Hong Kong Med J Vol 15 No 6 # December 2009 # www.hkmj.

org 427
Objective To examine the management practice of pneumothorax in
hospitalised patients in Hong Kong, especially the choice of
drainage options and their success rates, as well as the factors
associated with procedural failures.
Design Retrospective study.
Setting Multi-centre study involving 12 public hospitals in Hong Kong.
Patients All adult patients admitted as an emergency in the year 2004
with a discharge diagnosis of pneumothorax were included.
Data on the management and outcomes of the various types of
pneumothoraces were collected from their case records.
Results Altogether these patients had 1091 episodes (476 primary
spontaneous pneumothoraces, 483 secondary spontaneous
pneumothoraces, 87 iatrogenic pneumothoraces, and 45
traumatic pneumothoraces). Conservative treatment was offered
in 182 (17%) episodes, which were more common among patients
with small primary spontaneous pneumothoraces (71%). Simple
aspiration was performed to treat 122 (11%) of such episodes, and
had a success rate of 15%. Aspiration failure was associated with
having a pneumothorax of size 2 cm or larger (odds ratio=3.7; 95%
condence interval, 1.2-11.5; P=0.03) and a smoking history (4.1;
1.2-14.3; P=0.03). Intercostal tube drainage was employed in 890
(82%) episodes, with a success rate of 77%. Failure of intercostal
tube drainage was associated with application of suction (odds
ratio=4.1; 95% condence interval, 2.8-5.9; P<0.001) and presence
of any tube complications (1.55; 1.0-2.3; P=0.03). Small-bore
catheters (<14 French) were used in 12 (1%) of the episodes only.
Tube complications were encountered in 214 (24%) episodes.
Conclusion Notwithstanding recommendations from international
guidelines, simple aspiration and intercostal tube drainage
with small-bore catheters were not commonly employed in the
management of hospitalised patients with the various types of
pneumothoraces in Hong Kong.
Management of patients admitted with
pneumothorax: a multi-centre study of the practice
and outcomes in Hong Kong
O R I G I N A L
A R T I C L E
Key words
Chest tubes; Drainage; Pneumothorax/
therapy; Suction; Treatment outcome
Hong Kong Med J 2009;15:427-33
Department of Medicine, Queen
Elizabeth Hospital, Hong Kong
JWM Chan, FRCP, FHKAM (Medicine)
CK Ng, MRCP, FHKAM (Medicine)
Department of Medicine and
Therapeutics, Prince of Wales Hospital,
Hong Kong
FWS Ko, FRCP, FHKAM (Medicine)
Department of Medicine, Ruttonjee and
Tang Shiu Kin Hospital, Hong Kong
AWT Yeung, MB, BS, MRCP
Department of Medicine, Kwong Wah
Hospital, Hong Kong
WKS Yee, FRCP, FHKAM (Medicine)
Department of Medicine, Pamela Youde
Nethersole Eastern Hospital, Hong Kong
LKY So, MRCP, FHKAM (Medicine)
Department of Medicine, Queen Mary
Hospital, Hong Kong
B Lam, FRCP, FHKAM (Medicine)
Department of Medicine, Caritas
Medical Centre, Hong Kong
MML Wong, FRCP, FHKAM (Medicine)
Department of Medicine, North District
Hospital, Hong Kong
KL Choo, FRCP, FHKAM (Medicine)
Department of Medicine, Alice Ho Miu
Ling Nethersole Hospital, Hong Kong
ASS Ho, FRCP, FHKAM (Medicine)
Department of Medicine, Tseung Kwan
O Hospital, Hong Kong
PY Tse, MRCP, FHKAM (Medicine)
Department of Cardiothoracic Surgery,
Queen Elizabeth Hospital, Hong Kong
SL Fung, MRCP, FHKAM (Medicine)
Respiratory Medical Department,
Grantham Hospital, Hong Kong
CK Lo, FRCS, FHKAM (Surgery)
Department of Medicine, Princess
Margaret Hospital, Hong Kong
WC Yu, FRCP, FHKAM (Medicine)
Correspondence to: Dr JWM Chan
E-mail: chanwmj@ha.org.hk
Johnny WM Chan
Fanny WS Ko
CK Ng
Alwin WT Yeung
Wilson KS Yee
Loletta KY So
B Lam
Maureen ML Wong
KL Choo
Alice SS Ho
PY Tse
SL Fung
CK Lo
WC Yu

Introduction
Despite the presence of guidelines for the management of pneumothorax,
1-4
considerable
variations in practice have been reported in studies carried out in various countries.
5-13

Many such studies were either simple surveys,
5,7,9-11
or small retrospective single-centre
audits.
6,7,12
In addition, most studies only described the practice for managing primary
spontaneous pneumothorax (PSP).
7-9,13
Despite the advocacy of less invasive interventions
such as simple aspiration (SA)
1,3,4
and intercostal tube drainage (ITD), and use of small-bore
catheters
2-4
in the management of spontaneous pneumothorax (SP) and especially for PSP,
many studies have revealed suboptimal adherence to such guidelines.
5-13
In this study, we
aimed to examine the management practice of pneumothorax in hospitalised patients in
Hong Kong, especially regarding the choice of drainage options and their success rates, as
well as the factors associated with procedural failures.
Methods
Study design and patients
A multi-centre retrospective study was carried out in 12 public hospitals in Hong Kong,
CME
# Chan et al #
428 Hong Kong Med J Vol 15 No 6 # December 2009 # www.hkmj.org

2004

20041091476
48387
4518217%

71%12211%
15%2 cm
=3.795%1.2-11.5P=0.03
4.11.2-14.3P=0.03
89082%
77%=4.195%
2.8-5.9P<0.001
1.551.0-2.3P=0.03
121%
<14 F214
24%

including two university-afliated institutions. The

case records of adult patients with emergency
admissions between 1 January 2004 and 31 December
2004 with a discharge diagnosis of pneumothorax
were retrieved and studied. Cases with the
International Classication of Diseases 9th revision
(ICD9) diagnostic codes of 512, 011.7 and 860 were
identied by Clinical Data Analysis and the Reporting
System of the Hong Kong Hospital Authority.
Cases were subsequently excluded if (a) the actual
diagnosis upon review was not pneumothorax; (b)
the age was less than 18 years; (c) the patient had
been transferred from another hospital or electively
admitted for procedures related to the pre-existing
pneumothorax; and (d) the record could not be
retrieved despite repeated attempts. Data such as
demographic information, type of pneumothorax,
smoking status, underlying respiratory diseases,
co-morbid conditions, previous pneumothoraces,
management, outcomes, and length of stay were also
collected. Secondary spontaneous pneumothorax
(SSP) was dened as a pneumothorax associated
with underlying lung diseases, and without these, it
would be regarded as a PSP. Those with iatrogenic
or traumatic aetiologies (ie non-spontaneous) were
categorised as iatrogenic pneumothorax (IP) and
traumatic pneumothorax (TP), respectively, regardless
of any pre-existing respiratory diseases. The size
of the pneumothorax was categorised as small (<2
cm) or large (2 cm), depending on the maximal
distance between the lung margin and chest wall,
3
by
reviewing case notes and, if necessary, any available
chest radiographs. Successful resolution following
SA and ITD was dened as complete lung expansion
without the need for further interventions (SA, ITD,
or surgery) during the same admission. Approval
from the ethics committees of participating hospitals
was obtained prior to the study.
Statistical analysis
Results were expressed as mean and standard
deviation (SD) or median and interquartile range
(IQR) values for continuous variables, or numbers
(percentages) for categorical data. Students t test
or the Mann-Whitney U test were used to compare
the differences between continuous variables as
appropriate, while the Pearson
2
or Fishers exact
test were used to compare categorical data. Missing
values were imputed using the maximisation
method. Multiple logistic regression was used to
determine the independent factors affecting the
management outcomes. Results were reported as
adjusted odds ratios with 95% condence intervals.
All tests of statistical signicance were two-sided,
unless otherwise stated. A P value of less than 0.05
was considered statistically signicant. The analysis
was performed using the Statistical Package for the
Social Sciences (Windows version 11.0; SPSS Inc,
Chicago [IL], US).
Results
Among the 1119 episodes of pneumothorax
identied using the ICD9 diagnostic codes, 28 were
subsequently excluded (10 were in patients aged
<18 years, seven did not have pneumothorax after
case record review, two were electively admitted for
surgery, and for nine episodes hospital records were
missing). Altogether 1091 episodes (1057 patients)
were included in the analysis. The mean age of the
patients was 51 (SD, 24) years, and 935 (86%) of the
episodes were in males. Almost 90% of the episodes
were SPs (Fig). For most of the episodes (825, 76%),
the patients were admitted to general medical wards,
but to surgical wards for 128 (12%) and respiratory
medical wards for 117 (11%) of the episodes. The
pneumothorax was right-sided in 576 (53%), left-
sided in 489 (45%), and bilateral in 26 (2%) instances.
Smoking status of the patient was available for 993 of
# Management of pneumothorax in Hong Kong #
Hong Kong Med J Vol 15 No 6 # December 2009 # www.hkmj.org 429
prescribed to patients in the course of 897 (82%)
episodes. Simple observation only was employed in
182 (17%) of the episodes, including 76 (16%) of PSP,
70 (14%) of SSP, 30 (34%) of IP, and 6 (13%) of TP. The
commonest categories of pneumothorax for which
the patients were monitored conservatively were
small PSPs, small SSPs, and IPs (Table 1).
the episodes; for 713 (65%) they were either current
or ex-smokers. The most common underlying
respiratory diseases in patients with SSP were chronic
obstructive pulmonary disease (287 episodes, 59%),
old pulmonary tuberculosis (194 episodes, 40%) and
malignancy (37 episodes, 8%), and in 154 (32%) more
than one respiratory disease was present. Other
medical co-morbidities were encountered in patients
in the course of 285 (26%) episodes, and included
diabetes mellitus, cardiovascular and cerebrovascular
diseases. In 327 (30%) of the episodes, the patients
gave a history of pneumothorax, ranging from once
(218, 20%) to 8 times (1, 0.1%). Size categorisation was
possible in 1003 (92%) episodes; 289 (27%) being small
and 714 (65%) large. Chest pain or breathlessness
were associated with 964 (88%) of the episodes. For
the diagnosis of pneumothorax, a posteroanterior
chest X-ray was the sole investigation used in 940
(86%) episodes. Additional expiratory, lateral, and
decubitus radiographs were obtained for 77 (7%),
68 (6%), and 6 (0.5%) of the episodes, respectively.
Computed tomography was used for 42 (4%) of the
episodes.
The management of the 1091 episodes is
summarised in the Figure and the choice of initial
options selected are shown in Table 1. Oxygen was
787 (72%)
*
Intercostal tube insertion as initial choice
1091 Episodes of pneumothorax
476 (44%) PSP
483 (44%) SSP
87 (8%) IP
45 (4%) TP
18 (2%)

Discharged with residual

pneumothroax
5 (0.6%)

Death
73 (8%)

Surgery
18 (15%)

Success
104 (85%)

Failure
122 (11%)
*
Simple aspiration
60 (7%)

Medical pleurodesis
51 (6%)

Chest drain re-insertion after

removal in the same admission
1 (0.8%)

Discharged against medical advice

683 (77%)

Success
207 (23%)

Failure
890
Intercostal tube drainage
182 (17%)
*
Observations
103 (84%)
Underwent intercostal
tube drainage
FIG. Management and outcomes of the 1091 episodes of pneumothorax
PSP denotes primary spontaneous pneumothorax, SSP secondary spontaneous pneumothorax, IP iatrogenic pneumothorax, and TP traumatic
pneumothorax
*
% based on all episodes of pneumothorax (n=1091)

% based on all episodes of initial simple aspiration (n=122)

% based on all episodes of intercostal tube drainage (n=890)

Types of pneumothorax Initial choice (%)
Observation Aspiration Chest drain
Primary SP*
Overall (n=476) 16 17 67
Size <2 cm (n=95) 71 10 20
Size 2 cm (n=351) 2 18 80
Secondary SP
Overall (n=483) 14 7 73
Size <2 cm (n=145) 43 6 52
Size 2 cm (n=290) 2 9 89
Iatrogenic pneumothorax (n=87) 34 6 60
Traumatic pneumothorax (n=45) 13 2 84
TABLE 1. Choice of initial management options for the various types of pneumothorax
* SP denotes spontaneous pneumothorax
# Chan et al #
430 Hong Kong Med J Vol 15 No 6 # December 2009 # www.hkmj.org
Simple aspiration
Simple aspiration was performed for 122 (11%) of
the episodes; 80 (66%) by doctors in the emergency
departments, 32 (26%) in general medical wards,
and 5 (4%) each in respiratory medical and thoracic
surgical wards. The success rate was only 15%, with
subsequent ITD being undertaken in 103 cases,
including one after failure of repeated SAs (Fig). In
all, SA was performed for 81 (17%) of PSP episodes,
35 (7%) of SSP episodes, 5 (6%) of IP episodes, and
1 (2%) episode of TP yielded success rates of 19%,
6%, 20% and 0%, respectively. No complications were
encountered. A past or current smoking history, and
a large pneumothorax (2 cm) were associated with
procedural failures (Table 2). Only a smoking history
was associated with aspiration failures, when PSP
episodes were analysed separately (P=0.03).
Intercostal tube drainage
Intercostal tube drainage was carried out for 890
(82%) of the episodes. In the 655 (74%) episodes in
which the catheter sizes were documented, a size
larger than 24-French (F) was the most popular (293
episodes, 33%), followed by 20-24F (275 episodes,
31%) and 14-18F (75 episodes, 8%). Catheters of
smaller than 14F were used for 12 (1%) episodes only.
Patients admitted to surgical wards had larger tubes
(>20F) than those managed by physicians (87% vs
74%, P<0.01), while those under the care of general
physicians had larger tubes than those managed by
respiratory physicians (94% vs 85%, P=0.03). More
than one drain was used in 86 (10%) episodes. Suction
was applied to chest tube in 446 (50%) episodes. The
timing in relation to tube insertion was available in
437 instances. Suction was commenced immediately,
24 hours, and 48 hours after tube insertion in 162 (37%
of ITD with suction), 88 (20%) and 187 (43%) episodes,
respectively. Clamping before tube removal was
practised in 382 (43%) episodes. Complications of
ITD were identied in 214 (24%) episodes (Table 3).
The overall success rate of ITD was 77%. Subsequent
surgery or chemical pleurodesis was carried out for
133 (15%) episodes, because of persistent leakage
and failure of lung expansion. Successful ITD for PSP,
SSP, IP and TP were noted in 283 (74%), 314 (77%),
51 (91%), and 35 (90%) of the episodes, respectively.
Presence of any intercostal tube complication and
application of suction were independently associated
with ITD failure (Table 4). However, early application
of suction (within 24 hours of tube insertion) was
not associated with a higher failure rate; respective
early and late suction failure rates being 39% and 32%
(P=0.19). When analysed separately, application of
suction remained the only factor associated with ITD
failure for PSP (P<0.001) and SSP (P<0.001) episodes.
Referrals to respiratory physicians were made
for 312 (29%) of the episodes, at a mean interval of
3.6 (SD, 3.7) days, while referrals to thoracic surgeons
were made for 388 (36%) at a mean interval of 5.2 (SD,
6.7) days after admission. For 30 (3%) episodes, the
patients received intensive care, of whom 29 also
received mechanical ventilation. Their median length
of stay in hospital was 10 (IQR, 6-18) days, although
other co-morbidities also contributed to the length
of hospitalisation in 227 (21%) of these episodes. The
median length of stay for patients whose episodes
were managed by observation alone was 5 (IQR, 3-7)
days. Patients undergoing SA only had a signicantly
shorter median length of stay compared to those
having ITD only (9 [IQR, 5-16] days vs 12 [IQR, 7-20]
days; P<0.01).
Factor No. (%) Adjusted odds ratio
(95% condence interval)
P value
Successful aspiration
(n=18)
Failed aspiration
(n=104)
Male sex 15 (83) 92 (88) 1.39 (0.29-6.63) 0.68
Age >50 years 4 (22) 33 (32) 0.78 (0.17-3.60) 0.75
Smoking history (ex- or current smokers) 6 (33) 66 (63) 4.11 (1.20-14.31) 0.03
Secondary spontaneous pneumothorax 2 (11) 33 (32) 6.34 (0.72-55.61) 0.10
Pneumothorax size 2 cm 10 (56) 83 (80) 3.65 (1.16-11.46) 0.03
Presence of >1 respiratory co-morbidity 1 (6) 11 (11) 0.33 (0.02-6.94) 0.47
TABLE 2. Multivariate logistic regression analyses of factors associated with outcomes of simple aspiration (n=122)
Complication No. (%)
Aberrant placement of chest drain 18 (2)
Penetration of internal organs 20 (2)
Haemorrhage 19 (2)
Surgical emphysema 99 (11)
Exit site infection 16 (2)
Empyema thoracis 2 (0.2)
Kinking or blockage of chest tubes 29 (3)
More than 1 complication 26 (3)
No complication 678 (76)
TABLE 3. Complications associated with intercostal tubes (n= 890)
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Discussion
To the best of our knowledge, this is one of the largest
studies assessing the management practice of adult
subjects hospitalised with pneumothorax,
5-13
and also
the rst study of its kind in Hong Kong. In contrast
to previous surveys that employed hypothetical
scenarios,
9-11
this study assessed the actual clinical
management provided. Since the study involved a
majority of public hospitals in Hong Kong, it provides
representative data reecting current local practice.
The nding that most patients with small PSPs
were offered simple observation is in line with the
guidelines.
1-4
Our study also revealed that SA was
not commonly performed by Hong Kong doctors,
including respiratory physicians. Previous studies
also revealed that SA was not a favoured strategy,
7,8,12

especially among the general physicians,
6
and for
SSPs and PSPs of intermediate size.
9,10
Such ndings
appear strange in the light of comparable studies
14-17

and systematic reviews
18,19
that have demonstrated
similar immediate success rates for SA and ITD
in patients with PSP. Additional advantages of SA
include: shorter hospital stays,
14,17,18
less pain,
14
and
fewer patients requiring hospitalisation.
16,17
However,
the role of SA itself also differs between different
guidelines. While the British Thoracic Society (BTS)
proposes SA as rst-line treatment for all PSPs, small
SSPs and IPs deemed to need intervention,
3
the
American College of Chest Physicians (ACCP) Delphi
Consensus Statement (2001) stated that SA is only
rarely appropriate in usual clinical circumstances.
2
In
our study, a low immediate success rate was noted
for SA, in contrast to previously reported rates of
59 to 80%.
14-17
Since earlier studies from emergency
medicine specialists in Hong Kong had reported an
immediate success rate of 51% and a 1-year recurrence
rate of 18%,
20,21
our low success rate was possibly due
to subject selection criteria. As we only recruited
hospitalised patients; those successfully treated by
aspiration in the Emergency Department without
admission to hospital were not captured. Owing to
shorter hospital stays
14,17,18
and impressive success
rates in countries where SA is widely practised, this
simple intervention deserves more local attention in
the future. The nding that a large pneumothorax
was associated with failure of SA was in line with
BTS guidelines,
3
whereas we did not nd similar
associations with the other two known risk factors,
namely SSP and age exceeding 50 years. Although
smoking has been associated with the development
and recurrence of SP,
22,23
the exact explanation for this
association with SA failure is unclear.
Notably, tubes of relatively large size (>20F)
were more commonly selected for ITD. In the absence
of evidence supporting the use of larger tubes (20-
24F), the BTS guidelines recommend the initial use
of small-bore tubes in SP, except when there was a
persistent air leak.
3
There was also good consensus
about using small-bore catheters (14F) in clinically
stable patients with large PSPs, and according to ACCP
guidelines this preference could also be extended
to accommodate patient preference for those with
small SSPs.
2
A high success rate has been reported
with the use of small-bore catheters for SP and IP.
24

Although there were concerns about occlusion with
these catheters,
2
recent studies reported that the
risk was small,
25,26
though other complications such
as catheter displacement were quite frequent.
25,27
In
our study, the complication rate (24%) of intercostal
tubes was similar to that reported elsewhere for in-
patients.
28
The observation that tube complications
could predict failure of drainage is not surprising,
since optimal function of the catheters becomes
compromised.
Factor No. (%) Adjusted odds ratio
(95% condence
interval)
P value
Successful chest drain
management (n=683)
Failed chest drain
management (n=207)
Male sex 589 (86) 184 (89) 0.861 (0.51-1.46) 0.58
Age >50 years 367 (54) 109 (53) 0.911 (0.59-1.41) 0.67
Smokers 450 (66) 148 (72) 1.447 (0.98-2.15) 0.07
More than 1 underlying respiratory disease 112 (16) 29 (14) 0.757 (0.45-1.28) 0.30
Secondary spontaneous pneumothorax 314 (46) 97 (47) 1.023 (0.67-1.57) 0.92
Pneumothorax size >2 cm 529 (78) 160 (77) 1.140 (0.76-1.71) 0.52
Need more than 1 intercostal tube 53 (8) 33 (16) 1.318 (0.78-2.24) 0.31
Application of suction 288 (42) 158 (76) 4.087 (2.82-5.92) <0.001
Clamping chest drain before removal 306 (45) 76 (37) 0.81 (0.57-1.14) 0.23
Presence of any tube complications 143 (21) 69 (33) 1.55 (1.04-2.32) 0.03
Simple aspiration attempted before tube insertion 72 (11) 31 (15) 1.15 (0.71-1.88) 0.57
Not managed in respiratory wards 625 (92) 190 (92) 0.94 (0.51-1.72) 0.84
TABLE 4. Multivariate logistic regression analyses of factors associated with outcomes following intercostal tube drainage (n=890)
# Chan et al #
432 Hong Kong Med J Vol 15 No 6 # December 2009 # www.hkmj.org
Arguably, suction could have been conned to
the more difcult cases, yet its immediate application
after tube insertion was noted in 36% of the episodes.
For SP, IP and post-lobectomy patients, earlier studies
have shown that suction was not associated with
better outcomes compared to using underwater seal
drainage.
29-31
In view of the reported complications of
suction such as maintenance of air leaks, infections
and reperfusion pulmonary oedema,
3,31
it is advisable
to reserve its use for pneumothoraces with persistent
air leaks or failure of re-expansion.
2-4,31
Although the
BTS guidelines advised against clamping of tubes,
3

this was practised in more than 40% of the episodes.
Diversity of views towards clamping was also evident
in the ACCP Delphi Consensus Statement,
2
whilst
Belgian Guidelines suggest clamping for a few hours
with X-ray control before tube removal.
4
Pending
resolution of this controversy by randomised
controlled studies, clamping should be practised
with caution and close monitoring of patients is
advisable.
3
In contrast to the situation for patients
developing SP, there were no international guidelines
for those suffering IP and TP.
32
While there is
controversy as to whether ITD is always necessary
in TP,
33,34
our study revealed a high preference for
this treatment modality. While we did not assess the
causes of IP, a previous study reported transthoracic
lung biopsy, subclavian vein catheterization and
thoracocentesis to be the commonest explanations.
35

Although a conservative approach was adopted in
more than 30% of our patient cohort with IP, it seems
prudent to consider the size of the pneumothorax,
as well as the clinical stability and symptoms of the
patient before deciding on the management option.
32
As in the previous reports,
5-12
our patient cohort
management practices for pneumothorax varied from
the recommendations in guidelines. Possible reasons
include: lack of awareness, perceived ineffectiveness
of certain procedures, lack of condence about
existing evidence, and resistance to change.
7,8,10,11

Other reasons might entail patient preferences,
availability and costs of devices. All of these might
explain the difference between results obtained
from various surveys and case record reviews.
7
In
the absence of sufcient evidence from randomised
controlled studies on which to base guidelines, it is
likely that variations in practice will continue.
The major limitation of our study was its
retrospective nature, with all its inherent weaknesses.
Information about the size of pneumothorax, the
size of intercostal tubes employed, the experience
of the doctor performing the procedures, and the
level of suction applied were not available for all
the episodes. Moreover, we did not include patients
discharged from the Emergency Department, which
might have provided useful information concerning
the practice of SA. Also, no follow-up data were
collected to assess the subsequent outcomes of the
various management options adopted.
Conclusion
This study revealed management practices
for hospitalised patients with various types of
pneumothoraces in Hong Kong. Patients with small
PSPs were commonly managed by simple observation.
Where drainage was considered necessary (as in
most patients presenting with an SSP or large PSP),
ITD was the preferred drain option. Simple aspiration
and ITD with small-bore catheters was not commonly
practised. More studies are needed to clarify optimal
management options for patients presenting with
pneumothorax.
Acknowledgements
The authors would like to acknowledge the following
people for their assistance and support in the study:
Ms Maggie Lit (Queen Elizabeth Hospital), Prof David
Hui and Mr Kenneth Lai (Prince of Wales Hospital),
Mr Derek Chui (Caritas Medical Centre), Dr Henry
Kwok and Dr CW Lam (Ruttonjee Hospital), Miss
Yuen-ping Lam (Pamela Youde Nethersole Eastern
Hospital), Dr Wai-kei Lam, Dr Chun-man Wong, Dr
Chiu-wing Yu and Dr Hoi-yee Kwan (North District
Hospital), Dr Clara Poon, Dr Jones Kwok, and Dr
Chang Yui (Princess Margaret Hospital).
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