OutramNow July/August 09

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July/August 2009 ❙

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Patients. At the Heart of All We Do. A bi-monthly publication of Singapore General Hospital, the nation’s flagship hospital within the SingHealth group

Issue 15

July/August 2009 MICA (P) 008/01/2009

I N S I D E Looking for a Diabetes Patient Champion.

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Commit a crime while sleeping?

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77-year-old springs back to health after novel heart valve procedure.

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Trumping the odds

Singapore General Hospital (SGH) and its sister institution,the National Heart Centre Singapore (NHCS), recently performed the first combined heart and liver transplant in Asia. The medical teams involved in the rare procedure talk about the surgery and planning to overcome the many risks associated with this procedure.

By Yong Yung Shin

When Mr Lau Chin Kwee was diagnosed with Familial Amyloid Polyneuropathy (FAP) in 2005, it might as well have been a death sentence. The rare genetic condition,which disrupts the functions of the nervous system, heart, gut and kidney through a mutant protein produced in the liver, has no known cure - and the only solution was to replace the liver.

In September 2006, the 58-year-old retired pastor was referred to SGH’s Liver Transplant Service for a possible liver transplant. His heart, found to have been affected by the disease, would also need to be replaced. In November 2008, Mr Lau was put on the waiting list for a combined heart and liver transplant.

The surgery had posed a dilemma for

“

What we learnt was to not shy away from doing something just because we had never done it before, but to reason through all options carefully with the patient’s interests at heart.

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said Associate Professor Tan Chee Kiat, Director of the Liver Transplant Programme at SGH

doctors: Singapore doctors had never performed the complicated procedure.

As of 30 June 2008, only 17 heart and liver transplants had been successfully performed worldwide on patients with Mr Lau’s condition - and the mortality rate for such procedures was estimated at 30%.

“While it is usually not advisable to perform transplantation surgeries where the mortality rate is above 5%, we kept in mind that without the operation, it would have been certain death for him,” said Associate Professor Tan Chee Kiat, Director of SGH’s Liver Transplant Service and Senior Consultant of SGH’s

Department of Gastroenerology & Hapatology.

Doctors also worried if Mr Lau, extremely malnourished and weakened by prolonged diarrhoea after the abnormal protein began to affect his gut, would be able to cope with the stress of a double organ transplant.

Sequence of procedures crucial “Surgically, there were not too many technical challenges because both the heart and liver teams performed the same procedures as they would in a usual heart or liver transplant,” said Dr Tan Yu Meng, Surgical Director of the Liver Transplant Programme and

Our last OutramNow – we return with a bigger, better paper later this year Two and a half years. Fifteen issues.

And a readership that keeps rising.

When we embarked on our journey at the beginning of 2007 to publish Singapore’s only patient newspaper, we didn’t envisage that OutramNow would grow into the publication that it is today – a widely read, respected paper filled with information about SGH and its sister institutions, the latest services and treatments, illnesses and health conditions, and hospital processes.

It has been a road paved with lessons, and also of inspiration, from you, our patients, readers, our medical and nonmedical advisors, and advertisers. As we chart our next course to take this publication to the next phase, we will take a break from publication and return with a bigger, better newspaper and a new name later this year.

Thank you for your continued support!

Deputy Head & Senior Consultant Of National Cancer Centre Singapore (NCCS)’s Department of Surgical Oncology.

“The main challenge was in getting the sequence right while doing a technically perfect surgical operation.”

The complex surgery – involving the donor, heart and liver transplant teams – would have to work like clockwork with the handover between each team seamless to make sure the recovery of the transplanted organs wasn't compromised.

The teams wouldn’t know when the surgery would be scheduled – it would depend on when a donor became available. Thus, well before that happened, the teams had to ready a plan with detailed steps for the transplant procedures, and the sequence of these steps. The transplant teams brainstormed about the problems that could arise, and formulated backup plans in the event they do surface.

It was also crucial for the support teams to know their role and responsibilities. The coordinators, anaesthetists, operating room staff, ICU (intensive care unit) staff, pharmacists, physiotherapists, medical social workers – all needed to know how and when they should work with the others if the CONTINUED ON PAGE 5

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❙ July/August 2009

A silver lining to cost cutting

SingHealth institutions have long championed delivering quality service while remaining committed to conserving the environment and containing costs.The National Heart Centre (NHC) Singapore shares its use of an everyday kitchen item that improves patient outcomes and saves resources at the same time.

By Sheralyn Tay

Sometimes, it just takes a bit of creativity to overcome the challenges of life-saving heart surgery. For nurses at National Heart Centre, aluminium foil-lined blankets proved to be an effective method of keeping patients warm after surgery.

“Patients undergoing heart surgery are cooled down for surgery. Afterwards, the patient needs to be warmed back up (to normal body temperature), but at a slow and constant pace that doesn't cause any dramatic increase in the heart rate,” said Mr Ismail Sheriff, nurse manager of the cardiothoracic surgery intensive care unit (CTSICU) at NHC. To do this, a Bair Hugger disposable blanket - through which hot air is pumped from an external machine – is used. These are high-maintenance machines that require a lot of manpower to manage and maintain. “With only three such machines in the CTSICU,

than 1,300 cardiothoracic surgeries, including heart and lung procedures, and at least three to four patients need to use a Bair Hugger blanket a week. At $28 per disposable blanket, said Mr Ismail, the costs add up.

To come up with a more cost-efficient alternative, an 11-member team looked at other materials to enhance the warming process for post-operative patients in the ICU in 2007. “In our survey, we looked at the effectiveness of plastic, Patients found aluminium foil to be the most comfortable canvas and aluminium material. It traps the patient’s own body heat, gradually foil versus Bair Hugger warming the body until it reaches its natural temperature. blankets and found that the department sometimes struggles a particular aluminium foil, not your to cope with demand, especially if one regular kitchen foil, which costs only machine breaks down,” said Mr Ismail. $2 was the most practical solution,” Each year, NHC carries out more said Mr Ismail. “This foil, which comes

with a thin fibre layer, was found to meet the criteria set by the team as it was light, comfortable, easy to use, effective, affordable and available.

“We are able to insulate the patient in less than 30 seconds with this method as we just need to cover the patient with a draw sheet, the aluminium foil and a blanket,” Mr Ismail said.

Using aluminium foil saves a significant $22,000 a year in material and manpower costs. Since its implementation, Singapore General Hospital’s Department of Neonatal and Developmental Medicine, which looks after newborn babies, has also adopted this method for keeping newborns warm.

For its efforts, the NHC team received a bronze award at the International Exposition on Team Excellence 2008, competing against other team projects from China, India, Indonesia and Thailand.

another monitors temperatures, and the third ensures that only eligible nominated visitors enter the wards to see patients.

Visitors with temperatures above 37.50 Celsius are advised to seek medical help, especially if they have a travel history to affected countries.

couldn’t allow a visitor to enter the ward because he wasn’t in the nomination list, but he shouted at me, saying “you don’t know your job,” “you don’t do your job” “the salary they pay you is not worth it.”

Unexpectedly, the next visitor in the queue came to my defence, saying that I was just doing my job and should be respected and treated well. I was moved to tears!

FrontLine

Insults slide off her like water from a duck’s back A n n ali n e G e n e t a Samaniego, a Transportation Shift Leader of SGH’s General Services Department, is one of many hospital staff who was taken off her regular job temporarily to screen visitors and patients for fever and other flu-like symptoms as part of heightened measures adopted to contain the spread of Influenza A(H1N1). Since she was deployed at Block 7 in late April, the 34-year-old said she has been shouted and cursed at,

2. What problems do you encounter in this job?

As a frontline staff screening visitors, my challenge is to adhere closely to the hospital’s visiting policy while attempting to gain visitors’ understanding of the inconveniences that arise as a result.

Only nominated visitors who have been registered and who don’t have fever are allowed to visit patients. The biggest stress is handling visitors who are not allowed to enter the wards. I understand that having to wait in queue and then to be turned away can be frustrating.

One time, I had to explain why I

belittled, and even threatened by visitors inconvenienced by the visitor restriction policies. But Annaline, who describes herself as a determined, strong-minded and dependable individual, shrugs off the incidents as “a personal challenge to handle.”

1. Describe your work.

I work with three other people to check and register visitors to facilitate visitor control. One gives out stickers,

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4. What would you say are the qualities or skills that helped you with this job?

Patience and understanding, exemplary customer service skills at all times because I come in contact with people of diverse cultures, behaviours and preferences. I also need to have a clear understanding of the rationale behind hospital policies to be able to explain them to visitors.

Defending our patients from the flu. See pages 18-19

SGH CLINICAL ADVISORS • Associate Professor Goh Yeow Tee • Assoc Professor Hwang Nian Chih • Associate Professor Loo Chian Min • Associate Professor Tan Chee Kiat • Dr Sophia Chew • Dr Charles Chuah • Dr Goh Su-Yen • Dr Lai Fook Onn • Dr Mark Leong • Dr Lim Li Ling • Dr K Puvanendran • Dr Tan Yu Meng

Guest Clinical Advisors • Professor Wong Tien Yin • Associate Professor Goh Siang Hiong • Dr Tal Burt • Dr Paul Chiam • Dr Choo Chih Huei • Dr C Sivathasan • Dr Tan Teing Ee To advertise, please call 6236 5790 Email: mktgmedia@ntucmedia.org.sg For editorial content, email: editor@sgh.com.sg

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July/August 2009 ❙

Aug 1: Happy Nurses' Day!

The early days of nursing In the early years after the founding of Singapore, nursing duties were performed by convicts, who also served as compounders, dressers and sweepers. It was only until 1885, with the arrival of 11 convent sisters from England that female nurses made their presence at the hospital.

In 1922, construction began for a Nurses' Quarters and was completed in 1923, with accommodation for 100 nurses. At that time, all female nurses were unmarried and had to live in the quarters provided.

The Nurses' Quarters was re-named Brebner House after the Second World War in memory of a matron who died in 1942.

This building was demolished in 1978 to make way for the new Singapore General Hospital.

returned to school for a one-month training in the theory and practice of nursing prior to their second- and final-year examinations.

Male candidates were also accepted for training for the first time.

These improvements brought recognition to local nurse graduates who were accepted for registration with the General Nursing Council of England and Wales. The Nurses' Registration Ordinance passed in 1949 requiring all nurses to be registered for practice in Singapore also elevated the status of nurses.

In 1951, SGH saw its first batch of local nurses promoted to Ward Sister. They were Misses Lim Kwee Neo, Ti Sui Tsu, Helen

Chan, Goh Kim Swee and Wee Kim Siew. In tandem with the recruitment campaign for nurses and to cater to the increasing demand for more trained nurses, a new nurse training school and nurses' hostel were established.

Vicker's House, a new nurses' hostel, was declared opened by Mrs Tan Chin Tuan on Jul 29, 1953, while a new nurse training school and nurses' hostel (PTS Hostel) were formally opened by Lady Black, wife of the Governor, on Sep 10, 1956. The increased intake of student nurses also brought about a demand for more classrooms and training facilities. A School of Nursing, built on the site of the old Maternity Hospital, was officially opened in September 1959.

Nurses having lunch at long tables.

the preliminary training school hostel

The Sisters' Quarters

Bouquets

The immediate post-war period brought on urgent needs and improvisation. Medical equipment and supplies, and medical and nursing manpower were scarce.

The war had served as a catalyst for public recognition of nursing services.

In 1947, two scholarships were offered by the Australian Imperial Forces Nursing Scholarship Fund for Malaya- and Singaporetrained nurses to train in Australia. The preliminary training programme was increased to four months, after which the nurses were assigned to the wards. Student nurses attended lectures conducted by senior doctors during off-duty hours. They then

Thanks for thinking out of the box

Our nurses don’t just care for patients. As these letters show, nurses often take the initiative to make sure patients are not inconvenienced by hospital policy.

“

Please allow me to share my good experience at SGH on Apr 8 this year, which was in large part due to excellent service provided by Staff Nurse James Quah and Senior Staff Nurse Lee Yean of Ward 74. The care that staff of the ward provided my father, Mr Woon Siong Foo, when he was hospitalised earlier this year was excellent, but the way Nurses Quah and Lee went out of their way to help us deal with a problem weeks after my dad was discharged was truly outstanding.

My father has been under the care of Dr Philip Wong of National Heart Centre Singapore for many years. My dad, who is bedridden and afflicted by a few illnesses, suffered a minor heart attack/stroke and was admitted to Ward 74 in February this year.

During his hospitalisation, a new set of medication was prescribed for my dad.

On the day of his discharge, I was handed an envelope with instruction to renew his medication at any polyclinic or SGH a week before the medication prescribed by Ward 74 runs out.

On Apr 8, I went to a pharmacy at SGH to fill the prescription. However, I was told by the pharmacist he could not dispense the medication as there was no formal prescription in the envelope, merely a signed memo detailing the scope of treatment (including the medication prescribed) during my dad’s stay at SGH. I sought advice from the staff of the Admissions Office who then recommended I checked with staff at Ward 74. As my father was not due to see Dr Wong again till July, I had the other option of taking my dad to a polyclinic doctor to get the prescription validated. It would have been a big hassle for my father as he is bed-bound.

the first local nurses to be promoted to ward sisters in 1951 were Misses Wee Kim Siew, Ti Sui Tsu, Helen Chan, Goh Kim Swee and Lim Kwee Neo

At Ward 74, Staff Nurse James quickly took charge of the situation. He contacted the Heart Centre for help in getting Dr Wong to validate the medication requested.

At the same time, Senior Staff Nurse Lee Yean, SN James’s supervisor and Acting Nurse Clinician of the ward, took the initiative to contact the ward doctor to explore the possibility of validating the prescription. Dr Jasmine Lim, who was a House Officer with Neurology Department at the time, came down promptly to issue the validation which would allow me to buy the medication from the pharmacy.

Despite their busy work schedule, Staff Nurse James Quah and Senior Staff Nurse Lee Yuan of Ward 74 displayed initiative, professionalism and the ability to think outside the box. In doing so, they were able to provide excellent service, even to a patient who was discharged more than a month before.

I congratulate the management of SingHealth for inculcating and promoting this quality service culture to its staff. Compared to my experiences of many years back, SGH has come a long way.

Keep up the good work!

”

- Mr Woon Tai Hean PBM BBM

“

My mother was admitted to Ward 76 on Apr 7 this year, and when she was discharged a day after, she left behind her medicine. We needn’t have worried as the same afternoon, I received a call from Staff Nurse Nurul Huda bte Samsuddin to tell us she had found the medicine.

Nurse Nurul want further to help, saying she would return the medicine to us in the evening after work as she lives near us.

As my mum needed to take the medicine daily, we are very grateful to Nurse Nurul for her help. We were spared taking another visit to the hospital as well.

”

- Ms Neo Mee Ting

“

My grandmother was recently admitted to Ward 58 for herpes. As it was an isolation ward, the number of visitors was limited to four a day. Although she was very much alone during the day, the nurses and staff were very attentive to her needs and chatted with her to keep her occupied. Knowing that she's Teochew, the nurses took time and effort to buy her a packet of Teochew braised duck rice from the food court.

She truly enjoyed it.

Thanks for making my grandmother’s stay a pleasant one!

”

- Ms Constance Leng

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❙ July/August 2009

A landmark surgery 2350

Day 2

General anesthesia administered on recipient

0040

Preparation for liver removal by liver team

Start of transplant surgery by liver team

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0215

Start of donor’s surgery with heart and liver inspection*

Recovery of donor’s heart*

Donor’s liver sent for biopsy*

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Arrival of donor’s heart at SGH operating theatre

Day 1

0300

Recovery of donor’s liver* Preparation for recipient’s liver removal completed

0310

Commencement of heart transplant on recipient

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Arrival of donor’s liver at SGH operating theatre

0500

Completion of heart transplant on recipient

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Commencement of liver transplant on recipient

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Completion of liver transplant on recipient

1300

Completion of hemostasis (stop surgical bleeding) and skin closure

* Performed at donor’s hospital

Support teams – Caring for Mr Lau P re c e d i n g t h e f l u rr y of surgeons, cardiologists, hepatologists, anesthetists and nurses in the operating theatre were months of preparation carried out by a whole legion of multi-disciplinary medical and paramedical staff.

Said Ms Kerk Ka Lee, Manager of Heart and Lung Transplantation: “From the moment the patient was put on the waiting list (for a transplant), his followup needs came under the transplant coordinators 24/7. If he is not well at any time, we will arrange for him to be admitted if necessary.”

For instance, dietitians prescribed appropriate measures to help Mr Lau recover from nutritional problems. He was severely malnourished because of diarrhoea caused by his disease.

He was also assigned paramedical staff.

Medical social workers provided Mr Lau and his family with emotional support, and updates of his condition. They also helped source for financial assistance.

Post-surgery, transplant coordinators continue to work towards Mr Lau’s full recovery. They arrange for regular rounds of consultations with the heart and liver teams who look out for signs of organ rejection and other complications.

Dieticians and physiotherapists are present

Did you know?

• The heart and liver transplant surgery took about 13 hours, and involved about 40 personnel from various disciplines.

• Teams from 11 disciplines were involved in this landmark procedure: Coordinators, heart transplant surgeons, liver transplant surgeons, anaesthetists, cardiologists, hepatologists, ID(Infectious Disease) physicians, operating room staff, perfusionists to operate the heart-lung cardiopulmonary machine, ICU (intensive care unit) staff, pharmacists, physiotherapists and medical social workers.

• The heart transplant led by Dr C Sivathasan, Dr Lim Chong Hee and Dr Lim Yeong Phang was completed within 3.5 hours.

• The liver transplant led by Dr Tan Yu Meng, Dr Cheow Peng Chung and Dr Alexander Chung took 5 hours.

• Four litres of blood were used during the surgery (the average human body has a blood volume of about five litres).

at these sessions to evaluate the patient’s daily progress and recovery together.

Pharmacists are also involved as “it is crucial that the drugs prescribed separately by the heart and liver doctors don’t interact with each other,” said Ms Kerk.

• During surgery, a cardiopulmonary bypass machine took over the functions of the heart and lung to circulate blood and oxygen throughout the body. To prevent the blood from clotting in the machine, anti-coagulants were used but this increased the risk of excessive bleeding during the liver transplant.

• According to the FAP (Familial Amyloid Polyneuropathy) World Transplant Registry, as of 30 June 2008, there had been 55 cases of simultaneous organ transplantations performed on patients suffering from the condition, with 37 cases of liver and kidney transplant, 17 cases of heart and liver transplant, and just one case of heart, liver and kidney transplant.

July/August 2009 ❙

Outram Campus: Asia’s organ graft hub

Doctors at SGH’s Liver Transplant Programme weren’t entirely confident when faced with the prospect of performing a rare combined heart and liver transplant. After all, it was only three years before that the programme was started, compared with the nearly 20 years of experience racked up by the National Heart Centre Singapore (NHCS) where

the Heart Transplant Programme began in 1990.

But the team decided to go ahead - and today, they are glad they did.

“Five years ago we wouldn’t have been able to do this, but we now know that if we have to perform other multiple organ transplants in future, we will have the confidence to do so,” said Dr Tan Yu Meng, Surgical Director of

CONTINUED FROM PAGE 1

Trumping the Odds

surgery was to be performed with as few hitches as possible.

“It was like conducting an orchestra,” said Dr C Sivathasan, Co-Director of NHC’s Heart & Lung Transplant Programme, who oversaw the preparation and coordination between the two teams.

“As it was a long surgery, there was no room for error. Every person had to know exactly which key to press and what tune to play.”

Race against time It would also be a race against time for the surgeons involved in the combined transplant.

Both the organs would have to be recovered and transplanted into the recipient as quickly as possible to avoid complications setting in. The heart would have to be transplanted first as the organ had to be pumping blood in the recipient’s body within four hours after it was recovered to keep the risks of complications low. In comparison, liver transplant surgeons have a longer time to work with – 12 hours. But to save time, the liver team would first mobilise the patient’s liver before the donor heart arrived.

“Within a matter of hours, we had to get the newly transplanted heart to

work very hard for the second stage of the surgery. In fact, we had a standby recipient for the liver in case the donor heart failed,” said Associate Professor Tan. In other words, the heart had to hit the ground running. Fortunately, the donated heart was in good condition, and to check that the organ was functioning well and able to sustain a proper heart rate, “we allowed the heart to gradually receive the circulatory volume of blood,” said Associate Professor Hwang Nian Chih, Head of NHC’s Department of Cardiothoracic Anaesthesia.

Once it was established that the heart was functioning and in a stable condition, liver transplantation would proceed as planned. To par tiall y

the Liver Transplant Programme at SGH. Indeed, the success of the procedure as the first in Asia of a combined heart and liver transplant on a patient with Familial Amyloid Polyneuropathy cemented Outram Campus’s standing as a major transplant centre in the region.

“It could not have been possible without a fairly developed transplantation programme -

relieve the newly transplanted heart’s work of circulating blood and oxygen throughout the body during the liver transplantation, the patient would be kept on a cardiopulmonary bypass machine (CPB).

“

It was like conducting an orchestra. As it was a long surgery, there was no room for error. Every person had to know exactly which key to press and what tune to play.

”

said Dr C Sivathasan, Co-Director of NHC’s Heart & Lung Transplant Programme.

“We were pleasantly surprised that everything went smoothly,” said Dr Lai Fook Onn, Senior Consultant at SGH’s Department of Anaesthesiology.

“The greatest risk came from the unexpected. Many things could have gone wrong, as heart and liver transplants in themsel ves are already major o p e r a t i on s w h e re many uncertainties abound - what more a joint transplant. In a worst case scenario,the heart or the liver could have malfunctioned in the recipient’s body, o r u n c on t ro l l a b l e bleeding could have

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the success of this double organ transplant reflects the breath and maturity of various clinical disciplines under the Outram Campus,” said SGH Chief Executive Officer Professor Ang Chong Lye. Outram Campus houses most of the nation's national transplant programmes, including kidney, bone marrow or stem cell, heart, lung and cornea, supported by experts in 35 clinical specialties.

The national skin bank is also at SGH. To date, some 5,000 people have found a new lease of life after undergoing various transplants of the kidney, bone marrow, heart, liver, lung, skin grafts and cornea at Outram Campus.

“What we learnt was to not shy away from doing something just because we had never done it before, but to reason through all options carefully with the patient’s interests at heart,” said Associate Professor Tan Chee Kiat, Director of the Liver Transplant Programme at SGH. “People who have a highly specialised skill set such as medical professionals usually have certain mental barriers that dissuade them from undertakes something new or different.

This case provided a good opportunity for both the heart and the liver teams to break our mental barriers.”

“Most importantly, through this milestone achievement, we as a major transplant centre are able to show that we are there for the patient.”

occurred during the surgery.” Dr Lai said Two months after (around the time this paper went to print), Mr Lau’s recovery continued to progress well, with both “his heart and liver functioning well,” said Associate Professor Tan. Still, Mr Lau will remain on lifelong medication to prevent complications arising from organ rejection, among other kinds of heart medication. Additionally, he will have to be continuously treated for other symptoms because while the transplantation was able to halt the progression of the disease, it will not be able to remove the mutant protein already deposited in other parts of his body.

What is undisputed, however, is that through a combination of strategic planning, cohesive teamwork, generosity of strangers and a stroke of luck, Mr Lau is now able to enjoy a new lease of life.

“While every transplant we undertake is special to us, this one is especially memorable given the scope and the odds. After all, it is challenges like these that keep us in the field,” said Dr Tan.

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❙ July/August 2009

Don’t worry, be happy

By Dr Ng Beng Yeong

“The only certainty is that there is nothing certain.” – Ancient author and natural philosopher Pliny the Elder, AD 79.

To hear that someone is worried about their job during these difficult times may not come as a surprise. Indeed, worry – or fear of the uncertain - is a natural reaction to challenging situations.

Worry in itself is not a disease, and may represent an attempt to solve a problem or to gain control over potentially dangerous events. For some, however, worry can be taken to extremes, becoming exaggerated, unrealistic and/ or uncontrollable.

These extreme worriers have what is known as generalised anxiety disorder (GAD) and tend to worry almost all the time. They get caught up in a whirlwind of negative thoughts which often leads to the feeling that they are unable to stop worrying.

Over two-thirds of GAD patients say they “have always been worriers,’ and features of Dependent and/or Avoidant Personality (anxious personality) Disorder occur in over half of cases.

Dependent Personality Disorder is characterised by a pervasive psychological dependence on other people, while Avoidant or Anxious Personality Disorder is a condition characterised by extreme shyness, feelings of inadequacy, and sensitivity to rejection.

“

Sometimes referred to as the ‘what if?’ syndrome ‘What if the stock market does not ever recover?’, ‘What if I can’t fall asleep again tonight?’, ‘What if I have cancer?’, ‘What if something goes wrong?’ – these thoughts and images, if put together, could be a movie titled ‘Things That Went Wrong Today … and Things That Will Go Terribly Wrong Tomorrow.'

”

GAD patients often report that worry or rumination is largely involuntary, but some might deliberately initiate worry to try to solve problems and then have difficulty discontinuing it.

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Glucosamine acts more like a lubricant in the joints while collagen contributes to the global regeneration of the joint at all levels: tendons, ligaments, cartilage, muscles, membranes and synovial liquid (lubrification).

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Many individuals worry in bed, possibly because there is little else to occupy their attention. Worry is most likely to occur either in the later part of the evening or the early hours of the morning, underscoring the wellattested relationship between worry and insomnia. The majority of insomnia sufferers would attribute their sleep disturbance to a ‘racing mind.’

Not surprisingly, worriers often feel tense, tired, irritable, restless, keyed up or on edge, have difficulty sleeping and difficulty concentrating.

White bears keep coming back Some worriers try to manage their anxiety by blanking their minds or by trying to stop thinking about their problems.

However, an experiment conducted in 1989 by US psychology professor Daniel Wegner found that the more we try to control what we think, the more control slips away.

He had asked a group of university undergraduates to close their eyes and banish all thoughts of white bears. After a couple of minutes, he asked them to discuss their attempts at suppressing thoughts of white bears. The result: No one could stop thinking of white bears!

Wegner's experiment led to discussion of contrary thought management techniques such as worry exposure and worry breaks.

In worry exposure, GAD patients expose themselves to worry and its associated images for an extended period of time. The intention is to get the patient used to the worst possible outcome and the anxieties associated with it.

Similarly, in worry hour or worry breaks therapy, compulsive worriers are allowed to give in to their negative thoughts – but only during scheduled periods of each day. During these breaks, they are allowed to feel as worried, tense or anxious as possible by bombarding their minds with negative thoughts.

Worriers with insomnia should simply let their thoughts flow. Writing about their unwanted thoughts before going to bed may also reduce avoidance and facilitate the processing of emotional material.

Worry control experiments can help change the belief that worrying cannot be controlled. When anxiety strikes, the

person pushes back the stream of negative thoughts to a later scheduled time. When the time arrives, just 15 minutes will be allowed for the patient to fret about the problem.

In most cases, the patient is able to ‘postpone’ feelings of worry – and often does not resort to the scheduled worry period, suggesting that it is possible to exercise some control over worrying.

Interestingly, relaxation has been shown to heighten worrying in some patients with GAD. It may be that for these patients, relaxation signals a lack of control, which increases their fears and anxiety. Or it may be that when they sit quietly with their thoughts, they are more exposed to their worries.

Accepting uncertainty Worriers find uncertain situations intolerable and tend to avoid uncertainty if they can. Such people can be likened to those with allergies, said psychologists Michael Dugas and Melisa Robichaud.

People with a pollen allergy, for instance, will have a very strong reaction to even a minute quantity of the substance.

Similarly, people with an ‘allergy’ to uncertainty will have a strong reaction – excessive worry and anxiety – to only a small amount of uncertainty.

Uncertainty exists in many aspects of our lives. But will worrying help reduce uncertainties or solve a problem? Does worrying interfere with our lives, and by how much? What sort of uncertainties are we prepared to tolerate?

These are the questions we should ask when confronted with uncertainties and uncertain situations. We already tolerate all kinds of uncertainties, and we can learn to accept those with a low probability of occurring. Indeed, the majority of things that we worry about never actually happen.

Dr Ng is Senior Consultant and Head of SGH’s Department of Psychiatry.

(Adapted from an article published in SMA News November 2008 Vol 40. SMA is a monthly publication of the Singapore Medical Association.)

July/August 2009 ❙

❙ 7

WeHearYou

Out of noise and dust, better facilities to come My wife was warded after major surgery. She’s diabetic and had a fever after her operation, but wasn’t able to get proper rest because of the noise from construction nearby and renovation upstairs.

– Alfred, whose wife was in Ward 53A; subsequently moved to a quieter area. of Block 1. Renovations are continuing to construct a link platform between Blocks 3 and 5, due to be completed in early 2010, and various fire protection enhancement projects.

Projects in the pipeline include a planned expansion of the Specialist Outpatient Clinics Pharmacy, and the Rehabilitation Centre at Block 1 Level 1.

To create better facilities and services for patients, Outram Campus has been seeing a flurry of construction activity. Many projects are long term such as the recently completed Duke-NUS Graduate Medical School, and the SGH Pathology Building.

The 24,000-square-metre DukeNUS Graduate Medical School is scheduled to be operational by mid2009. Meanwhile, the new SGH Pathology Building, which will have

While changes ultimately lead to improvements for patients and staff alike, such activity will be accompanied by noise and dust – a problem that SGH tries to minimise.

Heavy construction is stopped at 6pm. For wards near construction areas, patients are provided with ear plugs and when possible, moved to other rooms or wards. Checks are also conducted on work sites to ensure project managers comply with measures to control both noise and dust pollution.

twin blocks of 13 storeys will be ready in 2010.

Other construction works are shorter term in nature. For instance, the new Kopitiam with a larger dining area reopened earlier in January after a month of refurbishment.

Renovations recently completed include impatient wards 44 and 56, offices for Neurology and Neurosurgery departments, and improved triage, registration areas and other Emergency Department facilities on the roof top

Help us make Outram Campus a better place for patients. Write to editor@sgh.com.sg and tell us of the problems you encounter.

Bypass patients recover faster when blood sugar levels controlled A project by an anaesthetist-led team to control blood glucose levels in bypass patients shows promising results, spurring broad interest from hospitals elsewhere to adopt the initiative in their ICUs.

By Hannah Lin

Over 1,000 people in SGH undergo a bypass every year, and they face infection-related complications or worse post-surgery because of high blood glucose levels.

This is because after undergoing a coronary artery bypass grafting procedure – major surgery lasting some four hours on average - the patient faces large physiological imbalances that increase blood sugar levels.

Such effects on the blood sugar level can last up to a week.

A significant number of patients also require adrenaline or similar drugs after surgery, and though they are typically used for short periods of less than 24 hours, they lead to increased blood sugar levels.

“We have to use insulin to control the blood glucose during surgery and immediately after because patients cannot take their

usual oral medications,” said Dr Tan Teing Ee, a Senior Consultant with National Heart Centre Singapore’s (NHC) Department of Cardiothoracic Surgery and a member of a team from SGH and NHC that looked to reducing blood sugar levels in patients who undergo bypass surgery.

“Insulin can cause hypoglycaemia (low blood sugar) that in rare cases can cause coma and even death.”

Patients with poor appetite, renal or liver impairment are especially at risk of hypoglycaemia. Indeed, a large number of patients who undergo a bypass suffer from kidney disease, high blood lipid levels or hypertension. Some 50%-60% of them are diabetic.

Recent research suggests that tight sugar control in patients recovering from

a bypass procedure reduces mortality and complications, especially from surgical wound infections.

The team comprising anaesthetists, surgeons, nurses, pharmacists and endocrinologists developed a protocol to control blood glucose levels – not just postsurgery but also during – by close monitoring and adjustment of insulin infusion rates.

“It is difficult to judge the insulin requirements of our patients, and close monitoring is required,” said Dr Tan, adding that “we used to do blood sugar levels six hourly. But now we do half-to-one hourly in OT (operating theatre), and two-four hourly in ICU (intensive care unit).”

After six months, the project involving over 200 patients was able to achieve a targeted blood glucose level of 4-8mmol/l (millimoles per litre) in patients during the bypass procedure and in the first 8 hours after surgery - a marked improvement from before when post-surgery patients warded in the ICU had blood glucose levels of above 11mmol/l.

Under 10mmol/l is the recommended level.

“This is an improvement project and the team managed to reach prescribed targets,” said team leader Dr Sophia Chew, Senior Consultant at SGH’s Department of

Anaesthesiology & NHC’s Department of Cardiothoracic Anaesthesia.

“The team has shown that we can achieve tight controls with frequent monitoring through the project.”

For patients, the team’s ability to control blood glucose levels has resulted in shorter hospital stays and fewer infection-related complications.

Controlling blood glucose levels has become a must for SGH’s ICU patients after cardiac anaesthetists decided to adopt this as a key performance indicator. Cardiac surgical units in other hospitals have also expressed interest in the project.

Progress for the initiative will be reviewed monthly, and plans are in the pipeline to introduce more time-saving ways of monitoring glucose levels.

A coronary artery bypass grafting procedure is performed to create new pathways for blood flow when an artery supplying the heart is blocked.

Veins are removed from the patient’s leg and arteries from the chest wall or forearm for grafting onto diseased vessels to bypass the obstruction.

8 ❙

❙ July/August 2009

July/August 2009 ❙

❙ 9

TheDoctor'sIn

Diabetes: Too sweet for comfort

Q A

I've heard of people who realised they are diabetic only after seeing ants in the toilet? How do we detect diabetes early and what types of people face higher risks?

Many people don’t realise they are diabetic because they are asymptomatic – showing no symptoms – or have symptoms developing so gradually that they don’t recognise them.

Symptoms include unusual thirst, a frequent desire to urinate, blurred vision and fatigue for no apparent reason.

Some people get diagnosed when they consult the doctor for a skin abscess or urinary tract infection.

Diabetes is caused by a combination of genetic and lifestyle factors. The more commonly seen types include Type 1 diabetes, Type 2 diabetes, and gestational diabetes. Type 1 occurs when the body can no longer produce insulin due to damaged pancreatic cells. Type

2 is the most common type of diabetes and occurs when the body does not respond well to the insulin it produces (insulin resistance). Being overweight increases the risk of Type 2 diabetes and if you have a sweet tooth, you are more likely to be overweight and unhealthy.

Pregnant women who are not known to have diabetes prior, but have high blood sugar levels during pregnancy, are said to have gestational diabetes. Some women with gestational diabetes go on to have it in subsequent pregnancies, or develop Type 2 diabetes later in life.

The 2004 National Health Survey shows more males (8.9%) being diabetic compared to females (7.6%).

Indians were found to have the highest prevalence of diabetes among the ethnic groups (15.3% compared to 11.0% in Malays and 7.1% in Chinese).

Doctors may use either the fasting plasma glucose test (FPG) or the oral glucose tolerance test (OGTT) to test for pre-diabetes. Both require a person to fast overnight. For the FPG test, a

Meal plan for diabetics

By Mdm Koay Saw Lan

Eating well is important, even more so as diabetics are at a greater risk of developing heart disease, stroke and other complications.

Eat a variety of nutrient packed foods every day. A healthy diabetic diet plan includes: • lean meat, fish, eggs, beans and nuts, fruits and vegetables, whole grains, low fat or fat free milk and milk products; low in saturated fats, trans fats, cholesterol, and salt.

• Moderate the carbohydrates consumed and spread the carbohydrates throughout the day for better blood glucose control.

•

Where possible for carbohydrates choose the whole grain variety as they provide not only high fibre and bulk for satiety but also vitamins, minerals and antioxidants. Studies on whole grains have shown improvement in insulin control, weight management, and triglycerides level.

•

Limit food and beverages high in sugar. Be selective; for the equivalent of three teaspoons of sugar, you can get more nutrients out of an apple (medium-size), 300ml of milk, one slice of bread, three heaped dessertspoons of rice, or three plain crackers etc.

• ‘Dietetic’ or special diabetic food should be taken with caution.

- Artificial sweeteners offer diabetics variety and flexibility in budgeting the total

carbohydrate intake and help satisfy the taste for sweet items like jams and sweet beverage without affecting the blood sugar - Some so-called diabetic products or dietetic products contain bulk sweeteners like fructose or sorbitol in place of natural sugar, but is often high in trans fats - Products labeled ‘diabetic’ can often mislead people in believing the product to be beneficial or essential. Apart from the extra costs, the carbohydrates and fats in these products need to be accounted for as these ingredients do affect the blood sugar control.

• Work with a dietitian to develop a personal meal plan to help manage blood glucose levels well and still allow favourite foods.

•

Apart from eating well, regular physical activity is important for overall health and fitness – plus it helps control body weight, promotes a feeling of well-being and reduces the risk of chronic diseases. Be physically active for at least 30 minutes most days of the week.

Mdm Koay is SGH’s Head of Dietetics and Nutrition Services

person's blood glucose is measured first thing in the morning before eating. For the OGTT, a person's blood glucose is checked after fasting and again two hours after drinking a glucose-rich drink.

In pre-diabetes – a condition where blood glucose levels are higher than normal but not high enough to be diagnosed as diabetes – the fasting blood glucose lies between 6.1 and 6.9 mmol/L (termed IFG: impaired fasting glycemia) or the two-hour blood glucose result is between 7.8 – 11.0 mmol/L(termed IGT: impaired glucose tolerance). If it rises to 11.1mmol/L or above, a person has diabetes. To monitor the onset of diabetes, screening should begin at age 40 or earlier if risk factors for diabetes are present, such as being overweight, sedentary lifestyle or family history of diabetes. Subsequently, go for a screening every two to three years if results indicate normal levels, and yearly if diagnosed with pre-diabetes.

Studies have shown that people with

pre-diabetes can prevent or delay the development of Type 2 diabetes by up to 58% through lifestyle changes. The expert panel recommends that people with pre-diabetes reduce their weight by 5%-10% and participate in modest physical activities for 30 minutes daily.

Early intervention may also return elevated blood glucose levels to the normal range.

Dr Goh Su-Yen Director Diabetes Clinical Services SGH

Have a question about a medical condition or disease? Write to us at editor@sgh.com.sg and we’ll get one of our doctors to discuss it.

10 ❙

❙ July/August 2009

Taking on the unknown to find a better treatment

By Nicole Lim

When she found herself in hospital with a severe rash and high fever, Dorothy Sng (photo on p11) thought she had made the wrong decision by enrolling in a clinical trial.

“I have never had any side effects taking my medications, but suddenly I ran a very high fever,” said the 21year-old freelance videographer who has been suffering from chronic myelogenous leukaemia (CML) since she was 12. Fevers are a common symptom of infections and as Ms Sng's immune system was weakened from her treatment, this could potentially signal a much more serious condition.

“This really made me wonder whether I’d made the wrong decision,” she added.

When she was diagnosed with the disease, Ms Sng did not have the option of standard treatment – chemotherapy

followed by a bone marrow transplant - as bone marrow from her brother, her only sibling, did not match hers.

So she opted to be treated with daily injections or pills, but the illness returned. After her second relapse, her doctor offered her two choices: increase the dose of her medication, or go on a trial of a new drug.

“It took me about one month to decide,” said Ms Sng. “My main concern was that I did not want my father and brother to worry about the cost of my treatment. But I also wanted to make a difference to people who might be diagnosed with my condition in the future. In the end, I decided that the risks were worth taking and I enrolled on the trial.”

A month after she started on the trial, Ms Sng fell ill. She spent eight days in the haematology ward at the

Singapore General Hospital (SGH), surrounded by other leukaemia patients.

“It was quite frightening to be hospitalised,” said Ms Sng. “Because I am on a drug that has not been fully tested, I wondered if I might be suffering from one of the more serious potential side effects doctors talked to me about when I enrolled, or even something that has never been seen before!”

To her doctors’ great surprise, Ms Sng didn’t want to quit the study.

“When I stayed on the ward, I saw other patients undergoing chemotherapy, which seemed only tough on their bodies and to affect them emotionally.

“So I decided that if by being on this trial, people could be spared this experience, then it was worth it.”

Dr Charles Chuah, Consultant

About clinical trials

By Dr Tal Burt and Professor Wong Tien Yin

inclusion and exclusion criteria to ensure no other conditions may influence the results.

1. What are clinical trials?

Clinical trials study the effects of new drugs or treatments on people to assess their safety and effectiveness before they are allowed as standard treatment. Clinical trials, essential to advancing medicine, are usually conducted in four phases to minimise the risks.

Phase III is the first large-scale study of a new drug or treatment and may involve hundreds or thousands of patients from around the world. This type of trial normally splits participants into two or more groups - one gets the trial drug or treatment, and the other receives the current standard therapy. This enables doctors to benchmark the trial against the best existing treatment.

Phase IV, conducted after a drug or treatment has been approved, evaluates side effects, risks, and benefits of a trial drug or treatment over a longer period of time and for additional indications.

2. What are these phases and what do they mean/do?

Phase I is carried out on a small group of healthy volunteers to establish the safety, dosage, and side effects of a new drug or treatment. Using healthy volunteers ensures the results are not influenced by illness.

Phase II studies provide preliminary information on the safety and efficacy of a new drug or treatment. Small numbers of patients with the condition being studied and who have shown no or a neutral response to existing treatments participate at this stage.

They will still have to meet stringent

3. How are risks in clinical trials addressed?

Obtaining information: Before a new drug is introduced into humans, it spends many years in pre-clinical tests aimed at obtaining as much information as possible about its safety and efficacy.

July/August 2009 ❙

at SGH’s Department of Haematology, has been treating Ms Sng since 2000 when the then-12-year-old was first diagnosed with the illness. “I am very happy that she is doing well on the clinical trial,” Dr Chuah said.

“Despite the initial allergic reaction, she was determined to continue on in the trial and I believe that this determination and the constant support from her family will benefit not only her but other patients as well.”

He and the trial team worked with Ms Sng to help her stay on the trial.

They lowered the dose, and since then, Ms Sng has not had any serious side effects.

“Apart from the occasional diarrhoea, I have no side effects at all,” said Ms Sng. Almost a year on, Ms Sng is well and busy. She has just finished working on the production of a movie and continues to take the test drug to manage her condition. She goes to SGH for regular checkups and tests every three months. The hope is that the treatment will keep the disease in remission.

“Of course, there is always a certain

a dedicated doctor, nurses and trial coordinators who know me and look after me well.”

For Associate Professor Goh Yeow Tee, Senior Consultant in the Department of Haematology and director of the Clinical Trials Resource Centre at SGH, clinical trials form an essential part of medical practice.

“Clinical trials are the only way for us to find better ways to treat or potentially even cure our patients. But we can’t do this without patients like Dorothy, who agree to take part,” he said.

Treatment trials test experimental treatments to determine whether a new treatment, new combination or combinations of drugs, new approaches to surgery or new radiation therapy is safe and effective.

fear of the unknown. But I enjoy the process of being on a clinical trial. It benefits me and if successful, other people will also benefit,” she said.

In the meantime, she is determined to enjoy life. “Even though I am on an unconfirmed drug, life is pretty much back to normal for me. I don’t have to visit the hospital more often and I get more or less the same tests as I would normally,” said Ms Sng. “The only thing that’s different is that I have

Preventive trials look for better ways to prevent disease. These researches are on drugs, vitamins, vaccines, minerals and lifestyle changes.

Diagnostic trials are conducted to find better tests or procedures for diagnosing a particular disease or condition.

Screening trials test the best way to detect certain diseases or health conditions.

Epidemiological trials try to answer health issues in large groups of people or populations in their natural environment.

Quality of life trials explore ways to improve comfort and quality of life for individuals with a chronic disease.

Mitigate risks: If a subject shows any undesired side effects, measures are already in place and doctors on hand to address these side effects immediately. Early phase clinical research units are usually located in close proximity to A&E departments and intensive care units of hospitals.

C o m p e n s a t e fo r a d ve r s e c o n s e q u e n c e s : Sometimes all precautions are unable to prevent adverse outcome. In such cases, an appropriate compensation is available for study participants.

Expert advice: An Ethics Committee (EC) or an Institutional Review Board (IRB) of experts and representatives of the general public study information available about a new drug before it is introduced into humans. Each country’s regulatory agency, in Singapore’s case the Health Sciences Authority, will also look at the same information before approving its use in humans.

Weighing risks and benefits: The ECs and the regulatory authorities conduct a risk-benefit analysis of the information.

Only if the information shows that the benefits outweigh the risks will it be

He added that there are plenty of opportunities for eligible patients to take part in clinical research and they themselves may stand to benefit, if the drug being tested turns out to be more effective than existing treatments.

“Currently the SGH Haematology Team is working on 11 trials for CML alone. Because we are investigating new drugs, our patients also can have earlier access while drugs are being still tested. This offers new hope to those patients who are not responding to existing treatments.”

Types of clinical trials

Anticipate risks: Units such as the SingHealth Investigational Medicine Unit (IMU) are equipped with several safety features including CCTV to monitor activity on the wards and individual alerts for subjects in case they feel unwell.

❙ 11

approved to be given to humans in a clinical trial.

Informed consent: Before any study can start, the participating individuals need to provide ‘informed consent,’ meaning they have been ‘informed’ of all the risks and benefits of participating in a study and have agreed to participate of their own free will. These ‘research subjects’ can be patients or healthy volunteers.

Minimise risks: Risks are minimised by giving only small doses to a small number of subjects for the shortest amount of time necessary for the study.

4. Will people on clinical trials have to go to the hospital more often?

Each trial has a very specific protocol covering the number of clinic appointments, hospital stays and tests. This information, explained clearly to volunteers, is included in the informed consent form.

5. How do clinical trials impact patients’ care at the hospital?

Clinical trials are good news not just for trial subjects, who may get early access to new drugs, but also for other patients.

Being involved in clinical research keeps clinicians up-to-date with the latest scientific discoveries and keeps

researchers in touch with patients’ needs. This has a positive impact on the care all patients receive as they can be confident that they are being cared for by very experienced doctors at the leading edge of their fields.

Dr Burt is Director of SingHealth’s Investigational Medicine Unit, which focuses on conducting early phase trials; and Associate Professor of Clinical Research at Duke-NUS Graduate Medical School Singapore.

Professor Wong is Director of the Singapore Eye Research Institute, the research arm of the Singapore National Eye Centre (SNEC), and Senior Consultant at SNEC’s VitreoRetinal Service.

12 ❙

Mar/Apr 2007 ❙

❙ July/August 2009

Sleepwalking a defence for crime?

Hunk loves milk and mineral water CelebInPerson

It’s possible, says SGH sleep expert Dr K Puvanendran. And you probably won’t even know what you did.

By Yan Shuwen

Blessed with brains and brawn, hunky TIMOTHY NGA doesn’t even have to work hard to stay fit.

Channel 5 viewers can see both sides of the 1.8m, 75kg Fly Entertainment artiste when he hosts A 48-YEAR-OLD man went into a young computer engineer flying back their breathing, brain a financial Insight and of fillssleep a fireman’s suit in Lifeline 2 (May). woman’s bedroom and hadmagazine sex with toprogramme, waves, stages Singapore from Public Los Angeles was (April), HAZEL YONG fithe nds outasleep how Timothy maintains her while she was sleeping. He was accused and wakefulness, muscle his bod. of molesting woman in the seat next to him. But the man said he had a sleep disorder and was Vitamins C and E along with a bottle oblivious – a claim which was backed by of water every morning. I’ve recently Dr K Puvanendran, Senior Consultant switched from tap water to bottled at National Neuroscience Institute spring water for its mineral content.

(Outram Campus) Department of I believe in keeping my body Neurology. properly hydrated with lots of water, “During a sleep test (conducted especially when I am on outdoor on the man), we noted that the shoots. But, not too much till I feel accused displayed lots of hand and leg bloated. movements while he was asleep,” said As for food, I can eat anything.

Dr Puvanendran, who is also a Senior No restrictions. Just don’t over-eat Consultant at SGH’s Sleep Disorder because it takes time for the brain to Unit. receive signals from the stomach that The doctor’s testimony was not it’s full. If I am gaining weight, I go accepted, with the public prosecutor for smaller portions. arguing that the accused’s actions of I still have the habit of drinking touching the woman’s groin seemed too milk every night from my childhood complicated to be unintentional. days so there will always be milk Nevertheless, Dr Puvanendran in my refrigerator. I am also toying believes it is hard to fake a sleep disorder. with the idea of switching to goat’s During tests for disorders, patients milk because I hear that it’s easier to are hooked up to monitors that track digest.

activity and air flow.

The patient’s behaviour Football and jogging during sleep is also Then there is exercise. Gym is too captured on video. boring so I play football or go jogging When one tries to along East Coast Park on weekends. I feign a sleep disorder, also make it a point to do chin ups or the brain waves and dips on the parallel bars at the fitness behaviour will tell a station near my home every evening different story, he after work. They help to develop my added. arms, shoulders and chest muscles So it is possible for without making me look too bulky. a person to engage in Overall, exercise helps me to reduce undesirable, or even stress too. criminal, behaviour One way I let off steam is with during sleep. At the friends at cybercafés, playing the new time of the incident, role-playing games such as Defense of the person will not the Ancients. I spend two hours in the be conscious of his evenings on weekdays or four hours on actions and its legal weekends gaming with friends. Each consequences. round doesn’t last more than an hour so In cases like Mr I’ll take regular 10 to 15 minute breaks Spencer’s, inappropriate to rest my eyes. That’s important too to sexual behaviour such not put my eye under heavy strain.

‘

‘

later arrested and charged with gross indecency and sexual intercourse I rank sleep, drinking lots of water without consent. andBut eating a balanced dietthe- accused, in that in a twist of events, order as being the most important Leonard Andrew Spencer, was found things to good health. not guilty of the charges and acquitted Life as an artiste be in erratic. from the 2008 courtcancase the When I am in the middle of a Northern Territory of Australia. shoot, I sometimes get just five hours His defense?

He four wastoasleep and sleep daily.

Last week, we on claimed no memory of his went criminal shooting from 8am till 6.30am the behaviour. next Thankfully, doesn’t A morning. psychiatrist who gave this evidence in happen often.

On days that, I nap court said memory loss islike “a hallmark of between takes (sleepwalker) to give my body some somnambulist behaviour” shut-down time. and it was possible that Mr Spencer Whenfrom I am“sexsomnia.” not filming, I sleep for suffered about seven or eight hours a“sexsomnia” day. I have Mr Spencer’s successful trouble going to sleep and that’s where plea was a legal first in Australia, and Iillustrates need books to help me wind down. the difficulty in using sleep Currently, I am Royale. disorders as a reading defence Casino in such cases even though sleep disorders are not Vitamin power uncommon.

To boost mya immunity levelsa In Singapore few years ago, and improve my complexion, I take

Photo: Fly Entertainment

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July/August 2009 ❙

as taking off clothes, fondling a bed partner and sexual intercourse have been described in people who suffer from sleepwalking, Dr Puvanendran said.

“Sleepwalkers can do odd things while they’re asleep. They may move around, or even unlock doors and walk out of the house. Their eyes may be open and they may seem wide awake but to quote Macbeth, their sense is shut,” he said.

said: “When a sleepwalker is in deep sleep and suddenly woken up, there’s a chance that he could go into a state of confusional arousal. This probably triggered the violent act.”

Sleepers usually go through five stages of sleep – stages one to four, and REM sleep. Light sleep occurs during stages one and two, while the latter two stages are deep sleep stages. REM sleep is a time when most dreams occur.

Awake, but not exactly so Sleepwalkers who are awoken from a deep sleep can become very confused, tr igger ing off violent automatic behaviour.

In 2002, an army boy with a history of sleepwalking and a habit of taking regular catnaps in camp almost choked his camp-mate – a close friend – to death after being awoken by him.

It later was found that he had narcolepsy, a condition which causes excessive daytime drowsiness and a sudden urge to sleep. The boy was eventually acquitted.

Dr Puvanendran, who had diagnosed the boy with narcolepsy,

When violent dreams become real Sleepwalking isn’t the only sleep disorder that has been linked to undesirable behaviour. Other forms of sleep problems can also sometimes cause sleepers to perform inappropriate acts.

For instance, those suffering from REM behaviour disorder can display movements like body jerks and flailing legs or arms during sleep.

These movements may sometimes be seen as violent or inappropriate by a neighbouring sleeper.

This can be seen in the case of Mr A who had been battering his wife unintentionally in his sleep. All he had

Sleep disorders can signal Parkinson’s Some time after falling asleep, the body enters a state known as rapid eye movement (REM) and the person typically starts to dream.

For people with REM behaviour disorder, however, their dreams are accompanied by action, which could be violent. Besides violence, researchers have found that REM behaviour disorder also may be a precursor to Parkinson’s disease.

Results of a Canadian study published last December in the journal, Neurology, indicate that 52% of REM behaviour disorder sufferers develop a neurodegenerative disease such as Parkinson’s disease within 12 years of being diagnosed.

Of the 93 patients, 14 developed Parkinson’s disease while 12 others developed other neurodegenerative disorders such as dementia and Alzheimer’s disease.

About three in 1,000 of the population here suffer from Parkinson’s disease, a debilitating neurodegenerative disorder in which brain cells containing dopamine die or become impaired. Dopamine is a neurotransmitter that supports critical brain functions such as movement and balance.

Besides REM behaviour disorder, Dr Lim Li Ling, Director of the Sleep Disorders Unit at Singapore General Hospital, estimated that over half of all Parkinson’s disease patients tend to experience other sleep disorders like insomnia and obstructive sleep apnea (OSA).

“Body stiffness may limit the patient’s ability to get into a comfortable sleep position. Obstruction of the upper air passage, which occurs in OSA, may also occur because of rigidity of the muscles”, she explained. “The patient may also experience mood disturbances because of his illness and this can affect sleep.”

If you sleep badly, don’t drive A good night’s rest is more important than you think.

This is because sleep deprivation may cause you to be more susceptible to road accidents.

According to Dr K Puvanendran, Senior Consultant at National Neuroscience Institute (Outram Campus) Department of Neurology. Microsleep – a brief episode of sleep that lasts for a second – can occur without warning while driving, resulting in road accidents. Those who are sleep-deprived or have obstructive sleep apnea (OSA) are more prone to experiencing microsleep.

In an in-house sleep study, Dr Puvanendran noted that a substantial number – six out of 43 – of those with OSA has encountered motorcar accidents.

“While it is common for people to stop breathing momentarily about five times during sleep, those with OSA can stop breathing 60 to 70 times per hour. Every time breathing stops, the brain wakes up so the person will feel sleepy and tired when he awakes the next day.”

wanted to do was to protect her from the “bad guys” in his dreams. On several occasions, the unfortunate man also injured himself while he acted out his violent nightmares.

Mr A’s bizarre experience is among several case studies discussed in Sleep Medicine: A Clinical Guide to Common Sleep Disorders (see sidebar). The guidebook was launched late last year to educate local healthcare professionals on various sleep disorders.

The 55-year-old suffers from a rare sleep disorder called rapid eye movement (REM) behaviour disorder, a condition that affects less than 1% of the population in Singapore. It is commonly seen in older men above 60.

According to Dr Lim Li Ling, Director of the Sleep Disorders Unit at Singapore General Hospital, those suffering from this condition tend to act out their dreams, often unpleasant or violent. This can cause injury or sleep disruption.

“In REM sleep, also known as dream sleep, the body’s muscles are relaxed.

A normal person in dream sleep does

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not move but those suffering from REM behaviour disorder may act out their dreams. They may punch, kick or even assault their bed partner,” said Dr Lim, who is the co-editor of the sleep guidebook.

Early diagnosis and treatment Sleep medicine is a relatively young specialty that has made tremendous progress around the world only in the past 25 years, and since 1987 in Singapore.

Most sleep problems, including REM behaviour disorder, can be treated, said Dr Lim. An early diagnosis followed by treatment can help nip sleep problems in the bud before any further damage is done.

“An occasional sleep problem is common but if it starts to affect and disrupt your daily life, it’s time to seek medical attention,” said Dr Lim. Sleep affects one’s overall health.

Chronic lack of sleep has been linked to an increased risk in a host of medical conditions such as diabetes, heart disease and even depression.

Sleep medicine: a clinical guide to common sleep disorders Dr Lim Li Ling and Dr K Puvanendran are among the writers of the recently launched Sleep Medicine: A Clinical Guide to Common Sleep Disorders.

Targeted at medical practitioners, the guidebook touches on sleep medicine and common sleep disorders in Singapore.

Amid escalating sleep problems and increasing concerns of sleeping pills overuse, Dr Lim, president of the Singapore Sleep Society and the book’s co-editor, said the book will help physicians and local medical students familiarise themselves with the diagnosis and management on common sleep disorders.

“Sleep disorders among Singaporeans are more common than previously thought. It is important for physicians to recognise the health dangers associated with these disorders,” said Dr Lim. More than just a clinical guide, the book also makes an interesting read for those who want to learn more about the disorders and its effects.

Sleep Medicine: A Clinical Guide to Common Sleep Disorders is available at Kinokuniya at $29.90.Visit http://www.singaporesleepsociety.com/overview.html for more book info.

Volunteers for SGH sleep study SGH Sleep Disorders Unit is conducting a research study on sleep disorders.

Healthy volunteers above 60 years without existing sleep problems are invited to undergo an overnight sleep study and receive a free sleep evaluation by a consultant neurologist.Volunteers will be provided a Class A ward and amenities for the night of the study. Each volunteer will be paid S$100.

The study of normal sleep patterns is needed as a basis of comparison with people suffering from Parkinson’s Disease. For more information, call the SGH Sleep Disorders Unit at 6326 6202.

Drifting to Lala-land Need a good night’s sleep? Look through this checklist before you tuck yourself into bed.

• Stick to a regular, consistent bed and wake time.

• For those who have problems falling asleep within 15 to 20 minutes, get out of bed and do something else. Return to bed only when you’re sleepy again.

• If you have insomnia, do not read, watch TV or work in bed. Associating the bed with other activities, other than sleep and sexual activity, can make it harder to fall asleep.

• Avoid caffeine and stimulating activities such as vigorous exercise or exciting, violent TV programmes close to bedtime.

• Avoid long afternoon naps.

• A daily relaxing ritual such as a warm bath followed by soft music at the end of the day helps people to fall asleep easily.

Source: Singapore Sleep Society’s website.

14 ❙

❙ July/August 2009

Friends of SGH

Volunteers have been the backbone of the Friends of SGH programme for more than a decade. From varied background, volunteers choose to serve in different programmes, such as Retail Carts, Guiders’, Games, Arts and Craft, Arts Concert, Fund Raising and Ad-hoc. In this issue, OutramNow gets a few Retail Cart volunteers talking.

By Hannah Lin

Canny Tay, 47. housewife

Who says patients can’t contribute? Former SGH patient Canny Tay, 47, has been volunteering at the Block 3 Retail Cart at least twice a week since 2005, travelling all the way from Hougang to do her bit for a good cause.

A vivacious character who likes to make new friends and give back to society, Mdm Tay used to give tuition for free to the underprivileged. With two sons aged 20 and 24, the housewife has plenty of free time as her husband, a hawker, manages the stall on his own.

“I’m very happy to be a volunteer at SGH as I get a lot of freedom and the volunteers treat each as like family!” Mdm Tay said.

“Juggling many responsibilities sounds difficult but many other volunteers are able to cope too, including graduates, retired teachers and nurses.”

This volunteer stint has helped her to become more sensitive towards other people, where a slip of the tongue can hurt their feelings. “The hospital is not a good place to say ‘Please come again’ to patients,” Mdm Tay said. “Instead, we try to say ‘Have a nice day’ or ‘Take care’.”

Recently, visitor restrictions at the hospital have reduced pedestrian activity everywhere, including Block 3 where the Retail Carts operate. This has affected business and the Retail Carts were closed for three weeks because of the Influenza A(H1N1) alert.

“The walkway in front of our cart was noticeably quieter during the closure.

Traffic was bad as patients delayed medical appointments. However, we’re lucky to have passionate customers who support us,” said Mdm Tay, confident that customers will return when the flu scare is over.

Volunteers Hear Ye!

Friends of SGH is constantly seeking enthusiastic and committed people to volunteer for the Retail Cart programme. The minimum commitment is a weekly session for half a day. Duties include setting up, cashiering, stock take and simple housekeeping. Contact Mumtaj at mumtaj.ibrahim@sgh.com.sg 6326 5158 for more information.

Koh Kim Guan, 61, full-time Retail Cart staff

Kim Guan, or Mr Koh, as he is respectfully addressed

by SGH staff and volunteers, was a retired subcontractor who turned to full-time volunteerism to make life more meaningful after a valve replacement

surgery in 1995.

Mr Koh, 61, has been onboard the Retail Cart project since it was conceived in September 1997, along with six others. The others have quit, leaving Mr Koh the sole remaining pioneer to mentor new volunteers to this scheme.

As the co-ordinator of the Retail Cart scheme, the ex-patient of SGH clocks a five-day work week. He is given an allowance as a token for his commitment.

“It was after my operation that I realised money wasn’t everything and decided to take it easy. Although going into full-time volunteering meant careful spending of my money, I found life more meaningful when I helped people,” said Mr Koh, who is married with no children.

Mr Koh devotes substantial time to give patients directions around the hospital while his team of volunteers follows a roster to man the Retail Carts in pairs.

As the Retail Cart scheme gets its supplies from Thailand, Mr Koh has had to learn Thai. As the only Thai-speaking volunteer, he has become the unofficial translator for Thai patients in SGH. In fact, it was one of them who introduced him to his Thai wife more than a decade ago.

Earrings, baby shirts, necklaces and other knick-knacks are sold for much cheaper than elsewhere, because the cart scheme pays no rent and supplies are bought in bulk. To provide variety, stocks are changed every two months, and Mr Koh tries not to sell what other hospital carts offer.

“The years of experience have taught me what bags and accessories to buy for different groups of people coming to SGH including staff, patients, visitors,” said Mr Koh. Mr Koh attributes the success of the retail carts to the friendly staff and supportive patients. He has picked up rudimentary medical knowledge and basic first aid from his volunteer work at the hospital.

“I don’t intend to retire, as I intend to carry on as long as possible. In Singapore, you can volunteer anywhere. All you need is interest and commitment to last the distance.”

Shop for the needy Located at Block 3 and Block 5, the two Retail Carts have been around for more than a decade and are run by more than 10 volunteers who are rostered in pairs on weekdays from 9.30am to 4.30pm.

The carts offer a wide range of goods such as handbags, accessories, shirts and other miscellaneous handicrafts, all neatly categorised for a pleasurable shopping experience. These products are sourced directly from the region, thus allowing volunteers to sell to staff, visitors and patients at attractive prices. Part of the profits goes to the SGH Needy Patients Fund which helps needy patients pay for patient care-related items such as nutritional supplements and nursing aids. Some of the profits go towards funding volunteer-related activities.

Revamped in May this year, the Retail Carts now sport a bright signboard differentiating them from the other tenanted carts in the hospital. As part of the revamp, all volunteers proudly wear a cheery blue badge bearing the new logo – reflecting a multi-coloured clover consisting of four hearts. Watch out for these friendly helpers!

July/August 2009 ❙

❙ 15

Needy patients benefit Part of the proceeds from the Retail Carts goes to patients such as Sin Chye.

Nandini Shivakumar, 34, homemaker

Being an expatriate wife does not mean endless afternoon tea sessions with fellow tai-tais. Instead, Mrs Shivakumar believes in making productive use of her time; she has been actively involved in volunteering schemes, including teaching orphans and helping less fortunate women.

A few months after moving from India with her banker husband and three children aged three to nine, she trawled the internet for volunteering vacancies, seizing the opportunity to work with the SGH Retail Cart programme shortly after the scheme’s coordinator replied to her query.

Mrs Shivakumar is motivated by a desire to give back to society. “I feel emotionally tied to people, not to any particular country,” said Mrs Shivakumar.

“God has been kind to me and it’s time for me to give back.”

She believes that volunteering should be part of everyone’s lives as there can never be a limit to such altruism. “Many times we think we’re doing something to satisfy others, but it’s actually to satisfy ourselves,” said Mrs Shivakumar. “It is only when you are happy that you can contribute more, because your time becomes so well-used.”

“

I just happened to see this shop today. The earrings are three for $5, half price compared to outside. It would be good if there were brooches as they appeal to Malays.

”

– Visitor Mdm Hayati, 48

“

I’m usually here to accompany my husband to see the doctor. This is not my first time, and I’m aware they’re volunteers. I previously bought a shawl here.

– Visitor Ng Siew Fong, 65 (declined to be photographed)

”

F I F T Y- F O U R YEAR-OLD Ang Sin Chye had been struggling to pay over $2,000 a month to treat his kidney disease. Then he found himself unable to afford dialysis when h i s s i s t e r w h o had supported him fi n a n c i a l l y – d i e d . If that wasn’t all, he developed end-stage kidney failure, and he had to leave his job as a pump attendant.

Without a regular income, he began to miss treatment, but that led to fluid overload and he had to be hospitalised.

Fortunately, SGH Medical Social

Services stepped in, enabling him to continue his thriceweekly dialysis sessions with assistance from the SGH Needy Patients’ Fund.

Nearly two-thirds of the Fund is used to help pay medical treatment fees of needy patients who qualify for the Fund, with the reminder allocated to medical equipment, drugs, transport and household maintenance.

In 2007, over $400,000 in grants was disbursed to more than 300 needy patients.

“At SGH, every dollar you donate makes lives better.”

Doctor’s prescription: A dose of laughter

By Gloria Chan

The usual Saturday afternoon chatter among the children at KK Women’s and Children’s Hospital (KKH) is suddenly silenced with the unexpected arrival of a group of visitors.

Dressed in colourful costumes, psychedelic wigs and red rubber noses, they call out bright and cheerful greetings, delighting the children.

Meet the Caring Clown Unit, a volunteer group who has been making the rounds of the children’s wards of KKH for the past four years. Members hail from all walks of life, from IT to teaching, and they perform for the kids one Saturday a month for some two hours.

Armed with magic tricks, balloon sculptures and jokes – learnt at Clown Camp, where the group met for the first time – to indulge the young patients with laughter therapy, the clowns also make it a point to entertain the hospital staff to help lighten their work stress.

Firm believers in the healing power of laughter, the clowns craft magic, balloons and silly jokes to soothe the children’s pain. Bringing a smile to the face of a sick

child is a million-dollar moment for them.

Dr Choo Chih Huei, a consultant psychiatrist with KKH’s mental wellness service, said that units such as the Caring Clown Unit help distract the children from any physical pain and discomfort. In addition, the volunteers also benefit from a deep sense of accomplishment for spreading good cheer. rOjO, a lecturer by day and a founding member of the group, is still raring to do his part for the monthly visits at KKH.The reason?

The touching experiences with patients often inspire and pull at his heartstrings.

Recalled rOjO: “A teenager was just about to go for a major operation at 3pm. Both mother and daughter looked very worried. I gave the girl a sticker and did the change cloth trick. I first showed her the black side of the cloth and told her that her fear was like the dark cloth. l encouraged her to look on the bright side and quickly flipped over the cloth to show the multi-coloured side.

“She broke into a smile, which gladdened her mum’s heart. It was a hope-filled moment which flooded my heart with much joy and warmth. ”

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❙ July/August 2009

A new valve, a new life Taking on the role of an active caregiver is no mean feat for any 77-year-old. But for Mr Tang Yat Cheong, being able to nurse his wife back to health following a major surgery is a particular joy.

Mr Tang, a retiree, was suffering from an obstruction of the valve of the heart’s main artery, a condition known as aortic valve stenosis. This is not only a life-limiting condition, but also one that knocked the wind out of his life.

“Before the surgery, I had to pause three times to get my breath back just going to the local market,” said Mr Tang. “Now with the help of my children and friends, who help with daily chores such as cooking, I have the energy to nurse my wife back to health.”

In February 2009, Mr Tang became the first patient in Asia to get his aortic valve replaced in a minimally invasive manner. A novel procedure known as a percutaneous aortic valve replacement, it spares patients from conventional valve replacement, a major surgery, where the chest has to be opened up.

Instead, a valve supported by a stainless steel frame to widen the diameter of the diseased valve is mounted on a balloon catheter. This is inserted through a small 4cm-6cm cut at the groin or chest.

Surgeons guide the catheter along the artery to the heart using x-ray and echocardiographic (ultrasound) imaging technology. Once the catheter reaches the heart, the new valve is placed across the diseased valve to manage blood flow.

The procedure requires a multidisciplinary team, including interventional cardiologists, cardiac s u r ge ons, ec hoc ardiologists and cardiac anaesthesiologists. The team from the National Heart Centre (NHC) Singapore which performed this first case included Associate Professor Koh Tian Hai, Dr Paul Chiam, Dr Chua Yeow Leng, Dr Victor Chao, Dr Lee Chung Yin and Dr See Tho Ving Yuen.

Patients undergoing this two-hour minimally invasive procedure may benefit from a faster recovery time and shorter hospital stay. Overseas statistics show that hospital stays are reduced by as much as four days, with average stays lasting between three to four days, compared to five to seven days for conventional surgery.

As Mr Tang had already undergone a h e a r t by p a s s 1 5 ye a r s a g o, t h e conventional aortic valve replacement surgery was deemed too high risk by

transcatheter heart valve

Once the replacement valve reaches the heart, it is placed across the patient’s diseased valve, where it will help restore normal blood flow.

aortic valve

An artificial valve supported by a stainless steel stent is mounted on the catheter before it is inserted into the artery at the groin.

Surgeons rely on imaging technologies, such as x-ray and ultrasound, to guide the valve along the artery to the heart.

Copyright: Edwards Lifesciences

the doctors. He was, however, found to be suitable for this new therapy.

“Almost immediately after the surgery, I felt much better. I could breathe and I felt alert,” said Mr Tang, who can now resume his usual routine of taking the stairs up to his flat instead of the lift.

In Singapore, eight patients have undergone this procedure so far.

Aortic valve stenosis is estimated to affect 2% of people in Singapore aged 65 and older and 4% of people aged 75 and older. The procedure was first carried out in France in 2002 and now boasts a success rate of more than 90%.

“We are confident that we can achieve comparable outcomes here in Singapore as we start to offer this treatment option to high surgicalrisk or inoperable patients,” said Dr

Paul Chiam, an NHC consultant cardiologist. “At NHC, we estimate that approximately 20 patients may benefit from this procedure each year.”

Even though he was the first patient to receive the procedure, Mr Tang wasn’t concerned. “I am generally an optimistic person,” he

said. “I have complete confidence in the medical team at NHC, so it didn’t worry me that I was going for a new treatment.”

Currently, patients only have to pay for the surgical and hospitalisation bills, while the SingHealth and Lee Foundations cover the cost of the valves.

Public forum “Obesity & Cholesterol Problems: Weighing Your Options” (In English) Date : Saturday, Aug 15, 2009 Time : Forum starts at 1.30 pm (registration half an hour before at 1pm Venue : DBS Auditorium, Level 3, DBS Building Tower 1, 6 Shenton Way Enquiry & Pre-registration : Call 63266944 during office hours or email pgmi.pf@sgh.com.sg.

Pre-registration required.

Price : $8 per person ($5 if registration, payment made by Aug 11) Organiser : Obesity & Metabolic Unit, Department of Endocrinology, SGH

July/August 2009 ❙

❙ 17

FromTheHeart

A dentist's journey with a special child and her extraordinary parents

By Dr Tan Wee Kiat

AMY (not her real name) came to see me when she was three years old. Her parents requested a dental check-up. She was a cute munchkin, shy, did not speak much. Her medical history as declared by her mother was unremarkable. Examining Amy was extremely difficult. She had to be restrained just to peer into her mouth.

My instincts prompted me to ask how she was doing in school. Her mother said she was doing fine.

Over the next year, Amy came to see me regularly. Her behaviour remained unchanged. She had no eye contact, spoke in monosyllables, often repeating them. Only with tactful prodding did the mother reveal that Amy was severely autistic.

I have been seeing Amy over a period of 13 years. Normally I discharge patients from my department when

they reach 12, but her parents had begged me to continue seeing her.

She grew bigger, stronger and each visit was a test of will and patience.

Yet her parents never let Amy miss a dental appointment.

She had to be examined standing up every time as she refused to sit.

Her mother had to hold her head and pretend she was brushing her teeth so I could peer into the mouth. Three times, Amy had to be treated under general anaesthesia.

Recently, Amy came for a checkup.

From a distance, I heard the familiar ‘popping’ sound she made by forcing air between her lips. Amy did the usual – checked out my clinic before entering, ignored me, but graced me with the customary 30 seconds for examination.

But that day, something different

happened. Before leaving, Amy came close to my face and peered into my eyes. In that split second, I knew she recognised me. Then ever so briefly, she touched my hand with one finger, turned and went ‘popping’ out of the clinic. I was over the moon! This was a breakthrough for a severely autistic child to initiate such contact on her own accord.

All too often, doctors are portrayed as heroes. But the real heroes in this story are Amy’s parents who continue to shower her with unconditional love and care. How could I, as her dentist, do any less?

I had no magic tricks in managing Amy – I just persisted in treating her as I would any other child. I chatted, teased and praised her, although for what it was worth to Amy, I could have been a pole.

A is for autism

By Gloria Chan

Autism is a condition affecting approximately six per 1,000 children worldwide and is four times more common in boys than girls. It is a disorder in the brain which begins to show in children as young as 18 months, but is not usually confirmed before the age of two to three.

This is because there is great individual variability in how young babies develop and many of the symptoms involve language and motor skills, such as catching objects, which are only developed later. The condition also comes in different degrees of severity.

“Autistic children have difficulties with social interaction, communication and imagination to varying degrees – hence the condition is also known as Autistic

the Department of Child Development at KK Women’s and Children’s Hospital.

Signs and symptoms Autistic children are often unable to relate to others, resist cuddling and holding, preferring to play by themselves.

They may not make eye contact or respond to their name. They start talking later, and often speak in an abnormal tone. Some are able to repeat whole sentences word-for-word, without understanding what they are saying.

Often, they play in unusual ways like lining up their building blocks repeatedly or spinning a top again and again.

Spectrum Disorder. Often, they appear to others as being in a world of their own,” said Dr Lim Sok Bee, Head of

As health professionals, there are times when we will slam against a brick wall in caring for our patients and feel disheartened by their seeming disinterest in their own health. Remember Amy and continue reaching out to them. Hopefully it will not take 13 years for the wall to crack but when it does, the high you get is indescribable.

In truth, that is why we do what we do – we are all addicted to this ‘high’.

Dr Tan Wee Kiat is a Senior Consultant at the National Dental Centre of Singapore’s Paediatric Dentistry Unit

Management “Although there is no known cure for autism, early diagnosis, intervention and specialised education can make a difference to the life of a child with mild to moderate autism,” added Dr Lim. Given the right therapy and training, the child can potentially go on to a normal school. Those with more severe autism may be enrolled in schools for children with special needs where they will be provided with training to help them be as independent as possible.

Not caused by MMR vaccine There is a fear among some parents that the MMR (Mumps, Measles, Rubella) vaccine can cause autism.A controversial UK study, published in 1998, originally suggested an association between the vaccine and autism. However, the scientific community agrees that this is because the MMR vaccine is given to children between the ages of one and two years old, which coincides with the time when symptoms of autism become apparent.The Ministry of Health assures parents here that there is no scientific proof of possible links between MMR and autism.

Children with autism are managed by KKH's Child Development Department. For initial assessment and diagnosis, contact KKH on the main appointment line at 6294 4050.

18 ❙

❙ July/August 2009

What is Influenza A (H1N1) What is Influenza A (H1N1)?

Influenza A (H1N1) is a new strain of virus that consists of a mixture of genetic material from swine, avian and human influenza viruses. Because this is a new type of flu virus, humans haven’t had a chance to develop immunity.

Checking for fever •

•

•

•

•

•

•

•

they know they are sick, as well as while they are sick. Children, especially younger ones, may be contagious for longer periods.

What are its symptoms?

Its symptoms are similar to those of regular human seasonal influenza – fever, cough, sore throat, runny nose, body aches, headache, chills and fatigue.

The symptoms can vary in severity from mild to severe.

How long can the Influenza A (H1N1) virus live outside the body?

Some viruses can live for at least two hours on surfaces like cafeteria tables, doorknobs, and desks. Practising hand hygiene - washing hands with soap, or disinfecting with an alcohol-based hand rub - often will help reduce the chance of getting contamination from these surfaces.

How does it spread?

It is thought to be spread in the same way as seasonal flu – mainly by personto-person contact when an infected person coughs or sneezes, and the droplets move through the air. Viruses can also be spread when a person touches respiratory droplets from another person on a surface like a desk and then touches their mouth or nose before washing their hands.

Are there medications to treat Influenza A (H1N1) infection in humans?

Antiviral drugs, Tamiflu (oseltamivir) or Relenza (zanamivir) is available to treat infection with Influenza A (H1N1) viruses. If you are infected, taking the drugs can make the symptoms milder and prevent complications. The drugs work best if taken within two days of the symptoms appearing.

How can someone with Influenza A (H1N1) infect someone else?

People with Influenza A (H1N1) flu may be able to infect others a day before flu symptoms develop and up to seven days or more after becoming sick. That means a person with the virus may be able to pass it on to someone else before

Is there a vaccine to protect from Influenza A (H1N1)?

There is no vaccine yet to protect humans from Influenza A (H1N1). The seasonal influenza vaccine is unlikely to protect against Influenza A (H1N1) viruses. The antiviral drug Tamiflu is not a vaccine.

When the body’s temperature rises above the normal accepted range, it could indicate an infection or disease.

Wait half an hour after exercising, food or drink, and shower before measuring the body’s temperature.

There are different ways of temperature taking for the different types of thermometers available. But at home, it more convenient to use a digital thermometer which is placed in the mouth or the armpit, or an ear (tympanic) thermometer for insertion in the ear.

If a common thermometer is used for the family, always put a disposable plastic cap over the tip.

Temperatures taken at different parts of the body present different readings – those taken from the armpit are lower than readings from the mouth and ear.

For adults: if the armpit temperature is over 37.0°C, the oral temperature is over 37.3°C, or the ear temperature is over 37.7°C, you have a fever.

Children (below 12 years) have a fever if the armpit temperature is over 37.3°C, the oral temperature is over 37.6°C or the ear temperature is over 37.9°C. The normal temperature for healthy adults and children ranges from 36.2°C to 37.2°C and the average normal temperature is taken as 37.0°C.

What should I do to prevent myself and others from getting the Influenza A (H1N1)?

• • • •

• • • • • •

Practise good hand hygiene.

Wash your hands often with soap and water, especially after coughing or sneezing Carry a small bottle of alcohol-based hand rub to clean hands anytime Wear a surgical mask or cover your nose and mouth with a tissue when sneezing or coughing. Dispose of the used tissue in a bin.

Avoid touching your eyes, nose or mouth If you get sick, stay away from work or school, to keep from infecting them.

Stay away from crowded places Get plenty of rest, drink clear fluids to prevent dehydration.

Avoid close contact (i.e. within six feet or 1.8 metres) with others.

Use paper towels/tissues for drying hands after hand washing. Do not share cloth towels.

Masks • Facemasks help stop droplets from being spread by the person wearing them. They also keep splashes or sprays from reaching the mouth and nose of the person wearing the facemask.

Seal it tight, Do it right 1

2

Tie the lower strings at the back of the neck.

Tie the upper strings at the top of the head.

Wear your surgical mask RIGHT! 3

4

Fix the metallic strip securely over the bridge of the nose.

Ensure that the mask fully covers the nose, mouth and is stretched gently over the chin, fitting snugly over the face.

5 Change mask every four hours or if it becomes moist or damaged.

July/August 2009 ❙

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Keeping flu at bay for safety of patients

Precautionary measures to protect patients and visitors were stepped up at SGH and SingHealth national specialty centres on Outram Campus when Influenza A (H1N1) emerged. Since then, temperature screening, registration and face masks have become the norm for anyone entering the premises. Frontline staff too have geared up, wearing protective equipment to contain the spread of the flu virus. We go behind the masks and screening desks to find out what these measures aim to do.

Be responsible

Killing bacteria and germs by regular and thorough hand cleaning with soap and water – or alcohol rub - is one way to keep the flu away.

The strongest defence against the flu virus remains people’s own personal hygiene and a sense of social responsibility.

Both visitors and staff mask up to minimise the spread of germs.

Be informed Posters inform visitors and staff of the latest flu developments around the world.

Visitors with fever, cough or sore throat are given surgical masks – and staff are on hand to help fit them properly.

Posters inform visitors and staff of the latest flu developments around the world.

Be prepared

Healthcare professionals wear plastic gowns, gloves and masks to help prevent the spread of germs.

This additional cover often leaves them feeling a little warmer than normal.

Visitors leave their contact details to be reached easily for necessary tests should there be an incidence of the disease.

Visitors and patients are screened for fever at all entrances – thermal scanners at high-traffic entrances and handheld devices at others.

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❙ July/August 2009

Buzz over EBUS

The accurate diagnosis and staging of lung cancer is made safer with a low-risk, minimally invasive procedure called Endobronchial Ultrasound.

By Hazel Yong

A 72-year-old woman coughed blood and was referred to the Singapore General Hospital (SGH) in January this year for help.

Her x-ray showed a mass in the upper part of the right lung as well as some enlarged lymph nodes in the mediastinum - the chest area between the lungs.

Under the care of Associate Professor Loo Chian Min, Head and Senior Consultant at the Department of Respiratory and Critical Care Medicine, she underwent two biopsies guided by Endobronchial Ultrasound (EBUS).

“EBUS helps diagnose and determine cancer stage accurately Associate Professor Loo Chian Min, Head and Senior Consultant at the Department of while avoiding more invasive Respiratory and Critical Care Medicine, explains how the EBUS system works. SGH is the only procedures and hospitalisation,” said hospital in Singapore to have an EBUS system with both radial- and linear probes.

Associate Professor Loo. “If there was no EBUS and she does cancer worldwide and is the biggest of probes – radial and linear (convex) not want to undergo mediastinoscopy, killer for both men and women in – to assess the lung and mediastinum we will assume from the enlarged lymph Singapore. About 1,000 Singaporeans respectively. If the preliminary CT scan nodes that she is suffering from cancer are diagnosed with the disease every shows possible abnormalities in both and treat her as such. However, not all year, highlighting the need for accurate areas, the patient has to undergo two enlarged lymph nodes are necessarily diagnosis and staging of lung cancer for EBUS procedures, each using a different due to cancer.” prompt, proper treatment. probe. Both these procedures can be EBUS is a low-risk, minimally The conventional biopsy methods done at the same bronchoscopy session. invasive bronchoscopic technique that used to diagnose lung cancer are The radial probe has been available helps doctors to assess the lungs and fluoroscopy-guided bronchoscopic for some time but cannot facilitate reallymph nodes for possible cancer spread. lung biopsy, CT-guided fine needle time biopsies. However, technology The use of EBUS meant that the patient aspiration biopsy, and Video-Assisted advancements have led to the did not have to undergo mediastinoscopy Thoracoscopy (VATS). development of a tiny radial probe for – a potentially risky surgical biopsy the EBUS system, such that it can now involving general anesthesia – to check reach the lung periphery easily to assess the mediastinal lymph nodes for lung small abnormalities. cancer and determine its cancer stage.

For the linear (convex) probe, its Done under the use of local anesthesia side-viewing tip of 30° cannot reach and sedation, she could also go home deep into the lungs but allows for realtime guided ultrasound biopsy of the mediastinal lymph nodes as small as 1cm in diameter. This is done via a 22gauge needle mounted securely onto the bronchoscope so that the instrument will move steadily as a unit during biopsies.

The radial probe (top) can reach the lung “Another advantage of EBUS-guided periphery to assess small abnormalities biopsies is that they have only 1-3% while the side-viewing linear probe (bottom) allows for real-time guided ultrasound risk of complications as compared to biopsy of the mediastinal lymph nodes. conventional detection methods such as 5-10% for open biopsy or VATS The EBUS-guided biopsy is an under general anesthetic, or 20-25% for two hours after the EBUS-guided improvement over the fluoroscopy- pneumothorax (punctured lung) during biopsies as compared to a one or two guided bronchoscopic lung biopsy. After CT-guided fine needle aspiration,” said day hospital stay for mediastinoscopy or gauging the location of the biopsy Associate Professor Loo. with a CT or PET (Positron Emission CT-guided biopsy.

“For regular bronchoscopy, the biopsy In this patient’s case, both EBUS- Tomography) scan, EBUS provides is guided only by pictures from the CT guided biopsies tested positive for ultrasound images of the biopsy area scan and x-ray during the procedure. cancer and she was given chemotherapy during bronchoscopy. The addition of Accuracy is lower than using ultrasound these ultrasound images will aid the guidance.” treatment. doctor in marking the biopsy positions more accurately.

Less risks, more specific use Room for improvement The EBUS system uses two types Lung cancer is the most common EBUS was invented about seven years

ago but adopted by SGH only in October last year when the hospital collaborated with the National Cancer Centre (NCC) to offer the service.

“The first-generation equipment had limitations to the quality of the ultrasound,” explained Associate Professor Loo. SGH and NCC are sharing a secondgeneration EBUS machine, the latest one in the market. They are one of the pioneers in Southeast Asia to use EBUS and are the only ones in Singapore to have both the radial- and linear probe EBUS equipment.

Five of SGH’s doctors were sent overseas to Australia, Japan and the United States to train in this technique.

To date, 65 biopsies have been done at SGH using the convex EBUS and 44 for the radial EBUS. The positive rate of diagnosing cancer in the mediastinum via the convex probe is 95% while radial diagnostics of cancer in the lungs is 70%.

“Current medical literature puts the success rate of radial EBUS at 75-80%, so there is still room for improvement for us in this aspect. But for linear (convex probe) EBUS, we have reached the best standards in the world,” he noted.

EBUS not an all-solving method As a low-risk procedure, anyone with low risk of respiratory failure can undergo EBUS. However, EBUS is not always the easiest or best way to detect lung cancer.

For example, a simple bronchoscopy can do the trick if the patient’s abnormality is located in the major airway. EBUSguided biopsies will also never replace mediastinoscopy, CT-guided biopsy or surgery completely, said Associate Professor Loo. “Mediastinoscopy is the gold standard in the mediastinal staging of lung cancer, with a positive rate of 98-100%. If the results from EBUS are non-diagnostic (the amount of tissue obtained is too small to make an accurate diagnosis), we will have to resort to mediastinoscopy for confirmation,” said Associate Professor Loo. “The EBUS project was chosen as the sole recipient of funding from the Health Services Development Programme by the Ministry of Health last year and we are still studying its utility as well as its cost savings over the next three to five years.

“When it proves to be a success, we hope EBUS will be included in a bigger funding project for the whole nation in future.”

Needle in lymph node

July/August 2009 ❙

AtHome

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❙ 21

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Woodlan

By Mdm Koay Saw Lan

A recent rojak poisoning case has shown how eating unhygienic food can turn fatal. Learn to cook smart even if you can’t cook well.

ANY food can be a vehicle for foodborne illness, but some are more likely than others. Foods that are potentially hazardous include meat, poultry, fish, eggs and fresh produce as they are excellent growth platforms for bacteria.

Conditions necessary for bacterial growth are nutrients, moisture, favourable temperature, PH level, atmosphere and time. Food-borne pathogens can also spread to the surfaces of hands and cooking equipment, or onto other foods.

As such, proper handling throughout the food production process – from purchase, production, storage and serving of food – is critical in safeguarding against contamination.

Factors that can contribute to the outbreak of food-borne diseases include: •

• •

•

•

•

•

•

Failure to thoroughly heat or cook food Failure to cool food properly Food prepared a day or more before they are ser ved, but not stored properly Raw contaminated ingredients incorporated into food that receive no further cooking Food stored at bacteria-growth temperatures Equipment which were improperly cleaned Cross-contamination of cooked foods with raw food Infected food handlers who practise poor personal hygiene at home and at the workplace

Errors can be avoided by educating food handlers in areas such as handling techniques, and understanding timetemperature relationships for food items. They must also pay attention to their personal hygiene, especially the washing of hands after using toilets or other non-food activities.

When buying food, observe the cleanliness of the place, the holding area

of the food items and the food handlers.

When in doubt, make your purchase elsewhere.

consumption even if it is re-cooked at temperatures above 100°C. This is because pathogens multiply so fast that the extra cooking may not kill them all.

In terms of food poisoning, the lag time differs between consumption of the bad food to the onset of symptoms like stomach aches. The incubation period for the salmonella bacteria is about three-36 hours, and 12-72 hours for E Coli.

Most vulnerable groups are young children, pregnant women, elderly adults and immuno-compromised patients like those on steroids, antibiotics or chemotherapy. People who are malnourished or alcoholics are also at higher risk.

Importance of temperature Disease-causing bacteria are capable of multiplying rapidly between 5°C and Mdm Koay 60°C. This temperature range is often is Head of SGH's referred to as the danger zone.

Dietetics and Nutrition Services In cooking meat, the heat should penetrate through the food sufficiently; a large joint of meat is potentially dangerous if the internal temperature is not high enough for the length of time to kill the organisms. Use a meat thermometer if unsure.

Pay extra attention to the temperature when cooking unthawed meat. Frozen meat is a poor conductor of heat so the inner parts may only reach incubation temperatures. For example, if a frozen chicken is to be cooked whole, the chicken should be thawed completely in the refrigerator before being cooked.

The temperature of food during storage is equally important as the cooking temperature. Hot food Trivia #1 should be kept hot and vice versa It’s safer not to heed the for cold food, which should so-called 'five-second rule' be stored at temperatures where food that is dropped below 4°C. If food has to be on the ground for less than cooked a day before the meal, five seconds can still be taken up and eaten. Pathogens are it should be covered and not visible to the naked eye cooled rapidly. The length of and we may not know who time required to reheat, say, a or what had contaminated chilled chicken, must be long that particular location and high enough to destroy any previously. bacteria that might have survived in the meat.

Trivia #2

Signs of decay Most times, food that contains dangerous bacteria may not look, smell or taste any different from food that is safe.

However, food spoilage can sometimes be observed by changes in colour, smell, texture or taste. We can see this in milk that has turned sour, or spoilt fruits and vegetables that become slimy.

D e c a ye d f o o d i s n o t s a f e f o r

Chilli sauces which are left outside food stalls for customers to help themselves are usually made with vinegar, sugar and salt. Many disease-causing pathogens will not grow in acidic media. In addition, sugar and salt are commonly used as preservatives.

Symptoms • Diarrhoea • Stomach pains • Nausea • Vomiting • Fever What causes food poisoning • Food poisoning is usually caused by micro-organisms(germs), including virus, bacteria and toxins which enter the body if the food isn’t cooked properly or if the person handling the food didn’t clean their hands properly.

• Some bacteria release poisons called toxins, which may give you symptoms of food poisoning after the food is eaten. Other bacteria multiply in the body first before causing symptoms – and this incubation period can be a few hours or up to a few days.

What to do for food poisoning • Drink plenty of cooled boiled water as fluid is often lost from vomiting and diarrhoea.

• See a doctor if the symptoms are serious or prolonged.

• To avoid infecting others, you should not handle or prepare food for others.

• If you suspect that the food from a food outlet is responsible, you should inform the Ministry of Health and the National Environment Agency.

Dr Mark Leong, Senior Consultant Department of Emergency Medicine, Singapore General Hospital

22 ❙

❙ July/August 2009

Helping is healthy

Is it more blessed to give than to receive? It's only in the last decade or so that researchers have begun to find proof suggesting generous people feel happier and thus live longer than those who aren't.

By Ineke Hommes/TCS

IN THE past few years, a rapidly growing group of researchers have observed that the giver receives benefits too from acts of altruism or kindness.

Initial results from studies include the reduction of depression and suicide risks among teenagers after they engage in generous activities or volunteer work, and the release of endorphins in the brain to cause feelings of joy (better known as the ‘helper’s high’) .

Focusing attention on other people’s problems also reduces your own. As one researcher puts it: “Helping gives meaning to your life, provides social contact, and a sense of usefulness.”

A longer, healthier life with kindness “Giving – whether in the form of money, time, energy or attention – has a positive effect on our physical and mental health,” said Professor Stephen Post of Stony Brook University in New York, a young-looking, ebullient man in his fifties who is directing a ‘love study.’

“People who lead generous lives are healthier and happier, suffer less from stress and depression, have greater self esteem, and even live longer compared to those less generous.”

Various studies have concluded that doing something for another person on a regular basis is at least as important for reaching healthy old age as taking a half-hour walk every day, added Professor Post.

His advice echoes that of Stephanie Brown, a psychologist at the University of Michigan. According to her, giving can also lead to greater longevity, even if you only start being more generous later

the newspapers, we see countless spontaneous acts of kindness around us. Whether we give up our seat for an elderly lady on a bus or we donate to charity – almost all of us do kind deeds.

Yet, self lessness, whereby in extreme cases the helper even gives his life for a complete stranger, is still a mystery.”

In 2001, Professor Post founded the Institute for Research on Unlimited Love (IRUL) at the Case Western Medical School in Cleveland, Ohio. The institute currently oversees studies on ‘unlimited love’ at over 50 universities including Harvard, Yale and Princeton. One of its aims is to find out if the new research on selfless love can help solve the world’s dire problems.

“Perhaps it is too simple but I believe that helping each other – which includes a fairer sharing of money, information and resources between countries – may eventually be the only answer to current crises,” said Professor Post, who clearly enjoys thinking outside the box.

Paradox Finally, there is one more pitfall on reaping the benefits from giving or kindness – the magic does not Singapore doctors and nurses provided medical help to victims in Myanmar hit by work anymore if you decide to Cyclone Nargis in May 2008. Under the banner of a unified Singapore Team, they go help someone in the hope of worked with Singapore Red Cross and Mercy Relief team members already on-site, becoming happier yourself. and local doctors and nurses.

The important thing is not so much philosopher Jean-Paul Sartre stated the helping activity itself, but the motive in life.

She spent five years that people are merely friendly in order behind it. It doesn’t have to be 100% altruistic – as it still remains to be seen studying over four to disguise selfish motives, he noted.

Partly through their influence, current whether we can remove self-interest hundred elderly couples and concluded – after science is conducted primarily in terms altogether – but the main motive should exclusion of all other of self-interest, with research focusing be ‘other-regarding.’

“It’s a remarkable paradox,” said factors – that those who on sickness and abnormalities. In that did not offer help of any period alone, 100,000 peer-reviewed Professor Post. “We do not find significance to others, scientific studies were published on happiness when we run after it, but it ran twice the risk of depression and schizophrenia; but only is the unsought by-product of care for others. So if you want to do it right, dying within that five- a few dozen appeared on love.

“Yes, of course this is odd,” said help others for the sake of helping, and year period than those who devoted time to partners, friends Professor Post. “Every day, despite forget all this information about the the strife and intolerance that fill positive side-effects for you.” or strangers.

Over at the University of Miami and Duke University in North Carolina, studies showed that ex-cardiac patients The bottom line: give from the heart, but use your head. Giving requires regular practice. and patients with HIV or Aids who You have to create time for it, know your limits, and not wear yourself out. No one benefits supported fellow-sufferers by simply if you aid someone out of guilt or duty or to make yourself feel better. listening to them, saw improvements in Consider well where, how, and how much you give. And build in consistency because their own health, immune system, and the researchers say it appears to be more effective to, for example, volunteer tutoring your mood. neighbour’s son two hours each week than to pull out your wallet once for the Developing “It’s hard to stay depressed when World. you’re helping someone else,” said a participant.

Potential solution to world’s problems • If you see a pregnant lady or elderly who needs a seat on the train, give yours up, even How is it that the world’s most sungthough that guy sitting nonchalantly in the ‘Priority Seat’ should be the first to do so. about theme has never been the subject • Always hold the door open for people behind you, or hold the lift if you see someone of intense research? Professor Post rushing towards it. attributes this largely to some influential • Offer to help buy takeaways for your busy colleagues if you have some spare time 20th century thinkers, who have dealt during lunch break.

•

Compliment others much more frequently. our collective self-image quite a blow.

•

Lend a listening ear to troubled friends and family; a well-placed joke can do wonders Psychiatrist Sigmund Freud, for too. instance, primarily saw human nature •

During the course of one year, give monthly donations to good causes close to your as a sizzling vessel full of selfish desires, heart. obsessed with conflict and death. And

The art of giving

Helping is hot!

❙ 23

July/August 2009 ❙

Not just a sinful indulgence

Marinated with spices, oil-glazed and barbecued over charcoal fire, satay seems like a sinful meat snack no matter how one looks at it. However, there is some nutritive value to satay and its accompaniments when taken in moderation or as a monthly indulgence.

By Ng Hwa Ling

According to the Health Promotion Board, 10 sticks of beef satay has 7g fat and 24g protein while 10 sticks of chicken satay has 5g fat and 27g protein. Can satay be a high protein, moderately-fattening alternative in the food court?

Satay is high in protein because it is mainly meat. It is also high in fat, especially saturated fat (SFA), from the blended vegetable oil and fatty meat parts used for its preparation.

SFA percentage is 20% in chicken satay, 30% in beef satay and 60% in mutton satay. Therefore, satay may not a good alternative for high protein, moderately-fattening food.

Turmeric is often used to marinate satay. Is it good for health in any way?

Turmeric gives satay its characteristic yellow color. Curcumin, the phytochemical found in turmeric, may act as an antioxidant with cancer-preventive effects, several studies suggest. However, there are no studies yet on turmeric (as

a whole) in lowering disease risks when used in cooking. The most reliable way to benefit from phytochemicals is still to have a diet with a wide variety of fruits and vegetables.

How fattening is the peanut gravy? Is there anything redeeming about the gravy?

The main ingredients for peanut gravy are roasted ground peanuts, onions, garlic, lemon grass, belachan, salt, sugar and oil. A 29g serving of peanut gravy provides 77 calories, of which 70% comes from fat. It also contributes 138g of sodium per serving. Generally peanuts are high in unsaturated fats, whereas onions and garlic contain some antioxidants compounds. However, the costs of eating oily satay and gravy far outweigh the benefits from the peanuts, garlic and onions.

Are there any health benefits from eating raw onions?

Onions are a rich source of dietary

flavonoids called anthocyanins and phytochemical quercetin. Some studies suggest that quercetin is associated with the reduced risk of coronary heart disease and stroke. Research also suggests that onions are related to the reduced risk of certain cancers like stomach, colorectal and prostate cancer.

However, quercetin is sensitive to heat and the degree of loss depends on the cooking method. Therefore, eating onions raw is a good choice. Further studies are needed to confirm the importance of flavonoids in preventing coronary heart diseases.

Ketupat is made from steamed white rice. Will eating it increase the glycemic load of the meal by a lot?

The glycemic index (GI) is a ranking of carbohydrates on a scale from 0 to 100, according to how they raise blood sugar levels after eating compared to white bread/glucose.

Foods with a high GI are those which are rapidly digested and result in

marked fluctuations in blood sugar levels.

GI represents the carbohydrate quality but not the quantity of the carbohydrates consumed. On the other hand, glycemic load (GL) combines both the quality and quantity of carbohydrates in one number. It is therefore a better way than GI to predict blood glucose values of different types and amounts of food. The formula is: GL = (GI x carbohydrate amount) divided by 100.

According to the international table of GI and GL, the GL of Thai rice is 37 (serving size = 150g). Thus, it is important not to eat too much ketupat or steamed plain rice. Moderation is key to a healthy diet.

Ms Ng is Dietitian at SGH's Dietetics and Nutrition Services

EatWell

Ayam Bakar Selasih

Serves 4

INGREDIENTS 800g chicken (remove skin, cut into pieces) 55g onion 2 cloves garlic ½ thumbsize piece of ginger 1 stalk lemon grass (3 cm length) 1 ¼ tsp chilli powder 1 ½ tsp coarse black pepper 1 tsp light soy sauce ½ tsp salt 3 tsp oil MEthod 1. Blend onion, garlic, ginger and lemon grass together to a fine paste.

2. Mix paste with chilli powder, black pepper, light soy sauce and salt.

3. Marinate chicken in this mixture for two hours.

4. Put chicken on a baking tray and brush with salt.

5. Bake at 180°C for 30 minutes.

Serve hot.

HEALTH TIP Chicken with or without skin contains cholesterol. On average, chicken skin contains about 35% to 40% of fat – saturated, monounsaturated and polyunsaturated. Removing the skin before cooking is important as it reduces both total fat (reduced calories) and saturated fat. Remember that increased saturated fat intake tends to raise blood cholesterol.

ESTIMATED NUTRIENT CONTENT (per serving) Energy Carbohydrate Protein Fat Sodium Cholesterol

159kcal 3g 21g 7g 466mg 67mg

CHICKEN, ROASTED Thigh (with skin)

Breast (with skin)

Thigh (skin removed) Breast (skin removed)

WEIGHT CALORIE FAT SATURATED CHOLESTEROL (G) (KCAL) (G) FAT(G) (MG)

60 60 50 50

148 118 105 83

9.3 4.6 5.5 1.8

2.6 1.3 1.5 0.5

This recipe is from Where is the Fat? Cookbook, a compilation of healthier dishes created by SGH Dietetics & Nutrition Services.

The book is available for sale at SGH’s Retail Pharmacy.

56 50 47 42

24 ❙

❙ July/August 2009

InTheKnow

Faster outpatient services ics (SOC) where I had a midAt the Specialist Outpatient Clin nter registration staff how long morning appointment, I asked the cou I wanted to be home before my the waiting time would be. The reason: son returned from school at 1pm. doctor soon, the counter staff After promising to let me see the ress which would save time as suggested I signed on to Ser vice Exp to be given a time for the next I needn’t wait to make payment or appointment. an SMS telling me my turn Soon after filling out the form, I received was due soon. What excellent service! an hour. I got home way before My visit to SOC was finished within live in Tampines, a distance from my son returned from school – and I SGH. Mdm S

Service Express @ Specialist Outpatient Clinics helps save time

Service Express @ SOC allows patients – pressed for time – to leave immediately after consultation. Patients signed on to this service don’t have to queue again to settle their bills or to get a follow-up appointment.

This is a pre-authorised cashless payment option where patients will be billed to their credit card account, via GIRO transfer, or a prepaid deposit.

As the name suggests, this is only available to Specialist Outpatient Clinics (SOC) patients, including Rehabilitation Services. Plans are also being made to extend Service Express to Pharmacy and other departments.

Skip Q with self-registration

Self-registration kiosks at Blocks 3 and 7 allow patients with appointments to register their arrival. The use of the kiosks helps cut patients’ waiting time and reduce crowding at the clinics as patients don’t have to queue at the registration counter.

SMS service betters time management

This reminder service uses SMSs to communicate with patients about their appointments.

Three to seven days before their appointment, an SMS is sent to the patient to remind them about their appointment. This service is available to patients of the SOCs, Rehabilitation Centre, Medical Social Services, Sleep Disorder Unit, Haematology Centre, Department of Diagnostic Radiology, and Pharmacy.

For SOC, Pharmacy and Diagnostic Radiology patients, on the appointment day and after registration, an SMS is sent to alert the patient to the number of patients ahead of their consultation when their queue number/consultation time is very near. In this way, patients aren’t confined to the clinic waiting areas but could have their meals at the food outlets while waiting, for instance.

Should the SOC or Rehabilitation Services patient miss their appointment, an SMS will be sent to advise them to get a new appointment date.

Patients scheduled for admissions receive reminders on punctuality, registration and payment procedures.

If there is a mass casualty or disease outbreak, patients who are signed on to this service will receive alerts informing them of the postponement of their admissions/ appointments.

Lab tests, other medical orders a mouse click away

By Sheralyn Tay

Clinical orders usually involve sheaves of order forms – and lots of time to fill in. But a new system known as computerised physician order entry (CPOE) allows doctors to order laboratory tests, medications, referrals and the like electronically.

This IT innovation was piloted at Changi General Hospital (CGH) in December 2008.

Having a computerised ordering system means that doctors and nurses

can now select clinical orders on their computers. This does away with the time taken previously to find and fill up physical order forms, allowing them to spend the time on patients.

Patients too benefit, said Assistant Director of Nursing, Ms Elaine Ng: “If a patient forgets to bring his or her order forms during an outpatient visit, nurses are now able to retrieve them from the CPOE system, reducing waiting time and the need for the

Self-service kiosk with instructions

Self registration kiosk in four languages

Taking queue ticket from the machine

patient to get an extra set from their doctor in-charge.”

Apart from the added level of convenience and better patient care for both doctors and patients, patient safety is also enhanced. Associate Professor Goh Siang Hiong, Deputy Chairman (Ambulatory) of the Chairman Medical Board's Office and senior consultant at CGH, said: “Experience elsewhere shows that ordering electronically reduces human error and raises the safety for patients.” For example, problems with illegible handwriting are eliminated, he added.

A built-in decision support mechanism in the system allows all users to cross check the orders for added safety. The CPOE system also has the benefit of saving money by cutting down

Queue ticket showing various information

on paper costs and duplicate tests.

With its successful implementation at CGH, the system – part of a threeyear upgrade of the SingHealth group's electronic medical records (EMR) infrastructure – will be rolled out to other institutions, such as KK Women’s and Children’s and Singapore General hospitals by 2011.

“While the rollout of CPOE at CGH was not without its challenges, the pilot has offered good insights on its future implementation,” said Associate Professor Goh. “Ultimately, CPOE is more than just automating clinical orders. It is a way for us to review, streamline and better structure the doctor’s order process to make healthcare faster, more affordable and safer for all our patients.”

July/August 2009 ❙

❙ 25

CelebInPerson

The J way

JJ Lin is more cute than a hunky rocker but he has fans all across Asia thanks to his musical talent and earnest demeanour. OutramNow gets Singapore’s poster boy for singing-songwriting to talk about fashion, love and of course, health.

By Hazel Yong

JJ LIN is one Mandopop artist who epitomises the ‘never say die’ attitude.

He’s often lambasted for his fashion sense but it didn’t stop him from opening a streetwear shop at Ann Siang Hill in March this year with three buddies.

The shop’s name? Smudge, an appropriate acronym for Still Moving UnDer GunfirE. “I don’t see myself as a fashion guru or anything close. I just wear what represents me, and it should never be rated with numbers,” said Lin when asked to rate his own fashion quotient.

“Smudge is a brand that reflects the condition of our world. But instead of complaining and swearing about how life sucks, it provides strength and faith to those who believe in the warrior mentality behind the brand.”

Lacking in the boy-band type of good looks, he walks the talk as he takes the tougher route to win fans over with his hardworking attitude, vocals and songwriting talents.

Discovered in a talent search by local record company Ocean Butterflies Music in 1999, the former ACS boy has been pushing himself hard to stay on top of the pop-idol pack. With so little personal time, he ended up celebrating his birthday belated and onstage at the Singapore Indoor Stadium as he turned 28 a day before his 2009 World Tour opened.

For his efforts, top awards garnered this year alone include the Top Local Artiste of the Year, Top Local Songwriter of the Year as well as Top Local Soundtrack award (for 2007 animation Legend of the Sea) at the 14th annual Composers and Authors Society of Singapore (Compass) Awards Presentations. The Singapore Entertainment Awards also honoured him with the Best Local Singer title, as well as K Box Most Popular Karaoke Hit for his duet Dimples with Hong Kong songbird Charlene Choi.

ray al Day, I p n io t a N is he Th b out of t m li c l il w is, ans Singapore h and economic cris lt a sing current he appy despite increa e eh and still b Let us make what w e . challenges orld, and not let th w r u want of o pe us! world sha

“

”

How do you prepare yourself physically for concerts or shows?

I usually spend an hour at the gym about four times a week and up to five hours every day for dance rehearsals. At the gym, I would do crunches and lift weights to build stronger biceps and triceps. Running on the treadmill helps build up my stamina too.

Besides exercise, ample water and rest are important in helping preserve my voice. I would also cut down on oily and fried food.

“My highest high is yet to come.

I’m always working to better myself and my craft,” he declared.

Being so driven has its price.

Late last year, his throat became so inflamed that he coughed blood during promotional tours in China, Taiwan and Hong Kong.

About three months ago, an endoscopy revealed gastric acid had damaged his vocal chords and the doctor ordered him to take a break from singing.

While he has decided to persist with work, it is unconfirmed by press time if his seventh album will be released around August as originally planned.

According to sources, he is in the midst of selecting the songs for the album lineup.

Still, there is something that JJ might consider slowing down his career for – love.

Currently rumoured to be dating Choi since their collaboration on Dimples, the usually obliging Lin turns remarkably tightlipped. What if his fans desert him because he has a girlfriend?

“I’d rather lose fans due to my dating status than lose them because of my music, or age! As with any and every important thing to me, I choose to protect it and if it means keeping secrets, I would gladly do so.”

What is your favourite sport and what would you like to try next?

Besides swimming, I like basketball and will play with other artistes like Jay (Chou), Jerry (Yan) and Energy. I want to try racing because I love cars! It’s a different form of sport to hone speed and mental endurance.

You were spokesman for foodstuff such as potato chips, ice-cream and soda in China. Why are you advocating junk food to impressionable teen fans?

Young people already like junk food. I always try to remind them to take everything in controlled proportions.

What is your daily diet like?

I always stay away from the oily and fried stuff, but I have a weakness for ice-cream. My favourite flavour is chocolate! Thick, brown, rich… yummy! I eat a small cup of ice-cream whenever the craving hits. To enhance my nourishment, my mum feeds me vitamins and bird’s nest.

You shuttle frequently between Taipei, Singapore and China for work. Any tips on dealing with jet lag?

Thank God there isn’t any time difference between these three regions! However, I get headaches from the air pressure so I avoid night flights which cause me the most discomfort. I always drink lots of water and usually take the chance to sleep the moment I’m on board. Rest and water is the best way to hydrate one’s skin! When I’m awake, I make a point to stand and stretch regularly to prevent numbness.

You are an avid player of computer games like World of Warcraft and Counter Strike. Do you think such games promote violence, and how do you take care of your eyes?

I think it’s just like watching a movie or reading a book – we have to approach it with maturity. In life, you have to keep yourself in constant check and balance.

For eye care, I take breaks and try not to stare into the screen for prolonged periods.

Gaming should always be for leisure, unless you are a professional gamer. And if you are a professional gamer, you would know how to control playing time to be at your competitive best.

Besides playing computer games, what else do you do to rest and relax?

I like to watch movies or chill with my friends at coffee joints just to catch up. Other times, I’ll chill at the Smudge store in Ann Siang Hill.

To what extent does love contribute to good health?

Love makes you want to stay healthy, happy and strong for your loved ones. It’s the largest source of energy to help achieve anything in life.

26 ❙

❙ July/August 2009

Luminaries: The lions among us

Remembering Gwee Ah Leng He wasn’t the most well known of physicians in Singapore. But to his colleagues and students, the late Dr Gwee Ah Leng was not just an excellent doctor with a special interest in neurology, he was a leader with a profound sense of right and wrong, a strong sense of civic responsibility, and a kind and caring spirit.

The late Dr Gwee had a relatively modest CV: He headed Medical Unit 3, an expansion of SGH’s Medical Faculty, when it was set up in the 1960s, until he retired from Government Medical Service in 1971. He then went into private practice.

But during his term of service, he earned the respect of all the medical students who came under him, many of whom became very prominent physicians or surgeons, “doubtless influenced largely by his own compassionate approach,” wrote Dr Robert CK Loh* in Dr Gwee’s eulogy in the June 2006 issue of the Singapore Medical Journal.

The late Dr Gwee, incidentally, was the first editor of the Singapore Medical

Association’s monthly publication.

“Never without a smile…(and)... never one to rebuke his staff, Dr Gwee was always encouraging and gave full reins and trust to his staff to manage the day’s routines,” said Dr William Chew* who joined Dr Gwee’s Medical Unit 3 in 1964.

“Dr Gwee was my teacher, my mentor and my friend. He taught me patience, care and concern for our patients,” Dr Chew said in a tribute in the June 2006 issue of SMA News.

The late Dr Gwee always stopped in at the tea room in the Medical Unit 3’s out-patients’ clinic at 10.30am “to avail himself for a dicussion with his staff – be it the politics of the day (a very hot topic then) or to discuss patient problems or research,” he said.

“Through all these, we developed a camaraderie of spirit that was never before seen.”

In 1967, the late Dr Gwee was awarded the Meritorious Service Medal for his contributions and public service to medicine and education in

Singapore. Among his contributions, the late Dr Gwee was in a governmentappointed committee to review the Prescott Report in which an expatriate professor was critical of the quality of education in Nanyang University and the influence of communist activities among its students. He was also in a committee that drafted the constitution of the University of Singapore.

The late Dr Gwee, whom Dr Loh described as “an excellent doctor, a Christian gentleman, an accomplished scholar, and a wonderful and exemplary citizen of Singapore,” was driven by a profound sense of right and wrong. Dr Loh said he was concerned with the debate on legalised abortion (he was against it), euthanasia, and matters of professional secrecy and medical ethics, and the principle of good medical practice. He had strong views and was very principled, always firmly and steadfastly standing by his beliefs. * Dr Robert Loh has retired and Professor William Chew is a Visiting Consultant at Alexandra Hospital’s Diabetes Centre.

Dr Gwee Ah Leng, 1920 – 2006 Early 1960s

Headed the newly establishment Medical Unit III

1971

Retired from Government Medical Service and went into private practice

Contributions Editor for the Singapore Medical Journal Founding member and Master of Academy of Medicine, 1961-1964 President of Singapore Medical Association, 1972-1973

S H O E S , FA S H I O N , CO M F O R T What woman can resist the idea of buying new shoes and being able to justify it as an investment in her wellbeing!

While we’re often urged to eat better and exercise more, the profound effect footwear can have on our health is underestimated.

Making a smart choice in shoes doesn’t mean you should forego fashion. It is possible to have it all –

the right fit, comfort, support and style.

At Kumfs, we achieve it by thinking a bit differently. We don’t ask you to sacrifice comfort for the sake of fashion. Instead, we’ve pushed our designers to re-invent fashion around the foot.

With innovative design, sourcing the best materials and investing in research, wear tests and new technology, shoes can not only look great but make you feel it too.

NURSE’S DAY PROMOTION Show your SNB practice nursing card and receive $30 off each pair of Kumfs Valid for July & Aug only Terms and conditions apply

Visit our retail outlets at: • #03-05 Palais Renaissance (next to Thai Embassy) Tel: 6737 1475 Mon - Sat 11am - 7pm Sun 12pm - 5pm • Tanglin Mall #02-36/37 Tel: 6238 7353 10am - 9pm Daily

Heel N Toe(july).indd 1

6/22/09 4:14:04 PM

July/August 2009 ❙

Postcards to the Moon!

Seven-year-old Mohd Nihal wants to fly to the moon – and what better way to articulate that h o p e t h a n on a p re t t y postcard which he designed and made himself.

Nihal is one of 25 children from SGH Listen & Talk, a programme which helps kids with hearing impairment develop communication skills, who recently participated in a Esplanade – Theatres on the Bay workshop. Postcards made by the children with beads, stickers and other recycled materials will be displayed during the Esplanade’s Octoburst! Festival on Oct 1-4 as part of Children’s Day celebrations.

More than 30 staff from Aviva, which sponsored the event as part of their community outreach programme, were on hand to guide their young ones in this fun project.

"It was fun to see the excitement on the faces of the kids as they worked on their special creations. We are really happy to partner SGH and Esplanade in this heart warming project," said Marie Sigsworth, HR Director, Asia Pacific Office, Aviva Asia Pte Ltd.

❙ 27

Contest

Win a backpack Just answer the following questions and be one of five readers to win a nifty SingHealth backpack.

1. Do you wear a surgical mask outside your home when you have a fever, runny nose or cough? If you don’t, why not?

2. Which story in this issue (OutramNow Jul/Aug 2009 Issue 15) did you enjoy reading the most?

Email your reply, name, address and contact number to editor@sgh.com.sg. We also welcome your comments and suggestions. You may also send your entry to The Editor, OutramNow, Communications, Singapore General Hospital, 7 Hospital Drive, Blk B, Level 2, Singapore 169611.

Closing date: Aug 31, 2009 * Duplicate entries will be disqualified. * All correct entries will be entered into a lucky draw to be conducted at the SGH Communications Office. * Five winners will be picked and notified by email on the collection of their prizes. * Their names will be published in the next issue of OutramNow.

Contest Results Results of the contest ‘We want to give away five copies of Where is the Fat? Cookbook’ in OutramNow May/Jun 2009 Issue 14.

RED-0153-A3-Poster-S1 5/18/07 12:40 PM Page 1

The answer is TRUE. Singapore General Hospital’s Hyperbaric and Diving Medicine Centre is Singapore’s newest and one of Southeast Asia’s largest and most advanced hyperbaric facilities.

The following winners will be notified by email.

• Chua Lye Kim • Ng Peng Kee • Sim Khoon Lee • Tan Chiang Chye • Ivy Yeo Mui Joo

We need your help, urgently.

Prizes must be claimed by August 31, 2009.

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Patients. At the Heart of All We Do.

Making brain surgery smarter and safer

Housemen’s Canteen roars to life

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Strategic sourcing saves over $90 14 in10past million 2 es five years hing liv

Hospital, group General Singapore SingHealth ation of within the nthly publicp hospital A bi-mo ’s flagshi the nation

Did you know that latex can threaten life?

I D E I N S

Nurse at Clinicians polyclinics longg help cut timess. waiting

MidAutumn joy lights up SGH

Planning that sweet vacation

h A breat of fresh air can help the wounded.

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The new Heart Centre.

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Issue 11

A bi-monthly publication of Singapore General Hospital, the nation’s flagship hospital within the SingHealth group

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her to the ed to send ts decid scan Her paren y (CT) hospital. uter tomograph in the left clot A comp ve blood The doctors a massi head. to showed of her erred her lower backAVM and transfaround 1am. to unit at suspected sive care up to machines brain the inten d

her was hookeas to minimise genital , so a con rs even She induce coma short by had a probe othe activities. morning, Gwen to monitor ple was cut ted to help t peop ng life g Office The next her forehead eigh e wan o the youadopts ee SingHealth’s Group Procurementen’s said her gave ga into ld hav anss. To Doctors inserted ed, Gwto generate strategies s – and o ga old wouesavings. pressure. prudent procurement e org 2008 end their live ight, a her ate 16-year-o don intracranialhad stabilised. before ef that the e to do last. Overn ency touched entss for condition respite did not t days h eaa lbeli par SingHealth el who andng.the purchases ang Jus t s pa c o sher An emerg her t h c a r eled the T O K E E. P But But up. inni theHealthcarebeg Mr Foo ase SingHealth Group. her e part of re shot National was dise affordable, th faced has ,explored r was the pressu was done to remov.her brain.

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D-0153-A3-Poster-S1 5/18/07 12:40 PM Page 1

Every 6 minutes, someone is in need of blood or blood product.

ONE PATIENT ONE RECORD

that loved no symp of to lower blood to a well- told Mrs Tan the shows In a recent exclusive interview with Amlodipine, used tangle Farewell ged – surgeon until the vessels daily Lianhe Zaobao, pressure, and Clopidogrel, an antiChinese-language The neuro brain was dama and Yong blood

By Hazel who have undergone dilated to cause a part of her left ols speech, vision SingHealth Group Chief Operating platelet for patients contr the e.”heart-stent surgery. For the former, the rupture Heeh.”Jug said Europ Foo Frenc Officer Mr learn part that or skills. ge. surgeon and GPO has already secured an equally haemorrha Australia Offi “MUST Groupin Procurement morning psychomot oon, a senior neuroabnormal SingHealth .” ce t study er in Korea On the effective generic substitute as the patent in non- and skimillion er and $92.5 has saved That aftern a scan of anoth head. The (GPO)“Mus t learn to ay in Antarctica 20, moth a bus. them “Musexpenditure of her set expired, saving more than $20 million in it wasmen.” of Dec manpower showed go holid since were on at the top cting the artery “Must 2003.igloos and snow da.” drug expenses. For the latter, the GPO daughter showed Gwen artery vein up in January conne aries to build down in Cana ed with the pharmaceutical negotiated a Mrs Tan to which bed of capill not formed.

Foo (photo), Mrlearn world reachgirl, n settle was like was article, and secured a discount worth know I to the vein a d s ers of the s o l ewond a news him, she w h o a l“The young company to pressure “You the d a a few million dollars. would “Accordingbomb. As the highs a i d Tan. But O , Gwen she replie the bus. I get t h e G PThe of the teenhood, er few thin wall time r read on record out to Mrs Tan is cusp of 9. ng bulk purchase walki can’t medical on page vein, the didsystem a matte on the just anoth GPO’s slip work gets more established Full story on the electronic che.” Little laint was to blood acts on the hed. It’s only poised n that in of many only one quickly heada stretc comp Mrs Tan. havesknow . and delivers impact that the last wordscost t - dreams would l e c othose vein is being it burst,” said them that p o s s i bnot savings. knowacquire medical began of time before the integration, The GPO has come a long way since upon the GPO to she daughter’s ltant told measures,her grasp. day last year, the cutting years, example, before be her moment from services.a train, Gwen For ce days when it coordinated the supplies and related her consu the early Anotused fort, and hospitals then athe December a triple Scien brandstheof machine. and evenaway 17 gone” Later on ofofdiscom the public , Before the establishment On hot would “be life support seemed Gwen herself of drugs, medical equipment, signs savings achieved undergoing a ed Gwen’s 16-year-oldl, would find buying e pain lancets draw blood. After to the show Th acquiring off ous were to hospitals as the such GPO, che. head inform vivacilimited. taken andn, non-medical items her schoo that statio Tan waswith ed a heada andmassa nurses, and may be fairly clinicians of a topHe noted receivresources the ge product review 24, Mrs a train electricity supply and IT systems, for their own onped condition. nt, who the develo studentare collap tried to sed in bydays a later, On Dec Tan.GPO narrowed monopolised critical patented drugs to two. stude it down kidneys Management severe. “I Departments of her a nly said Mrs theasthm , and so SingHealth hospitals and polyclinics. sporty Materials ates quite her me,” sudde coma ed and companies, a classm s. She few pharmaceutical stopp orders childh ing of scale d over a hand, economies d into from ood “On justa passively ousGPO builds a successful trackwaitewere to one by friend but she taking brain dead.

As the An aoutgo high. ioven due these drugs each than mild Foo. for the school band the price ofslippe uncedremain lower priceoved us to secure allowed ral Arter record Other said Mr born with top dmanagement, the nosebleeds had nital always Gwen was well-let forstaff was prono of securing substantial discounts : Cereb medicinesa conge child – the brand-name as well Switching from medical On the other hand, clarin occasional – waitean and ), procurement in while the integrated The cause will measurestionWith rane, Gwen lancets. championing badminton schools. feel too played thethemselves effectively flow the with on (AVMallow didn’t to generic alternatives seven years,reatening condi bloodand only need to familiarise nose memb providers dary d with public thin healthcare resources, hospitals workflow, Malformati down ctions utilise life-th y. Mrs Tan decided to take and traine to better interr drug conne onupts at her seconup till 1am to public hospitals toercutthat rare to sithave a fulld health of lancets, streamlining years. types an , and twogiven in terms able now r teams medical seeme picture abnormal In stay disord SingHealth Gwen’s the one-a outside nd-a-half Group, as socce said ent was can due to tion, Foo. , waking up for Mrtimes expenditure. at that pointdevise . She was some procedures and training,” recipiand the ofopera worried terand resource and veins. Singapore the brain it lwork to a clinic for giddiness and She would ve bloodCivil Defence e utilisation, The lungForce, after his Last year, this procurement arteries strategy schoo ON PAGE 2 day. To top CONTINUED rs. Th daugh to achieve strategies a day sent a massi her lete her comprehensive also called next between have of Defence medicine to visito a tutor the comp g m and disorderin drug Ministrycut saved GPO $30.4themillion upright, teered to eer, injection l at 6.30a and wavin was successful, y case, brain. eight lant nd, an engin , schoo occasionally volun young life has smiling for charit vomiting. clot to her promise of a her husba more than liver transp - but kids and off, she them home leged By the time clinic to take see things Yet the not end at death others. split not repeated since and under-privi ns. many feat d at the one has r able to cheerful short would beginning for would have ago. organisatio that every , it is arrive was no longe a lively, remembering new to years told myself Gwen Gwen led to a the gate that Gwen “She was always parents “I opened to buy and life. For person, girl,” said clearly.

The belief others led her lungs and on in sister Jane against it. “You thoughtful taking care ON PAGE 6 ys, a missi to save that little to help ed d Her elder UED birthdays, wanted liver, kidne a new life to bly CONTIN she bump Gwen just smile friends’ heart, know proba and to her Tan. her ion, giving offer rly ah?’ er Mrs would be happy lives of for for donat Mrs Tan. again. see prope n moth e she corneas ormed the do can’t went to bed,” said “I believ two wome e e. vomited has transf her nature to Gwen , and act eight peopl ents - five men, divers night the e. It was fullest and Late that The recipi girl - came fromas 61 and that many peoplher life to the little was as old al were so and a She lived s. One lation.”

Sever en. so. was our conso backgroundest was three. with childr that men the young were married The two few single, a waited for years.

Some had

350 units of blood are needed everyday to save lives.

Missed past issues of OutramNow? Now you can read them online at www.sgh.com.sg or any library

Features include • Smokers have higher risks of losing legs • Damage to hearing may be permanent • Untreated prolonged pain may become a disease

We need your help, urgently.

• Reveal the health of your kidneys in just 10 seconds • Donated skin needed for burns patients • Cord blood gives hope to adults

Don’t want to miss out on future issues? Join the OutramNow mailing list by emailing your name, address and contact number to editor@sgh.com.sg

1 bag of blood can save up to 3 lives.

* For more efficient allocation of resources, only one copy of OutramNow will be sent to each address. * ThisOnly complimentary service is population only for Singapore-based readers.

1.5% of Singapore’s donates blood regularly.

GiftOfLife

Better late than never

All it takes is just 60 minutes of your time today, to save lives tomorrow. Visit Bloodbank@HSA at Outram Road.

Arts Fest@Outcam Campus has been postponed from June to September due to the Influenza A (H1N1).

For more information, call 6220 0183

Keep these dates free and enjoy a fun afternoon with us at SGH! The ideal daily blood stock is 800

Arts & Soul Bazaar: Septblood, 9 – 11400 each for of O type A and B, and 200 for AB

Arts Concert: Sept 11 – 12

Singapore needs 120,000 units of blood annually to meet the needs of all hospitals.

All it takes is just 60 minutes of your time today, to save

You can also log on to www.redcross.org.sg www.donorweb.org

Every 6 minutes, someone is in lives tomorrow. Visit the Bloodbank@HSA at Outram 350 Road.units of blood are needed

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