis

N. Meningitidis and the serogroup of meningococci


should be identified in CSF culture and blood culture,
with sensitivity tests, together with the Polymerase
Chain Reaction (PCR) assay in confirming the diagnosis.

Haemophilus
influenzae b

Meningococcus

Pneumococcus

Available vaccines

MRI brain with contrast is better than CT scan in showing


the meningeal lesions, cerebral edema, and cerebral
ischemia. EEG can help to document epileptogenic
patterns predisposing to seizure development.

MANAGEMENT
Initial empiric therapy, until the etiology of the meningitis
is elucidated, should include dexamethasone, a
third generation cephalosporin, e.g. ceftriaxone
or cefotaxime, vancomycin, and acyclovir if initial
CSF showed lymphoctosis rather than neutrophilia.
Ceftriaxone or cefotaxime will be the drug of choice for
the treatment of meningococcal meningitis after the
diagnosis is confirmed.
As the disease is so serious with significant mortality rate
and morbidity, it is always important to prevent it. There are
effective vaccines to prevent meningococcal meningitis.

THE CONSEQUENCES OF
MENINGOCOCCAL DISEASES
According to World Health Organization (WHO), the
mortality rate of meningococcal meningitis is up to 10%.
About 20% of patients surviving meningococcal
meningitis suffer from sequelae such as:

Mental retardation
Hearing loss
Neurologic disability
Epilepsy
Gangrene extremities due to ischemia

www.hkmacme.org

Haemophilus
influenzae b
(Hib) conjugate
vaccine or
Hib-containing
vaccine

4-valent
(A, C, W-135
and Y)
Meningococcal
conjugate
vaccine

Pneumococcal
conjugate
vaccine

In the US, there are also vaccines combining


meningococcal vaccines with pertussis vaccine, and
vaccines combining with Hib vaccine. Recently, the FDA
also approves Group B meningococcal vaccine which is
indicated in areas where Group B meningococcus has
caused meningitis. Meningococcal vaccines in general do
not cause notorious side effects.

PRACTICES OF MENINGOCOCCAL
VACCINATION
In USA, the Advisory Committee on Immunization
Practices (ACIP) recommends routine vaccination
for all children aged 11-18 years old with 4-valent
meningococcal conjugate vaccine and children below
11 years old with high risk conditions (e.g. complement
deficiencies or travelling to endemic regions) with 4-valent
meningococcal conjugate vaccine.
The WHO recommends that in countries where
the disease occurs less frequently, meningococcal
vaccination is recommended for defined risk groups,
which include:
Children and young adults residing in closed communities
Travellers to endemic areas

HKMA CME Bulletin November 2015

SPOTlight -1

In Hong Kong, most people live in closed and very


crowded communities, with frequent mixing between
Hong Kongers and Mainlanders. The Chinese Center for
Disease Control and Prevention recommends children
to have meningococcal vaccination, and meningococcal
polysaccharide vaccine (serogroups A and C) is included
in the national childhood immunization programme. So
parents in Hong Kong might as well consider vaccination
of their children below 10 years of age to prevent
such a deadly disease, but with a better vaccine, the
4-valent meningococcal conjugate vaccine instead of
meningococcal polysaccharide vaccine (groups A & C),
and give meningococcal conjugate vaccinations to their
children before going to overseas universities.
Anyway, I had given both the meningococcal vaccine and
the JEV vaccine to Jenny, and wished her all the best.
References

1. Centre for Health Protection, Department of Health,


HKSAR, Japanese Encephalitis, http://www.chp.gov.hk/en/
content/9/24/28.html Accessed on 4 Jul, 2014.
2. Campbell GL et al. Estimated global incidence or Japanese
encephalitis: a systematic review. Bull World Health Organ.
2011;89:766-664E.
3. Diagana, M., Preux, P.M. & Dumas, M. Japanese encephalitis
revisited. J Neurol Sci 2007;262:165-70.
4. Solomon T, et al. Japanese encephalitis. J Neurol Neurosurg
Psychiatry, 2000 Apr;68(4):405-15.
5. Misra UK, Kalita J. Overview: Japanese encephalitis. Prog
Neurobiol. 2010 Jun;91(2):108-20.
6. Food and Environmental Hygiene Department, HKSAR.
Distribution of Culex tritaeniarhynchus (JE Vector survey 10/04
10/05). http://www.fehd.gov.hk/english/safefood/dengue_fever/
je_before.pdf Accessed on 4 Jul, 2014.
7. Centre for Health Protection, Department of Health, HKSAR.
Confirmed local case of Japanese encephalitis under CHP
investigation, Press releases on 17 Jun, 2014. http://www.chp.
gov.hk/en/view_content/35164.html Accessed on 4 Jul, 2014.
8. HKSAR. Stay on guard against Japanese encephalitis.
Press releases on 30 Jun, 2014. http://www.info.gov.hk/gia/
general/201406/30/P201406300986.htm Accessed on 4 Jul,
2014.
9. Centre for Health Protection, Department of Health, HKSAR.
Confirmed local case of Japanese encephalitis under CHP
investigation, Press releases on 21 Jul, 2014. http://www.chp.gov.
hk/en/content/116/35703.html Accessed on 22 Jul, 2014.
10. Centers for Disease Control and Prevention. Japanese encephalitis
surveillance and immunization Asia and the Western Pacific,
2012. MMWR 2013;62(33):658-662.
11. Therapeutic Goods Administration, Department of Health and
Ageing, Australia Government. Australian Public Assessment
Report for Japanese Encephalitis Chimeric Virus, 2010. http://
www.tga.gov.au/pdf/auspar/auspar-imojev.pdf Accessed on 22
Jul, 2014.

www.hkmacme.org

12. Feroldi E, et al. Memory immune response and safety of a


booster dose of Japanese encephalitis chimeric virus vaccine (JECV) in JE-CV-primed children. Hum Vaccin Immunother. 2013
Apr;9(4):889-97.
13. Feroldi E, et al. Single-dose, live-attenuated Japanese encephalitis
vaccine in children aged 12-18 months: randomized, controlled
phase 3 immunogenicity and safety trial. Hum Vaccin Immunother.
2012 Jul;8(7):929-37.
14. Lowry F. Traveling Children Should Get Japanese Encephalitis
Vaccine, Medscape Medical News. Jun 19 2013. Available at
www.medscape.com/viewarticle/806601. Accessed: Jun 26
2013.
15. Centre for Health Protection. Communicable diseases meningitis.
http://www.chp.gov.hk/en/content/9/24/32.html. Accessed on
5th Feb 2013.
16. World Health Organization. Weekly epidemiological record.
2011;47(86):521-540.
17. Pina LM et al. Safety and Immunogenicity of a quadrivalent
meningococcal polysaccharide diphtheria toxoid conjugate
vaccine in infants and toddlers: three multicenter phase III studies.
The Pediatric Infectious Disease Journal. 2012;31(11):1173-1183.
18. Chinese Center for Disease and Control and Prevention. National
immunization program. http://nip.chinacdc.cn/jzcx. Accessed on
7th Feb 2013.
19. Committee on infectious diseases. Meningococcal conjugate
vaccines policy update: Booster dose recommendations.
Pediatrics. 2011;128(6):1213-1218.
20. NHS choices website. Childhood vaccines. http://www.nhs.uk/
planners/vaccinations/pages/childvaccines.aspx. Accessed on
25 Nov 2013.
21. Centre for Health Protection. Recommendation for use and advice
for travelers on use of meningococcal vaccines. Jun 2005.
22. Morbidity and Mortality Weekly Report. Recommendation of the
Advisory Committee on Immunization Practices (ACIP) for Use of
Quadrivalent Meningococcal Conjugate Vaccine (MenACWY-D)
Among Children Aged 9 Through 23 Months at Increased Risk for
Invasive Meningococcal Disease. 14 Oct 2011;60(40):1391-2.
23. MIMS annual Hong Kong. 2012-13.
24. Brown T. First Serogroup B Meningococcal Vaccine Approved
by FDA. Medscape Medical News. Available at www.medscape.
com/viewarticle/834103. Accessed: November 10, 2014.
25. FDA. First vaccine approved by FDA to prevent serogroup
B Meningococcal disease. Available at http://www.fda.gov/
NewsEvents/Newsroom/PressAnnouncements/ucm420998.
htm. Accessed: November 10, 2014.
26. Chin RF, Neville BG, Scott RC. Meningitis is a common cause
of convulsive status epilepticus with fever. Arch Dis Child.
2005;90:66-69. [Medicine].
27. Stephens DS. Neisseria meningitidis. Infect Control 1985 Jan.
5(1):37-40. [Medicine].

Answers to October 2015


Spotlight 1 Multidisciplinary management of diabetic peripheral
neuropathy
1.T 2.T 3.F 4.T 5.T 6.F 7.F 8.T 9.T 10.T
Spotlight 2 Cognitive Behavioural Therapy with Older Adults
1.F 2.F 3.F 4.T 5.F 6.F 7.T 8.F 9.T 10.T

HKMA CME Bulletin November 2015

SPOTlight -1

Complete this
course and earn

Questions:
Q&A Self-assessment

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 or false.

1.
2.
3.
4.

Patients with Japanese encephalitis in an endemic area have an incubation period of 10-20 days.
MRI findings in Japanese encephalitis often show bilateral cerebral lesions with hemorrhage.
The new JEV vaccine available is a live-attenuated recombinant vaccine.
Protection rate is still 100% 28 days after a dose of JEV vaccine in children 12-24 months old, and
protection rate 85% 2 years afterwards.
5. Fever was reported in 50% of children after JEV vaccination.
6. Meningococcal infection always leads to predominant septicaemia and meningoencephalitis.
7. About 20% of patients surviving meningococcal disease suffers from sequelae such as hearing loss and
neurologic disability.
8. In countries where the disease occurs less frequently, meningococcal vaccination is recommended for
defined risk groups, which include children and young adults residing in closed communities, and travellers
to higher endemic areas.
9. In Mainland China, Chinese Center for Disease Control and Prevention recommends meningococcal
polysaccharide vaccine (serogroups A and B) to be included in the national childhood immunization
programme.
10. Hong Kong students going to USA for university education should usually receive Meningococcal A, C, Y,
W-135 conjugate vaccine before leaving Hong Kong.

HKMA CME Bulletin


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has been serving more than 10,000 readers each month through practical case studies and picture quizzes. To enrich its content, we
are inviting articles from experts of different specialties. Interested contributors may refer to the General Guidance below. Other formats
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:
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:
:

Deadline

General Practitioners
Approximately 8-10 A-4 pages in 12-pt fonts in single line spacing, or around 1,500-2,000 words (excluding
references).
Include 10 self-assessment questions in true-or-false format.
(It is recommended that analysis and answers to most questions be covered in the article.)
English
It is preferable that key messages in each paragraph/section be highlighted in bold types.
Recommended to include, if possible, a key message in point-from at the end of the article.
List of full name(s) of author(s), with qualifications and current appointment quoted, plus a digital photograph of
each author.
All manuscripts for publication of the month should reach the Editor before the 1st of the previous month.

All articles submitted for publication are subject to review and editing by the Editorial Board.

HKMA CME Bulletin November 2015

www.hkmacme.org

SPOTlight -2

Recent advances
in cataract and
refractive surgery
Cataract surgery has gone through major leaps in the
last decades with lot of advances in both technology
and the intraocular lens design. It enables patients
to gain vision with better accuracy, and decreases
the needs on spectacles after the surgery. Refractive
surgery also undergoes simultaneous advances that
enable refractive surgery do be done in great precision
and predictability. Currently not only the refractive
error of the young, such as myopia, hyperopia and
astigmatism, but also the refractive error of the old,
presbyopia can be managed with different refractive
surgery solutions. Depending on the condition, the
two surgeries are combining together to solve multiple
problems at the same time.

HOW THE INTRAOCULAR LENS (IOL)


HAS EVOLVED
Most elderly patients who need cataract operations have
presbyopia for many years. To them, reading glasses
is an indispensable tool for near vision. Most elderly
patients, especially those who are reliant on glasses
for both near and distance for years, are excited to
learn about how technology can help to gain spectacle
freedom. Having cataract operation to restore vision and
at the same time correcting their reading habits are in
fact not a remote scenario and nowadays the intraocular
lens design have allowed them to achieve this effect
with some good promise. Intraocular design has evolved
so far during the last two to three decades that the
capabilities of intraocular lens have greatly increased.
Intraocular lens are now broadly divided into monofocal
and multifocal types. Monofocal lens is one with the
optical component with one focal point, compared to
more than one focal point in the multifocal lens design.
Intraocular lens are usually made of acrylic or silicon.
It can be divided into an optic part with certain power
or designs and a haptic part which consists of a pair
www.hkmacme.org

Dr. PONG Chiu Fai, Jeffrey


MBChB, BHB, BSc, LLB,
MSc (Biostatistics and Epidemiology), PHD (CUHK)
Dip FM, Dip AIM, Dip TCM, Dip HSM
FCOphHK, FRCS Glas, FRCS Ed, FHKAM
(Ophthalmology)
Specialist in Ophthalmology

of leg distending the capsular bag and stabilizing the


lens. The lens can block ultraviolet rays, and sometimes
a certain spectrum of visible blue light (termed blueblocking IOL). The lens surface is usually biconvex and
aspheric, meaning the image refracted by these lens
will have spherical aberration corrected. Lens with
multiple focus can help to enable patients to achieve
correction for different distance, and hence presbyopia
correction. Essentially, intraocular lens which allows
presbyopia correction adopt a diffractive, refractive or
hybrid approach. Refractive multifocal IOLs have a lens
optic that has different optical powers in different parts
of the lens. The diffractive approach utilizes a series
of steps that are carved in a precise arrangement with
varying step heights and distances between steps. Each
of the steps of this diffractive optic bends the incoming
light differently, creating a near focus. A hybrid approach
is one which uses the diffractive properties together
with remaining refractive portion of the lens to create
two separate images. This large separation between
the two images allows for less artifacts or distortion in
either of the images, providing good quality of vision at
both distance and near (1, 2, 3). Studies evaluated the
different types of multifocal IOLs (MFIOL) compared to
the monofocal found that the refractive IOL gave better
image quality than the hybrid IOLs at distance and with
small pupils, and their difference disappear with pupils
larger than 3.5 mm. Hybrid IOLs gave significantly better
image quality for near vision with all pupil sizes but
poorer distance images than monofocal (4). Another
study found that both diffractive and refractive MFIOL
enable high rate of spectacle independency. In general,
refractive MFIOL provide better intermediate vision but
more halo and glare, while the diffractive lens slightly
better near vision and less haloes and glare (5). In
addition, patients with hyperopia in general perform
better with multifocal intraocular lens than emmetropes
or myopes (6, 7).

HKMA CME Bulletin November 2015

SPOTlight -2

People inserted with such lens need months of


neuroadaptation in order to maximize the vision gain.
Bilateral implantation is necessary to achieve better
results. Different multifocal lens may have different
degree of halo and glare but it is more noticeable
compared to the monofocal lens. This effect is more
pronounced in the dark when pupil is big. The final
image quality also hinges on the residual refractive
error after the cataract operation and LASIK can be
considered to correct the remaining refractive error.
An alternative intraocular lens designs that enables
presbyopia correction is known as accommodating IOL.
In an accommodating IOL, the haptics are designed to
keep the IOL securely in place and prevent any rotational
movement, but the legs are flexible in a way that allows
the optical portion of the IOL to move slightly forward
with the contraction of the ciliary muscle (8). So with
a similar mechanism as normal accommodation, the
lens can move forward and backward to allow focusing
effect. There is also a newer type of intraocular lens
named trifocal lens which give a better intermediate
focus apart from the near and distance focus.
Intermediate focus is important for computer viewing,
a crucial activity for many people. Currently, there
is not one type of lens which is perfect in all visual
acuity, image quality and depth of focus that can be
compared to a young accommodative eye. A mix and
match approach is sometimes necessary, taking into
account the patient needs, occupation, reading habits
and expectations. Approaches such as two monofocal
lens on each eye targeting different refraction to achieve
monovision, two multifocal lens with slightly different
refraction properties, such as combining a near and
distance lens with an intermediate and distance lens
(7). Some surgeons also consider a monofocal lens
on the dominant eye aiming for distant view and a
multifocal lens on the other eye. Patients need to be fully
explained about the effect of different lens and surgical
options before the operation so as to meet the patients
expectation and hence satisfaction.

HOW REFRACTIVE SURGERY EVOLVES


Refractive surgery has also undergone significant
advances in the last two decades. The important trend
in this period is the reliance on laser technology and
10

HKMA CME Bulletin November 2015

computer softwares to perform refractive correction to


ensure better accuracies and stability. In the early 90s
the most popular refractive surgery was Laser assisted
in-situ keratomileusis (LASIK) with microkeratome.
LASIK at that time was mainly for myopes. For
presbyopia correction, non-refractive surgery such as
conductive keratoplasty is used. This is a method where
the central corneal surface is modified by cryotherapy so
as to create scars and as a result changing the central
cornea curvature, thus enhancing near reading. Radial
keratectomy was still an operation performed in the
early 90s where the cornea was created with radial cuts
to change the central cornea curvature. Other manual
surgical procedures such as astigmatic keratectomy
(AK) or limbal relaxing incision (LRI) were also common
to correct astigmatism. The manual technique obviously
suffered from the disadvantage of lack of repeatability
and hence errors. Although normogram was widely used
as guidance, multiple attempts are sometimes needed
to achieve clinical effect.
Some other techniques build upon the principles of
LASIK. Laser assisted sub-epithelial keratomileusis
(LASEK), in which alcohol is applied to soften the corneal
epithelium enabling a thinner corneal flap to be lifted and
replaced and therefore more laser ablation and hence
higher range of correction can be performed on the
stromal bed. Epi-Lasik is a procedure where a specific
epi-keratome is used to cut thinner flaps to achieve the
same purpose. Photo refractive keratectomy (PRK) in
which no corneal flap is created. The corneal epithelium
is scrapped and laser is directly applied on the corneal
bed. This technology has advantage of gaining more
corneal tissue depth for ablation and therefore improving
the range of refractive correction. It is however
complicated with prolonged healing time and possible
corneal haze post-operatively.
The LASIK technology has exceled over the same
period. With better electronic program, there are
improvements in laser firing algorithm, laser frequency,
iris or eye movement tracking technology, and laser
energy profile. LASIK can now embrace a much larger
range of refractive error from 5 dioptres of hyperopia
to up to 12 dioptres of myopia and astigmatism of up
to 4 dioptres (1). Since the invention of femtosecond
laser, corneal flap can be cut at more precise angle,

www.hkmacme.org

SPOTlight -2

depth and size. Compared to traditional microkeratome,


femtosecond laser flap cutting is associated with fewer
flap problems such as free flap and button hole with
thinner, predictable depth (9, 10). Wavefront guided
LASIK and topography guided LASIK are further
upgrades of such laser ablation profile in which
correction is done not only on the refractive error, but
also to treat the high order aberrations. Wavefront
optimized or guided algorithms considers not just the
eyes refractive error and preoperative keratometry, but
also take into account the spherical aberrations induced
by the laser pulses on the periphery, together with
the individual eyes unique preoperative aberrometry
and eliminating preoperative high order aberrations
(11). Topography-guided laser ablation is increasingly
used with good efficacy and safety outcomes in highly
aberrated corneas with irregular astigmatism such as
eyes with refractive surgery complications, decentered
ablation, small optical zones and asymmetrical
astigmatism (12). In essence, human eye is not as
perfect as we thought and correcting the spherical
aberration and high order aberration can enhance vision
quality.

HOW CATARACT SURGERY EVOLVES


The first artificial lens was implanted in London in
1949. Since then, cataract surgery has evolved hand
in hand with the lens technology. The overall trend
is smaller wound, quicker healing and more reliable
surgical techniques and predictable visual outcomes.
Cataract surgery was initially performed manually with
big corneal wounds so that manual expression of lens
nucleus can be achieved. At first the whole lens was
removed together with its capsule through large wound
that spans 5-6 clock hours of the limbus (intracapsular
cataract extraction). Later on the capsule was left behind
via extracapsular cataract extraction so that intraocular
lens can be inserted directly above the posterior
capsule. In this latter type of surgery, the main wound
was still large and non-foldable polymethylmethacrylate
(PMMA) lens (with optic and haptic size 12.5 mm in
diameter combined) can be inserted into the sulcus
area directly. Ultrasonic technology was adopted since
90s to emulsify the lens matter, which is then absorbed
away. Phacoemulsification has since then become the

www.hkmacme.org

gold standard of minimal invasive cataract surgery.


Main wounds can now be created at size of around
2-3 mm. Over years of advances and improvement, in
particular the ultrasonic energy dissipation, aspiration
and fluidics mechanisms, together with the improvement
of surgical instrument and image quality of the operating
microscope have rendered phacoemulsification to an
unprecedented safer and better level. Dense cataract
with poor visualization is no longer a contraindication
for phacoemulsification. Phacoemulsification can
be performed in a diverse range of cataract and
operation can be performed under local anaesthesia
in around 10-15 minutes. Due to the small size of
wound construction, wound related complications
such as infection, surgically induced astigmatism
and suture related complications are low. These lead
to a more predictable surgical outcome and faster
recovery. Instruments that can accurately measure
keratometry and axial length help to improve the postoperative refraction with precision. Recent advances
such as torsional phacoemulsification, in which energy
generated to dissolve the cataract with less heat
dissipation and hence less cornea oedema has been
adopted in some phacoemulsification machines. The
pre-op measurements and wound entry, together with
lens orientation can now be registered on microscope
screens in order to provide more precision for surgeons
when it comes to wound creation and lens rotation.
The intraocular lens technology also evolves with
better designs, haptic size, materials used by different
companies. All these improvement have enabled
cataract surgery to be done in much better precision
and predictability.

ENHANCING DEPTH WITH


MULTIFOCALITY DESIGN
Multifocality is seen as one of the ways to enhance
depth of focus. Normal people can look at near and
distance targets with ease via accommodation in
which the lens will get thicker with the help of the ciliary
muscles for near viewing, and at the same time the
pupil will constrict on accommodation. Currently, both
the intraocular lens, corneal refractive surgery and even
contact lens have adopted this approach in order to gain
visual improvement both in near and distance (13). In

HKMA CME Bulletin November 2015

11

SPOTlight -2

LASIK the concept of multifocality is used in presbylasik,


where stromal bed laser ablation involves a central
positive power zone which corresponds to the zone
when pupil is constricted on near (14, 16, 17). Patients
over 45 with presbyopia and other refractive error can
consider this method to gain some depth of focus. The
same concept has also been adopted in the intraocular
lens (multifocal) and contact lens with similar principles.

INCORPORATING LASER INTO


REFRACTIVE AND CATARACT SURGERY
With the development of femtosecond laser, the
accuracy and predictability of laser ablation increases
with versatility. Femtosecond is one millionth of
one billionth of a second. A femtosecond laser is a
laser which emits optical pulses with a duration well
below 1 picosecond (1 fs = 10 -15 s). Its application in
ophthalmology is extensive and it can now be used to
create corneal wounds and flaps with different length,
angle and orientation, performing capsulotomy and even
cracking nucleus of the lens.
The use of femtosecond laser in LASIK has already
been mentioned above. It has surpassed microkeratome
in lots of aspects and be able to create corneal flaps
with great reliability. Riding on its excellent carving
ability, it has now replaced the role of excimer laser
as a refractive laser in a new technique called Small
Incision with Lenticule Extraction (SMILE). In SMILE,
femtosecond laser is used to create a lenticule within
the transparent corneal stroma and an opening channel
where the lenticule can be extracted after cutting open
the tunnel. Removing the lenticule within corneal stroma
changes the corneal curvature and hence the refractive
error. The benefit of SMILE is that it does not require the
creation of the corneal flap and therefore lower the risk
of infection and flap related problems. The fact that the
flap is not cut also means that the corneal nerves within
the stroma are intact and therefore less likely to develop
dry eyes. SMILE is useful for myopia and astigmatism,
but not a candidate for hyperopia (15). This relatively
new technology is just on market not long ago and it
is yet to see if the technology can become the norm of
refractive surgery in future.

12

HKMA CME Bulletin November 2015

Femtosecond laser cataract is also a new advance in


which femtosecond laser is incorporated as part of the
procedure for cataract surgery. Femtosecond laser can
be used to create main wounds and side wounds on
cornea, performing capsulotomy on anterior capsule
and even crack and segment the lens nucleus. By
performing these steps, it can aid the cataract surgeon
to handle the nucleus with phacoemulsification easier,
wound construction more reliable and achieving
more predictable refractive correction. Capsulotomy
performed by the femtosecond laser can also be more
central and accurate. Although femtosecond laser
cannot be used to perform cataract operation alone,
it is certainly useful for cataract surgeons to perform
refractive correction with cataract surgery with better
accuracy and predictability.
With the advances of lens design and application of
laser in refractive and cataract surgery, the distinction
between the two operations has rapidly narrowed.
Patients with higher demands on their visual quality
would like to achieve cataract removal and refractive
improvement in one operation. Premium lens such as
multifocal, toric and monofocal lens can be enlisted
to provide good refraction outcomes. In cases where
one operation cannot achieve all the goals, the surgical
planning for a biotpics approach may be necessary. In
bioptics, refractive surgery is performed after cataract
surgery to maximize the visual outcomes (20, 21, 22).
Patients with cataract are now met with more choices in
the types of operation, lens inserted and whether further
refractive correction is necessary. The two eyes need
to be planned in tandem to maximize the visual gains
and spectacle independence. An abundant preoperative
chair-time is necessary before devising an optimal
cataract and refractive solutions for the patient. Factors
such as age, reading habit, occupation and demands for
vision are important aspects that should not be missed.
With good understanding of patient requests and
wishes, the surgical and visual outcome usually turns out
well.

www.hkmacme.org

SPOTlight -2

References:

(1) Wong TY. The Ophthalmology examinations Review. World


Scientific.2001.
(2) Cohen AL. Diffractive bifocal lens designs. Optom Vis Sci. 1993
Jun;70(6):461-8.
(3) Lane SS, Morris M, Nordan L, Packer M, Tarantino N, Wallace
RB. Multifocal intraocular lenses. Ophthalmol Clin North Am.
2006 Mar;19(1):89-105, vi.
(4) Artigas JM, Menezo JL, Peris C, Felipe A, Dz-Llopis M. Image
quality with multifocal intraocular lenses and the effect of pupil
size: comparison of refractive and hybrid refractive-diffractive
designs. J Cataract Refract Surg. 2007 Dec;33(12):2111-7.
(5) Barisi A, Dekaris I, Gabri N, Bohac M, Romac I, Mravici I,
Lazi R. Coll Antropol. Comparison of diffractive and refractive
multifocal intraocular lenses in presbyopia treatment. 2008
Oct;32 Suppl 2:27-31.
(6) Bellucci R. Multifocal intraocular lenses. Curr Opin Ophthalmol.
2005 Feb;16(1):33-7.
(7) Mastropasqua R, Pedrotti E, Passilongo M, Parisi G, Marchesoni
I, Marchini G. Long-term visual function and patient satisfaction
after bilateral implantation and combination of two similar
multifocal IOLs. J Refract Surg. 2015 May;31(5):308-14.
(8) Dick HB. Accommodative intraocular lenses: current status. Curr
Opin Ophthalmol. 2005 Feb;16(1):8-26.
(9) Santhiago MR, Kara-Junior N, et al. Microkeratome versus
femtosecond flaps: accuracy and complications. Curr Opin
Ophthalmol. 2014 Jul;25(4):270-4.
(10) Chen S, Feng Y, et al. IntraLase femtosecond laser vs mechanical
microkeratomes in LASIK for myopia: a systematic review and
meta-analysis. J Refract Surg. 2012 Jan;28(1):15-24.
(11) Sles CS, Manche EE. One-year eye-to-eye comparison of
wavefront-guided versus wavefront-optimized laser in situ
keratomileusis in hyperopes.Clin Ophthalmol. 2014 Nov
12;8:2229-38.
(12) Holland S, Lin DT, Tan JC. Topography-guided laser refractive
surgery. Curr Opin Ophthalmol. 2013 Jul;24(4):302-9.
(13) Calladine D, Evans JR, Shah S, Leyland M. Multifocal versus
monofocal intraocular lenses after cataract extraction. Cochrane
Database Syst Rev. 2012 Sep 12.
(14) Ali JL, Chaubard JJ, Caliz A, Sala E, Patel S. Correction
of presbyopia by technovision central multifocal LASIK
(presbyLASIK). J Refract Surg. 2006 May;22(5):453-60.
(15) Lee JK, Chuck RS, Park CY. Femtosecond laser refractive
surgery: small-incision lenticule extraction vs. femtosecond laserassisted LASIK. Curr Opin Ophthalmol. 2015 Jul;26(4):260-4
(16) Ali JL, Amparo F, Ortiz D, Moreno L. Corneal multifocality with
excimer laser for presbyopia correction. Curr Opin Ophthalmol.
2009 Jul;20(4):264-71.
(17) Pallikaris IG, Panagopoulou SI. PresbyLASIK approach for
the correction of presbyopia. Curr Opin Ophthalmol. 2015
Jul;26(4):265-72.
(18) Abouzeid H, Ferrini W. Femtosecond-laser assisted cataract
surgery: a review. Acta Ophthalmol. 2014 Nov;92(7):597-603

www.hkmacme.org

(19) Ali JL, Abdou AA, Puente AA, Zato MA, Nagy Z. Femtosecond
laser cataract surgery: updates on technologies and outcomes. J
Refract Surg. 2014 Jun;30(6):420-7.
(20) Jendritza BB, Knorz MC, Morton S. Wavefront-guided excimer
laser vision correction after multifocal IOL implantation. J Refract
Surg. 2008 Mar;24(3):274-9.
(21) Velarde JI, Anton PG,et al. Intraocular lens implantation and
laser in situ keratomileusis (bioptics) to correct high myopia and
hyperopia with astigmatism. J Refract Surg. 2001 Mar-Apr;17(2
Suppl):S234-7.
(22) Leccisotti A. Bioptics: where do things stand? Curr Opin
Ophthalmol. 2006 Aug;17(4):399-405.

Q&A

Self-assessment
questions:

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 or
false.

1.

Intraocular lens consisted of two parts naming


optic and haptic.
2. Intracapsular cataract extraction is a procedure
which was largely obsolete. Newer version of
cataract surgery aims to have smaller wound
and faster recovery.
3. Intraocular lens are usually made of silicon and
acrylic.
4. Multifocal intraocular lens have a design in
which there are multiple focus through the
optics so patient can pick up any of these
image to focus in a large range of distance.
5. Photorefractive keratectomy involves removing
the corneal epithelium before laser ablation and
fold back in place after.
6. Bioptics is a technique which combines
refractive surgery with cataract surgery.
7. Cataract operation can now be done with a
wound around 2-3 mm, intraocular lens can be
inserted directly into the capsular bag without
need of folding.
8. The first intraocular lens was inserted in the
1950s in UK.
9. Femtosecond laser is a laser with firing rate
around 10-12 second.
10. Femtosecond laser can now be used in both
refractive and cataract surgery.

HKMA CME Bulletin November 2015

13

Cardiology

Complete BOTH Cardiology and


Dermatology courses and earn

0.5 CME POINT

The content of the November Cardiology Series is provided by:


Dr. WU Kwok Leung
MBBS(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in Cardiology

A lady presented with pulseless electrical activity


A 66-year-old lady who had past medical history of diabetes mellitus was admitted for progressive shortness
of breath. The attached electrocardiogram was the one performed in the casualty department. She lapsed into
pulseless electrical activity soon after admission. Cardiopulmonary resuscitation was commenced.

Q&A

14

Please answer ALL questions


Answer these on page 19 or make an online submission at: www.hkmacme.org

1. What is the diagnosis based on the ECG features


and the clinical profile?
A. Sinus tachycardia.
B. Non-ST segment elevation myocardial
infarction.
C. Pulmonary embolism.
D. ST-segment elevation myocardial infarction.
E. Unstable angina.

3. Which treatment is not recommended in the


acute phase?
A. Intravenous morphine for pain control.
B. Low molecular weight heparin.
C. Intravenous magnesium sulfate.
D. Intravenous thrombolytic therapy if failed
anticoagulation therapy.
E. Oxygen therapy.

2. Which of the following is not a typical feature of this


disease entity?
A. Sinus Tachycardia.
B. Left axis deviation.
C. P pulmonale (> 2.5mm in inferior leads).
D. S1QIIITIII.
E. Diffuse ST depression and T wave inversion over
precordial leads.

4. Which is not a risk factor of this disease entity?


A. Obesity.
B. Recent febrile illness.
C. Recent immobilization.
D. Oral contraceptive pills.
E. Family history of thrombophilia.

HKMA CME Bulletin November 2015

www.hkmacme.org

Cardiology

October Answers
Answer:
1) All correct
2) Torsades de pointe
3) All correct
4) Tranvenous pacing
5) Complete heart block
6) Permanent pacemaker
Figure 1

Figure 4

Figure 2

The content of the October Cardiology Series is provided by:


Dr. CHUNG Tak Shun MBBS(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in Cardiology
Dr. CHEUNG Ling Ling MBBS(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in Cardiology

Figure 3

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.

www.hkmacme.org

HKMA CME Bulletin November 2015

15

Dermatology

Complete BOTH Cardiology and


Dermatology courses and earn

Dermatology Series for November 2015 is provided by:


Dr. LEUNG Wai Yiu, Dr. TANG Yuk Ming, William, Dr. CHAN Hau Ngai, Kingsley, and Dr. KWAN Chi Keung
Specialists in Dermatology & Venereology

0.5 CME POINT

A lady with itchy skin for three years


A 34-year-old lady presented with a three-year history of itchy skin over right foot. This lesion waxed and
waned and became aggravated during climate changes. The patient enjoyed a good past health. She had
no ongoing medication taken or any relevant family history of similar lesion. Physical examinations showed
erythematous thickened scaly plaques on her right foot. There were no other skin manifestations of psoriasis
or contact dermatitis nor fungal infection.

Q&A
1.
2.
3.
4.
5.

Please answer ALL questions


Answer these on page 19 or make an online submission at: www.hkmacme.org

What are the differential diagnoses?


What is the diagnosis?
How do you confirm the diagnosis?
What are the associated skin diseases and relevant
investigations?
What are the treatments?

October Answers
Answers:
1. T h e d i a g n o s i s i s r o s a c e a . I t i s a c h r o n i c
inflammatory skin disorder, affecting the
cheeks, chin, nose and sometimes the
forehead, affecting more than 16 million
people in the United States. It can manifest as
different cutaneous signs such as erythema,
telangiectasias, papules, pustules, ocular lesions
(dryness, irritation, blepharitis, conjunctivitis and
keratitis) and rhinophyma. It is more prevalent in
women than in men.

5. It is important to educate the patient to avoid the


possible aggravating factor and wear sunscreen.
Topical antibiotic cream, azelaic acid are
commonly used to treat rosacea. Recently FDA
has approved a new medication Brimonidine gel
to treat facial redness by its vaso-constricting
effect. Apart from topical medication, oral
antibiotics and oral roaccantane can be used
to treat resistant cases. For serious rosacea
cases with persistent redness and telangectasia,
vascular laser and intense pulse light treatment
can be used to treat the condition.

2. Differential diagnoses include acne, folliculitis,


lupus, seborrhoic dermatitis, sunburn, etc.
3. The exact pathogenesis of rosacea remains
unknown. Several pathogenesis have been
postulated, for example vascular abnormalities,
dermal matrix degeneration, microorganisms,
environmental factors, etc. There are some
triggering factors like heat, alcohol, certain food,
sunlight, stress that can worsen rosacea.
4. Rosacea can be diagnosed clinically. There is
no specific test for rosacea. Occasionally, blood
investigation may be needed to rule out lupus

16

HKMA CME Bulletin November 2015

The content of the October 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

www.hkmacme.org

Complaints & Ethics

Overturning Medical
Council Inquiry
Decisions Part 1
Dr. CHOI Kin

Doctor X was charged with and found guilty of


giving steroid injection to the patient without proper
explanation and informed consent.
The Appeal Court found it was undisputed that Doctor
X gave local steroid injection on the patients right hand
for wrist pain and a swelling on the dorsum of the right
hand. Several days after the steroid injections, the
patient noticed dropping, loss of control, weakness and
mild pain initially in her right little finger and then her right
ring finger. She was diagnosed by other doctors to have
ruptured tendons of the right little and ring finger and
had to undergo surgery to repair the ruptured tendons.
The patient asserted that Doctor X did not tell her either
the nature or the side effects of the injection, whereas
the doctor said that he had explained to her the name
and dosage of the injections but not the side effects. The
actual words in English and Chinese he claimed to have
used for the name of the drug were cortisone (kik so
in transliteration). According to the complainant,
neither Doctor X nor his clinical assistants had informed
her that the injection into the right hand contained
steroid. Although she heard of the names Kik So and
Lui Ku Shun she knew nothing about them and
thought they were different drugs. When she asked
the doctor whether steroid was given after her tendons
ruptured, she told the inquiry that the doctor did not give
any answer.
Doctor X recalled that before he gave the patient the
injection, he had said to her that the drug is Cortisone
(Kik So), that the dosage was 8 mg which was lower
than the 40 mg recommended by the American
Rheumatology Association and was therefore very
safe. He did not inform her of the possible side effects
because the dose was very low and it would not cause
any side effects. After the injection, he advised her to

www.hkmacme.org

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

avoid lifting heavy objects and demonstrated the correct


way of carrying heavy objects.
A Professor of Rheumatology acted as expert. He was
of the opinion that patients should be informed that they
were receiving steroids when steroids were prescribed.
Steroid injections were regarded as invasive procedure.
In informing patients about steroids, he would use the
Chinese term Lui Ku Shun because it would be better
understood. Before administering steroid injection,
his normal procedure would be to inform patients that
infection might occur in 4 out of 100,000 injections.
Tendon rupture was not a common complication
associated local steroid injections, although the risk
of this would be higher in patients suffering from
rheumatoid arthritis. He would sometimes warn the
patient about the risk of tendon rupture but did not have
a consistent practice about this as the occurrence was
so rare.
In the report of one of the doctors who saw the patient
after the tendons ruptured, Doctor Y stated that the
patient gave history of right dorsal-lateral wrist pain and
had received two local steroid injections on dorsum of
right wrist by her treating doctor before.
The Medical Council Inquiry found that choosing the
Chinese Kik So over the better term Lui Ku Shun could
only be an attempt to obfuscate rather than to explain
the true nature of the medicine. Furthermore the Council
found that Doctor X should have informed the patient
of the side effect of steroid injections. The Council was
of the view that Doctor X knew the difference between
Kik So and Lui Ku Shun, that the case involved
concealment of the nature of the injections and the
failure to inform the patient in the face of direct inquiry.

HKMA CME Bulletin November 2015

17

Complaints & Ethics

The Senior Counsel in the Appeal Court pointed out


that Doctor Y who wrote a medical report to the
Medical Council, wrote in his clinical notes: local
steroid injections by GP. He suggested that Doctor Y
did not have Doctor Xs record and so the information
should have come from the patient herself, and this
demonstrated that she knew the nature of the injection.
The Court accepted that ex facie the statement in Dr.
Ys clinical notes undermined the evidence of the patient
that it was not conveyed to her that the injections were
steroid. The Court found that the facts pertaining to the
documents has not been fully investigated and explored
before the Medical Council. The Court ordered a fresh
inquiry. The Court found that the serious allegation of a
deliberate decision by Doctor X to use Kik So instead of
Lui Ku Shun as a means of concealing the fact that he
was not administering a steroid was not put to Doctor
X prior to the Inquiry. Doctor X had no opportunity to
answer this allegation with the kind of evidence for which

THE HONG KONG MEDICAL ASSOCIATION

he had sought leave to adduce on appeal. The Appeal


Court found that the findings of deliberate concealment,
an attempt to obfuscate and to mislead the patient
cannot stand. The Appeal Court also observed that the
Council made a mistake in stating the infection was
a common side effect when the expert witness was
stating that it was common knowledge that infection
was a side effect.
The Medical Council instructed the Preliminary
Investigation Committee to look into the case again. The
PIC had a new expert witness with different views and
decided not to put up the case for inquiry again.
So what are the lessons to learn? First a good barrister
can get a doctor off the hook. Second an Inquiry
Committee should not go beyond its boundaries during
an Inquiry and hang itself by writing excessive long
judgments with flaws for Appeal Court to pick on.

Kowloon Hospital Alumni Society

Date

12 December, 2015 (Saturday)

Venue

Conference Rooms 1&2, 2/F., Main Building, Kowloon Hospital, 147A Argyle Street, Kowloon

Time

12:45 12:50 p.m.


12:50 12:55 p.m.
12:55 1:00 p.m.
1:00 1:30 p.m.

1:30 2:00 p.m.

2:00 2:30 p.m.

2:30 3:00 p.m.


3:00 3:15 p.m.
3:15 3:30 p.m.
Capacity

Welcome Remarks by Dr. CHOY Yuen Chung, President of Kowloon Hospital Alumni Society
Speech by Dr. AU Yiu Kai, Council Member of Hong Kong Medical Association
Presentation of Souvenirs
Back and Neck Pain, Localize and Manage
Dr. CHIN Ping Hong, Consultant, Spine & Rehabilitation, Department of Orthopaedics and
Traumatology, Queen Elizabeth Hospital
Interventional Management of Neck and Back Pain
Dr. Steven WONG, Consultant, Department of Anaesthesiology & Operating Theatre Services,
Queen Elizabeth Hospital
Occupational Therapy Services for Chronic Pain Adaptation
Mr. LEUNG Kwok Fai, Cluster Manager, Occupational Therapy Services, Kowloon Central
Cluster, Hospital Authority
Contemporary Physiotherapy Management in Back & Neck Pain
Mr. Kenneth LEUNG, Senior Physiotherapist, Physiotherapy Department, Kowloon Hospital
Q&A
Vote of Thanks by Dr. CHOY Yuen Chung, President of Kowloon Hospital Alumni Society

100
All medical & health professionals are welcome. Registration not required.
MCHK/HKMA CME Accreditation: pending
CNE/CPE: pending
Lunch is sponsored by
Please contact Ms. CHOW FK on 9052 5550 for enquiries.

18

HKMA CME Bulletin November 2015

www.hkmacme.org

Name

Signature

Answer Sheet

HKMA Membership No. or HKMA CME No.

Contact Tel No.


HKID No.

xxx(x)

November 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

10

10

SPOTlight - 2

Complete Spotlight and earn 1 CME point


1

Complete BOTH Cardiology & Dermatology cases and earn 0.5 CME point

Cardiology
1

Please return the


completed answer sheet
to the HKMA Secretariat
(Fax: 2865 0943) on or
before 15 December 2015
for documentation.
If you complete
the exercise online,
you are NOT required to
return the answer sheet by
fax.

2015 12 15

( 2865 0943)

Dermatology
1

www.hkmacme.org

HKMA CME Bulletin November 2015

19

CMEnotifications
HKMA CME Programme

CME Lecture December 2015

HKMA Structured CME Programme with HKS&H Session XII:


Targeted Therapy for General Practitioners

Dr. KWAN Wing Hong

MBBS (HK), FRCR, FHKCR, FHKAM (Radiology), Specialist in Clinical Oncology


Associate Director, Comprehensive Oncology Centre, HKS&H
Director, Department of Radiotherapy, HKS&H

Date:
Time:
Venue:

[ ]

10 December 2015 (Thursday)


2:00-3:00 pm [Light lunch starts at 1:15 pm]
The HKMA Dr. Li Shu Pui Professional Education Centre, 2/F,
Chinese Club Building, 21-22 Connaught Road Central, HK

This symposium is co-organized with Hong Kong Sanatorium & Hospital.

Registration:
:
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

: 2865 0943
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)
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 2527 8452
you. If you have not received any replies, please do not hesitate to contact us at 2527 8452.

Please register for participation. First come, first served.


TYPHOON/BLACK RAINSTORM POLICY

When Tropical Storm Warning Signal No. 8 (or above) or the Black Rainstorm Warning Signal is hoisted When Tropical Storm Warning Signal No. 8 (or above) or the Black Rainstorm Warning Signal is hoisted
within 3 hours of the commencement time, the relevant CME function will be cancelled. (i.e. CME starting after CME commencement, announcement will be made depending on the conditions as to whether the
at 2:00 pm will be cancelled if the warning signal is hoisted or in force any time between 11:00 am and CME will be terminated earlier or be conducted until the end of the session.
2:00 pm).
The above are general guidelines only. Individuals should decide on their CME attendance according to
The function will proceed as scheduled if the signal is lowered three hours before the commencement their own transportation and work/home location considerations to ensure personal safety.
time. (i.e. CME starting at 2:00 pm will proceed if the warning signal is lowered at 11:00 am, but will be
cancelled even if it is lowered at 11:01 am).

Reply Slip

I would like to register for the following CME lecture(s):

Please as appropriate.

HKMA Member
HK$50

CME Participants
HK$80

HKMA Structured CME Programme with HKS&H


10 December 2015
(Thursday)

HKMA Structured CME Programme with HKS&H


Year 2015 Session XII: Targeted Therapy for General
Practitioners

I enclose herewith a cheque of

HK$

Name :
HKMA Membership No. or HKMA CME No.
Mobile No. :

Fax No. :

Mandatory for emergency contact or SMS

Signature :

Date

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.

20

HKMA CME Bulletin November 2015

www.hkmacme.org

CMEnotifications

CME Lectures in December 2015


THE HONG KONG
MEDICAL ASSOCIATION

Organizer

: HKMA Kowloon West Community Network

HKMA New Territories West Community Network

Date

: Tuesday, 15 December 2015

Thursday, 17 December 2015

Topic and Speaker

: Rosacea and Related Dermatoses


Dr. LEE Tze Yuen
Specialist in Dermatology & Venereology

New Insight for Atopic Eczema Treatment


Dr. CHAN Yung
Specialist in Dermatology & Venereology

Time

: 1:00 2:00 p.m.


2:00 2:45 p.m.
2:45 3:00 p.m.

Venue

: Crystal Room IV-V, 3/F., Panda Hotel,


3 Tsuen Wah Street, Tsuen Wan, N.T.

Moderator

: Dr. LAM Ngam, Raymond


Committee member,
HKMA Kowloon West Community Network

Dr. CHUNG Siu Kwan, Ivan


Vice-chairman,
HKMA NT West Community Network

Deadline

: Monday, 7 December 2015

Monday, 7 December 2015

Fee

: Free-of-charge

Capacity

: 50. Registration is strictly required on a first come, first served basis.


Priority will be given to doctors practising in Kowloon West districts (for the lecture
on 15 Dec)/NT West districts (for the lecture on 17 Dec).

Enquiry

: Miss Hana YEUNG, Tel: 2527 8285


*Please call and confirm that your facsimile has been successfully transmitted to the HKMA
Secretariat if you do not receive confirmation 14 days before the event.

Sponsor

CME Accreditation

: Pending

Registration & Lunch


Lecture
Q&A Session
Pearl Ocean, 1/F., Gold Coast Yacht and Country Club,
1 Castle Peak Road,
Castle Peak Bay, Hong Kong

REPLY SLIP
Fax: 2865 0943

HKMA KW & NTW Community Networks

CME Lectures in December 2015


I would like to register for the following lecture(s):
15 December 2015 (KW)

Please as appropriate

17 December 2015 (NTW)

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 you a confirmation letter.

Practising location:

In Kowloon West (Please specify *:

In New Territories West (Please specify *:

Others (Please specify:

* Null entry will be treated as non-Kowloon West or non-New Territories West 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 November 2015

21

CMEnotifications
CME Lectures in December 2015
THE HONG KONG
MEDICAL ASSOCIATION

Organizer

: HKMA Central, Western & Southern


Community Network

HKMA Kowloon East Community Network

Date

: Wednesday, 2 December 2015

Thursday, 10 December 2015

Topic and Speaker

: Early Infant Feeding & Allergic Disorders


Dr. Barbara CC LAM, JP
Specialist in Paediatrics,
Honorary Consultant, Queen Mary Hospital,
Honorary Clinical Associate Professor,
The University of Hong Kong

Shingles Prevention from Infectious Disease


Specialists Perspective
Dr. SO Man Kit, Thomas
Specialist in Infectious Disease

Time

: 1:00 2:00 p.m.


2:00 2:45 p.m.
2:45 3:00 p.m.

Venue

: The HKMA Central Premises,


Dr. Li Shu Pui Professional Education Centre,
2/F., Chinese Club Building,
21-22 Connaught Road Central

Lei Garden Restaurant,


Shop no. L5-8, apm, Kwun Tong,
No. 418 Kwun Tong Road,
Kwun Tong, Kowloon

Moderator

: Dr. YIK Ping Yin


Chairman,
HKMA CW&S Community Network

Dr. AU Ka Kui, Gary


Chairman,
HKMA Kowloon East Community Network

Deadline

: Monday, 23 November 2015

Monday, 30 November 2015

Fee

: Free-of-charge

Capacity

: 80

Registration & Lunch


Lecture
Q&A Session

48

Registration is strictly required on a first come, first served basis.


Priority will be given to doctors practising in CW&S districts (for the lecture on 2 Dec)/Kowloon
East districts (for the lecture on 10 Dec).
Enquiry

: Miss Hana YEUNG, Tel: 2527 8285


*Please call and confirm that your facsimile has been successfully transmitted to the HKMA
Secretariat if you do not receive confirmation 14 days before the event.

Sponsor

CME Accreditation

: Pending

REPLY SLIP
Fax: 2865 0943

HKMA CW&S & KE Community Networks


CME Lectures in December 2015

I would like to register for the following lecture(s):


2 December 2015 (CW&S)

Please as appropriate

10 December 2015 (KE)

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 you a confirmation letter.

Practising location:

In Central, Western & Southern (Please specify *:

In Kowloon East (Please specify *:


Others (Please specify:

)
)

* Null entry will be treated as non-Hong Kong Central, Western & Southern or non-Kowloon East member registration.

Signature:

Date:

Data collected will be used and processed for the purposes related to these events only.

22

HKMA CME Bulletin November 2015

www.hkmacme.org

CMEnotifications

CME Lectures in December 2015


THE HONG KONG
MEDICAL ASSOCIATION

Co-organized by

Hong Kong East Cluster, HA

Date

: Thursday, 3 December 2015

Thursday, 17 December 2015

Topic and Speaker

: A Pathophysiological Approach
to the Treatment of Type 2 Diabetes
Dr. MA Pui Shan
Specialist in Endocrinology, Diabetes &
Metabolism

Recent Development in DME Management


Dr. CHAN Hoi Yee, Catherine
Specialist in Ophthalmology

Time

: 1:00 2:00 p.m.


2:00 2:45 p.m.
2:45 3:00 p.m.

Venue

: The HKMA Wanchai Premises,


5/F, Duke of Windsor Social Service Building,
15 Hennessy Road, Wanchai

Moderator

: Dr. AU YEUNG Shiu Hing


Committee Member,
HKMA HK East Community Network

Dr. KONG Wing Ming, Henry


Committee Member,
HKMA HK East Community Network

Deadline

: Monday, 23 November 2015

Monday, 7 December 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 HK East district.

Enquiry

: Ms. Candice TONG, Tel: 2527 8285


*Please call and confirm that your facsimile has been successfully transmitted to the HKMA
Secretariat if you do not receive confirmation 14 days before the event.

Sponsor

CME Accreditation

: Pending

Registration & Lunch


Lecture
Q&A Session

REPLY SLIP
Fax: 2865 0943

HKMA Hong Kong East Community Network

CME Lectures in December 2015


I would like to register for the following lecture(s):
3 December 2015

Please as appropriate

17 December 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 Hong Kong East (Please specify *:

Others (Please specify:

* Null entry will be treated as non-Hong Kong East 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 November 2015

23

CMEnotifications
Advance in Rheumatic Diseases
Co-organized by
The HKMA Kowloon West Community Network
and Hong Kong Society of Rheumatology

THE HONG KONG


MEDICAL ASSOCIATION

Date

: Tuesday, 1 December 2015

Speaker

: Dr. TSUI Hing Sum, Kenneth

Specialist in Rheumatology

Time

: 1:00 2:00 p.m.

2:00 2:45 p.m.


2:45 3:00 p.m.

Venue

Registration & Lunch


Lecture
Q & A Session

: Crystal Room IV-V, 3/F., Panda Hotel,

3 Tsuen Wah Street, Tsuen Wan, N.T.

Moderator

: Dr. WONG Wai Hong

Hon. Secretary, HKMA Kowloon West Community Network

Deadline

: Monday, 23 November 2015

Fee

: Free-of-charge

Capacity

: 50. Registration is strictly required on a first come, first served basis.

Priority will be given to doctors practising in Kowloon West district.

Enquiry

: Miss Hana YEUNG, Tel: 2527 8285

*Please call and confirm that your facsimile has been successfully transmitted to the HKMA
Secretariat if you do not receive confirmation 14 days before the event.

CME
Accreditation

: Pending

This lecture is sponsored by


AbbVie Ltd.

REPLY SLIP
Fax: 2865 0943

HKMA Kowloon West Community Network

Advance in Rheumatic Diseases


I would like to register for the above event.

Please as appropriate

HKMA No.:
Fax No.:

Name:
Mobile No.*:

*Please fill in your updated mobile number so that you can be notified of your application via SMS. If you do not have a mobile phone,
the Secretariat will still issue a confirmation letter to you.

Practising location:

In Kowloon West (Please specify *:

Others (Please specify:

* Null entry will be treated as non-Kowloon West member registration.

Signature:

Date:

Data collected will be used and processed for the purposes related to this event only.

24

HKMA CME Bulletin November 2015

www.hkmacme.org

CMEnotifications

Complementary and Alternative Medicine (CAM)


for Childhood Asthma: An Overview of Evidence
Organized by
The HKMA Yau Tsim Mong Community Network

THE HONG KONG


MEDICAL ASSOCIATION

Date

: Tuesday, 8 December 2015

Speaker

: Prof. HON Kam Lun, Ellis

Professor, Department of Paediatrics, The Chinese University of Hong Kong

Time

: 1:00 2:00 p.m.

2:00 2:45 p.m.


2:45 3:00 p.m.

Venue

Registration & Lunch


Lecture
Q&A Session

: Pearl Ballroom, Level 2, Eaton, Hong Kong,

380 Nathan Road, Kowloon

Moderator

: Dr. CHENG Kai Chi, Thomas

Hon. Secretary, HKMA YTM Community Network

Deadline

: Friday, 27 November 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 YTM district.

Enquiry

: Ms. Candice TONG, Tel: 2527 8285

*Please call and confirm that your facsimile has been successfully transmitted to the HKMA
Secretariat if you do not receive confirmation 14 days before the event.

CME
Accreditation

: Pending

This lecture is sponsored by


Nestle Hong Kong Ltd.

REPLY SLIP
Fax: 2865 0943

HKMA Yau Tsim Mong Community Network

Complementary and Alternative Medicine (CAM) for Childhood Asthma: An Overview of Evidence
I would like to register for the above lecture.

Please as appropriate

HKMA No.:
Fax:

Name:
Mobile No.*:

*Please fill in your updated mobile number so that you can be notified of your application via SMS. If you do not have a mobile phone,
the Secretariat will still issue a confirmation letter to you.

Practising location:

In Yau Tsim Mong (Please specify *:

Others (Please specify:

* Null entry will be treated as non-Yau Tsim Mong member registration.

Signature:

Date:

Data collected will be used and processed for the purposes related to this event only.

www.hkmacme.org

HKMA CME Bulletin November 2015

25

Meeting Highlights

HKMA Structured CME Programme with Hong Kong


Sanatorium & Hospital 2015
Dr. MA Shiu Kwan, Edmond, Specialist in Pathology, delivered a luncheon lecture on
The Contribution of Pathology to Personalized Medicine on Thursday, 8 October 2015
at the HKMA Central Premises. Dr. NG Fook Hong, kindly acted as the moderator for the
event.

Dr. NG Fook Hong (right) presenting a


souvenir to the speaker, Dr. MA Shiu
Kwan, Edmond, (left)

Dr. KWAN Wing Hong, Specialist in Radiology, will give a talk on Targeted Therapy for
General Practitioners on Thursday, 10 December 2015. Interested members please refer
to the announcement on p.20 for details and enrolment.

The HKMA Central, Western and Southern Community


Network (CW&SCN) ~ Dr. YIK Ping Yin
Dr. CHAN Wing Bun, Specialist in Endocrinology, Diabetes & Metabolism,
delivered a lecture on Glycemic Control The Peak and The Trough on
Wednesday, 14 October 2015.
A CME lecture on Early Infant Feeding & Allergic Disorders will be given by
Dr. Barbara CC LAM, JP, Specialist in Paediatrics, Honorary Consultant of Queen
Mary Hospital and Honorary Clinical Associate Professor of the University of Hong
Kong, on Wednesday, 2 December 2015. Interested members please refer to the
announcement on p.22 for details and enrolment.

Dr. LAM Ming Yuen (left, moderator) presenting a


souvenir to Dr. CHAN Wing Bun (speaker) during the
lecture on 14 October 2015

The HKMA Shatin Doctors Network (SDN) ~


Dr. FUNG Yee Leung, Wilson and Dr. MAK Wing Kin
Dr. LAU Wing Yan, Winnie, Specialist in Endocrinology, Diabetes & Metabolism, delivered
a lecture on Recent Advances in Diabetes Management on Wednesday, 16 September
2015.

The HKMA Yau Tsim Mong Community Network (YTMCN)


~ Dr. LAM Tzit Yuen, David
The lecture on Management of Raised Prostate Specific
Antigen (PSA) Level was given by Dr. TAI Chi Kin,
Specialist in Urology, on Tuesday, 13 October 2015.
Dr. MAK Wing Kin (left, moderator) in
photo with Dr. Winnie LAU (speaker)
during the lecture on 16 September 2015

26

Prof. HON Kam Lun, Ellis, Professor of Department of


Paediatrics of the Chinese University of Hong Kong, was
invited to give a talk on Complementary and Alternative
Medicine (CAM) for Childhood Asthma: An Overview of
Evidence on Tuesday, 8 December 2015. Interested
members please refer to the announcement on p.25 for
details and enrolment.

HKMA CME Bulletin November 2015

Dr. TAI Chi Kin (left, speaker) receiving


the souvenir from Dr. SO Chun
(moderator) during the lecture on 13
October 2015

www.hkmacme.org

Meeting Highlights

The HKMA Kowloon East Community Network (KECN) ~ Dr. AU Ka Kui, Gary
Dr. CHAN Chun Chung, Specialist in Geriatric Medicine, gave a talk on Update on
Type 2 Diabetes Management in Elderly on Thursday, 8 October 2015. The final
session of the CME Course for Health Personnel 2015 titled Common Shoulder
and Upper Limb Problems was given by Dr. LUK Man Sze, Karen, Associate
Consultant of Department of Orthopaedics & Traumatology of United Christian
Hospital, on Saturday, 17 October 2015. Dr. CHAN Chi Kin, Hamish, Specialist in
Cardiology, delivered a lecture on Cardiac Arrhythmia Update on Thursday, 22
October 2015.
A CME lecture on Shingles Prevention from
Infectious Disease Specialists Perspective will be
presented by Dr. SO Man Kit, Thomas, Specialist
in Infectious Disease, on Thursday, 10 December
2015. Interested members please refer to the
announcement on p.22 for details and enrolment.

Dr. YAU Lai Mo (left, moderator) presenting the


Certificate of Appreciation to Dr. Karen LUK
(speaker) during the lecture on 17 October 2015

Dr. Gary AU (left, moderator)


presenting a souvenir to Dr. CHAN
Chun Chung (speaker) on 8 October
2015

Dr. Danny MA (left, moderator) presenting a souvenir


to Dr. Hamish CHAN (speaker) during the lecture on
22 October 2015

The HKMA Hong Kong East Community Network (HKECN) ~ Dr. CHAN Nim Tak, Douglas
The talk on Update on Diagnosis and Management of Psoriatic Arthritis was delivered by Dr. CHAN Pak To, Specialist in
Rheumatology, on Thursday, 8 October 2015. Moreover, the lecture on The Evolving Treatment Paradigm of Type 2 Diabetes
was given by Dr. CHAN Wing Bun, Specialist in Endocrinology, Diabetes & Metabolism, on Thursday, 22 October 2015.
Dr. MA Pui Shan, Specialist in Endocrinology,
Diabetes & Metabolism, will present on A
Pathophysiological Approach to the Treatment
of Type 2 Diabetes on Thursday, 3 December
2015. Dr. CHAN Hoi Yee, Catherine, Specialist
in Ophthalmology, will deliver a lecture on
Recent Development in DME Management
on Thursday, 17 December 2015. Interested
members please refer to the announcement on
p.23 for details and enrolment.
Dr. CHAH Pak To (left, speaker) receiving a
souvenir from Dr. Silas NGAN (moderator)
during the lecture on 8 October 2015

www.hkmacme.org

Group photo taken during the lecture on 22


October 2015
From left: Dr. Alvin YS CHAN, Dr. CHAN Wing
Bun (speaker) and Dr. Joseph LAM (moderator)

HKMA CME Bulletin November 2015

27

Meeting Highlights

The HKMA New Territories West Community Network (NTWCN)


~ Dr. CHEUNG Kwok Wai, Alvin
The final session of the Certificate Course on Mens Health titled Helping the Man with Premature Ejaculation: Our
Responsibility was given by Dr. NG Wing Ying, Angela, Family Physician and Sex Therapist, on Thursday, 8 October 2015.
There were 39 doctors awarded the Certificate of Attendance. Dr. YIP Wai Man, Specialist in Geriatric Medicine, presented
on Osteoporosis Management: A
Practical Guide to Screening, Diagnosis
and Treatment on Thursday, 22 October
2015.
Dr. CHAN Yung, Specialist in Dermatology
& Venereology, will give a talk on New
Insight for Atopic Eczema Treatment
on Thursday, 17 December 2015.
Interested members please refer to the
announcement on p.21 for details and
enrolment.

Group photo taken during the lecture on 8 October 2015


From left: representative from sponsor, Dr. Angela NG
(speaker), Dr. Lambert CHAN (moderator) and Dr. Alvin
CHEUNG

Group photo taken during the lecture on 22 October 2015


From left: Dr. Ivan CHUNG, Dr. Alvin CHEUNG,
Dr. YIP Wai Man (speaker) and Dr. TSANG Yat Fai
(moderator)

The HKMA Kowloon West Community Network (KWCN) ~ Dr. TONG Kai Sing
Dr. HSU Yau Que, Specialist in Internal Medicine, presented on Update on Non-Alcoholic Fatty Liver Disease (NAFLD) on
Tuesday, 6 October 2015. Dr. CHAN Kam Tim, Michael, Specialist in Dermatology & Venereology, gave a talk on Treatment
and Prevention of Eczema Flares by Combination Therapy (Latest AAD Guideline Update) on Tuesday, 20 October 2015.
Dr. TSUI Hing Sum, Kenneth, Specialist in Rheumatology, will deliver a lecture on Advance in Rheumatic Diseases which is
co-organized by the Network and Hong Kong Society of Rheumatology on Tuesday, 1 December 2015. Interested members
please refer to the announcement on p.24 for details and enrolment.
Dr. LEE Tze Yuen, Specialist in Dermatology & Venereology, will present on Rosacea and Related Dermatoses on Tuesday,
15 December 2015. Interested members please refer to the announcement on p.21 for details and enrolment.

Group photo taken during the lecture on 6 October 2015


From left: Dr. Raymond LAM, Dr. Bruce WONG (moderator),
Dr. HSU Yau Que (speaker), Dr. Bernard CHAN and Dr. LEUNG
Gin Pang

28

HKMA CME Bulletin November 2015

Group photo taken during the lecture on 20 October 2015


From left: Dr. Bernard CHAN, Dr. Alvin YS CHAN, Dr. Michael
CHAN (speaker), Dr. Kenneth LEUNG (moderator) and Dr. Bruce
WONG

www.hkmacme.org

CMECalendar

November 2015
17 Nov 2015
(Tue)
1:00 2:00 pm

17 Nov 2015
(Tue)
1:00 3:00 pm

17 Nov 2015
(Tue)
1:00 3:00 pm

HKU Family Medicine and Primary Care


Family Medicine Clinical Management Meeting Management Guidelines for
Common Problems
Department of Family Medicine and Primary Care, 3/F, Ap Lei Chau Clinic,
161 Main Street, Ap Lei Chau, Hong Kong
Ms. Crystal Wong Tel: 2518 5654
Hong Kong Doctors Union Wan Chai Study Group
Xanthine Oxidase Inhibitors, Hypersensitivity and Allopurinol-induced SCAR
Sportful Garden Restaurant, 2/F, Tai Tung Building, 8 Fleming Road,
Wanchai
Tel: 2388 2728
Hong Kong Medical Association Kowloon West Community Network
Update on the Treatment of Type 2 Diabetes: A Cardiologists Perspective
Crystal Room IV-V, 3/F, Panda Hotel, 3 Tsuen Wah Street, Tsuen Wan, NT
Miss Hana Yeung Tel: 2527 8285

18 Nov 2015
Hong Kong Medical Association and the Chinese Medical Association
(Wed)
17th Beijing/Hong Kong Medical Exchange: Recent Advances in
9:00 05:00 pm Orthopaedics
Chongqing Yuelai Wyndham Hotel
HKMA CME Dept. Tel: 2527 8452
19 Nov 2015
(Thu)
1:00 3:00 pm

19 Nov 2015
(Thu)
1:00 3:00 pm

19 Nov 2015
(Thu)
1:00 3:00 pm

Hong Kong Medical Association Hong Kong East Community


Network
(1) Audiology Update; (2) Speech Therapy Update
5/F, Duke of Windsor Social Service Building, 15 Hennessy Road, Wanchai,
Hong Kong
Ms. Candice Tong Tel: 2527 8285
Hospital Authority United Christian Hospital
Hong Kong College of Family Physicians
Hong Kong Medical Association Kowloon East Community Network
Certificate Course for GPs 2015 Stress Incontinence
V Cuisine, 6/F, Holiday Inn Express Hong Kong Kowloon East, 3 Tong Tak
Street, Tseung Kwan O
Ms. Polly Tai Tel: 3513 3430
Hong Kong Medical Association New Territories West Community
Network
Achieving Optimal Glycemic Control: What are the Current Options in
Management
Pearl Ocean, 1/F, Gold Coast Yacht and Country Club, 1 Castle Peak Road,
Castle Peak Bay, Hong Kong
Miss Hana Yeung Tel: 2527 8285

19 Nov 2015
(Thu)
2:00 3:00 pm

Hong Kong Doctors Union Tsuen Wan Study Group


Management of CA Breast
HGC Conference Room, 3/F, Block A, Yan Chai, Hospital
Tel: 2388 2728

21 Nov 2015
(Sat)
1:30 4:00 pm

Hong Kong Medical Association


Department of Health
Hospital Authority
Hong Kong Society of Transplantation
Hong Kong Liver Foundation
Organ Donation Saves Life Primary Care Physicians Can Make A Difference
Lecture Theatre, G/F, Centre for Health Protection, 147C Argyle Street,
Kowloon
HKMA CME Dept. Tel: 2527 8452

24 Nov 2015
(Tue)
6:30 9:30 pm

Hong Kong Medical Association


Medical Protection Society
Mastering Adverse Outcomes
Eaton Hotel
HKMA CME Dept. Tel: 2527 8452

25 Nov 2015
(Wed)
1:00 2:00 pm

HKU Family Medicine and Primary Care


Family Medicine Clinical Management Meeting Management Guidelines for
Common Problems
Department of Family Medicine and Primary Care, 3/F, Ap Lei Chau Clinic,
161 Main Street, Ap Lei Chau, Hong Kong
Ms. Crystal Wong Tel: 2518 5654

25 Nov 2015
(Wed)
1:00 3:00 pm

Hong Kong Medical Association Central, Western & Southern


Community Network
Novel Approach against Refractory Angina and the Role of the Primary
Physician
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

26 Nov 2015
Hong Kong Sanatorium & Hospital Orthopaedic & Sports Medicine
(Thu)
Centre
8:30 10:30 am Academic Professional Development Meeting 2015 of OSMC HKSH (Every
Fourth Thursday of the Month)
Hong Kong Sanatorium & Hospital
Ms. Cheng Hoi Yan Tel: 2835 7890

www.hkmacme.org

26 Nov 2015
(Thu)
1:00 3:00 pm

Hong Kong Medical Association Kowloon East Community Network


First 1000 Days of Life What Matter Most?
V Cuisine, 6/F, Holiday Inn Express Hong Kong Kowloon East, 3 Tong Tak
Street, Tseung Kwan O
Miss Hana Yeung Tel: 2527 8285

26 Nov 2015
(Thu)
1:00 3:00 pm

Hong Kong Doctors Union Wan Chai Study Group


New insights in the Diagnosis & Management of Percutaneous Coronary
Intervention
Dragon King Restaurant, 12/F, World Trade Centre, 280 Gloucester Road,
Causeway Bay, Hong Kong
Tel: 2388 2728

26 Nov 2015
(Thu)
1:00 3:00 pm

Hong Kong Doctors Union Tai Po Study Group


Update on HBV Treatment
Salon II-III, L/F, Hyatt Regency Hong Kong, Sha Tin, 18 Chak Cheung
Street, Shatin, Hong Kong
Tel: 2388 2728

27 Nov 2015
(Fri)
1:00 3:00 pm

Hong Kong Medical Association Yau Tsim Mong Community Network


New Horizons for Managing Type 2 Diabetes with High CV Risk
Jade Ballroom, Level 2, Eaton, Hong Kong, 380 Nathan Road, Kowloon
Ms. Candice Tong Tel: 2527 8285

28 Nov 2015
Hospital Authority
(Sat)
Hong Kong College of Community Medicine
9:30 11:30 am Case presentations and Journal presentations in areas related to
Administrative Medicine
Room 524N, 5/F, Hospital Authority Building, 147B Argyle Street, Kowloon
Ms. Yandy Ho Tel: 2871 8745
28 Nov 2015
(Sat)
2:30 4:30 pm

Hong Kong Medical Association


Medical Protection Society
Mastering Adverse Outcomes
Holiday Inn Golden Mile Hong Kong
HKMA CME Dept. Tel: 2527 8452

1 Dec 2015
(Tue)
1:00 3:00 pm

Hong Kong Medical Association Kowloon West Community Network


Advance on Rheumatic Diseases
Crystal Room IV-V, 3/F, Panda Hotel, 3 Tsuen Wah Street, Tsuen Wan, NT
Miss Hana Yeung Tel: 2527 8285

2 Dec 2015
(Wed)
1:00 3:00 pm

Hong Kong Medical Association Central, Western & Southern


Community Network
Early Infant Feeding & Allergic Disorders
HKMA 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

3 Dec 2015
(Thu)
1:00 3:00 pm

Hong Kong Medical Association Hong Kong East Community Network


A Pathophysiological Approach to the Treatment of Type 2 Diabetes
5/F, Duke of Windsor Social Service Building, 15 Hennessy Road, Wanchai,
Hong Kong
Ms. Candice Tong Tel: 2527 8285

8 Dec 2015
(Tue)
1:00 3:00 pm

Hong Kong Medical Association Yau Tsim Mong Community Network


Complementary and Alternative Medicine (CAM) for Childhood Asthma: An
Overview of Evidence
Pearl Ballroom, Level 2, Eaton, Hong Kong, 380 Nathan Road, Kowloon
Ms. Candice Tong Tel: 2527 8285

9 Dec 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

10 Dec 2015
(Thu)
1:00 3:00 pm

Hong Kong Medical Association Kowloon East Community Network


Shingles Prevention from Infectious Disease Specialists Perspective
Lei Garden Restaurant, Shop no. L5-8, apm, Kwun Tong, No. 418 Kwun
Tong Road, Kwun Tong, Kowloon
Miss Hana Yeung 2527 8452

10 Dec 2015
(Thu)
1:15 3:00 pm

Hong Kong Medical Association


Hong Kong Sanatorium & Hospital
HKMA Structured CME Programme with HKS&H Session 12: Targeted
Therapy for General Practitioners
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
Hospital Authority Tuen Mun Hospital Department of Obstetrics &
Gynaecology
CME Programme for July December 2015
Update on HPV Vaccine
Room SB1034 A&B, Conference Room, 1/F, Special Block, Tuen Mun Hospital
Ms. Angela Cheung Tel: 2454 5568
Hong Kong Medical Association
Hong Kong College of Family Physicians
Hospital Authority Our Lady of Maryknoll Hospital
Refresher Course for Health Care Providers 2015/2016
Update in dementia
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

2.5

11 Dec 2015
(Fri)
1:00 2:00 pm

12 Dec 2015
(Sat)
2:15 4:15 pm

HKMA CME Bulletin November 2015

29