A Review of Hallux Valgus Deformity

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B U L L E T I N A Review of Hallux Valgus DeformityDr. TAI Hei Yan, Diane

Editorial 1

Spotlight 2A Review of Hallux Valgus Deformity

Cardiology 8A Case Of Acute Pulmonary Edema

Dermatology 11A 73-Year-Old Man Presented With Asymptomatic Skin Discolouration

Answer Sheet 12

CME Notifications 15

Meeting Highlights 18

CME Calendar 20

Contents

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EDITORIALThe Impact of COVID-19 on Men’s Health

Professor Yuen Kwok-yung and his microbiology team reported the detrimental effect of coronavirus on male hamsters’ reproductive organ that is preventable by COVID vaccination.

Theories for virus affecting human testis included: 1. Direct immune damage, 2. Febrile illness and temperature effect on spermatogenesis, and 3. Disruption to Sertoli cell which maintain the blood-testis barrier.

Viral damage to testicular function is known for long time. Adult mumps orchitis is a well-known cause of infertility. It accounts for up to 13% of male infertility.

Febrile illness has been known to temporarily inhibit spermatogenesis. Studies have shown fever can induce azoospermia in normal adult. It takes time for complete recovery.

Past evidence in SARS-CoV infection (not SARS-CoV2), autopsy showed evidence of orchitis with thickened basement membrane and leukocyte infiltration. The exact pathogenesis mechanism is yet to be confirmed.

As clinician and as urologist, we should show the evidence to and educate our patients. Promoting COVID vaccination and preventing such complication in our population is our job.

Dr. MAK Siu KingCo-editor, Hong Kong Medical Association CME Bulletin

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A Review of Hallux Valgus Deformity

Dr. TAI Hei Yan, DianeMBChB (CUHK), FHKAM (Orthopaedic Surgery), MRCSEd, FRCSEd (Orth), FHKCOSSpecialist in Orthopaedics and Traumatology

Introduction

Hallux valgus is a common foot deformity. It was estimated to affect 23% of adults aged 18 to 65 years and is associated with a variety of symptoms. [1] If left untreated, the quality of life of patients with symptomatic hallux valgus has been shown to be lower than that of the general population. [2-3] Therefore proper evaluation and timely treatment are important to prevent symptom progression. After reading this article, you will have an understanding on the pathogenesis of hallux valgus, how we assess its severity and the treatment strategy with some case example illustrations.

Pathogenesis

The pathogenesis of hallux valgus is complex. First of all, there is no muscle attachment in the metatarsal heads, so they are more prone to extrinsic deformity forces, especially from tight shoe wear. The metatarsal becomes destabilized and subluxates medially. The tendons drift laterally and become deforming forces. The hallux drifts laterally over the metatarsal head and the deformity progresses. This will create tension at the medial side and compression at the lateral side of the metatarso-phalangeal joint (MTPJ). The lateral tension causes the sesamoid apparatus to fixate laterally, leading to further pronation of hallux and propagation of the hallux valgus deformity. [4-7]

Figure 1. A patient with hallux valgus. The blue arrow is pointing to the bunion, the tension side. Note the underlying bony deformity outlined.

Etiology

There are biomechanical, traumatic and metabolic factors. The most common etiology is biomechanical instabil ity. There are factors leading to biomechanical instability which may include hindfoot equinus, planovalgus deformity, forefoot varus, dorsiflexion of first ray, hypermobility of tarso-metatarsal joint (TMTJ) and short f irst metatarsal bone. Traumatic factors include non-union of metatarsal fractures, soft tissue injury of hallux, etc. Metabolic factors include gouty arthritis, rheumatoid arthritis, psoriatic arthritis, Ehlers-Danlos syndrome, Marfan syndrome, Down syndrome and generalized ligamentous laxity, etc. [8]

Signs and symptoms

Hal lux valgus is associated with a var iety of problems including:1. Inflammation of medial bursa called bursitis, which

indicates shoe irritation and pressure2. Synovitis of MTPJ3. Cartilage wear in metatarsal head and sesamoids4. Entrapment of dorsomedial cutaneous nerve leading to

burning sensation of the hallux5. Claw toes and hammer toes deformity6. Over-riding second toe7. Cal los i t ies on the p lantar sur face of the second

metatarsal head and plantar surface of hallux inter-phalangeal joint (IPJ)

8. Flat foot deformity9. Achilles tendon tightness10. Bunionette (Prominent deformity at the base of little toe)

Patients may present with pain over the first MTPJ during walking. Bunion is the term frequently used by patients to describe a swelling over the medial side of the first MTPJ. The development of swelling may be related to wearing a certain type of shoes especially shoes with tight toe box due to irritation at the metatarsal head. Patients may also complain of pain over the plantar surface of the second metatarsal head, called metatarsalgia. [9-11]

3HKMA CME Bulletin 持續醫學進修專訊 Apr 2022

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Investigation

Weight-bearing x-ray of the foot with anteroposterior (AP), oblique, lateral and sesamoid axial views are required. Weight-bearing films show the structural status of the foot. There are a few angles frequently used to assess the severity of hallux valgus.

• Small tips – weight-bearing views better reflect the deformity than non-weight bearing ones.

Angle How do we measure? Normal range

Hallux valgus angle (HVA)

Between shaft axis of first metatarsal and proximal

phalanx

< 15

Inter-metatarsal angle (IMA)

Between shaft axis of first and second metatarsal

< 9

Distal metatarsal articular angle

(DMAA)

Between distal articular surface and perpendicular line to long axis of first metatarsal

< 10

Inter-phalangeus angle (HVI)

Between shaft axis of distal and proximal phalanges

< 10

Table 1. Common angles used in assessment of hallux valgus on x-ray.

History and physical examination

I t should include a comprehensive assessment to help determine the etiology of the problem, evaluate its severity and guide the treatment plan. First of all, ask for history of trauma and history of metabolic disorders as mentioned previously. Explore how the pain and other symptoms affect the patients in terms of work, sports, social life and mental health.

Physical examination should be focused on evaluating the biomechanical instability. Start with observing the gait. Then check the degree of hallux valgus and pes planus deformity with the patient standing. At the same time, look for associated lesser toes deformity and bunionette deformity. Then have the patient seated and check the entire foot and sole for callosities. Plantar callosities over the hallux IPJ suggest excessive pronation at pushoff during gait cycle.

Next check the motion of ankle joint, sub-talar joint, TMTJ and MTPJ. Normal range of motion for first MTPJ is 65 to 75 degree dorsiflexion and less than 15 degree plantarflexion. Limitation in MTPJ range of motion suggests degenerative changes. Crepitation during movement indicates intra-articular cartilage degeneration. Differential diagnosis includes hallux rigidus.

Hypermobility of TMTJ is assessed with a dorsally directed force on the first metatarsal. The degree of instabil ity is evaluated with reference to the second metatarsal. It is defined as hypermobile if the motion exceeds between 8 to 10mm without a firm end point. [12-13] It has implication on the choice of surgical treatment which will be further elaborated. Don’t forget to check on the shoes the patient is wearing to your clinic. Wearing shoes with tight toe box is one of the extrinsic factors that can lead to hallux valgus.

Figure 2. A patient with hallux valgus and associated claw toe deformity. The left second toe is riding on the hallux, which is called over-riding second toe. The hallux is in pronation. Note also the callosity on the dorsum of proximal inter-phalangeal joint of left second toe (Blue arrow). It could be quite painful upon wearing shoes.

Figure 3. P a t i e n t c o m p l a i n e d o f p a i n o v e r the site where the blue arrow i s p o i n t i n g , which is called metatarsalgia.

Figure 4. Patient with hallux valgus and associated pes planus deformity. Note the collapse of foot arch (blue arrow).


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Figure 5. X-ray of a patient with right foot hallux valgus angle of 38 degree.

Table 2. Traditional radiographic classification of hallux valgus deformity. [14]

Conservative Treatment

Non-operat ive treatment cannot correct hal lux valgus deformity. It is important to understand that the aim of treatment is to control the disease and prevent i t from worsening. However, the underlying pathology is not corrected in conservative treatment and therefore the deformity is not reduced. These measures can be considered in patients with mild severity, which include:

1. Nonsteroidal anti-inflammatory drugs (NSAIDs)2. Physio therapy3. Self-stretching exercises4. Functional orthosis – Toe spacer and night splint5. Insoles – For associated flat foot deformity6. Activities modification7. Shoe wear modification – wear shoes with wide toe box

and add padding over medial first MTPJ

• Small tips – Please follow up these patients in 6-9 months to check if there is progressive deformity. Refer to Orthopaedic colleagues if so.

Figure 6. Examples of night splint, metatarsal pad and toe spacer as conservative treatment for hallux valgus.

Operative treatment

It is indicated in patients with failed conservative treatments. There are over 100 different techniques of corrective surgeries described in the literature, which most often involve soft tissue procedures, bony osteotomies and arthrodesis. There are some commonly performed soft tissue procedures and osteotomies as shown below:

Soft tissue procedures – Modif ied Mcbride procedure involves release of adductus hallucis tendon and lateral sesamoid suspensory ligament. The medial joint capsule is also excised and plicated. These are usually combined with other osteotomies. Isolated Mcbride procedure shows inferior results and higher recurrence rate when compared with distal osteotomies [15-16]

Akin’s osteotomy – It is a medial closing wedge osteotomy of the proximal phalanx. It is usually performed if the HVI is more than 10 degree.

Figure 7. X-ray of a patient with moderate hallux valgus. Proximal Chevron and Akin’s osteotomies were performed.


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Distal metatarsal osteotomy – Distal Chevron and biplanar Chevron. Distal Chevron osteotomy is indicated in mild to moderate cases. It is a V-shaped cut on the medial surface of dista l metatarsal head and neck region with lateral displacement of the distal osteotomy fragment. Biplanar Chevron allows reduction of DMAA with more bone cut from the dorsomedial and plantar-medial limbs.

Figure 8. A diagram showing the lateral view of the first metatarsal and the V-shaped cut of distal Chevron osteotomy.

Figure 9. X-ray of a patient with moderate hallux valgus and distal Chevron osteotomy was performed. The osteotomy was fixed with one screw.

Diaphyseal metatarsal osteotomy – Scarf osteotomy is used to treat moderate to severe cases. It involves three osteotomy cuts. It is usually fixed with two screws and offers good stability for bone union. Good to excellent results with significant improvement in functional outcome have been reported with correction with Scarf osteotomy. [17-18]

Figure 10. A diagram showing the lateral view of the first metatarsal and the Z-shaped cut of Scarf osteotomy.

Proximal metatarsal osteotomy – Proximal Chevron, opening or closing wedge, crescentic. They can be used to treat moderate to severe deformities. Proximal Chevron involves a similar V-shaped cut at proximal metatarsal. It is considered a more stable osteotomy than other proximal osteotomies. However, proximal Chevron may shorten the first metatarsal. Proximal opening wedge, on the other hand, lengthens the f i rst metatarsal . Proximal c losing wedge osteotomy is losing its popularity due to problems of shortening, recurrence, malunion. [19-20]

Figure 11. A diagram showing the dorso-plantar view of the first metatarsal and the crescentic cut of proximal metatarsal osteotomy.

Figure 12. A diagram showing the lateral view of the first metatarsal and the V-shaped cut of Chevron osteotomy.


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First TMTJ arthrodesis (Lapidus procedure) – It is used to treat moderate to severe cases with hypermobility of the first TMTJ. It is usually combined with distal soft tissue procedures and angular correction. Fixation can be screws fixation, staple fixation, external fixation and plating. Postoperatively patients need a few weeks of non-weight bearing walking. The most common complication is non-union (4%) [21]

Figure 13. X-rays of an example of hallux valgus with hypermobility of the first TMTJ and fusion was performed with plating.

First MTPJ arthrodesis – In patients with degenerative changes of the first MTPJ, arthrodesis or fusion is indicated. Fixation could be performed with screws, wires, staples, plates or a combination of the above. It was proven to restore the IMA and HVA in a level IV study. [22] Sometimes it was used as a salvage procedure for previous failed hallux valgus correction surgery. [23] It could also be used in severe hallux valgus, osteoarthritis and rheumatoid arthritis. It gives reliable symptomatic relief. [24-26]]

Figure 14. X-rays of a patient with valgus hallux and degenerative changes. First MTPJ fusion was performed with plating.

First MTPJ arthroplasty – The short-term follow up showed acceptable results. However, the overall revision rate was between 16% to 26%. Therefore a lot of surgeons still prefer fusion as the treatment of end-stage arthritis of MTPJ. [27-30]

Minimally invasive surgery (MIS) – There are different techniques reported in the literature. However, there were too few studies on each technique to assess whether one is more effective than the others. There is some evidence that MIS Chevron-Akin showed most potential for improvement of HVA. [31-32] Randomized controlled trials (RCTs) with long term follow up are required to assess the efficacy of MIS in hallux valgus surgery.

Conclusion

Hallux valgus is a commonly encountered foot and ankle problem. Conservative treatment is indicated in mild disease. Operative treatment involves mostly soft tissue procedure, osteotomies and fusion. Newer techniques including MIS correction will need more large scale RCTs for evaluation in the future.

References

1. Nix S, Smith M, Vicenzino B. Prevalence of hallux valgus in the general population: a systematic review and meta-analysis. J Foot Ankle Res. 2010;3:21. Published 2010 Sep 27. doi: 10.1186/1757-1146-3-21.

2. Yamamoto Y, Yamaguchi S, Muramatsu Y et a l . Qual i ty of l i fe in patients with hallux valgus. Foot Ankle Int. 2016;37(11):1171-1177. doi: 10.1177/1071100716655433.

3. Menz HB, Roddy E, Thomas E, Croft PR. Impact of hallux valgus severity on general and foot-specific health-related quality of life. Arthritis Care Res (Hoboken). 2011;63(3):396-404. doi:10.1002/acr.20396.

4. Wulker N. Hallux valgus – Hallux rigidus. Stuttgart: Enke 1997; 3-32.

5. Mann RA, Coughlin MJ. Hallux valgus--etiology, anatomy, treatment and surgical considerations. Clin Orthop Relat Res. 1981;(157):31-41.

6. Perera AM, Mason L, Stephens MM. The pathogenesis of hallux valgus. J Bone Joint Surg Am. 2011;93(17):1650-1661. doi:10.2106/JBJS.H.01630.

7. Wülker N. Hallux valgus. Orthopade. 1997;26(7):654-664. doi:10.1007/s001320050137

8. Frank CJ. Hallux Valgus. Medscape. April 2021.

9. Rosen JS, Grady JF. Neuritic bunion syndrome. J Am Podiatr Med Assoc. 1986;76(11):641-644. doi:10.7547/87507315-76-11-641.

10. Jahss, M. Disorders of the first ray. In: Jahss, M , editor. Disorders of the Foot and Ankle: Medical and Surgical Management. Philadelphia, PA: Saunders and Company, 1991:946.

11. Haas, M. Radiographic and biomechanical consideration of bunion surgery. In: Gerbert, J , editor. Textbook of Bunion Surgery. New York, NY: Futura Publishing, 1981:55.

12. Fraissler L, Konrads C, Hoberg M, Rudert M, Walcher M. Treatment of hallux valgus deformity. EFORT Open Rev. 2016;1(8):295-302. Published 2016 Aug 25. doi:10.1302/2058-5241.1.000005.

13. Voellmicke KV, Deland JT. Manual examination technique to assess dorsal instability of the first ray. Foot Ankle Int 2002;23:1040-1.

14. Ray, Justin & Friedmann, Andrew & Hanselman, Andrew & Vaida, Justin & Dayton, Paul & Hatch, Daniel & Smith, Bret & Santrock, Robert. (2019). Hal lux Va lgus. Foot & Ankle Orthopaedics. 4. 247301141983850. 10.1177/2473011419838500.

15. Johnson, JE, Clanton, TO, Baxter, DE, Gottlieb, MS. Comparison of Chevron osteotomy and modified McBride bunionectomy for correction of mild to moderate hallux valgus deformity. Foot Ankle. 1991;12:61–68.

16. Lee, HJ, Chung, JW, Chu, IT, Kim, YC. Comparison of distal chevron osteotomy with and without lateral soft tissue release for the treatment of hallux valgus. Foot Ankle Int. 2010;31(4):291–295.


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17. Adam, SP, Choung, SC, Gu, Y, O’Malley, MJ. Outcomes after scarf osteotomy for treatment of adult hallux valgus deformity. Clin Orthop Relat Res. 2011;469:854–859.

18. Bock, P, Kluger, R, Kristen, KH, Mittlbock, M, Schuh, R, Trnka, HJ. The scarf osteotomy with minimally invasive lateral release for treatment of hallux valgus deformity: intermediate and long-term results. J Bone Joint Surg Am. 2015;97:1238–1245.

19. Sammarco, VJ, Acevedo, J. Stability and fixation techniques in first metatarsal osteotomies. Foot Ankle Clin. 2001;6:409–432, v–vi.

20. Smith, WB, Hyer, CF, DeCarbo, WT, Berlet, GC, Lee, TH. Opening wedge osteotomies for correction of hallux valgus: a review of wedge plate fixation. Foot Ankle Spec. 2009;2:277–282.

21. Willegger M, Holinka J, Ristl R, et al. Correction power and complications of first tarsometatarsal joint arthrodesis for hallux valgus deformity. Int Orthop 2014;39:467-76.

22. Pydah, SK, Toh, EM, Sirikonda, SP, Walker, CR. Intermetatarsal angular change following fusion of the first metatarsophalangeal joint. Foot Ankle Int. 2009;30(5):415–418.

23. Grimes, JS, Coughlin, MJ. First metatarsophalangeal joint arthrodesis as a treatment for failed hallux valgus surgery. Foot Ankle Int. 2006;27(11):887–893.

24. Mahadevan D, Korim MT, Ghosh A, et al. First metatarsophalangeal joint arthrodesis – Do joint configuration and preparation technique matter? Foot Ankle Surg 2014;21:103-7.

25. Wassink S, van den Oever M. Arthrodesis of the first metatarsophalangeal joint using a single screw: retrospective analysis of 109 feet. J Foot Ankle Surg 2009;48:653-61.

26. Ellington JK, Jones CP, Cohen BE, et al. Review of 107 hallux MTP joint arthrodesis using dome-shaped reamers and a stainless-steel dorsal plate. Foot Ankle Int 2010;31:385-90.

27. Erkocak OF, Senaran H, Altan E, Aydin BK, Acar M. Short-term functional outcomes of first metatarsophalangeal total joint replacement for hallux rigidus. Foot Ankle Int 2013;34:1569-79.

28. Pulavarti RS, McVie JL, Tulloch CJ. First metatarsophalangeal joint replacement using the bio-action great toe implant: intermediate results. Foot Ankle Int 2005;26:1033-7.

29. Nagy MT, Walker CR, Sirikonda SP. Second-generation ceramic first metatarsophalangeal joint replacement for hallux rigidus. Foot Ankle Int 2014;35:690-8.

30. Dawson-Bowl ing S, Adimonye A, Cohen A, et a l . MOJE ceramic metatarsophalangeal arthroplasty: disappointing clinical results at two to eight years. Foot Ankle Int 2012;33:560-4.

31. Malagelada F, Sahirad C, Dalmau-Pastor M, et al. Minimally invasive surgery for hallux valgus: a systematic review of current surgical techniques. Int Orthop. 2019;43(3):625-637. doi:10.1007/s00264-018-413

CMEQUESTIONS:Q&A

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

QuestionsQ&AAnswer these on page 12 or make an online submission at: www.hkma.org.

Please indicate whether the following statements are true or false.

1. Hallux valgus is a rare foot and ankle problem.

2. Biomechanical instability is one of the most common etiologies of hallux valgus.

3. Hal lux valgus creates tension on the lateral s ide and compression on the medial side.

4. Bunion is the swelling over the medial side of MTPJ.

5. Conservative treatment can be considered in mild cases.

6. Claw toes and pes planus deformity can be associated with hallux valgus.

7. Hallux valgus angle of 40 degree is a mild disease.

8. Hypermobility of the first TMTJ will require fusion as surgical treatment.

9. Fusion is the salvage procedure for degenerative changes over the first MTPJ.

10. MIS hallux valgus correction is superior to traditional open surgery in large scale RCTs.

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Since its publication, the HKMA CME Bulletin has become one of the most popular CME readings for doctors. This monthly publication has been serving more than 10,000 readers each month through practical case studies and picture quizzes. To enrich its content, we are inviting articles from experts of different specialties. Interested contributors may refer to the General Guidance below. Other formats are also welcome.

For further information, please contact CME Dept. at 2527 8452 or by email at [email protected].

General Guidance for Authors

Intended Readers : General Practitioners

Length of Article : Approximately 8-10 A-4 pages in 12-pt fonts in single line spacing, or around 1,500-2,000 words (excluding references).

Review Questions : Include 10 self-assessment questions in true-or-false format.

(It is recommended that analysis and answers to most questions be covered in the article.)

Language : English

Highlights : It is preferable that key messages in each paragraph/section be highlighted in bold types.

Key Lessons : Recommended to include, if possible, a key message in point-from at the end of the article.

Others : List of full name(s) of author(s), with qualifications and current appointment quoted, plus a digital photograph of each author.

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

All articles submitted for publication are subject to review and editing by the Editorial Board.

Cardiology

8 www.hkma.orgHKMA CME Bulletin 持續醫學進修專訊 Apr 2022

The content of the April 2022 Cardiology Series is provided by:Dr. CHEUNG Ling Ling

MBBS(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in CardiologyDr. Karl CHAN

MBBS (HK), MRCP (UK) 四月臨床心臟科個案研究之內容承蒙張玲玲醫生及陳斯畧醫生提供。

A Case Of Acute Pulmonary Edema

An 81-year lady with history of diabetes mellitus, hypertension and mild coronary artery disease presents to the AED with complaints of chest pain and shortness of breath after news that her son had passed away the day prior. Her vitals on presentation are BP 131/71, HR 116 bpm, SpO2 97% on 4L O2 and afebrile. She is in marked respiratory distress on examination. CXR shows congested lung fields with no pneumothorax or widened mediastinum. ECG shows sinus tachycardia with ST-elevation in lateral leads V5-6. Bedside echo was performed with the apical four chamber view attached [Figure 1].

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

[Figure 1: Apical four chamber view in diastole on the left and systole on the right]

Q&A Please answer ALL questionsAnswer these on page 12 or make an online submission at: www.hkma.org.

1. Based on the clinical presentation, ECG and echocardiographic findings, what urgent investigation would you perform to elicit the diagnosis?

A. Repeat serial ECG and cardiac biomarkers

B. Urgent invasive coronary angiogram

C. CT coronary angiogram

D. Non-stress cardiac MRI with contrast

2. What is the suspected echocardiographic finding as pointed out by the arrow in image B of Figure1?

A. Aneurysm of the left ventricular apex

B. Left ventricular thrombus

C. Apical ballooning

D. None of the above

3. If the coronary angiogram eventually revealed no significant coronary artery obstruction, what would be the most likely differential diagnosis?

A. Myocarditis

B. Coronary artery spasm

C. Takutsubo cardiomyopathy

D. Old anterior myocardial infarct

Figure 3. Echo 90 days later

March Answer

9www.hkma.org HKMA CME Bulletin 持續醫學進修專訊 Apr 2022

Cardiology AnswersAnswer: 1. D 2. C 3. DExplanation:

This lady with systemic sclerosis presented with shor tness of breath and decreased exerc ise tolerance. Cardiac auscultation showed loud P2 which would suggest the possibility of pulmonary hypertension. Her chest X-ray showed cardiomegaly with prominent pulmonary artery and clear peripheral lung field. Her electrocardiogram showed right axis deviation and features of right ventricular hypertrophy (dominant R wave in V1/2). Echocardiogram showed di lated r ight ventr ic le with moderate tr icuspid regurgitation (TR), and peak TR velocity of 4.7m/sec suggestive of a high probability of pulmonary hypertension (PH).

Measuring peak TR velocity by echocardiogram provide an initial clue of probability of PH. Peak TR velocity > 3.4m/sec has high probability of PH, while those < 2.8m/sec without other echocardiographic signs of PH (e.g. dilated right ventricle, flattening of interventricular septum, dilated pulmonary artery, dilated inferior vena cava with reduced respiratory variation, or dilated right atrium) would suggest low probability. One should note that there is no direct relationship between the severity of TR and degree of peak TR velocity.

Systemic sclerosis associated PH is classified as Group 1 – Pulmonary Arterial Hypertension (PAH) associated with connective tissue disease (see Figure 1 for classification of PH). Group 1 PAH is characterized by disease processes that affect the pre-capillary pulmonary arterial vasculature which could be idiopathic, heritable, drug or toxin induced or with an associated condition. Systemic sclerosis is the most common cause of connective tissue diseases associated Group 1 PAH. The estimated prevalance is around 12-16% and the mortal ity can be up to 50% within 3 years of PAH diagnosis. Compared with idiopathic PAH, systemic sclerosis associated PAH carries a worse prognosis, having 3-fold increase risk of mortality.

It is recommended that those with high probability of PH by echocardiogram screening should have further investigation including right heart catheterization (RHC) to confirm the diagnosis, classify the subtyoe, and provide guidance of treatment options. Once the d iagnosis is conf i rmed, there are severa l classes of targeted drug therapy can be provided, including phosphodiesterase-5-inhibitor (PDE-5i ) , endothel in receptor antagonist (ERA) and prostanoid, either monotherapy or in combination. Referral to centre specializing in management of PH should be considered. Reuglar monitoring of clinical, biochemical and imaging parameters would be helpful in determining the risk profile of patient and the need of adjusting the therapy. N-terminal

The content of the February 2022 Cardiology Series is provided by:Dr. TAN Guang Ming

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

MBBS, MRCP, FHKCP, FHKAM (Medicine), Specialist in Cardiology 二月臨床心臟科個案研究之內容承蒙譚廣明醫生及張誠謙醫生提供。

pro-Brain Natriuretric Peptide (NT-proBNP) and echocardiographic assessment of right atrial size are some of the convenient laboratory and imaging parameters to be used (Figure 2).

Group 1. Pulmonary arterial hypertension (PAH)

Idiopathic

Heritable

BMPR2 mutation

Other mutations

Drug and toxin induced

Associated with:

Connective tissue disease

HIV infection

Portal hypertension

Congenital heart diseases

Schistosomiasis

1’ Pulmonary veno-occlusive disease and/or pulmonary capillary hemangiomatosis

Group 2. Pulmonary hypertension due to left heart disease

Left ventricular systolic dysfunction

Left ventricular diastolic dysfunction

Valvular disease

Congenital/acquired left heart inflow/outflow tract obstruction and congenital cardiomyopathies

Group 3. Pulmonary hypertension due to lung diseases and/or hypoxia

Chronic obstructive pulmonary disease

Interstitial lung disease

Other pulmonary diseases with mixed restrictive and obstructive pattern

Sleep-disordered breathing

Alveolar hypoventilation disorders

Chronic exposure to high altitude

Developmental lung diseases

Group 4. Chronic thromboembolic pulmonary hypertension (CTEPH)

Group 5. Pulmonary hypertension with unclear multifactorial mechanisms

Hematologic disorders

Systemic disorders

Metabolic disorders

Others, including chronic renal failure

BMPR2: bone morphogenic protein receptor type 2; CAV1: caveolin 1; ENG: endoglin; HIV: human immunodeficiency virus.

Adapted from Simonneau et al6 with permission of Elsevier; original content

© 2013 by the American College of Cardiology Foundation.

(Figure 1)

March Answer


(Figure 2)

1. A Beau’s lines are transverse indentations affecting all

nails due to acute systemic illness or drug reaction stopping nail growth. This nail condition was named by a French physician, Joseph Honoré Simon Beau (1806–1865), who first described it in 1846. Beau also means ‘beautiful’ in French pronounced like ‘blue’ while in English it is pronounced like ‘bo’. The indentation usually occurs on multiple nails in the same location, parallels the distal edge of the lunula and grows out distally, whereas similar change limited to a single nail would favour localized causes such as trauma. Besides, multiple Beau’s lines may indicate recurrent episodes of a systemic event including cycles of chemotherapy in oncology patients. Onychomycosis i s common ly p resented w i th d is ta l subungua l hyperkeratosis and affects different not necessarily all nails with varied severity. Onycholysis was distal separation of nailplate from the nailbed resulting a well-defined area of white opaque nail, and it may be idiopathic or secondary to trauma, nail infection, psoriasis, systemic disease (e.g. thyroid disease), subungual tumour or medications. Onychomadesis which can be considered as an extreme form of Beau’s line, is shedding of the nails beginning at the proximal end due to abrupt arrest of nail matrix activities and it is not uncommonly seen as a late complication of hand-foot-and-mouth disease occurring four to six weeks after the illness onset. The earliest change of psoriatic nail is ‘oil drop’ at the distal nailplate preceding onycholys is whi le na i l p i t t ing, leukonychia and subungual hyperkeratosis are common manifestations also.

2. Yes As fingernails take about 4-6 months to grow out the

full length, the transient arrest of nail matrix production of nail plate could be estimated to be 2-3 months

ago from the current midway location of Beau’s lines. Besides, the width of the indentation is an indicator of the duration of the systemic disease, of which the erythroderma lasted for a month.

3. E Beau’s line is usually a late manifestation of systemic

event which is commonly resolved at the time of nail presentation. The focus should be on a comprehensive medical history and physical examination to search for an accountable systemic event before. Nail clipping for fungal culture is investigation for suspicious cases of onychomycosis, while nail clipping could be sent for histology to look for any hyphae in the nailplate. Xray of fingers was occasionally ordered to rule out suspected underlying bony growth resulting nailplate abnormalities.

4. C If a systemic illness, medication, or other causative

factor is ident i f ied with recurrent potent ia l , the underlying causes should be managed. Otherwise, Beau’s l ines themselves do not have a speci f ic treatment if the systemic issue resolves, and the abnormality would grow out itself with nail growth. Hence, reassurance was given to our patient that the nail change was a transient and self-limiting process due to his previous erythroderma. Nai l care and emollient with white soft paraffin were advised while awaiting the self-resolution of Beau’s lines in coming months.

Dermatology Series for March 2022 is provided by: Dr. NG Shun Chin, Dr. TANG Yuk Ming, William,

Dr. CHAN Hau Ngai, Kingsley, Dr. KWAN Chi Keung, Dr. LEUNG Wai Yiu and Dr. CHENG Hok Fai

Specialists in Dermatology & Venereology三月皮膚科個案研究之內容承蒙吳順展醫生、鄧旭明醫生、陳厚毅醫生、

關志強醫生、梁偉耀醫生及鄭學輝醫生提供。

Dermatology Answers

Dermatology

11www.hkma.org HKMA CME Bulletin 持續醫學進修專訊 Apr 2022

Dermatology Series for April 2022 is provided by: Dr. CHENG Hok Fai, Dr. TANG Yuk Ming, William, Dr. CHAN Hau Ngai, Kingsley,

Dr. KWAN Chi Keung, Dr. LEUNG Wai Yiu, Dr. NG Shun Chin and Dr. KOH Chiu ChoiSpecialists in Dermatology & Venereology

四月皮膚科個案研究之內容承蒙鄭學輝醫生、鄧旭明醫生、陳厚毅醫生、關志強醫生、梁偉耀醫生、吳順展醫生及許招財醫生提供。

Q&A Please answer ALL questionsAnswer these on page 12 or make an online submission at: www.hkma.org.

1. Which of the following is the most likely cause for

the clinical presentation?

A) Traumatic bruising

B) Haemangioma

C) Angiolymphoid hyperplasia with eosinophilia

D) Vascular malformation

E) Angiosarcoma

2. What would be the expected dermoscopic finding?

A) Brownish dots, globules and streaks

B) Leaf-like areas

C) Spoke-wheel structures

D) Anastomosing network of red/purple structureless

areas

E) Comedo-like openings

3. How would you confirm your clinical suspicion?

A) Diascopy

B) Skin scraping for mycology

C) Plucked scalp hairs for potassium hydroxide wet

mount microscopy

D) Diagnostic incisional scalp biopsy

E) Wood lamp examination

4. Which of the following factor would adversely affect

the prognosis?

A) Gender

B) The size of the lesion being larger than 5 cm

C) A history of cigarette consumption

D) Ulceration of scalp surface

E) Presence of mitotic figure within the lesion

5. What would be the best treatment option?

A) Topical steroid application

B) Cryotherapy

C) Systemic immunosuppression

D) Observation and expectant management

E) Wide local excision with meticulous margin control

A 73-Year-Old Man Presented WithAsymptomatic Skin Discolouration

A 73-year-old man who enjoyed good health presented with

asymptomatic skin discolouration. The skin lesion started off as a

pea-size macule, which then enlarged rapidly across 2 months. It

bled easily upon minor trauma. The skin lesion was located at the

left frontal scalp region, and was associated with localized alopecia.

Complete Dermatology case, 0.5 CME POINT will be awarded for at least 3 correct answers in total

12 HKMA CME Bulletin 持續醫學進修專訊 Apr 2022 www.hkma.org

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

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

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

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SPOTlightComplete Spotlight, 1 CME point will be awarded for at least 5 correct answers

1 2 3 4 5 6 7 8 9 10

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

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

1 2 3 4 51 2 3

Answer Sheet

April 2022

The HKMA CME Live Lecture in April 2022

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

[Application

Closed]

Date Organizer and Topic Speaker CME Points

CME Accreditation from Colleges (Pending)

1. 20 April (Wed)

HKMA Central Western & Southern Community NetworkManagement of Paediatric AsthmaSponsor: GlaxoSmithKline

Dr. SIT Sou ChiSpecialist in Paediatrics

1 Yes

2. 22 April(Fri)

HKMA Kowloon City Community NetworkLatest Advancement in Clinical Data: SGLT2 Inhibitors in Heart FailureSponsor: Boehringer Ingelheim (Hong Kong) Limited

Dr. CHAN Ki WanSpecialist in Cardiology

1 Yes

3. 27 April (Wed)

The Hong Kong Medical AssociationThe Practice Of Telemedicine During The Current Covid EpidemicSponsor: No Sponsor

Dr. David KANPartner, Solicitor Advocate, Howse Williams

1 Yes

4. 28 April (Thu)

HKMA New Territories West Community NetworkUpdates in Management for IPFSponsor: Boehringer Ingelheim (Hong Kong) Limited

Dr. WAN Chi KinSpecialist in Respiratory Medicine

1 Yes

5. 29 April(Fri)

HKMA Shatin Community NetworkLow Back Pain & SciaticaSponsor: No Sponsor

Dr. WONG Wah BongSpecialist in Orthopaedics & Traumatology

1 Yes

Subscription

AvailableHKMA members are entitled to a FREE copy of CME Bulletin. Subscription is open to sponsors and interested individuals.

CME Live CME Notifications

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

Date Organizer and Topic SpeakerCME

Points

CME Accreditation from Colleges (Pending)

1. 4 May (Wed)

HKMA Central Western & Southern Community NetworkFrom Stepwise to Individualized Management for Angina, What are the Updates?Sponsor: Servier Hong Kong Ltd

Dr. NG Kei Yan, AndrewSpecialist in Cardiology

1 Yes

2. 5 May(Thu)

HKMA Kowloon East Community NetworkCommon Benign Perianal DiseasesSponsor: Johnson & Johnson (Hong Kong) Ltd

Dr. MAK Wing Chung, TonySpecialist in General Surgery

1 Yes

3. 6 May(Fri)

HKMA Kowloon City Community NetworkManagement of BPH in the Right TimeSponsor: GlaxoSmithKline Ltd

Dr. CHAN Chun KiSpecialist in Urology

1 Yes

4. 10 May(Tue)

The Hong Kong Medical AssociationA New Way To Protect Older Adults Against Inf luenza-Recombinant Vaccine TechnologySponsor: Sanofi Hong Kong Limited

Dr. WONG King YingSpecialist in Respiratory Medicine and Internal Medicine

1 Yes

5. 13 May(Fri)

HKMA Shatin Community NetworkIndiv idual ized Treatment in Osteoporosis – Beware of Increased Fracture Risk in Diabetes PatientsSponsor: Amgen Hong Kong Ltd

Dr. WU, EnochSpecialist in Endocrinology, Diabetes & Metabolism

1 Yes

6. 16 May(Mon)

The Hong Kong Medical AssociationPrevention And Risk Reduction Of CRC With The Recent Advancement Of Gut Microbiome ResearchSponsor: G-NiiB, Genie Biome Limited

Dr. LAM Long YanSpecia l ist in Gastroenterology & Hepatology

1 Yes

7. 19 May(Thu)

HKMA Hong Kong East Community NetworkHow to Close the Gap Between Perception and Reality in Asthma ControlSponsor: GlaxoSmithKline Limited

Dr. WONG Wing ChingSpecialist in Respiratory Medicine

1 Yes

8. 20 May(Fri)

The Hong Kong Medical AssociationUpdates On The Management Of H. Pylor i Infect ions – Diagnosis And Treatment ApproachSponsor: Abbott Laboratories Limited

Dr. LAM Long Yan, KelvinSpecialist in Gastroenterology and Hepatology

1 Yes

9. 24 May(Tue)

HKMA Kowloon West Community NetworkPersonalized Approach to Antiplatelet Therapy and Lipid ManagementSponsor: Sanofi Hong Kong Ltd

Dr. YUNG See Yue, ArthurSpecialist in Cardiology

1 Yes

10. 25 May(Wed)

The Hong Kong Medical AssociationUpdates Of COVID-19 Vaccines In Youth And ChildrenSponsor: Fosun Pharma

Dr. David LUKSpecialist in Paediatrics

1 Yes

11. 26 May(Thu)

HKMA New Territories West Community NetworkTherapeutic Nutrition on Effective Long Term DiabetesSponsor: Abbott Laboratories Limited

Dr. TING Zhao Wei, RoseSpecialist in Endocrinology, Diabetes and Metabolism

1 Yes

12. 27 May (Wed)

The Hong Kong Medical AssociationToday’s Psoriasis Management - Aim To ClearSponsor: AbbVie Ltd.

Dr. LAM Yuk KeungSpec i a l i s t i n De rma to l ogy and Venereology

1 Yes

13. 30 May(Mon)

The Hong Kong Medical AssociationRecommendations On Prediabetes ManagementSponsor: Merck Pharmaceutical (HK) Ltd.

Dr. AU YEUNG Yick CheungSpecialist in Endocrinology, Diabetes & Metabolism

1 Yes

14. 31 May(Tue)

HKMA Yau Tsim Mong Community NetworkChronic Venous Disease: A Common Pain Point with Effective Treatment StrategiesSponsor: Servier Hong Kong Ltd

Dr. CHENG, MinaSpecialist in General Surgery

1 Yes

The HKMA CME Live Lecture in May 2022

Please register through https://forms.gle/wjNqYLbgJMgScmh27 or scan the QR code if you are interested to attend. For enquiry, please contact the Secretariat at 2527 8285.

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

16 www.hkma.org

CME LiveCME Notifications

HKMA CME Bulletin 持續醫學進修專訊 Apr 2022

17HKMA CME Bulletin 持續醫學進修專訊 Apr 2022www.hkma.org

What Do We Learn from COVID-19?An Overview of Adult Immunization

Speaker : Dr. TSANG Kay Yan, Joseph

Specialist in Infectious Disease

Date : 11 May 2022 (Wednesday)

Time : 2:00 – 2:45pm Lecture

2:45 – 3:00pm Q&A

Fee : Free-of-charge

Registration Deadline : Friday, 6 May 2022

Registration : Please register through https://forms.gle/acBnngvGaz9nKAhn9

or scan the QR code if you are interested to attend.

Enquiry : Please contact the HKMA Secretariat at 2527-8452 or [email protected].

CME Accreditation for Non-specialist Doctors : 1 CME point for each lecture #

Accreditation for Specialist Doctors : Yes #

# Accreditation from various colleges are pending. For specialists, please complete the quiz online within two hours after the lecture

with at least 50% correct for CME/CPD points. Non-Specialists doctors must also complete lecture quiz (10 Q&A) within two hours

after the lecture with at least 50% correct.

The Hong Kong Medical Association


Meeting Highlights

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

Dr. HO Yung Yung delivering a CME Live lecture on 24 March 2022

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

Dr. CHAN Wah Fat giving a CME Live lecture on 11 March 2022

Dr. Adrian CHEONG presenting a CME Live lecture on 9 March 2022

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

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

Dr. Paul CHAN presenting a CME Live lecture on 10 March 2022

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

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

Dr. Charlotte WONG presenting a CME Live lecture on 17 March 2022

Dr. WONG Cheuk Lik delivering a CME Live lecture on 15 March 2022

The Hong Kong Medical Association

Dr. CHENG Kwun Chung, Br yan presenting a CME Live lecture on 16 March 2022

Dr. KAM Koon Ming, Michael presenting a CME Live lecture on 1 March 2022

The HKMA Shatin Community Network (SCN) ~ Dr. CHENG Chor Ho, Alvin and Dr. MAK Siu King

Dr. CHAN Yung presenting a CME Live lecture on 4 March 2022

28 www.hkma.orgHKMA CME Bulletin 持續醫學進修專訊 March 2021

香港醫生網The Hong Kong Doctors Homepage

www.hkdoctors.org

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

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

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

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

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

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

Receiving Electronic Copy Of CME Bulletin

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

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Please return the completed form to us by fax (2865 0943) or email ([email protected]).

CME Calendar


April 2022

20 April (Wed)2:00-3:00 p.m.

HKMA Central Western & Southern Community NetworkManagement of Paediatric AsthmaHKMA ZOOM CME Live LectureHKMA Community Network Dept. – Tel: 2861 1979

1

22 April (Fri)2:00-3:00 p.m.

HKMA Kowloon City Community NetworkLatest Advancement in Clinical Data: SGLT2 Inhibitors in Heart FailureHKMA ZOOM CME Live LectureHKMA Community Network Dept. – Tel: 2861 1979

1

26 April (Tue)2:00-3:00 p.m.

The Hong Kong Medical Association and the Gleneagles Hong Kong HospitalUpdate On Dementia And Mild Cognitive ImpairmentHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

27 April (Wed)2:00-3:00 p.m.

The Hong Kong Medical AssociationThe Practice Of Telemedicine During The Current Covid EpidemicHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

28 April (Thu)2:00-3:00 p.m.

HKMA New Territories West Community NetworkUpdates in Management for IPFHKMA ZOOM CME Live LectureHKMA Community Network Dept. – Tel: 2861 1979

1

29 April (Fri)2:00-3:00 p.m.

HKMA Shatin Community NetworkLow Back Pain & SciaticaHKMA ZOOM CME Live LectureHKMA Community Network Dept. – Tel: 2861 1979

1

May 2022

3 May (Tue)2:00-3:00 p.m.

The Hong Kong Medical Association and the Hong Kong Sanatorium & HospitalUpdates On Management Of Type 2 Diabetes MellitusHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

4 May (Wed)2:00-3:00 p.m.

HKMA Central Western & Southern Community NetworkFrom Stepwise to Individualized Management for Angina, What are the Updates?HKMA ZOOM CME Live LectureHKMA Community Network Dept. – Tel: 2861 1979

1

5 May (Thu)2:00-3:00 p.m.

HKMA Kowloon East Community NetworkCommon Benign Perianal DiseasesHKMA ZOOM CME Live LectureHKMA Community Network Dept. – Tel: 2861 1979

1

6 May (Fri)2:00-3:00 p.m.

HKMA Kowloon City Community NetworkManagement of BPH in the Right TimeHKMA ZOOM CME Live LectureHKMA Community Network Dept. – Tel: 2861 1979

1

10 May (Tue)2:00-3:00 p.m.

The Hong Kong Medical AssociationA New Way To Protect Older Adults Against Influenza-Recombinant Vaccine TechnologyHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

11 May (Wed)2:00 - 3:00 p.m.

The HKMA Adult Immunization CampaignWhat Do We Learn from COVID-19? An Overview of Adult ImmunizationHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

12 May (Thu)2:00-3:00 p.m.

The Hong Kong Medical Association and the Hong Kong Science ParkDiagnosis Of Common And Rare Neurological Diseases: Technological Updates And Clinical ApplicationsHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

13 May (Fri)2:00-3:00 p.m.

HKMA Shatin Community NetworkIndividualized Treatment in Osteoporosis – Beware of Increased Fracture Risk in Diabetes PatientsHKMA ZOOM CME Live LectureHKMA Community Network Dept. – Tel: 2861 1979

1

16 May (Mon)2:00-3:00 p.m.

The Hong Kong Medical AssociationPrevention And Risk Reduction Of CRC With The Recent Advancement Of GutMicrobiome ResearchHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

17 May (Tue)2:00-3:00 p.m.

The Hong Kong Medical Association and the Gleneagles Hong Kong HospitalUpdate In BPH ManagementHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

19 May (Thu)2:00-3:00 p.m.

HKMA Hong Kong East Community NetworkHow to Close the Gap Between Perception and Reality in Asthma ControlHKMA ZOOM CME Live LectureHKMA Community Network Dept. – Tel: 2861 1979

1

19 May (Thu)2:00-3:00 p.m.

HKMA Kowloon East Community Network , HA-United Christian Hospital and HK College of Family PhysiciansCertificate Course for GPs 2022 - Updates on Management of COVID-19Registration: Ms. Judy YU – Tel: 3949 3043

1

20 May (Fri)2:00-3:00 p.m.

The Hong Kong Medical AssociationUpdates On The Management Of H. Pylori Infections – Diagnosis And Treatment ApproachHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

24 May (Tue)2:00-3:00 p.m.

HKMA Kowloon West Community NetworkPersonalized Approach to Antiplatelet Therapy and Lipid ManagementHKMA ZOOM CME Live LectureHKMA Community Network Dept. – Tel: 2861 1979

1

25 May (Wed)2:00-3:00 p.m.

The Hong Kong Medical AssociationUpdates Of COVID-19 Vaccines In Youth And ChildrenHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

26 May (Thu)2:00-3:00 p.m.

HKMA New Territories West Community NetworkTherapeutic Nutrition on Effective Long Term DiabetesHKMA ZOOM CME Live LectureHKMA Community Network Dept. – Tel: 2861 1979

1

27 May (Wed)2:00 - 3:00 p.m.

The Hong Kong Medical AssociationToday’s Psoriasis Management - Aim To ClearHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

30 May (Mon)2:00-3:00 p.m.

The Hong Kong Medical AssociationRecommendations On Prediabetes ManagementHKMA ZOOM CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

31 May (Tue)2:00-3:00 p.m.

HKMA Yau Tsim Mong Community NetworkChronic Venous Disease: A Common Pain Point with Effective Treatment StrategiesHKMA ZOOM CME Live LectureHKMA Community Network Dept. – Tel: 2861 1979

1

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Documents

A Review of Hallux Valgus Deformity