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2014 a Bimonthly Publication of Singapore General Hospital and SingHealth ACADEMIC HEALTHCARE CLUSTER MCI (P) 173/05/2014 www.sgh.com.sg | www.singhealth.com.sg
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07
Medical breakthrough sheds light on fibroadenomas that mimic breast cancer
Drilling into bones to save lives
公共脐带 血库需要 更多父母 慷慨捐献
P3
P27
21
Music therapy can help patients with Parkinson disease to walk and speak better
Photo: jasper yu
More cord blood donations needed
09
慢性便秘可能由骨盆底异常引起
28
02
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Preciosa Reynoso Ramos For editorial enquiries, please e-mail editor@sgh.com.sg For advertising enquiries, please call 6319-3022 or e-mail jrani@sph.com.sg All rights reserved. Copyright by SGH (registration no: 198703907Z). Opinions expressed in Singapore Health are solely those of the writers and are not necessarily endorsed by SGH, SingHealth Group and/or SPH Magazines Pte Ltd (registration no: 196900476M) and their related companies. They are not responsible or liable in any way for the contents of any of the advertisements, articles, photographs or illustrations contained in this publication. Editorial enquiries should be directed to the Editor, Singapore Health, 168 Jalan Bukit Merah, #13-01 Surbana One, Singapore 150168. Tel:+65 6222 3322, Email: editor@sgh.com. sg. Unsolicited material will not be returned unless accompanied by a self-addressed envelope and sufficient return postage. While every reasonable care will be taken by the Editor, no responsibility is assumed for the return of unsolicited material. ALL INFORMATION CORRECT AT TIME OF PRINTING. MCI (P) 173/05/2014. Printed in Singapore by Singapore Press Holdings Limited (registration no: 198402868E).
NOV– DEC 2014
singapore health
NEWS
03
A match for life Cord blood derived from the umbilical cords of newborns is saving lives, but more is needed
By The Numbers
By Chua Hwee Leng
T
SCBB has received more than
26,000
cord blood donations since it officially opened in 2005
To date, there are
10,454 Photo: jasper yu
he call has been heeded. More mothers are donating cord blood to the Singapore Cord Blood Bank (SCBB) but there is still not enough to save everyone who needs it, especially those from minority and mixed races. Demand is high. Every month, local and international patients look for a suitable match in SCBB’s inventory. Some, who need it for life-saving transplants, cannot find a match either from SCBB or global registries. Dr William Hwang, Medical Director, SCBB, and Head and Senior Consultant, Department of Haematology, Singapore General Hospital (SGH), said it is difficult for Asians, minorities and mixed races to find a match from global bone marrow and cord blood registries, as many of those donors are of Caucasian origin, not from an Asian population. Matches are based on race and tissue type, so people with mixed heritage who have diverse tissue types will find it harder to find a match. Dr Hwang emphasised the need to build an inventory from minority races. “It is important for a multiracial nation like Singapore to build a national resource for Singaporeans of Chinese, Malay, Indian and Pan-Asian origins.”
After undergoing stringent tests, donated cord blood is banked in cryogenic tanks at –180°C at the Singapore Cord Blood Bank.
Photo: vee chin
Photo: alvinn lim
An act of altruism
Two mothers, Mdm Izyani Ayik (top, with her husband and children) and Mdm Low Tze Hui (above, with her husband and children), donated their babies’ cord blood to the Singapore Cord Blood Bank. They have four children each.
Two mothers, Mdm Low Tze Hui, 35, and Mdm Izyani Ayik, 35, went all out to donate their babies’ cord blood. Both Mdm Low and Mdm Izyani have four children each. With the support of their husbands, they donated cord blood when their children were born. Both mothers took the lead in having their children take part in acts of altruism even as they drew their first breaths. Their main motive in donating was to play a part in giving someone with a life-threatening disease a fighting chance to live. They found it wasteful to throw away the umbilical cord blood when the Singapore Cord Blood Bank (SCBB) could use it to save lives. Neither mother personally knew anyone who needed a stem cell transplant, but both were moved to act after they heard about what cord blood could do. Mdm Low said: “If every mother donates, a patient who needs it will have a high chance of finding a match. It doesn’t involve any pain or inconvenience.” She suggested making cord blood donation mandatory with an optout clause. “From what I know, the number
[of donors] is low. We need more people to donate.” Although none of her donations were stored at SCBB as they did not meet the initial banking criteria, she sees them as positive acts, and hopes her children will, one day, understand the value of giving and helping. Mdm Izyani had more luck. Three of her donations were successful. “It’s a pity,” she said of her third donation which did not meet the criteria. But she was not deterred and even gave up her desire for a home birth for her fourth child. SCBB prioritises the safety of mothers and does not collect cord blood from home births, which are deemed more risky than hospital births. Homes are also not equipped for cord blood donation. “I wanted my children to be born as naturally as possible, in a low stress environment, which I believe is better for their development. But as my first child was breeched at birth, I had no choice but to have a C-section. I considered a home birth for my fourth child, but gave up the idea largely because I wanted to donate the baby’s cord blood,” she said. Although Mdm Izyani does not know if her three successful donations have helped anyone, she hopes that they have, or someday, will.
usable units after testing
9
%
of mothers in Singapore have donated cord blood in the last three years
14 in
chance of finding a tissue match among biological siblings
70
%
of patients did not find a match within their family
> Continued on page 4 ( 华文版本请翻阅至27页 )
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NOV– DEC 2014
> Continued from page 3
A match for life
Donating cord blood to a centralised public cord blood bank increases the chances of finding a match for a patient in need of a life-saving transplant.
Photo: jasper yu
Urgent need for donations After initial evaluation and testing, less than half of the cord blood SCBB receives is found usable for cord blood transplants.
As every delivery is unique, the amount of umbilical cord blood collected after the safe delivery of each baby is unpredictable.
Donated cord blood is evaluated for volume, number of cells, and cell viability before processing. If it meets the criteria, it is tested for infectious diseases and other requirements to ensure it is safe for immune-compromised patients. These stringent standards are to ensure that the units, which are banked in cryogenic tanks at –180°C, are of the highest quality possible. As every delivery is unique, the amount of umbilical cord blood collected after the safe delivery of each baby is unpredictable. Although SCBB cannot bank all donated units, each donation contributes to the total public cord blood inventor y, and increases the chances of saving the lives of many patients. Currently, only a small proportion of mothers are donating. Dr Hwangʼs plea is for more of them to donate. “If every expectant mother pledges to make a cord blood donation, this helps to build the public inventory and ensure that a cord blood unit is available for every patient who may need it to survive. Rather than discarding the umbilical cord blood after delivery, which is done frequently, parents can donate it to give someone a chance of a cure.” He said that at present there is an urgent need; some patients truly need cord blood to survive. They could suc-
cumb to their diseases if they have to wait too long for a match. SCBB is reaching out to parents and exploring ways to increase awareness about cord blood donation, with other organisations. It hopes to increase cord blood collection from each race, to improve the chances of patients of any race finding a match when they need it. Why cord blood? The umbilical cord blood that remains in the placenta and the umbilical cord of newborns is a rich source of haematopoietic (blood-forming) stem cells, which produce red and white blood cells, and platelets, to keep the body healthy. They are used to treat serious blood-related conditions such as blood cancers including leukaemia and lymphoma, blood disorders, immune deficiencies and metabolic diseases. Stem cells from cord blood are used in Haematopoietic Stem Cell Transplants. This is usually the last treatment option for patients with high-risk medical conditions and who do not respond to other treatments. These stem cells are also found in bone marrow and mobilised peripheral blood. However, cord blood stem cells, being the earliest source of stem cells available, are able to accept higher levels of mismatch. Usually, patients receive unrelated cord blood, which comes from someone not biologically related to them. Doctors do not recommend that patients use their own cord blood, as it may already carry the genetic abnormality that led to their disease in the first place.
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Our tendons... Our body’s rubber bands Rather than discarding the umbilical cord blood after delivery, which is done frequently, parents can donate it to give someone a chance of a cure. Dr William Hwang, Medical Director, SCBB, and Head and Senior Consultant, Department of Haematology, SGH
Dr Hwang said it is important that people donate cord blood to give patients the best chance of finding blood stem cells for transplantation. There is a one-in-four chance of finding a sibling who is fully matched, and less than a 50 per cent chance of successfully getting a matched unrelated donor. Since cord blood transplants can be carried out despite mismatches in tissue type, there is a much higher chance of finding a suitable cord blood unit.
By observing the diagram of the human body on this page, we can easily recognize all the space that our muscles, ligaments and tendons occupy. The tendon is composed of thick, white fibres of collagen that are held tightly against one another. These fibres are made up in large part by collagen. Our ligaments act like a connection between the bones. Our tendons act like ties to our internal structure for our muscles and our bones. The tendons and the ligaments of our body act like rubber bands of different sizes. Since our tendons are used to bind our musculature to our bones, and to maintain elasticity and suppleness, our tendons necessitate a large amount of collagen, particularly after an injury or from aging.
Why collagen is important? In the composition of cartilage we find 67% of collagen versus 1% of glucosamine. Glucosamine is an aminosaccharide contrary to collagen which is a molecular complex containing amino acids. Glucosamine is found in interesting quantities only in the liquid of the synovial membrane. Collagen is also found in the synovial membrane but in larger quantities because the protein structure is more abundant in the body. Glucosamine acts more like a lubricant in the joints while collagen helps the tendons, ligaments, cartilage, muscles, membranes and synovial liquid (lubrification).
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NOV– DEC 2014
singapore health
NEWS
05
The HIV pharmacist is in Pharmacists trained in HIV drugs counsel patients warded for the disease on how to take their medication By suki lor
A
Photo: alvinn LIM
ll drugs, including seemingly innocuous supplements, can interact with each other. Taken together, some might reduce the effectiveness or increase the toxicity of other drugs. Patients whose immune systems have been weakened by the human immunodeficiency virus (HIV) are highly susceptible to numerous infections, so such drug interactions can be especially dangerous for them. Dedicated HIV pharmacists with detailed knowledge of HIV drugs play an important role in ensuring that patients suffering from this complex condition know and understand the proper way to take their medications. At Singapore General Hospital (SGH), a small team of HIV speciality pharmacists have been looking after this growing group of patients since February. “We provide drug counselling to HIV inpatients who are newly started on drugs or patients who have a change in their drug regime, in particular HIV medications, or medications to prevent opportunistic infections (infections that people with healthy immune systems don’t normally get),” said Ms Cheryl Lim Li Ling, Senior Clinical Pharmacist, SGH. People become infected with HIV through unprotected sexual contact with infected partners or sharing of needles as the virus is transmitted through infected blood, semen and vaginal secretions. HIV destroys CD4 cells, a type of white blood cell that helps the body fight disease. Many HIV patients suffer from other conditions like hypertension, diabetes and heart problems, in part because
According to Ms Cheryl Lim Li Ling, Senior Clinical Pharmacist, incorrect drug usage can lead to drug resistance and the patients might have to go on to second-line drugs which can be expensive.
they are usually older, between 35 and 50, when diagnosed. They might also have hepatitis B or C (also transmitted through needle sharing or unprotected sex). Because of their weak immune systems, HIV patients tend to be easily infected with other diseases like pneumocystis pneumonia (a form of pneumonia) and tuberculosis (TB). Some commonly prescribed medications for age-related cardiovascular, metabolic and bone conditions, for example, may not interact well with anti-HIV drugs. The HIV pharmacist will then look to replace them with drugs with a lower risk of interaction. If the patient is suffering from multiple medical conditions, the pharmacist will ensure he knows how to take his medications. One HIV patient, said Ms Lim, was taking nine different drugs at least once a day, as he also suffered from TB. With multiple drugs, it is easy to get the drug regime wrong – once a day instead of three times, three tablets instead of one, or forgetting to take the medication altogether. Incorrect usage can lead to drug resistance. When that happens, the patients might have to go on to second-line drugs which can be very expensive, Ms Lim said. She is one of three specially trained HIV pharmacists who counsel patients warded at the hospital, about five a day on average. “As we are pretty new, we are looking at just newlydiagnosed patients for now,” Ms Lim said.
For such patients, t h e p ha rmacis t s have devised a workflow encompassing counselling on the need for antiviral therapy and prophylaxis, which is protective or preventive treatment. “If they have a low CD4 count, we will suggest initiating prophylaxis drugs to prevent incidents of opportunistic infections,” said Ms Lim.
A significant proportion of HIV cases are diagnosed only at an advanced stage, according to a Singapore progress report submitted to UNAIDS, the United Nations agency dealing with HIV and Acquired Immune Deficiency Syndrome (AIDS). In 2012, 48 per cent of new cases already had late-stage HIV. Th e CD 4 count in di cates how strong someone’s immune system is and how advanced the disease is. The lower the count, the more prone the patient is to different types of infections. Without proper treatment, HIV will progress to AIDS. By the time AIDS develops, the immune system would have already become severely damaged. Sur veys in the US and UK have showed that with HIV pharmacists, the number of medication errors fell while drug adherence improved as patients had a better understanding of the drugs they were taking, Ms Lim said. The SGH team is hoping to expand the service to patients seen at SGH’s specialist clinics, especially since the number of HIV patients diagnosed is expected to increase. Since voluntary opt-out screening for HIV infection started being performed routinely for adult patients at public hospitals, more than 100,000 HIV screening tests have been done between 2011 and 2013, of which 0.1 per cent were found to be HIV-positive.
HIV infection mostly through sex Number of newly diagnosed HIV cases
2011 2012 2013 461
469
454
Number of people living with HIV
3,811
4,193
6,229
Total number of diagnosed cases
2011
2012
2013
Male Female
1985-2013
430 437 428 5,654 31 32 26 575
Mode of transmission Heterosexual sex Homosexual sex Bisexual sex Intravenous drug use Blood transfusion Renal transplant overseas Perinatal (mother to child) Others/Uncertain
210 220 181 3,741 195 210 209 1,712 42 27 38 446 4 2 4 115 0 0 0 3 0 0 0 5 0 0 0 31 10 10 22 176 Ministry of Health, UNAIDS
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singapore health
NOV– DEC 2014
NOV– DEC 2014
singapore health
NEWS
07
Singapore scientists discover gene mutation behind breast tumour
The breakthrough sheds light on a common condition affecting millions of women worldwide By Suki Lor
Photo: vernon wong
of Pathology, said: “It is amazing that these common breast tumours can be caused by such a precise disruption in a single gene. Our findings show that even common diseases can have a very exact genetic basis. Importantly, now that we know the cause of fibroadenomas, this research can have many potential applications, including telling them apart from related but different breast tumours with diverse treatment strategies.”
Some members of the 20-strong team who studied fibroadenomas for a year before making the discovery. (From left) Prof Steven Rozen, Dr Lim Weng Khong, Prof Tan Puay Hoon, Dr Benita Tan, Prof Teh Bin Tean, and Prof Patrick Tan.
S
ingapore scientists have uncovered a genetic mutation which makes it easier for doctors to recognise fibroadenomas (a common benign breast tumour). This will help doctors avoid occasions when fibroadenomas may be misdiagnosed as breast cancer. The breakthrough discovery happened after the scientists discovered that the MED12 gene is frequently mutated in fibroadenomas, but very rarely in breast cancer. This gene mutated in 60 per cent of the 98 fibroadenomas they studied in Singapore. The discovery paves the way for a potential test in about three years’ time which will ease patient anxiety and reduce or remove the need for surgery for breast lumps found in these women. Possible drugs to treat this common tumour may be available in five to 10 years’ time. About 20 scientists from multiple disciplines and organisations, including the National Cancer Centre Singapore (NCCS), Duke-NUS Graduate Medical School Singapore (Duke-NUS) and Singapore General Hospital (SGH), studied fibroadenomas for a year before hitting the medical jackpot. The team’s findings have been published as a paper in the highly-regarded journal Nature Genetics.
Telling the difference Currently, the best way to confirm if a patient has a fibroadenoma is to examine a tissue
Different tumors, common cause Dr Benita Tan, Senior Consultant at SGH’s Department of General Surgery and the paper’s co-author, explained how such tumours are treated in the clinic. If the lumps are small and proven to be non-cancerous, she is usually inclined to leave them alone, but surgery is needed for sizeable breast lumps, which can grow as big as 10cm across.
sample from the lesion under a microscope. Certain fibroadenomas While this form of examination is the gold may mimic breast standard in making a diagnosis, it is not cancers clinically and always clear cut. “Certain fibroadenomas may mimic radiologically, so breast cancers clinically and radio- doctors sometimes logically, so doctors sometimes face challenges in telling them apart,” said face challenges in Professor Teh Bin Tean, Director and telling them apart. Principal Investigator at NCCS’ LaboraProfessor Teh Bin Tean, Director and tory of Cancer Epigenome. Principal Investigator, Laboratory of Prof Teh, who is also a professor Cancer Epigenome, NCCS with Duke-NUS, reckoned that more researchers will continue to study the gene following the team’s discovery. Professor Patrick Tan of Duke-NUS’ She said that similar MED12 mutaCancer & Stem Cell Biology Program tions have been seen in uterine fibroids, described the mutation as a litmus test another common benign tumour for a benign breast tumour. in women. “While this gene is found to be freThe paper’s lead author, Dr Lim quently mutated in fibroadenomas, it Weng Khong, a Research Fellow at NCCS, almost never mutates in breast cancer,” said this suggests that the two types of he said. He hopes the team’s findings tumours occurring in very different locawill be validated independently by tions are related, and points to the possiother groups. bility of a common cause. The team will be continuing its “Now that we see this commonality of own research into MED12, and aims to very distinct shared mutations between develop a reliable and robust labora- the breast and the uterus, we can infer tory test that can help in the diagnosis that this could probably be related to of breast tumours. abnormal responses to hormonal stimIt will also study the gene’s func- ulation. Of course, this then generates tion. “If we better understand the con- questions and hypotheses for future studsequences of this mutation to MED12’s ies,” he said. function, it will raise the possibility of Associate Professor Steven Rozen of developing medical treatments.” Duke-NUS’ Cancer & Stem Cell Biology Professor Tan Puay Hoon, Head and Program was also one of the lead investiSenior Consultant at SGH’s Department gators in the study.
fibroadenoma
mammary ducts
What are fibroadenomas? Fibroadenomas are the most common breast tumours in women of reproductive age. The benign condition affects one in 10 women worldwide, with about 3,000 cases in Singapore yearly. Appearing as solid lumps that are usually painless, they vary in size and can grow over time or diminish on their own. Doctors may monitor a fibroadenoma to detect changes, and may carry out biopsies to further evaluate the lump. Usually, such breast lumps do not require treatment, but if they are large and become uncomfortable, surgery may be needed to remove them.
What are uterine fibroids? Uterine fibroids are growths of the uterus that develop from normal uterine smooth muscle cells that grow abnormally. Like fibroadenomas, fibroids are very common, non-cancerous, often appear during the child-bearing years, and there can be one or more. They can be so tiny that they are not visible to the human eye, or grow so big that they can enlarge the uterus to the point that the woman looks pregnant. Many women have uterine fibroids at some point in their lives, but most are unaware of these growths because there may not be any symptoms. Clinical diagnosis is done via manual pelvic examination and ultrasound.
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NOV– DEC 2014
New light on an old disease
Local researchers move a step closer to understanding what triggers Alzheimer’s disease By Thava Rani
R
esearchers may be one step closer to understanding the cause of Alzheimer’s disease, after a team led by the National Neuroscience Institute (NNI) identified a protein linked to the illness. Known as the amyloid precursor protein (APP), it has long been known as one of the main culprits of the disease. It is found in many tissues and organs, including the brain and spinal cord. The team found the protein influences microRNA-574-5p – a small molecule that promotes the creation of new neurons (brain cells) which maintains healthy brain function. In mice studies, they found that levels of the molecule were significantly higher in APP-deficient mice.
This means that this protein indirectly controls the growth and maturation of neurons. Problems with it could lead to abnormal levels of the molecule in question, leading to unregulated neuron production. In this case, brain activities go haywire, possibly leading to Alzheimer’s disease. The study was led by Dr Zeng Li, Principal Investigator and Senior Research Scientist, Neural Stem Cell Research Laboratory, NNI. The team also involved investigators from Duke-NUS Graduate Medical School (Duke-NUS) and the Agency for Science and Technology (A*STAR). Their findings were published in science journal Nature Communications earlier this year.
Alzheimer’s disease is the most common type of dementia. It affects memory, thinking and behaviour of patients, and symptoms usually develop gradually and get worse over time.
“Our findings highlight that microRNA-574-5p may be a potentially useful new target for drug development against Alzheimer’s disease,” said Dr Zeng. “However, we are just starting to understand how misregulated microRNA-574-5p expression can cause our brain activities to go wrong. Much more work needs to be done.” To further understand the link between the protein, the molecule and Alzheimer’s disease, the scientists will continue their research using post-mortem brain samples from patients. They hope, within the next five years, to be able to develop a non-invasive way to detect the onset of the disease by using the molecule as an identifier. The team will also look into other microRNAs in the brain which could play a role in neurological diseases. Their “misregulation is implicated in other devastating psychiatric disorders like autism and schizophrenia,”
said Assistant Professor Shawn Je from Duke-NUS. A*STAR’s Professor Stephen Cohen, a world expert on microRNA biology, said, “We are at an early stage of understanding how this microRNA might impact disease progression. But the prospects are exciting.” Alzheimer’s disease is the most common type of dementia. It affects memory, thinking and behaviour of patients. Symptoms usually develop gradually and get worse over time, eventually becoming so severe they interfere with daily tasks. About 28,000 people in Singapore aged 60 and above are currently affected. With a rapidly ageing population, this figure is set to drastically rise to 80,000 by 2030. The number of family members and caregivers who have the physical and emotional task of taking care of these patients will also be substantial.
The team led by Dr Zeng Li (centre) from the National Neuroscience Institute identified a protein linked to Alzheimer’s disease.
NOV– DEC 2014
singapore health
NEWS
09
The drill to save lives
SGH and SCDF paramedics are in a one-year trial to find out if drilling into bone to deliver life-saving adrenaline is faster than injecting the drug By Sol E Solomon
D
The evaluation findings have the potential to change current out-ofhospital cardiac arrest protocols, equipping SCDF paramedics with an additional medical procedure that they can use to enhance cardiac arrest treatment. Dr Ng Yih Yng, Chief Medical Officer, SCDF
When the heart stops beating during cardiac arrest, blood stops circulating. The blood vessels flatten as a result, making it hard to locate a blood vessel. This difficulty is compounded if the patient is obese, diabetic or on renal dialysis as his blood vessels are often narrowed or blocked, or if lighting is poor or space is tight at an accident site such as a car crash, said Dr Tan. Drilling into bone to deliver adrenaline directly is likely to be faster than the normal IV method. SGH and the Singapore Civil Defence Force (SCDF) have embarked on a year-long study to see if this alternative method will yield
The test method takes away the uncertainty of finding a suitable vein for injection, says SCDF’s Dr Ng Yih Yng (flanked by Associate Professor Marcus Ong, left, and Dr Kenneth Tan).
better results in cardiac arrest cases. Some SCDF ambulances will carry equipment for this method, which is known as intraosseous infusion: paramedics drill a hole into the bone just below the knee and quickly administer the drug. “It’s a very fast and effective procedure,” said Dr Tan, adding that because bone marrow is very rich in blood vessels, adrenaline, once it is pumped in, travels very quickly to the heart to stimulate it. Although various parts of the body can be used, the tibia (the larger bone in the lower leg) was chosen over the upper arm or breast bone because it is the area easiest to locate and farthest from the heart. In addition to adrenaline, cardiopulmonary resuscitation (CPR), where the chest is pumped repeatedly, is performed. According to Dr Ng Yih Yng, Chief Medical Officer, SCDF, the drilling method takes away the uncertainty of finding a suitable vein for injection. Locating a vein and then inserting a needle into it is different for each patient. But looking for the drill point is fairly consistent and precise, and easy to master: the spot is two finger breadths below the kneecap, and one finger breadth inward. With practice, finding the drill spot takes just a few seconds. It can take as long as a few minutes if veins are small or collapsed, when using the IV method. “The success rate using the intravenous (injection) method is about 50 per cent. Going by our experience (in using the intraosseous method) in the hospital, we think the success rate can be improved to over 90 per cent,” said Associate Professor Marcus Ong, Senior Consultant, Department of Emergency Medicine, SGH. Drilling a tiny hole into the leg bone for adrenaline to be injected directly into the bone marrow is an established standard of care in Singapore hospitals for
critically ill patients and for children, two groups whose veins are hard to locate. Elsewhere, in places like Australia and the US, intraosseous infusion is done regularly outside the hospital. Since July 2014, SCDF’s fleet of ambulances has been equipped with medical power drills and intraosseous needles that can drill through bone. In the first six months of the trial, half of these ambulances will use the conventional method only while the other half will use the test method if the con-
photos: alvinn lim
on’t be surprised or alarmed if you see a paramedic take out an electric drill and use it on a patient who has collapsed. He has not gone berserk but is using a procedure to test if adrenaline can be delivered more easily to get the cardiac arrest patient’s heart pumping more quickly. If cardiac arrest is not treated quickly, and blood and oxygen circulation in the body stops for more than four minutes, brain injury is likely to occur. Early treatment can improve survival and prevent brain injury and complications like paralysis. Out of the 1,800 people who suffer a sudden cardiac arrest outside the hospital every year, just 3 per cent survive. “Giving adrenaline to restore blood flow to a patient’s heart as early as possible is important, but placing an intravenous (IV) line can be difficult in a cardiac arrest,” said Dr Kenneth Tan, Associate Consultant, Department of Emergency Medicine, Singapore General Hospital (SGH).
ventional injection proves difficult. They will then switch roles in the second six months. Paramedics with the option to use the drill method will only use the drill if two attempts to set an IV line fail, or an attempt takes longer than 90 seconds. Even so, the drill method will not be used on everyone. Paramedics will be looking out for people with obvious signs of leg injuries or problems, or with a medical condition to exclude them from the drill method. They will also ask relatives or friends at the accident site if the patient has a medical condition, such as diabetes. The exclusions are to ensure that the trial does not deal with too many variables. The researchers aim to involve 400 out-of-hospital cardiac arrest patients, and they will compare several things, including how easily and quickly adrenaline can be delivered to the patient, and how soon after treatment the patient’s heart resumes beating on its own. “The evaluation findings have the potential to change current out-of-hospital cardiac arrest protocols, equipping SCDF paramedics with an additional medical procedure that they can use to enhance cardiac arrest treatment. This can further raise the standard of pre-hospital care given to such patients,” said Dr Ng.
Dr Kenneth Tan looks on as paramedic WO2 Casey Tan shows how a tiny hole is drilled into bone, usually in the area just below the knee.
10
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singapore health
nov– dec 2014
Give your eyes a workout A mobile app with eye exercises that help treat a type of squint has been given the nod from patients
Mobile app MyEyeGym has 18 interesting images and animations and offers patients eye exercises comprising three levels of difficulty. On the right are two incomplete images which can be brought together to form one complete image.
By Suki Lor
M
obile app MyEyeGym offers patients eye exercises that they can do at home, to help treat their intermittent exotropia (divergent squint) a condition where one eye occasionally deviates outwards. Developed by the Singapore National Eye Centre (SNEC), the study involved 103 patients, 32 of whom completed the study in its entirety (for six to eight weeks) using both the app and the traditional cardboard cards, which clinics usually give to patients to do eye exercises with for 10 minutes daily. Patients were to look at incomplete images of the same thing (e.g. a panda) and try to merge them into a third, complete picture. More than half the patients preferred the app to the cards. Three in four found the app more interesting, and 84.3 per
cent found it more accessible and convenient than the cards. The app, which won one of SingHealth’s Allied Health Innovation Practice Awards in February 2014, will now be studied further using a larger pool of patients. “We hope to complete a study on its effectiveness in treating intermittent divergent squint. We believe it will be a useful tool for us in the clinic, and for patients to use at home to improve control of their eyes,” said SNEC Orthoptist Tan Yi Ling. Why exercises help this squint In Asia, divergent squints are more common than convergent squints (where one eye drifts inwards). In Singapore, 92 per cent of all divergent squint cases are
intermittent (not present all the time). These eye exercises are suitable for at least half the intermittent divergent squint cases seen at SNEC. They are aimed at improving control over visual function, thus reducing the need for eye muscle surgery. It is also useful for patients with Convergence Insufficiency, a condition in which the eyes have difficulty coming together when performing near-vision tasks, resulting in occasional double vision, said Dr Yvonne Ling, Senior Consultant, Paediatric Ophthalmology and Adult Strabismus Service, who supervised the study team. As people with squints have impaired stereo-vision (3D vision), they will have poor hand-eye coordination, making it difficult for them to play ball games or do things like threading a needle. They may also want to improve their condition for cosmetic reasons. The traditional way of doing the exercises with cardboard cards is used in many clinics worldwide but there is a lack of compliance by patients, who complain of boredom. “Many patients who were given the cards tell us they’ve lost them. It shows how little they did the exercises,” said Ms Tan. The app, available for free, has 18 interesting images and animations. The variety is to motivate children to have a go. Black and white images were added this year after patients gave feedback that they were easier to fuse together. There are three levels of difficulty, two of which are locked. When patients are ready to move to a higher level, they will be given a password to unlock it. When they finish an exercise, there are games they can play. There is also an alarm function to remind patients to do their exercises and show up for their appointments at SNEC.
Eye these! MyEyeDrops Launched last year, this app helps glaucoma patients remember to take their medication or apply their eye drops. Earlier this year, it was expanded to include corneal transplant patients and those with dry eyes. Glaucoma is the leading cause of blindness in Singapore. If they keep forgetting to apply their eye drops, glaucoma patients risk going blind and corneal transplant patients could face rejection of transplanted corneal tissue. The app reminds them to apply their eye drops as prescribed by their doctors, and encourages them to be proactive in ensuring that their vision does not worsen. Users can select medication from a list and set reminder alerts. Patients with dry eyes can use the Dry Eye Diary to monitor and record the frequency and intensity of their condition, to help their doctors better manage their condition. MyEyeMatters This app offers comprehensive educational information on various eye conditions, symptoms, and useful eye care tips.
New home for NHCS The National Heart Centre Singapore now has a new home equipped with operating theatres, cardiac catheterisation labs, a short stay unit and a rehabilitation unit. Providing comprehensive one-stop cardiovascular care for heart patients, the 12-storey building located at the Outram campus is four times the size of its old premises. Since March 2014, more than 37,000 patients have walked through its doors. The dedicated facility for heart care, which was officially opened by Prime
Minister Lee Hsien Loong in September, offers increased opportunities for clinicians, researchers and educators to exchange ideas as they are housed under one roof, facilitating the push for new frontiers in heart care. In tandem with setting up a larger facility, more staff have been recruited to cater to an anticipated rise in workload. Besides the expansion of facilities, which include green and age-friendly features, key processes have also been streamlined to ensure the seamless delivery of care.
(From left) Professor Ivy Ng, Group CEO, SingHealth; Mr Peter Seah, Chairman, SingHealth; Prime Minister Lee Hsien Loong; Mr Gan Kim Yong, Minister for Health; Adjunct Professor Terrance Chua, Medical Director, National Heart Centre Singapore and Adjunct Professor Koh Tian Hai, Senior Advisor, National Heart Centre Singapore (NHCS), at the opening of NHCS’ new building in September.
NOV– DEC 2014
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Meet the perfusionist Her job is not widely known but she is a vital member of the cardiovascular surgical team By Wong Sher Maine
find out what a perfusionist was. I liked the thought of saving lives and found it hen a patient has open heart interesting that a machine could replace surger y such as a coronar y the functions of the heart and lungs. I artery graft bypass or valve applied and got the job,” she said. repair/replacement, the surgeon will stop Her first day on the job was a bapthe heart temporarily and let the heart- tism of fire – she witnessed open heart lung machine take over. This is when the surgery. “I wasn’t prepared for it. It was perfusionist’s job begins. overwhelming.” Up until then, the only The heart-lung machine sits beside surgery she had done was dissecting a the operating table. The perfusionist rat in university. uses it to regulate the patient’s blood What hit harder, though, was seeing supply, which is diverted to it through a patients die on the operating table. “It tube. The machine infuses the blood with was heartbreaking. I had nightmares. It oxygen, removes carbon dioxide from it, took me six months to overcome this but filters it, and pumps it back to the heart. my colleagues were very encouraging.” It is a crucial but little-known job. Not Mentored by a senior perfusionist, many people know what perfusionists she learnt to prepare and operate differare or what they do. Ms Chiu Kit Yi, 30, is ent life support machines, including the one of 15 perfusionists at the National Extra-Corporeal Membrane Oxygenator Heart Centre Singapore and among the (ECMO). estimated 50 in Singapore. When rostered, she is on call even A Life Sciences major, her interest was in the middle of the night, and has to piqued when she spotted a job advertise- rush in to the hospital within 30 minutes. ment in a newspaper. “I had to google to “Once I had to cut a taxi queue to do this,
Photo: vernon wong
W
Ms Chiu Kit Yi is one of 15 perfusionists at the National Heart Centre Singapore and among the estimated 50 in Singapore.
explaining to people what I had to do!” Ms Chiu has been on the job for seven years. Two years of on-the-job training prepped her well. She sometimes travels to other hospitals in Singapore to undertake perfusion duties, as some hospitals do not have perfusionists. One of these is KK Women’s and Children’s Hospital, where she does perfusion on children. “It’s more challenging with children because their anatomy, physiology and pathology can be very different from adults. They are more vulnerable,” she said. One case made her weep: A young girl, felled by a virus that attacked her heart, was sustained by ECMO for several days, but it became clear that she would not survive. “I cried so much that the doctors asked me if I was related to the patient,” Ms Chiu said. Her greatest satisfaction is when patients recover. “When I see them pull back from the brink, walking about, talking to their families, I feel very happy that I played a part in it.”
NOV– DEC 2014
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专家解答
无 论病 情 是 否已受 到 良 好 的 控 制，所 有 最近的烟霾使我的哮喘病病情恶 哮 喘 病 患 者 都 应 该 While on a fellowship in Europe, this 随 cardiologist discovered 化，经常发作。 我该怎么做？ 身携带一 个 吸入 cutting edge technology that was just up her street 在哮喘病发作时，患者的呼吸道会收 器，预防哮喘病随时 窄，导致呼吸困难。如果没有适当地 发作。 控制病情， 新加坡保健服务 By Gwen让呼吸道受到环境的触发 Sin see the heart’s structure from all angles 集团综合诊疗所 因素所刺激，病情很容易就会发作。 as it was beating, as if they were actually 家庭内科顾问 要减少哮喘病发作，就必须控制好病 inside the body looking at it. 医生黄忠伟 he could not have planned it Now, using the technology in Singa情。因此， 患者可能需要服用适量的控 better when she went to the Neth- pore, she said: “It is fast and quick. You 制性药物。 erlands in 2009 on a two-year fel- can find the cause of the problem and it 哮喘病的吸入性药物可被分为两大 lowship. is satisfying when you do. For example, 种类： During her two years at Leiden Uni- a patient who gets suddenly breathless 控制性药物：治疗肺炎，同时降 低 我经常感到情绪低落，对任何东 versity Medical Center, Dr Ewe See Hooi, while running a high temperature may 西都不感兴趣。这是不是抑郁症 肺部对于触发因素， Consultant, Department如烟霾这种环 of Cardiology, have infective endocarditis, an infection 的征兆？ 境污染物的敏感度， 从而减轻敏感 National Heart Centre Singapore, worked where the 月经来潮之前感到忧郁消 heart valve can suddenly rup沉是正常的吗？ 反应。 with the latest cardiac imaging technol- ture. With this technology, we can diagogy – exactly what her doctorate was it in a few seconds.” 月经来潮的前两周， 有些妇女可能会 缓解性药物： 在哮喘病发作时， 舒 nose about. “Valve disease intervention was Dr Ewe also marvels at how fast tech感到情绪低落是因为黄体酮（一种会 缓并扩张已收缩的气管。 in its emerging phase病情一般受到控制 in Europe, and cen- nology has moved – from ultrasound 导致情绪消沉的荷尔蒙）一直在体内 在阴霾笼罩时， tres there were using the latest non-in- and CT scans to catheters running up leg 的哮喘病患者可能会觉得病情转坏， 不断地增加所引起，又或者因为月经 vasive multi-modality cardiovascular veins to the heart, and now the 3-D echo, 而必须避免进行某些活动， 例如游泳/ 并需要服用控制性药物。至于已在服 imaging technology for data collation which is painless and lets doctors make 穿紧身或浅色衣服， 甚至性 药的患者， 则可能需要医生调整药物 and clinical research. The university was a水上运动、 better diagnosis while sparing frail old 行为，而感到沮丧。 剂量。 doing a lot of work in this area and it coin- patients from risky open heart surgery. cided with what my PhD work was about,” Although now 它主要的症状是情绪 heavily invested in her 至于抑郁症， 所有的哮喘病患者都应该有一份列 she said. it was not the one she orig低落和意志消沉， 或对任何东西失去 明指示的哮喘病控制行动计划： 识别 speciality, Known as 3-D echocardiography预防 – a inally chose. “I was more interested in 兴趣和无法透过任何事物感到欢愉。 早期症状， 以便采取适当的措施， moving scan of the heart in real time the holistic care of patients. Haemody发作程度恶化；发作时需要采取的步 其他症状还包括： – this was then the newest thing in the namics (how the blood flows) always fas 失眠（尤其是在凌晨醒来） 骤；以及如何辨别发作程度是否严重 field. Cardiologists could manipulate it to cinated me. I chose cardiology because 食欲不振和消瘦（或爆食和发胖） 到需要紧急救护治疗。
S
我患上抑郁症了吗？
无法集中精神或健忘 失去正能量或动力、无精打采（或 容易激动和焦躁不安） 意志消极、过度内疚、绝望感，以及 有自杀倾向。 但 如果以 上症 状 连 续出现 超 过两 周，并引起重大的痛苦或影响个人的日 常生活能力时，那可能就是抑郁症了。 竹脚妇幼医院心理医学科主管及高级顾问 医生陳瑜
Photo: jasper yu
烟霾使哮喘病加剧 The tech-savvy doctor
近视可以治疗吗？
眼镜或隐形眼镜和使用阿托品滴眼剂 （Atropine Eye Drop）。眼镜和隐形眼 镜的治疗效果因人而异，一般 成功率 从零至30%不等。如果选用隐形眼镜 来治疗，家长必须加倍小心护理，以确 保孩子的眼睛不会受到感染和威胁到 视力健康。 阿托品滴眼剂是一种能够减缓近视 恶化的有效药剂，控制效率可达50% 至80%。不过，不同浓度的滴眼剂可能 会造成瞳孔放大和近距离视力模糊。 副作用较轻的较低浓度滴眼剂去年 上市，给使用者更多样化的选择。如果 你希望知道自己的孩子是否适合接受 以上治疗，请咨询你的医生。
我其中一名孩子患有近视。请问有 During her two years at Leiden University Medical Centre, Dr Ewe See Hooi 什么方法治疗吗？ 如何预防近视度 新加坡全国眼科中心及竹脚妇幼医院幼儿 worked with the latest cardiac imaging technology. 继续加深？另外，我也开始限制小 眼科与斜视治疗组高级顾问医生谢玮玲 儿子使用电脑和电子产品的时间。 我是否过度反应了？ it involved the care of the whole 遗传和环境因素会导致近视。如果你 person as the heart and blood ves有近 视，你孩子患 上近 视的几率会更 sels connect the whole body.” 高。此外， 我们目前的生活模式也过份 Dr Ewe did not just bring tech偏重于室内工作和近距离聚精会神。 nology back from the Netherlands; 为了减轻以上因素， she also embraced the保健促进局推 Dutch attitude to work and play. At work, she 行了一个 计 划， 支持 孩子多到户外活 found the Dutch efficient,你也应该限 focused, 动， 避免长时间留在室内。 goal-orientated, precise, hardwork- 并 制孩子玩电脑游戏和看电视的时间， ing; and after work, able to com让他多到户外玩耍。 pletely relax. “In patient care there 果 近to 视be 持 very 续 加efficient, 深，我 们 可off 以通 is如 a need but 过其他方法来控制它，例如配戴特制
work, we need to unwind as that’s where new ideas spring from. So, I disconnect from the digital world,” said Dr Ewe, who is married to a fellow doctor. Dr Ewe does yogalates (a combination of yoga and pilates) and is a foodie who likes to try new tastes. Her philosophy in life is to make those she cares about happy and healthy. This includes patients, colleagues, family and friends. She said: “It applies at work and at home too.”
Wide circulation that reaches over 200,000 readers Available at strategic locations Contains authoritative health care news and information Singapore Health is the official publication of Singapore General Hospital and SingHealth
Published bimonthly in a handy Group, the largest health care group in Singapore. tabloid size, the newspaper aims to raise the health literacy level of Singaporeans. Singapore Health is available at Singapore General Hospital, KK Women’s and Children’s Hospital, Changi General Hospital, national speciality centres, and polyclinics under the SingHealth umbrella. It is also available at high-traffic points within the CBD area. Singapore Health ensures your message gets across to your target audience. For advertising enquiries, e-mail Lin Mi’er at mierlin@sph.com.sg
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Nov– Dec 2014
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Ag e - F r i e n d ly W EE K
Keep up your health
as you age Know the signs and symptoms of some common health conditions that affect the elderly, to take early action
Eyes
Cataracts and glaucoma Cataracts can result in blurred vision, sensitivity to glare and double vision. Glaucoma causes headaches, eye pain and nausea, and sometimes leads to blindness. What to do A yearly eye examination can detect glaucoma and other eye diseases with no early signs. Cataract surgery is a safe and common procedure. Treatment for glaucoma includes prescription eye drops, oral medication, laser treatment, or surgery.
HEART
Hypertension (high blood pressure) Most people with high blood pressure have no symptoms, even if blood pressure readings reach dangerously high levels. Obesity and diabetes increase the risk of hypertension. Complications include strokes and heart attacks. What to do Check for hypertension by measuring blood pressure regularly, or as advised by a doctor. Maintain a healthy diet and lifestyle.
BRAIN
Stroke A stroke can cause sudden numbness usually on one side of the body, difficulty speaking or swallowing, blurred vision, sudden difficulty walking and fainting. What to do Get a CT or MRI scan to find out if the stroke is due to a blood clot or burst blood vessel and where in the brain it occurred. A ECG checks for heart disease. An angiogram shows the degree of blockage in the blood vessels or the location of the bleeding in the brain. Prevent a stroke by not smoking and maintaining a healthy weight range.
EARS
Hearing loss Difficulty hearing people over the telephone or in person can lead to social isolation. Failure to hear warning sounds, like fire alarms and cars honking, can be dangerous. What to do Seek professional help for an assessment. A earnose-throat doctor or an audiologist can measure hearing and fit hearing aids.
Bones PANCREaS
Type 2 diabetes Symptoms include increased thirst and frequent urination, increased hunger, weight loss despite eating more, fatigue, blurred vision, slow-healing wounds and frequent infections. What to do Diabetes can be detected through a blood glucose test. Apart from medication, manage diabetes through diet and exercise.
TEXT: CELINE LIM
Osteoporosis Apart from pain in the bones or muscles, osteoporosis can cause spinal compression fractures resulting in a humped back. It causes bones to become weak, brittle, and prone to fractures especially in the hip, spine and wrist, which can lead to hospitalisation or even death. What to do Take a Bone Mineral Density test to find out if you have osteoporosis. Maintain strong, healthy bones by following a diet that is rich in calcium and by doing weightbearing exercises.
Sources: Health Promotion Board
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Health Xchange
Our experts answer all your questions about health
An itchy blister I had an itchy blister on my foot and went to a dermatologist who prescribed a cream and some oral medication to reduce the itch. It got better but recurred, this time as a blister that stopped itching only when it burst. I sometimes get this on my fingers too. The cream and medication only offer temporary relief. Are there any others? Is this due to a food allergy? I also have corns on my feet. It sounds like you may have hand and foot eczema. This is a long-term skin condition that can have intermittent flareups. As yet, there is no known cure but with good treatment, the condition can be improved and controlled. It is important to identify, and avoid or reduce any triggers such as the wearing of closed or covered shoes, sweaty feet, and contact with detergents.
Treatment usually involves the use of creams, including daily moisturisers and topical steroid creams. Topical steroids should be applied when rashes or blisters appear. Stop once they resolve. Oral antihistamines (e.g. piriton or atarax) can be taken to help with the itch during flareups. For severe flare-ups, your doctor may prescribe a short course of oral steroids, and when there is visible infection (e.g. oozing and crusting), you may be given a course of oral antibiotics. If the blistering is severe, soaking the affected areas in a diluted potassium permanganate solution or salt solution may help to dry them. Dr Mark Koh, Head and Consultant, Dermatology Service, KK Women’s and Children’s Hospital
Can I wear contact lenses after LASIK?
Hearing strange sounds I often hear humming, hissing or sharp whistling sounds in my ears, but cannot detect the source. I googled the symptoms and it seems I might be suffering from tinnitus. What causes it and how is it treated? In tinnitus, the sounds heard do not come from one’s external environment, but may be the result of injury to the inner ear and auditory pathways. Age-related hearing loss, loud noise, medications, injury, viral and bacterial infections, and tumours are other causes. In a quiet environment, a normal person with good hearing is able to sense or hear soft “cricket” sounds, high-pitched noises or even one’s own heartbeat. Currently, we have hearing test machines that can record these noises emitting from normal inner ear hair cells. Noticeable tinnitus becomes pathological when such soft sounds are heard under normal conditions. Some believe that injury to the inner ear and auditory pathway results in this tinnitus signal becoming magnified by compensatory mechanisms sited in the outer hair cells. Generally, most patients who suffer from tinnitus experience it for
a few weeks to a few months. About 75 per cent of patients get better after three months, with the tinnitus disappearing over time. There is cause for concern if the tinnitus is associated with hearing loss, dizziness or vertigo (a spinning sensation), nosebleeds or blood in the phlegm, swelling in the neck, headaches, or other general symptoms like weight loss, disturbed sleep and emotional changes. A rhythmic “heartbeat” sound may suggest abnormal blood vessel circulation in the brain and neck. Most general practitioners can treat tinnitus and ear conditions, although some patients may need to see an ENT doctor to have special tests conducted. Treatment of tinnitus ultimately depends on the cause. If it is due to an identifiable cause like an infection, treating the infection and giving time to allow the hearing to return to normal helps. In many cases, when the cause is unclear, there is a general feeling that it may be a minor viral or vascular injury to the inner ear that has resulted in hearing loss. Dr Chan Yew Meng, Senior Consultant, Department of Otolaryngology, Singapore General Hospital
I was told that if my eyesight degenerates after LASIK, I will not be able to wear contact lenses. Is this true? How long is the recovery period after LASIK and what is the rate of deterioration? Do existing medical conditions affect one’s suitability for LASIK? If you have undergone LASIK, there is a risk that you may not be able to wear contact lenses. This is because the contact lenses may not sit nicely on your corneas due to the difference in shape after LASIK. However, some people are still able to wear contact lens after LASIK. Most people can resume normal activities the day after LASIK. Full visual recovery may take a week to a month. LASIK is meant to be a permanent treatment for myopia and astigmatism but in some individuals, some myopia or astigmatism may recur over time. The timing varies among individuals and some may need a repeat treatment. Most common medical conditions are not contraindications for LASIK, so the answer to your concern depends on what your condition is. It is best to consult a LASIK surgeon to determine your suitability for it. Dr Mohamad Rosman Othman, Consultant, Refractive Surgery Service, Singapore National Eye Centre
These articles are from www.healthxchange.com.sg, Singapore’s first interactive health and lifestyle portal.
Please visit our website listed above to see the topics for discussion in Nov-Dec 2014.
nov– dec 2014
singapore health
Opinion
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If I don’t wake up… Most people know how they want to live, but what about how they want to die? It’s a good idea to think and talk about end-of-life issues early with loved ones Advance care planning helps patients and their families to think about, discuss and document their personal health care preferences.
By Andy Sim
I
f a stroke leaves you paralysed, and then your heart stops, do you want CPR? If you develop dementia and can no longer recognise your family and friends, and cannot feed yourself, do you want a feeding tube to provide you with nutrition? What if you develop a terminal disease? What sort of treatment and care do you want to receive when you are in the last stages of illness? For many of us, these are hypothetical questions. But they are also difficult questions about medical care that we should confront, think about and decide on at some time. Being clear while you are still able to communicate your ideas and decisions can give you control over the sort of treatment and care you want should you be struck down by a sudden and unexpected illness later. All too often, families face anguish and pain when they have to make a decision about the right treatment – or no treatment – for their loved ones. Do they prolong his life when he is likely to be bedridden, on tube-feeding and in need of round-the-clock care? If they don’t, are they giving up on someone who has spent his life looking after them? Last year, I met a patient in the last stage of kidney failure. The kidneys play an important role in ridding the body of waste products, regulating blood pressure and the body’s fluid levels. When the organs fail, dialysis is needed. Regular dialysis can and has helped prolong the lives of many people. They might live
another 20 years, or just a week. Dialysis can also be painful. This patient in particular felt that he had lived a good life. As a retiree, he envisioned starting dialysis as subjecting himself to a life of suffering. He would rather die peacefully. Not surprisingly, his family rejected that decision as they could not understand the patient’s decision to refuse a potentially life-sustaining treatment.
To this patient, taking away the burden of having to make the difficult decision about how to care for him at that stage of his life was a precious gift that he wANTED to give his family. I facilitated a discussion for the patient, his wife and family, and his doctors, after his case was referred to me. The meeting was intense and emotional as his family tried to change his mind. In the end, he won over his family. He would not – and did not – undergo dialysis, and was referred to palliative care services to
keep him comfortable at home. Advance care planning provided a platform for this family to openly discuss the patient’s health care preferences and be involved in decision-making. To this patient, taking away the burden of having to make the difficult decision about how to care for him at that stage of his life was a precious gift that he wanted to give his family. As people who work in a hospital for patients with serious illnesses, we are constantly faced with the subject of endof-life care. Our doctors often have to ask patients about their treatment choices or the extent of palliative care they want to receive. For me, the subject has been particularly relevant ever since I first became a social worker working with renal failure patients, eight years ago. But it has only been in recent years that a formal process to address such issues began to gain currency. Known as advance care planning or ACP, this process helps patients and their families think about, discuss and document their personal health care preferences. The decisions that result from the discussions can be documented and kept with a patient’s hospital medical files. Although not recognised as a legal document, it is kept with the patient’s medical notes and can help doctors understand his attitude towards death and care, should the need arise. There are three kinds of documents used in advance care planning: general
advance care plans for people who are generally healthy and which ask questions like, “To you, what is living well?”, disease-specific plans for those suffering from chronic and progressive illnesses like renal, lung or heart failure, and preferred plan of care for the terminally ill. Although the idea is well established in places in the West, Australia, Hong Kong and Taiwan, advance care planning is still a new concept in Singapore. But realising its growing relevance, restructured hospitals have begun gearing up, setting up pilot programmes and training staff to be advocates and facilitators of the process. Advocates, when they sense the need for such discussions, introduce the process to the patient, while facilitators guide the patient and his family through the process. Singapore has a diverse population with different cultural and religious needs, and death and dying are still taboo topics that aren’t easy to bring up. Then, there is language. It is difficult enough having to go into an emotive, complex dialogue about death without having to deal with the complexities of translating concepts in English into Malay, Tamil or the different Indian and Chinese dialects! Many who work in hospitals, like me, have seen the differences that advance care planning can make. But we know that not everyone is ready to talk about end-of-life care. Still, it is important that such a process is available so that when needed, patients and their families have an avenue and people trained to help them explore such issues.
Andy Sim, Senior Medical Social Worker, Singapore General Hospital (SGH), works mainly with kidney failure patients since joining the hospital eight years ago. After returning recently from New York University where he pursued a Master of Social Work degree specialising in palliative and end-of-life care on an SGH scholarship, he is participating in an SGH pilot project to formalise advance care planning (ACP). He is an ACP facilitator and also part of a team of medical social workers who provide advance care plan training for health care professionals. How can I make an advance care plan? If you are an SGH patient, you can approach the Office of Integrated Care. Tel: 6576-2152 or e-mail: livingmatters@sgh.com.sg
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your say
singapore health
NOV– DEC 2014
Why is pre-surgery admission so early?
Was pill passed out intact? I took my medicine as usual – a 60mg Adalat (Nifedipine 60mg GITS) tablet – but was surprised when I later noticed something in the toilet bowl. It was the tablet with its coating still intact. As my blood pressure has not gone down, I am concerned about whether I have a problem with absorption, or if this medicine has been administered effectively. I am also wondering if this is a one-time occurrence or if it has been happening since I started taking this pill. Could it also be due to weak digestion? Are you able to check with the manufacturer to see if the coating is okay? Mr D Teo
have checked the manufacturer’s product guidelines and it is SHP We explained that Adalat is contained within a non-absorbable shell
says
that slowly releases the drug for absorption by the body. When this process is completed, the empty tablet is eliminated from the body and may be noticed in the stool. We would like to assure you that this process is normal and you will still benefit from the therapeutic effect of the drug. However, if you still have some concerns, please consult your doctor during your next review. This letter wins a set of L-Glutathione Skin Plus (two bottles containing 60 tablets each). The products, worth $76 each bottle, is sponsored by VitaHealth Asia Pacific (S) Pte Ltd.
Cover story interesting, informative I found the article “Cut, mince and jab” in the Sep-Oct issue interesting and informative. It was easy to understand as it was written in simple language without medical jargon, and illustrated with a simple diagram and comparison table. The story was also translated into Chinese for readers who don’t understand English. I look forward to each issue. Mdm Chan Wing Yuk
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My surgery was scheduled for 9am but I was told to register at the Same Day Admission (SDA) Centre at 7am. Why do I need to come so early?
Patients admitted to SGH the SDA Centre need
sa y s
to arrive a couple of hours before their elective or scheduled surgery to register, take care of surgery-related paperwork, and make sure their medical conditions remain stable and unchanged since the pre-admission tests done about a week before. To make sure patients understand what is involved, SDA Centre nurses will explain to them again what happens before and after surgery, and how they might feel after surgery. Admission to the SDA Centre helps reduce waiting time and hospital charges for patients on scheduled surgeries. About 80 per cent of the patients who undergo surgery at SGH are admitted through the SDA Centre. Patients with complex medical conditions or due to undergo complex surgical procedures cannot be admitted on the same day as their surgery, but must be admitted to hospital earlier, usually a day before, for pre-surgery preparations and to ensure their conditions are stable before surgery.
Why can’t death be certified by doctor?
When our uncle passed away in hospital recently, we weren’t able to claim his body immediately as we were told his death had been referred to the coroner. Why couldn’t the doctor certify the death since our uncle had been under treatment at the hospital?
doc tor s are SGH When unable to determine
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the actual cause of death, they have to refer the case to the State Coroner, who will decide if a post-mortem is nec-
essary to determine the cause of death. An open casket is still possible after a post-mortem as it won’t disfigure the body. The family of the deceased can pay their last respects at the ward before the body is transferred to the Mortuary@HSA, situated at the Health Sciences Authority, Singapore General Hospital, Block 9 Level 1, Outram Road. A police officer will inform the family if a post-mortem is required, while staff at Mortuary @HSA will provide information relating to the expected time for registering the death and claiming procedures, including arrangements for the hearse to arrive at the mortuary. For the registration of death, the identity cards or passports of the deceased and the family member handling the procedures must be produced. A Certificate of Registration of Death and the Permit to Bury/Cremate the body are then issued; these are needed in order for the relatives to claim the body at the mortuary.
Can Medisave be used for tooth implant treatment?
Can we use our Medisave to pay for tooth implant treatment? If yes, please advise on the amount that we can use. dental implant NDCS Atreatment consists
sa y s
of a few s tages, depending on the complexity and extent of your oral condition. During consultation, a dental specialist will provide you with a dental assessment before advising you on suitable treatment options. Generally, treatment for dental implants range from $4,500 to $5,500 per tooth (without bone grafting) and about $800 to $1,000 is Medisave claimable. Detailed financial counselling will be provided at our centre when you are scheduled for such treatments. As dental implants are elective procedures, there will be no subsidies.
about your he alth experience and win a prize for best letter Letters must include your full name, address and phone number. Singapore Health reserves the right to edit letters and not all letters will be published. Write to editor@sgh.com.sg or The Editor, Singapore Health, Singapore General Hospital, Communications Department, Outram Road, Singapore 169608, or talk to us on Facebook.
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The winner will receive two bottles of Spirulina 100% Extra 10% Deep Ocean Water (750 tablets each) worth $118, sponsored by IMI Lifestyle Products Pte Ltd.
NOV– DEC 2014
singapore health
19
Good Digestion The basis of good health
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Supplementation with calcium is particularly important during the growth phase and among the elderly. For women, the increased need usually starts with menopause. With vitamin D3, the preferred form of vitamin D to enhance calcium absorption and normal mineralization of bones. Easy to absorb calcium balanced with magnesium and zinc with vitamin K for the protection and repair of bones.* *People on “Warfarin” or blood thinners should consult their medical physician before taking Osteosyl D3
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20
FYI
singapore health
NOV– DEC 2014
cuts asthma risk in babies
event Calendar
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Sleeping on animal fur
更年期一自由翱翔之年
Babies who sleep on animal fur during their first three months of life may have a reduced risk of developing asthma later in childhood, according to a study by German researchers. Asthma is one of the most common chronic diseases in children. The researchers found that children living in cities who had slept on animal skin were 79 per cent less likely to have asthma by the time they were six, compared to babies who had not been exposed to it. By the age of 10, the children who had slept on animal skin were 41 per cent less likely to have asthma. According to earlier studies, microbes found in rural settings could have a protective effect against asthma, and animal skin might be a reservoir for various kinds of microbes, said Dr Christina Tischer of the Helmholtz Zentrum Munchen Research Centre. Previous research has also indicated that exposure from a young age to different environments may help the body ward off asthma and allergies.
Date Nov 2, Sunday Time 10am-12pm (Chinese forum);
1.45pm-4.20pm (English forum) Venue KK Women’s and Children’s Hospital (KKH) Auditorium, Women’s Tower, Training Centre (Level 1) Fees Full forum – $10 per person (refreshments provided); Single workshops – $2 per person Registration Call 6394-5038 (Monday-Friday, 8.30am-5.30pm) or log on to www.kkh.com.sg for more information or to sign up. These public forums feature common issues and concerns like the maintenance of healthy skin, active living, graceful ageing, and how to deal with urinary incontinence. “Growing Old, Growing Cold? In Marriage” will be one of the topics discussed during the English forum.
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Source: Brigham and Women’s Hospital
Family meals help defuse cyberbullying’s impact Having regular family meals may help protect teens from the effects of cyberbullying, a new study suggests. Family meals, which provide social contact and support, help reduce the distressing effects that cyberbullying can have on teens, according to a study by McGill University professor Frank Elgar. One in five teenagers experience cyberbullying, which can lead to depression, anxiety and suicidal thoughts. The study included more than 20,000 teens in Wisconsin.
linked to memory loss in later years
People with blood type AB are 82 per cent more likely to develop memory problems that can lead to dementia later in life, compared to those with other blood types, according to a recent study published in Neurology. People with blood type AB made up 6 per cent of the group who developed cognitive impairment, which is higher than the 4 per cent found in the general population. Previous studies have shown that people with type O blood have a lower risk of heart disease and stroke. These conditions can increase the risk of memory loss and dementia. Researchers also found that people with blood type AB had higher average levels of factor VIII – a protein – than those with other blood types. High levels of this protein are related to higher risk of cognitive impairment and dementia.
Source: American Academy of Neurology
contest
1. Where is cord blood derived from? 2. Which story in this issue did you find the most informative? Closing date: Dec 7, 2014 Send in your answers and stand to win a tube of Bone Health cream (10% Glucosamine Sulphate Plus Bio-Calcium and Chondroitin), worth $49.50, sponsored by Urah Transdermal Pte Ltd.
6576-7658 (Monday-Friday, 9.30am-5.30pm) or e-mail pgmi@sgh.com.sg to sign up.
Include your name, age, gender, address and telephone number. Winners will be notified via phone or e-mail. Incomplete or multiple entries will not be considered. E-mail editor@sgh.com.sg Post The Editor, Singapore Health, Singapore General Hospital, Communications Department, #13-01 Surbana One, Blk 168, Jalan Bukit Merah, Singapore 150168 Winners of Contest 30: Each will receive a Kyäni SunriseTM 30-pack, worth $83.75, sponsored by Kyäni Singapore Pte. Ltd. Prizes must be claimed by Dec 7, 2014. 1. Sara George 2. Doris Quek Hui Nai 3. Ong Soo Ching 4. Teo Hai Poh 5. Jeany Teo
Learn about knee osteoarthritis and its treatment options, and how to exercise even with a sore knee.
Santa Run for Wishes
Date Nov 29, Saturday Time 4pm-10pm Venue The Promontory @ Marina Bay Fees $58 per adult (age 12 and up); $48 per child
under 12; $158 per family (two adults and two children, applicable to 2.2km run only) Registration Log on to www.santarunforwishes.sg for more information or to sign up.
Join 5,000 Santas in celebrating the spirit of giving this festive season! The Santa Run for Wishes is the first of its kind in Singapore, and the event also features a Christmas carnival at which participants will get to enjoy some family fun. Take a ride on the miniature trains and try your hand at the bowling lanes. All registration and donation proceeds will go to Make-A-Wish Singapore and be matched dollar for dollar by the Government as part of the Care and Share Movement, in conjunction with Singapore’s 50th birthday celebrations in 2015.
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Source: McGill University
Blood type
Academia, Level 1, Room S3
Fee Free Registration Pre-registration is required. Call
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Women who drink higher amounts of caffeine are less likely to have tinnitus, which is ringing or buzzing in the ear, a study by Brigham and Women’s Hospital in Boston has found. The study included more than 65,000 American women. It is unclear why higher caffeine intake appears to reduce the risk of tinnitus, but caffeine stimulates the central nervous system. Both bench science and animal studies have found that it has a direct effect on the inner ear.
Knee Osteoarthritis
Date Nov 29, Saturday Time 2pm-4pm Venue Singapore General Hospital,
Source: Medical News Today
Coffee may keep your ears from ringing
Menopause: The Age of Freedom
Footcare for Diabetes
Date Dec 13, Saturday Time 9am–10am Venue SingHealth Polyclinics-Geylang, Level 1
Class in a Glass Fee Free Registration Call 6547-6930 to sign up.
Learn how diabetes affects the feet and find out how diabetics can look after their feet properly.
Visit www.singhealth.com.sg/events or the websites of respective institutions for any changes, more information, and other listings.
NOV– DEC 2014
singapore health
21
YOUR GUIDE TO BETTER LIVING
Moving to the beat
The beat in music can help patients with Parkinson disease to walk and speak better. By Sol E Solomon
J
photos: alvinn Lim
ust as marching soldiers call out a cadence to help keep them in step and boost team morale, patients with Parkinson disease who have movement problems can use the rhythms in songs to help them walk. The beat in the music is a cue to prompt them to perform movements which they no longer do automatically. Patients with Parkinson disease, especially those in its more advanced stages, suffer from forms of motor or movement dysfunction like tremors of the hand, speech and swallowing difficulties, muscle rigidity, poor posture and balance. Parkinson disease is a neurological disorder with no known cure, and the symptoms worsen progressively. “Music therapists use timing cues in music rhythm to re-train Parkinson disease patients in movements like walking, gross (involving movements of the legs, arms or entire body) or fine motor skills (involving movements
of the hands, wrists, fingers, feet, toes, lips and tongue), and initiation of speech,” said Ms Christal Chiang, Music Therapist, Singapore General Hospital (SGH). “When they hear the tick-tock of a metronome or musical beat, it is a cue for them to start walking. And the regular beat (of the music) trains them to move more smoothly.” Losing one’s ability to walk is distressing, and patients may be anxious before walking or performing other move ments. Music can help calm a patient before he star t s to do seemingly simple tasks like walking, said Ms Chiang. She uses the keyb o a r d , g u i t a r, drums or auto harp during therapy, depending on a patient’s needs. Patients often become depressed and withdrawn because of the disabling effects of the disease. Again, music can play a role in providing social and emotional support. When a patient finds it difficult to confide in his family or friends about the problems he is facing, Ms Chiang uses music to initiate conversation with him. She might give him an exercise in writing the lyrics to well-known tunes as a way of expressing himself. Doctors recommend music therapy if they think a patient may benefit from it. Studies elsewhere have testified to the benefits of music therapy in treating various diseases, including Parkinson, although this type of The beat in music is used as a cue therapy is not considered standard to help Parkinson patients with movement problems walk. The hospital care. Still, since SGH began beat prompts them to take regular offering music therapy in August 2011, steps. Music therapist Christal it has received some 280 referrals, Ms Chiang (left), who often works with a physiotherapist (right in blue uniform), Chiang said. Each 30-minute session, for which favours the three-octave autoharp for Medisave cannot be used, costs about its rich sounds and harmony.
When messages don’t get transmitted The second most common neurodegenerative disorder after Alzheimer’s disease, Parkinson disease affects three out of every thousand individuals in Singapore aged 50 years and above. The disorder is more likely to affect older people. The disease occurs when the nerve cells in the brain that produce the chemical called dopamine die. Dopamine allows messages to be sent to the parts of the brain that coordinate movement. It is not known why these nerve cells die. In the early stages of Parkinson disease, symptoms may be so mild that they go undetected. As the disease progresses, symptoms become more obvious and worsen till they become disabling in the late stages. Among the more common symptoms are the shaking of the arms or legs when at rest, stiffness of the arms, legs or body, and slow movement. $92 and does not come under any welfare scheme. The number of sessions required depends on the patient’s condition and the short- and long-term goals set by his doctor. The music therapist structures the course of therapy to facilitate these objectives. When a patient is referred for gait training, he will first walk 10 metres for a physiotherapist to assess his walking speed in paces per minute. The music therapist then translates this into beats per minute to determine the required musical rhythm. When the patient becomes more adept at movement, this rhythm is used to train him to walk: the patient takes leftright steps according to the beat of the music. Ms Chiang usually works with a physical or occupational therapist, especially in gait training where there is a risk of the patient falling.
Patients with Parkinson disease are often prone to falling because their balance becomes impaired. They also have swallowing, speech and communication difficulties. Medication can help improve the symptoms, but currently, there is no cure for the disease. Dopamine-producing region
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singapore health
NOV– DEC 2014
NOV– DEC 2014
singapore health
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Cancer of the heart Heart cancer is rare but deadly and often affects young people in the prime of their lives. By Thava Rani
all cancers. Dr Richard Quek, Deputy Head and Senior Consultant, Division of Medical Oncology, National Cancer Centre Singapore (NCCS), said: “We see an average of four to five new patients with sarcomas per week at our centre. For sarcomas of the limbs and trunk, patients tend to seek treatment quickly because it’s a visible growth.” Unfortunately, sarcomas of the heart are not so obvious. The tumours can
occur anywhere – on the outside surface, in one or more chambers, or inside the muscle tissue. Heart sarcomas tend to occur in young patients in their 20s to 40s, but thankfully, they are extremely rare. “We see one to two patients with cardiac sarcomas a year. Even if we were to include sarcomas of the major blood vessels near the heart, the numbers are still very small – about five to seven patients a year. Many doctors may not even encounter a single case throughout their careers,” said Dr Quek.
Symptoms of heart failure
illustration: ng chin hooi
The cause of most sarcomas is still unknown. It is not yet understood if dietary or lifestyle choices, such as smoking, put people at risk. What is known is that symptoms vary depending on the location of the sarcoma. For instance, if tumours arise in the two right chambers of the heart, obstructing blood flow into the heart, patients may experience swelling of the feet, ankles and legs. If a tumour occurs in the muscle tissue of the heart, the heart’s ability to pump blood may be affected. Chest pain, shortness of breath, fatigue and palpitations are some of the signs that may point to this. Other non-specific symptoms may include fever, weight loss, night sweats and fatigue. Because patients tend to be young, their bodies are able to compensate for most of these symptoms, and they tend to ignore the symptoms and simply attribute them to tiredness. “But when symptoms go on for too long or become more severe, that’s when they consult a doctor. Unfortunately, the sarcomas are pretty large by then. These kinds of tumours also tend to be high grade, meaning they grow fast and cause more damage,” said Dr Quek. So when young patients consult a doctor for symptoms that seem to point to heart failure, alarm bells go off and further investigation is urgently initiated.
Size matters less
heart tumour As blood flows past the cancerous area in the heart before going to other parts of body, chances of the cancer spreading to the lungs are high. The cancer may also spread to the bones or liver.
Unlike most other cancers, with heart sarcomas, size is less of a factor when determining treatment. “The more impor tant question is whether the tumour is located in a place that makes it possible to surgically remove it completely. If it is inoperable, then it doesn’t matter how small it is. The ideal situation is, of course, if the tumour is small and operable,” said Dr Quek.
photo: alvinn lim
C
ancer very seldom starts in the heart. But when it does, it can be deadly. Cancer in the heart is most often a sarcoma, which is a malignant tumour that develops in the bones or soft tissues such as muscles, nerves, fat or blood vessels. There are about 50 different soft-tissue sarcomas. The more common ones occur as lumps in the arms, thighs, legs, abdomen, head or neck. As a whole, sarcomas represent 1 per cent of
According to Dr Richard Quek, unlike most other cancers, with heart sarcomas, size is less of a factor when determining treatment.
Where possible, surgery is done to remove as much of the cancer as possible. The patient will then undergo radiation to kill off any remaining cancerous cells. Chemotherapy may be used instead of radiation if the location of the tumour is not suitable for radiation.
when young patients consult a doctor for symptoms that seem to point to heart failure, alarm bells go off and further investigation is urgently initiated.
However, because it is the heart that is affected, surgery is often not an option. The alternative is to use radiation or chemotherapy to try and shrink the tumour, and in doing so, minimise the symptoms. The possibility of the cancer spreading to other areas is another concern. Because blood flows past the cancerous area in the heart before going to other parts of the body, chances of the cancer spreading to the lungs are high. The cancer may also spread to the bones or liver. This makes heart sarcoma patients poor candidates for heart transplants. But Dr Quek said there is still hope: There have been advancements in surgical techniques, development of more pinpointed, targeted radiation, as well as research into new drugs. “While these new treatment options may not provide a cure yet, they can most definitely delay the disease,” he said.
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singapore health
nov– dec 2014
Don’t forget to look down Feet are often neglected but they age like the rest of the body. By AJ Leow
M
said Mdm Koh, 64. She had been very active before, but had to stop brisk walking regularly because of her painful toes. She also had to cut back on travelling because it was difficult to walk. A common problem, ingrown toenails occur when the nails grow into the soft skin tissues on the sides of the toes. Ingrown toenails can become inflamed and infected if the condi-
photo: Alvinn Lim
dm Koh Sai Ngoh’s ingrown toenails didn’t give her problems until they became inflamed and swollen. She finally had the portions of the nails that were growing into her skin removed. After the procedures on both toes, Mdm Koh continued to see a podiatrist to have her nails trimmed every five to six weeks to help the nails grow properly. “I’m hoping to start walking again,”
According to Mr Ng Chee Hong, Senior Podiatrist, it is important for diabetics to check their feet every day for injuries and wounds because prolonged high blood sugar levels can lead to poor blood circulation or neurological damage, and affected patients may not feel pain from abrasions or blisters.
tion is not treated early. “It normally affects the big toes, and occasionally the second and fifth toes," said Mr Ng Chee Hong, Senior Podiatrist, Podiatry Department, Singapore General Hospital (SGH). Not cutting the nail down the sides will help it grow properly. Cutting down the sides might leave a sharp ridge of nail that can grow into the skin. If the condition is serious and there are accompanying symptoms such as pain and infection, surgery to remove the nail roots may be necessary. Patients will have to continue seeing a podiatrist after surgery to have their nails trimmed to help them grow properly, he added. Younger people tend to be the main sufferers of ingrown toenails as they are more active and their feet tend to get hot and sweaty, but the condition affects people of all ages. For older people, a range of footrelated problems such as pain in the heel, the front of the foot or under the ball of the foot, and fungal infections are common. Years of carrying the weight of the body can wear away the natural cushion of padding under the heel and the ball of the foot. Also, as people age, the arches of their feet start to flatten because the ligaments in that area “get more lax, and are not so tight”, said Mr Ng. With the arches becoming less flexible, and the ankles and foot joints also becoming stiffer, foot pain and other problems tend to develop among older people. Additionally, foot problems can be complicated by diabetes, which itself is a common condition among the elderly. Diabetics can suffer from poor blood circulation or neurological damage, and so may not feel pain from infections caused by abrasions or blisters. Their wounds also do not heal as quickly as non-diabetics. That is why it is important for diabetics to check their feet every day for injuries and wounds, said Mr Ng.
Foot workout
Prolonged high blood glucose levels can lead to a narrowing and even blockage of blood vessels. In the feet, this can cause tissue damage, and complications that require amputation in more serious cases. Besides taking good care of the feet and following a healthy diet and lifestyle, regular exercise like walking can help to keep the blood flowing to the feet. Other simple exercises are: • When sitting, move the ankles in a circular motion and wiggle the toes.
• Stand on the toes and lift the heel a few times every minute. • Avoid putting the feet up when sitting. Gravity helps to get blood to the feet. • Avoid crossing the legs when sitting as it can pinch off blood supply.
Buy shoes in the afternoon Shop for shoes in the afternoon as feet tend to swell in the later part of the day. It is best to have both feet measured while in a standing position. Always pick the size that corresponds to the larger foot. There should be a thumb space allowance. Test the fit of both shoes by walking around in the shop. Shoes should feel comfortable without the need for a breaking-in period. Always ensure that the shoes fit the widest part of the foot comfortably.
diabetics need to mind their feet Quit smoking. Exercise and maintain a healthy diet. Wear thick dry socks to absorb pressure on the feet. Cotton or wool is better than nylon. Avoid tight socks or stockings. Wear well-padded shoes with open toes or a deep toe box (the part of the shoe that surrounds the toes). If necessary, have the shoes stretched in the area where corns or calluses – an accumulation of dead skin
layers – are likely to occur. Use doughnut-shaped pads over corns to lower pressure and friction. Apply petroleum jelly or lanolin hand cream to corns or calluses to soften them. Do not trim corns or calluses with a razor blade or other sharp tool to avoid accidental cuts and infection. Instead, soak in very warm water for five min-
utes or more to soften the hardened tissue before gently sanding it with a pumice stone. A pumice stone or fine foot file can also be used around the heels if the skin is thickened or dry. Wash feet daily. D r y t h e m t h o roughly and use a cream to prevent cracks that can lead to infections.
Do not use cream on the area between the toes to avoid fungal growth. Use a soft bristle brush or toothbrush to clean the area between the toes. Do not delay seeking help for a foot problem. Early intervention is crucial for diabetics: about one in four diabetic patients will develop foot ulcers. Without treatment and if complications occur, amputation may be necessary.
NOV– DEC 2014
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MDI362 SHLS Singapore health 345x260 Nov Dec FA.indd 1
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singapore health
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Managing menopause While some women experience menopause with few problems, others find it troublesome. But help is at hand.
M
enopause begins when the menstrual cycle ends, and along with it, the ability to get pregnant. It is a natural phase of life for women, a rite of passage into the third phase of life. Natural menopause is diagnosed after menstruation stops for 12 consecutive months. Laboratory tests are only done to rule out other medical causes that may mimic menopause symptoms. These can include thyroid problems, tumours, and medication such as niacin, calcium channel blockers and nitroglycerin. In Asia, menopause usually occurs in women between the ages of 45 and 55. The average age at which it hits women in Asia is 50, while in Singapore, it is 49. Menopause can occur earlier. This is linked to genes, smoking (which brings it forward by about 2½ years), chemotherapy and surgery involving the pelvic organs. In 2012, close to 30 percent of Singapore’s female population was aged between 45 and 65 years. As about 50 percent of women going through menopause will experience some symptoms, the number of women seeking consultation for issues relating to menopause is expected to be substantial. Dr Ang Seng Bin, Head and Consultant Family Physician of the Family Medicine Service’s Menopause Unit at KK Women’s and Children’s Hospital (KKH) said that in recent years, KKH has seen a 30 per cent rise in women seeking con-
sultation for issues relating to menopause, particularly hot flushes, irritability and sleep disturbance. More women are also having hot flushes compared to those in previous studies. Sex after menopause Lower oestrogen levels in menopause can affect a woman’s sexual functions. This can lead to painful intercourse and problems with intimacy, libido and sexual desire. Vaginal dryness can occur, and it worsens with time. One’s primary care physician should make a thorough holistic assessment of a patient’s sexual, medical and psychosocial history, said Dr Ang, who is also Adjunct Assistant Professor, DukeNUS Graduate Medical School, and Associate Program Director, SingHealth Residency Family Medicine Program. Measures can be taken to improve psychological well-being and intimacy, while medication and substances that aggravate vaginal dr yness should be avoided. The use of vaginal lubricants and topical oestrogen can also be considered. Hot flushes Hot flushes begin about two years before the final menstrual period and peak about a year after it. They are usually short-lived, lasting between five to ten minutes per episode. The frequency can vary from once every few days, to two to four times an hour. Hot flushes also vary
Managing stress and exercising often improve symptoms of mild to moderate hot flushes.
in severity, and so require different types and combinations of intervention. Managing stress and exercising often improve symptoms of mild to moderate hot flushes. Women with severe symptoms, or those who do not see improvement with lifestyle management, may consider hormone therapy, the most effective treatment for hot flushes. Those who have hot flushes that last for more than 30 minutes each time should seek medical advice to exclude
Severity and management of hot flushes Severity
Mild
Moderate
Severe
Symptoms
Sensation of heat without sweating
Sensation of heat with sweating; able to continue activities
Sensation of heat with sweating causing cessation of activities
Management
Lifestyle management
Lifestyle management
Lifestyle management
Hormone therapy if lifestyle measures fail
Hormone therapy after weighing risks and benefits
medical conditions such as hyperthyroidism and brain tumours. Irritability and sleep disturbance Severe hot flushes can also disturb sleep and cause irritability. Menopause can also trigger depression in women with a previous history of depression or negative reactions to life stressors. To deal with sleep disturbances and irritability, improve sleep hygiene, manage stress, use mind-body therapies and maintain an active and supportive social life. Primary care physicians can help patients identify and address other potential causes including depression, anxiety, joint pain, backache, stress and caffeine consumption. If symptoms affect a menopausal woman’s life and daily activities, she should see a doctor. These symptoms can include post-menopausal or unexplained vaginal bleeding, a pelvic mass, or any other medical issue that may require surgical intervention. This article is adapted from Managing Menopause – The Role of the GP, by Dr Ang Seng Bin, in Special Delivery, a publication of KK Women’s and Children’s Hospital (KKH). Dr Ang is Head, Menopause Unit, Department of Obstetrics & Gynaecology; Family Physician, Consultant and Head, Family Medicine Service, KKH.
新加坡中央医院与新加坡保健服务集团的双月刊
2014 年11– 12月刊
为生命配对
的脐带血还不到库存的一半。 尽管如此，任何捐献都是挽救生命的 希望。可是，愿意捐献的孕妇并不多。 黄医 生 恳 求更多孕 妇 捐 献 脐 带血： “与其生产后将脐带血丢弃，不如把它捐出 来，给有需要的人一个存活的机会。” 他说，目前需要脐带血来挽救生命的 病人正迫切地等候着合适的单位。若等 候时间一直延长，那么病情一加剧，他们 血。但是，某些生命危在旦夕、急需脐带血来 的性命随时都有被夺走的可能。 原文 蔡慧玲 进行移植的病人，往往无法从中或全球的库 为了促进公众对捐献脐带血的意识以 存登记中，找到合适的配对。 及呼吁更多父母们伸出援手，新加坡公共 在有 越 来 越多母 亲将婴儿的脐 新加坡公共脐带血库的查询量与日俱增。 脐带血库与其他机构也积极地联办各种 带血捐献给新加坡公共脐带血库 不只本地病人，连那些无法从国际库存中找 推广活动，希望借此增加每个种族的脐带 （Singapore Cord Blood Bank）。 到合适脐带血的国际病人包括亚洲人，也会 血捐献量，从而提高病患寻找合适脐带血 呼吁捐献虽然得到了一些反应，可是仍旧供 前来查询并寻找合适的配对。 的几率。 不应求。 新加坡公共脐带血库的医务总监及新加坡 每月，不少本地和国际病人都会查询新加 中央医院血液科主任及高级顾问医生黄殷祺 脐带血的用途 坡公共脐带血库的库存，以寻找合适的脐带 表示说， “因为那些国际骨髓和脐带血库的 脐带血是遗留在新生儿的胎盘和脐带里 捐献者大部分是来自西方国家，所以亚洲人、 的血液，是丰富的造血干细胞来源，可被 少数种族和混血血统的人士很难从中找到合 用于干细胞移植治疗与血液相关的严重 适的单位。” 疾病，例如白血病和淋巴瘤等血癌、血液 所谓合适的单位是决定于种族和组织类 失调症、免疫缺陷和代谢性疾病。 型，因此对那些拥有多元组织类型的混血人 干细胞虽然也存在于骨髓和外周血里， 士来说，要找到匹配的脐带血单位，更是难上 可是相比之下脐带血干细胞是最先取得的 加难。 来源，对匹配度的要求也较低。 黄医生说，新加坡是个多元种族国家，所 一般来说，若其他传统治疗对高风险 以我们必需为本土的华族、马来族、印度族 病患者起不了疗效，干细胞移植就是唯一 和泛亚裔同胞建立一个国立资源中心。他也 剩下的选择。医生通常也不建议病患使用 强调，设立一个少数族裔的脐带血库是必要 自己的脐带血，因为它很可能已带有致病 的。 “捐出来的脐带血将会集中在公共脐带 的异常遗传基因，所以没有血缘关系的脐 血库里，这样不仅能提升配对的几率，也能 带血会比较好。 帮助挽救更多病患。” 由于脐带血移植可以在组织类型不匹 在新加坡公共脐带血库，每个脐带血单位 配的情况下成功进行，因此找到合适的脐 都要经过一番严格的评估与测试。除了需要 带血单位的可能性相对偏高。比方说，病 确定容量、细胞数量和细胞活力符合标准以 人只有四分之一的机会能够在兄弟姐妹之 外，也要进行各类传染病和其他测试，证实 中找到完全匹配的干细胞，而从无血缘关 合用于移植用途后，才将之储存在摄氏180 系捐献者中，成功匹配的有近五成。黄医 度的低温储存罐中。这一切繁琐的步骤是为了 生说，所以捐献脐带血是至关重要，这样 经过一番严格的评估与测试，证实合用 让即使是免疫系统受损的病人也能够安全使 病人才会有更多机会去寻找合适的血液 于移植用途后，脐带血单位将被储存在 用这些脐带血。然而，顺利通过评估和测试 干细胞来进行移植手术。 摄氏180度的低温储存罐中。
27
新闻
脐带血捐献的数字
能够挽救生命的新生儿脐带血需要更多父母慷慨捐献
Photo: jasper yu
现
无私的捐献
26,000 脐带血单位
至今，血库共有
10,454 经过测试合用的 脐带血单位
9
在过去3年里，有
%
的新加坡妇女 已捐献其脐带血
亲生兄弟姐妹 之间有
1/4
Photo: alvinn lim
的机会可找到 匹配的组织
Photo: vee chin
两名35岁母亲 — 刘芝慧女士和依思雅妮 奉献与帮助他人的价值与意义。 （Izyani Ayik）女士不约而同地选择捐献宝 她还提出有关方当局应该将脐带血捐 宝的脐带血。这两名同龄母亲各育有四名子 赠设定为法定条例的建议。 “据我所知，捐 女。在她们丈夫的支持下，她们将每名孩子 献 者的人数寥 寥无几。我们需 要更多的 的脐带血都捐献了出来，与初生的孩子们一 捐赠者。” 起分享无私精神。 相对来说，依思雅妮的四次捐献有三次 给生命垂危的病人得以延续生命的机会 是通过标准的，为无私的行动取得较佳的 是她们捐赠的主要动机。其实，两人并没 结果。 有亲友也不认识任何需要移植干细胞的人。 “那一次真很遗憾啊。”她所指的是自己 只是当她们得知脐带血的功用后，令她们觉 第三次没有符合标准的捐献。不过，当她 得丢弃它是何等的浪费，便促使她们付诸于 怀上第四胎时，她仍然期待着捐献，甚至还 行动，让新加坡公共脐带血库代替她们履 因此放弃了在家分娩的愿望。 行意愿。 “我希望我的孩子可以在最自然、无压力 刘芝慧说： “如果每个母亲都作出捐赠， 的环境下诞生，因为我相信这对他们的成 那么需要脐带血的病人找到合适配对的机 长发育比较有益。可是因为我想捐出宝宝 会也会增高。反正捐献不痛不痒也不会造 的脐带血，再说，家中环境也没有脐带血捐 成任何不便，何乐而不为？” 赠所需的技术与配备，所以最终还是放弃 虽然她所捐献的单位没有符合评估标准 了这个念头。” 而不获储存，但她还是认为捐献是正确的 不管她捐献是否真的帮助了其他人，对 行为，并希望当她的孩子长大后能够体会 她来说她的目的已经达到了。
自2005年 正式成立以来， 新加坡公共脐带 血库共收到了
依思雅妮女士(上图)和刘芝慧女士 (下图)选择将每名孩子的脐带血捐献 给新加坡公共脐带血库。这两名母 亲各育有四名子女。
70
%
的病人无法在 亲属当中找到 合适的配对
28
健康
2014 年11– 12月刊
排便不畅 慢性便秘可能由骨盆底异常引起
者检查发现没有什么大问题的人，往 往会忽视问题的存在，而像许女士一 样依赖于泻药。 王医生说，其中一个原因是他们没 有意识到便秘问题是由骨盆底异常所 引起，而这是可以治疗的。新加坡中央 医院骨盆底异常服务中心配有先进设 备，能扫描和评估肛管及肌肉群，以及 它们进行适当收缩和放松的能力。 “有时，整个结肠因某种原因而收缩 不良，或者，病人的肌肉收缩正常，但 必须用力，犹如有阻塞一样的梗阻性 便秘问题，”王医生说道。 对于确诊为排便协调不良的病人， 我们可以教授他们如何适当地收缩 和放松排便相关的肌肉群，直到协调 正常化为止。这与凯格尔健肌法很相 似，后者是女性缓解尿失禁问题的一 种练习，而尿失禁是发生在生育后的 另一种骨盆底异常，王医生说道。
便秘的常见原因 除了骨盆底异常，还有其他因素可 能导致便秘： 饮水过少
纤维素摄入过少或过多
很多人默默忍受慢性 便秘问题，却没有意识 到，假若这是因骨盆区 肌肉群协调不良而引起 的，它是可以治疗的。
缺乏运动
原文 Jamie Ee
十
多年以来，从事秘书工作的 许 特里 莎小姐 因 便 秘 问 题 而天天服用泻药。即使如此， 她还是需要费很大的力气才能排便。 50多岁的她在各大小诊所和医院 里四处求医，盼望能解决这个慢性问 题，但医生总是开泻药和纤维素饮料 给她，这些只会使腹胀加剧，感觉更 加难受。 “我的情况很严重，就算吃很少的 东 西，肚 子 也会 膨 胀，一 摸 就 痛，” 许小姐说。 她在新加坡中央医院进行了一系 列 检 查 后，结果 显示她 患有 某种骨 盆底异常问题，导致排便所涉及到的 肌肉群不能正常地协调工作。
压力 中央医院直肠外科顾问兼骨盆底异常 服务中心主任王德庆医生说道。 骨盆底的无力或缺陷可能会造成 功能失调。便秘通常在年纪较大时才 较为常见，但患者可能早在10多20岁 时就有此症状。 “每个人都会有便秘问题。便秘很 常见，因此，一段时间后，人们逐渐接 受它作为自己生活的一部分。他们不 会再花功夫去进一步探究这个问题，” 王医生说道。 “但 我 们 希 望 找 出 更 多因 功 能 性 原因而造成便秘的病人，以改变这一 状况。” 有便秘问题，但并无其他症状、或
女性的骨盆底支撑着更多的器官， 因此 更容 易出现 无力状况 。目前已 知老化 和分娩可增加骨盆底疾病的 风险。 许小姐在骨盆底异常服务中心的 护士那里学到的练习方法，已经能帮 助她实现有规律的排便。她不 再依 赖泻药，甚至在国外度假时也能顺畅 排便了。 她说： “找出问题的根源非常重要。 有时候我还是难以排便，但两三天后 就会排便顺畅。现在我更了解自己的 身体了，所以会避免对自己抱有太高 的期望。为了让排便正常，坚持练习 是很重要的。”
非常见便秘 构成骨盆底的肌肉群，形成了一个吊 索状 结 构，与相连的组 织一起 支 撑 和支持着骨盆上方的器官，例如直肠、 腺体、子宫等。 排便过程中，骨盆底肌肉放松，同 时腹部肌肉收 缩，将粪 便 推向直 肠 （即大 肠 最下 面的 部位）排出体外。 这一过 程本应是不同肌肉群之间自 动进 行并 协调的工作，但有 时 候收 缩 动作的协调不良，致使骨 盆 底 肌 肉群该 放 松 时却在收 缩，从而出现 排便困难。 “粪便的移动需要依靠各肌肉群在 适当的时侯放松和收缩。当这些相互 作用受到了扰乱或发生了紊乱，就像 电路一样，需要重新接线，”新加坡
王德庆医生发现，许特里莎小姐的骨盆底异常扰乱了她的排便。专门练习有 助于解决她的问题。
中风、抑郁 症、饮食失调等 疾 病 状况 抗抑郁药丸和含铁药丸等药物的 副作用 怀孕 结肠癌
息息相关 骨盆底无力往往会导致多 种症状，包括泌尿问题和 子宫脱垂等多种问题。 因此，病人可到多学科 诊所求医，例如新加坡中央 医院骨盆底异常服务中心 拥有直肠外科、泌尿科和 妇产科的医生。 “ 我 们 相 信，三 个 臭 皮 匠胜过一个诸葛亮。有时， 病人可能需要接受联合手 术，这样，各专科医生将协 同工作，让 患 者只需 一次 手术就能解决多个问题，” 新加坡中央医院直肠外科 顾问兼 骨 盆 底异 常服务 中心主任王德庆医生说。
2014 年11– 12月刊
与哮喘病一起成长 由于儿童哮喘病不会随着时间而痊愈，已经长大成人的患者必需提防哮喘病发作 原文 Sol E Solomon
PHOTOs: MORVEN KOH
自
小患有哮喘病的札丽娜 （Zarinah Mahmood）女士，成 年后病情 稳定，甚少发作。不 过，在她40岁那年为了医治乳癌而接受 放射性治疗后，情况就改变了。 “由于放 射 性 治疗的范围在我的 胸部，我的肺部也受到了影响。在那之 前，我几乎20年没有哮喘病发作了，”今 年60岁的她说。 现在，如果遇上环境改变，她的哮 喘病就可能会发作。她最近曾到过中东 地区并遇上突如其来的沙尘暴，使她的 哮喘病一发不可收拾。这名已退休的翻 译员说： “开始时，我只是咳嗽和有一 点喉咙痛，然后，我就开始喘鸣。” 札丽娜的经历突显了一项鲜为人知 的事实：表面上，哮喘病的症状可能随 着患者成长而消失，但患者还是必须有 所戒备，不该掉以轻心。 哮喘病患者长大成人后，可能病情 表面上已随时间而消失，但他们始终必 须时时提高警惕。 新加坡保健服务集团（简称新保集 团）综合诊疗所研究主任陈业川医生 说： “无论年龄，哮喘病患者都要提防 它随时病发。” “你无法改变一个人的基因。当患 有哮喘病的孩子长大，他们的呼吸道会
在札丽娜女士的协助下，一名护士示范综合诊疗所的职员在发现有气喘迹 象的病人时，会如何进行援救治疗。
变宽，症状也可能变少。但是，如果他 们接触到触发因素，他们的哮喘病就可 能再次发作。” 哮喘病是一种肺部疾病，会影响负 责输送氧气给人体的呼吸道。当肺部气 道发炎时，它们会收窄和产生痰液，造 成进一步的阻塞。患者将因此承受气 喘之苦，而当他们必需通过狭窄的气道 呼吸时，就会出现哮喘病的其中一种特 征，称为喘鸣。
绿色阶段 • 没有咳嗽 • 没有胸闷 • 没有喘鸣 • 没有气喘 • 没有在半夜醒来 病人没有不适，
能够正常地进 行日常活动，不 过某些病人可能 还是需要继续服 用控制性药物。
哮喘病 护理计划 它以交通灯的颜色来 分类说明症状的严重程度， 以及病人在每个阶段必须 服用的药物。
病人必须开始根据处方，调整 他们的吸入药物的剂量。如果 在数天内没有感到病情好转， 就必须去看医生。
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士将检查病人的医疗记录，以确认他们 是否患有哮喘病。 出现气喘和已知有哮喘病历的病人 将被立即送到治疗室，并由特别受训 的护士展开援救治疗。 这是一项新计划的一部分。在计划 下，护士学会检查病人的胸腔，一旦检 测出哮喘病发作，就会立即进行急救。 由于哮喘病可能威胁生命，这措施让 急性哮喘病患者能够快速获得治疗。 在计划实施之前，所有病人都必须 排队等候看医生，才能够获得治疗。 陈医生说： “当哮喘病发作时，病人 会感到不舒服和气喘。因此，我们希望 尽快展开治疗，以减轻症状。实施这项 计划后，至少70%病人的病情在15分钟 内受到控制。” 当状况稳定后，医生续而为患者检 查病情，并教育他们自理的方发，包括 为他们提供一份哮喘病护理计划。 札丽娜的医生为她量身定做了一个 护理计划。她需要按计划，短暂 调整 她的药物剂量，以预防病发。 此外，她需要随身携带快速缓解药 物，以便在病发时扩张呼吸道，增加进 入肺部的气流。 平 时，她 只需 每天 服 用 控 制 性 药 物。当她感到不适时，她知道如何增加 药物剂量，或根据护理计划服用口服 类固醇。 如果她的症状持续数天不退，她必 须按照指示，立即去看医生。札丽娜 说： “这项护理计划让我懂得妥善地照 顾自己。”
综合诊疗所管理哮喘病的方式 陈医生服务的白沙综合诊疗所是新保 集团旗下的综合诊疗所之一。每一家诊 疗所都会委派护士在入口站岗，留意出 现气喘迹象的病人。万一发生状况，护
陈业川医生注意到新加坡的哮喘病个 案有增加的趋势，并正在调查造成这 种趋势的原因。
哮喘病个案不断上升
黄色阶段 • 流鼻涕 • 咳嗽带痰 • 喘鸣 • 气喘 • 胸闷 • 半夜醒来
由于儿童的呼吸道较窄，他们也就 比较容易患上哮喘病。只要呼吸道稍 微收窄，孩子就会感到不适，但长大成 人后，除非呼吸道的收窄情况非常显 著，否则成人不会出现严重的症状。 即使孩子无需接受定期治疗，他们 还是必须每隔三至六个月定期接受医 生检查。 哮喘病的其中一种诊断方法是进行 肺功能的测试。患者必须向肺活量计 呼气，让医务人员测量他的肺部所排出 的气流。 哮喘病的其他症状包括鼻子敏感或 湿疹。同时，研究显示，湿疹问题严重 的儿童绝大部分都患有哮喘病。 某些 患 者 也可能出现 双 眼容 易发 痒、流泪等敏感症状。哮喘病是遗传性 的。札丽娜的母亲也是哮喘病患者。
健康
红色阶段 • 药物不奏效 • 呼吸 重且急促 • 无法一口气 从1数到10 • 哮喘病症 状急速恶化 • 呼吸时
肋骨凸现
病情已处于紧急阶段，必须 立即由医生诊治。如有必要， 致电995召唤救护车。
新加 坡保 健 服务集团的 九家综合 诊疗所每月为2,300至2,500名哮喘 病患者看诊，并按月收集哮喘病数 据。其中56%是女性。 该集团综合 诊疗所研究总监陈 业川医生说，在过去数年，新加坡 的哮喘病个案有上升的趋势，而该 集团正试着了解原因。 可幸的是，到综合诊疗所求诊的 哮喘病患者之中，仅有9.3%的人需
要援救治疗。当这种情况发生时，患 者将透过贮雾器服药，以直接把药 物吸入肺部内。 卫 生 部 在 2 0 01年 推 出 新 加 坡 全国哮喘病管理计划（Singapore National Asthma Programme），以应 付本地哮喘病患病率高企的问题。 它的目的在于教育患者更妥善地自 我管理病情，同时通过促进预防性 治疗，改善患者控制病情的能力。
健康
2014 年11– 12月刊
追根究底
治疗步骤
根管治疗并不如想象中那么恐怖，它可以救回您的问题牙齿
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原文 Thava Rani
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当提起根管治疗（Root canal treatment）时，许多人都不 寒而栗。事实上，它并不会 造成巨大的痛楚。 尽管它让人闻风丧胆，牙医却可以 通过根管治疗，保留要不然无法挽救的 牙齿。在治疗过程中，牙医会清除牙内 已发炎或受感染的牙髓包含血管、神经 和结缔组织的活组织。清空后的空间 会被仔细清洗、填充和密封，如有必要 可盖上牙冠，让牙齿看起来一切如常。 “通过根管治疗，我们可以挽救坏 牙，要不然就必须把它拔掉。除了智慧 齿，大部分的牙齿都值得挽救，因为智 慧齿若在错误的位置或方向长出，对 咀嚼反正也没什么作用，”新加坡国立 牙科中心修复牙科牙髓病科组高级顾 问医生雷珍妮解释说。 根管问题的根源 牙髓发炎和受感染的主要原因是龋牙 和蛀牙，但隐 裂牙也日渐成为重要的 罪魁祸首。 牙髓问题由发炎开始。最终，牙髓 坏死，牙齿就失去神经或血液供应。 这样的牙齿失去了防御感染的能力， 让细菌后容易通过龋牙或裂缝进入牙 内。此外，如果猛力撞击牙齿，也可能 切断其血液供应，导致牙髓坏死和受 感染。 牙痛、长期对冷热温 度敏感、牙齿 变色、牙龈肿胀发痛或口臭，都可能是 牙髓发炎或受感染的症状。不过，对于 某些患者来说，她们可能完全没有任 何症状。 “有一些病人对其症状根本懵 然不知。所以我们必须每六个月接受
一次定期的牙科检查。若发现任何问 题，牙医会及早处理，或转介患者去看 专门治疗根管问题的牙髓病专家，”雷 医生说。 牙医会 进 行 测 试以便 确 诊。他 们 也 经常通 过 X 光检 查，找出受感染的 部位。 战胜恐惧 由于周边范围会被 局部麻醉，因此在 大部分情况下，治疗过程都是无痛的。 如果在治疗前出现严重痛楚，就可能 难以进行局部麻醉，因而在过程中患者 会感觉些不适。 在 过 程中，医 生会 在 患 者 的口腔 上盖上一片乳胶薄膜。患者可能会觉 得自己无法与牙医沟通或吞咽而产生 焦虑。 “我们通常会仔细地向患者解释治 疗的步骤，让他们知道每一个阶段会 发生什么事。当感到任 何疼痛或不适 时，就给我们比手势。虽然他们还是可 以吞咽的，但我们会用抽吸泵去吸除唾 液，以策万全，”雷医生说。 完成治疗后，即使麻醉药已消退，大 部分患者不会有任何痛楚。不过，牙医 一般都会给药性温和的止痛药以防万 一。如果患者在开始治疗前就已经历 剧痛，那么治疗后出现痛楚的机会也会 偏高，因此牙医会给药性较强效的止 痛药。 “如果药物无法减轻疼痛，或疼痛 持 续超 过两至 三天，或出现 肿胀，患 者最好再次咨询牙医，”雷医生说。不 过，她补充道，这些情况不超过治疗个 案的5％。
photo: vernon wong
雷珍妮医生会仔细 地告诉患者根管治 疗的步骤，让他们 知道每一个阶段会 发生什么事。
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准备牙齿 牙医彻底检查受 感染的牙齿，然 后在患者的口腔 上盖上一块橡皮 障，以锁定牙齿 的位置，并维持 一个清洁和没有 唾液的治疗环境。
造孔进入 牙髓腔 在局部麻 醉下，牙 医在牙齿 上 钻 洞 ， 深入牙髓 腔和根管。
清除受感染或 发炎的牙髓 牙医从牙髓腔 清除牙髓。通 过使用专门设 计的锉刀，牙 医清洁根管 和调整其形 状，然后以抗 菌溶液把碎屑 冲出。
填充牙齿，盖上牙冠 牙医利用不同尺寸的圆锥 形牙胶（一种橡胶类材 料）去填充根管，并以胶 浆连接圆锥形牙胶，全面 地填满剩余的根管空间。 一种永久性的填料会完 全密封牙齿。 根据牙齿的位置再决 定是否需要盖上牙冠。
注: 在治疗过程中，牙医可能需要重复拍摄X光照片，以计划下 一个步骤。整个过程可能需要来回几次复诊，每次需时约一个小 时。 牙医会给抗菌药物来保持根管清洁，并利用临时的填料去覆 盖牙齿，直到下一次治疗为止。
illustrations: heymans tho
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2014 年11– 12月刊
新闻
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photo: Pascal BROZE/Onoky/Corbis
专家解答
手指僵硬 我经常感到手指僵硬，尤其是在早上。 我是否患上了类风湿关节炎或其中一种 自体免疫病？ 手 指 和脚趾有时包括其他关节的 疼痛和僵硬感觉是类风湿性关节炎的 症状。这是一种自体免疫疾病。一般来 说，僵硬感在早上起床时最为严重，然 后在活 动受影响的关节、洗温水澡或 服用消炎止痛药后，就会有所改善。 对于某些人，尤其是女性为何会患
上类风湿关节炎，目前还没有定夺。不 过，吸烟、受感染和遗传因素，都被认 为是增加风险的原因。人体的免疫系 统的作用是保护我们免受外来入侵者 如细菌和病毒的伤害，同时也防止我 们自己的细胞不受控制地增长。当我 们的免疫系统失常，类风湿关节炎、系 统性红斑狼疮疾病等自体免疫病就可 能会发生，开始破坏我们的身体。 到目前为止，以上病症都无法被治 愈。服用葡糖胺、软骨素等营养补助品 并未被完全证实能够预防或治疗类风 湿关节炎，然而，控制以上复杂病症的 治疗方案已有显著的进展。 由于治疗通常是针对免疫系统来进 行的，患者需要密切监测任 何不良反 应，以确保取得正面的成果。如果痛楚 和僵硬的感觉，加上关节肿胀持续， 请向您的家庭医生或风湿病专科医生 求诊。 新加坡中央医院风湿免疫科顾问医生楊曉音
更年期带来的焦虑 更年期带来的焦虑与一般的焦虑到底有 什么不同？ 在围绝经期期间，女性的月经来潮情 况会有所改变，月经量可能会变少或增 多，频率也会变得没有规律或减少。在 这段期间，女性一般都会经历一些情
绪上的波动。这是因为荷尔蒙变化所引 起，尤其是雌激素（令女性“感觉良好” 的荷尔蒙）水平下降。 处于更年期的女性经常会出现显著 的生理症状，例如潮熱、盗汗、失眠等 等，加上心悸或紧张和焦虑。 其他年龄的女性的典型症状包括焦 虑，极 端 和持 续的担忧，精 神处于紧 绷的状态，并伴随其他生理症状，例如 心悸、气喘、眩晕、震颤、肌肉痉挛和头 痛。这些症状可能是持续性、阵发性或 针对具体情况而发生的，也可能定期重 复爆发，形成恐慌症。 荷尔蒙变化不大可能是焦虑的主要 原因，但某些患者曾反映她们的焦虑情 况往往会在月经来潮前恶化。 竹脚妇幼医院心理医学部门主任及高级顾问 医生陳瑜
配 戴隐 形眼镜 是否有 期限? 我在过去20多年来都经常配戴隐形眼 镜，但在两年前，我转用日抛型隐形眼 镜，因为我感到眼睛不适，甚至引起眼 睛抽搐。配镜师说我的眼睛里积聚了不 少蛋白质。最近，即使是在配戴日抛型 隐形眼镜时，我还是常在下午开始感到 眼里有砂粒。请问配戴隐形眼镜是否有 期限吗？我是否应该使用洗眼剂？
如果您因为配戴隐形眼镜而感到不适， 您必须让您的配镜师为您检查眼睛。 如果您已配戴隐形眼镜多年，您可能已 患上一种称为巨乳头性结膜炎的过敏 症。这是一种与配戴隐形眼镜相关的 慢性眼部过敏症。 如果您患上过敏症，配戴日抛型隐 形眼镜是适当的做法，因为这样镜片上 就不会积聚蛋白质。然而，即使配戴日 抛型隐形眼镜，病症也可能不会完全解 决。如果您持续感到不适，您就应该停 止配戴隐形眼镜一段时间，例如六个星 期，好让眼睛恢复健康。 您的情况并没有必要使用洗眼剂， 因为眼睛会自然产生眼泪。即使您在配 戴隐形眼镜时没有出现任何问题，您也 必须定期接受配镜师的眼睛检查。 新加坡全国眼科中心眼角膜和眼表疾病高级 顾问医生林俐
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2014 年11– 12月刊 ADVERTORIAL