Letters to the Editor

LETTERS TO THE EDITOR

Branded versus generic drug use in chronic disease management in Hong Kong

KH Poon, FHKAM (Paediatrics)

Kinder Healthcare, Hong Kong

Corresponding author: Dr KH Poon (poonkinhung@hotmail.com)

To the Editor—The study by Lee et al1 increases our understanding of people’s knowledge and acceptance of generic drugs. Several points warrant further discussion.

Public doctors, unlike those in the private sector, generally have little knowledge of the drug source. A choice of brands is rare. For example, the Clinical Management System of the Hospital Authority commonly uses the original brand name as an alias for a drug because these are better remembered. The final drug dispensed will depend on stock availability. On-screen support at the prescribing page may better inform doctors. Since the patient pays only according to the duration of use, it is not justifiable to routinely ask the patient’s consent when selecting a generic versus a branded medicine.

Relatively poor public knowledge about generic drugs might not be due to lower local literacy as Lee et al suggest.1 The adult literacy (primary education and above) rate in Hong Kong is quite good: 96% in 2015 and 2016.2 This is similar to that in the current study (96.4%).1 Japan implemented a generic drug policy in 2002. Patients pay less and their doctors and pharmacists are given financial incentives to use generic drugs. Hence, unsurprisingly, Japanese are more knowledgeable about generic drugs. A choice of branded and generic drugs has been explicit on the prescription since 2006.3 4 In contrast, Hong Kong has no policy or public information. On the consumer webpages of the Drug Office of the Department of Health, under “General Knowledge on the Use of Medicines”, generic drugs are not mentioned.5 The public would benefit from official views.

Health literacy on drugs can be improved by official healthcare programmes and by encouraging the public to read medical news, drug labels and to search official websites. Nevertheless individual counselling by healthcare professionals is essential. There are barriers for both healthcare professionals and patients but they should nonetheless become familiar with both the trade and generic names of prescribed drugs. A patient’s proficiency in English may be an advantage because most doctors know the English names of drugs but are not routinely taught the Chinese names. The Cantonese or Putonghua pronunciations are particularly challenging. The two local medical schools play a pivotal role in preparing new doctors in this regard.

Author contributions

The author had full access to the data, contributed to the study, approved the final version for publication, and takes responsibility for its accuracy and integrity.

Conflicts of interest

The author has disclosed no conflicts of interest.

References

1. Lee VW, Cheng FW, Fong FY, et al. Branded versus generic drug use in chronic disease management in Hong Kong—perspectives of health care professionals and the general public. Hong Kong Med J 2018;24:554-60. Crossref

2. HK Council of Social Service. Adult literacy rate. Social Indicators of Hong Kong 2016. Available from: https://www.socialindicators.org.hk/en/indicators/education/7.7. Accessed 16 Jan 2019.

3. Hassali MA, Alrasheedy AA, McLachlan A, et al. The experiences of implementing generic medicine policy in eight countries: a review and recommendations for a successful promotion of generic medicine use. Saudi Pharm J 2014;22:491-503. Crossref

4. Kuribayashi R, Matsuhama M, Mikami K. Regulation of generic drugs in Japan: the current situation and future prospects. AAPS 2015;17:1312-6. Crossref

5. Drug Office, Department of Health. General Knowledge on the Use of Medicines. June 2017. Available from: https://www.drugoffice.gov.hk/eps/do/en/consumer/news_informations/knowledge_on_medicines/general_use_on_ medicine.html . Accessed 7 Jan 2019.

Authors' reply

Vivian WY Lee, PharmD; Franco WT Cheng, BPharm, MCP; Felix YH Fong, BPharm; Enoch EN Ng, BA; Laadan LH Lo, BA; Livia YS Ngai, BPharm; Amy SM Lam, BPharm

School of Pharmacy, The Chinese University of Hong Kong, Shatin, Hong Kong

Corresponding author: Prof Vivian WY Lee (vivianlee@cuhk.edu.hk)

To the Editor—In our recently published study, we evaluated the understanding of generic substitution among healthcare professionals (HCPs) and members of the general public in Hong Kong. Our findings showed that the knowledge and perception of generic substitution among the general public and HCPs remain low. We thank Dr Poon for his comments and respond to each point raised.

Public versus private health care system

We agree and acknowledge the point raised by Dr Poon about the awareness of HCPs in the Hospital Authority (HA) compared with private physicians who run their own clinic about drug source. Kumar et al1 have shown that most physicians at private hospitals in Malaysia have a negative perception of generic drugs with consequent limited use in the private sector. Public physicians have limited knowledge about or influence on the final drug dispensed. The drug formulary in each HA hospital is developed and overseen by various internal committees including the drug management committee (DMC), drug advisory committee (DAC), and drug formulary committee (DFC).2 The role of the DMC is to oversee the overall drug management of the HA whereas that of the DAC is to review new drugs and new indications for the HA drug formulary. Finally, the DFC reviews the existing drug lists to remove obsolete drugs and evaluate the indications for special drugs when necessary.2 The members of these three committees may include the chairman of the cluster service and the chief pharmacist of the HA, the Chief Nursing Manager, and two academics in healthcare-related disciplines from local universities.1 They are responsible for the centralised decision process for the drug formulary. We agree that we should better inform our HCPs about the choice of drugs available in the HA. In addition, we advise patients whether the drugs they are taking are a generic or branded product by appropriate labelling. Patients should be reminded to record any potential adverse drug reactions (ADRs)/side-effects or alert their physician if they feel unwell if any of their medications are switched.

Understandably, routinely obtaining patient consent could be challenging in the public sector, given the current workload of the HA and the funding of the healthcare system. Nonetheless with advances in technology and a higher level of education and awareness of the general public, it is not surprising that patients are increasingly aware of their health conditions and may be confused by generic substitution. To avoid any potential conflict among patients and HCPs, public and professional education to enable an understanding of drug quality as well as bioavailability and bioequivalence should not be delayed.

Education of the general public and professionals

Undeniably, the adult literacy rate in Hong Kong has been improving but this may not apply to the existing elderly population. More than one-fifth of the current elderly did not attend primary school according to a report published in 2016.3 It may therefore be difficult for them to fully understand the concept of generic substitution and the need to alert HCPs about any potential ADRs. Our findings are in line with other published studies. In Malaysia, less than one-third of Malaysian consumers were aware of generic medicines.4 In India, over 60% of patients did not know the difference between branded and generic drugs.5

It was clearly emphasised by Dr Poon the need to train future doctors and other HCPs in health literacy on drugs as well as their trade and generic names. In the local pharmacy curriculum, we generally use generic names. We usually include the trade names in the supplementary information. Similar to Hong Kong, Australian pharmacology students may lack an in-depth understanding of generic medicines and need further teaching about the quality and safety of generic medicines versus branded products.6 In Ireland, general practitioners showed a lack of knowledge and problems with perception of generic medicines.7

Conclusions

The knowledge and perception of generic medicines remains low in many countries including Hong Kong. Prescribing behaviour with regard to generic drugs may vary between different sectors (public vs private) of the healthcare system. Education of both the general public and HCPs as well as HCP trainees is crucial to enable a better understanding of generic versus branded drug use.

Author contributions

Concept and design: VWY Lee.
Acquisition and analysis of data: FYH Fong, EEN Ng, LLH Lo, LYS Ngai, ASM Lam.
Interpretation of data and drafting the manuscript: FWT Cheng.
Critical revision for important intellectual content: VWY Lee.

All authors had full access to the data, contributed to the study, approved the final version for publication and take responsibility for its accuracy and integrity.

Conflicts of interest

All authors have disclosed no conflicts of interest.

References

1. Kumar R, Hassali MA, Saleem F, et al. Knowledge and perceptions of physicians from private medical centres towards generic medicines: a nationwide survey from Malaysia. J Pharm Policy Pract 2015;8:11. Crossref

2. Hospital Authority Drug Formulary Management. Available from: http://www.ha.org.hk/hadf/en-us/Drug-Formulary-Management. Accessed 31 Jan 2019.

3. Census and Statistics Department, Hong Kong SAR Government. Thematic Report: Older Persons (2016). Available from: https://www.bycensus2016.gov.hk/data/16BC_Older_persons_report.pdf. Accessed 31 Jan 2019.

4. Al-Gedadi NA, Hassali MA, Shafie AA. A pilot survey on perceptions and knowledge of generic medicines among consumers in Penang, Malaysia. Pharm Pract (Malaysia) 2008;6:93-7. Crossref

5. Choulera MY, Amruta VD, Borkar AS, Date AP. Knowledge and perception about generic drugs in patients coming to outpatient department of tertiary care centre. Int J Basic Clin Pharmacol 2018;7:1024-7. Crossref

6. Hassali MA, Kong DC, Steward K. Knowledge and perceptions of recent pharmacy graduates about generic medicines. Pharm Educ 2007;7:89-95. Crossref

7. Dunne SS, Shannon B, Cullen W, Dunne CP. Beliefs, perceptions and behaviours of GPs towards generic medicines. Fam Pract 2014;31:467-74. Crossref

Detecting cognitive impairment in hospitalised patients with acute heart failure: using a sensitive tool does matter

Hong Kong Med J 2019 Feb;25(1):81–2

https://doi.org/10.12809/hkmj187772

LETTER TO THE EDITOR

Detecting cognitive impairment in hospitalised patients with acute heart failure: using a sensitive tool does matter

Mohammad Ali Heidari Gorji, PhD

Diabetes Research Centre, Department of Medical-Surgical Nursing, Nasibeh Faculty of Nursing and Midwifery, Mazandaran University of Medical Sciences, Imam Hospital, Sari, Iran

Corresponding author: Dr Mohammad Ali Heidari Gorji (drheidarigorji@yahoo.com)

Full paper in PDF

To the Editor—Delirium is an acute deterioration of cognitive function, which frequently occurs in hospitalised elderly patients with chronic and critical diseases.1 It is associated with prolonged hospital stay and increased morbidity and mortality. Heart failure (HF) is also a major health problem in the elderly population and is one of the main reasons for hospital admission worldwide. Much evidence shows that, compared with other chronic diseases, cognitive impairment is more common in patients with HF. Delirium is a common cause of cognitive impairment in these patients, and has prognostic value for HF outcomes and deterioration of cognitive function.2 Previous research has found a positive relationship between delirium and increased risk of readmission as well as prolonged hospital stay among elderly patients with HF.3 Therefore, developing a specific screening tool for early identification of hospitalised patients at risk for cognitive impairment, and prompt management of delirium, may improve HF outcomes and quality of care.

Screening for cognitive impairment is recommended as a routine clinical assessment for patients with HF worldwide.4 However, no consensus has been achieved on the optimal screening tool for detecting cognitive impairment in hospitalised patients with HF. Currently, a number of screening tools are available for detecting delirium in the general population of older adults,5 such as the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment, and Mini-Cog. However, a more specific tool is needed for elderly patients with HF. The cognitive status of elderly patients with HF is affected by low cerebral perfusion status, which is a common condition in the pathophysiology of HF. The MMSE was originally designed for dementia screening, but most elderly patients with HF have mild cognitive impairment. In this regard, previous research showed that the MMSE is a suitable screening tool for detecting moderate to severe cognitive impairment; however, its sensitivity in detecting mild cognitive impairment is questionable.6 In addition, Montreal Cognitive Assessment can detect an unrecognised cognitive impairment in a group of stable community-dwelling patients with HF6; however, it has low specificity in ruling out mild cognitive impairment, owing to cut-offs that are inappropriate for elderly patients with HF. The applicability of the Montreal Cognitive Assessment in clinical settings, particularly in acute situations, needs to be confirmed in further research.7

Certainly, recognising cognitive impairments in elderly patients with HF is an important and challenging issue. However, developing a tailored screening tool can be a solution to improve patients’ outcome. In this regard, future studies are warranted for both new instrument development and adaptation of current available tools in the context of HF.

Author contributions

The author contributed to the concept or design, acquisition of data, analysis or interpretation of data, drafting of the manuscript, and critical revision for important intellectual content. The author had full access to the data, contributed to the study, approved the final version for publication, and takes responsibility for its accuracy and integrity.

Conflicts of interest

The author has no conflicts of interest to disclose.

References

1. Lee AT, Chan WC, Chiu HF, et al. Physical health and lifestyle predictors for significant cognitive impairment in community-dwelling Chinese older adults in Hong Kong. Hong Kong Med J 2016;22 Suppl 6:37-9.

2. Uthamalingam S, Gurm GS, Daley M, Flynn J, Capodilupo R. Usefulness of acute delirium as a predictor of adverse outcomes in patients >65 years of age with acute decompensated heart failure. Am J Cardio 2011;108:402-8. Crossref

3. Ayatollahi Y, Liu X, Namazi A, et al. Early readmission risk identification for hospitalized older adults with decompensated heart failure. Res Gerontol Nurs 2018;11:190-7. Crossref

4. Cameron J, Worrall-Carter L, Page K, Riegel B, Lo SK, Stewart S. Does cognitive impairment predict poor self-care in patients with heart failure? Eur J Heart Fail 2010;12:508-15. Crossref

5. Sakaguchi T, Watanabe M, Kawasaki C, et al. A novel scoring system to predict delirium and its relationship with the clinical course in patients with acute decompensated heart failure. J Cardiol 2018;71:564-9. Crossref

6. Harkness K, Demers C, Heckman GA, McKelvie RS. Screening for cognitive deficits using the Montreal cognitive assessment tool in outpatients ≥65 years of age with heart failure. Am J Cardiol 2011;107:1203-7. Crossref

7. McLennan SN, Mathias JL, Brennan LC, Stewart S. Validity of the montreal cognitive assessment (MoCA) as a screening test for mild cognitive impairment (MCI) in a cardiovascular population. J Geriatr Psychiatry Neurol 2011;24:33-8. Crossref

Empowering elderly patients to overcome "self-imposed immobility" due to fear of falling

Hong Kong Med J 2018 Dec;24(6):642–3

DOI: 10.12809/hkmj187722

LETTER TO THE EDITOR

Empowering elderly patients to overcome “self-imposed immobility” due to fear of falling

Reza Ganji, MD

Department of Orthopedic Surgery, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran

Corresponding author: Dr Reza Ganji (r.ganji@nkums.ac.ir)

Full paper in PDF

To the Editor—In countries with long life expectancies, geriatric fractures due to falls, particularly hip fractures, are an increasing health concern associated with high morbidity and mortality.1 The overall 1-year mortality rate of elderly patients with hip fracture has been estimated as 17%.2 3 Orthopaedic reparative surgeries in elderly patients are intricate, and most patients need to be hospitalised for a long period of time with restricted mobility. Activity restriction or immobility for elderly patients is a degenerative process that contributes to several complications, such as ulceration, infection, decreased cardiovascular function, deep vein thrombosis, and psychophysiological dysfunction such as delirium.4 These complications can increase the length of hospital stay and the cost of care; therefore, efforts must be made to prevent these complications by early mobilisation of these elderly patients.

Several barriers to mobilising elderly patients have been identified, including pathophysiological and psychological factors.5 6 Previous studies have shown that history of falls and self-perceived mobility problems are among the independent predictors for recurrent falls.5 Fear of falling, typically due to the lack of self-confidence in sustaining stability during walking, is a major psychological impediment to mobilising a patient with a previous fall.7 More than 55% of patients with previous fall experience are frightened of falling again; thus, they prefer to stay immobile.8 From the patient’s perspective, immobility may be considered as a psychological response to previous falls or a self-protective behaviour to prevent a next possible fall.9 However, from the medical perspective, fear of falling is a vicious cycle that can physically and psychologically restrict patient activity and mobility, owing to the physical imbalance, lack of self-confidence, low self-efficacy, and low self-reliance.7 8 Whatever the cause, this type of fear can lead the patient to experience ‘self-imposed immobility’, an immature concept that I use to express the consequence of fear of falling.

Many health care providers around the world have experienced patients with self-imposed immobility, either in hospitals or in other settings such as nursing homes.9 A key responsibility of the health care team is helping and empowering such elderly patients to overcome their fear.10 In recent years, several physical interventions have been implemented, by either nurses or other members of the health care team, to strengthen and empower the elderly to overcome the fear of falling.9 11 However, evidence suggests that these interventions only reduce the fear of falling to a limited extent and for a short time. In addition, there is a lack of practical interventions that are suitable for helping elderly patients to overcome the fear of falling.6 11 Consequently, fear of falling remains a major obstacle to patient mobility. One of the possible reasons for the failure of physical interventions is that these interventions cannot affect and change the cognitive and psychological state of the patient. Thus, it seems that interdisciplinary teamwork is needed, to provide both physical and psychological interventions. Accordingly, further well-designed trials are required to evaluate the optimal physical interventions to overcome this fear, and psychological interventions, such as cognitive emotional behavioural therapy, must be evaluated and integrated into physical rehabilitation therapies. Future research should focus on the possible psychological interventions that can be combined with physical interventions in order to overcome the self-imposed immobility of elderly patients with previous fall experience.

Declaration

The author has disclosed no conflicts of interest. The author had full access to the data, contributed to the study, approved the final version for publication, and takes responsibility for its accuracy and integrity.

References

1. Man LP, Ho AW, Wong SH. Excess mortality for operated geriatric hip fracture in Hong Kong. Hong Kong Med J 2016;22:6-10. Crossref

2. Liu SK, Ho AW, Wong SH. Early surgery for Hong Kong Chinese elderly patients with hip fracture reduces short-term and long-term mortality. Hong Kong Med J 2017;23:374-80. Crossref

3. Leung KS, Yuen WF, Ngai WK, et al. How well are we managing fragility hip fractures? A narrative report on the review with the attempt to set up a Fragility Fracture Registry in Hong Kong. Hong Kong Med J 2017;23:264-71. Crossref

4. Saunders CB. Preventing secondary complications in trauma patients with implementation of a multidisciplinary mobilization team. J Trauma Nurs 2015;22:170-5. Crossref

5. Luk JK, Chan TY, Chan DK. Falls prevention in the elderly: translating evidence into practice. Hong Kong Med J 2015;21:165-71. Crossref

6. Park JH, Cho H, Shin JH, et al. Relationship among fear of falling, physical performance, and physical characteristics of the rural elderly. Am J Phys Med Rehabil 2014;93:379-86. Crossref

7. Jefferis BJ, Iliffe S, Kendrick D, et al. How are falls and fear of falling associated with objectively measured physical activity in a cohort of community-dwelling older men? BMC Geriatr 2014;14:114. Crossref

8. Mendes da Costa E, Pepersack T, Godin I, Bantuelle M, Petit B, Levêque A. Fear of falling and associated activity restriction in older people. results of a cross-sectional study conducted in a Belgian town. Arch Public Health 2012;70:1. Crossref

9. Taylor-Piliae RE, Peterson R and Mohler MJ. Clinical and community strategies to prevent falls and fall-related injuries among community-dwelling older adults. Nurs Clin North Am 2017;52:489-97. Crossref

10. Ebrahimipour H, Mirfeizi SZ, Najar AV, et al. Developing an Appropriateness Criteria for Knee MRI Using the Rand Appropriateness Method (RAM)-2013. Arch Bone Jt Surg 2014;2:47-51.

11. Kendrick D, Kumar A, Carpenter H, et al. Exercise for reducing fear of falling in older people living in the community. Cochrane Database Syst Rev 2014;(11):CD009848. Crossref

Dextrose prolotherapy for rotator cuff lesions: the challenges and the future

Hong Kong Med J 2018 Oct;24(5):538–9

DOI: 10.12809/hkmj187528

LETTER TO THE EDITOR

Dextrose prolotherapy for rotator cuff lesions: the challenges and the future

Regina WS Sit, MB, BS, FHKAM (Family Medicine)¹; David Rabago, MD²

¹ The School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong

² Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States

Corresponding author: Dr Regina WS Sit (reginasit@cuhk.edu.hk)

Full paper in PDF

To the Editor—We appreciated the letter by Dr Reza Ganji1 about chronic rotator cuff lesions (RCLs), in which he identifies prolotherapy as a potential treatment, noted a potential mechanism of action, reviewed three studies, and concluded that prolotherapy is promising but not ready for general use due to insufficient evidence. Although we agree with some elements of his letter, each of his assertions requires either additional information or respectful correction to better serve both physicians and their patients.

Dextrose prolotherapy is an evidence-based injection therapy for chronic musculoskeletal pain.2 It has been used for approximately 100 years and its modern applications can be traced to the 1950s when prolotherapy injection protocols were formalised by George Hackett,3 a general surgeon in the United States, based on his clinical experience of over 30 years. Although a variety of injectants have been used, hypertonic dextrose is the most commonly used and best studied. The number of papers devoted to prolotherapy has steadily grown over the past 20 years, as has the number of countries from which these studies originate. This suggests increased clinical use, although whether this is true and to what extent are unknown.

The fundamental innovation brought by prolotherapy to the treatment of chronic musculoskeletal pain is its potential therapeutic effects on multiple pain generators within and around joints. Prolotherapy is unique in its non-surgical targeting of multiple pathological structures and its mechanism of action is likely multifactorial. Hypertonic dextrose is thought to facilitate healing and subsequent pain control through tissue change or proliferation, potentially mediated by an inflammatory mechanism, thus improving joint stability and biomechanics, and ultimately decreasing pain.4 However, other mechanisms have been proposed and are evidence-based, including the direct sensorineural effect of dextrose on pain control.5 6 This potential effect has been suggested in clinical studies of epidural injection of dextrose for chronic recalcitrant low back pain,7 and dextrose injections for carpal tunnel syndrome and Achilles tendinosis.8 9

Studies have shown that prolotherapy is efficacious in the management of knee osteoarthritis and tendinopathy.10 11 We agree that the evidence to support its use in the context of RCLs is less robust and that more and better evidence is needed to determine its precise contribution to care of RCLs. However, in clinical life, no treatment works for every patient. We suggest that ample evidence exists for clinicians to add prolotherapy to their therapeutic armamentarium for carefully selected patients. As Dr Ganji notes:

1. Prolotherapy in the described studies is safe, well-tolerated, and satisfactory to patients. This is impressive given that injection-based care is inherently mildly traumatic and uncomfortable. Patients appear to be voting with their feet.
2. Prolotherapy is reported to improve chronic rotator cuff pain refractory to other modalities. Pain is the main reason patients come to see physicians.
3. Prolotherapy is reported to improve function, an essential outcome that is both related to and separate from pain.

In the complex work of treating chronic pain in RCLs, we believe prolotherapy has a more robust place in care than that suggested by Dr Ganji. We advocate conservative management as initial treatment for RCLs, including activity modification, anti-inflammatory medication, and physical therapy. Surgery is typically reserved for young athletes, or patients with full thickness tears or those who have failed conservative treatment. Injection therapy is generally regarded as adjuvant therapy to non-operative treatment, among which corticosteroid is commonly studied and is well-known for its short-term pain relief, but its detrimental effect on cartilage that should not be overlooked. We are using fewer corticosteroid injections and we consider prolotherapy to be a part of non-surgical care for patients with RCLs who are refractory to the more conservative steps.

We agree with Dr Ganji’s assertion that more high quality clinical trials are needed to determine specific elements of the efficacy of prolotherapy in RCLs. We suggest consideration of some important elements in trial design. First, an accurate diagnosis of pathology in RCLs should be made. Prolotherapy is effective for tendinopathies10 but may be less so for pathologies such as impingement and SLAP lesions. Second, it is reasonable to begin prolotherapy for RCLs using a whole joint approach with the clinical standard of 15% dextrose for extra-articular injections and 25% for intra-articular injections.12 13 However, in time, formal assessment of different concentrations will be needed. If the aetiology of pain is mostly neuropathic, the use of 5% dextrose may be preferred.8 Third, although there is no consensus on the optimal injection frequency, again it is reasonable to use the clinical standard of 3 to 5 injection sets 4 weeks apart followed by a booster session 8 weeks later.12 13 Fourth, the choice of control therapy should be made with caution. Although many clinical trialists and granting agencies consider a blinded placebo injection to be necessary, normal saline injections are now understood to be active therapy.14 Even sham needling has been shown to provide therapeutic effects in pain control.15 Therefore, non-injection control groups, such as standard-of-care therapy, while having some disadvantages, may be appropriate in some trials. Finally, validated and guideline-recommended self-reported and objectively assessed patient outcomes specific to shoulder injury should be used to assess the effects of prolotherapy.16

In conclusion, we agree that dextrose prolotherapy is not yet the first-line treatment for RCLs but clinicians can feel comfortable with its use in carefully selected patients who are refractory to other conservative treatments.

Declaration

All authors have disclosed no conflicts of interest. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

References

1. Ganji R. Dextrose prolotherapy for improvement of rotator cuff lesions: ready for clinical use? Hong Kong Med J 2018;24:429-30. Crossref

2. Reeves KD, Sit RW, Rabago DP. Dextrose prolotherapy: a narrative review of basic science, clinical research, and best treatment recommendations. Phys Med Rehabil Clin 2016;27:783-823. Crossref

3. Hackett GS. Ligament and Tendon Relaxation (Skeletal disability). Springfield, IL: Charles C Thomas; 1956.

4. Banks AR. A rationale for prolotherapy. J Orthopaedic Med 1991;13:54-9.

5. Burdakov D, Jensen LT, Alexopoulos H, et al. Tandem-pore K+ channels mediate inhibition of orexin neurons by glucose. Neuron 2006;50:711-22. Crossref

6. Lyftogt J. Subcutaneous prolotherapy treatment of refractory knee, shoulder, and lateral elbow pain. Australasian Musculoskeletal Med 2007;12:110-2.

7. Maniquis-Smigel L, Dean Reeves K, Jeffrey Rosen H, et al. Short term analgesic effects of 5% dextrose epidural injections for chronic low back pain: a randomized controlled trial. Anesth Pain Med 2016;7:e42550.

8. Wu YT, Ho TY, Chou YC, et al. Six-month efficacy of perineural dextrose for carpal tunnel syndrome: a prospective, randomized, double-blind, controlled trial. Mayo Clin Proc 2017;92:1179-89. Crossref

9. Yelland MJ, Sweeting KR, Lyftogt JA, Ng SK, Scuffham PA, Evans KA. Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial. Br J Sports Med 2011;45:421-8. Crossref

10. Rabago D, Nourani B. Prolotherapy for osteoarthritis and tendinopathy: a descriptive review. Curr Rheumatol Rep 2017;19:34. Crossref

11. Hassan F, Trebinjac S, Murrell WD, Maffulli N. The effectiveness of prolotherapy in treating knee osteoarthritis in adults: a systematic review. Br Med Bull 2017;122:91-108. Crossref

12. Rabago D, Patterson JJ, Mundt M, et al. Dextrose prolotherapy for knee osteoarthritis: a randomized controlled trial. Ann Fam Med 2013;11:229-37. Crossref

13. Sit RW, Wu RW, Reeves KD, et al. Efficacy of intra-articular hypertonic dextrose prolotherapy versus normal saline for knee osteoarthritis: a protocol for a triple-blinded randomized controlled trial. BMC Complement Altern Med 2018;18:157. Crossref

14. Saltzman BM, Leroux T, Meyer MA, et al. The therapeutic effect of intra-articular normal saline injections for knee osteoarthritis: a meta-analysis of evidence level 1 studies. Am J Sports Med 2017;45:2647-53. Crossref

15. Lund I, Lundeberg T. Are minimal, superficial or sham acupuncture procedures acceptable as inert placebo controls? Acupunct Med 2006;24:13-5. Crossref

16. Dworkin RH, Turk DC, Farrar JT, et al. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain 2005;113:9-19. Crossref

Strengthening the 'chain of brain survival' for acute stroke patients

Hong Kong Med J 2018 Oct;24(5):540–1

DOI: 10.12809/hkmj187632

LETTER TO THE EDITOR

Strengthening the ‘chain of brain survival’ for acute stroke patients

SH Tsui, FRCP (Edin), FHKAM (Emergency Medicine)

Department of Accident and Emergency, Queen Mary Hospital, Pokfulam, Hong Kong

Corresponding author: Dr SH Tsui (tsuish@ha.org.hk)

Full paper in PDF

To the Editor—I refer to the original article titled “Ambulance use affects timely emergency treatment of acute ischaemic stroke” written by Lau et al1 in the August issue of the Hong Kong Medical Journal. The authors established that stroke patients who took an ambulance to hospital had a higher chance of fulfilling the time criteria for thrombolytic therapy. This finding can be readily explained as this group of patients had been aware of the significance of their symptoms and promptly resorted to the correct means to seek help.

In the last paragraph of the discussion, the authors have hinted that the publicity campaign against misuse of ambulances adversely affected their utilisation by acute stroke patients. I am afraid this is an allegation that is unsubstantiated unless it can be supported by more robust information. In my opinion efforts at improvement should focus on promoting vigilance for acute stroke symptoms and thus strengthen the ‘chain of brain survival’.

There are various reasons why stroke patients delay seeking help:
1. Unlike acute myocardial infarction that usually is associated with alarming chest pain, stroke symptoms can be subtle and patients may not be aware of their significance and urgency.
2. Stroke presents with negative symptoms and loss of function. Patients may lose the ability to seek for help.
3. Stroke symptoms may wax and wane. Patients may adopt a wait-and-see policy to see if they recover.

Efforts should focus on these issues. The key is to increase public awareness of the signs and symptoms of acute stroke, as already mentioned by the authors in their conclusion. Public education should reach potential patients, relatives, caregivers, and even neighbours through appropriate channels. The fact that acute stroke is a medical emergency and that suspected cases require urgent transfer to an acute hospital by ambulance cannot be over-emphasised. Advances in technology enable digital devices such as Safety Phones and smart watches to facilitate early identification of patients who have difficulty calling for help. To further strengthen the ‘chain of brain survival’, some hospital accident and emergency departments and the Hong Kong Fire Services Department are developing pre-hospital stroke identification and notification protocols to shorten the door-to-intervention time. This pilot project has just commenced in the Queen Mary Hospital catchment area. It will be interesting to see if this system change can improve acute stroke management and outcome.

Declaration

References

1. Lau KK, Yu EL, Lee MF, Ho SH, Ng PM, Leung CS. Ambulance use affects timely emergency treatment of acute ischaemic stroke. Hong Kong Med J 2018;24:335-9. Crossref

Authors' reply

KK Lau, FRACP, FHKAM (Medicine)¹; ELM Yu, BSc (Stat & Fin), MSc (Epi & Biostat)²; MF Lee, BS (Nursing), MSc¹; SH Ho, BS (Nursing)¹; PM Ng, BS (Nursing), MSc¹; CS Leung, FHKCEM, FHKAM (Emergency Medicine)³

¹ Department of Medicine and Geriatrics, Princess Margaret Hospital, Laichikok, Hong Kong

² Clinical Research Centre, Princess Margaret Hospital, Laichikok, Hong Kong

³ Accident and Emergency Department, Princess Margaret Hospital, Laichikok, Hong Kong

Corresponding author: Dr KK Lau (laukk2@ha.org.hk)

To the Editor—We thank Dr Tsui for his letter. Early in the planning stage, we did not underestimate the potential consequence of collecting data about why patients may or may not call an ambulance. We decided not to collect such data for several reasons. First, we felt that including the patients’ reasons for not calling an ambulance may have diverted the attention of the reader from the main aim of our study. Second, when such questions are asked, patients’ relatives may be made to feel guilty for their decision to not call an ambulance.

When relatives volunteered a reason for not calling an ambulance, we carefully considered whether to include such information in the discussion. This information was ultimately included for the following reasons. First, the effect of “the government public information campaign that encouraged individuals to not misuse the ambulance” was the principal reason that relatives reported for not calling an ambulance. Second, this feedback may arouse the interest of other research groups who are better equipped to research this topic. We look forward to a well-planned study that will address this issue and that will improve stroke services in Hong Kong.

The three reasons mentioned in the letter are hypothetical. They are not from our paper and we decline to comment further.

Dextrose prolotherapy for improvement of rotator cuff lesions: ready for clinical use?

Hong Kong Med J 2018 Aug;24(4):429–30

DOI: 10.12809/hkmj187480

LETTER TO THE EDITOR

Dextrose prolotherapy for improvement of rotator cuff lesions: ready for clinical use?

Reza Ganji, MD

Department of Orthopedic Surgery, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran

Corresponding author: Dr Reza Ganji (r.ganji@nkums.ac.ir)

Full paper in PDF

To the Editor–Rotator cuff lesions (RCLs) are among the major causes of shoulder pain and dysfunction and affect the quality of life of many individuals including athletes, manual workers, and older adults. Most cases of RCLs, except for massive tears, are helped in the short term by conservative treatments such as rest, range of motion exercises, physiotherapy, analgesia, local corticosteroid injection, and minimally invasive therapeutic approaches. Chronic RCLs require more advanced invasive therapies to diminish shoulder pain and improve joint function.1

Prolotherapy is a minimally invasive regenerative therapy for chronic musculoskeletal disorders and tendinopathies. It involves injection of a nonbiological solution into the soft tissue or joint spaces. Hypertonic dextrose is the most commonly used prolotherapy solution. Tissue renewal and healing by injection of hypertonic dextrose, which is called dextrose prolotherapy (DP), has recently increased in popularity for treating musculoskeletal disorders and tendinopathies. It is believed that the injections can cause local tissue irritation by osmotic rupture of local cells and subsequently activate inflammatory responses. Thereafter, initiation of acute inflammatory responses can increase the proliferation of fibroblasts and collagen synthesis. This process can lead to healing and tissue renewal.2

Accordingly, recent studies have examined the effectiveness of DP on improvement of RCLs and reported some promising results. In a retrospective study with a 1-year follow-up period, Lee et al3 compared the efficacy of DP with conservative treatment in patients with RCLs. Their results revealed that DP improved shoulder pain, abduction, flexion, and external rotation with no adverse events.3 Although the study findings are promising, due to the nature of observational studies, it is difficult to conclude whether the observed association between DP treatment and improved outcome was related to that intervention. In a controlled trial, Bertrand et al4 evaluated the effects of dextrose and 0.1% lidocaine mixture along with physiotherapy on shoulder pain levels and degenerative changes of rotator cuff tendinopathy. The study solutions were injected at baseline, 1, and 2 months after the initiation of the study and the participants were followed up for 9 months. Results revealed that DP reduced shoulder pain and increase range of motion. However, DP failed to prevent or revert the degenerative changes of chronic rotator cuff tendinopathy.4 These findings are promising; however, the precise benefits of DP remain inconclusive because Bertrand et al4 used physical therapy along with DP in all studied groups without considering the control group. They also did not perform a covariance analysis to identify any significant effect of physical therapy on patient outcomes. In another clinical trial, Seven et al5 compared the effectiveness of DP versus physiotherapy in the treatment of pain and shoulder dysfunction in chronic RCLs. The authors found an improvement in the overall outcomes for both groups compared with baseline, but the intervention group had significantly lower pain and better shoulder range of motion in the first weeks of study. In addition shoulder abduction, flexion and internal rotation did not benefit from the DP intervention initially and shoulder external rotation did not benefit from DP at all.5

The discovery of new and innovative minimally invasive approaches should be a priority for orthopaedic surgeons. On the basis of the available evidence, DP may be useful for pain relief of RCLs along with current conservative treatment options. However, the limited available evidence on the efficacy of DP is inconclusive and further research is needed. Further well-designed clinical trials are warranted to determine the effectiveness of DP in patients with RCLs. In addition, the optimal concentration of dextrose, number of injections, time between injections, site and volume of injection, and follow-up period are yet to be determined.

Declaration

The author has disclosed no conflicts of interest. The author had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

References

1. Page MJ, Green S, McBain B, et al. Manual therapy and exercise for rotator cuff disease. Cochrane Database Syst Rev 2016;(6):CD012224. Crossref

2. Reeves KD, Sit RW, Rabago DP. Dextrose prolotherapy: a narrative review of basic science, clinical research, and best treatment recommendations. Phys Med Rehabil Clin N Am 2016;27:783-823. Crossref

3. Lee DH, Kwack KS, Rah UW, Yoon SH. Prolotherapy for refractory rotator cuff disease: retrospective case-control study of 1-year follow-up. Arch Phys Med Rehabil 2015;96:2027-32. Crossref

4. Bertrand H, Reeves KD, Bennett CJ, Bicknell S, Cheng AL. Dextrose prolotherapy versus control injections in painful rotator cuff tendinopathy. Arch Phys Med Rehabil 2016;97:17-25. Crossref

5. Seven MM, Ersen O, Akpancar S, et al. Effectiveness of prolotherapy in the treatment of chronic rotator cuff lesions. Orthop Traumatol Surg Res 2017;103:427-33. Crossref

Population-based mammography screening programme should be rigorously evaluated

Hong Kong Med J 2018 Aug;24(4):428

DOI: 10.12809/hkmj187547

LETTER TO THE EDITOR

Population-based mammography screening programme should be rigorously evaluated

TH Lam, MD

School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong

Corresponding author: Dr Regina Ching (regina_ching@dh.gov.hk)

Full paper in PDF

To the Editor–Screening programmes must be rigorously evaluated using epidemiological principles. Arguments put forward by Chow1 provide only part of the picture.

An implicit assumption underlying the concept of screening is that detection before symptoms develop leads to a more favourable prognosis because earlier treatment is more effective than treatment started later. This assumption has intuitive appeal but the concept of screening is not as straightforward as it may appear. Any standard textbook of epidemiology will caution that issues such as appropriateness and evaluation of the screening test, subsequent diagnosis and management, and associated risks or costs, need to be rigorously considered to achieve the best value in population health terms.

Hong Kong has never established a population-based breast cancer screening programme. The Cancer Expert Working Group on Cancer Prevention and Screening (CEWG) regularly revisits the literature and has never claimed that screening is of little value. Neither has it ruled in or out the possibility of breast cancer screening for local women at average risk. The CEWG states that there is insufficient evidence to recommend for or against population-based mammography screening for local asymptomatic women at average risk. This is a prudent approach when countries like the United Kingdom, Switzerland, and France have a decreased passion for similar mass screening programmes.2 3 4

Women and doctors alike should be aware of the potential risks and benefits of breast cancer screening. For women whose risk level is average or low but who nevertheless consider undergoing the procedure, the doctor has a duty of care to explain not only the pros but also the cons of the procedure, including the possibility of a false-positive result, overdiagnosis, and overtreatment. Development of a validated risk prediction tool for the local population, which has been commissioned by the Government and is ongoing, can be used to guide screening decisions and enable women and clinicians to make an informed choice.

Of equal importance is the need for all stakeholder groups to encourage women to adopt healthy lifestyle habits that protect against breast cancer development, such as avoiding alcohol consumption, engaging in moderate and vigorous physical activity, maintaining a healthy body weight and waist circumference, and breastfeeding for as long as possible5; as well as raising breast awareness and literacy so that women seek medical attention as soon as they notice any unusual breast changes.

Declaration

The author has no conflicts of interest to disclose.

References

1. Chow LC. Is now the right time to abolish breast cancer screening in Hong Kong? Hong Kong Med J 2018;24:216-7. Crossref

2. Marmot MG, Altman DG, Cameron DA, Dewar JA, Thompson SG, Wilcox M. The benefits and harms of breast cancer screening: an independent review. Br J Cancer 2013;108:2205-40. Crossref

3. Biller-Andorno N, Jüni P. Abolishing mammography screening programs? A view from the Swiss Medical Board. N Engl J Med 2014;370:1965-7. Crossref

4. Barratt A, Jørgensen KJ, Autier P. Reform of the national screening mammography program in France. JAMA Intern Med 2018;178:177-8. Crossref

5. World Cancer Research Fund. Summary of conclusions. Available from: https://www.wcrf.org/sites/default/files/Matrix-for-all-cancers-A3.pdf. Accessed 10 Jul 2018.

An integrated stroke system in Hong Kong

Hong Kong Med J 2018 Jun;24(3):318

DOI: 10.12809/hkmj187413

LETTER TO THE EDITOR

An integrated stroke system in Hong Kong

Kevin KC Hung, FHKCEM, FHKAM (Emergency Medicine); Colin A Graham, MD, FHKCEM

Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Shatin, Hong Kong

Corresponding author: Prof Colin A Graham (cagraham@cuhk.edu.hk)

Full paper in PDF

To the Editor—There have been repeated calls to establish a coordinated acute stroke system in Hong Kong.1 2 Overseas experience demonstrates that intravenous thrombolysis (IVT) can be reliably administered at a mean of 52 minutes from alerting prehospital services.3 This study from Berlin3 utilising ambulances equipped with computed tomography scanners (among other system changes in care delivery) may have little resemblance to the current situation in Hong Kong. Nonetheless it shows what is possible with appropriate vision, determination, and resources.

Similar to other time critical interventions, the speed and coverage of IVT in the stroke system must be balanced with the potential risks and harm for our patients. An integrated system will lead to stroke mimics (SM)—patients who present with nonvascular neurological conditions that closely resemble stroke—presenting in greater numbers to the emergency department. These patients are often ignored in the planning of acute stroke services as they have far more impact on emergency physicians than stroke physicians. Therefore, the impact of establishing an acute stroke system on emergency departments must be factored into the planning of these services at the outset.

We concur with Leung1 and the findings of a recent meta-analysis that systems change interventions can increase the proportion of eligible stroke patients receiving IVT.4 An integrated approach between prehospital providers, emergency department staff, and stroke physicians will improve outcomes. The establishment of stroke centres with clear protocols for primary diversion will require coordinated multidisciplinary input, and with careful consideration given to the resources required for the triage, transport, investigation, and ongoing care of SM patients who will inevitably be diverted to stroke centres inadvertently.

Declaration

All authors have no conflicts of interest to disclose.

References

1. Leung GK. We need a stroke system. Hong Kong Med J 2018;24:9-10. Crossref

2. Graham CA. Rational emergency stroke care in Hong Kong. Hong Kong Med J 2012;18:262-3.

3. Ebinger M, Winter B, Wendt M, et al. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. JAMA 2014;311:1622-31. Crossref

4. Paul CL, Ryan A, Rose S, et al. How can we improve stroke thrombolysis rates? A review of health system factors and approaches associated with thrombolysis administration rates in acute stroke care. Implementation Sci 2016;11:51. Crossref

Breast screening controversy and the ‘mammography wars’—two sides to every story

Hong Kong Med J 2018 Jun;24(3):320–1

DOI: 10.12809/hkmj187405

LETTER TO THE EDITOR

Breast screening controversy and the ‘mammography wars’—two sides to every story

Ashley Kieran Clift, BA, MB, BS

Department of Surgery and Cancer, Imperial College London, United Kingdom

Corresponding author: Dr Ashley Kieran Clift (ashley.k.clift@gmail.com)

Full paper in PDF

To the Editor—Whilst the emphasis on shared decision making in breast screening of Sitt et al1 is warmly welcomed, one struggles to visualise how this can be promoted when their overview could arguably be condensed into three major take-home messages: (1) any study critical of screening is ‘controversial’; (2) risks of screening are overstated; and (3) harms of not screening are overestimated.

The “mammography wars” are predicated by the multiple ways one may analyse mammography screening studies. Estimates of the harms versus benefit “balance sheet” vary wildly depending on the approach utilised (Table).2 3 Furthermore, estimates of overdiagnosis rates can range from 0% to 54%,4 dependent on whether studies are based on modelling or cohort observation, which denominator is used, and what adjustments are made (themselves sometimes debated). Essentially, the body of evidence can be “tortured” to give almost any answer you desire. Surely no other topic in medicine can show so many ways to slice the same cake?

Table. Collection of recent studies of varying methodologies and resulting estimation of benefits and harms of breast screening

The most ardent supporter and passionate dissident can agree that breast screening is imperfect—arguably favourable to suppressing any component of the debate is providing a balanced view. This does not need to constitute a conciliatory back-of-the-envelope calculation—this ‘third way’ could manifest as the (importantly) independent United Kingdom panel report5 which calculated that screening 233 women for 20 years can prevent one death, but three women will be overdiagnosed and overtreated.

Only when Hong Kongers are fully informed of the potential benefits and harms can they make truly informed choices.

Declaration

The author has no conflicts of interest to declare. The author had full access to the data, contributed to the study, approved the final version for publication, and takes responsibility for its accuracy and integrity.

References

1. Sitt JC, Lui CY, Sinn LH, Fong JC. Understanding breast cancer screening—past, present, and future. Hong Kong Med J 2018;24:166-74. Crossref

2. Gøtzsche PC, Jørgensen KJ. Screening for breast cancer with mammography. Cochrane Database Syst Rev 2013;(6):CD001877. Crossref

3. Paci E, Broeders M, Hofvind S, Puliti D, Duffy SW, EUROSCREEN Working Group. European breast cancer service screening outcomes: a first balance sheet of the benefits and harms. Cancer Epidemiol Biomarkers Prev 2014;23:1159-63. Crossref

4. Løberg M, Lousdal ML, Bretthauer M, Kalager M. Benefits and harms of mammography screening. Breast Cancer Res 2015;17:63. Crossref

5. Independent UK Panel on Breast Cancer Screening. The benefits and harms of breast cancer screening: an independent review. Lancet 2012;380:1778-86. Crossref

An integrated stroke system in Hong Kong

Hong Kong Med J 2018 Jun;24(3):318

DOI: 10.12809/hkmj187413

LETTER TO THE EDITOR

An integrated stroke system in Hong Kong

Kevin KC Hung, FHKCEM, FHKAM (Emergency Medicine); Colin A Graham, MD, FHKCEM

Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Shatin, Hong Kong

Corresponding author: Prof Colin A Graham (cagraham@cuhk.edu.hk)

Full paper in PDF

Declaration

All authors have no conflicts of interest to disclose.

References

1. Leung GK. We need a stroke system. Hong Kong Med J 2018;24:9-10. CrossRef

2. Graham CA. Rational emergency stroke care in Hong Kong. Hong Kong Med J 2012;18:262-3.

Pages