Management of chronic kidney disease: a Hong Kong consensus recommendation.

Chronic kidney disease (CKD) imposes a significant burden on healthcare systems worldwide, and diabetes is a major risk factor for CKD. There is currently no consensus in Hong Kong regarding the prioritisation of early identification and intervention for CKD. A comprehensive and Hong Kong-specific diabetes and CKD treatment guideline is also lacking. A multidisciplinary group of experts discussed issues surrounding the current management of CKD and reviewed evidence in the context of local experience to support recommendations. The experts used a modified Delphi approach to finalise recommendations. Consensus was regarded as ≥75% acceptability among all expert panel members. The panel members finalised 14 CKD-focused consensus statements addressing disease definition, screening, disease monitoring, lifestyle management, and treatment strategies. The recommendations provided are relevant to the Hong Kong healthcare setting and can be used as a guide by physicians across various specialties to facilitate the appropriate management of CKD.

Fat necrosis in the breast: a multimodality imaging review of its natural course with different aetiologies.

Fat necrosis of the breast is a commonly encountered condition in daily practice. It is a benign pathology, but it can have variable manifestations and patterns that may sometimes mimic malignancy, depending on its stage of evolution and its underlying cause. This review demonstrates the wide spectrum of appearances of fat necrosis on mammography, digital breast tomosynthesis (DBT), ultrasound, magnetic resonance imaging (MRI), computed tomography (CT), and positron-emission tomography (PET). Sequential follow-up images are included in some cases to illustrate the temporal change of the findings. The typical location and distribution of fat necrosis from a comprehensive list of aetiologies are discussed. Improved knowledge of the multimodality imaging features of fat necrosis could enhance diagnostic accuracy and clinical management, thus avoiding unnecessary invasive investigations.

Effect of a structured diabetes education programme in primary care on hospitalizations and emergency department visits among people with Type 2 diabetes mellitus: results from the Patient Empowerment Programme.

AIM: To assess whether a structured diabetes education programme, the Patient Empowerment Programme, was associated with a lower rate of all-cause hospitalization and emergency department visits in a population-based cohort of patients with Type 2 diabetes mellitus in primary care. METHODS: A cohort of 24 250 patients was evaluated using a linked administrative database during 2009-2013. We selected 12 125 patients with Type 2 diabetes who had at least one Patient Empowerment Programme session attendance. Patients who did not participate in the Patient Empowerment Programme were matched one-to-one with patients who did, using the propensity score method. Hospitalization events and emergency department visits were the events of interest. Cox proportional hazard and negative binomial regressions were performed to estimate the hazard ratios for the initial event, and incidence rate ratios for the number of events. RESULTS: During a median 30.5 months of follow-up, participants in the Patient Empowerment Programme had a lower incidence of an initial hospitalization event (22.1 vs 25.2%; hazard ratio 0.879; P < 0.001) and emergency department visit (40.5 vs 44%; hazard ratio 0.901; P < 0.001) than those who did not participate in the Patient Empowerment Programme. Participation in the Patient Empowerment Programme was associated with a significantly lower number of emergency department visits (incidence rate ratio 0.903; P < 0.001): 40.4 visits per 100 patients annually in those who did not participate in the Patient Empowerment Programme vs. 36.2 per 100 patients annually in those who did. There were significantly fewer hospitalization episodes (incidence rate ratio 0.854; P < 0.001): 20.0 hospitalizations per 100 patients annually in those who did not participate in the Patient Empowerment Programme vs. 16.9 hospitalizations per 100 patients annually in those who did. CONCLUSIONS: Among patients with Type 2 diabetes, the Patient Empowerment Programme was shown to be effective in delaying the initial hospitalization event and in reducing their frequency.

Patient Empowerment Programme in primary care reduced all-cause mortality and cardiovascular diseases in patients with type 2 diabetes mellitus: a population-based propensity-matched cohort study.

AIMS: To assess whether a structured diabetes education programme, the Patient Empowerment Programme (PEP), was associated with a lower risk of first cardiovascular disease (CVD) event and all-cause mortality in a population-based cohort of patients with type 2 diabetes mellitus (T2DM) in primary care. METHODS: A Chinese cohort of 27 278 patients with T2DM and without previous CVD events on or before the baseline study recruitment date was linked to the Hong Kong administrative database from 2008 to 2013. The PEP was provided to patients with T2DM treated at primary care outpatient clinics through community trained professional educators. PEP non-participants were matched one-to-one with the PEP participants using a propensity score method with respect to their baseline covariates. Cox proportional hazard regression was performed to estimate the associations of the PEP with the occurrence of first CVD event, coronary heart disease, stroke, heart failure and death from any cause, controlling for baseline characteristics. RESULTS: During a median of 21.5 months follow-up, 795 (352 PEP participants and 443 PEP non-participants) patients experienced a first CVD event. After adjusting for confounding variables, PEP participants had a lower rate of all-cause mortality [hazard ratio (HR) 0.564, 95% confidence interval (CI) 0.445-0.715; p < 0.001], first CVD (HR 0.807, 95% CI 0.696-0.935; p = 0.004) and stroke (HR 0.702; 95% CI 0.569-0.867; p = 0.001) than those without PEP. CONCLUSIONS: Enrolment in the PEP was associated with lower all-cause mortality and a lower number of first CVD events among patients with T2DM. The CVD benefit of PEP might be attributable to improving metabolic control through empowerment of self-care and the enhancement of quality of diabetes care in primary care.

Is there a role for primary care clinicians in providing shared care in HIV treatment? A systematic literature review.

BACKGROUND: Despite HIV being increasingly considered as a chronic illness, there is as yet no consensus about how primary care should be integrated with specialty care to provide optimal clinical management for people living with HIV. OBJECTIVE: To examine the effectiveness of shared care models of HIV between primary care and specialty care and how primary care providers can assist in improving the care of people with HIV. METHODS: Three databases, PubMed, Medline and EMBase, were searched for relevant terms from studies published in the period from 1996 to 2011. Studies that integrated primary care in HIV management and included highly active antiretroviral therapy (HAART) as part of the treatment modality were included. RESULTS: Eleven studies that met the inclusion criteria were included in this review. Primary care was found to be at least as effective in HIV counselling, testing and treatment and, to a lesser degree, prevention, when compared with specialty care alone. Screening for HIV at a primary care level was cost-effective, especially in a high HIV prevalence and high-risk community. There were no significant adverse clinical outcomes reported in a primary care approach. Effectiveness of various interventions using a primary care approach was demonstrated in the review, including HAART adherence programmes, home care, the involvement of peer health workers and perinatal use of HAART. CONCLUSIONS: Primary care has an important role in the shared care of the diagnosis and management of people with HIV. Some improvements with current guidelines on the management in primary care of people with HIV in developing countries should be considered.

Validation of the Chinese Version of Obsessive-Compulsive Inventory-Revised.

BACKGROUND: The Obsessive-Compulsive Inventory-Revised (OCI-R) is a psychometrically sound and valid self-report measure for evaluating the severity of six dimensions of obsessive-compulsive symptoms: washing, obsessing, hoarding, ordering, checking, and neutralising. We aimed to validate the Chinese version of the OCI-R (C-OCI-R) in patients with obsessive-compulsive disorder (OCD) in Hong Kong. METHODS: The C-OCI-R was forward and backward translated and reviewed by an expert panel and a focus group. The internal consistency and test-retest reliability (2-week interval) were examined. Confirmatory factor analysis was used to examine the construct validity of the C-OCI-R. Concurrent validity was examined by the correlation between the C-OCI-R and the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), whereas divergent validity was examined by the correlation of the C-OCI-R with the Beck Depression Inventory-Second Edition and the Hamilton Depression Rating Scale. RESULTS: 130 OCD patients were recruited. The C-OCI-R showed excellent internal consistency (Cronbach's alpha = 0.92) and test-retest reliability (Spearman's rho correlation coefficient = 0.96). The original six-factor model was supported by confirmatory factor analysis. Concurrent validity and divergent validity were established. However, the neutralising subscale may need further development, and the divergent validity of the obsessing subscale was unsatisfactory. The structure of OCD symptoms was similar in Chinese and western patients. CONCLUSION: The C-OCI-R is a valid and reliable measure for assessing the severity of obsessive-compulsive symptoms in local Chinese patients with OCD.

Silent killer of the night: a feasibility study of an outreach well-women clinic for cervical cancer screening in female sex workers in Hong Kong.

The purpose of this study was to see if an outreach model could be a feasible option for early detections of preinvasive cervical cancer in women with double identities of female sex workers (FSW) and illegal migrant workers in Hong Kong who most needed cervical screening but were often deprived of such a service. High turnover rates, acceptability, and compliance for follow-ups could potentially render such a clinical model unsuccessful. A total of 245 FSW were screened at the outreach clinic from January 2004 to December 2005, which was set up in a nongovernmental organization in a red light district. A questionnaire regarding their lifestyles and demographic details was used before a gynecological history, Papanicolaou (PAP) smear, and other health checkup were conducted. Chi-square test and multinomial logistic regression were used to analyze the results. Of 235 women tests, 9.8% of them had CIN I-III, and places of origin were found to be important risk factors for abnormal PAP smears. The nonlocal workers were significantly more likely to have abnormal PAP smears (chi(2)= 10.55, P= 0.04). Among the women, 88.1% of them who had the tests returned for follow-up with poorer compliance among those with an abnormal result. We conclude that an outreach well-women clinic seems to be an acceptable option for these women and an effective way for the early detection of cervical cancer.

Practice of breastfeeding and factors that affect breastfeeding in Hong Kong.

OBJECTIVES: To describe the patterns of and factors affecting breastfeeding and to find out any significant relationship between breastfeeding and health of the child. DESIGN: Cohort study. SETTING: Postnatal ward of the Prince of Wales Hospital. PARTICIPANTS: A total of 243 infants born in 1998 to 2001 at the hospital. Each infant was followed up for 3 years. Home visits were carried out at 3, 15, 24, and 36 months of age by medical students from the Chinese University of Hong Kong. A questionnaire was completed at each visit. Independent sample t-tests and Pearson Chi squared tests were used. RESULTS: Of the 243 subjects, 213 provided data on the method of infant feeding. There were 66.7% of mothers initiating breastfeeding, with a median duration of 1 month. Only 13.4% met the World Health Organization's recommendations on breastfeeding. Breastfeeding was found to have a statistically significant relationship with (i) the infant's birth order and (ii) the mother's and father's education level. During follow-up, 44.6% of the infants were hospitalised but there was no significant relationship between breastfeeding and number of hospitalisations. CONCLUSIONS: The current breastfeeding rate in Hong Kong falls below expectations when compared with other developed nations. To raise this rate, more support is needed for families with parents having a lower education level or more than two children, as they are the least likely to breastfeed. This might be achieved by encouraging antenatal class attendance, counselling of husbands, and more support for breastfeeding from doctors.

Primary care of patients with sexually transmitted diseases or genitourinary symptoms in Hong Kong.

OBJECTIVES: To determine the adequacy of care received from general practitioners by patients with sexually transmitted diseases or genitourinary symptoms. DESIGN: Prospective study. SETTING: Hong Kong. PARTICIPANTS: Diagnoses and drug data obtained from logbooks submitted by doctors studying for the Diploma in Family Medicine and candidates for Fellowship examinations between 1999 and 2002. MAIN OUTCOME MEASURES: Diagnosis or symptom of a sexually transmitted disease and prescribed treatment. RESULTS: Sexually transmitted diseases and genitourinary symptoms accounted for 1.1% of the workload of these community doctors in Hong Kong. The majority of patients were young adult males. The overall standard of treatment was inadequate: both multi-pharmacy and inappropriate treatment was common; in up to 30% of cases, doctors ignored local or international guidelines. CONCLUSION: Primary care doctors play an important role in the diagnosis and management of sexually transmitted diseases or genitourinary symptoms in Hong Kong. A high index of suspicion should be maintained and continuing education made available if doctors are to provide an equally high standard of care.

How did general practitioners protect themselves, their family, and staff during the SARS epidemic in Hong Kong?

CONTEXT: Severe acute respiratory syndrome (SARS) is a newly emerging infectious disease and how the frontline community doctors respond to it is not known. OBJECTIVES: To explore the impact of SARS on general practitioners (GPs) in Hong Kong. DESIGN: A cross sectional survey. SETTING: Community based primary care clinics. PARTICIPANTS: 183 family medicine tutors affiliated with a local university. Postal survey sent to all tutors with a 74.8% response rate. MAIN OUTCOME MEASURES: Change of clinical behaviour and practices during the epidemic; anxiety level of primary care doctors. RESULTS: All agreed SARS had changed their clinical practices. Significant anxiety was found in family doctors. Three quarters of respondents recalled requesting more investigations while a quarter believed they had over-prescribed antibiotics. GPs who were exposed to SARS or who had worked in high infection districts were less likely to quarantine themselves (10.8% versus 33.3%; p<0.01; 6.5% versus 27.5%; p<0.01 respectively). Exposure to SARS, the infection rates in their working district, and anxiety levels had significant impact on the level of protection or prescribing behaviour. CONCLUSION: The clinical practice of GPs changed significantly as a result of SARS. Yet, those did not quarantine themselves suggesting other factors may have some part to play. As failure to apply isolation precautions to suspected cases of SARS was one major reason for its spread, a contingency plan from the government to support family doctors is of utmost importance. Interface between private and public sectors are needed in Hong Kong to prepare for any future epidemics.

Cost-effectiveness analysis of influenza and pneumococcal vaccination for Hong Kong elderly in long-term care facilities.

BACKGROUND: To compare cost and quality-adjusted life-years (QALYs) gained by influenza vaccination with or without pneumococcal vaccination in the elderly living in long-term care facilities (LTCFs). METHODS: Cost-effectiveness analysis based on Markov modelling over 5 years, from a Hong Kong public health provider's perspective, on a hypothetical cohort of LTCF residents aged > or = 65 years. Benefit-cost ratio (BCR) and net present value (NPV) of two vaccination strategies versus no vaccination were estimated. The cost and QALYs gained by two vaccination strategies were compared by Student's t-test in probabilistic sensitivity analysis (10,000 Monte Carlo simulations). RESULTS: Both vaccination strategies had high BCRs and NPVs (6.39 and US$334 for influenza vaccination; 5.10 and US$332 for influenza plus pneumococcal vaccination). In base case analysis, the two vaccination strategies were expected to cost less and gain higher QALYs than no vaccination. In probabilistic sensitivity analysis, the cost of combined vaccination and influenza vaccination was significantly lower (p<0.001) than the cost of no vaccination. Both vaccination strategies gained significantly higher (p<0.001) QALYs than no vaccination. The QALYs gained by combined vaccination were significantly higher (p = 0.030) than those gained by influenza vaccination alone. The total cost of combined vaccination was significantly lower (p = 0.011) than that of influenza vaccination. CONCLUSION: Influenza vaccination with or without pneumococcal vaccination appears to be less costly with higher QALYs gained than no vaccination, over a 5-year period, for elderly people living in LTCFs from the perspective of a Hong Kong public health organisation. Combined vaccination was more likely to gain higher QALYs with lower total cost than influenza vaccination alone.

To determine factors in an initiation of a same-sex relationship in rural China: using ethnographic decision model.

The sexual behaviour and HIV risks among Chinese MSM in rural areas are grossly under-researched. The aims of this study were to explore the process and formation as well as the factors in an initiation of sexual relationship or act in among MSM in this cultural setting. Twenty-four in-depth interviews and observation were conducted in Dali prefecture in two field visits in 2004 and the data were analysed using grounded theory and an ethnographic decision model. We found their sexual relationship can be understood as a negotiation process with self, family and society, some of which (e.g. emotional and physical needs; rationalization in choosing partners) are common in all MSM groups while others (e.g. sex hierarchy or role of family) are geographically and culturally more unique or prominent for rural China. By better understanding of these decision processes, more effective and target-orientated intervention programmes can be implemented fighting against HIV/AIDS in this sexually marginalized sub-group of the population.

The all-powerful and 'happy' drug: the use of steroids among primary care doctors in Hong Kong.

BACKGROUND: Steroids are commonly used, but their prescribing pattern and factors associated with their use in the primary care setting are largely unknown. METHODS: Using diagnosis and drug data obtained from logbooks submitted by participants in the Diploma in Family Medicine course between 1999 and 2004, we selected and analysed all patients with a prescription of steroid as well as conditions in which it was prescribed. Factors, relating to patients or doctors, which could be associated with steroid prescription were recorded for both the prescribed and the non-prescribed groups. The results were compared using chi-square tests. RESULTS: Steroids were prescribed in 7.1% of all patient encounters, of which dermatological and respiratory diseases were the most two common conditions. Upper respiratory tract infections accounted for a third of all respiratory diseases in which steroid was prescribed. Female or 'minor' patients (OR 1.16, 95% CI 1.01-1.32 and 1.16, 1.00-1.36 respectively) were more likely to be given a steroid and younger doctors (1.52, 1.25-1.86) were more likely to prescribe them. CONCLUSION: Some patterns of poor prescribing practice were demonstrated in this study. Campaigns by professional bodies may improve prescribing among our community doctors and effective public education programmes are needed to modify the health beliefs and expectations of the general public.