LISTEN TO YOUR HEART
Tensoval duo control. Simply more secure. ÂŽ
10 Rules of Blood Pressure Monitoring Using Tensoval duo control Blood Pressure Monitors 1.
BHS â€“ British Hypertension Society A/A Grade Accuracy
Measure daily at the same time, ideally in the morning as your blood pressure changes throughout the day 2. Do not smoke or take tea/coffee before taking your blood pressure 3. Rest your arm on a table and sit down while taking your blood pressure 4. Go to the toilet before taking your blood pressure 5. Avoid eating a heavy meal before taking your blood pressure 6. Do not move while taking your blood pressure 7. Do not talk while taking your blood pressure 8. When taking a second reading,rest for one minute 9. Always record you blood pressure down 10. Blood pressure measurement should be done daily
SINGAPORE HE ALTH
JUL⁄ AUG 2012
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PHOTOS: MORVEN KOH
Student volunteers befriend patients and visitors as part of their school project
Student volunteers from Fairfield Methodist School (Secondary) stationed themselves at SGH Block 3 in late May and early June, and got visitors and patients to paint on white glazed tiles, which helped enliven the hospital environment.
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I]ZgZl^aaVahdWZ^ciZgVXi^kZ\VbZhVcY [gZZ\ddY^ZWV\hl]^aZhidX`haVhi# Fundraising for a good cause ;gdb 6j\ &! H^c\=ZVai] l^aa WZ gV^h^c\ bdcZn [dg i]Z IGJ: [jcY Ä l]^X] WZc" ZÒih cZZYn igVcheaVci eVi^Zcih Ä i]gdj\] i]Z hVaZ d[ IgVcheaVci 6lVgZcZhh G^WWdc E^ch# :VX] e^c Xdhih ( VcY i]dhZ hedi" iZY lZVg^c\ i]Zb Yjg^c\ i]Z H^c\=ZVai] IgVcheaVci 6lVgZcZhh LZZ` hiVcY id l^c \^[i kdjX]Zgh# ;dg bdgZ ^c[dgbV" i^dc! XVaa +('+"*&.* Yjg^c\ d[ÒXZ ]djgh dg Z"bV^a h^c\]ZVai]#igVcheaVci5h^c\" ]ZVai]#Xdb#h\# ;dg bdgZ ^c[dgbVi^dc dc H^c\=ZVai] igVcheaVci egd\gVbbZh! k^h^i lll#h^c\]ZVai]#Xdb#h\$igVcheaVci#
Highlights Aug 27 – SGH Block 2/3 (outside Specialist Outpatient Clinics on Level 1) Aug 28 – SGH Block 2/3 (outside Specialist Outpatient Clinics on Level 1) Aug 29 – SNEC lobby Aug 30 – SNEC lobby Aug 31 – KKH, Women’s Tower Podium
Jul⁄ Aug 2012
singapore he alth
Dummy helps doctors sharpen skills one of them started coughing and gasping for breath. That triggered an alarm and, within seconds, a team of young doctors, nurses and a respiratory therapist rushed to his bedside. They swung into action to maintain his airway, breathing and circulation, monitor his vital signs and initiate emergency treatment. One of the medical team members asked: “Hello? Mr James Tan? Can you hear me?” “I have difficulty breathing,” the patient mumbled. “What are the latest vital signs?” the medical team leader asked. “BP (blood pressure) is low. Can we prepare to intubate the patient? BP is 54/2...” “Mr Tan, because you’re breathless, we’re going to put a tube into your lungs to help you breathe. Prepare the oral laryngoscope and endotracheal tube.” Soon, Mr Tan’s condition stabilised and the worst was over. It was not a real emergency but a simulation of an urgent medical situation which doctors, nurses and other medical professionals have to respond to at any time. And Mr James Tan was actually a life-size doll. Still, the team showed they had learnt their lessons well by swiftly and confidently responding to the “emergency”. Helping the hospital create the emergency situation realistically is a crucial piece of machinery – the sophisticated,
high-tech doll or manikin capable of emulating complex medical conditions and responding to treatment. Although such so-called high-fidelity manikins have been used at SGH’s Institute for Medical Simulation and Education (IMSE) since 2008, this was the first time one was “called into action” in a hospital ward – with the participants, doctors, nurses and therapist on actual duty, attending to real patients in the intensive care unit. In comparison to training at the hospital’s simulation training centre, “the real life ward setting, the ventilator and other equipment made it easier for us to be immersed in the situation”, said Dr Jonathan Yap, an Internal Medicine Resident. “The experience was more realistic (compared to that in a simulation lab).” According to Dr Peter Mack, Senior Consultant, Department of General Surgery, and Director, IMSE, SGH, this more realistic approach to training, known as an in-situ simulation, became possible after recent technological advances enabled wireless manikins to be produced. The trainer manipulates the manikin’s “body functions” by controlling signals from a laptop. “In the ward, participants can check that their equipment and drugs are in order and things are within reach, that they know what to do and where to reach for their equipment. It is a chance for them to find out where the gaps in their processes are and how they work in the real world, and know what can really go wrong,” Dr Mack said. Simulation in the hospital ward offers valuable opportunities to identify
In-situ simulation is a more realistic approach to training, with manikins like this one being used in the wards to emulate medical conditions.
By manipulating controls on a computer, a trainer can bring on a “heart attack”, “lung collapse” or other medical conditions in the manikin.
potential dangers and flaws in the clinical systems, the environment and the acute care team. Having doctors and nurses attend to a wireless manikin like a real patient enhances their learning, corrects their mistakes, fine-tunes their skills and improves team communication. Simulated training also allows participants to experience rare clinical scenarios as often as necessary, and helps them keep
up with changing technology, with the ultimate aim of increasing patient safety and delivering quality care. “In the simulation laboratory, participants often say, ‘We are unfamiliar with this artificial environment, which is why we did things wrongly; but in the ward, we’ll be fine.’ But will they? The only way to find out is to have the situation play out in a real-life setting,” Dr Mack said.
PHOTO: vernon wong
At Singapore General Hospital’s (SGH) Medical Intensive Care Unit, patients lay quietly in their beds. Many were unconscious and were breathing with the help of ventilators. Suddenly,
PHOTO: Alvinn lim
With the help of a high-tech lifelike doll, SGH staff train for emergencies in simulated real situations
Can you guess what this is? See page 26 for the answer.
singapore he alth
Jul⁄ Aug 2012
Wanted: More cord blood donors As the Singapore Cord Blood Bank celebrates facilitating its 100th cord blood transplant, it is appealing for more donors BY Jamie Ee
In March this year, the Singapore Cord Blood Bank (SCBB) made a landmark announcement that it had facilitated its 100th cord blood transplant since its official opening in 2005. The cord blood came from its banked inventory and was donated by an unrelated donor. It was a major milestone for SCCB. However, the non-profit bank, which is Singapore’s only public cord blood bank, is still looking for more cord blood donations to help other Singaporeans in need of haematopoietic stem cell transplants (blood stem cell transplants). Drawn from the umbilical cord of a baby after delivery, cord blood is a rich source of self-renewing blood stem cells that can develop into different mature blood cell types, which can save lives after a blood stem cell transplant. Blood stem
cells have proved highly effective in the treatment of blood cancers such as leukaemia and lymphoma. The stem cells in cord blood are naive (without prior exposure to any bacteria, virus, parasite or other stimuli) and are unlike bone marrow blood cells. The matching between a cord blood donor and recipient is also less stringent compared to the matching requirements for bone marrow cells. Few mothers donate to SCBB Collecting cord blood presents minimal risk, and is painless and non-invasive, but few mothers in Singapore donate it to SCBB. Of the 35,000 or so births each year, only 10 per cent of mothers donate. The donation rate could be much better, said Dr William Hwang, Medical Director, SCBB, and Head and Senior Consultant, Department of Haematology, Singapore General Hospital. “The bank’s limited units mean that
about 40 to 60 per cent of Singaporeans in need of stem cell transplants cannot find a suitable match,” said Dr Hwang, who is also an Assistant Professor with Duke NUS Graduate Medical School. He thinks the key reason for the low donation rate is the lack of awareness about donations. “Some mothers may fear donating or choose to keep the cord blood for their own baby or family’s use in the future.” Doctors in the haematopoietic stem cell transplantation field currently favour public donation, as studies suggest that the chance of using one’s own cord blood is very small and currently does not give better results in treatment.
If we have between 10,000 and 20,000 cord blood units, we would have a 60 to 80 percent chance of finding a suitable match for transplantation for the majority of Singaporeans.
Teng Hong Yi (far left, pictured here with his mother Ms Regina Soong and his two siblings) underwent cord blood transplantation two years ago.
A perfect match from a stranger When Primary 6 pupil Teng Hong Yi was nine, he was diagnosed with chronic myelogenous leukaemia, a rare blood cancer. His condition did not improve even after being on medication for a year. So, his doctor, Associate Professor Tan Ah Moy, Head and Senior Consultant, Paediatric Subspecialties, KK Women’s and Children’s Hospital, recommended a haematopoietic stem cell transplant. His parents and two siblings were tested and tissue-typed, but none were found to be suitable donors. So they turned to SCBB for help. On their second search, they found a
perfect match. His mother Ms Regina Soong, 33, said: “I knew from the doctors and nurses that it was not common to get a match, so I didn’t think we’d be so fortunate to find one and, what’s more, a 100 per cent match.” Two years ago, the Yishun Primary pupil underwent cord blood transplantation and, today, the cancer is in remission. “I will definitely encourage parents to donate their baby’s cord blood because it gives another person a shot at life. If they don’t donate it, it will be discarded and go to waste,” said a thankful Ms Soong.
PHOTOS: Alvinn Lim
Dr william hwang, medical director, singapore cord blood bank
Donation to a public cord blood bank is strongly encouraged by organisations such as the American Medical Association and the European Group on Ethics in Science and New Technologies. Cord blood from a different person (not the patient’s own cord blood) is most commonly used for cord blood transplants, as another person’s cord blood will not contain the genetic deficiencies that caused the disease, which led to the need for a transplant. The bank aims to increase its cord blood units from its current inventory of 8,100 to 10,000 by 2014. “If we have between 10,000 and 20,000 cord blood units, we would have a 60 to 80 per cent chance of finding a suitable match for transplantation for the majority of Singaporeans,” said Dr Hwang. He added that bone marrow registries around the world have a large pool of Caucasian donors but comparatively fewer Asian donors. As a result, 65 to 80 per cent of Asian patients in need of bone marrow or blood stem cells for transplant are unable to find a suitable match. This is made worse as patients have only a one-in-four chance of finding a match among siblings.
Why I donated
When her son, Cristan, was born last year, housewife Mandy Loh, 32, donated his cord blood to SCBB. “My husband and I decided that we were not going to store the cord blood in a private bank. So rather than discarding it, we thought we should donate it to someone who needs it,” she said. “It is a good option that mothers should think about because it really brings hope to another person. “There is so much beauty in bringing a child into this world and mothers can share this joy by giving hope to other people who may be suffering.” For more information, visit www.scbb.com.sg. To donate, please call 6394-5011 or write in to firstname.lastname@example.org.
Enlarging the pool He said that, “with cord blood, there is an increased chance of finding a match because it can be partially mismatched to the patient when used for transplants”. Agreeing, Associate Professor Tan Ah Moy, Head and Senior Consultant, Paediatric Subspecialties, KK Women’s and Children’s Hospital, said: “When you donate cord blood to a common shared resource like the SCBB, more patients are able to access and benefit from it. Although there is a one-in-four chance of a match among siblings, it doesn’t mean every child will find a match among his siblings. In these instances, we still have to search through SCBB for a suitable match.” To raise awareness here, Dr Hwang and his counterparts have been giving talks to the public and the medical community. Also, to include donors from minority races, SCBB has reached out to organisations like Majlis Ugama Islam Singapura (MUIS) for their endorsement of cord blood donation. It has had some effect. Mr Steve Sobak, CEO of SCBB, said: “Through various media, obstetricians/gynaecologists, clinic and hospital staff, as well as word of mouth, expectant mothers are coming forward to donate their cord blood. But we need more to increase the chances of patients finding a suitable match.”
04 News-CordBloodBank V3 WF path.indd 5
14/6/12 10:32 PM
SINGAPORE HE ALTH
JUL⁄ AUG 2012
;^cYdjindjgVXijVa bZiVWda^XgViZ SGH kick-starts a new study to establish a more accurate formula for calculating the metabolic rates of Singaporeans
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Build more muscle mass As muscle burns more calories than fat, building up more lean muscle will help burn more calories every day. Doing some weight-bearing exercises, such as weight-lifting or walking, will add muscle mass and burn calories. To find out their body composition, participants stand on a scale that sends a harmless electric current up through the body.
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To measure the resting metabolic rate, a small plastic hood or canopy is put over the head of the participant who is lying down on a comfortable bed. The canopy measures the amount of oxygen and carbon dioxide breathed in and out by the participant. This is based on the principle that gases and heat are produced and used when the body expends energy to power its basic functions while it is at rest. The participant has to remain still and quiet, but not fall asleep during this test, which takes about half an hour. People who are interested in taking part in the study can call Miss Stephanie Tan at 6326-6794 or email her at email@example.com for more information. Generally, participants have to be healthy, and not pregnant or experiencing significant weight loss or gain, to participate in the study. They will need to spend a weekday morning at SGH Lifestyle Improvement and Fitness Enhancement (LIFE) Centre, and fast and refrain from smoking as well as moderate to vigorous activity 10 hours before the test.
A sensible, balanced diet, regular exercise and good sleeping habits can give a boost to energy and lead to good health. Other ways of boosting the metabolism include:
Avoid skipping meals Significantly decreasing the caloric intake will slow the metabolic rate as the body enters “fasting” mode and reacts by hoarding fat and burning lean muscle for energy.
Get adequate sleep Not sleeping enough affects the levels of appetite-regulating hormones, and the capacity to metabolise carbohydrates in the body. The metabolic rate nosedives as less fat is burned for energy.
Eat enough protein Protein forms the building blocks for muscle, and having inadequate protein can lead to the loss of desirable, lean muscle mass.
Drink less alcohol Alcohol slows the fat-burning process. The body needs to burn calories from alcohol before fat can be lost through diet and exercise. Adapted from Beautiful Inside Out, The SingHealth Guide to Women’s Health, produced by Reader’s Digest for SingHealth.
By using a small plastic hood, Miss Stephanie Tan (left) is able to measure the amount of oxygen and carbon dioxide a patient breathes in and out while at rest. She will use the data to develop a formula for estimating resting metabolic rates.
PHOTOS: VERNON WONG
BY JAMIE EE
SINGAPORE HE ALTH
HncX]gdc^hZYh]dX` SGH embarks on world’s first study to improve survival chances of sudden cardiac arrest patients BY THAVA RANI
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Where can I get trained in CPR and AED techniques? The following centres provide courses in CPR and AED: Singapore Heart Foundation Singapore Civil Defence Force St John Ambulance Singapore Singapore Red Cross Society
PHOTOS: ALVINN LIM
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The best time to deliver an electric shock to the chest may be during the upstroke of a CPR compression. “Early CPR is important at that point to get some blood flowing,” said Associate Professor Marcus Ong as Ms Samantha Yong looked on. “With the residual oxygen in the blood, the heart is prepared, giving it a greater chance of restarting when a defibrillator is used.”
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When someone suddenly collapses
L]Vih]djaY>Yd4 If the victim is unconscious and not breathing, call 995 for an ambulance Start CPR early to get the blood flowing If there is an automated external defibrillator (AED), use it to deliver an electric shock to the heart
* The AED, a simple device that can be used by anyone, is able to analyse the heart rhythm and prompt the first-aid provider to deliver the electric shock if necessary. * A registry that lists venues with AEDs can be found at www.myheart.org.sg.
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singapore he alth
JuL⁄ AUG 2012
News > Continued from page 1
interviews and counselling at SGH Lifestyle Improvement and Fitness Enhancement (LIFE) Centre. Staffed by a multidisciplinary team of doctors, dietitians, physiotherapists, psychologists, occupational therapists and medical social workers, the centre promotes integrated and holistic care for patients with lifestylerelated medical conditions, such as eating disorders and obesity. Since his 20s, Mr Lawrence had been seeing Dr Tham Kwang Wei, Consultant, Department of Endocrinology, SGH, and Director, Obesity and Metabolic Unit. It was only late last year that he made up his mind that he was ready for the procedure and the commitment it entailed. “He was first referred to the Diabetes Centre at SGH as a 19-year-old after he was diagnosed with type 2 diabetes during his national service pre-enlistment screening,” said Dr Tham. “He was a typical diabetic. He battled with his weight for a long time. He would lose 10kg and bounce back with a 15kg weight gain. He had been seeing us for a good seven years. Then he disappeared off the radar and came back about a year later with very poorly controlled diabetes. His blood pressure was high and his cholesterol levels were off the charts. I said, ‘Look, you are young and you can’t go on like that. You are a candidate for a heart attack at 40.’ And that was when we discussed surgery.” For Ms Rozita, the turning point came a year later when she was in and out of the hospital four times for a host of medical problems which included diabetes, inflamed stomach ulcers, sleep apnoea and an ovarian cyst. Fed up that her weight was causing her so many problems, she opted for gastric bypass. “I told my husband, ‘I don’t care if you allow me to or not, I am signing the consent form for the surgery.’” Such determination and commitment is key when assessing patients for bariatric surgery, said Dr Shanker Pasupathy, Senior Consultant, General Surgery, and Director, LIFE Centre, SGH. “There is a common misconception that the operation will fix everything and, after that, you will go on with your life. But that is not true. The surgery is a reset button and, after that, you embark on a new life, not just in terms of eating but your whole approach to life.” Patients who go to LIFE Centre learn to modify their eating habits. “We talk about eating, selecting food and being relaxed. They need to understand that these are important and they need to make changes. Undergoing surgery to lose weight will help them only 20 to 30 per cent of the way,” Dr Shanker said. Bariatric procedures – whether it is a gastric bypass, gastric lap band surgery or gastric sleeve surgery – are doomed to fail if patients do not make dietary and lifestyle changes, he added. They could regain all the weight they worked so hard to lose in the first place.
Post-surgery After surgery, a patient’s stomach is reduced to the size of a tiny pouch that is attached to the middle portion of the small intestine. Eat more than what the pouch can handle and the patient will throw up. Mr Lawrence typically eats a slice of bread for breakfast, a small piece of fish for lunch and a small piece of chicken for dinner. “Less carbohydrates, no fried chicken, which I loved, and no rice. I no longer remember what rice tastes like.” Ms Rozita, who admitted she used to not know the word “full” when it came to food, has taught herself to say “no” to a lot of it. She and Mr Lawrence are now committed to a life of careful eating, exercise, a regimen of daily supplements and regular visits to LIFE Centre to monitor their progress. They have become advocates of a healthy lifestyle as family members and friends follow their new habits. Mr Lawrence’s family alone has collectively lost over 30kg since his surgery. “That one person who has had surgery and has been taught about eating becomes a nucleus of change for the family,” Dr Shanker said. Patients are helped by the support of others in the same boat. Prospective patients and people going through the various post-operative phases attend support group meetings at LIFE Centre, held every other Wednesday evening.
Obesity brings on other diseases Obesity refers to abnormal or excessive fat accumulation that represents a risk to health. According to the National Health Survey 2010, the obesity rate increased to 10.8 per cent in 2010 from 6.9 per cent in 2004. The Health Promotion Board considers people with a BMI of 27.5 and more to be at high risk of developing a number of diseases, including the following:
Abnormal heart function Asthma Obstructive sleep apnoea Gall bladder disease Osteoarthritis Joint pains Leg swelling Stroke Cataract Diabetes Hypertension Cancer Abnormal periods Infertility Polycystic ovarian syndrome Coronary artery disease
Banding and stapling Procedure
Laparoscopic adjustable gastric banding
An adjustable silicone band is placed around the upper part of the stomach to reduce its size, so the person feels full faster and thus eats less and loses weight A port implanted under the skin allows for fine adjustment of the outlet diameter
Relatively simple surgery No cutting of stomach Initially low complication rate post-surgery Improves mild diabetes Reversible (if band is removed before complications set in)
Foreign body inserted Requires regular adjustments in clinic About 10 per cent of patients do not achieve any weight loss Significant late complications, including infection, band erosion or slippage, requiring repeat surgery
Laparoscopic sleeve gastrectomy
About 75 per cent of the stomach is removed The early results of this relatively new procedure are promising
No foreign body is inserted as with banding One-off surgery Rapid initial weight loss Reduces hunger pangs more than banding Improves mild diabetes Patients can eat better than after banding, but still experience good weight loss
Permanent and irreversible Long-term (over five years) results are not known Staple line on stomach can bleed or leak
Laparoscopic Roux-en-Y gastric bypass
A small gastric pouch is first created, then a bypass to the small intestine is performed This reduces calorific intake and alters the way food is digested
Greater weight loss than other methods Can reverse established type 2 diabetes Well-understood procedure which has been performed for more than 40 years
Surgeon requires more training Staple line and gastrointestinal connections can bleed or leak Late complications such as stomach ulcers and twisting of intestines can occur Nutritional deficiencies can develop Requires lifelong specialist care and nutritional supplements
FACTS Our tendons... Our bodyâ€™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).
Distributes and provides supplies to healthcare professionals
GenacolÂŽ and GenacolÂŽ Instant are Canadian products internationally recognized for their effectiveness.
CALL US TO FIND OUT THE SPECIALIST DOCTOR, ASSOCIATE CLINIC OR PRIVATE PHARMACY NEAREST TO YOU
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JUL⁄ AUG 2012
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Plasma to the rescue Health Sciences Authority of Singapore, which will also aid in storing them for the individual patient. “As the freezing facility at BSG is reliable and more spacious, patients can have half their stock of plasma eye drops stored there. When they run out of their supply about five or six months later, they can collect the other portion without having to undergo another plasma extraction process,” explained Dr Tong. For patients like Mr Hoesny, it is good news indeed. “The plasma eye drops are purely from our plasma, so they are very safe and effective. I was lucky to be part of the study. Although I will now need to pay for them as the study period is over, it will still be a lot cheaper than buying over-the-counter eye drops which are not completely effective,” he said.
was using them every half an hour, especially when I had to work on my computer for a long period. After a while, I started getting a gritty feeling in my eyes. On some days, my eyes became so inflamed, I had to rush to the emergency department,” said the 55-yearold procurement manager in the telecommunications industry. When she was approached to be part of a study to try new eye drops made of her own plasma, Mrs Ng was more than willing to give it a go. Commercial products are not able to completely replicate the tears we produce, which contain many proteins. Researchers from the Singapore Eye Research Institute (SERI) and Singapore National Eye Centre (SNEC) believe that the closest substitute is plasma – the yellowish fluid in blood that carries all the different blood cells.
These are definitely encouraging results. When we recently announced the findings at an international meeting, the audience was equally enthusiastic. PHOTOS: ALVINN LIM
dr LOUIS TONG, CONSULTANT, SINGAPORE NATIONAL EYE CENTRE, AND LEAD INVESTIGATOR OF THE PLASMA EYE DROPS STUDY
Mrs Ng Guan Lee stores the narrow tubes containing the plasma eye drops in her freezer, and breaks off a segment of the tube for use every day. She has undergone a painless one-hour procedure to extract the plasma from her blood.
“While its composition is not perfectly identical to tears, plasma contains many proteins that are present in tears. The proteins provide a normal, anti-inflammatory environment for the eye surface and, therefore, plasma could well be a tear substitute,” said Dr Louis Tong, Consultant, SNEC, and lead investigator of the study. Oh, what a relief! Dry eye, a common condition that affects the quality of life of its sufferers, is caused by multiple factors such as ageing, trauma to the eye or certain disease conditions. It may also be a side effect of certain drugs or treatment. For example, Mr Hartono Hoesny, 61, developed dry eyes after undergoing a bone marrow transplant for cancer. “I had the transplant about 10 years ago. After that, I developed various reactions that affected my mouth, skin and nails. But my eyes bothered me the most because it felt like there was sand in them,” said the supervisor of a food distribution company.
Mr Hoesny also tried several over-thecounter eye drops and eye gels, but found relief only when he joined the study and started using the plasma eye drops. Patients in the study undergo a painless one-hour procedure, similar to a blood donation, to extract the plasma from their blood. The plasma is then placed in narrow tubes clamped about an inch apart. Stored in the freezer Patients store these tubes in the freezer and break off the required segments for their daily use. Some, like Mr Hoesny, even double-bag them before keeping them in the freezer to ensure they do not get contaminated. Although patients have to ensure the segment they are using remains in a cool environment throughout the day, neither Mrs Ng nor Mr Hoesny considers it a chore. “I don’t think it’s an inconvenience at all. In fact, it is worth the trouble because it really improved my dry eyes,” said Mrs Ng, who stores her eye drops in a baby
food container, which is then kept in an insulated bag. Researchers optimistic The improved comfort experienced by patients is backed by observations of the study team. “We observed reduced damage on the epithelial cells (cells at the surface of the eye) after six weeks of treatment. These are definitely encouraging results. When we recently announced the findings at an international meeting, the audience was equally enthusiastic,” revealed Dr Tong. The team is optimistic that treatment based on this principle may, in future, become the gold standard in dry eye treatment for challenging cases. In the meantime, the team will continue with an observational study for one to two years to look at the long-term effects of the treatment. Future availability The plasma eye drops will be manufactured at the Blood Services Group (BSG) of
Why do the eyes get dry? A flow of tears is necessary to provide constant moisture and lubrication to the eyes. Tears are made up of: Water (for moisture) Oils (for lubrication) Mucus (for even spreading) Antibodies and special proteins (for resistance to infection) Special glands located around the eyes secrete these components. An imbalance of these can cause dry eyes.
How do I know my eyes are dry? When tears are not effective in lubricating your eyes, you may experience: Pain Light sensitivity A gritty sensation A feeling of sand in the eye Itching Redness Blurring of vision
SINGAPORE HE ALTH
JUL⁄ AUG 2012
Tell us Doc’s nationality shouldn’t matter I refer to the Viewpoint article Where are you from, Doctor? in the May/Jun issue of Singapore Health. From the letters to the press, it apparently matters whether the doctor is a foreigner or Singaporean. People are concerned if the foreign doctor is attuned to the local culture and language, and whether he is as competent as his local counterpart. For instance, the patient may get frustrated if the healthcare professional isn’t able to understand why he is reluctant to undergo surgery. There may be issues specific to the local context that the foreign doctor may not understand
immediately. The foreign doctor may also not be able to understand the local accent and vice versa. But in my opinion, it really shouldn’t matter whether the healthcare professional is a foreigner or Singaporean as long as the service given is competent. - Mr Chim Wai Chong
This letter wins one bottle each of Odour Controlled Garlic (300mg), Glucosamine Gel (100ml), Cod Liver Oil with Multi Vitamins Capsules and Maximum Strength Triple Omega 3-6-9 (1,200mg). The products are worth $111.60 in total.
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 firstname.lastname@example.org or The Editor, Singapore Health, Singapore General Hospital, Communications Department, Outram Road, Singapore 169608, or talk to us on Facebook. The winner will receive one bottle each of Ultra C-Complex Rose Hips, Acerola, Rasberry & Citrus Bioflavonoids Veggie Capsules and 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.
Singapore Health Isfazrina Ismail Called admission at 6394-1220 from yesterday till today, nobody picked up. Need to ask regarding my delivery admission. Like · Unlike · April 18 0 people like this KK Women’s and Children’s Hospital Hi Isfazrina, the correct number for Admissions is 6394-1200. Do try to call again. Alternatively, you can email email@example.com if the enquiry is on KKH’s maternity packages. Hope this helps! April 18 at 10.26am · Like · Unlike
Sean Hoo Hi. Is there a cure for scoliosis posture without operation? Can going to sports medicine help? Or whom do I see? Like · Unlike · April 26 at 4.37am 10 people like this Singapore General Hospital Hi Sean, you can go to your GP or family physician for a preliminary examination, then ask for a referral to an orthopaedic specialist at SGH. April 26 at 9.36am · Like · Unlike
Why patient has to be present at registration I tried to register on behalf of my elderly and immobile parents at the polyclinic, but was advised by the counter staff that my parents have to be present during registration. I understand the need to verify a patient’s identity, but I feel that verification is more important during consultation than at registration. Also, only the patient’s name has to be verified, so why do patients need to be present at registration? LZ gZ\gZi i]Z ^cXdckZc^ZcXZ XVjhZY id ndj VcY ndjg eVg" Zcih# EVi^Zci hV[Zin ^h d[ eVgVbdjci ^bedgiVcXZ id jh# LZ kZg^[n eVi^ZcihÉ ^c[dgbVi^dc hjX] Vh cVbZ VcY CG>8 cjbWZg Vi ZkZgn hZgk^XZ ed^ci id ZchjgZ i]Vi lZ egdk^YZ i]Z g^\]i XVgZ id i]Z XdggZXi eVi^Zci# 6h gZ\^higVi^dc ^h d[iZc djg Òghi XdciVXi ed^ci l^i] eV" i^Zcih!^i^h^bedgiVciidZchjgZi]Vii]Z XdggZXieVi^Zci^hgZ\^hiZgZYWZ[dgZhZZ^c\ i]ZYdXidgdgcjghZ#
No MC for blood test
I have been advised to have a blood test and was told that I need to visit the hospital. Can you issue me with a medical certificate for this? 6 bZY^XVa XZgi^ÒXViZ ^h jhj" Vaan ^hhjZY l]Zc i]Z eVi^Zci ]Vh ]VY V XdchjaiVi^dc l^i] V YdXidg VcY! VXXdgY^c\ id i]Z YdXidgÉh VhhZhhbZci! i]Z bZY^XVa XdcY^i^dc lVg" gVcih V bZY^XVa XZgi^ÒXViZ# 6 WaddY iZhi ^hXVgg^ZYdjiWncjghZh!VcYVi^bZX]^i XVc WZ ^hhjZY id ndj id ZmeaV^c ndjg VWhZcXZ[gdbldg`dghX]dda#
Puzzled by SMS reminders My father died a few months ago. Why does Singapore General Hospital (SGH) continue to send us SMS reminders of his clinic appointments? LZVgZhdggnid]ZVgi]Vindjg [Vi]Zg ]Vh Y^ZY# Djg eVi^Zci YViV hnhiZb VjidbVi^XVaan gZ\" ^hiZghi]ZeVi^ZciÉhYZVi]^ZY^ZhViH<=# >[i]ZeVi^ZciY^ZhVi]dbZ!Vcjgh^c\]dbZ dg V ]dhe^XZ! ]^h [Vb^an cZZYh id ^c[dgb i]Z]dhe^iVaidjeYViZi]ZeVi^ZciÉhÒaZ# I]Z [Vb^an XVc Yd i]^h Wn hZcY^c\ V Xdend[i]ZYZVi]XZgi^ÒXViZidi]Z]dhe^" iVa!WnedhidgWnZbV^a#>[VYZVi]XZgi^Ò" XViZ^hcdiVkV^aVWaZ!i]Z[Vb^anXVchjWb^i di]Zg YdXjbZciVi^dc hjX] Vh V eda^XZ dg ]dhe^XZ gZedgi# 6 bZbWZg d[ i]Z [Vb^an XVc Vahd lg^iZ id i]Z ]dhe^iVa dg hZcY Vc ZbV^a id bZY^XVagZedgi5h\]#Xdb#h\! hiVi" ^c\]^hgZaVi^dch]^el^i]i]ZeVi^Zci# 7Z[dgZ lZ gZXZ^kZ V cdi^ÒXVi^dc! i]Z ]dhe^iVaÉh hnhiZb l^aa cdi `cdl i]Z eVi^Zci]VhY^ZYVcY]^h[Vb^anbVnXdc" i^cjZ id gZXZ^kZ HBH VcY di]Zg gZb^cY" Zgh[dgVeed^cibZcih#
Tributes I went to Bukit Merah Polyclinic for some administrative issues and consultation, and was amazed and delighted by the excellent service there. The staff who attended to my wife and me were professional, courteous, dedicated and friendly. One of them was Health Attendant Nurrul Aine binte Hussaini and the other was Senior Nurse Anabukkarasi Sakadevan Naidu. Please commend them for their excellent service. - Impressed
I am writing to say that you have such wonderful and dedicated staff. When my daughter was hospitalised at National Heart Centre Singapore for myocarditis and subsequently at Singapore General Hospital’s Rehabilitation Centre, the family went through an extremely stressful period. However, the commitment and professionalism of your staff made us feel we were in good hands. They were there for us in many ways. They kept in touch with us, comforted and encouraged us when we were down, explained things when we were confused and were available when we needed support or someone to talk to. They gave us the best medical care. My daughter is now undergoing therapy at the Society for the Physically Disabled. My family will always treasure the love we received from your staff. My heartfelt thanks to all of you. - Peter Lim
I would like to express my thanks and gratitude to the staff of SGH’s Department of Obstetrics and Gynaecology for its warm and efficient service. My wife is into her 12th week of pregnancy, and experienced some spotting. We were concerned and I took her to see a doctor. I understand that it typically takes some time to see an obstetrician and an appointment usually needs to be made. The nurse who took my call was very understanding and helped arrange a checkup for me in the early pregnancy unit on the same day. We didn’t have to wait long to see the doctor on duty. A checkup was performed and we were assured that all was fine. We found the entire experience very positive and are looking forward to our next appointment. Keep up the excellent service! - M Soh
JUL⁄ AUG 2012
Ask the pros
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SINGAPORE HE ALTH
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=ZVai]MX]Vc\Zide^Xh[dgY^hXjhh^dc/ EVg`^chdcÉhY^hZVhZVcYdWZh^in^cX]^aYgZc ?jan!]^\]WaddYegZhhjgZVcYZmZgX^h^c\ idadhZlZ^\]i6j\jhi Don’t want to miss a session? Register for free at www.healthxchange.com.sg and receive early alerts on upcoming topics.
Wide circulation that reaches over 100,000 readers Available at strategic locations Contains authoritative healthcare news and information H^c\VedgZ=ZVai]^hi]Zd[ÒX^VaejWa^XVi^dcd[H^c\VedgZ<ZcZgVa=dhe^iVaVcYH^c\=ZVai] H^c\VedgZ=ZVai] <gdje! i]Z aVg\Zhi ]ZVai]XVgZ \gdje ^c H^c\VedgZ# H^c\VedgZ# EjWa^h]ZY W^bdci]an ^c V ]VcYn iVWad^Y h^oZ! i]Z cZlheVeZg V^bh id gV^hZ i]Z ]ZVai] a^iZgVXn aZkZa d[ H^c\VedgZVch# H^c\VedgZ =ZVai] =ZVai] ^h VkV^aVWaZ Vi H^c\VedgZ <ZcZgVa =dhe^iVa! @@ LdbZcÉh VcY 8]^aYgZcÉh=dhe^iVa!8]Vc\^<ZcZgVa=dhe^iVa!cVi^dcVaheZX^VainXZcigZhVcYedanXa^c^Xh jcYZgi]ZH^c\=ZVai]jbWgZaaV#>i^hVahdVkV^aVWaZVi]^\]"igV[ÒXed^cihl^i]^ci]Z879 VgZV# H^c\VedgZ=ZVai]ZchjgZhndjgbZhhV\Z\ZihVXgdhhidndjgiVg\ZiVjY^ZcXZ# For advertising enquiries, call 6319-3088 or 6319-3022, or email Bernard Chen at firstname.lastname@example.org.
15 HEALTH+CommunalEating V4 WF path.indd 14
14/6/12 10:24 PM
Nutrition Follow SGH kitchen staff as they prepare lunch for patients
It’s easy to protect your child against hepatitis
What does baking and having a meal in a group have in common? They are part of a treatment strategy that fights eating disorders. By Jamie Ee
YOUNG AND FEMALE
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Eating disorders are getting more common, with an average of
new cases seen at SGH LIFE
Those who suffer from eating disorders may be anxious at the sight of butter and sugar.
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Ms Florence Chiang (left) conducts a weekly baking class for patients who have eating disorders.
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IZaa"iVaZh^\ch Feeling fat or overweight despite a dramatic weight loss Being preoccupied with weight, food, calories, fat grams and dieting; or being extremely concerned with body weight and shape Refusing to eat certain food, worsening to not eating whole categories of food Feeling anxious and intensely fearful about gaining weight or being fat Denying hunger
PHOTO: ALECIA NEO
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Food fears 6i ]Zg lZZ`an WV`^c\ XaVhh! H^c" \VedgZ <ZcZgVa =dhe^iVa H<= dXXjeVi^dcVa i]ZgVe^hi ;adgZcXZ 8]^Vc\ ^beVgih bdgZ i]Vc _jhi gZX^eZhid]ZghijYZcih#H]ZiZVX]Zh
SINGAPORE HE ALTH
per cent of people suffering from an eating disorder are women
Bulimic patients tend to be in their late teens to
Anorexic patients tend to be in their early teens to
Developing food rituals such as eating food in a certain order, rearranging food on a plate or cutting food up into tiny pieces Giving excuses to avoid meals or situations involving food Withdrawing from friends and activities Having irregular menstrual periods Having an excessive or rigid exercise regimen
singapore he alth
Jul⁄ Aug 2012
Lunch is served
Imagine having to cook several meals a day for over 1,000 patients with different dietary needs. That’s the job of SGH Food Services Department. We take a peek inside its kitchen as it whips up lunch
8am: Breakfast is over,
Top and right: Not everything can be done with technology: Some vegetables are prepared by hand, though most are cut and washed in huge machines.
get ready for lunch The cooks and kitchen helpers, numbering 31 at any one time, work two shifts – from 6am to 7.30pm – with a small group in as early as 5am to prepare breakfast. The main kitchen closes at around 7.30pm, but a satellite kitchen in the main hospital block stays open for another hour. At the wards, biscuits and milk drinks are available for patients who get hungry between meals or late at night. A variety of meals cater to different tastes, and dietary and religious requirements.
Spices and seasoning for each dish are carefully measured and prepared according to the recipe and the number of orders.
Right: Chicken is roasted in trays for a Western meal. Pork, a Chinese mainstay, is also available. Fish is served as fillets because of the danger of bones.
(Left) For dessert, patients who are diabetic get a larger portion of fruit such as watermelon, papaya or apple.
Rice porridge is cooked in huge vats and is served plain or used to make pork or halal chicken congee.
10.15am-12pm: Roll out the trolleys The cooks dish the food onto plates according to order chits attached to each tray. The orders indicate the patients’ preferences and dietary restrictions. The order chits for halal meals are printed on green paper. The Food Services staff check the orders before they print the chits, and also before the meal trays are loaded into the trolleys bound for the wards. The trolleys have a cold compartment to keep fruits and desserts fresh and separate from a compartment preheated to 75ºC. A last check is made before the trolleys are locked and sent to the wards. There, the food is reheated for 20 minutes so patients are served a hot meal.
For patients on a low-sodium diet, no soya sauce is added to the little saucers of cut chilli.
Below: At every meal, samples of food that is cooked and served to patients are taken. This is a safety precaution to allow the hospital to quickly track down the source of contamination in the event of food poisoning. SGH is ISO 22000, including HACCP, compliant. This means it ensures food safety – through approved safeguards in areas with the potential for contamination.
Left: After cooking, kitchen staff dish the meat and rice onto plates and soup into bowls placed on trays, reading off the individual order chits attached to each tray.
To make sure orders are served correctly, food order chits for each patient are printed, and arranged by ward and bed numbers.
JUL⁄ AUG 2012
SINGAPORE HE ALTH
Preparing the menus
Western, Chinese, Muslim and vegetarian meals are available at each meal. Only the Chinese meal is non-halal. If their choice isn’t available on the regular menu, patients can ask for the a la carte menu of mostly Asian-style noodles, while new mothers sticking to tradition can order nutritious food from the Chinese confinement menu.
Top and right: Vegetables stay fresh and colourful, and retain their goodness in the halal chiller.
8.30-10.15am: Boil, fry, roast, bake
What it takes to feed a hospital:
1,300 meals prepared each time 100kg of rice used a day 26 white and 61 wholemeal loaves of bread served at breakfast 110 trolleys used to transport meals to the wards Youngest cook is 36, who started work at SGH Food Services at 25 Oldest cook is 68 Longest service of 32 years is by a 53-year-old cook
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Watching the clock:
Left: Everything is huge in the kitchen. Vegetables like the cabbage fried in this wok can feed 80 people.
Staff work at various times, but the two main shifts are from 6.30am to 2.30pm, and from 10.30am to 6.30pm A small group starts as early as 5am to cook breakfast Satellite kitchen at ward 72 stays open till 8.30pm for late orders Breakfast is served from 7-8am, and the food trolleys leave the kitchen at 6.45am Lunch is served from 11.30am to 1pm, and the food trolleys leave the kitchen at 11am Dinner is served from 5-6.40pm, and the food trolleys leave the kitchen at 4.30pm
Right: Trays holding crockery and eating utensils must fit well in the trolleys. Constantly striving to improve their operations and meal services, Senior Manager Mdm Koay Saw Lan and Executive Chef Tan Loon Liang check out alternative crockery designs.
What the colours mean:
PHOTOS: VEE CHIN
Floors can get dirty and oily after cooking, and are cleaned after every meal preparation and when necessary.
Green-, blue-, grey-patterned plates and bowls for halal diet; pink and maroon for others Cooks wear white, kitchen helpers wear green and those who do the washing and housekeeping wear blue
SINGAPORE HE ALTH
JUL⁄ AUG 2012
A jab in time Protecting your child against hepatitis is not as hard as you think. By Thava Rani 9d ndj `cdl i]Vi cZVgan Vaa ^c[Vcih VcY X]^aYgZc ^c[ZXiZY l^i]i]Z]ZeVi^i^h7k^gjhYdcdi YZkZade Vcn h^\ch dg hnbeidbh4 I]Vi bZVch i]Zn bVn jcl^ii^c\an eVhh i]Zk^gjhdciddi]ZgX]^aYgZc# I]^hcj\\Zid[^c[dgbVi^dcXdjaYhVkZ ndjg X]^aYÉh a^[Z# 7ji bVcn eZdeaZ VgZ hi^aa V a^iiaZ ]Von VWdji VheZXih d[ ]ZeV" i^i^h!^cXajY^c\i]ZY^[[ZgZciineZhd[i]Z Y^hZVhZVcYi]Z^gbdYZhd[igVchb^hh^dc# IdXdbbZbdgViZLdgaY=ZeVi^i^h9Vndc ?ja '-! lZ \^kZ ndj i]Z adlYdlc dc i]Z YZW^a^iVi^c\Y^hZVhZ#
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Infants in Singapore are vaccinated against hepatitis B as part of a national programme Three doses of vaccine administered: at birth, at one month and at five to six months First two doses offer rapid protection, while the third extends protection for as long as possible
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It is not recommended for some children Those who develop a lifethreatening allergic reaction to a previous dose of vaccine Those who have known allergies to any vaccine constituents such as yeast
Generally, repeat vaccinations are not necessary Protection is believed to last at least 25 years for many children, and is probably lifelong for some Repeat testing and jabs are advised in children (or adults in later life) if they are at risk, such as if they come into contact with an infected person, require blood transfusions or engage in highrisk sexual behaviour
The ABCs of hepatitis The disease is essentially an inflammation of the liver, which may be due to a viral infection or exposure to toxic substances, alcohol or certain medication. Although hepatitis A, B and C are similar in nature, the virus that causes each disease is different.
Hepatitis B or C can be transmitted through infected blood left on contaminated needles or razor blades. Hepatitis A, however, is easily spread by eating raw or partially cooked shellfish or unsanitary food, like a banana served peeled.
Hepatitis A virus (HAV)
Hepatitis B virus (HBV)
Hepatitis C virus (HCV)
Tiredness, loss of appetite, fever, nausea, vomiting, stomach pain, weight loss, joint pains, yellowing of eyes and skin (jaundice), dark urine, pale stools
Less than six years old. Usually do not experience noticeable symptoms, with jaundice occurring in only about 10 per cent
Experience more severe symptoms, with more than 70 per cent developing jaundice
Recovery usually takes several weeks or months without complications
Vast majority of infections are “silent” or without symptoms
Ninety per cent of children may become chronic hepatitis B carriers. Of these, up to a third may develop chronic liver cirrhosis (liver hardening which can lead to liver failure) or even liver cancer
About 15 to 20 per cent may develop chronic liver cirrhosis or cancer, although this may take decades in children
JUL⁄ AUG 2012
singapore h e alth
Who should pay for healthcare? While the idea of universal health coverage is noble, there is no one-size-fits-all solution that balances citizens’ needs with rising healthcare costs BY Lim Meng Kin
(with the notable exception of the US) first established the foundations of the modern welfare state. Based on an egalitarian vision of society, one of its tenets was that citizens would enjoy universal access to healthcare, funded either by taxes (as it was in Britain, Canada and Sweden) or statemandated social insurance schemes (the practice in France, Germany and the Netherlands). Unfortunately, the euphoria did not last long. Well before the recent global financial crisis, healthcare costs in many developed countries were already spiralling out of control, fuelled by ageing populations, rising patient demand and escalating costs associated with advances in medical technology. What was once “affordable” grew into a crushing burden. Healthcare comes at a cost Healthcare does not come free. Someone must pay. But who and how? And having settled that question politically, what if healthcare costs grow (they inexorably will, as new treatments and more effective drugs come on stream) into a bottomless pit? There are no easy answers, which is why no country appears to be completely happy with its healthcare system, with many in the midst of reform (and some even moving in contradictory directions with each change of government). Much of the current debate on healthcare reform revolves around the key issue of sustainability. Apart from rationing and queuing, various governments have in recent years sought to achieve this by diversifying funding sources, encouraging greater individual responsibility through co-payments and turning to the free market in order to deliver healthcare services more efficiently. It is in this light that the concept of national health insurance and its relevance to Singapore, as extolled by advocates, such as Dr Jeremy Lim (The Moral Case for Health Insurance for All; The Straits Times, April 26, 2012), ought to be examined. National health insurance entails a state-mandated, risk-pooling system into which all must pay, and from which all will benefit, so the burden on any one individual is ameliorated. The idea of universal health coverage is a noble one. But it does not automatically lead to better healthcare at affordable costs. On the contrary, countries with such healthcare systems invariably struggle with cost containment, since increased
PHOTO: SPH Library
It was during the euphoric years after World War II that Western industrialised nations
Patients in a Class C ward at Changi General Hospital, which has six beds in a room. Some Class C wards have eight beds.
access must necessarily mean increased utilisation of healthcare services, not to mention the greater potential for abuse, fraud and wastage. Indeed, a close examination of healthcare systems worldwide suggests that there has to be a more nuanced and multidimensional approach to healthcare financing, and that a one-size-fits-all approach would, at best, be a partial solution. The current trend towards hybrid and structurally complex healthcare systems seems to bear this out.
Singapore’s multilayered healthcare financing system has enabled it to achieve the same goal of universal access to healthcare, while keeping services affordable and ensuring the system remains sustainable in the long term.
Consider Taiwan’s National Health Insurance (NHI). It is a mandatory, singleplayer health insurance scheme that covers the entire population, with contributions from households, employers and the government. While the coverage is meant to be extensive, NHI and other
government expenditure account for only 57 per cent of total health expenditure at the national level, with individuals forking out a significant proportion out of pocket. Furthermore, because of high consumption and the inability (politically) to raise premiums to cover rising costs, the scheme was plunged into financial difficulties just a few years after it was introduced in 1995. Since then, NHI’s deficit ballooned further – to NT$60 billion (S$2.6 billion) in 2009. Singapore’s system works In contrast to Taiwan, Singapore’s healthcare financing system consists of multiple channels of financial support. The 3M system – Medisave, MediShield and Medifund – treats the majority of healthcare consumers as co-paying partners, while making special provisions for the minority who cannot afford the co-payment. Aside from 3M, Singaporeans have access to government subsidies at public hospitals. Thus, the basic medical needs of all Singaporeans, including the minority without insurance cover, are taken care of. In addition, the government periodically pays money (from budget surpluses) into the savings schemes of low-income families and the elderly. Such an approach not only counters the “moral hazard” generally associated with free-for-service, third-party reimbursement (Singaporeans know this as the “buffet syndrome”), but also avoids providing the rich with healthcare handouts (as would be the case under a universal coverage system that ignores income status).
Singapore’s multilayered healthcare financing system has enabled it to achieve the same goal of universal access to healthcare, while keeping services affordable and ensuring the system remains sustainable in the long term. Over the years, it has purchased for Singaporeans good health outcomes, comparable and often superior to those of other developed countries, at a much lower cost. The country’s total health spending is at four per cent of its gross domestic product (GDP), compared with countries of the Organisation for Economic Cooperation and Development, which spent an average of 9.6 per cent of their GDP on healthcare. In the case of Taiwan, the figure is 6.6 per cent. The system is not perfect, but it has served Singaporeans well for the last 28 years. Rather than totally redesigning it, what is required is to continue building on its strengths while addressing existing gaps (such as tackling coverage for costly, non-catastrophic illnesses). Greater efforts should also be made to balance efficiency with compassion (for example, showing more flexibility in the implementation of the safety net so no one falls through the cracks). And yes, the next phase of the evolution of the healthcare system should continue to be shaped by the national conversation regarding the kind of society Singapore wants to be. But make no mistake – despite claims to the contrary, there is no “magic bullet”. The writer is Associate Professor at the Yong Loo Lin School of Medicine and Saw Swee Hock School of Public Health, National University of Singapore. This article was first published in The Straits Times on May 9, 2012.
Jul⁄ Aug 2012
singapore he alth
Becoming a guinea pig for the greater good
Healthy volunteers who take part in clinical trials accept the potential risks in the hope that taking part will benefit patients in future
A doctor briefing a healthy volunteer about a clinical trial to ensure he understands what it entails before he gives his consent to taking part.
BY Nicole Lim
Most of us have probably seen advertisements – like those hanging from bus and MRT handrails, plastered on lightboxes and websites or printed in newspapers – recruiting healthy individuals for clinical research. I never really paid attention to them. I was never going to take part in a clinical trial. I was wrong. During my student days, my friends took part in trials out of curiosity or to earn a bit of extra cash. At the time, I was never in such a need of money to consider this income opportunity and definitely not curious enough. In 2006, the UK was shaken by the “elephant man disaster” at Northwick Park Hospital. Six healthy young men took part in a study of a targeted cancer therapy, which was being tested for the first time in humans. Within hours of getting the drug, they were all in intensive care with something close to multi-organ failure. They swelled up so much that the local media dubbed them the “elephant men”. None have fully recovered. I was glad that I’d never been foolish enough to risk my life like that. Then, I joined the healthcare industry. Suddenly, I was reading about clinical trials all the time. I was talking to patients whose disease had been stabilised by a trial drug when everything else had failed. There were also stories of patients who did well for a while before the disease caught up with them again. But they all had one thing in common –
they took part because they hoped that, if this didn’t work for them, it would benefit patients in future. I was also talking to doctors who were trying to raise awareness of ongoing trials to attract more healthy volunteers. Unlike patient volunteers, who suffer from illnesses that cannot be treated or for whom current treatment options no longer work, healthy volunteers don’t stand to gain any personal health benefits. The researchers said it is often harder to recruit healthy subjects. As memories of the “elephant men” faded, and feeling safe in the knowledge that only a few studies allowed young women to take part, I enthusiastically volunteered myself to one of the researchers. Little did I expect her to tell me that they were about to start a trial that required both men and women. Half hoping that she would forget my pledge, I didn’t think much about it again. But she did remember. Still, I wasn’t really
worried about taking part in a clinical trial because I had the right to change my mind about participating at any point – even after signing on. But the least I could do was find out more about the study. So I found myself listening to the principal investigator of the study explain the trial details – how it was going to work, what kind of study it was and what was required of me. This procedure is now standard for any clinical trial involving healthy and patient volunteers. But, as recently as the last century, doctors saved patients’ lives by taking chances with treatments that were not fully understood or tested. In 1937, Professor ES Monteiro decided to give a patient, who had been admitted to the old Singapore General Hospital with cardiac beri beri, a dose of vitamin B1. A deficiency of vitamin B1 was suspected – but not yet proven – to be the cause of beri beri. Within half an hour of getting the treatment, the patient sat up in bed, confounding the nurse’s expectations; she had already laid out a sheet in anticipation of the patient’s death. Prof Monteiro used the treatment on other patients after that, achieving a 100 per cent success rate. There are also instances where such lack of control and protocol led to the exploitation of research subjects. The infamous Tuskegee syphilis study is probably the best-known example. In this study, about 400 poor African-Americans with syphilis were recruited for a study on “bad blood” – a term used to describe various ailments including syphilis. They never got the treatment they needed (even after penicillin became available) because the scientists wanted to observe how the disease developed. All the participants died. In 1997, President Bill Clinton apologised for this atrocity. Since then, safeguards have been put in place. I was benefiting from the principle of informed consent that has been
A group of healthy volunteers passes the time with different activities. They are taking part in a study that requires them to stay in a unit for an extended period of time.
enshrined in research ethics since the end of World War II. Throughout the explanation by the principal investigator, I felt pretty comfortable with the idea of taking part in the study. Nothing much was required of me, the only down side was that the study included a followup period of several years. But when the principal investigator got to the side effects, which included very rare instances of a possibly fatal condition, my heart stopped. He said that the chance of this happening was very small, but he could obviously not guarantee that it wouldn’t happen. Gulp. Was I ready to risk my health, and possibly my life, to help test this new drug? Or could I become an “elephant woman”?
If this drug proved effective, then yet another potentially fatal disease (one that I could very easily get) could be thwarted.
If I developed this rare side effect, I’d regret it forever. But then I realised that if all the other potential volunteers felt like I did at that particular moment, and if everyone walked away, then this drug – good or bad – would never be available. Even the incident in the UK didn’t stop people from supporting clinical research, and countless treatments have since been launched, including a vaccine against cervical cancer and a treatment for Hepatitis C. There will always be some risk. Even taking a fully licensed medicine involves risks. It is just that you know what the risks are. I am a firm believer in modern medicine. If this drug proved effective, then yet another potentially fatal disease (one that I could very easily get) could be thwarted. Surely that was worth taking a small risk for? A postscript These days, most serious studies have multiple “arms”, which are like teams. Participants in each arm either get the test drug or a placebo. When I signed up for the study, neither the doctor nor I knew which arm I was in. It was only several years after the first consultation that I finally found out. It turned out that I had received the placebo. I felt disappointed. Somehow, my contribution seemed less meaningful than it would have been had I been given the trial drug.
Nicole Lim works for SingHealth. She has been living in Singapore for close to five years.
SINGAPORE HE ALTH
JUL⁄ AUG 2012
What you should know about HFMD:
Young children are not the only ones who can get hand, food and mouth disease. Adults and youth are vulnerable too
How can I protect myself against it?
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HFMD may show up as ulcers in the throat and mouth, and on the tongue. The disease can also cause sore throats.
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The disease can also lead to fever and a general feeling of being unwell.
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What should I do if I contract HFMD? The disease is self-limiting, which means it will usually clear up in five to seven days. During that period, you should ensure you get enough rest and fluids. Change to a soft diet if mouth ulcers cause too much pain.
What complications should I look out for?
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PHOTOS: GETTY IMAGES
BY THAVA RANI
Wash hands regularly and observe general hygiene measures Avoid exposure to nasal discharge, saliva, faeces or body fluids of an infected person Do not share eating utensils Keep toys, books, eating utensils, towels and clothes separate Avoid close contact such as hugging and kissing Clean and disinfect toys and appliances thoroughly if previously used by someone with HFMD
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Shortness of breath Drowsiness and disorientation Severe headache Neck stiffness Vomiting Poor oral intake Fits See a doctor immediately if such signs are observed.
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23 Money Matters-Myths4-7 V4 WF path.indd 23
19/6/12 9:10 AM
singapore he alth
JUL⁄ AUG 2012
The artist in the dentist By Usha Das
A silicone eye is hardly something you would expect to see on a visit to the National Dental Centre Singapore (NDCS). But then again, Dr Teoh Khim Hean is not your average dentist. Artificial eyes, ears, jaws and other facial prosthetics are tools of his trade. Senior Consultant and Director, Department of Restorative Dentistry, NDCS, Dr Teoh, whose work is in prosthodontics, is also a specialist in maxillofacial prosthetics. The only such specialist in NDCS and one of a handful in Singapore, Dr Teoh was trained in maxillofacial prosthetics at the prestigious Memorial Sloan-Kettering Cancer Center in New York. Patients at NDCS who see him for prosthetics generally have facial defects brought on by horrific accidents or after they have had cancer surgery. With his knowledge of medicine and dentistry, he crafts prosthetics that “plug” gaps in the face and jaws. The work calls for artistic flair, as the artificial parts have to blend seamlessly with facial features and skin tones. Interestingly, he counts portrait photography as a hobby.
The prosthetics are not permanently attached to the face but can be taken out and cleaned every day. They minimise the disfigurement and offer patients hope and confidence to face the world again. Many patients who see him are emotionally devastated, desperate, and distraught by their illness and ravaged appearance. He often finds himself having to counsel as well as treat them.
PHOTO: Vernon wong
Among a rare breed, Dr Teoh Khim Hean’s work requires medical expertise, a kind heart and a touch of artistry
Dr Teoh Khim Hean is one of only a few maxillofacial prosthetics specialists in Singapore.
The demanding circumstances we work in call for perseverance to see cases through from start to finish. Dr teoh khim hean, senior consultant and director, national dental centre singapore
He has had patients who had their faces “fixed” after the surgery, only to have a relapse; they needed another round of surgery, which, in turn, destroyed all the earlier work to make
the prosthesis. He recounted how an elderly cancer patient, in this situation, chose not to seek further medical care. “She felt that she had gone through so much in the previous six to eight months. She told me: ‘I’ve lived enough. I’ve seen enough, I don’t want to continue.’” The scene was so distressing that Dr Teoh’s nurse could hardly hold back her tears. Emotionally draining but rewarding Dr Teoh confessed that the work can take a toll on emotions, which is probably why, he said, not many people are inclined towards maxillofacial prosthetics. He unwinds by spending time with friends or colleagues, and occasionally taking vacations. However, despite the emotional challenges he faces, he is motivated to soldier on. “You carry on because you feel you
Supporting medical research As a clinical research coordinator, Ms Liew Yee Yun helps doctors with their research studies at the National Heart Centre Singapore
PHOTO: ALECIA NEO
My job is to… Help principal investigators conduct their research studies. I approach patients, explain the study to them and if they agree, recruit them for the study. Careful planning, precise coordination, meticulous data collection and diligent pouring through of case notes are all part and parcel of my job. I work very closely with doctors, nurses and technicians. Currently, I’m working on two studies with another potentially in the pipeline.
What most people don’t know about me is that… I can be really stern. Because I look soft and innocent, people, especially my
Bahru. It helps me relax since I’m so far away from work. On special occasions like Mother’s Day, my siblings and I will cook a special meal for our parents. I am… An introvert. Previously, I worked as a lab technician where there was no need for me to interact with people and I was quite happy with that. But after four years, I realised I needed a change. I decided to challenge myself with a job like this so I could improve my communication skills.
By THAVA RANI
In the seven months I’ve been here… I have become better at approaching people and understanding doctors’ handwriting. I’m also grateful for the help I have received from my colleagues.
can do more for these patients, and it’s so rewarding when you see them doing well, or having some normality handed back to them,” he said. This dentist with a big heart has more that he wants to do. He hopes that NDCS will one day be home to a regional training centre for maxillofacial prosthetics, as such expertise is needed in Asian Third World countries, which tend to have a high incidence of oral cancers. Currently, he is engaged in training others in the subspecialty at NDCS. He said that to succeed in this field, entrants need two qualities: passion and perseverance. “The demanding circumstances we work in call for perseverance to see cases through from start to finish. And passion drives us to pursue better outcomes for our patients, to see them healed and whole again.”
Ms Liew Yee Yun enjoys listening to patients as they share their life stories.
colleagues, don’t expect me to be aggressive. However, I don’t think you can accomplish much at work if you’re stern. The one thing I’ll never forget is… The day a patient, whom I had been following up on, died. I had spoken to him a few days earlier to confirm our appointment. But when he did not show up, I called
his mobile phone. His wife informed me that he had died that morning from a heart attack. I was shocked. It made me think how fragile life is. Life outside work is… All about family. I like spending time with my family and I particularly enjoy the times we go back to our house in Johor
I think research is… A very important aspect in the practice of medicine. Although we may not see results immediately, in the long run, it helps to improve patient care. It’s a much-needed part of medicine because it pushes us to be better and not settle for the current status quo. I smile the most when I am… Listening to patients’ experiences and life stories. Whether they end up participating in the study or not, they all appreciate the sharing session. Within the next five years… I would like to take more courses to improve my skills at work.
25 Header PATH.indd 21
18/6/12 4:43 PM
SINGAPORE HE ALTH
JUL⁄ AUG 2012
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1. Where is cord blood drawn from and why is it important? 2. Which story in this issue did you find the most informative?
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Closing date: Aug 6, 2012 Send in your answers and stand to win a bottle of Genacol Collagen (30 capsules) worth $20.
Include your name, age, gender, address and telephone number. Winners will be notified via phone or email. Incomplete or multiple entries will not be considered. Email: email@example.com Post: The Editor, Singapore Health, Singapore General Hospital, Communications Department, Outram Road, Singapore 169608 Winners of Contest 16 Each will receive a Backjoy device worth $64.90.
Brain training helps treat depression
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A Cardiff University study has shown that a brain-training technique that helps people control activity in a specific part of the brain could help treat depression. Researchers at the university used MRI scanners to show eight participants how their brains reacted to positive imagery. After four sessions, their depression improved significantly. But there was no improvement in eight others who were asked to think positively, but did not see images as they did so. The scientists said further research with more people is needed to test the technique’s long-term effectiveness.
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Source: Mayo Clinic Proceedings
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他们都得在新加坡中央医院康跃中心 通过一连串的严格面试和咨询。由多学 科专业医疗人士组成，包括医生、营养 医师、心理治疗师、心理学家、职能治 疗师和医学社会工作者，康跃中心是专 为患有与生活方式相关病症，例如患有 饮食障碍和肥胖症的病人提供综合式全 面护理的治疗中心。 自 20 多岁开始， Lawrence 先生已经 是谭光慧医生的病人了。谭医生是新加 坡中央医院内分泌科的顾问医生兼肥 胖及代谢组的主任。直到去年下半年， Lawrence先生才下定决心接受手术。 谭医生说：“当时他在全国征兵预检 时被诊断患有2型糖尿病，随后被转诊到 新加坡中央医院糖尿病中心时才19岁。” “他是个典型糖尿病患者，长久以来 与他的体重交战。他的体重可以减少 10公斤，随后又反弹增多15公斤。他来 我这里就诊前后有7年多然后消失了一 年，再次找我时是因为他已难以控制糖 尿病病况。他的血压高，胆固醇水平也 远远超过正常范围。我对他说，‘你还 年轻，不能这样下去，否则你在40岁时 就已经患有心脏病。’就在这时候我们 才开始谈论手术。” Rozita女士患有多种疾病，包括糖尿 病、炎症性胃溃疡、睡眠呼吸暂停症及 卵巢囊肿。她在一年之内前后住院 4 次。 正因如此让她改变了想法。
普通润眼液无法起作用的干眼症 患者能选择一种新的有效疗法 原文 THAVA RANI
王银花女士竭力寻找能治疗干眼症的方 法有近三年了。她每眨眼一次就会感到 眼睛表面层好像被刀削掉一样。甚至有 时，疼痛剧烈到半夜都会被痛醒。于是， 她将自己的血液制成润眼液缓解症状。 王女士说：“用血浆制成的润眼液对 缓解干眼症真的很有效。因为它是用我 自己的蛋白质制成的，所以能缓解眼部 干涩，不会刺激到眼睛。” 王女士的干眼症是因治疗视网膜疾病 时而进行多次手术后所引起的。除了使 用非处方的润眼液缓解症状外，她还尽 量避免到有冷气的地方，甚至在卧室内 也安装了加湿器，为的就是避免让眼睛 谭光慧医生（左一）和Shanker Pasupathy医生（右一）与接受胃旁路手术后的 Shuan Lawrence 干涩。尽管如此，频繁使用润眼液却带 先生和 Rozita Ramlee女士。 来其他问题。 目前，两人都无需再服用治疗糖尿 现年 55 岁的王女士是电信行业采购 原文 Valerie Lee 病、高血压和高胆固醇的药物，也不用 经理，她说：“直接从药房购买的润眼 继续接受睡眠呼吸暂停症的治疗。 液只能暂时缓解我的症状，所以我几乎 现年32岁的Shuan Lawrence先生和36岁 是每半小时就得滴一次，尤其是在我长 的 Rozita Ramlee 女士的体重曾经超过 巨大的改善 时间使用电脑时。过了一阵子，我开始 100公斤。 Lawrence先生的空腹血糖指数也曾在前 感觉眼里好象有沙子。有时，我的眼睛 如今遇到他们时，您无法想象他们 两年飚升至15.5mmol/L，但最近的一次 会变得红肿且发炎，以致必须赶紧去急 曾经患有肥胖症。为了治疗肥胖症、糖 血液检测发现血糖已经降至5.7mmol/L 诊室求诊。” 尿病及其他并发症，两人不约而同地在 的健康水平。去年Rozita女士每三个月 所以当她受邀参与一项使用自己的血 新加坡中央医院接受胃旁路手术。这是 测量的血糖水平（也称为糖化血红蛋白 浆制成新型润眼液的研究时，王女士是 一种减肥手术，对逆转糖尿病和其他代 或HbA1c）高达8.6%。手术后的6个月， 非常乐意参加的。血浆是呈黄色的液体 谢性疾病都有非常好的疗效。 也降至5.7%的良好水平。可见已停止服 在血液中运载所有不同种类血细胞。 “过去，我不能行走远程，不能搭乘公 用降血糖药的两人，新血糖水平也有着 因为人们体内所产生的泪水中涵盖多 新加坡中央医院康跃中心主任兼普外科高级顾问 医生Shanker Pasupathy 共巴士，也不敢乘坐捷运。这手术让我 卓越的改善。 种蛋白质，所以市售上的润眼液不能完 重获新生，”Lawrence先生说。现在定期 Lawrence 先生曾经鼾声如雷，甚至 全复制泪水。新加坡眼科研究所和新加 跑步的他也开始游泳和健身。“活了30 会吵醒邻居，如今他晚上睡觉时再也不 坡全国眼科中心的研究人员相信最接近 多年，我现在可以对食物说‘不’了”。 打鼾了。而 Rozita 女士曾经患有阻塞性 泪水的替代物是血浆。 在手术前， Lawrence 先生的体重是 睡眠呼吸暂停症。这种病症使患者在深 新加坡全国眼科中心角膜及眼表疾病 117 公斤，身高体重指数（ BMI ）为 35 。 度睡眠时由于气道闭塞而会周期性地 对肥胖问题而患上的疾病厌烦不堪， 科顾问医生童学天说：“虽然血浆成份 去年11月动手术后，如今他的体重是 停止呼吸，因此不得不使用连续气道 她便要求做胃旁路手术。“我告诉我丈 与泪水并不完全相同，但是血浆含有泪 85公斤。 正压通气（continuous positive airway 夫说，不管你是否同意我做手术，我都 水中所有的多种蛋白质。蛋白质为眼表 Rozita女士在手术前是属于“超级肥 pressure ，简称 CPAP ）装置帮助睡眠。 要在手术知情同意书上签字。” 面营造了一个正常、抗炎的环境，因此 胖”型， BMI 为 50 ，体重高达 128 公斤。 现在，她再也不需要它也能睡得安稳。 据新加坡中央医院康跃中心主任兼普外 血浆可以是很好的泪水代替物。”童医 于去年9月做了减肥手术后，她现在的体 不过，接受胃旁路手术的过程并非一 科高级顾问医生 Shanker Pasupathy 所说， 生也是这项研究的第一负责人。 重已减至93公斤。 帆风顺。 3文转 eV\Z'3文转 eV\Z'-
许多人认为减肥手术可以 解决所有问题，但关键不 在于手术，而是了解如何 进食和如何面对生活。
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新闻 > 文接 page 27
眼睛表面持续由具湿润作用的 泪水保护着。眼泪的成份是： 水份以保持湿润 油脂以保持润滑 粘液以保持均匀涂布 抗体和特殊蛋白质以抗感染 图：ALVINN LIM
干眼症是一种能影响患者生活质量常见 的疾病。造成干眼症的因素包括老化、 眼睛创伤或某些疾病，也可能是由于某 些药物或治疗的副作用。例如，61岁的 Hartono Hoesny 先生就是因患有癌症而 在骨髓移植后而患上了干眼症。 这位食品配送公司的主管说：“我 在10年前做了骨髓移植后出现了各种排 斥反应影响了口腔、皮肤和指甲。但是， 给我带来最大困扰的还是眼睛，因为总 感觉眼睛里有沙粒。” 王银花女士是试用血浆润眼液的一位研究参与人。她将装有血浆润眼液的细管存放在冰箱中，然 后依日常所需把部分解冻使用。为了从她的血液中提取血浆，她接受了长达一小时类似捐血且无 痛的程序。
了研究小组观察结果的证实。 “我们观察到，经过六周治疗后，上 皮细胞既眼表面的细胞的损伤减轻了。 存放在冰箱中 这些研究结果非常鼓舞人心。我们最 患者将这些细管存放在冰箱中，然后依 近在一次国际会议上宣布这些研究结果 日常所需把部分细管折断使用。有些患 时，在场的医疗同行也同样感到兴致勃 者如Hoesny先生，甚至用双层袋子包装 勃。”童医生说道。 细管才放入冰箱，以确保细管不受污染。 研究小组很乐观地认为，未来以这 虽然王女士和Hoesny先生都必须确保他 原理为基础的疗法将会成为较难治疗的 新加坡全国眼科中心角膜及眼表疾病科顾问医生 们使用的部分血浆整天都处于阴凉的环 干眼症病例的“黄金标准”。与此同时， 童学天 小组必须继续进行一至两年的研究，以 境中，但是他们都不嫌它麻烦。 王女士说：“我根本不觉得有任何 观察它的长期疗效。 的不方便。事实上，那样大费周章还是 血浆润眼液将由新加坡卫生科学局血 值得的，因为我的干眼症真的得到了改 液服务处生产，该部门也会帮助患者储 Hoesny 先生也试用了几种非处方润 善。”王女士将她的润眼液存放在一个 存其血浆润眼液。 眼液和眼用凝胶，不过全都不管用，直 婴儿食物容器中，然后再放入一个保温 “由于血液服务处的冷藏设施更为可 到他参加此项研究，开始使用自己的血 袋里。 靠、也更为宽敞，患者可以将其一半的 浆所制作的润眼液后，症状才有了好转。 血浆润眼液存放在那里。当患者用完存 参加研究的患者得接受一小时类似捐 研究人员对前景感到乐观 放在家中的血浆润眼液后，他们可以从 血且无痛的程序，以便从其血液中提取 对于干眼症患者所得到的改善，也得到 血液服务处拿取其余的存货，而不必再
研究小组很乐观地认为， 未来以这原理为基础的 疗法将会成为较难治疗 的干眼症病例的“黄金 标准”。
眼睛周围的特殊腺体会分泌这 些成份。这些成份的失衡则会 引起干眼症。
如何知道眼干 当泪水无法有效润滑眼睛， 你就会感到：
疼痛 畏光 沙粒感 眼睛含沙粒的感觉 眼睛发痒 眼睛发红 视力模糊
次进行血浆提取。”童医生解释道。 对于像Hoesny先生这样的患者而言， 这确实是一个好消息。 他说：“血浆润眼液纯粹来自我们体 内的血浆，因此非常安全有效。我很荣 幸能参于这项试验。虽然现在研究期已 结束而需要付费，不过相比于购买并不 完全有效的非处方润眼液，还是便宜得 多了。”
> 文接 page 27
囊，与小肠中段直接相连。如果进食量 超过小囊的容量，病人就会呕吐。 Law re n c e 先 生 早 餐 通 常 吃 一 片 面 这样的决心和意志对评估病人是否适合 包，午餐吃一小块鱼，晚餐吃一小块鸡 减肥手术至关重要。 肉。“我只吃少量的碳水化合物，不能 “许多人认为减肥手术可以解决所有 吃我爱吃的炸鸡，也不能吃米饭。” 问题，手术后就可以随心所欲。其实， Rozita女士断言，对于食物她从来不 事实并非如此。手术就象个‘复位’按 曾有过‘吃饱了’的感觉，不过她已经 钮，可以让你展开新生活，不仅仅是 学会克制自己，对很多食物说‘不’了。 饮食上，而是面对整个生活方式的态 现在他们两人终身都得坚守严谨的饮 度，”他说。 食习惯、锻炼和每日营养补充品的摄入， 在康跃中心，病人学习如何改变饮食 并且定期到康跃中心监测自己的进展情 习惯。“我们讨论饮食、食物选择以及 况。他们也当起健康生活方式的大使， 放松心情。他们需要了解这些事项的重 因为他们的家人和朋友都以他们为榜样， 要性以便作出调整。减肥手术只能帮助 从而为自己选择健康的生活方式。自从 他们减轻 20% 至 30% 的体重。” Lawrence先生接受手术后，其家人的总 要是病人不调整饮食和生活方式，任 体重也削了超过 30 公斤！ 何的减肥手术，不管是胃旁路手术、腹 Shanker 医生说：“关键不在于手术， 腔镜下胃束带术或胃囊袋切除术都将 而是了解如何进食和如何面对生活。这 注定要失败 Shanke r 医生补充道。这样 样一来，手术后还学会如何正确饮食的 辛辛苦苦削掉的体重也会因调整不当而 人就会成为改变其家庭成员的饮食习惯 复胖。 的核心人物。” 拥有同样经历的病人之间也会互相扶 手术后 持。在康跃中心，每隔周三傍晚都会举 Lawrence先生和Rozita女士异口同声地表 行支援小组聚会，让将要接受手术的人 示他们手术后的复健过程也不是件易事。 和已接受代谢手术或经历了各种术后阶 手术后，病人的胃容量被减小成小 段的人参与。
肥胖能带来其他疾病 肥胖症指的是能危害健康的异常或过量脂肪累积。根 据2010年全国健康调查，肥胖率已从2004年的 6.9%飙升到2010年的10.8%。保健促进局认 为身高体重指数（BMI）超过27.5的人患上 一些疾病的可能性会比较高，譬如: 心功能异常 哮喘 阻塞性睡眠呼吸暂停症 胆囊疾病 骨关节炎 关节疼痛 腿肿 中风 白内障 糖尿病 高血压 癌症 月经异常 不育症 多囊卵巢综合症 冠心病
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价格昂贵的乳霜更好： “不一定。 重要的是这款产品适不适合你。”
许多女性都会尝试任何能保证青春源泉 的产品。但樟宜综合医院皮肤科顾问医 生王逸诗却提醒大家不要对那些瓶瓶罐 罐有过高的期望。 王医生表示：“抗皱产品能够延缓 衰老迹象，但却不能预防皱纹产生或消 除皱纹。这方面只有整形手术才能做 到。”她补充说，皱纹，例如笑纹和鱼
从年轻时开始，保持年轻： “你 图：ALLEN TAN
原文 RUTH LOH
尾纹，是由脸部表情还有年龄增长所形 成的，通常会在30岁左右出现。曾经紧 致的肌肤也会因骨质的流失导致面部骨 骼形状改变而松弛。
享有盛名的乳霜 至于美白产品，她说：“除非那是你不 暴露于太阳底下的自然肤色，不然无论 你使用多少乳霜，也不会像电影明星妮
王逸诗医生表示：“我对那些希望保持肌肤白皙 的女性建议使用防晒霜，避免日晒并在晚上涂抹 维生素A乳霜。”
可基德曼一样白皙。” 那是否意味着我们需要撤走梳妆台 上所有的美容产品？那倒未必。 王医生表示，信誉良好的企业也生 产出不少相当不错也具有一定的抗皱效 果的产品。 那些产品也含有功效特强处方产品 当中找得到的少量成份，例如，用于黄 褐斑（也被称为妊娠斑）的淡化色素美 白霜来对抗脸上的褐色斑点。正因如 此，零售产品的副作用相比之下虽然比 较低，但却没有显著的效果。 “然而，美容产品 公司常常将其特殊成份 大肆吹嘘为下个大热 门，例如，声称干细 胞能够改变肌肤基因。 理论上听起来是很不 错，但实际上却缺乏科 学根据。”
身体力行 清洗：“我使用洁面乳来清除肥 皂和污垢，用什么样的产品其实 也没太大的区别。但要找那些你 负担得起又适合你肤质的产品。 属于油性肌肤又有青春痘倾向的 青少年比干性肌肤的年长女性， 可以使用配方更强的产品。” 晚霜：“我所使用的维生素A乳 霜是处方药物，每周两到三次。 它能清洁毛孔，预防粉刺的生 成。在我20多岁有了粉刺后，便 开始使用它。它不但能迅速使肌
王逸诗医生与我们分享她 的个人美容秘诀 肤更新还能减缓皱纹和细纹的出 现。这种乳霜会令你的肌肤对阳光 照射更加敏感，所以不能在白天使 用，也不能暴露于阳光底下。我每 周两到三次还会使用果酸乳液来祛 除死皮。” 防晒霜：“我的防晒霜可在零售商 店购得，价格也便宜。” 特别护理：“我每半年会做一次脉 冲光。就像光学治疗一样，能令肌 肤重获新生，且有助于均匀色素。
王医生唯一知晓的科学 研究是广泛地用于美容 产品上的维生素A衍生物。她说：“从 减缓肌肤中的胶原蛋白和弹性组织退化 显示，它们是具有一定的延缓肌肤衰老 迹象的功效。” “类维生素A （Retinoid，维生素 A局部衍生剂）有经过医学研究证实有 一定的可信度，研究结果曾被刊登在医 学期刊上。A 酸（Retin-A ）是处方药 物不能在外购得，但较为温和的维生素 A乳霜可轻易在零售商店买得到。” 抗皱乳霜中的其他活性成份都是抗 氧化剂，这包括维生素C和E、谷胱甘肽 和天然有机酸（果酸），例如甘醇酸和 乳酸。抗氧化剂是被认为能够减缓肌肤 细胞损伤，果酸则是能够祛除死皮令肌 肤更具有光泽的成份。
保持白皙 除了维生素A以外，美白产品通常也含 有维生素C、天然有机酸、甘草以及曲 酸 （一种源自蘑菇的天然亮肤成份）。
无法在年轻时期通过使用抗皱乳霜来延 缓皱纹的出现。青少年和20岁的年轻人 的肌肤中都含有天然油脂，况且在这潮 湿的新加坡，更不需要润肤膏。”
填充物： “玻尿酸和动物胶原蛋 白的混合物注入肌肤可填充面部下 垂的区域，或创造更为丰满的下巴，效 果惊人。”
王医生表示：“虽然零售产品能够 淡化最常见的色素沉淀问题，但往往都 不能完全清除它。” “通常，避免日晒是女性达到白皙 肌肤的方法。对那些希望保持肌肤白皙 的女性，我建议使用防晒霜，避免日晒 并在晚上涂抹维生素A乳霜。” 她说：“防晒还能降低患皮肤癌的 风险以及预防早期幼纹。”王医生也建 议那些喜欢水上运动或长时间在阳光下 的人们，使用至少30防晒系数的防晒 霜。由于有效性会逐渐消退，所以必须 在每两至三个小时重新再涂抹一次。 但另一方面，持久防晒的皮肤会缺 乏充足阳光照射。她说：“在这种情况 下，就得到诊所监督你的维生素D的水 平，如有必要，可服用补充剂。”
JUL⁄ AUG 2012
半小时到稍微过4小时之久，而微创手 术则需要1到6小时。 她说：“但我们发现高龄患者并不 受此影响。与麻醉有关的并发症主要会 出现在手术后。微创手术的并发症风险 或许来得更高，但我们发现实际情况并 非如此。微创手术的并发症发生率是相 似的，而不是更高。”
新加坡中央医院的一项研究发现，与传 统的开放式手术相比，大肠腹腔镜或微 创手术并不会带来更高的术后并发症风 险，这是高龄患者的福音。 研究显示，如果患者健康状态适合 接受手术，就应该让微创手术列为选项 之一。微创手术是通过微小的切口，借 助微型摄像放大手术部位并呈现于屏幕 上以进行手术。 新加坡中央医院结肠直肠科副顾问 医生陈华锈说：“我们发现手术不受年 龄限制。研究发现接受腹腔镜手术的患 者恢复得更快，住院时间更短，而且疼 痛程度也较轻。” 陈医生表示这项研究的目的在于证 明大肠癌年长患者进行腹腔镜手术后不 会有更高术后并发症风险，年长患者应 该可从这项手术中获益。研究人员也尝 试更深的了解高龄患者在长时间的麻醉 下是否会出现更多的并发症。这是由于 技术较为复杂，所以微创手术的时间会 比传统手术稍长。 陈医生说：“我们的数据显示接受 微创手术的高龄患者术后并发症的发生 率并不比接受开放式手术的患者高。”
研究对700余名年龄介于70至95岁 之间的患者进行了回顾性调查。这些患 者均在2005至2008年之间接受了开放 式手术和微创手术。虽然这不是一个随 机研究，但是研究所涉及的人数较大， 因此陈医生认为“研究结果很可能是确 凿无误的”。 陈医生补充说，一般来说，根据复 杂程度相比，传统开放式手术的时间为
陈华锈医生认为 微创手术在技术 上比传统开放式 手术更困难和更 有挑战性。
原文 RUTH LOH
我们的研究发现接受腹 腔镜手术的患者恢复得 更快，住院时间缩短， 而且疼痛程度也较轻。 新加坡中央医院结肠直肠科副顾问医生陈华锈
接受微创手术的患者除了恢复期缩 短以外，对吗啡止痛药的需求也减少 了。因此由吗啡带来的副作用如恶心、 呕吐、便秘和排尿困难也相符的降低。 陈医生认为微创手术在“技术上 比传统开放式手术更困难也富有挑战 性。”新加坡中央医院也有足够训练 有素且经验丰富的外科医生，能为那些 须要或适合进行微创手术的患者提供 选择。 “最重要的还是安全。如果无法确 保安全，我们不会坚持进行微创手术， 危及患者的性命。比如说，如果是肿 瘤晚期，我们可能就会选择进行开放式 手术。” 微创手术已经实行了15年，最近5年 才日趋成熟。近年来使用机器人辅助手 术进一步推动了微创手术的发展，因为 机器人的技术、特殊微小器械和电脑辅 助技术都大大提升了外科医生的技术。
我的女儿两岁又两个月大，睡觉 时打鼾已经有一段时间了。她一 度经常感冒，医生说这是打鼾的 主因。即使她的感冒复原后，打 鼾问题仍然存在。有时候，她看 似一面睡、一面打鼾。有时候， 又像是因打鼾而有呼吸困难。请 问我们应该怎么办? 如果您发现女儿有时似乎有“呼吸困 难”，那就应该向家庭医生或儿科医生 咨询。她有可能患上阻塞性睡眠呼吸暂 停，是会导致睡眠时上呼吸道出现间歇 性障碍。 您的家庭医生或儿科医生将能检查 孩子的鼻喉，确定是否有过敏性鼻炎的 症状、扁桃腺肿大以及其他能导致阻塞 性睡眠呼吸暂停的因素。医生会根据打 鼾的原因让你的孩子通过口服或鼻腔， 用药物治疗过敏性鼻炎，或者转介到儿 科睡眠专家作进一步检查。 竹脚妇幼医院儿科部门主任兼呼吸系统医科顾问 医生张运豪
我们的身体会随着年龄的增长而经历一 场生理和代谢的变化。新陈代谢使我们 体内迅速转换能量来运作各种功能，它 的波动对基本营养成分的吸收有一定的 影响。 除了一般必需的维他命和矿物质外， 老年人还需要更多特定的营养成分，如 钙和维他命D。 维他命和矿物质的不足会导致各种 健康问题，而这些问题对老年人来说可 能是非同小可的事。 包含各种全谷类、水果、蔬菜、瘦
肉、豆类以及乳制品的膳食有助于满足 这些基本需求。液体也 是保持良好的水化 作用的必需品。营 养丰富的膳食对获 得足够卡路里是非 常重要的。以复合碳 水化合物为其中主粮， 可以修复细胞的蛋白 质、脂溶性和水溶性的 维他命以及矿物质都有 利于总体健康。
缺乏维他命和矿物质可使50岁以上 的人面临以下风险： 钙和维他命D - 增加骨质流失，导致 更高的骨质疏松症和骨折的风险 适当的营养和维 他命对老年人尤 其重要。
铁 - 贫血，因为肺部需要运用铁往 身体各组织输送氧气 锌 - 免疫系统受损以及味觉与嗅觉 功能退化 叶酸 - 恶性贫血，因为人体需要叶 酸来制造红血球和白血球 维他命B12 - 肠道系统的细胞功能 减弱。长期缺乏可能导致神经系统以 及脑部功能退化。尤其是缺乏维他命 B群，它可能会导致人的认知能力衰 退。而当一个人年迈体弱时，不管是 手术或疾病，他们康复的速度可能会 变得更慢。 摄入足够的卡路里固然重要，但摄入 过多的脂肪和糖分可不是一件好事。我 们会先增胖，然后接踵而来的便是繁多 的健康问题，例如糖尿病、高血压以及 心血管疾病。
JUL⁄ AUG 2012
财经 下表是对自付额为3,000元、共保额 为10%的例证： 医药费 自付额 净额 共保额 保险公司赔付金额
一份保险可能无法报销所有的医药费。了解自付额 和共保额，以免收到医药费账单时大吃一惊。 46岁的亚莫先生买了一份附加险，以 使自己的医疗保险更加全面。附加险的 保险义务如下： 每日住院医疗补助：每日住院他都 将获得一定金额的现金补贴 重大疾病医疗补助：如果确诊患有 条款约定里的30种重大疾病之一， 他将获得一次性全额支付的重大疾 病保险金 涵盖自付额和/或共保额：帮他支付 全部自付额和/或共保额，这是受某 一极限限制的 自付额是投保人根据保单条款自付 的一次性为期一年的费用。共保额是需 投保人在支付自付额后自己承担付出医 疗费用的部分，通常是支付自付额后赔 付金额的一个固定比例。 后来，亚莫患病需要实施手术。他 以为自己的医疗保险会报销全额医药 费，所以未核查保单、也未与保险公司 确认其他约定的条款便确定了手术日 期。出院后，他把所有医药费账单拿到 保险公司进行报销。 没想到自己迎来的却是当头棒喝。 保险公司拒绝报销全额医药费，因为 亚莫的附加险项只涵盖共保额，而没 有涵盖自付额。他必须自行承担自付额 部分。 此外，每份保单每年都需支付自付 额和共保额。由于亚莫部分住院费的支
付时间属于新的保险年度，所以这些账 单需要根据个别年度的自付额和共保额 另行报销。
保险条款 亚莫的案例说明，了解自付额和共保额 以及它们是否适用承保范围内的所有报 销费用非常重要。 医疗保险的保单中通常有自付额 和共保额的规定。由投保人自己承 担部分医药费不但能够避 免医疗保健机构过度 消费，也使投保人 能够担负得起保 险费。
健康保险计划 不会自动为您 报销所有的医 疗开销。
$13,000 $ 3,000 $10,000 $ 1,000 $ 9,000
每份保单中不同类型的保险都有自 己的赔付限额。如果开支超出这一限 额，投保人就需自己支付其余的费用。 在上述示例中，医疗费账单应在保单的 赔付限额之内。 投保人需了解保险公司能够赔付多 少医药费，这一点至关重要，因为各医 疗保险保单都有限定的赔付限额。保单 可能对所有情况的赔付都已规定了最高 限额，包括年度或终身疾病以及伤残的 赔付限额。 投保人可享用两份或多份保单的赔 付，但同时拥有多份医疗保险保单 未必能为投保人带来额外的利 益给付，因为总数的利益 给付受限于投保 人的实际医疗 开销。
一次性买全所需药品 我父亲在新加坡国立癌症中心接 受治疗。他总是得在该中心的药 房领药后再花另一小时在新加坡 中央医院大牌4号的药房等候买 其哮喘药。如果我们能在新加坡 国立癌症中心药房同时买完全部 所需药品，这不但不用穿梭两 地，还可以减少等侯时间。 新加坡国立癌症中心答复： 我们 对于患者需要往不同的药房领药所带 来的不便，感到非常抱歉。遗憾的是， 新加坡国立癌症中心的药房是以癌症 药品为主，因此无法提供非癌症治疗的 药物。 我们的药剂与疗效委员会会定期审 核列入药物清单中的药品。如果发现任 何一种药品需求有增加的趋势，我们的 药剂师会提交申请，将这些药品添加到 药物清单中。 我们建议您父亲在下次会诊时，与 医生探讨这一项问题。
健康保险计划涵盖的范围 支付有关事故或疾病的医疗 费用。支付范围通常包括： • 住院治疗/手术 • 某些门诊手术 • 住院前和出院后的专家 咨询 • X光 • 实验室测试 “重大”医疗费用保险通常 赔付由重大疾病(例如，心 脏搭桥或器官移植)造成较 长期住院开支
注意事项 不论投保人拥有多少份保单，报销的费 用涵盖投保人应付的实际费用(自付额较 低)。因此，购买额外的医疗费用保单未 必能为投保人带来额外的利益给付 保单均有对自付额和/或共保额的条款约 定，自付额和/或共保额在投保人要求赔 付之前就规定了投保人应自行支付的最 低限额 对于投保人的赔付要求，每份保单都有 最高赔付额度。保单可能对所有情况的 赔付都已规定了最高限额，包括年度或 终身疾病以及伤残的赔付限额。为获得 更高的利益给付，投保人可综合两份或 多份保单的赔付限额 可能不予报销某些疾病的医疗费，例如 既存病历 可能需要一直等到发生意外伤害时才能 获得医疗费的赔付 保险费率可能得不到保证
前往外科手术室的途中，医院工 作人员不断反复地询问我的姓 名、身份证号码和排定的手术型 式。医院已存有我个人和就医的 档案，但他们还会在病房和手术 室里询问着同样的问题。 新加坡中央医院答复：我们拥有病 人的病历，但是为了避免可能出现的疏 忽或失误，譬如遣派错误的医疗文件或 与病人到手术室的医疗记录不完整， 所以我们的工作人员必须在病房和手术 室各个地方核对病人的姓名、身份证号 码、手术型式以及病人本身允许手术等 信息。 积极参与并有效的沟通是防范失误 的重要因素，病人也在确保自身安全方 面扮演着重要的角色。在进行手术前， 手术团队成员会做最后的核，确实他们 是在为正确的病人和正确的部位实施正 确的手术。
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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Gastric bypass surgery can help people with serious diabetes and other chronic medical conditions brought on by obesity. Read about how the...