持續醫學進修專訊 - hkma.org · Alzheimer’s Disease: to be or not to be. HKMA CME Bulletin Editorial 1 Spotlight 1 2 Advance in diagnosis of Alzheimer’s Disease: to be

香港醫學會The hong Kong

Medical associaTion

September 2015www.hkmacme.org

持續醫學進修專訊

B u l l e t i n

by Dr. WONG Yat Hin, Ian

An update on the treatment and prevention

of age related macular degeneration

Review and update on management of Rosacea (I)by Dr. CHAN Hau Ngai, Kingsley

by Dr. SHEA Tat Ming, Paul

Advance in diagnosis of Alzheimer’s Disease:

to be or not to be

HKMA CME Bulletin

Editorial 1

Spotlight 1 2Advance in diagnosis of Alzheimer’s Disease: to be or not to be

Spotlight 2 6Review and update on management of Rosacea (I)

Spotlight 3 10An update on the treatment and prevention of age related macular degeneration

Cardiology 16Stroke in a young lady

Dermatology 18Small reddish spots on forearms

Complaints & Ethics 19

Answer Sheet 20

CME Notifications 21

Advertorial 29

Meeting Highlights 30

CME Calendar 33

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 October 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)

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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10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）

Contents

Spotlight 3An update on the treatment and prevention of age related macular degeneration

Spotlight 2Review and update on management of Rosacea (I)

Spotlight 1Advance in diagnosis of Alzheimer’s Disease: to be or not to be

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

After the bright and beautiful summer holiday, most of our youngsters started their new school year 2 weeks ago. As usual, after sending them back to school, we are now trying our best to concentrate on our daily clinical works and continuous medical education (CME), once again.

All of us are trying to acquire as much knowledge as possible every day. Today, we are continuously drowning with information (most of them from electronic sources) but only a very minute proportion of them is genuine knowledge.

My dearest HKMA fellow colleagues, let me share with you some of my beloved famous quotes of wisdom, talking about knowledge.

“Information is not knowledge”~ Albert Einstein (1879-1955), Theoretical Physicist

“When I examine myself and my methods of thought, I come to the conclusion that the gift of fantasy has meant more to me than my talent for absorbing positive knowledge.”~ Albert Einstein (1879-1955), Theoretical Physicist

“Imagination is more important than knowledge. For while knowledge defines all we currently know and understand, imagination points to all we might yet discover and create.”~ Albert Einstein (1879-1955), Theoretical Physicist

“Whoever undertakes to set himself up as a judge of Truth and Knowledge is shipwrecked by the laughter of the gods.”~ Albert Einstein (1879-1955), Theoretical Physicist

“Ignorance more frequently begets confidence than does knowledge: it is those who know little, and not those who know much, who so positively assert that this or that problem will never be solved by science.”~ Charles Darwin (1809-1882), Naturalist and Geologist

“It is not enough to have knowledge, one must also apply it. It is not enough to have wishes, one must also accomplish.”~ Johann Wolfgang von Goethe (1749-1832), Poet, Novelist, Play-writer, Natural Philosopher, Diplomat, Civil Servant

“If you don’t read the newspaper, you are uninformed; if you do read the newspaper, you are misinformed.”~ Mark Twain (1835-1910), Author and Humorist

“The good life is inspired by loves and guided by knowledge.”~ Bertrand Russell (1872-1970), Philosopher, Logician, Mathematician, Historian, Writer, Social Critic and Political Activist

“Bodily exercise, when compulsory, does no harm to the body; but knowledge which is acquired under compulsion obtains no hold on the mind.”~ Plato (428BC-348BC), Philosopher and Mathematician

“Know well what leads you forward and what holds you back, and choose the path that leads to wisdom.”~ Buddha (563BC-400BC)

“Those who knows are wise. Those who know themselves are enlightened.”~ Laozi (Lao Tzu) (5-6 Century BC, Zhou Dynasty)

The HKMA CME Bulletin Editorial Board wishes you and your family a prosperous, healthy and happy Autumn.

Dr. WONG Bun Lap, BernardChief Editor

CME Bulletin & Online Editorial Board

Chief EditorDr. WONG Bun Lap, Bernard 黃品立醫生

Executive CommitteeDr. 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

CardiologyDr. 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

Cardiothoracic SurgeryDr. 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 SurgeryDr. 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

DermatologyDr. 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

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

ENTDr. CHOW Chun Kuen 周振權醫生

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

GastroenterologistDr. NG Fook Hong 吳福康醫生

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

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

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

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

Medical OncologyDr. TSANG Wing Hang, Janice 曾詠恆醫生

NephrologyDr. 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

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

NeurosurgeryDr. CHAN Ping Hon, Johnny 陳秉漢醫生

Obstetrics and GynaecologyDr. CHAN Kit Sheung 陳潔霜醫生

OphthalmologyDr. 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 TraumatologyDr. 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

PaediatricsDr. 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 SurgeonDr. NG Wai Man, Raymond 吳偉民醫生

PsychiatryDr. 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

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

Respiratory MedicineDr. LEUNG Chi Chiu 梁子超醫生Dr. YUNG Wai Ming, Miranda 容慧明醫生

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

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

HKMA SecretariatMs. 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 September 2015 www.hkmacme.org

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Advance in Diagnosis of Alzheimer’s Disease: To be or not to be

Researchers discovered new Alzheimer’s test that measure two kinds of protein in cerebrospinal fluid (CSF), namely beta-amyloid and tau protein. Reduction in CSF level of beta-amyloid 1-42 (a marker of amyloid plagues) and elevation of tau protein (a marker of axonal damage and neurofibrillary tangles) are well established as biomarkers useful for AD diagnosis(4). The use of AD CSF biomarkers is the way forward for early detection of AD and enable early treatment of the disease in the prodromal phase, once effective drug treatment becomes available.

Definite diagnosis of AD relies on the demonstration o f su f f ic ient amount o f beta-amy lo id p lague or neurofibrillary tangle in autopsy brain. Recently, the development of PET tracer Pittsburgh Compound-B (PIB) has made the in-vivo imaging of amyloid possible (Figure 1). Fluoro-2-deoxy-D-glucose (FDG) PET shows the decrease in cerebral glucose metabolism with a characteristic pattern of posterior temporo-parietal region hypometabolism in AD(5) (Figure 2). PIB has been found to bind specifically to beta-amyloid 40 and beta-amyloid 42 fibrils and insoluble beta-amylod plagues in AD patients. Abnormal uptake of PIB has been consistently demonstrated from a very early stage of AD, and it is likely an in-vivo pathological hallmark of preclinical AD(6).

Figure 1: High 11C-PIB retention was recorded in patients with AD, while b | age-matched, healthy individuals exhibited low retention of this radioligand.

A lzhe imer ’s d isease (AD) , the commonest form of aged-related dementia, is a neurodegenerative disorder leading to progressive impairment of brain funct ions inc lud ing memory , l anguage, spat ia l orientation, behaviour and personality. In May 2011, three consensus groups organized by the National Institute on Aging (NIA) and the Alzheimer’s Association (AA) published a new set of diagnostic guidelines for Alzheimer’s diseases (ADs) — the first revision since 1984(1). In those intervening 27 years, findings about the prevalence of AD and its clinical-pathophysiologic relationships have refined and altered the medical field’s concept of the disease. The clinical manifestation of Alzheimer’s disease is preceded by an insidious and silent preclinical phase, which is followed by the prodromal phase, cl inical ly characterized as mild cognitive impairment, and finally dementia(2) (Graph 1).

Graph 1

Current ly , in many countr ies, lots of hea l thcare organizat ion and doctors voice out the need for screening and early diagnosis of Alzheimer’s disease(3). Such drive has been accompanied by research into early detection of dementia, including preclinical identification of underlying neuropathology that might be associated wi th Alzheimer’s d isease. Ear ly ident i f icat ion of Alzheimer’s, will initiate a new wave of drug trial aiming at arresting the progression of the disease, even at the preclinical phase.

Dr. SHEA Tat Ming, PaulMBChB (CUHK), MRCP (UK), FHKCP, FHKAM (Medicine), FRCP (Edin), Specialist in Geriatric MedicineExecutive Committee Member, Hong Kong Alzheimer’s Disease AssociationPrivate Practice

3HKMA CME Bulletin 持續醫學進修專訊 September 2015www.hkmacme.org

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temporal, paralimbic and temporo-parietal isocortex is a biomarker of AD-related neurodegeneration. MRI measurement of hippocampal volume was shown to be related to the conversion of mild cognitive impairment (MCI) to AD. Structural MRI is regarded as a marker of neuronal loss and thus have a close relationship with the cognitive performance(7) (Figure 3).

Figure 3

However, even with the advance in the preclinical diagnosis of AD, more work is needed to clarify the optimal CSF assays, PET or MRI analytic techniques, and in particular the specific thresholds needed to meet these criteria. There are significant challenges in implementing standardized biomarker “cut-off” values across centres, studies and countries. There is also a need to work out the sensitivities and specificities of individual markers to minimize the false positive and false negative diagnosis and to improve the prediction of development into clinical symptomatic AD. Nowadays, it is still regarded as immature to predict the development of AD by these biomarkers in clinical settings, but are more often used in research studies to identify the at risk cases for further intervention(8).

Cognitive test is applicable in the clinical phase of dementia, in which neuronal loss is signif icant to affect the cognition. Cognitive assessment is useful in screening older patient with dementia. Tests have also been performed on community elderly to screen for mild cognitive impairment, which preceded the

Figure 2: FDG-PET brain images in a normal volunteer (left panel) and in a patient with Alzheimer’s disease (right panel).Red, orange, and yellow areas are (in decreasing order) the most active, while green, blue, and violet areas are progressively less active. In the patient with Alzheimer’s disease, the arrows indicate areas of diminished metabolic activity in the patient’s parietotemporal cortex, a region important for processing of language and associative memories. (SOURCE: Courtesy of Daniel Silverman, UCLA.)

Graph 2

With the accumulation of beta-amyloid plague, the amyloid biomarkers become abnormal first, and prior to the appearance of clinical symptoms. The biomarkers of brain dysfunction, neuronal injury and degeneration are dynamic later in the disease, and unlike amyloid biomarkers, the severity and change over t ime in these biomarkers do correlate with clinical symptoms (Graph 2). Decreased uptake FDG uptake on PET in a characteristic posterior temporo-parietal pattern is a biomarker of AD-related synaptic dysfunction (Figure 1).

Structural magnetic resonance imaging (MRI) is the last biomarker to become abnormal. Brain atrophy on a structural MRI in a characteristic pattern involving medial


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dementia. These tests have been validated and can be used in clinical settings. The most widely used test is Mini-Mental State Examination (MMSE). The other tests include Clock drawing test (CDT), the short and full informants questionnaire on Cognitive Decline in Elderly (IQCODE), Mini-Cog, Telephone Interview for Cognitive Status (TICS), Montreal Cognitive Assessment (MCoA), and the Free and Cued Selective Reminding Test (FCSRT)(9).

The emphasis on early diagnosis of mild cognitive impairment and Alzheimer’s disease stems from the assumption that people with dementia have an illness that progresses through a precl inical period that interventions are more likely to be effective. However, up till now, there is no medication available effective in the treatment of preclinical dementia. The current available medications including cholinesterase inhibitors, are only indicated in symptomatic dementia and is proven not effective in preclinical dementia or mild cognitive impairment.

Healthy lifestyle activities, physical exercise, dietary intervention have been proven as protective factors on Alzheimer’s disease. Early diagnosis may alert the patients to undergo such modification, but do we need a positive test to improve our lifestyle and diet?

In some patients, early diagnosis may have effect on their future healthcare planning, and may affect their plan on their own career and family. Financial planning may be important for certain patients. Enduring power of Attorney and advance directives are available to help patients with early diagnosis(10).

T h e n e w D S M - 5 c l a s s i f i c a t i o n d e f i n e s m i n o r neurocognitive disorder as a modest decline in any cognitive domain, reported by a clinician, informant or the patient, where any formal testing or cl inical evaluation lies more than one standard deviation below the appropriate norm. Under this definition, theoretically, about 16% of population will be automatically defined as having a minor neurocognitive disorder. Such over-diagnosis would lead to anxiety, depression in such group of population unnecessarily, and depression itself is a risk factor for Alzheimer’s disease(11).

The tests available now are still expensive. They carry various clinical risk such as radiation, infection etc. The specificity and sensitivity of these tests are still questionable. The predictive value still has the room for further improvement. And currently, no medication available is effective for preclinical or pre-symptomatic stage of Alzheimer’s disease. The diagnosis itself may create more adverse reaction than any benefit. The society is not yet ready for the preclinical diagnosis of dementia. Legal procedure, mental capacity may be one of those considerations. Insurance planning coverage are still questionable(10,12).

Preclinical diagnosis is currently mainly uti l ized in research settings, to recruit at risk patients for clinical research and drug tr ia l . In dai ly cl in ical pract ice, screening patient for dementia before any symptom is still debatable(13,14,15).

References:

(1) Sperling RA, et al. Toward defining the preclinical stages of Alzheimer’s disease: recommendations from the National Institute on Aging and the Alzheimer’s Association workgroup. Alzheimers Dement 2011;7:280–292.

(2) Criteria for Preclinical Alzheimer’s Disease. Preclinical Alzheimer’s Disease Workgroup – June 2, 2010

(3) Cordell CB, et al. Alzheimer’s Association recommendation for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting. Alzheimers Dement. 2013 Mar;9(2):141-50.

(4) Molinuevo JL et al. The clinical use of cerebrospinal fluid biomarker testing for Alzheimer’s disease diagnosis: A consensus paper from the Alzheimer’s Biomarkers Standardization Initiative. Alzheimers Dement 2014 Nov;10(6):808-17.

(5) Cohen AD, Klunk WE. Early Detection of Alzheimer’s disease using PIB and PDG PET. Neurobiol Dis 2014 Dec;72 Pt A:117-122.

(6) Vlassenko AG et al. PET amyloid-beta imaging in preclinical Alzheimer’s disease. Biochim biophys Acta 2012 Mar;1822(3):370-9.

(7) Jack CR et al. Prediction of AD with MRI-based hippocampal volume in mild cognitive impairment. Neurology 1999 April 22;52(7):1397-1403.

(8) Bocchetta M, et al. The use of biomarkers for the etiologic diagnosis of MCI in Europe: An EADC survey. Alzheimers Dement 2015 Feb;11(2):195-206.

(9) Lin JS, et al. Screening for Cognitive Impairment in Older Adults: An Evidence Update for the U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality (US); 2013 Nov. Report No.: 14

(10) Karlawish J. Addressing the ethical, policy and social challenge of preclinical Alzheimer’s disease. Neurology 2011 Oct 11;77(15):1487–93.

(11) Antoine P, et al. Emotional and Psychological implication of early AD diagnosis. Med Clin North Am. 2013 May;97(3):459-75.


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(12) Screening for Dementia: Can screening bring benefit to those with unrecognized dementia, their carers and society? An Appraisal against UKNSC criteria. Solutions for Public Health 2014 Oct.

(13) UK NSC dementia screening recommendation 2015 Jan. UK National Screening committee.

(14) David G, et al. Political drive to screen for pre-dementia: not evidence based and ignores the harms of diagnosis. BMJ. 2013 Sep 9;347:f5125

(15) Moyer VA, et al. Screen ing for Cognitive Impairment in Older Adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2014 Jun 3;160(11):791-7

Answers to August 2015

Spotlight 1 – An Update on Pharmacotherapies of Post-menopausal Osteoporosis1.F 2.T 3.F 4.F 5.T 6.F 7.T 8.T 9.F 10.F

Spotlight 2 – Update on management of uterine fibroids1.F 2.T 3.F 4.F 5.T 6.T 7.F 8.F 9.T 10.T

Spotlight 3 – From haemodialysis to haemodiafiltration – a step closer to a physiological kidney1.T 2.T 3.F 4.F 5.T 6.T 7.F 8.T 9.T 10.T

Answer these on page 20 or make an online submission at: www.hkmacme.org

Please indicate whether the following statements are true or false.

1. It is impossible to diagnose Alzheimer’s disease before memory deficit.2. There is treatment to arrest the progression of Dementia.3. Alzheimer’s disease and vascular dementia are two different diseases with different presentation and different

rate of progression.4. PIB scan is superior to PET FDG scan in diagnosis of Alzheimer’s disease.5. PIB scan is the first investigation showing the possibility of preclinical Alzheimer’s disease.6. CT scan of brain is useful in diagnosis of preclinical Alzheimer’s disease.7. Early diagnosis of preclinical Alzheimer’s disease is beneficial to the patients.8. Patient with diagnosis of preclinical Alzheimer’s disease is still mentally capacitated.9. Clinical investigations for preclinical Alzheimer’s disease are widely done in USA.10. MRI brain is a must for the diagnosis of Alzheimer’s disease.

Q&A Self-assessment Questions:

Complete thiscourse and earn1 CME Point

HKMA CME BulletinMonthly Self-Study Series

Call for ArticlesSince 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.

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6 HKMA CME Bulletin 持續醫學進修專訊 September 2015www.hkmacme.org

Review and update on management of Rosacea (I)INTRODUCTION

Rosacea is a common chronic inf lammatory skin

d isorder , a f fec t ing the cheeks, ch in , nose and

sometimes the forehead. It can manifest as different

cutaneous signs such as erythema, telangiectasias,

papules, pustules, ocular lesions and rhinophyma. For

those rosacea patients with ocular involvement, it can

manifest as dryness, irritation, blepharitis, conjunctivitis

and keratitis. Rosacea is more prevalent in women

than in men. However, men are more likely to develop

phymatous changes in rosacea.1,2 Rosacea are more

likely to occur in patients with fair skin people than dark

skin people. Studies have shown that the prevalence of

rosacea in the United States was around 5% affecting

around 13 – 14 million people.3,4 Patients are often

diagnosed during 30 to 50 years of age.

The exact pathogenesis of rosacea remains unknown.

Several pathogenesis have been postulated, for

example for vascular abnormalit ies, dermal matrix

degeneration, microorganisms, environmental factors,

etc. There are a number of triggering factors that can

worsen rosacea, for example heat, alcohol, certain

food, sunlight, stress etc.5 It can be challenging in

distinguishing rosacea with other skin diseases as

they may present as similar signs and symptoms, like

flushing, papules and pustules. Differential diagnoses

of rosacea include acne vulgaris, seborrhoic dermatitis,

perioral dermatitis, etc. (Figure 1).

Dr. CHAN Hau Ngai, KingsleyMBBS (HK), MRCP (UK), Dip Derm (Glasg), FHKCP,

FHKAM (Medicine), FRCP (Glasg), FRCP (Edin),

Specialist in Dermatology & Venereology

CLASSIFICATION OF ROSACEAThe initially used classification of rosacea was to define

the disease into pre-rosacea and three different stages

(I – III) (Table 1) as the disease usually progresses from

one stage to another. In 2002 the National Rosacea

Society proposed a new classification system based on

the predominant signs and accompanying symptoms.6

This new system def ines rosacea into four major

subtypes – erythematotelangiectatic, papulopustular,

phymatous and ocular – rather than stages (Table 1 and

Figure 2).

Stage ClassificationStages Symptoms

Subtype ClassificationStages Symptoms

Pre-rosacea Transient erythema Intermittent blushingSkin easily irritable

Pre-rosacea not defined as separate subtype

Stage IRosacea erythematosateleangiectatica

Persistent erythema Telangiectasia of different severityStinging, burning, and itching

Subtype 1Erythematotelangiectatic

Flushing Central erythema TelangiectasiaStinging, burning, roughness, scaling may be present.

Stage IIRosacea papulopustulosa

Inflamed erythematous papules and pustulesCentrofacial erythemaTelangiectasia of different severity

Subtype 2Papulo-pustular

Persistent central facial erythema Papules, pustulesTelangiectasia may be present

Stage IIIGlandular,hyperplastic rosacea

Large inflammatory nodules and plaquesTissue and sebaceous gland hyperplasia (phymas)

Subtype 3Phymatous

Thickened, coarse skin Enlarged poresTissue hyperplasiaNodules

Ocular rosacea not defined as separate stage Ocular manifestations occur independent of the stage of rosacea.

Subtype 4Ocular

Burning, stinging, dryness Foreign-body sensationEye photosensitivityTelangiectasia of conjunctiva possible

Figure 1. Rosacea with main involvement over nose. It can mimic clinical features of acne vulgaris and perioral dermatitis.

Figure 2. Different subtypes of Rosacea

Table 1. Classification of rosacea

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TREATMENT OF ROSACEAAlthough rosacea is not a curable disease, the aims of the treatment are (1) to alleviate signs and symptoms such as redness or irritation, (2) to delay or prevent development of more advanced stages (3) to sustain disease in remission and (4) to improve quality of life. The treatment modalities depend mainly on the severity and stage of the rosacea (Figure 3). In this article, we focus mainly on the medical treatment of rosacea, and will discuss more on the laser treatment of rosacea in a later issue.

Episodicerythema(flushing)

Persistenterythemawith or withouttelangiectasia

Papules and pustules

Nodules and Plaques

Ocular Phymas Oedema

Adjunct measures: sunscreens (SPF ≥15) , camouflage (eg. green tint), cooling, avoid irritants, avoid lifestyle and environmental triggers

Exploratory:• Oxymetazoline• Nadolone ?• Clonidine ?

Topical therapy Oral therapy Massage

Azelaic acidSulfacetamideDiet

Azelaic acid,MetronidazoleSulfacetamide-sulfurTopical clindamycinTopical retinoids

Combined topical(eg azelaic acid) &nonantibiotic dosedoxycycline (40 mg/d)

Oral antibiotics (high dosetetracyclines, macrolides) Oral isotretinoin(0.5-1.0 mg/kg/d)Intralesionalcorticosteroids

For telangiectasia:• Laser• Electrosurgery

Add short termoral antibiotics(tetracyclines, masrolides)

Severe cases: initialhigh dose antibioticsLow dose oralisotretinoin (10 mg/d)

Combine with topicals azelaic acid metronidazole, topical antibiotice topical retinoids

Refer toophtalmologist

Topical and oralantibiotics

LaserSurgeryDermabrasion

Oral isotretinoin

Figure 3. Treatment algorithm based on the signs and symptoms of rosacea. Eleeski BE, Draelos Z, B Dreno, et al Rosacea – global diversity and optimized outcome: proposed International consensus from the Rosacea International Expert Group. J Eur Acad Dermatol Venereol 2011, 25, 188-200.

TOPICAL TREATMENT

Topical metronidazoleMetronidazole is an imidazole antibiotic which acts by inhibiting the generation of reactive oxygen species and other anti-inflammatory actions. It has shown to be effective for the treatment of moderate-to-severe rosacea. It helps to reduce papules and pustules, but not effective against telangiectasia.7,8 Reviews have shown that topical metronidazole reduced inflammatory lesion count by 48 – 65% and reductions in burning, stinging and dryness associated with rosacea.9,10 It is generally well tolerated except those preparations containing alcohol which may be irritating.

Topical azelaic acidAze l a i c ac id i s a d i ca rboxy l i c ac id wh i ch has antimicrobial, anti-inflammatory, and antikeratinizing properties. It is believed that its anti-inflammatory effect by reducing pro-inflammatory reactive oxygen species that helps rosacea.11 Double-blind randomized controlled studies had demonstrated that efficacy of azelaic acid in treating the papulopustular lesions and erythema of rosacea.12 It may cause local skin irritations, such as stinging and pruritus.12

Topical clindamycinClindamycin is a semi-synthetic antibiotic that can be available as topical solution, lotion or gel to treat pustular lesions of rosacea. Apart from treating inflammatory les ions, randomized cont ro l led t r ia l has shown clindamycin to be effective in treating erythema.13

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Topical brimonidineTopical brimonidine is latest topical treatment for rosacea. It is a selective alpha-2 adrenergic agonist and helps to reduce erythema of rosacea by constricting the dilated blood vessels. It is the first FDA-approved topical treatment specifically indicated for facial erythema in rosacea.14,15 It is applied once daily and its effects can last up to 12 hours. The possible adverse reactions included erythema, flushing and tingling sensation.

ORAL TREATMENTS

TetracyclinesTetracycline is effective to treat the papulo-pustular lesions of rosacea by modulate the inf lammatory response through down-regulating the production of pro-inflammatory cytokines such as IL-1 and TNF-a and the production of reactive oxygen species. Repeated courses of tetracycline have shown to achieve remission 3 to 6 months after stopping treatment.16-18 Doxycycline has also shown to be effective by randomized, double-blind, placebo-controlled trial in treating rosacea.19 It can cause gastric upset and has the possibility of developing antibiotic resistance in long term use and should be avoided in pregnancy.

Oral isotretinoinOral isotretinoin is effective in treating rosacea by its anti-inflammatory effect. Although it avoids the risk of antibiotic resistance in long term, it has potential serious side-effects including deranged l iver function and cholesterol level. It should also be avoided in pregnancy because of its potential tetratogenic effect. Studies have suggested that lower dosage -0.1–0.3 mg⁄kg⁄day of oral isotretinoin was the optimal dosage for treating rosacea.20

Skin careApart from using topical or oral treatment, patients are advised to have good skin care for better control of rosacea. Patients should avoid using irritating soaps or cleansers, be advised to use sunscreens or sunblocks regularly to protect against damage by UVB ⁄ UVA radiation, and use of non-irritating concealing cosmetics to camouflage erythema. Environmental and lifestyle triggers include heat, exercise, alcohol, sunlight, certain medications or foods should also be minimized or

avoided. In cases of heat-induced flushing, cooling with ice or cold towel may be beneficial.

CONCLUSION

In summary, rosacea is a common chron ic sk in disease af fect ing the face. Proper skin care and avoidance of possible triggers play an important role in management of rosacea. Although it is not curable, topical and systemic treatments are able to alleviate signs and symptoms of rosacea and to delay or prevent worsening of it. In our next issue, we will focus on the psychological and social impact of rosacea and other new advancement in the treatments of rosacea.

References

1. Powell FC. Rosacea. N Engl J Med 2005; 352: 793–803.

2. Berg M, Liden S. An epidemiological study of rosacea. Acta Derm

Venereol 1989; 69: 419–423.

3. Bamford JTM. Rosacea: current thoughts on origin. Semin Cutan Med

Surg 2001; 20: 199–206.

4. Zuber TJ. Rosacea. Prim Care 2000; 27: 309–318.

5. Kligman AM. A personal critique on the state of knowledge of rosacea.

Dermatology 2004; 208: 191–197.

6. Wilkin J, Dahl M, Detmar M et al. Standard classification of rosacea: report

of the National Rosacea Society Expert Committee on the Classification

and Staging of Rosacea. J Am Acad Dermatol 2002; 46: 584–587.

7. Schmadel LK, McEvoy GK. Topical metronidazole: a new therapy for

rosacea. Clin Pharm 1990; 9: 94–101.

8. McClellan KJ, Noble S. Topical metronidazole. A review of its use in

rosacea. Am J Clin Dermatol 2000; 1: 191–199.

9. Del Rosso JQ. Cutaneous tolerability of metronidazole topical gel 0.75%

for rosacea. Cos Dermatol 2005; 18: 559–562.

10. Del Rosso JQ. A status report on medical management of rosacea: focus

on topical therapies. Cutis 2002; 70: 271–275.

11. Del Rosso JQ, Baum EW, Draelos ZD et al. Azelaic acid gel 15%: clinical

versatility in the treatment of rosacea. Cutis 2006; 78(5 Suppl.): 6–19.

12. Thiboutot D, Thieroff-Ekerdt R, Graupe K. Efficacy and safety of azelaic

acid (15%) gel as a new treatment for papulopustular rosacea: results from

two vehicle-controlled, randomised phase III studies. J Am Acad Dermatol

2003; 48: 836–845.

13. Breneman D, Savin R, VandePol C et al. Double-blind, randomized,

vehicle-controlled clinical trial of once daily benzoyl peroxide/clindamycin

topical gel in the treatment of patients with moderate to severe rosacea. Int

J Dermatol 2004; 43: 381–387.

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1. Rosacea is a common systemic disorder.

2. Rosacea is more prevalent in men.

3. Rosacea can present in papules and pustules.

4. Heat, alcohol and sunlight can worsen rosacea.

5. Topical medication is not effective to treat rosacea.

6. Topical metronidazole is effective in treating telangectisia.

7. Topica l br imonid ine is the o ldest topica l treatment for rosacea.

8. Topical brimonidine is the first FDA-approved topical treatment indicated for facial erythema in rosacea.

9. Oral tetracycline can be used to treat the papulo-pustular lesions of rosacea.

10. Skin care is not important in the management of rosacea.



14. Fowler J et al. Efficacy and Safety of Once-Daily Topical Brimonidine

Tartrate Gel 0.5% for the Treatment of Moderate to Severe Facial

Erythema of Rosacea: Results of Two Randomized, Double-Blind,

Vehicle-Controlled Pivotal Studies. Journal of Drugs in Dermatology. 2013;

12:650-656.

15. Fowler J, Jarratt M, Moore A, Meadows K, Pollack A, Steinhoff M,

Liu Y, Leoni M; Brimonidine Phase II Study Group. Once-daily topical

brimonidine tartrate gel 0·5% is a novel treatment for moderate to severe

facial erythema of rosacea: results of two multicentre, randomized and

vehicle-controlled studies. Br J Dermatol. 2012 Mar; 166(3): 633-41.

16. Sneddon I. A clinical trial of tetracycline in rosacea. Br J Dermatol 1966;

78: 649–653.

17. Marks R., Ellis J. Comparative effectiveness of tetracycline and ampicillin in

rosacea. Lancet 1971; 2: 1049–1052.

18. Bartholomew RS, Reid BJ, Cheesebrough MJ, MacDonald M, Galloway

NR. Oxytetracycline in the treatment of ocular rosacea: a double-blind trial.

Br J Ophthalmol 1982; 66: 386–388.

19. Del Rosso JQ, Webster GF, Jackson M et al. Two randomized phase

III clinical trials evaluating anti-inflammatory dose doxycycline (40-mg

doxycycline, USP capsules) administered once daily for treatment of

rosacea. J Am Acad Dermatol 2007; 56: 791–802.

20. Hofer T. Continuous ‘microdose’ isotretinoin in adult recalcitrant rosacea.

Clin Exp Dermatol 2004; 29: 204–205.

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。


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An update on the treatment and prevention of age related maculardegenerationBACKGROUND

Age-related macular degeneration (AMD) is one of the leading causes of blindness in the developed world.1-4 It usually affects people aged 50 and up. Up to 11.5% of the population in the United States is affected.3 Although there are no precise data for the population in Hong Kong, the impact from AMD will only increase as the problem of aging population sets in.4 Whilst scientists are still investigating the exact pathogenesis of AMD,5 some evidences suggested that it maybe related to oxidative stress.6,7 When it occurs, AMD can take the form of either ‘dry’ or ‘wet’. ‘Dry’ refers to geographical atrophy (GA) of the central macular, where there is accelerated atrophy without exudation or hemorrhage (Figure 1). ‘Wet’ refers to neovascular AMD (nAMD), which is characterized by neovascular membrane format ion in the choro id , subret ina l exudat ion, hemorrhage (Figure 2), and eventually disciform scar formation (Figure 3). An updated classification system of AMD is presented in Table 1.8,9

Symptoms of AMD include reduction and distortion of central vision. In early cases the patient would still be

able to see although central vision is affected. However, in advanced cases, the central visual defect will worsen and will eventually become an absolute visual field defect (scotoma) in the center. This would render reading and other daily activities using the central visual field very difficult. Progression in dry AMD is slower, while that in wet AMD can be more dramatic. Diagnosis is based on history, and a detailed examination of the macula. Fundus fluorescein angiogram (FFA) and optical coherence tomography (OCT) scan of the macula are often performed to aid diagnosis. OCT can also be performed serially to monitor response before and after treatment.

For dry AMD, no effective treatment has yet been found.10,11 On the contrary, there have been promising new treatments developed for wet AMD in recent years since the emergence of anti-vascular endothelial growth factors (Anti-VEGF).12,13 Although effective when given timely, there is stil l ongoing debate as to the cost-effectiveness, dosing regimen, as well as the choice of agent across different health systems.14-18 Drug cost of anti-VEGFs is still a problem for many societies including Hong Kong, where many patients stil l have to self-finance the drug.

In view of the situation for both types of AMD, effective preventive measures are perhaps as important as the development of effective treatment itself.4 Furthermore,

from an economical point of view, preventive measures may be more ef fect ive in saving healthcare cost in the long run. Over the years, m u c h e f f o r t h a v e b e e n spent in identifying effective p r e v e n t i v e m e a s u r e s , t h e s e i n c l u d e t a k i n g nut r i t iona l supp lements , l i f e s t y l e m o d i f i c a t i o n , filtering sunlight, etc. In this

Dr. WONG Yat Hin, IanMBBS, M.Med (Ophth, Singapore), FRCSEd, FRCOphth, FCOphthHK, FHKAM (Ophthalmology), Specialist in OphthalmologyClinical Assistant Professor, Department of Ophthalmology, HKU

Figure 1. Picture of the right macula, showing large oval area of geographical atrophy in the center, representing dry AMD.

Figure 2. Picture of the right macula, showing hemorrhage (red), exudates (white) in the central macula, representing neovascular AMD.

Figure 3. Picture of the left macula, showing dense whitish fibrous tissue in the center of the macula, representing advanced scarring of the macular due to wet AMD.


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article, we will first discuss the current opinions on the prevention of AMD. We will also discuss the most updated treatment strategies for nAMD with a local perspective.

PREVENTIVE MEASURES

Preventive measures can be broadly divided into: 1) Nutritional supplements, and 2) Life style modification.

Nutritional Supplements

AREDS-2 or similar formulas

The Age-Related Eye Disease Study (AREDS) was a large-scale prospective study concluded in 2001, to investigate the effect of an active supplement to the development of advanced AMD.19 The formula contained higher-than-normal doses of Vitamin A, C, E, and zinc. Results showed a 25% reduction in risk of progression to advanced AMD if recommended doses of the ingredients were taken on a daily basis, for high risk individuals only (i.e. Category 3 & 4 subjects in Table 1). For other individuals, the benefit was not significant when compared to tak ing p lacebos.19 However, subsequent reports have found that in those who smoke, the risk of having lung cancer was increased due to the presence of beta-carotene (a precursor to Vitamin A),20 a later revised version of the formula was tested in a more recent trial, the Age-Related Eye Disease Study-2 (AREDS2).9 The newer AREDS2 formula removed beta-carotene, and added in lutein, zeaxanthin, omega-3 fatty acids, in hope to enhance the protective effect against AMD progression, and reducing the risk of lung cancer among smokers.8

The results of AREDS2, published in 2013, have failed to demonstrate any additional benefit in the risk reduction by adding in lutein, zeaxanthin, and omega-3 fatty acids.8 Nevertheless, the removal of beta-carotene made this formula probably safer for smokers or ex-smokers, although in the trial the numbers of actual lung cancers were too small to draw such a conclusion.

A point worth mentioning is that the result of 25% risk reduction in high risk individuals, i.e. Category 3 or 4

subjects in Table 1, are only applicable should they take this on a daily basis. Whether this result can be generalized to all subjects, i.e. including those with normal fundus findings, is not certain. Whether taking it intermittently would influence on the outcome or not, is still unknown.4 In addition, the risks of taking these supplements other than lung cancer include reversible yellow discoloration of the skin, genitourinary symptoms, and increased self-reported anemia.19 Therefore, this has to be mentioned when counseling our patients.

In general, this formula is relatively safe, and has been adopted by many manufacturers. It has been modified into many over-the-counter supplements in the market. Some variat ions of i t may not repl icate the exact dosage. Please refer to Table 2 for a detailed list of the ingredients and recommended dosage.

A balanced diet

Other than actively taking supplements to enrich anti-oxidant levels within our body, some have suggested that a balanced diet would probably be sufficient to cater for this need. In the Rotterdam Study, the effect of a vitamin and mineral enriched diet was investigated in relation to the progression of AMD.21 It was noted that for those who had above-median intake of vitamin C, E, beta-carotene, and zinc, had a striking 35% reduction in risk of incident AMD.21 Although this was based upon a European diet, this already gave us an idea that a well-balanced diet would have provided us sufficient anti-oxidants to battle against AMD. When compared to the 25% risk reduction in high-risk groups from taking the AREDS2 formula, this may actually be more attractive, since there is no additional effort required other than taking a balanced diet. Again, this proves the importance of recommending a balanced diet to our patients in light of prevention of AMD.

Berry extracts

It is not diff icult to f ind advertisements promoting products containing berry extracts of various kinds claiming to have protective effects on the eye. Of these, probably the most well known are blueberry and wolfberry.


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As far as the eyes are concerned, anthocyanin is the active anti-oxidant content that is being sought after in these berry extracts. It is able to absorb blue-green light, and protect cells from light stress.22 Other than this, it was found to be able to reduce risk of AMD.23-25 Others also claimed that it has anti-angiogenic and anti-cancer abilities.26,27 However, up to this date, the evidences on this aspect is still at a very preliminary stage, and at most, confined to the laboratory. The exact dosage and form still has to be defined and investigated. In addition, potential side effects from taking too much berry extracts are to be elicited. For instance, whether patients with diabetes can take this regularly has to be found out. Therefore, from an evidence based point of view, berry extracts for the prevention of AMD may not be justified at this moment.4

Lifestyle Modifications

Smoking

Smoking cessation is the most established causative factor for AMD. It was reported to be associated with the increased oxidative stress, platelet aggregation, higher fibrinogen level, and a reduced plasma high-density lipoprotein and anti-oxidant levels.28,29 It has been reported that for smokers of 10 pack-years or more, the odds ratio for development of advanced AMD was 1.55.30 In another study on twins, current smokers have a 1.9-fold increased risk of having AMD. Even ex-smokers have a 1.7-fold increased.31

Furthermore, if smokers take supplements containing beta-carotene, in hope to reduce the risk of AMD, they will be subjected to increased risk of lung cancer. Hence, this is another reason to encourage smokers to stop smoking.

Weight reduction

A higher risk of the dry type of AMD, geographical atrophy, has been reported to be associated with higher body-mass-index (BMI).1,32 An odds ratio of 1.93 was reported in obese subjects with BMI ≥30 kg/m2.1 In another study, those with BMI ≥30 kg/m2, the relative risk was 2.35. For those with a BMI of 25 to 29 kg/m2, the relative risk was found to be 2.32.32 Appropriate weight reduction should BMI be over the desired range is in general advisable. With the current evidence, it adds more reasons to advise accordingly.

TREATMENT

As mentioned earlier, there is still no effective treatment for geograph ica l a t rophy, the dry type of AMD. Therefore, the mainstay of management currently for dry AMD remains in modification of risk factors in general,4 and supplementation of anti-oxidants for high-risk groups.

For wet AMD, the situation is different. Choroidal neovascularization is the hallmark of wet AMD. This is formed in the choroid, and this abnormal vascular membrane is susceptible to exudation, leakage, and hemorrhage underneath the retina. This would lead to eventual scarring and fibrosis. Central vision would be greatly affected, and the patient would be left with a central scotoma in the visual field, which would render daily activities such as reading and driving very difficult. This condition usually occurs at a faster pace then geographical atrophy, and if proper treatment is not commenced in time, irreversible changes will ensue, and vision would be beyond salvage. Fortunately, drastic advancements have been made in the past decade or so.

Direct focal laser

In the 80s and 90s, a series of trials have explored the possibility of using direct focal photocoagulation, i.e. laser, to damage the abnormal choroidal neovascular membrane (CNVM), in hope to limit the formation of scar and hence, save vision. The Macular Photocoagulation Study (MPS) was the first large randomized clinical trial in this regard. However, the effect of the direct focal laser not only damages the CNVM, but also the assoc iated normal re t ina l t i ssue. There fore patients would rarely be able to see ‘better’ after treatment. However, due to the limited technology and understanding of the disease at that time, this was the only option available, for quite some time. This type of direct laser is seldom used nowadays unless for pathologies outside the center of the macula. In the 90s, transpupillary thermal therapy (TTT) has been advocated for the treatment of the CNVM. However, as with the use of direct focal laser, the outcome was not satisfying, hence its use did not become widespread.


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Photodynamic therapy

In the early 2000s, the use of photodynamic therapy (PDT) for wet AMD became popular. This util izes a photosensitive drug, verteporfin. After being infused intravenously, the target area would be treated with a special laser, such that the drug is photosensitized to produce its effect. In the Treatment of Age-related Macular Degeneration with Photodynamic Therapy Study (TAP study), and the Verteporfin in Photodynamic Therapy (VIP study), its efficacy was being investigated thoroughly. When compared to direct focal laser, PDT seemed to be able to stop vision from deteriorating, and was able to stab i l i ze v is ion i f done in t ime. Although long-term results showed that vision would still reduce a bit before stabilizing, when compared to the absolute scotoma created by direct focal laser, it was already an improved treatment option. However, there were still no ways to restore vision once wet AMD has occurred. PDT is still being used nowadays, but seldom as monotherapy. More often, it is being used in combination with intravitreal injections.

Anti-vascular endothelial growth factors

In 2005, i t was d iscovered that bevacizumab, a kind of anti-vascular endothelial growth factor (anti-VEGF) labeled for use in colorectal cancer, was able to produce stable vision in a patient with wet AMD when given intravitreal ly.33 In two pivotal studies using ranibizumab (another anti-VEGF agent), namely MARINA and ANCHOR, it was further ascertained that intravitreal injections were able to improve vision.34,35 This was a revolutionary new treatment option since after treatment, vision improved and remained stable as long as repeated injections were given on a monthly basis.34,35 In some patients, vision actually improved after treatment. This quickly became the treatment of choice and gold standard of care worldwide. Ranibizumab was first introduced into the local market around 2007, and was made available to both private and public patients.

In the protocol of the MARINA and ANCHOR trials, monthly injections of ranibizumab for 24 months was required to sustain the results. Although effective, repeated intravitreal injection has potential risks. These include infection, retinal detachments, lens damage, vitreous hemorrhage. When absorbed into the body, there may be increased risk of thromboembolic events. The risk of stroke was 2.5% among the 239 cases treated with 0.5mg ranibizumab (standard dose) in

the MARINA trial, but the control group (N=236) also had 0.8% risk.35 In the same trial, those given 0.5mg ranibizumab had an incidence of 1.3% for myocardial infarction, while that for the control group was 1.7%.35 Similar risks of adverse events were found to be similar for different anti-EVGF agents.13 Cost was also a major concern as no reimbursement system was available from the government. Since then, many trials have looked into the possibility of using various treatment protocols to achieve the best eff icacy, and cost-effectiveness. One of the most popular protocols would be to give an initial 3 monthly loading injections, followed by monthly follow-ups and PRN re-injection.36 This would lower the cost, and reduce the risks from reduced number of injections. This became more popular, and quickly became the routine for new wet AMD cases.

I n Hong Kong , t he re a re cu r r en t l y t h ree an t i -VEGF agents being used for this disease, namely bevacizumab, ranibizumab, and aflibercept, both in the public and the private sector. These agents were well studied in relation to their efficacy and safety profiles, and were proven to be effective against wet AMD.13,37,38 The choice of drug to be used will largely depend on the attending ophthalmologist’s judgment, and the patient’s informed decision. A point to note is that bevacizumab is currently not available for use in the Hospital Authority.

Current injection protocol and technique

Currently the most common treatment protocol after diagnosis of wet AMD is 3 monthly loading intravitreal injections, followed by regular follow-ups later, usually at an interval of 1 to 2 months, and PRN injection should re-treatment criteria being met. Re-treatment criteria include 1) recent drop in vision, 2) new subretinal hemorrhage, 3) presence of new or persistence of subretinal f luid on optical coherence tomography (OCT) scan. The injection itself can usually be done under topical or local anesthesia, in the theatre or in a sterile treatment room under strict aseptic technique. The injection is done through a 30-gauge needle, at a distance around 3.5mm to 4mm behind the limbus (junction between the cornea and the sclera), usually at the temporal quadrants. As the injection volume is only 0.05ml (same for all 3 anti-VEGF agents), usually no paracentesis is required. After the injection, disc perfusion is checked and the patient is discharged with a course of 5 to 7 days topical antibiotic to be used at home.


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Nutrient AREDS29 DRI41 Orange# Apple# Blueberry# Banana# Mango# Strawberry# Watermelon# Units

Vitamin A@ 0 3000 225 54 22 64 765 18 569 International Unit (IU)

Vitamin C 500 90 53.2 4.6 0.7 8.7 27.7 13.7 8.1 Milligram (mg)

Vitamin E 400 15 0.1 0.18 0.23 0.10 1.12 0.1 0.05 mg

Zinc 80 or 25 11 0.07 0.04 0.1 0.15 0.04 0.06 0.1 mg

Lutein/Zeaxanthin

10000/2000 Not a/v 129 29 33 22 0 9 8 Microgram(mcg)

@ Vitamin A as beta-carotene* Dietary Reference Intakes from the United States Department of Agriculture# Nutrient contents of common fruit items are measured per 100 grams99

Table 2. Dosages of the Age-Related Eye Disease Study 2 (AREDS2) type formulas in comparison to common fruit items.

LONG-TERM OUTCOMES AND CONCLUSION

7 years after the initial MARINA and ANCHOR trials, almost half of the subjects achieved stable vision, and about a third of the subjects had declined vision, when compared with baseline.39 This ascertained the value of treatment of this disease with anti-VEGF injections. However, at the same time, this reminded us despite treatment, patients are still at risk of deterioration. Again, this highlights the importance of prevention.

KEY LESSIONS

1. Age-related Macular Degeneration (AMD) can be grossly divided into dry and wet types. Dry type refers to geographical atrophy, while wet type refers to neovascularization formation.

2. Advanced AMD can cause central visual field defect, making reading and other activities using the central visual field difficult, severely disabling the patient.

3. There is current ly no ef fect ive treatment for dry AMD. Mainstay of management is preventive measures and dietary supplementation.

4. There is effective treatment against wet AMD, in the form of anti-vascular endothelial growth factor injections directly into the vitreous. If given early, can suppress disease activity and improve vision.

Category Brief description

Clinical features Visual acuity

Category 1

Free of AMD in both eyes

< 5 small drusen in one or both eyes.

20/32 or better in both eyes

Category 2

Mild to borderline AMD in one or both eyes

Multiple small or intermediate drusen in one or both eyes.Pigment abnormalities in one or both eyes.

20/32 or better in both eyes

Category 3

Absence of Advanced AMD in both eyes

Intermediate or large drusen.Geographical atrophy.Features not involving central macular.

20/32 or better in better eye

Category 4

Advanced AMD in one eye

Advanced AMD or geographical atrophy in worse eye.No such features in better eye.

20/32 or better in better eye

Key:• Smalldrusen–<63µmindiameter(discdiameteraround

1500µm).• Intermediatedrusen–63to124µmindiameter.• Largedrusen–>125µmindiameter.• Pigmentabnormalitiesrefertoeitherhyperpigmentationor

depigmentation.Table 1. Categorization of Age-Related Macular Degeneration (AMD) according to the Are-Related Eye Disease Study (AREDS) guidelines.40

REFERENCES

1. Evans J, Wormald R. Is the incidence of registrable age-related macular degeneration increasing? The British journal of ophthalmology. 1996; 80(1): 9-14.

2. VanNewkirk MR, Weih L, McCarty CA, Taylor HR. Cause-specific prevalence of bilateral visual impairment in Victoria, Australia: the Visual Impairment Project. Ophthalmology. 2001; 108(5): 960-967.

3. Friedman DS, O’Colmain BJ, Munoz B, et al. Prevalence of age-related macular degeneration in the United States. Archives of ophthalmology. 2004; 122(4): 564-572.

4. Wong IY, Koo SC, Chan CW. Prevention of age-related macular degeneration. International ophthalmology. 2011; 31(1): 73-82.

5. Bressler NM. Age related macular degeneration. New hope for a common problem comes from photodynamic therapy. Bmj. 2000; 321(7274): 1425-1427.

6. Zarbin MA. Current concepts in the pathogenesis of age-related macular degeneration. Archives of ophthalmology. 2004; 122(4): 598-614.

7. Beatty S, Koh H, Phil M, Henson D, Boulton M. The role of oxidative stress in the pathogenesis of age-related macular degeneration. Survey of ophthalmology. 2000; 45(2): 115-134.

8. Age-Related Eye Disease Study 2 Research G. Lutein + zeaxanthin and omega-3 fatty acids for age-related macular degeneration: the Age-Related Eye Disease Study 2 (AREDS2) randomized clinical trial. Jama. 2013; 309(19): 2005-2015.

9. Group AR, Chew EY, Clemons T, et al. The Age-Related Eye Disease Study 2 (AREDS2): study design and baseline characteristics (AREDS2 report number 1). Ophthalmology. 2012; 119(11): 2282-2289.

10. Querques G, Rosenfeld PJ, Cavallero E, et al. Treatment of dry age-related macular degeneration. Ophthalmic research. 2014; 52(3): 107-115.

11. Damico FM, Gasparin F, Scolari MR, Pedral LS, Takahashi BS. New approaches and potential treatments for dry age-related macular degeneration. Arquivos brasileiros de oftalmologia. 2012; 75(1): 71-76.


SPOTlight -3

12. Group CR, Martin DF, Maguire MG, et al. Ranibizumab and bevacizumab for neovascular age-related macular degeneration. The New England journal of medicine. 2011; 364(20): 1897-1908.

13. Investigators IS, Chakravarthy U, Harding SP, et al. Ranibizumab versus bevacizumab to treat neovascular age-related macular degeneration: one-year findings from the IVAN randomized trial. Ophthalmology. 2012; 119(7): 1399-1411.

14. Stein JD, Newman-Casey PA, Mrinalini T, Lee PP, Hutton DW. Cost-effectiveness of bevacizumab and ranibizumab for newly diagnosed neovascular macular degeneration (an American Ophthalmological Society thesis). Transactions of the American Ophthalmological Society. 2013; 111: 56-69.

15. Stein JD, Newman-Casey PA, Mrinalini T, Lee PP, Hutton DW. Cost-effectiveness of bevacizumab and ranibizumab for newly diagnosed neovascular macular degeneration. Ophthalmology. 2014; 121(4): 936-945.

16. Dakin HA, Wordsworth S, Rogers CA, et al. Cost-effectiveness of ranibizumab and bevacizumab for age-related macular degeneration: 2-year findings from the IVAN randomised trial. BMJ open. 2014; 4(7): e005094.

17. Formoso G, Marata AM, Magrini N, Bero L. A clearer view of evidence in treating macular degeneration: off-label policies and independent research. The Cochrane database of systematic reviews. 2014; 9: ED000090.

18. Hutton D, Newman-Casey PA, Tavag M, Zacks D, Stein J. Switching to less expensive blindness drug could save medicare part B $18 billion over a ten-year period. Health affairs. 2014; 33(6): 931-939.

19. Age-Related Eye Disease Study Research G. A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no. 8. Archives of ophthalmology. 2001; 119(10): 1417-1436.

20. Albanes D, Heinonen OP, Huttunen JK, et al. Effects of alpha-tocopherol and beta-carotene supplements on cancer incidence in the Alpha-Tocopherol Beta-Carotene Cancer Prevention Study. The American journal of clinical nutrition. 1995; 62(6 Suppl): 1427S-1430S.

21. Van Leeuwen R, Boekhoorn S, Vingerling JR, et al. Dietary intake of antioxidants and risk of age-related macular degeneration. Jama. 2005; 294(24): 3101-3107.

22. Liakopoulos G, Nikolopoulos D, Klouvatou A, Vekkos KA, Manetas Y, Karabourniotis G. The photoprotective role of epidermal anthocyanins and surface pubescence in young leaves of grapevine (Vitis vinifera). Annals of botany. 2006; 98(1): 257-265.

23. Bagchi D, Sen CK, Bagchi M, Atalay M. Anti-angiogenic, antioxidant, and anti-carcinogenic properties of a novel anthocyanin-rich berry extract formula. Biochemistry. Biokhimiia. 2004; 69(1): 75-80, 71 p preceding 75.

24. Sadilova E, Carle R, Stintzing FC. Thermal degradation of anthocyanins and its impact on color and in vitro antioxidant capacity. Molecular nutrition & food research. 2007; 51(12): 1461-1471.

25. Bagchi D, Roy S, Patel V, et al. Safety and whole-body antioxidant potential of a novel anthocyanin-rich formulation of edible berries. Molecular and cellular biochemistry. 2006; 281(1-2): 197-209.

26. Faria A, Oliveira J, Neves P, et al. Antioxidant properties of prepared blueberry (Vaccinium myrtillus) extracts. Journal of agricultural and food chemistry. 2005; 53(17): 6896-6902.

27. Lamy S, Blanchette M, Michaud-Levesque J, et al. Delphinidin, a dietary anthocyanidin, inhibits vascular endothelial growth factor receptor-2 phosphorylation. Carcinogenesis. 2006; 27(5): 989-996.

28. Roy S, Khanna S, Alessio HM, et al. Anti-angiogenic property of edible berries. Free radical research. 2002; 36(9): 1023-1031.

29. Tomany SC, Wang JJ, Van Leeuwen R, et al. Risk factors for incident age-related macular degeneration: pooled findings from 3 continents. Ophthalmology. 2004; 111(7): 1280-1287.

30. Clemons TE, Milton RC, Klein R, Seddon JM, Ferris FL, 3rd, Age-Related Eye Disease Study Research G. Risk factors for the incidence of Advanced Age-Related Macular Degeneration in the Age-Related Eye Disease Study (AREDS) AREDS report no. 19. Ophthalmology. 2005; 112(4): 533-539.

31. Seddon JM, George S, Rosner B. Cigarette smoking, fish consumption, omega-3 fatty acid intake, and associations with age-related macular degeneration: the US Twin Study of Age-Related Macular Degeneration. Archives of ophthalmology. 2006; 124(7): 995-1001.

32. Seddon JM, Cote J, Davis N, Rosner B. Progression of age-related macular degeneration: association with body mass index, waist circumference, and waist-hip ratio. Archives of ophthalmology. 2003; 121(6): 785-792.

33. Rosenfeld PJ, Moshfeghi AA, Puliafito CA. Optical coherence tomography findings after an intravitreal injection of bevacizumab (avastin) for neovascular age-related macular degeneration. Ophthalmic surgery, lasers & imaging: the official journal of the International Society for Imaging in the Eye. 2005; 36(4): 331-335.

34. Brown DM, Kaiser PK, Michels M, et al. Ranibizumab versus verteporfin for neovascular age-related macular degeneration. The New England journal of medicine. 2006; 355(14): 1432-1444.

35. Rosenfeld PJ, Brown DM, Heier JS, et al. Ranibizumab for neovascular age-related macular degeneration. The New England journal of medicine. 2006; 355(14): 1419-1431.

36. Lalwani GA, Rosenfeld PJ, Fung AE, et al. A variable-dosing regimen with intravitreal ranibizumab for neovascular age-related macular degeneration: year 2 of the PrONTO Study. American journal of ophthalmology. 2009; 148(1): 43-58 e41.

37. Comparison of Age-related Macular Degeneration Treatments Trials Research G, Martin DF, Maguire MG, et al. Ranibizumab and bevacizumab for treatment of neovascular age-related macular degeneration: two-year results. Ophthalmology. 2012; 119(7): 1388-1398.

38. Heier JS, Brown DM, Chong V, et al. Intravitreal aflibercept (VEGF trap-eye) in wet age-related macular degeneration. Ophthalmology. 2012; 119(12): 2537-2548.

39. Rofagha S, Bhisitkul RB, Boyer DS, Sadda SR, Zhang K, Group S-US. Seven-year outcomes in ranibizumab-treated patients in ANCHOR, MARINA, and HORIZON: a multicenter cohort study (SEVEN-UP). Ophthalmology. 2013; 120(11): 2292-2299.

40. Age-Related Eye Disease Study Research G. Risk factors associated with age-related macular degeneration. A case-control study in the age-related eye disease study: Age-Related Eye Disease Study Report Number 3. Ophthalmology. 2000; 107(12): 2224-2232.

41. United States Department of Agriculture NAL. Food Composition. http://fnic.nal.usda.gov/food-composition. Accessed 27 July 2015.



1. Age-related macular degeneration usually occurs in people aged 50 years and above.

2. Symptoms of Age-related Macular Degeneration include blurring of vision, and metamorphopsia.

3. Age-related Macular Degeneration can be grossly divided into the dry type, and the wet type.

4. In advanced cases, age-related macular degeneration affects mainly the peripheral retina.

5. Effective treatment has been found for the dry type of age-related macular degeneration.

6. Current first line treatment option for newly diagnosed wet age-related macular degeneration is direct focal photocoagulation to the lesion.

7. Risk of stomach cancer is raised in smokers who take the vitamin A supplements to prevent age-related macular degeneration.

8. Weight reduction, smoking cessation, and eating a healthy diet are measures to reduce the risk of developing age-related macular degeneration.

9. Injections of anti-vascular endothelial growth factors can be done directly into the vitreous to achieve best treatment outcomes in cases with wet age-related macular degeneration.

10. Anti-vascular endothelial growth factors, when injected directly into the vitreous, do not cause systemic side effects.




Cardiology

Complete BOTH Cardiology andDermatology courses and earn0.5 CME POINT

The content of the September Cardiology Series is provided by:Dr. WONG Chi Yuen MBBS, MRCP, FHKCP, FHKAM, Specialist in Cardiology

九月臨床心臟科個案研究之內容承蒙黃志遠醫生提供。

Stroke in a young lady

A 35-year-old lady with unremarkable past health was admitted to Neurology unit with sudden onset of left-sided weakness and slurred speech. A CT scan of brain on admission is shown in Figure 1.

1. What is the best description of the CT brain finding?

A. Large cerebral infarct involving a single vascular territory

B. Cerebral infarct involving multiple vascular territories

C. Intracerebral hemorrhage

D. Multiple cerebral mass lesions

E. Cerebral edema

2. The following investigations are appropriate EXCEPT

A. 24 hour Holter monitoring

B. Carotid Doppler ultrasound

C. Transthoracic Echocardiography

D. Transesophageal Echocardiography

E. Electroencephalography

Extensive investigations have been arranged for this lady, and most of which were unremarkable. Figure 2 shows a cardiac imaging study with images taken at end-systole (left) and end-diastole (right).

Q&A Please indicate one answer to each questionAnswer these on page 20 or make an online submission at: www.hkmacme.org

3. What physical sign could be expected on cardiac auscultation?A. Ejection systolic murmur at right upper

sternal borderB. Pansystolic murmur at left lower sternal

borderC. Mid-diastolic murmur at apexD. Continuous machinery murmur at left

upper sternal borderE. Early diastolic murmur along left sternal

border4. What is the most appropriate management

strategy for this patient?A. AspirinB. WarfarinC. Novel oral anticoagulantsD. AntibioticsE. Surgery

Figure 1


Cardiology

August AnswersAnswers:

1) E 2) A 3) C 4) B

Discussion:The in i t ia l ECG showed bradycardia with A-V dissocation. Therefore the diagnosis was third degree (complete) heart block. The use of AV nodal blockade agents and electrical disturbances should be excluded. In particular the QT interval (a measure of the time between the start of the Q wave and the end of the T wave) of this case was significantly prolonged. It measured around three and a half middle squares in the initial ECG (3.5 x 0.2 seconds = 0.7 seconds).

Definitions of normal QT interval vary from ≤ 0.4 seconds to ≤ 0.4 seconds.

T h e p a t i e n t t h e n l a p s e d i n t o T o r s a d e s d e Pointes due to prolonged QT interval. Long QT intervals predispose the pat ient to an R-on-T phenomenon, where the R wave representing ventricular depolarization occurs during the relative refractory per iod at the end of repolar izat ion (represented by the latter half of the T-wave). Drugs that increase patient’s tendency towards Torsades de Pointes should be withdrawn. The only effective treatments during the acute phase were administration of intravenous magnesium sulfate and transvenous temporary pacing wire insertion. Ventricular fibrillation might develop before successful transvenous cannulation for temporary pacing wire insertion. In such case patient requires electrical defibrillation, not synchronized electrical cardioversion.

In this case, the cause of prolonged QT interval leading to Torsades de Pointes was third degree heart block. The definit ive long term treatment should be implantation of permanent pacemaker.

References:① Lesson III. Characteristics of the Normal ECG

Frank G. Yanowitz, MD. Professor of Medicine. Un ive rs i t y o f U tah Schoo l o f Med ic ine . Retrieved on Mars 23, 2010.

② “Drugs That Prolong the QT Interval or Induce Torsades de Pointes”. Point of Care Quick Reference. March 11, 2010.

③ Link, MS; Atkins, DL; Passman, RS; Halperin, H R ; S a m s o n , R A ; W h i t e , R D ; C u d n i k , MT; Berg, MD; Kudenchuk, PJ; Kerber , RE (2 November 2010). “Part 6: electrical therapies: automated external defibrillators, def ibr i l lat ion, cardioversion, and pacing: 2010 American Heart Association Guidelines for Card iopu lmonary Resusc i ta t ion and Emergency Cardiovascular Care”. Circulation 122 (18 Suppl 3): S706–19.

The content of the August Cardiology Series is provided by: Dr. WU Kwok Leung MBBS(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in Cardiology八月臨床心臟科個案研究之內容承蒙胡國樑醫生提供。


Dermatology

Small reddish spots on forearmsA 55-year-old man complained of red spots on his forearms for about one year. The lesions were asymptomatic but increased in number. Physical examination revealed multiple small erythematous dome-shaped papules on the forearms. The lesions were 2 to 3 mm in diameter.

1. What are the differential diagnoses?2. What is the diagnosis?3. What investigation would you like to order?4. What is the underlying pathophysiology?5. How do you treat this patient?

Q&A Please answer ALL questionsAnswer these on page 20 or make an online submission at: www.hkmacme.org

Answers:

1. The diagnosis is irritated seborrheic keratosis. Seborrheic keratoses is commonly found in the trunk and all sun-exposed areas such as face, extremities and scalp. Lesion around the neck and waist can catch on clothing and becomes irritated.

2. It includes viral warts, cutaneous horn, actinic keratoses and squamous cell carcinoma.

3. The precise cause of the development of seborrheic keratoses is unknown. However, human papilloma virus and epidermal growth factor have been suggested as a possible etiology due to its verrucous appearance and association with various internal malignancies.

4. No investigation is necessary in most patients un less a sudden appearance of mul t ip le seborrheic keratoses (Leser-Trélat sign) occurs, which is associated with the development of adenocarcinoma of the gastrointestinal tract

and hematological malignancies. Dermoscopy may be used to assist in the diagnosis. A skin biopsy could be considered in doubtful or suspicious lesions. Relevant investigations should be performed if there are any associated internal malignancies suspected.

5. Seborrheic keratoses is harmless and do not need treatment unless it is cosmetically undesirable or becomes irritated or inflamed where lesions catch on clothing. Surgical removal such as curettage and cautery and shave excision is often adopted for large or irritated lesions. Cryotherapy and laser therapy are also effective for solitary thinner lesions.

August Answers

Complete BOTH Cardiology andDermatology courses and earn0.5 CME POINT

The content of the August Dermatology Series 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八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。

Dermatology Series for September 2015Dr. KWAN Chi Keung, Dr. TANG Yuk Ming, William, Dr. CHAN Hau Ngai, Kingsley and Dr. LEUNG Wai Yiu

Specialists in Dermatology & Venereology九月皮膚科個案研究之內容承蒙關志強醫生、鄧旭明醫生、陳厚毅醫生及梁偉耀醫生提供。

Complaints & Ethics

HKMA CME Bulletin 持續醫學進修專訊 September 2015www.hkmacme.org 19

A medical student who just completed his MB program sent me an e-mail. He is scheduled to start internship on 1st July, but is concerned that his internship may be delayed because he reported to the Central Registration Office, based on a pre-internship session (Common Medico-legal Problems faced by Interns and How to Avoid Them. A Practical Guide for Interns), that he was fined $800 in a Magistrate Court for careless driving contrary to section 38(1) of the Road Traffic Ordinance (Cap. 374). This is a crime punishable with imprisonment though he was only given a fine. He submitted the relevant documents including court summons, receipt of court fine, transcript of the police testimony etc. to the Central Registration Office to be forwarded to the Medical Council. He was informed by the secretary that the duration of the formal procedure may take months and until then provisional registration may be withheld. He is concerned that the delay may affect his career as specialty training position may be more difficult to obtain if completion of his internship is delayed by even a month, since his classmates would have captured all the best spots.

Under sect ion 12(1) of the Medical Registrat ion Ordinance:

A person who has passed the Licensing Examination or a qualifying examination may be provisionally registered, on application to the Registrar and production to the Registrar of evidence to the satisfaction of the Registrar that –

(a) He has been engaged in employment as is mentioned in section 9(1),

Or

(b) He has been engaged to undergo a period of assessment as mentioned in section 10A(1),

and on payment of a prescribed fee.

There have been other misdemeanors like ‘riding as a passenger in rear seat of public light bus but not securely fastened with seat belt’ contrary to Regulation 7B(1) and 12(1) of Road Traffic (Safety Equipment) Regulations made under Road Traffic Ordinance (Cap. 374). Even riding a bicycle in the country park may be a crime.

Given that these cases are misdemeanors, the Registrar (Director of Department of Health) can approve their applications for provisional registration and al low them to join their rank of interns in time. However, the cases will be referred to the PIC for consideration and necessary follow up actions under section 12(2)(b) of the MRO.

The Chairman of the PIC will request the defendant doctors to write in to explain their ‘crimes’ and the full Committee will decide if an inquiry will need to be held or if the Committee would refer to the Medical Council that no inquiry be held at all.

Hopefully, if the reply is submitted early enough and if the PIC can refer back to the Medical Council for no inquiry before July of the year, the career of the young defendant doctors will not be affected.

Medical students should be aware that by joining the medical profession, they are obliged to be even more careful of their actions in the eyes of the public lest their career be thwarted.

Misdemeanor and Provisional Registration

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


ANSWER SHEET

Dermatology1

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Complete BOTH Cardiology & Dermatology cases and earn 0.5 CME point

Cardiology

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

SPOTlight - 1Complete Spotlight and earn 1 CME point

Please return thecompleted answer sheetto the HKMA Secretariat(Fax: 2865 0943) on orbefore 15 October 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10月 15日前將答題紙傳真或寄回香港醫學會 (傳真號碼：2865 0943)。如果選擇在網上完成練習，便無需將答題紙傳真到秘書處。

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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)

Answer Sheet

September 2015

答題紙


CMEnotifications

HKMA CME Programme香港醫學會持續進修計劃

CME Lecture – October 2015 進修講課－二零一五年十月

HKMA Structured CME Programme with HKS&H Session X: The Contribution of Pathology to Personalized Medicine

Dr. MA Shiu Kwan, Edmond

MBBS (HK), MD (HK), MRCP (UK), FRCP (Edin), FRCP (Lond), FRCP, RCPS (Glasg), FRCPath, FRCPA, FHKCPath, FHKAM (Pathology),Specialist in HaematologyDirector, Clinical Pathology and Molecular Pathology, Department of Pathology, HKS&H

Date: 8 October 2015 (Thursday)Time: 2:00–3:00 p.m. [Light lunch starts at 1:15 pm]Venue: The HKMA Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese

Club Building, 21–22 Connaught Road Central, HK

香港醫學會分科持續醫學進修計劃第十節：病理學於個體化醫學的貢獻

講者：馬紹鈞醫生

香港大學內外全科醫學士、香港大學醫學博士、英國皇家內科醫學院院士、英國愛丁堡皇家內科醫學院榮授院士、英國倫敦皇家內科醫學院榮授院士、英國格拉斯哥皇家醫學院內科榮授院士、英國皇家病理科醫學院榮授院士、澳洲皇家病理科醫學院榮授院士、香港病理學專科學院院士、香港醫學專科學院院士（病理科）、血液學專科醫生、養和醫院臨床病理科及分子病理科主任

日期：二零一五年十月八日（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 MemberHK$50

CME ParticipantsHK$80

8 October 2015 (Thursday)

HKMA Structured CME Programme with HKS&H Year 2015 Session X: Robotic Surgery for Ca Prostate

HKMA Structured CME Programme with HKS&H


Medical associaTion


Osteoporosis Management: A Practical Guide to Screening, Diagnosis and Treatment

Date : Thursday, 22 October 2015

Speaker : Dr. YIP Wai ManSpecialist in Geriatric Medicine

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

Venue : 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. TSANG Yat FaiCommittee member, HKMA NT West Community Network

Deadline : Friday, 9 October 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 NT West district.

Enquiry : Miss Hana YEUNG, Tel: 2527 8285*Please call and confirm that your facsimile has been successfully transmitted to the HKMA Secretariat if you do not receive confirmation 14 days before the event.

CME Accreditation : Pending

REPLY SLIP

HKMA New Territories West Community Network Fax: 2865 0943Osteoporosis Management: A Practical Guide to Screening, Diagnosis and Treatment

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

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 a confirmation letter to you.

Practising location: In New Territories West (Please specify *: )

Others (Please specify: )* Null entry will be treated as non-New Territories West member registration.

Signature: Date:

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

Organized by

This lecture is sponsored byGlaxoSmithKline Limited

The hong KongMedical associaTion

CMEnotifications


Update on Diagnosis and Managementof Psoriatic Arthritis

The HKMA Hong Kong East Community Networkand Hong Kong Society of Rheumatology

Date : Thursday, 8 October 2015

Speaker : Dr. CHAN Pak ToSpecialist in Rheumatology

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

Moderator : Dr. NGAN Sze Yuen, SilasHon. Treasurer,HKMA HK East Community Network

Deadline : Friday, 25 September 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*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


REPLY SLIP

HKMA Hong Kong East Community Network Fax: 2865 0943Update on Diagnosis and Management of Psoriatic Arthritis

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


Practising location: In Hong Kong East (Please specify *: )

Others (Please specify: )* Null entry will be treated as non-Hong Kong East member registration.

Signature: Date:

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

Co-organized byThe hong KongMedical associaTion

CMEnotifications


Date : Wednesday, 14 October 2015 Wednesday, 28 October 2015

Topic and Speaker : Glycemic Control – The Peak and The TroughDr. CHAN Wing BunSpecialist in Endocrinology, Diabetes & Metabolism

Doctor, What is this Swelling in My Neck?Dr. WONG Chun KuenSpecialist in Radiology


Venue : The Hong Kong Medical Association Central Premises,Dr. Li Shu Pui Professional Education Centre,2/F., Chinese Club Building, 21-22 Connaught Road Central, Hong Kong

Moderator : Dr. LAM Ming YuenHon. Treasurer,HKMA CW&S Community Network

Dr. LAW Yim KwaiVice-chairman,HKMA CW&S Community Network

Deadline : Friday, 2 October 2015 Friday, 16 October 2015


Capacity : 80. Registration is strictly required on a first-come, first-served basis. Priority will be given to doctors practising in the Hong Kong Central, Western and Southern districts.


Sponsor :


CME Lectures in October 2015

REPLY SLIP

HKMA Central, Western & Southern Community Network Fax: 2865 0943CME Lectures in October 2015

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

14 October 2015 28 October 2015


Practising location: In Central, Western & Southern districts (Please specify *: )

Others (Please specify: )* Null entry will be treated as non-Hong Kong Central, Western & Southern member registration.

Signature: Date:

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

Organized byThe hong Kong

Medical associaTion

CMEnotifications


REPLY SLIP

HKMA Kowloon East Community Network Fax: 2865 0943CME Lectures in October 2015




Practising location: In Kowloon East (Please specify *: )

Others (Please specify: )* Null entry will be treated as non-Kowloon East member registration.

Signature: Date:



Date : Thursday, 8 October 2015 Thursday, 22 October 2015

Topic and Speaker : Update on Type 2 Diabetes Management in ElderlyDr. CHAN Chun ChungSpecialist in Geriatric Medicine

Cardiac Arrhythmia UpdateDr. CHAN Chi Kin, HamishSpecialist in Cardiology


Venue : Lei Garden Restaurant (利苑酒家 ),Shop no. L5-8, apm, Kwun Tong,No. 418 Kwun Tong Road, Kwun Tong, Kowloon

V Cuisine, 6/F., Holiday Inn Express Hong KongKowloon East, 3 Tong Tak Street, Tseung Kwan O(將軍澳唐德街3號香港九龍東智選假日酒店6樓彩雲軒 )

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

Dr. MA Ping Kwan, DannyVice-chairman,HKMA Kowloon East Community Network

Deadline : Friday, 25 September 2015 Friday, 9 October 2015


Capacity : 48. Registration is strictly required on a first-come, first-served basis. Priority will be given to doctors practising in the Kowloon East district.


Sponsor :



Organized by

CMEnotifications


REPLY SLIP

HKMA Yau Tsim Mong Community Network Fax: 2865 0943CME Lectures in October 2015




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

Others (Please specify: )* Null entry will be treated as non-Yau Tsim Mong member registration.

Signature: Date:



Organizer : HKMA Yau Tsim Mong Community Network

Date : Tuesday, 13 October 2015 Friday, 30 October 2015

Topic and Speaker : Management of Raised Prostate Specific Antigen (PSA) LevelDr. TAI Chi KinSpecialist in Urology

Latest COPD Management –Dual BronchodilationDr. WONG Ka ChunSpecialist in Respiratory Medicine


Venue : Diamond Ballroom 1, Level B1, Eaton, Hong Kong, 380 Nathan Road, Kowloon

Nathan Room, III-Hall, Level 1, Eaton, Hong Kong, 380 Nathan Road, Kowloon

Moderator : Dr. SO ChunCommittee Member,HKMA YTM Community Network

Dr. CHAN Wai Keung, RickyVice-chairman,HKMA YTM Community Network

Deadline : Friday, 2 October 2015 Monday, 19 October 2015


Capacity : 80. Registration is strictly required on a first come, first served basis. Priority will be given to doctors practising in Yau Tsim Mong districts.

Enquiry : Ms. Candice TONG, Tel: 2527 8285

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

Sponsor :



CMEnotifications


REPLY SLIP

HKMA Kowloon West Community Network Fax: 2865 0943CME Lectures in October 2015



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 *: )

Others (Please specify: )* Null entry will be treated as non-Kowloon West member registration.

Signature: Date:


Date : Tuesday, 6 October 2015 Tuesday, 20 October 2015

Topic and Speaker : Update on Non-Alcoholic Fatty Liver Disease (NAFLD)Dr. HSU Yau QueSpecialist in Internal Medicine

Treatment and Prevention of Eczema Flares – by Combination Therapy (Latest AAD Guideline Update)Dr. CHAN Kam Tim, MichaelSpecialist in Dermatology & Venereology


Venue : Crystal Room IV-V, 3/F., Panda Hotel, 3 Tsuen Wah Street, Tsuen Wan, N.T.

Moderator : Dr. WONG Wai Hong, BruceHon. Secretary,HKMA Kowloon West Community Network

Dr. LEUNG Kin Nin, KennethCommittee member,HKMA Kowloon West Community Network

Deadline : Friday, 25 September 2015 Friday, 9 October 2015


Capacity : 50. Registration is strictly required on a first come, first served basis. Priority will be given to doctors practising in Kowloon West district.


Sponsor :



Organized byThe hong Kong

Medical associaTion

CMEnotifications


Meeting Highlights

Dr. FAN Sheung Tat, Specialist in General Surgery, delivered a luncheon lecture on “Diagnosis and Treatment of Early Liver Cancer” on Thursday, 13 August 2015 at the HKMA Central Premises. Dr. YEUNG Yuk Pang, kindly acted as the moderator for the event.

Dr. MA Shiu Kwan, Edmond, Specialist in Pathology, will give a talk on “The Contribution of Pathology to Personalized Medicine” on Thursday, 8 October 2015. Interested members please refer to the announcement on p.21 for details and enrolment.

HKMA Structured CME Programme with Hong Kong Sanatorium & Hospital 2015

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

Dr. TSE Tak Sun, Consultant Cardiologist and Head of the Department of Cardiology of St. Paul’s Hospital, delivered a lecture on “Update in Stroke Prevention in Atrial Fibrillation Patients” on Wednesday, 5 August 2015.

Dr. CHAN Wing Bun, Specialist in Endocrinology, Diabetes & Metabolism, will give a talk on “Glycemic Control – The Peak and The Trough” on Wednesday, 14 October 2015. Dr. WONG Chun Kuen, Specialist in Radiology, will present on “Doctor, What is this Swelling in My Neck?” on Wednesday, 28 October 2015. Interested members please refer to the announcement on p.24 for details and enrolment.

Group photo taken during the lecture on 5 August 2015From left: Dr. POON Man Kay, Dr. TSANG Chun Au (moderator), Dr. TSE Tak Sun (speaker) and Dr. LAW Yim Kwai

Dr. YEUNG Yuk Pang (left) presenting a souvenir to the speaker, Dr. FAN Sheung Tat, (right).

The HKMA Hong Kong East Community Network (HKECN) ~ Dr. CHAN Nim Tak, Douglas

Dr. TSANG Man Wo, Specialist in Endocrinology, Diabetes & Metabolism, delivered two lectures on different aspects of diabetes

mellitus on Thursdays, 6 August and 20 August 2015. The topics were “The Journey to Optimize Type 2 Diabetes Therapy” and

“Type 2 Diabetes: Clinical Implications and Early Intensification Strategy” respectively.

Dr. CHAN Pak To, Specialist in Rheumatology, will present on “Update on Diagnosis and Management of Psoriatic Arthritis” on

Thursday, 8 October 2015. Interested members please refer to the announcement on p.23 for details and enrolment.

Dr. TSANG Man Wo (left, speaker) receiving a souvenir from Dr. TUET On Sang (moderator) during the lecture on 6 August 2015

Dr. TSANG Man Wo (left, speaker) receiving a souvenir from Dr. Dominic YOUNG (moderator) during the lecture on 20 August 2015


Meeting Highlights

A CME lecture on “Reference Framework for Preventive Care for Older Adults in Primary Care Settings” which was co-organized by the Network and the Primary Care Office (PCO) of the Department of Health (DH) was given by Dr. SIN Ka Ling, Cecilia, Specialist (Primary Care) of PCO of DH, on Thursday, 13 August 2015. The third session of the “CME Course for Health Personnel 2015” titled “Adolescent Mental Health Issues” was presented by Dr. LEE Yiu Ki, Associate Consultant of the Department of Psychiatry of United Christian Hospital, on Saturday, 15 August 2015.

Dr. CHAN Chun Chung, Specialist in Geriatric Medicine, will give a talk on “Update on Type 2 Diabetes Management in Elderly” on Thursday, 8 October 2015. Dr. CHAN Chi Kin, Hamish, Specialist in Cardiology, will present on “Cardiac Arrhythmia Update” on Thursday, 22 October 2015. Interested members please refer to the announcement on p.25 for details and enrolment.

The HKMA Kowloon East Community Network (KECN) ~ Dr. AU Ka Kui, Gary

Dr. Gary AU (left, moderator) presenting the Certificate of Appreciation to Dr. Cecilia SIN (speaker) during the lecture on 13 August 2015

Dr. Danny MA (left, moderator) presenting the Certificate of Appreciation to Dr. LEE Yiu Ki (speaker) during the lecture on 15 August 2015

A CME lecture on “Management of Dyslipidemia: Strategies for Long-Term Success” was given by Dr. TSANG Kin Keung, Specialist in Cardiology, on Tuesday, 4 August 2015. Another CME lecture on “An Insulin-Independent Approach to Manage Patients with Type 2 Diabetes Mellitus” was given by Dr. CHEUNG Fu Keung, Specialist in Endocrinology, Diabetes & Metabolism, on Tuesday, 18 August 2015.

Dr. HSU Yau Que, Specialist in Internal Medicine, will present on “Update on Non-Alcoholic Fatty Liver Disease (NAFLD)” on Tuesday, 6 October 2015. Dr. CHAN Kam Tim, Michael, Specialist in Dermatology & Venereology, will give a talk on “Treatment and Prevention of Eczema Flares – by Combination Therapy (Latest AAD Guideline Update)” on Tuesday, 20 October 2015. Interested members please refer to the announcement on p.27 for details and enrolment.

TThe HKMA Kowloon West Community Network (KWCN) ~ Dr. TONG Kai Sing

Dr. CHAN Ching Pong (right, moderator) presenting a souvenir to Dr. TSANG Kin Keung (speaker) during the lecture on 4 August 2015

Group photo taken during the lecture on 18 August 2015 From left: Dr. TONG Kai Sing, Dr. CHEUNG Fu Keung (speaker), Dr. Bruce WONG (moderator) and Dr. Bernard CHAN


Meeting Highlights

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

Dr. CHIU Cheung Shing, Daniel, Specialist in Paediatrics, delivered a lecture on “Primary Prevention of Infancy Allergy and Latest International Guidelines” on Thursday, 6 August 2015.

Dr. YIP Wai Man, Specialist in Geriatric Medicine, will present on “Osteoporosis Management: A Practical Guide to Screening, Diagnosis and Treatment” on Thursday, 22 October 2015. Interested members please refer to the announcement on p.22 for details and enrolment.

Dr. LEE Huen (right, moderator) presenting a souvenir to Dr. Daniel CHIU (speaker) during the lecture on 6 August 2015

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

Dr. CHEON Willy Cecilia, Specialist in Obstetrics & Gynaecology, and Ms. Anny TONG, Advanced Practice Nurse, were invited to give talk on “Treatment of Female Stress Urinary Incontinence” on Tuesday, 11 August 2015.

Dr. TAI Chi Kin, Specialist in Urology, will present on “Management of Raised Prostate Specific Antigen (PSA) Level” on Tuesday, 13 October 2015. A lecture on “Latest COPD Management – Dual Bronchodilation” will be delivered by Dr. WONG Ka Chun, Specialist in Respiratory Medicine, on Friday, 30 October 2015. Interested members please refer to the announcement on p.26 for details and enrolment.

Dr. WONG Kam Ho (left, moderator) in photo with Dr. CHEON Willy Cecilia (speaker) during the lecture on 11 August 2015

Dr. WONG Kam Ho (left, moderator) in photo with Ms. Anny TONG (speaker) during the lecture on 11 August 2015

CMECalendar


September 2015

16 Sep 2015(Wed)9:30 – 12:30 pm

Hong Kong Poison Information CentreHong Kong College of Emergency MedicineCertificate Program in Clinical Toxicology 2015 (Monthly Sessions)Conference Room, 1/F, Block F, United Christian HospitalMs. Winnie Cheung – Tel: 3513 5096

3

16 Sep 2015(Wed)12:45 – 2:00 pm

Hospital Authority – Our Lady of Maryknoll HospitalGrand Round/Journal Club/Medication (Wednesday Educational Meeting July-Sept 2015)Conference Room A, 1/F, OPD Block, Our Lady of Maryknoll HospitalMs. Clara Tsang – Tel: 2354 2440

1

16 Sep 2015(Wed)2:00 – 4:00 pm

Hong Kong Academy of Medicine1) Approach to Sports Injury in General Practice2) General Principles in the Management of OsteoarthritisRoom 2, G/F, Block M, Queen Elizabeth Hospital, KowloonMs. Joanne Ho – Tel: 2871 8747

2

16 Sep 2015(Wed)4:15 – 5:15 pm

HKU – Department of Obstetrics & GynaecologyTumour Board Meeting – clinical-pathological conference on gynaecological oncology casesRoom 215, 2/F, Seminar Room, Clinical Pathology Building, Queen Mary HospitalMs. Phyllis Kwok – Tel: 2255 4518

1

16 Sep 2015(Wed)7:00 – 8:30 pm

Federation of Medical Societies of HKHong Kong Thoracic Society (Ltd)CHEST delegation Hong Kong and Macau LimitedCertificate Course on Respiratory Medicine 2015Lecture Hall, 4/F, Duke of Windsor Social Service Building, 15 Hennessy Road, Wanchai, Hong KongMs. Erica Hung – Tel: 2527 8898

10#

17 Sep 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 – Common Skin Aging ProblemsV Cuisine, 6/F, Holiday Inn Express Hong Kong Kowloon East, 3 Tong Tak Street, Tseung Kwan OMs. Polly Tai – Tel: 3513 3430

1

17 Sep 2015(Thu)1:00 – 3:00 pm

Hong Kong Medical Association – New Territories West Community NetworkCertificate Course on Men’s HealthSession 2: A Step Forward towards Better BPH & LUTS ManagementPlentiful Delight Banquet, 1/F, Ho Shun Tai Building, 10 Sai Ching Street, Yuen LongMiss Hana Yeung – Tel: 2527 8285

1

17 Sep 2015(Thu)1:00 – 3:00 pm

Hong Kong Medical Association – Hong Kong East Community NetworkAdvances in Hypertension Management5/F, Duke of Windsor Social Service Building, 15 Hennessy Road, Wanchai, Hong KongMs. Candice Tong – Tel: 2527 8285

1

18 Sep 2015(Fri)7:00 – 8:30 pm

Federation of Medical Societies of Hong KongHong Kong Society for Emergency Medicine & SurgeryCertificate Course on Sports Medicine and EmergenciesLecture Hall, 4/F, Duke of Windsor Social Service Building, 15 Hennessy Road, Wanchai, Hong KongMs. Erica Hung – Tel: 2527 8898

10#

19 Sep 2015(Sat)10:00 – 12:00 pm

Hong Kong University – Department of Obstetrics & GynaecologyMultidisciplinary emergency obstetric drillsS5, Queen Mary HospitalMs. Miranda Tang – Tel: 2255 3914

2

19 Sep 2015(Sat)2:30 – 5:30 pm

Hong Kong Medical AssociationMedical Protection SocietyMastering Shared Decision MakingHong Kong Medical Association Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese Club Building, 21-22 Connaught Road, Central, Hong KongHKMA CME Dept. – Tel: 2527 8452

2.5

20 Sep 2015(Sun)1:00 – 4:00 pm

Hong Kong Doctors UnionThe 310th HKDU Sunday Afternoon SymposiumLecture Hall, 8/F, Block G, Princess Margaret Hospital, Kwai Chung, NTTel: 2388 2728

1.5

20 Sep 2015(Sun)3:30 – 5:30 pm

Hong Kong Doctors UnionThe 311th HKDU Sunday Afternoon SymposiumLecture Hall, 8/F, Block G, Princess Margaret Hospital, Kwai Chung, NTTel: 2388 2728

1.5

21 Sep 2015(Mon)8:30 – 9:30 am

Union Hospital – Department of PaediatricsPaediatrics Departmental RoundNew Seminar Room 2, 2/F, Hospital Building, Union Hospital Ms. Kay Ho – Tel: 2608 3800

1

21 Sep 2015(Mon)1:00 – 2:00 pm

HKU – Department of Obstetrics & GynaecologyObstetric/Maternal-Fetal Medicine Postgraduate ActivitiesRoom 415, 4/F, Block K, Queen Mary HospitalMs. Miranda Tang – Tel: 2255 3914

1

21 Sep 2015(Mon)7:00 – 8:30 pm

The Federation of Medical Societies of Hong Kong; Hong Kong Urological AssociationCertificate Course on Contemporary Management for Common Urological DiseasesLecture Hall, 4/F, Duke of Windsor Social Service Building,15 Hennessy Road, WanchaiMs Erica Hung – Tel: 2527 8898

2

22 Sep 2015(Tue)1:00 – 3:00 pm

Hong Kong Medical Association – Kowloon West Community NetworkFirst 1000 Days of Life – What Matter Most?Panda Grand Ballroom B, 5/F, Panda Hotel, 3 Tsuen Wah Street, Tsuen Wan, NTMiss Hana Yeung – Tel: 2527 8285

1

22 Sep 2015(Tue)1:00 – 3:00 pm

Hong Kong Doctors Union – Hong Kong East Study GroupManagement of Chronic Hepatitis B Patients and Treatment OptionsForum Room II-III, Basement 2, Regal Hong Kong Hotel, 88 Yee Wo Street, Causeway Bay, Hong KongTel: 2388 2728

1

22 Sep 2015(Tue)6:30 – 9:30 pm

Hong Kong Medical AssociationMedical Protection SocietyMastering Your RiskHong Kong Medical Association Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese Club Building, 21-22 Connaught Road, Central, Hong KongHKMA CME Dept. – Tel: 2527 8452

2.5

23 – 24Sep 2015(Wed-Thu)

Hong Kong College of Emergency MedicineAmerican Heart Association (AHA) Advanced Cardiovascular Life Support (ACLS)HKEC Training Centre for Healthcare Management & Clinical Technology, Pamela Youde Nethersole Eastern HospitalMs. Cherry Kwok – Tel: 2871 8877

10#

23 Sep 2015(Wed)12:45 – 2:00 pm

Hospital Authority – Our Lady of Maryknoll HospitalGrand Round/Journal Club/Medication (Wednesday Educational Meeting July-Sept 2015)Conference Room A, 1/F, OPD Block, Our Lady of Maryknoll HospitalMs. Clara Tsang – Tel: 2354 2440

1

23 Sep 2015(Wed)1:00 – 3:00 pm

Hong Kong Medical Association – Central, Western & Southern Community NetworkThe Breast Mouse – A GP’s Approach in 2015Hong 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

23 Sep 2015(Wed)1:00 – 3:00 pm

Hong Kong Medical Association – Shatin Doctors NetworkUpdate in the Management of GoutJasmine Room, Level 2, Royal Park Hotel, ShatinMr. Wilson Hon – Tel: 3954 5003

1

23 Sep 2015(Wed)7:00 – 8:30 pm


10#

# for whole function

CMECalendar


24 Sep 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

24 Sep 2015(Thu)1:00 – 3:00 pm

Hong Kong Medical Association – New Territories West Community NetworkHow to Avoid being Brought to the PIC?Pearl Ocean, 1/F, Gold Coast Yacht and Country Club, 1 Castle Peak Road, Castle Peak Bay, Hong KongMiss Hana Yeung – Tel: 2527 8285

1

24 Sep 2015(Thu)1:00 – 3:00 pm

Hong Kong Medical Association – Kowloon East Community NetworkDiagnosis and Treatment of Axial-Spondylarthropathy (Axial-SpA)V Cuisine, 6/F, Holiday Inn Express Hong Kong Kowloon East, 3 Tong Tak Street, Tseung Kwan OMiss Hana Yeung – Tel: 2527 8285

1

24 Sep 2015(Thu)1:00 – 3:00 pm

Hong Kong Doctors Union – Wan Chai Study GroupSGLT2 inhibitors, a novel mechanism for the treatment of type 2 diabetesShanghai Lu Yang Cun Restaurant, 11/F, World Trade Centre, 280 Gloucester Raod, Causeway Bay, Hong KongTel: 388 2728

1

24 Sep 2015(Thu)6:00 – 7:00 pm

Queen Mary Hospital – Department of NeurosurgeryNeuroscience Working Group Meeting (4th Thursday of every month)Lecture Theatre, 5th Professorial Block, Queen Mary HospitalMs. Sherla Yu – Tel: 2255 3368

1

25 Sep 2015(Fri)1:00 – 3:00 pm

Hong Kong Medical Association – Yau Tsim Mong Community NetworkWhy Do You Need to Know Your Kidney Tubules? (Practical Tubulology)Jade Ballroom, Level 2, Eaton, Hong Kong, 380 Nathan Road, KowloonMs. Candice Tong – Tel: 2527 8285

1

25 Sep 2015(Fri)1:00 – 3:00 pm

Hong Kong Medical Association – Shatin Doctors NetworkUpdate in Treatment Option for Symptomatic Control of GERDJasmine Room, Level 2, Royal Park Hotel, ShatinMs. Janice Tang – Tel: 2133 9883

1

25 Sep 2015(Fri)7:00 – 8:30 pm


10#

26 Sep 2015(Sat)8:30 – 4:30 pm

Hong Kong College of AnaesthesiologistsEnhancing Safety in Sedation Workshop (Identical)NTE Simulation & Training Centre 3E Ward, North District HospitalMr. Thomas Tam – Tel: 2683 8343

5

26 Sep 2015

(Sat)

7:00 – 10:00 pm

Hong Kong Medical Association2015 Hong Kong Medical Association Dragon Boat Team CME Lecture cum Celebration Dinner – Cardiology Update 2015 for everyday clinical practice Hong Kong Medical Association Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese Club Building, 21-22 Connaught Road, Central, Hong Kong; Holiday Inn Golden Mile Hong KongMiss Denise Kwok – Tel: 2527 8285

1

29 Sep 2015(Tue)8:30 – 9:30 am

Hong Kong Sanatorium & Hospital – Respiratory Medicine Centre & Clinical Oncology CentreLung Cancer Tumour Board MeetingRm1103, 11/F, Li Shu Pui Block, Hong Kong Sanatorium & HospitalMs. Wong – Tel: 2835 8673

1

29 Sep 2015(Tue)2:00 – 4:00 pm

Hong Kong College of Family PhysiciansCertificate Course on Bringing Better Health to Our Community 2015Lecture Theatre, G/F, Block M, Queen Elizabeth HospitalMs. Teresa Liu – Tel: 2528 6618

2

29 – 30Sep 2015(Tue-Wed)

Hong Kong College of Emergency MedicineAmerican Heart Association (AHA) Pediatric Advanced Life Support (PALS) Courses HKEC Training Centre for Healthcare Management & Clinical Technology, Pamela Youde Nethersole Eastern HospitalMs. Cherry Kwok – Tel: 2871 8877

10#

30 Sep 2015(Wed)7:00 – 8:30 pm


10#

2 Oct 2015(Fri)7:00 – 8:30 pm


10#

5 Oct 2015(Mon)1:00 – 2:00 pm


1

6 Oct 2015(Tue)1:00 – 3:00 pm

Hong Kong Medical Association – Kowloon West Community NetworkUpdate on Non-Alcoholic Fatty Liver Disease (NAFLD)Crystal Room IV-V, 3/F, Panda Hotel, 3 Tsuen Wah Street, Tsuen Wan, NTMiss Hana Yeung – Tel: 2527 8285

1

6 Oct 2015(Tue)6:30 – 9:30 pm

Hong Kong Medical AssociationMedical Protection SocietyMastering Professional InteractionHong Kong Medical Association Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese Club Building, 21-22 Connaught Road, Central, Hong KongHKMA CME Dept. – Tel: 2527 8452

2.5

7 Oct 2015(Wed)1:00 – 3:00 pm

Hong Kong Doctors Union – Tsuen Wan Study GroupCan anti-HBV meds ever be stopped?Crystal Room IV-VI, 3/F, Panda Hotel, 3 Tsuen Wah Street, Tsuen Wan, NTTel: 2388 2728

1

7 Oct 2015(Wed)2:00 – 4:00 pm

Hong Kong Academy of Medicine1) Is Panadol Safe?2) Approach to EpistaxisRoom 2, G/F, Block M, Queen Elizabeth Hospital, KowloonMs. Joanne Ho – Tel: 2871 8747

2

7 Oct 2015(Wed)4:15 – 5:15 pm

HKU – Department of Obstetrics & GynaecologyTumour Board Meeting – clinical-pathological conference on gynaecological oncology casesRoom 215, 2/F, Seminar Room, Clinical Pathology Building, Queen Mary HospitalMs. Phyllis Kwok – Tel: 2255 4518

1

7 Oct 2015(Wed)5:00 – 7:30 pm

Hong Kong College of Emergency MedicineJoint Clinical Meeting & Didactic Lecture (JCM)Lecture Theatre, G/F, Block M; Multi-Function Room, G/F, Block D; Seminar Room, G/F, Block A, 12/F, Block R, Lecture Theatre, Queen Elizabeth HospitalMs. Cherry Kwok – Tel: 2871 8877

2

7 Oct 2015(Wed)7:00 – 8:30 pm


10#

8 Oct 2015(Thu)8:30 – 9:30 am

Hong Kong Sanatorium & Hospital – Neurology CentreJoint neurology – neurosurgery clinical meeting4/F, Function Room, Hong Kong Sanatorium & HospitalMs. Linda Chan – Tel: 2835 7287

1

8 Oct 2015(Thu)8:30 – 10:30 am

Union HospitalAssociation of Private Orthopaedic SurgeonsHong Kong Sanatorium & Hospital – Orthopaedic & Sports Medicine CentreOrthopaedic Clinical Meeting – Teleconference (Every Second Thursday of the Month)Hong Kong Sanatorium & Hospital/Union HospitalMs. Cheng Hoi Yan – Tel: 2835 7890

2


CMECalendar


8 Oct 2015(Thu)1:00 – 3:00 pm

Hong Kong Medical Association – New Territories West Community NetworkCertificate Course on Men’s HealthSession 3: Helping the Man with Premature Ejaculation: Our ResponsibilityPlentiful Delight Banquet, 1/F, Ho Shun Tai Building, 10 Sai Ching Street, Yuen LongMiss Hana Yeung – Tel: 2527 8285

1

8 Oct 2015(Thu)1:15 – 3:00 pm

Hong Kong Medical AssociationHong Kong Sanatorium & HospitalHKMA Structured CME Programme with HKS&H Session 10: The Contribution of Pathology to Personalized MedicineFunction 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

8 Oct 2015(Thu)6:30 – 9:30 pm

Hong Kong Medical AssociationMedical Protection SocietyMastering Difficult Interactions with PatientsHong Kong Medical Association Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese Club Building, 21-22 Connaught Road, Central, Hong KongHKMA CME Dept. – Tel: 2527 8452

2.5

9 Oct 2015(Fri)7:00 – 8:30 pm


10#

10 Oct 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– ENT symptoms in primary careTraining 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

12 Oct 2015(Mon)1:00 – 2:00 pm


1

14 Oct 2015(Wed)8:30 – 9:30 am

Union HospitalMortality and Morbidity Meeting (Regular Meeting 2015)Training Room, MIC, 8/F, Hospital Building, Union HospitalMs. Penny Fok – Tel: 2608 3287

1

14 Oct 2015(Wed)2:00 – 3:30 pm

Hong Kong Academy of MedicineBack Pain and Adult Spine DeformityLecture Theatre, G/F, Block M, Queen Elizabeth Hospital, KowloonMs. Joanne Ho – Tel: 2871 8747

2

14 Oct 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

14 Oct 2015(Wed)7:00 – 8:30 pm


10#

15 Oct 2015(Thu)6:30 – 9:30 pm

Hong Kong Medical AssociationMedical Protection SocietyMastering Difficult Interactions with PatientsHong Kong Medical Association Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese Club Building, 21-22 Connaught Road, Central, Hong KongHKMA CME Dept. – Tel: 2527 8452

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Medical associaTion

The Hong Kong Medical Association Banquet Department香港醫學會宴會部

Features 特色• Centrallylocatedandeasilyaccessible 位置適中，交通方便

• Idealforsmallscaleseminar&privateparty 適合舉行小型講座及私人宴會

•Banquet&Buffetcateringservice 宴會及自助餐飲服務

We provide 我們提供•Conference&diningfacilities 會議餐宴設備•Withfreeaudio-visualequipment 免費借用影音器材• Superbcuisine 名廚主理美酒佳餚• ExquisitedécorandImpeccableservice 舒適雅緻清幽環境，及賓至如歸體貼服務

Address & Reservation 地址及訂座電話•WanchaiClubhouse灣仔會所25278324 5thFloor,DukeofWindsorSocialServiceBuilding,15HennessyRoad,HongKong 香港灣仔軒尼詩道15號溫莎公爵社會服務大廈5樓

•CentralClubhouse中環會所25369388 2ndFloor,ChineseClubBuilding,21-22ConnaughtRoad,Central,HongKong 香港中環干諾道中21-22號華商會所大廈2字樓


Documents

持續醫學進修專訊 - hkma.org · Alzheimer’s Disease: to be or not to be. HKMA CME Bulletin Editorial 1 Spotlight 1 2 Advance in diagnosis of Alzheimer’s Disease: to be