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01-07-08 News-Aquapheresis+Vascular V4 WF path.indd 1
15/8/12 4:00 PM
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02 News-Door-to-Balloon V4 WF path.indd 2
15/8/12 5:04 PM
SEp⁄ OCT 2012
singapore h e alth
A President’s Award nurse may be caring for you Two of the three nurses who received this year’s President’s Award for Nurses are from SingHealth To most of us, green tea is a healthy and refreshing beverage. To Ms Lian Siew Bee, it is much more – it is an alternative to the antibiotic powder wash that is used to clean the infected tumour wounds of cancer patients. An Advanced Practice Nurse and the Assistant Director of Nursing at Singapore General Hospital (SGH) Ms Lian, 42, led a team of researchers to discover this novel use of green tea. This is just one of the many projects that Ms Lian, an oncology-trained nurse, has helmed to improve the care of cancer patients. Although she feels oncology is where she can make her biggest contribution, her efforts extend even further. She conducts induction programmes for new nurses at SGH, guides colleagues who visit discharged patients at home, volunteers in palliative nursing and has even joined a project to establish a Palliative Care Unit in Hanoi. In recognition of her outstanding dedication, she was one of three nurses who received the President’s Award for Nurses this year. The other SingHealth nurse was Ms Teresa Ng Ruey Pyng, 44, Senior Nurse Clinician at the breast
department of KK Women’s & Children’s Hospital (KKH). Also receiving the award was Ms Poh Chee Lien, 37, Senior Nurse Educator at the Nursing Training Department of the Institute of Mental Health (IMH). They were picked by a panel comprising the chairman of the Government Parliamentary Committee for Health, the Chief Nursing Officer and board members of public institutions. All three recipients received a trophy and a certificate from President Tony Tan Keng Yam at the Istana, as well as $6,000 for their professional and personal development. Ms Ng, also an oncology nurse, may already have a development project in mind: She hopes to extend a training programme, which she set up for breast cancer nursing at KKH, to the region. A passionate advocate of breast cancer awareness, Ms Ng has been involved in many efforts to improve the care of breast cancer patients. She established KKH’s Alpine Blossoms Breast Cancer Support Group and founded the Blossom Buddy programme to train volunteer breast cancer survivors to counsel newly diagnosed patients. She strongly believes in the holistic
From left: Mr Gan Kim Yong, Minister for Health; Ms Poh Chee Lien from IMH; Ms Lian Siew Bee from SGH; President Tony Tan Keng Yam and his wife Mrs Mary Tan; Ms Teresa Ng Ruey Pyng from KKH and Ms Pauline Tan, Chief Nursing Officer, Ministry of Health, at the President’s Award for Nurses celebration at the Istana.
care of patients. Her inability, when she was younger, to nurse her father, who had liver cancer, convinced her of the importance of helping patients and their
Singapore Health wins silver at international awards years old, Cherie was technically dead, but a team of National Heart Centre Singapore (NHCS) doctors refused to give up and fought heroically to revive her. They did, and the story of the young girl’s near-death experience made it to the cover of the Jul/Aug 2011 edition of Singapore Health. The news of Cherie’s miraculous recovery, and the dogged perseverance of the NHCS doctors and medical team, struck a chord with many readers and contributed
Tensoval TO YOUR HEAR T duo control . Simply mo re secure. ®
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to Singapore Health winning Silver for Best Overall Editorial at the Magnum Opus Awards for the second year running. A US-based accolade that honours excellence in editorial and design in custom publishing, the Magnum Opus Awards drew more than 500 entries this year. Singapore Health is designed to offer readers an informative mix of hard and soft news. Published for Singapore General Hospital (SGH) and the SingHealth Group by SPH Magazines, Singapore Health is available every two months at SingHealth’s three hospitals, five national specialty centres, polyclinics and selected MRT stations. Content advisor Mrs Tan-Huang Shuo Mei, Group Director, Communications and Service Quality, SingHealth and SGH, said: “We are thrilled with our win. Our team is committed to producing and delivering a quality healthcare publication with interesting and relevant content to our readers.”
PHOTO: ALvinn Lim
Late in 2010, Cherie Lim’s heart stopped for 45 minutes. Then 15
families come to terms with serious illnesses. What she finds most heartening is when patients recover and come back to help other patients.
Can you guess what this is? See page 26 for the answer.
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singapore he alth
Sep⁄ OCT 2012
Shorter, sharper scan for prostate cancer A new imaging technique makes use of a substance to locate prostate cancer cells, producing highly accurate results that help doctors design the best treatment regime for a patient BY Teh Joo Lin
A patient lies down inside a high-tech positron emission tomography (PET) scanner. He is given an injection of a clear liquid, a type of chemical substance that seeks out the areas in his body that may be cancerous. Known as radiotracers, these chemical substances circulate through the patient’s blood vessels and target tissues with abnormal metabolic behaviour. For prostate cancer, the radiotracer used is 18F-Fluorocholine (FCH), which accumulates more avidly in the abnormal cells. The scanner picks up the radioactive signals from FCH, which show up as colourful images on a computer monitor. The imaging, which takes just 30 minutes, will reveal just how bad – or not so bad – the situation is. This new imaging technique – called the FCH PET/CT – breaks new ground because it is capable of delivering scans with very high levels of accuracy, helping doctors assess whether a patient’s prostate cancer is still confined to the prostate, or if the cancer cells have spread to other organs.
Cancer spots This picture shows the CT (images on the left) and FCH PET/CT (images on the right) scans of the abdominal/pelvic area of a 65-year-old Chinese man who has undergone surgery for prostate cancer. The 18F-Fluorocholine (FCH) PET/CT scans highlight clearly the
Dr Anthony Goh, Senior Consultant and Head, Department of Nuclear Medicine and PET, Singapore General Hospital (SGH), described the imaging technique as “a valuable addition to the currently available tests in the care of patients with prostate cancer”. “No scan is perfect, and much depends also on good clinical judgement,” said Dr Goh.
(The FCH PET/CT scan) is a valuable addition to the currently available tests. Dr anthony goh, senior consultant and head, department of nuclear medicine and pet, singapore general hospital
Most patients will undergo surgery to remove the primary tumours. In the subsequent monitoring of these patients, they may undergo other tests such as the prostate-specific antigen blood test, magnetic resonance imaging (MRI), computed tomography (CT) and bone scans.
presence of cancer spots. The arrows point to lymph nodes. The FCH PET/CT scan uses a substance called choline to detect prostate cancer cells, which absorb choline in order to multiply. Choline is chemically tagged to the radioactive 18F to produce FCH. The scanner maps the areas where choline accumulates and possibly pinpoints prostate cancer spots.
Bone scans are highly effective in finding cancer hot spots in the bones, but conventional scans have not been as useful in tracing the spread of cancer to the lymph nodes. Conventional imaging techniques include CT, a kind of x-ray that provides 3-D images of internal organs and glands; and MRI, which uses a magnetic field and radio waves to obtain pictures of body structures. MRI images show a clearer contrast between the different kinds of soft tissue than do x-rays, which perform a better job of showing the contrast between soft tissue and bone, for instance. FCH PET/CT imaging, which combines both CT and PET scans, is more sensitive to cancer spots that are microscopic in size, making it helpful when doctors are concerned about the early spread of the disease. Key to this technique is choline – a substance that is produced naturally in the liver and which is chemically tagged to the radioactive 18F to produce FCH. Prostate cancer cells have been found to absorb choline in order to multiply and studies have found that in prostate cancer cells, the rate of accumulation is even more significant. Choline accumulation has also been observed in breast, liver and some brain tumours. The PET/CT scanner maps the areas where choline accumulates in the body, possibly pinpointing the organs that may contain prostate cancer cells. This scan, already used widely in Europe, was launched as a new service at SGH in August 2011, after doctors evaluated it in a pilot trial of 21 patients in 2010. Since the service was introduced, some 50 patients have used the technique. The procedure costs about $2,600 for Singaporeans and $3,000 for foreigners. Prostate cancer is the third most common cancer among Singapore men, and four in every 100 prostate cancer patients die from the disease, which can spread to the bones as well as the lymph nodes, an essential part of the immune system. The prostate – a gland found below the bladder in men – helps to control urine flow and produces fluids that are found in semen. The prostate is prone to cancer, with more than 500 new cases diagnosed every year. Men as young as their early 40s can get the disease, although prostate cancer mostly shows up in men over 70 years of age.
Diagnosing prostate cancer It’s not clear what causes prostate cancer, but men who are over 55 years old, eat a diet rich in animal fat and red meat or have a family history of the disease, appear to be more likely to develop the condition. But, at the same time, most men who fit this profile never develop prostate cancer. Patients with this cancer may or may not have any symptoms, but some of the common symptoms include urinary problems, difficulty having an erection, frequent lower back, hips or upper thigh pain, or blood in the urine or semen. When prostate cancer is suspected, doctors rely on a few methods to diagnose the disease, including: Digital rectal examination, where the doctor uses his finger to feel the surface of the prostate gland. The tissue could be malignant if it is firm and feels hard to the touch. Blood test, which allows the doctor to review the level of a substance called the prostatespecific antigen. An elevated reading indicates prostate cancer. Biopsy, where some tissue is drawn from the prostate gland and inspected under a microscope. The sample is histologically graded, or assessed, to determine the aggressiveness of the tumour. Imaging techniques help doctors determine the extent and spread of the disease (known as cancer staging process). The techniques include: Bone scan, where a small amount of radioactive material is injected into the body, so cancerous areas of the bones can show up. Computed tomography (CT), a kind of x-ray scan that provides 3-D images of internal organs and glands. Magnetic resonance imaging scans, which use a magnetic field and radio waves to make pictures of body structures. 18F-Fluorocholine PET/CT, which combines the CT and positron emission tomography (PET) scans. The new scan uses radioactively tagged agents – choline in the case of prostate cancer – to observe the activities of organs and tissues. Doctors decide on the treatment after evaluating the seriousness of the prostate cancer.
singapore h e alth
News > Continued from page 1
The diabetic foot
A tiny cut that saves life and limb
Warning signs Diabetics who start to experience muscle cramps after walking a short distance should take heed and seek treatment. It could be an early sign of peripheral vascular disease, a condition which can lead to blocked arteries, ulcers, gangrene and even death. “At this stage, patients should see a doctor because there are treatments available. If they wait until they sustain an injury, more invasive treatment may be required,” said Dr Benjamin Chua, Consultant,
With a little extra care, a diabetic patient need not lose his limbs or toes
Staying in good health Control your blood sugar levels Be mindful of your diet and eat less if you are overweight
PHOTOS: ALECIA NEO (BELOW); SPH LIBRARY (RIGHT)
Dr Benjamin Chua, Consultant, Department of General Surgery, performed surgery on Mr Ang to open the blood vessels of his leg, so oxygen and medication could flow through, treating and nourishing the wounded area. Dr Chua said: “Our goal is very simple: We want to improve the blood flow for a wound to heal, so the patient’s quality of life can be restored.” About a decade ago, surgeons started to perform a minimally invasive angioplasty procedure to widen narrowed vessels or unclog blockages in the leg. Using x-rays to help them perform the surgery, doctors would guide balloon catheters through the blood vessels to unclog the blocked vessel. The targeted keyhole procedure didn’t require the patient to be put under general anaesthesia, making it suitable for patients who were old or unfit. More recent ly, a r e f i ne d ve r sion o f the procedure, known as retrograde angioplasty, came into practice. The balloon is fed through a puncture in the foot and guided up the body, towards the blockage, to open the blood vessel, unlike previously where the puncture was made in the groin and the balloon fed downwards to the blockage. The angioplasty balloons used currently are small enough to open even a 1mm blood vessel. The balloons can also deliver drugs that prevent the blood vessel from narrowing again. In some cases, wire-mesh tubes, known as stents, are placed at the site of the blockage to keep the blood vessel open. The stents can also contain drugs that are slowly released. “Thanks to these advances, we’re now able to target smaller and smaller vessels and keep them open longer. If we can get to the patients early enough, major amputations can be avoided,” said Dr Chua. Patients suffering from diabetes are susceptible to peripheral vascular disease, in which arteries supplying blood to
Wash and moisturise your feet at least twice daily to prevent cracks that present openings for bacterial infections Check feet for cuts, injuries or pressure ulcers daily
Preventing injuries Wear a good comfortable pair of slippers at home, preferably with padding During vascular surgery, surgeons like Dr Benjamin Chua (above, centre) guide tiny balloon catheters through blood vessels to unclog blockages. This keyhole procedure doesn’t require general anaesthesia and is suitable for patients like Mr Ang Sin Yong (left) who aren’t fit.
the lower limbs gradually narrow and, in very bad cases, get completely blocked off. Mr Ang, for instance, had to retire early from his job as a safety coordinator of a construction firm because of the pain he felt when walking. It got progressively worse, to the point where he had to rest every few steps. Up to about a third of all diabetic patients are prone to peripheral vascular disease. Some get it because of long-standing diabetes, but most get it because their disease isn’t properly controlled. The narrowing of the arteries can occur in other parts of the body. In the heart, it leads to complications like heart attack; in the brain, it causes strokes; and in the kidneys, it can result in kidney failure. “Due to peripheral vascular disease, there is inadequate blood supply to promote healing. So, even a stubbed toe or a small wound can become very serious
because it doesn’t heal and may get infected,” said Dr Chua. “Sometimes, it progresses to ulcers with infection or, in very bad cases, there is tissue death and the toes become black or gangrenous.” So far, the results with angioplasty have been positive – the blood vessels of 80 per cent of patients who undergo angioplasty of the leg at SGH remain open one year after treatment and, after two years, the figure is 70 per cent. In the few cases where the patient’s vessels narrow once more, angioplasty can be performed again. Before the procedure was introduced, 80 per cent of amputations done in Singapore were diabetes related, compared with less than 20 per cent currently. Mr Ang has recovered well, though another hip injury is keeping him at home. He can move about with a walker and hopes to return to work after he recovers. “I was really fortunate. With the help of Dr Chua, I lost only a toe rather than a whole foot or half a leg,” he said.
Department of General Surgery, Singapore General Hospital. Medication like aspirin can help in the early stages and patients are encouraged to continue walking a little further each time they have a cramp. This helps to open up newer, smaller blood vessels that can take over the job of transporting blood to parts of the body. While such preventive measures work for most patients, they won’t for about a third of them. This smaller group of patients will need procedures like angioplasty. If gangrene or ulcers are already
present, the damaged tissue is removed first. This sometimes involves the amputation of one or a few toes. In Mr Ang Sin Yong’s case, his big toe was removed because gangrene had started to set in. He then underwent angioplasty to improve his blood flow and facilitate healing of the wound. Keeping blood sugar levels under control, not smoking and living a healthy lifestyle are some ways that can help diabetics lower the risk of developing peripheral vascular disease.
Wear good protective footwear when going out , for example, covered shoes See a podiatrist if you have corns or calluses
Wound management at SGH Diabetic patients need to pay attention when they sustain an injury, as wounds can take longer to heal. At Singapore General Hospital, a wound specialist nurse may have to step in to treat a badly infected wound by using: Vacuum suction to suck on a wound to encourage growth of healthy tissues Maggots to remove the infected part of the wound Special dressings or gels, along with suitable antibiotics In cases with very big wounds, a plastic surgeon’s expertise is sought.
singapore he alth
SEP⁄ OCT 2012
News > Continued from page 1
New therapy for excess fluid
What causes the fluid overload A few years before she underwent aquapheresis, Mdm Chinnamah had been diagnosed with congestive heart failure. This meant her heart was no longer able to pump enough oxygen-rich blood to meet the needs of her body. That led to water retention (in her body) or fluid overload.
Heart failure patients will, at some point, experience one or two acute episodes of fluid retention. Some of them tend to come back to hospital with fluid retention, despite taking medicines and making lifestyle changes. dr david sim, consultant and codirector, heart failure programme, department of cardiology, national heart centre singapore
“Heart failure patients will, at some point, experience one or two acute episodes of fluid retention. Some of them recover quite well and only need medication to manage their symptoms after that. Others, however, tend to come back to the hospital with fluid retention despite taking medicines and making lifestyle changes,” said Dr David Sim, Consultant and Co-Director, Heart Failure Programme, Department of Cardiology, NHCS. Heart failure is a top cause of cardiac admissions with about 5,000 cases annually in Singapore. NHCS sees about 1,000 such cases a year, and more than 90 per cent of them are hospitalised for fluid overload. Patients with fluid overload typically experience breathlessness especially
About 20 to 30 per cent of patients with fluid retention are diuretic resistant, which means their kidneys do not respond to diuretics. This commonly occurs in patients with moderate to severe heart failure. The only option open to them until now was to undergo dialysis to remove the fluid. With Mdm Chinnamah, diuretic resistance was not the problem. She had an allergy to almost all diuretic drugs, which left dialysis as the only solution, if not for aquapheresis. PHOTO: ALECIA NEO
Because aquapheresis helps to relieve symptoms such as weight gain, swelling in the legs, arms and abdomen, breathlessness and fatigue, patients also benefit from reduced re-admissions, shortened hospital stays and fewer unscheduled clinic and emergency room visits. The aquapheresis machine can run from eight to 72 hours, but most patients only require a 12- to 15-hour session, depending on the severity of their condition. In Mdm Chinnamah’s case, after 12 hours, doctors removed two litres of excess fluid. She stayed in hospital for two days for the procedure. “They put a small catheter into a blood vessel in my neck, but it was not painful. I could see results within the first few hours. By the time the procedure ended, my swollen legs had returned to normal,” she said.
Mdm Chinnamah was diagnosed with congestive heart failure, which led to water retention in her body. The excess fluid was removed through aquapheresis.
when lying flat, and have swelling in their legs, scrotum and abdomen. They also suffer from abdominal discomfort. Mr Soh’s case Taxi driver Mr Soh Teow Cheng, 59, also underwent aquapheresis. Like Mdm Chinnamah, he suffered from breathlessness and fluid retention. But the swelling was in his abdomen, legs and feet. “I couldn’t walk and would feel breathless after covering a distance of less than 10m. The swelling in my abdomen was so bad, I looked like I was 10 months pregnant,” he said. He too had congestive heart failure. Nine years earlier he had been diagnosed with cancer, and the chemotherapy he underwent damaged his heart muscle, resulting in heart failure. Mr Soh was put on a low-salt, low-fluid diet and treated with diuretic drugs or “water pills”, which induce production of more urine. But he did not respond to this conventional treatment. High doses and injectable forms of the diuretics failed to drain the excess fluid in his body, too. He had what is known as diuretic resistance.
Catching fluid retention early Fluid overload can be caused by disorders of the heart, liver or kidneys. It is important for patients with these conditions to look out for symptoms. If left untreated, the condition can become fatal
Symptoms to look out for: Experiencing more breathlessness than usual
The doctors put a small catheter into a blood vessel in my neck but it was not painful. I could see results within the first few hours. By the time the procedure ended, my swollen legs had returned to normal. mdm chinnamah vellasamy
“Although dialysis is very effective in removing excess fluid, it has its limitations. It can only be done in the Intensive Care Unit and patients need a few sessions before they can be slowly weaned off the machine,” said Dr Sim. With aquapheresis, only a single session is needed and it can be done in the wards. Mr Soh went through one such session in November 2011 and shed 12 litres of excess fluid. Along with the fluid, he lost 8.8kg in weight. However, aquapheresis cannot be used for all patients. Those with advanced renal impairment, or very low blood pressure, are unsuitable for it. Those who are allergic to heparin (a blood thinner that
Finger pressure applied on the legs leaves a depression on the skin Gaining more than 2kg in weight within two days
is used during the ultra-filtration process) should also not undergo aquapheresis. Happy endings These days, Mr Soh is a much happier person. He feels a lot lighter and has returned to his usual routine. “I no longer suffer from breathlessness. I can walk so much better, too, and am able to continue working as a taxi driver. I feel very healthy now,” he shared. Mdm Chinnamah, too, is able to walk without having to stop and rest. Although she no longer takes care of her grandchildren as her doctor has advised her to take it easy, she enjoys their company during the school holidays. She intends to take on a part-time job soon to keep herself occupied, but has come to realise that her health is important too. She is aware that the more severe her heart failure, the higher the likelihood that fluid will re-accumulate in her legs. So, she takes her medication regularly. “I also have to watch my fluid intake,” she said. “I can’t take more than one litre a day.”
Dialysis versus aquapheresis For a small group of patients who are resistant or allergic to diuretics, the only options are conventional dialysis or aquapheresis. Here are the differences between the two therapies:
Where it can be done
Intensive Care Unit
Large, so may cause bleeding or bruising at puncture site
Small, so less damage caused during insertion
Amount of extracorporeal blood (blood drawn outside the body)
At any point, about 100ml to 300ml of blood is extracorporeal, so patients may experience low blood pressure
A maximum of 33ml of blood is extracorporeal, so there is no concern about causing low blood pressure
Number of sessions
A few sessions required
Completed in a single session
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15/8/12 4:12 PM
singapore he alth
SEp⁄ OCT 2012
Can Parkinson’s Disease be predicted? Very early signs of the condition have been found, which may greatly boost chances of treating it
Parkinson’s Disease (PD) is the second most common neuro-degenerative disease after Alzheimer’s and currently has no cure. Patients cannot coordinate their movements, find it difficult to walk and balance, and have stiffness and shakiness in their limbs. In advanced stages of PD, the patients have problems swallowing food and may experience hallucinations.
BY Koh Joh Ting
A hushed silence fell on the crowded conference room as the image of a Caucasian man, sleeping in a hospital bed, was shown on the screen. Fast asleep, the man groaned and made jerky movements with one hand, as if fending off an attacking animal. Then, he stopped and started singing in a slurred voice, but with great gusto – to the amusement of the audience. “He’s singing a Mexican song!” Professor Eduardo Tolosa said light-heartedly in his talk “Can We Predict Who Will Get Parkinson’s Disease?” at the 5th Singapore International Parkinson’s Disease and Movement Disorders Symposium at the National Neuroscience Institute. Prof Tolosa is a neurologist from the University of Barcelona in Catalunya, Spain, and a world expert on Parkinson’s Disease (PD). A new way to look at the disease He said the man in the video has a sleep disorder called Rapid Eye Movement Behaviour Disorder (RBD). This is the loss of muscle control during deep sleep and is one of the very early symptoms of Parkinson’s Disease (PD), showing up long before more obvious motor symptoms like tremors and mobility issues.
A person suffering from RBD may appear to be having a nightmare.
PHOTO: GETTY IMAGES
A vaccine in the future?
The loss of smell can be one of the early symptoms of Parkinson’s Disease.
RBD, due to neurological changes, makes the man more prone to PD later in life. PD patients slowly lose brain cells that create dopamine, a chemical that affects emotion, perception and movement. These changes can start years before motor symptoms appear and a diagnosis is made. He presented data which showed that death in these cells starts five to 13 years before tremors happen. A signature symptom A person with RBD appears to be having a nightmare, making loud noises and jerky movements while in deep sleep. The movements can be of varying intensity and the sufferer can hurt himself or the person next to him. “The patient usually dreams of being attacked or chased by strangers or wild
NNI’s study on Parkinson’s Disease Can Parkinson’s Disease (PD) be predicted? Commenting on the topic, Associate Professor Louis Tan, Senior Consultant, Department of Neurology, National Neuroscience Institute (NNI), said: “This is an exciting topic being researched around the world.” He said NNI is conducting its own research on PD in Singapore and is involved in ongoing studies in collaboration with the Singapore Chinese Health Study. This is a long-term study of 60,000 elderly Chinese. The aim is to determine what health and lifestyle factors may
What is Parkinson’s Disease?
predict or modify the risk of them developing PD. He said this is an ongoing study and some additional results are expected at the end of this year or early next year. On predicting PD, he added: “The main goal is to develop drugs and agents that can delay or prevent the onset of PD in people who are at a higher risk of developing it. “However, we need to first define these individuals who are at risk, based on genetic and/or clinical factors.”
animals, arguing with somebody or falling down,” said Prof Tolosa. “The dreams occur every one to two hours, can last for several minutes and usually happen between 12 and 30 years before PD is diagnosed.” He added that doctors have documented cases in which people had unpleasant dreams and RBD 10 years and, in extreme cases, 50 years prior to getting PD. “The risk of developing PD rises dramatically for those who have a longer history of RBD,” he said. Other early signs Another significant early symptom is the loss of smell. Prof Tolosa said that between 70 and 90 patients interviewed remembered losing their sense of smell, on average, five years before they were diagnosed with PD. This loss of smell correlates with changes in the olfactory bulb, located just above the eyes, under the frontal lobes. “This early symptom is like a canary in a coal mine, which can warn us of further brain changes down the road,” he said. Other symptoms include constipation, erectile dysfunction, depression and cardiac abnormalities. Taken as a whole Prof Tolosa said recent research has shifted from motor to pre-motor symptoms, to find ways to predict and delay the effects of the disease. Doctors can view pre-motor symptoms as evidence of an accelerated loss of neurological brain function. He said: “Nowadays, we diagnose PD only when a patient has mobility issues. To detect it early, we should look at the pre-symptomatic phase too. The goal is
Researchers are now studying alphasynuclein – an abnormal protein present in the brains of PD patients. The protein spreads from one cell to another, causing neurons to malfunction. Scans can track the protein in live subjects, a breakthrough Professor Eduardo Tolosa, a neurologist from the University of Barcelona, believes will lead to a vaccine to keep neurons safe from synuclein. It is not known how much synuclein has to be in the brain before PD is diagnosed, but a mutation in the synuclein gene shows PD can run in families. It was not previously deemed hereditary. “This is very exciting,” said Prof Tolosa. “As the pre-motor phase is a matter of years, we have a big therapeutic window during which we can use neuro-protective drugs that are being developed now. “If you have been suffering from RBD for years, we won’t just give you an anticonvulsant to stop the flailing movements. We will also help delay the onset of PD, by delaying the death of brain neurons as much as possible.”
not just to treat, but also to prevent, delay or even eliminate PD.” He advised doctors to consider the combination of risk factors, including genetics. “If your father had PD and you are losing your sense of smell, and have abnormal sleep movements and constipation, you may be prone to PD,” he said. Currently, there are no definitive diagnostic criteria, but Prof Tolosa said it is important to develop them, as pre-motor symptoms alone are not a reliable diagnosis of PD, as they could also be signs of other conditions. For clear diagnostic criteria, studies on high-risk populations, such as the relatives of PD patients, and advances in imaging are needed. “It is imperative for diagnostic tools to be developed to give PD patients a better chance,” he said.
singapore h e alth
It’s not the flu, it’s cancer
Potential new treatment
Natural-killer/T-cell lymphoma is an aggressive cancer that mimics the symptoms of influenza and must be diagnosed early for successful treatment
Mr Lau Wei Ming went, in a matter of weeks, from being strong enough to have multiple wisdom teeth extracted to being diagnosed with Natural-killer/T-cell Lymphoma (NKTCL) – an aggressive cancer that can wreak havoc in a matter of months if not treated. A week after his extractions, his left nostril became runny and a big reddish lump developed on the left side of his neck. “I thought it was just a runny nose,” he said. He saw a general practitioner (GP) who suspected a saliva infection and prescribed antibiotics. But that did not work, so he took the advice of another GP and went to hospital for treatment. There, specialists from the Ear, Nose and Throat (ENT) department did thorough checks and took a biopsy of his left nostril. “A week later, the doctor told me I had cancer. It was Stage 2 NKTCL. I was very shocked. I couldn’t accept it,” said the 35year-old senior technician, who has two children in primary school. Mr Lau was referred to the National Cancer Centre Singapore (NCCS), where doctors wanted to ward him immediately, but he refused as he wanted a second opinion. Another biopsy confirmed his diagnosis. What is NKTCL? Explaining the illness, Dr Kevin Tay, Consultant, Department of Medical Oncology, NCCS, said the immune system has many kinds of immune cells which protect and
Mr Lau Wei Ming (above) had aggressive lymphoma, which responded well to a new type of chemotherapy. Dr Kevin Tay (right, with tie) with patient Mr Chang Wai Man, who initially mistook his symptoms as signs that his body was too “heaty”.
help the body fight against viruses and bacteria. Natural-killers/T-cells are among them. NKTCL happens when Natural-killer/ T-cells in the immune system become cancerous. The cause is thought to be the Epstein Barr virus, which is common in South-east Asia, making the incidence of the cancer higher in Asians than Caucasians. In Singapore, the NCCS sees about 10 to 20 cases a year.
It’s like a persistent flu that doesn’t go away. It might even get worse, with severe symptoms such as bleeding from the nose and significant weight loss over a period of time. Dr Kevin Tay, Consultant, Department of Medical Oncology, National Cancer Centre Singapore, explaining symptoms of the disease
Dr Tay said that in the early stages, the cancer occurs in the nose area, leading to symptoms such as a runny nose, nasal blockage and fever – similar to flu symptoms, except that they do not respond to antibiotics. “It’s like a persistent flu that doesn’t go away. It might even get worse, with severe symptoms such as bleeding from the nose and significant weight loss over a period of time.”
In the early stages, the disease can be treated successfully with chemotherapy and radiation. But in the advanced stages, because of its aggressive nature and rapid progression, it can be lethal. Dr Tay said this lymphoma usually affects those 65 years old and above. “This is because as we age, our immune system is more likely to fail, predisposing us towards lymphoma.” However, a small number of younger patients, such as Mr Lau, who have a genetic predisposition, can also be affected and they often get the more aggressive form, which no amount of immunity boosting can prevent. The older patient Retiree Mr Chang Wai Man, 65, was diagnosed with malignant lymphoma in 1980, but regular treatment and check-ups at NCCS and Singapore General Hospital’s ENT department kept him healthy for more than 30 years. But in July last year, one of his nostrils got blocked with persistent discharge and occasional bleeding. “I had no pain, fever or cold, but my mouth was very dry and I drank a lot of water. I thought my body was too ‘heaty’, so I tried taking Chinese medicine,” said Mr Chang, who has three children and one grandchild. As he had an appointment with an ENT doctor in September, he waited until then to consult the specialist. After various tests, including a biopsy, he was told he had NKTCL and was referred to NCCS.
For Mr Lau, though, the treatment included something new. His doctors suggested a new chemotherapy regimen GIFOX-Velcade. He opted for it and the lump on his neck subsided the next day after his first chemotherapy session. Both patients had strong family support. Mr Chang’s family encouraged him by reminding him of his successful treatment in 1980. They told him that, since he managed to pull through before, he could do it again. Mr Lau stayed positive for himself and others. He related an encounter he had with a fellow patient who felt like giving up. “I talked to him about positive things. The next day, he thanked me and told me he wouldn’t give up on his treatment. I was very happy when I saw him recover. His family was overjoyed as well and thanked me for my support.”
Treatment and family support Both Mr Chang and Mr Lau underwent chemotherapy and radiotherapy. According to Dr Tay, patients in the early stages usually go through chemotherapy for two to three months, followed by radiotherapy for two months.
PHOTOS: Alvinn Lim
By Sol E Solomon
Researchers in Singapore have found gene mutations associated with Natural-killer/T-cell Lymphoma (NKTCL), paving the way for a potential new treatment. The researchers from the National Cancer Centre Singapore (NCCS) and Duke-NUS Graduate Medical School Singapore found mutations in a gene called Janus Kinase 3 (JAK3) in the tumour cells of 35 per cent of the patients they tested. Normal cells do not have this mutation. The discovery creates the possibility of developing an inhibitor for targeted chemotherapy, said Dr Kevin Tay, Consultant, Department of Medical Oncology, NCCS, who is among the 20 or so people involved in the study. The inhibitor would target only tumour cells with JAK3 because it recognises that only Natural-killer tumour cells have this mutation. Scientists here are now planning clinical trials. It will take a few months to a year to get them running and to recruit patients, said Dr Tay. The trials will probably run for two years and also include Stage 4 NKTCL patients.
Catch it early Although NKTCL is an aggressive form of lymphoma which can manifest and spread very quickly in weeks or months, the rate of cure is relatively good if the condition is diagnosed early. The fiveyear survival rate in Singapore for Stage 1 NKTCL is about 70 per cent, said Dr Tay. He added: “A delay in seeing the doctor can allow the cancer to advance undetected. “There are times when the tumour is simply more aggressive. Always be mindful of symptoms that just don’t go away – you should have them investigated.”
SEP⁄ OCT 2012
Where to get plasma drops? I found the article Plasma to the Rescue in Singapore Health (Jul/Aug 2012) – about eye drops for dry eyes made from a patient’s plasma – very informative. I have dry eyes and was wondering if you could let me know how to get the eye drops and how much they cost? - Mr Terence Tay
The plasma eye drops were used in a clinical trial and were specifically made for the participants. We have had positive
responses in this trial, so we are working on ways to make it more widely available to others with dry-eye problems. We are currently collaborating with other organisations to facilitate this process and work out the cost. This letter wins one bottle of Ultra C-Complex Rose Hips, Acerola, Rasberry & Citrus Bioflavonoids Veggie Capsules and one bottle of Ultra Calcium Plus Vitamin D, Mag & Zinc Dairy Free Veggie Capsules. The products, worth a total of $102.72, are from our sponsor United Pharma.
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 email@example.com or The Editor, Singapore Health, Singapore General Hospital, Communications Department, Outram Road, Singapore 169608, or talk to us on Facebook.
The winner will receive four bottles of Genacol 30 Capsules (exclusive Bioactive Collagen Matrix) and two bottles of Genacol Instant Gel (30ml). The products, worth a total of $112, are sponsored by Medica Solutions Pte Ltd.
Singapore General Hospital Singapore General Hospital shared a link. July 15 Something to ponder as you are planning what to have for lunch or dinner on weekends. Western-style fast food can increase risk of diabetes: Study www.straitstimes.com Eating Western-style fast food can increase one’s risk of developing diabetes and dying from heart disease, a local study has found.
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Mona Chew Life is too short, you can treat yourself and your kids to beef burgers (double/triple deck) once in a while. I’m thinking of a New York family burger as I write. It tastes so good. But remember it’s just a treat and self-control is needed to avoid the unhealthy overindulgence. Why not try an alternative such as a vegetable burger? You may just like it. July 16 at 8.55pm · Like · Unlike 2
Medical appointment repeatedly delayed I was due to see one of your specialists for a six-monthly review on March 15. But I received a letter on March 1 informing me that the appointment had to be postponed to March 30 because the doctor was scheduled to attend an overseas conference. On March 10, I received another letter that the appointment had to be moved to April 10 instead. Why was my appointment repeatedly changed? We apologise for causing you inconvenience by changing your appointment. Sometimes, we need to rearrange an appointment usually made months in advance when the doctor is ill, unable to work, has to attend a conference, is on leave or has resigned. In the event of a resignation, the new doctor assigned to the patient may ask for a later consultation date to give himself time to review the case. If an appointment has been postponed twice, the doctor will be notified and he will try and review the patient as soon as possible. If that isn’t possible, he may ask another doctor to see the patient or arrange for an additional clinic session. If an appointment has to be rescheduled at short notice, usually within seven days of the appointment date, the hospital will call to inform the patient of the change and arrange for a new consultation date. Otherwise, the patient will be notified of the appointment change by post. SGH sends an SMS reminder to patients a week before their appointments. Should you need to change your appointment, please call 6321-4377 at least three days in advance. This will help us reassign another patient to your appointment slot. If the patient doesn’t have enough medication to last till the next appointment because of the change in appointment date, he can ask for a prescription top-up. The clinic staff will call when the prescription is ready for collection.
Bus timings don’t match those on website Why do the intervals of your shuttle service differ from the frequency indicated at your shuttle-bus stop and on your website? Our shuttle bus service is scheduled to operate every 15 minutes from Mondays to Fridays, and every half hour on Saturdays. However, these intervals, which are indicated on our website and at our shuttle-bus stop, are only an estimated guide. The actual frequency of services is usually dependent on factors such as traffic conditions, the weather and so on. We seek your understanding if these factors cause unexpected delays and for any inconvenience caused.
Tributes I want to thank Dr Cheng Heng Kok, Emeritus Consultant, Cardiology Service, Department of Paediatric Subspecialties, KK Women’s & Children’s Hospital, for her “heart work” caring for my heart all these years. When I was a child, I dreaded seeing doctors, but never Dr Cheng. She always asked me what I was doing. A few years ago, I told her I was doing counselling because I was inspired by many others, including her. From her, I learnt that besides medical knowledge and healing hands, you have to have a heart for people. Thank you Dr Cheng for being a wonderful doctor. In fact, you are more than a doctor to me – you are an inspiration! – R Chen
I wish to compliment Dr Victor Chao Tar Toong, Senior Consultant, Department of Cardiothoracic Surgery, National Heart Centre Singapore (NHCS), for his care and professionalism. He is a dedicated doctor, and was humble and patient when taking care of my mother, who had a heart bypass operation at NHCS. My family was concerned about her condition after the operation and, though we did not understand the medical terms, Dr Chao repeatedly explained her condition to us, and did so again when she was discharged. We are very pleased with his care and look forward to seeing a similar level of care by other doctors. – Ms Chan
I was recently warded in the Respect ward of Bright Vision Hospital and wish to thank the staff, including Joshua, Sufyan, Felicia and Corazon, for being helpful and attentive to me. They also helped other people in the ward patiently and wholeheartedly. I wish all of you a bright future. – KW Loh
During our trip to Singapore in mid-June, my wife suffered an arm injury at a restaurant and was sent to SGH at about 10pm. She was discharged a few hours later. We wish to thank your staff for their care, especially the doctor who attended to my wife and the young Chinese female doctor who helped us with a claim-related matter. Despite the accident, we had a good time in Singapore. Being a doctor is challenging, but I believe all of you can manage this well. Keep up the good work! – R Ho (from Hong Kong)
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Wellness Solution to myopia in children may be in sight
Good oral hygiene can cut risk of chronic diseases
Some kinds of chronic constipation can be treated
The right tune for therapy A music therapist uses singing and melody to help a pair of overly active twins get used to their newfound ability to hear clearly. By Sheralyn Tay
to chime in with their percussion instruments during breaks in the melody. “I like to sing Ode to Joy!” said Yumin with a big grin. “I have two favourite songs, Do Re Mi and Edelweiss!” added his brother. Five years ago, the twins could hear only intermittently because of a congenital condition called large vestibular aqueduct syndrome, in which one of the channels in the inner ear responsible for conducting sound is larger than normal. This makes hearing others seem like listening to an underwater conversation. “The twins were healthy babies and we were upset to learn shortly after their birth that they had a hearing disability,” said their mother, Mdm Michelle Ng, 36. Doctors told her that a cochlear implant could help with her sons’ hearing. When the twins were three years old, they underwent surgery. The boys received implants that allowed them – affectionately called Minmin and Kaikai – to hear clearly for the first time. But it took a while for them to make sense of new sounds. Children who have undergone cochlear implants have to learn “to not just hear, but also listen, make sense of sounds, differentiate between them and understand what they mean”, said Dr Patsy Tan, Music Therapist, Music and Creative Therapy Unit, Dr Patsy Tan (far right), joined by the twins’ mother Mdm Michelle Ng, uses music to help the boys focus on their lessons.
Eight-year-old twins Minmin and Kaikai enjoy their newfound ability to hear music and sounds clearly.
Allied Health Division, Singapore General Hospital (SGH). “Prior to therapy, the twins tended to keep to themselves because they could not communicate with others. And because they are twins, they have developed their own language, using gestures to communicate with each other,” said Dr Tan. The twins were also hyperactive and had difficulty keeping still for lessons or exercises. Music therapy proved useful in holding their attention. “If a young child has a physical developmental delay and cannot sit well, we might work together with a physiotherapist on his treatment,” said Dr Tan. “For example, we help make an activity less boring by inviting him to sit and play music.” Dr Tan is an accomplished musician, but she does not teach hearing-impaired children how to play instruments like the piano or guitar. Instead, music therapists support the work of other therapists. Most people respond positively to music. This allows a music therapist to quickly build rapport with a patient, which in turn can motivate the patient to participate
classes, I realised the sessions were helping them. They learnt to focus on the music, move to it and even express themselves through it.” The twins use music in their lessons. They sing out letters of the alphabet when spelling words, and the compositions they write are put to music. The boys also use these techniques at home to study and do their homework, said Mdm Ng. “The twins have caught up with other children in terms of learning and language skills. Despite the three-year delay in their learning, they are now doing well in a normal school. “Their teachers say they are very confident and love to participate in class and answer questions.”
more actively in exercises prescribed by his physiotherapist, for instance. A music therapist plays a particularly useful role when working with serious stroke patients, who may become depressed because of their illness. Music helps to lift the spirit and breaks the monotony of exercises designed to help them regain mobility and flexibility. Dr Tan said music therapy – which comprises singing, movement and melody – appears to “activate all parts of the brain”. She added: “Studies have shown that this can help rewire the brain and restore some functions. “A stroke patient may be unable to speak if the speech centre of the brain is affected, but they can use the right side of the brain to sing and express themselves. “In music therapy, we begin with singing, then wean the stroke patients off the melody. Gradually, they learn to talk again.” Similarly, music therapy has dramatically changed Minmin and Kaikai’s lives. “At first, they could not even talk, let alone sing,” said Mdm Ng. “But after a few
Hearing tests for newborn babies
PhotoS: VERNON WONG
As the piano tinkled out a sprightly tune, eight-year-old twins Niyu Yumin and Yukai – each holding a pair of castanets – listened intently and took turns
It is important for infants to be tested as early as possible for hearing loss as delayed detection and treatment can affect speech, language and psychosocial development, resulting in poor academic achievement. And parents can – and should – opt for their newborn babies to be screened under the Universal Newborn Hearing Screening programme, said Associate Professor Low Wong Kein, Senior Consultant, Department of Otolaryngology, Singapore General Hospital (SGH). In an earlier study, Assoc Prof Low – who is also Director, Centre for Hearing and Ear Implants, SGH – found that about four in 1,000 infants had hearing loss. “Of these, one in 1,000 had severe to profound loss,” he said. Under the screening programme, infants can be tested for hearing as early as two or three days after birth. If they fail the screening after a repeat test, the infants will be referred for more elaborate diagnostic hearing tests, he said.
singapore he alth
SEP⁄ OCT 2012
Hope on the horizon Myopia rates in children are falling, and eye drops to stop myopia from worsening show encouraging results. By Elsa Lim
I wear glasses, so I thought Ryan must have inherited our myopia,” she said. An eye check at KK Women’s and Children’s Hospital (KKH) confirmed that Ryan was, indeed, myopic. What was more worrying was that his myopia worsened every year, increasing by as much as 100 degrees every six months. At the age of seven, Ryan was wearing spectacles with 700-degree lenses, while most other children his age still had relatively good vision. Atropine trial The experience affected Ryan greatly. “I felt silly wearing specs,” he said. “I didn’t socialise much in kindergarten because I felt different from my classmates.” Now an active 12-year-old, Ryan loves to read, solve mathematical problems and play soccer. To prevent his eyesight from getting worse, Mdm Yeo has restricted the time he spends watching TV and playing computer games. She looked for other ways to curb the problem and eventually found an article about the Singapore National Eye Centre’s (SNEC) research on atropine, which promises to slow down the progression of myopia in children. SNEC was testing atropine and needed research subjects. Ryan met all the research criteria and was enrolled in the atropine trial in late 2006.
He had to apply the atropine eye drops nightly and go for an eye check-up every three months. Mdm Yeo carefully recorded every application of atropine, a routine that lasted five years, including a short break in the third year to observe the effects of the eye drops. “It was challenging, especially when Ryan’s eyes became extra sensitive to light because of the effects of atropine. But the dosage was gradually adjusted and he got used to it,” said Mdm Yeo. Though the progression of Ryan’s myopia varied throughout the trial, it started slowing down in the fourth year. He still wears glasses today, but his eyesight now deteriorates at a slower rate. “Before the programme, it was normal for my vision to become blurred every year. Now, I hardly experience any blurring,” he said. Another success story The atropine trial was conducted on about 400 children, including Nikhil Anggapan, now 15. His vision started to blur when he was nine. He was diagnosed with mild myopia of 150 degrees, which was attributed to his habit of reading in bed and playing video games.
Play outdoors more Children are being advised to play outdoors to reduce the risk of myopia. In Britain, researchers found that for each additional hour spent outside a week, the risk of myopia is cut by 2 per cent. This is apparently because of a greater exposure to natural light
and a greater amount of time spent looking at distant objects. A study on Chinese children in Singapore and Sydney found that 3 per cent of the Australian children have myopia, compared to 29 per cent of the children here. The Australian children spent an average of 14 hours a week outdoors,
After six years of applying atropine, his vision stabilised and the myopia has not worsened. “I’m very impressed. I can now play rugby without my glasses!” he said.
Nikhil Anggapan’s myopia stabilised over six years by applying atropine.
Less than a year after the diagnosis, his myopia worsened to 250 degrees. “I was in the rugby team and was worried that I wouldn’t be able to see the ball,” said Nikhil. He was accepted into the atropine programme, which he completed in 2011.
PhotoS: GETTY IMAGES
When Mdm Katherine Yeo’s son, Ryan Tan, was five years old, she grew concerned when she noticed him blinking and squinting incessantly. “My husband and
compared to the three hours a week spent outdoors by Singapore children. Dr Audrey Chia, Senior Consultant and Paediatric Ophthalmologist, Singapore National Eye Centre, said preventing myopia may mean a lifestyle change, such as doing less near-work activity like reading or playing video games. She said:
Myopia prevention in schools Up to 65 per cent of Primary 6 children here have myopia, compared to 12 per cent of the cohort in Australia and 30 per cent in Britain. Among teenagers here, the prevalence is 70 per cent; and among national servicemen, it is 80 per cent. “Myopia is the No. 1 visual disability among Singaporeans and the fourth leading cause of blindness here,” said Professor Donald Tan, Medical Director of SNEC and Chairman of the National Myopia Prevention Programme (NMPP). Launched by the Health Promotion Board (HPB) in 2001, the NMPP promotes good eye-care habits in schools. Teachers are encouraged to allocate more time for outdoor activities and reduce the time pupils spend on nearwork activities. Annual vision screenings were introduced in kindergartens and, between 2004 and 2009, HPB monitored about 20,000 primary school pupils for myopia. Myopia rates drop The results were encouraging: There was a 5 percentage point drop (from 38 to 33 per cent) in the number of pupils with myopia between 2004 and 2009. Prof Tan stressed the importance of stopping the progression of myopia among the young. “Children with serious myopia – 600 degrees or more – have a high risk of developing retinal detachment in their 20s and cataracts in their 30s. Visual disability, even in its mildest form, can affect their quality of life,” he said. The SNEC hopes that atropine would prove potent against myopia. Though it is too early to publish conclusive results from the atropine study, Prof Tan is confident the prevalence of serious myopia among children can be reduced by 50 per cent through the joint efforts of SNEC, HPB, schools and the healthcare community.
“We should consider moving our kids towards a lifestyle like that of our grandparents... (one) with more outdoor activities.” She also advised parents against unproven “cures”, such as pinhole spectacles, eye massagers, acupressure and health supplements.
SEP⁄ OCT 2012
singapore h e alth
Brush up on dental health Studies suggest that good oral health may lower your risk of getting chronic diseases and even cancer. By Desmond Ng
of us are not very bothered by this, but what if you are told that poor oral hygiene may be linked to cancer? A study called The Association Of Dental Plaque With Cancer Mortality, published in June in Sweden, suggests that poor oral hygiene may be associated with premature death from cancer. The study found that the accumulation of high levels of bacterial plaque (the biofilm of bacteria) on teeth surfaces and in the gingival pockets (the crevices around a tooth, between the wall of unattached gum tissue and the enamel of the tooth) over many years, may have a role in causing cancer. Cause for worry? The good news is that the study does not prove whether oral plaque levels directly or indirectly contribute to death due to cancer, said Dr Chee Hoe Kit, Consultant, Periodontic Unit, Department of Restorative Dentistry, National Dental Centre Singapore (NDCS). He added: “The interesting thing about the study is that it did find that those who died from cancer had significantly poorer dental hygiene at the beginning of the study than those who survived. “Overall, it can be inferred that, in cancer patients, poor oral hygiene may be associated with an increased risk of dying. But more research is needed to confirm the findings and determine if there is a causal link in the observed association.” He added that periodontal (gum) disease has been associated with other medical risks in the last decade. Studies have associated it with chronic inflammatory conditions, such as diabetes and heart disease, as well as with stroke, osteoporosis, respiratory diseases and pre-term low birth rates. Dr Chee said: “Some studies show that pregnant mothers with untreated existing gum diseases may deliver smaller or premature babies.” Poor oral hygiene and uncontrolled gum disease may also exacerbate diabetes and worsen blood sugar levels. “I have had patients who’ve come to me unaware that they might already have diabetes,” said Dr Chee. “If patients have a family history of diabetes, and if I find they have severe gum disease, I would urge them to go to a polyclinic or their family doctor for a fasting blood glucose test, to rule out the possibility of diabetes. This is important, as gum disease is one of the complications of diabetes.” He added that blood vessels in the gums are linked to the body’s larger blood
vessels. Bacteria from gum diseases can pass through oral crevices in the gum, enter the bloodstream and travel to other parts of the body. Dr Chee said: “The mouth is a portal of entry for bacteria. For example, in a tooth extraction, bacteria in the mouth can go through the fresh extraction site, travel through the blood vessels and infect other parts of the patient’s body. Luckily, in most cases, the body’s defence mechanisms will counter these attacks.”
Brush the chewing surfaces of teeth. However, do not brush too vigorously with a hard bristle brush, as this can be too abrasive on the enamel.
Putting up a defence Much can be done to prevent oral problems. A new study published in the American Journal of Medicine found that older adults who receive thorough dental cleaning may be less likely to have a heart attack or stroke than those who are less careful about oral hygiene. Another study (reported by Reuters in April 2012), involving nearly 22,000 Taiwanese adults aged 50 and above, found that those who had undergone professional tooth scaling in the past year were less likely to suffer a heart attack or stroke over the next seven years. Dr Chee said the best line of defence is to practise good oral hygiene at home and visit a dentist regularly. Singapore’s statistics In Singapore, a study last year found that six in 10 Singaporeans did not have dental check-ups every six months as advised by dentists, and 43 per cent visited a dentist only when they had problems like a toothache. Also, 56 per cent of them spent less than two minutes a day brushing their teeth and 18 per cent did not brush their teeth twice a day. Dr Chee said Singaporeans have a good level of dental health awareness, and oral hygiene here is fairly satisfactory, due to the emphasis on oral care in schools in the past 20 years. “But about 40 to 50 per cent of the population still have fairly poor oral hygiene. They are either unaware that this can lead to gum disease, or are possibly deterred by the cost of dental treatment. They may not know that they can visit a polyclinic, which has dental services, for a simple cleaning. These barriers may lead to poor dental hea lt h,” he said.
10 tips for clean teeth Here is some advice from Dr Chee Hoe Kit, Consultant, Periodontic Unit, Department of Restorative Dentistry, National Dental Centre Singapore
Use a soft toothbrush, as hard bristles may be too abrasive on the gum line and teeth surfaces.
Don’t brush too hard, as this can damage teeth by being too abrasive on the enamel or dentine surfaces.
Brush at a 45-degree angle to ensure you reach the areas between the teeth and gum line, where plaque builds.
4 PHOTOS: ROGER CHUA
Not brushing your teeth enough, snacking on sweet foods constantly and not visiting the dentist often – all these constitute poor oral hygiene. Some
Jiggle the brush by using small circular or a left-top-right motion to clean and remove plaque build-up at the gum line. Up and down brushing, or vigorous left to right movements across the teeth, will not adequately get to where the plaque is located.
Where to brush? Use the jiggling motion to brush teeth surfaces at the gum line. For the inner front teeth, use the up-down motion. Brush the chewing surfaces of the teeth as well.
Brush for two to three minutes to ensure all your teeth are adequately cleaned. The average person spends about one to 1½ minutes, which is too little.
Brush at least twice a day. Three times a day (after each meal) is excellent.
Do not snack after brushing as this causes plaque to accumulate again. Saliva flow is reduced when you sleep, so if you go to bed with bits of food still in your mouth, there will be less saliva to clean your teeth naturally.
Floss using an upward scooping motion against the teeth and not a sawing motion, which may cut your gums.
Visit a dentist at least once a year. Only a dentist can properly diagnose your dental health. Ask for a proper gum examination, during which the dentist will measure the gum pockets around each tooth to see if there are any disease sites that will need proper gum treatment. Left: A small interdental brush can get in between the gaps in teeth to clean more thoroughly. Far left: Dr Chee Hoe Kit, Consultant, NDCS, said nearly half the population here still have poor oral hygiene.
singapore he alth
SEP⁄ OCT 2012
Stuck in motion Chronic constipation can be caused by pelvic floor disorders. At SGH, a multidisciplinary team can help relieve such problems. By Jamie Ee
looking out for more patients who may suffer from functional causes.” People who suffer from constipation, but have no other symptoms or are found to have nothing seriously wrong, tend to live with the problem, relying on laxatives, much like what Ms Koh has done. One reason, said Dr Wong, is a lack of awareness that a constipation problem that is due to a malfunction of the pelvic floor can be treated. At the Pelvic Floor Disorder Service, state-of-the-art equipment that may not be readily available at clinics can scan and assess the anal canal and muscles, and their ability to contract and relax appropriately. “Sometimes, the entire colon contracts poorly for some reason or other, or there is obstructed defecation – meaning the patient is contracting normally, but must strain at the end as if there is blockage,” said Dr Wong. “Our message to doctors is that if you’ve tried everything for your patients, are at your wit’s end and find that you’re going nowhere (in addressing the problem), please send them to us,” said Dr Wong.
Common causes of constipation Besides having a pelvic floor disorder, there are other factors that can cause constipation:
Drinking too little water
Taking too little or too much fibre Lack of exercise
Relieving the pain
Many suffer chronic constipation in silence, unaware that it can be treated if it is caused by the poor coordination of some muscles in the pelvic area.
For more than 10 years, secretary Theresa Koh took laxatives every day for her constipation. Even then, she only managed to move her bowels with great difficulty on many days. The 51-year-old sought treatment from various clinics and hospitals for her chronic problem, but was always offered laxatives and fibre drinks that made her feel only more bloated and uncomfortable. “The problem became so bad that even when I ate light meals, my tummy would become bloated and painful to the touch,” said Ms Koh. But in April this year, she was seen by Dr Mark Wong, Consultant, Department of Colorectal Surgery, and Director, Pelvic Floor Disorder Service, Singapore General Hospital (SGH). Dr Wong put her through a series of tests, which revealed that she was suffering from a form of pelvic floor disorder, where the muscles involved in bowel movement weren’t coordinating the way they should.
contracting when they should be relaxing, leading to difficult bowel movement. “The passing of stools is a complex interplay of relaxing and contracting the muscles at appropriate times. In some people, this interplay is disrupted or just mixed up and, like an electric circuit, needs to be rewired,” said Dr Wong. This malfunction can be due to a weakness or deficiency of the pelvic floor and can occur in patients as young as in their late teens. However, such causes of constipation are more often picked up only when patients are much older. “Probably everyone has suffered from constipation at some point of his life. Constipation is so common that, after a while, people come to accept it as a part of their lives. They stop bothering to investigate (the problem) further,” said Dr Wong. “But we hope to change this by
Patients found to be suffering from poorly coordinated bowel movement may be taught to contract and relax the bowelrelated muscles appropriately. Much like the Kegel exercises that women do to reduce urinary incontinence – another pelvic floor disorder – after childbirth, patients are trained until they get the coordination right, Dr Wong said. They also do the exercises regularly at home. Women are more prone to pelvic floor disorders as their pelvic floor supports more organs and, so, weakens more easily. Ageing and childbirth are also known to increase the risk of pelvic floor disorders. The exercises that Ms Koh learnt from the Pelvic Floor Disorder Service nurses have helped her to have more regular bowel movement. She no longer relies on laxatives and is able to pass motion, even when on vacation overseas. She said: “It’s very important to find out the root cause of the condition. There are still days when my bowel moves with difficulty, clearing well after two to three days. Now that I know my body better, I avoid putting too much expectation on myself. It is important to keep up with the exercises to get the bowel movement.”
Stress Medical conditions such as stroke, depression and eating disorders Side effects from medication like antidepressant pills and iron pills Pregnancy Colon cancer
Dr Mark Wong discovered that Ms Theresa Koh was suffering from a pelvic floor disorder that disrupted her bowel movement. Special exercises helped to solve her problem.
PHOTO: MAX CHAN
The pelvic floor consists of muscles that form a sling-like structure that, together with connecting tissues, holds up or supports the organs above the pelvis, such as the rectum, bladder and womb. During a bowel movement, the pelvic floor muscles relax while the muscles of the abdomen contract to push faeces out of the rectum – the lowest portion of the large intestine. This process is an automatic, coordinated effort between different muscles but, sometimes, the contractions don’t coordinate well, meaning the pelvic floor muscles are
PHOTO: ALVINN LIM
Not your usual constipation
A weakness in the pelvic floor often leads to not only one condition, but multiple problems such as urinary problems and a womb prolapse. For that reason, it is easier for the patient to be seen at a multidisciplinary clinic such as Singapore General Hospital’s (SGH) Pelvic Floor Disorder Service, which is staffed by doctors from its Colorectal Surgery, Urology and Obstetrics and Gynaecology departments. “We believe that three minds are better than one. Sometimes, patients may need combined surgery, so the doctors will work together so patients will need only one operation to solve multiple problems,” said Dr Mark Wong, Consultant, Department of Colorectal Surgery, and Director, Pelvic Floor Disorder Service, SGH. To make an appointment at the centre, call 6321-4377.
SEp⁄ OCT 2012
singapore he alth
A labour of loss, and love
A woman’s long-awaited joy of becoming a mother was dashed within minutes of delivery. But instead of wallowing in despair, she was determined to carry on BY Felicia Tan
It had taken many attempts, all to no avail. Finally, my husband and I received the news we had been longing to hear: I was pregnant.
I was rushed to hospital, where I lay in bed for two days. I was induced to deliver as I was running a fever, and also an additional risk of infection. Before long, Dominic was born. He weighed only 525g.
PHOTO: GETTy images
The baby was due for delivery on Feb 29, 2012. I was going to have a leap-year baby! Though my husband and I knew this was an estimated date, we were excited just to know that our baby would arrive around then. My husband and I had been looking forward to the little person who would make us a complete family. We named our baby, Dominic. His Chinese name, Jiaming, represented our hope that, no matter what happens, he would always put his family first. Like many couples, I dreamt of having a child of my own; to take care of him until he becomes an adult; to see him through school, graduate from university, land a job, get married and start a new cycle of life. But work and other commitments got in the way. Shortly after graduation, I started my first job at a semiconductor company. That was where I met my husband. Like me, he joined the company after graduation. It wasn’t love at first sight, but we fell in love and, four years later, got married in 2004. I started my graphic design business in 2005. My husband and I were engrossed in our careers and, as a result, had no immediate plans to start a family. Meanwhile, friends and relatives around our age were getting married and, soon enough, we began hearing news of them having children. That prompted us to wonder: “When are we going to have our own child?” And so, as we both entered our 30s, we became keen to start a family. We gathered advice from our friends and relatives, and tried all kinds of methods, even those derived from old wives’ tales. Yet, try as we might, I just couldn’t get pregnant. It was clear we needed professional advice so, on Sept 4, 2010, we consulted a gynaecologist who specialises in in-vitro fertilisation (IVF). Following his advice, I underwent one cycle of intrauterine insemination (IUI), along with a cycle of IVF. Finally, Dominic was conceived on June 10, 2011. We were going to be parents! I was 33 and my husband was 37. My pregnancy went smoothly. There was no bleeding or spotting; none of the usual pain nor anything out of the ordinary. I underwent a full baby scan during the 20th week, and was told that Dominic was healthy in every way. We were overjoyed.
were very hard. I still had to undergo confinement to allow my health to recover. During this time, I realised I had to calm down and think about my plans. With no baby to take care of and nothing to do, I had too much time on my hands and no clue as to how I should make use of it. I searched online to find out more about cervical incompetence, and discovered that there is no clear or accurate way to detect it in advance. It’s only after multiple miscarriages that experts can confirm it as a root cause. Obviously, I have no wish to endure multiple miscarriages, so my only option was to do a stitch – that is, a cervical cerclage to seal the cervix – and remove it after about 37 weeks. This, in itself, carries the risk of infection.
Cervical incompetence causes a pregnant woman’s cervix to dilate and become thinner before her pregnancy reaches its full term. The writer might have suffered from it.
Then, tragedy struck in the 23rd week. My water bag broke suddenly. I was rushed to hospital, where I lay in bed for two days. I was induced to deliver as I was running a fever, and also an additional risk of infection. My baby was already in position for delivery and I started having painful contractions. Before long, Dominic was delivered, four months premature. He weighed only 525g. He received immediate medical attention. The doctors valiantly tried to resuscitate him as his heartbeat started to falter. But, within minutes, I was told it wasn’t going to work. He left this world shortly afterwards. I remember watching him gasping desperately for air. I was devastated. As I sobbed, it hazily occurred to me that it
should have been him who was crying, not me. The questions inevitably surfaced: Why me? What happened? Was it my fault? I was discharged a few days later and I went immediately to my gynaecologist to get some answers. But there was nothing unusual to discuss – no obvious signs from the placenta, nor any tell-tale symptoms. The only likely culprit was a weak cervix – that is, cervical incompetence – a medical condition that causes a pregnant woman’s cervix to dilate and become thinner before her pregnancy reaches its full term. However, as it was my first pregnancy, it was hard to confirm this as the root cause. The following four to five months
After my confinement, I strove to keep fit through activities like swimming and cycling. I quickly recovered my health. I also discussed with my husband my plans for another round of IVF as soon as I was ready. I wanted a new goal, a new target – anything I could look forward to and ensure that I wouldn’t dwell on the past. I could have succumbed to depression but, as I watched my husband and family struggle with their sadness, I knew I had to be strong, not just for myself but also for them. I haven’t given up on being a mother and, though my ordeal was painful, I hope to show other women that such a tragedy is not insurmountable. I am determined to move on, but I haven’t forgotten Dominic. My husband said he would always be our first child. My son’s Chinese name, incidentally, means “engraved in our hearts”. That will never change.
Felicia Tan, a business manager, contributed this article. To learn more about how she pulled through her heartbreaking experience, email her at feliciatan22 @yahoo.com, or check out her book To Baby with Love: A Mother’s Journey through Hope, Loss and Renewal, available now at all major bookstores.
singapore he alth
SEp⁄ OCT 2012
Teaming up to battle cancer At the National Cancer Centre Singapore, difficult cancers are treated by teams of specialists whose combined expertise attracts patients from here and overseas BY Francis Chin
At the National Cancer Centre Singapore (NCCS), we treat people from here and overseas who have all sorts of difficult cancers. Mr
Cancer is a complicated disease and dedicated teams of doctors are needed to tackle the problem.
Singapore bound The urologist urgently referred him to Singapore and he turned up at NCCS. We doctors discussed his case at our weekly meetings and decided he needed a larger surgery to clear the remaining tumour cells in a technically difficult area. After that, he would need a muscle graft to patch up the defect after the surgery, as well as post-operative radiation and chemotherapy. He came to NCCS because of its reputation for treating difficult cases. He had done his research over the Internet and knew it was a rare tumour and that, at NCCS, we work in teams of doctors specialising in particular groups of cancers. Soft tissue cancer, or sarcoma, is a rare tumour that can occur in any part of the body where there is muscle and bone. We see close to 200 cases a year at NCCS and each case presents unique challenges. A tumour in the groin may be more difficult to remove than one in the thigh. We have to consider if the patient still has good functional outcome of the muscle and joints, and if further treatment is
ILLUSTRATION: Cheng Puay KOON
M from Mersing is one of them. He has a rare soft tissue tumour in the groin area. The 40-year-old technician has two school-going children and is the sole breadwinner of the family. Months earlier, he noticed a small lump near his left groin, but did not pay much attention to it because it was painless and he was too embarrassed and busy to seek a medical opinion. Finally, he went to a urologist in his hometown, who did surgery to remove the lump. But his whole world came crashing down when he was told the lump was cancerous and there was a possibility the tumour was not cleanly removed. He led a healthy lifestyle, didn’t smoke or drink and thought cancer struck only older people. He was in the prime of his life.
Cancer patients who need complicated treatments not available in their own countries are making their way here, where skilled medical teams can help them.
required. There is no one standard treatment that suits every patient, hence the difficulty. Coming up with treatment plans We discuss every new patient at doctors’ meetings and look at cells under the microscope, MRI and CT scans, then agree on the best treatment plan. These meetings, which we call tumour boards, are attended by oncology surgeons, medical oncologists, radiation oncologists, radiologists, pathologists and students in attendance. Each case is discussed in detail and ideas on how best to treat the patients are agreed upon. The meetings also serve as academic forums to educate the next generation of doctors and specialists. Cancer is a complicated disease and dedicated teams are needed to tackle the problem. Large cancer centres worldwide organise themselves into teams to treat, research and discuss problems related to different types of cancer treatment. It is
rare for a single doctor to have the time and energy to keep up with the huge volume of scientific literature, from cutting-edge research from all over the world for every single tumour group, while also running a busy clinical practice. A win-win situation We treat foreign patients because some of the treatments are complicated and not available in their countries and, for humanitarian reasons, we do our best for them. Apart from that, the full fees they pay enable us to continue our primary mission of ensuring affordable healthcare for Singaporeans. It is a win-win situation, because we maintain our technical skills to treat in a manner consistent with best practices, while our patients are assured of a high standard of care. Mr M completed his treatment and was very grateful and pleased with the outcome. He still felt some stiffness in his leg and remained worried about recurrence.
He was given a detailed medical report so he could receive follow-up care back in his country. That gave him hope. To Mr M, it was not the look and feel of our hospital nor our advanced equipment that impressed him, but the compassionate and passionate people in our hospital teams. He gave special mention to our dedicated nurses and the radiographers who administered his daily radiotherapy. He was also pleased with the care he received from the specialist doctors managing and coordinating his care. When battling cancer, everyone in the team has an important role to play.
Dr Francis Chin is a radiation oncologist at NCCS specialising in paediatrics, soft tissue sarcomas and gynaecological cancers. This article first appeared in The Straits Times’ Mind Your Body section on March 8, 2012.
SEp⁄ OCT 2012
singapore h e alth
Patients less jittery when better informed A study shows that good doctor-patient communication is beneficial to post-operative treatment
BY JR Wu
Ask, ask, ask… Having a clear idea of what surgery involves can help calm patients before their procedures, and asking questions like the ones on this question prompt list can be a starting point for patients to frame their concerns
Patients who are inherently positive and generally trusting of others may suffer less anxiety before going under the knife. Patients who
What is the diagnosis of my condition?
PHOTOS: Alecia Neo
Are there any dangers/risks during surgery? How long do I have to remain in hospital after surgery?
Associate Professor Leslie Lim (left) and Professor Pierce Chow have found that patients who know more about their conditions tend to be less anxious about surgery.
to have lower anxiety levels after their operations. The use of question prompt lists during consultations resulted in favourable outcomes in the anxiety levels of Western patients, other studies have found. But in the SGH study, it was found that Southeast Asian patients perceived the question lists as “not so helpful”, although they might not have realised that the prompt lists helped them ask better or more indepth questions. Instead, the local study showed that doctors’ interpersonal skills played a far greater role than the use of question prompt lists in easing patients’ anxiety.
Looking at a patient’s mental state as he goes into surgery is important, as his emotional state has a bearing on his physical state. associate professor leslie lim, senior consultant, department of psychiatry, singapore general hospital
Besides these factors, it seemed that lowering patient stress levels was key to whether a doctor could answer all the questions a patient had about his condition and the surgical procedure. Satisfaction with the consultation and the ability of the doctor to address uncertainties
about the operation were both significant factors in reducing patient anxiety, according to the study. “When you are very anxious to start with and you don’t trust your doctor, that’s when a lot will seem to go wrong,” said Assoc Prof Lim. In an Asian setting, doctor-patient communication is not only between two people, but also involves family members, especially when it comes to care for an elderly patient. This means that a doctor must manage the anxiety levels of younger family members, who may be the main decisionmakers for the older patient. Otherwise, an already anxious patient might be influenced by worried family members and end up making bad judgement calls, pulling out of surgery at the last minute or stopping post-operative treatment early, said Professor Pierce Chow, Senior Consultant, Department of General Surgery, SGH, who also contributed to the study. Just as patients armed with information before surgery suffer less anxiety, the same can be said for family members who stay informed about a disease and treatment for another family member. How information is disclosed is important, said Prof Chow. While it is important to give all the facts and treatment options to a patient and his family about, say, a cancer diagnosis, the information needs to be delivered in a “digestible” format. Giving details of bad prognosis all at once does not help the patient much. Instead, providing the information in moderate doses over several meetings may be more beneficial, as it allows the patient time to absorb what is a
If the diagnosis is cancer • What is the stage of my cancer? • If we get rid of the cancer, what are the chances of recurrence? What will happen to me during surgery?
How much pain will I experience after surgery? What other treatments will I need in addition to the surgery? What are my chances of recovery? Will my condition affect my ability to work or perform other activities?
PHOTO: MORVEN KOH
undergo breast surgery as opposed to abdominal surgery may also suffer less anxiety, particularly after an operation, because they can readily see the physical results of a mastectomy or lumpectomy. Regardless of the type of surgery carried out, patients armed with more information about their conditions are usually less anxious about operations. And their doctors’ communication skills, as well as the patients’ satisfaction with their consultations, are the two most important factors in soothing patients’ nerves. Those were some of the findings that Associate Professor Leslie Lim, Senior Consultant, Department of Psychiatry, Singapore General Hospital (SGH), gleaned from a study he conducted on how doctorpatient communication can affect anxiety levels in patients. Common sense will tell you that trust and communication between a patient and a doctor is critical in medical care. “But then you ask somebody, ‘Can you show us the data?’” said Assoc Prof Lim, who noted that whereas the answer used to be negative, “Now, we have the data.” The study, which was published earlier this year in the Asian Journal of Surgery, is the first of its kind in Southeast Asia. The patients in the randomised controlled study, which was carried out between 2006 and 2010, were all from SGH and were either scheduled for breast or abdominal surgery. Their anxiety levels were gauged before and after their operations. The study provides empirical evidence for factors that contribute to a patient’s stress level. It may also be a springboard for future collaborative studies between psychiatry and surgery, Assoc Prof Lim said. “Anxiety causes a person to secrete stress hormones. Increased anxiety levels may affect post-operative care,” said Assoc Prof Lim. “Looking at a patient’s mental state as he goes into surgery and when he comes out of the operation is important, as we’ve seen that a person’s emotional state has a bearing on his physical state. So we want to study that in further detail.” Patients said they gathered information about their conditions from the Internet or from friends and family. Regardless of their education level, the acquisition of knowledge resulted in increased confidence and reduction in anxiety levels for patients, according to the study results. The SGH study also showed that compared to abdominal surgery patients, those who have had breast surgery were more likely
Anxiety disorders are some of the most common afflictions, and can seriously disrupt a person’s daily life. In Freedom from Fear, Associate Professor Leslie Lim, Senior Consultant, Department of Psychiatry, Singapore General Hospital, discusses the characteristics, causes and features of these conditions. The book, published in January, costs $18 and is available at most major bookshops.
life-changing event. “We give (the bad news) to them in stages, which is a very good approach,” he said. In this way, the physician also recognises that the outcome of a disease for a particular patient has yet to unfold, and does not give him the impression that the disease will inevitably proceed along a predestined path. Details of the study can be found at www.sciencedirect.com/science/article/pii/S1015958411000145.
singapore he alth
SEP⁄ OCT 2012
Know your medicines Medicines, supplements and vitamins can interact with each other, and taking them incorrectly can lead to serious consequences BY Jamie Ee
After his doctor questioned him closely, Mr Tan admitted that he hadn’t been following the instructions given – the instructions for the several drugs he had to take every day were simply too much to remember. Mr Tan takes four types of medication: aspirin, a blood-thinning tablet taken after breakfast; two omeprazole capsules, taken before breakfast to protect his stomach against the side effects of aspirin; enalapril, taken twice a day to lower his blood pressure; and isosorbide dinitrate, taken three times daily for his heart condition. Mr Tan isn’t a real patient, but what he went through is not uncommon. According to a 2004 study done on nursing homes in Singapore, nearly two-thirds of the elderly patients were on five or more medicines, and 70 per cent had medication-related problems, such as taking the wrong dosage or taking medicine they weren’t supposed to consume. “If you are taking only one or two medicines, it’s quite easy to remember how to take them and when to take them. But when the list goes on, it gets quite hard to remember and patients would either forget or not want to take all their medicines,” said Ms Shannon Ng, Pharmacist, Singapore General Hospital (SGH). “Taking eight to 20 tablets a day isn’t uncommon for our older patients.” Medication-related problems are increasingly a concern, especially as Singapore’s population ages. Older patients tend to suffer from chronic diseases such as diabetes and heart-related conditions.
How drugs interact “A person who is first diagnosed with diabetes may be given one type of medicine for a start. If his condition isn’t well controlled, he may be given several more drugs later and/or insulin therapy where he has to inject himself regularly,” said Ms Ng. “Diabetic patients are more likely to have other conditions, such as high blood pressure, heart disease and stroke, leading to an even longer list of medication to take.” More people today are also taking herbal supplements and vitamins. While these are billed as natural or from plants or vegetables, they can interact with the medicines patients are taking or duplicate their effects, sometimes with dangerous consequences. “Every drug, whether it is medicine for gastric pain or a laxative, prescribed or bought over the counter, has its side effects. It’s a question of how often or how serious the side effect is,” said Ms Ng.
Many patients don’t know the names of the drugs they are taking, or how much they are supposed to take. When asked to describe what they are taking, they might say a white tablet. But there are so many medicines in the form of white tablets. MS shannon ng, pharmacist, singapore general hospital
Many people take a calcium supplement, usually bought over the counter and so isn’t likely to be included in the medical records kept by their doctors. But calcium taken with some types of antibiotics can reduce the effectiveness of the antibiotics. For instance, calcium tablets should be taken two hours before
PHOTO: VERNON WONG
Although the doctor gave him tablets to protect his stomach from the possible side effects of his blood-thinning medicine, Mr Tan continued to complain of gastric pain.
It is common for older patients to take eight to 20 different tablets a day. Thus, it is important to keep an updated list of these drugs to avoid accidents.
Pharmacists like Ms Shannon Ng can help patients sort out their medicines, including those which have expired or were improperly stored.
or after taking the antibiotic ciprofloxacin, said Ms Ng. A drug that interacts with many other types of medicine is warfarin, which is used to prevent blood clot formation and stroke in patients with some heart conditions. If a patient on warfarin therapy goes to see a GP for flu and doesn’t tell the doctor that he is on the drug, he may be prescribed an antibiotic that can interact with warfarin and increase the risk of bleeding. To prevent accidents caused by taking medicines incorrectly, it is important for patients to take ownership of their medicines and that means knowing their names, what they are for, their usage and common side effects, said Ms Ng. Keeping an updated list of the medicines, including supplements and herbal or natural extracts, is also useful when consulting a doctor, especially if the patient sees different doctors for different conditions. “Many patients don’t know the names of the drugs they are taking, or how much they are supposed to take. When asked to describe what they are taking, they might say a white tablet. But there are so many medicines in the form of white tablets,” said Ms Ng. “The best prevention (of dangerous drug interaction) is for patients to take ownership of their medicine regime,” said Ms Ng.
Drugs can interact with dietary supplements, vitamins and other drugs, as well as food and beverages. So it’s important to find out what a medicine, especially for a long-term condition, interacts with. Grapefruit juice, for instance, can interact with certain cholesterollowering drugs and immune suppressants, elevating the levels of the medicine in the body and increasing the risk of side effects. It’s important to not just note the name of the medication you are taking, but also the generic name of the drug which is usually printed below the brand name. For instance, Panadol and Tylenol are both the brand names of the drug, paracetamol. Taking both without realising they are similar will duplicate the effects of paracetamol. Warfarin can interact with many things, including some antibiotics, painkillers, herbal supplements such as gingko and garlic tablets, alcohol and food high in vitamin K, such as dark green leafy vegetables and green tea. Ageing alters the way the body uses and handles medication. Most medicines taken by a young person is flushed out of his system faster than in the case of an older person, whose liver and kidney functions are not as efficient.
Patients can make use of medication management services, offered by polyclinics, hospitals and retail pharmacies, to sort out their medication. All drugs, including prescription and over-the-counter medication, herbal products as well as supplements, should be shown to the pharmacist, who looks out for duplicate or mismatched drugs, those which are no longer needed and medicines which have expired or were improperly stored. The pharmacist will help to update the patient’s medical list, advise him on correct usage and may also refer the patient back to his doctors for a review.
FACTS Our tendons... Our body’s rubber bands 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.
CAN HELP SUPPORT CARTILAGE, PROMOTE JOINT HEALTH AND MAINTAIN JOINT FLEXIBILITY & MOBILITY
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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singapore he alth
SEP⁄ OCT 2012
As a bone marrow transplant physician, Dr Yvonne Loh, Senior Consultant at SGH’s Department of Haematology, helps her patients get successful matches
If I hadn’t become a doctor… I would be in a profession that I don’t like. In that sense, I am quite single-minded. My three siblings and I grew up listening to my dad’s stories. He was a general practitioner, but only I followed in his footsteps.
Finding a match… is not easy, especially among the nonChinese. As there is a higher likelihood of finding a match within one’s ethnic group, our Chinese patients often get matches from Taiwan’s much bigger and more established registry. Unfortunately, there are no similar registries for the non-Chinese.
Life at work… is a balancing act. When a blood stem cell is transplanted from a donor to a leukaemia patient, the patient is getting a new immune system to fight his condition. But it’s a double-edged sword – the new immune system may also attack his body.
Life outside work centres around… running. It takes up quite a bit of my time. I wake up at 3am or 4am to train on weekends, and run about 20 to 30km. During the week, I usually manage to squeeze in an 8km run after work on most days. It has become quite an addiction! I ran in the Sundown Marathon in May and completed it in 4 hours 46 minutes – not bad for someone who is not a professional and not Kenyan!
Championing bone marrow donation… came about when I lost a patient who had become a good friend. She had no sibling match and we were unable to find her a match through the Bone Marrow Donation Programme (BMDP). I was sad when she passed away and her death highlighted to me the importance of having more donors on the registry. I started volunteering with BMDP and was roped in to draw blood samples during donor
The thing in my life that would be the hardest to give up is… apart from my three cats, coffee. I have
PHOTO: ALVINN LIM
recruitment drives. Now that only cheek swabs are required, I serve in a different capacity: I sit on the board and act as BMDP’s medical adviser.
By Thava Rani
Saddened by the loss of a friend, Dr Yvonne Loh (left) started volunteering with the Bone Marrow Donation Programme to boost transplant outcomes for patients.
always wanted to have cats, but I was not allowed to. So, when I moved out (of my family home), I got two cats because I didn’t want one to be lonely. The third cat came along after I watched Puss in Boots. Taking care of them is the closest I have come to motherhood. As for coffee, I try to restrict it to two cups a day. But if I have two shots of double espresso, does that count as two or four? That excludes the energy shots I drink when I run. They
Restoring the spring in their step Physiotherapist Shelby Tan of Bright Vision Hospital loves helping her patients with exercises that improve their mobility By Teh Joo Lin
The patient, who was used to moving around on her own, was in no mood to listen after fracturing her hip in a bad fall. Ms Tan, 27, said: “When I first went into her ward and approached her, she made a very nasty remark, ‘You just want to see me for the sake of money.’ “Her comment made me a bit upset. After all, I do what I do to help people.” But the physiotherapist at Bright Vision Hospital (BVH) persevered and eventually won the trust of the patient, who regained much of her cherished mobility. To Ms Tan, going the extra mile is what her job is about. “What you choose to prescribe can change the patient’s life,” she said. “If you choose to do more for a patient, she can become more independent. “For example, a patient has the highest
PHOTO: VERNON WONG
Ms Shelby Tan remembers getting a tongue lashing when she tried to persuade an elderly patient to attend a physiotherapy session last year.
Ms Shelby Tan talks to her older patients in Hokkien and Teochew to help them understand exercise instructions.
potential of recovery in the first few months after suffering a stroke or fall. As physiotherapists, we must use this window of opportunity to give them the best we can offer.
“Going the extra mile can change the patient’s life – instead of requiring a caregiver’s support when she moves around, she may be able to walk again on her own.” Ms Tan has spent three years at BVH, a community hospital in Yio Chu Kang Road under SingHealth. Patients, whose medical conditions have stabilised but who need further care, can move to community hospitals for rehabilitation, staying until they are able to move about on their own. Ms Tan, who previously worked at a restructured hospital for about a year, prefers working at BVH because she’s able to spend more time with her patients. At a community hospital, she can work with her patients from the early stages of recovery until they regain mobility to return to their families. As patients also tend to stay longer at community hospitals, Ms Tan is able to continually monitor their progress and modify their treatment plans. “I get to spend quality time with the patients for therapy. I get to talk to them to know what they want to achieve,” she said. “I become a friend, instead of just being their therapist.”
contain caffeine too. It’s my perfectly legal, performance-enhancing drug. Within the next five years… as the Medical Director of (SGH’s) Haematopoietic Stem Cell Transplant Programme, I want to get more people to come on board the service. I aim to collaborate with other centres on clinical studies to improve outcomes after transplants. I hope to run 100km and will try not to get more cats!
Ms Tan studied physiotherapy at Nanyang Polytechnic because she wanted a healthcare-related job that allowed her to interact with people. Most of her day is spent in a spacious and brightly lit gym, where she and her colleagues help patients with various exercises, including lifting small weights to strengthen specific muscle groups and walking on pieces of foam to improve balancing skills. The physiotherapists often perform the exercises with their patients and are generous with their words of encouragement. Many of Ms Tan’s patients are elderly people who have hurt themselves in a fall or suffered a stroke. As these patients may speak only dialect, she communicates with them in Hokkien and a smattering of Teochew to help them “better understand the instructions”. It’s Ms Tan’s job to help relieve the pain of others but, ironically, she suffers from pain of her own. “Because of the repetitive routines (that I go through with the patients), there can be quite a bit of a strain (on my body). But I just put koyok (plaster), rest and start again. “The most rewarding part of my work is seeing patients’ conditions improve, from the time they are lying in bed, unable to even sit up, to the point when they walk out of the hospital,” she said.
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SEP⁄ OCT 2012
Pools aren’t germ-free While swimming is good exercise, doing so in pools poses some risk as even chlorinated pools contain many germs that can make children ill. “A swimming pool is basically a community bathtub without the shampoo,” said Dr Thomas Boyce, a paediatric infectious diseases specialist at Mayo Clinic Children’s Center. “Children can still get sick in a properly chlorinated pool. Chlorine does not kill germs instantly and, in fact, does not kill cryptosporidium – a common germ that causes water-associated gastrointestinal illness.” Dr Boyce said parents can keep children safe by having them rinse off before entering the pool, not allowing them to swim if they have diarrhoea and teaching them not to swallow pool water while they swim.
Closing date: Oct 8, 2012
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Source: Mayo Clinic
Scientists have successfully tested a new tuberculosis (TB) treatment that can potentially check a deadly, drug-resistant strain that has been threatening to sweep the globe. In a groundbreaking trial of three drugs given in combination, more than 99 per cent of the TB bacteria in patients were killed after two weeks of treatment. The trial was carried out in 85 patients at two centres in Africa. A larger trial is now under way. If successful, people with drug-resistant TB could see a dramatically shorter, simpler and more effective treatment regime. Source: The Guardian
Singapore Health issue 18 contest 1. What is the name of the substance used as a tracer in the new and highly accurate scan for prostate cancer? 2. Which story in this issue did you find the most informative?
Late-night TV can New drug cocktail leave you depressed may halt TB
Sitting in front of a TV screen late into the night, or leaving it on when you sleep, may boost your chance of getting depressed, a new study has found. Scientists at Ohio State University said a surge in exposure to artificial light at night in the last 50 years coincided with rising rates of depression. The researchers exposed hamsters to dim light at night, and picked up changes in behaviour that strikingly resembled those of depressed people. The animals were found to produce more of a protein linked to depression.
Content Advisor Tan-Huang Shuo Mei Group Director, Communications & Service Quality, SingHealth & SGH Editorial Team Angela Ng (SGH), Lim Mui Khi (SGH), Tina Nambiar (SingHealth), Ann Peters (SingHealth), Deborah Moh (SGH), Wendy Seah (SGH) Singapore Health is partially funded by SGH Integrated Fund, SingHealth Foundation, Tote Board and Singapore Turf Club to advance the health literacy of Singaporeans.
Post: The Editor, Singapore Health, Singapore General Hospital, Communications Department, Outram Road, Singapore 169608 Winners of Contest 17 Each will receive a bottle of Genacol Collagen (30 capsules) worth $20. 1. Choo Jia Qing 2. Koh Shyet Kuim 3. Lai Bee Chng 4. V Pushpa 5. Wong Choy Yeen Prizes must be claimed by Oct 8, 2012.
Answer to In focus (Page 3): This is a cochlear implant – an electronic device surgically embedded in the inner ear to stimulate the auditory nerve fibres responsible for picking up sounds and transmitting them to the brain. Another part of the system, including a microphone and a transmitting coil, is worn on the ear, acting as a hearing aid. Hearing impairment is usually caused by damage to the inner ear, a complex bony structure of canals and loops that detect sound.
Sept 1 (Sat)
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Public Forum: Fit Mummy and Baby Public Forum
Sept 22 (Sat)
Time 2pm-5.30pm Venue KKH Auditorium, Women’s Tower, Level 1 Registration Call 6394-5038/1582 for enquiries and to register Price $5 per person, $8 per couple This interactive public forum is a guide to pre- and postnatal exercises, and optimising your child’s potential.
Public Forum: Resilient Parent, Resilient Child
Oct 6 (Sat)
Time 8.30am-12pm Venue KKH Auditorium, Women’s Tower, Level 1 Registration Call 6394-2205 for enquiries and to register Price $5 per adult for only the public forum, $5 per adult for any one workshop (for forum attendees) Through talks and workshops, participants will learn about building resilient families and gain an overview of what constitutes the mental well-being of parents and children. Topics to be covered include those on women’s wellness, understanding your child and methods for raising resilient children. There will also be workshops on stress management and relaxation, communicating your needs as a couple and ways to enjoy being a parent, as well as a parent-and-child art workshop called Capture the Moment. Visit www.singhealth.com.sg/events or the websites of respective institutions for more information and other listings.
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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, 7 Hospital Drive, #02-09 Block B, Singapore 169611. 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. MICA (P) 070/06/2012. Printed in Singapore by Singapore Press Holdings Limited (registration no: 198402868E).
体液潴留新疗法 国家心脏中心引进新疗法，帮助对利尿剂产生抵抗性的心力衰竭病人 排除多余体液
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双全 计划 受保
但大多数的病人只需接受一次12至15个 小时的疗程（视具体病情的严重性而 定）即可。就如琴纳玛只住院两天，便 成功地在 12 小时内将 2 公升多余的体液 排除。 “他们在我的颈部血管中插入一个小 导管，插管的过程没有痛楚。治疗进行 没几个小时就开始见效了。等到整个疗 程结束后，我原本肿胀的双腿也恢复了 正常，” 琴纳玛说。
在接受水分置换治疗之前，琴纳玛女士 是被诊断患有充血性心力衰竭。这意味 着她的心脏再也无法输出富含氧气的血 液来满足身体的需求，继而导致体内积 水或体液潴留。 “心力衰竭的病人难免会发生一、两 次急性水肿的情况。有些病人恢复后只 需服用药物就可以把症状控制下来。但 有些病人则会因体液潴留问题而重返医 院，即使吃了药和改变生活方式也无 济于事，”新加坡国家心脏中心心内科 部门顾问医生兼心衰计划联席主任沈庆 龙说。
微创切口拯救 生命，免除截肢 血管外科手术主要针对毛细血管 堵塞，帮助患者、特别是糖尿病 患者免除由于伤口无法愈合而导 致的重大截肢手术 原文 Thava Rani
自从洪信融先生跌倒后，小腿上留下的 伤口不但没有愈合反而不断恶化且呈黑 色。伤口起初有约两角硬币大，虽然接 受过治疗但也无济于事，伤口仍然没有 愈合。医生告诉他可能需要截肢以阻止 感染扩散。要是出现坏疽，大量组织将 坏死是足以致命的。 “医生说我可能需要进行膝下截肢。 失去我的腿是我不愿也无法接受的，” 洪信融说。
现年 65岁已患糖尿病 30多年的洪信融一 直坚持寻找免截肢的治疗方法。可幸的 沈庆龙医生为琴纳玛女士实施了水分置换疗法，成功地将她体内多余的2公升液体排除。 是，他终于在新加坡中央医院找到一项 能让他免除截肢痛苦的最新技术。 新加坡中央医院普通外科顾问医生 （Aquapheresis）的治疗。这种新疗法可 原文 Thava Rani 蔡思颖为洪信融实施了一项外科手术， 排除体内多余的体液，帮助她恢复到以 是通过切开腿部血管让氧气和药物流通 往健步如飞的状态。 来治疗与滋养受伤的部位。 “我们的目标非常简单：就是改善血 要 照 顾 四 名 孙 子 ， 对 琴 纳 玛 排除积液 液循环，促进伤口愈合，恢复患者的生 （Chinnamah Vellasamy Kathireso）女士 这种新疗法是利用超滤（Ultrafiltration） 活品质。”蔡医生说。 来说，已是件越来越吃力的事了。因体 的技术，先将含有多余液体的血液导出 大概十年前，医生已实行微创血管 液潴留造成双腿严重肿胀，使琴纳玛在 体外，然后通过一种特殊仪器过滤掉多 成形术，以疏通腿部狭窄或被阻塞血管。 走路时感到气喘及呼吸困难，让她难以 余的水分和盐分，再将过滤后的血液输 新加坡国家心脏中心心内科部门顾问医生兼心衰 医生借助X光，通过插入血管的球囊 跟上孙子们的步伐。 回体内。 计划联席主任沈庆龙说。 导管来疏通被阻塞的血管。这是定向锁 “我觉得走起路来很辛苦，没走几分 新加坡国家心脏中心于 2011 年 10 月 孔手术，患者无需全身麻醉，适合身体 钟就要喘口气休息一下，连站在厨房给 成为亚洲首家引进水分置换疗法的医疗 较弱或老年患者。 孩子们做饭也很费劲，”现年62岁的琴 机构。琴纳玛是在2011年12月接受治疗 最近，被称为逆行血管成形术改良 纳玛说。 的。除了她以外，另有12名病人已接受 她年轻时曾在工厂里工作，早已习 过这种疗法。治疗后90天，没有一名病 心衰竭是心脏病患者入院的首要原 版也开始应用了。在手术的过程中，医 惯长时间站着。退休后，她专为他人提 人因体液潴留情况复发而再次入院就医。 因，新加坡每年约有5000个案例。新加 生会从患者脚上穿孔然后引入球囊导管， 据新加坡国家心脏中心预计，每年将 坡国家心脏中心每年接诊约1000名心衰 再指引球囊在体内往阻塞的血管进行疏 供餐饮服务，在朋友圈当中是有口皆碑 的。她曾经能够不费吹灰之力承办200人 会有大约50名病人受益于这种新疗法。 竭的病人，其中有九成以上是因体液潴 通。而之前的顺行血管成形术则是在腹 股沟部位穿孔，让球囊由上往下排除 的宴席，如今她那双肿胀的腿使她不得 水分置换疗法有助于缓解四肢及腹部 留而入院治疗。 不放弃这一切，可是却又不愿意成天无 肿胀、呼吸困难、疲乏、体重增加等症 患有体液潴留的病人通常会有呼吸困 阻塞。 目前使用的血管修复球囊非常细微， 所事事。 状，还能缩短住院时间，减少再入院以 难（特别是平躺时），甚至双腿、阴囊、 足以疏通小脚趾下直径仅有1毫米的血 可幸的是，新加坡国家心脏中心为 及临时就诊和急诊的几率。 腹部肿胀，以及腹部不适。 她实施了一种被称为水分置换疗法 整个疗程的时间可设为 8 至 72 小时， > 文转 page 30 > 文转 page 28
水分置换疗法有助于缓解 四肢及腹部肿胀、呼吸困 难、疲乏、体重增加等症 状，还能缩短住院时间， 减少再入院以及急诊的几 率。但不是所有的患者都 适合接受此疗法。
SEp⁄ OCT 2012
> 文接 page 27
管。球囊还可进而输送药物，防止血管 再度狭窄。在某种情况下，血管阻塞处 会置入金属网管支架以保持血管通畅。 支架也含有缓慢释放药物。 “技术上有了这些进展，我们现在能 够治疗越来越细小的血管，并延长血管 通畅的时间。如果患者能尽早治疗，就 可以避免重大截肢。”蔡医生说。
女人为何会随着年龄而“缩水”？ 这是不是骨质疏松症的症状？食 用高钙食物如牛奶和乳酪，或服 用钙片是否会减缓骨质疏松症的 形成？
女人会随着年龄的增长而变矮，男人也 一样。这是衰老的自然过程。然而，一 个人的身高若减少超过四公分，就应该 特别留意。身高的大幅度改变可能是因 其他状况，例如脊椎萎陷所造成的。 均衡的饮食对骨骼的发展、维持和 整体健康极为重要。研究显示足够的钙 质对骨密度峰值的形成扮演重要的角色， 也能避免骨质疏松。 19 岁或以上的人们每天需摄取至少 700 毫克的钙质。较年幼者则建议摄取 800至1000毫克的钙质。 高钙食物应是摄取钙质的主要源头， 因为这些食物也含有其他重要的营养。 若无法从日常饮食中摄取日常所需的钙 质，钙片和加钙食物也是额外的来源。
糖尿病患者易患周围血管疾病，主要是 因为提供下肢血液的动脉逐渐变窄，甚 至完全阻塞。以洪信融为例，走几步就 得停下来休息，情况日渐恶化。而身为 一名建筑安全协调员的他，由于无法承 受行走时所带来的剧痛，不得不在几年 前提前退休。 高达三分之一的糖尿病患者易患周 围血管疾病。有些是由于长期的糖尿病 所导致，但大部分人是因为没有适当地 控制血糖水平。身体其他部位也会出现 动脉狭窄。若在心脏就会导致心脏病等 并发症；在大脑就会引发中风； 在肾脏则会导致肾功能 衰竭。 “由于周围血管 疾病会导致血液 供应不足，所以 无法促进愈合。 因此，即使是 脚趾骨折或小 伤口，都久愈不 合且还会受到感 染使病症加重。” 蔡医生说。 “有时感染会演 变为溃疡，在极端严重 的情况下会出现组织坏死， 脚趾变黑或坏疽。” 血管成形术的治疗效果令人乐观。 80% 的患者在新加坡中央医院接受治疗 的一年后血管还保持通畅；两年后该比 例达 70%。血管再次变窄的个别患者仍 可接受血管成形术。
图：ALECIA NEO (下 ); SPH LIBRARY ( 右 )
外科医生蔡思颖（上， 中）通过插入血管的球 囊导管来疏通被阻塞的 血管。这微创手术无需 全身麻醉，适合健康 状况较差的患者如洪 信融先生（左）。
在新加坡引入血 管成形术之前，所有 截肢手术中， 80% 是 与糖尿病相关的。如今 这比例已降至20%以下。 洪信融手术后恢复得很好， 但由于髋部受伤而囿于家中。不过他可 以借助助行器四处走动，并考虑康复后 重新开始工作。 “我真的很庆幸。在蔡医生的帮助下， 我只失去了一根脚趾，而不是整只或半 条腿，”洪信融说。
及早发现病情 糖尿病患者要是行走近距离后出现 肌肉痉挛应谨慎留心并寻求治疗。 这种情况可能是周围血管疾病的征 兆，可以导致动脉阻塞、溃疡、坏 疽甚至死亡的病症。 “在这阶段，患者应该及早接受 治疗。如果等到受伤后才求诊，那 可能就需要接受侵入性的治疗了，” 新加坡中央医院普通外科顾问医生 蔡思颖说。 除了服食阿司匹林等药物来帮助 缓解早期的病症，医生也鼓励患者 在每次出现痉挛时多走动。这是有 助于扩张更新、更小的血管，使其
接起往身体部位输送血液的任务。 虽然这些预防措施在大多数患者 身上都能奏效，然而还有约三分之一 的患者需要血管成形术等治疗方式。 如果已出现溃疡或坏疽，首先， 应清除那些受损的组织，有时也需 要截掉一根或几根脚趾。以洪信融 先生的情况为例，因为坏疽已经侵入 伤口，所以不得不切除他的大拇脚 趾。然后再进行血管成形术来改善 血液循环，促进术后伤口愈合。 糖尿病患者可通过控制血糖水平、 戒烟、保持健康生活方式等途径降 低罹患周围血管疾病的风险。
糖尿病足 只需小心谨慎，糖尿病足患者就可免除 截肢之苦。 保持身体健康 控制血糖水平 注意饮食。如果超重，请节食 足部护理 每天至少清洗足部两次和保持滋润 以防止皮肤裂开，让细菌有机可乘 每天检查足部是否有切口、伤口或 压力性溃疡
新加坡中央医院内分泌科顾问医生兼骨质疏松及 骨代谢单位主任 Manju Chandran
我有胃病而且正在服药，但我担 心长期服用质子泵抑制剂会有不 良的影响。我是否应该在一年后 接受肠胃内窥镜检查以查看胃病 是否已痊愈？
预防受伤 在家穿舒适的拖鞋，最好带有衬垫的 外出时穿防护鞋，例如包脚鞋 如有鸡眼或胼胝（或生茧），要看 足科医生
伤口护理 由于伤口需要更长的时间愈合， 所以糖尿病患者在受伤时要特别注 意。严重感染的伤口可到新加坡 中央医院接受专科护士的治疗， 包括： 真空抽吸：促进健康组织生长 蛆虫疗法：清理伤口的感染部分 以特殊敷料或凝胶来辅助适用的 抗生素 创口较大时，则需整形外科医生的 专业介入。
胃病是很普遍的，而且通常和胃酸有关。 如果有幽门螺旋杆菌存在，消灭细菌将 可以帮助改善症状。即使长期服用，质 子泵抑制剂大致上是安全的。 服用质子泵抑制剂常见的副作用包 括头痛和便秘。不过，患者通常只需服 药6至8周，之后，建议有必要时才服用。 目前并无证据证明需要重复检查来确认 胃炎问题是否已解决。 樟宜综合医院肠胃病科顾问医生傅子贤
SEp⁄ OCT 2012
谨 防 这 个 沉 默 小 偷 盗 走 你 的视力
何谓青光眼？ 青光眼是视神经损伤，造成视力渐 渐丧失的一种眼疾。常见的青光眼 类 型 是 开 角 型 青 光 眼 和 闭 角 型 青 光眼。
原文 Vivien Chan
误区 陈麦可的案例突显了一般人认为只有老 年人才会得青光眼的误解。 新加坡全国眼科中心青光眼科高级 顾问医生兼部门主任胡庆麟，专攻主治 儿童与成人青光眼防护。她说:“我的病 人中有三成可能都在35岁以下，尽管这 年龄层患青光眼的人不到0.5%.”
难以接受的真相 由于眼内的流体压力增高，传递视觉信 息给大脑的视神经受到损伤，因而产生 青光眼。 许多成人在例行体检和视力检查中 才发现自己患有青光眼。这种眼疾在不 知不觉中逐渐恶化。有时患者感觉眼睛 疼痛、发红、头痛和恶心。患者也可能
视觉模糊，或出现虹视。那些有失明现 象的患者或许有这些症状好几年了。 胡医生说光圈、头痛和视觉模糊这 些急性症状是因眼压急速上升而引起 的，这意味着患者处于青光眼早期或者 是长期青光眼疾病出现了急速恶化。 青光眼是不可逆转的，但是如果治 疗得当，药物和手术是可以缓解或抑制 失明。定期检查对有家族病史的人至关 重要。
年龄增长 性别（闭角型青光眼常见于女性） 种族（闭角型青光眼常见于华人） 青光眼的家族史 屈光不正（近视会提高患上开角 型青光眼的风险，而远视会提高 患上闭角型青光眼的风险）
失明的风险 年龄是另一项风险因素。在新加坡， 50 岁以上的人患青光眼的几率约 3% ， 而 70 岁以上的人患病风险的机率则约 10%。其它风险因素还包括已患有其他疾 病，如糖尿病、高血压、近视和远视。 胡医生说与老年患者相比，年轻 的青光眼患者更有可能在有生之年失 明。“这是因为即使眼疾以同样的速度 发展，比起老年患者，年轻患者如早年 患疾，他们有足够的寿命完全磨损视神 经纤维，最终造成失明。” “急性青光眼可能会让患者在短短
一旦患有青光眼，视神经会不断遭到损伤， 使视野范围逐渐缩小。患者会感觉视野像通 过“隧道”般缩小或范围受限。
几天之内失明。而慢性青光眼患者，若 不加以治疗，可能会在几年后失明。有 效的治疗不能逆转任何丧失的视觉，但 是可以放缓或抑制失明进展。如果发现 得早，而且采取并保持适当的治疗措 施，失明是可以预防的。”
那你患青光眼的可能性比一般人 高2 - 3 倍
有青光眼，那你患青光眼的可 能性比一般人高3 - 5 倍 如果你患有青光眼，务必告知 你的亲人，鼓励他们接受检查
在全球大约3800万个失明的个案中， 有510万个是由青光眼造成的。它也 是全球永久性失明的主要原因之一。 随着全球老年人口的快速增长， 青光眼患者的人数也将有上升的趋 势，造成保健费用增加和沉重的 经济负担。青光眼将成为本世纪永 久性失明的最主要原因，全球将有 7000万人患上青光眼。 在新加坡，大约有3%年龄50岁 以上的人士患有青光眼。这个比例 随着年龄的增长而增加，大约有 10% 的 70岁以上老年人患上青光眼。 约半数的人属于闭角型青光眼患者。 一般而言，这种疾病毫无症状。 超过 90% 的人在诊断时都不知道自 己患上了青光眼。因此，青光眼又 称“沉默的视力小偷”。虽然青光 眼不能治愈，但及早发现和治疗可 预防失明。你应定期接受眼睛检查， 以便及早发现问题。
本是一次得偿所愿之行，接受激光手术 以永久摆脱隐形眼镜。但是医生的发现 让他大吃一惊。 销售经理陈麦可（译名）说：“医 生发现我的视神经萎缩，而且眼角膜细 薄。”经过视力测试，他得知自己患了 青光眼。青光眼无法治愈，还会导致视 力逐渐丧失直到失明，是目前造成永久 性失明的主要原因之一。 他说：“我觉得一切都很正常，没 有任何特别症状或感到眼睛疼痛。” 陈麦可被诊断出患有青光眼时才 35岁。在这之前，他唯一接触到这种病 例是当他的一个朋友在年仅18岁时因青 光眼而失去了一半的视力。 目前，他每6个月进行一次检查，每 晚睡觉前都会滴眼药水，眼疾情况才得 已受到控制。 除此之外，育有一名8岁大的孩子， 陈麦可有份稳定的工作，喜欢跑步、网 球、举重和潜水等运动，生活其实并没 有太大的改变。“我很庆幸及早诊断出 了眼疾。”
针对不同种类的青光眼和年龄组，不同 的疗法和矫正手术有不同的疗效。 胡医生说：“我有一些病人在一岁 时便进行了手术。他们现在视力正常， 生活也正常。有些则因有难治性疾病而 失明，或因其他状况如视网膜异常，病 症发现得晚或未能遵循治疗和复诊。”
青光眼可以预防吗？ 开角型青光眼是不可预防的。但是， 及早发现和治疗可预防视力受损及 失明。 闭角型青光眼却是可以预防的。 在这个眼疾的初期阶段（眼睛出现 闭角但还未形成青光眼），你可接 受激光虹膜切除术，以预防失明。
药物是年龄较大的儿童和青年的一 线治疗方式。然而，对于年龄较小的儿 童，手术的效果往往比药物更有效。 胡医生回忆起7年前，涉及一个刚满 月的婴儿的病例。当眼科医生告知父母 孩子患有青光眼，可能失明时，父母 都“惊呆了”。 胡医生为婴儿进行的手术很成功。 如今，该小孩的情况得到了控制。他的 视力正常，只需要每半年进行复查，以 及观察眼内液压和疾病发展的情况。
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疹 患 者 的 免 疫 系 统 较 容 易 对 尘 螨 和 动物毛皮等各种无害的细菌产生反应。 相反的，与生活在极其卫生环境的人 比较，儿时的环境中如果经常接触到各 15岁的佳玲从孩童时期就患有皮肤瘙痒 种细菌的人通常不会那么容易对各种无 症，使她的皮肤有如鳞屑般且还泛红。 害细菌产生反应。彭医生补充说：“在 尤其在晚上，皮肤更是奇痒无比。搔抓 卫生条件比较恶劣的国家，人们可能从 后的皮肤变得肿胀，刺痛感且非常敏感。 小就受到各种细菌的侵染。所以，他们 湿疹部位通常出现在手部、足部、肘关 的皮肤自然就形成了可对抗异位性皮炎 节内侧和膝盖后方。 的自我保护层。” 佳玲患有异位反应性皮肤炎或异位性 湿疹。新加坡中央医院皮肤科主任兼高 级顾问医生彭绍明说：“异位反应性皮 肤炎是一种相当常见的皮肤病，有一定 请： 的特征模式。在新加坡，每5人当中就 恢复皮肤的保护层 有1人患有这种皮肤病。” 湿疹是皮肤炎症的一种，广义上指一 减少沐浴次数，缩短沐浴时间， 系列顽固性皮肤病，包括皮肤干燥、复 用温水沐浴 发性皮疹等。过度沐浴、使用刺激性肥 使用温性、不含香料的洁面乳和 皂和流汗都会引起湿疹。湿疹可通过药 沐浴乳 物和保湿剂来控制。 一般来说，超过半数的异位性皮肤炎 患者都在两岁前开始发病。然而这种疾 病是没有年龄限制的。很多人会在成年 后治愈，而有些人则会偶尔突然病发， 防止皮肤感到不适 原文 Rachel Chan
甚至会持续多年不能治愈。湿疹患者通 常还会有其他过敏症，如哮喘、过敏性 鼻炎或花粉症。 彭医生说，“有人认为湿疹可能是因 为环境过于卫生所造成的。因为处在非常 卫生的环境里，可能就不会与各种细菌结 缘，这便大大提高患湿疹的几率。”湿
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体液潴留新疗法 现年 59 岁的德士司机苏朝清先生和 琴纳玛一样，也有呼吸困难及体液潴留 现象，主要是腹部和腿脚出现肿胀。 苏朝清说：“我基本上没办法走路， 走不到10米就气喘。我的腹部肿得非常 厉害，犹如10月怀胎的孕妇似的。” 同样患有充血性心力衰竭的他，在九 年前就被诊出患上癌症。可是化疗却严 重损害了他的心肌，进而造成现在的心 衰竭。
进屋前打开空调 有充足的休息 学习如何更好地管理压力 远离高温
大约有两、三成患有水肿的病人对利 尿剂产生抵抗，也就是说他们的肾脏对 利尿剂不会产生反应。这种情况通常发 生在患有中度到重度心力衰竭的病人身 上。迄今为止，他们唯一的治疗途径只 有通过透析来排除体内积液。 琴纳玛没有利尿剂抵抗的问题，但她 几乎对所有的利尿剂药物产生过敏。如 果没有水分置换疗法，她也别无选择， 只能接受透析治疗。
转时，可用局部类固醇药膏控制反复发 作的个别部位。 如果病情较轻，可用抗组胺药物控制 瘙痒症状，在湿疹发作时则用不同强度 的类固醇药膏和非固醇类药膏镇静和舒 缓皮肤。其他治疗方法还包括光线疗法， 即通过使皮肤在各种波长的光线中暴露 一定时间来治疗湿疹。 皮肤干燥会使病情恶化，所以不含香 料的保湿剂或润肤膏对缓解瘙痒症状也 请勿： 至关重要。因此，湿疹患者须避免接触 肥皂、香水和刺激性强的清洁剂。 待病情稳定后，湿疹患者适宜进行游 沐浴时间过长 使用温度较高的热水，因为这样会加 泳等轻度锻炼运动。但患者应避免会引 起大量流汗的体育活动，以免加重病情。 速皮肤水份流失 用肥皂清洁皮肤，因为这样会损害皮 肤的保护层并使皮肤感到不适 洗泡泡浴、使用香皂或沐浴油，因为 在发炎部位敷用处方类固醇药膏 这样会使皮肤感到不适 在发炎部位敷用湿润剂 用湿巾轻拭有渗液的急性炎症 部位 穿羊毛或合成纤维的衣物，这些织 每天有充足的时间敷用药物和 物会刺激皮肤 湿润剂 习惯性地搔抓瘙痒部位 药膏、特别是非固醇类药膏可在 吃会过敏的食物 敷用前放置冰箱冷藏，以减轻皮 从事会促进排汗的活动 肤的灼热感
“虽然透析能有效地排除多余体液， 但它是有局限的。比如疗程必须在加护 病房里进行，还有病人需要接受几个疗 程才能慢慢脱离透析机，”沈医生说。 相比之下，水分置换疗法不但可以在 普通病房里进行，而且病人只需一次疗 程就够了。苏朝清在2011年11月接受一 次疗程后就成功地将体内多余的12公升 液体排除，同时体重也减轻了8.8公斤。 然而，不是所有的患者都适合接受水 分置换疗法。像重度肾功能衰竭者或低 血压者就不适合。此外，对肝素（超滤 过程中使用的血液稀释剂）过敏的病人 也同样不适合接受水分置换疗法。
利尿剂抵抗 苏朝清每天不只摄入少量液体和低盐分 食物，同时还服用利尿剂或“水丸”来 增加尿液量。然而这些传统疗法对他始 终没有奏效，甚至在静脉上注射大量的 利尿剂也无法帮他排除体内多余的液体。 琴纳玛女士患有充血性心力衰竭，导致体内积 水或体液潴留。 这种情况被称为利尿剂抵抗。
“在卫生条件良好的城市化环境中， 孩子们接触不到这些细菌，所以患上湿 疹的几率更大。” 最新研究显示，大多数湿疹患者的皮 肤都出现蛋白质突变，导致皮肤自然保 护层机能削弱。而且，湿疹患者皮肤中 的脂肪含量往往较低，所以他们的皮肤 比正常人的皮肤更加干燥。 湿疹患者的另一个特点就是皮肤上的 细菌数量较多。每个人的皮肤上都有细 菌，同时也有所谓的抗菌素，能够保护 我们不受细菌的侵染。异位性皮炎患者 皮肤的保护性抗菌素水平要低很多，所 以皮肤表面会附着更多细菌。 彭医生说，严重的湿疹患者有时需服 药来抑制过于活跃的免疫系统。情况好
如今，苏朝清开心多了。他感觉身体轻 松了不少，也恢复了往常的生活。 “我不再有呼吸困难，走起路来也轻 松了很多，而且又能继续开德士。现在 我觉得自己很健康，”他说。 同样也能够正常地走路的琴纳玛，也 已不需要时刻停下来歇息。虽然她不再 照顾孙子，过着清闲的生活，可是她也 非常享受他们的陪伴。
为了打发时间，琴纳玛也打算尽快去 找份兼职工作，但又意识到健康的重要性。 她心里也明白，一旦心衰竭病情恶 化，腿部水肿复发的几率也会随着提高。 因此，她定时服药。 “我也必须注意自己摄入的液体，每 天不能超过一公升，这包括咖啡和汤类。 此外，虽然目前我的体重已经减轻了不 少，我还是得控制自己的饮食。这样也 能为心脏减少负荷，”她补充说。
提早发现水肿症状 心、肾、肝等器官功能紊乱是导致病患 体内体液潴留的原因。患有这些情况的 病人应当留意相关的症状，这一点非常 重要；如果不及时诊治，可能会致命。 需要注意的症状： 与正常情况相比，呼吸更急促 手指按压腿部时会出现凹痕 两天之内体重增加两公斤以上
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健保双全计划（MediShield）和长者保障计划 （Eldershield）确保所有新加坡人享有医疗保险 在儿子出生几个月后，李先生发现他的 央公积金医疗储蓄账户划出了金额支付 儿子的健保双全计划保费。 李先生和李太太与中央公积金局核 实后发现自 2007年 12月起，所有新加 坡新生儿和永久居民都将会自动接受 健保双全计划的保障。健保双全计 划是新加坡全国基本保险计划，帮 助参保人支付 B2 和 C 级病房大额的 住院费用。 在此之前，新加坡公民和永 久居民是在首次缴纳中央公积 金后才会被自动包括在健保双 全计划里。 健保双全计划在出现病症 之前就将新生儿纳入投保， 以保证尽可能多的人拥有 基本的健保双全计划。作为一 项医疗保险政策，健保双全计划可能排 除已有的疾病。健保双全计划自动投保 方案和保险范围会发送给参保人，其中 包括健康申明表，只需在有必要时才须 填写。 41岁 的 陈 先 生 也 对 他 中 央 公 积 金 医疗储蓄账户划出的金额感到非常不 解。他发现自己支付了长者保障计划 的保费，但他却想不起自己参加过这项 保险。 他和指定提供长者保障计划的保险 公司核实了情况才发现这是一项卫生部 制定的严重残疾保险计划。当新加坡公 民和永久居民年满40之后，这项计划将 会自动实施。卫生部随机指定Aviva 保
意见箱 后续治疗，请到综 合诊疗所 我在新加坡国立牙科中心做了一 副假牙。我很满意那里的服务。 但之后，我得到综合诊疗所附属 的牙科部门做后续治疗。我家离 新加坡国立牙科中心很近，可是 为什么我不能继续在那里接受治 疗反而得舍近远赴到综合诊疗所 复诊呢？ 新加坡国立牙科中心答复： 获悉 您对我们所提供的医疗服务感到满意， 让我们倍感欣慰。由于有许多患者到本 中心接受专科治疗，我们会尽量以快捷 的方式为每位患者提供贴心的服务。 然而目前，鉴于专科资源有限，本 中心采取分症治疗以确保急需关注的病 人能即时获得治疗。分症治疗是依照病
保障 计划 受保
双全 计划 受保
险、大东方人寿保险和职总英康保险合 作社当中的其中一家为中央公积金的成 员投保。 符合参保条件的新加坡公民和永久 居民会在 40岁生日的前 3个月从指定的 保险公司收到长者保障计划方案。只要 他们没有回绝参与这项保险计划，指 定的保险公司就会从他们的医疗储蓄账 户扣除保费。在此期间，参保人也可选 择向另一家保险公司参保，而且不会有 任何罚金。但是如果在 3 个月结束后才 决定更换保险公司，则会被视为新的申
健保双全计划保费可由医疗储蓄账户支付。 如果你或你的家人拥有综合健保双全计划， 也可以使用医疗储蓄账户支付保费 健保双全计划和综合健保双全计划有个人 承担和自负额的选项 个人医疗储蓄账户或直系亲属的储蓄账户 都能够用来支付个人承担和自负额的费用 保费不固定，并会随着参保人的年龄逐渐 增加 可能有等待期间。如果索赔发生在保单生 效后的指定期间内，保险公司是不会进行 赔付
新加坡公民或永 久居民在年满 40岁会被指定 的保险公司参保 长者保障计划。
是中央公积金成员的新加坡公民或永久居 民将会在年满40岁后自动投保，除非他们 选择退出 长者保障计划可由医疗储蓄账户支付 中央公积金成员可使用医疗储蓄账户为父 母、配偶、子女，或孙辈支付长者保障计 划的保费 本文信息摘自www.moneysense.gov.sg网站
请。新保险公司在接受投保人之前可能 会要求申请人进行健康评估。 陈先生的参保公司因没有收到他的 回绝，所以就从他的医疗储蓄户头里扣 除了保费。
6项 日 常 生 活 活 动 包 括 ： 洗 漱 或 洗 澡 、
厅中，约八成至九成的食物摊位 都应该减少菜肴中油、糖和盐的 用量，并且所有摊位都不应该售 卖油炸食品。
将会享有一些折扣。 温馨提示：全麦食品是抗氧化剂如 维生素E和植物化合物这些有益植物成 分的重要来源。这些物质协同作用，有 助于降低患心脏病、糖尿病和某些癌症 的风险，甚至还有助于控制体重。
穿衣、吃饭、上厕所、行走，和从床上 或椅子上起身。 负责长者保障计划的 3 家保险公司所 收的保费相同，在基本的长者保障计划 下也提供相同的补偿金额。即使在保单 残疾申报 生效之后，参保人依然可以改变主意。 长者保障计划为需要长期照顾的人提供 他们享有60天的宽限期，既保单生效后 经济资助。该计划每月会提供现金帮助 的 60 天内取消保单并将获得全额退款。 因故造成严重残疾的人支付费用，为期 但在这期限之后，取消则没有退款，而 最多72个月。 且保单会在下一次付费时才被取消。 残疾被定义为无法独立完成指定的 预知更多与长者保障计划有关的信 6 项日常生活活动中的 3 项或 3 项以上。 息，请到卫生部网站（www.moh.gov.sg）。
人的健康状况和严重程度来配合所需的 专业水平。 如果预约席位运用恰当，专科预约 的等候时间就可以缩短。要是后续治疗 不复杂，一般全科牙医就能为您提供治 疗与护理，而到综合诊疗所或社区牙科 诊疗所也可以降低您的费用。 接受专科治疗后，您的牙医会从您 的口腔现况，决定您是否适合转介到综 合诊疗所或社区牙科诊疗所的全科牙医 继续接受治疗。 任何时候，如果你需要看专科医 生，你的全科牙医能将你转诊到新加坡 国立牙科中心。 *根据新加坡卫生部的社区卫生协助计划 ( www.chas.org )，现在全岛有200余家牙科全科诊 所提供受资助的牙科治疗。参与该计划的诊所很 多均位于组屋市中心地区。
更健康的食物选择 真希望看到所有的医院，包括新 加坡中央医院都能在他们的餐厅 提供更健康的食物。在你们的餐
新加坡中央医院答复：我们非常赞 同您的观点。新加坡中央医院的所有餐 厅都提供更健康的食物选择，比如全麦 面条、糙米和粉条，并减少食用油的 量。如果选择这些更为健康的食物，您
若有任何关于入院手续、账单及程序等疑问，可 电邮至 email@example.com，我们会在这个栏目解 答您的问题。
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Published on Aug 20, 2012
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