Osteoporosis is a skeletal disorder characterised by low bone mass and micro-architectural deterioration of bone tissue that results in compromised bone strength and a predisposition to fracture.1 Childhood and adolescence are critical periods for bone mineralisation. Peak bone mineral density (BMD) achieved by early adulthood determines the risk of pathological fracture. Bone mass can be objectively measured by BMD and is correlated with risk of osteoporotic fracture.2

Dual-energy X-ray absorptiometry (DXA) scanning enables cost-effective quantitative measurement of BMD. Such methodology is the gold standard because it can detect bone mineral loss of 2% to 5%. Abnormal homeostasis of vitamin D, calcium, and phosphorous may lead to imbalanced osteoclastic and osteoblastic dynamics that will result in osteopenia and even osteoporosis. There have been reports from large- and small-scale studies of problems in bone mineralisation and vitamin D or calcium metabolism in patients with cerebral palsy (CP).3 4 Dietary restrictions, oromotor dysfunction, malabsorption, and limited sunlight exposure may lead to poor nutrition, low calcium intake, or altered vitamin D metabolism. These in turn contribute to poor mineralisation. Limited weight-bearing during the period of skeletal growth may also lead to reduced BMD. Chronic therapy with antiepileptic drugs (AEDs) may cause hypocalcaemia, hypophosphataemia, raised serum alkaline phosphatase, elevated serum parathyroid hormone, reduced biologically active vitamin D metabolites, rickets, and osteomalacia. The mechanism is unclear, however.5

A study revealed that AED use was associated with reduced BMD in 35 pairs of twin adults, and the effect was more marked in those prescribed enzyme-inducing AEDs, for example, phenytoin and phenobarbitone.6 A decrease in BMD (in g/cm²) of 6.4% and 4.6% at the lumbar spine and femoral neck respectively in their twin control pair was detected. For valproate, the effect was not consistently demonstrated.7 8

Chronic treatment with AEDs was observed to be significantly correlated with a lower BMD in 96 ambulatory children and young adults with epilepsy with a mean Z-score of -1.23 compared with 0.16 of a control group.9 In our retrospective study of 109 CP children in 2006, however, we could not demonstrate any association of AEDs with increased fracture rate in non-ambulatory CP children.10 In children with CP and a Gross Motor Function Classification System (GMFCS) level of 4 to 5 (bed-bound), the possible impact of anticonvulsants on BMD was not clearly demonstrated.

The primary objective of this study was to evaluate the effect of AEDs on BMD in non-ambulatory children with CP. The secondary objective was to identify the risk factors for low BMD in this group of children.

Patients at the Developmental Disabilities Unit (DDU) of Caritas Medical Centre, Hong Kong were enrolled in the study from 1 October 2012 to 30 September 2013. The DDU is the largest long-term care facility for children with severe developmental disabilities and special health care needs in Hong Kong. Among the 100 residents, over 90% were non-ambulatory and over 50% had CP.

The inclusion criteria in this study were: (1) children and adolescents aged between 5 and 19 years; (2) GMFCS level 4 or 5; (3) the presence of spastic or mixed spastic dyskinetic CP; and (4) prescribed AED for more than 2 years.

The control group without anticonvulsant therapy comprised concomitant non-ambulatory DDU residents with CP who were not prescribed AEDs for more than 2 years prior to recruitment to the study.

The exclusion criteria included (1) GMFCS level of 1 to 3; (2) patients with underlying hepatic or renal disease; (3) presence of disease primarily involving bone metabolism or a family history of bone metabolic disorders; (4) known thyroid or parathyroid disease; (5) history of pathological long bone fracture; (6) history of chronic diarrhoea or malabsorption; (7) long-term intake of the following medications: non-physiological dose of glucocorticoid, anabolic steroid, vitamin A, non-steroidal anti-inflammatory drugs, bisphosphonates, thiazide diuretics, or calcitonin.

Coppola et al9 reported a mean BMD Z-score of -1.23 and 0.16 in 96 ambulatory epileptic patients and 63 controls, respectively. In 2012, the same group showed the mean Z-score to be -1.69 (n=47) and -0.83 (n=40) respectively in mentally retarded children with CP, with and without epilepsy.11 Based on these findings, we proposed a difference in Z-score of ≥1 to indicate a clinically significant reduction in BMD. In order to detect a Z-score difference of 1 with power of 0.8, 16 subjects were recruited in each group.12

Upon entry, data were collected for age, gender, body weight, body height, body mass index (BMI), presence of contractures, skinfold thickness (triceps, lower biceps, and subscapular), and pubertal stage according to Tanner’s classification. Weight-for-age Z-score was calculated based on referenced data from a 1993 territory-wide growth survey of Hong Kong children.13 Blood taking was performed on the same day of DXA scan to evaluate calcium, phosphorous, alkaline phosphatase, transaminase, total protein, urea, creatinine, serum osmolality, and total cell count. A spot urine calcium-to-creatinine ratio (mmol/mmol) and urine calcium-to-osmolality ratio (mg/L:mosmo/kg) was also determined on the same day. Current dietary information was reviewed and daily calcium and vitamin D content were calculated by a dietitian.

In this study, BMD was determined by DXA of total body less head (TBLH) using a Lunar Prodigy Advance DXA bone densitometer (GE Healthcare, Madison [WI], US) with the latest Chinese children total BMD database installed.14 15 All subjects had BMD measured by the same validated densitometer to eliminate measurement error. Individual BMD value was expressed as g/cm² and Z-score. Z-score is the number of standard deviations of the patient’s BMD above or below the average age- and sex-matched reference value. For the paediatric age-group, the current definition for osteoporosis includes BMD Z-score of ≤–2.0 adjusted for age, gender, and body size plus a clinically significant fracture defined in the International Society for Clinical Densitometry (ISCD) 2007 official positions.16 The head is disproportionately large in young children and may mask deficits at other skeletal sites, thus TBLH (subtotal/TBLH) BMD, which was recommended by ISCD 2007 official positions for the evaluation of child’s bone health, was used in this study. For children with CP, TBLH BMD is more feasible and provides a holistic picture for BMD estimation.

In bivariate analysis, normally and non-normally distributed data were analysed by independent sample t tests and Mann-Whitney U tests, respectively. Categorical data were compared using Chi squared and Fisher’s exact tests. Clinically relevant covariates (presence of puberty, daily calcium intake, and number of AED use) and the covariate (weight-for-age Z-score) approaching statistical significance (P<0.05) in bivariate analysis were entered into multivariable analysis (Enter Method). Statistical significance was defined as two-tailed probability below 0.05.

Data of TBLH were split into low-BMD group versus normal-BMD group—those with TBLH Z-score of ≤–2.0 were considered to have low BMD. Baseline characteristics of the low- and normal-BMD groups were compared. Multivariable logistic regression analysis was used to examine the independent effect of puberty, weight-for-age Z-score (gender adjusted), number of AEDs, and daily calcium intake on TBLH Z-score.

All statistical analyses were performed using the Statistical Package for the Social Sciences (Windows version 13.0; SPSS Inc, Chicago [IL], US).

The study was approved by the Ethics Committee of Kowloon West Cluster of Hospital Authority, Hong Kong. Informed consent was obtained from respective parents or the legal guardians from the Social Welfare Department, Government of the Hong Kong Special Administrative Region.

The subjects were enrolled from 1 October 2012 to 30 September 2013 in DDU. Sixty-two children with CP aged 5 to 19 years were identified. Informed consent was obtained from a legal guardian for 44 patients of whom 12 were excluded from study—four had a history of fracture, two had severe deformity making DXA technically difficult, one had poorly controlled asthma and required long-term steroid therapy, and five had deranged liver or renal function. Of the remaining 32 children and adolescents, 18 (6 males, 12 females) aged 5.0 to 19.5 (mean ± standard deviation, 13.8 ± 4.7) years comprised the study group. The control group consisted of 14 children and adolescents (6 males, 8 females) aged 7.0 to 19.1 (mean, 16.4 ± 3.0) years.

Among the 18 subjects in the study group, eight were prescribed one AED and 10 were prescribed two or more. Sodium valproate was prescribed to eight children, carbamazepine to three, topiramate to three, phenobarbitone to five, phenytoin to one, and lamotrigine to four. In view of the limited population size, the impact of individual anticonvulsants was not analysed.

The two groups showed no significant difference in age, gender, BMI, weight-for-age Z-score, CP type, daily calcium intake, or daily vitamin D intake (Table 1).

Twelve (67%) patients in the study group were in puberty, compared with 13 (93%) patients in the control group (P=0.104). Sixteen (89%) patients in the study group were tube feeders compared with four (29%) in the control group (P=0.001). Among the oral feeders, all were reported by their caretaker to have a satisfactory dietary intake. Mean weight-for-age Z-score showed no significant difference between the study and control groups (P=0.226) [Table 1]. There was also no significant difference in the TBLH Z-scores (P=0.989; Table 1) or biochemical parameters of bone metabolism between the two groups (Table 2).

Low BMD was defined as TBLH Z-score of ≤–2.0 and was evident in 18 (56%) patients. When comparing groups with low and normal BMD, there was no significant difference on univariate analysis in gender, age, CP, BMI, feeding mode, use of AEDs, puberty, or daily calcium and vitamin D intake (Table 3). Weight-for-age Z-score was significantly lower (-2.57 vs -1.12; P=0.001) in the low BMD group (Table 3).

When covariates including weight-for-age Z-score, presence of puberty, daily calcium intake, and number of AEDs used were analysed by multiple logistic regression, higher weight-for-age Z-score (adjusted odds ratio [OR]=0.015; 95% confidence interval [CI], 0.001-0.390) and presence of puberty (adjusted OR=0.027; 95% CI, 0.001-0.948) remained significant independent predictors for occurrence of a relatively normal BMD (ie TBLH Z-score >2.0). Hosmer-Lemeshow goodness of fit test (P=0.315) was non-significant, indicating a model prediction that was not significantly different to observed values. Nagelkerke R² was 0.677, again signifying a relatively well-fitting model (Table 4).

In the present study, DXA evaluation in non-ambulatory children with CP, with or without AED use, revealed a low BMD in 56% of those who underwent DXA. This is concordant with the findings in previous studies4 17 18 19 with prevalence of low BMD ranging from 27% to 77%. Low BMD is the proximate cause of low-energy fracture in this group of children. Other factors such as stiff joints, poor balance leading to falls, and violent seizures may also contribute. Nearly 20% of such children have sustained a femoral fracture at some point.20

The impact of AED on BMD was unclear in non-ambulatory children with CP. The physician often faces a dilemma in optimising anticonvulsant treatment in this group of children who are already at high risk of developing osteoporotic long bone fracture.

Early studies revealed that treatment with enzyme-inducing anticonvulsants—for example, phenytoin and phenobarbitone—may induce catabolism of 25-hydroxyvitamin D, leading to rickets.21 22 Recent research on the effect of AED on BMD is inconclusive, and the results are often confounded by methodological flaws. In a cross-sectional study, Farhat et al5 measured the BMD in 71 ambulatory subjects who were prescribed AED for more than 6 months. Reduced BMD was found in adults (n=42) but not children (n=29). There was no control group and the findings were only compared with paediatric data from the manufacturer, rendering it difficult to detect any small but significant difference secondary to AED treatment. Ecevit et al23 measured femoral neck BMD in 31 healthy children and 33 subjects with idiopathic epilepsy treated with either carbamazepine (n=17) or valproate (n=16). Valproate but not carbamazepine monotherapy was associated with a significant reduction in BMD. In this study, however, more children had attained puberty in the control group (n=13, 93%) than in the AED group (n=12, 67%), which may have confounded the results. Coppola et al9 compared the BMD of 96 children with epilepsy alone or in association with CP and/or mental retardation against a control group of 63 healthy ambulatory subjects. While univariate analysis illustrated a reduced BMD Z-score in the AED group, no difference was found after adjustment for ambulatory status, mental retardation, lack of physical activity, and BMI in multivariate analysis.

In this study, we focused on non-ambulatory children with CP and severe mental retardation. This is the population most vulnerable to pathological long bone fracture, with a lifetime risk estimated to be 20%. This group of children is also prone to develop refractory epilepsy that requires multiple AEDs at high doses. By recruiting concomitant residents from the same facility as the control group, we minimised the confounding effect of factors that may contribute to low BMD, namely ambulatory status, physical activity, and nutritional status. Our findings support that long-term use of AED in this group of children does not have any significant adverse effect on BMD. Optimal pharmacological treatment can be pursued without jeopardising bone mineralisation.

In multivariable analysis, there was a significant association of BMD Z-score with the presence of puberty. This may be due to the physiology and time frame for bone mineralisation that surges in puberty and reaches a peak at 20 years of age. Variation in time of starting puberty was a confounding factor as BMD Z-score was adjusted for gender and age only.

This study was carried out in a single institution for disabled children in Hong Kong. Because of the need for sedation and exposure to radiation, guardians of children with more severe neurological disease tended not to consent for the study. Moreover, DXA could not be properly performed in patients with severe deformity. These children were not included in the study.

An inadequate number of patients in each group may have impacted the power of this study. Nevertheless, the result showed a strong association for weight-for-age Z-score with TBLH BMD. We believe the association was highly statistically significant.

Children with CP are at risk of malnutrition that has a significant impact on linear growth, wound recovery, motor function, and even survival. In addition to poor linear growth, malnourished children with severe CP are likely to have poor bone mineralisation leading to painful pathological fracture. In a retrospective study of 107 CP children (90 non-ambulatory), weight-for-age Z-score proved to be the best predictor of BMD Z-score.24 In the present study, we demonstrated a significant correlation of low weight-for-age Z-score with low BMD, with a relatively well-fitting model after adjusting for pubertal stage, calcium intake, and AED use. This is concordant with our previous findings in the same population in which there was a significant protective effect of increase in weight-for-age Z-score in reducing fracture risk (adjusted OR=0.41).10 A recent review of 32 cross-sectional, cohort, case-control, and randomised controlled trials suggested that reduced bone density, impaired bone growth, and vitamin D deficiency may be seen in children treated with anticonvulsants.25 In our study, individual vitamin D daily intake was calculated by dietitians. Sun exposure was limited in the institutional setting. Thus, we assumed that the calculated daily oral vitamin D intake correlated well with the serum vitamin D level. Although the daily vitamin D intake was similar in the low- and normal-BMD groups (P=0.297) as well as the study and control groups (P=0.702), 10 out of 32 subjects in the study consumed less than the recommended daily vitamin D intake (400 IU/day). To improve BMD and decrease fracture risk, regular nutritional assessment is necessary to identify malnourished children. Supplementation of vitamin D and calcium should be considered if the calculated daily need cannot be met. A nutritional rehabilitation programme should be implemented to optimise weight-for-age Z-score. Early gastrostomy tube placement should be considered in children with poor oral feeding. In children with weight-for-age Z score of ≤–2.0, serial BMD measurements can help to identify severe osteoporosis before fracture occurs. This window of time allows implementation of intensive nutritional rehabilitation, pharmacological intervention, and precautions in handling to prevent fracture occurrence.

Use of AED in non-ambulatory children with CP is unlikely to pose a detrimental impact on BMD. A low weight-for-age Z-score is a significant independent risk factor predictive of low BMD. Optimising nutritional status in this group of children is paramount to improving bone mineralisation and thus decreasing pathological fracture.

The authors would like to thank Ms Geraldine Ng, dietitian of Caritas Medical Centre, for her arduous effort to assess dietary calcium and vitamin D intake for our study patients.

All authors have disclosed no conflicts of interest.

1. Houlihan CM, Stevenson RD. Bone density in cerebral palsy. Phys Med Rehabil Clin N Am 2009;20:493-508. Crossref

2. Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 1996;312:1254-9. Crossref

3. Lee JJ, Lyne ED, Kleerekoper M, Logan MS, Belfi RA. Disorders of bone metabolism in severely handicapped children and young adults. Clin Orthop Relat Res 1989;245:297-302. Crossref

4. Henderson RC, Lark RK, Gurka MJ, et al. Bone density and metabolism in children and adolescents with moderate to severe cerebral palsy. Pediatrics 2002;110:e5. Crossref

5. Farhat G, Yamout B, Mikati MA, et al. Effect of antiepileptic drugs on bone density in ambulatory patients. Neurology 2002;58:1348-53. Crossref

6. Petty SJ, Paton LM, O’Brien TJ, et al. Effect of antiepileptic medication on bone mineral measures. Neurology 2005;65:1358-65. Crossref

7. Sheth RD, Wesolowski CA, Jacob JC, et al. Effect of carbamazepine and valproate on bone mineral density. J Pediatr 1995;127:256-62. Crossref

8. Triantafyllou N, Lambrinoudaki I, Armeni E, et al. Effect of long-term valproate monotherapy on bone mineral density in adults with epilepsy. J Neurol Sci 2010;290:131-4. Crossref

9. Coppola G. Fortunato D, Auricchio G, et al. Bone mineral density in children, adolescents, and young adults with epilepsy. Epilepsia 2009;50:2140-6. Crossref

10. Ko CH, Tse PW, Chan AK. Risk factors of long bone fracture in non-ambulatory cerebral palsy children. Hong Kong Med J 2006;12:426-31.

11. Coppola G, Fortunato D, Mainolfi C, et al. Bone mineral density in a population of children and adolescents with cerebral palsy and mental retardation with or without epilepsy. Epilepsia 2012;53:2172-7. Crossref

12. Portney LG, Watkins MP. Foundations of clinical research applications to practice. 3rd ed. Upper Saddle River, NJ: Pearson/Prentice Hall; 2009: 832-47.

13. Leung SS, Lau JT, Tse LY, Oppenheimer SJ. Weight-for-age and weight-for-height references for Hong Kong children from birth to 18 years. J Paediatr Child Health 1996;32:103-9. Crossref

14. Xu H, Chen JX, Gong J, et al. Normal reference for bone density in healthy Chinese children. J Clin Densitom 2008;10:266-75. Crossref

15. Guo B, Xu Y, Gong J, Tang Y, Xu H. Age trends of bone mineral density and percentile curves in healthy Chinese children and adolescents. J Bone Miner Metab 2013;31:304-14. Crossref

16. Lewiecki EM, Gordon CM, Baim S, et al. International Society for Clinical Densitometry 2007 Adult and Pediatric Official Positions. Bone 2008;43:1115-21. Crossref

17. Hartman C, Brik R, Tamir A, Merrick J, Shamir R. Bone quantitative ultrasound and nutritional status in severely handicapped institutionalized children and adolescents. Clin Nutr 2004;23:89-98. Crossref

18. King W, Levin R, Schmidt R, Oestreich A, Heubi JE. Prevalence of reduced bone mass in children and adults with spastic quadriplegia. Dev Med Child Neurol 2003;45:12-6. Crossref

19. Ali O, Shim M, Fowler E, Cohen P, Oppenheim W. Spinal bone mineral density, IGF-1 and IGFBP-3 in children with cerebral palsy. Horm Res 2007;68:316-20. Crossref

20. Sturm PF, Alman BA, Christie BL. Femur fractures in institutionalized patients after hip spica immobilization. J Pediatr Orthop 1993;13:246-8.

21. Crosley CJ, Chee C, Berman PH. Rickets associated with long-term anticonvulsants therapy in a pediatric outpatient population. Pediatrics 1975;56:52-7.

22. Keck E, Gollnick B, Reinhardt D, Karch D, Peerenboom H, Krüskemper HL. Calcium metabolism and vitamin D metabolite levels in children receiving anticonvulsant drugs. Eur J Pediatr 1982;139:52-5. Crossref

23. Ecevit C, Aydoğan A, Kavakli T, Altinöz S. Effect of carbamazepine and valproate on bone mineral density. Pediatr Neurol 2004;31:279-82. Crossref

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According to the Family Planning Knowledge, Attitude and Practice in Hong Kong Survey 2012 among Hong Kong couples,1 the male condom was the most popular contraceptive. The proportion of couples who used a male condom doubled from 32.2% in 1987 to 69.6% in 2012. Combined oral contraceptive (COC) pill was the second most common form of contraception, though the proportion of women using a COC pill declined from 20.3% in 1987 to 10.8% in 2012. The failure rate of the male condom when used correctly is 6 times higher than that for the COC pill.2 Although the low-dose COC pill has a low incidence of complications, high efficacy, and many non-contraceptive benefits, relatively few women use it in Hong Kong. The report of the United Nations world contraceptive patterns 2013 estimated that the prevalence of pill use in Hong Kong women aged 15 to 49 years was 6.7%, which is much lower than other countries with similar development, wealth, and culture such as Australia (30.0%), Canada (21.0%), Singapore (10.0%), the UK (28.0%), and the US (16.3%).3 Unlike these countries, the COC pill is not a prescription drug in Hong Kong. Women can buy a low-dose COC pill that contains either 30-µg or 20-µg ethinylestradiol and one of the progestogens: levonorgestrel, gestodene, desogestrel, or drospirenone at any of the large-chain personal health and beauty retailers or pharmacy stores. All pills have similar efficacy. Their failure rate is 0.3% within the first year of perfect use.2 Low-dose pills are safer, better tolerated, and have equal or higher efficacy than high-dose pills that contain 50-µg ethinylestradiol.

With 70% of couples in Hong Kong using the male condom,1 the demand for abortion due to failed contraception cannot be ignored. It was shown that 77.4% of women who underwent an abortion were using contraception during the index pregnancy and 51.2% of them were using a male condom.1 The number of legal abortions in Hong Kong has reduced from 25 363 in 1995 to 10 359 in 2014 (personal communication, Department of Health), though the number of abortions carried out across the border is unknown. According to the results from the serial 5-yearly territory-wide family planning survey,1 the proportion of married women who went to China for their last abortion increased from 24.3% in 1992 to 47.2% in 2012. Given the limited resources assigned to abortion in public hospitals, women have to resort to the more expensive legal abortion service in private hospitals or the Family Planning Association of Hong Kong (FPAHK). The FPAHK performs 3000 medical and surgical first-trimester abortions each year and has reached its full service capacity. There is a need to further reduce unplanned pregnancies and abortion in Hong Kong. One plausible solution is to encourage more women to use more effective contraception such as the combined hormonal contraceptive pill, progestogen-only contraceptives, intrauterine contraceptive device, or sterilisation. The failure rate of these effective contraceptives when used correctly is <1% in the first year of use.2

Studies have shown that identifying women’s perspective can help doctors understand their motive to choose one contraceptive over another.4 One study identified personal choices, local factors, women’s perceived safety, effectiveness, and convenience of the method as determinants of contraceptive choice.5 Among the effective contraceptives available in Hong Kong, the COC pill is the most accepted. We performed this survey to determine the motivators and barriers to COC pill use.

The Family Planning Association of Hong Kong invited ESDlife to host the survey that was open to its female members aged between 18 and 45 years. The questionnaire was designed by the investigators. ESDlife is an online lifestyle media in Hong Kong. It is a joint venture between the Hong Kong SAR Government and a commercial firm that began in 2000 with the aim of providing e-government and e-commerce services. With the establishment of the Government’s own website in 2008, all government services have migrated to the official website and ESDlife remains a solely commercial portal. As of 2 January 2015, it had 297 152 members of whom 64.4% were female. Among the female members, 89.0% were within our target age range: 32.3% were 30-34 years old, 23.3% were 35-39 years old, 19.3% were 25-29 years old, 10.3% were 40-45 years old, and 3.8% were 18-24 years old.

ESDlife sent out 100 000 invitations randomly to its female members aged between 18 and 45 years on 21 April 2015 and invited them to participate in this online survey between 21 April 2015 and 20 May 2015. There were 16 questions that explored the basic demographic characteristics of respondents (6), their contraceptive choice (3), and their motivators and barriers to COC use (7). Invited members entered the survey via a link and those who had not used any contraception in the previous 12 months were screened out by the first question. Only eligible subjects could proceed with the survey. They could stop at any question and the questionnaire would be voided. To encourage participation, a $50 supermarket coupon was given to every 10th respondent via ESDlife. This study was reviewed and approved by the Health Services Subcommittee and Ethics Panel of the FPAHK.

Data analyses were accomplished using the Statistical Package for the Social Sciences (Windows version 22.0; SPSS Inc, Chicago [IL], US). Descriptive statistics were presented. Bivariate Chi squared test was performed to analyse the demographic characteristics that predicted COC pill use.

During the survey period, only completed questionnaires were captured by the system so the number of incomplete questionnaires was unknown. A total of 1566 women completed the survey within the 1-month period, 271 were screened out by Question 1 because they had not used regular contraception in the past 12 months and 1295 questionnaires were analysed. The response rate was 1.57%. The median age of the respondents was 32 years (interquartile range, 29-36 years). Half of them (50.7%) had a university education, 20.5% had a post-secondary education (diploma or associate degree), and 28.3% had a secondary education. The majority (65.5%) were married, 29.0% were unmarried, 3.3% were cohabiting, 2.1% had separated or divorced, and 0.2% were widowed. Over half of the respondents were nulliparous (56.7%) and had no plan for pregnancy (52.3%). They usually purchased contraceptives from a chain of personal health and beauty retailers (52.8%), convenience store and supermarket (43.9%), or pharmacy (23.6%). They usually sought contraceptive information from an online health website (46.5%), online forum (40.1%), gynaecologists (27.8%), or family planning clinic (21.6%). A summary of the socio-demographic characteristics is shown in Table 1.

Among the 1295 respondents, 453 (35.0%) had used more than one type of contraceptive in the previous 12 months. The contraceptive choices of the whole group were: male condom (76.1%), coitus interruptus (20.9%), safe period (16.2%), and COC pill (12.6%) [Table 1]. The contraceptive choices of the 986 male condom users were further analysed to estimate their risk of unplanned pregnancy. Among them, 598 (60.6%) used a male condom alone, 295 (29.9%) also used other less effective contraceptives such as a female condom, safe period, and coitus interruptus but whether they used them all together during coitus or switched between these contraceptives was unknown. Therefore, these condom users were indisputably at risk for unplanned pregnancy because they did not use other effective contraceptives with the male condom.

In this study sample, 842 (65.0%) women had never tried a COC pill. The main reasons were fear of side-effects (72.1%), satisfied with their current contraceptive (32.1%), and pill-taking was inconvenient for them (18.5%) [Table 2]. Among 453 women who had tried a COC pill, the median age they started use was 24 years (interquartile range, 20-28 years). Use of COC pill was associated with older age (mean ± standard deviation: users and non-users was 33.4 ± 5.8 and 32.4 ± 5.5 years, respectively; t test, P=0.003), not planning to get pregnant (P=0.002), and university education (P=0.004). There was no association with relationship status (P=0.968) or parity (p=0.427). These women preferred the COC pill because of convenience (47.7%), effectiveness (44.8%), menstrual regulation (33.6%), recommendation by their doctor (24.7%), reduced burden to partner (17.0%), for relief of dysmenorrhoea (14.1%), and improvement of acne (12.6%) [Table 3]. They chose a COC pill based on the dosage of hormones, type of hormones, and price. Among the 453 ever-users, 177 (39.1%) had been taking a COC pill in the previous 12 months. Use had stopped in 276 because they feared side-effects (39.1%); they experienced side-effects such as nausea, vomiting, breast tenderness, oedema, or weight gain (27.9%); they consistently forgot to take pills (19.9%); their doctor told them to stop (14.1%); or they were having less frequent coitus (12.3%) (Table 4).

The pattern of contraceptive use in this study sample was similar to that in the 2012 territory-wide survey.1 Male condom was the most popular contraceptive, used by 76.1% of couples in our study. The proportion of women using a COC pill in our study was also similar to that in the 2012 survey. Our survey has provided some information about the characteristics of women who chose to take the COC pill, such as older age, university education, and no plan for future pregnancy. A similar age profile and education attainment were identified in a national survey conducted in the US,6 in which parity and relationship status were also characteristics associated with COC pill use.

Fear of side-effects was the major reason cited by both subgroups of women who stopped or had never tried a COC pill. Studies carried out in both developed and developing countries have also shown that the experience of side-effects as well as the fear of side-effects are major reasons for discontinuation.7 8 9 10 It appeared that fear of side-effects was a unique barrier across different countries and cultures. Minor side-effects such as breast tenderness, fluid retention, nausea, and vomiting were transient and usually subsided after one to two cycles. Major health hazards such as myocardial infarction, stroke, thromboembolism, breast cancer, and cervical cancer are rare. Two meta-analyses showed a 2-fold increase in myocardial infarction and stroke in low-dose COC pill users compared with non-users.11 12 The risk of venous thromboembolism was increased by 3- to 5-fold depending on the type of progestogen used.13 Since the baseline incidence of these vascular events in women of reproductive age is very low (myocardial infarction: 0.2 per 100 000 at age 30-34 years to 2.0 at age 40-44 years14; stroke: 1 per 100 000 at age 30-34 years to 1.6 at age 40-44 years14; thromboembolism: 2 per 10 000 women at reproductive age15), the absolute risk of such vascular complications is very small. Breast cancer risk with a low-dose COC pill is also small. A large meta-analysis of case-control studies from 25 countries showed a modest increase in breast cancer risk with the COC pill (relative risk=1.24; 95% confidence interval [CI], 1.15-1.33).16 The risk of cervical cancer depends on the duration of use. Women who used a COC pill for less than 5 years have no increased risk of cervical cancer. The odds ratio for cervical cancer after using COC for 5 to 9 years was 2.82 (95% CI, 1.46-5.42) and 4.03 (95% CI, 2.09-8.02) for 10 years or longer.17 Cervical cancer is largely preventable by regular cervical smears, safe sex, as well as avoidance of smoking. The overall morbidity and mortality associated with the low-dose COC pill are low and most healthy women can use it without major concerns.

The lack of access to consultation services has exacerbated concern about side-effects, both for women who experience them and for those who fear them.9 At our clinics, women are counselled about the common side-effects and complications of the COC pill. This prevents them from panicking when minor side-effects occur. They are also told to stop taking the COC pill immediately and consult a doctor if they develop signs and symptoms of a major complication. Such counselling helps women establish realistic expectations and they are able to use COC safely. An information sheet detailing side-effects and complications, warning signs and symptoms for major complications, commonly used drugs that interact with COC pill, and missed pill management is given to all users. When first prescribed, we usually provide two packs and then review acceptability after 2 months. Women are advised that different COC pills vary slightly in their side-effect profile and they can change to another formulation if they have problems. We also offer walk-in clinics for any woman who wishes to get contraceptive advice from nurses. The above COC pill delivery mode conforms to the World Health Organization recommendations.18

Apart from side-effects and complications, women should be informed of the non-contraceptive benefits of the COC pill, such as menstrual regulation and relief of dysmenorrhoea; reduced risk for endometrial, ovarian, and colorectal cancers; lower incidence of gynaecological diseases such as endometriosis, pelvic inflammatory disease, ectopic pregnancy; and improved acne and bone health. All such information should be shared with women to help them establish an impartial perspective on the risks and benefits of the COC pill.

The main limitation of this survey is the very low response rate, albeit not unexpected with online survey. There was also selection bias as members of an exclusive group were invited to participate. Those who participated in the survey prompted self-selection bias as they might be systematically different from those who chose not to respond. When we planned the study, we had explored other alternatives such as face-to-face interview, phone interview, or online survey for the general public. Nonetheless, the first would be too expensive and in the last two alternatives, we would be unable to verify respondent’s age or gender. We settled with this arrangement as it was the most convenient means to reach our target group since ESDlife only allowed female members aged 18 to 45 years to participate. The demographic statistics provided by ESDlife revealed that the education attainment and income reported by its female members were better than the population average. The contraceptive choice in this group matched that of the population study and the sample size was not small. Although the results obtained cannot be generalised to the local population, we believe they provide useful insight into the reasons why women do or do not use the COC pill. The other limitation is the number of questions we could ask was limited by the budget. If we had a larger budget to include more questions, we would have explored the type of COC pill used, total duration of use, and the switch pattern in women who used more than one contraceptive in the previous 12 months. Lastly, there was a discrepancy in the number of women who were using a COC pill in the past 12 months. For “Question 15. Are you still on COC in the past 12 months?”, 177 responded positively. In response to Question 7, however, only 163 chose COC pill as one of the contraceptives they had used in the past 12 months. Some women might have omitted COC when they selected their contraceptives from the list provided in Question 7.

The COC pill remains underutilised in Hong Kong compared with many western countries. The male condom is the most popular contraceptive and the proportion of women using a COC pill is one sixth of that of women who use a male condom. A considerable proportion of respondents expressed concerns about actual or anticipated side-effects. Doctors should focus on this area during contraceptive counselling and help dispel the underlying myths and misconceptions surrounding COC pill use. Studies have shown that minor side-effects are transient, major complications are rare in healthy women, and there are many non-contraceptive benefits of the COC pill. These facts should be emphasised during COC counselling to help women balance the risks and benefits of the COC pill and make an informed choice about contraception.

Sponsorship was provided by Pfizer Corporation Hong Kong Limited to cover all costs incurred with ESDlife and incentives for participants. The company was not involved in the study design, execution, data interpretation, or manuscript preparation.

1. Family Planning Knowledge, Attitude and Practice in Hong Kong Survey 2012. Available from: http://www.famplan.org.hk/fpahk/en/template1.asp?style=template1.asp&content=info/research.asp. Accessed 6 Aug 2015.

2. Trussell J. Contraceptive failure in the United States. Contraception 2011;83:397-404. Crossref

3. United Nations. Department of Economic and Social Affairs. Population Division. World contraceptive patterns 2013. Available from: http://www.un.org/en/development/desa/population/publications/pdf/family/worldContraceptivePatternsWallChart2013.pdf. Accessed 6 Aug 2015.

4. Heise L. Beyond acceptability: reorienting research on contraceptive choice. In: Ravindran TS, Berer M, Cottingham J, editors. Beyond acceptability: users’ perspectives on contraception. London: Reproductive Health Matters; 1997: 6-14.

5. User preferences for contraceptive methods in India, Korea, the Philippines, and Turkey. World Health Organization Task Force on Psychosocial Research in Family Planning and Task Force on Service Research in Family Planning. Stud Fam Plann 1980;11:267-73.

6. Hall KS, Trussell J. Types of combined oral contraceptives used by US women. Contraception 2012;86:659-65. Crossref

7. Ali M, Cleland J. Contraceptive discontinuation in six developing countries: a cause-specific analysis. Int Fam Plan Perspect 1995;21:92-7. Crossref

8. Sanders SA, Graham CA, Bass JL, Bancroft J. A prospective study of the effects of oral contraceptives on sexuality and well-being and their relationship to discontinuation. Contraception 2001;64:51-8. Crossref

9. D’Antona Ade O, Chelekis JA, D’Antona MF, Siqueira AD. Contraceptive discontinuation and non-use in Santarém, Brazilian Amazon. Cad Saude Publica 2009;25:2021-32. Crossref

10. Larsson G, Blohm F, Sundell G, Andersch B, Milsom I. A longitudinal study of birth control and pregnancy outcome among women in a Swedish population. Contraception 1997;56:9-16. Crossref

11. Baillargeon JP, McClish DK, Essah PA, Nestler JE. Association between the current use of low-dose oral contraceptives and cardiovascular arterial disease: a meta-analysis. J Clin Endocrinol Metab 2005;90:3863-70. Crossref

12. Khader YS, Rice J, John L, Abueita O. Oral contraceptives use and the risk of myocardial infarction: a meta-analysis. Contraception 2003;68:11-7. Crossref

13. Faculty of Sexual and Reproductive Healthcare Statement. Venous thromboembolism and hormonal contraception. November 2014. Available from: http://www.fsrh.org/pdfs/FSRHStatementVTEandHormonalContraception.pdf. Accessed 6 Aug 2015.

14. Farley TM, Meirik O, Collins J. Cardiovascular disease and combined oral contraceptives: reviewing the evidence and balancing risks. Human Reprod Update 1999;5:721-35. Crossref

15. European Medicines Agency. Benefits of combined hormonal contraceptives (CHCs) continue to outweigh risks. Product information updated to help women make informed decisions about their choice of contraception. London, UK: EMA, 2014. Available from: http://www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/referrals/Combined_hormonal_contraceptives/human_referral_prac_000016.jsp&mid=WC0b01ac05805c516f. Accessed 6 Aug 2015.

16. Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and hormonal contraceptives: collaborative reanalysis of individual data on 53 297 women with breast cancer and 100 239 women without breast cancer from 54 epidemiological studies. Lancet 1996;347:1713-27. Crossref

17. Moreno V, Bosch FX, Muñoz N, et al. Effect of oral contraceptives on risk of cervical cancer in women with human papillomavirus infection: the IARC multicentric case-control study. Lancet 2002;359:1085-92. Crossref

18. World Health Organization. Family Planning: A Global Handbook for Providers. 2011 edition. Available from: https://www.fphandbook.org/sites/default/files/chap_1_eng.pdf. Accessed 6 Aug 2015.

In Hong Kong, thousands of patients undergo breast surgery every year for both benign and malignant conditions.1 Patients expect a good cosmetic outcome and satisfactory postoperative wound management. This is in addition to the expectation of a cure, or in the case of breast cancer, complete removal of lesions with optimal survival.

Several studies have demonstrated that octylcyanoacrylate (OCA) tissue adhesive provides an equivalent cosmetic outcome to wound suturing in repair of lacerations,2 3 head and neck surgery,4 plastic surgery,5 and breast surgery.6 7 The OCA tissue adhesives are supplied as monomers in a liquid form. They polymerise on contact with tissue anions, forming a strong bond that holds the opposed wound edges together. The OCA tissue adhesive usually sloughs off with time. The wound epithelises within 5 to 10 days and the adhesive does not require removal.

In-vitro studies have shown that OCA provides an effective antimicrobial barrier for the first 72 hours after application.8 It is approved by the US Food and Drug Administration as a topical skin adhesive that protects the wound from bacteria. It also facilitates postoperative wound care as patients are allowed to shower immediately. There is no need for suturing, staple removal, or dressings. Higher patient satisfaction following skin closure with OCA tissue adhesive compared with sutures has been observed.6 Studies also show faster wound closure with OCA.9

This study aimed to assess the outcome of elective breast surgical incision repair with OCA tissue adhesive compared with standard wound suture (SWS). We compared the cosmetic outcome, complication rates, and patient satisfaction score for breast incisions in elective surgery closed with OCA tissue adhesive versus SWS.

The study was in compliance with the Declaration of Helsinki and ICH-GCP (International Conference on Harmonisation, Good Clinical Practice). It was reviewed and approved by the institutional review boards.

Based on a randomised trial of OCA versus SWS in breast surgery,5 patient satisfaction in an OCA group has been reported to be significantly higher than that of a SWS group. To detect a difference with a power of 90% and α=0.05, 35 patients were needed for each arm.

A total of 70 female patients, who underwent elective excision of clinically benign breast lump between February 2009 and November 2011 in this randomised controlled trial, were randomly allocated to have wound closure using either OCA or SWS with a continuous monofilament subcuticular method. They were seen on the morning of the surgery, consented, and randomly allocated to a study arm. Each randomisation number was computer-generated, sealed in an envelope, and kept in a secure designated place. At the time of wound closure, the surgeon would call a third-party nurse to open the sealed envelope that would determine the method to be used for wound closure. The surgery was performed by specialists or surgical trainees under a specialist’s supervision. Two evaluation forms were administered to collect information on wound condition and cosmetic grading by different parties.

Postoperatively, the wound condition was examined by a surgeon who was not involved in the study. An evaluation form was completed to note any indication of (1) wound infection, (2) dehiscence, (3) oozing, and (4) discharge on day 0-1 (early postoperative period) and day 10-14 (first follow-up).

The cosmetic grading of the surgical wound was checked on day 30 and 180 by an evaluator (surgeons not involved in the study or the above evaluations) who looked for any sign of (1) step-off borders (edges not on same plane), (2) contour irregularities (wrinkled skin near wound), (3) margin separation (gap between sides), (4) edge inversion (wound not properly everted), and (5) excessive distortion (swelling/oedema/infection); and (6) evaluated the overall appearance of the wound.

Patient evaluation of whether the appearance of the wound was “good” or “bad” over a score of 1 (very bad) to 10 (very good) on day 30 and day 180 was also recorded.

Patients were also asked five questions about self-care of the wound at the day-30 visit. Questions were answered and rated on a 5-point Likert scale (very good, good, neutral, bad, very bad) regarding (1) pain, (2) ease of caring, (3) self-showering, (4) frequency of hospital/clinic visits for wound cleansing, and (5) comfort level of wound dressing.

Data were summarised with descriptive statistics. Means and standard deviations (for numeric variables) and numbers and percentages (for categorical variables) were calculated where appropriate. We checked the normality of the data and found that it did not follow the normal distribution. Therefore the Wilcoxon rank sum test and Fisher’s exact test were applied to determine any significant difference between the OCA and SWS groups. All statistical analyses were done using the Statistical Package for the Social Sciences (Windows version 16.0; SPSS Inc, Chicago [IL], US) and R version 3.0.2 (the R Foundation). All statistical tests were two-sided and statistical significance was considered at P<0.05.

A total of 70 patients, half of whom were randomised to receive OCA or SWS, were entered into this study. One patient from the suture group was lost to follow-up and excluded from subsequent analysis, leaving a total number of 69 patients (35 for OCA group and 34 for SWS group).

The demographics of the two groups were comparable. There was no statistical difference in terms of age, tumour size, co-morbidity including diabetes, pathology, laterality and location of the lesion, or the rank of the surgeon involved (Table 1).

Use of OCA was associated with significantly less time to complete the wound closure process compared with suture (mean, 80.6 seconds vs 344.6 seconds; P<0.001; Table 1). With similar length of surgical wound, OCA required 7.1 times less time to close the wound than suture (P<0.001).

The occurrence of adverse wound condition is shown in Table 2. There was no unfavourable condition noticed upon first-day follow-up. Wound complications on day 10-14 all occurred in the OCA group.

Table 3 summarises the incidence of any wound cosmetic problem on day 30 and 180. Cosmetic problems were found only on day 30, and were not confined to any one group. One patient from the suture group felt that the overall appearance of the surgical wound on day 30 was bad but subsequently commented it was “good” on day 180. No bad comments were received from any patient who had undergone wound closure with OCA.

For the patient’s view of cosmetic outcome, a higher score was given to wounds closed by sutures compared with OCA on both day 30 and 180, although the standard deviations were larger in the OCA group, and the differences were not statistically significant (Table 4). Higher scores were given on day 180 compared with day 30 in both groups.

The actual number of hospital or clinic visits was recorded. Patients in the OCA group required fewer visits than those in the suture group (16 OCA vs 18 sutures, 1.19 ± 2.66 vs 2.50 ± 4.57; P=0.063). A higher percentage of patients in the OCA group felt “very good” on ‘self-showering’ (OCA vs suture, 66.7% vs 21.2%; P<0.001), ‘frequency of hospital/clinic visits for wound cleansing’ (OCA vs suture, 66.7% vs 25.0%; P=0.001), and ‘comfort level of wound dressing’ (OCA vs suture, 58.8% vs 18.2%; P=0.003) [Table 5]. More patients in the suture group rated “good”, instead of “very good” for these three categories. The same applied for ‘ease of caring’ although statistical significance was not reached. For patients who commented “bad” or “very bad”, the percentages were generally higher from the OCA group. There was no significant difference between the two groups for reports about pain (P=0.564).

Tissue adhesive material has long been used in wound closure in western countries, and offers the advantages of faster closure, need for less postoperative wound care, and higher patient satisfaction.

In this study among Chinese women, we demonstrated that time required for wound closure was much less in the OCA group compared with the SWS group (P<0.001). Although the difference was significant, time required for wound closure was not a significant concern for the surgeon.

There were three instances of postoperative complications in the OCA group. In two patients, the surgery was performed by a trainee under supervision, and in one by a specialist. One patient required secondary suturing 3 weeks later. The other two were treated conservatively with antibiotics. We postulate that there is a learning curve for closure with OCA, thus technical skill and experience of the surgeon may play a role.

For cosmetic outcome, the score was comparable in both groups, although slightly higher in the SWS group. Nonetheless, the difference was less than 1 point on a scale of 10. The standard deviation in the OCA group was wider (OCA 2.17 vs SWS 1.36) at day 30 but was not statistically significant.

For wound problems, margin separation occurred on postoperative day 30 in five patients in the OCA group compared with two in the SWS group. There was no statistical difference in cosmetic problem grading between the two study groups. It should be noted that tissue adhesive wound repair is a manual skill, just like suturing, and requires practice and careful application. Factors such as wound oozing or discharge may hinder proper functioning of the tissue adhesive.

The skin of patients of Chinese or Asian descent is more prone to keloid scarring and pigmentation, thus the effect of using tissue adhesives may differ to that of a western population. A previous study did not show any difference in the rate of hypertrophic scar formation.10 In our study, there was no hypertrophic scar or keloid formation in either group.

There was a significant difference in preference in terms of self-showering, frequency of hospital/clinic visits, and comfort level of dressing between OCA and SWS groups. These factors affect patients since they impact on daily activities and saving of time. On the other hand, there was no statistical difference in degree of pain, although the Phi value was very small, thus a larger sample size may be required to detect any difference. The sample size for all other values was adequate.

In terms of cost, a study in Hong Kong has shown that tissue adhesive is more expensive than SWS,11 but may be more cost-effective from a social viewpoint in terms of superior cosmetic outcome and overall patient satisfaction.

First, this was a prospective randomised study confined to closure of benign breast lump wounds and thus not necessarily applicable to all surgical wounds. We did not determine the number of eligible patients for the study, or note how many of them refused to take part. This may have led to self-selection bias. Second, the operation was performed by different surgeons of different seniority, and may have led to varying levels of surgical technique. This was not shown to be statistically significant but the sample size was not designed to reflect this. Lastly, during wound evaluation, the surgeon might not have been totally blind to the type of closure if sutures or stitch marks were visible. This may be a cause of blinding bias. The use of a scoring scale is also a subjective evaluation, and may be influenced by the patient’s mood and other factors.

The use of OCA should be discussed and offered to patients as an option for wound closure in breast surgery. It achieves faster wound closure, is not inferior to standard wound closure, has a higher comfort level, and requires less frequent clinic visits. Understanding cost-effectiveness is essential in medical care, thus OCA should be offered as an option to be provided as a self-financed item in the public sector where it is now widely available.

We thank Mr Jack Chau and Miss Fidelia Wong for performing the early statistical analysis, and Mr Ling-hiu Fung and Mr Wing-pan Luk of the Hong Kong Sanatorium & Hospital for the later review and re-running of the statistical analysis methods. We also thank Ethicon, Johnson and Johnson Company for providing the OCA study material.

Johnson and Johnson provided the study material. No other conflict of interests was declared by authors.

1. Top ten cancers in 2013. Hong Kong Cancer Registry. Available from: http://www3.ha.org.hk/cancereg/statistics.html. Accessed Jan 2016.

2. Singer AJ, Quinn JV, Clark RE, Hollander JE; TraumaSeal Study Group. Closure of lacerations and incisions with octylcyanoacrylate: a multicenter randomized controlled trial. Surgery 2002;131:270-6. Crossref

3. Chow A, Marshall H, Zacharakis E, Paraskeva P, Purkayastha S. Use of tissue glue for surgical incision closure: a systematic review and meta-analysis of randomized controlled trials. J Am Coll Surg 2010;211:114-25. Crossref

4. Maw JL, Quinn JV, Wells GA, et al. A prospective comparison of octylcyanoacrylate tissue adhesive and suture for the closure of head and neck incisions. J Otolaryngol 1997;26:26-30.

5. Toriumi DM, O’Grady K, Desai D, Bagal A. Use of octyl-2-cyanoacrylate for skin closure in facial plastic surgery. Plast Reconstr Surg 1998;102:2209-19. Crossref

6. Gennari R, Rotmensz N, Ballardini B, et al. A prospective, randomized, controlled clinical trial of tissue adhesive (2-octylcyanoacrylate) versus standard wound closure in breast surgery. Surgery 2004;136:593-9. Crossref

7. Nipshagen MD, Hage JJ, Beekman WH. Use of 2-octylcyanoacrylate skin adhesive (Dermabond) for wound closure following reduction mammaplasty: a prospective, randomized intervention study. Plast Reconstr Surg 2008;122:10-8. Crossref

8. Quinn JV, Osmond MH, Yurack JA, Moir PJ. N-2-butylcyanoacrylate: risk of bacterial contamination with an appraisal of its antimicrobial effects. J Emerg Med 1995;13:581-5. Crossref

9. Soni A, Narula R, Kumar A, Parmar M, Sahore M, Chandel M. Comparing cyanoacrylate tissue adhesive and conventional subcuticular skin sutures for maxillofacial incisions—a prospective randomized trial considering closure time, wound morbidity, and cosmetic outcome. J Oral Maxillofac Surg 2013;71:2152.e1-8. Crossref

10. Wilson AD, Mercer N. Dermabond tissue adhesive versus Steri-Strips in unilateral cleft lip repair: an audit of infection and hypertrophic scar rates. Cleft Palate Craniofac J 2008;45:614-9. Crossref

11. Wong EM, Rainer TH, Ng YC, Chan MS, Lopez V. Cost-effectiveness of Dermabond versus sutures for lacerated wound closure: a randomised controlled trial. Hong Kong Med J 2011;17 Suppl 6:4-8.

Breast cancer is the second leading cause of death due to cancer in the world with an age-standardised incidence rate of 43.1 per 100 000 population in 2012.1 Gøtzsche and Nielsen2 showed that early detection of breast cancer can reduce mortality. The benefit of mammographic screening in terms of lives saved is greater than the harm caused by overdiagnosis; according to Duffy et al,3 2 to 2.5 lives are saved for every overdiagnosed case.

Breast cancer is also a significant health problem in Hong Kong. It is the third leading cause of death due to cancer and the most common cancer of women.4 The crude incidence rate of breast cancer in Hong Kong increased from 57 per 100 000 in 2000 to 91.7 per 100 000 in 2012.4

Despite this, Hong Kong does not have a universal breast cancer screening programme for the whole population. Women who wish to be screened must arrange and pay for it. As the incidence of breast cancer in Hong Kong is low compared with western populations, there is concern about the cost-effectiveness of a universal screening programme. The incremental cost-effectiveness ratio for mammography examination is relatively higher than in the United States.5

In view of the controversy there is a need for further studies in Hong Kong to provide local data on the efficacy of breast cancer screening by mammogram. This will enable policy makers, doctors, and patients to decide on the most cost-effective method of early breast cancer detection.

This study aimed to investigate whether there are any prognostic differences between screen-detected (mammography, ultrasound examination of breasts, or clinical examination) and self-detected breast cancers in a cohort of Hong Kong breast cancer patients and to determine whether there is any benefit of detection by screening.

A retrospective study was conducted at the Hong Kong Sanatorium & Hospital (HKSH), a private hospital in Hong Kong where the Breast Care Centre provides a comprehensive breast screening programme and breast cancer consultation services for patients. Since 2003, all breast cancer cases in the hospital have been discussed at a weekly multidisciplinary breast conference. Over 50% of cases are referred from public hospitals spread across the whole territory.

Clinical history, and information about diagnosis, neoadjuvant chemotherapy, surgical treatment, postoperative pathology, and treatment recommendations for each patient are recorded in a structured datasheet before the conference. The Chairman of the conference validates data by checking the data logic during case presentation and, if necessary, clarifying details with the doctor-in-charge. A research assistant again checked data validity and logic by computer for cases selected for analysis. Frequency tables, scatter plots, and cross-tabulation tables were generated for each required variable to ensure completeness and to determine whether any data deviated from usual clinical practice.

All Chinese females confirmed to have in-situ or invasive breast cancer from or referred to HKSH between 2003 and 2010 were included in this study. For analysis of trends of prognostic factors, only patients between 2004 and 2010 were included as the sample size for year 2003 was small after dividing data into subsets by year and prognostic factors.

The use of the database for data analysis for health care research purposes was approved by the Research Ethics Committee of HKSH.

Patients were classified into two groups, screen-detected or self-detected tumour, before the outcomes were reviewed. The screen-detected group included screening mammogram, screening ultrasonogram, or clinical examination. The self-detected group included self-examination or presence of symptoms at presentation. Such information was recorded on the datasheet that was anonymised. Demographic data of patients were retrieved and significant prognostic factors according to St Gallen’s risk categorisation were analysed.

The Statistical Package for the Social Sciences (Windows version 18.0; SPSS Inc, Chicago [IL], US) was used for analysis. Descriptive statistics were used to summarise demographics, as well as pathological and clinical characteristics of patients. Univariate logistic regression was used to determine odds ratio (OR) of screening status for different pathological characteristics. Association between type of surgery and screening status, tumour size, and age was determined by univariate logistic regression. In order to know how effective the models were in predicting the type of surgery, Hosmer-Lemeshow goodness-of-fit test was used, in which the null hypothesis was no significant difference between observed and predicted values of dependent variable. Multivariate analysis was performed on the type of surgery, which was dichotomous having breast-conserving surgery (BCS) as reference group with adjustment of confounding factors that included detection mode, lymph node status, tumour size, tumour grade, tumour stage, oestrogen receptors (ER), progesterone receptors (PR), HER2 score, and age. Nagelkerke’s R² was used to show explanatory power of model.

Data for invasive tumour size were plotted against screening status to gain an overview of changes between 2004 and 2010.

Data from 2763 Chinese women out of 3373 cases confirmed to have in-situ or invasive breast cancer between 2003 and 2010 were analysed. Of the 610 cases excluded from analysis, 210 were due to unknown histology, 258 with unknown report type, and 142 with unknown first-detection method. Of the patients included, 75.7% were in the self-detected group and 24.3% in the screen-detected group. The mean age of patients was 50.2 (range, 24-92) years, with the highest number in both groups aged 40 to 49 years (Table 1). There was also a significant proportion of younger patients (<40 years) in the self-detected group (16.6%). The screen-detected group had a statistically significant higher age at first live birth, though the difference in mean age was only 1 year.

Pathological characteristics of self-detected and screen-detected groups are shown in Table 1. There was a significant difference in ER, but no demonstrable significant difference in PR or HER2 status. Approximately 4% of patients in both groups did not undergo surgery for a variety of reasons, thus only limited information was available from biopsy specimens about pathological characteristics.

The odds of having 0 lymph nodes, smaller tumour size, or ER/PR positivity were all higher in the screen-detected group. Results were not statistically significant for HER2 positivity although it showed higher odds in the self-detected group (Table 2).

Table 3 shows that after adjustment for potential confounding factors, patients with screen-detected cancers were less likely to require mastectomy (OR=0.658, P=0.004). Statistically significant factors associated with a higher risk of mastectomy included: positive lymph node, tumour grading higher than 1, tumour size of >2 cm, older age, and positive HER2 score. The Hosmer-Lemeshow test had a P value of 0.88, meaning the goodness of fit of the model was satisfactory at the 5% significance level.

The Figure shows the trend in differences between groups for invasive tumour size between 2004 and 2010. In the screen-detected group, there was an increasing proportion of invasive tumours detected when ≤2 cm and a decreasing trend for detection of tumour of >2 to 5 cm. There was, however, no significant difference between groups for trend of histology, lymph node involvement, tumour grade, type of surgery, ER positivity, or HER2 positivity.

Although the incidence of breast cancer in Hong Kong is half that of the United Kingdom, the screen-detected group showed a pattern of breast cancer diagnosis at an earlier stage compared with the self-detected group. This is consistent with the findings of similar studies in other countries, such as Singapore.6 This study may provide evidence that supports the benefits of regular screening to detect breast cancer lesions at an early stage in Hong Kong women. This will facilitate less invasive surgery and a possibly better overall clinical outcome. Breast cancer screening programmes have been established in many countries around the world. In order to bring Hong Kong in line with world health care standards, more research that will result in established and unified guidelines for the local population is required.

Significant prognostic factors in the St Gallen’s risk categorisation, including number of lymph nodes with disease, size of primary tumour, and histological grade between the self-detected and screen-detected groups were analysed. These prognostic factors were chosen because they have been verified as significant in the local population.7

In this study, screen-detected breast tumours were of smaller size, at a lower stage and grade, and with less lymph node involvement. Screen-detected breast cancers in the Hong Kong population may thus carry a better prognosis than self-detected ones. This can serve as evidence that fulfils most of the Wilson and Jungner criteria for a screening evaluation programme8 and also supports breast cancer screening in Hong Kong. Some of the criteria for breast cancer screening that have been fulfilled include: an important health problem (it is the second leading cause of death from cancer in Hong Kong), acceptable treatment is well established, facilities for diagnosis and treatment are widely available, natural history of the disease is well understood, and effective treatment is available for early-stage disease. Findings of this study suggested that breast tumours detected on screening have a better prognosis. The cost-benefit balance was not addressed, however, nor screening/case-finding policies.

In the screen-detected group, a higher percentage of tumours were ER positive. It was revealed that ER and PR are significant prognostic factors within the first 10 years following diagnosis.9 It is known that HER2 positivity shows poorer prognosis8 but there was no significant difference in HER2 status between screen-detected and self-detected groups.

By observing the trend in size of invasive tumour at first presentation, the stable pattern in the self-detected group suggests that tumour detection by the general population has not improved. On the contrary, an increasing detection of tumours of ≤2 cm in the screen-detected group is an evidence of the improved efficacy of screening using new technology such as mammogram or sonogram. There remains room for improvement in the application of radiology. Apart from magnetic resonance imaging, digital mammography may be more efficacious in women younger than 50 years.9 This may change future trends in early diagnosis.

Unlike tumour size and number of lymph nodes involved, both of which are increased in breast tumours detected at a later stage with a consequent poorer prognosis, prognostic factors such as status of ER/PR and HER2 are intrinsic characteristics of tumours. They should not differ whether or not a tumour is detected at an earlier stage. Therefore no statistically significant difference in these intrinsic characteristics was expected between screen-detected and self-detected tumours. Nonetheless, in this study, tumours in the screen-detected group were more likely to be positive for ER, and this may carry some prognostic implication. Further studies may be required to investigate whether tumours detected at an earlier stage show differences in intrinsic factors.

When choosing between BCS and mastectomy, detection mode, number of positive lymph nodes, invasive tumour size, grading, staging, ER, PR, HER2 score, and age were potential significant factors. With adjustment of these factors, detection mode may be an independent factor that affects choice of surgery. Screen-detected patients tended to have BCS when the effect of number of positive lymph nodes, tumour size, grading, HER2 score, and age was excluded. Such surgery is less invasive than mastectomy and is associated with better cosmetic outcome, and may have an important impact on the psychological health and coping ability of patients recovering from breast cancer. Breast cancer screening may lead to less invasive treatment with better rehabilitation outcome.

Many studies have claimed longer survival in patients with breast cancer detected by screening mammogram. Nonetheless, this may be due to lead-time bias: survival time appears longer because diagnosis is earlier than in patients where tumour has been self-detected or become symptomatic. In addition, there is selection bias since women with a family history of breast cancer or who are better informed are more likely to submit to breast cancer screening.

A local study suggested that population-based breast cancer screening by mammography may not be cost-effective in Hong Kong women.5 This balance between cost and benefit may be altered by the rising incidence of breast cancer in Hong Kong and the availability of advanced breast imaging technology that is associated with fewer false-positive diagnoses. There may also be a broader range of screening options, hence cost will be lowered. Therefore, the incremental cost-effectiveness ratio may be lowered.

A prospective randomised controlled trial would be the most effective study design to evaluate the effectiveness of mammogram screening. This would require a huge amount of resources, however. In addition, education level and household income, which are risk factors for breast cancer, may affect a woman’s decision to undergo a mammogram. These confounding factors should be considered when determining the effect of mammogram examination on development of breast cancer. Postmenopausal hormone replacement therapy also affects the density of breast tissue that may hinder the effectiveness of mammography for breast cancer screening.10

The lack of a population-based breast cancer screening programme in Hong Kong should prompt study of the attitude of Hong Kong women towards breast cancer screening. Quantitative surveys or qualitative interviews such as focus groups could help determine their opinion of mammogram screening, what proportion of women perform regular self-examination or undergo clinical breast examinations and regular mammogram examinations and how often, and whether age is a contributing factor. Trend study may also be meaningful if a particular age-group shows an increasing or decreasing trend for any of the examinations. Understanding level of knowledge about risk factors for breast cancer can also guide appropriate education about breast cancer prevention.

The major strength of this study is the large number of cases in the database, which is one of the most comprehensive breast cancer databases available in Hong Kong in terms of surgical and pathological characteristics. This provides valuable information about the characteristics of breast cancers detected by oneself and through screening, thus allowing a better understanding of the potential benefits of screening by mammogram or ultrasound examination.

This study has limitations. First, it was not a randomised controlled trial. The presence of confounding factors such as living standard, household income, and education level could not be totally excluded. There were also more self-detected than screen-detected patients in this study, thus data might skew towards self-detected cases. It is ethically difficult to randomise women to a control group of education and regular breast self-examination, or an intervention group of regular breast cancer screening by imaging.

Second, data were derived from a single private hospital and findings may not be representative of the Hong Kong population in general. Self-selection bias, especially for attending a private hospital, is also possible. Nonetheless, this is probably one of the largest breast cancer databases in Hong Kong, thus one of the best available sources of information options at present.

Third, secondary data that had been used in this study may not be in a format that met the research question. Some information required may not be available from secondary data. Only 2198 (79.6%) patients were included in the multivariate logistic regression. Other medical and non-medical factors that could have affected the choice of surgery in individual patients might be related to the practice of screening. Data on parity of women and breastfeeding experience, which may be of interest/relevance, were also not available. Also, the potential benefits and harm of screening were not thoroughly examined due to the unavailability of data for survival, mortality, and side-effects. For this study, a long period of time was required to examine the data and filter out required variables for analyses as there were more than 200 variables in the database. Information bias also exists as complete blinding of the analysts was not possible.

This study suggests that in the local Hong Kong population, breast cancers detected by screening mammogram or ultrasound tend to be of smaller size, lower stage, lower grade and with less lymph node involvement, and consequent better prognosis. Although this may not be considered conclusive evidence to support regular screening imaging of Hong Kong women on a population-wide basis, it provides indirect evidence that women in our local population may gain clinical benefit from such a programme.

This article is adapted from a dissertation submitted in partial fulfilment of the requirements for the Master of Public Health at the University of Hong Kong, Hong Kong Special Administrative Region, China. The dissertation was awarded distinction in 2012. Part of the material in this article was presented in the Hong Kong Sanatorium & Hospital Li Shu Pui Symposium 2012 in Hong Kong.

The first author would like to acknowledge Dr Joseph Wu, Assistant Professor, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, for his supervision of the project leading to completion of the dissertation for the Master of Public Health course. The authors would also like to thank Dr Andrew Ho, Senior Research Assistant, who is statistical advisor of the project. Finally, the authors would like to express sincere appreciation to staff of Information Technology Department of Hong Kong Sanatorium & Hospital, who helped retrieve all necessary data for the study.

All authors have disclosed no conflicts of interest.

1. GLOBOCAN 2012: Estimated cancer incidence, mortality and prevalence worldwide in 2012. Available from: http://globocan.iarc.fr/Pages/fact_sheets_population.aspx. Accessed Dec 2015.

2. Gøtzsche PC, Nielsen M. Screening for breast cancer with mammography. Cochrane Database Syst Rev 2011;(1):CD001877. Crossref

3. Duffy SW, Tabar L, Olsen AH, et al. Absolute numbers of lives saved and overdiagnosis in breast cancer screening, from a randomized trial and from the Breast Screening Programme in England. J Med Screen 2010;17:25-30. Crossref

4. Hong Kong Cancer Registry. Female breast cancer in Hong Kong. Available from: http://www3.ha.org.hk/cancereg/breast_2012.pdf. Accessed Jan 2016.

5. Wong IO, Kuntz KM, Cowling BJ, Lam CL, Leung GM. Cost-effectiveness analysis of mammography screening in Hong Kong Chinese using state-transition Markov modelling. Hong Kong Med J 2010;16(Suppl 3):38S-41S.

6. Chuwa EW, Yeo AW, Koong HN, et al. Early detection of breast cancer through population-based mammographic screening in Asian women: a comparison study between screen-detected and symptomatic breast cancers. Breast J 2009;15:133-9. Crossref

7. Yau TK, Soong IS, Chan K, et al. Evaluation of the prognostic value of 2005 St. Gallen risk categories for operated breast cancers in Hong Kong. Breast 2008;17:58-63. Crossref

8. Wilson JM, Jungner G. Principles and practice of screening for disease. Public Health Papers. No. 34. Geneva: World Health Organization; 1968.

9. Soerjomataram I, Louwman MW, Ribot JG, Roukema JA, Coebergh JW. An overview of prognostic factors for long-term survivors of breast cancer. Breast Cancer Res Treat 2008;107:309-30. Crossref

10. Cox B, Ballard-Barbash R, Broeders M, et al. Recording of hormone therapy and breast density in breast screening programs: summary and recommendations of the International Cancer Screening Network. Breast Cancer Res Treat 2010;124:793-800. Crossref

In Hong Kong, as in most developed countries, one of the most common types of burn injury that requires hospital admission is scald. If we view a scald as a ‘contact burns due to a liquid’, the severity of burn injury will be a function of starting temperature, contact time, and the thermal capacity of the causative agent. In a previous study performed in our centre, it was hypothesised that both viscosity and thermal capacity of the agent were important factors in prolonging heat exposure of the skin.1 Patients who were scalded by congee (a popular local dish where rice with excess water is simmered until a porridge-like mixture is formed) were more likely to require surgery than those scalded by hot water (31% vs 14%, respectively).1 This may be partly explained by congee’s greater thermal capacity (causing more effective heat transfer) and viscosity (prolonging contact time).

In order to minimise the severity of burn injury, it is essential that effective first-aid measures be properly taught to the public. The two basic principles are to stop the burning process and to cool the burn wound. As patients are usually wearing clothes and underwear at the time of scalding, the most effective way to achieve the first objective is to remove the involved clothing as quickly as possible. For many reasons, however, this straightforward act is sometimes not performed in a timely manner (eg scald occurring in a restaurant where a patron is too embarrassed to take off his/her clothing or simple ignorance of first aid). It is in this context that a simple model was designed in an attempt to demonstrate the importance of prompt clothing removal after scalding has occurred.

In the first part of our study, the effect of delayed clothing removal on skin temperature was assessed using our experimental burn model. As in our centre’s previous study, a piece of Allevyn foam dressing (Smith & Nephew Medical Limited, Hull, England) served as our skin model. It was placed on a metal plate above a heated water bath (JP Selecta, Barcelona, Spain) until its surface temperature reached 34°C when measured using the Raytek non-contact thermometer (Raytek Corporation, Santa Cruz [CA], US) 1 cm above the centre, in an attempt to simulate ‘skin temperature’. Cotton underwear was then placed on top of the Allevyn dressing. The scalding agents (hot water and congee) were boiled to 88°C and poured onto the model. The underwear was then removed at various times following the ‘injury’ (10, 20, 30, 60, and 120 seconds). The temperature of the Allevyn was immediately measured at the aforementioned position by the same observer starting from the moment of clothing removal and every 10 seconds thereafter for 2 minutes. The same procedure was repeated 3 times for each time interval, and the mean value was taken as the final data point. Standard cooling curves were subsequently plotted using these average data points along with calculated standard deviations.

In the second part, all patients admitted to our unit via the emergency department with scalding by congee over a 10-year period (January 2005 to December 2014) were first retrospectively identified from our hospital’s computer records. Clinical notes were physically traced in order to examine the admission details as well as subsequent management of the patients.

The results of our experimental burn model are shown in Figures 1 and 2. The temperature of the Allevyn partly reflected the amount of heat transferred from the causative agent. A higher cooling curve translated to a higher skin temperature (hence higher potential injury). Examination of the cooling curves revealed a difference in the behaviour of hot water and congee. With hot water, the 10-second cooling curve was lower than its counterparts (the 20-, 30-, 60-, and 120-second cooling curves) that essentially lie along the same curve above. With congee, the cooling curves appeared to lie progressively higher with further delay in clothing removal—the 30- and 60-second cooling curves were in a significantly higher position compared with the 10- and 20-second cooling curves, while the 120-second cooling curve was higher than that of 30 and 60 seconds.

During the study period, 35 patients were admitted (21 males, 14 females) for scalding by congee. Of note, two paediatric patients were admitted to the Intensive Care Unit (ICU) for initial resuscitation due to the extent of their burns (16% and 20% of total body surface area [TBSA]) and one patient was discharged against medical advice after being admitted for 1 day. The demographic distribution, percentage of TBSA burnt, and length of hospital stay are shown in Table 1. On average, our unit admitted two to four cases per year except in 2010 when there were seven cases. Although most of these congee scalds were relatively minor as evidenced by the small mean percentage of TBSA involved and a mean hospital stay of approximately 11 days, more than two thirds of patients were children. Table 2 shows the statistics for clothing removal/first-aid measures and the subsequent management. While most of our patients received some form of first aid, it was found that the act of clothing removal was not documented in the majority (27/35) of cases. Despite an extended review period, it is recognised that the sample size remains small. Consequently, only descriptive statistics could be shown and a formal statistical analysis could not be conducted for this retrospective review. Nonetheless, those patients who received first aid or in whom clothing was removed (or both) did seem to fare better than those without.

This was a preliminary study of the potential relationship between the time of clothing removal and depth of scald burns. While ‘cooling the burn wound’ is an important step in the first-aid process, it must be recognised that ‘stop the burning process’ should take precedence in order to maximise the benefit of first aid. To this end, the contact time of the offending agent with the skin should be minimised. A cooling study was performed by our centre in 2006 to examine the cooling curves of different food/drinks. Of seven common agents examined for their rate of cooling, congee cooled significantly slower compared with the other agents (eg tea, coffee, noodles, etc).1 It was also shown that a higher percentage of patients required surgery if scalded by congee compared with hot water. As congee is a common dish for children in Hong Kong from which scalds could lead to greater morbidity, congee was specifically selected for further investigation.

We showed that delay in clothing removal could increase the severity of scald burns by congee as demonstrated by the increased temperature in our skin model when clothing removal was delayed. The experiment did not persist beyond a delay of 120 seconds since clothing would generally be removed within that time or not at all.

Hot water was first examined as a ‘control’ compared with congee. In our results, the cooling curves of 20, 30, 60, and 120 seconds essentially lay along the same curvature while the 10-second cooling curve was significantly lower. This implies that if clothing removal occurs within the first 10 seconds, the surface temperature of our skin model would be significantly lower at all subsequent time points; thus in hot water scalds, immediate clothing removal may prove to be the most beneficial.

On subsequent examination of the effect of congee, the cooling curves behaved differently—there appeared to be a stepwise progression from the 10- and 20-second curves to the 30- and 60-second curves, and then finally to the 120-second curve. Observation of the error bars showed that the 10- and 20-second curves did not differ significantly and this also applied to the 30- and 60-second curves. The 120-second curve generally lay significantly above the rest; therefore, it appears that delay in clothing removal significantly affected the surface temperature of our skin model—removing it within the first 20 seconds may lead to a less-severe injury compared with a 30- to 60-second delay, which in turn is better than a 2-minute delay.

At the time points between 120 and 140 seconds where all the curves have overlapping temperature measurements, one is able to observe that there are three distinct ‘tiers’ (10/20, 30/60, 120 seconds). In our model, heat was transferred to the Allevyn with the garment initially acting as a ‘barrier’ since the underwear was removed before the congee could soak through, resulting in a lower temperature detected. By increasing the time interval, the garment increasingly acted as a ‘reservoir’ for heat as the congee gradually soaked through. Due to the greater thermal capacity and viscosity of congee compared with water, the temperature of the entire ‘congee-underwear-Allevyn complex’ was maintained with more heat being transferred to the Allevyn for the same given period, resulting in a higher temperature detected. Overall, our findings corroborate our hypothesis that with a viscous agent such as congee, the severity of scald burns could potentially be reduced with earlier removal of clothing as evidenced by lower temperatures detected in our skin model.

Although our experimental study did succeed in demonstrating effects in our skin model, the ideal model for this study would be human skin (eg cadaveric or surgically excised) but it is rather difficult to source in practice. For the sake of scientific reproducibility, Allevyn was used instead (a bilayer dressing material with an outer waterproof layer analogous to the epidermis along with an inner absorbent sponge layer). Although Allevyn does not exactly mimic the ‘in-vivo’ behaviour of human skin per se, this model allows the opportunity for comparative study. Another potential improvement of our model is to set up a thermometer to measure the skin model’s temperature underneath the surface so that temperature can be tracked while clothing is still in place. In this experimental model, we were only able to measure the temperature after the garment was removed. Having continual temperature monitoring would enable us to plot ‘complete’ curves starting from 0 second onwards for all five time intervals, and the temperature change both before and after clothing removal could be more accurately depicted. In an early study by Moritz and Henriques,2 porcine skin was found to bear a remarkable resemblance to human skin. If the experiment can be repeated with porcine skin along with improved accuracy of temperature measurement (ie setting up a thermometer intradermally within the porcine skin), the validity of our conclusions may be strengthened. Nonetheless, this experimental study lends support to the notion that timely clothing removal before first-aid application may reduce the severity of burn injury.

The paediatric population (especially those under the age of 2 years) is particularly susceptible to scalds with a male preponderance.3 4 5 This age-group is particularly vulnerable as it is an age of great curiosity about the environment (hence the tendency to grab/tip over things) but limited motor development does not allow a child to move away from danger, such as a falling bowl of congee. It is also compounded by the fact that children have relatively thinner skin and this results in more significant injuries. Our statistics from this congee scald review do not deviate much from our centre’s previous experience: slightly over 50% of our patients were aged 2 years or younger with a male predominance, and 24 out of 35 patients were within the paediatric age-group.

It seems almost intuitive that clothing should be removed as soon as possible whenever a scald burn is sustained. This may not necessarily be so. In a recent UK study where parents were interviewed and asked about first-aid measures they would provide for a child with a large scald, 61% of parents failed to state that clothes should be stripped and several thought that it would cause further skin damage.6 The question of whether removing clothing would cause further skin damage is commonly asked by parents of paediatric burn patients admitted to our unit.

In our retrospective review, analysis of the efficacy of clothing removal was hindered because such action was not recorded in the majority of cases (27 out of 35). The location of burns was further studied: in 10 of these 27 cases, injury occurred over an exposed area (eg face and hands), while the remaining 17 cases could have benefited from clothing removal. In six of eight patients where clothing was removed, the exact timing was not documented. Such lack of documentation demonstrates the benefit of education about prehospital treatment for both the public and frontline medical staff. An increased awareness of correct prehospital treatment of burns would mean relevant questions are asked during history taking, and this would facilitate proper documentation and subsequent patient management. As mentioned in the Results section, our sample size did not permit any meaningful statistical analysis to be carried out pertaining to the potential usefulness of early clothing removal in reducing morbidity from scalds. Nonetheless, it appeared that those patients who had clothing removed fared quite well. One exception was a 50-year-old man with a relatively larger scald (TBSA, 13%) involving the face/neck/chest/bilateral upper limbs who eventually required skin grafting.

After the burning process is stopped, the next logical step is to cool the burn by applying first aid. Ideally, first aid for burns should provide pain relief and reduce potential morbidity associated with the injury. Although many first-aid treatments to cool burns have been studied, the application of cold water has the strongest supporting evidence. Currently, an ‘adequate’ first aid is defined as 20 minutes of running tap water over the burn within the first 3 hours of injury.7 Apart from removing heat energy from the damaged tissue, the benefits of cooling continue and include decreased oedema formation, preservation of dermal perfusion, decreased inflammatory response, and improved wound healing.8 9 Regrettably, our centre’s previously published paper showed that first aid was applied only to half of our paediatric patients.5 In our current review, although 27 patients received some form of first aid, only 15 (43%) patients received cool-water treatment of variable duration. The duration of first aid with cool water was either not recorded or fell short of the recommended 20 minutes. This state of affairs is certainly unsatisfactory and more public education is warranted.

Our data once again do not enable formal statistical analysis, and a number of factors such as percentage of TBSA burnt and depth of burn would affect the eventual outcome of our patients. Nonetheless, it does appear that those who received first aid required fewer surgeries. Detailed analysis of those who received no first aid revealed that none of the burns was classified as major even though four out of eight patients underwent skin grafting. In patients who received cool water as first aid, only one needed surgery—a 14-month-old boy with a TBSA of 13.5% burnt involving the left flank and bilateral lower limbs. In patients who received other types of first aid, three required surgeries (one of whom had a major burn and required ICU admission). Of note, for patients in whom clothing was removed and first-aid measures applied, all were managed conservatively. Although definite conclusions from our data cannot be drawn, clothing removal and first aid do seem to have beneficial effects, especially in smaller burns that constitute most of our case load. It is our hope that with better medical documentation and education of our frontline staff, the quality of our future data can be enhanced with a view to facilitate formal data analysis.

Before a simple and effective message can be delivered to the public about post-burn prehospital management, it is equally important to consider the local food characteristics. For instance, the population of Hong Kong may find it easier to relate burns to congee or cup noodle than burns to coffee. Since half of our paediatric burn patients received no first aid upon admission, simply emphasising the importance of ‘stop the burning process’ may reduce potential morbidity. Our experimental skin model showed that earlier clothing removal post-burn reduces skin temperature and thus beneficial. Although our retrospective review was unable to reflect any concrete statistical results, it was certainly suggestive of the potential usefulness of proper prehospital management. Last but not least, the financial cost of managing acute uncomplicated minor paediatric scalds is significant (including hospital beds, theatre visits, dressings, medications etc). This is an important social and economic issue since burns sustained by children often require many years of follow-up for scar management and psychosocial support.10 If preventive measures fail and accidents occur, it is in the best interests of the public to understand how to minimise morbidity.

1. Chiu TW, Ng DC, Burd A. Properties of matter matter in assessment of scald injuries. Burns 2007;33:185-8. Crossref

2. Moritz AR, Henriques FC. Studies of thermal injury: II. The relative importance of time and surface temperature in the causation of cutaneous burns. Am J Pathol 1947;23:695-720.

3. Ray JG. Burns in young children: a study of the mechanism of burns in children aged 5 years and under in the Hamilton, Ontario Burn Unit. Burns 1995;21:463-6. Crossref

4. Dewar DJ, Magson CL, Fraser JF, Crighton L, Kimble RM. Hot beverage scalds in Australian children. J Burn Care Rehabil 2004;25:224-7. Crossref

5. Tse T, Poon CH, Tse KH, Tsui TK, Ayyappan T, Burd A. Paediatric burn prevention: an epidemiological approach. Burns 2006;32:229-34. Crossref

6. Graham HE, Bache SE, Muthayya P, Baker J, Ralston DR. Are parents in the UK equipped to provide adequate burns first aid? Burns 2012;38:438-43. Crossref

7. First aid. Australian and New Zealand Burn Association. Available from: http://anzba.org.au/care/first-aid/. Accessed Feb 2016.

8. Cuttle L, Pearn J, McMillan JR, Kimble RM. A review of first aid treatments for burn injuries. Burns 2009;35:768-75. Crossref

9. Wright EH, Harris AL, Furniss D. Cooling of burns: mechanisms and models. Burns 2015;41:882-9. Crossref

10. Griffiths HR, Thornton KL, Clements CM, Burge TS, Kay AR, Young AE. The cost of a hot drink scald. Burns 2006;32:372-4. Crossref