To the Editor—The Hospital Authority launched the Greater Bay Area Healthcare Talents Exchange Programmes in September 2022 for capacity enhancement.1 Following the Sharing Activity for Non–Locally Trained Healthcare Professionals, also known as 深化醫療團隊協作計劃 (Phase I),1 this project (Phase II) included brief open-ended questions to elicit qualitative responses on common themes of healthcare acculturation barriers, and distributed a questionnaire to quantify preferences for crew resource management (CRM) elements,2 experiences with integrating innovative approaches to healthcare education, and perceived levels of knowledge acquisition at three time points.3 4

Our multidisciplinary team comprised medical and surgical consultants, a nurse, administrators, and a research psychologist. All non–locally trained doctors and nurses who had completed Phase I (for introduction and interactive CRM sharing purposes) were invited to participate in Phase II (for innovative education and research exposure purposes) 3 months later (acceptance rate=91%) [Fig].3 The study was approved by the Hospital Authority Research Ethics Committee, Kowloon Central/Kowloon East, Hong Kong (IRB Ref No.: KC/KE-23-0174/FR-3). Written informed consent was obtained from all participants included in the study.

After a full review, the research team identified common themes related to CRM, service gaps in innovative medical education, and barriers to the healthcare acculturation process. Matched scale data from Phase I were retrieved, and the same items on contextual knowledge acquisition (covering overall service and CRM elements) were re-evaluated using a 5-point Likert scale (1=strongly disagree; 5=strongly agree) to assess the learning effect across three time points.1 4

Participants (n=31) considered healthcare simulation training effective in enhancing the quality and safety of healthcare services (mean score=9.71/10, standard deviation=±0.63). Despite the perceived enhancement of training quality by innovative technologies (mean score=9.34/10, standard deviation=±1.00), almost all participants had prior experience with traditional training modalities (standardised patient, 97%; part-task trainer, 94%) but limited exposure to advanced technology counterparts (virtual/augmented reality, 26%; three-dimensional printed simulators, 29%).

Major challenges encountered in the acculturation process by participants were themed around communication barriers (45%) and service culture (35%).1 5 With a significant main effect of time [F(2,60)=35.82, P<0.001], post-hoc tests using Bonferroni correction revealed that contextual knowledge in service overview and CRM elements increased by 1.07 unit scores after Phase I (P<0.001), then dropped by 0.36 unit scores after a 3-month washout period (P<0.05).

The findings confirmed high acceptance of, and a perceived need for, innovative simulation training modalities among non–locally trained professionals to enhance the quality and safety of healthcare services. The observed learning retention curve (peaking at the completion of Phase I but declining by >30% in 3 months) reminded simulation educators of the importance of memory consolidation with post-learning materials and scenario-based practice in CRM elements. Further studies should explore specific patterns of cross-cultural behaviour,2 4 themes of communication barriers in clinical handover, and coping strategies in the acculturation process.3 5

All authors contributed to the concept or design of the letter, acquisition of data, and analysis or interpretation of data. EHK So and VKL Cheung drafted the letter. All authors critically revised the letter for important intellectual content. 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.

All authors have disclosed no conflicts of interest.

The authors express their gratitude to the Hospital Authority Head Office Medical Grade and the hospital management of the Kowloon Central Cluster for their support and contribution to the Crew Resource Management programme specialised for non–locally trained healthcare professionals from the Greater Bay Area.

This letter received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. So EH, Cheung VK, Leung AS, et al. Specialised crew resource management programme for non–locally trained healthcare professionals: expediting healthcare cultural adaptation. Hong Kong Med J 2024;30:80-1. Crossref

2. Chan CK, So EH, Ng GW, Ma TW, Chan KK, Ho LY. Participant evaluation of simulation training using crew resource management in a hospital setting in Hong Kong. Hong Kong Med J 2016;22:131-7. Crossref

3. Cheung V, So EH, Nestel D, et al. Technology-enhanced training for central venous catheter insertion training: a reflective essay. Int J Healthc Simul 2024 Apr 19. Epub ahead of print. Crossref

4. So EH, Cheung VK, Ng CW, et al. Maintaining facilitative conflict management style and self-efficacy through O&G specific CRM Classroom Training in Queen Elizabeth Hospital. Proceedings of the KCC Convention; 2024 October 25; Hong Kong SAR, China.

5. Ng GW, Cheung VK, So SS, et al. Practice of medical interns on clinical handover with artificial intelligence [abstract]. Simul Healthc 2024;19:e10.

To the Editor—I read the article by Hon et al1 with interest. Although the seasonality of respiratory syncytial virus (RSV) is mostly year-round in tropical and subtropical regions, this should not be a barrier to universal maternal RSV vaccination.2 This approach could work well in Hong Kong, as unlike the monoclonals, the RSV vaccine’s effects are designed to be longer-lasting, and all pregnant women are eligible. In contrast to its much more restricted predecessor, palivizumab, nirsevimab has fewer limitations and can be given to all newborns, providing protection against RSV for up to 5 months after a single dose. Due to its more limited duration of protection, the recommendation is for it to be administered just before the onset of the RSV season (eg, during September/October to March in the Northern Hemisphere).2 3 Nirsevimab can still be given to particularly vulnerable babies following maternal vaccination, especially when vaccination occurs within 14 days of delivery since the maternal vaccine response can take up to 2 weeks to develop.3 In addition, the United States Centers for Disease Control and Prevention recommends that non-vulnerable babies above 8 months of age should not receive nirsevimab, and it is not recommended for any baby over 20 months.3 Nonetheless, the optimal scheduling, combination and effectiveness of these two interventions (RSV vaccines vs monoclonals) clearly require further experience. In the meantime, recommendations from different countries can be confusing, and the local teams in Hong Kong may find it useful to wait a little longer before developing their own local guidelines. Therefore, I agree with the authors that no new practice recommendations should be made at this time regarding RSV vaccines or the long-acting monoclonal nirsevimab.

The author solely contributed to the letter and critical revision of the letter 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.

The author has disclosed no conflicts of interest.

This letter received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Hon KL, Cheung EW, Li AM, et al. Practice recommendations for respiratory syncytial virus prophylaxis among children in Hong Kong. Hong Kong Med J 2025;31:48-57. Crossref

2. Benzaken TR, Watson C, Drysdale SB. Prevention of respiratory syncytial virus disease by immunisation. Arch Dis Child Educ Pract Ed 2024:edpract-2024-326964. Crossref

3. United States Centers for Disease Control and Prevention. RSV Immunization Guidance for Infants and Young Children. 30 Aug 2024. Available from: https://www.cdc.gov/rsv/hcp/vaccine-clinical-guidance/infants-young-children.html. Accessed 25 Feb 2025.

To the Editor—Chen et al’s article1 in the Hong Kong Medical Journal, “Enhancing human papillomavirus vaccine acceptance in Hong Kong: a call for action and public education,” underscores the pressing need to enhance human papillomavirus (HPV) vaccine acceptance. We propose a multifaceted strategy to bolster parental support for HPV vaccination among schoolchildren in Hong Kong. First, we suggest the creation of accessible, scientifically backed educational material that clearly outlines the benefits and safety profile of HPV vaccines, addressing common misconceptions and knowledge gaps.2 These materials should be easily understood by parents with varying levels of health literacy. Second, employing Fischhoff’s risk perception framework can provide a structured approach to communicate the risks associated with HPV and the protective benefits of vaccination, both vital in reducing vaccine hesitancy.3 4 This framework can help parents make more informed decisions regarding their children’s health. Third, advocating for policy reforms that underscore the importance of HPV vaccines for both genders is essential. These reforms should emphasise the broader implications of HPV-related cancers and the role of vaccination in cancer prevention.5 This approach can help eliminate gender biases and ensure that all children receive the protection they need. Strengthening the communication skills of healthcare providers is another critical area. Training programmes can equip providers with the tools to effectively discuss the necessity and safety of HPV vaccines, thereby alleviating parental concerns and fostering trust.6 Lastly, fostering cross-sectoral collaborations to integrate HPV vaccine education into school health programmes can significantly enhance community health literacy and awareness.7 By leveraging schools as platforms for health education, we can reach a wider audience and instil the importance of HPV vaccination from a young age. These strategic initiatives, underpinned by scientific evidence and community engagement, are essential steps towards significantly increasing HPV vaccine acceptance and compliance in Hong Kong.

Concept or design: J Ke.
Critical revision of the manuscript for important intellectual content: D Zhu.

Both 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.

Both authors have disclosed no conflicts of interest.

This letter received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Chen Z, Chan JY, Chan PK. Enhancing human papillomavirus vaccine acceptance in Hong Kong: a call for action and public education. Hong Kong Med J 2024;30:352-4. Crossref

2. Chu JK, Sing CW, Li Y, Wong PH, So EY, Wong IC. Factors affecting human papillomavirus vaccine acceptance among parents of Primary 4 to 6 boys and girls in Hong Kong. Hong Kong Med J 2024;30:386-99. Crossref

3. Thomas RK. Contemporary approaches to health communication. In: Health Communication. New York [NY]: Springer; 2006: 133-47.

4. Fischhoff B, Bostrom A, Quadrel MJ. Risk perception and communication. Annu Rev Public Health 1993;14:183-203. Crossref

5. Drolet M, Bénard É, Pérez N, Brisson M; HPV Vaccination Impact Study Group. Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and meta-analysis. Lancet 2019;394:497-509. Crossref

6. Gilkey MB, Calo WA, Moss JL, Shah PD, Marciniak MW, Brewer NT. Provider communication and HPV vaccination: the impact of recommendation quality. Vaccine 2016;34:1187-92. Crossref

7. Rolland Y, de Souto Barreto P, Abellan Van Kan G, et al. Vitamin D supplementation in older adults: searching for specific guidelines in nursing homes. J Nutr Health Aging 2013;17:402-12. Crossref

To the Editor—We write in response to an article that highlighted the experience of two Cantopop artists whose son was diagnosed with a rare disease.1 Because of its complexity, immediate discussion is warranted of the critical aspects of managing rare diseases in Hong Kong.

Rare disease, which impacts about 300 million individuals globally, encompasses a number of medical conditions across different specialties.2 Neurological disorders and metabolic causes account for 40% and 10% of rare diseases, respectively, with tuberous sclerosis and spinocerebellar ataxia being examples in Hong Kong.3 In general, there is a lack of awareness about rare diseases among healthcare professionals and the public, with consequent delayed diagnosis and treatment.3 Families who cope with diseases often encounter emotional and psychological problems that are compounded by a lack of specialised psychosocial support and palliative care access.4 Moreover, the financial strain of managing diseases is substantial; drug costs for rare diseases are reportedly up to 13.8 times higher than those of more common ailments.3 It is crucial to provide comprehensive care for rare disease patients and their families.

The healthcare system for rare diseases in Hong Kong is not as advanced or well equipped as comparable centres in the US2 and Mainland China.5 It faces challenges at different levels. Key issues include insufficient patient support, absence of a specific registry, limited availability of genetic testing, and a high financial burden for patients. To bridge these gaps, Hong Kong could learn from the well-established networks and care models of the US,2 as well as the central registry in Mainland China,5 and adopt supportive policies and financial assistance programmes. As a starting point, the Hong Kong Genome Institute (https://hkgp.org/en/) provides a strong platform from which to promote public awareness of rare diseases in Hong Kong. In addition, with the newly established Genetics and Genomics (Medicine) Fellowship of the Hong Kong Academy of Medicine,6 genetic testing and counselling that target rare disease could be streamlined.

All authors contributed to the letter and critical revision of the letter for important intellectual content. 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.

The authors have disclosed no conflicts of interest.

This letter received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Cheng L. Hong Kong star couple Stephanie Ho, Fred Cheng share story of son’s Angelman syndrome diagnosis to raise public awareness. South China Morning Post. 2024 Jun 2: Health & Environment. Available from: https://www.scmp.com/news/hong-kong/health-environment/article/3265045/hong-kong-star-couple-stephanie-ho-fred-cheng-share-story-sons-angelman-syndrome-diagnosis-raise. Accessed 17 Feb 2025.

2. Baynam G, Hartman AL, Letinturier MC, et al. Global health for rare diseases through primary care. Lancet Glob Health 2024;12:e1192-9. Crossref

3. Chung CC, Ng NY, Ng YN, et al. Socio-economic costs of rare diseases and the risk of financial hardship: a cross-sectional study. Lancet Reg Health West Pac 2023;34:100711. Crossref

4. Chan KY, Yap DY, Singh Harry Gill H. Rethinking palliative care in psychiatry. JAMA Psychiatry 2023;80:1089-90. Crossref

5. Guo J, Liu P, Chen L, et al. National Rare Diseases Registry System (NRDRS): China’s first nation-wide rare diseases demographic analyses. Orphanet J Rare Dis 2021;16:515. Crossref

6. Hong Kong Academy of Medicine. Specialty descriptions. 2024 Feb 6. Available from: https://www.hkam.org.hk/sites/default/files/PDFs/2024/SPECRE25%20(Specialty%20descriptions%20-20240206).pdf?v=1736316996530. Accessed 6 Feb 2025.

To the Editor—Ketamine analogues are new psychoactive substances that share the arylcyclohexylamine backbone of ketamine and produce dissociative effects through antagonistic activity at the N-methyl-D-aspartate receptor.1 Ketamine and its analogues have plagued Hong Kong over the last two decades. Our laboratory has identified outbreaks of multiple ketamine analogues in Hong Kong, including 2-oxo-phenylcyclohexylethylamine in 2017,2 2-fluorodeschloroketamine (2F-DCK) and deschloroketamine in 2019,3 and tiletamine in 2019 to 2022 (according to data on file in the Hospital Authority Toxicology Reference Laboratory).

We report identification of a new ketamine analogue, fluoro-2-oxo-phenylcyclohexylethylamine, also known as fluorexetamine (FXE). Recreational use of FXE was first reported in 2018.4 Our laboratory has detected increasing use of FXE in Hong Kong since mid-2023, with FXE now identified in urine samples of 14 patients. Detection of FXE can be difficult since it does not cross-react with bedside ketamine immunoassay and shares common metabolites with 2F-DCK. This may lead to misidentification of FXE metabolites as 2F-DCK metabolites on routine toxicology testing. Clinically, FXE appears to possess similar toxicity to ketamine and 2F-DCK and co-ingestion with other recreational drugs is common, often complicating the clinical presentation.

Effective prevention of the emergence of new psychoactive substances can be achieved through prompt communication and accurate toxicology testing. This approach has been successful in halting the upward trajectory of various ketamine analogues. When encountering patients with clinical features of ketamine abuse but negative immunoassay or urine toxicology results, clinicians are encouraged to submit urine specimens to our laboratory for further testing.

Concept or design: All authors.
Acquisition of data: All authors.
Analysis or interpretation of data: All authors.
Drafting of the manuscript: TM Han, YK Chong.
Critical revision of the manuscript for important intellectual content: All authors.

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.

All authors have disclosed no conflicts of interest.

This letter received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Morris H, Wallach J. From PCP to MXE: a comprehensive review of the non-medical use of dissociative drugs. Drug Test Anal 2014;6:614-32. Crossref

2. Chong YK, Tang MH, Chan CL, Li YK, Ching CK, Mak TW. 2-oxo-PCE: ketamine analogue on the streets. Hong Kong Med J 2017;23:665-6. Crossref

3. Li C, Lai CK, Tang MH, Chan CC, Chong YK, Mak TW. Ketamine analogues multiplying in Hong Kong. Hong Kong Med J 2019;25:169. Crossref

4. National Drug Early Warning System. Alert from the NDEWS Web Monitoring Team: online mentions of fluorexetamine. 2022. Available from: https://ndews.org/wordpress/files/2023/04/8.12.22.pdf. Accessed 12 Jul 2024.