Family medicine training in Hong Kong: similarities and differences between family and non-family doctors

ABSTRACT
Hong Kong Med J 2011;17:47–53 | Number 1, February 2011
ORIGINAL ARTICLE
Family medicine training in Hong Kong: similarities and differences between family and non-family doctors
YT Wun, TP Lam, KF Lam, Donald KT Li, KC Yip
Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong
 
 
OBJECTIVE. To study the local medical profession’s opinions on the training requirements for the specialty of family medicine. This was to serve as a reference for future planning of the health care system.
 
DESIGN. Cross-sectional study.
 
PARTICIPANTS AND SETTING. All registered doctors in Hong Kong.
 
MAIN OUTCOME MEASURES. Doctors’ ratings on the importance of vocational training, professional assessment, job nature, and experience to become suitably qualified as a family doctor, and their opinions on the length of necessary vocational training.
 
RESULTS. A total of 2310 doctors (23% of doctors in the local register) responded. Professional assessment was mostly agreed as a qualification, followed by vocational training, clinical experience, and job nature. Over 70% agreed on a training period of 4 years or less. Non-family doctors were more likely to opt for professional assessment as the qualification and also opt for a longer training period.
 
CONCLUSION. Vocational training was considered important as a qualification for the specialty of family medicine. The length of training was mostly agreed to be 4 years or less, not the 6 years currently required by the Hong Kong Academy of Medicine. The vocational training programme for family medicine might require re-examination.
 
Key words: Clinical competence; Family practice; Health services; Primary health care; Quality of health care
 
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Cross-clade immunogenicity and safety of an AS03A-adjuvanted prepandemic H5N1 influenza vaccine in Hong Kong

ABSTRACT
Hong Kong Med J 2011;17:39–46 | Number 1, February 2011
ORIGINAL ARTICLE
Cross-clade immunogenicity and safety of an AS03A-adjuvanted prepandemic H5N1 influenza vaccine in Hong Kong
Daniel WS Chu, Alfred SK Kwong, Wendy WS Tsui, Jenny HL Wang, Charles KH Ngai, Peter KT Wan, Gary Ong, HW Tang, François Roman, Mamadou Dramé, Hans L Bock
Department of Medicine, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong
 
 
OBJECTIVE. To present Hong Kong–specific data from a large Asian population (also involving Thailand, Singapore, and Taiwan) on safety and manufacturing consistency across four AS03A-adjuvanted H5N1 vaccine formulations in terms of immune response against the A/Vietnam/1194/2004 strain. Immunogenicity against the heterologous A/Indonesia/05/2005 strain was also assessed. NCT Number: 00449670.
 
DESIGN. Prospective, observer-blind study.
 
SETTING. Out-patient clinic of a tertiary hospital in Hong Kong.
 
PARTICIPANTS. A total of 360 subjects aged 18 to 60 years were randomised into six groups to receive two doses (21 days apart) of the study vaccine. Interventions One of the four adjuvanted formulations (3.75 _g H5N1 haemagglutinin [HA]+AS03A) of the vaccine (H5N1-AS03A) or one of the two non-adjuvanted (3.75 _g H5N1 [HA]) formulations of the vaccine (H5N1-DIL).
 
MAIN OUTCOME MEASURES. Blood samples collected before vaccination and 21 days after each vaccine dose were analysed using haemagglutinationinhibition and neutralisation assays. Solicited, unsolicited, and serious adverse events were recorded.
 
RESULTS. Manufacturing consistency across all four vaccine formulations was demonstrated. After two doses, the AS03A-adjuvanted prepandemic influenza vaccine demonstrated high seroprotection rates against the A/Vietnam/1194/2004 strain (95.8%) and good immunogenicity against the heterologous A/Indonesia/05/2005 strain (45.7%), as compared to the non-adjuvanted vaccine (4.6% and 1.5%, respectively). The seroconversion rates induced by the adjuvanted formulations in terms of viral neutralising antibodies against the two strains were much higher than those induced by the non-adjuvanted formulations. There were no safety concerns for any of the adjuvanted vaccine formulations.
 
CONCLUSIONS. The AS03A-adjuvanted H5N1 prepandemic influenza vaccine demonstrated good immunogenicity and an acceptable safety profile in Hong Kong.
 
Key words: Adjuvants, immunologic; Disease outbreaks; Influenza A virus, H5N1 subtype; Influenza vaccines; Influenza, human
 
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Robot-assisted versus standard laparoscopic partial nephrectomy: comparison of perioperative outcomes from a single institution

ABSTRACT
Hong Kong Med J 2011;17:33–8 | Number 1, February 2011
ORIGINAL ARTICLE
Robot-assisted versus standard laparoscopic partial nephrectomy: comparison of perioperative outcomes from a single institution
CL Cho, KL Ho, Simon SM Chu, PC Tam
Division of Urology, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong
 
 
OBJECTIVE. To evaluate the perioperative outcomes of robot-assisted laparoscopic partial nephrectomy and standard laparoscopic partial nephrectomy in a teaching hospital.
 
DESIGN. Retrospective study.
 
SETTING. Division of Urology, Department of Surgery, Queen Mary and Tung Wah hospitals, Hong Kong.
 
PATIENTS. The first 10 consecutive patients who had robot-assisted laparoscopic partial nephrectomy for renal tumours between January 2008 and September 2009 with prospective data collection were evaluated. Their outcomes were compared with the last 10 consecutive patients in our database, who had standard laparoscopic partial nephrectomy between November 2004 and October 2007.
 
MAIN OUTCOME MEASURES. Demographics, tumour characteristics, perioperative outcomes, renal function, and pathological outcomes.
 
RESULTS. There were no differences between the groups with regard to age (63 vs 56 years; P=0.313) and tumour size (2.7 vs 2.8 cm; P=0.895). No significant difference was found between the two groups with respect to the operating room time (376 vs 361 min; P=0.722), estimated blood loss (329 vs 328 mL; P=0.994), and length of hospital stay (7 vs 14 days; P=0.213). A statistically significant shorter mean warm ischaemic time for the robotassisted group was noted (31 vs 40 minutes; P=0.032). Respective renal functional outcomes as shown by the difference between day 0 and day 60 serum creatinine levels were comparable (+10 vs +7 mmol/L; P=0.605). In both groups, there were no intra-operative complications or instances of surgical margin tumour involvement. Three patients endured postoperative complications in the standard laparoscopic group (a perinephric haematoma, urine leakage, and lymph leakage) compared with one in the robot-assisted group (a perinephric haematoma). These complications all resolved with conservative treatment.
 
CONCLUSIONS. Robot-assisted laparoscopic partial nephrectomy is a technically feasible alternative to standard laparoscopic partial nephrectomy, and provides comparable results. Robot-assisted laparoscopic partial nephrectomy appears to offer the advantage of decreased warm ischaemic time. Longer follow-up is required to assess renal function and oncological outcomes. Further experience and randomised trials are necessary to compare robot-assisted with standard laparoscopic partial nephrectomy.
 
Key words: Kidney neoplasms; Laparoscopy; Nephrectomy; Robotics; Suture techniques
 
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Clinical outcome of open and laparoscopic surgery in Dukes' B and C rectal cancer: experience from a regional hospital in Hong Kong

ABSTRACT
Hong Kong Med J 2011;17:26–32 | Number 1, February 2011
ORIGINAL ARTICLE
Clinical outcome of open and laparoscopic surgery in Dukes' B and C rectal cancer: experience from a regional hospital in Hong Kong
Weida Day, Patrick YY Lau, KM Li, SY Kwok, Andrew WC Yip
Department of Surgery, Kwong Wah Hospital, 25 Waterloo Road, Hong Kong
 
 
OBJECTIVE. To compare the long-term outcome of open and laparoscopic surgery for Dukes' B and C rectal cancer in a regional hospital in Hong Kong.
 
DESIGN. Retrospective study.
 
SETTING. A regional hospital in Hong Kong.
 
MAIN OUTCOME MEASURES. Survival and local recurrence rates.
 
PATIENTS. Patients with Dukes' B and C rectal cancers underwent elective curative open or laparoscopic surgery during the period December 2000 to December 2006.
 
RESULTS. A total of 222 patients (open surgery, n=133; laparoscopic surgery, n=89) were assessed. The overall 3- and 5-year survival rates for all patients were 72% and 58%, respectively. Local recurrence rates were similar in both groups. Laparoscopic group had better overall survival (P=0.014), however. The overall 3-year survival rates were 79% and 68% in the laparoscopic and open groups, respectively. The corresponding 5-year rates were 75% and 52%. Multivariate analysis also demonstrated that laparoscopic surgery was a significant independent factor for better survival. Chemotherapy, local recurrence, lymph node metastasis, and poorly differentiated tumour were significantly associated with survival.
 
CONCLUSION. Laparoscopic surgery for Dukes' B and C rectal cancer was associated with more favourable survival than with open surgery.
 
Key words: Disease-free survival; Laparoscopy; Neoplasm recurrence, local; Rectal neoplasms; Treatment outcome
 
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Total knee arthroplasty for primary knee osteoarthritis: changing pattern over the past 10 years

ABSTRACT
Hong Kong Med J 2011;17:20–5 | Number 1, February 2011
ORIGINAL ARTICLE
Total knee arthroplasty for primary knee osteoarthritis: changing pattern over the past 10 years
CH Yan, KY Chiu, FY Ng
Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong
 
 
OBJECTIVE. To review the epidemiology of total knee arthroplasty for primary osteoarthritis and the change of patient characteristics over the last decade.
 
DESIGN. Retrospective review.
 
SETTING. A tertiary referral centre for joint replacement surgery in a teaching hospital in Hong Kong.
 
PATIENTS. All patients who underwent primary total knee arthroplasty for primary knee osteoarthritis from January 2000 to December 2009.
 
RESULTS. In all, 1157 total knee arthroplasties (589 left and 568 right) were performed on 588 females and 162 males. The annual number of total knee arthroplasties increased from 91 in 2000 to 181 in 2009. The annual number of patients increased from 58 (46 female, 12 male) in 2000 to 159 (117 female, 42 male) in 2009. When compared yearly results, there were no significant changes in the preoperative Knee Society Knee Score, Knee Society Functional Assessment, and passive range of motion of these patients. However, there was a significant decreasing trend with regard to lower limb mechanical axis mal-alignment, from 15.1º deviation from the neutral axis in 2000, to 14.8º deviation in 2004, and then 12.9º deviation in 2009 (mostly varus deformity). There was no difference between left knees and right knees, and between females and males. The mean age of the patients did not show significant change over the past decade, but the number and proportion of patients over 80 years old showed an increase from 4.8% (2000 to 2004) to 13.8% (2005 to 2009). On the other hand, the number and proportion of patients under the age of 60 years did not change.
 
CONCLUSIONS. There was an increasing trend towards total knee arthroplasties, both in terms of number of operations and patients. The number of younger patients having total knee arthroplasty did not increase over the last 10 years, whereas the number of those older than 80 years increased significantly over that period.
 
Key words: Arthroplasty, replacement, knee; Hong Kong; Knee joint; Osteoarthritis, knee; Registries
 
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Hepatocarcinogenesis of regenerative and dysplastic nodules in Chinese patients

ABSTRACT
Hong Kong Med J 2011;17:11–9 | Number 1, February 2011
ORIGINAL ARTICLE
Hepatocarcinogenesis of regenerative and dysplastic nodules in Chinese patients
CH Ng, SW Chan, WK Lee, Lawrence Lai, KH Lok, KK Li, SH Luk, ML Szeto
Department of Medicine, Tuen Mun Hospital, Tuen Mun, Hong Kong
 
 
OBJECTIVES. To determine the development rate of hepatocellular carcinoma and survival of patients diagnosed to have regenerative, and low-grade and high-grade dysplastic liver nodules.
 
DESIGN. Retrospective descriptive study.
 
SETTING. Acute public hospital, Hong Kong.
 
PATIENTS. Patients with non-malignant liver nodules confirmed by imagingguided liver biopsy between January 1997 and December 2008.
 
MAIN OUTCOME MEASURES. Rates of hepatocellular carcinoma development and survival.
 
RESULTS. A total of 147 patients with non-malignant liver nodules were followed up over a median duration of 29 months. The initial histological diagnosis included regenerative nodules (n=74), low-grade dysplastic nodules (n=34), and high-grade dysplastic nodules (n=39). The respective cumulative hepatocellular carcinoma development rate during the first, second, third, and fourth year were 3%, 5%, 9% and 12% for simple regenerative nodules, 29%, 35%, 38% and 44% for low-grade dysplastic nodules, and 38%, 41%, 51% and 51% for high-grade dysplastic nodules. The hepatocellular carcinoma development rate was highest in those with high-grade dysplastic nodules. Multivariate analysis showed that histological dysplastic changes were associated with increased alpha-fetoprotein levels and advanced age, which were both independent predictors of hepatocellular carcinoma development. Histological dysplastic changes, male sex, advanced age, prolonged prothrombin time, and ultrasound appearances were independent predictors of mortality.
 
CONCLUSION. The presence of dysplastic change in liver nodules increased the risk of hepatocellular carcinoma development and death.
 
Key words: Carcinoma, hepatocellular; Cell transformation, neoplastic; Liver cirrhosis; Liver neoplasms; Survival rate
 
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Effects of laparoscopic ovarian drilling in treating infertile anovulatory polycystic ovarian syndrome patients with and without metabolic syndrome

ABSTRACT
Hong Kong Med J 2011;17:5–10 | Number 1, February 2011
ORIGINAL ARTICLE
Effects of laparoscopic ovarian drilling in treating infertile anovulatory polycystic ovarian syndrome patients with and without metabolic syndrome
Grace WS Kong, LP Cheung, Ingrid H Lok
Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
 
 
OBJECTIVE. To compare the effects of laparoscopic ovarian drilling in treating infertile polycystic ovarian syndrome in patients with and without metabolic syndrome.
 
DESIGN. Retrospective review.
 
SETTING. A university-affiliated hospital in Hong Kong.
 
PATIENTS. A total of 89 infertile anovulatory polycystic ovarian syndrome patients, who underwent laparoscopic ovarian drilling with completed metabolic screening and seen over a 5-year period from 2002 to 2007.
 
MAIN OUTCOME MEASURES. The clinical, hormonal, and metabolic characteristics as well as spontaneous ovulation rates, reproductive outcomes, and diabetes risks during pregnancy observed after laparoscopic ovarian drilling.
 
RESULTS. Approximately one fifth (21%) of polycystic ovarian syndrome patients had the metabolic syndrome. There were no differences in spontaneous ovulation rates (68% vs 61%, P=0.76), cumulative pregnancy rates (68% vs 61%, P=0.77), and diabetes risks during pregnancy (64% vs 42%, P=0.13) between patients with and without metabolic syndrome.
 
CONCLUSION. Laparoscopic ovarian drilling was equally effective in inducing ovulation in polycystic ovarian syndrome patients with metabolic syndrome. Thus, patients with metabolic syndrome should not be precluded from laparoscopic ovarian drilling, which has the additional advantage of enabling full tubo-peritoneal assessment at the same time.
 
Key words: Diabetes mellitus, type 2; Hyperandrogenism; Infertility, female; Metabolic syndrome X; Polycystic ovary syndrome
 
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Public awareness of hepatitis B infection: a population-based telephone survey in Hong Kong

ABSTRACT
Hong Kong Med J 2010;16:463–9 | Number 6, December 2010
ORIGINAL ARTICLE
Public awareness of hepatitis B infection: a population-based telephone survey in Hong Kong
CM Leung, WH Wong, KH Chan, Lawrence SW Lai, YW Luk, JY Lai, YW Yeung, WH Hui
Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
 
 
OBJECTIVE. To test our hypothesis that there is inadequate knowledge and awareness of hepatitis B infection among the general population in Hong Kong.
 
DESIGN. A random telephone survey using a structured multiple-choice questionnaire.
 
SETTING. Hong Kong community.
 
PARTICIPANTS. Hong Kong residents aged 18 years or above.
 
RESULTS. A total of 506 respondents were successfully interviewed in February 2010. Approximately half of respondents (55%) were aware that hepatitis B virus is the most common cause of chronic viral hepatitis in Hong Kong. Regarding knowledge about the mode of transmission, mother-to-infant transmission and blood contact were recognised as risk factors by 67% and 65% of respondents, respectively. Transmission by sexual contact, sharing a razor or toothbrush, and tattooing or body piercing were appreciated by 44%, 41%, and 37% of respondents, respectively. A majority (73%) had the mistaken belief that the virus is transmitted by eating contaminated seafood. Over half of respondents (53%) knew nothing about the clinical presentation of acute hepatitis B. Only 35% of respondents realised that periodic abdominal ultrasonographic examinations are indicated for asymptomatic hepatitis B carriers. While 51% of respondents reported being tested for hepatitis B virus infection, only 36% acknowledged being vaccinated against the infection. Education level, occupation, and marital status were factors associated with both hepatitis B virus screening and vaccination.
 
CONCLUSION. These findings support our hypothesis that there is inadequate knowledge and awareness about hepatitis B infection in the general population in Hong Kong.
 
Key words: Awareness; Health knowledge, attitudes, practice; Health surveys; Hepatitis B
 
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An expedited stroke triage pathway: the key to shortening the door-to-needle time in delivery of thrombolysis

ABSTRACT
Hong Kong Med J 2010;16:455–62 | Number 6, December 2010
ORIGINAL ARTICLE
An expedited stroke triage pathway: the key to shortening the door-to-needle time in delivery of thrombolysis
Alexander YL Lau, Yannie OY Soo, Colin A Graham, WK Woo, Edward HC Wong, Howan Leung, Anne YY Chan, Lisa WC Au, Vincent HL Ip, Cecilia SF Leung, Venus Hui, WC Shum, Jill Abrigo, Deyond YW Siu, Simon CH Yu, Lawrence KS Wong, Thomas W Leung
Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong
 
 
OBJECTIVES. To assess time management of stroke thrombolysis triage and functional outcomes in patients receiving recombinant tissue plasminogen activator for hyperacute stroke, and identify bottlenecks in delivery of the treatment.
 
DESIGN. Prospective study.
 
SETTING. A university teaching hospital in Hong Kong.
 
PATIENTS. Patients with suspected hyperacute stroke referred to the stroke thrombolysis team during October 2008 to September 2009.
 
MAIN OUTCOME MEASURE. Time performance records including door-to–stroke team, door-to-needle, and onset-to-thrombolysis times. Functional outcomes by modified Rankin Scale score at 3 months, and thrombolysis-related complications including haemorrhagic transformations and mortality.
 
RESULTS. During the 12-month period, 95 thrombolysis calls were received; recombinant tissue plasminogen activator was given intravenously to 17 (18%) of the patients and intra-arterially to 11 (12%). The mean (standard deviation) door-to–stroke team and the door-to-needle times for intravenous recombinant tissue plasminogen activator patients were 33 (25) and 80 (25) minutes, respectively; both were about 20 minutes longer than that recommended by the National Institute of Neurological Disorders and Stroke. The mean National Institute of Health Stroke Scale score for patients received intravenous recombinant tissue plasminogen activator was 16 (standard deviation, 7). The mean (standard deviation) onset-to-treatment time was 144 (42) minutes. Nine (53%) patients who received intravenous recombinant tissue plasminogen activator achieved favourable outcomes at 3 months, with a modified Rankin Scale score of 0 to 1. Symptomatic haemorrhage and mortality occurred in one (6%) patient.
 
CONCLUSION. A dedicated stroke triage pathway is essential to ensure efficient and safe delivery of thrombolysis therapy. Improvements in door-to–stroke team time through integration with emergency medicine staff and neuroradiologists may improve thrombolysis eligibility.
 
Key words: Brain ischemia; Emergency medical services; Recombinant proteins; Stroke; Tissue plasminogen activator
 
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Hong Kong's experience on the use of extracorporeal membrane oxygenation for the treatment of influenza A (H1N1)

ABSTRACT
Hong Kong Med J 2010;16:447–54 | Number 6, December 2010
ORIGINAL ARTICLE
Hong Kong's experience on the use of extracorporeal membrane oxygenation for the treatment of influenza A (H1N1)
Kenny KC Chan, KL Lee, Philip KN Lam, KI Law, Gavin M Joynt, WW Yan
Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
 
 
OBJECTIVE. To report Hong Kong's experience on the use of extracorporeal membrane oxygenation for the treatment of acute respiratory distress syndrome caused by influenza A (H1N1).
 
DESIGN. Multi-centred, retrospective observational study.
 
SETTING. Intensive care units in Hong Kong.
 
PATIENTS. Recipients of extracorporeal membrane oxygenation for confirmed influenza A (H1N1) infection from 1 May 2009 to 28 February 2010.
 
MAIN OUTCOME MEASURE. Hospital mortality.
 
RESULTS. During the study period, 120 patients were mechanically ventilated in intensive care units, among whom seven received veno-venous extracorporeal membrane oxygenation. The median (interquartile range) age of the latter patients was 42 (39-50) years, four had various chronic illnesses and one had a body mass index of greater than 30 kg/m2. The median (interquartile range) time from symptom onset to hospital admission was 5 (4-7) days. Corresponding values for the duration of extracorporeal membrane oxygenation, mechanical ventilation, intensive care unit stay, and hospital stay were 6 (6-10), 19 (11-25), 19 (18-30), and 31 (25-55) days, respectively. One patient died (hospital mortality, 14%) and six made full recoveries. All seven patients received oseltamivir; in addition three received intravenous zanamivir, four received convalescent plasma, and one received hyperimmune immunoglobulin. Nosocomial infection was the commonest complication. There was no life- or limb-threatening complication directly attributable to extracorporeal membrane oxygenation.
 
CONCLUSION. In response to the pandemic of influenza A (H1N1), some intensive care units in Hong Kong were able to offer extracorporeal membrane oxygenation to selected cases. In this small series, patient outcomes were similar to those reported in other observational studies, indicating that intensive care units in Hong Kong are capable of successfully introducing this technology. However, the cost-effectiveness and optimal delivery of this strategy remain uncertain.
 
Key words: Extracorporeal membrane oxygenation; Influenza A virus, H1N1 subtype; Intensive care units; Respiratory insufficiency
 
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