Milk powder issue - A medcial or marketing issue

Milk product is essential in every part of human life.  There is no doubt that the best choice for infant feeding being breast milk.  For practicality, in every modern society, milk formula is popular as alternative.

From 2010, there is widely known fact or news that milk formula is the target of every Mainland visitors.  Especially in northern district, the dispensary retail outlets run out of infant milk formular in days and weeks.  Actually, it also occurs from time to time in urban Kowloon. The situation in Hong Kong island may be better.  But the cost of inflation, salary and shop rental push the price of milk product to sky high. Therefore the search for cheap milk products in some selected retail is much keener.  In big retail chains, they transfer all cost of high rental to customer. The price of milk formula is higher in such chains. But in individual shop, the demand of milk formula is much more intense if they do not raise price tremenduouly.

So the problem is there for 2008, 2009 , 2010 then 2011 - 13.  Local birth rises and climaxes at year of 2012.  Therefore the voice of milk powder control is higher and stronger.  For same reason, the privilege of choice exists for mainland mother too. If not all Hong Kong mothers give breast milk to their kids, why can't mainland mothers give better quality milk formula to their off springs.  So there is no wrong or right for them to search milk formula in Hong Kong or through their agents.. Even if mainlanders buy milk formula in Hong Kong and resell for profit. They are not morally right or wrong.

To curb the high competition for milk formula in local stores, immigration control of milk formula is instituted.
This is drastic measure. Back in 2008 or 2009, the competition of milk products is left to the market force that the place where demand is high push up the price. When the price is high the customers drift to other region. Then the supply is back and price is adjusted down and the customer flog back and push up the price once again.
The market control is successful but slow.

Urgency for securing supply of milk formula is there.  So rules set in.
Some scholars advise the baby to switch to whatever brand the mother can get hold of. Theorectically it is sound. But we can do better by sticking to one brand.
Actually, on can observe the same strategy exist for mainland visitors too. They are not just buying on brand only. They prefer one brand. Then if it is out of stock, they don't mind and purchase other brands and transfer up to mainland.


Milk formula are no different from one and other. The only difference is the confidence in the brand.
So that lies on the marketing strategy of each brand.
For milk formula sold solely in HK without distributors in mainland, they can obviously attract more customer.
But of course, no firm or company will look down on the vastness of mainland market.
For some reason, they cannot enter to mainland market directly, then they promote itself more intense in HK so that mainland customers prefer to ship large amout ot it to China.

For local mothers, I would suggest that most infants are capable of tolerating adult milk formula once they reach the age of 8 to 9 months. There body system develop stronger adaptability. In fact the difference between adult and infant milk formula is only minute. As in dfference of different brand, the adult milk may contain more sodium or other substance. So long as trial of milk by infant is successful, they can tolerate adult formula. Then the competition for infant formula can be left to neonate under age of 8 months.

Lastly, I wound point out that milk powder demand fluctuate widely. Maybe in next 5 or 10 years, no one would buy infant formula from Hong Kong. They may buy it direct from supplier. Then, for Hong Kong government, they will limit their own business by insituting so called proctecting local mother rules.

Pneumothorax - a life threatening disease

 

Recently I came across a news peculiar to pneumothorax.  An adolescent aged 18 of a single parent family committed suicide becasue of health trouble of recurrent pneumothorax.  Even working in the field specialising for pneumothorax surgery, I am not aware of similar case.





Although there is high chance that this patient may have psychiatric illness, it is shocking such a treatable disease lead to this tragedy.  The adolescent with pneumothorax must be dissatisfied with the treatment. The recurrence must be frequent causing disruption of school and social life.  With the introduction of minimally invasive thoracic surgery (also named VATS for Video assisted Thoracic Surgery), pleural disease like pneumothorax is easily treated.  However, the popularity of using VATS do induce non -expert surgeons to operate more.  Recurrent pneumothorax (if recur after the first attempt of surgery) do need referral to specialised experienced thoracic surgeons with keen interest in VATS.

Operations maneuvers for treating recurrence must include:

1. Proper identification of lung bleb (weakness of lung causing air leak)

2. Consideration of additional procedure like: pleurectomy, limited deocortication and adhesiolysis esp for lung adhering to medial part of diaphragm
and pleural tenting or transient phrenic nerve paralysis

3. Adding chemical agents like talc insufflation and chemical agents silver nitrate, fibrin glue and oxytetracycline , concentrated glucose

4. Position of suitable drain or drains (2 drains)

5. If patient allow and prefer early discharge, use of ambulatory draiange device or drainage bag with valve.

Proper procedure can reduce the recurrence to less than 3 %.

With patient aging beyond 35, the possiblity is low by nature. But with good surgery, if there is no recurrence in the post operative 3 - 4 years, the chance of recurremce is much less though not unheard of.

Sometime, pneumothorax cause problem of immobilisation. In old days, a young patient has open pleurodesis operation and subsequent deep vein thrombosis. He was put on anticoagulant but unfortunately develop hemothorax in recent operated chest. A redo thoracotomy is needed and patient has prolonged hospital stay.

In patient with Marfan's syndrome, recurrent hemopneumothorax may be troublesome.


By Dr Chung Shiu Shek

Multiple recurrence of spontaneous pneumothorax

Treatment of pneumothorax has not been standardised until 18- 19 years ago with the introduction of video assisted thoracoscopic surgery.
With simplicity of steps inovolved in bleb ligation and mechanical rub pleurodesis, the vision and access to majority of chest wall by videoscope allow easy performance of pleurodesis for patient.

Also the patient is usually is young and fit other than the pleural disease, the general anaesthesia procedure with double lumen endobronchial tube is well tolerated.

I remember the excitement when the laparoscopic instrument was put in the first few patient for VATS surgery back in 1992. We have looked at the bleb and feel extremely appealing and derive great satisfaction of putting the endo-loop on the apex. But not long after two or three such cases, dislodgement of the endo loop occur and we stick to using the endo stapler (the first generation of Autosuture endo GIA) for pneumothorax bleb resection.

For successful pleurodesis, certain amount of dense or extensive adhesion should be formed after the drain pulled and patient went home. Not infrequently, we do see patients with failed adhesion formation.

The means to prevent this include:

1. Keep the drain longer (but ususally drain has to pulled out after 6 or 7 days, usually the maximal duration that a young patient can tolerate without complaint.

2. Meticulous rubbing of pleural surface and chest wall is required.

3. Secure sealing of air leak point in lung

4. Modification of technique with addition of chemical sclerosant for every case.

There is discussion of the philosophy of first operation for VAT pleurodesis.
Some surgeon propose inclusion of small axillary or small maximally minithoracotomy in anteior port for better stapling of weak apex. The lung is mobilised down to the lung root near the SVC and hilar and lung apex delivered to outside through the throacotomy and single GIA application +/- oversewing is better than multiple fire.
Through the thoracotomy, the air leak can be tested and additional procedure of limited open pleurectomy can be added. Also the problem of intercostal neuralgia due to fulcrum pressure on the port site is avoided. The only small instrument port site will be the final drain site.

So there is revertion to minithoracotomy and Video assisted open thoracic surgery rather than keyhole VATS for pneumothorax.

The recurrence rate can be brought down from previously 10% to 4 or 5 %.

Recently I come across patients with immediate persistent air leak after first VAT surgery for pneumothorax and contralateral recurrence of pneumothorax.
I applied VAT endoscopic pleurectomy and ambulatory drainage method. The success is high and expected adhesion formation is secure.

I am practising specialist in pnemothorax and all kinds of thoracic surgery. I welcome question and queries for their problem with reasonable low consultation fee.
Clinic phone number: 3160 8865

Current trend of wound-less surgery in lung cancer: pushing to the limit of single 25mm wound

Single port surgery is the current trend in minimally invasive surgery. For lung cancer surgery, the adoption of extreme small wound is cautioned by the possibility of compromise of oncological clearance. However, as experience accumulate since the introduction of VATS surgery, the worry of delayed relapse or early recurrence is less of a concern. More and more surgeon believe in the reverse. With less immune suppressive effect of minimal access surgery, survival is prolonged for VAT operable lung cancer.
Recently I attend a workshop for the update of VATS in lung resection. Without expecting anything new to discover, the enthusiasm of speakers for VATS experience remains high despite coming along all those years of minimally invasive surgery. Yet they stress on the fact that only surgeon with a vision can push for limit of traditional belief and constraint.
So long as the surgeon believe in doing surgery with due care and good suprevision, pushing to the limit of two small wound then single uniport wound is best to achieve good recovery for same type of lung resection surgery. However, there is limit to everything. If it takes hours for the lung cancer to be removed when a slightly larger wound could allow swifter but not necessarily better clearance of tumour. One may not be too dogmatic to fight for shorter wound length.
Moreover, the reason of learning curve is not short for Uniport surgery.
From example of uniport laparoscopic cholesystectomy, the time will much vary with the inflammatory condition of the gallbladder. In occasional attempt, surgeon will take twice the usual time for difficult gallbladder.
I believe well trained surgeons do know the limit of his own and possiblitly of fatigue and psychological burden of prolonged surgery, they would convert at appropriate time. The imperative is patient's safety and the least of concern is surgeon's ego.

I applaud the skill and determination of surgeon pursing uniport VAT lobectomy. But  I personally would select less than 10% of all operable lung cancer for such attempt.

Value of Life or Health - Perspective from health care helper

As doctors, most of the medical ailments are commonly known to us. We understand that most of the complaint about pain and ache or discomfort did not signify important illness. This is to be said with a caution such as coughing out blood, severe weight loss, depression with suicidal thought or severe spontaneous syncope.
Conversely, some severe life threatening disease may not have symptoms.

I have talked about screening in previous blog and stress that the benefit of screening for example in lung cancer is not to be down played. However, there is a need for mentality and financial resource for proper screening. Acutally the drive is more important than money in such cases.

But when it come to important illness such as severe pneumonia, renal failure, severe trauma or stroke, medical personnels are the least to cope with this. Their knowledge would bring some advantage but add worry to the treatment course.

To me, the loss of life turn out to be some daily events. More eye cathing are victims in natural disaster, violence such as rape or terrorism or medical mishap or early cancer in young adults. Acutually, life is quite vulnerable. The possibility of serious blow to it is always there.

To treasure it is really necessary for us to rethink eveything. Our existence certaily would be transient in the history of time. If at one time and at one place, we can make our surrounding or family happy. Out existence will add meaning to us all.

For me, I would try my best to give the best possible treatment to them. I cannot change my patient's fate. At most, I hope to give them the best attiotude to face life and death. Treasure existing life but forget tommorrow trouble.

Dr Chung Shiu Shek tel of clinic: 31608865

Sino Japanese Relationship

As a medical professional, we like to talk about politics but seldom take it serious. With wide coverage and nearly daily report of riots in China, the tension between China (PRC) and Japan is on every news' front page.  We all know from the day of birth that Chinese and Japan are competing countries and seldom in good terms. But the value of peaceful coexistence is more than everything to avoid mutual terror at World War II.  As Chinese, the sense of being treated unfairly is especially sharp. From Japanese society, their education may be deviated towards self righeousness; but most japanese are well educated and also believe in peace rather than militarism.

Why do the approach of the subject create so many news and tension?  The answer should be timing. As Diaoyu island is an old problem, whehter you want or not, practically it is under the control of Japanese force.  As these problem has been years, and nearly no interest about it by Japanese governement. Why japanese want action or something to be done recently. Usually the target against another nation help stabilise force and create unity in home country in favour of the existing power. They are used by both government to consolidate  power. In China, the future of post HU Jianto governement has been clear but not fully established. To push aside discrepancy of opinion, the need of unity for different ages or different force within the central government is important. More than anything, the hate against japanese invasion can be used once again for Vice Premiere Xi to assume good central control of power.

To Japanese government, the power of democratic party has never been stable since take over of premiereship from opposing self democratic party. They are faced again by tragedy of nuclear incident. They need more fame and esteem to stay solid in control of Japan. To unify the parliament, the pride of owning Diaoyu island is brought in again. In fact Japan own this island for ages. is there any need for power or petroleum over there? I thnik no, the economic advantage is not great, The susceptibility of being invaded or destroyed by other force make investment risky. From recent report on Japaneses newsmedia, there is comment or criticism of current act of Japanese government. So not all japanese want War as depicted by chinese media.

Why the newspaper always focus on this? To sell more paper and be only source for news. In War times, newspaper sell. Remember 9/11, suddenly everyone want to grap newspaper as research by reporter attract more attention and bring satiety to news hunger in public.

So we would heard about riots , tension, demonstration against Japan in Chinese news. But not after the 18th NPC commitee. By then, every protest will be suppressed. Peaceful talk with Japan will begin. Concession for mutual benefit will be granted. Any civilian upset about government weakness will be gone. No news about Diayo island will be publicised. Like the control of internet, there would be information control as tight that even thought there is protest, it will not be reported or mentioned in any media.

As for the Japanese, the status of the island will remained the same. You can call it nationalisation. You can call is isolation. Thus, there is no real owners and no transaction of money ever to be made in the Bank for the ownership of the island. Japanese media has no interest and never want to be made use of by their polictian. The Diaoyu island cannot be anything of financially as one thousandth of Tokyo or even the nuclear accident town. They are just hyperbole of the news media.

Thank to the gift of life: on the recieving end

As medical professional, the preciousness of life make some of our patients extremely grateful to us. But is it our preference to have such feeling and reaction. Or is it the absence of such action make us uncomfortable or dissatisfied. From the patient point of view, will our action of grafeful feedback secure better follow up service?

I recently read about the ICU dying patient news about recieving a generous cavdever organ donation. The news state that as an emotional reaction, the heart surgeon shed his or her tears saying that the patient should treasure this timely gift of life.  I usually feel uneasy about that emotional side of providing medical treatment. But the meaning of doctors act should however touches heart of most patient and people.

For doctor either recieving pay from public money or from paying patient 's pocket, they are suitably remunmerated with proportionally correct sum. The doctor has the de facto responsibility to carry out a good and technically right work.  Compliment to doctor success is thus an extra.  Having said that, doctors usually appreciate very much the thankfullness of their patient. Sometime these are driving force for doctors altruism.

Once I have the experience of being touched by my patient's word. He is a gentlemen and always thanks me for whatever procedure or treatment I provide him.  Once I talked casually to him. Do not be too courteous , you know you have paid me for my professional service. I owe you the trust. He responded calmly. Dr Chung, I know I have paid all the professional fee related to my treatment and I knowed I am entitled to high standard care. But regarding your service and careful adminstration of care, I still owe you a words of thank because of trueworthiness of your work. Our care and attention if acted from our heart are much valued by our patient.

Occasionally as private specialist, the care of long term disease bring much concern to financial burden.  So some of my patients will not return for follow up. This is reasonable as chronic disease can bear the burden of waiting list and these conditions can best be dealt with in public sectors. Anyway, I would not anticipate that all patient will be my faithful followers for life.  Sometimes, I heard complimentary words about my service but later default in follow up. I find it perplexing to understand. But In the real world, this is not uncommon.

In essence, I do feel good on the recieving end of thank and gratefullness. But do not take it too serious as your driving force. Some patients and most indeed has the concern of financial constraint.  They are entitled to develop way to secure best mode of care to them. So they would swarm between private and public care depending what fit them most.  However, I do feel satisfied after tough surgery or long operation, the patient or patient's relative say from their heart: You have done a great job. You have done a favour to them.

Surgeon with a heart: I am Dr Chung Shiu Shek specialist in Cardiothoracic Surgery, Clinic phone no: 3160 8865