cme201511.pdf

November 2015

香港醫學會THE HONG KONG

MEDICAL ASSOCIATION

www.hkmacme.org

持續醫學進修專訊

B U L L E T I N

by Dr. PONG Chiu Fai, Jeffreyb D PONG Chi FF i J ff

Recent advances in cataract and refractive surgery

Encephalitis and Meningococcus Vaccineby Dr. CHAN Yee Shing, Alvin

HKMA CME Bulletin

Editorial 1

Spotlight 1 2Encephalitis and Meningococcus Vaccine

Spotlight 2 9Recent advances in cataract and refractive surgery

Cardiology 14A lady presented with pulseless electrical activity

Dermatology 16A lady with itchy skin for three years

Complaints & Ethics 17

Answer Sheet 19

CME Notifications 20

Meeting Highlights 26

CME Calendar 29

Contents

持續醫學進修專訊

Advertising Enquiry: 2527 8452 Fax: 2865 0943 / Email: [email protected]

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.

Please read the fol lowing art icles and answer the

questions. Participants in the HKMA CME Programme

will be awarded credit points under the Programme

for returning the completed answer sheet v ia 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)

HKMA CME Bulletin – MONTHLY SELF-STUDY

SERIES to help you grow!

香港醫學會體察到業界有必要設立完善的持續進修計劃，致力推動持續醫學進修，為同僚建立有系統的進修記錄機制，以及為全科醫生提供適切的進修課程。藉著這個計劃，我們期望將優良的進修傳統推展至醫學界中每一角落，同時為業界締造一個充滿活力的進修文化。我們誠意邀請您參與醫學會持續進修計劃，不論您是否醫學會的會員，均歡迎您同來與我們一起學習，以及享用醫學會為所有醫生設立的進修記錄機制。如欲了解香港醫學會持續醫學進修計劃的詳情，請聯絡本會秘書處查詢。

請細閱本期文章，並利用答題紙完成自我評估測驗，於2015年12月15日前，將已填妥之答題紙傳真（號碼：2865 0943）或寄回本會秘書處，您將可獲持續醫學進修的積分點; 至於是期自我評估測驗之答案，將刊於下一期《持續醫學進修專訊》之中。（您亦可透過網站www.hkmacme.org 完成自我評估測驗）

Spotlight 1Encephalitis and

Meningococcus

Vaccine

Spotlight 2Recent advances in

cataract and refractive

surgery

NOTICEMedical 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.

EDITORIAL

There is no question about the

dedication of HKMA in maintaining our

professionalism. I am sure most of us benefit from the

articles in our Bulletins and the CME lectures organized

by our community networks. However, one could

hardly deny the growing pessimism about the future

of Hong Kong & our profession. Political stability, fair

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 Government’s 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

interference towards our professional autonomy. HKMA

should welcome reports and gather evidence for future

action. Why don’t we save Hong Kong ourselves rather

than relying on the others!

Dr. HO Hung Kwong, Duncan

Co-Chairman, CME Committee

CME Bulletin & Online Editorial Board

Chief Editor

Dr. WONG Bun Lap, Bernard 黃品立醫生

Executive Committee

Dr. CHAN Yee Shing, Alvin 陳以誠醫生Dr. CHENG Chi Man 鄭志文醫生Dr. CHEUNG Hon Ming 張漢明醫生Dr. CHOI Kin 蔡堅醫生Dr. CHOW Pak Chin, JP 周伯展醫生Dr. HO Chung Ping, MH, JP 何仲平醫生Dr. HO Hung Kwong, Duncan 何鴻光醫生Dr. LAM Tzit Yuen, David 林哲玄醫生Dr. LI Sum Wo, MH 李深和醫生Dr. SHIH Tai Cho, Louis 史泰祖醫生Dr. TSE Hung Hing, JP 謝鴻興醫生Dr. WONG Bun Lap, Bernard 黃品立醫生

Cardiology

Dr. CHEN Wai Hong 陳偉康醫生Dr. HO Hung Kwong, Duncan 何鴻光醫生Dr. LEE Pui Yin 李沛然醫生Dr. LI Siu Lung, Steven 李少隆醫生Dr. WONG Bun Lap, Bernard 黃品立醫生Dr. WONG Shou Pang, Alexander 王壽鵬醫生Dr. WONG Wai Lun, Warren 黃煒倫醫生

Cardiothoracic Surgery

Dr. CHENG Lik Cheung 鄭力翔醫生Dr. CHIU Shui Wah, Clement 趙瑞華醫生Dr. CHUI Wing Hung 崔永雄醫生Dr. LEUNG Siu Man, John 梁兆文醫生

Colorectal Surgery

Dr. CHAN Cheung Wah 陳長華醫生Dr. LEE Yee Man 李綺雯醫生Dr. TSE Tak Yin, Cyrus 謝得言醫生

Dermatology

Dr. CHAN Hau Ngai, Kingsley 陳厚毅醫生Dr. HAU Kwun Cheung 侯鈞翔醫生Dr. SHIH Tai Cho, Louis 史泰祖醫生

Endocrinology

Dr. LEE Ka Kui 李家駒醫生Dr. LO Kwok Wing, Matthew 盧國榮醫生

ENT

Dr. CHOW Chun Kuen 周振權醫生

Family Medicine

Dr. LAM King Hei, Stanley 林敬熹醫生Dr. LI Kwok Tung, Donald, SBS, JP 李國棟醫生

Gastroenterologist

Dr. NG Fook Hong 吳福康醫生

General Practice

Dr. YAM Chun Yin 任俊彥醫生

General Surgery

Dr. LAM Tzit Yuen, David 林哲玄醫生Dr. Hon. LEUNG Ka Lau 梁家騮醫生

Geriatric Medicine

Dr. KONG Ming Hei, Bernard 江明熙醫生Dr. SHEA Tat Ming, Paul 佘達明醫生

Haematology

Dr. AU Wing Yan 區永仁醫生Dr. MAK Yiu Kwong, Vincent 麥耀光醫生

Hepatobiliary Surgery

Dr. CHIK Hsia Ying, Barbara 戚夏穎醫生Dr. LIU Chi Leung 廖子良醫生

Medical Oncology

Dr. TSANG Wing Hang, Janice 曾詠恆醫生

Nephrology

Dr. CHAN Man Kam 陳文岩醫生Dr. HO Chung Ping, MH, JP 何仲平醫生Dr. HO Kai Leung, Kelvin 何繼良醫生

Neurology

Dr. FONG Chung Yan, Gardian 方頌恩醫生Dr. TSANG Kin Lun, Alan 曾建倫醫生

Neurosurgery

Dr. CHAN Ping Hon, Johnny 陳秉漢醫生

Obstetrics and Gynaecology

Dr. CHAN Kit Sheung 陳潔霜醫生

Ophthalmology

Dr. CHOW Pak Chin, JP 周伯展醫生Dr. LIANG Chan Chung, Benedict 梁展聰醫生Dr. PONG Chiu Fai, Jeffrey 龐朝輝醫生

Orthopaedics and Traumatology

Dr. IP Wing Yuk, Josephine 葉永玉醫生Dr. KONG Kam Fu 江金富醫生Dr. POON Tak Lun 潘德鄰醫生Dr. TANG Yiu Kai 鄧耀楷醫生

Paediatrics

Dr. CHAN Yee Shing, Alvin 陳以誠醫生Dr. FUNG Yee Leung, Wilson 馮宜亮醫生Dr. TSE Hung Hing, JP 謝鴻興醫生Dr. YEUNG Chiu Fat, Henry 楊超發醫生

Plastic Surgeon

Dr. NG Wai Man, Raymond 吳偉民醫生

Psychiatry

Dr. LAI Tai Sum, Tony 黎大森醫生Dr. LEUNG Wai Ching 梁偉正醫生Dr. WONG Yee Him, John 黃以謙醫生

Radiology

Dr. CHAN Ka Fat, John 陳家發醫生Dr. CHAN Yip Fai, Ivan 陳業輝醫生

Respiratory Medicine

Dr. LEUNG Chi Chiu 梁子超醫生Dr. WONG Ka Chun 黃家進醫生Dr. YUNG Wai Ming, Miranda 容慧明醫生

Rheumatology

Dr. CHAN Tak Hin 陳德顯醫生Dr. CHEUNG Tak Cheong 張德昌醫生

Urology

Dr. CHEUNG Man Chiu 張文釗醫生Dr. KWOK Ka Ki 郭家麒醫生Dr. KWOK Tin Fook 郭天福醫生

Vascular Surgery

Dr. TSE Cheuk Wa, Chad 謝卓華醫生Dr. YIEN Ling Chu, Reny 顏令朱醫生

HKMA Secretariat

Ms. Jovi LAM 林偉珊女士Miss Sophia LAU 劉思妃小姐Miss Irene GOT 葛樂詩小姐

2 HKMA CME Bulletin 持續醫學進修專訊 November 2015www.hkmacme.org

SPOTlight -1

Encephalitis and Meningococcus Vaccine

INTRODUCTION

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?

They l ive 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

during the evening and night time. There is no specific

therapy that cures Japanese Encephalitis.

Dr. CHAN Yee Shing, Alvin

MBBS (HK), DCH (Glasgow),

MRCP (UK), FHKAM (Paed),

FHKCPaed, MRCPCH, FRCP (Edin),

Specialist in Paediatrics

VIRAL AMPLIFICATION

Uninfected mosquitoes bit pigs and waterbirds infected by Japanese Encephalitis virus

Infected mosquitoes reintroduce virus to vertebrates

Infected mosquitoes transmit virus to humans

1

2

3

CLINICAL MANIFESTATION

Patients with Japanese encephalitis have a history

of mosquito exposure in an endemic area, with an

incubat ion per iod 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, del ir ium 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.

3HKMA CME Bulletin 持續醫學進修專訊 November 2015www.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

Ant id iuret ic hormone secret ions 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 T2-

weighted 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

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 encephalit is is so severe, with no

definitive treatment but only supportive measures with

debilitating neurological sequelae, prevention by anti-

mosquito 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 worr ied especia l ly i f l iv ing 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.


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

unti l 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

mening i t ides 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

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 l eas t , 13 se rogroups have been descr ibed.

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

mortal i ty rate and persistent neurological def icit,

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 ser ious form of meningococcal d isease,

though less common, is meningococcal septicemia,

characterized by a hemorrhagic rash, and a rapid

c i rcu latory col lapse. I f there are large petechia l

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

genera l ized convuls ions, and a bulg ing anter ior

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.


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).

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.

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 e lucidated, should inc lude dexamethasone, a

th i rd generat ion cephalospor in, e.g. ceftr iaxone

or cefotaxime, vancomycin, and acyclovir i f init ial

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 pat ients surv iv ing meningococcal

meningitis suffer from sequelae such as:

➢ Mental retardation

➢ Hearing loss

➢ Neurologic disability

➢ Epilepsy

➢ Gangrene extremities due to ischemia

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

Meningococcus Haemophilus influenzae b

Pneumococcus

Available vaccines

4-valent (A, C, W-135

and Y) Meningococcal

conjugate vaccine

Haemophilus influenzae b

(Hib) conjugate vaccine or

Hib-containing vaccine

Pneumococcal conjugate vaccine

I n t he US , t he re a re a l so vacc ines comb in i ng

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 count r ies 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


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 chi ldren 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

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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 encephal it is. 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.

12. Feroldi E, et al. Memory immune response and safety of a booster dose of Japanese encephalitis chimeric virus vaccine (JE-CV) 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


SPOTlight -1

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. Patients with Japanese encephalitis in an endemic area have an incubation period of 10-20 days.

2. MRI findings in Japanese encephalitis often show bilateral cerebral lesions with hemorrhage.

3. The new JEV vaccine available is a live-attenuated recombinant vaccine.

4. 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.

Q&A Self-assessment Questions:

Complete thiscourse and earn

1 CME Point

HKMA CME Bulletin

Monthly Self-Study Series

Call for Articles

Since its publication, the HKMA CME Bulletin has become one of the most popular CME readings for doctors. This monthly publication has been serving more than 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 are also welcome.

For further information, please contact Miss Sophia Lau at 2527 8452 or by email at [email protected].

General Guidance for Authors

Intended Readers : General PractitionersLength of Article : Approximately 8-10 A-4 pages in 12-pt fonts in single line spacing, or around 1,500-2,000 words (excluding

references).Review Questions : 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.)Language : EnglishHighlights : It is preferable that key messages in each paragraph/section be highlighted in bold types.Key Lessons : Recommended to include, if possible, a key message in point-from at the end of the article.Others : List of full name(s) of author(s), with qualifications and current appointment quoted, plus a digital photograph of

each author.Deadline : 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.


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 predictabil ity. 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

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 blue-

blocking 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).

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


SPOTlight -2

People inser ted wi th 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 apar t f rom the near and d is tance 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 patient’s

expectation and hence satisfaction.

HOW REFRACTIVE SURGERY EVOLVES

Refractive surgery has also undergone signif icant

advances in the last two decades. The important trend

in this period is the reliance on laser technology and

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 t ime was main ly fo r 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 re f ract ive correct ion. I t 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,


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 ablat ion prof i le 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

eye’s 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 eye’s 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

ab lat ion, smal l opt ica l zones and asymmetr ica l

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 artif icial 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 direct ly above the poster ior

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

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 phacoemulsif ication. Phacoemulsif ication 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, surgical ly 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 post-

operative 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. Al l 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


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 versat i l i ty . Femtosecond is one mi l l ionth 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.

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 construct ion more re l iable 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.


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, Díz-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) Sáles 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) Alió 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 laser-assisted LASIK. Curr Opin Ophthalmol. 2015 Jul;26(4):260-4

(16) Alió 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

(19) Alió 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.

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.

Self-assessment questions:

Complete thiscourse and earn

1 CME PointQ&A


Cardiology

A lady presented with pulseless electrical activityA 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.

Complete BOTH Cardiology andDermatology 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

十一月臨床心臟科個案研究之內容承蒙胡國樑醫生提供。

Q&A 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 e levat ion myocardia l

infarction.

C. Pulmonary embolism.

D. ST-segment elevation myocardial infarction.

E. Unstable angina.

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.

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.

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.


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 2

Figure 3

Figure 4

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

十月臨床心臟科個案研究之內容承蒙鍾德惇醫生及張玲玲醫生提供。

香港醫生網The Hong Kong Doctors Homepage

www.hkdoctors.org

This web site is developed and maintained by the Hong Kong Medical Association

for all registered Hong Kong doctors to house their Internet practice homepage. The

format complies with the Internet Guidelines which was proposed by the Hong Kong

Medical Association and adopted by the Medical Council of Hong Kong.

We consider a practice homepage as a signboard or an entry in the telephone

directory. It contains essential information about the doctor including his specialty and

how to get to him. This facilitates members of the public to communicate with their

doctors.

This website is open to all registered doctors in Hong Kong. For practice page design

and upload, please contact the Hong Kong Medical Association Secretariat.

由香港醫學會成立並管理的《香港醫生網》，是一個收錄本港註冊西醫執業網頁的網站。內容是根據由香港醫學會擬訂並獲香港醫務委員會批准使用的互聯網指引內的規定格式刊載。

醫生的「執業網頁」性質與電話索引內刊載的資料相近。目的是提供與醫生執業有關的基本資料，例如註冊專科及聯絡方法等，方便市民接觸個別醫生。

任何香港註冊西醫都可以參加《香港醫生網》。關於網頁版面安排及上載之詳情，請與香港醫學會秘書處聯絡為荷。


Dermatology

October AnswersAnswers:

1. The d iagnos is i s rosacea. I t i s a chron ic

in f lammatory sk in d isorder , a f fect ing the

cheeks , ch i n , nose and some t imes t he

forehead, a f fect ing more than 16 mi l l ion

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.

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

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

possible aggravating factor and wear sunscreen.

Topical ant ib iot ic cream, azela ic 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.

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

十月皮膚科個案研究之內容承蒙陳厚毅醫生、鄧旭明醫生、關志強醫生及梁偉耀醫生提供。

A lady with itchy skin for three yearsA 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.

1. What are the differential diagnoses?

2. What is the diagnosis?

3. How do you confirm the diagnosis?

4. What are the associated skin diseases and relevant investigations?

5. What are the treatments?

Q&A Please answer ALL questions

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

Complete BOTH Cardiology andDermatology courses and earn

0.5 CME POINT

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

十一月皮膚科個案研究之內容承蒙梁偉耀醫生、鄧旭明醫生、陳厚毅醫生及關志強醫生提供。

Complaints & Ethics


Doctor X was charged wi th and found gu i l t y o f

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 patient’s 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

激素 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 類固醇 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 Amer ican

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

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 complicat ion

associated local steroid injections, although the risk

of this would be higher in patients suffer ing 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.

Overturning Medical Council Inquiry Decisions – Part 1

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 NephrologyDr. CHOI Kin

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 cl inical notes: ‘ local

steroid injections by GP’. He suggested that Doctor Y

did not have Doctor X’s 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.

Y’s 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

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 Medica l Counc i l inst ructed the Pre l iminary

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.

THE HONG KONG MEDICAL ASSOCIATION 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. Welcome Remarks by Dr. CHOY Yuen Chung, President of Kowloon Hospital Alumni Society

12:50 – 12:55 p.m. Speech by Dr. AU Yiu Kai, Council Member of Hong Kong Medical Association

12:55 – 1:00 p.m. Presentation of Souvenirs

1:00 – 1:30 p.m. Back and Neck Pain, Localize and Manage

Dr. CHIN Ping Hong, Consultant, Spine & Rehabilitation, Department of Orthopaedics and

Traumatology, Queen Elizabeth Hospital

1:30 – 2:00 p.m. Interventional Management of Neck and Back Pain

Dr. Steven WONG, Consultant, Department of Anaesthesiology & Operating Theatre Services,

Queen Elizabeth Hospital

2:00 – 2:30 p.m. Occupational Therapy Services for Chronic Pain Adaptation

Mr. LEUNG Kwok Fai, Cluster Manager, Occupational Therapy Services, Kowloon Central

Cluster, Hospital Authority

2:30 – 3:00 p.m. Contemporary Physiotherapy Management in Back & Neck Pain

Mr. Kenneth LEUNG, Senior Physiotherapist, Physiotherapy Department, Kowloon Hospital

3:00 – 3:15 p.m. Q&A

3:15 – 3:30 p.m. Vote of Thanks by Dr. CHOY Yuen Chung, President of Kowloon Hospital Alumni Society

Capacity : 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.


ANSWER SHEET

Dermatology

1

2

3

4

5

Complete BOTH Cardiology & Dermatology cases and earn 0.5 CME point

Name 姓名 Signature簽名：

HKMA Membership No. or HKMA CME No.香港醫學會會員編號或持續進修號碼：

Contact Tel No.聯絡電話：

HKID No. 香港身份証號碼： - xxx(x)

Please return thecompleted answer sheetto the HKMA Secretariat(Fax: 2865 0943) on orbefore 15 December 2015for documentation.If you completethe exercise online,you are NOT required toreturn the answer sheet byfax.請回答所有問題，並於2015年12月15日前將答題紙傳真或寄回香港醫學會 (傳真號碼：2865 0943)。如果選擇在網上完成練習，便無需將答題紙傳真到秘書處。

Answer Sheet

November 2015

答題紙

SPOTlight - 2Complete Spotlight and earn 1 CME point

1 2 3 4 5 6 7 8 9 10

Cardiology1 2 3 4

Please answer ALL questions and write the answers in the space provided.

SPOTlight - 1Complete Spotlight and earn 1 CME point

1 2 3 4 5 6 7 8 9 10


CMEnotifications

HKMA CME Programme香港醫學會持續進修計劃

CME Lecture – December 2015 進修講課－二零一五年十二月

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: 10 December 2015 (Thursday)

Time: 2:00-3:00 pm [Light lunch starts at 1:15 pm]

Venue: The HKMA Dr. Li Shu Pui Professional Education Centre, 2/F,

Chinese Club Building, 21-22 Connaught Road Central, HK

香港醫學會分科持續醫學進修計劃第十二節：普通科醫生的標靶治療

講者：關永康醫生

香港大學內外全科醫學士、英國皇家放射科學醫學院院士、香港放射科醫學院院士、香港醫學專科學院院士（放射科）、臨床腫瘤科專科醫生、養和醫院綜合腫瘤科中心副主任（放射治療）、養和醫院放射治療部主任

日期：二零一五年十二月十日（星期四）時間：下午二時至三時正[輕膳於下午一時十五分開始]地點：香港中環干諾道中二十一至二十二號華商會所大廈二樓香

港醫學會李樹培醫生專業教育中心

This symposium is co-organized with Hong Kong Sanatorium & Hospital. 講課與養和醫院合辦

Registration:Please fill in and return the Registration Form together with a cheque of adequate amount made payable to “The Hong Kong Medical Association” to 5/F Duke of Windsor Social Service Building, 15 Hennessy Road, Hong Kong. Each lecture will carry 1 CME point under the MCHK/HKMA CME Programme (unless otherwise stated). Accreditation from other colleges is pending. (The Secretariat fax no.: 2865 0943)

To be more eco-friendly and avoid postal delay, notification to registrants will no longer be made through sending confirmation letters but via SMS. Please fill in your updated mobile number so that you can be notified of your application. If you do not have a mobile phone number, the Secretariat will issue a confirmation letter to you. If you have not received any replies, please do not hesitate to contact us at 2527 8452.

報名方法:請填妥表格連同支票寄交香港灣仔軒尼詩道十五號溫莎公爵社會服務大廈五樓，支票抬頭請書明支付「香港醫學會」。參加者可獲醫務委員會/香港醫學會持續醫學進修計劃積分一分（除特別註明外）。其他專科學院之學分尚在申請中。（秘書處傳真號碼: 2865 0943）

為響應環保及為免郵遞延誤，秘書處將以手機短訊通知講課報名結果。因此，請準確填上閣下之手機號碼以便接收通知，倘若閣下沒有手提電話，秘書處仍會以郵寄方式把講課確認通知書寄上。參加者如沒有收到任何通知，請致電2527 8452查詢。

Please register for participation. First come, first served.名額有限請早登記TYPHOON/BLACK RAINSTORM POLICYWhen 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 at 2:00 pm will be cancelled if the warning signal is hoisted or in force any time between 11:00 am and 2:00 pm).

The function will proceed as scheduled if the signal is lowered three hours before the commencement time. (i.e. 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).

When Tropical Storm Warning Signal No. 8 (or above) or the Black Rainstorm Warning Signal is hoisted after CME commencement, announcement will be made depending on the conditions as to whether the CME will be terminated earlier or be conducted until the end of the session.

The above are general guidelines only. Individuals should decide on their CME attendance according to their own transportation and work/home location considerations to ensure personal safety.

Reply Slip 回條I would like to register for the following CME lecture(s): 本人欲報名參加以下講課：

Please “✓” as appropriate. 請在適用處加上✓號

Name 姓名 :

I enclose herewith a cheque of

現隨表格付上支票一張作為講課之報名費用： HK$ 港幣

HKMA Membership No. or HKMA CME No. 會員編號或進修號碼：

Signature 簽名 : Date 日期：

Data collected will be used and processed for the purposes related to the MCHK/HKMA CME Programme only. All registration fees are not refundable or transferable.

個人資料將用於有關香港醫學會持續醫學進修計劃之事宜。所有報名費用將不給予退還或轉授予其他會員。

（Mandatory for emergency contact or SMS 必須填寫用以緊急聯絡或接收短訊）

Mobile No. 手機號碼 : Fax No. 傳真 :

HKMA Member

HK$50

CME Participants

HK$80

10 December 2015

(Thursday)

HKMA Structured CME Programme with HKS&H

Year 2015 Session XII: Targeted Therapy for General

Practitioners

HKMA Structured CME Programme with HKS&H


REPLY SLIP

HKMA KW & NTW Community Networks Fax: 2865 0943CME Lectures in December 2015

I would like to register for the following lecture(s): Please “✓” as appropriate

15 December 2015 (KW) 17 December 2015 (NTW)

Name: HKMA No.:

Mobile 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.

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. Registration & Lunch

2:00 – 2:45 p.m. Lecture

2:45 – 3:00 p.m. Q&A Session

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

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

Pearl Ocean, 1/F., Gold Coast Yacht and Country Club,

1 Castle Peak Road,

Castle Peak Bay, Hong Kong

（黃金海岸鄉村俱樂部‧遊艇會一樓金霞殿）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

THE HONG KONGMEDICAL ASSOCIATION

CME Lectures in December 2015

CMEnotifications


REPLY SLIP

HKMA CW&S & KE Community Networks Fax: 2865 0943CME Lectures in December 2015


2 December 2015 (CW&S) 10 December 2015 (KE)

Name: HKMA 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 *: )


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

Signature: Date:


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

Shingles Prevention from Infectious Disease Specialist’s PerspectiveDr. SO Man Kit, ThomasSpecialist in Infectious Disease

Time : 1:00 – 2:00 p.m. Registration & Lunch2:00 – 2:45 p.m. Lecture2:45 – 3:00 p.m. Q&A Session

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 （利苑酒家）,Shop no. L5-8, apm, Kwun Tong,No. 418 Kwun Tong Road,Kwun Tong, Kowloon

Moderator : Dr. YIK Ping YinChairman,HKMA CW&S Community Network

Dr. AU Ka Kui, GaryChairman,HKMA Kowloon East Community Network

Deadline : Monday, 23 November 2015 Monday, 30 November 2015


Capacity : 80 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 :




CMEnotifications


REPLY SLIP

HKMA Hong Kong East Community Network Fax: 2865 0943CME Lectures in December 2015


3 December 2015 17 December 2015

Name: HKMA 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 *: )


* Null entry will be treated as non-Hong Kong East member registration.

Signature: Date:



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


2:00 – 2:45 p.m. Lecture

2:45 – 3:00 p.m. Q&A Session

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


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



Sponsor :



Co-organized by 港島東醫院聯網Hong Kong East Cluster, HA

CMEnotifications


Advance in Rheumatic Diseases

REPLY SLIP

Date : Tuesday, 1 December 2015

Speaker : Dr. TSUI Hing Sum, Kenneth

Specialist in Rheumatology


2:00 – 2:45 p.m. Lecture

2:45 – 3:00 p.m. Q & A Session

Venue : 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



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

Enquiry : Miss Hana YEUNG, Tel: 2527 8285



CME

Accreditation

: Pending

This lecture is sponsored by

AbbVie Ltd.

HKMA Kowloon West Community Network Fax: 2865 0943Advance in Rheumatic Diseases

I would like to register for the above event. Please “✓” as appropriate

Name: HKMA No.:



Practising location: In Kowloon West (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.


Co-organized by

The HKMA Kowloon West Community Network

and Hong Kong Society of Rheumatology

CMEnotifications


Complementary and Alternative Medicine (CAM)

for Childhood Asthma: An Overview of Evidence

REPLY SLIP

Date : Tuesday, 8 December 2015

Speaker : Prof. HON Kam Lun, Ellis

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


2:00 – 2:45 p.m. Lecture

2:45 – 3:00 p.m. Q&A Session

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

380 Nathan Road, Kowloon

Moderator : Dr. CHENG Kai Chi, Thomas

Hon. Secretary, HKMA YTM Community Network

Deadline : Friday, 27 November 2015



Priority will be given to doctors practising in YTM district.

Enquiry : Ms. Candice TONG, Tel: 2527 8285



CME

Accreditation

: Pending

This lecture is sponsored by

Nestle Hong Kong Ltd.

HKMA Yau Tsim Mong Community Network Fax: 2865 0943Complementary and Alternative Medicine (CAM) for Childhood Asthma: An Overview of Evidence

I would like to register for the above lecture. Please “✓” as appropriate

Name: HKMA No.:

Mobile No.*: Fax:


Practising location: In Yau Tsim Mong (Please specify *: )


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

Signature: Date:

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


Organized by

The HKMA Yau Tsim Mong Community Network

CMEnotifications


Meeting Highlights

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 Central, Western and Southern Community Network (CW&SCN) ~ Dr. YIK Ping Yin

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.

Dr. MAK Wing Kin ( left, moderator) in photo with Dr. Winnie LAU (speaker) during the lecture on 16 September 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. 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.

HKMA Structured CME Programme with Hong Kong Sanatorium & Hospital 2015

Dr. NG Fook Hong (right) presenting a souvenir to the speaker, Dr. MA Shiu Kwan, Edmond, (left)

The HKMA Yau Tsim Mong Community Network (YTMCN) ~ Dr. LAM Tzit Yuen, DavidThe 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.

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.

Dr. TAI Chi Kin (left, speaker) receiving the souvenir from Dr. SO Chun (moderator) during the lecture on 13 October 2015


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 Prevent ion from

Infectious Disease Specialist’s 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

Dr. CHAH Pak To (left, speaker) receiving a souvenir from Dr. Silas NGAN (moderator) during the lecture on 8 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, wil l 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, wil l del iver 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.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)


Meeting Highlights

The final session of the “Certificate Course on Men’s 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 “Os teopo ros i s Managemen t : 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”

o n T h u r s d a y , 1 7 D e c e m b e r 2 0 1 5 .

Interested members please refer to the

announcement on p.21 for details and

enrolment.

The HKMA New Territories West Community Network (NTWCN) ~ Dr. CHEUNG Kwok Wai, Alvin

Group photo taken during the lecture on 8 October 2015From 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 2015From 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 2015From left: Dr. Raymond LAM, Dr. Bruce WONG (moderator), Dr. HSU Yau Que (speaker), Dr. Bernard CHAN and Dr. LEUNG Gin Pang

Group photo taken during the lecture on 20 October 2015From left: Dr. Bernard CHAN, Dr. Alvin YS CHAN, Dr. Michael CHAN (speaker), Dr. Kenneth LEUNG (moderator) and Dr. Bruce WONG

CMECalendar


November 2015

17 Nov 2015(Tue)1:00 – 2:00 pm

HKU – Family Medicine and Primary CareFamily Medicine Clinical Management Meeting – Management Guidelines for Common ProblemsDepartment of Family Medicine and Primary Care, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong KongMs. Crystal Wong – Tel: 2518 5654

1

17 Nov 2015(Tue)1:00 – 3:00 pm

Hong Kong Doctors Union – Wan Chai Study GroupXanthine Oxidase Inhibitors, Hypersensitivity and Allopurinol-induced SCARSportful Garden Restaurant, 2/F, Tai Tung Building, 8 Fleming Road, WanchaiTel: 2388 2728

1

17 Nov 2015(Tue)1:00 – 3:00 pm

Hong Kong Medical Association – Kowloon West Community NetworkUpdate on the Treatment of Type 2 Diabetes: A Cardiologist’s PerspectiveCrystal Room IV-V, 3/F, Panda Hotel, 3 Tsuen Wah Street, Tsuen Wan, NTMiss Hana Yeung – Tel: 2527 8285

1

18 Nov 2015(Wed)9:00 – 05:00 pm

Hong Kong Medical Association and the Chinese Medical Association17th Beijing/Hong Kong Medical Exchange: Recent Advances in OrthopaedicsChongqing Yuelai Wyndham HotelHKMA CME Dept. – Tel: 2527 8452

5

19 Nov 2015(Thu)1:00 – 3:00 pm

Hong Kong Medical Association – Hong Kong East Community Network(1) Audiology Update; (2) Speech Therapy Update5/F, Duke of Windsor Social Service Building, 15 Hennessy Road, Wanchai, Hong KongMs. Candice Tong – Tel: 2527 8285

1

19 Nov 2015(Thu)1:00 – 3:00 pm

Hospital Authority – United Christian HospitalHong Kong College of Family PhysiciansHong Kong Medical Association – Kowloon East Community NetworkCertificate Course for GPs 2015 – Stress IncontinenceV Cuisine, 6/F, Holiday Inn Express Hong Kong Kowloon East, 3 Tong Tak Street, Tseung Kwan OMs. Polly Tai – Tel: 3513 3430

1

19 Nov 2015(Thu)1:00 – 3:00 pm

Hong Kong Medical Association – New Territories West Community NetworkAchieving Optimal Glycemic Control: What are the Current Options in ManagementPearl Ocean, 1/F, Gold Coast Yacht and Country Club, 1 Castle Peak Road, Castle Peak Bay, Hong KongMiss Hana Yeung – Tel: 2527 8285

1

19 Nov 2015(Thu)2:00 – 3:00 pm

Hong Kong Doctors Union – Tsuen Wan Study GroupManagement of CA BreastHGC Conference Room, 3/F, Block A, Yan Chai, HospitalTel: 2388 2728

1

21 Nov 2015(Sat)1:30 – 4:00 pm

Hong Kong Medical AssociationDepartment of HealthHospital AuthorityHong Kong Society of TransplantationHong Kong Liver FoundationOrgan Donation Saves Life – Primary Care Physicians Can Make A DifferenceLecture Theatre, G/F, Centre for Health Protection, 147C Argyle Street, KowloonHKMA CME Dept. – Tel: 2527 8452

2

24 Nov 2015(Tue)6:30 – 9:30 pm

Hong Kong Medical AssociationMedical Protection SocietyMastering Adverse OutcomesEaton HotelHKMA CME Dept. – Tel: 2527 8452

2.5

25 Nov 2015(Wed)1:00 – 2:00 pm

HKU – Family Medicine and Primary CareFamily Medicine Clinical Management Meeting – Management Guidelines for Common ProblemsDepartment of Family Medicine and Primary Care, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong KongMs. Crystal Wong – Tel: 2518 5654

1

25 Nov 2015(Wed)1:00 – 3:00 pm

Hong Kong Medical Association – Central, Western & Southern Community NetworkNovel Approach against Refractory Angina and the Role of the Primary PhysicianHong Kong Medical Association Central Premises, Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese Club Building, 21-22 Connaught Road, Central, Hong KongMiss Hana Yeung – Tel: 2527 8285

1

26 Nov 2015(Thu)8:30 – 10:30 am

Hong Kong Sanatorium & Hospital – Orthopaedic & Sports Medicine CentreAcademic Professional Development Meeting 2015 of OSMC HKSH (Every Fourth Thursday of the Month)Hong Kong Sanatorium & HospitalMs. Cheng Hoi Yan – Tel: 2835 7890

2

26 Nov 2015(Thu)1:00 – 3:00 pm

Hong Kong Medical Association – Kowloon East Community NetworkFirst 1000 Days of Life – What Matter Most?V Cuisine, 6/F, Holiday Inn Express Hong Kong Kowloon East, 3 Tong Tak Street, Tseung Kwan OMiss Hana Yeung – Tel: 2527 8285

1

26 Nov 2015(Thu)1:00 – 3:00 pm

Hong Kong Doctors Union – Wan Chai Study GroupNew insights in the Diagnosis & Management of Percutaneous Coronary InterventionDragon King Restaurant, 12/F, World Trade Centre, 280 Gloucester Road, Causeway Bay, Hong KongTel: 2388 2728

1

26 Nov 2015(Thu)1:00 – 3:00 pm

Hong Kong Doctors Union – Tai Po Study GroupUpdate on HBV TreatmentSalon II-III, L/F, Hyatt Regency Hong Kong, Sha Tin, 18 Chak Cheung Street, Shatin, Hong KongTel: 2388 2728

1

27 Nov 2015(Fri)1:00 – 3:00 pm

Hong Kong Medical Association – Yau Tsim Mong Community NetworkNew Horizons for Managing Type 2 Diabetes with High CV RiskJade Ballroom, Level 2, Eaton, Hong Kong, 380 Nathan Road, KowloonMs. Candice Tong – Tel: 2527 8285

1

28 Nov 2015(Sat)9:30 – 11:30 am

Hospital AuthorityHong Kong College of Community MedicineCase presentations and Journal presentations in areas related to Administrative MedicineRoom 524N, 5/F, Hospital Authority Building, 147B Argyle Street, KowloonMs. Yandy Ho – Tel: 2871 8745

2

28 Nov 2015(Sat)2:30 – 4:30 pm

Hong Kong Medical AssociationMedical Protection SocietyMastering Adverse OutcomesHoliday Inn Golden Mile Hong KongHKMA CME Dept. – Tel: 2527 8452

2

1 Dec 2015(Tue)1:00 – 3:00 pm

Hong Kong Medical Association – Kowloon West Community NetworkAdvance on Rheumatic DiseasesCrystal Room IV-V, 3/F, Panda Hotel, 3 Tsuen Wah Street, Tsuen Wan, NTMiss Hana Yeung – Tel: 2527 8285

1

2 Dec 2015(Wed)1:00 – 3:00 pm

Hong Kong Medical Association – Central, Western & Southern Community NetworkEarly Infant Feeding & Allergic DisordersHKMA Central Premises, Dr. Li Shu Pui Professional Education Centre, 2/F., Chinese Club Building, 21-22 Connaught Road Central, Hong KongMiss Hana Yeung – Tel: 2527 8285

1

3 Dec 2015(Thu)1:00 – 3:00 pm

Hong Kong Medical Association – Hong Kong East Community NetworkA Pathophysiological Approach to the Treatment of Type 2 Diabetes5/F, Duke of Windsor Social Service Building, 15 Hennessy Road, Wanchai, Hong KongMs. Candice Tong – Tel: 2527 8285

1

8 Dec 2015(Tue)1:00 – 3:00 pm

Hong Kong Medical Association – Yau Tsim Mong Community NetworkComplementary and Alternative Medicine (CAM) for Childhood Asthma: An Overview of EvidencePearl Ballroom, Level 2, Eaton, Hong Kong, 380 Nathan Road, KowloonMs. Candice Tong – Tel: 2527 8285

1

9 Dec 2015(Wed)5:00 – 7:00 pm

Hong Kong Poison Information CentreHospital Authority – United Christian HospitalMonthly Meeting of HKPIC (Presentation and discussion on interesting cases of the month)Lecture Theatre, Block F, United Christian HospitalMs. Winnie Cheung – Tel: 3949 5096

2

10 Dec 2015(Thu)1:00 – 3:00 pm

Hong Kong Medical Association – Kowloon East Community NetworkShingles Prevention from Infectious Disease Specialist’s PerspectiveLei Garden Restaurant, Shop no. L5-8, apm, Kwun Tong, No. 418 Kwun Tong Road, Kwun Tong, KowloonMiss Hana Yeung – 2527 8452

1

10 Dec 2015(Thu)1:15 – 3:00 pm

Hong Kong Medical AssociationHong Kong Sanatorium & HospitalHKMA Structured CME Programme with HKS&H Session 12: Targeted Therapy for General PractitionersFunction Room A, HKMA Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese Club Building, 21-22 Connaught Road Central, Hong KongHKMA CME Dept. – Tel: 2527 8452

1

11 Dec 2015(Fri)1:00 – 2:00 pm

Hospital Authority – Tuen Mun Hospital – Department of Obstetrics & GynaecologyCME Programme for July – December 2015Update on HPV VaccineRoom SB1034 A&B, Conference Room, 1/F, Special Block, Tuen Mun HospitalMs. Angela Cheung – Tel: 2454 5568

1

12 Dec 2015(Sat)2:15 – 4:15 pm

Hong Kong Medical AssociationHong Kong College of Family PhysiciansHospital Authority – Our Lady of Maryknoll HospitalRefresher Course for Health Care Providers 2015/2016 –Update in dementiaTraining Room II, 1/F, OPD Block, Our Lady of Maryknoll Hospital, 118 Shatin Pass Road, Wong Tai Sin, KowloonMs. Clara Tsang – Tel: 2354 2440

2

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