OBJECTIVES. To examine the utilisation pattern of accident and emergency services and to study the possible impact of a user-fee policy on non-emergency attendances in Hong Kong.

DESIGN. Retrospective study.

METHODS. Four different scenarios are postulated to examine the impact on the number of accident and emergency attendances of a user-fee policy from 2000 to 2029. Patient volume data of accident and emergency attendances for 2000 were made available by the Hospital Authority of Hong Kong.

RESULTS. Non-emergency use of the accident and emergency service is the main cause of over-utilisation and contributes to more than 70.0% of its use. Only 22.0% of patients attending accident and emergency departments were admitted to a ward for further treatment. By 2029, the number of accident and emergency attendances would increase by more than 47.0% if the present utilisation pattern prevails. However, if patients at triage levels 3, 4, and 5 were discouraged from using the accident and emergency service, the number of attendances would decrease by 76.4%.

CONCLUSION. The proposed user-fee policy would act as a deterrent by preventing unnecessary use of accident and emergency services. However, the use of out-patient services may be increased as a result and attendance should be carefully monitored. Community health education and civic education relating to abuse of accident and emergency services would be effective in reducing over-utilisation of these services.

Key words: Emergency service, hospital; Health care reform; Social welfare

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OBJECTIVES. To identify factors affecting cervical and breast cancer screening attendance among women aged 44 to 55 years by comparing self-reported uptake of cervical smear and clinical breast examination between patients and a population sample.

DESIGN AND SETTING. Telephone survey and audit of clinic records to confirm patients’ self-report.

PARTICIPANTS. Two thousand and sixty-seven women identified through random telephone dialling from the residence directory and 319 patients ever-registered at a family practice teaching clinic.

MAIN OUTCOME MEASURES. Uptake of cervical smear and clinical breast examination.

RESULTS. The proportion of patients undergoing cervical smear tests and clinical breast examination in the previous 12 months were 35.4% and 22.6%, respectively, for randomly selected women, while the figures were 47.2% and 50.6%, respectively, for patients. Record audit confirmed high rates of screening for patients according to evidence-based protocols (85.1% had had a cervical smear within 3 years). For women in the random sample (mean age, 48.9 years; standard deviation, 3.3 years), those who were older, postmenopausal, not receiving hormone therapy, educated to primary level, and with no chronic diseases were least likely to have had screening. For clinic patients (mean age, 47.9 years; standard deviation, 2.8 years), lower education level was the only variable associated with no recent smears.

CONCLUSIONS. Healthy perimenopausal and postmenopausal women in the community with lower educational level and not receiving hormone therapy were more likely to be underscreened. Attendance of 44- to 55-year-old women at a family medicine clinic that actively promotes preventive medicine was associated with high screening uptake.

Key words: Colorectal neoplasms; Hepatectomy; Survival analysis

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OBJECTIVE. To study the clinical outcomes of patients with invasive or non-invasive breast cancer after breast conservation treatment.

DESIGN. Retrospective study.

SETTING. Clinical oncology department of a public hospital, Hong Kong.

PATIENTS. Two hundred and three patients who received postlumpectomy radiotherapy in Pamela Youde Nethersole Eastern Hospital between January 1994 and June 1999.

INTERVENTIONS. Adjuvant radiotherapy with or without systemic adjuvant treatment.

MAIN OUTCOME MEASURES. Actuarial local control rate, progression-free survival rate, disease-specific survival rate, and cosmetic score.

RESULTS. The median follow-up of the whole group was 3.5 years. Two out of the 25 patients with carcinoma-in-situ only developed local recurrence; the 5-year actuarial local control rate was 91.3%. Among the 178 patients with invasive cancer, seven suffered local recurrence and 12 developed distant metastases without local failure. The 5-year actuarial local control, progression-free survival, and disease-specific survival rates for patients with invasive cancer were 95.5%, 85.8%, and 95.2%, respectively. The risk of local recurrence was significantly increased in younger patients (age <40 years) and those with positive final margins. Cosmetic scores were rated good to excellent by 95.6% of patients.

CONCLUSIONS. The early clinical outcomes of our patients are comparable to that in large overseas trials, which have demonstrated the equivalence of mastectomy and breast conservation treatment in terms of survival. In addition to mastectomy, with or without breast reconstruction, breast conservation treatment should be offered as an alternative in suitable Chinese women. To maximise local control, further excision or mastectomy is recommended for patients with positive final margins.

Key words: Breast neoplasms; Mastectomy; Radiotherapy

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OBJECTIVES. To investigate the total daily energy expenditure and physical activity pattern of a group of obese and non-obese Hong Kong children.

DESIGN. Cross-sectional study.

SETTINGS. University teaching hospital, Hong Kong.

PARTICIPANTS. Eighteen obese children aged 6 to 17 years and 18 age- and sex-matched non-obese children in the local Hong Kong community.

MAIN OUTCOME MEASURES. Total daily energy expenditure and physical activity pattern were estimated for 3 days using the heart rate monitoring. Body composition was measured by dual-energy X-ray absorptiometry.

RESULTS. In obese children, both total fat mass and fat-free mass were greater than in non-obese children. Total daily energy expenditure and its sleep and sedentary components were higher in absolute terms (by 42%, 43%, and 126%, respectively) for obese children. When normalised for body weight, the basal metabolic rate was no different between obese and non-obese children, while the total daily energy expenditure of the obese children was significantly lower (by 22%) than that of non-obese children. When normalised for fat-free mass, basal metabolic rate and the sedentary component of total daily energy expenditure were significantly higher in obese children. Obese children spent 12% less time asleep, but 51% more time in sedentary activity and 30% less time physically active—a ratio of active-to-sedentary waking time of 0.6 for obese children and 1.9 for non-obese children.

CONCLUSIONS. Although the basal metabolic rate may be influenced by body composition, the finding of a normal basal metabolic rate when normalised for body weight suggests that an intrinsic difference of metabolic rate is not a major contributory cause of obesity. The study pointed particularly to the potential benefit of increasing physical exercise time relative to sedentary activities to reduce the prevalence of childhood obesity. Obese and non-obese children had similar basal metabolic rate when adjusted by fat-free mass and fat mass. Obese children spent more time in sedentary activities.

Key words: Body composition; Child; Energy metabolism; Exercise; Obesity

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OBJECTIVES. To study the morbidity and mortality patterns of transfusion-dependent thalassaemia major patients in Hong Kong, and compare the outcomes of these patients according to different periods of birth.

DESIGN. Retrospective study.

SETTING. Paediatric departments of three regional hospitals, Hong Kong.

SUBJECTS AND METHODS. Medical records of thalassaemia major patients were reviewed. Data gathered included demographic and survival data, complications of iron overload, repeated transfusion, and bone marrow transplantation; the probability of survival of three cohorts was also estimated.

RESULTS. Two hundred and thirty-two patients were studied at a median age of 15.5 years (range, 1.4-30.3 years). There were 60 patients born before 1980 (cohort 1), 117 patients born between 1980 and 1989 (cohort 2), and 55 patients born after 1989 (cohort 3). The median age of starting desferrioxamine was 8 years, 4 years, and 3 years for cohorts 1, 2, and 3, respectively. Cardiomyopathy, diabetes mellitus, and hypothyroidism occurred in 15.1%, 8.6%, and 6.9% of patients with thalassaemia major, respectively. The above complications developed in 5% to 12% of cohort 2 patients. Delayed puberty was present in 38.4% and hormonal replacement for gonadal failure was required in 29.7% of evaluable patients. Short stature was common and the median height standard deviation score was -1.63. Twenty patients had died, and cardiomyopathy was the leading cause of death, followed by complications of bone marrow transplantation. The probability of survival beyond the age of 20 years was 87.6%.

CONCLUSION. Despite the use of iron chelation in the past two decades, severe complications of iron overload still occurred even in those who started chelation therapy early. Cardiomyopathy was the leading cause of death, while endocrinopathies and short stature were common complications especially in teenagers and adults.

Key words: Beta-thalassemia; Morbidity; Mortality

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