June 2021HK$ 100

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LIVECME

持 續 醫 學 進 修 專 訊

B U L L E T I N

A Brief Overview On Cancer Pain Assessment And Evidence-Based Pharmacological Management

Review Of Recommendations Of Fitness To Drive / Fly – 2021 Suggestions

Dr. WOO Kam Wing

Dr. SO Yui Chi

Astellas Pharma Hong Kong Co., Ltd.Unit 1103-08, 11/F, Tower 1, Grand Century Place, 193 Prince Edward Road West, Mongkok, Kowloon.Tel : (852) 2377 9801 Fax : (852) 2856 1440 https://www.astellas.com/hk/en/ AHK-BET-202103-04

Abbreviations: LUTS, lower urinary tract symptoms; OAB, overactive bladder

References: 1. Wagg A, et al. Efficacy, safety, and tolerability of mirabegron in patients aged≥ 65 yr with overactive bladder wet: a phase IV, double-blind, randomised, placebo-controlled study (PILLAR). Eur Urol. 2020;77(2):211-20. 2. Griebling TL, et al. Effect of mirabegron on cognitive function in elderly patients with overactive bladder: MoCA results from a phase 4 randomized, placebo-controlled study (PILLAR). BMC Geriatr. 2020;20(1):1-0. 3. Chapple CR, et al. Persistence and adherence with mirabegron versus antimuscarinic agents in patients with overactive bladder: a retrospective observational study in UK clinical practice. Eur Urol. 2017;72(3):389-99.

Abbreviated prescribing information of Betmiga® prolonged-release tabletsVersion: 003 Composition: Mirabegron Indication: Symptomatic treatment of urgency, increased micturition frequency and/or urgency incontinence as may occur in adult patients with overactive bladder (OAB) syndrome. Dosage: Adult including elderly 50 mg once daily with or without food. Administration: Swallow whole with liquids. Do not chew/divide/crush. Contraindications: Mirabegron is contraindicated in patients with - Hypersensitivity to the active substance or to any of the excipients. - Severe uncontrolled hypertension defined as systolic blood pressure ≥ 180 mm Hg and/or diastolic blood pressure ≥ 110 mm Hg. Special warnings and precautions for use: Renal impairment Betmiga has not been studied in patients with end stage renal disease (GFR < 15 mL/min/1.73 m2 or patients requiring haemodialysis) and, therefore, it is not recommended for use in this patient population. Data are limited in patients with severe renal impairment (GFR 15 to 29 mL/min/1.73 m2); based on a pharmacokinetic study a dose reduction to 25 mg is recommended in this population. Betmiga is not recommended for use in patients with severe renal impairment (GFR 15 to 29 mL/min/1.73 m2) concomitantly receiving strong CYP3A inhibitors. Hepatic impairment Betmiga has not been studied in patients with severe hepatic impairment (Child-Pugh Class C) and, therefore, it is not recommended for use in this patient population. Betmiga is not recommended for use in patients with moderate hepatic impairment (Child-Pugh B) concomitantly receiving strong CYP3A inhibitors. Hypertension Mirabegron can increase blood pressure. Blood pressure should be measured at baseline and periodically during treatment with Betmiga, especially in hypertensive patients. Data are limited in patients with stage 2 hypertension (systolic blood pressure ≥ 160 mm Hg or diastolic blood pressure ≥ 100 mm Hg). Patients with congenital or acquired QT prolongation Betmiga, at therapeutic doses, has not demonstrated clinically relevant QT prolongation in clinical studies. However, since patients with a known history of QT prolongation or patients who are taking medicinal products known to prolong the QT interval were not included in these studies, the effects of mirabegron in these patients is unknown. Caution should be exercised when administering mirabegron in these patients. Patients with bladder outlet obstruction and patients taking antimuscarinics medications for OAB Urinary retention in patients with bladder outlet obstruction (BOO) and in patients taking antimuscarinic medications for the treatment of OAB has been reported in postmarketing experience in patients taking mirabegron. A controlled clinical safety study in patients with BOO did not demonstrate increased urinary retention in patients treated with Betmiga; however, Betmiga should be administered with caution to patients with clinically significant BOO. Betmiga should also be administered with caution to patients taking antimuscarinic medications for the treatment of OAB. Undesirable effects: Summary of the safety profile The safety of Betmiga was evaluated in 8,433 patients with OAB, of which 5,648 received at least one dose of mirabegron in the phase 2/3 clinical program, and 622 patients received Betmiga for at least 1 year (365 days). In the three 12-week phase 3 double blind, placebo controlled studies, 88% of the patients completed treatment with Betmiga, and 4% of the patients discontinued due to adverse events. Most adverse reactions were mild to moderate in severity. The most common adverse reactions reported for patients treated with Betmiga 50 mg during the three 12-week phase 3 double blind, placebo controlled studies are tachycardia and urinary tract infections. The frequency of tachycardia was 1.2% in patients receiving Betmiga 50 mg. Tachycardia led to discontinuation in 0.1% patients receiving Betmiga 50 mg. The frequency of urinary tract infections was 2.9% in patients receiving Betmiga 50 mg. Urinary tract infections led to discontinuation in none of the patients receiving Betmiga 50 mg. Serious adverse reactions included atrial fibrillation (0.2%). Adverse reactions observed during the 1-year (long term) active controlled (muscarinic antagonist) study were similar in type and severity to those observed in the three 12-week phase 3 double blind, placebo controlled studies. List of adverse reactions The table below reflects the adverse reactions observed with mirabegron in the three 12-week phase 3 double blind, placebo controlled studies. The frequency of adverse reactions is defined as follows: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness. Infections and infestations: Common: Urinary tract infection. Uncommon: Vaginal infection, Cystitis Psychiatric disorders: Not known (cannot be estimated from the available data): Insomnia* Eye disorders: Rare: Eyelid oedema Cardiac disorders: Common: Tachycardia. Uncommon: Palpitation, Atrial fibrillation Vascular disorders: Very rare: Hypertensive crisis* Gastrointestinal disorders: Common: Nausea*, Constipation*, Diarrhoea*. Uncommon: Dyspepsia, Gastritis. Rare: Lip oedema Skin and subcutaneous tissue disorders: Uncommon: Urticaria, Rash, Rash macular, Rash popular, Pruritus. Rare: Leukocytoclastic vasculitis, Purpura, Angioedema* Musculoskeletal and connective tissue disorders: Uncommon: Joint swelling Reproductive system and breast disorders: Uncommon: Vulvovaginal pruritus Investigations: Uncommon: Blood pressure increased, GGT increased, AST increased, ALT increased Renal and urinary disorders: Rare: Urinary retention* Nervous system disorders: Common: Headache*, Dizziness* *observed during post-marketing experience Full prescribing information is available upon request.

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Editorial 2

Spotlight-1 4Review Of Recommendations Of Fitness To Drive/Fly – 2021 Suggestions

Spotlight-2 8A Brief Overview On Cancer Pain Assessment And Evidence-Based Pharmacological Management

Cardiology 15A 48-Year-Old Male Smoker Has Hypertension With Sudden Retrosternal Chest Pain

Dermatology 17Pigmented Mole On Thigh

Answer Sheet 18CME Notifications 23Meeting Highlights 27CME Calendar 28

Contents

The Hong Kong Medical Association is dedicated to providing a coordinated CME programme for all members of the medica l profess ion. Under the HKMA CME Programme, a CME registration process has been created to document the CME efforts of doctors and to provide special CME avenues. The Association strives to foster a vibrant environment of CME throughout the medical profession. Both members as well as non-members of the Association are welcome to join us. You may contact the HKMA Secretariat for details of the programme.

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HKMA CME Bulletin – MONTHLY SELF-STUDY SERIES to help you grow!

NOTICEMedical knowledge is constantly changing. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on experience and knowledge of the patient, to determine dosages and best treatment for each individual patient. Neither the Publisher nor the Authors assume any liability for any injury and/or damage to persons or property arising from this publication.

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No parts of articles can be reproduce without the express permission of the editor.

CME Bulletin & Online Editorial Board

Co-editorDr. CHENG Chi Man 鄭志文醫生Dr. HO Hung Kwong, Duncan 何鴻光醫生Dr. LAM Ho 林賀醫生Dr. MAK Siu King 麥肇敬醫生Dr. WONG Bun Lap, Bernard 黃品立醫生

CardiologyDr. CHAN Kit 陳杰醫生Dr. CHEN Wai Hong 陳偉康醫生Dr. LEE Pui Yin 李沛然醫生Dr. LI Siu Lung, Steven 李少隆醫生Dr. TAM Chor Cheung 譚礎璋醫生Dr. WONG Shou Pang, Alexander 王壽鵬醫生

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

Colorectal SurgeryDr. CHAN Cheung Wah 陳長華醫生Dr. LEE Yee Man 李綺雯醫生Dr. TSE Tak Yin, Cyrus 謝得言醫生

DermatologyDr. CHAN Hau Ngai, Kingsley 陳厚毅醫生Dr. HAU Kwun Cheung 侯鈞翔醫生

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

ENTDr. CHOW Chun Kuen 周振權醫生

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

GastroenterologyDr. NG Fook Hong 吳福康醫生

General PracticeDr. YAM Chun Yin 任俊彥醫生

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

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

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

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

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

NephrologyDr. CHAN Man Kam 陳文岩醫生Dr. HO Chung Ping, MH, JP 何仲平醫生Dr. HO Kai Leung, Kelvin 何繼良醫生Dr. LAM Man Fai 林萬斐醫生Dr. LEE Hoi Kan, Achilles 李海根醫生

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

NeurosurgeryDr. CHAN Ping Hon, Johnny 陳秉漢醫生

Obstetrics and GynaecologyDr. CHAN Kit Sheung 陳潔霜醫生

OphthalmologyDr. LIANG Chan Chung, Benedict 梁展聰醫生Dr. PONG Chiu Fai, Jeffrey 龐朝輝醫生

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

PaediatricsDr. CHAN Yee Shing, Alvin 陳以誠醫生Dr. TSE Hung Hing, JP 謝鴻興醫生Dr. YEUNG Chiu Fat, Henry 楊超發醫生

Plastic SurgeryDr. NG Wai Man, Raymond 吳偉民醫生

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

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

Respiratory MedicineDr. LEUNG Chi Chiu 梁子超醫生Dr. WONG Ka Chun 黃家進醫生Dr. WONG King Ying 黃琼英醫生Dr. YUNG Wai Ming, Miranda 容慧明醫生

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

UrologyDr. CHEUNG Man Chiu 張文釗醫生Dr. KWOK Ka Ki 郭家麒醫生Dr. KWOK Tin Fook 郭天福醫生Dr. YEUNG Hip Wo, Victor 楊協和醫生

Vascular SurgeryDr. TSE Cheuk Wa, Chad 謝卓華醫生

HKMA SecretariatMs. Jovi LAM 林偉珊女士Miss Irene GOT 葛樂詩小姐Miss Giselle YIP 葉冬晨小姐Mr. Jeff CHENG 鄭嘉信先生

持續醫學進修專訊HKMA CME Bulletin

EDITORIALIt is sad at the first glimpse of the title “.....to fly” in the spotlight article by Dr. Y C SO. After a whole year of lockdown and strict quarantine measures, I am sure we are longing to “fly”.

On the other hand, our earth is recovering with more days of blue sky and fresh air after slowing down traveling and industrial activities. We should have treasured our health, our family, our peaceful society and the Mother Nature more but efforts have to be taken if we really love them!

Hong Kong, an oriental city with western taste, is still enjoying the privilege of this hub.....

Up to now, global vaccination seems to be the only light of the tunnel in the termination of this deadly pandemic and we still have spared vaccine. Moreover, HK citizens have free choice of 2 kinds of vaccine coupled with well-organized inoculation logistics. As one member of the medical society, we have no excuse not to encourage our patients, friends and even relatives to get vaccinated ASAP!

Dr. HO Hung Kwong, DuncanCo-editor, Hong Kong Medical Association CME Bulletin

Dear General Practitioners,

HKMA as your CME Program Administrator

HKMAMembership

Please choose your CME Administrator and register for CME Program for Non-Specialist!

The HKMA is one of the CME Programme Administrators. For HKMA MEMBERS, please find the registration form on www.hkma.org !

(HKMA Website Homepage → Links & Downloads → Downloads → Registration form for choosing HKMA as Administrator under MCHK

CME Programme)

Remarks: A maximum of 20 points can be awarded for self-study per year and no upper limit of CME points for attending CME lectures per year.

Please contact the HKMA Secretariat at 2527 8452 or by email cme@hkma.org for assistance.

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HKMA bulletin Ad_OL.pdf 1 17/5/2021 3:04 PM

4 HKMA CME Bulletin 持續醫學進修專訊 June 2021

Spotlight–1

www.hkma.org

Review Of Recommendations Of Fitness To Drive/Fly – 2021 Suggestions

Dr. SO Yui ChiMBBS(HK), FRCP, FACCPrivate practice, Hon consultant (HK San), Cardiologist (Matilda Hospital)

As a cardiological routine consultation, we always face with the fitness to drive/fly after a cardiac event. Therefore, I summarize some available guidelines and experiences to answer the concerns for fitness to move!

Before we start to go through the recommendations, we should understand the mechanics of air fl ight. Normally, aircraft fly between 6,500m-13,500m. However, the aircraft is usually pressurized to about 1,500-2,500m (5,000-8,000 feet) with Pa O2 9 kPa (O2 saturation drop about 3% to around 92-95%). Basically, if you fly above 3,500m without pressurizing the plane (you should have below 88% Saturation of O2 with around 6 kPa.

The effects of hypoxia will cause local vasodilation of coronary and cerebral blood vessels. That wi l l increase cardiac contractility, cardiac output and tachycardia as compensatory responses. The respiratory centre of the mid brain will also stimulate hyperventilation too.

The barometric pressure of the cabin is about 565 mmHg (sea level is 760 mmHg). According to Bohr Effect, air cavity will expand 30% if in an enclosed cavity such as surgical wound.

The humidity inside the cabin is around 10-20%. The excess water evaporization (usually around 200 ml for 6-8 hours flight) are easily compensated by our body adaptive mechanism.

Reommendations for flight

1. Heart failure – NYHA 1 and 2 – No restriction; Class 3 (Breathless on walking 100 meters)– May need O2; Class 4 (breathless at rest)– Not fit with travel unless medical assistance with O2

For acute heart failure, fly after 6 weeks of stabilization.

2. Angina – CCS 1-2 – No restriction; Class 3 (chest pain on minimal exertion) – May need O2; Class 4 (chest pain at rest) defer travel.

3. Post MI

Low risk- EF>45%, age <65, No complications; No further revasularization – fly after 3 days

Medium risk EF>40%, No complications and no further interventions- fly after 10 days

High risk EF<40% – defer travel until stabilization.

4. Elective PCI (angioplasty) – For uncomplicated PCI; Can fly after 2 days

5. Elective CABG- can fly after 10 days if no complications.

6. Following pacemaker implantation- 2 weeks after the procedure; can be as early as 2 days if documented no pneumothorax. Pacemaker must be checked before travel to assure stable parameters and enough battery power. A baseline ECG should be provided

7. ICD implanted – as pacemaker recommendations + rhythm stability should be attained before travel. ICD must be checked before travel to assure stable parameters and enough battery power. A baseline ECG should be provided

8. Arrhythmia – if stable; No hemodynamic disturbance with fainting or becomes more frequent – No restriction.

9. After EPS + ablation – delay 1 week better to avoid DVT and can fly 2 days after the procedure if avoidance steps of DVT taken with no recurrence of rhythm

5HKMA CME Bulletin 持續醫學進修專訊 June 2021

Spotlight–1

www.hkma.org

10. Canadian Cardiac Society recommends a Hemoglobin level Hg >=9 g/L before travel

Deep vein thrombosis: Prophylaxis

There should be no increase in DVT for normal people. But some high r isk people such as recent DVT, pelv ic malignancies, oral contraceptives, genetic variant (factor V Leiden) and surgery lasting >30 min within last 4 weeks maybe prone to recurrency of DVT.

General measures such as enough hydration, addition of compression stockings and avoid alcohol intake

Enoxiparine 40 mg injected before the f l ight and on the following day is recommended for high risk patients.

Fitness to drive (own private vehicle) due to Cardiovascular incidents

Recommendations:

1. Heart Fai lure: NYHA Functional class 1 and 2 – No restriction. Class 3 with no signs of cerebral ischemia and dyspnea at rest – No restriction. Otherwise, class 3 and 4 with resting symptoms – defer and reassess every 6 months.

2. Angina – Stable – No restriction; Unstable – Disqualified

3. PCI (angioplasty) – can resume dr iv ing 2-7 days i f uncomplicated procedure.

4. Myocardia l Infarct ion – Uncompl icated cases can resume driving 2 weeks later; Complicated cases need revascularization and stabilize with no symptoms for at least 1 month.

5. CABG/Open heart surgery- at least 4 weeks and for heart transplant at least 8 weeks. For mid CAB or minimal invasive surgery) can consider shortening the waiting time for driving.

6. Arrhythmia

Atrial:

SVT – No restriction if no cerebral ischemic symptoms; If symptomatic, patient can resume driving after controlled by ablation or antiarrhythmic drugs for 6 months

AF- With symptoms of cerebral ischemia such as dizziness or syncope should be banned from driving

Sick sinus node – No restriction if no symptoms and banned for driving if symptomatic

LBBB, RBBB, Bifascicular block; First degree block; Type IIa block; Intraventricular block --- No restrictions if asymptomatic.

Type IIb, trifasicular block, acquired 3rd degree block—should be banned from driving. Patients should be implanted with a pacemaker and resume driving 4 weeks later if asymptomatic.

Ventricular:

Non- sustained VT – No restriction if asymptomatic.

Sustained VT, VF, cardiac arrest – should be assessed by cardiologist general principle is to defer for at least 6 months without any arrhythmic events; there should have an adult by seater

7. After ICD – should defer 6 months without any shock/arrhythmic events.

8. After pacemaker – Can resume driving after 1 week if asymptomatic and pacemaker function well.

9. Hype r tens ion – No res t r i c t i on un less ma l i gnan t hypertension especially with cerebral ischemia.

10. Hypotension – No restriction if asymptomatic; Ban from driving if symptomatic with sitt ing causing cerebral hypoperfusion and especially during clusters of attacks

11. Cardiomyopathy (HCM; dilated CMP etc) No restriction if asymptomatic; if signs of cerebral ischemia such as dizziness and syncope ban from driving. Follow other disease entities listed in above guidelines too

12. Valve disease – No restriction if asymptomatic; If signs of cerebral ischemia banned for driving;

13. Valve replacement- Patient usually wait for 6 weeks post-op to resume driving. Stabilize the anticoagulants if prescribed.

Conclusion

From the above discussion, you can perceive that the air traveler and private car driver, more or less experience the same restrictions. Fundamentally, the mechanism of tolerance is different for air travel. Patients have to deal with dryness of air and borderline hypoxia sometimes with long haul. For the driver, we can concentrate on the reaction time of the driver even he gets an underlying cardiac disease or post operation periods, we safeguard the patient and the road users as well. It is not an easy task but hopefully, after reading this article, you can have some grasp of ideas behind the recommendations summarizing after several international protocols.

Final but not the least, kindly consult your specialist colleague in case of doubt in giving the advice of travel/drive. It means lives!

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References

1. Fitness to fly for CVS disease- report of the British CVS society. Heart 2010;96: ii1-ii16

2. Assessing fitness to drive by DVLA UK 2020

3. Assessing fitness to drive 2016 NTC – Australia

4. Manual of civil aviation -ICAO 2012

5. Fit to fly; MPS 2014

6. Medical standards – UK Civil Aviation Authority

CMEQUESTIONS:Q&A

Complete Spotlight, 1 CME Point will be awarded for at least five correct answersAssessment

QuestionsQ&AAnswer these on page 18 or make an online submission at: www.hkma.org.

Please indicate whether the following statements are true or false.

1. Most airplane is pressurized to 2500 meters or below

2. Hypoxia with high altitude will initially cause: bradycardia-

3. Heart failure stage 3 with <100 meters walking will be banned for travel:–

4. Heart failure with Class 3 without signs of cerebral hypo perfusion will be banned for driving

5. Post MI patient (EF >40%) without any complications can fly after 10 days.

6. For elective angioplasty patients, they can fly even 2 days after the procedure if uncomplicated.

7. For post PCI patients, they can drive 7 days after the procedure if uncomplicated.

8. Post MI patient, the can resume driving 2 weeks after MI if uncomplicated and no revascularization procedure planned.

9. Asymptomatic AF patients should ban from driving during attack

10. Hypertension patients with BP 160/90 without end organ damage signs should ban from driving

Answer to May 2021

Spotlight 1 – Advances In Bronchoscopy, From Endobronchial Ultrasonography (EBUS) To Robotic Bronchoscopy1. F 2. F 3. F 4. T 5. T 6. F 7. T 8. F 9. F 10. T

Spotlight 2 – Should We Take Vitamin D Supplement?1. T 2. F 3. F 4. T 5. T 6. T 7. F 8. T 9. T 10. F

Spotlight 3 – Expectation Gaps In The Use Of PDE5 Inhibitors And The Role Of Avanafil In Patients With Erectile Dysfunction1. F 2. T 3. T 4. F 5. T 6. T 7. F 8. F 9. F 10. T

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11285 Lixiana NVAF Ad_Jun2020 R03.pdf 1 18/6/2020 下午4:29

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8 HKMA CME Bulletin 持續醫學進修專訊 June 2021 www.hkma.org

A Brief Overview On Cancer Pain Assessment And Evidence-Based Pharmacological ManagementIntroduction

Malignant neoplasm remains the major cause of death in Hong Kong, and on average there are 93 people diagnosed with cancer each day.1 Pain can be the presenting symptom of cancer. The prevalence of pain among patients completed curative treatment, receiving anticancer treatment and having advanced, metastatic disease were 39.3%, 55.0% and 66.4% respectively.2 Cancer pain has significant impact on patient’s quality of live and survival,3 yet around 30% of patients still experience under-treatment.4

The Definition of Pain

The International Association for the Study of Pain (IASP) has revised the definition of pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” in 2020.5 I t should be emphasized that pain is “always a personal experience” and “pain and nociception are different phenomena”. Cicely Saunders, the founder of modern palliative care movement, described the concept of ‘total pain’, which addressed the physical, psychological, social and spiritual components of pain and suffering.6 Pain assessment should evaluate all components of suffering, including the psychological distress, as recommended by the European Society of Medical Oncology (ESMO).7 The recent World Health Organization (WHO) guideline also address the importance of psychosocial care and spiritual counselling appropriate to patients and family members’ belief as part of pain management.8

Cancer pain is a heterogenous syndrome with diversified cause, development course and presentation. A simplified classification of cancer pain is listed in Table 1. The pain can be resulted from the tumour effect or its complication, as well as secondary to the treatment and intervention. Nevertheless, one should not forget the pain related with comorbidity, such as diabetes.

Dr. WOO Kam WingMBChB(CUHK), MRCP(UK), FHKCP, FHKAM (Medicine)MSc Mental Health (CUHK), Dip Med (CUHK) PG Dip. Pall. Med (Cardiff), PDip Epidemiology and Biostatistics (CUHK)Specialist in Palliative Medicine

Pain Assessment

Structured pain assessment is essential to make the diagnosis, assess severity and formulate treatment plan. The mnemonic PQRSTUV can be used to evaluate the pain syndrome. (See Table 2). The ESMO recommends regular assessment of pain intensity and treatment outcome using consistent scale by asking “what has been your worst pain in the last 24 hours”. The pain intensity can be assessed by standardized tools such as Numerical Rating Scale (NRS)7. For patients with difficulties to comprehend, Verbal Rating Scale could be employed as alternative. (See Figure 1). There are different complex pain assessment tools such as Integrated Palliative Outcome Scale (IPOS) or Brief Pain Inventory (BPI), they can be employed in the appropriate settings.8 Moreover, patient’s comorbidities, age-related frailty, relevant physical examination and laboratory investigations and even imaging studies should be part of the pain assessment.9

Principles of Pain Management

According to WHO, The goal of pain management is to reduce pain to a level that allows for a quality of life that is acceptable to the patient.8 ESMO emphasized patient’s active role in pain management. Pain management should be tailored made to individual needs and preference and it combines both drug and non-drug treatment, anti-cancer treatment, rehabilitation as well as psychological, social and spiritual support.9

The WHO recommends the p r i nc ip l es o f ana lges i c management as:

1. “By Mouth”: the analgesic should be given by mouth if possible;

2. “By the Clock”: the analgesic should be given at fixed interval of time;

3. “For the individual”: as patients will have variation in pain syndromes, response to pain as well as side effect profile, management should be individualized. The correct dose is the that relieves the patient’s pain to the level acceptable to patients.

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9HKMA CME Bulletin 持續醫學進修專訊 June 2021www.hkma.org

4. “Attention to Details”:

• First dose and last dose of analgesic should be linked to patient’s waking time and bedtime

• Analgesic regimen should be clearly written out

• Patients should be warned about the side effects of individual drugs being given.

The widely adopted WHO analgesic ladder was based on previous edition of cancer pain relief guideline.10 It has repositioned to “general guidance and teaching tool” in the latest guideline.8

Non-opioid Analgesic for Mild Pain

Paracetamol and NSAIDs (non-steroidal anti-inflammatory drug) are commonly used in mild cancer pain.

Paracetamol

Despite its widely use, the evidence to support its use in cancer pain, either alone or in combination with opioids, is lacking.11 Nevertheless it is a safe option as long as the prescribed dose is within recommendation. Dose reduction to 3g per day in frail elderly and underweight patients is recommended.12 The healthcare practitioner should review patient’s drug on hands as combination pills are common and unintentional overdose can occur. In recent years, its safety profile has been challenged, as its risk of cardiovascular disease, gastrointestinal and renal adverse effects, bleeding and mortality gained increasing attention.13,14 The routine use of paracetamol in combination with strong opioids to treat moderate or severe pain should be discouraged given the evidence of limited efficacy.11,15

NSAIDs

NSIADs provide anti-pyretic, analgesic and anti-inflammatory effects. The recent Cochrane review, however, concluded that there was no high-quality evidence to support or refute its use, either alone or in combination with other opioids. The evidence of its role in moderate or severe cancer pain is of very low-quality.16 Most of the included studies assessed the short-term analgesic effect only. While the COX-2 selective NSAIDs demonstrated a better gastrointestinal risk profile than non-selective NSAIDs, both classes of NSAIDs increased the cardiovascular and renal adverse events, even the use was short-term (<7 days).17,18

Opioids for Mild to Moderate Pain

Codeine and Dihydrocodeine

Codeine is metabolised by CYP2D6 to morphine.19 For poor metabolizers, they will experience no analgesic effect, while for the ultrarapid metabolizers, they may be more prone to morphine toxicity. According to a local study with 800 subjects (735 were Asians), around 3.5% were predicted to be ultrarapid metabolizers while 0.8% were predicted to be a poor metabolizers.20 The Cochrane review in 2014 concluded that codeine is more effective than placebo in treatment of cancer pain, with increased risk of nausea, vomiting and constipation.21 Dihydrocodeine is the semisynthetic analogue of codeine.22 Both drugs are mu-opioid receptor agonists.23 Dihydrocodeine is metabol ized by CYP2D6 to dihydromorphine. However, the impact of CYP2D6 metabolism on analgesic effect is unknown.7,23

Tramadol

Tramadol is a synthetic opioid. It is a mu-opioid receptor agonist, N-methyl-D-aspartate (NMDA) receptors antagonists, as well as serotonin-norepinephrine reuptake inhibitor (SNRI).24 Tramadol has its advantage in neuropathic pain.25 but its analgesic effect is inferior to morphine.26 Besides the opioid related side effects, tramadol is associated with serotonin syndrome and seizure attack given its pharmacological properties, especially if this is combined with the use of antidepressants, for example selective serotonin reuptake inh ib i tors (SSRIs ) or set rons group ant iemet ics (e .g. ondansetron).27

Initiating “strong opioid” in moderate pain

ESMO recommends the weak opioids can be given in combination with non-opioids in treatment of mild to moderate pain.7 However, the position of weak opioids in analgesic ladder had been questioned.21,26 The routine use of weak opioids has been discouraged by the experts given its low quality of evidence.15 The European Association of Palliative Care considered the use of low dose morphine (less than oral morphine 30mg per day) or oxycodone (less than 20mg per day) as step II opioids.28 The Early Strong Opioid Treatment Study enrolled 240 opioid-naïve patients with moderate cancer pain in either low-dose morphine group (normal-release oral morphine up to 30mg/day) or weak-opioid group (tramadol up to 400mg/day or codeine 240mg/day). The proportion of achieving more than 30% and 50% pain reduction from baseline was higher in morphine group (p<0.001) without increasing the adverse effects.29 The ESMO also recommends that initiating low dose of strong opioid could be an alternative option to weak opioids in moderate pain.7

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10 HKMA CME Bulletin 持續醫學進修專訊 June 2021 www.hkma.org

Morphine

Morphine is the prototype of strong opioids and it is the first choice among different opioids for moderate to severe cancer pain due to its familiarity, availability and cost.7,28 The effectiveness of oral morphine in cancer pain reduction has been demonstrated in Cochrane review.30 Both immediate-release and slow-release morphine provide similar analgesic activity,30 and immediate-release morphine can be used as rescue medicat ion in case of uncontro l led pain or breakthrough pain.7,8 Rapid t i t rat ion by intravenous or subcutaneous route is feasible, and it can be converted back to oral morphine later.

Oxycodone

Oxycodone acts on mu and kappa opioid receptors,31,32 therefore early study postulated its superiority in visceral pain syndromes.33 However, recent randomized clinical trials and systematic reviews failed to demonstrate the hypothesized superior effect of oxycodone in terms of analgesic effects and tolerability.31,34-36 Oxycodone was better tolerated than morphine in patients with lower glomerular filtration rate and may be a safer choice if patient is prone to develop renal impairment.37 The combination of oxycodone and naloxone may provide additional benefit in opioid induced constipation.7

Fentanyl

Fentanyl is a potent mu-receptor agonist.32 Parenteral form (intravenous and subcutaneous) and transdermal form are commonly used in cancer pain. ESMO recommends fentanyl and buprenorphine, either intravenous route or transdermal route) as the safest option in patients with stage 4 or 5 chronic kidney disease.7 The availabil ity of transdermal fentanyl provides an attractive alternative to patients with impaired oral intake. Transdermal fentanyl patch decreases cancer pain severity,38 however it is contraindicated in patients who are severe cachexia, fevers or frequent sweating.8

Transdermal fentanyl should be only used in patients who demonstrate opioid tolerance with stable opioid requirement, despite there are attempts to init iate i t in opioid-naive patients.7,39 It is associated with respiratory depression which can be fatal.39 Even for the preparation with lowest dosage (12 microgram per hour) it already equals to oral morphine 45mg per day.40 Patients and caregivers education are essential to ensure safe use of this potent analgesics, including how to handle the patches as well as identifying the signs and symptoms of overdose.

The recent development of t ransmucosal immediate-release fentanyl (TIRF) has revolutionized the management of breakthrough pain, which is defined as the transient aggravation of pain in the background of stable or well control led basel ine pain.41 TIRFs have short onset t ime and analgesic only last for a short period. They are easily administered and well-tolerated.41 While immediate-release opioid remains the recommended choice to treat breakthrough pain in opioid-responsive cancer pain with background pain optimized, ESMO also suggested the potential role of TIRF in unpredictable and rapid-onset breakthrough pain.7 Nevertheless, the Cochrane review on the opioid management of breakthrough pain has been withdrawn since 2015,42 and the cost as well as risks of overdose (including intentional abuse and unintentional overdose) are concerning.43,44 The European Pain Federation reserved TIRF for specialist use only.9

Methadone

Methadone is a synthetic opioid acting on mu, kappa and delta receptor. Similar to tramadol it is also a NMDA receptor antagonist as well as SNRI.45 Cochrane review concluded methadone as a drug with similar analgesic benefits to morphine. However, given its complex pharmacology with wide inter-individuals pharmacokinetics profile, the drug is recommended to be commenced by experienced practitioners or specialists.7-9,15

Buprenorphine

Being a partial agonist, the position of buprenorphine in cancer pain management has not been fully established. ESMO recognized the its role in patients with severe renal impairment.7 On the other hand, in a recent phase IV trial transdermal buprenorphine demonstrated simi lar pain control efficacy, response rate and main adverse reactions when compared with oral morphine, oral oxycodone and transdermal fentanyl recipieint.34 Further studies are needed to establish its role.46

Non Opioid Adjuvants

Adjuvants can be applied in all steps of the analgesic ladder.

Anticonvulsant and Antidepressants for Neuropathic Pain

The ESMO ext rapo lated the ev idence of non-cancer neuropathic pain and recommends the use of tr icycl ic

Spotlight–2

11HKMA CME Bulletin 持續醫學進修專訊 June 2021www.hkma.org

antidepressants, duloxetine, gabapentin and pregabalin as first-line single neuropathic analgesics in general, while WHO makes no recommendation for or against the use of antidepressants or anticonvulsants for cancer-related neuropathic pain, given the quality of evidence is low.7,8

Steriods

Steroid is commonly prescribed for metastatic bone pain, neuropathic pain and visceral pain and evidence suggests its short term effect.8,47 Limit the treatment duration if possible to avoid side effect.

Bone Modifying Agents

Both bisphosphonates and densoumab are important bone modifying agents with proven role in preventing skeletal-re lated events (SREs) . WHO recommends the use of bisphosphonates to prevent and treat bone pain.8 While the ESMO recommends it to be considered if pain is not localized or radiotherapy is not readily accessible.7 Denosumab is regarded as effective treatment to delay bone pain recurrence by ESMO.7 Nevertheless, the overall quality of evidence to support their analgesic role is weak.48

Ketamine and Lidocaine

They should be reserved under the hands of specialists in difficult pain syndromes given the limited evidence and difficulties in titration.7,15

Other Aspects of Cancer Pain Management

Anti-cancer treatment such as surgery, chemotherapy, radiotherapy, targeted therapy as well as immunotherapy are essential part of cancer pain management. The non-pharmacological approaches of pain management are equally important, including but not limited to psychotherapy, counselling, social intervention, physiotherapy, occupational therapy, dietitian review, music and expressive art therapy as well as spiritual support.

Conclusion

Cancer pain is common and heterogenous. A variety of analgesic is available and supported by growing evidence. Addressing the psychological, social and spiritual needs are equally important. Multidisciplinary intervention is essential to provide optimal cancer pain management.

Figure 1: Commonly employed pain assessment tools7

Visual Analogue Scale (VAS)

No pain Worst pain

Visual Rating Scale (VRS)

Numerical Rating Scale (NRS)

No pain Worst pain0 1 2 3 4 5 6 7 8 9 10

No pain 1Very mid 2Mild 3Moderate 4Severe 5Very severe 6

Figure 2: The three-step analgesic ladder8

Freedom from cancer pain

Opioids for moderate to severe pain

+/- non-opioid

+/- adjuvant

Opioids for mild to moderate pain

+/- non-opioid

+/- adjuvant

Non-opioid

+/- adjuvant

Pain Persisting

or Increasing

Pain Persisting

or Increasing

3

2

1

Table 1: Classification of Cancer Pain According to Neural Mechanisms7,8

Nociceptive Visceral Stimulation of pain receptors on normal sensory nerve endings

Aching, Cramping, Gnawing, Sharp

Somatic Aching, Throbbing, Pressure

Neuropathic NerveCompression

Stimulation of nervi nervorum ShootingSharpTingling and numbnessPins and NeedlesItchingPainful cold or hot

Nerve Injury Peripheral: lowered firing threshold of sensory nerves

Central: injury to central nervous system

Mixed

Sympathetically maintained

Dysfunction of sympathetic system

Table 2: PQRSTUV Mnemonic in Pain Assessment

P Provoking or Palliating Factors

Q Quality

R Region and Radiation

S Severity

T Timing

U Utilization of treatment

V Value and Viewpoint of Pain Treatment

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12 HKMA CME Bulletin 持續醫學進修專訊 June 2021 www.hkma.org

References

1. Hong Kong Cancer Registry. Overview of Hong Kong Cancer Statistics of

2017. 2018; 1-9.

2. van den Beuken-van Everdingen MHJ, Hochstenbach LMJ, Joosten EAJ, et

al. Update on Prevalence of Pain in Patients with Cancer: Systematic Review

and Meta-Analysis. J Pain Symptom Manage 2016; 51: 1070-1090.e9.

3. Mantyh PW. Cancer pain and its impact on diagnosis, survival and quality of

life. Nat Rev Neurosci 2006; 7: 797-809.

4. Greco MT, Roberto A, Corli O, et al. Quality of cancer pain management: An

update of a systematic review of undertreatment of patients with cancer. J

Clin Oncol 2014; 32: 4149-4154.

5. Raja SN, Carr DB, Cohen M, et al. The revised International Association for

the Study of Pain definition of pain. Pain 2020; 161: 1976-1982.

6. Clark D.‘Total pain’, disciplinary power and the body in the work of Cicely

Saunders, 1958-1967. Soc Sci Med 1999; 49: 727-736.

7. Fallon M, Giusti R, Aielli F, et al. Management of cancer pain in adult patients:

ESMO Clinical Practice Guidelines. Ann Oncol 2018; 29: iv166-iv191.

8. World Health Organization. WHO guidelines for the pharmacological and

radiotherapeutic management of cancer pain in adults and adolescents.

2018.

9. Bennett MI, Eisenberg E, Ahmedzai SH, et al. Standards for the management

of cancer-related pain across Europe—A position paper from the EFIC Task

Force on Cancer Pain. Eur J Pain (United Kingdom) 2019; 23: 660-668.

10. Balboni TA, Balboni M, Enzinger AC, et al. Provision of spiritual support to

patients with advanced cancer by religious communities and associations

with medical care at the end of life. JAMA Intern Med 2013; 173: 1109-17.

11. Wiffen PJ, Derry S, Moore RA, et al. Oral paracetamol (acetaminophen) for

cancer pain. Cochrane Database Syst Rev; 2017. CD012637.pub2.

12. Saragiotto BT, Abdel Shaheed C, Maher CG. Paracetamol for pain in adults.

BMJ 2019; l6693.

13. Roberts E, Delgado Nunes V, Buckner S, et al. Paracetamol: not as safe

as we thought? A systematic literature review of observational studies. Ann

Rheum Dis 2016; 75: 552-9.

14. Gonzalez-Valcarcel J, Sissani L, Labreuche J, et al. Paracetamol, Ibuprofen,

and Recurrent Major Cardiovascular and Major Bleeding Events in 19 120

Patients With Recent Ischemic Stroke. Stroke 2016; 47: 1045-52.

15. Chapman EJ, Edwards Z, Boland JW, et al. Practice review: Evidence-based

and effective management of pain in patients with advanced cancer. Palliat

Med 2020; 34: 444-453.

16. Derry S, Wiffen PJ, Moore RA, et al. Oral nonsteroidal anti-inflammatory drugs

(NSAIDs) for cancer pain in adults. Cochrane Database Syst Rev. CD012638.

pub2.

17. Ho KY, Cardosa MS, Chaiamnuay S, et al. Practice advisory on the

appropriate use of NSAIDs in primary care. J Pain Res 2020; 13: 1925-1939.

18. Schjerning AM, McGettigan P, Gislason G. Cardiovascular effects and safety

of (non-aspirin) NSAIDs. Nat Rev Cardiol 2020; 17: 574-584.

19. Wootton M. Morphine is not the only analgesic in palliative care: literature

review. J Adv Nurs 2004; 45: 527-32.

20. Chan W, Li MS, Sundaram SK, et al. CYP2D6 allele frequencies, copy

number variants, and tandems in the population of Hong Kong. J Clin Lab

Anal 2019; 33: 1-7.

21. Schremmer C, Derry S, Jackson KC, et al. Codeine, alone and with

paracetamol (acetaminophen), for cancer pain. Cochrane Database Syst

Rev; 2013. CD006601.pub3.

22. Leppert W. Dihydrocodeine as an opioid analgesic for the treatment of

moderate to severe chronic pain. Curr Drug Metab. 2010; 11(6): 494-506.

23. Leppert W. Pain management in patients with cancer: Focus on opioid

analgesics. Curr Pain Headache Rep 2011; 15: 271-279.

24. Barakat A.R evisiting Tramadol: A Multi-Modal Agent for Pain Management.

CNS Drugs 2019; 33: 481-501.

25. Duehmke RM, Derry S, Wiffen PJ, et al. Tramadol for neuropathic pain in

adults. Cochrane Database Syst Rev. CD003726.pub4.

26. Wiffen PJ, Derry S, Moore RA. Tramadol with or without paracetamol

(acetaminophen) for cancer pain. Cochrane Database Syst Rev; 2017..

CD012508.pub2.

27. Hassamal S, Miotto K, Dale W, et al. Tramadol: Understanding the Risk of

Serotonin Syndrome and Seizures. Am J Med 2018; 131: 1382.e1-1382.e6.

28. Caraceni A, Hanks G, Kaasa S, et al. Use of opioid analgesics in the

treatment of cancer pain: evidence-based recommendations from the EAPC.

Lancet Oncol 2012; 13: e58-68.

29. Bandieri E, Romero M, Ripamonti CI, et al. Randomized trial of low-dose

morphine versus weak opioids in moderate cancer pain. J Clin Oncol 2016;

34: 436-442.

30. Wiffen PJ, Wee B, Moore RA. Oral morphine for cancer pain. Cochrane

Database Syst Rev; 2016. CD003868.pub4.

31. Schmidt-Hansen M, Bennett MI, Arnold S, et al. Oxycodone for cancer-

related pain. Cochrane Database Syst Rev; 2017. CD003870.pub6.

32. Trescot AM, Datta S, Lee M, et al. Opioid pharmacology. Pain Physician

2008; 11: 133-154.

33. Staahl C, Christrup LL, Andersen SD, et al. A comparative study of

oxycodone and morphine in a multi-modal, tissue-differentiated experimental

pain model. Pain 2006; 123: 28-36.

34. Corli O, Floriani I, Roberto A, et al. Are strong opioids equally effective and

safe in the treatment of chronic cancer pain? A multicenter randomized phase

IV ‘real life’ trial on the variability of response to opioids. Ann Oncol 2016; 27:

1107-1115.

35. Riley J, Branford R, Droney J, et al. Morphine or Oxycodone for Cancer-

Related Pain? A Randomized, Open-Label, Controlled Trial. J Pain Symptom

Manage 2014; 49: 161-172.

36. Guo K, Deng C, Lu G, et al. Comparison of analgesic effect of oxycodone

and morphine on patients with moderate and advanced cancer pain: a meta-

analysis. BMC Anesthesiol 2018; 18: 132.

37. Kurita GP, Lundström S, Sjøgren P, et al. Renal function and symptoms/

adverse effects in opioid-treated patients with cancer. Acta Anaesthesiol

Scand 2015; 59: 1049-1059.

38. Hadley G, Derry S, Moore RA, et al. Transdermal fentanyl for cancer pain.

CD010270.pub2.

Table 3: Example of cancer pain analgesic, modified from Bennett MI et al.8

Group Class Examples

Non-opioids simple analgesic

Paracetamol Paracetamol

NSAIDs Non-selective NSAIDs: diclofenac, naproxen, ibuprofen COX-2 inhibitors: celecoxib, etoricoxib

Opioids Opioids for moderate pain Codeine, DihydrocodeineTramadol

Opioids for moderate to severe pain

MorphineOxycodoneMethadoneFentanyl, including parenteral, transdermal and transmucosal immediate-release fentanyl (TIRF)

Adjuvants Antidepressant Amitriptyline, Duloxetine, Venlafexine

Antiepileptics Gabapentin, Pregabalin, Carbamazapine

Corticosteroids Prednsiolone, Dexamethasone

Bisphosphonates Pamidronate, Zoledronate

RANKLi Denosumab

Other Lidocaine, Ketamine

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13HKMA CME Bulletin 持續醫學進修專訊 June 2021www.hkma.org

CMEQUESTIONS:Q&A

Complete Spotlight, 1 CME Point will be awarded for at least five correct answersAssessment

QuestionsQ&AAnswer these on page 18 or make an online submission at: www.hkma.org.

Please indicate whether the following statements are true or false.

1. Pain is always subjective experience. It has both physical, psychological, social and spiritual components.

2. Whenever possible, intravenous analgesic should be considered as first-line treatment in cancer pain management to provide rapid relief.

3. Paracetamol is a safe analgesic option without the risk of overdose in frail elderly.

4. As codeine is metabolized to morphine by CYP2D6, the experience of analgesic and side effect would be affected by rather you are a ultra-rapid metabolizer or poor metabolizer.

5. The analgesic effect of tramadol is similar to morphine, and it is a safer drug of choice in patients with seizures.

6. One should go step-by-step in analgesic ladder: we should start “weak opioids” for cancer pain before attempting strong opioids such as morphine.

7. Oxycodone has similar analgesic effect and tolerability when compared with morphine.

8. It is not recommended to initiate transdermal fentanyl in opioid-naïve patients.

9. The analgesic effect of transmucosal immediate-release fentanyl (TIRF) is rapid-onset and yet short-lived, it provided an attractive option for breakthrough pain.

10. There is strong level of evidence to support the use of adjuvant analgesic, such as duloxetine and gabapentin, in cancer-related neuropathic pain.

HKMA CME BulletinMonthly Self-Study Series Call for Articles

Since its publication, the HKMA CME Bulletin has become one of the most popular CME readings for doctors. This monthly publication has been serving more than 10,000 readers each month through practical case studies and picture quizzes. To enrich its content, we are inviting articles from experts of different specialties. Interested contributors may refer to the General Guidance below. Other formats are also welcome.For further information, please contact CME Dept. at 2527 8452 or by email at cme@hkma.org.General Guidance for AuthorsIntended Readers : General PractitionersLength of Article : Approximately 8-10 A-4 pages in 12-pt fonts in single line spacing, or around 1,500-2,000 words

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

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

month.All articles submitted for publication are subject to review and editing by the Editorial Board.We welcome submissions for consideration which are original and not under consideration for any other publication at the same time. Articles submitted will be checked using originality detection software. For details please contact CME Bulletin Editorial Office of the HKMA.

39. U.S. Food & Drugs Administration. Fentanyl Transdermal System (marketed

as Duragesic) Informationhttps://www.fda.gov/drugs/postmarket-drug-

safety-information-patients-and-providers/fentanyl-transdermal-system-

marketed-duragesic-information (2015, accessed 14 March 2021).

40. Drug Office, Department of Health. Transdermal fentanyl patches for non-

cancer pain: do not use in opioid-naive patientshttps://www.drugoffice.gov.

hk/eps/upload/eps_news/41669/ZH/1/Transdermal fentanyl patches for

non-cancer pain do not use in opioid-naive patients_HP.pdf (2020).

41. Brząkała J, Leppert W. The role of rapid onset fentanyl products in the

management of breakthrough pain in cancer patients. Pharmacol Reports

2019; 71: 438-442.

42. Zeppetella G, Davies AN. Opioids for the management of breakthrough pain

in cancer patients. Cochrane Database Syst Rev. CD004311.pub4.

43. Mercadante S, Portenoy RK. Understanding the Chameleonic Breakthrough

Cancer Pain. Drugs. Epub ahead of print 2021. DOI: 10.1007/s40265-021-

01466-5.

44. Fleischman W, Auth D, Shah ND, et al. Association of a Risk Evaluation and

Mitigation Strategy Program With Transmucosal Fentanyl Prescribing. JAMA

Netw open 2019; 2: e191340.

45. Leppert W. The role of methadone in cancer pain treatment--a review. Int J

Clin Pract 2009; 63: 1095-109.

46. Schmidt-Hansen M, Bromham N, Taubert M, et al. Buprenorphine for treating

cancer pain. Cochrane Database Syst Rev; 2013. CD009596.pub3.

47. Haywood A, Good P, Khan S, et al. Corticosteroids for the management

of cancer-related pain in adults. Cochrane Database Syst Rev. CD010756.

pub2.

48. Porta-Sales J, Garzón-Rodríguez C, Llorens-Torromé S, et al. Evidence

on the analgesic role of bisphosphonates and denosumab in the treatment

of pain due to bone metastases: A systematic review within the European

Association for Palliative Care guidelines project. Palliat Med 2017; 31: 5-25.

Fresenius Kabi Hong Kong Ltd.

Room 5001-5027, 50/F, Sun Hung Kai Centre,

30 Harbour Road, Wanchai, Hong Kong

Tel : (852) 2152 1330 Fax : (852) 2119 0815

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Smofkabiven Ad_210Wx280H_HK-DA-071-2021_1.pdf 1 8/4/2021 10:52 PM

Cardiology

15www.hkma.org HKMA CME Bulletin 持續醫學進修專訊 June 2021

A 48-Year-Old Male Smoker Has Hypertension With Sudden Retrosternal Chest Pain

A 48-year-old gentleman, smoker, has known medical history of hypertension defaulted follow-up. He presented with sudden onset very severe retrosternal chest pain, which woke him up from sleep. The chest pain was tearing in nature, with radiation to the back. He did not experience any shortness of breath or loss of consciousness. His blood pressure on presentation was 210/110mm Hg with pulse rate 104 beats per minute. Pulse oximetry was 99% on room air. CXR and ECG was done (see Figure 1 and 2).

The content of the June 2021 Cardiology Series is provided by:Dr. CHUI Shing Fung

MBChB (CUHK), MRCP (UK), FHKCP, FHKAM (Medicine), Specialist in CardiologyDr. WONG Chi Yuen

MBBS (HK), FHKCP, FHKAM (Medicine), FRCP (Edin), Specialist in Cardiology六月臨床心臟科個案研究之內容承蒙徐城烽醫生及黃志遠醫生提供。

Complete Cardiology case, 0.5 CME POINT will be awarded for at least 2 correct answers in total

Figure 2 Figure 5

Figure 1

Figure 2

Figure 4Figure 3

Q&A Please answer ALL questionsAnswer these on page 18 or make an online submission at: www.hkma.org.

1. What is the most appropriate further investigation?A. CT brain C. Coronary angiogramB. CT aortogram D. CT pulmonary with contrast angiogram

2. Which of the following would NOT be the appropriate INITIAL management of this patient?A. Analgesics C. IV thrombolyticsB. IV beta-blocker D. Nitroglycerin (TNG)

3. After initial management, further imaging investigation was performed (see Figure 3 and 4). What should be the definitive treatment for this gentleman?A. Primary percutaneous coronary intervention

with stentingB. Thrombolytic therapyC. Open heart surgeryD. Conservative management

May Answers

16 www.hkma.orgHKMA CME Bulletin 持續醫學進修專訊 June 2021

Dermatology Answers

Discussion:

The ECG in Figure 1 showed suspected severe LVH (left ventricular hypertrophy) with straining pattern. Echocardiogram showed evidence of Asymmetric septal hypertrophy (ASH) and dynamic LVOT obstruction, thus confirming the diagnosis of HOCM (hypertrophic obstructive cardiomyopathy). The LVOT gradient will increase in dynamic LVOT obstruction with maneuvers that reduces LV filling volume such as Valsalva or standing, whereas the LVOT gradient will be unchanged or decreased with these maneuvers in fixed LVOT obstruction such as commonly seen in aortic stenosis. The initial medical treatment for patients with HOCM is with beta-blocker (or calcium channel blocker if not tolerating beta-blocker), plus disopyramide if refractory symptoms. If patient remained symptomatic after optimal medical therapy, septal reduction therapy either by surgical or alcohol septal ablation can be offered. A follow-up

Cardiology Answers

1. BThe clinical diagnosis is Fordyce spots.Fordyce spots are ectopic sebaceous glands. They become more prominent from puberty onwards and are present in most adults in some degree. They are common in both males and females. They may appear on the lips or genitals.A mucous cyst is due to extravasation of mucus and retention and is usually develops on the lower lips. As for oral thrush, it can be scrapped off easily with a tongue depressor.

2. FalseFordyce spots are visible sabaceous glands without hair follicles. They are not a sexually transmitted disease and they are not infectious.

3. DFordyce spots can be clinically diagnosed and skin biopsy is not necessary unless in suspicious cases such as oral lichen planus or leukoplakia. Oral thrush could easily be diagnosed with a simple scrape to reveal the inflamed base and cultures are rarely indicated. While cold sores can be diagnosed clinically, a positive HSV-1 result could only indicate a past infection but not confirming the diagnosis of active mucocutaneous lesion(s).

4. AFordyce spots are harmless and do not present any health risks. While they do not usually require medical treatment, options are available for cosmetic treatments. They include topical or oral isotretinoin, CO2 laser therapy and micro-punch surgery.

Answer: 1 E 2 A 3 B 4 B

echocardiogram after titrating up beta-blocker in the same patient showed a significant reduction of LVOT gradient (Figure 4).

Figure 4

Reference:2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients with Hypertrophic Cardiomyopathy: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2020 Dec 22; 142(25):e558-e631.

The content of the May 2021 Cardiology Series is provided by:Dr. TAN GuangMing

MBChB, MRCP, FHKCP, FHKAM (Medicine), Specialist in CardiologyDr. CHEUNG Shing Him, Gary

MBBS, MRCP, FHKCP, FHKAM (Medicine), Specialist in Cardiology五月臨床心臟科個案研究之內容承蒙譚廣明醫生及張誠謙醫生提供。

Dermatology Series for May 2021 is provided by:Dr. LEUNG Wai Yiu, Dr. TANG Yuk Ming, William,

Dr. CHAN Hau Ngai, Kingsley, Dr. KWAN Chi Keun g and Dr. NG Shun ChinSpecialists in Dermatology & Venereology

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

17HKMA CME Bulletin 持續醫學進修專訊 June 2021www.hkma.org

DermatologyDermatology Series for June 2021 is provided by:

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

Specialists in Dermatology & Venereology六月皮膚科個案研究之內容承蒙關志強醫生、鄧旭明醫生、

陳厚毅醫生、梁偉耀醫生及吳順展醫生提供。Complete Dermatology case, 0.5 CME POINT will be awarded for at least 3 correct answers in total

Q&A Please answer ALL questionsAnswer these on page 18 or make an online submission at: www.hkma.org.

1. What may be the possible diagnoses of this gentleman?a) Melanocytic Naevusb) Early Seborrhoeic Keratosisc) Solar Lentigod) Melanomae) All of the above

2. What do you advise on the gentleman?a) Do nothing as it will resolve spontaneouslyb) Regular follow-up and excisional skin biopsy if the lesion becomes elevatedc) Regular follow-up and excisional skin biopsy if the lesion becomes ulcerated or erodedd) Regular follow-up and excisional skin biopsy if groin lymph node enlargede) Excisional skin biopsy immediate

3. This lesion is due to trauma. (True or False)

4. What is (are) the treatment for this gentleman?a) Surgical excisionb) Chemotherapyc) Targeted therapyd) Radiation therapye) All of the above

5. This lesion is never happened on palm or sole. (True or False)

Pigmented Mole On Thigh

A 48-year-old gentleman complained a pigmented mole on his left thigh for many years. He noticed that the mole was getting darker within 6 months. It is not painful nor itchy. There is no bleeding. Physical examination revealed a well-defined brownish macule with a black centre on left thigh which is around 1cm in diameter. (see Figure 1)

ANSWER SHEET

Answer Sheet

June 2021

Name Signature:

HKMA Membership No.

Contact Tel No.:

HKID No. - xxx(x)

Please return thecompleted answer sheetto the HKMA Secretariat(Fax: 2865 0943) on orbefore 15 July 2021for documentation.If you completethe exercise online,you are NOT required toreturn the answer sheet by fax.

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

A maximum of 20 points can be awarded for se l f -study per year and no upper limit of CME points for attending CME lectures

(revised in August 2019)

CME Lecture Policy and ProcedureRegistration1. Please complete the reply slip and return to HKMA Secretariat in person

or by fax/mail/email.2. Enrollment priorities will be given to doctors who have purchased

packages. For Community Network Lectures, priorities will be given to doctors from that Community Network with Packages, then doctors from that Community Network.

3. No walk in or on-site payment will be accepted. Attendance without registration will not be recognized and CME point will not be accredited.

4. Please ensure that your registration is confirmed before attending lecture. Only successfully registered doctors who paid could attend the lecture.

5. The HKMA Secretariat will notify doctors who have successfully enrolled to arrange for payment. If doctors have not arranged for payment within a specified period after the notification, the seat will be released to doctors on waiting list without further notice.

Payment1. All HKMA CME lectures that involve registration and enrollment through

the HKMA would require the collection of lecture fee (unless otherwise specified).

2. The lecture fee is $50 for HKMA members and $100 for non-members per lecture.

3. Online payment is available to doctors who have registered the HKMA website online system. One transaction is for one lecture only.

4. Packages could be purchased through cash or cheque only.5. Cash payments have to be paid in person at HKMA Secretariat and

cheque payments have to be mailed or paid in person at HKMA Secretariat.

6. Fee can be paid together in one cheque for lecture within the same month. Only combined cheque payment for not more than 2 packages will be accepted.

7. No refund or transfer will be allowed after payment is made. Payment cannot be transferred to other lectures or for other specified doctors.

CME Online Payment & CME Self-Studies SeriesCME Online PaymentThe HKMA is excited to introduce online payment for CME Lectures:1. Login to CME Portal to apply for a lecture2. Receive SMS notification3. Pay online!

Online payment available ONLY for attending a single lesson, payment for package is unavailable currently.CME Self-Studies SeriesYou can register the CME Lectures and finish the CME Self-Studies Series within the webpage (www.hkma.org).Don’t wait! Please register and create your own account through https://www.thkma.org/members/register.php (1st time register account is limited on desktop ONLY) to experience our new Members Portal.Information for ParticipantsSpecial weather arrangementWhen Tropical Storm Warning Signal No. 8 (or above) or a Black Rainstorm Warning Signal is in force within 3 hours of the commencement time, the relevant CME function will be cancelled. (i.e. CME starting at 2:00 pm will be cancelled if the warning signal is hoisted or in force any time between 11:00 am and 2:00 pm).The function will proceed as scheduled if the signal is lowered three hours before the commencement time. (i.e. CME starting at 2:00 pm will proceed if the warning signal is lowered at 11:00 am, but will be cancelled even if it is lowered at 11:01 am).When Typhoon No. 8 Signal or a Black Rainstorm signal is in force after CME commencement, announcement will be made depending on the conditions as to whether the CME will be terminated earlier or be conducted until the end of the session.The above are general guidelines only. Individuals should decide on their CME attendance according to their own transportation and work/home location considerations to ensure personal safety.General lecture policy1. Doctor should sign for own CME.2. Registration will cease when Q & A Session starts.3. No recording unless permission is granted by the HKMA.4. If doctor has attended CME Lecture and CME Live at the same point of

time, only CME Points for the Lecture would be counted.5. The HKMA will investigate when non-compliance at CME Session is

reported, further action will be considered to ensure all CME activities are properly held.

6. For enquiries, please contact the CME Department of the HKMA Secretariat at 2527-8452.

SPOTlight-1Complete Spotlight, 1 CME point will be awarded for at least 5 correct answers

1 2 3 4 5 6 7 8 9 10

DermatologyCardiologyComplete Dermatology, 0.5 CME point will be awarded for at least three correct answers

Complete Cardiology, 0.5 CME point will be awarded for at least two correct answers

1 2 3 41 2 3 5

SPOTlight-2Complete Spotlight, 1 CME point will be awarded for at least 5 correct answers

1 2 3 4 5 6 7 8 9 10

Remarks: A maximum of 20 points can be awarded for self-study per year and no upper limit of CME points for attending CME lectures per year.

Please contact the HKMA Secretariat at 2527 8452 or by email cme@hkma.org for assistance.

Dear HKMA Members,

The HKMA Monthly Self-Study Video is launched in HKMA website!

This is to acknowledge you that the HKMA Monthly Self-Study Video had been launched in our website for non-specialist doctors to gain 1 CME point for each video. Interested doctors, please click www.hkma.org for more details!

(HKMA Website Homepage → Login to Members Home Page → CME → Monthly Self-Study Series)

Important Note:

1. CME point is accredited for non-specialist ONLY.

2. No extra CME point will be granted if you have already attended the same lecture through Live broadcasting.

3. Quiz submission period: 16th of each month to 15th of next month (Submission before/after the stated dates will NOT be considered)

4. Complete each quiz, 1 CME point will be awarded for at least FIVE correct answers (only 1 attempt). A confirmation email will be automatically sent to doctors once who have submitted the quiz.

5. No CME point will be granted for incorrect personal information. Data collected will be used and processed for the purposes related to this self-study only. All personal information will be used to process CME records, and if required, may transfer to other CME Administrators for cross-checking and recording purposes.

HKMA Monthly Self-Study Video

22 www.hkma.orgHKMA CME Bulletin 持續醫學進修專訊 June 2021

HKMA CME Lecture Online Scheme 2021 PolicyWith the continuous implications of COVID-19, the HKMA Council has decided to organize CME Live lectures only until September 2021. In view of the new restrictions imposed by Facebook Live, all Live Lectures will be arranged through ZOOM ONLY from now on. The registration link will be posted on https://www.thkma.org/cme_calendar.html under the CME section in our HKMA webpage (https://www.thkma.org). Doctors could check our website for registration information regularly.

• Fill in Registration Form (Google Form)

• Receive noti�cation email (1 day & 1 hour prior to each lecture)

• Click "Click Here to Join" in noti�cation email

• Download or open the ZOOM.exe to watch the Live Lecture

• Attend ZOOM Lecture

• Complete Lecture Quiz with at least 50% correct

• Earn CME point for non-specialists (and specialists of speci�ed lectures)

1

2

3

4

5

6

7

Policy for HKMA CME Lecture Online Scheme1. Doctors must install ZOOM app/launcher system to join the CME Live Lectures.2. Doctors can watch only ONE online lecture at a time regardless of the CME providers. Only 1 Lecture will be counted if doctor

watches multiple CME Live Lectures conducted at the same time.3. Doctors must watch the lecture in real-time and complete the online quiz within the designated time after the lecture. Late

submission of the quiz will not be accepted. CME point(s) will be awarded for 50% correct answers in the quiz.4. Doctors must register with the HKMA Secretariat in order to attend CME Live Lectures. Registered non-specialists doctors may

gain CME point after successful completion of the CME Live lecture and the quiz.5. You are recommended to connect to Wi-Fi on your mobile device or computer while watching the lecture through ZOOM. Unstable

internet connection may cause interruption to your viewing.6. In case of technical issue and broadcast interruption, please be patient while our technicians work on fixing the problem; the video

should resume in a few minutes.7. Due to copyright issues, ZOOM broadcast is exclusive to doctors who have registered; and all the Live streaming, video

recordings, PowerPoint/PDF slides and quiz links MUST NOT be shared with non-registrants.

FAQ:1. Where can I find the upcoming CME Live schedule?

You may refer to the HKMA CME Bulletin, CME Calendar on our webpage or the HKMA RCS.2. Where can I find the quiz for each lecture?

The link would be posted at the below time slots:1) At 2:30pm during the lecture; 2) Around 2:45pm for the 2nd time. 3) A pop-up page named “Survey” after the lecture

3. Can I join the lecture later or leave during the lecture?You may re-login to ZOOM multiple times during the lecture if there is any poor connection or sudden case, e.g. seeing a patient.

4. After I press the “Click here to join”, the screen shows the loading logo for a long period of time, what should I do?You may try to refresh the page once. If it still fails, please close all the browsers and start the CME Live again from Step 3 (by clicking the “Click Here to Join” button in the email sent 1 hour before the lecture). If the error persists, please contact the HKMA Secretariat at 2527 8452 for assistance.

5. If I have not registered, what should I do?We usually close the registration one week before the lecture. Please contact the HKMA Secretariat at 2527 8452 or email cme@hkma.org for the registration form, it usually takes a few days for the process.

6. How can I check my CME points?It takes a few working days to update members’ CME Report. Please contact the HKMA Secretariat at 2527 8452 or email cme@hkma.org for your latest CME report.

Tutorial Video:

23HKMA CME Bulletin 持續醫學進修專訊 June 2021www.hkma.org

CME Live CME notifications

Date Organizer and Topic Speaker CMEPoints

CME Accreditation

1. 7 July(Wed)

HKMA Central, Western & Southern Community Network Overview of Adult Attention Deficit Hyperactivity Disorder (ADHD) and Long-Term Management Strategy Sponsor: DCH Auriga (Hong Kong) Limited

Dr. NG Man Kin, Roger Specialist in Psychiatry

1 Yes

2. 8 July (Thu)

The Hong Kong Medical Association Leading Edge of Ultra-long acting Basal Analogue – Optimizing HbA1c with a safe and convenience therapySponsor: Novo Nordisk Hong Kong Limited

Dr. CHUNG Chi TungSpecialist in Endocrinology, Diabetes & Metabolism

1 Yes

3. 9 July (Fri)

The Hong Kong Medical Association Tailor-made BPH treatment: data update and experience sharingSponsor: Synmosa Biopharma (HK) Co., Ltd

Dr. WONG Kwok Tin, MartinSpecialist in Urology

1 Yes

4. 10 July (Sat)2-4pm

The Hong Kong Medical Association and Macau Physician Association of Public Hospital1. Herpes Zoster and the local situation2. A new paradigm in Herpes Zoster preventionSponsor: GlaxoSmithKline Limited

1. Prof. HUNG Fan Ngai, IvanClinical Professor and Assistant Dean (Admissions), Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong2. Dr. Peter WEISENSEELSenior Doctor, Dermatologikum Hamburg

2 Yes

5 12 July (Mon)

The Hong Kong Medical Association Recombinant Vaccine Technology for Seasonal Influenza PreventionSponsor: Sanofi Hong Kong Limited

Dr. Wilson LAM Specialist in Infectious Disease

1 Yes

6. 13 July (Tue)

HKMA Yau Tsim Mong Community Network Acting on Key Factors for Hypertension Management Sponsor: Servier Hong Kong Ltd

Dr. CHAN Leung Kwai, Jason Specialist in Cardiology

1 Yes

7. 15 July (Thu)

HKMA Kowloon East Community Network A New Perspective on Rotavirus Disease Prevention Sponsor: GlaxoSmithKline Limited

Dr. SHAM Chak On, Philip Specialist in Paediatrics

1 Yes

8. 16 July (Fri)

The Hong Kong Medical Association Update on the Management of OsteoarthritisSponsor: A. Menarini Hong Kong Limited

Dr. WAN Yik Cheung, SamuelSpecialist in Orthopaedics & Traumatology

1 Yes

9. 20 July (Tue)

HKMA Kowloon West Community Network Paediatric Asthma – How Well are We Treating our Patients?Sponsor: Boehringer Ingelheim (Hong Kong) Limited

Dr. NG Kwok Keung, DanielSpecialist in Paediatrics

1 Yes

10. 22 July (Thu)

HKMA New Territories West Community NetworkCOVID-19 and Update on the Management of Hypertension with Vasodilating Beta-BlockersSponsor: A. Menarini Hong Kong Limited

Dr. WONG Bun Lap, BernardSpecialist in Cardiology

1 Yes

11. 23 July (Fri)

HKMA Kowloon City Community Network Weight Loss Surgery for Diabetes Sponsor: Johnson & Johnson (Hong Kong) Ltd.

Dr. WONG Chung Tak, Dennis Specialist in General Surgery

1 Yes

12. 28 July (Wed)

The Hong Kong Medical Association Latest Insights into Antihistamine and Gut microbiome in Management of Urticaria Sponsor: A. Menarini Hong Kong Limited

Dr. LOO King Fan, Steven Specialist in Dermatology & Venereology

1 Yes

13. 29 July (Thu)

HKMA Hong Kong East Community Network Local Clinical Experience on Obesity Management Sponsor: iNova Pharmaceuticals

Dr. YUEN Mae Ann, Michele Specialist in Endocrinology, Diabetes & Metabolism

1 Yes

14. 30 July (Fri)

HKMA Shatin Community NetworkFracture Prevention in Postmenopausal Osteoporosis WomenSponsor: Amgen Hong Kong Limited

Dr. KONG Wing Ming, Henry Specialist in Community Medicine

1 Yes

Please register through https://forms.gle/czN4R5QEcT6VXoVr8 or scan the QR code if you are interested to attend. For enquiry, please contact the Secretariat at 2527 8285.

# Accreditation from various colleges pending, for specialists, please complete the quiz online within two hours after the lecture with at least 50% correct for CME/ CPD points. For lecture without “Yes”, CME Accreditation is for Non-Specialists Only. Non-Specialists doctors must complete lecture quiz (10 Q&A) and answer questions within two hours after the lecture with at least 50% correct.

The HKMA CME Live Lecture in July 2021

All lectures start at 2:00-3:00 p.m.

The HKMA CME Live Lecture in June 2021

All lectures start at 2:00-3:00 p.m.

Date Organizer and Topic Speaker CME Points

CME Accreditation from Colleges (Pending) #

1. 21 June (Mon)

The Hong Kong Medical Association Medical Nutrition for Cognitive Impairment: New Kid on Board Sponsor: Nestle Hong Kong Ltd.

Dr. CHAN Chun Chung, Ray Specialist in Internal Medicine

1 Yes

2. 23 June (Wed)

The Hong Kong Medical Association Update on the diagnosis and management of Axial Spondyloarthritis (Axial SpA) Sponsor: AbbVie Ltd.

Dr. LEE Tsz Yan Specialist in Rheumatology

1 Yes

3. 24 June (Thu)

HKMA New Territories West Community Network New Strategy to Protect Infants’ Pertussis from Caregivers Sponsor: GlaxoSmithKline Limited

Dr. Helene WAN Specialist in Paediatrics

1 Yes

4. 28 June (Mon)

The Hong Kong Medical Association Renin Angiotensin Aldosterone System Modulation in the Treatment of Hypertension Sponsor: Sanofi Hong Kong Limited

Dr. HAI Siu Han, Jo Jo Clinical Assistant Professor, Cardiology Division, Department of Medicine,Queen Mary Hospital andLKS Faculty of Medicine,the University of Hong Kong

1 Yes

5. 29 June (Tue)

The Hong Kong Medical Association The New Challenge: Optimal Hypertensive Control In The Pandemic Era Sponsor: Pfizer Corporation Hong Kong Ltd

Dr. YIP Wai Cheong Specialist in Cardiology

1 Yes

6. 30 June (Wed)

The Hong Kong Medical Association Sympathetic Overdrive and the Role of Beta Blockers Sponsor: Merck Pharmaceutical (HK) Ltd.

Dr. CHEONG Yan Yue, Adrian Piers Specialist in Cardiology

1 Yes

[Registration closed]

24 HKMA CME Bulletin 持續醫學進修專訊 June 2021 www.hkma.org

CME LiveCME notifications

Background:

2021 marks the 60th Anniversary of the Department of Orthopaedics & Traumatology of The University of Hong Kong. The Department is launching the HKU Bone & Muscle Health Series (May to July 2021). With the success of CME lectures and public talks in May and June 2021, you are cordially invited to register the CME lectures in July 2021. For registration, please scan the QR Code underneath or find more details in the webpage: https://ortho60.hku.hk/boneandmusclehealth. For enquiry, please contact the Secretariat at 2527 8452 or cme@hkma.org.

Programme:

Date & Time Topic and Speaker

14 July 2021 (Wed)2:00 – 3:00 p.m.

Technological Advances in Joint Replacement SurgeryDr. FU Chun Him, HenryHonorary Clinical Assistant Professor,Department of Orthopaedics and Traumatology, The University of Hong Kong

21 July 2021 (Wed)2:00 – 3:00 p.m.

Management of Sport Injury: What’s New in 2021?Dr. WONG Tak ManClinical Associate Professor,Department of Orthopaedics and Traumatology, The University of Hong Kong

Non-specialist CME Point : 1 for each lecture

Specialist Accreditation : Yes#

# Accreditation from various colleges pending, for specialists, please complete the quiz online within two hours after the lecture with at least 50% correct for CME/ CPD points. For lecture without “Yes”, CME Accreditation is for Non-Specialists Only. Non-Specialists doctors must complete lecture quiz (10 Q&A) and answer questions within two hours after the lecture with at least 50% correct.

27www.hkma.org HKMA CME Bulletin 持續醫學進修專訊 June 2021

Meeting Highlights

The Hong Kong Medical Association

Dr. FONG Ka Yeung presenting a CME Live lecture on 5 May 2021

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

The HKMA Kowloon City Community Network (KCCN) ~ Dr. CHIN Chu Wah and Dr. CHAN Man Chung, JP

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

The HKMA Yau Tsim Mong Community Network (YTMCN) ~ Dr. CHENG Kai Chi

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

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

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

Dr. KWONG Wing Hang presenting a CME Live lecture on 4 May 2021

Prof . WONG Chi Sang, Martin presenting a CME Live lecture on 21 May 2021

Dr. Ray NG presenting a CME Live lecture on 28 May 2021

Dr. Nelson LAI presenting a CME Live lecture on 11 May 2021

Dr. T AM Chun Hay presenting a CME Live lecture on 14 May 2021

Dr. Angus LO presenting a CME Live lecture on 6 May 2021

Dr. CHONG King Yee presenting a CME Live lecture on 13 May 2021

Dr. Micah CHAN presenting a CME Live lecture on 18 May 2021

Dr. Nelson HUI presenting a CME Live lecture on 27 May 2021

Dr. Jack y CHAN presenting a CME Live lecture on 12 May 2021

CME Calendar

28 HKMA CME Bulletin 持續醫學進修專訊 May 2021 www.hkma.org

June 2021

21 June (Mon)2:00 – 3:00 p.m.

The Hong Kong Medical AssociationMedical Nutrition for Cognitive Impairment: New Kid on BoardHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452.

1

23 June (Wed)2:00 – 3:00 p.m.

The Hong Kong Medical AssociationUpdate on the diagnosis and management of Axial Spondyloarthritis (Axial SpA)HKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

24 June (Thu)2:00 – 3:00 p.m.

HKMA New Territories West Community NetworkNew Strategy to Protect Infants’ Pertussis from CaregiversHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

25 June(Wed)2:00 – 3:00 p.m.

HKU Bone & Muscle Health SeriesCommon Orthopaedic Myths and Misunderstandings (Public Talk)ZOOM / YouTubeHKMA CME Dept. – Tel: 2527 8452

28 June (Mon)2:00 – 3:00 p.m.

The Hong Kong Medical AssociationRenin Angiotensin Aldosterone System Modulation in the Treatment of HypertensionHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

29 June (Tue)2:00 – 3:00 p.m.

The Hong Kong Medical AssociationThe New Challenge: Optimal Hypertensive Control In The Pandemic EraHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

30 June (Wed)2:00 – 3:00 p.m.

The Hong Kong Medical AssociationSympathetic Overdrive and the Role of Beta BlockersHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

July 2021

5 July(Mon)2:00 – 3:00 p.m.

The Hong Kong Medical Association and the Gleneagles Hong Kong HospitalManagement On Musculoskeletal TumorHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

6 July(Tue)2:00 – 3:00 p.m.

The Hong Kong Medical Association and the Hong Kong Sanatorium & HospitalSurgical Management Of LymphoedemaHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

7 July (Wed)2:00 – 3:00 p.m.

HKMA Central, Western & Southern Community NetworkOverview of Adult Attention Deficit Hyperactivity Disorder (ADHD) and Long-Term Management StrategyHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

8 July (Thu)2:00 – 3:00 p.m.

The Hong Kong Medical AssociationLeading Edge of Ultra-long acting Basal Analogue – Optimizing HbA1c with a safe and convenience therapyHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

9 July (Fri)2:00 – 3:00 p.m.

The Hong Kong Medical AssociationTailor-made BPH treatment: data update and experience sharingHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

10 July (Sat)2:00 - 4:00 p.m.

The Hong Kong Medical Association andMacau Physician Association of Public Hospital1. Herpes Zoster and the local situation2. A new paradigm in Herpes Zoster preventionHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

2

12 July (Mon)2:00 – 3:00 p.m.

The Hong Kong Medical AssociationRecombinant Vaccine Technology for Seasonal Influenza PreventionHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

13 July (Tue)2:00 – 3:00 p.m.

HKMA Yau Tsim Mong Community NetworkActing on Key Factors for Hypertension ManagementHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

14 July(Wed)2:00 – 3:00 p.m.

HKU Bone & Muscle Health SeriesTechnological Advances in Joint Replacement SurgeryHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

15 July (Thu)2:00 – 3:00 p.m.

HKMA Kowloon East Community NetworkA New Perspective on Rotavirus Disease PreventionHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

16 July (Fri)2:00 – 3:00 p.m.

The Hong Kong Medical AssociationUpdate on the Management of OsteoarthritisHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

20 July (Tue)2:00 – 3:00 p.m.

HKMA Kowloon West Community NetworkPaediatric Asthma – How Well are We Treating our Patients?HKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

21 July(Wed)2:00 – 3:00 p.m.

HKU Bone & Muscle Health SeriesManagement of Sport Injury: What’s New in 2021?HKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

22 July (Thu)2:00 – 3:00 p.m.

HKMA New Territories West Community NetworkCOVID-19 and Update on the Management of Hypertension with Vasodilating Beta-BlockersHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

23 July (Fri)2:00 – 3:00 p.m.

HKMA Kowloon City Community NetworkWeight Loss Surgery for DiabetesHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

27 July(Tue)2:00 – 3:00 p.m.

The Hong Kong Medical Association and the Gleneagles Hong Kong HospitalWhen Medication Don’t Work In Rhinitis PatientsHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

28 July (Wed)2:00 – 3:00 p.m.

The Hong Kong Medical AssociationLatest Insights into Antihistamine and Gut Microbiome in Management of UrticariaHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

29 July (Thu)2:00 – 3:00 p.m.

HKMA Hong Kong East Community NetworkLocal Clinical Experience on Obesity ManagementHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

30 July (Fri)2:00 – 3:00 p.m.

HKMA Shatin Community NetworkFracture Prevention in Postmenopausal Osteoporosis WomenHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

29www.hkma.org HKMA CME Bulletin 持續醫學進修專訊 March 2021

香港醫生網The Hong Kong Doctors Homepage

www.hkdoctors.org

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

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

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

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

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

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

Receiving Electronic Copy Of CME Bulletin

The CME Bulletin has been mailed to members on the 15th of each month since year 2000. As an initiative to protect the environment and smart costing, HKMA encourages members to receive these documents via email or read them online at the HKMA website (http://www.hkma.org/), rather than receiving hard copies by post.

If you would like to receive the CME Bulletin by email, or to complete the self-assessment questions on the HKMA website, please indicate your preference by filling in the reply slip below.

REPLY SLIPI would like to receive the HKMA CME Bulletin (chose either one below)

By email (Please provide your valid email address):

By downloading from the HKMA website (http://www.hkma.org/)

Name: HKMA Membership No:

Signature: Date:

Please return the completed form to us by fax (2865 0943) or email (cme@hkma.org).

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