Calmness and clarity

Kathy KL Tsim 詹觀蘭

HK Pract 2020;42:1-2

As we enter March, spring is in the air. It is the time for new beginnings and bright futures. Winter has passed with its cold grim evenings; the rain is over. As we look out onto a hopeful Hong Kong getting back on track with life below the Lion Rock, we all take heart with this month’s Hong Kong Practitioner article by Drs Yeung and Lee informing us that cancer might not be an imminent early death sentence but could be a chronic condition. With the advances of medicine, immunotherapy in the form of immune checkpoint inhibition might be the new mode of cancer treatment today bringing this possibilities to many. It does not cause a “Re-Zero” situation to occur but at least it would disappoint and bring the Grim Reaper, Thanatos to visit another day.

It is surprising that this therapy began with Bacillus Calmette– Guérin (BCG) being used as an immunotherapy to treat superficial bladder cancer back as far back as nearly 40 years ago. ¹ The BCG has certainly come a long way from being used just as a vaccination against Tuberculosis. The body’s own humoral immune response to BCG vaccination remains poorly defined. It would appear that BCG has complex and diverse immunomodulatory influences ranging from effects on autoimmune disease (possible postulated benefit for Multiple Sclerosis, Insulin-dependent diabetes mellitus) to atopic disorders. ² The most significant so far as a treatment for bladder carcinoma-in-situ and possible prevention of tumor recurrence with maintenance therapy.

We are getting a glimpse of the battle raging within our own body to disease in the immune cellular level with our current knowledge and research. This better knowledge has made the breakthrough of considering some cancers as being chronic illnesses, e.g. breast cancer, prostate cancer and even some types of ovarian cancer, with hopefully more on the way. ³ With immunotherapy even some metastatic e.g. non small-cell stage IV lung cancers can now be very well-controlled for a long period of time to be chronic illnesses. Along with this development, the patient and their carer now face a different type of stress and management issues. We as Family Physicians who care for them would need to adjust our roles as their main carers.

Another disease entity that has become better understood and hence more defined is Parkinsonism. As highlighted by Dr Tsang’s article, all that is masked facies, stiffness and tremors is not Parkinson’s disease. Parkinson’s disease (PD) is a chronic progressive neurodegenerative disorder affecting older individuals. In a meta-analysis study done by Ma et al in 2014, the pooled prevalence and incidence of PD in China was noted to 2 per 100,000 population and 797 per 100,000 person-years. ⁴ It would also appear that this is lower than in western countries. However, it would appear that Asian PD patients report higher levels of subjective cognitive impairment than White patients, noting a difference in ethnic manifestations of this illness. ⁵

This disorder needs to be differentiated from Parkinsonism which refers to a group of neurological disorders that results in similar movement problems as to those seen in Parkinson’s disease patients. Study of the prevalence of both diseases have found that in 5 European countries both appear to increase with age, without any significant differences between men and women. There was no convincing evidence for differences in prevalence across these countries but no study has been so far undertaken for the Asian population. ⁶ The need for differentiation between them is important for the sufferer’s disease management. Dr Tsang has given us a valuable guide to help us Family Physician to maneuver through the maze of imaging modalities available, helping us to find the most appropriate for the patient in front of us.

As Family Physicians, we do not only need the knowledge base to choose the most appropriate investigative procedure for our patient but an ever up-to-date attitude with our acquirement of valuable skills . Dr Chuh has shown us how as Family Physicians we can also master complex dermatological equipment and go beyond to use this equipment not only as a diagnostic tool but as a real time aide for surgical dermatological procedures. His case report of a patient who underwent dermosope-guided excision biopsy is just such the encouragement that we need. The humble dermoscope which was developed back in 1989 has evolved and advanced so much that it is now used widely by dermatologist and dermatology-interested Family Physicians alike. It was once a valuable diagnostic tool and now has been reinvited thanks to Dr Chuh to become a real-time imaging tool for dermatological surgery.

According to a 2018 online questionnaire of the United Kingdom Primary Care Dermatology Society members (comprising of approximately 1,600 General Practitioners and other Primary Care Providers; being affiliated to the British Association of Dermatologists) found that access to a dermatoscope and its frequent use is commonplace. It would seem that even for a busy General Practitioner, the dermatoscope can be incorporated into their routine clinical practice. ⁷ With time and effect, the small dermatoscope might soon be seen as an office equipment in most clinic setting in the near future. As they say, “we live and learn”, especially with the great speed of technical advancement in our society and medicine nowadays. We as the advocate for family health have an important role to not only seek out the most up to date knowledge but to master it for the benefit of our patients.