A BIMONTHLY PUBLICATION OF SINGAPORE GENERAL HOSPITAL AND SINGHEALTH ACADEMIC HEALTHCARE CLUSTER MCI (P) 069/06/2013 WWW.SGH.COM.SG | WWW.SINGHEALTH.COM.SG
BEST OVERALL EDITORIAL
4-PAGE NURSING SUPPLEMENT
MAGNUM OPUS AWARDS 2012
(PATH).inddindd (PATH). 1 5 AB
AM 17/6/13 10:43
Untitled-2 2 3
17/6/13 10:43 AM 14/6/13
Mutant gene study breaks new ground in cancer research
TONGUE CANCER ON THE RISE IN YOUNG WOMEN
Cold therapy can save lives of cardiac arrest patients
年轻女性 舌癌患者 不断增加 PHOTO: GETTY IMAGES
What parents can do to help their toddlers speak
JUL– AUG 2013 PUBLISHER
Tan-Huang Shuo Mei
Group Director, Communications & Service Quality, SingHealth & SGH EDITORIAL TEAM
Angela Ng (SGH) Lim Mui Khi (SGH) Corinne Tan (SingHealth) Chio Shu Yu (SingHealth) Ann Peters (SingHealth) Deborah Moh (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.
Read Singapore Health online at www.sgh.com.sg/singaporehealth
Caroline Ngui GROUP EDITOR
Joanna Lee-Miller EDITORIAL & CREATIVE SENIOR EDITOR
Low Ching Ling EDITOR
Serene Foo SUPPLEMENT EDITOR
Denyse Yeo SUB-EDITOR
Annabelle Bok CREATIVE DIRECTOR
Christopher Chan SALES & CLIENT MANAGEMENT ACCOUNT MANAGER, ADVERTISING SALES
SENIOR EXECUTIVE, CLIENT MANAGEMENT
Neo Pei Shi
PUBLISHING SERVICES SENIOR EXECUTIVE
Preciosa Reynoso Ramos For editorial enquiries, please e-mail email@example.com For advertising enquiries, please call 6319-3022 or e-mail firstname.lastname@example.org All rights reser ved. 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: email@example.com. Unsolicited material will not be returned unless accompanied by a self-addressed envelope and sufficient return postage. While every reasonable care will be taken by the Editor, no responsibility is assumed for the return of unsolicited material. ALL INFORMATION CORRECT AT TIME OF PRINTING. MCI (P) 069/06/2013. Printed in Singapore by Singapore Press Holdings Limited (registration no: 198402868E).
JUL– AUG 2013
More young women get tongue cancer BY SATISH CHENEY
An evolving incidence In the past decade, NCCS has seen a three- to four-fold increase in tongue cancer cases among young women aged 35 to 55. Previously, most sufferers were men, with the ratio being three male cases to one female. Now, the incidence is equal between the genders. This trend is seen in other developed countries, but what is puzzling doctors
Patches in your mouth. They could be white or red and look like thrush but you cannot scrape them off.
Lumps on the tongue. Not every lump is cancerous, but it needs to be examined.
SYMPTOMS OF TONGUE CANCER
Mouth ulcers that don’t heal. Painless ulcers are more worrying. Catching a small cancerous ulcer means only a small portion of the tongue needs to be removed.
Pain when chewing or swallowing food.
Inflammation or swelling in the mouth. Problems can start small.
Tongue cancer can be treated effectively, usually by removing part of the tongue. If caught early, only a small portion of the tongue needs to be removed as the surgeon will make a circular cut. If the cancer is more advanced, the surgeon may have to remove half the tongue or more. After surgery, most patients will be able to speak and use their tongues normally. However, if more than twothirds of the tongue is removed, patients may have difficulty speaking and swallowing. Doctors may recommend reconstruction of the tongue and speech therapy, along with radiotherapy and chemotherapy to fight the cancer.
PHOTO: VERNON WONG
PHOTO: GETTY IMAGES
here is that these female patients do not have the same triggers as before. In the past, a typical tongue cancer patient was an elderly man who had been smoking and drinking his whole life. Smoking is a known cause of tongue cancer, along with sexually transmitted diseases (STDs) such as HPV (human papillomavirus). Today’s female patients do not have HPV or other STDs. They do not smoke, drink, or chew betel nut or tobacco. Nor are they associated with recently suspected causes – poor dentition (sharp teeth or badly fitted dentures) or the long-term consumption of immunosuppressants following treatment for kidney cancer, leukemia or lymphoma. NCCS’ clinician scientists embarked on a complex study to get to the bottom of the mystery. Principal investigator Dr Gopal said they have ruled out HPV as a cause. “In tongue cancer, the first thing we look for is HPV, but their tests proved negative. I confirmed this finding with a group in the United States engaged in a similar study. We also looked for genes the tumour might express, but there weren’t any clear-cut answers.”
TREATMENT AND THE AFTERMATH
An NCCS study tries to find out why today’s female patients do not have the same triggers as before
HEN 35-YEAR-OLD Karen (not her real name) discovered an ulcer on her tongue, she consulted her family doctor. When it did not heal, she had it checked at a hospital, where they did a biopsy and told her she had nothing to worry about. But she had an uneasy feeling as the lesion was growing, although there was no pain. She researched it, then consulted a specialist at the National Cancer Centre Singapore (NCCS). Dr Gopal Iyer, Consultant Surgeon, NCCS, examined it and was worried even though the biopsy was negative. “I suggested surgery to remove it. I reasoned that if I was wrong she’d lose just a bit of her tongue. But if I was right, I’d have saved her from tongue cancer.” She agreed. “I removed a quarter of her tongue. She recovered well and went home two days after the operation. A week later, the results confirmed that the lesion was indeed cancerous,” Dr Gopal said. Karen was lucky to have caught it early. Her persistence, in the absence of obvious symptoms, paid off.
Dr Gopal Iyer is the principal investigator of a complex study on tongue cancer. Undeterred, they moved on to genome sequencing − at press time they had sequenced 18 samples, and were decoding the tumour’s genetic information and analysing the data they had collected. “Some promising genetic markers have come up, and we’re trying to validate this. If we find specific genes such as enzymes causing the cancer, and if they can be targeted, that will be very promising. It’ll not just tell us what’s causing the cancer, but open up the possibility of creating an inhibiting drug,” said Dr Gopal. Two theories Definitive answers have not yet been found, but Dr Gopal has learnt enough to propose two theories. Firstly, many women with tongue cancer may already have a higher genetic risk of the disease. This risk, combined with a previous short but sustained exposure to cigarettes (whether by smoking or inhaling second hand smoke), may kickstart the cancer. Secondly, there is a suspected (though unconfirmed) link with diet. According to Dr Gopal, these young women with a higher genetic risk of tongue cancer may have also been eating processed foods and cooked food with carcinogens. Besides this, he also cited a study showing a link between the overuse of alcohol-based mouthwash and tongue cancer.
TONGUE CANCER CAN BE TREATED EFFECTIVELY, USUALLY BY REMOVING PART OF THE TONGUE. Early detection and swift treatment is important, Dr Gopal said. “I had a 22-year-old female patient from Malaysia with a lesion on her tongue. When she saw me, one-third of her tongue had already been removed in Malaysia.” He confirmed that the lesion was cancerous, and removed more of her tongue and also operated on a big lymph node in her neck. Towards the end of her radiotherapy, the tumour returned and the patient decided to go to China for medication. By the time she returned to Singapore, her cancer had spread everywhere − it was already too late and she died. Dr Gopal said tongue cancer can be prevented and advised everyone to mind the five S’s – smoking, spirits, spices, STDs, and sharp teeth. “See the dentist twice a year. It’s important to have good dental hygiene.”
JUL– AUG 2013
Cancer research takes a step forward
WHY THE P53 MUTATES
NCCS scientists have made progress studying a gene which suppresses tumours but can also cause cancer when it mutates
LUNG CANCER/HEAD AND NECK CANCERS
It is widely believed that smoking and pollutants can cause the mutation. Smoking is also believed to cause the mutation that leads to head and neck cancers.
LIVER CANCER Prof Sabapathy’s team is developing a compound that can attack the mutated p53 gene without hurting the normal one.
There is a fungi which grows on rice, wheat and peanuts, that produces a toxin called aflatoxin. In the liver, aflatoxin causes a p53 mutation, which leads to liver cancer, especially in Hepatitis B carriers.
PHOTOS: JASPER YU
BY SATISH CHENEY
N THE field of cancer research, companies are putting in money to find potential drugs that activate the normal p53 gene – tumour suppressors in our bodies – so they can work better against cancer cells. Professor Kanaga Sabapathy, Head, Division of Cellular and Molecular Research, National Cancer Centre Singapore (NCCS), on the other hand, has set his focus on the mutant p53 gene instead. Everyone has two copies of the p53 gene. Normally, both copies are tumour suppressor s, but sometimes one mutates, disrupting the role of the other, and causes cancer. Studying the mutant gene The mutant gene is linked to half of all sporadic cancers (those not caused by hereditary factors) in the world. They include lung, stomach, breast, colorectal and liver cancers. Doctors are aware that the mutant gene can lose its ability to suppress tumours but they are relatively unclear how it makes cancer treatments and drugs ineffective. Knowing this can open doors to new ways of enhancing treatment in the future. Prof Sabapathy and his research team had previously been trying to prove the link between the mutant gene and ineffective cancer treatment. They had run tests which proved that if one copy mutates, the other’s ability to suppress tumours gets disrupted. They found that cancer-stricken mice with no mutant p53 gene responded well to treatment, while those with the mutant gene responded poorly.
“The challenge was to design tests to prove that getting rid of the mutant gene or reducing its levels, would improve treatment,” said Prof Sabapathy. He wondered about using stemcell technology to modify levels of the mutant gene in mice.
WE PROVED THAT WHEN THERE IS A REDUCED AMOUNT OF MUTANT P53, THERE WILL BE A CORRESPONDING INCREASE IN THE EFFECTIVENESS OF CANCER TREATMENTS AVAILABLE TODAY. PROFESSOR KANAGA SABAPATHY, HEAD, DIVISION OF CELLULAR AND MOLECULAR RESEARCH, NATIONAL CANCER CENTRE SINGAPORE, ON BREAKING NEW GROUND.
This was a departure from what most drug companies and laboratories in the world were and are trying to do – focusing on making the normal gene work better, rather than getting rid of the mutant. He said: “The challenge is how to activate the normal gene without doing the same to the mutant as the two are virtually indistinguishable. They are like two identical T-shirts with the only difference
being a tiny dot, the size of a mole, on one of them.”
I n s t o m a c h ( g a s t r i c) cancer, the helicobacter pylori bacteria in the stomach promotes the mutation. The bacteria grows in the coating of the inner stomach.
Breaking new ground Prof Sabapathy took the idea to the lab where his team reduced levels of the UROTHELIAL CANCER mutant gene in mice and found the Dietary contamination is linked to p53 mutation in patients with answer they were looking for. urothelial cancers (bladder, ure“We proved that when there is a ters and renal pelvis cancers). reduced amount of mutant p53, Aristolochic acids are said to be there will be a corresponding one of the main culprits which increase in the effectiveness cause mutation. The acid comes of cancer treatments availfrom aristolochic plants which are used in certain herbal remedies. able today.” Until they did it, no one had been able SKIN CANCER to prove (in the Harmful UV radiation from the sun can cause p53 genes to mutate. The organismal setstrong and harmful rays are said to ting) that reductarget the tumor suppressor genes ing the amount early. In fact, some researchers have of mutant p53 reported that experiments on mice genes is equivashow mutations in the p53 genes can be detected even before lent to helping symptoms of cancer are seen on patients respond the skin. better to cancer treatment. “Now, Sources: Online if we can come up with a drug to reduce the levels of mutant p53 genes, we will improve how patients respond to current cancer treatments.” His team has begun work on the next step – developing a compound or method that can attack the mutated p53 gene without hurting the normal one. “Right now, we haven’t identified one that can distinguish between the two.” He hopes to have good results within five years. “These things are tough to predict, but we certainly hope to come up with something that can help millions of cancer sufferers out there.”
JUL– AUG 2013
Cooling down can save your life Cold therapy on cardiac arrest patients can reduce chances of death and brain damage
OWERING the body temperature of a person whose heart suddenly stops can triple his chance of survival, according to a recent study by the Singapore General Hospital (SGH). In Singapore, some 1,500 people suffer a cardiac arrest outside of a hospital every year, with a dismal survival rate of 2.7 per cent. And for those who survive, many will suffer irreversible damage to the vital organs and the brain, possibly becoming vegetative or comatose. But the SGH study showed that when therapeutic hypothermia is used on cardiac arrest patients to lower the core body temperature to about 33-340C, it can greatly reduce the chances of death and brain damage. Normal body temperature is around 370C. “This is using cold therapy to protect a person’s vital organs after they have had a severe event, such as a cardiac arrest,” said Associate Professor Marcus Ong (right), Senior Consultant, Department of Emergency Medicine, and the lead researcher in the study. Cardiac arrest occurs when a person’s heart stops beating and there is no blood flow and supply of oxygen to the organs. If the heart and brain are deprived of blood flow and oxygen for a prolonged period, the organs will be damaged. Bringing the body temperature down
helps to protect the patient’s vital organs and preserve tissues, he said. In the SGH study, the patients, who were aged 18 to 80, were randomly divided into two groups: those given the standard treatment, and those with standard treatment as well as cold therapy. The trial aims to study about 100 people. Early results involving 40 cardiac arrest patients between 2008 and 2012 found that fewer patients who were given the body cooling treatment died – 35 per cent survived versus 10 per cent of those given just the standard treatment. Survivors also fared better. “In the past, very few (cardiac arrest) patients were discharged with their brain function intact. Now about half who survive go on to lead normal lives,” said Assoc Prof Ong.
“The findings are very encouraging, suggesting that this therapy can reduce the number of deaths, and improve and preserve the brain function.” Not every cardiac arrest patient is suitable for this new treatment though. They must have a stable pulse and blood pressure. Those who suffered the cardiac arrest because of a severe accident are also not suitable for the treatment as cooling can increase bleeding in injuries. Hypothermia treatment, said Assoc Prof Ong, is acceptable treatment elsewhere, having been used in Europe and Australia for the past 10 years. SGH started using the treatment about seven years ago, the first hospital to do so in Singapore. In the treatment, the body’s temperature is lowered either by pumping cool saline into the body, or by wrapping large cooling-gel pads around the body. The former method is more effective and has the advantage of better temperature control and regulation. Inserting a catheter into a vein, though, comes with risks such as infection, bleeding and venous thrombosis. After the patient’s body temperature has been quickly lowered to 33-340C, the temperature is maintained at that level as the patient goes into an induced coma for about 24 hours. Then, the temperature is slowly restored over 12 hours to normal at around 36-370C. Cool therapy is one of several new therapies being studied or introduced to increase the chances of survival in people who suffer a sudden collapse or heart failure. For instance, Assoc Prof Ong has looked at whether delivering electrical shocks or defibrillation at a specific time during cardiopulmonary resuscitation (CPR) can improve survival for cardiac arrest patients.
EARLY ACTION SAVES CARDIAC ARREST PATIENT Mr Peng Hua (right), 39, had not been suffering from any illness when he suddenly collapsed at work last September. “I have no idea what happened. I don’t remember being in an ICU or a high-dependency ward. Everything was a blur,” he said. When he was brought to SGH, Mr Peng was quickly given the new therapeutic hypothermia treatment. His body temperature was cooled using the catheter system. As a result, he has recovered with little damage to his brain.
“I can recognise people, I can do everything just as before. My memory came back to me all in one piece.” In Mr Peng’s case, early action by his colleagues was crucial. He was found slumped in his chair, and his colleagues took turns to perform cardiopulmonary resuscitation (CPR) while waiting for an ambulance to arrive. The first SCDF medic arrived on a bike and found that Mr Peng’s heartbeat had an irregular rhythm. The medic administered defibrillation several times to shock his heart into establishing a regular rhythm.
In Singapore, the rate of survival of the 1,500 or so people who suffer out -of-hospital cardiac arrest every year is under three per cent. This is way below the 16 per cent survival reported in other countries. “Every minute of delay in getting help cuts a victim’s chance of survival by 10 per cent. After 10 minutes, the victim’s chance of survival becomes very small if nobody starts CPR,” said Associate Professor Marcus Ong,
PHOTOS: ALECIA NEO
BY DESMOND NG
Cold therapy involves the body’s temperature being lowered either by pumping cool saline into it, or by wrapping large cooling-gel pads around it.
TO HEIGHTEN AWARENESS OF THE IMPORTANCE OF EARLY ACTION IN SUCH SITUATIONS, 60 PEOPLE WERE GIVEN SURVIVOR AWARDS BY SGH AND THE SOCIETY FOR EMERGENCY MEDICINE SINGAPORE IN APRIL FOR THEIR EFFORTS IN RESUSCITATING CARDIAC ARREST VICTIMS.
Senior Consultant, Department of Emergency Medicine, SGH. In Singapore, just 20 per cent of bystanders can or are willing to perform CPR on someone who has collapsed. “So when a person suffers a cardiac arrest, someone should be willing and able to do CPR and use an AED (automated external defibrillator) for the victim to have a chance to survive. Otherwise, brain damage will start within four to six minutes of initial collapse and the consequences can be fatal,” added Prof Ong.
JUL– AUG 2013
Made friendlier for the elderly
Older patients are now served better at the Geylang Polyclinic through its redesigned facilities BY JAMIE EE
HE REFURBISHED Geylang Polyclinic reopened in May with, among other things, more elder-friendly features. The $6 million-facelift of the 6,200 sq m, four-storey polyclinic, which last year saw close to 208,000 patients, took four months to complete. It is now a safer place for its increasing number of older patients to visit. Dr Tan Chee Beng, Chief Executive Officer, SingHealth Polyclinics said more than 60 per cent of its patients are above 40 years old, and close to 30 per cent are above 65 years old. “As our population ages and the prevalence of chronic diseases increases, we have to adopt a needs-driven approach in designing our care. Not only are we focus-
ing on prevention and early detection of diseases, we are stepping up efforts in patient education and empowerment, especially for the elderly and their caregivers,” he added. To this end, its new Geriatric Centre – the first for a SingHealth polyclinic screens and manages elderly patients with conditions such as osteoporosis and dementia. Dr Amy Khor, Minister of State for Health and Manpower, who was at the reopening, said Geylang Polyclinic is an example of the Government’s initiative to upgrade existing polyclinics, and build new ones to improve service delivery and address gaps in healthcare coverage. Here’s a guide on what to expect when you visit the polyclinic.
The $6 millionfacelift of the 6,200 sq m, fourstorey Geylang Polyclinic took four months to complete.
CONVENIENCE & COMFORT
Pharmacies and payment counters are located on both the first and second levels, where the main consultation rooms are. The counters at the registration, pharmacy and payment areas are fitted with curved, low-height counters to allow wheelchair users to communicate easily with counter staff. More space is also carved out for wheelchairs in the waiting areas.
Handrails are fitted along both sides of the corridor for safe movement.
I LIKE THAT THERE IS AN ADDITIONAL LIFT AND PHARMACIES ON TWO LEVELS. THIS IS CONVENIENT AS THE WAITING TIME IS SHORTER.
IMPROVED NAVIGATION Once you walk into the reception, you will notice that colours are used to differentiate services and guide patients to where they need to go (blue is used in the registration area and green in the pharmacies). The colour guide is on the reception wall.
MDM KHATIJAH MOHD ALI, 63, HOUSEWIFE
Signs are in large, bold fonts and accompanied by pictograms to help elderly patients with poor eyesight. Key signage and directories are in English, Chinese, Malay and Tamil.
Key clinical services, such as foot screening and retinal photography for diabetics, are located near each other so that elderly patients need not walk far to reach them.
The flooring used in the clinic is an anti-slip material in a neutral colour. All chairs in the waiting area have armrests for patients to support themselves as they stand up from their seats. Chairs in the clinic are in darker colours so that elderly patients can see them more clearly.
JUL– AUG 2013
JUL– AUG 2013
Beyond the call of duty These two foreign nurses from Bright Vision Hospital were among this year’s healthcare workers awarded the Singapore Health Quality Service Award for excellent service Nursing Officer Ms Jessie Zhao is happy going the extra mile for patients and colleagues.
MS REMEZEL DE LEON, 30 Singapore Health Quality Service Award 2013 (Silver)
BY LEDIATI TAN
When Ms Jessie Zhao Ruihong first came to Singapore to work as a staff nurse at Bright Vision Hospital (BVH) in 2006, she encountered language problems. Having been educated in China and working in a hospital there for 14 years, she knew little English, but overcame the problem with English classes and help from kind colleagues. Now she finds herself wanting to give back. She never hesitates to help, even if it means going out of her way or dipping into her own pockets to render a service. Such an occasion arose last December when she was on a clinical attachment at Dover Park Hospice. She overheard a terminally-ill cancer patient say she wanted to eat salted duck eggs. The patient’s two daughters and some nursing students tried in vain to find them at a nearby hawker centre, but Ms Zhao promised to bring them in the next day. After finishing her shift that evening, she rushed to the supermarket to buy them. She boiled them and brought them in the next morning for the patient, who was so touched that she gave her a big hug. “As a palliative nurse, I know I can’t fulfil every patient’s last wish, but if it’s reasonable and within my control, I’ll do whatever I can, hoping it’ll make a slight difference to them and their families,” she said. Ms Zhao, 41, now a nursing officer at BVH, is equally dedicated to the nurses under her charge.
She takes full responsibility for their well-being, and their personal and professional growth. Last November, when a foreign nursing aide applied for urgent leave to attend her father’s funeral, Ms Zhao immediately made arrangements for it and also enquired about the air fare. The aide did not have enough money and was unsure where to apply for a loan. Without hesitation, Ms Zhao handed her $2,000, even though she was in the process of buying a new home and had no idea if the money would be returned. It was.
WHEN I WENT BACK HOME RECENTLY, I SHOWED MY FAMILY THE AWARD AND PHOTOS OF THE AWARD CEREMONY, AND THEY WERE VERY HAPPY FOR ME. MS REMEZEL DE LEON, ENROLLED NURSE
On her recent win, she said: “I’m flattered because it’s a rare opportunity to receive the Silver Award. And I’m proud of myself. When I went back home recently, I showed my family the award and photos of the award ceremony, and they were very happy for me.”
Enrolled nurse Ms Remezel De Leon wins patients and colleagues over with her happy personality and caring nature.
I’M SURPRISED BUT ALSO GRATEFUL TO MY MANAGEMENT. I FEEL RESPECTED, SUPPORTED AND RECOGNISED FOR MY CONTRIBUTION. MS JESSIE ZHAO RUIHONG, NURSING OFFICER
Ms Zhao believes that kindness begets kindness. Her own graciousness and empathy have not gone unnoticed. In January this year, she was among more than 2,500 healthcare workers honoured at the awards ceremony at Kallang Theatre, after receiving a Singapore Health Quality Service Award 2013 (Gold). “I’m surprised but also grateful to my management. I feel respected, supported and recognised for my contribution.”
PHOTOS: ALECIA NEO
MS JESSIE ZHAO RUIHONG, 41 Singapore Health Quality Service Award 2013 (Gold)
Ms Remezel De Leon’s cheerfulness is contagious. It catches on quickly with her patients, their caregivers and her colleagues at Bright Vision Hospital (BVH). Her winning smile is matched by her caring nature. She often thinks nothing of helping out, even if it is after her shift or if she cannot speak the patient’s language. Once, when a patient passed away, she voluntarily stayed behind after work to comfort the grieving relatives. She couldn’t speak their Chinese dialect but managed to reach out and comfort them, buying them drinks from a vending machine with her own money. “I just wanted to offer them some comfort, as a member of their family had just passed away. I didn’t know how they were taking the news but I wanted to help in any way I could,” said Ms De Leon, 30, who joined BVH in 2008 as a nursing aide after working as a staff nurse in the Philippines. Her kindness extends to co-workers as well. Noticing that some colleagues skipped meals because they did not have money for food, she started bring-
ing extra cooked food from home to work and offering it to them tactfully. “To me, it was about the happiness of sharing the extra I had with them,” she said. She also helped a colleague who needed to buy a ticket home because of an emergency. “It’s important to help in such moments,” she said simply. Her winning ways bagged her the Singapore Health Quality Service Award 2013 (Silver) in January – a testament to her dedication. It was not the first time that her positive outlook has been recognised. At last year’s Nurses’ Day celebration, she received the Best Nursing Aide Award after winning over patients, their caregivers, her supervisors and colleagues with her knack for staying cheerful despite a heavy patient load.
JUL– AUG 2013
Smoking ban extends to hospitals’ outdoor areas
PHOTOS: VERNON WONG
Signs are put up around SGH Campus to alert visitors and patients of the affected areas
Sheltered walkways are new no-smoking areas.
The no-smoking areas now extend to outdoor areas such as carparks and gardens.
No-smoking zones now cover hospital compounds, as well as other outdoor areas on SGH Campus.
BY TEO KUAN YEE
T IS NOW illegal to smoke within hospital compounds, as well as other outdoor areas on SGH Campus. Since Jan 15 this year, the National Environment Agency (NEA) has extended the national no-smoking zones to the common areas of residential buildings, as well as to multi-purpose halls, covered walkways and linkways, and the areas within 5m of bus shelters. The outdoor compounds of hospitals, such as carparks and sheltered walkways, are included in the new nosmoking areas. To alert people to the ban, signs have been erected prominently on SGH Campus and at exits to outdoor areas. Patients and visitors can approach the hospital’s security and other staff if they see anyone smoking on SGH Campus. Anyone found smoking in the prohibited areas will be asked to stub out his cigarette. If he refuses to stop
smoking, he will be asked to leave the area immediately. Anyone convicted in court for smoking can be fined up to $1,000. Also, under the Smoking (Prohibition in Certain Places) Act, anyone who hinders, obstructs, threatens or assaults hospital staff carrying out their duties can be fined up to $1,000, jailed up to six months, or both. The expanded ban followed discussions between the Ministry of Health and hospitals in Singapore. The Ministry won support from hospitals to extend the no-smoking zones to the outdoor areas of their compounds. The key message is that there is no safe level of exposure to secondhand smoke. Secondhand smoke contributes to a range of serious and potentially fatal conditions. Smokers are encouraged to observe the ban. Better yet, they should quit smoking.
JUL– AUG 2013
Calcium can reduce risk of pregnancy-related condition SGH’s study finds that expectant women are less likely to develop pre-eclampsia if they increase their calcium intake
BY LEDIATI TAN
N INCREASE in calcium intake can reduce the risk of pre-eclampsia in pregnant women by as much as 56 per cent, a group of doctors from the Singapore General Hospital (SGH) has found. This finding is significant as the number of older first-time mothers in Singapore, who may also be obese, is rising. Advanced age and weight can increase the risk of pre-eclampsia. Pre-eclampsia occurs when a pregnant woman develops high blood pres-
sure and protein is found in her urine after the 20th week of pregnancy. It is a serious condition that affects multiple organs and can threaten the lives of the mother and her foetus. The symptoms can be treated but the only “cure” for pre-eclampsia is delivery, which can be before term if the disease is serious. The mother’s blood pressure can be expected to return to normal within a few weeks of delivery. Pregnancy-induced high blood pressure or gestational hypertension, without the presence of protein in the urine, can also develop in pregnant women who are older and overweight. Gestational hypertension, which usually goes away after delivery, can lead to premature delivery and very low-weight babies. Pre-eclampsia affects about 4 per cent of pregnancies in Singapore, said Dr Tan Lay Kok, Senior Consultant, Department of Obstetrics and Gynaecology, SGH, who was involved in the study. Dr Tan and his colleagues reviewed the results of seven trials conducted on pregnant women in various countries between 1991 and 2009. The trials investigated the effects of calcium intake on the risks of developing pre-eclampsia and gestational hypertension. “We wanted to find out if there are simple things that patients and their doctors can do to reduce their risk of contracting either condition,” said Dr Tan. The SGH study looked at two groups of women. One group comprises those with a low calcium intake, that is, below the recommended dietar y allowance (RDA) of 1g per day. The other one made up of those whose calcium intake is more than the RDA of 1g per day. The women took an additional daily calcium supplement of at least 1g per day. Dr Tan’s team discovered that the supplement had the most significant effect on the group of women with a low calcium intake. Based on the SGH study, when a woman with a low daily calcium intake was given more than 1g of calcium per day during her pregnancy, her risk of getting pre-eclampsia was reduced by as much as 56 per cent. However, said Dr Tan, the number of women studied was too small for them to pinpoint the optimal amount of calcium that pregnant women should take to reduce their risk of developing preeclampsia. The challenge now lies in applying this finding to clinical practice. “In Singapore, women don’t seem to take enough
OTHER RISKS FACED BY PREGNANT WOMEN Gestational diabetes
This is high blood sugar (diabetes) that develops during pregnancy, usually late pregnancy. If gestational diabetes is not detected or managed effectively, the baby may be born premature. The delivery, too, may be difficult and more dangerous as the baby may be bigger than normal. The baby also runs the risk of developing low blood glucose (hypoglycaemia) after birth and a higher chance of dying before or soon after birth. One of the best ways to maintain the mother’s blood glucose level within a target range is to follow a healthy diet and exercise.
Deep-vein thrombosis (DVT)
This is a serious condition involving the formation of blood clots in a vein deep inside a part of the body, often in the lower leg and thigh. It can be fatal if the clot travels to the lungs. Pregnant women are more likely to suffer from DVT than non -pregnant women of the same age. A clot can form at any stage of pregnancy and up to six weeks after the birth. The treatment of DVT during pregnancy usually involves the injection of an anticoagulant.
PHOTO: ALECIA NEO
Dr Tan Lay Kok recommends a daily 1g calcium supplement for pregnant women at high risk of developing pre-eclampsia.
calcium. If their calcium intake is not adequate, doctors can encourage pregnant women to take more calcium, and this may help reduce their risk of getting preeclampsia,” said Dr Tan. He added that he would give pregnant women, especially those at high risk of developing pre-eclampsia, a daily 1g calcium supplement. As long as the women don’t take more than the recommended dosage, the extra calcium will not pose any harm.
JUL– AUG 2013
All in a day’s work Advanced practice nurses are a relatively new addition in Singapore hospitals, augmenting the range of senior nurses with specialised skills. Meet Ms Sivagame Maniya and find out more about their job
HE REGULARLY works 10-hour days, sometimes longer. She eats lunch on the go, often finding the time for a quick bite only in the middle of the afternoon. She also wants more time with her family, especially with her two young children. Yet, Ms Sivagame Maniya goes to work every day, feeling on top of the world. She is a wound care or vascular specialist nurse at Singapore General Hospital (SGH) – and she loves her job. “I am given responsibility for my patients and autonomy to treat them. I also have recognition from my doctors that my professional opinion matters. That makes my job very satisfying,” said Ms Sivagame. As one of a growing cohort of highly educated and skilled nurses, Ms Sivagame plays an important role in her clinical area, looking after patients who are mostly diabetic and often at risk of losing their limbs. As an advanced practice nurse, Ms Sivagame takes on some of the responsibilities of the doctors she works with, allowing them to spend more time on patients who need a higher level of medical care. She assesses the patients’ conditions and then updates the doctors during their ward rounds, whether they
A TYPICAL DAY
are improving or at risk of developing infection. “They might ask if I think a patient is ready to be discharged. Or I might suggest that we hold off amputating a limb to observe the wound for a bit longer. We work together to discuss our patients’ conditions. They respect my decisions and what I say about the patients, as I monitor them so closely,” said Ms Sivagame. Ultimately, she added, the teamwork between the doctors and her benefits their patients. Ms Sivagame has been looking after patients with vascular diseases for the last 12 years − the last three in the capacity of an advanced practice nurse. To become a certified advanced practice nurse, she underwent a one-and-ahalf year full-time postgraduate nursing programme, followed by a year-long internship in vascular surgery, before she was interviewed by a panel of doctors and the nursing board. Advanced practice nurses are a relatively new addition in Singapore hospitals, augmenting the range of senior nurses with specialised skills to deal with complex medical conditions. As of May, SGH has 29 advanced prac-
Ms Sivagame starts her day at 7.30am, clearing emails and other routine administrative work. She then goes to the wards to check on her patients, attending to the more complicated cases personally. In the early part of the day, she follows the vascular surgeons on their ward rounds, updating them about each patient’s condition and their progress. She counsels patients who are scheduled for amputation, explaining to them the procedure, recovery and care, as well as their rehabilitation process. She also plans the patients’ post-discharge care with their family members. She sees at least 10 cases a day, and as many as 20 on a busy day. In addition, Ms Sivagame is also involved in voluntary and community work. She was the previous chairperson of the Amputee Support Group in SGH. Now she is involved in helping the support group organise in-patient activities, home visits and external outings. She is also a member of the Hindu Endowment Board’s medical support team, participating in health fairs and community activities.
Unlike other senior ranking nurses, advanced practice nurses can perform clinical assessments and order tests to reconfirm their diagnoses without having to consult a doctor first. Ms Sivagame’s clinical training has helped her spot sudden changes in her patients’ conditions, such as a wound turning infectious, and even early signs of stroke and cardiac arrest. “If I notice that the patient isn’t looking as well as usual, I might order further investigations,” she said. She updates the doctors when they go round the wards to assess how well the patients are recovering.
tice nurses who specialise in pelvic floor disorders, renal diseases and other disciplines. Within the SingHealth group, including the national heart, cancer and eye centres, there are another 30. As the sole advanced practice nurse in SGH’s vascular surgery department, Ms Sivagame can only focus on patients with very complex conditions. “Ideally, it would be nice to be able to see every patient because the simplest of wounds can turn nasty. But we aren’t always able to see everyone,” she added. Still, she has her work cut out for her. For patients suffering from diabetes or arterial insufficiency
(where there is insufficient blood flow through the arteries), a small wound can easily turn into an ulcer. If not managed properly, a wound can deteriorate until amputation is needed. So drumming home the message to patients that it’s crucial to follow her instructions in caring for their feet is a big part of Ms Sivagame’s work. But patients who are elderly and have little or no family support often come to her with wounds that need her specialised skills. “Equally important is to be able to understand my patients’ social and family circumstances,” said Ms Sivagame. Only then can she plan a treatment regime that takes the patient’s needs into account.
WE WORK TOGETHER TO DISCUSS OUR PATIENTS’ CONDITIONS. THEY RESPECT MY DECISIONS AND WHAT I SAY ABOUT THE PATIENTS, AS I MONITOR THEM SO CLOSELY. ADVANCED PRACTICE NURSE, MS SIVAGAME MANIYA ON HER WORKING RELATIONSHIP WITH DOCTORS
JUL– AUG 2013
Discharged patients are seen at Ms Sivagame’s clinic where their wounds are cleaned and dressed. She checks that ulcers are healing properly, that there is no infection, and that patients are following their treatment regime. If the patient isn’t recovering as well as he should, Ms Sivagame will probe him to find out why, and then update and work out a treatment plan with the surgeon. During her weekly clinic, a podiatrist is present to help patients with special footwear fittings and other concerns.
Ms Sivagame is upholding a tradition sacred to the medical profession – passing on her knowledge and skills to younger nurses. She teaches monthly classes for nurses, and occasionally has nurses and students shadowing her in the wards and clinic. Looking on as Ms Sivagame performs debridement (removal of dead, damaged or infected tissue in a wound to speed up healing) and dressings for a patient’s foot are Ms Wen Jing (pictured below in white), an SGH Resident Nurse specialising in orthopaedic and hand surgery, and Ms Cheng Shuhua, a Changi General Hospital nurse who is in a Masters programme and undergoing clinical attachment to become an advanced practice nurse.
PHOTOS: ALECIA NEO
AFTER WORK AND FAMILY
To work around her heavy schedule, Ms Sivagame plans the time she spends with her two young children. She leaves home by 6.15am to accompany her children to the MRT station on schooldays. “It’s not how much time I spend with them, but how well I spend that time,” she said. Ms Sivagame makes sure she leaves the hospital in time to eat dinner with her children, usually around 8pm, and to help them with their homework after. Occasionally, she runs after work (usually to nearby Mt Faber) and on weekends with her children.
To find out more about nursing, read the special supplement in this issue.
JUL– AUG 2013
Raising awareness of living liver donations
The amiable and youthful Dr Chan Chung Yip was crowned “The Royal Physician” in a popularity poll at SGH’s dinner and dance last year.
PHOTO: ALECIA NEO
Dr Chan Chung Yip wants more people to know that such procedures are safe and can save lives BY SATISH CHENEY
F YOU happen to hear the faint sound team, Dr Chan specialises in minimally of pop music when you walk past a sur- invasive laparoscopic surgery and disgical theatre at the Singapore General eases of the liver, pancreas, gallbladder Hospital (SGH), don’t be alarmed. It is and bile ducts, or the biliary system. He chose this specialty as he found probably the sound of Dr Chan Chung Yip “the intimate relationship between the and his team hard at work. Dr Chan, 42, takes his iPod to the the- structures” of the biliary system and atre and uses it to play music while he their close association with the functionperforms surgery. “Music helps in several ing of the liver a challenge to operate on. ways,” he said. “It doesn’t quite distract “Potentially devastating complications you from the work you’re doing, it can can take place if one isn’t meticulous lighten the mood, and can be calming. It’s and careful about the structures that this idea of operating in a familiar envi- need to be preserved,” he said. Dr Chan also found inspiration in ronment, with a familiar team, and with music that’s familiar, you know what’s hepatobiliary and pancreatic surgeons like Dr Chew Soo Ping, now in private going to come next, just like in surgery.” Having grown up in the 1980s, it’s no practice; Professor London Ooi, chairsurprise that Dr Chan enjoys the music of man of SGH’s Division of Surgery; and that era. He also likes to listen to mood- Associate Professor Alexander Chung, Senior Consultant, Department of Surcalming jazz in the operating room. As a member of SGH’s liver transplant gery, SGH. “It was a great privilege to be
guided by these great doctors, with great hands (operating skills), and great interpersonal skills,” he said. Just as he was taught by senior doctors, he doesn’t miss an opportunity to pass on knowledge and skills to his younger colleagues. “Training the next generation of doctors is part of the calling (of the medical profession),” he said. Despite his long hours and demanding schedule, Dr Chan manages to find time to meet friends. He also exercises three times a week. For him, the best reward at the end of a tiring day is to spend time with his wife and three young children. “I know it sounds cliched, but having kids gives you a sense of purpose. The time I have with them at the end of a day is not long, but during that time, whatever lethargy I feel is forgotten,” he said.
CHAMPIONING LIVER CANCER AWARENESS MONTH His work as a surgeon doesn’t end at the operating theatre. As chairman of the organising committee of this year’s Liver Cancer Awareness Month in September, Dr Chan Chung Yip hopes to increase public awareness about living liver donations and how such donations, usually from relatives, can save patients with end-stage liver disease. Some patients die while waiting in the queue for a liver from a deceased donor. “We hope to change misconceptions, and spread the message that a living liver donation can not just save the life of a relative, but is also safe,” he said. While there is always the potential for risks and complications in surgery, “major complications are actually few and far between,” Dr Chan added. As much as 70 per cent of a liver can be removed for transplant from a healthy donor, and the organ regenerates quickly after surgery, growing back to as much as 90 per cent within a week and close to its original size within a month. Dr Chan performs about 10 to 15 liver transplants a year.
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
Genacol® and Genacol® Instant are Canadian products internationally recognized for their effectiveness.
Products available at:
No. 190 Clemenceau Ave #03-33 Singapore Shopping Centre S(239924) • Phone: (65) 6468-4948 • Email: firstname.lastname@example.org
JUL– AUG 2013
Insuring your child’s health Choose a suitable policy to cover your kid’s needs and manage rising medical costs BY STELLA THNG
ETTING adequate and comprehensive health insurance for your child is your best bet to hedge against increasing medical costs, according to Ms Wendy Soong, an executive financial consultant with NTUC Income. She suggests considering the following points before shopping for a policy.
Assess your current financial and medical situation Medisave funds can be used to pay the annual premiums of basic health insurance or the government-approved Integrated Shield Plans only. All other insurance plans must be paid in cash. How much you pay depends on your child’s age, the age of both parents, the sum assured, and the payment terms
and period. How much insurance to buy depends on your desired lifestyle, expectations, affordability and objectives. Review your family’s medical history. If there is a strong history of cancer, it is better to buy medical insurance for a child when he is as young as possible to lock in his insurability and serve as a back-up. Choose your plan and hospital ward class wisely If you choose a plan that only allows your child to stay in a Class B ward but you upgrade him to an Class A ward, your bill will be subjected to proration and you’ll need to pay a higher deductible. However, if you take a higher plan but downgrade hospital wards, some Integrated Shield Plans even offer you a cash benefit in return.
Types of medical insurance for kids
Hospital and surgical plans
Savings or endowment plans For the child’s education or other expenses; can either be in a parent’s or the child’s name Riders, such as those covering critical illnesses, can be added Payment terms can be tailored to one’s needs
Be honest in your application Always disclose all information on your child’s health and medical care when you are applying for a policy. Any non-disclosure or misrepresentation that’s discovered later may result in policy rejection or termination. Consider other unavoidable factors Observe your child’s lifestyle and learning environment – is he prone to common diseases? Choose comprehensive health insurance plans that offer all aspects of coverage, from child-related illnesses and infectious diseases to all forms of hospitalisation.
Personal accident and infectious disease plans Provide comprehensive global protection against personal accident and 17 infectious diseases (including hand, foot and mouth disease and dengue fever) Weekly cash benefits for infectious disease claims Medical expenses for injury or infectious diseases cover treatment by Chinese medicine practitioners and chiropractors
Medisave-approved Integrated Shield Plans offered by private insurers which cover hospitalisation and surgical expenses Premiums can be paid by Medisave funds Help to cover hospitalisation bills as a result of accident or illness, including day surgery bills, on an “as charged” basis, as well as expenses for treatment or surgery in hospital Cover pre- and posthospitalisation expenses for up to 90 days Like MediShield, these private shield plans have co-insurance and deductible features to keep premiums affordable Can add on a range of riders for more comprehensive coverage
Lock in your insurability If your child has no preexisting health conditions, he will not face any insurability issues. But if he unexpectedly develops a condition during his growing years, that medical history will follow him for the rest of his life, making it difficult for him to get life insurance with critical illness coverage in future. If he needs surgery, hospitalisation bills can eat into your savings. So, it is essential to start with comprehensive insurance coverage while children are young and not leave it to chance. It is best to buy medical insurance for children about a month after they are born, once the birth certificate is obtained. This locks in their insurability while they are healthy.
Critical illness plans Available on a whole lifetime basis or on term insurance but with a limited payment period Help to reduce the financial burden by paying a lump sum if the child is diagnosed with a critical illness like heart attack, stroke or cancer Offer alternative sources of income or cash for treatment options not covered under a hospital and surgical plan Payout does not depend on hospital admission or the actual medical expenses incurred Medical expense and critical illness insurance policies are both essential and complement each other
JUL– AUG 2013
Our experts answer all your questions about health
How to remove my toddler’s birthmark and deal with eye discharge?
Clinical Associate Professor Yeo Cheo Lian, Senior Consultant and Head, Department of Neonatal and Developmental Medicine, Singapore General Hospital
Should teeth correction be done for children?
How much cardio exercise should one do weekly? Cardio exercises are often promoted for weight loss. How much cardio exercise would you recommend per week? The amount of cardio exercise you can and should do will depend on your age, health and baseline fitness. In general, we like the American Heart Association’s recommendation of the following: At least 30 minutes of moderate-intensity aerobic activity at least 5 days per week for a total of 150 minutes or at least 25 minutes of vigorous aerobic activ-
Am I at risk of nose cancer if my dad has it? My dad had Stage 1 nose cancer which resolved with radiotherapy in 2007. Am I at risk of developing it too? If so, is there a screening test that can be done and what age would be an appropriate time for it?
ity at least 3 days per week for a total of 75 minutes; or a combination of the two (moderate-intensity and vigorous aerobic activity) And moderate to high intensity muscle-strengthening activity at least 2 or more days per week for additional health benefits Dr Yeo Khung Keong, Consultant, Department of Cardiology, National Heart Centre Singapore
Screening for nasopharyngeal cancer is generally not recommended as the pickup rate is very low. For high-risk individuals such as those with a strong family history, screening is justified. It would involve doing a blood test for EBV serology and an endoscopic examination of the nasopharynx for those with abnormal results. Dr Terence Tan, Senior Consultant, Department of Radiation Oncology, National Cancer Centre Singapore
My seven-year-old daughter’s lower two front teeth have fallen out and her adult teeth have grown in their place. However, they have not grown straight but in an inverted “V” shape. Should any correction be done now? Before adult permanent teeth erupt, they appear as tooth “buds” inside the jaw. The position of these tooth buds determines the position of the newly grown teeth. While they may appear crooked at first, they may be slowly moved into position by the lower lip and the tongue as the teeth erupt further. This stage is transitional and commonly known as the “ugly duckling stage”. Depending on the availability of space, the teeth may end up being well-aligned if there is enough space, or crooked if there is insufficient space. No correction of alignment is usually needed at this stage. An orthodontic consultation in the future may be advised if crowding persists or if there is a “bite” problem. Dr Lai Wen Pui, Bien, Registrar, Paediatric Dentistry Unit, Department of Restorative Dentistry, National Dental Centre Singapore
These articles are from www.healthxchange.com.sg, Singapore’s first interactive health and lifestyle portal.
Topics for discussion in July-August 2013: Spine problems, baby’s health, LASIK, contact lenses and breastfeeding
IMI Lifestyle Products Pte Ltd Food for Life!
for Kanehide Bio Co., Ltd, Japan
r in sodi we
My five-month-old daughter has a red patch on the back of her neck, which according to the doctor, is a birthmark. Although the doctor assured me that about 90 per cent of the patch should fade with time, is there anything to be done to have the mark removed? Also, she has a perpetual yellowish discharge from her left eye, but not the right. One doctor said the discharge was caused by an eye infection, while another said it was the result of a blocked tear duct. She has no pain and there is no swelling in the eye area. From your description, the patch is likely due to a collection of fine blood vessels in the layer of the skin. This is a congenital capillary malformation, also known as a stork bite mark, that occurs in 25-50 per cent of newborns. No treatment is needed, but if by age three, the stork bite has still not gone away, laser surgery can be considered to remove the mark and improve the appearance. Stork bites on the back of the neck usually do not go away. Regarding your child’s eye problem, the discharge from her left eye is unlikely to be caused by an infection as she has no pain or swelling. A blocked tear duct occurs in about a third of newborn babies. Infants born with a blocked tear duct have a small membrane blocking the opening, which opens spontaneously as the infant grows. Usually the membrane opens by 10 to 12 months of age, with spontaneous remission occurring by age one in 95 per cent of cases. While waiting for the problem to be resolved on its own, be sure to keep the eye clean. You can also massage the lacrimal sac, near the inner corner of the eye. In cases where tearing persists, surgery to open the lacrimal duct and improve the drainage of tears can be considered. It is recommended that you visit your paediatrician or an ophthalmologist if the problem persists.
T’S NOT really clear how guinea pigs came into the picture. But the refrain “Doc, I don’t want to be a guinea pig!” is usually made, sometimes in jest, when a junior doctor is about to carry out a minor procedure such as setting up a drip. Or when a patient is told that the regular or standard therapy no longer seems to work for him and he should consider novel therapies. Guinea pigs are actually rarely used for medical research, and never for learning minor procedures. Mice could be quite miffed by this refrain though. They are the ones most frequently used for research. But rarely are their contributions acknowledged by: “Doc, I don’t want to be a mouse!” Humour aside, do patients benefit from participation in clinical trials, and how are they protected if they do? What clinical trials entail Medical research on animal or human subjects are strictly screened and monitored by the Institutional Animal Care and Use Committee in the case of animals, or by an Institutional Review Board (IRB) in the case of humans.
CLINICAL TRIALS ARE GOVERNED BY STRICT INCLUSION AND EXCLUSION CRITERIA AND ONLY A VERY SPECIFIC GROUP OF PATIENTS IS ELIGIBLE FOR ANY GIVEN CLINICAL TRIAL. Both organisations ensure that research subjects are appropriately and well taken care of. Additionally, an IRB is guided by the principle of equipoise when considering approval of all clinical trials on human subjects, except for well or non-ill patients in phase I studies. A position of clinical equipoise occurs when “there is genuine uncer taint y within the expert medical communit y − not necessarily on the part of the individual investigator − about the preferred treatment”, according to a paper by Benjamin Freedman published in the New England Journal of Medicine in 1987. What this means is that at that point in time, the scientific world does not have any definite data that any one of two or more possible treatment options available is the most efficacious for the patient. An individual doctor, the
patient or indeed anyone, can sometimes hold the firm opinion that a specific treatment is the “best” even when no definitive data is available. Such an opinion can turn out to be right, or wrong. Holding such a belief in the absence of definitive data can prevent the patient from getting better treatment, and even be harmful, in the worst-case scenario. When it is scientifically unclear which of two or more possible treatments is best for the patient, a position of equipoise exists. This can only b e re s olve d by conducting a scientifically rigorous study. For some medical conditions, this would in fact be the only way to be fair to the patient in question. For example, in a randomised controlled or a phase III trial, one of two treatments for the same clinical condition is randomly assigned to the patient by a computer programme. Either therapy or treatment arm is likely to have its own associated risks and potential benefits. Without a properly conducted clinical trial, there will be insufficient scientific data for doctors to know which treatment benefits a patient better. During the course of the study, if data emerges that one therapy is better for patients,
the trial will be stopped and the better therapy will be recommended. In a double-blind study where neither the doctor nor patient knows which of two drugs a patient is allocated to, an independent Data and Safety Monitoring Committee decides if the study should be stopped. The members of the committee have no direct contact with the patients in the trial but have full access to data. Clinical trials are governed by strict inclusion and exclusion criteria and only a very specific group of patients is eligible for any given clinical trial. An IRB, for instance, will consider the condition of the patients eligible for the trial when considering approval of a clinical trial. Using cancer as an example, if there is standard therapy available for the stage of that specific disease, this therapy must be used first. Only when the standard therapy is no longer effective, or if the standard therapy is not suitable for the patient, can the patient be enrolled into a clinical trial. Some phase I trials enrol both patients as well as healthy individuals who are compensated for their participation. Phase I studies can have different aims, such as to investigate what doses of a new drug are appropriate for patients, and may also be different from later phase clinical trials which investigate how effective the new drugs are. Phase I trials are very important, as without them, no new therapies will be introduced. Benefits to patients Clinical trials are certainly important for society. But can individual patients benefit from clinical trials?
Professor Pierce Chow is a Senior Consultant of Singapore General Hospital’s Depar tment of General Surgery, and Course Director at the DukeNUS Graduate Medical School, Singapore. He has published extensively on hepato-biliary cancers and gastrointestinal stromal tumours, and carried out both pre-clinical and clinical research on brachytherapy in hepatocellular carcinoma and pancreatic cancers. Professor Chow has received two National Medical Research Council Research Fellowships.
Doc, I don’t want to be a guinea pig! For patients who no longer respond to standard treatment, participating in a clinical trial offers the possibility of a cure BY PROFESSOR PIERCE CHOW
When standard therapies are no longer applicable or useful for the patient, new therapies may avail. But even if costs are not an issue, such new therapies are not usually available outside the tightly controlled and legislated environment of a clinical trial. Because clinical trials are very closely monitored by regulatory authorities, patients in clinical trials are also more closely looked after than patients with similar conditions not on clinical trials. In countries with a developed medical and scientific culture, patients sometimes travel long distances to avail themselves of the new therapies offered by clinical trials, knowing that such treatments may be their only hope for recovery. Very often, they are referred by their altruistic regular physicians, who may have been the first to inform their patients that a trial being conducted at a particular institution may benefit them. So in some circumstances, it may not be a bad idea to be a guinea pig. Hmm... I mean a mouse.
PHOTO: ALECIA NEO
JUL– AUG 2013
No mailing of test results I was asked to return to see a doctor two weeks after my laboratory test to review my test results. I requested for the results to be mailed to me, so that I could interpret them myself. However, the staff declined. Why should I see the doctor for my laboratory test results?
It is important for the doctor to review the results so that he can better assess your health status. Based on your test results and medical history, the doctor can then recommend the appropriate treatment, medication or action plan.
No condiment with meals
During my recent hospital stay, I was very disappointed with the ward service. Although I repeatedly asked for soya sauce or salt to be served with my meals, the meal trays always came without the condiment. Why can’t the hospital accede to such a simple request? the meals we provide are SGH All specially planned by our dieti-
cians to meet your medical requirements as well as your nutritional needs. They generally use less salt and oil for a healthier diet.
JUL– AUG 2013
Discourage smokers from lighting up Many initiatives have been taken to deter people from smoking. The National Environment Agency recently extended the smoking ban to more places, including the common areas of residential buildings such as common corridors, staircases, stairwells and void decks, covered walkways and linkways, all pedestrian overhead bridges, and within five metres of bus shelters. There has also been much talk in the media about educating the public, especially the young, in various ways about the ill-effects of smoking.
In addition, for medical reasons, some patients might have been prescribed a diet that is low in fat, cholesterol, salt, protein or sugar by their doctors or dietitians. Patients who have difficulty chewing will be served with soft diet meals. The hospital’s dietitians and chefs work together to make sure that the
Those of us who deal with smokers know that smoking is an addiction which requires much resolve to shake off, and many smokers just cannot do it. An effective way of discouraging smoking is to raise the price of cigarettes. Currently the price is about $10 per pack. Increasing the price significantly, say to $20, may serve as a strong disincentive to smoking. Smokers might be encouraged to quit as a result of the higher prices, while non-smokers, especially the younger people, could be discouraged from starting. Fewer smokers would be better for the environment, in terms of less litter (fewer cigarette butts or
meals served to our patients are both healthy and appetising. A selection of Chinese, Indian/Muslim and Western cuisines is available to cater to the different palates of our patients. A vegetarian meal service is also available. Special diets are available to patients who need specific diet control or who are undergoing special diet therapy. New
packets thrown on the ground) and cleaner air. Hopefully, as nicotine addicts find their health improving as a result of smoking less, they might become less resentful of the various punitive moves to stop them from lighting up. We all know the social and health costs of smoking. But we need courage and conviction to fight this scourge that kills millions every year. Mdm Tang Wee Lee This letter wins a 42g bottle of Okinawa Mozuku Fucoidan, 100% Pure Okinawa Mozuku Seaweed Extract (180 capsules). The product, worth $320, is sponsored by IMI Lifestyle Products Pte Ltd.
mothers who prefer traditional Chinese confinement food may order such meals from the hospital’s confinement menu. Should you require a consultation with one of our dieticians, please approach any of your ward nurses for assistance. For more information, go to www.sgh. com.sg/patient-services/admission/hospitalcuisine/pages/hospital-cuisine.aspx
JUL– AUG 2013
Dental subsidies available for seniors I have noticed that there is a different rate for private and subsidised patients. My father, 58, would like to have his teeth checked. How can he get subsidised status? Which medical institutions should he go to?
General examinations and treatments at subsidised rates can be arranged at polyclinic dental clinics or dental GP clinics participating in the Ministry of Health’s
Community Health Assist Scheme (CHAS). There are more than 200 dental GP clinics participating in CHAS, and many are located in the HDB heartlands. For more information go to www.chas. sg/indexpatients.aspx. If the general dentist attending to your father diagnoses an oral problem that requires specialist care, he will refer him to an appropriate specialist for further treatment. At the National Dental Centre Singapore, patients aged 40 and above who are referred from CHAS clinics for specialist care will be accorded subsidised status.
ABOUT YOUR HEALTH EXPERIENCE AND WIN A PRIZE FOR BEST LETTER Letters must include your full name, address and phone number. Singapore Health reserves the right to edit letters and not all letters will be published. Write to 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 a satchel of Spirulina 100% Extra 10% Deep Ocean Water Spirulina Blended (2000 Tablets). The product, worth $128, is sponsored by IMI Lifestyle Products Pte Ltd.
He and his team took good It was mutton eggplant pie, ing. She even celebrated her sure they were all right. befitting a senior staff nurse of care of me when I had surgery served with corn and soup. It birthday and Chinese New We saw how he coaxed an a respectable hospital. for my thyroid problem. was very delicious. When a Year. Although she didn’t pull old man to finish his dinner. She provided clear direcThey made my treatment patient is unwell, one thing through, our family is very The patient had refused to eat. tions and instructions to help endurable and my stay a that makes them smile is good grateful to Dr Goh for his care. Mr Tan is a valuable asset me settle in comfortably and pleasant one. food. Thank you, chef! Well – Ms AST Ng to your hospital. His excellent be anxiety-free. I am especially grateful to done! service gives people like us She was ver y helpful, Dr Tan for his advice, encour- – Ms MM Our father received ex- peace of mind when our rela- caring and concerned. agement and clear explanatremely good care during his tives are in his care. S h e e n s ure d that my tion of the treatment process. My late mother had been five-day stay at SGH’s Ward 45 – Ms LL Hoe and Mr K Hoe meals were served on time (as He even went the extra treated by Dr Goh Yaw Chong, from Staff Nurse Tan Guo Hua. requested) and provided clear mile by dropping in to check Senior Consultant, DepartWe are grateful to Mr Tan I was admit ted to the explanations on procedures on me on his day off, truly ment of General Surgery, SGH, for being so attentive, caring, National Heart Centre Sin- and care until the day I was embodying the spirit of an for esophageal cancer for six cheerful and friendly when gapore for a coronary angio- discharged. excellent doctor. months before her death in attending to the needs of our gram. Ms Mesnah Omar, Senior She also possesses exemI wish to say thanks to Dr March. dad as well as other patients Staff Nurse (Clinical), Ward plary patience! Tan Ngian Chye, Senior Con- – Madam Chiang During that time, she in the ward. 44 discharged her duties and – Mr L sultant, Department of SurgiI had a wonderful lunch didn’t despair or lose hope He frequently checked on responsibilities with due dilcal Oncology at the National prepared by the SGH kitchen. as Dr Goh was very encourag- the other patients to make igence and professionalism, Cancer Centre Singapore.
I want to commend Dr Lim Sor Kheng, Consultant, Endodontic Unit , Depar tment of Res torative D entis tr y, National Dental Centre of Singapore. I was afraid of pain but Dr Lim reassured me and did whatever she could to reduce the pain during treatment. For me, a visit to the dentist has never been this pleasant! ” - P Chan
JUL– AUG 2013
Auditorium, Training Centre, Women’s Tower, Level 1 REGISTRATION Call 6394-5038 or 6394-1582 to register. PRICE $5 per person Chronic pain can affect one’s mood and sleep, and is a top cause of absenteeism from work. Have you ever wondered if it will ever go away? Are you worried about the side effects of medication? Experts at the KKH Women’s Pain Centre will share recent advances in pain medicine, combined therapies with physiotherapists, and how to lead a pain-free life again.
87 24 mg mg
LOADED WITH CALORIES AND FATS
Eating out may be convenient, but it can be unhealthy. Two studies, published online in JAMA Internal Medicine, have found that eating just one restaurant meal provides diners with most of the calories, fats and salt they require for an entire day. Adults are recommended to take in about 2,000 calories daily.
calories in a restaurant meal from these cuisines
“Clenching your right hand immediately prior to learning information, and clenching your left hand immediately before recalling it, would be helpful to improve memory,” said Dr Propper.
Past research has shown that right hand clenching activates the left hemisphere of the brain, while left hand clenching activates the right hemisphere. Both sides of the brain are thought to be involved in memory processing.
1,755 Source: WebMD
Singapore Health issue 23 contest 1. Name one symptom of tongue cancer. 2. Which story in this issue did you find the most informative? Closing date: August 7, 2013 Send in your answers and stand to win a bottle of Ultra Selenium Dietary Supplement (60 Veggie Capsules) worth $68.50. There are five sets to be won.
Include your name, age, gender, address and telephone number. Winners will be notified via phone or e-mail. Incomplete or multiple entries will not be considered. E-MAIL firstname.lastname@example.org POST The Editor, Singapore Health, Singapore General Hospital, Communications Department, #13-01 Surbana One, Blk 168, Jalan Bukit Merah, Singapore 150168 Winners of Contest 21: Each will receive two teddy bears wearing surgical gowns and holding pouches in SingHealth and Singapore General Hospital (SGH) colours. The bears are sponsored by SGH’s Division of Surgery. Prizes must be claimed by August 7, 2013. 1. Daniel Chan Weng Kin 2. Chan Wai Peng 3. Ramasubramanian Chandramohan 4. Quek Hui Nai 5. Sherlin Wong Mei Ling
Average amount of
for the workshops. Visit www.kkh.com.sg for more details. As part of its effort to create awareness and encourage breastfeeding, KKH will unveil the winners of its Healthy Breastfed Baby Contest 2013 at this event. Expect a fun-filled carnival that includes a children’s activity corner, stage performances, and games. Members of the public can also attend special parenting workshops conducted by KKH experts.
Fist clenching can improve memory Clenching the right hand for 90 seconds helps in memory formation, while the same movement in the left improves memory recall, US psychologists have found. In an experiment, 50 adults performed better at remembering words from a long list when they carried out these movements. Lead researcher Ruth Propper of Montclair State University, New Jersey, said the results suggest that simple body movements can improve memory by temporarily changing the way the brain functions.
Healthy Breastfed Baby Contest 2013
DATE August 3–4, Saturday and Sunday TIME 10am–4pm VENUE United Square Shopping Mall REGISTRATION Pre-registration is required
Overcome Pain, Live Well Again
DATE July 20, Saturday TIME 2pm–4pm VENUE KK Women’s and Children’s Hospital
Lipsticks and lip glosses give you more than colourful kisses, according to a new study by California scientists, which indicates that the products contain lead, cadmium, chromium, aluminum and five other toxic metals. The research team tested 32 different lip glosses and lipsticks commonly sold at drug and department stores in the US. They found lead in 24 of the 32 products, but usually at a concentration lower than acceptable daily intake levels. On the other hand, the estimated intake of chromium – linked to stomach tumours – in 10 products exceeded the acceptable daily intake level. “At an average level of use, it’s not likely to be an issue”, said researcher Katharine Hammond, a professor of environmental health. But she is concerned about children playing with makeup, as no level of lead exposure is considered safe for them. Heavy users who slather on lip colour and reapply it repeatedly might want to consider cutting down too.
Rise and Shine 2013
DATE September 27–29, Friday–Sunday TIME 10.30am–8pm VENUE Suntec Singapore International
Convention & Exhibition Centre, Hall 401 and Level 3 REGISTRATION Register at www.riseandshine-expo.com or call 6908-0891 PRICE $20–$30 per person for each workshop, with discounts for multiple participation in some workshops. This three-day event for parents of babies and young children features an exhibition and a series of seminars and workshops by local and foreign health, food and education experts on raising healthier and happier children. Some workshops run by SingHealth experts include:
Raising a healthy and happy baby DATE September 29, Sunday TIME 10.30am–12pm SPEAKER Dr Varsha Atul Shah, Senior
Consultant, Department of Neonatal and Developmental Medicine, SGH, and KKH
Care of pregnant mothers
DATE September 29, Sunday TIME 10.30am–12pm SPEAKER Dr Tan Eng Loy, Consultant,
Department of Obstetrics and Gynaecology, SGH
Beyond words: how to communicate with your child before they talk DATE September 29, Sunday TIME 12.30pm–2pm SPEAKER Mr Goh Huai Zhi,
Speech Therapist, SGH
Visit www.singhealth.com.sg/events or the websites of respective institutions for more information and other listings.
JUL– AUG 2013
YOUR GUIDE TO BETTER LIVING
child to talk Kids develop speech at their own paces but there are some signposts that parents can watch out for. By Karen Tee
AS EASY AS
ONE, TWO, THREE
A one-year-old child should be able to say simple words like “car”, “mummy” or “milk”.
capable of speech are unable to do so in specific situations. But it is difficult to know for sure if psychological conditions are the cause as children develop verbal skills at different speeds. It may well be that a particular child simply needs more time to learn to speak. Parents worried that their infants might have delayed verbal skills should consult a paediatrician to determine an appropriate course of action or therapy. Learn naturally and without pressure At home, parents can make use of many everyday opportunities to help their children pick up speech. For instance, daily activities like showers or meals are a good time for children to pick up verbal communication skills from their parents. Or they can try to find out what interests their child, and use these things to encourage them to speak, said Mr Goh. The idea is for parents and children to learn naturally, and parents should not put too much pressure on their children. Otherwise, said Mr Goh, this might have the opposite effect – and cause the child to clam up instead. To help parents with children suffering from delayed speech development, SGH’s Speech Therapy Department is running a workshop on the subject in September. For more details, refer to page 20.
WAYS TO ENCOURAGE KIDS When your child starts to babble, repeat the sounds your child makes. This will encourage him to babble more. Keep this up for a fun “conversation” with your child. Children are always curious about the world around them, so look out for non-verbal signals, such as what he is looking at or what he is holding. Use such opportunities to engage your child’s interest in verbal communication. Get your child to repeat words before you give him an item of interest. For example, during snack time, get your child to say words like “mum mum” or “cookie” before you give him the biscuit.
According to Mr Goh Huai Zhi, psychological conditions can contribute to selective mutism, in which children normally capable of speech are unable to do so in specific situations.
Children learn through imitation, so interact and play with them to encourage them to talk. Don’t leave them alone with an iPad or in front of the TV.
PHOTO: JASPER YU
A two-year-old child should be able to join two words to form simple phrases, like “blue car” or “mummy milk”.
A three-year-old should be able to speak short sentences of about three to four words in length, like “mummy drink milk” or “daddy drive car”.
PHOTOS: GETTY IMAGES
HOULD you be concerned if your If your child doesn’t talk even when two-year-old is not talking as much he appears very interested in the letters as his peers or his vocabulary is less of the alphabet, or is able to identify letextensive than other children around ters like “A” or “Z” by the age of two, “you his age? may want to be concerned, as this would Not necessarily, said Mr Goh Huai Zhi, be atypical”, said Mr Goh. Speech Therapist, Singapore General The ability to recognise letters of the Hospital (SGH). It is normal for every child alphabet is a relatively advanced skill for to develop speech and language skills at a two-year-old so one would expect the different speeds, he added. child to be able to speak as well. That said, there are typical speech There are many reasons for delayed development patterns that parents can speech among children. A child might look out for. For example, your baby have an ear infection which affects his should start babbling and making redu- hearing, making it difficult for him to pick plicated sounds by the time he is a few up sound cues from his parents. months old, said Mr Goh. Mr Goh remembers a child who Reduplication refers to the repetition “would not look at the person who called of certain sounds to make new “words”, out to him. It was only after doctors have like “bababa” or “kakaka”. As he grows tested him that we realised that he had older, your baby should start to string an ear infection”. He added that the together different sounds to make child’s speech and language developspeech-like phrases such as “ba-pa-ka”. ment improved greatly after the infection When your child is between one and was treated. three years old, the “one, two, three” rule There are other, more serious con(see below) should apply, said Mr Goh. ditions that can cause a child to be a “late talker”. For example, autistic chilWhen to be concerned dren and premature babies tend to be at Parents need not be too worried about greater risk of delayed language developtheir children’s pronunciation until the ment. Genetic factors can also contribchildren are about three to seven years ute to slower speech and language develold. It is at around this time that they opment, as can psychological conditions. begin to be able to correctly pronounce For instance, selective mutism is a conconsonants like B, P, M and H. dition where children who are normally
Avoid long, complex sentences. Use short, simple sentences, but stress specific words. For example, when you say, “this is a blue ball”, put more emphasis on the words “blue ball”.
JUL– AUG 2013
Piles need not be an embarrassing condition Understand how haemorrhoids arise and can be dealt with. By Lediati Tan said Dr Wong, who is also Director, SGH Anorectal Ultrasound and Physiology Laboratory. Experts are divided over the exact cause of haemorrhoidal disease. It is commonly associated with a sustained increase in intra-abdominal pressure, which can lead to the blood vessels becoming engorged. The pressure can be caused by excessive straining during bowel movements (made worse by constipation), pregnancy, or even severe diarrhoea. Haemorrhoids may be classified as internal or external, depending on where they occur. True haemorrhoids are internal and only protrude when they swell excessively. External haemorrhoids are actually blood clots that are formed out-
side the anus because of straining during bowel movements. The condition is more common among people between 25 and 50 years of age, and affects men and women equally. Pregnancy may increase one’s risk of developing haemorrhoids, as the foetus puts greater pressure on the veins in the mother’s pelvis, and this can lead to swelling of the haemorrhoids, said Dr Wong. The risk increases as the foetus grows, and again during delivery when the mother is forced to strain and push. Thankfully, as with leg swelling during pregnancy, such haemorrhoids usually shrink after the baby is born. When treating haemorrhoids, the primary goal is to restore them to their normal position in the anal canal, said
Dr Wong. “Depending on the severity of the condition, treatment may involve just medications to reduce the swelling, or surgery to remove excessive tissue or both.” Each treatment has its advantages. “It is important that a surgeon selects the best technique for each patient. The treatment has to be customised to optimise outcomes,” said Dr Wong. Equally important is the identification and correction of any bad habits contributing to the symptoms, such as habitual straining and spending an unnecessarily long time on the toilet bowl (to read, for example). Consuming moderate amounts of dietary fibre and adequate fluids daily to prevent hard stools can help many patients avoid surgery.
According to Dr Mark Wong, when treating haemorrhoids, the primary goal is to restore them to their normal position in the anal canal.
For persistent bleeding or painful haemorrhoids, minor procedures may be needed. These include:
Rubber band ligation, where a doctor places up to three tiny rubber bands around the base of an internal haemorrhoid to cut off its circulation. The haemorrhoid will then wither and fall off within a week.
Mild symptoms can be relieved by moderating the intake of dietary fibre, including fruit, vegetables and cereals, as too much or too little can result in hard stools. Doctors may also recommend medication such as creams and ointments.
PER SIST ENT
Sclerotherapy, where the doctor injects a chemical solution into the haemorrhoid tissue to shrink it.
SE RIO US
In more serious cases or those that don’t respond to the less invasive measures, surgery is performed. These operations, usually done as day procedures, include:
Conventional haemorrhoidectomy, where excessive haemorrhoidal tissue is surgically removed. Haemorrhoid stapling, where a special device is used to staple and remove excessive haemorrhoidal tissue. Transanal haemorrhoidal dearterialisation, where a customised ultrasound device is used to accurately identify the location of the haemorrhoidal blood vessels. The vessels are then stitched up to cut off the blood supply and reduce the swelling and bleeding.
PHOTO: JASPER YU
ID YOU know that haemorrhoids – or piles, as they are more commonly known – are actually a normal part of our anatomy? Haemorrhoids are “vascular cushions” located inside our anal canals and they help us move our bowels, said Dr Mark Wong, Consultant, Department of Colorectal Surgery, Singapore General Hospital (SGH). Unfortunately, the words “haemorrhoids” and “piles” have been misused in popular media, and are now taken to mean the disease. Haemorrhoids only become a problem – termed as symptomatic haemorrhoidal disease – when they swell excessively, and result in symptoms such as bleeding or pain, or if they protrude from the anus,
JUL– AUG 2013
The common cold can leave you in a spin In some rare cases, patients’ ears become inflamed, leading to vertigo. By Sol E Solomon
organ – contains the organ of balance (which senses our position in space) and the cochlear – the organ of hearing. “When the labyrinth is inflamed, a patient may experience a drop in his hearing and ability to maintain his balance. This dizziness, or vertigo, is felt as if the environWhat hit him? ment is moving and spinning around him. It turns out that Dr Young had labyrinthi- The vertigo is usually very intense and tis, a condition where the labyrinth (the causes severe nausea and vomiting. The inner ear) is inflamed and not functioning patient can be disabled to the point of normally, said Dr Barrie Tan, Consultant, being unable to get out of bed, because and Head, Department of Otolaryngology, any movement aggravates the vertigo. Singapore General Hospital (SGH). Because the onset is usually sudden Dr Tan said labyrinthitis is relatively and acute, it can cause anxiety. There is uncommon in Singapore, but he has also the danger of falls and head injuries treated a number of patients with it, from the vertigo, and dehydration if the most of them young, healthy individuals nausea and vomiting is severe. between 20 and 50 years old. “The acute vertigo usually lasts from He said the inner ear – the vestibular a few days to two weeks. As it resolves, the patient experiences slight imbalance or unsteadiness while walking. This rehabilitation phase may last for one or two months. The hearing function may or may not fully recover. The recovery period is fastest during the first month but the patient may still recover up to six months after the onset of the disease,” said Dr Tan. In the best-case scenario, the patient completely recovers his hearing and balance within two weeks. In the worst-case scenario, he could be deaf in one ear and have persistent vertigo for several weeks, followed by unsteadiness and imbalance while walking for months. But patients usually recover their balance within two weeks, said Dr Tan. PHOTO: MORVEN KOH
Dr Barrie Tan explained that in the worse-case scenario, a patient with labyrinthitis could have permanent hearing loss.
least stagger to the sofa to watch TV. By the fourth day, I could slowly walk to the GP’s clinic, though I was slower and less steady than my toddler!” Dr Young fully recovered from the attack, but it took two weeks or so before he was completely free of symptoms. He said, half in jest, “But I spent another week at work wandering around like I was intoxicated, unsteady every time I turned my head!”
PHOTO: GETTY IMAGES
R BARNABY Young, 33, started an otherwise ordinary day with a mild sore throat and a runny nose – like he was coming down with a cold. The symptoms persisted for a few days but there was no fever or any headaches. However, by the third evening, he started to feel light-headed and awoke the following morning with severe vertigo. He felt as if the room was spinning around him. “For the first two days after the vertigo set in, I couldn’t eat, drink, turn my head or even move my eyes from side to side without vomiting or feeling the room spin around me,” he said. Dr Young, an infectious disease specialist from Britain who works at a local hospital, self-medicated with vestibular suppressants and antiemetics. These are prescription drugs to suppress dizziness and nausea. “But they had little effect. It was really just time, and trying to do as much as I could each day to help re-train the brain,” he said. From the third day (of the vertigo attack), symptoms of the upper respiratory tract infection gradually subsided. “I was able to keep my eyes open and at
WHAT BRINGS IT ON?
Labyrinthitis is often spontaneous and idiopathic but can occur after a cold, flu or upper respiratory tract infection (URTI). “These infections don’t usually affect the inner ear. More often, in URTIs, the middle ear is affected when bacteria and nasal secretions pass through the eustachian tubes to the middle ear causing fluid accumulation. A bad middle ear infection can lead to the spread of infection to the brain, or in rare cases, labyrinthitis as well,” said Dr Tan. Although an MRI (magnetic resonance imaging) scan can also show the inflammation, diagnosis is usually made after history taking and a physical examination. The hearing loss is confirmed on a ‘pure tone audiogram’. The doc tor may also spot signs like fast oscillating eye movements, or abnormal eye movements with the movement of the head.
What you should do if you contract labyrinthitis Treatment consists of:
VESTIBULAR SUPPRESSANTS to reduce the dizziness. These are usually given as an oral tablet or as a patch placed behind the ear. ORAL STEROIDS to reduce inflammation of the inner ear, which is the cause of labyrin-
thitis. Some literature also recommend using anti-viral medication like acyclovir. BED REST at home, to avoid stimulating the ear’s balance mechanisms. Many cases of labyrinthitis are cured by a few days or weeks of bed rest.
After-effects and prevention
Long-term effects can occur if the inner ear does not fully recover. Patients may suffer from impaired balance, especially when suddenly changing body positions. There may also be permanent hearing
loss. “These cases are difficult to predict and idiosyncratic. So there is no definite ways of saying who will have permanent hearing loss.” Labyrinthitis rarely affects a patient more than once. “Again, very little is known about who may be affected
more than once. However, it is not necessarily more severe or threatening at the subsequent attacks.” Labyrinthitis is also not preventable. “However, URTIs are a risk factor, so one way is to minimise contact with people with URTIs,” said Dr Tan.
JUL– AUG 2013
Don’t lose sight of the basics
Contact lenses are medical aids, not cosmetic products, and should be worn with proper care. By Ng Hui Hui
ASSIE*, 15, had been wearing contact lenses may result in permanent visual impairment or blindness. for about a year. She got so used to them that one “Infections such as this would have to be treated with night she forgot to remove her lenses and went to corneal transplantation,” she said. bed. In fact, she did not remove her contact lenses for a few days. Care for cosmetic lenses similar She ended up with a white spot on her cornea which The same rules of care that apply to clear lenses apply to turned out to be an infective corneal ulcer. She needed cosmetic contact lenses, which are trendy among teenhospitalisation and intensive antibiotic treatment. agers and young adults. Another patient, Vicky*, 25, reused her daily dispos“Wearing cosmetic lenses is the same as using clear able lenses for a week instead of discarding them daily lenses. Like clear lenses, they come in several sizes, so as required, because she wanted to save money. it’s advisable to see a registered contact lens practiOne day, while removing her contact lenses, one of tioner to get your eyes examined to ensure a proper fit.” them broke and she could only retrieve half the lens. She Many youngsters go online to get supplies because consulted an ophthalmologist who managed to retrieve they find it cheaper, but lenses bought off the Internet the other half, which was hidden in the upper eyelid. may not fit the wearer’s eyes, which can lead to contact lens-related complications. Poor habits create risks “Some ome teenagers and young adults buy their contact Not using and caring properly for your contact lenses lenses without prior examination. They also don’t get can have serious consequences. “If severe enough, the their lenses fitted by an optometrist and don’t go for infections can lead to blindness,” said Dr Lim Li, Senior regular eye check-ups with their practitioners. Consultant Ophthalmologist, Singapore National Eye “You need to have regular check-ups with Centre (SNEC). your practitioner every six months to a year, On average, doctors see about 50 cases of contact even if you don’t experience problems with the lens-related corneal infections admitted to the Singa- lenses. This his is because wearing contact lenses pore General hospital each year, said Dr Lim. can create problems that have no symptoms. Common poor habits include wearing disposable For example, chronic corneal hypoxia (lack of lenses beyond their recommended duration, soak- oxygenation) may initially have no symptoms.” ing lenses in saline instead of disinfectant solutions Cosmetic lenses can also increase the risk of overnight, and not washing hands before handling side-effects if not enough care is taken in their the lenses. use. These hese include dry eyes, corneal infections and “Some of the worse cases involve corneal infections allergic conjunctivitis. such as acanthamoeba keratitis, especially if the appro“Contact lenses should always be worn with priate treatment is delayed and the disease is severe,” care. They hey are medical devices not cosmetic said Dr Lim. products. So, o, if wearers can’t comply with Acanthamoeba keratitis is a rare disease where an instructions for taking care of their lenses, organism known as an amoeba invades the cornea. The they shouldn’t continue to wear them,” disease is often associated with contact lens use and said Dr Lim.
Wash your hands before handling your contact lenses. Clean and disinfect contact lenses properly after each use. Clean and air-dry the contact lens case every day. Follow the lens care instructions from your eye care professional. Arrange for periodic eye examinations (at least once every six months to a year) by an eye care professional.
Store cases and solution in the bathroom. Reuse your contact lens solution. Store contact lenses in non-sterile fluids such as distilled water or tap water. Wear contact lenses past their expiration date. Wear damaged contact lenses. Wear lenses overnight (even for extended wear lenses) as this increases the risk of corneal infections. Wear contact lenses when swimming as this can increase the risk of lens contamination by harmful microorganisms. Wear your lenses if your eyes turn red, there is discharge or your vision goes blurry. Consult your eye care practitioner or doctor to find out the cause.
*Names of patients have been changed to protect their privacy.
JUL– AUG 2013
Getting to the of the
Root of the trouble The main causes of pulp inflammation and infection are caries and decay but cracks are increasingly becoming a big contributor too. Pulp trouble starts with inflammation. Eventually the pulp dies off, leaving the tooth with no nerves or blood supply. It therefore loses its ability to defend itself against infection, making it a target for bacteria which enter through the caries or cracks. A hard knock to the tooth can also cut off blood supply causing the pulp to die and become infected. Tooth pain, prolonged sensitivity to heat or cold, tooth discolouration, swollen and tender gums or a bad taste in the mouth could all mean pulp inflammation or infection. For some patients, there may be no symptoms at all. “We also have patients who are not aware
Overcoming the fear In most cases, the procedure is not painful, as the surrounding area is numbed with local anaesthesia. If there is severe pain before treatment, administering the local anaesthesia may be difficult and there may be some discomfort during the procedure. The placement of the rubber dam (a thin sheet of latex placed over the mouth) also causes some anxiety as patients feel they may not be able to communicate with the dentist or swallow. “We usually walk patients through the procedure and tell them what they can expect to feel at each stage. We ask them to signal us if they feel any pain or discomfort. They will still be able to swallow but as a backup, a suction pump is always used to remove the saliva,” said Dr Lui. Most patients do not experience any pain after treatment, even when the anaesthesia wears off, but as a precaution, mild painkillers are often prescribed. Stronger ones are given if patients experience a lot of pain to start with, as chances of having post-treatment pain are higher in these cases. “If the medication doesn’t help to alleviate the pain, or the pain lasts for more than two to three days, or if there’s swelling, it’s best to consult the dentist again,” said Dr Lui, adding that these make up less than 5 per cent of cases.
PHOTO: VERNON WONG
Dr Lui Jeen Nee walks patients through the root canal procedure and tells them what to expect at each stage.
PREPARING THE TOOTH
The infected tooth is thoroughly examined. A rubber dam is placed over the patient’s mouth to isolate the tooth and provide a clean and saliva-free environment.
CREATING AN ACCESS TO THE PULP CHAMBER
Under local anaesthesia, the dentist makes an opening into the tooth to reach the pulp chamber and root canals.
REMOVING THE INFECTED OR INFLAMED PULP
The pulp is removed from the pulp chamber. Using specially designed files, the canals are then cleaned and shaped. Debris is flushed out with an antibacterial solution.
FILLING THE TOOTH AND CAPPING IT WITH A CROWN
Canals are filled with coneshaped gutta-percha (a rubberbased material), which comes in different sizes. Adhesive cement is used to seal the cones to each other and to fill up the remaining canal space. A permanent filling seals the tooth completely. Depending on its location, the tooth may be capped with a crown.
NOTE X-rays may be taken several times during treatment to help the dentist plan the next steps. The entire process may involve more than one visit, each lasting about an hour. Anti-bacterial medication is used to keep the canals clean and a temporary filling is used to cover the tooth between appointments.
ILLUSTRATIONS: HEYMANS THO
of the symptoms even if they are there. That is why regular six-monthly visits to the dentist are necessary. The dentist will be able to pick up any problems and deal with them early, or refer them to an endodontist specialising in treating root conditions,” said Dr Lui. To confirm any diagnosis, dentists run tests. X-rays are also often used as they highlight infected areas.
STEPS IN THE TREATMENT
A root canal procedure is not as terrifying as some people think and it can save your teeth. By Thava Rani
ANY people get shivers down their spine at the mention of a root canal treatment, but the truth is that it is a relatively painless procedure. Despite its reputation, it allows dentists to save teeth that might otherwise be lost. In the procedure, inflamed or infected pulp inside the tooth (the living tissue with blood vessels, nerves and connective tissue) is removed. The space is carefully cleaned, filled and sealed, and then capped with a crown (if necessary) so it looks like a normal tooth. “We can save teeth which would otherwise be extracted. Most teeth are worth saving except perhaps wisdom teeth, which, if they erupt in the wrong position or orientation, would not be useful for chewing anyway,” explained Dr Lui Jeen Nee, Senior Consultant, Endodontic Unit, Department of Restorative Dentistry, National Dental Centre Singapore (NDCS).
JUL– AUG 2013
Plug the leak
Urinary incontinence is an embarrassing but not uncommon problem that women both young and old, are afflicted with. Thankfully, they do not have to suffer in silence. By Thava Rani
OW MANY times has a sneeze turned into an embarrassing “leak”? Do you tighten the muscles in your nether regions when you anticipate a cough? Well, you are not alone. The accidental and involuntary leakage of urine at unfortunate moments is actually a medical condition known as stress urinary incontinence (SUI). It affects about 15 per cent of women in Singapore. It can be triggered by any physical exertion, such as sneezing, coughing, laughing or exercising, which increases pressure on the bladder. Contrary to popular belief, SUI is neither a part of ageing nor a concern of older women only, although post-menopausal women do make up a large proportion of those with the condition. It can affect women of all ages, including young mothers and pre-menopausal women. One third of women with SUI actually start having symptoms before they turn 35. The main cause of SUI is a weakening of the pelvic floor – which is the group of muscles and ligaments that keep the urethra closed so that urine remains in the bladder. Any weakening of the pelvic floor due to physical changes in the body, such as pregnancy, childbirth or menopause, can result in leakage of urine. Sometimes, but to a lesser extent, the condition can be caused by problems in the urethra, which is the short tube through which urine flows from the bladder and out of the body. Conditions that continuously put pressure on the bladder may worsen the problem. These include obesity, chronic coughing, constipation and the lifting of heavy objects. In post-menopausal women, the situation can be aggravated by hormone deficiency. SUI is the most common type of incontinence and affects about half the women with urinary leakage. Another type known as urge incontinence is the second
Pelvic floor exercises Repeat pelvic floor muscle contractions. Imagine you are trying to stop the flow of urine without moving your legs or buttocks, but while breathing normally.
Stress urinary incontinence (SUI)
Electrical stimulation If the above exercises do not work, an electric current can be used to stimulate the pelvic floor muscles to contract.
Burch colposuspension Bladder support is brought on by permanent sutures placed at the bladder neck.
Vaginal cones Hold cones of increasing weight, one at a time, in the vagina by contracting the pelvic floor muscles.
Surgery Minimally invasive mid-urethral sling procedures which involve inserting a sling under the urethra to form a support.
HOW TO MANAGE THE CONDITION
Overactive bladder syndrome (OAB)
most common, and is associated with what is known as overactive bladder syndrome (OAB). OAB involves a sudden, intense need to urinate which may be accompanied by the involuntary loss of urine. Women with OAB may find themselves emptying their bladder more than seven times during the day and waking up more than once at night to do the same. Some may suffer leakage before they get to the toilet. In some women, it can happen during sex. Women may develop symptoms of OAB if their bladders are not as stretchable as they should be, or if their bladders are hypersensitive or prone to abnormal contractions. The cause of these bladder problems is not usually known. A urinary tract infection, a tumour or an obstruction in the urethra can produce similar symptoms and therefore needs to be treated first before OAB can be conclusively diagnosed. Certain medication, previous pelvic surgery or radiation therapy can also result in OAB. Conditions like constipation, diabetes, congestive heart failure and anxiety may contribute to a worsening of symptoms. Some women may experience symptoms of both SUI and OAB. This is known as mixed incontinence. There are also other forms such as overflow incontinence, where there is an inability to empty a full bladder, resulting in dribbles. True incontinence, on the other hand, occurs when a hole develops between the bladder and the vagina as a result of childbirth, surgery or radiation therapy. In some cases, patients may be born with this hole. Seek help as there are devices, medication and, if required, surgery to help manage the condition (see below). Don’t suffer in silence – take control to plug that leak. This article was adapted from Urogynaecology and You, A Handbook for Women with Bladder Disorders, Womb and Vaginal Prolapse, by Adjunct Associate Professor Han How Chuan, Dr Lee Lih Charn, Dr Arthur L A Tseng and Dr Wong Heng Fok, KK Women’s & Children’s Hospital.
Manage medical conditions and medication Keeping conditions like diabetes under control can help. Check with your doctor about stopping medication that can aggravate OAB symptoms.
Lifestyle changes Reduce fluid intake. Cut down on alcohol and caffeine-containing beverages. Try to lose weight through diet and exercise.
Physiotherapy Do pelvic floor exercises and bladder retraining methods.
Surgery Several types are available but are used only as a last resort. Some involve increasing the capacity of the bladder and reducing unwanted contractions, while others divert the urine to flow out through a hole in the abdomen, where a stoma bag is attached.
Medication Oxybutynin and tolterodine are the most commonly used medication. These help to relax and stretch the bladder, allow urine to accumulate before the urge is felt and stop abnormal contractions.
2013 年7– 8月刊
患舌癌的年轻 女性不断增加 原文 SATISH CHENEY
发病率攀升 新加坡国立癌症中心发现在过去的十年 里，35至55岁的女性患舌癌的病例增加 了三至四倍。之前，绝大多数患者为男
口腔内有斑点。 它们可能白色或 红色，无法刮除。 看上去像鹅口疮。
舌头上有肿块。 并非每个肿块是 癌性的，必须由 医生检查。
难以愈合的口腔 溃疡，尤其无痛 性溃疡更要警惕。 如果癌性溃疡小， 必须切除的部 分相对也小。
口腔发炎肿涨。 尽早治愈。 阻止炎症进 一步恶化。
图： VERNON WONG
性，男女患者比例为3比1。现在，患者 性别比例却旗鼓相当。其他发达国家也 察觉到这个趋势。 但是最让医生费解的是，这些女性 患者并没有相同的起病诱因。过去，舌 癌患者主要是长期吸烟酗酒的老年男 性，还有性传播疾病如人乳头瘤病毒 （human papillomavirus，简称HPV）的 患者。 现在的女性舌癌患者不但没有吸烟 酗酒、嚼槟榔或烟丝，没有HPV病毒 或其他性病，更与其他疑似诱因无关 联，包括牙列不齐（尖牙或不合适的义 齿引起的经常性口腔损伤）和因治疗肾 癌、白血病或淋巴瘤而长期服用免疫抑 制剂。 于是，新加坡国立癌症中心的临床 科学家便着手探究，试图揭开那神秘的 面纱。 首席研究员Gopal医生说，“我们已 排除HPV病毒为其中诱因了。那是因为 在所有的病例检测结果都呈现了阴性。
天 ， 35岁 的 郭 小 姐 （ 非 真 名）忽然发觉到自己的舌头 上有溃疡，便到自己的家庭 医生就诊。 但是溃疡一直不能愈合，所以她便 到医院做一次活检。结果被告知那并不 是什么需要担心的问题。虽然溃疡没 有引起疼痛却越长越大，这让她焦虑不 安。于是她翻查所有有关信息，并向新 加坡国立癌症中心的专科医生咨询。 活检结果仍然呈现阴性，但新加坡 国立癌症中心外科顾问医生Gopal Iyer 还是为检验结果感到担忧。“我建议 她动手术把病变部分切除。我考虑到 的是假如我判断错误，她仅受的是皮肉 之苦。但假如我的判断正确，这将让她 免受患癌的折磨。”郭小姐同意了这项 手术。 “我把她舌头切掉了四分之一。术后 她恢复良好，隔两天便回家了。一周 后，化验结果出来，证实病变部分的确 是癌性的。” 郭小姐是幸运的，因为癌变发现得 早。在缺乏明显症状的情况下，她的坚 持终于取得了成效。
新加坡国立癌症中心外科顾问医 生Gopal Iyer是舌癌研究团队的 首席研究员。
美国研究团队也得出同样的结果。我们 曾试着寻找该肿瘤的基因表达，但始终 没有任何明确的结果。” 顶着不屈不挠的精神，他们再接再 厉把视线转向基因组测序。目前，已有 18例测序样本，并在为该肿瘤的基因信 息进行解码和数据分析。 “信息中已出现了一些可能性较高的 基因标记，我们还在努力验证。要是发 现一些像酶素之类可能导致恶性肿瘤 的特异基因，并且还能针对性地实施治 疗，这不仅揭开诱因所在也能帮助研制 抑制性药物。”
切除舌头的病变部分是最有 效的治疗方法。 如果发现得早，即舌头 上长出一颗如豌豆大小的癌 性溃疡，医生就会以环形切 除法，切除少于四分之一舌 头。如果是属于晚期，那就 可能不得不切除一半或更多 的舌头。手术后，患者一般 还是可以说话和使用舌头。 然而，如果切除三分之 二或以上的话，患者就可能 会有说话和吞咽困难。医生 这时可能会建议重造舌头和 进行语言治疗，连同电疗和 化疗一起对抗癌症。 新加坡国立癌症中心的 外科顾问医生Gopal Iyer提 醒说，及早发现和及时治疗 是非常重要的。 “曾有一位来自马来 西 亚 的 22岁 女 患 者 前 来 看 诊。当时，她的舌头已被 切了三分之一，可是肿瘤 依然存在她口腔内。经过 一番检测确认，肿瘤果然 是癌性的。我们随即替她 切除更多的舌头和颈部的 大淋巴结，和进行电疗与 化疗。” “不过电疗还没结束她 的肿瘤就复发了。这时，她 却决定前往中国寻求中医治 疗，但仍旧无效。当她回到 新加坡时，她的癌细胞已扩 散到全身各处。” 舌癌是可以预防的。 Gopal医生提醒说：“每年 一定要期看牙医两次，并保 持口腔卫生。”他还建议人 们远离五大恶习（“5S”）:
两种假设 虽然Gopal医生还未从研究中得出决定 性的答案，却足够让他从中得出两种 假设。 首先，舌癌基因或许是跟这些女性 与生俱来的，如果加上有吸烟的习惯或 持续曝露在二手烟的环境里，便可能触 发这种癌症。 其次，舌癌或许和饮食有关。Gopal 医生推测，这些有高舌癌风险的年轻女 性，也许都在长期食用加工或含致癌物 的食品。 此外，也有另一项研究显示，舌癌 也有可能因过度使用含酒精漱口水而 引起。
吸烟（smoking） 烈酒或酒精（spirits） 嚼槟榔和烟丝（spices） 性传播疾病（sexually transmitted diseases） 利牙尖齿（sharp teeth） （牙列不齐或不合适的 义齿）
2013 年7– 8月刊
疗专业人员组成的团队，专门指导那些 患有糖尿病、肥胖病和其他与生活方式 息息相关疾病的病人，如何通过运动和 调节饮食使生活更为健康。 骨质疏松症的疗法通常是服用能促 进骨骼生长的药物、吃高钙食品和做运 动。“尤其是饮食和运动方面，对治疗 起着重要的互补作用，” 新加坡中央医 院的高级物理治疗师黄丁萍说。 “平衡力差或姿势不良的人会更容易 如今年逾七旬的玛利已完全坚信运动 骼的雌激素。年轻人则是因为其他原因 摔跤导致骨折。” 黄丁萍补充道。 对人体的益处。在新加坡中央医院康跃 如缺乏维生素D、过度使用类固醇或患 于是，康跃中心的物理治疗师先为玛 中心（LIFE Centre）的健身房里能经常 上厌食症、甲状腺功能亢进症等而患上 利的情况进行评估，并找出需要关注的 骨质疏松症。” 找到她的踪影。 地方，再为她量身定制一套可锻炼体力、 骨质疏松症一般上是不易被察觉的， 阻力、平衡力以及改善姿势的方案，从 骨质疏松症是一种骨骼疾病，是当体 内无法再增生形成骨质的骨组织，和不 发觉时往往已是后期。的确，玛利除了 而促进骨骼生长。 断地吸收清除老死骨质的情况下，导致 感到身体酸痛之外，几乎没有其他骨质 此外，物理治疗师也会在场监督确保 疏松的症状。如果当初没做切除子宫手 患者在锻炼时维持正确姿势及良好的身 骨骼脆弱易碎，增加骨折的危险性。 “尽管骨质疏松症常见于年长的女性， 术和术后体检，玛利也不会知道自己早 体状况，还要不时的为患者检测，然后 却同样能够影响年轻男女，” 新加坡中 已出现骨质疏松症状。 把检测报告传给其主治医生。 随后，玛利到骨质疏松症门诊接受治 央医院内分泌科骨质疏松症和骨代谢组 “医生要对他们的进度感到满意才 疗。医生除了给她开药方，也把她转介 行，”黄丁萍说。她还指出，每转诊的 的顾问兼主任Manju Chandran医生说。 她还指出：“更年期女性骨质流失的 到康跃中心。该中心有一组由医生、专 病人，不论是新的还是重复的病例，都 主要原因是因为身体不再产生可保护骨 科护士、营养师、物理治疗师和其他医 得接受两轮的疗程方可停止。
经常运动能驱逐骨质脆弱 原文 CLARENCE CHEN
果有人对你说运动对骨质 疏松症有益，您或许会觉 得纳闷。然而当年被确诊 时，医生正是这样告诉玛利女士（Mary Gnanapragasam）的。 “那时的诊断真让我感到忧虑。我不 想哪天跌伤骨折还要依赖拐杖行动或他 人来照顾我，剥夺我的自由，”玛利女 士说。
从基本开始 单腿站立式：改善并 提高平衡力和身体的 协调能力。也可以双 脚前后站。
在新加坡中央医院的高级物理 治疗师黄丁萍的协助下，玛利 女士示范了几种她常做的运动 以锻炼体力、阻力、平衡力以 及改善姿势。
阔胸运动：利用弹力 带来锻炼上半身的肌 能力。也可以使用哑 铃或自身的体重。
年轻男性也会患上骨质疏松症 年轻人极度节食也 能引起骨质疏松症 骨的形成是个不断生长 和代谢的过程。在成长期时，骨 组织的形成会比流失来得快，可 是到了约20多岁或30岁初时，骨 质量便达到了巅峰，这时就会变 成流失比形成还要快，骨密度也 会因而降低，导致骨质变薄，脆 弱易碎。 其他因素例如过度节食使体重 锐减、长期使用类固醇等都会影 响骨密度并造成骨质疏松症。
任何人都有可能患骨质疏 松症，即使是年轻男性。在所有病 例中，青年占约20%。骨质疏松症 也可以由其他病症引起，包括厌食 症、甲状腺功能亢进及用药过度， 如类固醇。 在男性骨质疏松症病人中，约 50%是患上性腺功能减退症。这是 由于身体无法产生足够的睾丸素。 睾酮是男性青春期发育与成长起着 主要作用的激素。
本信息由新加坡中央医院内分泌科骨质疏松症和 骨代谢组的顾问兼主任Manju Chandran医生提供。
手臂骑车式：增强体能 和改善心肺功能。也可 以使用跑步机、综合训 练机或健身机。
腿压式：增强下肢、大腿 股四头肌或大腿前侧的肌 肉。也可以做其他动作包 括蹲坐或弓箭步。
2013 年7– 8月刊
新加坡研究人员 发现新型致命癌症 的治疗。 直到最后肠道被肿瘤穿孔才确诊是 癌症。 新加坡科研人员发现，陈先生所患 的是一种鲜为人知、罕见的免疫细胞 癌。这新发现日后将让医生能更准确地 作出诊断并对症下药。 新加坡国立癌症中心肿瘤学高级顾 问医生兼任副主任林顺泰副教授说：“ 这疾病的发现让医生能够迅速地做出准 确的诊断，确定统一的疗程以及研发新 的药物。” 这真是件出乎意料的发现。 病理学家陈树荣副教授说道：“这完 全是无心之举，纯属巧合。” 他在检查肿瘤样本的当而却无意间 发现，取出的小肠肿瘤中所有的细胞都 含有超量的蛋白基因MATK，而这种蛋白 基因在癌细胞中是极为常见的。 “我这才意识到我正在观察一种特 殊类型的肿瘤，”新加坡保健服务集团 细胞组织储存库署长兼任新加坡中央医 院病理学高级顾问医生陈副教授说。 为了进一步了解，研究团队从该地 区中被认为患有这种癌症的60位患者进 行了检查。 “当时，关于这种癌症的文献矛盾
（左起）郑敏展教 授、林顺泰副教授和 陈树荣副教授的研究 团队发现了这种常见 于亚洲的癌症。
重重，无论是什么样的研究结论，总有 另一个结论与其相反，”陈副教授说。 唯一一致的结论是：这种疾病主要 是出现在亚洲地区，每年约有五例患者 发病。它可在数月内导致死亡。 “许多病理学家都从未听说过这种 癌症。在过去，它拥有许多不同的名 称，就这样根据所呈现的症状，以不同 的方法进行治疗。”他说。 然而，这种癌症的发病机理非常特 殊。它的癌变是从细胞核内发作的。这 个发现很可能揭示了某些癌症的潜在病 理，以及与之对抗的方法。陈副教授补 充道。 “一旦我们能辨识它，那么这种癌 症再也不会像之前那样罕见了。” MATK蛋白基因通常在细胞外缘的细 胞质中生成，而在病变细胞中，这蛋白 基因却出现在细胞核内。 “分子分布位置异常也反映了这种 癌症发展的方式，以及肿瘤基因的机 制，”陈教授说。
新加坡国立癌症中心兼任杜克－国 大医学研修学院的郑敏展教授说：“最 终，只要我们知道分子的特征，无论病 变在哪个位置也可以对症下药。” “这种癌症主要是侵害亚洲人群。 开展这类研究工作是必要的。如果我们 不去努力研发，那还能指望谁呢？” 该团队的研究成果已在权威研究期 刊《白血病》上发表。 这项研究引起了美国国立卫生研究 院（National Institutes of Health，简称 NIH) 专家的关注。他们表示，这是医生 和科研人员首次对这种癌症有了较为深 入的认识。 近期曾赴新加坡参加会议并讨论 合 作 事 宜 的 NIH淋 巴 瘤 治 疗 科 主 任 Wyndham Wilson医生说，这项发现将为 确定潜在的治疗目标奠定基础。 “鉴于这种癌症预后极差，我们也 绝不能低估这项发现的影响，而是应该 继续支持其后续研究工作，”Wilson医 生说。
物理疗法和休息等各种传统疗法来缓解 疼痛。可调适睡姿的床可能会让患者睡 得更舒适些，并且维持良好背部姿势和 保养习惯对康复也有很大的帮助。
量会很差。为了减轻腰椎间盘的负担和 改善睡眠质量，患者应该采取仰卧的姿 势，因此可调床有可能能让他们睡得更 舒适些。
告别背痛 背痛是一种常见的症状，所幸 的是，缓解的方法有很多
什么是背痛？人们为什么会感到背痛？ 原因有哪些？ 背痛是一种十分常见的症状，它可以是 因为疾病或创伤所引起的刺痛感或钝痛。 近90%的人都会有背痛的经历。 导致背痛的原因有很多。它可以是从 脊柱的结构上，例如椎间盘、神经、关 节和骨头等，或者是器官的周围，如胃、 肾脏、胰腺、子宫和卵巢等。也可以是 因为某些药物，像治疗高胆固醇等病症， 而引起背痛。
椎间盘突出症、椎管狭窄症或椎关节强 硬症（一种严重的腰椎痛）的患者应该 采取怎么样的睡 姿来提高睡眠质 量？他们能使用 可调床吗？ 由于患者在睡觉 有哪些非手术、非药物的方法可以缓解 时会习惯性地 病人所遭受的“痛苦折磨”？能适应各 弯曲身体，腰椎 种睡姿的可调床有用吗？ 间盘带受到很 大多数的背痛都不需要进行手术治疗。 大的压力造成疼 患者可以通过药物，如非甾体类抗炎药、 痛，所以睡眠质
原文 Chang ai-Lien
数月内，陈先生（非真名） 因腹泻和肠炎等症状就前后 辗转多家医院接受了一系列
不论患的是哪一种背痛，即便在睡觉时， 患者都要面对心里和生理的压力。那么， 微调高床位是否能为他们的背部减轻压 力，好让自己的身体感到更放松并获得 更好的休息呢？ 慢性背痛的困扰的确令人特别身心疲惫。 任何的姿势都有它的优缺点，绝大多数 患者可以仰卧在硬板床上来缓解疼痛， 有些患者则需要采取头高足低斜体位的 睡姿来缓解背痛。
本地的医生和科研人员一直在积 极发展癌症研究的新领域。但 是，如果没有丰厚资金和同意捐 献组织样本的患者的支持，这些 研究工作根本无以为继。 与西方国家不同，呼吁人们捐 献组织样本以及筹集研究资金， 对本地研究团队而言仍是一项 挑战。 由新加坡国立癌症中心兼任杜 克－国大医学研修学院郑敏展教 授所领导的团队，在短短的三年 内便已在癌症研究领域中取得了 多项突破性的进展，尤其是针对 本区域癌症发病率较高的种类。 这只来自新加坡国立癌症中 心、新加坡中央医院和杜克－国 大医学研修学院的研究团队已在 顶尖的期刊上发表了多篇论文， 发现了数百种新的癌症突变基 因，以及研发有治疗潜力的药物。 若没有患者愿意将切除的癌变 组织捐献出来而是术后弃置，这 一切是无法进行下去的。对于那 些致力于研究更有效的癌症疗法 的科研人员而言，这些组织样本 是无价的。 “癌变组织就是了解癌症和其 他疾病的关键。我们可以从病变 组织的基因变化和蛋白质的表现 了解病因，为我们研究治疗方法 提供思路，”新加坡保健服务集 团细胞组织储存库署长兼任新加 坡中央医院病理学家陈树荣副教 授说。 “为了增进对疾病的了解，科 研人员必须研究组织样本，尤其 是本地人口的样本，因为他们可 能会呈现与西方患者不同的症状 和反应，”陈副教授补充道。 我们希望患者能够捐出手术切 除组织剩余的部分，以便研究工 作得以继续，给未来的患者带来 福音。 与郑教授的团队相似，本地 的研究人员也通过血液和组织样 本，对老年病和精神疾病等一系 列病症进行研究，以及观察基因 和环境之间如何互相作用而引发 疾病。 新加坡国立癌症中心肿瘤学高 级顾问医生林顺泰副教授强调募 集资金的重要性。他的团队能够 顺利起步也是因为得到香港上海 汇丰银行信托45万元的慷慨捐赠。 “就像很多人愿意捐款给有 需要的患者一样，我们也希望越 来越多人能够意识到研究的重要 性和捐献的价值，让研究有更多 的发挥空间。没有研究，就不 能延续研发新疗法了，”林副教 授说。 原文首次刊登于海峡时报2013年3月31日。
2013 年7– 8月刊
哮喘控制测验 如果您患有哮喘病且年龄在12岁 以上，请完成以下的哮喘控制测 验问卷，看看您的治疗计划是否 把病情控制住了。请与医生或护 士一起检讨测验结果。 圈出您的答案，然后计算总 分。例如，您的第一个问题答案 是“有时”，得 3分，如果答案 是“从未”，则得5分。
问题1 在过去4周内，您可因为哮喘而在 工作上、学习或家庭生活中受到 影响？ 1.总是 2.多数时候 3.有时 4.很少时候 5.从不
原文 ANGELINE NEO
当哮喘发作时，他总是要竭 尽所能用力呼吸，让自己的 肺部空气饱满。可是他却感 到胸紧气短，胸腔发出哮鸣声，还不停 地咳脓痰。要是近身药物不能缓解病情， 他就得另寻急救治疗。 “我总觉得我的气管像是被堵住了一 样，我几乎无法呼吸，”陈星华先生说。 他从少年时期便开始患上哮喘。 由于家境贫寒，自己也并没太留意 病况，只是把它当成普通伤风感冒来处 理。陈星华患的哮喘病是气管或肺气道 慢性炎症。由于未经诊断和适当治疗， 就在几年前，他的哮喘不断地恶化，以 至每周几天都要到医院接受紧急治疗。
控制病情 年逾七旬的陈星华，病情目前已得到控 制，严重发作次数也减少了。他把这一 切归功于新加坡中央医院呼吸和重症监 护科的顾问医生高思越。 曾经十分依赖并过度使用缓解哮喘 药物的陈星华说: “多亏高医生，我现 在不必靠雾化吸入器也能很有自信地活 下去。” 在高医生的指导下，陈星华开始按 时使用控制性药物。事实证明，每天使 用控制性药物或抗炎药是治疗哮喘最有 效的方法。因为这些药物能降低气管对 环境刺激物的敏感度，从而预防哮喘发 作。它们还助于缓解气管肿胀，减少产 生痰液。 在医生的辅导下，陈星华终于明白
为了快速扩张气管，哮喘病人必须使 用装有诸如沙丁胺醇（salbutamol）缓 解药物的吸入器。但如果病情严重，单 靠吸入器可能无效，病人还需服用药物， 比如泼尼松龙（prednisolone）来加强 药效。 高医生说，“在哮喘恶化之前，及早 接受治疗是非常重要的。要是不断拖延， 病人可能需要靠人工呼吸机来维持生命。 如果病人无法供应足够氧气给大脑和其 他重要器官，就会进入植物人状态，甚 至死亡。 “一般上，约80%哮喘病例都是轻中 度哮喘。每日服食控制性药物能把病情 加以控制，生活也不会受到影响。他们 可以照常上学、上班，甚至可以参加锻 炼或竞技运动，” 高医生说。 有趣的是，足球名将贝 克汉姆与曾在1972年 放松，平稳的肌肉 慕尼黑奥运连获7 面金牌的游泳健 气道壁发炎，增厚 将马克-斯皮茨， 也是成功克服哮 喘的著名人士。 “像陈星华一 样的病例，要是 出现哮喘症状，就 理应尽早就医，按 照医生的建议使用药 物，定期复诊，哮喘 是可以得到控制的，哮 正常的气道 喘病人也可以过正常、充 发作时的哮喘气道 实的生活。”
哮喘是怎么一回事；了解发作的诱因、 怎么控制症状，避免发作以及发作时， 如何处理。 高医生说：“哮喘是一种常见病。在 新加坡，成人的发病率占5%左右，儿 童则约20%。哮喘虽然无法根治，但通 过正确的药物治疗和环境控制，还是可 以有效地缓解症状。” 她说，由于哮喘病人的气管“过度 活跃”，对任何刺激物都难以招架。无 论是寒冷气候、运动，还是灰尘、花粉、 烟草都会触发病情。高医生补充道，不 同的哮喘引发原因能影响病情的好坏。 当病人曝露于某些刺激因素时，就 会触发哮喘，其气管将变窄，气管内壁 发炎，跟着产生粘液或痰液， 此时病人必须通过药物， 协助呼吸。
问题2 在过去4周内，您出现气促的频率 是多少？ 1.一天两次以上 2.一天一次 3.一周三次至六次 4.一周一次至两次 5.从不 问题3 在过去4周内，您可因为出现哮喘 症状（哮鸣、咳嗽、气促、胸紧 或胸痛）而在夜晚或清早提前醒 来的频率是如何？ 1.一周四次或更多 2.一周两晚至三晚 3.一周一次 4.一次或两次 5.从不 问题4 在过去4周内， 您使用的急救吸入 器或雾化吸入药剂（例如沙丁胺 醇）的频率如何？ 1.一天三次及更多 2.一天一次或两次 3.一周两次至三次 4.一周一次或更少 5.从不 问题5 您如何评价在过去四周内您的哮 喘控制情况？ 1.未得到控制 2.控制很差 3.有点得到控制 4.控制不错 5.完全得到控制 总分为25分 祝贺您！您的哮喘已完全得到 控制。 总分为20-24分 达标。您的哮喘病情尚可，但 还没有完全得到控制。 总分低于20分 未达标。您的哮喘未得到控制。
2013 年7– 8月刊
复诊档案两年后自动取消 我曾到新加坡国家心脏中心定期 复诊。身体状况好转后，我再也 没回到中心复诊了。现在，我又
开始觉得身体不适，可当我尝试 预约我之前的那名医生时，中心 人员却告诉我，如果要再约见这 名医生，就必需重新申请转介， 只因过去的两年里我没有回诊， 所以管理系统便自动取销了我的 复诊档案。为什么？ 新加坡国家心脏中心答复：本中心
是全国心血管疾病的主要转介中心，每 年到门诊部会诊的病人超过十万名。另 外，我们也负责诊治那些患有急性且复 杂的心脏病患者。 为了让病人能够更快地得到专科医 疗服务，我们的管理系统便会自动地 把两年内没有复诊记录的病人档案消除 掉。如果在排期间病人感到身体不适， 就应该依自己状况的严重程度，向他们 的家庭医生或医院急诊部门求医。
医疗记录管理处除了负责保管所有病人 的医疗记录外，也负责协调和处理所有 病历记录，包括医疗报告申请表。我 们每年总共收到多达26,000份，既平均 每月2,160份的医疗报告申请表，而当 中普通的医疗报告和与保险相关报告最 多，各占总报告申请表约四分之一。 一般申请的处理时间是四到六个星 期；保险表格是大概25天，比较复杂的 个案可能需要更长的时间。
我向新加坡中央医院申请一份 医疗报告表，好让我提交给保 险公司办理索赔手续。但为什 么院方要花那么长的时间来办 理我的申请？ 新加坡中央医院答复： 本医院的
病人提交申请的理由不尽相同，影 响到处理时间的因素也有很多，包括： 不同学科或部门每月接收有增无减的申 请表、作为就业或入学申请的支持文件 或要向另一名专科医生征求意见。其 他可能延迟处理时间的原因包括医生 请病假、正在休假或身处国外参加科研 会议等。 除此之外，病人也可能同时在不同 病理的诊所就医，所以医疗报告得向 各诊所内部申请调到医疗记录室。新加 坡中央医院的每名病人只有一套病历 记录，如果发生以上情况，负责准备报 告的医生便需要更多时间去处理病历记 录了。 若有任何关于入院手续、账单及程序等疑问，可 电邮至editor@sgh.com.sg，我们会在这个栏目里 解答您的问题。
帕金森病能否引起慢性晕眩？ 我的母亲患有帕金森病。过去几年，她一直出现慢性晕眩的症 状。最近，情况更是变本加厉，几乎每天都头晕，影响她的日 常活动。我母亲同时也患有糖尿病、脑动脉瘤，还在2006年接 受过左内耳修复手术。到底是什么原因导致她头晕？
我 今 年 55 岁 ， 想 做 一 次 心 脏 检 查，但又不知道该做哪种好：心 脏负荷试验，还是心脏 CT扫描？ 我不想接受多重检查，更不想接 受不必要的辐射。
对于没有症状的人来说，进行“心脏检 查”前要先做综合风险评估。这是评估 发生心脏病或心脏猝死的几率。国际上 有好几种评估工具，其中一个适合新 加坡人的是佛莱明汉危险预估评分表 （Framingham Risk Score）。它包括对 吸烟、血压、胆固醇水平及其他危险因 素的评分。 如果您尚未接受佛莱明汉危险预 估，应该先检查您的血压和胆固醇水 平。如果您属于低危险性的病人，那 我们不建议您接受进一步的冠状动脉疾 病检查。即使您属于中或高危险性的病 人，我们也只建议特定类别的病人接受 心脏检查。您应该多注意预防心脏病， 预防措施包括保持健康的体重和饮食、 经常锻炼身体、保持理想的胆固醇和血 压水平。
首先，确定您母亲的帕金森症状和慢性晕眩的症状是否由药物所引起。一 些药物例如抗精神病药（Stemetil）、胃复安片（Maxolon）和血管扩张药 （Stugeron），可能会 引起类似帕金森病的症 状。另外，某些用来治 疗帕金森病的药物也会 导致低血压，这可能会 让患者在做某些动作时 感到晕眩，例如从座椅 或起床站起来等。再 来，患者的晕眩症状是 否与内耳修复术有关 联。如果排除以上的各 种情况后，患者（您母 亲）仍然持续反映晕眩 的症状，那有可能就是 由帕金森病产生的非运 动性的症状。 国立脑神经医学院神经科部 门顾问医生郑继燿
抑郁症 我有抑郁症。因为我觉得心理和 药物治疗都没有用，我终止了治 疗。可是有时，不管我在那里 或做些什么，即使是看电视、洗 澡、用电脑或者在外面办事，我 只想哭。每当我做个决定后我都 会感到后悔。一名心理医生建议 我到心理卫生学院接受治疗，可 是我不愿再服用抗抑郁药了。还 有其他疗法吗？ 抑郁症是完全可以治愈的，治疗方法也 随手可得，如服用抗抑郁药、心理疗
法，以及电休克疗法。许多患者在接受 了治疗后都能恢复正常人的生活。 抗抑郁药有提高血清素输送到大脑 的能力的作用，长期服用也不会使人上 瘾。患者需要不间断地服用至少两到四 个星期后才能看到改善效果。患者康 复、不再感觉抑郁后，也仍然需要继续 服用药物六个月到一年，以防止病情复 发。抗抑郁药即使有任何副作用，也是 轻微及暂时性的。患者可要求医生减少 药物剂量，或转用另一种药物以减少副 作用。 心理疗法可以帮助因面对困难而导 致抑郁的患者。治疗师会引导患者通过 一套有组织的办法来处理这类问题，帮
助患者更好地理解问题并了解自我，同 时帮助患者学习应对这类困难的技巧。 一般可用来治疗抑郁病的心理治疗法 包括认知行为治疗法、人际关系的行为 疗法，和精神动力学心理治疗。在某 些情况下，还可使用艺术和其他辅助 疗法。 电休克治疗法是一种既安全又有效 的抑郁症治疗方法。患者由麻醉师现场 进行轻度麻醉，之后以电流通过患者的 大脑数秒钟。 对那些无法接受药物治疗，心理治 疗无效，并持续患有严重忧郁症的患者 来说，可以选择这种治疗方法。 新加坡中央医院精神病科顾问医生陈恒宁
眼内漂浮物 我眼前总是看到漂浮物，左眼一 直觉得有黑点在动，还有一道持 续大概五分钟左右的闪光。这种 情况已持续了好几个月，大大地 干扰了我的视力。由于工作需 要，我必须长时间使用电脑，而 这些漂浮物令我非常困扰。请问 有得医治吗？ 视线中出现浮影和闪光是40到50岁之间 的人群最为常见的问题。一般来说，眼 前出现浮影是属于正常现象，有时也可 能是因为基于老化，眼睛的凝胶体（又 称玻璃体）变性而引起的。 年轻时，玻璃体有坚固的凝胶性可 紧密地粘连晶状体，可是随着年龄增 长，凝胶体溶液化使晶状体更容易游移 并从眼睛内壁脱离。 这种被称为玻璃体后脱离（Posterior Vitreous Detachment）的情况是每个人 都会经历的问题，尤其是高度近视者或 眼睛受过伤的人。玻璃体后脱离绝大多 数都是无害的，浮影在数月后也会慢慢 消失。只是在偶尔的情况下，晶状体从 眼睛内壁脱落时会牵拉或撕裂视网膜及 血管导致出血，进而造成视力模糊，还 有许多漂浮物。 如果视网膜破裂，眼中瞬间会出现 很多漂浮物。这种情况下，请尽快咨询 您的眼科医生。为了减少视网膜脱落的 风险，视网膜破裂需要进行激光修补。 玻璃体后脱离是随着年龄增长的自 然常态，没有相应的治疗方法。漂浮物 会随着时间逐渐消失，可是如果您望着 亮眼的表层，像一面白色墙壁等，或迅 速左右移动眼睛时，您便会再次看到漂 浮物。 新加坡全国眼科中心白内障和综合眼科高级顾问 李淑燕副教授
2013 年7– 8月刊
SingHealth (May2013).indd 1
5/31/13 4:29 PM
The latest issue of Singapore Health (Jul/Aug 2013) is out. Read about why more young women are getting tongue cancer even though they do no...