A curvilinear nomogram of peak expiratory flow rate for the young.

OBJECTIVE: Peak expiratory flow rates (PEFRs) differ among populations and between times. The new EU scale of the mini-Wright flow-meter has been introduced since 2004. This study updated the PEFR nomograms with the new scale for Chinese children and adolescents (aged 6-19 years) in Hong Kong. METHODS: A convenience sample was recruited from 34 primary care practices (patients' companions/children) and four schools. Standardization workshops were run for the physicians, and the proper use of the flow-meter was demonstrated to students prior to the data collection. Brand new meters were used. For each sex, the linear regression model was used to determine the relationship between PEFR and the variables of age and body height. The open-source software PyNomo was used to generate the nomograms. RESULTS: After excluding 66 participants with past/current history of respiratory tract diseases, heart disease, incomplete data, and poor effort, PEFRs were collected from 798 males and 794 females. The PEFR had a linear relationship with age but a curvilinear relationship with height. The regression equations for predicted PEFR were ln(PEFR) = 1.810256*ln(height) + 0.038297*age - 3.734139 for males and ln(PEFR) = 1.525509*ln(height) + 0.033275*age - 2.368592 for females. The corresponding nomograms were constructed. They were tested with 230 patients in primary care; 9.6% (12 males and 10 females) had PEFR less than the predicted value by ≥20%. CONCLUSION: The body height was a stronger determinant than age for PEFR. The predicted PEFR with these determinants bear a curvilinear relationship.

Antibiotic use: do parents act differently for their children?

BACKGROUND: Many children in the community take antibiotics inappropriately. Previous studies comparing parents with other adults suggest that parents are more judicious with antibiotics for their children. This study aims to explore the difference between parents' use of antibiotics for themselves and for their children. METHODS: The study adopted a combined qualitative and quantitative approach. Eight focus groups were conducted with 56 participants purposively recruited from community centres and of different socio-economic strata. The qualitative data collected were used to construct a questionnaire for the telephone survey, which recruited 2471 adults randomly selected from the local household directory, of whom 547 had ever brought their children or grand children for medical consultation. RESULTS: Both the qualitative and quantitative approaches showed that parents were more cautious with antibiotics for children than for themselves. The main reason was their concern of side effects. Fever was the most important drive for their desire of antibiotics for children. The misconception of antibiotics' effectiveness for sore throat was another determinant of the desire. These attitudes and behaviour were not affected by the respondents' sex, age, education or household income. CONCLUSION: On the whole, parents did to their children what they would do for themselves, but to a lesser extent. Parents' better knowledge and attitudes will lead to more appropriate use of antibiotics for their children.

Family medicine training in Hong Kong: similarities and differences between family and non-family doctors.

OBJECTIVE: To study the local medical profession's opinions on the training requirements for the specialty of family medicine. This was to serve as a reference for future planning of the health care system. DESIGN: Cross-sectional study. PARTICIPANTS AND SETTING: All registered doctors in Hong Kong. MAIN OUTCOME MEASURES: Doctors' ratings on the importance of vocational training, professional assessment, job nature, and experience to become suitably qualified as a family doctor, and their opinions on the length of necessary vocational training. RESULTS: A total of 2310 doctors (23% of doctors in the local register) responded. Professional assessment was mostly agreed as a qualification, followed by vocational training, clinical experience, and job nature. Over 70% agreed on a training period of 4 years or less. Non-family doctors were more likely to opt for professional assessment as the qualification and also opt for a longer training period. CONCLUSION: Vocational training was considered important as a qualification for the specialty of family medicine. The length of training was mostly agreed to be 4 years or less, not the 6 years currently required by the Hong Kong Academy of Medicine. The vocational training programme for family medicine might require re-examination.

Introducing family medicine in a pluralistic health care system: how patients and doctors see it.

BACKGROUND: The health care systems in many countries are focused on specialist care. In those countries that have recently changed to a primary care-based system, some doctors and patients were dissatisfied with the change. OBJECTIVE: To explore the opinions of the general public and the doctors on the change to a family medicine (FM)-based health care system. METHODS: Qualitative study with focus groups of doctors working in different practice settings. Quantitative study with questionnaires sent to all doctors registered in Hong Kong and a telephone survey targeting the general public aged ≥18. RESULTS: Doctors in the focus groups generally supported a FM-based health care system. They were concerned that there were not enough family doctors for such a system and the patients' current free choice of any doctor for primary care would impede its success. Thousand six hundred and forty-seven adults took part in the telephone survey (response rate 67.6%) and 2310 doctors (22.8%) responded to the questionnaire. Nearly 95% of the general public respondents agreed to the FM system though only 66.3% of them had ever heard of the term family doctor. About 65% of the doctors supported this system but only 33% agreed that the system would work. The specialist-doctors were less supportive of mandatory referral than the non-specialists, while the public was equally divided on this issue. CONCLUSIONS: The public accepts the FM-based system but needs education on the benefits of primary health care. Direct access to the specialist would be the greatest barrier. Government involvements are essential for the reform.

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

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

PBL curriculum improves medical students' participation in small-group tutorials.

BACKGROUND: Group learning is the core of problem-based learning (PBL) but has not been extensively studied, especially in Asian students. METHODS: This study compared students of PBL and non-PBL curricula in students' talking time and participation in small-group tutorials in a medical school in Asia. The proportions of student talking of 46 tutorials in three teaching rotations of the PBL curriculum and those of 43 corresponding tutorials in the non-PBL curriculum were counted. Twelve videotapes of tutorials (six from each curriculum), stratified for tutor, case scenario and students' learning stage, were randomly selected and transcribed. They were rated with the group-interaction (5 items) and active-participation (four items) tutorial assessment scales developed by Valle et al. These outcomes were compared between the students of PBL and non-PBL curricula. RESULTS: Students from the PBL curriculum talked significantly more. In only two (4.7%) of 43 tutorials in the non-PBL curriculum did the students talk more than the tutors; but students talked more than the tutors in 17 (37.0%) of 46 tutorials in the PBL curriculum. PBL students scored significantly higher than non-PBL students in all items except one item (respect to peers) of the tutorial assessment scales, and in the mean scores of both the group interaction scale (items 1-5) and the active participation scale (items 6-9). CONCLUSIONS: The results suggested that PBL starting from the early years of a medical curriculum was associated with more active student participation, interaction and collaboration in small-group tutorials.

Association between air pollution and general practitioner visits for respiratory diseases in Hong Kong.

BACKGROUND: Few studies have explored the relation between air pollution and general practitioner (GP) consultations in Asia. Clinic attendance data from a network of GPs were studied, and the relationship between daily GP consultations for upper respiratory tract infections (URTI) and non-URTI respiratory diseases and daily air pollutant concentrations measured in their respective districts was examined. METHODS: A time series study was performed in 2000-2002 using data on daily patient consultations in 13 GP clinics distributed over eight districts. A Poisson regression model was constructed using the generalised additive model approach for each GP clinic, and associations with daily numbers of first visits for URTI were sought for daily concentrations of the following air pollutants: SO(2), NO(2), O(3), PM(10,) and PM(2.5). A summary relative risk of first visits to the GP for URTI per unit increase in concentration for each air pollutant was derived using a random effect model. First visits for non-URTI respiratory diseases were analysed in three GP clinics. RESULTS: Significant associations were observed between first visits for URTI and an increase in the concentrations of NO(2), O(3), PM(10), and PM(2.5). The excess risk was highest for NO(2) (3.0%), followed by O(3) (2.5%), PM(2.5) (2.1%), and PM(10) (2.0%). Similar associations with these air pollutants were found for non-URTI respiratory diseases. CONCLUSIONS: These results provide further evidence that air pollution contributes to GP visits for URTI and non-URTI respiratory diseases in the community.

Communication skill of general practitioners: any room for improvement? How much can it be improved?

OBJECTIVE: To measure any changes in the communication skills of primary care physicians before and after a part-time Diploma course in Family Medicine. SUBJECTS: 79 Hong Kong Chinese doctors (46 of whom were local graduates, with an average of 7 years in general practice). METHODS: Over the 10-month course in 2000-01, participants had 11 2.5-hour lecture/demonstrations in communication skills, 2 sessions of role play practice in groups of 20, self-analysis of a videotaped interview and skills evaluation. A before-after design measured scores in videotaped simulated patient interviews (rated by a research assistant using a structured observation guide, after standardisation by a psychologist) and scores in Objective Structured Clinical Examinations (OSCE) (rated by experienced family physician examiners with standardised checklists). RESULTS: There were wide variations in baseline skills, with scores ranging between 24-78 (out of 100) for video and 18-68 for OSCE, which were related to prior training and inversely associated with years after graduation. Significant improvements occurred in both video (from 53 to 61) and OSCE (from 46 to 56) post-course (P < 0.001). The group in the lowest quartile improved from 36 to 54 for video and from 29 to 48 for OSCE, while those in the second lowest quartile improved from 50 to 61 for video and from 44 to 56 for OSCE (F = 12.2, P < 0.001). Doctors who graduated more than 20 years ago made as much improvement as more recent graduates. CONCLUSIONS: Communication skills can be effectively taught to, and improved among experienced Chinese doctors by a combination of large-class teaching and medium-sized group practice with feedback, and without intensive individual supervision.

Alpha-fetoprotein and/or liver ultrasonography for liver cancer screening in patients with chronic hepatitis B.

BACKGROUND: Chronic hepatitis B infection may cause liver cancer (hepatocellular carcinoma (HCC)). Alpha-fetoprotein (AFP) and liver ultrasonography (US) are used to screen these patients for HCC. It is uncertain whether screening is worthwhile. OBJECTIVES: To review randomized trials on screening for HCC with alpha-fetoprotein and/or liver ultrasonography among people with hepatitis B surface antigen (HBsAg) whether asymptomatic or with clinical liver disease. SEARCH STRATEGY: Relevant reports were searched from electronic databases until August 2002 (The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Controlled Trials Register, MEDLINE, EMBASE, HealthStar, and the Chinese Medical Literature Electronic Databases, MedCyber) supplemented with manual searches on the bibliographies of papers found and communication to people familiar with chronic hepatitis B. SELECTION CRITERIA: Randomized trials on screening for liver cancer were included irrespective of language. Studies were excluded if the hepatitis B status was uncertain, if patients were not adequately followed, if the screening tests were not sensitive, widely-used ones, or if the test was used for diagnosis rather than screening for HCC. DATA COLLECTION AND ANALYSIS: We analyzed independently all the studies considered for inclusion. We wrote to the relevant authors for further information. Data were analyzed with Peto's odds ratio (OR) with 95% confidence interval (CI). MAIN RESULTS: Two trials met the selection criteria. One trial (n = 18,816) compared bi-annual AFP plus US screening with no screening for five years. No data on all-cause mortality were available. The two groups did not differ significantly regarding HCC mortality (OR 0.81; 95% CI 0.54 to 1.22). Number of patients with HCC was significantly increased in the screeened group (OR 1.37; 95% CI 1.00 to 1.88). Most HCCs in the screened group, but none in the control group, were at an early stage. The survival rate of patients with resected HCC in the screened group reached 52.7% after three and five years, but was 0% for those in the control group. The authors' estimated lead-time for HCC was 5.4 months, suggesting that screening prolonged the survival of HCC. Another trial (n = 1069) compared AFP plus US versus AFP screening, but could not decide which approach was superior due to the small sample size (number of detected HCC: OR 0.74; 95% CI 0.26 to 2.12). REVIEWER'S CONCLUSIONS: There are not enough quality trials to support or refute screening of HBsAg-positive patients for HCC. It is possible that screening may be effective, but also that harm caused by screening/treatment may outweigh any gain. More and better-designed large randomized trials are required.

Graduates' evaluation of a postgraduate diploma course in family medicine.

BACKGROUND: Postgraduate programmes offer an opportunity to learn family medicine for physicians in practice who were unable to obtain formal training in the immediate postgraduate phase of their career. Since 1985, the Chinese University of Hong Kong has provided a part-time 1-year diploma course at hours convenient for private practitioners. The curriculum has evolved, reducing public health components and increasing family medicine concepts. Between six and 16 students took the course each year until 1999, when formal recognition led to increased popularity. OBJECTIVE: The aim of this study was to evaluate the components and outcomes of the course as a prelude to further development. METHODS: Evaluation comprised a structured telephone interview conducted with two enrollees from each year of the course (total 28), selected randomly from class lists. RESULTS: Participants were mostly young doctors, with an average of 5 years in general practice. Many graduates are now prominent in training and development of family medicine in Hong Kong. Graduates rated most components favourably, but found the original research components too demanding, and not useful subsequently for most. Counselling, family dynamics, consultation and practice organization skills were valued. Conventional continuing education components, such as lectures by specialists, were evaluated poorly. CONCLUSIONS: This course has proved useful in the Hong Kong context, being practical for physicians, and allowing them to study ideas they would not otherwise encounter. Critical appraisal and evidence-based medicine exercises now replace the former research components.

Primary care physicians in public and private sectors perceive different learning needs.

We compared the perceived learning needs of primary care physicians from the public and private sectors who responded to a questionnaire before taking educational courses in Family Medicine. They rated their perceived learning needs on 71 items of clinical practices and practice management on a scale of 1-10. The ratings of their learning needs were closely related to the perceived needs of their daily work. The private physicians gave higher ratings to most items. Both groups of physicians shared similar least-preferred items (e.g. suturing, plastering, taking Pap smears) but had very different most-preferred ones. Public physicians wished to improve their care of individual patients (e.g. skin, eye, ear-nose-throat problems). Private physicians were more concerned with professional development to improve their practice (e.g. audits, counselling, adult learning). Organizers of educational programmes should assess and discuss with physicians their expected learning needs at the planning stage of a programme.

Modelling death rates for carriers of hepatitis B.

Hepatitis B carriers who acquired the infection perinatally die from hepatocellular carcinoma (HCC) and cirrhosis at high rates. Published cohort studies are largely limited to males and are too small to estimate the age-specific risk of death. We therefore used routinely collected Hong Kong data to estimate the risks. Deaths were partitioned between carriers and non-carriers, then current life table calculations determined life expectancy and probability of dying from HCC or cirrhosis. HCC is the dominant cause of death for male carriers in middle adulthood with a lifetime risk of 27% for HCC compared to 4% for females. Predicted life expectancy is 72 years for male carriers, compared to 79 years for non-carriers. Female carriers have a life expectancy of 81 years and non-carriers 83 years. This model probably applies to all southern Chinese populations and emigrants with similar life history, and other populations that acquired infection early in life.

Determinants of physicians' attitude towards prescribing.

OBJECTIVE: To identify the primary care physicians' (PCP) characteristics that are associated with their prescribing attitude. METHODS: A validated questionnaire was sent to randomly selected PCPs stratified in three groups according to any higher qualification in family medicine. RESULT: The best predictor for orientation of quality of care in prescribing was the country of qualification. Duration after qualification was negatively associated with PCP's belief in the use of drugs. Physicians who were female, with higher qualification, sooner after qualification, and working in group practice were less likely to perceive pressure from patients to prescribe, with group practice being the most significant determinant. CONCLUSION: Different physician factors affect different aspects of PCPs' prescribing attitude. As duration after qualification was an important but negative attribute, quality use of medication should be emphasized in continuing medical education.

Hyperuricaemia in Type 2 diabetes mellitus.

This study was undertaken to find the significant parameters associated with hyperuricaemia in patients with Type 2 diabetes, and hence to determine if hyperuricaemia is associated with poor control of diabetes or increased coronary heart disease. All the diabetic patients seen at a Family Medicine Teaching Clinic within the period January to September 1997 were recruited into the study. In 273 Type 2 diabetics, serum uric acid was analysed against basic demographic data (age, sex, smoking and alcohol habits, body mass index, number of years since the diagnosis of diabetes), present medications, control of diabetic state (attending physician's estimation of the patient's diet compliance, fasting serum sugar, HbA1c), and complications (serum creatinine, total cholesterol, triglyceride, urine proteinuria, retinopathy, last blood pressure readings, history of hypertension, coronary heart disease, stroke). Serum uric acid was significantly associated with body mass index, history of hypertension, serum triglyceride and serum creatinine, but was not related to coronary heart disease, stroke or control of the diabetic state. Female diabetics were more likely to have elevated uric acid. There is not enough evidence for monitoring serum uric acid or for intervention to lower asymptomatic hyperuricaemia in Type 2 diabetic patients.

Ultrasound characterization by stable statistical patterns.

It is shown that automated characterization of ultrasound images can be achieved effectively if the images are confined to single internal organs. The ultrasound image of a particular organ gives statistical textures of its structures, which are consistent with stable patterns. Analysis of these patterns leads to the construction, from a few statistical parameters, of a fast and effective algorithm to characterize these ultrasound images. A small training set is adequate. A similar approach may be used to detect tumour sites from liver ultrasonograms. The algorithms are implemented on an IBM-compatible personal computer for future incorporation into existing ultrasound machines.

The Asia Pacific Association for Medical Informatics (APAMI) and World Organisation of Family Doctors (WONCA) Consortium on General and Family Practice Informatics--a statement of intent.

This paper describes the establishment of a consortium to advance health and medical informatics in general/family practice in the Asia Pacific Region. The objectives, current activities currently taking place in the region and key activities planned will be outlined.

Impaired vision in the elderly: a preventable condition.

BACKGROUND: Vision is thought to deteriorate with age as a number of factors in later life endanger eyesight. Assessment of the visual acuity of the elderly and identification of endangering factors help in detecting those with impaired vision which in turn impairs daily activities. OBJECTIVE: This study measured the visual acuity of the senior citizens and identified those with impaired vision. The probable contributing factors for impaired vision were studied with the aim of preventing visual impairment. METHOD: The study was part of a screening campaign for elderly glaucoma in the community. A convenience sample of ambulatory senior citizens from stratified localities had their visual acuity measured with a standard Snellen's chart. The test was repeated with pinholes if the visual acuity was less than 0.5. Those without improvement after pinhole were considered as having impaired vision. People with elevated intraocular pressure by the Pulsair were selected for examination by an ophthalmologist for ocular pathology. RESULTS: For the ambulatory population aged > or = 65 the mean visual acuity of either eye before pinhole was 0.3. Nearly 72% had impaired vision (visual acuity not corrected above 0.5 with pinhole). There was a significant association between this impairment and female sex, history of diabetes mellitus or glaucoma, cataract, and infrequent eye examination. CONCLUSION: Impaired vision is highly prevalent in the elderly ambulatory population, a condition which is preventable by tight surveillance of predisposing factors and regular simple measurement of visual acuity. The primary care setting is most suitable for these activities.