Development of extracorporeal membrane oxygenation in Hong Kong: current challenges and future development

Hong Kong Med J 2017 Jun;23(3):216–7
DOI: 10.12809/hkmj175065
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
Development of extracorporeal membrane oxygenation in Hong Kong: current challenges and future development
Simon WC Sin, MB, BS, FHKAM (Medicine)1,2; Karl Young, MB, BS, FHKAM (Anaesthesiology)1
1 Department of Adult Intensive Care, Queen Mary Hospital, Pokfulam, Hong Kong
2 Department of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
 
Corresponding author: Dr Simon WC Sin (swc710@ha.org.hk)
 
 Full paper in PDF
 
Reviews of the clinical application of venovenous (VV) and venoarterial (VA) extracorporeal membrane oxygenation (ECMO) were published in the April and June issues, respectively, of the Hong Kong Medical Journal.1 2 These issues have presented practical aspects of ECMO, including recent technological advances, practical physiology, patient selection, bedside management, complications, and current evidence. Here, we will discuss about the development of ECMO in Hong Kong.
 
The present
Fifty years have passed since the first successful clinical application of ECMO. Over these decades, despite a lack of robust supportive data, ECMO has been used for severe respiratory and cardiac failure refractory to conventional treatment. With the global H1N1 influenza outbreaks of 2007-2008 and 2008-2009, ECMO experienced a resurgence in use to support patients with acute respiratory distress syndrome (ARDS) who failed conventional mechanical ventilation. In 2010, five ECMO centres focusing on VV-ECMO were established under the governance of the Coordinating Committee in Intensive Care Units (COC ICU) of the Hong Kong Hospital Authority. The goal was to provide accessible ECMO facilities during an influenza outbreak. Since that time, these ECMO services have faced a steady increase in service demand, especially for VA-ECMO (unpublished data from ECMO workgroup, COC ICU). This trend is similar to that for international registry data published by the Extracorporeal Life Support Organization (ELSO).3
 
Current ECMO support provided by ICUs is not confined to VV-ECMO for patients with severe ARDS. Most ECMO ICUs also provide VA-ECMO support for patients with severe circulatory failure and some to rescue patients with refractory cardiac arrest. The early local survival outcomes appear comparable with international data.4
 
As a sophisticated technology, there is a grave risk of patient harm from human error and equipment failure, necessitating a higher level of vigilance, staff training, and equipment maintenance. Moreover, ECMO remains a low-volume clinical activity. This ‘high-risk low-volume’ nature of ECMO means globally, nursing and medical clinical educators need to develop ECMO simulation education programmes to improve clinical practice. Simulation training has been used to train novice ECMO providers, to refresh experienced ECMO users, and to enhance team communication during ECMO crisis management. It may also be part of an ECMO credentialing programme.5
 
Although there is as yet no demonstrable mortality benefit for simulation training in ECMO, most studies have shown an improvement in self-perceived confidence and knowledge of ECMO.6 Some have demonstrated shorter ECMO cannulation times after simulation.7 In Hong Kong, some ECMO educators, with the support of the Hospital Authority and Asia-Pacific Chapter of the ELSO, have organised ECMO simulation training for local ECMO providers and those in South-East Asia. Feedback indicates a high level of satisfaction from local and international attendees.
 
How ECMO developed in Hong Kong deserves mention. Such technique evolved from perfusionist-run cardiopulmonary bypass in the operating theatre. When ECMO then emerged as an ICU service, it was heavily reliant on perfusionists,8 or at least required perfusionist support in most centres.9 This created manpower stress and financial concern for the hospital administrator, especially during the H1N1 pandemic when there was a lack of ECMO-trained staff to meet the demands for service. In 2010, ELSO guidelines advised that nurses could be trained as ‘ECMO specialists’,10 especially when a perfusionist may not be readily available. Globally, there are variations in practice; ‘ECMO specialists’ can be doctors, nurses, perfusionists, or respiratory therapists.9
 
With the latest-generation miniaturised and simplified ECMO circuits, less technical expertise is required. As a result, in Hong Kong, many units have not used perfusionists in the establishment and running of an ECMO service. In Hong Kong, the nursing-led bedside care model, the ‘single caregiver model’, that complements ECMO physicians has dominated, and contributed to a successful roll-out of Hong Kong ECMO services over a relatively short period of time.
 
Challenge
The planning of future ECMO services will be a challenge for the Hospital Authority. First, it is an expensive, labour-intensive technology associated with life-threatening complications that lacks unequivocal evidence to support its generalised use over conventional therapy. High-level-evidence recommendations to initiate ECMO are lacking, leading to highly variable practices: across countries, across institutions, and even within one ICU.11 Ironically, the use of ECMO is increasing despite the lack of supportive evidence. Quintel et al12 pointed out that the burgeoning use of VV-ECMO in Germany and the United States may be driven by national regulations, reimbursement policies, financial interests, fascination with new gadgets, and ambition rather than solid clinical evidence. Chen et al13 also reported that the internet and newspapers tend to be over-optimistic about ECMO survival and this may result in unrealistic requests from or expectations of the general public. The development of a local registry is urgently needed to monitor the appropriateness of case selection and outcome while awaiting the results of more clinical trials.
 
Second, there is no standard model for an ECMO programme. For example, there are only five ECMO centres in the United Kingdom whereas in France and Germany, the number of centres is unrestricted. In 2012, the ELSO published a consensus paper by an international group of ECMO physicians and health care workers. The focus of the paper provided an insight into various aspects of organising an optimal and safe ECMO programme for adults with acute respiratory failure.14 It concluded that a restrained approach was advisable until further evidence is available. This paper can provide a framework when hospital administrators consider a new ECMO programme.
 
Future
The use of VA-ECMO for cardiac arrest refractory to conventional cardiopulmonary resuscitation (CPR) is a rapidly expanding indication for ECMO. The technique, VA-ECMO, maintains cerebral circulation during circulatory arrest and facilitates rescue cardiac interventions, eg percutaneous cardiac intervention, during the arrest period. It usually involves multidisciplinary collaboration, eg emergency physicians, cardiologists and intensivists, and a well-trained resuscitation team who can maintain good-quality CPR while ECMO cannulation is performed in the emergency situation.15 Nonetheless despite a seemingly good outcome in a large case series, the lack of randomised controlled trial data and potential ethical issues16 prohibit its widespread use during resuscitation.
 
To conclude, ECMO is a developing technology with substantial potential in patients with critical cardiorespiratory failure. It may also be a double-edged sword, however, given its significant complications. More data are required before widespread use of ECMO can be advocated. Finally, in order to maximise the benefit of ECMO technology, an ECMO programme director and hospital administrator should focus on quality and safety.
 
Declaration
Dr SWC Sin is the Education Co-chair of Extracorporeal Life Support Organization Asia-Pacific Chapter.
 
References
1. Ng GW, Yuen HJ, Sin KC, Leung AK, Au Yeung KW, Lai KY. Clinical use of venovenous extracorporeal membrane oxygenation. Hong Kong Med J 2017;23:168-76. Crossref
2. Ng GW, Yuen HJ, Sin KC, Leung AK, Au Yeung KW, Lai KY. Clinical use of venoarterial extracorporeal membrane oxygenation. Hong Kong Med J 2017;23:282-90. Crossref
3. ECLS Registry Report. International Summary. January 2016. Available from: https://www.elso.org/Portals/0/Files/PDF/International%20Summary%20January%202016%20FIRST%20PAGE.pdf. Accessed Apr 2017.
4. Stub D, Bernard S, Pellegrino V, et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation 2015;86:88-94. Crossref
5. Johnston L, Oldenburg G. Simulation for neonatal extracorporeal membrane oxygenation teams. Semin Perinatol 2016;40:421-9. Crossref
6. Chan SY, Figueroa M, Spentzas T, Powell A, Holloway R, Shah S. Prospective assessment of novice learners in a simulation-based extracorporeal membrane oxygenation (ECMO) education program. Pediatr Cardiol 2013;34:543-52. Crossref
7. Allan CK, Pigula F, Bacha EA, et al. An extracorporeal membrane oxygenation cannulation curriculum featuring a novel integrated skills trainer leads to improved performance among pediatric cardiac surgery trainees. Simul Healthc 2013;8:221-8. Crossref
8. Mongero LB, Beck JR, Charette KA. Managing the extracorporeal membrane oxygenation (ECMO) circuit integrity and safety utilizing the perfusionist as the “ECMO Specialist”. Perfusion 2013;28:552-4. Crossref
9. Daly KJ, Camporota L, Barrett NA. An international survey: the role of specialist nurses in adult respiratory extracorporeal membrane oxygenation. Nurs Crit Care 2016 Sep 21. Epub ahead of print. Crossref
10. ELSO Guidelines for training and continuing education of ECMO specialists. February 2010. Available from: https://www.elso.org/Portals/0/IGD/Archive/FileManager/97000963d6cusersshyerdocumentselsoguidelinesfortrainingandcontinuingeducationofecmospecialists.pdf. Accessed Apr 2017.
11. Kuo KW, Barbaro RP, Gadepalli SK, Davis MM, Bartlett RH, Odetola FO. Should extracorporeal membrane oxygenation be offered? An international survey. J Pediatr 2017;182:107-13. Crossref
12. Quintel M, Gattinoni L, Weber-Carstens S. The German ECMO inflation: when things other than health and care begin to rule medicine. Intensive Care Med 2016;42:1264-6. Crossref
13. Chen YY, Chen L, Kao YH, Chu TS, Huang TS, Ko WJ. The over-optimistic portrayal of life-supporting treatments in newspapers and on the Internet: a cross-sectional study using extra-corporeal membrane oxygenation as an example. BMC Med Ethics 2014;15:59. Crossref
14. Combes A, Brodie D, Bartlett R, et al. Position paper for the organization of extracorporeal membrane oxygenation programs for acute respiratory failure in adult patients. Am J Respir Crit Care Med 2014;190:488-96. Crossref
15. Rousse N, Robin E, Juthier F, et al. Extracorporeal life support in out-of-hospital refractory cardiac arrest. Artif Organs 2016;40:904-9. Crossref
16. Riggs KR, Becker LB, Sugarman J. Ethics in the use of extracorporeal cardiopulmonary resuscitation in adults. Resuscitation 2015;91:73-5. Crossref

Challenges in prenatal screening and counselling for fragile X syndrome

Hong Kong Med J 2017 Apr;23(2):108–9
DOI: 10.12809/hkmj175064
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
Challenges in prenatal screening and counselling for fragile X syndrome
Annisa SL Mak, MRCOG, FHKAM (Obstetrics and Gynaecology); KY Leung, MD, FHKAM (Obstetrics and Gynaecology)
Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Jordan, Hong Kong
 
Corresponding author: Dr KY Leung (kyleung@ha.org.hk)
 
 Full paper in PDF
 
Fragile X syndrome (FXS) is the most frequent cause of intellectual disability after Down syndrome. It is caused by the expansion of an unstable cysteine-guanine-guanine (CGG) trinucleotide repeat on the 5’ untranslated region of the fragile X mental retardation-1 (FMR1) gene. In full mutation (FM), the expansion is >200 CGG repeats with aberrant methylation of the promoter region causing loss of the gene expression. Affected individuals display a spectrum of neurological, psychiatric, and developmental problems, as well as abnormal ophthalmological and facial features.
 
Fragile X syndrome is an X-linked, dominant disorder. Although all males with a FM have FXS, only half of the females with a FM are clinically affected because of X-chromosome inactivation. The inheritance pattern of FXS is distinctive because a healthy woman who carries a pre-mutation (PM) or a mild expansion of 55-200 CGG repeats can pass on a FM to a child through mitotic expansion of the unstable PM allele. In Cheng et al’s article,1 two PM carriers (1 in 1325) and one FM carrier (1 in 2650) were detected in a sample of 2650 Hong Kong Chinese pregnant women. In Chinese children with unknown intellectual developmental disorder, the prevalence of FXS has been reported to be 0.93%.2 It would appear that FXS is not rare in the Chinese population.
 
Prenatal screening
To predict the birth of a FXS-affected children, PM carriers can be identified through screening. According to the American College of Obstetricians and Gynecologists (ACOG), prenatal screening and genetic counselling for FXS should be offered to women with a family or personal history of FXS, unexplained mental retardation or developmental delay, or premature ovarian insufficiency.3 The Society of Obstetricians and Gynaecologists of Canada also suggest that fragile X testing is indicated in a woman who has at least one male relative with autism, mental retardation, or developmental delay of an unknown aetiology within a three-generation pedigree.4 Such screening should also be offered to all women who request it after appropriate genetic counselling.3 It is controversial, however, to offer universal screening to all pregnant women. In Hong Kong, this screening is self-financed.
 
Conventionally, analysis of maternal blood samples by Southern blot is performed to identify PM carriers. Recently, polymerase chain reaction (PCR)–based approaches have enabled more rapid and easy testing, and can be relied upon to characterise CGG repeat size. Nonetheless, amplification of large CG-rich fragments and the study of the methylation pattern can be difficult. Cheng’s team used a specific FMR1 PCR-based assay that could detect CGG repeat numbers up to 1000, allowing the identification of PM and FM.1 The sensitivity of this PCR test was reported to be high (99%) and the false-positive rate was approximately 1.3% although this was probably overestimated.1 The cost of the test is US$44, which is not high.1
 
Genetic counselling
Although obtaining a maternal blood test for FXS carrier screening is relatively simple, genetic counselling is not, as rightly pointed out by Cheng et al.1 In their study, pre-test counselling was given by a research assistant with a bachelor’s and master’s degree in human genetics, supplemented by written information.1 Pre-test counselling for FXS is more difficult than for Down syndrome screening. First, an extensive multigenerational family history must be taken to assess whether FXS, developmental, neurodegenerative, or reproductive disability is present in the mother or any of her family members. Taking such a history is not easy because most patients are not familiar with FXS, and typical phenotypic features of FXS often are not apparent until later childhood.5
 
Second, the inheritance pattern of FXS is complex. Women should be informed about the various outcomes possible and the implications of detecting FM, PM, and intermediate-sized allele (ie 45-54 CGG repeats) results. Prenatal diagnosis should be offered to all pregnant women who are FM or PM carriers.6 For a female PM carrier, the risk of expanding to a FM in offspring is dependent on the size of the PM, and is above 98% for alleles with >100 repeats.7 For PM carriers with <69 repeats, the number of AGG (adenine-guanine-guanine) interruptions within the CGG repeat tract (eg occurrence of one AGG interruption after nine uninterrupted CGG repeats is described as: [(CGG)9AGG(CGG)9AGG(CGG)9]) may predict the risk.8 The latter risk is higher when there is a positive family history of FXS.
 
The prevalence of intermediate-sized allele carriers was shown to be 1.1% in a local study.1 It is difficult to counsel these carriers because the risk for CGG expansion, although very low, is uncertain. Thus, prenatal diagnosis may be offered on a case-by-case basis. Expansion of an intermediate-sized allele into FM may occur in two generations. The European Molecular Genetics Quality Network recommends genetic counselling be offered to family members of intermediate carriers with 50-54 CGG repeats because they may carry a PM.9
 
Prenatal diagnosis can be achieved by determination of CGG expansion and methylation status using a combination of PCR and Southern blot analysis on a sample from chorionic villus sampling (CVS) or amniocentesis. Methylation results from CVS must be interpreted with caution because methylation of a FM is not always present before 14 weeks of gestation,10 and the FMR1 gene is not methylated on the inactive X chromosome in a female fetus. A follow-up amniocentesis may be required if (a) determination of the methylation status is required to differentiate a large PM from a small FM, or (b) exclusion of somatic mosaicism with FM is required in PM. In all cases, maternal contamination should be excluded, and the gender of the fetus determined to interpret the results of the mutation study.
 
If a female FM carrier fetus is identified through prenatal diagnosis, there is no way to tell whether the fetus is affected by FXS. Their parents will face uncertainty and anxiety about the resulting phenotype, and have a difficult choice to make. Termination of such pregnancy was reported previously and in the study by Cheng et al.1 On the contrary, in the same study, a woman with PM declined prenatal diagnosis owing to the unpredictable phenotype in a FM female.1
 
Pre-mutation carriers are at risk of developing fragile X–associated tremor/ataxia syndrome (FXTAS) and fragile X–associated primary ovarian insufficiency (FXPOI). Onset of FXTAS is typically in the sixth decade of life, and older males are at high risk.11 Approximately 20% of female PM carriers may suffer from early menopause below the age of 40 years,12 and thus appropriate reproductive interventions should be informed.
 
Sufficient time should be allowed for women to review and consider the information given, including the complex inheritance pattern and implications of FXS. Women generally know little about FXS prior to counselling. Adequate psychosocial support should be given to the mutation carriers who may become anxious when they know the uncertain inheritance risk of expansion from PM to FM, the uncertain phenotype of a female FM carrier, or the future risks of FXPOI and FXTAS. Family dynamics must also be considered. Although screening for FXS should be offered to other at-risk family members, such extended or cascade screening may be declined as in Cheng et al’s study.1
 
In summary, ACOG recommends offering prenatal screening and genetic counselling for FXS to all at-risk women.3 Risk factors can be identified by taking an extensive multigenerational family history although this may be difficult. The provision of appropriate counselling is a challenge in view of the time and knowledge required to discuss the screening process, the complex inheritance pattern and heterogeneous phenotype of FXS, and its potential impact on psychosocial status and family members. Providing medical education to obstetricians, midwives and genetic counsellors, and targeted education materials to pregnant women may help.13
 
References
1. Cheng YK, Lin CS, Kwok YK, et al. Identification of fragile X pre-mutation carriers in the Chinese obstetric population using a robust FMR1 polymerase chain reaction assay: implications for screening and prenatal diagnosis. Hong Kong Med J 2017;23:110-6. Crossref
2. Chen X, Wang J, Xie H, et al. Fragile X syndrome screening in Chinese children with unknown intellectual developmental disorder. BMC Pediatr 2015;15:77. Crossref
3. American College of Obstetricians and Gynecologists Committee on Genetics. ACOG Committee Opinion No. 469: Carrier screening for fragile X syndrome. Obstet Gynecol 2010;116:1008-10. Crossref
4. Genetics Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC); Prenatal Diagnosis Committee of the Canadian College of Medical Geneticists (CCMG), Chitayat D, et al. Fragile X testing in obstetrics and gynaecology in Canada. J Obstet Gynaecol Can 2008;30:837-46. Crossref
5. Bailey DB Jr, Raspa M, Bishop E, Holiday D. No change in the age of diagnosis for fragile X syndrome: findings from a national parent survey. Pediatrics 2009;124:527-33. Crossref
6. Ram KT, Klugman SD. Best practices: antenatal screening for common genetic conditions other than aneuploidy. Curr Opin Obstet Gynecol 2010;22:139-45. Crossref
7. Nolin SL, Glicksman A, Ding X, et al. Fragile X analysis of 1112 prenatal samples from 1991 to 2010. Prenat Diagn 2011;31:925-31. Crossref
8. Nolin SL, Sah S, Glicksman A, et al. Fragile X AGG analysis provides new risk predictions for 45-69 repeat alleles. Am J Med Genet A 2013;161A:771-8. Crossref
9. Biancalana V, Glaeser D, McQuaid S, Steinbach P. EMQN best practice guidelines for the molecular genetic testing and reporting of fragile X syndrome and other fragile X–associated disorders. Eur J Hum Genet 2015;23:417-25. Crossref
10. Devys D, Biancalana V, Rousseau F, Boué J, Mandel JL, Oberlé I. Analysis of full fragile X mutations in fetal tissues and monozygotic twins indicate that abnormal methylation and somatic heterogeneity are established early in development. Am J Med Genet 1992;43:208-16. Crossref
11. Jacquemont S, Hagerman RJ, Leehey MA, et al. Penetrance of the fragile X–associated tremor/ataxia syndrome in a premutation carrier population. JAMA 2004;291:460-9. Crossref
12. Sherman SL. Premature ovarian failure in the fragile X syndrome. Am J Med Genet 2000;97:189-94. Crossref
13. Espinel W, Charen K, Huddleston L, Visootsak J, Sherman S. Improving health education for women who carry an FMR1 premutation. J Genet Couns 2016;25:228-38. Crossref

Exerting an impact on clinical practice—upholding quality, visibility, and timeliness of publications

Hong Kong Med J 2017 Feb;23(1):4–5
DOI: 10.12809/hkmj175063
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
Exerting an impact on clinical practice—upholding quality, visibility, and timeliness of publications
Martin CS Wong, MD, MPH
Editor-in-Chief, Hong Kong Medical Journal
 
 Full paper in PDF
 
Since its inception in 1995, the Hong Kong Medical Journal has evolved to have an official impact factor in the Journal Citation Report, and it continues to be a flourishing academic journal. Over the last 6 years, the number of articles we received has increased by 52% to 440 in 2016, and the total number of non-local articles submitted has risen drastically by 320%. This is a true reflection of the journal’s increasing popularity in the clinical and academic communities. The acceptance rate has decreased from 50% to less than 30%, reflecting the inevitably more rigorous and stringent criteria applied in the evaluation of all submissions. Our heartfelt gratitude goes to the capable and visionary leadership of our past Editors-in-Chief, Dr CK Lee, Dr YL Yu, Dr Richard Kay, and Prof Ignatius Yu who have undoubtedly laid a solid foundation for our Journal. We are also appreciative of the relentless efforts of our editorial members and reviewers, both locally and internationally, who have jointly made the journal to be one with growing prestige and quality.
 
In previous inaugural and valedictory editorials by our past Editors-in-Chief,1 2 3 4 5 the importance of articles making an impact, whether on clinical practice, public health policy or future research, has been repeatedly emphasised. I believe this still holds very true as it is an ultimate aspiration of all authors who are determined to publish their original works. One major question remains to address—how can we make our published articles more influential? As the new Editorial Board is appointed, we have in mind three important criteria that we consider crucial: quality, visibility, and timeliness of publication.
 
We are most interested in articles that are of high methodological quality. To further make this a top priority in the coming years, the editorial team will place an increasing weight on the quality of the research methodology when they make editorial decisions. The peer reviewer report has been modified to ensure this is an overriding criterion for article acceptance. In particular, we have solicited more support from senior members of the Editorial Board, together with the our epidemiology and biostatistics advisors, to rigorously review and clarify the methodological details of all provisionally accepted original articles well before they are formally published. We hope that this process will help strengthen the validity and presentation of the information we publish. Apart from original research papers, we solicit high-quality reviews as well as medical practice papers that describe recent technological advances or summarise current guidelines for addressing common medical problems. We hope these papers will help readers in their daily practice.
 
Another important aspect of our future work is to enhance the visibility of our journal articles. Without effective dissemination, no high-quality articles can realise their actual impact. The initiative began in 2015 when a responsive, user-friendly, web technology was built to enhance browsing of the journal via desktops, smartphones, and tablets. The “online first” feature of the publication since 2013 is yet another attempt to make our articles easily accessible. Our senior editors will also offer advice for authors to make their articles more “search engine optimised”6 by suggesting potential modifications to the keywords of all original contributions as displayed in MEDLINE versions. We do of course recommend that our authors present their findings at academic conferences, share them with their colleagues and appropriate social media, and expand their professional network.
 
Timely publication is a crucial aspect, and indeed responsibility, of every academic journal to ensure efficient dissemination of research findings. In the coming years, our editorial members will be working towards the target of making the first editorial decision of whether to send a paper for external peer review within an average of 15 working days for all original articles. Whilst this requires very diligent and committed work from all Editorial Board members, we believe this initiative is worthwhile. Authors as well as readers will welcome the reduced time between acceptance of a manuscript and its appearance in our Journal via expeditious review.
 
We strongly believe that HKMJ will continue to be an internationally world-class academic journal that publishes articles of “high quality reflecting the current practice in the science and art of medicine and public health”.5 We are also confident that the Journal will continue the proud history over 32 years of the Journal of the Hong Kong Medical Association and its predecessors in “providing a useful source of medical information on advances in medical research and clinical practice.”5 To this end, we must emphasise that the continuing support of our international advisors, board members, editorial staff, reviewers, authors, and all Academy Fellows is essential. To quote our Immediate Past Editor-in-Chief Prof Ignatius Yu, we sincerely “call on your continued love and support”2 to make the Journal a great success. We are always attentive and appreciative of your invaluable comments, and of course your submissions.
 

Hong Kong Medical Journal—papers processed from 2011 to 2016
 
References
1. Yu IT. Helping the Hong Kong Medical Journal and Hong Kong to advance their impact on medical practice. Hong Kong Med J 2016;22:524-5. Crossref
2. Yu IT. Calling on your continued love and support. Hong Kong Med J 2011;17:4.
3. Yu YL. Building upon a firm foundation. Hong Kong Med J 2001;7:4.
4. Kay R. Valedictory remarks. Hong Kong Med J 2010;16:420.
5. Lee JC, Yu YL. Inaugural editorial. Hong Kong Med J 1995;1:4.
6. Burger M. How to improve the impact of your paper. Available from: https://www.elsevier.com/authors-update/story/publishing-tips/how-to-improve-the-impact-of-your-paper. Accessed 29 Dec 2016.

Helping the Hong Kong Medical Journal and Hong Kong to advance their impact on medical practice

Hong Kong Med J 2016 Dec;22(6):524–5
DOI: 10.12809/hkmj165062
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
Helping the Hong Kong Medical Journal and Hong Kong to advance their impact on medical practice
Ignatius TS Yu, FHKAM (Community Medicine)
Editor-in-Chief, Hong Kong Medical Journal
 
 Full paper in PDF
 
Six years ago, the Hong Kong Medical Journal (HKMJ) vowed to improve the impact of papers published in the Journal, “We publish not for the sake of publication, but to have an impact on medical practice”, by ensuring “that the medical information that we are providing (what we publish) is basically correct and valid”.1
 
Greater emphasis was to be placed on methodology to produce valid results. A process of methodological review by clinical epidemiologists for all original articles was introduced.1
 
To improve our capacity to assess the validity of research results, we introduced a series of 12 workshops on Clinical Epidemiology in HKMJ that ran from August 2011 to June 2013 (http://www.hkmj.org/clinical-epidemiology-workshop-series). Their aim was to facilitate authors and reviewers in adopting a more important role in the process of publishing work of a high standard.
 
The new Editorial Board also introduced a new requirement for original articles to include two boxes of text: ‘New Knowledge Added by This Study’ and ‘Implications for Clinical Practice or Policy’.2 This was intended to improve and emphasise the potential impact of our published original research papers.
 
During every Editorial Board meeting, it has been the practice for a number of years to identify papers in each issue of HKMJ that are suitable for continuing medical education (CME). A Senior Editor then works with the authors to prepare questions and answers suitable for CME purposes. We also select papers that may be of public interest and the Editorial Office works with the authors to produce Issue Digests that are released to the local media. These have been widely cited and the impact of local medical research published in HKMJ on improving medical knowledge of the public is now evident.
 
To further enhance the educational role of HKMJ for doctors and its impact on medical practice, two Senior Editors have taken leading roles to plan and solicit high-quality review papers and contributions to the Medical Practice section.3
 
In August 2012, we introduced the section ‘Doctor for Society’ to report the activities and achievements of medical doctors who contribute substantially to society on a voluntary basis. We wished to disseminate the message that medical doctors can have a significant impact in the community, outside of their clinic or hospital practice.4 The impact has been further extended to the next generation of doctors by engaging medical students from the two local medical schools to interview the nominated interviewee doctors and write a comprehensive report.
 
In 2013, we began to phase in ahead-of-print versions with DOIs (Online First) for original articles and review articles that had already been accepted and copy-edited.5 This has helped to advance the formal release of information available in those articles by months and maximise the impact on medical practice.
 
Improving accessibility to papers published in HKMJ should help improve its impact. All papers are freely available on the HKMJ website (http://www.hkmj.org), and the ‘mobile website’ that was introduced in 2015. This re-styled website is based on ‘responsive web’ technology that can automatically adjust a website according to the device that is browsing, thus making the content user-friendly and easily accessible.6
 
As a result of open recruitment and invitation, the Editorial Board now has 55 members, including the Editor-in-Chief and five Senior Editors, representing all the 15 Colleges of the Hong Kong Academy of Medicine. This ensures that all aspects of medical and dental practice are adequately covered and impacted by the content in HKMJ.
 
With the joint efforts of all authors, reviewers, advisors in Biostatistics and Clinical Epidemiology, International Editorial Advisory Board members, Editorial Board members, and the Editorial Office, HKMJ received its first official impact factor in the 2014 version of Journal Citation Reports of Thomson Reuters. The impact factor, however, should not be the only parameter to measure the impact of HKMJ. Papers published in the journal attract much media attention and some local journalists use HKMJ as their prime source to identify new developments in medical practice in Hong Kong.6
 
How much is HKMJ actually influencing medical practice? It will be for you readers to inform us.
 
The current Editorial Board will be stepping down in mid-December this year, and HKMJ will appoint a new Editorial Board under the capable leadership of Prof Martin Wong (currently Senior Editor). He will expand on his vision for the further development of HKMJ in the coming issue.
 
I would like to close by taking this opportunity to give a big ‘Thank You’ to all of you! Do not forget to continue your love and support for HKMJ and help the journal to further advance its impact on medical practice!
 
References
1. Yu IT. Calling on your continued love and support [editorial]. Hong Kong Med J 2011;17:4.
2. Yu IT. New blood, new initiatives [editorial]. Hong Kong Med J 2011;17:88.
3. Yu IT. Taking stock [editorial]. Hong Kong Med J 2012;18:2.
4. Wong M, Chan KS, Chu LW, Wong TW. Doctor for Society: a corner to showcase exemplary models and promote volunteerism [editorial]. Hong Kong Med J 2012;18:268-9.
5. Yu IT. From strength to strength [editorial]. Hong Kong Med J 2013;19:100.
6. Yu IT. The Third Term [editorial]. Hong Kong Med J 2015;21:4. Crossref

Transition care in Hong Kong

Hong Kong Med J 2016 Oct;22(5):408–9
DOI: 10.12809/hkmj165060
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
Transition care in Hong Kong
Keith K Lau, FHKCPaed, FHKAM (Paediatrics)
Department of Paediatrics, The University of Hong Kong–Shenzhen Hospital, No. 1, Haiyuan 1st Road, Futian District, Shenzhen, China 518053
 
Corresponding author: Dr Keith K Lau (keithklau@hku-szh.org)
 
 
The main objective of the transition from paediatric to adult health care services is to ensure that all adolescents continue to receive coordinated care after reaching adulthood.1 Medical personnel understand that when children grow up, there are adulthood-related issues such as pregnancy or drug-related illnesses that many paediatricians are not equipped to deal with. Thus, transferring patient care to adult facilities is often an essential and unavoidable event in the medical journey for children.
 
There is now ample evidence that children who acquire a major physical illness at an early age, such as chronic kidney disease, are also at risk of cognitive developmental delays.2 Thus, while all youths eventually experience transition in health care, paediatricians are particularly concerned about youths with physical and/or cognitive disabilities. Medical care for these individuals is often more complex: they will generally also need long-term therapies and require extra attention due to the accompanying suboptimal cognitive maturity. In order for their health care to successfully transition to adult facilities, it is crucial that these vulnerable youths receive sufficient and appropriate preparation.
 
Although the literature suggests that many children with physical and cognitive disabilities suffer profound and prolonged morbidities due to ineffective health care transitioning, paediatric caregivers in Hong Kong face wide-ranging predicaments both within and outside the health care system. Problems include the lack of a comprehensive health care policy, scarcity of transition programmes, inadequate physician training, and inadequate education and preparation of patients and/or their family. In “A proposal on child health policy for Hong Kong” published by the Hong Kong Paediatric Society in August 2015,3 paediatric health care professionals expressed their desire to set up and implement a comprehensive, yet effective child health care policy to address the many health care challenges in Hong Kong. The professional panel pointed out that among all major concerns, there was ultimately a lack of coordinated and uninterrupted care for children with special care needs and medical complexities. In particular, the transition of care for such children was especially fragmented.
 
Transition preparations for children with special needs have been a public concern in many developed countries.4 The US Government has also identified the need to involve more physicians in transition planning as a public health objective in the Healthy People 2020 project.4 5
 
Efforts have been made to develop transition programmes, for example, with the establishment of transition clinics that are directed by transition coordinators in conjunction with adult-care physicians.6 During the past decade, more and more organisations have taken the initiative to set up ‘Family-Centered Medical Homes‘ in order to integrate care for children with special needs.4
 
In 2011, the Transitions Clinical Report Authoring Group, along with representatives from the American Academy of Pediatrics, the American Academy of Family Physicians and the American College of Physicians, issued a clinical report on the practice-based implementation of transition for youth.7 The report offered a framework for training not only for the medical team, but also for educators, assistants, and families of youths in medical homes. This year, the National Institute for Health and Care Excellence in England also published their guidelines on the transition of care for young people.8 They provide practical advice for caregivers attempting to improve young people’s engagement with services.
 
There are also some other transition tools available through the Internet that may be able to be adapted for use in education for the general public or even as a means to assess whether patients are ready for health care transitions.9 One such tool that could be particularly beneficial is the MyHealth Passport,10 as well as other tools listed in the Health Care Transition Resources.11 Since children with special needs are heterogeneous in nature, there is currently no universal tool although most tools can potentially be customised for each individual child and his/her family according to cultural background and underlying disabilities.
 
In 2007, approximately 10 900 adolescents with disabilities between the ages of 14 and 17 years took part in the Survey of Adult Transition and Health.12 The results showed that only 21.6% of adolescents had undergone successful transition to adult care. This finding reflects the dire fact that despite all the efforts made, the health care system in its current state still fails to support the majority of youths with special needs who are exiting paediatric care. There remains a great need for research and evaluation on the outcome of the transition of children with disabilities into adult facilities.
 
In the current issue, Pin et al13 reports on their local pilot data on the clinical transition of adolescents with developmental disabilities. Among the surveyed children and their families, approximately 60% considered the transfer process to be suboptimal. Although the study was confounded by many limitations and the findings are far from conclusive, it sheds light on the underlying causes of dissatisfaction and hurdles associated with youth transition in Hong Kong. Since a solid understanding of the underlying problems is important in finding a solution, we desperately need more local and relevant information on how to improve the effectiveness and success of health care transfer for children with special needs.
 
One of the six core goals of the care of children with special needs, as identified by the Maternal and Child Health Bureau, is to ensure that these individuals continue to receive the support necessary for transitioning to adulthood.14 The ultimate goal is not just to provide the necessary medical care during transition, but also to enable individuals to succeed in all aspects of life so that they are able to work, to assimilate into society, and to achieve independence.
 
Now that the deficiencies have been identified, it is time for medical professionals to take the initiative and work together to help shape the future of health care for children with special needs.
 
References
1. Davis AM, Brown RF, Taylor JL, Epstein RA, McPheeters ML. Transition care for children with special health care needs. Pediatrics 2014;134:900-8. Crossref
2. Johnson RJ, Warady BA. Long-term neurocognitive outcomes of patients with end-stage renal disease during infancy. Pediatr Nephrol 2013;28:1283-91. Crossref
3. The Hong Kong Paediatric Society, The Hong Kong Paediatric Foundation, and Child Healthcare Professionals in Hong Kong. A proposal on child health policy for Hong Kong. 2015. Available from: http://hkpf.org.hk/download/20150920 Child Health Policy for Hong Kong_Final.pdf. Accessed Aug 2016.
4. McManus MA, Pollack LR, Cooley WC, et al, Current status of transition preparation among youth with special needs in the United States. Pediatrics 2013;131:1090-7. Crossref
5. Office of Disease Prevention and Health Promotion. 2020 Topics & Objectives: Disability and Health. Available from: https://www.healthypeople.gov/2020/topics-objectives/topic/disability-and-health/objectives. Accessed Aug 2016.
6. McQuillan RF, Toulany A, Kaufman M, Schiff JR. Benefits of a transfer clinic in adolescent and young adult kidney transplant patients. Can J Kidney Health Dis 2015;2:45. Crossref
7. American Academy of Pediatrics; American Academy of Family Physicians; American College of Physicians; Transitions Clinical Report Authoring Group, Cooley WC, Sagerman PJ. Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics 2011;128:182-200. Crossref
8. NICE Pathway—Transition from children’s to adults’ services for young people using health or social care services. NICE Guideline 43. 24 February 2016. Available from: https://www.nice.org.uk/guidance/NG43. Accessed Aug 2016.
9. Schwartz LA, Daniel LC, Brumley LD, Barakat LP, Wesley KM, Tuchman LK. Measures of readiness to transition to adult health care for youth with chronic physical health conditions: a systematic review and recommendations for measurement testing and development. J Pediatr Psychol 2014;39:588-601. Crossref
10. The Hospital for Sick Children, Good 2 Go Transition Program—MyHealth Passport. Available from: https://www.sickkids.ca/myhealthpassport/. Accessed Aug 2016.
11. Got Transition. Health care transition resources. Available from: http://www.gottransition.org/resources/. Accessed Aug 2016.
12. Oswald DP, Gilles DL, Cannady MS, Wenzel DB, Willis JH, Bodurtha JN. Youth with special health care needs: transition to adult health care services. Matern Child Health J 2013;17:1744-52. Crossref
13. Pin TW, Chan WL, Chan CL, et al. Clinical transition for adolescents with developmental disabilities in Hong Kong: a pilot study. Hong Kong Med J 2016;22:445-53. Crossref
14. US Department of Health and Human Services. The National Survey of Children with Special Health Care Needs Chartbook 2005-2006. Rockville: Department of Health and Human Services; 2008.

Psychological insulin resistance: scope of the problem

Hong Kong Med J 2016 Aug;22(4):304–5
DOI: 10.12809/hkmj165025
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
Psychological insulin resistance: scope of the problem
Andrea Luk, FHKCP, FHKAM (Medicine)
Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
 
Corresponding author: Dr Andrea Luk (andrealuk@cuhk.edu.hk)
 
 Full paper in PDF
 
Diabetes mellitus is a pandemic that is infiltrating our society in tandem with the rising prevalence of obesity. Based on population surveys, up to one in 10 people in China have diabetes and half have pre-diabetes with the majority of them undiagnosed.1 Diabetes reduces life expectancy by an average of 12 years and contributes to death in close to 10% of affected adults.2 Prevailing evidence indicates that diabetes-related vascular complications are highly preventable through intensive glycaemic and global risk factor management, and that optimisation of blood glucose early in the disease trajectory translates into latent benefits for decades beyond.3 4
 
Maintenance of optimal glycaemic control requires successive up-titration of antidiabetic drug treatment, and insulin is necessary for the majority of patients due to a natural progressive decline in pancreatic beta-cell function. Whilst international guidelines strongly advocate insulin supplementation upon failing two or three non-insulin antidiabetic drugs,5 initiation of insulin therapy is often delayed as a result of clinical inertia and resistance by patients.6 In a survey of patients with type 2 diabetes who attended general practices in the United Kingdom, there was a time lag of 5 years to the commencement of insulin during which glycaemic control had remained unsatisfactory on two or more non-insulin agents.6 Refusal of insulin is commonly encountered and between 20% and 40% of insulin-naïve patients with type 2 diabetes express unwillingness to inject insulin when prescribed.7 8 9 Furthermore, among existing insulin users, adherence to the prescribed regimen is suboptimal in up to one third of patients.10 Failure to initiate insulin therapy in a timely manner and to comply with the recommended injection doses and schedule are key factors that lead to low rates of glycaemic target attainment. Among participants of a multinational study that evaluated the quality of care of patients with diabetes in Asia, more than half of the enrolled patients did not reach the glycated haemoglobin (HbA1c) target of <7.0%, and the situation was worse in those with young-onset diabetes.11
 
Psychological insulin resistance is a phenomenon that describes barriers to starting insulin therapy and/or adhering to prescribed treatment.12 It encompasses a range of psychological factors that include fear of injection and/or pain, fear of hypoglycaemia and/or weight gain, poor self-efficacy about the skills required to administer insulin, anxiety over interference with daily living, anticipated social stigmatisation, and misconceptions about the rationale and efficacy of insulin therapy. Depending on the assessment method and clinical setting, psychological insulin resistance is detected in approximately 40% to 70% of patients.13 14
 
Culture, age, and gender are variables that may influence the scope of psychological insulin resistance.15 Based on studies conducted in western countries, the most important factor contributing to patients’ reluctance to commence insulin therapy is the belief that insulin is not able to improve disease control and prognosis.16 17 Additionally, patients often perceive insulin therapy as a form of punishment for their personal failure to self-manage their diabetes, a point that is reinforced by the physician when insulin therapy has previously been presented as a threat to motivate self-care.18 19 It is noteworthy that fear of injection or pain was infrequently reported in these populations.8 In a recent study of local Chinese patients with type 2 diabetes, patients’ impression of insulin therapy was explored using the Chinese Attitudes to Starting Insulin Questionnaire.20 In contrast to observations in their western counterparts, Chinese patients, particularly females, were much more likely to fear needles and be apprehensive about pain associated with injection, whilst most were confident that insulin would improve their health outcome.
 
Fear of hypoglycaemia and weight gain is another critical factor that diminishes treatment satisfaction leading to compliance problems particularly among insulin users. In a survey of insulin-treated patients, frequent hypoglycaemia was reported in 40% and high fear score for hypoglycaemia in 15%.21 Predictors of fear of hypoglycaemia included young age, prior experience of severe hypoglycaemia, and perceived disruption of work life attributable to hypoglycaemia.21 It is not uncommon for patients to intentionally omit doses of insulin and/or eat excessively to avoid hypoglycaemia.
 
Despite a high prevalence, psychological insulin resistance is often under-recognised and inadequately addressed. Studies have demonstrated an association of psychological insulin resistance with high HbA1c.22 A link between depression and psychological insulin resistance has also been identified, suggesting that patients who carry negative emotions are less willing to start and to comply with insulin therapy.17 23 It may be that efforts to alleviate aversion to insulin therapy should be extended to tackling triggers of diabetes-related distress and other emotional concerns.
 
From a practical standpoint, when faced with patients’ unwillingness to initiate insulin, the health care provider should encourage acceptance by exploring the underlying issues and managing concerns in a positive manner, in order to minimise unnecessary delay in treatment titration. In the current issue of the Hong Kong Medical Journal, Lee24 examined the prevalence of psychological insulin resistance in a cross-sectional study of Chinese patients with type 2 diabetes who attended a general out-patient clinic in Hong Kong and assessed the validity and reliability of the Chinese version of the Insulin Treatment Appraisal Scale. Using this instrument, psychological insulin resistance was prevalent in about half of the study subjects. The author, however, also identified a translation problem in at least one of the 20 questions in the questionnaire that may limit its general use in clinical practice. Psychological insulin resistance is a common reaction in people with diabetes and obstructs the necessary transition from oral antidiabetic drug to insulin. Health care professionals who care for patients with diabetes should be alerted to the multi-dimensional nature of psychological insulin resistance and be equipped to attend to various concerns, ease ambivalence, and facilitate a pathway for timely and effective use of insulin therapy.
 
References
1. Xu Y, Wang L, He J, et al. Prevalence and control of diabetes in Chinese adults. JAMA 2013;310:948-59. Crossref
2. Roglic G, Unwin N, Bennett PH, et al. The burden of mortality attributable to diabetes: realistic estimates for the year 2000. Diabetes Care 2005;28:2130-5. Crossref
3. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998;352:837-53. Crossref
4. Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 10-Year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359:1577-89. Crossref
5. Standards of medical care in diabetes—2016. Diabetes Care 2016;39(Suppl 1):S1-106.
6. Rubino A, McQuay LJ, Gough SC, Kvasz M, Tennis P. Delayed initiation of subcutaneous insulin therapy after failure of oral glucose-lowering agents in patients with type 2 diabetes: a population-based analysis in the UK. Diabet Med 2007;24:1412-8. Crossref
7. Polonsky WH, Fisher L, Guzman S, Villa-Caballero L, Edelman SV. Psychological insulin resistance in patients with type 2 diabetes: the scope of the problem. Diabetes Care 2005;28:2543-5. Crossref
8. Larkin ME, Capasso VA, Chen CL, et al. Measuring psychological insulin resistance: barriers to insulin use. Diabetes Educ 2008;34:511-7. Crossref
9. Woudenberg YJ, Lucas C, Latour C, Scholte op Reimer WJ. Acceptance of insulin therapy: a long shot? Psychological insulin resistance in primary care. Diabet Med 2011;29:796-802. Crossref
10. Doggrell SA, Chan V. Adherence to insulin treatment in diabetes: can it be improved? J Diabetes 2015;7:315-21. Crossref
11. Yeung RO, Zhang Y, Luk A, et al. Metabolic profiles and treatment gaps in young-onset type 2 diabetes in Asia (the JADE programme): a cross-sectional study of a prospective cohort. Lancet Diabetes Endocrinol 2014;2:935-43. Crossref
12. Peyrot M. Psychological insulin resistance: overcoming the barriers to insulin therapy. Pract Diabetol 2004;23:6-12.
13. Jenkins N, Hallowell N, Farmer AJ, Holman RR, Lawton J. Participants’ experiences of intensifying insulin therapy during the Treating to Target in Type 2 Diabetes (4-T) trial: qualitative interview study. Diabet Med 2011;28:543-8. Crossref
14. Wong S, Lee J, Ko Y, Chong MF, Lam CK, Tang WE. Perceptions of insulin therapy amongst Asian patients with diabetes in Singapore. Diabet Med 2011;28:206-11. Crossref
15. Fitzgerald JT, Gruppen LD, Anderson RM, et al. The influence of treatment modality and ethnicity on attitudes in type 2 diabetes. Diabetes Care 2000;23:313-8. Crossref
16. Polonsky WH, Hajos TR, Dain MP, Snoek FJ. Are patients with type 2 diabetes reluctant to start insulin therapy? An examination of the scope and underpinnings of psychological insulin resistance in a large, international population. Curr Med Res Opin 2011;27:1169-74. Crossref
17. Snoek FJ, Skovlund SE, Pouwer F. Development and validation of the insulin treatment appraisal scale (ITAS) in patients with type 2 diabetes. Health Qual Life Outcomes 2007;5:69. Crossref
18. Polonsky WH, Jackson RA. What’s so tough about taking insulin? Addressing the problem of psychological insulin resistance in type 2 diabetes. Clin Diabetes 2004;22:147-50. Crossref
19. Brod M, Kongsø JH, Lessard S, Christensen TL. Psychological insulin resistance: patient beliefs and implications for diabetes management. Qual Life Res 2009;18:23-32. Crossref
20. Fu SN, Wong CK, Chin WY, Luk W. Association of more negative attitude towards commencing insulin with lower glycosylated hemoglobin (HbA1c) level: a survey on insulin-naïve type 2 diabetes mellitus Chinese patients. J Diabetes Metab Disord 2016;15:3. Crossref
21. Shiu AT, Wong RY. Fear of hypoglycaemia among insulin-treated Hong Kong Chinese patients: implications for diabetes patient education. Patient Educ Couns 2000;41:251-61. Crossref
22. Fu AZ, Qiu Y, Radican L. Impact of fear of insulin or fear of injection on treatment outcomes of patients with diabetes. Curr Med Res Opin 2009;25:1413-20. Crossref
23. Makine C, Karşidağ C, Kadioğlu P, et al. Symptoms of depression and diabetes-specific emotional distress are associated with a negative appraisal of insulin therapy in insulin-naïve patients with type 2 diabetes mellitus. A study from the European Depression in Diabetes [EDID] Research Consortium. Diabet Med 2009;26:28-33. Crossref
24. Lee KP. Validity and reliability of the Chinese version of the Insulin Treatment Appraisal Scale among primary care patients in Hong Kong. Hong Kong Med J 2016;22:306-13. Crossref

Mammography for breast cancer detection in Hong Kong

Hong Kong Med J 2016 Jun;22(3):200–1
DOI: 10.12809/hkmj164916
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
Mammography for breast cancer detection in Hong Kong
Kathy CK Wong, FHKCR, FHKAM (Radiology)1; CY Lui, FHKCR, FHKAM (Radiology)2
1 Department of Diagnostic and Interventional Radiology, Kwong Wah Hospital, Yaumatei, Hong Kong
2 Hong Kong Women’s Imaging Limited, Suite 319, 3/F, Central Building, 1-3 Pedder Street, Central, Hong Kong
 
Corresponding author: Dr Kathy CK Wong (kathyckwong@gmail.com)
 
 Full paper in PDF
 
Breast cancer poses a significant health burden worldwide. It is the most common cancer in women with nearly 1.7 million new cases diagnosed globally in 2012.1 Early detection reduces mortality and mammogram screening has been shown to achieve a mortality reduction of 25% to 28%.2 3 Many countries have a breast screening programme, including the UK, Australia, Norway, Sweden, the US, Singapore, Japan, and Korea. Population screening for breast cancer remains controversial, however, especially the decision on whom, when, and how to screen due to different epidemiological characteristics of breast cancer in different populations. In Hong Kong, the incidence and mortality of Asian female breast cancer is lower compared with the Caucasian population. In the Surveillance and Health Services Research in 2013, the American Cancer Society published a lifetime risk of 1 in 8 for developing invasive female breast cancer,4 similar to the findings of Cancer Research UK in 2010.5 The median age at diagnosis of cancer was 61 years in 2006 to 2010 in these studies. In Hong Kong, breast cancer is the number-one female cancer with 3524 cases of invasive cancer diagnosed in 2013. The lifetime risk of female breast cancer before the age of 75 years was 1 in 17. Breast cancer in Hong Kong occurs at a younger age compared with the western population. The median age at diagnosis of breast cancer was 54 years.6 Due to different tumour characteristics and the overall smaller size and denser fibroglandular tissue of Asian women’s breasts, local epidemiology and clinical studies are important to facilitate our understanding of this common disease in Hong Kong. In this issue of the Hong Kong Medical Journal, studies conducted by Lau et al7 and Chan et al8 in Hong Kong provide valuable local data on this important topic.
 
Lau et al7 compared the surgical outcome and pathology of breast cancer in self-detected and screen-detected women (physical breast examination, mammogram, or ultrasound) in their institute in Hong Kong. Several interesting aspects are raised. First, the screen-detected group had a smaller tumour of an earlier stage and lower grade with less lymph node involvement. This could imply that early detection may result in better prognosis. Previous studies have suggested reduced mortality with early breast cancer detection.9 Less-invasive surgery is feasible such as breast-conserving surgery with better cosmetic outcome. Second, there was a trend towards increased detection of smaller tumours of <2 cm in the screen-detected group, likely explained by the advances in radiological imaging technology in mammogram and ultrasound. The self-detection trend remained static suggesting no significant change in skills throughout the study period. While the difference did not reach statistical significance, the trend could suggest a higher sensitivity of radiological imaging to detect small tumours. Third, the mean age at first diagnosis of breast cancer was 50 years (range, 24-92 years) and median age of 40 to 49 years in both the self-detected and screen-detected groups in this study. This is substantially lower than the median age of 54 years reported in the Hong Kong Cancer statistics in 20136 and the age of 61 years reported for the UK and the US in 2010.4 5 Notably, the highest proportion of breast cancer was detected in the 40- to 49-year-old age-group in this study (38.6% and 43.5% of the self-detected and screen-detected group, respectively). A striking proportion of breast cancer was also detected in the 20- to 39-year-old age-group (16.6% and 7.0% in the self-detected and screen-detected group, respectively). This finding of breast cancer at younger age deserves further research and attention.
 
Chan et al8 explored the impact of a radiolucent MammoPad (Hologic Inc, Bedford [MA], US) during mammogram on pain/comfort level, radiation dose, and image quality. Mammography involves breast compression in two or more views with radiation exposure. Discomfort and pain are often encountered during breast compression and may affect a woman’s willingness to undergo a mammogram. In their study, most women (71%) experienced less pain, coldness, and hardness of the paddle with a better overall feeling. None of the patients reported additional discomfort with the pad. Women with less-dense breasts were more likely to experience more comfort with the pad. Age and breast size did not relate to the degree of discomfort during mammogram. Comparable image quality between the padded and non-padded side was noted in 92% of women. While image quality difference was perceived in 4%, none was considered to have affected the diagnostic accuracy. Furthermore, glandular dose was 6.5% less in the mediolateral oblique view and 4.5% less in the craniocaudal view when a pad was used. Nonetheless, the role and efficacy of the MammoPad in diagnostic mammography was not determined in this study due to the exclusion of women with known carcinoma, scarring, or pathology detected by clinical breast examination. Further, the additional time required and cost of applying a single-use MammoPad may raise financial concerns in the setting of a publicly funded large-scale breast screening programme, unless the cost can be further lowered or pads can be recycled following effective sterilisation.
 
Despite agreement on the benefit of early cancer detection and treatment, debate about population-based breast cancer screening remains. The younger age of disease onset identified by Lau et al7 deserves further attention as high breast density, associated with younger age and lower body mass index, reduces mammogram sensitivity. Newer technology such as digital breast tomosynthesis may provide higher sensitivity and increase cancer detection rate compared with digital mammography because of its ability to remove overlapping glandular tissue, the main reason for both false-positive and -negative results with traditional mammography.10 11 12 13 14 Although tomosynthesis requires breast compression similar to mammogram, the compression force may be lower without affecting image quality.14 Further studies would be helpful to determine whether the benefits of the MammoPad used by Chan et al8 could have further benefit in tomosynthesis.
 
Hong Kong currently has no government-subsidised programme for breast cancer screening. Self-financed opportunistic screening is available mostly in the private sector. The suitability of breast cancer screening on a population-wide level in Hong Kong, including cost-effectiveness,15 remains to be determined. Such a decision should be evidence-based and tailored to local epidemiology so that the benefits of screening outweigh the risks. In addition, the method of screening should be sensitive and suitable for the woman’s breast density, age, and personal and family risk of developing breast cancer.
 
References
1. Ferlay J, Soerjomataram I, Ervik M, et al. GLOBOCAN 2012 v1.1, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11. Lyon, France: International Agency for Research on Cancer; 2014. Available from: http://www.wcrf.org/int/cancer-facts-figures/data-specific-cancers/breast-cancer-statistics. Accessed 16 Jan 2015.
2. Weedon-Fekjær H, Romundstad PR, Vatten LJ. Modern mammography screening and breast cancer mortality: population study. BMJ 2014;348:g3701. Crossref
3. World Health Organization. IARC handbooks of cancer prevention: handbook 7: breast cancer screening. IARC Press; 2001.
4. American Cancer Society. Breast Cancer Facts & Figures 2013-2014. Atlanta: American Cancer Society Inc; 2013.
5. Lifetime risk estimates calculated by the Statistical Information Team at Cancer Research UK. Based on data provided by the Office of National Statistics, ISD Scotland, the Welsh Cancer Intelligence and Surveillance Unit and the Northern Ireland Cancer Registry, on request, December 2013 to July 2014. Available from: http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/breast-cancer/incidence-invasive#heading-Four. Accessed Apr 2016.
6. Female breast cancer in 2013. Hong Kong Cancer Registry, Hospital Authority, February 2016. Available from: http://www3.ha.org.hk/cancereg/breast_2013.pdf. Accessed Apr 2016.
7. Lau SS, Cheung PS, Wong TT, Ma MK, Kwan WH. Comparison of clinical and pathological characteristics between screen-detected and self-detected breast cancers: a Hong Kong study. Hong Kong Med J 2016;22:202-9. Crossref
8. Chan HH, Lo G, Cheung PS. Is pain from mammography reduced by the use of radiolucent MammoPad? Local experience in Hong Kong. Hong Kong Med J 2016;22:210-5. Crossref
9. Gøtzsche PC, Nielsen M. Screening for breast cancer with mammography. Cochrane Database Syst Rev 2011;(1):CD001877. Crossref
10. Lei J, Yang P, Zhang L, Wang Y, Yang K. Diagnostic accuracy of digital breast tomosynthesis versus digital mammography for benign and malignant lesions in breasts: a meta-analysis. Eur Radiol 2014;24:595-602. Crossref
11. Friedewald SM, Rafferty EA, Rose SL, et al. Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA 2014;311:2499-507. Crossref
12. Ciatto S, Houssami N, Bernardi D, et al. Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study. Lancet Oncol 2013;14:583-9. Crossref
13. Skaane P, Bandos Al, Gullien R, et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology 2013;267:47-56. Crossref
14. Förnvik D, Andersson I, Svahn T, Timberg P, Zackrisson S, Tingberg A. The effect of reduced breast compression in breast tomosynthesis: human observer study using clinical cases. Radiat Prot Dosimetry 2010;139:118-23. Crossref
15. Wong IO, Kuntz KM, Cowling BJ, Lam CL, Leung GM. Cost-effectiveness analysis of mammography screening in Hong Kong Chinese using state-transition Markov modelling. Hong Kong Med J 2010;16 Suppl 3:38S-41S.

Tobacco control policy in Hong Kong

Hong Kong Med J 2016 Apr;22(2):96–7
DOI: 10.12809/hkmj164848
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
Tobacco control policy in Hong Kong
Jeff PM Lee, FHKCCM, FHKAM (Community Medicine)
Tobacco Control Office, Department of Health, Hong Kong
 
Corresponding author: Dr Jeff PM Lee (pmlee@dh.gov.hk)
 
 Full paper in PDF
 
Present policy
Tobacco dependence is a chronic disease that is responsible for over 6900 deaths a year in Hong Kong1 and nearly 6 million deaths a year worldwide. It is also the single most important preventable risk factor responsible for death and chronic disease, including cancer and cardiovascular diseases. The harm of smoking, including exposure to second-hand smoke, is well-established by scientific research and well-recognised by the community both locally and internationally. The Framework Convention on Tobacco Control (FCTC) of the World Health Organization (WHO) represents the international efforts to address tobacco dependence as a public health epidemic. China is a signatory of and has ratified FCTC, the application of which has been extended to Hong Kong since 2006.
 
The Hong Kong SAR Government’s tobacco control policy seeks to safeguard public health by discouraging smoking, containing the proliferation of tobacco use and minimising the impact of passive smoking on the public. Our multipronged approach—comprising legislation and enforcement, taxation, publicity and education, as well as smoking cessation services—has gradually reduced the smoking prevalence from 23.3% in early 1982 to 10.5% in 2015.2
 
Legislation and enforcement
The Smoking (Public Health) Ordinance stipulates statutory no-smoking areas and regulates the advertisement, promotion, packaging, and labelling of tobacco products. Smoking is banned in all indoor areas of workplaces and public places, including restaurants and bars, as well as certain outdoor areas, including open areas of schools, leisure facilities, bathing beaches, and public transport facilities. Persons who smoke or carry a lighted cigarette, cigar, or pipe in statutory no-smoking areas or on public transport are liable to a fixed penalty of HK$1500 under the Fixed Penalty (Smoking Offences) Ordinance. Advertising and promoting tobacco products is prohibited in Hong Kong. As a principal enforcement agency under the Ordinance, the Department of Health (DH) Tobacco Control Office (TCO) conducted over 27 000 inspections and issued 7500 fixed penalty notices/summonses for smoking offences in 2015.
 
Further legislative measures
To further strengthen our tobacco control efforts, we are working on the following three key legislative proposals taking into account overseas experience and in response to new developments in the tobacco market.
 
First, since 2010, the smoking ban has been extended to over 200 public transport facilities. There have been suggestions to designate more transport facilities as no-smoking areas to further protect the public from secondhand smoke exposure. As a first step, we propose to extend the statutory no-smoking areas to include bus interchange (BI) facilities located at the eight tunnel portal areas to protect the public while waiting at these BIs—the relevant legislation has been passed in January and should be enacted on 31 March 2016. We will keep this initiative under review and consider further extension of no-smoking areas.
 
Second, pictorial health warnings have appeared on tobacco products since 2007. To further enhance their effectiveness as a deterrent and educate smokers about the health risks associated with smoking, the Government proposed to enlarge pictorial health warnings from at least 50% to 85% of the pack size, increase the number of forms of health warning from six to 12, and display details of Quitline.
 
Third, overseas reports reveal that electronic cigarettes (e-cigarette) are becoming increasingly popular, particularly among children and adolescents.3 4 5 6 E-cigarettes have been shown to contain respiratory irritants and even carcinogenic substances. Apart from health effects, the WHO has also expressed concerns about the “gateway” and “renormalisation” effects that have the potential to significantly undermine our tobacco control efforts. The scientific evidence to support the effectiveness of the e-cigarette as a cessation tool is limited and inconclusive so far. Given the potential impact of the use of e-cigarettes on tobacco control efforts, especially for the young population, the Government proposes to strengthen the existing legislative framework and prohibit their import, manufacture, sale, distribution, and advertising, before they become prevalent and harm human health. In the meantime, we will increase publicity and public education, by making use of mass media channels and working with relevant stakeholders including schools and health care professionals, to publicise the potential harm of e-cigarettes.
 
Tobacco duty
Tobacco duty rate was last increased by 11.72% in 2014, so that duty constituted 70% of the retail price of cigarettes. The Government will monitor closely changes in cigarette retail prices and the overall smoking situation in Hong Kong and review the tobacco duty rate regularly.
 
Smoking cessation services
Nicotine is addictive. While the above legislative and taxation measures serve as incentives to quit, smokers require adequate support to do so successfully. The Government holds the view that smoking cessation is an integral and indispensable part of its tobacco control policy to complement other tobacco control measures. The TCO operates an integrated Smoking Cessation Hotline (Quitline: 1833 183) to provide general professional counselling and information on smoking cessation, and arrange referrals to various smoking cessation services in Hong Kong.
 
At present, DH operates five smoking cessation clinics, while the Hospital Authority operates 16 full-time and 42 part-time smoking cessation clinics. To further strengthen the provision of smoking cessation services in the community, the Government has in recent years engaged local non-governmental organisations (NGOs) in providing free community-based smoking cessation services. As reported in the original article in this issue by Ho et al,7 the Tung Wah Group of Hospitals is one of our NGO partners that provides smoking cessation services through its Integrated Centre on Smoking Cessation set up in different districts of Hong Kong. They have adopted an integrated model of counselling and pharmacotherapy, and the quit rate at week 26 is 35.1%.7 Apart from counselling and pharmacotherapy, the Government also engages other NGOs to enhance smoking cessation services with different approaches including acupuncture, an outreach service to workplaces, and services for ethnic minorities and new immigrants. The quit rate of these services ranges between 25% and 30%.
 
Given the expertise of health care professionals in the area, we have a prominent role to play in helping patients to quit smoking. There is evidence that the provision of brief advice from a physician can increase the chance of quitting when compared with no advice (relative risk, 1.66; 95% confidence interval, 1.42-1.94).8 As such, doctors may incorporate brief cessation advice and counselling into their consultations with patients who are smokers. This may motivate smokers to quit and contribute significantly to their health.
 
The health of the public is every health care professional’s paramount concern. The Government strives to control tobacco use through a multipronged approach. We will continue our efforts to strengthen the tobacco control regimen. With the concerted efforts of health care professionals, community organisations and the public, we will continue to work towards our next target—a single-digit smoking prevalence.
 
References
1. McGhee SM, Ho LM, Lapsley HM, et al. Cost of tobacco-related diseases, including passive smoking, in Hong Kong. Tob Control 2006;15:125-30. Crossref
2. Thematic Household Survey Report, Report No. 59: Pattern of smoking. Hong Kong: Census and Statistics Department; 2016. Available from: http://www.statistics.gov.hk/pub/B11302592016XXXXB0100.pdf. Accessed Feb 2016.
3. Arrazola RA, Neff LJ, Kennedy SM, Holder-Hayes E, Jones CD; Centers for Disease Control and Prevention (CDC). Tobacco use among middle and high school students—United States, 2013. MMWR Morb Mortal Wkly Rep 2014;63:1021-6.
4. Centers for Disease Control and Prevention (CDC). Tobacco product use among middle and high school students—United States, 2011 and 2012. MMWR Morb Mortal Wkly Rep 2013;62:893-7.
5. Johnston LD, O’Malley PM, Miech RA, Bachman JG, Schulenberg JE. Monitoring the future national survey results on drug use: 1975-2014: overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, The University of Michigan. Available from: http://www.monitoringthefuture.org/pubs/monographs/mtf-overview2014.pdf. Accessed Jan 2016.
6. Knowledge and Analytical Services of Welsh Government. Exposure to secondhand smoke in cars and e-cigarette use among 10-11 year old children in Wales: CHETS Wales 2. Welsh Government Social Research, 3 December 2014. Available from: http://gov.wales/statistics-and-research/exposure-secondhand-smoke-cars-ecigarette-use-among-children/?lang=en. Accessed Jan 2016.
7. Ho KS, Choi BW, Chan HC, Ching KW. Evaluation of biological, psychosocial, and interventional predictors for success of a smoking cessation programme in Hong Kong. Hong Kong Med J 2016;22:158-64. Crossref
8. Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev 2013;(5):CD000165. Crossref

To improve the quality of life in elderly people with fragility fractures

Hong Kong Med J 2016 Feb;22(1):4–5
DOI: 10.12809/hkmj154782
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
To improve the quality of life in elderly people with fragility fractures
PY Lau, FHKCOS, FHKAM (Orthopaedic Surgery)
Department of Orthopaedics and Traumatology, United Christian Hospital, Hong Kong
 
 Full paper in PDF
 
The global increasing elderly population is placing a great burden on the financial and health systems of all countries. A major source of this burden is fragility fracture.1 In Hong Kong, around 6000 patients present each year with hip fracture, and current projections indicate that the numbers will double by 2050.2 3
 
Fragility fracture has long been a major source of the workload for orthopaedic departments in Hong Kong. Patients with hip, vertebral, or wrist fracture occupy a high percentage of orthopaedic beds in all public hospitals. Most hip fractures require either internal fixation or hip replacement to alleviate fracture pain and allow early ambulation.4 5 A decade ago, most hip fracture patients in Hong Kong would wait 5 to 6 days for surgery because health personnel—including orthopaedic surgeons, anaesthetists, and nurses—did not consider the condition to be important. Nonetheless such a delay is now known to increase in-patient and postoperative mortality and morbidity. The Blue Book of the British Orthopaedic Association 2007 stated that hip fractures should be operated on within 48 hours.2 In 2009, the Hospital Authority selected geriatric hip fracture as the first Key Performance Indicator for orthopaedics in Hong Kong.6 The aim was to confine preoperative stay to no more than 2 days for 70% of hip fracture patients. Prior to 2007 this figure was approximately 30%, but had improved to 62% by August 2008. The mean preoperative length of stay has now been reduced by 3.5 days, from the previous 6 days. By 2009, the hard work of all orthopaedic surgeons, geriatricians, and allied health colleagues had shortened the waiting time to 2 days in 70% of patients.6 Postoperative mortality and morbidity are also much reduced and, more importantly, the length of time the patient has fracture pain. These elderly now walk earlier and are discharged earlier. Thus their quality of life is improved and more hospital beds are available for other patients.
 
There are a few tests that help the orthopaedic surgeons to assess mortality risks of hip fracture patients. They are discussed in one of the articles in this issue, and improve communication between the doctor and patient’s family, as well as minimising any misunderstanding.7
 
In patients with vertebral fracture, treatment is mostly conservative although some suffer significant back pain and may be bedridden for a few months. Nonetheless with advances in technology patients who do not respond well to conservative treatment now benefit from vertebroplasty, which implies injection of bone cement into the fractured vertebra.8 Good pain relief is achieved in many patients postoperatively, enabling early rehabilitation.
 
Wrist fracture is a very common problem in the elderly after a fall. For a long time, treatment was focused on closed reduction and application of plaster-of-Paris (POP) although such plaster immobilisation resulted in stiffness and pressure sores. Patients often required a long period of physiotherapy to regain movement. Internal fixation was seldom performed because the failure rate with old implants was high. The development of new locking anatomical plates and bone substitute has greatly improved the success rate of surgery and these patients can now move their wrist much earlier following surgery and avoid the complications associated with POP immobilisation.
 
With increasing use of new surgical techniques and implants, the number of operative complications is expected to rise. The price of the implants is also considerably increased and management of complications is often difficult in these elderly patients. This may place increasing demands on hospital services and budget. Adequate training and supervision of junior doctors is required to ensure the job is done well.
 
Prevention is always better than treatment. Several osteoporotic drugs are widely used to help in the treatment and prevention of osteoporosis. Their use is usually long-term and they are not cheap, however.
 
Apart from osteoporosis, sarcopenia is another factor that causes fall of the elderly and is also discussed in this issue of the journal.9 Paying more attention to nutrition is very important in these elderly to build up muscle bulk. Many of these patients have medical co-morbidities so collaboration of geriatricians with orthopaedic surgeons is of utmost importance to ensure uninterrupted and well-coordinated pre- and post-operative care. All patients with fragility fracture after a fall should be offered a multidisciplinary service to prevent another fall. It is advisable for public hospitals to organise a team of staff that includes orthopaedic surgeons, geriatricians, allied health colleagues and nurses with special interest in this field to manage these patients with fragility fracture together.
 
Longevity is nothing to admire, rather we should pursue a better quality of life for our senior citizens. Looking after patients with fragility fracture well is a lot cheaper than looking after them badly. The Hong Kong SAR Government and community should invest more in the care of these patients. The rewards can be surprisingly high.
 
References
1. American Academy of Orthopaedic Surgeons. Position statement: Recommendations for enhancing the care of patients with fragility fractures. June 2003. Revised December 2009. Available from: http://www.aaos.org/CustomTemplates/Content.aspx?id=22324&ssopc=1. Accessed Dec 2015.
2. The care of patients with fragility fracture. British Orthopaedic Association. September 2007. Available from: http://www.fractures.com/pdf/BOA-BGS-Blue-Book.pdf. Accessed Dec 2015.
3. 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
4. Hip fracture: management. Clinical guideline. National Institute for Health and Care Excellence (NICE). 22 June 2011. Available from: http://www.nice.org.uk/guidance/cg124/resources/hip-fracture-management-35109449902789. Accessed Dec 2015.
5. Chan VW, Chan PK, Chiu KY, Yan CH, Ng FY. Why do Hong Kong patients need total hip arthroplasty? An analysis of 512 hips from 1998 to 2010. Hong Kong Med J 2016;22:11-5. Crossref
6. Report of the Chairman. COC in Orthopaedics and Traumatology. Hong Kong: Hospital Authority; 2009.
7. Lau TW, Fang C, Leung F. Assessment of postoperative short-term and long-term mortality risk in Chinese geriatric patients for hip fracture using the Charlson comorbidity score. Hong Kong Med J 2016;22:16-22. Crossref
8. Heini PF, Wälchli B, Berlemann U. Percutaneous transpedicular vertebroplasty with PMMA: operative technique and early results. A prospective study for the treatment of osteoporotic compression fractures. Eur Spine J 2000;9:445-50. Crossref
9. Ho AW, Lee MM, Chan EW, et al. Prevalence of pre-sarcopenia and sarcopenia in Hong Kong Chinese geriatric patients with hip fracture and its correlation with different factors. Hong Kong Med J 2016;22:23-9. Crossref

Intensive care unit outcome in the elderly

Hong Kong Med J 2015 Dec;21(6):488–9
DOI: 10.12809/hkmj154727
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
Intensive care unit outcome in the elderly
Karl Young, FHKCA (Intensive Care), MPH (HK)
Department of Intensive Care Unit (Adult), Queen Mary Hospital, Pokfulam, Hong Kong
 
Corresponding author: Dr Karl Young (karlkyoung@gmail.com)
 
 Full paper in PDF
 
Worldwide, intensive care units (ICUs) are experiencing a burgeoning crisis: not enough beds for apparently endless needs.1 2 Every day intensivists must make hard choices. This triage task is truly daunting; how does one choose which patient to admit or reject from a dizzying melange of elective and emergency cases, all manner of medical and surgical diseases, the gamut of clinical severity from stable to near death, and an age spectrum from teenager to centenarian?
 
In making these choices, age must be one of the implicit or explicit factors. On the one hand, increasing elderly ICU demand reflects many factors: changing demographics, increased expectations of patients and their family, more aggressive and successful medical and surgical procedures in the elderly, and strong ethical and political advocacies against age discrimination. On the other hand, the elderly may have less capacity to benefit from intensive care, often suffer poor quality of life and infirmity, may be demented or otherwise cognitively impaired, and strain the health-acare budget to a point where other age-groups are compromised.
 
Many publications have recently focused on the elderly and ICU: what proportion of patients are elderly, what resources they consume, and what their outcome is.3 4 5 6 The retrospective study by Shum et al7 published in this issue is the first Hong Kong study to analyse the outcomes of elderly ICU patients. A reader would not be surprised that findings are broadly consistent with those of other studies: the elderly constitute an increasing proportion of patients, they have a greater disease severity and burden of co-morbidity, and they have significant in-hospital and post-discharge mortality rates. On the flip side, the hospital/180-day survival rates for the 60-79 years’ age-group were 82.8%/74.5% and for the ≥80-years’ age-group they were 71.7%/62.2%... perhaps better than expected! Resource utilisation was considerable, however. The overall ventilation rate was 50.6% and the use of renal replacement therapy was 15.0%. Although the ICU length of stay (LOS) for survivors was only 3.7 (standard deviation, 5.5) days, the hospital LOS was 22.1 (62.9) days. Convalescent hospital care was required for 23.6% of survivors.7
 
As a single-centre study, the question arises whether these findings are representative of Hong Kong ICUs in general. An examination of the data reveals a unit that has good standardised mortality outcomes, a broad mix of sources of admission and attending specialties, and a range of admission diagnoses. What is not so clear is the reason why even though 39.6% were postoperative admissions, 83.8% of all elderly admissions were emergencies. There is no information on what triage guidelines may have been used, and there are no demographic or outcome data on those patients that were refused admission. Also missing are any data from age-groups other than these two elderly cohorts. The extent of withdrawal or limitation of therapy is unknown. Importantly, the quality of life of survivors is also unknown.
 
This study7 helps to fill a gap in the available information about ICU care of the elderly in Hong Kong. The authors acknowledge that missing information limits the ability to draw inferences, and conclude that further investigation is indicated.7 So what further questions could guide research?
 
First, what is the attitude of Hong Kong intensivists regarding their imposed role as agents to ration limited resources? Triage is only avoidable if one strictly adopts a ‘first come, first served’ decision-making rule. Is it fair to expect doctors to trade off their duty to individual patients against their duty to society?8 The ethical dilemmas and practical problems posed by triage for intensive care are well described.9 10 11
 
Second, what do they understand and believe about the ethics of health-care rationing, in particular whether the ‘women and children first’ moral code of the lifeboat dilemma applies to ICU. If one believes younger lives are more valuable, one would also adhere to the principles behind the ‘complete lives system’ or economic rationalism.12 13 14 On the other hand, these beliefs have been rejected.15 16
 
Third, the quality of life of patients both before and after hospitalisation is important. Formerly, it may have been an important predictor of both life expectancy and the likelihood of benefit of care.17 18 More recently the results of studies on the quality of life after ICU admission have been conflicting and there are no data for Hong Kong.19 20
 
References
1. Halpern NA, Pastores SM. Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med 2010;38:65-71. Crossref
2. Nguyen YL, Angus DC, Boumendil A, Guidet B. The challenge of admitting the very elderly to intensive care. Ann Intensive Care 2011;1:29. Crossref
3. Bagshaw SM, Webb SA, Delaney A, et al. Very old patients admitted to intensive care in Australia and New Zealand: a multi-centre cohort analysis. Crit Care 2009;13:R45. Crossref
4. Roche A, Wiramus S, Pauly V, et al. Long-term outcome in medical patients aged 80 or over following admission to an intensive care unit. Crit Care 2011;15:R36. Crossref
5. Reinikainen M, Uusaro A, Niskanen M, Ruokonen E. Intensive care of the elderly in Finland. Acta Anaesthesiol Scand 2007;51:522-9. Crossref
6. Fuchs L, Chronaki CE, Park S, et al. ICU admission characteristics and mortality rates among elderly and very elderly patients. Intensive Care Med 2012;38:1654-61. Crossref
7. Shum HP, Chan KC, Wong HY, Yan WW. Outcome of elderly patients receiving intensive care in a regional hospital. Hong Kong Med J 2015;21:490-8. Crossref
8. Weinstein MC. Should physicians be gatekeepers of medical resources? J Med Ethics 2001;27:268-74. Crossref
9. Joynt GM, Gomersall CD. Making moral decisions when resources are limited—an approach to triage in ICU patients with respiratory failure. Southern African Journal of Critical Care 2005;21:34-44.
10. Sprung CL, Danis M, Iapichino G, et al. Triage of intensive care patients: identifying agreement and controversy. Intensive Care Med 2013;39:1916-24. Crossref
11. Courtwright A. Who is “too sick to benefit”? Hastings Cent Rep 2012;42:41-7. Crossref
12. Persad GC, Wertheimer A, Emanuel EJ. Standing behind our principles: Meaningful guidance, moral foundations, and multi-principle methodology in medical scarcity. Am J Bioeth 2010;10:46-8. Crossref
13. Persad G, Wertheimer A, Emanuel EJ. Principles for allocation of scarce medical interventions. Lancet 2009;373:426-31. Crossref
14. Relman AS. Is rationing inevitable? N Engl J Med 1990;322:1809-10. Crossref
15. Kerstein SJ, Bognar G. Complete lives in the balance. Am J Bioeth 2010;10:37-45. Crossref
16. Hunt RW. A critique of using age to ration health care. J Med Ethics 1993;19:19-27. Crossref
17. Lubitz J, Cai L, Kramarow E, Lentzner H. Health, life expectancy, and health care spending among the elderly. N Engl J Med 2003;349:1048-55. Crossref
18. Hofhuis JG, Spronk PE, van Stel HF, Schrijvers AJ, Bakker J. Quality of life before intensive care unit admission is a predictor of survival. Crit Care 2007;11:R78. Crossref
19. Cuthbertson BH, Roughton S, Jenkinson D, Maclennan G, Vale L. Quality of life in the five years after intensive care: a cohort study. Crit Care 2010;14:R6. Crossref
20. Hofhuis JG, van Stel HF, Schrijvers AJ, Rommes JH, Spronk PE. ICU survivors show no decline in health-related quality of life after 5 years. Intensive Care Med 2015;41:495-504. Crossref

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