香港醫學會 T H K MEDICAL ASSOCIATION - hkma.org · Dr. CHEN Wai Hong 陳偉康醫生 Dr. HO Hung Kwong, Duncan

香港醫學會THE HONG KONG

MEDICAL ASSOCIATION

www.hkmacme.org May 2015

持續醫學進修專訊B U L L E T I N

Overview ofChronic Kidney

Disease in Elderly

Patients-A Local Perspective

by Dr. TSE Kai Chung

Dr. LAM Chi Leung

Prof. Helen CHIU

Mind the Gap: Assessing

Financial Capacity for the Elderly

Dr. CHUI Wing Hung

Video-assisted Thoracoscopic Lobectomy and Sublobar Resection for Early Non-small Cell Lung Cancer

HKMA Constitutional Reform Survey in MayPage 1 – Editorial page

HKMA CME Bulletin

Editorial 1

Spotlight 1 2Overview of Chronic Kidney Disease in Elderly Patients – A Local Perspective

Spotlight 2 5Video-assisted Thoracoscopic Lobectomy and Sublobar Resection for Early Non-small Cell Lung Cancer

Spotlight 3 11Mind the Gap: Assessing Financial Capacity for the Elderly

Cardiology 19A Patient with Acute Pulmonary Edema

Dermatology 22A 10-year-old Boy With Itchy Skin Rash Over Body and Limbs

Complaints & Ethics 23

Answer Sheet 25

CME Notifications 26

Meeting Highlights 32

CME Calendar 35

Contents

持續醫學進修專訊

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

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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 June 2015. Answers to questions will

be provided in the next issue of the HKMA CME

Bulletin. (Questions may also be answered online at

www.hkmacme.org)

HKMA CME Bulletin – MONTHLY SELF-STUDY

SERIES to help you grow!

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

請細閱本期文章，並利用答題紙完成自我評估測驗，於2015年6月15日前，將已填妥之答題紙傳真（號碼：2865 0943）或寄回本會秘書處，您將可獲持續醫學進修的積分點; 至於是期自我評估測驗之答案，將刊於下一期《持續醫學進修專訊》之中。（您亦可透過網站www.hkmacme.org 完成自我評估測驗）

Spotlight 3Mind the Gap: Assessing

Financial Capacity for the

Elderly

Spotlight 1Overview of Chronic

Kidney Disease in

Elderly Patients –

A Local Perspective

Spotlight 2Video-assisted

Thoracoscopic Lobectomy

and Sublobar Resection

for Early Non-small Cell

Lung Cancer

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

CME Bulletin Editorial May 2015

“I am the winner as I can get the job done!” A black lady law

professor said in a TV series trailer. As she further elaborated

about what she would teach, students about to leave the lecture

theatre sat down again… “How can one get away with murder?”

Despite sarcastic & weird, it is so true and vivid in the life of a

lawyer. Among the lawyers, not many are successful and can

get the job done.

This phenomenon applies to the medical field too! Clinicians

find it more and more difficult to communicate with the public

and health authority as they are dreaming in the superstition

of “Guidelines, Administrative management, Accreditation &

Academia”. For those close to reality and really help the patient

solve their problems, it is understandable that Guidelines

only form the backbone and can evolve into a mammal or an

amphibian, depending on the individual history and external

environmental factors. It is the experience that determines how

good a clinician can amalgamate the chaos of information,

orchestrate various treatment options and formulate a workable

solution. Package treatment as Menu A, B, C will certainly

decerebrate we clinicians and transform us to a manual worker

in the healthcare production line! Just dosing our medical

system with minute doses of heavy metal, sending us to the

graveyard insidiously and unnoticeably.

Fortunately, there is a group of good-hearted clinicians

writing articles for the Bulletin, sharing their invaluable clinical

experience and telling us how to get the job done. I guarantee

this Bulletin is as interesting and attractive as the TV series “How

to get away from Murder”. Get prepared, once you read it, you

cannot leave until the last word of this issue.

Dr. HO Hung Kwong, Duncan

Co-Chairman, CME Committee

CME Bulletin & Online Editorial Board

Chief Editor

Dr. WONG Bun Lap, Bernard 黃品立醫生

Executive Committee

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

Cardiology

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

Cardiothoracic Surgery

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

Colorectal Surgery

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

Dermatology

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

Endocrinology

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

ENT

Dr. CHOW Chun Kuen 周振權醫生

Family Medicine

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

Gastroenterologist

Dr. NG Fook Hong 吳福康醫生

General Surgery

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

Geriatric Medicine

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

Haematology

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

Hepatobiliary Surgery

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

Medical Oncology

Dr. TSANG Wing Hang, Janice 曾詠恆醫生

Nephrology

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

Neurology

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

Neurosurgery

Dr. CHAN Ping Hon, Johnny 陳秉漢醫生

Obstetrics and Gynaecology

Dr. CHAN Kit Sheung 陳潔霜醫生

Ophthalmology

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

Orthopaedics and Traumatology

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

Paediatrics

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

Plastic Surgeon

Dr. NG Wai Man, Raymond 吳偉民醫生

Psychiatry

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

Radiology

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

Respiratory Medicine

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

Rheumatology

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

Urology

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

Vascular Surgery

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

HKMA Secretariat

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

Important!

The HKMA is going to conduct a survey

on the “Proposals on the Method

for Selecting the CE by Universal

Suffrage”.

You may receive the questionnaire on or

around 20 May 2015.

P l e a s e k e e p a n e y e a n d r e p l y

by 2 June 2015 (Tuesday).

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

SPOTlight -1

Overview of Chronic Kidney Disease in Elderly Patients – A Local Perspective

hour urine collection. Creatinine clearance can then

be stratified using the international staging of CKD by

the National Kidney Foundation, and an arbitrary cut

off of GFR below 60ml/min/1.73m2 for more than 3

months is used for definition of CKD and below 15ml/

min/1.73m2 as definition for kidney failure [2,3] (Table).

This system is simple to use, but there are special

considerations in elderly patients. The normal GFR for

adults is approximately 120-130ml/min/1.73m2 and

depends on age, sex and body size, but there are

considerable variations even among normal individuals

[4]. With normal aging, there is a variable decline in

creatinine clearance, with an approximate drop of

creatinine clearance by 1ml/min/1.73m2 per year from

age 30 onwards. In this context, some patients who

are old enough may have creatinine clearance below

the threshold for CKD cutoff. This is attr ibuted to

normal aging and does not necessarily reflect genuine

CKD. It is therefore important to document evidence

of chronic kidney damage in addition to low creatinine

clearance in these elderly patients to define CKD.

This will include simple assessment by urine routine,

microscopy, assessment of proteinuria (or albuminuria)

and ultrasound (USG) imaging of kidneys. Abnormal

urinary casts, microscopic hematuria and proteinuria

are important clues of underlying CKD. USG kidneys

wi l l a lso document ev idence of chronic damage

including small kidney size, cortical thinning, loss of

corticomedullary differentiation and may give specific

diagnosis of CKD, e.g. polycystic kidney disease,

obstructive uropathy, etc. Among these tests proteinuria

is the most important factor for chronic kidney damage,

and renal biopsy is sometimes necessary for patients

with heavy proteinuria for definitive diagnosis. In the

circumstance of elderly patients with GFR < 60ml/

min/1.73m2 without evidence of chronic kidney damage,

they should not be labelled as having CKD.

Introduction

T h e b u r d e n o f c h r o n i c k i d n e y d i s e a s e ( C K D )

i s increas ing in the loca l popu la t ion. I t may be

unrecognized in the early stage as patient may be

asymptomatic or having non-specific symptoms only.

There is an increasing trend in the overall number of

patients with end stage renal failure (ESRF) entering

into the dialysis program in the public sector in the past

decades with more patients belonging to the 75+ age

group [1]. This number does not include patients who

are managed in the private sector, with a significant

proport ion being elderly patients, some of whom

are declined long term dialysis due to old age in the

public sector and come to private sector for long term

hemodialysis (HD). The overall increase in prevalence

of CKD is partly due to a longer life expectancy in the

population with improved standard of life and a higher

prevalence of hypertension (HT), diabetes mellitus (DM)

and atherosclerosis related disease in elderly patients.

Assessment of renal function in elderly patients

In the primary health care setting, routine blood tests

may identify patients with elevated serum creatinine

and raise suspicion for CKD. However, there are other

causes of high serum creatinine apart from genuine

impairment of kidney function. On the other hand, a

normal serum creatinine in elderly patients may not

truly ref lect normal renal function due to reduced

muscle mass commonly seen in old age. A more

accurate assessment of glomerular filtration rate (GFR)

using creatinine clearance is therefore necessary.

In this regard, common methods for assessment of

creatinine clearance include calculation equations

such as the Cockcroft-Gault formula or abbreviated

MDRD study equation and measurement using 24

Dr. TSE Kai ChungMBBS (Hons), MRCP (UK), FHKCP, FHKAM,

FRCP (Edin), FRCP RCPS (Glasg)

Staff Consultant, St. Paul’s Hospital

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

SPOTlight -1

Management of CKD

Regardless of etiology, elderly patients with confirmed

CKD should be managed with diet control with protein

restriction but one may need to balance the risk of

malnutr it ion and renal protection, and referral for

dietitian assessment may be necessary. More stringent

blood pressure (BP) control to aim for BP target of <

130/80 and control of proteinuria are also important as

both are risk factors linked to more rapid progression

of CKD. In this regard, angiotensin inhibition drugs

are usually the first line medical therapy for their dual

antihypertensive and proteinuria reduction effect.

Even in normotensive patients with proteinuric CKD,

angiotensin inhibition therapy should also be given if

tolerated for renal protection. There is no therapeutic

advantage of angiotensin converting enzyme inhibitor,

angiotensin blocker or renin inhibitor over one another

and choice of medication really depends on their side

effect profile, price and physician’s preference. The use

of combination of angiotensin inhibition drugs, however,

remains controversial. In any case, close monitoring

during initiation of angiotensin inhibition therapy is

important for potential side effects of hyperkalemia and

transient increase in serum creatinine in the initial stage

of therapy.

Specif ic management of CKD is directed towards

the underlying cause. In elderly patients, common

causes of CKD include DM nephropathy, HT related

kidney disease and chronic glomerulonephritis (GN).

These shou ld be managed accord ing ly and DM

should best be managed by insulin injection to achieve

optimal control. In patients with chronic GN, steroid

or immunosuppressive agents may sometimes be

necessary, but once again this needs close monitoring

for the risk of serious infections in elderly patients.

For elderly patients with a low creatinine clearance in

whom no definite cause of CKD is identified, no specific

therapy is required. However, they are more susceptible

to various nephrotoxic insults and are more prone to

acute kidney injury. Common scenarios include use

of non-steroidal anti-inflammatory drugs (NSAID) for

treatment of common conditions in elderly patients

and intravenous contrast for computer tomogram

examination. One should therefore have caution and

prescribe these agents only when necessary.

Renal replacement therapy in elderly patients

In elderly patients with ESRF, decision should be made

regarding conservative therapy or renal replacement

therapy (RRT). Life expectancy, social support, quality of

life and personal decision should be taken into account.

While elderly patients may still be considered for long

term dialysis, renal transplantation is in general not an

option due to scarcity of cadaveric kidneys in Hong

Kong.

From a local perspective, there is an increasing number

of elderly patients with ESRF started on dialysis and

most of them are doing peritoneal dialysis (PD) in the

public sector. It is generally held true that PD is more

cardiovascular friendly in elderly patients in whom a

higher prevalence of underlying cardiovascular disease

is expected, and thus PD is more suitable for them

compared with HD. However, there are also elderly

patients who opt for long term HD in the private sector

either out of their own choice or because they are

declined PD in the public sector. Compared with their

younger counterparts, there is a higher proportion of

elderly patients using Gortex graft or tunneled catheters

for long term HD due to more frequent access problems

related to arteriovenous fistula (AVF) in elderly patients,

but it is generally observed that most of them in fact

tolerate HD quite well with a reasonable quality of life.

This may be related to better technological advances

in HD therapy such as use of dialyzers with more

biocompatible membranes, hemodiafiltration, body

composition monitoring allowing better assessment

of dry weight and online blood volume monitoring to

prevent excessive ultrafiltration and hence hypotension

during HD, etc. These wil l al l contr ibute to better

tolerance and hemodynamic stability during HD for

elderly patients. Local data in this aspect is limited and

further studies on the tolerability and outcomes of long

term HD in elderly patients are recommended to confirm

these observations.


SPOTlight -1

References

1. Yiu-Wing Ho, Ka-Foon Chau, Bo-Ying Choy et al: Hong Kong Renal Registry Report 2012, Hong Kong Journal of Nephrology, Apr 2013 vol 15, issue 1, pp28-43

2. KDIGO. Summary of recommendation statements. Kidney Int 2013; 3 (Suppl): 5

3. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis 2002; 39 (Suppl 1): S1

4. Stevens LA, Coresh J, Greene T et al: Assessing kidney function – measured and estimated glomerular filtration rate. N Engl J Med 2006; 354: 2473

Table

CKD staging

GFR (ml/min/1.73m2) Stage

>/=90 1

60-89 2

45-59 3a

30-44 3b

15-29 4

<15 5

CKD is defined as GFR <60ml/min/1.73m2 for more than 3 months + evidence of chronic kidney damage

Answer these on page 25 or make an online submission at: www.hkmacme.org

Please indicate whether the following statements are true or false.

1. DM nephropathy is the most common cause of CKD in elderly patients.

2. GFR < 60ml/min/1.73m2 is the cut off of GFR to define CKD.

3. Creatinine clearance drops by ~1ml/min/1.73m2 per year from age 30 onwards.

4. Aim of BP control in CKD is the same as in patients with essential HT.

5. Role of angiotensin inhibition is controversial in normotensive proteinuric CKD.

6. Angiotensin inhibition should be given in elderly patients with low creatinine clearance without chronic kidney damage.

7. Combined angiotensin inhibition is beneficial in prevention of CKD progression.

8. Elderly patients tolerate PD much better than HD due to better efficacy of PD.

9. Elderly patients use AV fistula as the predominant access for HD.

10. Renal transplantation is not commonly done for elderly patients in HK.

Q&A Self-assessment Questions:

Complete thiscourse and earn

1 CME Point

Answers to April 2015Recent advances in interventional cardiologyMitraClip – Percutaneous Intervention for Mitral Regurgitation:1.T 2.F 3.T 4.T

An Overview of Transcatheter Aortic Valve Implantation (TAVI)5.T 6.F 7.T 8.T

Bioabsorbable stents in coronary angioplasty9.T 10.T 11.F 12.T

Unresectable CA pancreas – What can we offer to the patient?1.F 2.F 3.T 4.F 5.T 6.F 7.T 8.F 9.T 10.F

HKMA CME Bulletin

Monthly Self-Study Series

Call for Articles

Since its publication, the HKMA CME Bulletin has become one of the most popular CME readings for doctors. This monthly publication has been serving more than 9,500 readers each month through practical case studies and picture quizzes. To enrich its content, we are inviting articles from experts of different specialties. Interested contributors may refer to the General Guidance below. Other formats are also welcome.

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

General Guidance for Authors

Intended Readers : General PractitionersLength of Article : Approximately 8-10 A-4 pages in 12-pt fonts in single line spacing, or around 1,500-3,000 words (excluding

references).Review Questions : Include 10 self-assessment questions in true-or-false format. (It is recommended that analysis and answers to most questions be covered in the article.)Language : EnglishHighlights : It is preferable that key messages in each paragraph/section be highlighted in bold types.Key Lessons : Recommended to include, if possible, a key message in point-from at the end of the article.Others : List of full name(s) of author(s), with qualifications and current appointment quoted, plus a digital photograph of

each author.Deadline : All manuscripts for publication of the month should reach the Editor before the 1st of the previous month.

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

SPOTlight -2


Video-assisted Thoracoscopic Lobectomy and Sublobar Resection for Early Non-small Cell Lung Cancer

Dr. CHUI Wing HungMBBS (HK), FRCS (Edin), FCSHK, FHKAM (Surgery)

Specialist in Cardiothoracic Surgery

Introduction

Surgery currently offers the greatest opportunity for

long-term cure for early stage non-small cel l lung

cancer (NSCLC) and remains the cornerstone of any

multimodality approach to locally advanced disease.

Tradit ional ly , the pr imary and preferred surgical

treatment has been performed by lobectomy or greater

resection procedures (1). Minimally invasive lobectomy

— predominantly the video-assisted thoracic surgery

(VATS) approach — has achieved equipoise with open

lobectomy in terms of safety and efficacy, and the role of

VATS continues to expand.

Although lobectomy has generally been accepted as

the standard extent of resection required for NSCLC

surgery, sublobar resections in the form of wedge

resections or segmentectomies have been reported as

an alternative surgical technique, especially in patients

with significant comorbidities or l imited pulmonary

function. Surgical leaders in the thoracic oncology

community continue to vigorously debate the relative

merits of using less invasive techniques for cancer

resection, while also re-initiating discussions of sublobar

resection in an era of screening detection of very small

and peripheral lung cancers.

Two important developments in lung cancer wi l l

challenge the thoracic surgery community to reconsider

the role of more limited pulmonary resection using a

minimally invasive approach (2). First, with the generally

longer life expectancy of the worldwide population, and

therefore the incidence of lung cancer in the elderly

population will increase; and second, the provocative

results of the National Lung Screening Trial showed that

low-dose computed tomography (LDCT) lung cancer

screening irrefutably saves lives (3). These two trends

predict that patients with lung cancer will be older

and diagnosed at an earlier stage and will therefore

most likely have a preference for less invasive surgical

intervention.

VATS lobectomy: current evidence for outcomes in

surgery for NSCLC

Numerous reports have been published over the past

decade that promote the benefits of using the VATS

approach for lung cancer resection — benefits achieved

without compromising oncological eff icacy. Early

proponents argued that VATS offered less perioperative

morbidity, shorter hospitalizations, and less surgical

stress, with decreased serum levels of measured pro-

inflammatory cytokines, implying an immunological

benefit in cancer survival over the traditional open

thoracotomy (4-8). However, most of these studies

were criticized for selection bias because patients with

smaller, peripheral tumours underwent VATS, whereas

those patients with larger, more central tumours were

resected using the traditional open approach.

SPOTlight -2


In fact, there are very few direct comparisons between

VATS lobectomy and open lobectomy approach

for lung cancer resect ion. There have only been

two small, prospective, randomized controlled trials

comparing VATS with open lobectomy (9,10). Kirby et

al randomly assigned 61 stage I lung cancer patients

to either VATS or open lobectomy and found that

postoperative air leaks were reduced in the VATS

group, with no signif icant differences observed in

operating time, intraoperative blood loss, duration of

chest tube drainage, or length of hospital stay (9). The

other prospective study, by Sugi et al, randomized 100

patients with early stage lung cancer and likewise found

no significant differences between those patients who

received VATS lobectomy and those who underwent

open thoracotomy; 5-year survival after surgery was

90% in the VATS group and 85% in the open cohort

(10). These two small randomized studies suggested

that the results of the VATS procedure were comparable

to the conventional open approach, but that VATS

did not provide the purported improvement in early

postoperative outcomes reported in multiple non-

randomized case series. The widespread acceptance

of these studies was limited by the small numbers of

patients enrolled, their single-centre design, and the

fact that they were conducted during the early VATS

experience (2).

However, as the thoracoscopic approach to lung

surgery gained popularity worldwide, a substantial

body of literature accrued — including several large

published studies and systematic reviews — promoting

the benefits of the VATS lobectomy and comparing the

VATS approach with open anatomical lung resection

(11-15). These studies have emphasized improvements

in perioperative patient outcomes (presumably due to

the limited chest wall trauma with the VATS approach),

c i t ing less pulmonary morbidity, shorter hospital

lengths of stay, and less acute postoperative pain, with

improved immediate postoperative pulmonary function.

The faster postoperative recovery and return to baseline

quality of life associated with the VATS lobectomy has

also arguably implied quicker recovery for administration

of adjuvant chemotherapy in those patients who require

it.

In a comparison of VATS lobectomy and thoracotomy,

Whitson et al collected 39 studies, with a total of 3,114

VATS patients and 3,256 thoracotomy patients, and

found statistically significant decreased chest tube

duration and hospitalization, and improved 4-year

postresection survival in the VATS group (14). A similar

review published in 2009 by Yan et al also suggested

that the VATS approach had more favourable outcomes

than open lobectomy. These authors analyzed 21

comparative studies of VATS and open resection

and found no overal l d i f ference in postoperat ive

morbidity (defined as prolonged air leaks, arrhythmia,

and pneumonia) or mortality with VATS, but did find

improvement in systemic recurrence and long-term

mortality (15). These large meta-analyses had their

limitations, however, including lack of correction for

important variables, such as surgeon experience/

expertise, and nuances of tumour characteristics not

accounted for in staging (i.e. peripheral rather than

central location).

Although the accumulated body of evidence suggests

that VATS lobectomy for early NSCLC can be safely

performed with minimal, and arguably less procedural

morbidity, the oncological equivalence of this approach

compared with the gold standard of thoracotomy has

been justifiably scrutinized (16) Central to this issue

has been the thoroughness of mediast inal lymph

node dissection and subsequent accuracy of lung

cancer staging. The lack of contemporary multicentre,

prospective, randomized controlled trials limits the

evaluat ion of the oncological ef f icacy of VATS in

retrospective studies. A number of single-institution

experiences with VATS resection have suggested that

fewer mediastinal lymph nodes have been examined

compared with the open approach, thereby potentially

understaging patients with early stage lung cancer who

might have benefited from adjuvant therapy if they had

been accurately staged. Denlinger et al found in their

relatively early VATS experience that significantly fewer

mediastinal lymph node samples were obtained with the

VATS approach compared with thoracotomy; notably,

fewer N2 nodes (particularly station 7) and N2 stations

were sampled in the VATS group (17). Other recently

published retrospective single-institution studies have

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found similar results (18,19). Despite the significant

statistical differences reported in these studies with

regard to the number of lymph nodes and nodal stations

evaluated in VATS resection vs open resection for early-

stage lung cancer, significant differences in rates of

disease-free or overall survival have not been reported.

Weighing the cumulative evidence from the past decade

evaluating the oncological efficacy of VATS lobectomy in

early NSCLC treatment, the current recommendations

by the National Comprehensive Cancer Network (NCCN)

and the American College of Chest Physicians for stage

I NSCLC propose that VATS lobectomy is not inferior

to open lobectomy when performed at experienced

centres in appropriately selected patients (20,21).

More importantly, regardless of the selected method,

a systematic approach to lymph node evaluat ion

for accurate cancer staging is paramount when

making decisions regarding multimodality treatment

requirements. NCCN guidelines recommend N1 and

N2 lymph node resection and mapping during curative

surgery, with a minimum of three different N2 stations

sampled (22).

VATS lobectomy/sublobar resection in an aging

population

NSCLC remains a disease that is especially common

in the elderly; two-thirds of NSCLC patients are older

than 65 years, with an average age at diagnosis of

70 years (23). Historically, surgeons were reluctant to

offer surgery to older patients, presumably because

of increased perioperative morbidity and mortality

independently associated with advanced age. Different

single-institution studies suggest that minimally invasive

lung cancer resect ion in the very e lder ly can be

conducted with acceptable perioperative morbidity and

mortality (24-26).

Furthermore, a l though lobectomy is the current

standard of care for early stage lung cancer, a less

invasive approach combined with limited lung resection

for curative intent may also be considered in elderly

patients with lung cancer who are too debil i tated

to undergo lobectomy but might otherwise tolerate

surgery. A less extensive lung resection using VATS

that achieves negative tumour margins is currently still

preferred over non-surgical options for treating early-

stage NSCLC when a patient is unable to tolerate

the physiological impact of a lobectomy — although

outcomes of stereotactic radiation are promising and

may provide a reasonable alternative to surgery in

some patients. On the other hand, a practical but still

unanswered question is whether healthy individuals with

very advanced age should undergo sublobar resection,

trading the oncological superiority of a lobectomy —

open or VATS — for the perceived lesser perioperative

morbidity of a resection of lesser extent. The effect of

limited resection on overall long-term functional status

and quality of life balanced with overall actuarial survival

in this cohort has not been well studied (2).

VATS sublobar resection for very small/indolent

NSCLC detected by LDCT lung cancer screening

The increasingly used LDCT lung cancer screening

programmes allow more very early stage NSCLC to be

detected. Additionally, CT imaging technology allows

better characterization and detection of subcentimetre

lung lesions, which has generated interest among

thoracic surgeons in evaluating whether lobectomy is

uniformly superior to more limited resections.

Two large retrospective studies found statistically

significant worse 5-year survival in patients with stage IA

NSCLC who underwent sublobar resection compared

with lobectomy; Chang et al found that 5-year survival

was 44% for sublobar resection compared with 61%

for anatomical resection (27), and Whitson et al found

decreased overall and cancer-specific survival in the

sublobar group compared with the lobectomy group

(28). In contrast, other investigators have not found

inferior outcomes following sublobar resections —

particularly anatomical segmentectomy — compared

with lobectomy in early stage lung cancer patients

(29-32) and this is likely to be especially true for less

invasive or more indolent cancers detected during lung

cancer screening. Although both types of sublobar

resection preserve greater lung volume than lobectomy,

wedge resections are performed without regard to

anatomical bronchial segmental anatomy and do not

allow intrapulmonary lymph node sampling, which may

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result in higher rates of cancer recurrence. Performing

segmentectomy does allow for lymph node sampling but

is technically more challenging, particularly if performed

with VATS, as it requires detailed dissection of the

bronchial segment and pulmonary arterial supply.

A number of Japanese studies have shown promising

outcomes with VATS segmentectomy (30-32). These

studies reported that VATS segmentectomy compared

favourably with VATS lobectomy and had simi lar

perioperative outcomes without evidence of increased

locoregional recurrence. Altorki et al found adjusted

10-year survival outcomes comparable to those seen

with lobectomy when sublobar resection was used

to treat early solid nodule lung cancers (clinical stage

1A tumors) identified by a lung cancer CT screening

protocol (31). At this time, larger prospective clinical

studies are needed to more decisively qualify the role

of VATS segmentectomy in early stage lung cancer;

consequently, the thoracic oncology community awaits

the completion of two randomized studies investigating

the extent of lung resection necessary — lobectomy or

sublobar resection — for optimal surgical outcomes in

early stage NSCLC (33,34).

Conclusion

The popularity of minimally invasive thoracic surgery has

expanded the surgical options that thoracic surgeons

can offer to patients with early stage lung cancer.

VATS lobectomy has been associated with decreased

perioperative morbidity, and similar rates of locoregional

recurrence and cancer-free survival can be achieved

compared with the standard open surgical procedure.

The growth of the elderly population and the support

for LDCT screening of individuals at high risk for lung

cancer portends a growing demand for minimal ly

invasive approaches as surgically curable lung cancer is

identified at earlier stages. Although lobectomy currently

remains the standard of care for early NSCLC, for

patients with very small-sized lung tumours and indolent

lesions, cancer-free survival may not necessarily be

compromised by undergoing less invasive approaches

that intentionally resect less lung tissue by performing

sublobar resections.

References

1. Howington JAQ, Blum MG, Chang AC, et al. Treatment of stage I and II non-small cell lung cancer: Daignosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143:e278S-313S.

2. Cheng AM, Wood DE. Minimally invasive resection of early lung cancers. Available from: http://www.cancernetwork.com/oncology-journal/minimally-invasive-resection-early-lung-cancers. Accessed March 15, 2015.

3. Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395-409.

4. Yim AP, Wan S, Lee TW, Arifi AA. VATS lobectomy reduces cytokine responses compared with conventional surgery. Ann Thorac Surg. 2000;70:243-7.

5. Craig SR, Leaver HA, Yap PL, et al. Acute phase responses following minimal access and conventional thoracic surgery. Eur J Cardiothorac Surg. 2001;20:455-63.

6. Whitson BA, D’Cunha J, Maddaus MA. Minimally invasive cancer surgery improves patient survival rates through less perioperative immunosuppression. Med Hypotheses. 2007;68:1328-32.

7. Ng CS, Wan S, Hui CW, et al. Video-assisted thoracic surgery for early stage lung cancer – can short-term immunological advantages improve long-term survival? Ann Thorac Cardiovasc Surg. 2006;12:308-12.

8. Whitson BA, D’Cunha J, Andrade RS, et al. Thoracoscopic versus thoracotomy approaches to lobectomy: differential impairment of ce l lu lar immunity. Ann Thorac Surg. 2008;86:1735-44.

9. Kirby TJ, Mack MJ, Landreneau RJ, Rice TW. Lobectomy – video-assisted thoracic surgery versus muscle-sparing thoracotomy. A randomized trial. J Thorac Cardiovasc Surg. 1995;109:997-1001; discussion 01-2.

10. Sugi K, Kaneda Y, Esato K. Video-assisted thoracoscopic lobectomy achieves a satisfactory long-term prognosis in patients with clinical stage IA lung cancer. World J Surg. 2000;24:27-30; discussion 30-1.

11. Gopaldas RR, Bakaeen FG, Dao TK, et al. Video-assisted thoracoscopic versus open thoracotomy lobectomy in a cohort of 13,619 patients. Ann Thorac Surg. 2010;89:1563-70.

12. Paul S, Altorki NK, Sheng S, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg. 2010;139:366-78.

13. Scott WJ, Allen MS, Darling G, et al. Video-assisted thoracic surgery versus open lobectomy for lung cancer: a secondary analysis of data from the American College of Surgeons Oncology Group Z0030 randomized clinical trial. J Thorac Cardiovasc Surg. 2010;139:976-81; discussion 81-3.

14. Whitson BA, Groth SS, Duval SJ, et al. Surgery for early-stage non-small cell lung cancer: a systematic review of the video-assisted thoracoscopic surgery versus thoracotomy approaches to lobectomy. Ann Thorac Surg. 2008;86:2008-16; discussion 16-8.

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15. Yan TD, Black D, Bannon PG, McCaughan BC. Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer. J Clin Oncol. 2009;27:2553-62.

16. Mathisen DJ. Is video-assisted thoracoscopic lobectomy inferior to open lobectomy oncologically? Ann Thorac Surg. 2013;96:755-6.

17. Denlinger CE, Fernandez F, Meyers BF, et al. Lymph node evaluation in video-assisted thoracoscopic lobectomy versus lobectomy by thoracotomy. Ann Thorac Surg. 2010;89:1730-5; discussion 36.

18. Merritt RE, Hoang CD, Shrager JB. Lymph node evaluation achieved by open lobectomy compared with thoracoscopic l obec tomy fo r N0 l ung cance r . Ann Tho rac Su rg 2013;96:1171-7.

19. Lee PC, Nasar A, Port JL, et al. Long-term survival after lobectomy for non-small cell lung cancer by video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg. 2013;96:951-60; discussion 60-1.

20. Howington JA, Blum MG, Chang AC, et al. Treatment of stage I and II non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed. American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143:e278S-e313S.

21. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) non-small cell lung cancer, version 4.2015. Available from: http://www.nccn.org/professionals/physician_glos/PDF/nscl.pdf. Accessed February 11, 2015.

22. Farjah F, Flum DR, Varghese TK, Jr, et al. Surgeon specialty and long-term survival after pulmonary resection for lung cancer. Ann Thorac Surg. 2009;87:995-1004; discussion 05-6.

23. American Cancer Society. What are the key statistics about lung cancer? Available from: http://www.cancer.org/cancer/lungcancer-non-smallcell/detailedguide/non-small-cell-lung-cancer-key-statistics. Accessed February 11, 2015.

24. Cattaneo SM, Park BJ, Wilton AS, et al. Use of video-assisted thoracic surgery for lobectomy in the elderly results in fewer complications. Ann Thorac Surg. 2008;85:231-5; discussion 35-6.

25. Mun M Kohno T. Video-assisted thoracic surgery for clinical stage I lung cancer in octogenarians. Ann Thorac Surg. 2008;85:406-11.

26. Port JL, Mirza FM, Lee PC, et al. Lobectomy in octogenarians with non-small cell lung cancer: ramifications of increasing life expectancy and the benefits of minimally invasive surgery. Ann Thorac Surg. 2011;92:1951-7.

27. Chang MY, Mentzer SJ, Colson YL, et al. Factors predicting poor survival after resection of stage IA non-small cell lung cancer. J Thorac Cardiovasc Surg. 2007;134:850-6.

28. Whitson BA, Groth SS, Andrade RS, et al. Survival after lobectomy versus segmentectomy for stage I non-small cell lung cancer: a population-based analysis. Ann Thorac Surg. 2011;92:1943-50.

29. Okada M, Koike T, Higashiyama M, et al. Radical sublobar resection for small-sized non-small cell lung cancer: a multicenter study. J Thorac Cardiovasc Surg. 2006;132:769-75.



1. Surgery offers the greatest opportunity for cure of

NSCLC.

2. Lobectomy has been the standard operation for

early NSCLC.

3. VATS lobectomy leads to higher level of serum

pro-inflammatory cytokines.

4. VATS lobectomy leads to less pulmonary

morbidity.

5. Many randomized control studies compared VATS

vs open lobectomy.

6. Thoroughness of mediastinal lymph node

dissection should be the same in VATS and open

lobectomy.

7. Sublobar resection should be considered in elderly

with marginal lung function.

8. LDCT screening does not identify more very early

NSCLC.

9. Segmentectomy is technically more demanding

than wedge resection.

10. Wedge resection is preferred to segmentectomy in

surgery for early NSCLC.



1 CME Point

30. Yamashita S, Chujo M, Kawano Y, et al. Clinical impact of segmentectomy compared with lobectomy under complete video-assisted thoracic surgery in the treatment of stage I non-small cell lung cancer. J Surg Res. 2011;166:46-51.

31. Altorki NK, Yip R, Hanaoka T, et al. Sublobar resection is equivalent to lobectomy for clinical stage 1A lung cancer in solid nodules. J Thorac Cardiovasc Surg. 2014;147:754-62; Discussion 62-4.

32. Watanabe A, Ohori S, Nakashima S, et al. Feasibility of video-assisted thoracoscopic surgery segmentectomy for selected peripheral lung carcinomas. Eur J Cardiothorac Surg. 2009;35:775-80; discussion 80.

33. Cancer and Leukemia Group B. A phase III randomized trial of lobectomy versus sublobar resection for small (≤ 2 cm) peripheral non-small cell lung cancer. ClinicalTrials.gov identifier: NCT00499330. Available from: https://clinicaltrials.gov/ct2/show/NCT00499330. Accessed February 11, 2015.

34. Nakamura K, Saji H, Nakajima R, et al. A phase III randomized tr ial of lobectomy versus l imited resection for small-sized peripheral non-small cell lung cancer (JCOG0802/WJOG4607L). Jpn J Clin Oncol. 2010;40:271-4.


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Older people in Hong Kong are often challenged by

difficult decisions related to their estates in a filial culture.

In the very first community survey in 201310, 55.4% of

local older people required assistance in financial affairs

because of poor health, refusal and mental incapacity

but only 2% of the older people are using the Enduring

Power of Attorney11. Cognitive ageing in tandem with

other common risk factors such as sensory impairment,

medical and psychiatric co-morbidit ies and social

isolation can put the older people at risk for impaired

capacities and also become vulnerable to exploitation12.

There are more frequent court hearings for dispute in

wills and/or ownership of business in the last decade13.

On the other hand, more than 70% of the applications

for guardianship order are for the older people incapable

of managing their financial affairs since the inception

of the Hong Kong Guardianship Board every year14-16.

As a result, the Guardianship Board is promoting wider

coverage of the Enduring Power of Attorney with the

rationale of prevention is always better than cure16.

Like many western societies, a registered medical

practitioner in Hong Kong has de facto authority to

perform capacity assessment. Nonetheless, there are

few researches, guidelines or training opportunities on

the assessment of mental capacity in general, and in

particular, on the financial capacity assessment for the

elderly. Recent studies3,17-20 reveal that subtle cognitive

decline may result in financial incapacity among the

apparent “cognitively healthy” older people. On the

other hand, not all the older people with dementia are

incapable of managing financial affairs19-21. There is

a notable gap in the appreciation of the clinical and

Mind the Gap: Assessing Financial Capacity for the Elderly

In the last few decades, the alarm of ageing populations

has been ringing repeatedly across countries and

boundaries. Governments and healthcare providers

often share pessimistic views for the risk of encumbering

the public systems. On the contrary, the business and

financial sector are uncovering potential “longevity

economy” or “si lver hair market” among the older

people1-2. Their optimistic views are based on the forecast

that upcoming cohorts are more “healthy and wealthy”,

especially in the western countries. For instance, the

baby-boomers comprise of 13% of the population and are

holding 34% of the national wealth in the United States3.

They have to manage their investment and financial

affairs in order to arrange better healthcare schemes and

maintain their living standards after retirement 3-5.

In Hong Kong, the number of millionaires and multi-

millionaires is increasing over the past decade. In a

recent community survey, it is estimated that 12% of the

adult population are millionaires as defined by having at

least one million of “liquid cash” and 56,000 out of the

7.2 million Hong Kong people are multi-millionaires6.

They will become the upcoming cohorts of older people

and wil l constitute up to 30% of the population by

20417. Even for the present cohort of older people,

according to a population-based survey conducted by

the government in mid-2008, twenty-seven percent of

them own a flat and 3% of them has rented out a flat

or shop8. The crux is that the average price of a private

domestic flat has been escalating, for example, the

price of a flat in Kowloon has been nearly tripled for the

last two decades9 and the owners are multi-millionaires

owing to their estates.

Dr. LAM Chi LeungMBChB (CUHK), MSc Clinical Gerontology (CUHK),

MSc (Health and Hospital Mgt) (Birm), FHKCPsych, FHKAM (Psychiatry),

Specialist in Psychiatry

Prof. Helen CHIUMBBS(HK), MRCPsych, FRCPsych, FHKCPsych, FHKAM(Psychiatry)

Professor of Psychiatry, Department of Psychiatry, Faculty of Medicine,

Chinese University of Hong Kong


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ethical aspects, risks and problems associated with the

assessment of financial capacity in ageing societies19,20.

This article will review the basic principles of capacity

assessment and wi l l prov ide pract ica l s teps on

assessing testamentary capacity and general financial

capacity in the older people with cognitive impairment

via the below case scenarios.

Case scenarios

A. Mr. X, a 70-year-old widower who has just handed

over h is business to h is son. He has stable

hypertension and diabetes mellitus and has been

attending your clinic for more than a decade. Mr. X

is lately admitted to a private hospital for syncope

due to transient ischaemic attack. His son, who

was your high school classmate, invites you to visit

Mr. X at the hospital and sign on his father’s living

will….

B. Mr. X attends your clinic after the discharge. His

daughter comes along and reports that Mr. X

becomes less smart than before. She explains to

you that Mr. X has had a heated argument with his

son just before the admission. Mr. X is angry about

his son. They worry about his health and assets

and ask you to complete a medical certificate for

applying Mr. X’s enduring power of attorney….

As the family doctor who knows Mr. X and his family

well, will you sign on the documents as per request at

the hospital (scenario A) and at your clinic (scenario B)?

Do you have any areas of concern before signing the

legal documents for Mr. X? If you are going to complete

the legal procedures, what will be included in your

assessment?

Basic principles in capacity assessment

Capacity is pivotal in everyday decision-making, which

may or may not have legal consequences. Everyone

is f ree to make his own choices. Unless there is

evidence to the contrary, an adult is presumed to have

the capacity under common law24,25. It reflects the

fundamental legal (and ethical) principle of respecting

autonomy of an adult24-26. Different professionals such

as lawyer, medical practitioner and social worker have

been observing these principles in their daily practices.

In the same vein, medical and legal professionals

are presumed to have tested his cl ient’s capacity

before offering treatments and taking their instructions

respectively24. An important consideration in capacity

assessment is whether there is undue influence act

upon the decision process26,27. Undue influence refers

to dynamic between an individual and another person.

It describes the intentional use of social influence,

deception and manipulation to gain control of the

decision making of another person27.

The functional approach

There are dif ferent approaches, namely outcome

approach, status approach and functional approach

in contemporary capac i ty assessment 26,27. The

Mental Capacity Act in the United Kingdom has laid

down important pr inciples and guidel ines for the

assessment28. Hong Kong jurisdiction has adopted

a functional approach to assess the mental capacity

for adult older than 18 years old, i.e. the assessment

is specific to time and task25,26,29. In other words, the

standard of capabil i ty may vary with the t ime and

situation of assessment and the complexity of the task

involved in the same person. For example, an elderly

man with mild dementia may be capable to give consent

for surgical procedure to remove his skin nodule but

he may have big problem in deciding his future mode

of care. Ferrars and Shankar30 suggest a few key

questions to help the capacity assessment (Table 1). In

essence, the older person should show his capability

to remember and understand specific and relevant

information. He should have the ability to appreciate

and reason the given information and arrive at the

decision and communicate his decision to the assessor

voluntarily29,30.


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Table 1 Key questions for assessing capacity30

1 Does the person have a general understanding of what decision he needs to make and why he needs to make it?

2 Does the person have a general understanding of the likely consequences of making, or not making, this decision?

3 Is the person able to retain, understand, use and weigh up the information relevant to this decision?

4 Can the person communicate the decision?

5 Is there a need for a more thorough assessment perhaps by involving a professional expert?

Documentation

The number of referral for capacity assessment in

hospitals in the United Kingdom has been surging since

the implementation of the Mental Capacity Act31,32. From

our clinical experiences, it is also true in Hong Kong (see

introduction). As the concept of mental capacity is more

of a legal one and medical practitioners sometimes over-

estimate their patient’s capacities24,33, it is therefore a

good practice for the assessor to document important

clinical information28,29, for examples, the aim of the

examination, where and when the assessment take

place, what is the patient’s cl inical condition, any

sensory loss or dialect barrier, what kind of information

is given to the patient, what are the replies of the

patient verbatim, and anyone else is present during

the assessment so that the record can be used for

retrospective assessment and court evidence. It is

because “whether an individual has or lacks capacity to

do something is ultimately for a court to answer” 24.

Case analysis fo r scenario A

As his family doctor and friend, it is reasonable to visit

Mr. X at the hospital upon invitation. We will expect

questions about his medical problems, recent stroke

and current treatments. However, we may not be

prepared for formal or informal request for signing any

legal documents; especially we are invited by one of his

children. The invitation may appear to be “as a witness”

in completing the legal documents governed by section

5 and 10 of the Wills Ordinance of Hong Kong Law.

Nonetheless, as a medical practitioner, it implies that we

are satisfied with the testamentary capacity of Mr. X to

make a living will on ward (see Kenward v Adams)24,26,34.

We need to understand what testamentary capacity is,

appreciate the family dilemma and consider important

ethical issues in this case.

Assessing testamentary capacity

First of a l l , Mr. X ( the testator) must agree to be

assessed on ward for the above-mentioned purpose25.

Taking the basic principles of capacity assessment, we

will look for specific components in the testamentary

capacity27. The assessor should test if Mr. X i) knows

what a will is; ii) have knowledge about his potential

heirs e.g. his children; iii) aware of the nature and extent

of his assets e.g. his business; and iv) have a general

plan of distribution of assets to his heirs e.g. who will

get his companies and properties. In the judgment

of the famous case Banks v Goodfellow34, the judge

also deliberated that the testator should NOT have a

mental disorder which affects him to make bequests

(dispositions) in the will and that he would not otherwise

have included, in addition to the understanding of the

following components29,34:

• The nature and effect of making a living will

• The extent of his estate in general

• The claims of those who might expect to benefit

from the testator’s will (both those being included

in, and being excluded from, the will)

Testator with neurodegenerative disorders such as

Alzheimer’s disease and Parkinson’s disease; acquired

neurological injuries such as stroke, traumatic brain

injury and developmental disorders (for examples,

mental handicap and autism) may have different degree

and aspect of cognitive impairment3,27,34. In addition,

elderly with severe mental disorders like schizophrenia

and bipolar disorder may exclude potential beneficiaries

under psychotic influence. It is better for the testator

to write down the reason(s) for excluding particular

beneficiary in the will29,34.

14 HKMA CME Bulletin 持續醫學進修專訊 May 2015 www.hkmacme.org

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Recent studies20,22,27 note that the testator relies heavily on the verbal (language) and executive function instead of using pragmatic skills in forming the testamentary capacity. Executive function refers to higher cerebral processes in the areas of goal formation, planning, response inhibition, self-monitoring, and coordination of series of complex behaviors20. For instance, the testator with cognitive impairment may give clear account of all the specific components except he may have problem to form working estimates of the value for key assets (which should reasonably approximate their true value in a capable person)20,27. If there is evidence that Mr. X has problem with one or more of above components, the assessment should be concluded with incapacity.

For medica l pract i t ioner wi th specia l in terest in testamentary capacity, Jacoby and Steer34 suggest the process of assessment should include (Table 2):

Table 2 Process of assessment for testamentary capacity34

1 Get a letter from the solicitor detailing the legal tests

2 Set aside enough time for the process

3 Assess (in the standard way) whether the patient has dementia or other mental disorder

4 Check that the patient understands each of the Banks v Goodfellow points

5 Record the patient’s answers verbatim

6 Check the facts, such as the extent of the assets with the solicitor

7 Ask about and review previous wills

8 Ask why potential beneficiar ies are included or excluded

9 If in doubt about capacity, seek second opinion from an old age psychiatrist or other expert

Nonetheless, in Mr. X’s scenarios, we should read between the l ines and “smel l ” something wrong between his children. Therefore, a formal psychiatric evaluation is recommended for Mr. X to prepare for future legal challenge.

Professional duty of care

Whether or not the medical practitioner is responsible for the capacity assessment, we have the duty to take care of the best interest of our patients. Older people with diminished capacity are at risk for abuse and financial exploitation35. A local case of f inancial abuse was discovered because hospital staff was vigilant in helping the potential victim36. Besides, it is not uncommon for older people develop hypoactive, hyperactive or mixed type of delirium which disturbs their cognitive functions temporarily in hospital. Despite the fact that Mr. X does not have pre-existing risk factors such as major psychiatric disorders and dementia, we need to look for any temporary cognitive impairment resulted from complications of transient ischaemic attack, unstable blood glucose and blood pressure on ward. We have the duty to optimize and stabilize his clinical condition as much as possible before doing the capacity assessment; otherwise, we may put ourselves at risk for professional misconduct28.

Case analysis for scenario B

Accord ing to the Endur ing Powers o f A t to rney Ordinance11, an enduring power of attorney is a legal instrument which allows its donor (i.e. the person who wishes to give his power of attorney to someone) to appoint attorney(s) to take care of his financial affairs in the event that he becomes mentally incapacitated subsequently. A registered medical practitioner (not necessarily a specialist) must sign on the prescribed form of the Enduring Power of Attorney to certify the donar’s mental capacity. In this scenario, we need to pay attention to Mr. X’s anger towards his son which may impair his judgment and may be used as an undue influence. Considering Mr. X’s advancing age and vascular risk factors (hypertension and diabetes mellitus), it is not wise to agree with the suggestion that (if being asked) Mr. X’s admission was the result of argument with his son. As Mr. X has recovered from his transient ischaemic attack with probable neurocognitive impairment, we are in a better position to examine his cognitive functions, functional status and the capacity to manage financial affairs in the clinic.


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Assessing f inancial capacity in cognit ively

impaired elderly

Marson et al3,19,22,23 def ine f inancial capacity as a

medico-legal construct that “represents the abil ity

to manage one ’s f i nanc ia l a f f a i r s i n a manne r

consistent with one’s personal se l f- interest and

values”. It also includes specific capacities, namely

contractual, donative and testamentary in the United

States27. In contrast to the capacity for consent to

medical treatments, this concept is broadly based

and depends on the older person’s socioeconomic

status, occupational achievement and overall financial

experience3,23. The capacity to manage one’s financial

affairs, ranging from basic skills like counting coins

and currency to more complex skills such as paying

bills, managing a checkbook and exercising financial

j udgment has impor tan t economic and sa fe t y

consequences for the older people23,35. The problem is

that financial capacity is highly susceptible to cognitive

impai rment which is o f ten missed by the fami ly

caregivers. One of the reasons is that the older people

with early dementia may still be able to perform some

financial activities (e.g. handle basic cash transactions)

but not the others (e.g. make investment decisions or

asset transfers)37. In fact, the ability to manage financial

affairs is one of the first instrumental ADLs to decline in

mild cognitive impairment and Alzheimer disease17.

The importance of obtaining information regarding one’s

lifelong values and approaches in managing money and

financial affairs has been emphasized in the assessment

of financial capacity for the older people23,27. A number of

general or specific rating scales can be used to aid the

assessment18,21,27. It is noteworthy that the commonly

used Mini-Mental State Examination38 is now protected

by copyright and is charged for use. In fact, making

a referral to experienced occupational therapist or

psychologist for testing the neurocognitive functions

of older people can be an option and use of modern

technology e.g. voice or video recording is increasingly

common in complicated situation29,39.

The role of family doctor

Mr. X’s fami ly has been seeking the advices and

treatments from family doctor for more than a decade.

The rapport and duration of contact is a powerful mean

to monitor the financial capacity of older people. In

western countries, the family doctor may share the role

of (1) educating the patients and families about the need

for advance financial planning; (2) recognizing signs of

diminished financial capacity; (3) assessing financial

impairments in cognitively impaired older people; (4)

recommend interventions to help patients maintain

financial independence; and (5) knowing when and

to whom to make medical and legal referrals12,30. The

World Psychiatric Association also reminds medical

professionals against ageism and discrimination in

examining the older people with mental problems40.

The court always considers the expertise of medical

professionals in giving expert evidence in writing or

in person41. In order to safeguard our profession, we

need to consider five main questions29 before doing

the capacity assessment and then proceed with the

suggested framework for the older people in the

community (Table 3)30:

What: What types of decisional or functional processes

are in quest ion? What data are needed? Am I an

appropriately qualified evaluator? Do I have a conflict of

interest?

Who: Who is the client? What is the older person’s

background? Who is requesting the evaluation? Who are

the interested parties? Who sees the report? Is the court

or litigants involved?

When: How urgent is the request? Is there a court

date? What is the time frame of interest? Is the individual

medically stable?

Where: In what context/setting does the evaluation take

place?

Why: Why now? What is the history of the case? Will a

capacity evaluation resolve the problem?


SPOTlight -3

Table 3 Checklist for assessing financial capacity30

a) Personal information: Age and life expectancy

Social, cultural and family background

Medical and psychiatric history

The extent to which capacity could

fluctuate

Amount of support needed

b) The extent of the person’s

property and investments:

Income, capital, expenditure and liabilities

The skills, knowledge and time required to

manage business affairs properly

Whether the person would be likely to seek,

understand and act on appropriate advice

when needed

c) A person’s vulnerability: Could inability to manage business affairs

lead to the person making rush decisions?

Could inability to manage lead to

exploitation by others?

Conclusion

The alarm of ageing population is ringing in Hong Kong.

The number of financially incapacitated older people

will increase sharply in the coming decades. Older

people need the support of their relatives to handle their

financial affairs in a filial society but it may impose the

risk of being financially exploited. Registered medical

practitioners can perform capacity assessment by law

and have the duty to safeguard the best interest of our

patients. We should consider clinical, ethical and legal

aspects in assessing financial capacity for the older

people and should be prepared for legal challenge.

There is a pressing need for further education, training

and research on financial capacities for the older people.

References

1. Bank of American Corporation (Merrill Lynch). The end of old [Internet], 2015. (cited 2 Jan 2015). Available from: www.ml.com/articles/the-end-of-old.html

2. Sau Po Centre on Ageing and Policy 21 Limited. A study on silver hair market development in selected economies [Internet], June 2011. (cited 2 Jan 2015). Available from: www.cpu.gov.hk/doc/tc/research_reports/SHM%20Volume%202.pdf

3. Marson DC, Sabatino CP. Financial capacity in an ageing population [Internet], Generations, Summer 2012. (Cited 6 Jan 2015). Available from: www.asaging.org/blog/financial-capacity-aging-society-0

4. Merrill Lynch (Bank of American Corporation) and Age Wave. Health and retirement: Planning for the great unknown [Internet], 2014. (cited 2 Jan 2015). Available from: www.ml.com/publish/pdf/mlwm_health-and-retirement-2014.pdf.

5. Weierich MR, Kinsinger EA, Munnell AH, Sass SA, Dickerson BC, Wright CI, et al. Older and wiser? An affective science perspective on age-related challenges in financial decision making. SCAN 2011; 6, 195-206.

6. Siu P. Number of Hong Kong multimillionaires up 14 per cent (and one in 10 wants to leave) (cited 25 Mar 2015). SCMP; 24 Mar 2015, Available from: www.scmp.com/news/hong-kong/article/1746310/10pc-hong-kong-multimillionaires-thinking-about-leaving-city-next

7. Census and Statistics Department (The Government of HKSAR). Hong Kong Population Projections (Internet) (cited 4 Jan 2015). Available from: www.censtatd.gov.hk/press_release/pressReleaseDetail.jsp?charsetID=1&pressRID=2990

8. Census and Statistics Department (The Government of HKSAR). Thematic Household Survey Report No. 40: Socio-demographic Profile, Health Status and Self-care Capability of Older Persons. Hong Kong SAR; Aug 2009.

9. Rating and Valuation Department (The Government of HKSAR). Property Market Statistics. (cited 4 Jan 2015). Available from: www.rvd.gov.hk/en/property_market_statistics/

10. The CADENZA project: A Jockey Club Initiative for Seniors releases research findings on Elderly Financial Management (Internet) (Cited 25 Mar 2015). Available from: www.hku.hk/press/press-releases/detail/9177.html

11. The Government of the Hong Kong Special Administrative Region (Department of Justice). Enduring Power of Attorney. (cited 8 Jan 2015). Available from: http://www.doj.gov.hk/eng/epa/

12. Moye J, Marson DC, Eldelstein B. Assessment of capacity in an aging society. American Psychologist, April 2013, Vol. 68, No. 3, 158-171 DOI: 10.1037/a0032159

13. Bloomsberg News. Macau billionaire Ho says, dispute ends, driving up SJM stocks. (Internet). 11 Mar 2011. Available from: http://www.bloomberg.com/news/articles/2011-03-10/macau-casino-magnate-stanley-ho-says-family-dispute-resolved

14. Hong Kong Guardianship Board. Second Report 2003-2006. Hong Kong: Hong Kong Guardianship Board; Jan 2007. (cited 4 Jan 2015). Available from: http://www.adultguardianship.org.hk/content.aspx?id=publications&lang=en

15. Hong Kong Guardianship Board. Third Report 2006-2008. Hong Kong: Hong Kong Guardianship Board; Dec 2009. (cited 4 Jan 2015). Available from: http://www.adultguardianship.org.hk/content.aspx?id=publications&lang=en

16. Hong Kong Guardianship Board. Fourth Report 2009-2011. Hong Kong: Hong Kong Guardianship Board, 2012. (cited 4 Jan 2015). Available from: http://www.adultguardianship.org.hk/content.aspx?id=publications&lang=en

17. Boyle PA, Yu L, Wilson RS, Gamble K, Buchman AS, et al. Poor decision making is a consequence of cognitive decline among older persons without Alzheimer’s disease or mild cognitive impairment. PLoS ONE August 2012; 7(8), e43647.

18. Okonkwo OC, Wadley VG, Griffith HR, Ball K, Marson DC. Cognitive correlates of financial abilities in mild cognitive impairment. J Am Geriatr Soc 2006; 54, 1745-1750.


SPOTlight -3

19. Widera E, Steenpass V, Marson D, Sudore R. Finances in the older patient with cognitive impairment. JAMA Feb 16 2011; 305, 7, 698-706.

20. Kim SYH, Kalawish JHT, Caine ED. Current state of research on decision making competence of cognitively impaired elderly persons. Am J Geriatr Psychiatry Mar 2002; 10(2), 151-165.

21. Lui VWC, Lam LCW, Chau RCM, Fung AWT, Wong BML, Leung GTY, et al. Structured assessment of mental capacity to make financial decisions in Chinese older persons with mild cognitive impairment and mild Alzheimer disease. J Geriatr Psychiatry Neurol 2013; 26(2), 69-77.

22. Knight AJ, Marson DC. The emerging neuroscience of financial capacity. [Internet] Generations, Summer 2012; 36, 2, 46-52. (Cited 6 Jan 2015). Available from: www.asaging.org/blog/emerging-neuroscience-financial-capacity

23. Marson DC. Clinical and ethical aspects of financial capacity in dementia: a commentary. Am J Geriatr Psychiatry, April 2013; 21, 4, 382-390.

24. British Medical Association. Assessment of Mental Capacity: Guidance for doctors and lawyers, 2nd edition. London: BMJ Publishing; 2004, Chapter 1&3.

25 Wong JG, Scully P. A practical guide to capacity assessment and patient consent in Hong Kong. Hong Kong Med J 2003; 9, 284-289.

26. Lam TCP. Testamentary Capacity, HKMA CME Bulletin, May 2012. (Cited 6 Jan 2015). Available from: www.hkma.org/english/cme/cmebulletin.htm

27. American Psychological Association. Assessment of Older Adults with

Diminished Capacity: A Handbook for Psychologists. United States:

American Bar Association Commission on Law and Aging – American

Psychological Association. (cited 6 Jan 2015). Available from: www.apa.

org/pi/aging/programs/assessment/capacity-psychologist-handbook.pdf

28. British Medical Association. The Mental Capacity Act 2005: Guidance for

health professionals. Sep 2009

29. Jacoby R. Mental Capacity in Old Age Psychiatry, Presented at the

Workshop on Testamentary Capacity and Other Types of Mental

Capacities. Hong Kong, 11 Nov 2011.

30. Ferrars F, Shankar R. Assessing Mental Capacity [Internet], InnovAiT 2011;

4, 2, 98-103. (cited 8 Jan 2015). Available from: http://ino.sagepub.com/

content/4/2/98

31. Mujic F, Heising MV, Stewart RJ, Prince MJ. Mental capacity assessments

among general hospital inpatients referred to a specialist liaison psychiatry

service for older people. Int Psychogeriatr 2009; 21:4, 729-737.

32. Kornfeld DS, Muskin PR, Tahil FA. Psychiatric evaluation of mental

capacity in the general hospital: a significant teaching opportunity.

Psychosomatics 2009; 50: 468-473.

33. Lepping P. Overestimating patients’ capacity, Br J Psychiatry 2011; 199,

355-356. doi: 10.1192/bjp.bp.111.094938

34. Jacoby R, Steer P. How to assess capacity to make a will. BMJ 2007;

335:155-7.

35. Centre for Policy on Ageing. The financial abuse of older people [Internet].

(cited 8 Jan 2015). Available from: www.cpa.org.uk/policy/briefings/

financial_abuse.pdf

36. Chan TC, Luk JKH, Liu A, Chiu PKC, Chan FHW, Chu LW. Financial abuse

in a mentally incapacitated old man. Hong Kong Med J 2009; 15, 213-

216.

37. Martin R, Griffith HR, Belue K, Harrell L, Zamrini V, Anderson B, et al.

Declining financial capacity in patients with Alzheimer’s disease: a one-

year longitudinal study. Am J Geriatr Psychiatry, March 2008; 16, 3, 209-

219.

38. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical

method for grading the cognitive state of patients for the clinician. J

Psychiatr Research 1975; 12, 3, 189-98.

39. Appelbaum PS. Assessing and reporting other mental capacities.

Presented at the Workshop on Assessment of Mental Capacities. Hong

Kong, 22 June 2012.

40. Katona C, Chiu E, Adelman S, Baloyannis S, Camus V, Firmino H, et al.

World psychiatric association section of old age psychiatry consensus

statement on ethics and capacity in older people with mental disorders. Int

J Geriatr Psychiatry 2009; 24: 1319-1324.

41. The Academy of Experts. Role & responsibilities of the expert. Expert

Witness Training, March 2015; Hong Kong.



1. Medical practitioner in Hong Kong is entitled to

perform capacity assessment by law.

2. An adult is presumed to have capacity and is

responsible for his decisions.

3. A diagnosis of dementia or mental disorder can

justify mental incapacity.

4. Basic capacity assessment should be specific

to time and task irrespective of the patient’s

diagnoses.

5. A medical practitioner’s signature on a living will

makes no difference as an ordinary witness in

court.

6. Medical practitioner is encouraged to assess

financial capacity when the patient is hospitalized.

7. The Enduring Power of Attorney is authorized by

the Mental Capacity Act in Hong Kong.

8. Financial capacity is the first instrumental ADL to

decline in the elderly.

9. If an elderly lost his money in the stock market, he

must have diminished financial capacity.

10. Guardianship order can cover the financial affairs

of the mentally incapacitated person.



1 CME Point


Cardiology

A Patient with Acute Pulmonary Edema.

Complete BOTH Cardiology andDermatology courses and earn

0.5 CME POINT

The content of the May Cardiology Series is provided by:

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

五月臨床心臟科個案研究之內容承蒙胡國樑醫生提供。

A 56-year-old gentleman was admitted for palpitation and dyspnoea. Clinically he was in acute pulmonary

edema. His blood pressure was 85/45mmHg and pulse was 130/min. His SaO2 was 93% while on 10L oxygen

therapy. Subsequently he required non-invasive ventilator (NIV) support.

1). What is the ECG diagnosis?

A. Ventricular fibrillation

B. Ventricular tachycardia

C. Atrial fibrillation

D. Pre-excited atrial fibrillation

E. Atrial tachycardia

2). What treatment should be given in the acute

phase?

A. Intravenous metoprolol

B. Oral metoprolol

C. Intravenous adenosine triphosphate (ATP)

D. Synchronized electrical cardioversion

E. External chest compression

After receiving appropriate treatment in the acute

phase, this was the ECG of the same patient:

3). What should be the long term treatment?

A. Percutaneous coronary intervention

B. Permanent pacemaker implantation

C. Radiofrequency ablation

D. Transesophageal Echocardiogram

E. Holter study

Q&A Please indicate one answer to each question



Cardiology

April AnswersA Young Lady Presented with Severe Dyspnea and Edema

Answers:

1) Central and peripheral cyanosis.

2) Transthoracic echocardiograhy suggested

severe pulmonary hypertension, there was D

shaped LV with grossly dilated RV/RA.

3) Idiopathic pulmonary arterial hypertension.

4) Right heart catheterization with vasoreactivity

test.

5) Oxygen, anticoagulant, diuretics.

6) Yes, non-responders to acute vasoreactivity testing and in WHO-FC

II, or responders who remain in (or progress to) WHO-FC III should be

considered candidates for treatment with either an endothelin receptor

antagonist or a phosphodiesterase type-5 inhibitor, or a prostanoid.

7) Yes, There are no studies using flight simulation to determine the

need for supplemental O2 during prolonged flights in patients with

PAH. The known physiological effects of hypoxia suggest that in-flight

O2 administration should be considered for patients in WHO-FC III

and IV and those with arterial blood O2 pressure consistently <8 kPa

(60 mmHg). A flow rate of 2 L/min will raise inspired O2 pressure to

values seen at sea level. Similarly, such patients should avoid going

to altitudes above 1500–2000m without supplemental O2. Patients

should be advised to travel with written information about their PAH

and be advised how to contact local clinics in close proximity to where

they are travelling.

Figure 1.

Figure 2. CXR on admission suggested cardiomegaly.

Figure 3. Para-long para-short Apical-4 Subcostal


Cardiology

The content of the April Cardiology Series is provided by:

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

Dr. LO Ka Yip, David MbChB(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in Cardiology

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

四月臨床心臟科個案研究之內容承蒙張玲玲醫生、盧家業醫生及鍾德惇醫生提供。

Figure 4. Contrast CT thorax showed pulmonary hypertension with dilated right atrium, right ventricle and pulmonary trunk (~ 53mm)

Figure 5. No mismatch defect could be identified to suggest the presence of pulmonary thromboembolism, low probability for pulmonary thromboembolism.

Reference

ESC Guidel ines for the diagnosis and

treatment of pulmonary hypertension.

2009.

香港醫生網The Hong Kong Doctors Homepage

www.hkdoctors.org

This web site is developed and maintained by the Hong Kong Medical Association for all registered Hong Kong doctors to house their Internet practice homepage. The format complies with the Internet Guidelines which was proposed by the Hong Kong Medical Association and adopted by the Medical Council of Hong Kong.

We consider a practice homepage as a signboard or an entry in the telephone directory. It contains essential information about the doctor including his specialty and how to get to him. This facilitates members of the public to communicate with their doctors.

This website is open to all registered doctors in Hong Kong. For practice page design and upload, please contact the Hong Kong Medical Association Secretariat.

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

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

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


Dermatology

A 10-year-old Boy With Itchy Skin Rash Over Body and Limbs

The content of the May Dermatology Series is provided by:

Dr. CHAN Hau Ngai, Kingsley, Dr. TANG Yuk Ming, William, Dr. KWAN Chi Keung and Dr. LEUNG Wai Yiu

Specialists in Dermatology & Venereology

五月皮膚科個案研究之內容承蒙陳厚毅醫生、鄧旭明醫生、關志強醫生及梁偉耀醫生提供。

A 10-year-old boy with good past health complained of itchy skin

rash over body and limbs for 1 year. There was no systemic upset.

Physical examination showed fine scaly erythematous papules over

body and limbs and sparing the face. The eye and oral mucosae

were unremarkable.

1. What is the diagnosis?

2. What are the differential diagnoses?

3. What is the underlying cause of this skin disease?

4. How do you confirm the diagnosis?

5. What are the treatments?

Q&A Please answer ALL questions


Answers:

1. The cl inical diagnosis is Angiokeratoma of

Fordyce, which is characterized by multiple

small bright red vascular papules of 1-4 mm in

diameter appearing over the scrotum and the

onset could be as early as adolescence.

2. It includes genital wart, pyogenic granuloma,

melanocytic nevi and malignant melanoma.

3. Angiokeratoma of Fordyce is a benign vascular

condition of which the exact cause is yet to

know. It is believed that increased venous

pressure might be a poss ib le factor and

therefore examination of the abdomen for intra-

abdominal mass is necessary when urinary tract

tumour or hernia is suspected.

4. Other than the scrotum, the papules are

commonly found in penile shaft, labia majora

of the vulva, inner thigh and lower abdomen as

well.

5. The condition may

simply be managed

b y e x p l a n a t i o n

and reassurance.

N o t r e a t m e n t i s

required except for

cosmetic reason or

recurrent bleeding.

Effective therapy reported includes surgical

exc is ion, cr yosurger y, laser therapy and

electrocautery.

April Answers

A Gentleman with Multiple Papules on His Scrotum

The content of the April 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

四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。

Complete BOTH Cardiology andDermatology courses and earn

0.5 CME POINT


Complaints & Ethics

Some 30 years ago when I first started private practice,

I was approached by a surgeon who came to me with

two gold coins to thank me for my two referrals. When I

opened the package and realized what he did, I had to

rush out to the lift to push back the coins into his pocket

with a firm ‘NO’.

At around the same period, I was phoned up by a

doctor who graduated outside of Hong Kong and

referred me some patients in internal medicine. He

very frankly asked me how much I would rebate him

for each referral. I had to tell him that with the rate I

charged ($250 per consultation at that time), I didn’t

think it was appropriate to send him any kickbacks, and

furthermore, it was immoral.

Nearly two decades ago, one of the disputing partners

of a laboratory passed to the ICAC a little black book

listing the names of doctors who were given rebates for

sending their patients to the laboratory. It was fortunate

that no charge was laid subsequently or it would be a

most damaging scandal for the profession.

On 5 January 2003, the HKMA, in collaboration with

the ICAC, released a guidebook entitled “Integrity in

Practice: A Practical Guide for Medical Practitioners

on Corruption Prevention”. The Guidebook contains

information on the anti-corruption laws and on the

corruption prone areas in the practice of medicine,

illustrated by cases or hypothetical cases from both

the public and private sectors. All doctors in Hong

Kong received a CD with the electronic version of the

Guidebook then and printed copies were distributed

via HA, DH and the private hospitals. They were also

available through HKMA secretariat and the ICAC

Regional Offices. It is regrettable that doctors graduating

after 2003 may not be aware of the guidebook and may

commit offences punishable in a Court of Law as well as

by the Medical Council Inquiry.

In the Code of Professional Conduct, 13.1 states that

‘a doctor may refer a patient to any hospital, nursing

home, health center or similar institution, for treatment

by himself or other persons only if it is, and is seen

to be, in the best interest of the patient……doctors

proposing to refer a patient to an institution in which they

have a financial interest, whether by reason of a capital

investment or a remunerative position, should always

disclose the interest to the patient before making the

referral’. 14.1 stipulates that ‘a doctor shall not offer to,

or accept from, any person or organization (including

diagnostic laboratories, hospitals, nursing homes,

health centers, beauty centers or similar institutions)

any financial or other inducement (including free or

subsidized consulting premises or secretarial support)

for referral of patients for consultation, investigation or

treatment’. 14.2 makes it clear that ‘a doctor shall not

share his professional fees with any person other than

the bona fide partners of his practice. However, it is not

a form of fee-sharing for a doctor to make payment to

other doctors and healthcare professionals collaborating

in the provision of bona fide medical services to the

patient, provided that the patient is informed of their

involvement and services as soon as reasonably

practicable.’

Integrity in Practice MBBS (HK), MFM (Clin)(Monash), LRCP (Lond), MRCS (Eng), MRCP (UK), FRCP (Irel), FHKCP, FRACGP, FHKCFP, DFM (CUHK), FHKAM (Medicine), FHKAM (Family Medicine), DCH (Lond), DOM (CUHK), DPD (Cardiff), PDipID (HK), PDipComPsychMed (HK), PDipCommunityGeriatrics (HK), Dip Ger Med RCPS (Glasg)Specialist in NephrologyDr. CHOI Kin


Complaints & Ethics

As PIC Chairman, I sti l l receive complaints on this

issue of fee spl i t t ing and rebate, even from non-

loca l g raduates , but the cases are few and in-

between. Recently, however, a rather senior doctor

asked the duty council member of HKMA whether

he could, as a surgeon, write a cheque of $1000 to

the referring doctor, as a gesture of thanks, for ‘the

trouble of referring which would involve a detailed and

comprehensive letter with chronological events, copies

of laboratory reports, ECGs and other investigations

etc. as well as physically writing down the address,

telephone numbers and office hours and ringing on

behalf of the patient to make a booking and telephone

communications between each other for the sake of

understanding the patient’s case’?

The Guide in 2.1.1 talked about the PBO – Prevention

of Bribery Ordinance, which is the piece of legislation

against corruption in Hong Kong. Doctors in private

practice are required to observe Section 9 of the PBO.

The spirit of Section 9 is to maintain fair play in the

private sector and to uphold market integrity. The gist of

the law follows:

1) It is an offence for the agent to solicit or accept an

advantage when conducting his principal’s affairs

or business without the permission of his principal.

2) Any person who offers such an advantage is also

guilty of an offence.

3) I t is an offence for an agent to use any false

document, receipt or account to deceive his

principal.

In the above description, agent is a person acting for,

or employed by, the principal, and hence is the doctor.

The Principal generally refers to an employer and in this

case should be the patient who is paying. Advantage

refers to anything that is of value such as money, gift,

employment, service or favor etc. but does not include

entertainment which is def ined as food or dr inks

provided for immediate consumption on the occasion. If

the agent is given permission by his principal to accept

an advantage in relation to his official duties, then it is

lawful. A person convicted of an offence under Section 4

or Section 9 of the PBO is subject to a maximum penalty

of seven years’ imprisonment and a fine of $500,000

while the maximum penalty of violating Section 5 is ten

years’ imprisonment and $500,000 fine.

In the member’s inquiry, he challenged why he cannot

thank the doctor who referred him the case with a

monetary reward – that referring doctor has done so

much during the process of referral, writing a proper

referral letter etc. The questions ar is ing from the

challenge are obvious: did the referring doctor not

receive his fees for writing the referral letter already?

Was it not his duty to write a proper referral letter for

his patient with the proper details? By accepting the

$1000, was he referring because of the skil l of the

surgeon or because of the rebate? Has the referring

doctor informed the principal, his patient who paid him,

that he will be receiving such a monetary reward for

the referral? Did the principal (patient) agree to such a

financial arrangement between the referring doctor and

the surgeon to whom he/she was referred to? Was a

level playing field for other surgeons created who might

be more competent than the one dishing out the $1000

when such an arrangement was allowed?

It is obvious that the surgeon has committed a crime if

he provided the rebate and it is obvious that he should

stop lest he be thrown to prison. The same would apply

to doctors who are in partnership with laboratories and

refer patients to the laboratory with which they have

financial arrangements. The only allowance permitted

under the Code is proper explanation to the patient

that they are financially involved with the laboratory to

which they are sending the patient and with the patient’s

agreement. Receiving rebates for looking at laboratory

reports and radiological reports are not allowed. It is

time that doctors are aware of the risk they are taking

for these improper financial transactions lest they be

brought to a criminal court.


Dermatology

1

2

3

4

5

1 2 3

Complete BOTH Cardiology & Dermatology cases and earn 0.5 CME point

Cardiology

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

Name 姓名 Signature簽名：

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

Contact Tel No.聯絡電話：

HKID No. 香港身份証號碼： - xxx(x)

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

SPOTlight - 1Complete Spotlight and earn 1 CME point

ANSWER SHEETPlease return thecompleted answer sheetto the HKMA Secretariat(Fax: 2865 0943) on orbefore 15 June 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6月15日前將答題紙傳真或寄回香港醫學會 (傳真號碼：2865 0943)。如果選擇在網上完成練習，便無需將答題紙傳真到秘書處。

Answer Sheet

May 2015

答題紙

1 2 3 4 5 6 7 8 9 10

1 2 3 4 5 6 7 8 9 10


1 2 3 4 5 6 7 8 9 10

1 2 3 4 5 6 7 8 9 10

1 2 3 4 5 6 7 8 9 10


1 2 3 4 5 6 7 8 9 10


CMEnotifications

HKMA CME Programme香港醫學會持續進修計劃

CME Lecture – June 2015 進修講課－二零一五年六月

HKMA Structured CME Programme with HKS&H Session VI: Ultrasound for Head & Neck Disease

Dr. WONG Kim Ping, RexMBBS (HK), FRCR, FHKCR, FHKAM (Radiology), Specialist in Radiology

Date: 11 June 2015 (Thursday)

Time: 2:00–3:00 p.m. [Light lunch starts at 1:15 p.m.]

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六節：頭和頸部疾病的超聲波檢查

講者：黃劍平醫生香港大學內外全科醫學士、英國皇家放射科學醫學院院士、香港放射科醫學院院士、香港醫學專科學院院士（放射科）、放射科專科醫生

日期：二零一五年六月十一日（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 POLICY

When Tropical Storm Warning Signal No. 8 (or above) or the Black Rainstorm Warning Signal is hoisted within 3 hours of the commencement time, the relevant CME function will be cancelled. (i.e. CME starting 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：

Fax No. 傳真 : Date 日期：

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

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

（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 : Signature 簽名 :

HKMA Member

HK$50

CME Participants

HK$80

11 June 2015

(Thursday)

HKMA Structured CME Programme with HKS&H Year

2015 session VI: Ultrasound for Head & Neck Disease

HKMA Structured CME Programme with HKS&H


MEDICAL ASSOCIATION


CME Lectures in June 2015

REPLY SLIP

Organizer : HKMA Yau Tsim Mong Community Network

Date : Tuesday, 9 June 2015 Friday, 26 June 2015

Topic and Speaker : Diet and Chest Pain

Dr. KO Wai Chin

Specialist in Cardiology

Update on the Management of Hypertension

Dr. LEUNG Tat Chi, Godwin


Time : 1:00 – 2:00 p.m. Registration & Lunch

2:00 – 2:45 p.m. Lecture

2:45 – 3:00 p.m. Q&A Session

Venue : Pearl Ballroom, Level 2, Eaton, Hong Kong, 380 Nathan Road, Kowloon

Moderator : Dr. SO Chun

Committee Member,

HKMA YTM Community Network

Dr. HO Fung

Committee Member,

HKMA YTM Community Network

Deadline : Friday, 22 May 2015 Friday, 12 June 2015

Fee : Free-of-charge

Capacity : 60. Registration is strictly required on a first come, first served basis. Priority will be given to

doctors practising in 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 :

CME

Accreditation

: Pending

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

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

9 June 2015 26 June 2015

Name: HKMA No.:

Mobile No.*: Fax:

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

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

Others (Please specify: )

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

Signature: Date:

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

THE HONG KONGMEDICAL ASSOCIATION

CMEnotifications


Reference Framework for Preventive Care

for Older Adults in Primary Care Settings

HKMA Hong Kong East Community Network

and Primary Care Office of the Department of Health

REPLY SLIP

Date : Thursday, 11 June 2015

Speaker : Dr. LUK Kam Hung

Deputy Consultant in-charge (Primary Care), Primary Care Office, Department of Health


2:00 – 2:45 p.m. Lecture

2:45 – 3:00 p.m. Q & A Session

Venue : The HKMA Wanchai Premises,

5/F, Duke of Windsor Social Services Building,

15 Hennessy Road, Wanchai

Moderator : Dr. LAM See Yui, Joseph

Committee Member, HKMA Hong Kong Community Network

Deadline : Friday, 29 May 2015



doctors practising in Hong Kong East 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.

CME Accreditation : Pending

HKMA Hong Kong East Community Network Fax: 2865 0943Reference Framework for Preventive Care for Older Adults in Primary Care Settings

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

Name: HKMA No.:

Mobile No.*: Fax:

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

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

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

Signature: Date:

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


MEDICAL ASSOCIATIONCo-organised by

CMEnotifications


Reference Framework for Preventive Care

for Older Adults in Primary Care Settings

The HKMA Kowloon West Community Network

and Primary Care Office of the Department of Health

Date : Tuesday, 23 June 2015

Speaker : Dr. MOK Chun Keung, Francis

Chief of Service, Department of Medicine and Geriatrics, Tuen Mun Hospital


2:00 – 2:45 p.m. Lecture

2:45 – 3:00 p.m. Q & A Session

Venue : Crystal Room I-III, 30/F., Panda Hotel,

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

Moderator : Dr. WONG Wai Hong, Bruce

Hon. Secretary, HKMA Kowloon West Community Network

Deadline : Friday, 12 June 2015



doctors practising in Kowloon West district.

Enquiry : Miss Hana YEUNG, Tel: 2527 8285

*Please call and confirm that your facsimile has been successfully transmitted to the HKMA

Secretariat if you do not receive confirmation 14 days before the event.


REPLY SLIP

HKMA Kowloon West Community Network Fax: 2865 0943Reference Framework for Preventive Care for Older Adults in Primary Care Settings

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

Name: HKMA No.:

Mobile No.*: Fax No.:


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


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

Signature: Date:


THE HONG KONGMEDICAL ASSOCIATION Co-organized by

CMEnotifications


REPLY SLIP


MEDICAL ASSOCIATION

Date (All Tuesdays) Topic and Speaker Moderator

16 June 2015

Sponsored by

1. Can We Prevent Sudden Cardiac Death during Sports Event?

Dr. CHAN Wai Kwong, Andy


Dr. LAM Tzit Yuen, DavidChairman,

HKMA Yau Tsim Mong

Community NetworkSponsored by 2. Common Sports Lower Limbs Injuries

Dr. HO Hok Ming

Specialist in Orthopaedics & Traumatology

30 June 2015

Sponsored by

1. Exercises-Induced Asthma

Dr. CHAN Ka Wing, Joseph

Specialist in Respiratory Medicine

Dr. CHENG Kai Chi, ThomasHon. Secretary,

HKMA Yau Tsim Mong

Community NetworkSponsored by 2. Common Sports Upper Limbs Injuries

Dr. HO Hok Ming

Specialist in Orthopaedics & Traumatology

7 July 2015

Sponsored by

1. Musculoskeletal Ultrasound as a Point of Care for Diagnosing

and Managing Common Musculoskeletal and Sports Injuries

Dr. LAM King Hei, Stanley

Specialist in Family Medicine

Dr. CHAN Wai Keung, RickyVice-chairman,

HKMA Yau Tsim Mong

Community Network

2. Fundamentals of Sports and Exercise Nutrition

Ms. Sylvia LAM

Senior Registered Dietitian,

Chairman of Hong Kong Dietitians Association

Time : 1:00 – 1:45 p.m. Registration & Lunch1:45 – 2:15 p.m. Lecture 1 and Q&A session2:15 – 2:45 p.m. Lecture 2 and Q&A session

Venue : Jade Ballroom, Level 2, Eaton, Hong Kong, 380 Nathan Road, Kowloon

Deadline : Monday, 1 June 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 (HKMA Secretariat)* 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.

Certification : Certificate will be issued to registrants who attend 2 sessions or more.


Certificate Course on Sports Medicine

The HKMA Yau Tsim Mong Community Network

HKMA Yau Tsim Mong Community Network Fax: 2865 0943Certificate Course on Sports Medicine

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

16 June 2015 30 June 2015 7 July 2015

(*Certificate will be issued to registrants who attend 2 sessions or more).

Name: HKMA No.:

Mobile No.*: Fax No.:


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


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

Signature: Date:


Organized by

CMEnotifications


Meeting Highlights

HKMA Structured CME Programme with Hong Kong Sanatorium & Hospital 2015

Dr. YEUNG Yuk Pang (right) presenting a souvenir to the speaker, Dr. SIU Wing Tai (left).

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

Dr. HO Kwan Lun (left, speaker) receiving a souvenir from Dr. YIK Ping Yin (moderator) during the lecture on 15 April 2015

Dr. HO Kwan Lun,

Specialist in Urology,

delivered a lecture

on “Management of

Erectile Dysfunction in

Primary Practice – An

Urologist’s Perspective”

on Wednesday, 15 April

2015.

Dr. SIU Wing Tai,

Specialist in General

Surgery, delivered a

luncheon lecture on

“What does a General

Surgeon Do Nowadays?”

on Thursday, 9 April

2015 at the HKMA

Central Premises. Dr.

YEUNG Yuk Pang kindly

acted as the moderator

for the event.

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

The “Certificate Course on Neurology” began on Thursday, 16 April 2015 with

the first lecture entitled “Update on Stroke”, which was delivered by Dr. TSOI

Tak Hong, Specialist in Neurology.

Dr. LUK Kam Hung, Deputy Consultant in-charge (Primary Care) of Primary Care

Office of Department of Health, will deliver a talk on “Reference Framework for

Preventive Care for Older Adults in Primary Care Settings” on Thursday, 11 June

2015. Interested members please refer to the announcement on p.28 for details

and enrolment.

Group photo taken during the lecture on 16 April 2015From left: Dr. Kenneth YIP, Dr. Douglas CHAN, Dr. TSOI Tak Hong (speaker), Dr. TSANG Kin Lun and Dr. Dominic YOUNG (moderator)

The HKMA Kowloon West Community Network (KWCN) ~ Dr. TONG Kai SingThe Network and the Primary Care Office of the Department of Health will co-organize a lecture on “Reference Framework for

Preventive Care for Older Adults in Primary Care Settings” on Tuesday, 23 June 2015. Dr. MOK Chun Keung, Francis, Chief of

Service of the Department of Medicine and Geriatrics of Tuen Mun Hospital, is invited to be the speaker. Interested members

please refer to the announcement on p.29 for details and enrolment.

The HKMA New Territories West Community Network (NTWCN) ~ Dr. CHEUNG Kwok Wai, AlvinDr. CHAN Hoi Chung, Samuel, Family Doctor and Personal Physical Trainer, delivered

a lecture on “Management of Ketamine Abusers with Various Medical and Psychiatric

Complications” on Thursday, 23 April 2015.

The 2 remaining sessions of the “Certificate Course on Pain” will be organized in June

2015. Details are shown below:

Date (Thursdays) Topic Speaker

11 June 2015 A New Approach for Treating Elderly

Patients Suffering from Postherpetic

Neuralgia (PHN)

Dr. LO Man Wai

18 June 2015 Herpes Zoster and Post Herpetic

Neuralgia – Are They Related?

Dr. TONG Ka Fai,

HenryDr. Samuel CHAN (right, speaker) receiving a souvenir from Dr. TSANG Yat Fai (moderator) during the lecture on 23 April 2015


Meeting Highlights

The HKMA Yau Tsim Mong Community Network (YTMCN) ~ Dr. LAM Tzit Yuen, DavidA lecture on “Treating Patient Present with Joint Pain” was delivered by Dr. SUNG Chi Keung, Specialist in Rheumatology, on Tuesday, 14 April 2015.

Dr. KO Wai Chin, Specialist in Cardiology, will present on “Diet and Chest Pain” on Tuesday, 9 June 2015. Dr. LEUNG Tat Chi, Godwin, Specialist in Cardiology, will present on “Update on the Management of Hypertension” on Friday, 26 June 2015. Interested members please refer to the announcement on p.27 for details and enrolment.

The 3-session “Certificate Course on Sports Medicine” will be organized on Tuesdays, 16 June, 30 June and 7 July 2015, each consists of two mini lectures. Details of the Course is as below. Interested members please refer to the announcement on p.30 for details and enrolment.

Date (Tuesdays) Topic Speaker

16 June 2015 Can we Prevent Sudden Cardiac Death during Sports Event? Dr. CHAN Wai Kwong, Andy

Common Sports Lower Limbs Injuries Dr. HO Hok Ming

30 June 2015 Exercises-Induced Asthma Dr. CHAN Ka Wing, Joseph

Common Sports Upper Limbs Injuries Dr. HO Hok Ming

7 July 2015 Musculoskeletal Ultrasound as a Point of Care for Diagnosing and Managing Common Musculoskeletal and Sports Injuries

Dr. LAM King Hei, Stanley

Fundamentals of Sports and Exercise Nutrition Ms. Sylvia LAM

Dr. HO Hok Ming (left, moderator) presenting a

souvenir to Dr. SUNG Chi Keung (speaker) during

the lecture on 14 April 2015

The HKMA Shatin Doctors Network (SDN) ~ Dr. FUNG Yee Leung, Wilson and Dr. MAK Wing KinDr. HO Ka Keung, Specialist in Dermatology & Venereology, presented on “Update in Management of Acne Vulgaris” on Wednesday, 15 April 2015.

The following lectures will be held in May:

Date Topic Speaker Registration/Enquiry

27 May 2015 (Wednesday) Cervical Myelopathy and it's Treatment Dr. HO Chin Hung Ms. Sharon LAMT: 8226 9582

29 May 2015 (Friday) An Insulin-Independent Approach to Managing Patients with Type 2 Diabetes

Dr. FUNG Lai Ming Mr. Johnson SHUMT: 8209 9667

Group photo taken during the lecture on 15 April 2015From left: Dr. MAK Wing Kin (moderator), Dr. HO Ka Keung (speaker) and Dr. WONG Tsz Kau

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

The first session of the “CME Course for Health

Personnel 2015” t it led “Update on Macular

Degeneration” was given by Dr. TANG Hoi Yau,

Heather, Associate Consultant of the Department

of Ophthalmology of United Christian Hospital,

on Saturday, 18 April 2015.

Dr. CHUNG Lap Yan, Kenneth, Specialist in

Paediatric Surgery, presented on “Update on

Management of Nocturnal Enuresis of Children”

on Thursday, 23 April 2015.

Dr. Kenneth CHUNG (left, speaker) receiving a souvenir from Dr. Danny MA (moderator) during the lecture on 23 April 2015

CMECalendar


# for whole function

May 2015

16 – 17 May 2015

(Sat-Sun)

Hong Kong University – Department of Medicine

20th Hong Kong Medical Forum

Room N101, 1/F (New Wing), Hong Kong Convention & Exhibition Centre

Administrative Assistant – Tel: 2255 4607

10#

17 May 2015

(Sun)

1:00 – 4:00 pm

Hong Kong Doctors Union

The 302nd HKDU Sunday Afternoon Symposium

Lecture Hall, 8/F, Block G, Princess Margaret Hospital, Kwai Chung, NT

Tel: 2388 2728

1.5

17 May 2015

(Sun)

3:30 – 5:30 pm


The 303rd HKDU Sunday Afternoon Symposium

Lecture Hall, 8/F, Block G, Princess Margaret Hospital, Kwai Chung, NT

Tel: 2388 2728

1.5

18 May 2015

(Mon)

8:30 – 9:30 am

Union Hospital – Department of Paediatrics

Paediatrics Departmental Round

New Seminar Room 2, 2/F, Hospital Building, Union Hospital

Ms. Kay Ho – Tel: 2608 3800

1

18 May 2015

(Mon)

1:00 – 3:00 pm


172nd Luncheon Meeting

Seminar Room, Hall 3F-3G, Level 3, Hong Kong Convention and

Exhibition Centre (Old Wing), 1 Harbour Road, Wanchai

Miss Cheng – Tel: 2388 2728

1

18 – 19 May 2015

(Mon-Tue)

Hospital Authority

Hospital Authority Convention

Theatre 1&2, Convention Hall, Hong Kong Convention and Exhibition Centre,

Wanchai

Mr. Banny Wong – Tel: 2300 6569

10#

19 May 2015

(Tue)

1:00 – 2:00 pm

Hong Kong College of Psychiatrists

Hospital Authority – United Christian Hospital – training centre

Balint Group

Conference Room, United Christian Hospital/Conference Room,

Yung Fung Shee Psychiatric Centre

Ms. Lucita Chan – Tel: 2871 8777

1

20 May 2015

(Wed)

9:30 – 12:30 pm

Hong Kong Poison Information Centre

Hong Kong College of Emergency Medicine

Certificate Program in Clinical Toxicology 2015 (Monthly Sessions)

Conference Room, 1/F, Block F, United Christian Hospital

Ms. Winnie Cheung – Tel: 3513 5096

3

20 May 2015

(Wed)

12:45 – 2:00 pm

Our Lady of Maryknoll Hospital

Grand Round/Journal Club (Wednesday Educational Meeting April-June 2015)

Conference Room A, 1/F, OPD Block, Our Lady of Maryknoll Hospital

Ms. Clara Tsang – Tel: 2354 2440

1

20 May 2015

(Wed)

1:00 – 2:00 pm

Castle Peak Hospital

Improvement of Schizophrenia Treatment and the Place of Asenapine

(Video Lecture)

Lecture Theatre, Block D, Castle Peak Hospital

Ms. Wong Suk Yee – Tel: 2456 7153

1

20 May 2015

(Wed)

2:00 – 4:00 pm

Hong Kong Academy of Medicine

Acute Shoulder Injuries and Non-acute Shoulder Disorders

Multi-function Room, G/F, Block D, Queen Elizabeth Hospital, Kowloon

Ms. Joanne Ho – Tel: 2871 8747

2

20 May 2015

(Wed)

4:15 – 5:15 pm

Hong Kong University – Department of Obstetrics & Gynaecology

Tumour Board Meeting – clinical-pathological conference on gynaecological

oncology cases

Rm 215, 2/F, Seminar Room, Clinical Pathology Building, Queen Mary Hospital

Ms. Phyllis Kwok – Tel: 2255 4518

1

21 May 2015

(Thu)

1:00 – 3:00 pm

Hospital Authority – United Christian Hospital

Hong Kong College of Family Physicians

Hong Kong Medical Association – Kowloon East Community Network

Certificate Course for GPs 2015 – Common ENT Problems in the Community

V Cuisine, 6/F, Holiday Inn Express Hong Kong Kowloon East, 3 Tong Tak Street,

Tseung Kwan O

Ms. Polly Tai – Tel: 3513 3430

1

21 May 2015

(Thu)

1:00 – 3:00 pm

Hong Kong Medical Association – New Territories West Community Network

Certificate Course on Pain

G/F, Marina Club House, Gold Coast Yacht and Country Club, 1 Castle Peak

Road, Castle Peak Bay, Hong Kong

Miss Hana Yeung – Tel: 2527 8285

1

22 May 2015

(Fri)

1:00 – 2:00 pm

Tuen Mun Hospital – Department of Obstetrics & Gynaecology

CME Programme for January-June 2015

Room SB1034 A&B, Conference Room, 1/F, Special Block, Tuen Mun Hospital

Ms. Angela Cheung – Tel: 2468 5404

1

23 May 2015

(Sat)

9:30 – 11:30 am

Hospital Authority

Hong Kong College of Community Medicine

Case presentations and Journal presentations in areas related to Administrative

Medicine

Room 524N, 5/F, Hospital Authority Building, 147B Argyle Street, Kowloon

Ms. Yandy Ho – Tel: 2871 8745

2

26 May 2015

(Tue)

1:00 – 3:00 pm

Hong Kong Medical Association – Kowloon West Community Network

Psoriatic Arthritis: Does Early Diagnosis Make A Difference?

Crystal Room I-III, 30/F, Panda Hotel, 3 Tsuen Wah Street, Tsuen Wan, NT


1

26 May 2015

(Tue)

5:30 – 6:30 pm

Hospital Authority – Hong Kong East Cluster – Cluster Trauma Service

Committee

HKEC Trauma Audit

Lecture Theatre, 1/F, Pathology Block, Pamela Youde Nethersole Eastern

Hospital, 3 Lok Man Road, Chai Wan, Hong Kong

Ms. Natalie Choi – Tel: 2595 7312

1

26 – 27 May 2015

(Tue-Wed)


American Heart Association (AHA) Pediatric Advanced Life Support

(PALS) Courses

HKEC Training Centre for Healthcare Management & Clinical Technology,

Pamela Youde Nethersole Eastern Hospital

Ms. Cherry Kwok – Tel: 2871 8877

10#

27 May 2015

(Wed)

12:45 – 2:00 pm





1

27 May 2015

(Wed)

1:00 – 3:00 pm

Hong Kong Medical Association – Central, Western & Southern Community

Network

Advances in Diagnosis and Management of Male Pattern Hair Loss

HKMA Central Premises, Dr. Li Shu Pui Professional Education Centre, 2/F,

Chinese Club Building, 21-22 Connaught Road, Central, Hong Kong


1

27 May 2015

(Wed)

1:00 – 3:00 pm

Hong Kong Medical Association – Shatin Doctors Network

Cervical Myelopathy & it’s Treatment

Chairman Room, Level 2, Royal Park Hotel, 8 Pak Hok Ting Street, Shatin, NT

Ms. Sharon Lam – Tel: 8226 9582

1

27 May 2015

(Wed)

4:15 – 5:15 pm



oncology cases



1

28 May 2015

(Thu)

8:30 – 10:30 am

Hong Kong Sanatorium & Hospital – Orthopaedic & Sports Medicine Centre

Academic Professional Development Meeting 2015 of OSMC HKSH

(Every Fourth Thursday of the Month)

Hong Kong Sanatorium & Hospital

Ms. Cheng Hoi Yan – Tel: 2835 7890

2

28 May 2015

(Thu)

1:00 – 3:00 pm

Hong Kong Medical Association – Hong Kong East Community Network

Certificate Course on Neurology

Session 4: Parkinsonism: First Encounter and Subsequent Management

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

Hong Kong

Ms. Candice Tong – Tel: 2527 8285

1

28 May 2015

(Thu)

1:00 – 3:00 pm

Hong Kong Medical Association – Kowloon East Community Network

Treatment Options in DM Treatment

V Cuisine, 6/F, Holiday Inn Express Hong Kong Kowloon East,

3 Tong Tak Street, Tseung Kwan O


1

28 May 2015

(Thu)

1:00 – 3:00 pm

HKDU – Tsimshatsui Study Group

Advance Treatment Strategy for Atrial Fibrillation

Nathan Room 3-Hall, 1st Floor, Eaton Hong Kong, 380 Nathan Road, Kowloon

Miss Cheng – Tel: 2388 2728

1

28 May 2015

(Thu)

6:00 – 7:00 pm

Queen Mary Hospital – Department of Neurosurgery

Neuroscience Working Group Meeting (4th Thursday of every month)

Lecture Theatre, 5th Professorial Block, Queen Mary Hospital

Ms. Sherla Yu – Tel: 2255 3368

1

28 – 29 May 2015

(Thu-Fri)


American Heart Association (AHA) Advanced Cardiovascular Life Support (ACLS)

HKEC Training Centre for Healthcare Management & Clinical Technology,



10

29 May 2015

(Fri)

1:00 – 3:00 pm

Hong Kong Medical Association – Yau Tsim Mong Community Network

Male LUTS: Beyond BPH Management

Diamond Room V-Hall, Level B1, Eaton, Hong Kong, 380 Nathan Road, Kowloon


1

31 May 2015

(Sun)

1:30 – 3:00 pm

Association of Licentiates of Medical Council of Hong Kong

1) The Overview of Asthma Treatment

2) Update on Management in Dementia

九龍亞皆老街147B號醫院管理局大樓M/F研討室ALMCHK – Tel: 2327 2869

3

CMECalendar


Jun 2015

2 Jun 2015

(Tue)

3:30 – 5:30 pm


Kwai Chung Hospital

Level 1 Topic 18: Rehabilitation & Social Psychiatry – Explain antipsychotic treatment

Meeting Room, 1/F, Admin Block, Kwai Chung Hospital

Ms. Kaman Chan – Tel: 2871 8717

2

2 Jun 2015

(Tue)

3:30 – 5:30 pm


Kwai Chung Hospital

Level 2 Topic 18: Rehabilitation & Social Psychiatry – Explain rehabilitation

plans to patients (part 1)

Seminar Room, 1/F, Admin Block, Kwai Chung Hospital


2

2 Jun 2015

(Tue)

3:30 – 5:30 pm



Queen Mary Hospital


J2 Seminar Room, Queen Mary Hospital


2

2 Jun 2015

(Tue)

3:30 – 5:30 pm


Kowloon Hospital

United Christian Hospital

Level 1 Topic 18: Rehabilitation & Social Psychiatry – Explain antipsychotic

treatment

Conference Room, 13/F, Block S, Untied Christian Hospital


2

2 Jun 2015

(Tue)

3:30 – 5:30 pm


Kowloon Hospital




Conference Room 2, Kowloon Hospital


2

2 Jun 2015

(Tue)

3:30 – 5:30 pm



Queen Mary Hospital



Room 36, 1/F, East Block, Pamela Youde Nethersole Eastern Hospital


2

2 Jun 2015

(Tue)

3:30 – 5:30 pm


HA-NT East Cluster


Multicentre Seminar Room, Tai Po Hospital


2

2 Jun 2015

(Tue)

3:30 – 5:30 pm


HA-NT East Cluster





2

2 Jun 2015

(Tue)

3:30 – 5:30 pm



Level 1 Topic 18: Rehabilitation & Social Psychiatry – Explain antipsychotic

treatment

Kaizen Room, Block D, Castle Peak Hospital


2

2 Jun 2015

(Tue)

3:30 – 5:30 pm



Level 2 Topic 18: Rehabilitation & Social Psychiatry – Explain rehabilitation plans to

patients (part 1)

Seminar Room 4, Block F, Castle Peak Hospital


2

2 Jun 2015

(Tue)

6:00 – 8:00 pm

Hong Kong College of Physicians

Palliative Medicine Grand Round

Conference Room 118, 1/F, Wai Shun Block, Caritas Medical Centre

Ms. Kathy Wong – Tel: 2991 1348

2

3 Jun 2015

(Wed)

1:30 – 3:30 pm

Hong Kong Medical Association

Medical Protection Society

Mastering Adverse Outcomes – 2 hours

Eaton, Hong Kong, 380 Nathan Road, Kowloon

HKMA CME Dept. – Tel: 2527 8452

2

3 Jun 2015

(Wed)

2:00 – 4:00 pm


1) Infant and Young Child Feeding Approach to Increase Vegetable and

Fruit Intake and Weaning from Bottle;

2) Urogynaecology for Non-urogynaecologists

Lecture Theatre, G/F, Block M, Queen Elizabeth Hospital, Kowloon


2

3 Jun 2015

(Wed)

4:15 – 5:15 pm



oncology cases



1

3 Jun 2015

(Wed)

5:00 – 7:30 pm


Joint Clinical Meeting & Didactic Lecture (JCM)

Lecture Theatre, G/F, Block M; Multi-Function Room, G/F, Block D; Seminar

Room, G/F, Block A, 12/F, Block R, Lecture Theatre, Queen Elizabeth Hospital


2

4 Jun 2015

(Thu)

8:30 – 9:30 am

Hong Kong Sanatorium & Hospital-Neurology Centre

Joint neurology – neurosurgery clinical meeting

4/F, Function Room, Hong Kong Sanatorium & Hospital

Ms. Linda Chan – Tel: 2835 7287

1

5 Jun 2015

(Fri)

1:00 – 2:00 pm


Mortality and Morbidity Meeting – Obstetrics

Room SB1034 A&B, Conference Room, Special Block, Tuen Mun Hospital


1

9 Jun 2015

(Tue)

3:30 – 5:30 pm


Kwai Chung Hospital

Level 1 Topic 19: Forensic Psychiatry – Assess violent risk, with subsequent

verbal report to a consultant



2

9 Jun 2015

(Tue)

3:30 – 5:30 pm


Kowloon Hospital




Conference Room, Room 2080, 2/F, PYPC


2

9 Jun 2015

(Tue)

3:30 – 5:30 pm


Kowloon Hospital



plans to patients (Part II)



2

9 Jun 2015

(Tue)

3:30 – 5:30 pm


Kwai Chung Hospital





2

9 Jun 2015

(Tue)

3:30 – 5:30 pm



Queen Mary Hospital





2

9 Jun 2015

(Tue)

3:30 – 5:30 pm



Queen Mary Hospital

Level 2 Topic 19: Rehabilitation & Social Psychiatry – Explain rehabilitation plans to

patients (Part II)



2

9 Jun 2015

(Tue)

3:30 – 5:30 pm


HA-NT East Cluster





2

9 Jun 2015

(Tue)

3:30 – 5:30 pm


HA-NT East Cluster





2

9 Jun 2015

(Tue)

3:30 – 5:30 pm







2

9 Jun 2015

(Tue)

3:30 – 5:30 pm







2

10 Jun 2015

(Wed)

8:30 – 9:30 am

Union Hospital

Mortality and Morbidity Meeting (Regular Meeting 2015)

Training Room, MIC, 8/F, Hospital Building, Union Hospital

Ms. Penny Fok – Tel: 2608 3287

1

10 Jun 2015

(Wed)

12:45 – 2:00 pm





1

CMECalendar


10 Jun 2015

(Wed)

2:00 – 4:00 pm


1) Updates on DM Nephropathy; 2) Nuclear Medicine & Molecular Imaging-An

Evolution from “Unclear Medicine”



2

10 Jun 2015

(Wed)

4:15 – 5:15 pm



oncology cases



1

10 Jun 2015

(Wed)

5:00 – 7:00 pm


Hospital Authority – United Christian Hospital

Monthly Meeting of HKPIC (Presentation and discussion on interesting cases

of the month)

Lecture Theatre, Block F, United Christian Hospital


2

10 Jun 2015

(Wed)

6:30 – 9:30 pm



Mastering Professional Interactions

HKMA Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese Club

Building, 21-22 Connaught Road, Central, Hong Kong


2.5

11 Jun 2015

(Thu)

1:00 – 3:00 pm

Hong Kong Medical Association – New Territories West Community Network

Certificate Course on Pain

G/F, Marina Club House, Gold Coast Yacht and Country Club, 1 Castle Peak

Road, Castle Peak Bay, Hong Kong


1

11 Jun 2015

(Thu)

1:00 – 3:00 pm

Hong Kong Medical Association – Hong Kong East Community Network

Reference Framework for Preventive Care for Older Adults in Primary

Care Settings

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

Hong Kong


1

11 Jun 2015

(Thu)

1:15 – 3:00 pm


Hong Kong Sanatorium & Hospital

HKMA Structured CME Programme with HKS&H Session 8: Ultrasound for

Head & Neck Disease

Function Room A, HKMA Dr. Li Shu Pui Professional Education Centre, 2/F,

Chinese Club Building, 21-22 Connaught Road Central, Hong Kong


1

11 Jun 2015

(Thu)

8:30 – 10:30 pm

Union Hospital

Association of Private Orthopaedic Surgeons

Hong Kong Sanatorium & Hospital – Orthopaedic & Sports Medicine Centre

Orthopaedic Clinical Meeting – Teleconference (Every Second Thursday of the

Month)

Hong Kong Sanatorium & Hospital/Union Hospital

Ms. Cheng Hoi Yan – Tel: 2835 7890

2

12 Jun 2015

(Fri)

1:00 – 2:00 pm


CME Programme for January-June 2015

Room SB1034 A&B, Conference Room, 1/F, Special Block, Tuen Mun Hospital


1

13 Jun 2015

(Sat)

2:15 – 4:15 pm


Hong Kong College of Family Physicians


Refresher Course for Health Care Providers 2014/2015

– Primary care rheumatology

Training Room II, 1/F, OPD Block, Our Lady of Maryknoll Hospital, 118 Shatin

Pass Road, Wong Tai Sin, Kowloon


2

13 Jun 2015

(Sat)

2:30 – 5:30 pm



Mastering Difficult Interactions with Patients

HKMA Dr. Li Shu Pui Professional Education Centre, 2/F, Chinese Club Building,

21-22 Connaught Road, Central, Hong Kong


2.5

15 Jun 2015

(Mon)

8:30 – 9:30 am

Union Hospital – Department of Paediatrics

Paediatrics Departmental Round

New Seminar Room 2, 2/F, Hospital Building, Union Hospital

Ms. Kay Ho – Tel: 2608 3800

1

15 Jun 2015

(Mon)

1:00 – 2:00 pm

Hong Kong University – Family Medicine and Primary Care

Department of Family Medicine and Primary Care Research Meetings

Department of Family Medicine and Primary Care, 3/F, Ap Lei Chau Clinic,

161 Main Street, Ap Lei Chau, Hong Kong

Ms. Crystal Wong – Tel: 2518 5654

1

16 Jun 2015

(Tue)

1:00 – 2:45 pm

Hong Kong Medical Association – Yau Tsim Mong Community Network

Certificate Course on Sports Medicine

Session 1A: Can We Prevent Sudden Cardiac Death during Sports Event?

Session 1B: Common Sports Lower Limbs Injuries

Jade Ballroom, Level 2, Eaton, Hong Kong, 380 Nathan Road, Kowloon


1

16 Jun 2015

(Tue)

1:00 – 5:00 pm

Matilda International Hospital

Certificate course on incident/accident reporting and documentation for hospital

staff

Lecture Hall, 4/F, Matilda International Hospital

Ms. Bonita Lam – Tel: 2849 0358

3

16 Jun 2015

(Tue)

3:30 – 5:30 pm


Kwai Chung Hospital

Level 1 Topic 20: Forensic Psychiatry – Interview a patient with schizophrenia who

has committed an offence for the purpose of writing a medical report



2

16 Jun 2015

(Tue)

3:30 – 5:30 pm


Kwai Chung Hospital

Level 2 Topic 20: Substance Misuse & Addiction Psychiatry – Assessment of

substance abuse (Part 1)



2

16 Jun 2015

(Tue)

3:30 – 5:30 pm



Queen Mary Hospital





2

16 Jun 2015

(Tue)

3:30 – 5:30 pm


Kowloon Hospital




Conference Room, Room 2096, CPS Office, 2/F, PYPC


2

16 Jun 2015

(Tue)

3:30 – 5:30 pm


Kowloon Hospital






2

16 Jun 2015

(Tue)

3:30 – 5:30 pm



Queen Mary Hospital





2

16 Jun 2015

(Tue)

3:30 – 5:30 pm


HA-NT East Cluster





2

16 Jun 2015

(Tue)

3:30 – 5:30 pm


HA-NT East Cluster





2

16 Jun 2015

(Tue)

3:30 – 5:30 pm







2

16 Jun 2015

(Tue)

3:30 – 5:30 pm







2

17 Jun 2015

(Wed)

9:30 – 12:30 pm



Certificate Program in Clinical Toxicology 2015 (Monthly Sessions)

Conference Room, 1/F, Block F, United Christian Hospital


3

17 Jun 2015

(Wed)

12:45 – 2:00 pm





1

17 Jun 2015

(Wed)

2:00 – 4:00 pm


1) Pitfalls in Interpreting Chemical Pathology Laboratory Results;

2) Management of Thyroid Nodule



2

17 Jun 2015

(Wed)

4:15 – 5:15 pm



oncology cases



1

Documents

香港醫學會 T H K MEDICAL ASSOCIATION - hkma.org · Dr. CHEN Wai Hong 陳偉康醫生 Dr. HO Hung Kwong, Duncan