Singapore Health Nov/Dec 2012

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kesan jika s, obesiti pesakit dan penyak tidak merubah hidup mereka. it lain gaya dia menghilan Selepas gkan diri pembedah dengan dan timbul dikecilkan an, diabetes ke saiz kantung perut pesakit semula yang tidak berisiko ambung terkawal kecil yang terkena ke bahagian dan serangan dismenjangk Pesakit akan tengah usus sakit jantung au usia kecil. han daripada muntah jika makan Puan Rozita 40 tahun.” berlebiapa yang pula bosan hospital kantung boleh diterima keluar sebanyak tersebut. oleh galami diabetes, empat kali keranamasuk En Lawrence menradang ulser tidur dan biasanya sekeping perut, sista ovari. roti untuk memakan komited sarapan, Beliau berazamapnea ikan untuk untuk menjalani makan tengahari sekeping kecil dan kata Dr kecil ikan pintasan dan sekeping Shanker untuk makan gastrik Kanan, Pembedah Pasupathy, malam.

Puan Rozita, Perunding yang mengakui an Am, Pusat LIFE, lum ini dan Pengarah, SGH. tidak memaham beliau sebeapabila “Terdapat i erti “kenyang” makan, salah tanggapan telah mengajar bahawa pembedah untuk berkata umum Dr Tham dirinya an boleh semuanya Kwang besar makanan. “tidak” kepada menyelesa sakit pintasan Wei (paling dan, selepas sebahagia ikan kiri) menerusk n gastrik itu, anda Kedua-dua mereka dan Dr Shanker an hidup boleh nya kini En Shaun Pasupathy ini sekadar anda. Pembedah pemakana Lawrence komited (paling butang set n sihat, kanan) bersama dan Puan dengan an itu, anda semula dan makanan senaman, Rozita Ramlee.

Oleh Valerie pemesti mulakan tambahan selepas regimen kepada lee tetap ke harian dan pendekata kehidupan Pusat LIFE n baru lawatan anda hanya dari En Lawrence kemajuan untuk mengawas segi pemakana namun bukan mereka. mendapat daripada Mereka kini i gaya hidup Pesakit pergi n saja.” kan rawatan Dr Tham penyokon sihat dan ke Pusat Berat badan Jabatan Endokrino Kwang Wei, mengubah g melibatka keluarga LIFE untuk Perunding suai tabiat En Shaun serta rakan-rak n juga ahli belajar logi, SGH, 32, dan , Unit Obesiti “Kami berbincan pemakana mengikut an mereka Puan RozitaLawrence, n mereka. dan Metabolik dan Pengarah, tabiat baru 36, melebih untuk jukkan ke mereka.

NOV setelah diru- memilih makanang tentang pemakana “Seorang Ramlee, Pusat Diabetes i 100kg individu n, penyaring dan bersantai.

Hari ini, sebelum perlu membuat yang menjalani bedahan tiada siapa an pra-penga di SGH semasa dan ini.

Mereka telah mereka perubahan yang dapat matan negara.

DIS diajar mengenai pembedahan mbilan anan menjadi pernah menduga hanya membant kerana pemperkhidpemaknukleus gambil pelbagai obes. Atau pernah sekadar 20 “Dia seorang ebuah keluarga,” perubahan 2012 u menurunk mensehingga jenis ubat pesakit penyakit an yang berat ujar Dr Shanker bagi ses30 peratus mereka,” untuk pelbagai diabetes yang berkaitan Pesakit berat badan badannya ujar Dr Shanker. lagi. dibantu mendapat dengan obesiti. turun naik. tipikal Mereka pesakit Prosedur melalui kan rawatan berdua yang Setelah bariatrik sokongan telah tasan gastrik, TerbiTan selama tujuh gastrik, Bakal pesakitmempunyai masalah satu pembedahmenjalani pinpembedah – sama ada pintasan tahun HosPiTal besar serupa. menurunk dan pesakit an ikat lap band) an membant melalui Dan an berat perut (gastric yang sedang atau ‘gastric pelbagai singaPur a u badan atau bariatrik fasa selepas sleeve’ – menghadi yang berkesan prosedur pembedah tidak berKuMPul an ri mesyuara baiki/mem an untuk mempergan di Pusat t kumpulan ulihkan singHealTH. diabetes LIFE, setiap sokonmetabolis dan gangguan me lain. petang Rabu.

M4 Prosedur Untuk melawan diabetes dan obesiti, M3 Apa yang tan, mereka penyakit lain terjadi Lingkaran telah menjalani yang berkaimeNgembalIkaN tersebut M3 laparoskop pembedah N di Hospital Pro SeNyumalingkaran ik an BesarlaNgkah Satu hujung tahun silikon Singapura VISI gastrik boleh dilaras diletakkanyang boleh lalu.

(SGH) M2 laras (Laparosco SemPurNa “Sebelum Saja ke arah Kontra di sekeliling pembedah bahagian SeNamaN pic ini, saya an yang atas perut adjustable jauh atau tidak teraNg agak ringkas tidak memerluka mengurang untuk menaiki yaNg boleh berjalan gastric uNtuk tulaNg kan saiznya, MRT dan banding) n perut bedahan PembeDah aN dibedah Benda asing seseorang bas awam. supaya ini telah itu lebih dimasukka PemyaNg kuat memberi Kadar komplikasi kedalam cepat baru,” ujar berasa kenyang n huraIka N saya kehidupan badan En selepas dan makan pembedah Memerluka kurang lagi lari, berenang Lawrence, yang sekarang an n pelarasan dan yang ObeSItI mOrbID dengan Boleh menjadikan agak rendah kerap di dapat mengurang beryang itu dengan kerap. dan pergi ke pusat klinik diabetes kan berat senaman peringkat lebih kurang badan awal En Lawrence Boleh diterbalikkbertambah baik tidak berjaya 10 peratus pesakit satu porta turun dari diimplanka indeks jisim an (jika lingkaran 117kg dengan penurunan mencapai sebarang kulit untuk n di bawah tubuh (BMI) dikeluarka berat badan memboleh sementara terjadi komplikasi n sebelum 35 kepada Komplikas pelarasan kan Puan Rozita i lewat yang halus diameter Gastrekto ) dari 128kg, termasuk turun kepada 85kg, mi outlet jangkitan, ketara, BMI 50, lengan 93kg hakisan gelinciran selepas pembedah masing-m Kira-kira atau 75 peratus lingkaran, asing Laparosko pembedah memerluka an perut dikeluarka tember tahun pada November pik an ulangan n n (Laparosco dan Seplepas. tiada benda hasil awal pic Mereka tidak prosedur asing dimasukka sleeve sepertima baru ini memberan yang agak n untuk mengawallagi perlu mengamb na gastrectom sangkan pembedah teknik lingkaran Kekal dan y) tidak boleh an tinggi, kolestrol diabetes, tekanan il ubat penurunan sekali sahaja diterbalikk an berat badan tidur obstruktif dan rawatan untuk darah yang pantas hasil jangka awal u pesakit itu berhenti apnea , keadaan panjang Mengurang lima tahun) (melebihi di mana seseorang boleh membant kan kelaparan tidak bernafas daripada garis pengokot diketahui pernafasa disebabka baru ditemui teknik lingkaran lebih n tertutup n pada perut yang sukar dikawal Boleh menjadikan Prosedur yang berdarah semasa tidur saluran boleh atau bocor darah tinggi lena. diabetes peringkat Penilaian awal bertambah mengawal tekanan rapi Janpesakit baik boleh makan Kardiologi, Pusat Mereka menjalani lebih baik dengan dalam Perunding, Jabatan berbanding Singapura (NHCS) ing rapi di Pusat temuduga dan kaunsellingkaran, teknik pesakit tung Nasional tetapi masih Pembaika darah Laparosco dan Peningkat mengalam ini tekanan Rani anaknya pic ubat i penurunan lagi an Kesihatan n Gaya Hidup sementara Oleh Thava varieti resisten Roux-en-Y Malia Dawan badan yang Kantung berat (LIFE), di walaupun memakan kakitangannya gastric darah Puan gastrik baik mana tekanan bypass kekal tinggi terdiri pakar dicipta terlebih yang kecil Chieh memeriksa .

Tan Weidaripada doktor, dewasa pemakana dulu, Dr Jackn, dengan betul. penurunan pintasan tekanan kemudian ahli Yusi memerhatikan dapat daripada populasi psikologi, kepada usus berat yang menurunkan Puan Yusminah fisioterapi, ahli “Se per lima ke atas jurupulih banyak berbanding Dawan, 71, tidak dijalankan lebih kecil pekerjaan laluan ini sambil Puan Malia berusia 60 tahun sosial perubatan dan pekerja supaya arteri Tan. kaedah lain Boleh menterbal pakar bedah tekanan darahnya 3 - 5% hari ini yang berbilang saraf renal) darah,” ujar Dr ini mengurangkan dan sekitarmenggala memerluka menurunkan ikkan diabetes ginjal (melalui disiplin. lebih garam dan pengambil enam jenis ubat kkan jenis 2 yang banyak latihan kalori dan n lebih penjagaan menghidap hipertensi bentuk rintangan.

LIFE an mengubah sedia ada holistik untukmencerut dan menyimpan menga– meskipun memakan bersepadu prosedur garis pengokot sejenis makanan cara lebih selamat tekanan darah. hari untuk pesakit dengan menua, yang sangat mengalami dan dihadam meningkatkan Prosedur yang dan penyambu batan yang semakin berlainan setiap memandan gastrousus difahami berkaitanisyarat otak bukanlah air, sekaligus kondisi perusemula isyarat ng gkan ia telah juga kes boleh berdarah Dengan penduduk gaya hidup,menghantar Konsep mengganggu telah mengeluarkan guan dijalankan bocor walnya. pemakanaGinjal juga meningkat, begitu seperti gang-jantung berdeatau berada di sekitar bedah lebih dari n dan otak mengarahkan kadar ini akan 40 tahun Komplikas baru. Para pakar sejak 1930an - lebih Tekanan sistoliknya dan ini kepadaobesiti. i lewat, seperti arteri ginjal raksa (mmHg) rintangan,” tambahnya. disebabkan oleh apabila tertekan perut dan terbuka saraf di sekitar 200 dan 210 milimeter wajar untuk usus terpulas, ulser pembedahan gup lebih kencang mmHg yang Hipertensi resisten ketidak seimbanberlaku terboleh tekanan darah. lagi menggunakan daripada paras140 seperti bentuk juga menjejas Walaupun berkesan, Kekuranga beberapa keadaan atau sebab mengamuk dalam yang amat invasif. n nutrisi 55, juruseorang seusianya.

“Saluran ini sentiasa kegagalan ginjal mengalami komplikasi boleh berlaku Memerluka Yusminah Yusi, gan hormon, Otak dan ginjal teruk pada n lalu ramai pesakit air kecil yang tidak terAnaknya Puan Ia bertambah keterpembungkudan nutrisi penjagaan pakar hipertensi resisten. isyarat yang pembuangan mengubah cara yang diketahui. tambahan menghidap Kaedah jumlah seperti atau terlatih, rawat hayat sepanjang tua, obes menghantar fungsi seksual. ibunya memakan bukan hanya individu lebih memastikan satu sama lain, kawal dan masalah anti-hipertensi air, san pil untuk ini tidak juga laluan kepada apabila ubat pilihan betul namun kencing manis. atau kekurangan ini dihentikan ubat dengan kini mempunyai Malia. semasa tertekan berada di pasaran. tenang. Dengan Namun pesakit keadaan Puan denervasi renal. yang berkesan telah menketika keadaan memulihkan invasif prosedur simpamalahan kurang saraf saraf untuk menjalani Kini, teknologi secara terpilih sehingga renal renal mengandungi melumpuhkan selama 40 minit isyarat terhadap rawatan Saraf simpatetik arteri renal, denervasi keterjadikan prosedur yang berkeTiada respons yang menghantar tetik di sekitar isyarat selamat. Kaedah mengalami hipertensi di aferen dan eferen sejam itu lebih balas sewajarnya. tingginya Puan Malia didapati telah diamalkan membantu mengurangkan otak yang bertindak isyarat kepada tekanan darah tahan lama ini kepada dan mana di san rawatan semula resisten dua tahun. respons kepada n Otak menghantar negara luar selama tidak memberi kombinasi tidak menyembuhka menggunakan Walaupun ia mengumeskipun tinggi, ia mampu gnya tiga ubat.

32/12 tekanan darah sekurang-kuran walaupun sebanyak purata sesak nafas paras sasaran rangkan tekanan yang telah Beliau sentiasa Keadaan perubatan lain, di tiga pesakit, atau berbaring. patut berada SeptemmmHg. Kesemua normal sepatutnya ketika bercakap mendapat tekanan darah ini di NHCS Tekanan darah ibunya berisiko mmHg. lebih menjalani prosedur paras 140/90 ini membuat bawah 140/90 mencapai penurunan berada di bawah jantung. berlaku sekecil 5 ber tahun lalu, Malia pertama adalah strok dan penyakit Hipertensi resisten mmHg. Penurunan mmHg (angka tahun ini, Puan darah tidak daripada 20 Pada Januari Jantung sistolik, manakala apabila tekanan boleh mengurangkan renal di Pusat tekanan darah ke paras mmHg sekalipun baru menjalani denervasi adalah tekanan boleh diturunkan 14 peratus, penyakit (NHCS). Prosedur yang kedua darah dengan risiko strok sebanyak kematian 7 peratus.

Dengan setiap gelomNasional Singapura sasaran tekanan jenis dan darah diastolik). ini menggunakan mmHg tiga atau lebih berada jantung 9 peratus kurang invasif sebanyak 20 menghapusmenggunakan dos Puan Malia kini peningkatan radio untuk diuretik pada Tekanan darah renal dia juga mendarah sistolik bang frekuensi ubat, termasuk mmHg dan di sekitar arteri dalam tekanan di paras 140/90 dramanormal, risiko kan saraf simpatetik yang optima. yang kecil. tekanan secara melebihi paras ubat tekanan dos ada seseorang r rintangan saya gambil untuk menurunkan Diagnosis beradik ibu penyakit kardiovaskula disasarkan. penjagaan kerana “Semua adik meninggal, hari yang tik ke paras yang darah perlukan tinggi dan telah dilihat pada itu berganda. terkawal mungkin tekanan darah “Kesannya dapat 50 tahun. Mereka yang mempunyai hipertensi tidak berasa sesak menjangkau Bagi pesakit dia tidak lagi kurang pematuhan baru ini ada sebelum ginjal dan jantung, sama juga dan Hipertensi berlaku kerana menjalani prosedur masalah diabetes, ubat, atau adalah Puan Yusminah. tiada pilihan Puan Yusminah tekanan darah nafas,” ujar dapat dikedalam pengambilan (cemas ibu saya,” kata paras sasaran senyap” – hanya tidak seperti mmHg. – “pembunuh dan pesakit hipertensi 'white-coat' di bawah 130/80 bertambah teruk gembira. san apabila ia yang menghidap berada di klinik) strok atau serangan Bagi pesakit tiada masalah mengalami komplikasi seperti sakit kepala, hipertensi tetapi simptom jantung atau pening kepala.

Chieh, sesak nafas dan Jack Tan Wei Menurut Dr

Lingkaran

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FOTOS: alecia

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There’s hope in the long run A cancer survivor gives back by joining a run with her baby to raise funds for cancer research The last time they participated, Eliza was carried by her father. “This time, I will walk and she’ll be in her stroller,” said Ms Lim, 33, who conceived Eliza just eight months after she completed a stem cell transplant to treat her cancer.

“It was such a surprise. I never expected to get pregnant so soon after recovering,” she said.

BY Audrina Gan

PHOTO: ALvinn Lim

It will be the second time that Ms Fay Lim and her 16-month-old miracle baby, Eliza Tok, will take part in the annual Run For Hope to raise funds for cancer research.

Ms Fay Lim and her baby Eliza Tok will join the Run For Hope 2012 event in November.

SingHealth Group CEO named Woman of the Year Professor Ivy Ng, Group CEO of SingHealth, has been given the Woman of the Year 2011/2012 award by Her World magazine.

PHOTO: SPH LIBRARY

The award recognises her contribution as a clinician-leader and for being an inspirational role model for women.

At SingHealth, Prof Ng strives to ensure that each patient receives better care than the last. She achieves this by building “a culture where our clinicians are not satisfied with the status quo, but are constantly looking for answers, examining gaps in medical care and innovating treatment”.

Aware that women face challenges balancing work and family, she is inspired by her colleagues. She said: “Healthcare is a demanding industry that attracts a high percentage of female employees who effectively juggle their multiple roles.

“At SingHealth, many of our female staff take on leadership and management responsibilities in clinical care, nursing, allied health and healthcare administration.

“We support them with initiatives that help them balance their career demands with family commitments.”

She said working alongside them has inspired her personally and professionally. “I see my role as encouraging them to be confident that there are no limits to the positive impact we can make in the lives of others – whether they are patients, colleagues, junior staff or family members.”

The award recognises women who have contributed to society. Previous recipients include Professor Chan Heng Chee, Ambassador at Large, Ministry of Foreign Affairs, as well as Mdm Halima Yacob, Minister of State for Community Development, Youth and Sports.

Ms Lim, who was a strategic business development analyst, and her husband, then a market access manager, were thinking of starting a family when her cancer struck.

It started in 2009 with a backache and some inflammation. “An orthopaedic specialist told me it was a slipped disc. But the pain got increasingly worse till I could barely walk or bend down to put on my socks or wash my face,” she said.

Her husband took her to the hospital one night after she broke down and cried because of the intense pain. An MRI scan and a biopsy revealed the worst possible news – she had Stage 4 NonHodgkin’s Diffused Large B Cell Lymphoma. This is a cancer of the lymphatic system, which is made up of organs such as the bone marrow, thymus, spleen and the lymph nodes.

Non-Hodgkin’s Lymphoma is one of the more common forms of lymphoma.

“I was devastated and wondered how it could happen to me,” said Ms Lim. She pulled through six cycles of chemotherapy and a stem-cell transplant, which felt like a marathon to her. The swelling in her back gradually decreased, allowing her to walk normally again.

Her encounter with cancer has changed her views on life. She has no plans to return to work just yet, and sees life as a passage through seasons. “I have gone through a season of recovery, and now I’m in the season of being a mother,” she said.

Joining the run is her way of doing her bit to support cancer research. “I benefited from the research and I hope we can raise enough money to keep it going strong, so that others can benefit too.”

This year’s run, held in the city area for the first time, will see participants cover 3.5km or 10km in the Marina Bay and Kallang River areas.

The organisers – National Cancer Centre Singapore, Four Seasons Hotel Singapore and Regent Singapore – hope to raise more than $700,000 from the run.

JOIN the Run For Hope 2012

Nov 18 (Sun)

Time 7am Venue The Padang Run categories 3.5km/10km Fees Adult: $45; child/youth: $25 (participants must be five to 18 years old at the time of race. Entry is free for those four years old and below); Buddies Special (2 adults): $80; Group Special (only for 20 adults or more): $35 per person For more information, visit www.runforhopesingapore.org.

In focus

SingHealth raised a record amount for beneficiaries of the President’s Challenge this year, the highest since it started fundraising for the challenge nine years ago. The cheque for $388,000 was presented to the President at Symphony for Health – the finale event of SingHealth’s fundraising efforts held at Punggol Waterway. At the ceremony were (from left) Mr Peter Seah, Chairman, SingHealth; President Tony Tan Keng Yam; Professor Ivy Ng, Group CEO, SingHealth; and Professor Ang Chong Lye, Deputy Group CEO, SingHealth, and CEO, Singapore General Hospital.

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A step forward in battle against dengue A drug that may be effective for treating dengue fever is being tested for the first time on patients

BY Lediati Tan

What is dengue fever?

The clinical trial of Celgosivir, a medicine derived from the seeds of the Moreton Bay Chestnut tree, was started in mid-July, and conducted by researchers at the Singapore General Hospital (SGH) and the Duke-NUS Graduate Medical School (Duke-NUS).

This is the first time that Celgosivir is being tested on patients with dengue fever.

Dengue fever affects up to 100 million people worldwide each year. Last year alone, about 5,330 cases were reported in Singapore.

Associate Professor Subhash Vasudevan, who directs the Emerging Infectious Diseases Therapeutics Laboratory at Duke-NUS, said: “Laboratory experiments at Duke-NUS have shown that Celgosivir inhibits four serotypes of dengue virus, so we took this important next step to find out how well it works in patients.”

Dr Jenny Low, the principal investigator of the study and consultant at SGH’s Department of Infectious Diseases, said: “The trial aims to find out if Celgosivir can reduce the amount of virus, fever duration and pain in patients who receive the treatment early in the course of dengue fever.

“The approach is different from that of dengue vaccines, which cannot be used to treat a dengue patient once he becomes ill.”

Assoc Prof Subhash said the trial will also investigate whether Celgosivir can be used to treat dengue fever, and whether it is able to prevent more severe forms of dengue, such as dengue hemorrhagic fever and dengue shock syndrome.

PHOTO: SIMON ONG

an antiviral drug may prove effective for treating patients with early stages of dengue fever – an illness for which there is currently no vaccine or cure.

Associate Professor Subhash Vasudevan and Dr Jenny Low want to test Celgosivir on 50 patients suffering from the early stages of dengue fever.

The $1.6 million clinical trial was approved by the ethics board of Singapore Health Services and the Health Sciences Authority of Singapore.

It is funded by the STOP Dengue Translational Clinical Research Programme under the Ministry of Health’s National Medical Research Council and the National Research Foundation.

Conducting the trial The trial is ongoing and the investigators are aiming to recruit 50 dengue patients, aged 21 to 60.

To be eligible, the patients must be suffering from the early stages of dengue fever, diagnosed within one to two days of infection.

The participants are to be referred by doctors from polyclinics, general practitioner clinics and the Communicable Diseases Centre (CDC).

They will be given Celgosivir tablets or a placebo, and monitored by SGH’s Investigational Medicine Unit (IMU), where they will stay for five days.

After completing the course of the medicine, they will be assessed to see if they are well enough to be discharged.

After discharge, the participants will

return to the IMU on three separate occasions – seven, 10 and 15 days later – for further assessment. Their medicine and treatment are provided for free.

A safe medicine Celgosivir is a safe medicine that was tested in the United States, Canada and Europe against other viral infections, said Dr Low. About 600 patients took Celgosivir in those studies. The medicine was tested on human immunodeficiency virus (HIV) patients in the early 1990s, and on patients with chronic hepatitis C virus infections from the late 1990s to around 2007 in the US and Europe.

In those studies, when patients first started taking the medicine, there were mild gastro-intestinal side effects such as gas production and mild diarrhoea. But these did not affect the patients’ lifestyle, said Dr Low. She added that the symptoms disappeared for some patients who took the drug for three to six months as their bodies adapted to the drug.

The side effects can also be mitigated by changes in dietary habits and the types of food eaten, said Dr Low.

Dengue fever is caused by the dengue virus, which is carried and spread by an infected Aedes mosquito. The disease cannot be spread by physical contact between humans.

There are four types of dengue virus.

Infection by one type usually provides lifelong immunity to that virus strain, but only short-term immunity to the other types of dengue. The incubation period is between three and 14 days.

Dengue haemorrhagic fever and dengue shock syndrome are more severe forms of dengue which can result in death.

What are the symptoms?

Symptoms usually develop four to seven days after infection. Symptoms include: Sudden onset of fever Severe headache, especially behind the eyes Severe joint and muscle pain Nausea and vomiting Body rash

What are the treatment options available?

There is currently no vaccine for dengue and no approved medicine for treating dengue fever. However, supportive care with intravenous fluids and frequent blood tests can help to reduce complications. In severe cases, blood transfusions may be required.

Patients need plenty of bed rest.

They should drink a lot of fluids and take medicine to reduce the fever.

Adapted from information available on the Ministry of Health, Health Promotion Board and National Environment Agency websites.

PHOTO: VERNON WONG

A painful experience During his second-year law exams at the National University of Singapore in 2009, Mr Sean Yeo Swee Quan (left) suddenly came down with a high fever.

Mr Yeo, now 25, consulted a doctor who prescribed paracetamol for the fever and pain. He continued to sit his exams even though his fever persisted for about three days.

After his exams, his parents took him to the hospital when the fever did not recede. Mr Yeo was eventually diagnosed

with dengue fever and was warded for about three days.

As there are no drugs to treat dengue fever, he was given medicine to alleviate the fever and aches, and was put on an intravenous drip and told to drink lots of water.

It was a “painful” experience, Mr Yeo said. He suffered intermittent headaches and “it felt like someone was hammering my head”.

His body ached and rashes developed

all over his body. He lost close to 6kg during his hospital stay as he could swallow only some biscuits and iced Milo.

Mr Yeo still cannot figure out where he contracted dengue. “You can get bitten by mosquitoes anywhere, and that’s kind of scary,” he said.

He added: “When you get a high, persistent fever, it may not be dengue, but it’s probably good to see a doctor and see what he says.”

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Department of Rheumatology and Immunology will be opening the Autoimmunity and Rheumatology Centre in November.

The centre, which synergises service, education and research, will have clinics dedicated to the treatment of specific autoimmune diseases such as scleroderma, systemic lupus erythematosus and rheumatoid arthritis.

Multidisciplinary services such as physiotherapy and occupational therapy will be available to patients suffering from autoimmune disorders and senior nurses trained in rheumatology will be on hand to educate and counsel patients.

Patients suffering from autoimmune diseases need long-term care, but Dr Low urged them to stay positive as effective treatments are available. To keep the diseases under control, regular reviews are also important, she said.

She added: “Get in touch with other patients to understand the illness. Aim to build a support network among your friends and family. There is no need to be frightened.”

When the body becomes its own enemy The immune system stops foreign invaders from harming the body. Sometimes, though, it mistakes the body as the enemy and causes harm instead

BY Sol E Solomon

Our immune system is meant to protect us from “foreign invaders” such as viruses and bacteria.

WOMEN ARE MORE PRONE PHOTO: winston Chuang

But when someone suffers from an autoimmune disorder, his immune system mistakes his own body as the “enemy” and starts attacking it.

“The best way to describe this is to imagine a civil war breaking out inside your body,” said Dr Andrea Low, Consultant, Department of Rheumatology and Immunology, Singapore General Hospital (SGH).

Autoimmune disorders can affect any part of the body, including the joints, skin and internal organs, such as the kidneys or the brain. There are over 80 types of such diseases, which include rheumatoid arthritis, spondyloarthritis, systemic lupus erythematosus and systemic sclerosis.

Rheumatoid arthritis, spondyloarthritis and lupus are among the most common autoimmune disorders in Singapore.

Autoimmune diseases occur when a person’s immune system turns against his own body, but Dr Andrea Low urged patients to stay positive as effective treatments are available.

Detective work The conditions are thought to be caused by genetic predispositions, or by environmental factors such as infections and viral attacks. Drugs or chemicals can also trigger such diseases in some people.

The effects of autoimmune disorders vary. For some patients, the disease causes the autoimmune system to attack their kidneys or brain, while in other people, it could be their blood or lungs that are affected.

The symptoms vary too, depending on the type of autoimmune disorder. A disease may manifest itself in one patient as weight loss or fever, while another patient may suffer a rash or an inflammation of the skin.

What is lupus?

What is scleroderma?

It is one of the more common types of autoimmune diseases in Singapore.

Butterfly-shaped rashes on the face are one of the “textbook” signs of the disease, appearing in about 30 per cent of lupus patients, said Dr Andrea Low, Consultant, Department of Rheumatology and Immunology, Singapore General Hospital.

It is common for lupus patients to have some form of joint problem.

Patients may feel fatigued at times.

They may also suffer intermittent fevers that do not go away after a month.

Lupus can affect the heart, lungs and kidneys.

Scleroderma is another type of autoimmune disorder, but it is relatively less common in Singapore.

The disease affects the blood vessels and the body’s fibrous tissues. It is often characterised by the hardening of the skin.

When scleroderma attacks the blood vessels, the fingers and toes may turn bluish-purple or white because of poorer blood circulation, and cuts may take longer to heal.

Ulcers may also develop on the fingers and toes and, in more serious cases, gangrene may set in.

Another common symptom is swelling of the hand. The skin thickens and becomes very tight and the hand looks shiny. In some patients, the joints are affected, making it hard to use the hand.

Scleroderma can be life-threatening if it affects the vessels that supply blood to the heart, lungs and kidneys.

As these symptoms can be evidence of other diseases, being able to recognise patterns of behaviour that typically show up in autoimmune disorders is key to correct diagnosis, said Dr Low, adding that it is also important to examine the patient and his medical history closely.

“It’s very much like detective work, supported by thorough investigation,” she said.

Autoimmune disorders can sometimes be life-threatening. Lupus, an autoimmune disease characterised by acute and chronic inflammation of various tissues anywhere in the body, can become dangerous when it affects the kidneys or leads to bleeding in the lungs.

Autoimmune diseases are treated with immunosuppressant drugs. They suppress a patient’s overactive immune system, but must be used with care as the drugs can weaken the immune system by too much and increase the risk of infections.

There is room for optimism. The 10year survival rate for lupus patients today, for example, exceeds 90 per cent.

“The sooner an autoimmune disease is detected and brought to the attention of doctors, the earlier it can be treated and the better we can prevent or reverse some of the organ damage,” said Dr Low. New Autoimmunity and Rheumatology Centre at SGH A lot of research on autoimmune diseases has been conducted in the last five to 10 years and doctors “are hoping that new treatments will become available”, she added.

And in a step towards serving more patients and improving the care of people with autoimmune diseases, SGH’s

Over

90%

of lupus patients are women

Women are usually diagnosed with lupus between

20 & 40 years of age

Safe to be pregnant A woman who has been diagnosed with lupus does not need to shelve her plans for starting a family, said Dr Andrea Low, Consultant, Department of Rheumatology and Immunology, Singapore General Hospital.

The illness does not directly affect fertility. Dr Low said she has seen many lupus patients go through successful pregnancies, with the children of many patients now grown up.

“In the past, we advised female lupus patients to avoid pregnancy,” she said. “But today, the survival and management treatments have advanced to a level where we can tell patients how to control their disease for at least six months, and then do family planning together with their doctors.”

For many female patients, the key is to ensure that their autoimmune disease does not flare up and attack major organs before they start their family planning.

“We will monitor things like kidney function and ensure the patients are taking their medicines correctly,” said Dr Low.

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Local discovery advances brain tumour research

biochemical pathways associated with the abnormal regulation of parkin. If all goes well, new findings will open up possibilities for more drugs to treat brain tumours and bring new hope to patients.

“But it is still early days,” cautioned one team member, Associate Professor Christopher Ang Beng Ti, Consultant, Department of Neurosurgery, National Neurological Institute (NNI). Assoc Prof Ang is also the Senior Principal Investigator, Singapore Institute for Clinical Sciences (SICS) at A*STAR.

Who gets gbm?

People in their 40s to 60s.

The condition is rare in children.

Unlike nose cancer (nasopharyngeal carcinoma) which is frequently diagnosed in the Chinese, particularly the Cantonese, GBM does not

What is GBM? The brain’s nerve cells (neurons) and supporting cells (glia) optimise brain function. If the “checkpoints” that inhibits the growth of the glia cells are disabled, the cells grow uncontrollably and form a glioma.

About 50 new cases of gliomas are seen annually at the NNI. GBM is the most malignant glioma, because its cancer cells reproduce quickly and are fed by a large network of blood vessels.

When a glioma first forms, it is usually very small and the patient will not experience any symptoms, which makes it hard for doctors to detect GBM early.

As it grows, it infiltrates the rest of the brain. It builds up pressure in the skull as it enlarges, causing tell-tale symptoms like headaches, nausea and vomiting.

Other symptoms may appear, depending on the glioma’s location in the brain.

For instance, if it is near the area of the brain that controls leg and arm movements, the patient may experience weakness in one half of his body. If it is in the area that controls speech, the patient may slur or find it difficult to recall words.

affect any particular ethnic group.

There are no gender associations locally, although some European studies have suggested that

males have a slightly higher risk of suffering the condition.

awake, if the tumour is close to critical functional areas of the brain. After surgery, the patient would need a few weeks of radiotherapy and chemotherapy. This is the current international standard of care for GBM. However, obstacles exist. If the glioma has spread from one half of the brain to the other, it cannot be removed completely. It would be challenging even to remove substantial parts of the tumour.

Even if it is successfully removed, there is no guarantee that chemotherapy will work, as different patients respond differently to treatment.

“We may be able to surgically remove every visible part of a tumour but, inevitably, there will be microscopic seeding of tumour cells in the brain that may lead to the recurrence of the tumour,” said Assoc Prof Ang. With each recurrence, the outcome of treatment will deteriorate, and patients will become increasingly disabled. Overall, only 60 to 80 per cent of GBM patients survive longer than a year.

Treatment options Ideally, the glioma should be surgically removed as soon as possible. With advances in neurosurgery, operations can now be done safely even with the patient

PHOTO: VEE CHIN

The landmark discovery The discovery was made by the collaborative team of Assoc Prof Ang with Dr Carol Tang, Research Scientist, NNI, and Associate Professor Lim Kah Leong, Department of Physiology, National University of Singapore.

Assoc Prof Ang said: “The parkin gene, when present, prevents uncontrolled growth of cells and, thus, the development of cancer. We found that the parkin gene in gliomas (a type of brain tumour) becomes disrupted or dysfunctional.”

Parkin is not the only tumour suppressor available, but it is the first that is well established in medical and research circles for movement disorders. When medical literature showed that the parkin gene could be linked to cancer, the Singapore team explored its possible link with GBM, the most common but highly malignant glioma.

In the lab, they showed that parkin regulated the growth of cancer cells. They searched international patient databases for survival outcomes and gene expression of patients with gliomas. From this, they proved that low levels of parkin led to poorer patient survival.

“That was the Eureka moment! We knew we were on the right track when

we saw the patient survival data corroborate the lab data,” said Assoc Prof Ang. Now, the team wants to find details of how parkin disruption leads to tumours developing. They hope this will shed more light on the biochemical pathways involved.

“Once we narrow that down, we may be able to identify some commercially available drugs to target those pathways. Then, we’ll be able to run clinical trials to test our theory. We’re hoping that can happen in the next five to 10 years,” said Assoc Prof Ang.

Associate Professor Christopher Ang Beng Ti and his colleagues showed that parkin regulated the growth of cancer cells, and proved it with data from around the world.

Hope present if research goes well If the new study bears fruit, treatment options for patients will increase. If the team successfully identifies the molecular pathways linked to parkin, existing chemotherapy drugs could potentially be used to target them.

This type of targeted treatment is not new and has already been employed in other cancers, such as breast and lung cancers.

“A one-size-fits-all regimen does not work on everyone. By the time a suitable alternative regimen is found, the patient may have deteriorated so much that the outcome is uniformly poor. But now, if we can profile each patient for parkin expression, the chemotherapy can potentially be tailored to the patient to maximise survival,” said Assoc Prof Ang.

When it may not be just a headache A headache will usually respond to medication, but brain tumours may exhibit the following characteristics:

Symptoms vary depending on the location of the tumour in the brain, but may include headaches nausea/vomiting blurred vision loss of appetite weakness in the limbs changes in mood changes in the ability to think and learn new seizures speech difficulty Symptoms are usually progressive in the onset, for example, progressive weakness in the arm intractable, meaning they are persistent and do not go away Headaches are usually of exceptional severity persistent of a different pattern from what you may usually experience particularly bad in the early mornings associated with vision problems or nausea

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News > Continued from page 1

the safety of patients on warfarin, the anticoagulation clinic was staffed mainly by doctors. But as a growing number of patients began to be put on warfarin, pharmacists joined the team in 2001 to take on the work of reviewing patients whose condition is stable, allowing the doctors – haematologists or blood specialists – to focus on patients with more complex conditions or new cases. More healthcare professionals at the clinic means that patients enjoy a longer consultation time and greater attention.

The anticoagulation patients are seen by their primary physician once a year.

In between these annual visits, they are seen more frequently – every two weeks to every three months, depending on their condition – by the clinic’s pharmacists, said SGH Pharmacist Lim Seng Han. Apart from reviewing the patient’s blood test result, the pharmacist will also probe the patient for significant changes in his lifestyle and diet. Exercise, for instance, can cause the body to metabolise warfarin, and the patient may then need to be prescribed a higher dose of the drug.

“During our pharmacist consultation, we will titrate (adjust) the warfarin dose for the patient if necessary and prescribe the necessary amount of medication for the patient. We also look out for side effects and symptoms of bleeding or thrombosis,” said Mr Lim. Educating patients about warfarin, how it works and reacts with certain foods and drugs, and the danger signs to be wary of – the darkening of urine and stool can indicate internal bleeding – is an important part of the consultation.

Lower hospitalisation rate Thanks to the clinic’s collective efforts, the overall quality of care has improved.

This was recently published in a study by the clinic’s pharmacists and doctors. The study, which tracked the performance of the clinic after pharmacists came on board, found that the hospitalisation rate of patients due to warfarin-linked complications dropped to less than 2 per cent in 2011, from about 9 per cent in 2001.

The study also found that the percentage of time that patients’ international normalised ratio or INR readings stayed within target increased over the same period, from about 47 per cent to 66 per cent. The INR is a standard test to measure blood-clotting time.

Having the INR fall out of range often can be dangerous: when it is above the target range, the risk of bleeding increases; while the risk of forming a blood clot rises when it is below the target range, said Mr Kong Ming Chai, Senior Principal Pharmacist, SGH, and the lead investigator of the study.

The data are the more impressive as the clinic is seeing a growing number of patients on warfarin. Since 2001, the number of patients referred to the anticoagulation clinic has doubled to about 500, about one-third of the 1,500 SGH patients who have been prescribed warfarin.

PHOTO: MORVEN KOH

Pharmacists take charge

Mr Kong Ming Chai (right), Senior Principal Pharmacist, and Mr Lim Seng Han, Pharmacist, work together to lighten the load of the clinic’s doctors.

Warfarin patients who are not seen by the clinic continue to be managed by their doctors, who come from various disciplines, such as cardiology and neurology.

In the meantime, the anticoagulation clinic has embarked on research projects to further improve warfarin therapy.

For example, its pharmacists are investigating why Indian patients tend

to breach their target ranges more often than patients from other ethnic groups.

In another project, they are examining how fasting affects the blood-clotting ability of Muslim patients during the Ramadan period.

“The results can help us manage our Muslim patients better, especially during the Ramadan month. If we know that fasting can increase the INR, we can adjust their dosage pre-emptively,” said Mr Lim, who is also part of the investigating team.

The clinic aims to increase the time the INR is within the therapeutic range (or TTR) to 70 per cent and higher. That is, the blood of warfarin patients must be adequately “thin” for at least 70 per cent of the therapy period.

Mr Kong said: “We hope to increase the range to 70 or 80 per cent, so that warfarin can keep pace with new drugs. If we can push this up to 80 per cent, it may mean that warfarin is even better than the new drugs.”

Ultimately, the safety of patients is key. “The important thing is patient safety and satisfaction, and we want to reduce unnecessary hospitalisation,” said Mr Kong.

Warfarin and its alternatives Warfarin Warfarin came into common usage almost

Alternative drugs Alternatives to warfarin became available only recently.

years ago

of them are dabigatran – known commercially as Pradaxa – and rivaroxaban, commonly known as Xarelto

Users must undergo blood tests and medical reviews every few weeks as changes in diet can disrupt the drug’s effectiveness.

Dabigatran and rivaroxaban are relatively unaffected by diet.

Both drugs take effect in a few hours, compared to a few days for warfarin.

Users need only an injection of vitamin K to boost their blood’s ability to clot and, hence, counteract the effects of the drug.

Warfarin costs about

No “antidote” is available for dabigatran or rivaroxaban, raising the risk of bleeding to death if the patient meets with an accident.

Dabigatran (must be taken twice daily)

costs about cents a day

a day

Rivaroxaban costs about a day

The choice of drug depends heavily on a patient’s profile. Pharmacist Lim Seng Han said the new drugs may be more suitable for patients who are taking many different medicines, whose blood-clotting time often strays from target, or who don’t have time for regular follow-ups.

How warfarin works The drug helps patients with conditions that cause blood clots to be formed in the blood vessels. When a blood clot breaks free, it can travel in the bloodstream until it lodges in a narrow blood vessel leading to or within the brain, causing a stroke. Warfarin alleviates these conditions by slowing the blood’s ability to clot.

Careful monitoring needed A warfarin patient must take regular blood tests to determine if his blood can clot within a target range, measured by the international normalised ratio or INR. The average person has an INR of one. Most patients who are prescribed warfarin must maintain INRs of between two and three.

This means they must take just enough warfarin for their blood to clot two to three times slower than the average person.

An overly high INR places the patient at greater risk of bleeding, and can be potentially fatal in cases like severe gastric bleeding or bleeding in the brain.

But an overly low INR raises the risk of stroke.

Watch your diet Vitamin K, found in food like broccoli and green tea, can neutralise the effect of warfarin. Vitamin K is used by the liver to make blood-clotting proteins.

Patients need not stop eating broccoli or other foods rich in vitamin K, but they do need to maintain a moderate and consistent weekly consumption of the vitamin.

Changes in a patient’s lifestyle and diet can amplify or nullify the effect of the drug, causing a patient’s blood to become too “thin” or too “thick”.

If green tea isn’t part of a patient’s regular diet, drinking it can cause his INR to drop from two to one the next day, said Mr Lim Seng Han, Pharmacist, SGH. But he added: “If green tea is already part of the patient’s usual diet, then drinking it should not affect the INR.” This is why warfarin patients must be monitored regularly and have their dosage altered when necessary.

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News

New heart valve, new baby

One lucky man becomes a new dad after getting donated heart valve

BY Tan May Ping

Mr Lim Hwee Chong calls his daughter, Gracia, a miracle baby as she was conceived only months after he received a heart valve transplant.

The bank for valves and tissues Mr Lim received the heart valve tissue from an anonymous donor through the National Cardiovascular Homograft Bank (NCHB). The bank recovers, screens and stores donated human cardiovascular tissues (homografts), such as heart valves, vascular tissues and tracheas (recovered homografts are transplanted from a deceased donor into a recipient).

He is among 45 patients, almost half

An NCHB employee storing the homograft in a metal column, which is then submerged in liquid nitrogen at minus 180 deg C.

of them aged 18 and below, who have received homografts since NCHB was set up in 2008.

Dr Lim Chong Hee, Senior Consultant, Department of Cardiothoracic Surgery, National Heart Centre Singapore, and NCHB’s Programme Director, said recipients who receive a cardiovascular homograft do not suffer side effects like organ rejection and do not require long-term medication.

PHOTO: Alvinn lim

The transplant in March 2011 was to fix a leaky heart valve which caused blood to flow back into his heart. Without it, he would have risked heart failure.

The operation’s success was cause for celebration, but baby Gracia was even more. Cradling the infant in his arms, the 33-year-old-youth pastor, who had been married for three years, said: “I didn’t expect to have a child so soon after the operation. I’m sure the transplant contributed to this success.”

Now, he is not only enjoying being a new father, but is also much fitter. The breathlessness, tiredness and tightness in his chest have gone. The avid cyclist is now back on track. He was given the green

light to resume sports three months after the operation.

Mr Lim is no stranger to heart problems. As a child, he had tetralogy of fallot, a heart defect that is present from birth.

His heart had four abnormalities, including a hole.

When he was eight years old, he had surgery to mend the hole in his heart. His health was stable until 2011, when his faulty pulmonary valve caused a severe backflow of blood into his heart. He was told he needed a heart valve transplant to fix the leak.

Mr Lim Hwee Chong and his wife Ms Emily Chia became new parents to baby Gracia just months after Mr Lim received a heart valve transplant in March 2011.

NCHB gets accreditation The National Cardiovascular Homograft Bank (NCHB) was accredited by the American Association of Tissue Banks in February this year, making it the first tissue bank outside North America to be accredited by the association.

All NCHB staff also sat an exam, conducted by the association, to become certified tissue-bank specialists.

Commenting on NCHB’s accreditation, Dr Lim Chong Hee, Senior Consultant, Department of Cardiothoracic Surgery, National Heart Centre Singapore, and NCHB’s Programme Director, said: “When we recover cardiac and vascular tissues from a deceased person, there is always a risk of contamination and infection. We need to make sure we have standards in place to make sure the tissues are of a high standard.”

Donors are scarce Mr Lim did not wait long for his heart valve but this is not always the case, as demand for cardiovascular homografts outstrips supply. Patients typically wait about three months for a transplant. On average, there are six to eight patients on the waiting list.

It can be difficult to get donors, as some people believe that donations will interfere with having an open casket funeral. “This is a misperception as the cardiovascular homograft recovery is performed by a trained surgeon in the most respectful manner,” said Dr Lim. He said human heart valves, are required mainly for patients with tetralogy of fallot or infected valves. Patients with mechanical valves need to take lifelong blood-thinning medication, which pose a high risk of stroke, and tissue valves from animals, only last for eight to 10 years.

Studies show that a human heart valve can last for 15 to 20 years. Mr Lim is profoundly grateful to the donor. “I thank him for his selfless decision. He has added years to my life,” he said.

He intends to pledge his body for donation and encourages those around him to do the same. He also plans to share his experiences with his daughter, and looks forward to bonding with her.

“I look forward to teaching her to enjoy sports when she grows up. And, thanks to my improved stamina, I would love to give her a piggyback ride!”

Donors needed Ms Tracy Seck, Senior Clinical Coordinator, National Cardiovascular Homograft Bank (NCHB) has a challenging job: She seeks donors.

Most people do not want to discuss death with family members before they die. “As a result, they don’t know the wishes of the deceased, and decisionmaking process is difficult,” she said.

When a suitable donor is identified, Ms Seck said she will try to understand the potential donor’s personality and ask the family whether he was a generous, caring person, and would have wanted to help someone in need. About one third of the families agree to donate.

After consent from the family and clearance by NCHB’s Medical Director, the following takes place: 1 A surgeon recovers the section of the heart with the aortic and pulmonary valves from the deceased.

The aortic and pulmonary valves are 2 separated in the NCHB laboratory.

3 The valves are incubated with antibiotics and tested for contamination.

4 They are packed using cryopreservatives and stored in liquid nitrogen at minus 180 deg C. 5 They are stored in a quarantine tank until cleared by lab results, then moved to a clinical tank, ready for transplants. Homografts can be stored for up to five years.

NCHB also holds roadshows and gives talks to students to increase awareness among the young of the need for donors. “We hope, that when they grow up, they will decide to pledge their organs or tissues,” said Ms Seck.

How to become a donor Tissues such as human heart valves, vascular tissue and trachea are covered under the Medical (Therapy, Education and Research) Act (MTERA).

People can opt into this scheme to donate their tissues after they die, for transplant or research purposes.

An individual has to be 18 and above to pledge to donate his tissues.

Under MTERA, a donor can specify which tissues he wants to donate.

If an individual has not pledged his tissues, his family can choose to donate them through MTERA upon his death.

Those who wish to pledge their tissues can do so by completing the yellow Organ Donation Pledge Form (go to the Live On website at www. liveon.sg). Send the form to the National Organ Transplant Unit.

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LISTEN TO YOUR HEART

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10 Rules of Blood Pressure Monitoring Using Tensoval duo control Blood Pressure Monitors 1.

BHS – British Hypertension Society A/A Grade Accuracy

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Measure daily at the same time, ideally in the morning as your blood pressure changes throughout the day 2. Do not smoke or take tea/coffee before taking your blood pressure 3. Rest your arm on a table and sit down while taking your blood pressure 4. Go to the toilet before taking your blood pressure 5. Avoid eating a heavy meal before taking your blood pressure 6. Do not move while taking your blood pressure 7. Do not talk while taking your blood pressure 8. When taking a second reading,rest for one minute 9. Always record you blood pressure down 10. Blood pressure measurement should be done daily

16/10/12 11:54 PM

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NOV

Terbitan Hospital Besar Singapur a dan Kumpul an SingHealth.

DIS 2012

M2

M3

M3

M4

Pembedahan huraikan obesiti morbid

Senaman untuk tulang yang kuat

Satu langkah saja ke arah visi yang terang

Mengembalikan senyuman sempurna

Apabila segala yang lain gagal Oleh Thava Rani

Puan Malia Dawan, 71, tidak dapat menurunkan tekanan darahnya – meskipun memakan enam jenis ubat berlainan setiap hari untuk mengawalnya.

Tekanan sistoliknya berada di sekitar 200 dan 210 milimeter raksa (mmHg) - lebih daripada paras140 mmHg yang wajar untuk seorang seusianya.

Anaknya Puan Yusminah Yusi, 55, jururawat terlatih, mengubah cara pembungkusan pil untuk memastikan ibunya memakan ubat dengan betul namun ini tidak juga memulihkan keadaan Puan Malia.

Tiada respons terhadap rawatan Puan Malia didapati mengalami hipertensi resisten di mana tekanan darah tingginya tidak memberi respons kepada rawatan meskipun menggunakan kombinasi sekurang-kurangnya tiga ubat.

Beliau sentiasa sesak nafas walaupun ketika bercakap atau berbaring. Keadaan ini membuat ibunya berisiko mendapat strok dan penyakit jantung.

Pada Januari tahun ini, Puan Malia menjalani denervasi renal di Pusat Jantung Nasional Singapura (NHCS). Prosedur baru kurang invasif ini menggunakan gelombang frekuensi radio untuk menghapuskan saraf simpatetik di sekitar arteri renal untuk menurunkan tekanan secara dramatik ke paras yang disasarkan.

“Kesannya dapat dilihat pada hari yang sama juga dan dia tidak lagi berasa sesak nafas,” ujar Puan Yusminah. Hipertensi – “pembunuh senyap” – hanya dapat dikesan apabila ia bertambah teruk dan pesakit mengalami komplikasi strok atau serangan jantung atau simptom seperti sakit kepala, sesak nafas dan pening kepala.

Menurut Dr Jack Tan Wei Chieh,

Perunding, Jabatan Kardiologi, Pusat Jantung Nasional Singapura (NHCS) dalam varieti resisten ini tekanan darah pesakit kekal tinggi walaupun memakan ubat dengan betul.

“Se per lima daripada populasi dewasa hari ini yang berusia 60 tahun ke atas menghidap hipertensi dan sekitar 3-5% mengalami sejenis bentuk rintangan.

Dengan penduduk yang semakin menua, kadar ini akan meningkat, begitu juga kes rintangan,” tambahnya.

Hipertensi resisten disebabkan oleh beberapa keadaan seperti ketidak seimbangan hormon, kegagalan ginjal atau sebab yang diketahui. Ia bertambah teruk pada individu lebih tua, obes atau menghidap kencing manis.

Namun pesakit kini mempunyai pilihan untuk menjalani prosedur denervasi renal.

Saraf simpatetik renal mengandungi saraf aferen dan eferen yang menghantar isyarat kepada otak yang bertindak balas sewajarnya.

Otak menghantar semula isyarat kepada

FOTO: alecia neo

Prosedur yang baru ditemui boleh membantu pesakit mengawal tekanan darah tinggi yang sukar dikawal

Dr Jack Tan Wei Chieh memeriksa tekanan darah Puan Malia Dawan sementara anaknya Puan Yusminah Yusi memerhatikan.

ginjal (melalui saraf renal) supaya arteri mencerut dan menyimpan lebih garam dan air, sekaligus meningkatkan tekanan darah.

Ginjal juga menghantar semula isyarat kepada otak mengarahkan jantung berdegup lebih kencang apabila tertekan dan ini juga menjejas tekanan darah.

“Saluran ini mengamuk dalam bentuk hipertensi resisten. Otak dan ginjal sentiasa menghantar jumlah isyarat yang keterlaluan kepada satu sama lain, bukan hanya semasa tertekan atau kekurangan air, malahan ketika keadaan tenang. Dengan melumpuhkan secara terpilih saraf simpatetik di sekitar arteri renal, denervasi renal membantu mengurangkan isyarat keter-

Apakah rintangan tekanan darah?

Tekanan darah normal sepatutnya berada di bawah paras 140/90 mmHg (angka pertama adalah tekanan darah sistolik, manakala yang kedua adalah tekanan darah diastolik). Dengan setiap peningkatan sebanyak 20 mmHg dalam tekanan darah sistolik melebihi paras normal, risiko penyakit kardiovaskular seseorang itu berganda.

Bagi pesakit yang mempunyai masalah diabetes, ginjal dan jantung, paras sasaran tekanan darah adalah di bawah 130/80 mmHg. Bagi pesakit yang menghidap hipertensi tetapi tiada masalah

perubatan lain, paras sasaran tekanan darah patut berada di bawah 140/90 mmHg. Hipertensi resisten berlaku apabila tekanan darah tidak boleh diturunkan ke paras sasaran tekanan darah dengan menggunakan tiga atau lebih jenis ubat, termasuk diuretik pada dos yang optima.

Diagnosis rintangan tekanan darah perlukan penjagaan kerana hipertensi tidak terkawal mungkin berlaku kerana kurang pematuhan dalam pengambilan ubat, atau hipertensi 'white-coat' (cemas berada di klinik)

laluan ini sambil menurunkan tekanan darah,” ujar Dr Tan. Prosedur yang lebih selamat Konsep mengganggu isyarat otak bukanlah baru. Para pakar bedah telah mengeluarkan saraf di sekitar arteri ginjal sejak 1930an lagi menggunakan pembedahan terbuka yang amat invasif. Walaupun berkesan, terlalu ramai pesakit mengalami komplikasi seperti pembuangan air kecil yang tidak terkawal dan masalah fungsi seksual. Kaedah ini dihentikan apabila ubat anti-hipertensi yang berkesan berada di pasaran.

Kini, teknologi kurang invasif telah menjadikan prosedur selama 40 minit sehingga sejam itu lebih selamat. Kaedah yang berkesan dan tahan lama ini telah diamalkan di negara luar selama dua tahun.

Walaupun ia tidak menyembuhkan tekanan darah tinggi, ia mampu mengurangkan tekanan sebanyak purata 32/12 mmHg. Kesemua tiga pesakit, yang telah menjalani prosedur ini di NHCS September tahun lalu, mencapai penurunan lebih daripada 20 mmHg. Penurunan sekecil 5 mmHg sekalipun boleh mengurangkan risiko strok sebanyak 14 peratus, penyakit jantung 9 peratus dan kematian 7 peratus.

Tekanan darah Puan Malia kini berada di paras 140/90 mmHg dan dia juga mengambil dos ubat yang kecil.

“Semua adik beradik ibu saya ada tekanan darah tinggi dan telah meninggal, ada sebelum menjangkau 50 tahun. Mereka tiada pilihan menjalani prosedur baru ini tidak seperti ibu saya,” kata Puan Yusminah gembira.

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Rawatan kecantikan ekstrem

FOTO: alecia neo

Pembedahan turunkan berat badan bantu dua pesakit lawan diabetes, obesiti dan penyakit lain

Dr Tham Kwang Wei (paling kiri) dan Dr Shanker Pasupathy (paling kanan) bersama pesakit pintasan gastrik mereka En Shaun Lawrence dan Puan Rozita Ramlee.

Oleh Valerie Lee

Berat badan En Shaun Lawrence, 32, dan Puan Rozita Ramlee, 36, melebihi 100kg sebelum ini.

Hari ini, tiada siapa yang dapat menduga mereka pernah obes. Atau pernah mengambil pelbagai jenis ubat untuk pelbagai penyakit yang berkaitan dengan obesiti.

Mereka berdua telah menjalani pintasan gastrik, satu pembedahan membantu menurunkan berat badan atau prosedur bariatrik yang berkesan untuk memperbaiki/memulihkan diabetes dan gangguan metabolisme lain. Untuk melawan obesiti, diabetes dan penyakit lain yang berkaitan, mereka telah menjalani pembedahan tersebut di Hospital Besar Singapura (SGH) hujung tahun lalu.

“Sebelum ini, saya tidak boleh berjalan jauh atau menaiki MRT dan bas awam. Pembedahan ini telah memberi saya kehidupan baru,” ujar En Lawrence, yang sekarang berlari, berenang dan pergi ke pusat senaman dengan kerap.

En Lawrence turun dari 117kg dengan indeks jisim tubuh (BMI) 35 kepada 85kg, sementara Puan Rozita turun kepada 93kg dari 128kg, BMI 50, selepas pembedahan masing-masing pada November dan September tahun lepas.

Mereka tidak lagi perlu mengambil ubat untuk mengawal diabetes, tekanan darah tinggi, kolestrol dan rawatan untuk apnea tidur obstruktif, keadaan di mana seseorang itu berhenti bernafas disebabkan saluran pernafasan tertutup semasa tidur lena.

Penilaian rapi Mereka menjalani temuduga dan kaunseling rapi di Pusat Pembaikan Gaya Hidup dan Peningkatan Kesihatan (LIFE), di mana kakitangannya terdiri daripada doktor, pakar pemakanan, ahli fisioterapi, ahli psikologi, jurupulih pekerjaan dan pekerja sosial perubatan berbilang disiplin. LIFE menggalakkan penjagaan bersepadu dan holistik untuk pesakit dengan kondisi perubatan berkaitan-gaya hidup, seperti gangguan pemakanan dan obesiti.

En Lawrence mendapatkan rawatan daripada Dr Tham Kwang Wei, Perunding, Jabatan Endokrinologi, SGH, dan Pengarah, Unit Obesiti dan Metabolik setelah dirujukkan ke Pusat Diabetes di SGH semasa penyaringan pra-pengambilan perkhidmatan negara.

“Dia seorang pesakit diabetes tipikal yang berat badannya turun naik. Setelah mendapatkan rawatan selama tujuh tahun

dia menghilangkan diri dan timbul semula dengan diabetes yang tidak terkawal dan berisiko terkena serangan sakit jantung menjangkau usia 40 tahun.”

Puan Rozita pula bosan keluar masuk hospital sebanyak empat kali kerana mengalami diabetes, radang ulser perut, apnea tidur dan sista ovari. Beliau berazam dan komited untuk menjalani pintasan gastrik kata Dr Shanker Pasupathy, Perunding Kanan, Pembedahan Am, dan Pengarah, Pusat LIFE, SGH. “Terdapat salah tanggapan umum bahawa pembedahan boleh menyelesaikan semuanya dan, selepas itu, anda boleh meneruskan hidup anda. Pembedahan ini sekadar butang set semula dan selepas itu, anda mesti mulakan pendekatan baru kepada kehidupan anda namun bukan hanya dari segi pemakanan saja.”

Pesakit pergi ke Pusat LIFE untuk belajar mengubah suai tabiat pemakanan mereka.

“Kami berbincang tentang pemakanan, memilih makanan dan bersantai. Mereka perlu membuat perubahan kerana pembedahan hanya membantu menurunkan sekadar 20 sehingga 30 peratus berat badan mereka,” ujar Dr Shanker.

Prosedur bariatrik – sama ada pintasan gastrik, pembedahan ikat perut (gastric lap band) atau ‘gastric sleeve’ – tidak

berkesan jika pesakit tidak merubah gaya hidup mereka.

Selepas pembedahan, perut pesakit dikecilkan ke saiz kantung kecil yang disambung ke bahagian tengah usus kecil.

Pesakit akan muntah jika makan berlebihan daripada apa yang boleh diterima oleh kantung tersebut.

En Lawrence biasanya memakan sekeping roti untuk sarapan, sekeping kecil ikan untuk makan tengahari dan sekeping kecil ikan untuk makan malam.

Puan Rozita, yang mengakui beliau sebelum ini tidak memahami erti “kenyang” apabila makan, telah mengajar dirinya untuk berkata “tidak” kepada sebahagian besar makanan.

Kedua-duanya kini komited dengan pemakanan sihat, senaman, regimen makanan tambahan harian dan lawatan tetap ke Pusat LIFE untuk mengawasi kemajuan mereka. Mereka kini penyokong gaya hidup sihat dan melibatkan juga ahli keluarga serta rakan-rakan mereka untuk mengikut tabiat baru mereka.

“Seorang individu yang menjalani pembedahan dan telah diajar mengenai pemakanan menjadi nukleus perubahan bagi sesebuah keluarga,” ujar Dr Shanker lagi.

Pesakit dibantu melalui sokongan pesakit yang mempunyai masalah serupa.

Bakal pesakit dan pesakit yang sedang melalui pelbagai fasa selepas pembedahan menghadiri mesyuarat kumpulan sokongan di Pusat LIFE, setiap petang Rabu.

Lingkaran dan pengokot Prosedur

Apa yang terjadi

Pro

Kontra

Lingkaran laparoskopik gastrik boleh laras (Laparoscopic adjustable gastric banding)

Lingkaran silikon yang boleh

Pembedahan yang agak ringkas Tidak memerlukan perut dibedah Kadar komplikasi selepas pembedahan yang agak rendah Boleh menjadikan diabetes peringkat awal bertambah baik Boleh diterbalikkan (jika lingkaran dikeluarkan sebelum terjadi komplikasi)

Benda asing dimasukkan kedalam badan Memerlukan pelarasan yang kerap di klinik Lebih kurang 10 peratus pesakit tidak berjaya mencapai sebarang penurunan berat badan Komplikasi lewat yang ketara, termasuk jangkitan, hakisan atau gelinciran lingkaran, memerlukan pembedahan ulangan

Gastrektomi lengan Laparoskopik (Laparoscopic sleeve gastrectomy)

Kira-kira 75 peratus perut dikeluarkan Hasil awal prosedur yang agak baru ini memberansangkan

Tiada benda asing dimasukkan sepertimana teknik lingkaran Pembedahan sekali sahaja Penurunan berat badan awal yang pantas Mengurangkan kelaparan lebih daripada teknik lingkaran Boleh menjadikan diabetes peringkat awal bertambah baik Pesakit boleh makan dengan lebih baik berbanding teknik lingkaran, tetapi masih lagi mengalami penurunan berat badan yang baik

Kekal dan tidak boleh diterbalikkan Hasil jangka panjang (melebihi lima tahun) tidak diketahui Garis pengokot pada perut boleh berdarah atau bocor

Laparoscopic Roux-en-Y gastric bypass

Kantung gastrik yang kecil dicipta terlebih dulu, kemudian pintasan kepada usus kecil dijalankan Ini mengurangkan pengambilan kalori dan mengubah cara makanan dihadam

Penurunan berat yang lebih banyak berbanding kaedah lain Boleh menterbalikkan diabetes jenis 2 yang sedia ada Prosedur yang sangat difahami memandangkan ia telah dijalankan lebih dari 40 tahun

Pakar bedah memerlukan lebih banyak latihan Garis pengokot dan penyambung gastrousus boleh berdarah atau bocor Komplikasi lewat, seperti ulser perut dan usus terpulas, boleh berlaku Kekurangan nutrisi boleh berlaku Memerlukan penjagaan pakar dan nutrisi tambahan sepanjang hayat

dilaras diletakkan di sekeliling bahagian atas perut untuk mengurangkan saiznya, supaya seseorang itu lebih cepat berasa kenyang dan makan kurang lagi dan dengan itu dapat mengurangkan berat badan Satu porta diimplankan di bawah kulit untuk membolehkan pelarasan halus diameter outlet

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Bersenam dengan penuh semangat Hapuskan tulang yang lemah dan rapuh dengan bersenam secara tetap Oleh Clarence Chen

Mungkin agak pelik apabila diberitahu bahawa senaman bagus untuk osteoporosis. Tetapi itulah yang disarankan oleh doktor kepada Puan Mary Gnanapragasam, yang telah didiagnos dengan kondisi tersebut sewaktu umurnya menjangkau 50an.

“Saya amat bimbang sewaktu saya mulamula didiagnos dengan osteoporosis. Saya tidak ingin jatuh dan mengalami patah atau retak tulang,” katanya.

Sekarang pada umur 70an, Puan Mary percaya sepenuhnya dengan manfaat senaman, dan boleh ditemui di pusat senamanLIFE Hospital Besar Singapura hampir setiap hari.

Osteoporosis adalah penyakit tulang yang terjadi apabila badan gagal untuk membentuk tulang baru yang mencukupi atau apabila terlalu banyak tulang lama yang diserap semula oleh badan, atau keduaduanya, yang menyebabkan tulang menjadi lemah dan rapuh.

Wanita tua cenderung kehilangan tulang dengan cepat semasa menopaus, iaitu apabila badan mereka tidak lagi menghasilkan estrogen, hormon pelindung tulang, kata Dr Manju Chandran, Perunding dan Pengarah, Unit Osteoporosis dan Metabolisma Tulang, Jabatan Endokrinologi, Hospital Besar Singapura.

Selain daripada lenguhlenguh dan sakit-sakit badan, Puan Mary tidak mengalami apa-apa tanda lain bahawa beliau menghidap osteoporosis. Penyakit ini biasanya dikesan agak lewat tetapi Puan Mary bertuah kerana penyakitnya didiagnos pada tahap awal semasa kajian semula perubatan.

Beliau dirawat di klinik osteoporosis oleh pakar osteoporosis dan dirujuk ke Pusat LIFE, di mana sepasukan doktor, jururawat pakar, pakar diet, ahli fisioterapi dan profesional perubatan lain mengajar pesakit yang menghidap kencing manis, obesiti dan kondisi

lain yang berkaitan dengan gaya hidupbagaimana untuk hidup secara sihat melalui senaman dan diet.

Pesakit osteoporosis menerima rawatan yang merangkumi ubat untuk merangsang pertumbuhan tulang, terapi senaman dan diet yangkaya-kalsium. “Diet dan senaman adalah elemen pelengkap rawatan mereka yang penting,” ujar Ahli Fisioterapi Kanan SGH, Puan Ng Deng Peng.

Di pusat tersebut, Puan Mary dinilai terlebih dahulu untuk mengetahui keadaan kesihatannya dan bahagian bermasalah sebelum pelan senaman dibuat untuknya.

Senaman ini termasuk latihan rintangan, keseimbangan, postur serta kekuatan, dan juga senaman menahan berat untuk merangsang pertumbuhan tulang.

Puan Ng dan ahli terapi lain

Tekan kaki: Untuk menguatkan bahagian bawah badan, kuadriseps atau otot bahagian depan peha.

Oleh Tan May Ping

Tidak memerlukan cermin mata Kanta multifokal premium telah dimasukkan ke mata En Kang, satu demi satu, selang dua minggu. Selepas prosedur itu, beliau tidak lagi perlu menggunakan cermin mata multifokalnya, yang telah digunakan selama 10 tahun. “Penglihatan saya hampir sempurna sekarang. Yang paling bagus

Kanta premium seperti yang di atas boleh meningkatkan hasil visual pembedahan katarak dengan membetulkan astigmastisme, rabun dekat (hyperopia) dan penglihatan jarak dekat (presbiopia).

sekali ialah saya tidak perlu lagi menggunakan cermin mata,” ujarnya. En Kang ialah di antara sejumlah pesakit katarak yang semakin bertambah di Pusat Mata Nasional Singapura (SNEC) yang telah memilih implan kanta intraokular premium.

Dalam pembedahan katarak, lapisan kabut yang mengaburkan penglihatan dibuang dan kanta diimplankan. Beberapa tahun kebelakangan ini, pembedahan katarak telah menjadi bukan hanya sekadar membuang katarak saja. Kanta premium membolehkan keadaan-keadaan lain seperti yang dialami oleh En Kang, serta juga miopia (rabun jauh) dirawat pada masa yang sama.

Kanta premium adalah hasil

di Pusat LIFE hadir sama sewaktu pesakit bersenam, merawat seorang sehingga empat pesakit semasa sesi latihan. Mereka memastikan para pesakit melakukan senaman mereka dengan betul, dan membuat pemeriksaan kerap untuk memastikan para pesakit tidak menghadapi kesukaran atau berasa tidak selesa.

Para pesakit juga diawasi secara tetap oleh doktor, jururawat dan ahli fisioterapi pusat tersebut, dan kemajuan mereka dilaporkan kembali kepada pakar perubatan utama mereka. “Doktor pesakit tersebut pasti gembira dengan kemajuan yang dicapainya,” ujar Puan Ng, menambah bahawa pesakit melalui dua pusingan program untuk setiap rujukan, sama ada yang baru atau berulang, dan selepas itu mereka dibenarkan keluar.

Dengan bantuan Puan Ng Deng Peng, Ahli Fisioterapi Kanan di SGH, Puan Mary Gnanapragasam menunjukkan beberapa senaman asas yang kerap dilakukannya untuk meningkatkan kekuatan, kefleksibelan, postur dan keseimbangannya.

Dengan kanta masa kini, pesakit yang menjalani pembedahan katarak boleh “membetulkan” penyakit mata yang lain pada masa yang sama

hariannya dan merasakan beliau tidak memerlukan pembedahan.

Akhirnya, beliau menjalani pembedahan pada tahun lepas dan gembira mengetahui bahawa beliau bukan hanya boleh membuang kataraknya, malahan juga boleh membetulkan astigmatismenya, rabun dekat (hiperopia) dan penglihatan jarak dekatnya (presbyopia) sekaligus.

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Pembedahan katarak semua-dalam-satu

Selama hampir tiga tahun, En Roger Kang, ejen hartanah, hidup dengan penglihatan yang semakin teruk disebabkan oleh katarak. Tetapi meskipun penglihatannya semakin kabur, beliau tetap meneruskan aktiviti

singapore he alth

penumpuan katarak dan teknologi pembedahan biasan. Menurut Profesor Madya Chee Soon Phaik, Perunding Kanan Oftalmologi, SNEC, 11 peratus daripada 10,500 prosedur katarak yang dijalankan setiap tahun di SNEC melibatkan penggunaan implan kanta intraokular premium.

Sekitar 50 sehingga 70 peratus pesakitnya – dari profesional muda sehingga suri rumah lebih tua – memilih kanta premium. “Kanta premium membolehkan pakar bedah menawarkan pesakit pilihan bukan saja untuk mensasarkan jarak penglihatan yang baik, tetapi juga membetulkan astigmatisme untuk memberikan penglihatan yang sangat jelas,” ujar Prof Madya Chee.

Tekan bahagian atas badan atau dada: Untuk menguatkan bahagian atas badan.

Apa yang dilakukan oleh kanta “Di samping itu, ia boleh memperbaiki aberasi visual, menjelaskan lagi penglihatan apabila anak mata mengembang pada waktu malam.”

Sesetengah butik, kanta intraokular premium boleh juga mempertingkatkan penglihatan, tetapi perlu disesuaikan mengikut individu tersebut. Namun, keadaan mata serentak boleh membataskan kejayaan visual yang boleh capai. Pakar bedah boleh memberi nasihat mengenai kanta mana yang paling sesuai untuk mata pesakit.

Prof Madya Chee mengingatkan bahawa tidak semua orang dapat memanfaatkan kanta premium ini dan kebebasan sepenuhnya dari menggunakan cermin mata mungkin tidak berlaku kepada sebahagian pesakit kerana hasilnya bergantung kepada keadaan mata individu tersebut.

Contohnya, kanta intraokular monofokal dan torik boleh digunakan untuk sebarang keadaan mata, termasuk mata yang mengalami astigmatisme. Walau bagaimanapun, implan dengan komponen multifokal dikhususkan untuk mata yang betul-betul sihat dan hanya menghidap katarak.

“Keputusan bergantung kepada keadaan mata pesakit, keperluan visual, gaya hidup dan kos,” ujar Prof Madya Chee.

Kanta premium juga umumnya adalah lebih mahal. Kos pembedahan katarak boleh dituntut dari Medisave dan bergantung kepada polisi tertentu yang dilanggan oleh seseorang itu insurans kesihatan mungkin melindungi prosedur ini untuk sebarang jenis kanta.

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Hampir kepada perkara sebenar Mendapatkan senyuman yang sempurna tanpa gigi palsu telah menjadikan implan gigi pilihan yang semakin popular (dental bridge), di mana gigi bersebelahan perlu dikikir. Implan juga lebih selesa dan kurang menonjol di dalam mulut berbanding gigi palsu, dan ia tidak memerangkap makanan.

Warga tua yang kehilangan hampir kesemua gigi mereka boleh memilih implan yang berfungsi seperti klip untuk mengikat gigi palsu. Untuk ini, dua implan dimasukkan ke dalam rahang. Tetapi sebaliknya, gigi palsu dengan sisipan sepadan bahagian bawah dipasang ke atas implan dan bukannya gigi prostetik.

Oleh Sheralyn Tay

Jika anda kehilangan gigi, implan gigi adalah yang paling hampir dengan gigi sebenar yang boleh anda dapati.

Pilihan untuk gigi yang hilang Dr See Toh memberitahu bahawa terdapat beberapa kelebihan dalam penggunaan implan untuk menggantikan gigi yang hilang. Implan tidak menjejaskan gigi yang lain, tidak seperti jejambat gigi

Beritahu kami Keliru dengan peringatan SMS Bapa saya meninggal beberapa bulan lalu. Kenapa Hospital Besar Singapura (SGH) masih terus menghantarkan peringatan SMS kepada kami mengenai temujanji kliniknya?

Kami bersimpati atas kematian bapa anda. Sistem data pesakit kami mendaftarkan secara automatik kematian pesakit jika dia meninggal di SGH. Jika pesakit meninggal di rumah, rumah penjagaan atau hospis, ahli keluarganya perlu memaklumkan kepadapihakhospital bagi mengemaskini fail pesakit.

Ahli keluarga boleh berbuat demikian dengan menghantarkan satu salinan sijil kematian kepada hospital, melalui pos atau e-mel. Jika tiada sijil kematian, ahli keluarga boleh menyerahkan dokumen lain seperti laporan polis atau hospis. Ahli keluarga juga boleh menulissuratkepada pihakhospital surat atau menghantar e-mel kepada medicalreport@sgh.com.sg, menyatakan hubungannya dengan pesakit.

Sebelum kami menerima makluman, sistem hospital tidak akan mengetahui

FOTO: alecia neo

Pusat Pergigian Nasional Singapura (NDCS) mendapati lebih ramai pesakit yang mahukan implan, dan bilangan implan yang dijalankan, meningkat tiga kali ganda sejak 2005 sehingga 2010.

Kemajuan dalam teknologi dan teknik, di samping kesedaran yang semakin meningkat, telah meningkatkan permintaan, ujar Dr See Toh Yoong Liang, Pendaftar Kanan, Unit Prostodontik, Jabatan Pemulihan Pergigian.

Katanya: “Dalam dekad kebelakangan, permintaan meningkat ketika sains semakin maju. Kita sekarang boleh menjangka dengan ketepatan yang lebih baik mengenai kadar kejayaan implan. Implan rahang bawah, contohnya, mempunyai kadar kejayaan 95 peratus manakala 90 peratus untuk rahang atas.”

Tetapi implan mempunyai beberapa risiko berkait dan bukannya untuk semua orang. Pesakit dengan ketumpatan tulang rendah pada rahang atau masalah perubatan yang menghadkan penyembuhan luka mungkin tidak sesuai mendapatkan implan.

Dr See Toh memberitahu bahawa ianya penting untuk doktor gigi menjalankan prosedur diagnostik, seperti x-ray dan imbasan ‘conebeam’ untuk menilai lebar dan ketumpatan tulang rahang sebelum pembedahan. Imej tersebut membolehkan

Dr See Toh Yoong Liang menjalankan implan gigi untuk pesakit.

bahawa pesakit telah meninggal dan ahli keluarganya mungkin akan terus menerima peringatan SMS dan peringatan lain berkenaan temujanji.

Bergegas ke sana tetapi tidak boleh mendaftar Saya tiba di Poliklinik pada pukul 11.35 pagi tetapi diberitahu bahawa pendaftaran telah ditutup kerana klinik terlalu sesak. Laman web menyatakan bahawa pendaftaran ditutup pada pukul 12 tengah hari. Saya diberitahu agar datang semula untuk sesi tengah hari. Ianya tidak adil memandangkan saya telah bergegas untuk tiba sebelum waktu sesi pagi tamat.

Kami cuba sedaya upaya untuk merawat seramai mungkin pesakit setiap hari. Apabila klinik sesak, kami menutup pendaftaran bagi memastikan doktordoktor kami mempunyai masa yang mencukupi, bagi menjaga keselamatan pesakit, untuk memberikan rawatan dan jagaan yang sewajarnya kepada setiap pesakit. Pendaftaran terakhir untuk semua poliklinik SingHealth (SHP) adalah pada pukul 4 petang. Tetapi kes-kes kecemasan akan dirawat dengan segera. Klinik kami

biasanya sangat sibuk pada malam cuti umum dan hari selepasnya, hari Isnin dan hari Sabtu. Orang awam boleh memeriksa bilangan pesakit di klinik melalui Pengawasan Giliran di laman web SHP. http://polyclinic.singhealth.com.sg.

Menggunakan agensi luar untuk mengutip bil tertunggak Saya menerima surat peringatan daripada agensi kutipan hutang menuntut pembayaran segera bil hospital berjumlah $150, atau Hospital Besar Singapura (SGH) akan memulakan tindakan undang-undang. Kenapa hospital tidak mengingatkan saya mengenai bil tersebut tetapi sebaliknya melantik agensi kutipan hutang luar?

Ia adalah amalan standard hospital, termasuk SGH, untuk melantik firma luar bagi membantudalamproses kutipan hutang yang rumit dan menyusahkan, supaya mereka boleh memberi tumpuan untuk merawatpesakit. Salah satu tugas agensi kutipan ialah untuk memaklumkan pesakit bahawa mereka telah terlupa membayar bil mereka.

doktor gigi menilai sama ada terdapat tulang yang mencukupi untuk menyokong implan dan menentukan panjang implan.

Prosedur implan gigi boleh mengambil masa lebih kurang tiga hingga empat bulan. “Dalam kes-kes yang sukar, di mana terdapat tulang yang tidak mencukupi dan graf tulang diperlukan, prosesnya boleh memakan masa enam hingga lapan bulan,” ujar Dr See Toh. Graf tulang adalah prosedur untuk “menumbuhkan” lebih banyak tulang. Proses ini membantu doktor gigi mengenal pasti struktur yang perlu dielakkan, seperti saraf dan tulang, dan menggunakan implan dengan saiz yang betul.

Doktor gigi biasanya memberikan dua bulan untuk penyembuhan, dan tulang untuk bercantum dengan implan sebelum memasang korona (crown). “Anda tidak ingin membebankan implan (dengan korona kekal) terlampau cepat,” beritahu Dr See Toh. Adakah implant mini selamat?

Baru dalam pasaran adalah implan mini, yang menggunakan beberapa skru lebih kecil untuk memasang korona kepada tulang rahang. Ia alternatif yang lebih murah dan lebih cepat, tetapi ia mempunyai risikonya sendiri.

“Biasanya, implan mini digunakan di NDCS sebagai pengangkoran dalam rawatan ortodontik,” kata Dr See Toh. “Tidak ada banyak bukti jangka masa panjang implan untuk menyokong penggunaan implan mini sebagai penyelesaian pengganti gigi yang kekal. Ini kerana ia mempunyai diameter yang amat sempit dan, oleh itu, lebih berisiko untuk pecah atau patah selepas beberapa lama.”

“Implan agak banyak terdedah kepada haus dan lusuh kerana mengunyah dan menggigit, jadi ia amat penting untuk memilih jenis yang betul,” tambah Dr See Toh.

Klinik pesakit luar mengenakan bayaran ke atas pesakit selepas rawatanmereka, dan pesakit yang tidak mampu untuk melangsaikan akaun mereka ketika itu boleh membayarnya kemudian. Para pesakit yang dibenarkan keluar dari wad akan menerima bil akhir mereka selepas tiga hingga empat minggu kemudian, apabila tuntutan dari Tabung Simpanan Pekerja (CPF) dan syarikat insurans perubatan telah diselesaikan.

Para pesakit boleh melangsaikan akaun mereka yang tertunggak melalui cek, di cawangan Singpost, kedai-kedai 7Eleven dan stesen SAM atau AXS. Agensi kutipan akan mengingatkan pesakit apabila bil telah tertunggak lebih dari sebulan. Sekiranya bil masih tidak dibayar, dua lagi surat peringatan akan dihantar – setiap satunya dalam jarak sebulan – sebelum tindakan undang-undang dimulakan. Ketika ini, agensi akan berusaha untuk menghubungi pesakit melalui telefon jika terdapat nombor telefon.

Pesakit yang mempunyai kesukaran untuk membayar bil mereka boleh dirujuk kepada Pekerja Sosial Perubatan kami, yang akan menilai dan memberitahu mereka jika mereka layak menerima bantuan kewangan, seperti Medifund.

Nov⁄ Dec 2012

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Beauty

Lifting the veil on cosmetic eye surgery Apart from treating medical conditions, the Singapore National Eye Centre also does cosmetic surgery. By Celine Lim Many people go to private clinics – or even overseas – for cosmetic eyelid surgery, but few realise that doctors at the Singapore National Eye Centre (SNEC) perform these procedures as well.

Specialists at SNEC’s Oculoplastic Service, who deal with medical conditions affecting the eyes, also perform surgery – creating double eyelids, removing eyebags and correcting droopy eyelids – for purely aesthetic reasons. All three are cosmetic concerns, but droopy eyelids can turn into a medical condition, if they begin to affect sight, which sometimes happens in older patients.

Droopy eyelids Dr Sunny Shen, Consultant, Oculoplastic Service, said: “Having droopy eyelids is like having a curtain in front of your eyes.”

They are caused by weak levator muscles – the muscles which create double eyelids and are responsible for raising the eyelids. Some people are born with weak levator muscles, but most find these muscles weaken through wear and tear with age, giving rise to droopy eyelids. Dr Shen said if the problem is just a case of slight asymmetry between the eyes, it may be a cosmetic concern, but if it affects vision and normal activities, it becomes a medical condition.

People with droopy eyelids often find the top part of their vision blocked. In

Estimated surgery costs Droopy eyelid surgery

$2,400-$5,500

Double eyelid surgery

$2,300-$3,600

Eyebag surgery

$2,300-$3,600 Medisave may be used only for non-cosmetic treatments.

Surgery to correct droopy eyelids and eyebags, and to create double eyelids, can be performed by SNEC’s Oculoplastic Service.

severe cases, they may even have to tilt their heads and lift their chins to see what is ahead of them. They tend to raise their eyebrows constantly to lift their eyelids, and this can cause headaches.

They also suffer from eye strain and have difficulty reading for a long time when looking down. In young patients without congenital problems, the most common cause of weakening levator muscles is the use of contact lenses.

Blinking makes the edges of the lenses rub constantly against the levator muscles, weakening them over time.

Fixing droopy eyelids Some patients can be managed with medication and “crutches” (metal wires mounted on the back of spectacles to hold the upper eyelids open) but most need surgery to lift their upper eyelids, and in some cases, remove excess skin.

“But eyelids cannot be lifted too high as this can result in incomplete eye closure. Moisture can then escape from your eyes and you’ll end up developing corneal problems,” said Dr Shen.

In cases of congenital droopy eyelids, the surgery might also involve a sling operation, where a piece of tissue is used as a “sling” to connect the upper eyelid to the forehead muscle.

What causes eyebags?

They occur when fat tissue behind the lower eyelids bulge forward. This happens when the membrane in the eyelid which holds the fat back, weakens with age, said

Dr Audrey Looi, Senior Consultant and Head, Oculoplastic Service, SNEC. Surgery removes eyebags by repositioning the protruding fat, and in some cases, by removing excess skin under the eyes. But doctors are conservative when removing excess skin to prevent the lower eyelid from turning out after surgery – which would expose the inner membrane along the lower edge of the eye. “We have to judge carefully how much excess skin we can remove, without risking such complications. So, sometimes, there may still be fine lines under the eye after surgery.”

She said surgeons also avoid the inferior oblique muscle hidden in the fat, as disturbing it can cause double vision.

The muscle – located at the base of the eye – is responsible for the movement of the eye. Dr Looi said surgeons take care not to pull excessively on the fat as this can trigger haemorrhage behind the eye and cause visual loss. “This is very rare, but it has been reported in the past when the trend was to remove as much fat as possible.”

Surgery for eyebags There are two different approaches to eyebag surgery.

Transconjunctival approach: A cut is made on the inner lower eyelid through which a bit of fat is removed.

There is no scar, so healing is faster.

It is suitable for patients in their late 30s to early 40s who have fairly elastic skin and mild bulging of fat. It is also

ideal for young thyroid patients with increased fat volume around the eyes.

Subciliary subcutaneous approach: A cut is made below the lower lash line and the inner membrane is opened up. The sagging fat is repositioned.

If the lower eyelid is lax, the muscle or tendon of the outer eye corner is tightened for improved support. It is suitable for patients with excess skin, which can be removed as well.

High demand for double eyelids Double eyelid surgery is the most common cosmetic surgery among Asians, said Dr Elaine Chee, Consultant, Oculoplastic Service, SNEC. The upper eyelid, controlled by the levator muscle, is attached to the skin above the eye. In Westerners, this forms a fold that results in a double eyelid but, in some Asians, this attachment does not occur, said Dr Chee, who was trained locally and in South Korea. In addition, some Asians have bulky fat tissue in their upper lids, resulting in protruding or puffy eyelids, which may even hide natural double eyelids. They also tend to have prominent skin folds (epicanthic folds) in the upper eyelids that cover the inner corners of the eyes. These folds can cover the upper eyelashes and part of the upper eyelids, making the eyes look “almond-shaped” and smaller.

While surgery may alter these physical traits, differences such as bone structure around the eyes, cannot be changed. Dr Chee advises Asians with these characteristics to have realistic expectations. “We cannot look like Angelina Jolie or Cindy Crawford because we don’t have deep-set eyes. But we can enhance what we have, even as we maintain our Asian features.

Doing so allows our eyes to complement the rest of our face,” she said.

Surgery for double eyelids The following surgical methods for double eyelid surgery are done under local anaesthesia.

Open: Some fat and excess skin is removed from the upper eyelid, and the wound stitched to create a double eyelid crease. It is suitable for patients with excess skin and fat in the upper lid area.

Small incisions: Three 2mm cuts are made in the upper eyelid. Small amounts of fat are removed and the incisions stitched up. Recovery time is faster compared to open surgery.

It is suitable for those with a small amount of fat and skin in the upper lid area.

Non-incision: Three small punctures are made and a thread is passed through the openings to create the double eyelid crease. This procedure can be done quickly. Recovery time is usually very short, but the results may not last as long. It is suitable for younger patients with thin skin.

Epicanthoplasty: An operation to reduce prominent epicanthic folds so the new double eyelid fold created is not hidden.

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Nov⁄ dec 2012

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Viewpoint

Finding peace despite the pain

BY TOH HAN CHONG

During a morning ward round in Ward 48 of Singapore General Hospital, my medical oncology team and I met Mdm Goh, who had advanced breast cancer.

She was undergoing radiation therapy to control her headaches, which were caused by cancer spread to the brain.

Mdm Goh, a mother of two teenage children, smiled broadly as she made two requests in Mandarin.

“Doctor, my husband wants to take me to Marina Bay Sands to stay over the weekend. Can I take home leave?”

Her second request was: “Doctor, I am not afraid to die, but can you make sure I am not in pain when it happens?”

She had received several lines of chemotherapy before her cancer progressed to the brain, usually a sign of poor prognosis.

Her schoolteacher husband was the sole breadwinner and, despite their financial situation, I could sense her happiness at the thought of spending a memorable “staycation” weekend with her husband.

This incident evoked haunting images from an award-winning Hong Kong film called That’s Life, My Love, in which Anita Yuen portrayed a spunky street opera artiste afflicted by terminal bone cancer.

Up to 70 per cent of patients will encounter pain in their cancer journey. Today, modern medicine and solid supportive care can alleviate 90 per cent of it.

One night in hospital, she mentions to her struggling musician boyfriend, played

by Lau Ching Wan, that she is hungry.

He then faithfully rushes out to buy her favourite woon jai ko (Chinese kueh) but, upon his return to her bedside, he finds her dead.

There have been many poignant stories recounting the last wishes of cancer patients.

Movie company Pixar organised a special home screening of its then yetto-be released film Up for a 10-year-old girl Colby, who was weak from terminal cancer and desperately wanted to watch it. Seven hours after the screening of the film, Colby died.

Then there was fiveyear-old Bethany Fenton with terminal brain cancer, whose last wish was to sing for celebrity Simon Cowell.

Her wish was granted at the Britain’s Got Talent final, where she sang Twinkle Twinkle Little Star backstage to a visibly moved Cowell.

She died peacefully two days later in her parents’ arms at an Oxford hospice.

As cancer specialists, we do receive such “last wish” requests.

From the father with terminal colon cancer determined to be alive and strong enough to walk his daughter down the aisle on her wedding day, to the young pregnant mother-to-be with advanced breast cancer receiving chemotherapy and fighting for time to deliver her child safely and in good health.

Alleviating pain The cancer specialist will work hard to achieve this with the latest in medical treatment, which includes tailoring drug therapy.

Unlike the slim odds of winning at the casino, the odds of cancer shrinkage, as a result of anti-cancer treatment, keep improving.

More importantly, the odds of survival have also risen for many cancer patients.

Recent landmark discoveries that unique gene profiles of patients can predict specific anti-cancer drug benefits further push up cancer treatment responses and survival rates significantly.

But, in cases where there is no evidence that life can or should be prolonged, there comes a point when it is no longer meaningful to keep prescribing anti-cancer drugs.

Instead, the patient may end up suffering more undue side effects and unnecessary financial burden.

The focus then should be to best control the patient’s symptoms, thereby enhancing his quality of life.

Most cancer patients’ last wish, like Mdm Goh’s, is simply to be free of pain.

Family members will do everything they can to fulfil the last wishes of their terminally ill loved one.

Up to 70 per cent of patients will encounter pain in their cancer journey.

Today, modern medicine and solid supportive care can alleviate 90 per cent of such cancer pain. The late Dame Cicely Saunders, founder of the hospice movement, coined the term “total pain”, which encompasses not just physical pain, but also social, psychological and spiritual pain.

The “gift of pain” So, while we can use pain medication and state-of-the-art interventions to relieve physical pain, we must not ignore these other pain dimensions which require a more holistic approach.

Pain hurts. Why does it exist? As a young medical student, I had the privilege of hearing the great pioneer surgeon in leprosy, the late Dr Paul Brand, speak.

In his talk, he explained why pain was an essential part of the human experience and called it the “gift of pain”.

Leprosy patients are infected with bacteria that eat into their nerves and skin, causing them to lose the sensation of pain.

Their numbed bodies experience damage from trauma and burns, and their limbs even get ravaged and scavenged by animals.

Not able to blink from normally annoying irritants, their eyes become scarred.

Illustration: cheng puay koon

The last wish of most terminally ill patients is simply to be free of pain in their final days

So, pain is like a warning light that steers us away from deadlier danger, destruction, disintegration and demise.

Pain makes us more aware of being alive and human.

But towards the end of life, pain is also no longer that vital.

On the morning the medical ward team met Mdm Goh, we also met Mdm Haslinda, an 80-year-old granny with terminal pancreas cancer.

She was surrounded by generations of her supportive family, including squealing toddlers merrily playing by her bedside.

With the morning sun streaming onto her face and thin, cancer-racked body, her pain was nevertheless well controlled and she was a portrait of peace, calm and dignity.

She was ready.

Helping to make last wishes come true is part of making the trial of cancer an easier journey.

This article was first published in The Straits Times on May 3, 2012. Dr Toh Han Chong is Head and Senior Consultant, Department of Medical Oncology at the National Cancer Centre Singapore.

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singapore he alth

NOV⁄ DEC 2012

Viewpoint

The importance of trust

unprofessional, but can lead to a surrender of professional autonomy. Extra tests and procedures may help “cover the doctor’s back”, but they come with risks that often outweigh the reassurance they are intended to provide.

Some people in the profession think regulations and litigation will ensure good professional standards and conduct.

I disagree. These can ensure a minimal standard of care and professional behaviour, but relying solely on them may make litigation more important than the patient’s welfare.

The doctor’s primary goal then may be to stay out of trouble. A trusting patient-doctor relationship is unlikely to grow in a hostile environment dominated by fear.

Trust between doctor and patient is critical, so what can both sides do to build and sustain it?

BY Chin Jing Jih

Recently, an exasperated doctor remarked that more patients nowadays seem incapable of trusting their doctors’ clinical judgments. They question almost every

With ‘smart trust’, a patient’s trust in his doctor is complemented with the doctor’s efforts to help him understand his illness, analyse his treatment options and make an informed decision.

We may laugh, but the story raises important points. It reminds us that despite advances in medical technology and research, the doctor’s ability to make clinical judgments is still key. This is a composite skill, honed through experience, knowledge, practice and years of fine-tuning.

Medicine is a scientific discipline without absolutes. Outcomes and patient responsiveness are never certain. Some patients closely comply with treatment guidelines but fail to recover, while others don’t comply and do recover.

PHOTO: GETTy images

decision, and insist on many “hightech” investigations before accepting their doctors’ advice.

Although I think such patients are in the minority, they remind me of a story: A man ran into a vet’s office carrying his dog and screaming for help. After examining the dog, the doctor told him it was dead.

Agitated, the man demanded a second opinion. The vet went into the back room and returned with a cat, which sniffed and poked the dog, then looked at the vet and meowed.

The vet told the man: “I’m sorry, but the cat thinks your dog is dead too.”

Unwilling to accept it, the man threatened to sue. The vet shrugged and brought out a labrador, which sniffed the dog, then looked at the vet and barked. The vet told the man: “I’m really sorry, but the labrador also thinks your dog is dead.”

Resigned, the man thanked the vet and asked for the bill but, when he saw it, he exclaimed: “What? $1,650 just to tell me my dog is dead?”

The vet replied: “I charged you only $50.

The rest is for the cat scan and lab test.”

The majority of doctors here strive to be technically dependable. They uphold high ethical standards and do their best to provide good care.

There is also inherent uncertainty in the findings of “evidence-based medicine”. It is impossible for a layperson to understand all the medical methodology on which his diagnosis rests. Despite this, doctors must still provide their professional opinion on what is best for their patients.

Nurturing “smart trust” So, how should doctors cope?

The answer lies in trust, which is the basis of any good patient-doctor relationship. With trust, a patient can be assured that every doctor in the system is properly trained, certified and able to provide safe and competent medical care. He knows his doctor will do what’s best for him, adhere to ethical and professional standards, and make full disclosure if there is a medical error.

At the highest level, the patient will continue trusting his doctor even if the outcome is negative, because he accepts that the result was unavoidable despite his doctor’s best efforts.

Without trust, the patient-doctor relationship is untenable.

In his books, The Speed of Trust: The One Thing That Changes Everything and Smart Trust, Stephen Covey and his colleagues advocate “smart trust”, which balances the propensity to trust with an equally high level of analysis. With “smart trust”, a patient’s trust in his doctor is complemented with the doctor’s efforts to help him understand his illness, analyse his treatment options and make an informed decision based on his doctor’s advice.

Regulations not a long-term answer In societies where medical litigation is an almost habitual response to negative outcomes, doctors will manage the legal threat by practising defensive medicine.

When a patient does not trust his doctor, and the doctor does not believe the patient will be reasonable and forgiving, the doctor will use technology (deemed less fallible) in place of his professional judgment.

Defensive medicine is not always

Invest in a culture of professionalism In the long term, trust in the medical profession cannot be sustained by regulations and litigation. What is needed is a continuous investment in a culture of professionalism and good doctors to drive it.

Good Medical Practice, published by Britain’s General Medical Council (GMC), offers a simple and succinct description: “Patients need good doctors. Good doctors make the care of their patients their first concern. They are competent, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy, and act with integrity.”

I am confident that the majority of doctors in Singapore strive to be the good doctors described here. They are technically dependable, earnestly uphold high ethical standards, and always do their best to provide good care while within the defined boundaries of the profession.

Doctors should practise in a way that enhances, not erodes the trust of their patients and the public. They should nurture this trust with the help of healthcare institutions and professional organisations such as the Singapore Medical Association (SMA). They should share medical methodology and the intrinsic limitations of clinical research with patients, to manage their expectations without compromising their confidence.

The SMA is committed to lead the profession in this mission, and increase its impact by collaborating with fellow professional organisations, the Academy of Medicine and the College of Family Physicians. Ultimately, winning and strengthening trust should be the mission of every doctor.

Associate Professor Chin Jing Jih is President of the Singapore Medical Association and Chairman of Tan Tock Seng Hospital’s Division of Integrative and Community Care. He serves on several medical ethics committees and is actively engaged in medical education here. This is an abridged version of his article, The Importance of Trust, which was first published in SMA News, Vol. 44 No. 7, in July 2012.

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People

Beating burnout

simple to unwind and relieve stress. It could be window shopping, browsing in the library or stopping at the supermarket to pick up some groceries before heading home.

“It’s my ‘me’ time when I unwind,” said Ms Chee, who has two children, aged 13 and nine. This way, she returns home relaxed and in a much lighter mood.

The second thing that helps her is her love for the job. In university, when inspecting the prospectus, she was delighted to discover that social work would allow her to do good while still earning a living.

Listening to other people’s problems every day can take its toll, but Medical Social Worker Chee Ching Yee is not fazed

By Sol E Solomon

Looking back to when she graduated in 1992, Ms Chee Ching Yee said that out of the 90-strong cohort of social work graduates, only about 10 still do social work.

Attitude makes the difference The third thing is her attitude. As a medical social worker with SingHealth Polyclinics, she helps assess the financial needs of patients, many of whom have chronic illnesses and need help to pay their medical bills.

But she feels that her patients help her as much as she helps them.

“They often share their stories with me and when I recall what they’ve done – whether they’ve done it well or not so well – I learn from their experiences. This way,

PHOTO: WONG WEI LIANG

“Burnout is a big issue for social workers, especially among the new ones. I was lucky because I had strong support.”

But that does not mean it is plain sailing for her. A social worker’s life revolves around the problems and hardships of patients.

Three things in particular keep her going. First, she avoids taking problems home by creating a buffer between work and home. Every day before heading home, she spends an hour doing something

Ms Chee Ching Yee always takes some time out before going home from work.

Job makes him value family more Dr Iain Tan’s work in cancer research makes him acutely aware of how precious life and family are

as an award-winning clinician scientist involved in cutting-edge cancer research, while also pursuing further studies, Dr Iain Tan, 34, is a very busy man.

But it is precisely the work he does that makes the father of two even more devoted to his family.

With his packed schedule, time is something Dr Tan has little of, so he counts the time he spends with his family as a blessing. At home, he spends most of his time with his daughters, aged five and two. He enjoys teaching them and taking them swimming.

“My work makes me treasure life more,” he said. “Good lifestyle habits generally lead to better health but there are people who lead healthy lifestyles and still get stricken by diseases. If nothing else, my work has made me even more acutely aware of the gift of life.”

Dr Tan exercises regularly and relaxes by listening to music. “I have to admit that after a hard day’s work, it takes a lot of effort to exercise,” he said. “But I view it not only as a way to keep fit, but also as a form of enjoyment.”

The Associate Consultant Medical Oncologist specialising in digestive tract cancers at the National Cancer Centre Singapore (NCCS) is pursuing a PhD at

the Duke-NUS Graduate Medical School under the National Research Foundation – Ministry of Health Healthcare Research Scholarship.

His current research involves characterising molecular features of patients with gastric cancer (a top cause of cancer deaths worldwide) so physicians can customise the best treatment for patients.

Dr Tan has several international and local research-related awards under his belt, including the 2010 Young Investigator Award from the American Society of Clinical Oncology for his research on personalised treatment of stomach cancer.

His most recent accolade was the SingHealth Publish! Award (Outstanding) in August for his research paper on gastric cancer that was published in Gastroenterology last year.

Quality of care is key Molecular science has always fascinated him. As a medical student, he was spellbound by the field of oncology.

He said: “Cancer has a stigma and people fear it. Yet, advances in science and medicine have made monumental inroads in this disease, making certain cancers curable and substantially prolonging the lives of people with advanced cancers.

“For instance, certain patients with late stage (Stage 4) colon cancer can now be cured. The average survival of patients with Stage 4 colon cancer has more than tripled in the last 15 years.”

But he added that there is no “one size fits all” treatment for cancer patients.

“Patients of the same age, from the same demographic group and who appear to have the same type of disease, may end up with very different treatment outcomes.

“Some do very well with standard treatment regimens, while others don’t and might benefit from novel treatment strategies.”

This is where research comes in – to identify molecular features that can help

pinpoint specific treatments likely to benefit patients, to tailor treatment appropriately and improve the overall quality of patient care.

In his research on gastric cancer, Dr Tan has identified several molecular characteristics of stomach cancer. Each could benefit from specific novel or new treatment strategies. This could potentially pave the way for personalised treatments for patients.

“This is perhaps how the next generation of ‘stratified medicine’ will transform healthcare,” he said.

“I’m a big advocate of research to improve outcomes for patients. It is only by applying research knowledge to patient care that we can truly make a difference.”

PHOTO: MORVEN KOH

By Eveline Gan

they help me become a better person.”

Most of her patients are middle-aged or older. “Many are in the sandwiched class, with children still schooling and parents who need their support. They may also be people who have difficulty finding jobs because their skills are no longer in demand. There are also bettereducated people who were retrenched in their 50s and have difficulty getting reemployed.”

While she tries her best to help them, she hopes society can be more understanding. “When people can’t find suitable jobs, others often think they are not trying hard enough. For the majority, however, this is not true.”

She is happiest when situations improve for her patients. She is touched by the handful of patients who return to thank her and tell her that they are fine.

However, she hopes that social workers will get more recognition and support for what they do.

“Many people think social workers just want to do good deeds. They’re surprised that we’re professionals. To do this job, you need a lot of commitment and a degree.

We’re not the same as volunteers.”

Dr Iain Tan believes applying research to healthcare is key to improving outcomes for patients. His current research may help doctors tailor treatment for cancer patients.

FACTS Our tendons... Our body’s rubber bands By observing the diagram of the human body on this page, we can easily recognize all the space that our muscles, ligaments and tendons occupy. The tendon is composed of thick, white fibres of collagen that are held tightly against one another. These fibres are made up in large part by collagen.

Our ligaments act like a connection between the bones. Our tendons act like ties to our internal structure for our muscles and our bones. The tendons and the ligaments of our body act like rubber bands of different sizes.

Since our tendons are used to bind our musculature to our bones, and to maintain elasticity and suppleness, our tendons necessitate a large amount of collagen, particularly after an injury or from aging.

Why collagen is important?

Distributes and provides supplies to healthcare professionals

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Blood vessel

Fascicule

Bone

BEWARE

OF IMITATIONS

Collagen fibers

Tendon Muscle

In the composition of cartilage we find 67% of collagen versus 1% of glucosamine.

Glucosamine is an aminosaccharide contrary to collagen which is a molecular complex containing amino acids. Glucosamine is found in interesting quantities only in the liquid of the synovial membrane. Collagen is also found in the synovial membrane but in larger quantities because the protein structure is more abundant in the body.

Glucosamine acts more like a lubricant in the joints while collagen helps the tendons, ligaments, cartilage, muscles, membranes and synovial liquid (lubrification).

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FYI

Eating cherries may cut gout risk

event Calendar

Singapore Health issue 19 contest

The study showed that eating up to three servings of cherries over two days would progressively lower the risk of gout attacks. Eating more cherries after that provided no further benefit.

The scientists said cherries contain anthocyanins, which are antioxidants that have anti-inflammatory properties.

More clinical trials are needed to investigate and confirm the initial findings, they added.

Gout is a common type of arthritis that can cause sudden and very severe attacks of pain and swelling in the joints, particularly in the feet. It is caused by too much uric acid in the bloodstream.

Eating cherries can reduce the risk of gout attacks, a study has suggested.

Researchers at Boston University in the US found that gout patients who ate cherries over a two-day period had a 35 per cent lower risk of attacks compared to those who did not.

Source: BBC

1. What is the name of the drug being tested for the first time on dengue fever patients?

2. Which story in this issue did you find the most informative?

Closing date: Dec 7, 2012 Send in your answers and stand to win a bottle of Spirulina 100% Extra 10% Deep Ocean Water (750 tablets) worth $69.

Include your name, age, gender, address and telephone number. Winners will be notified via phone or email. Incomplete or multiple entries will not be considered.

Email: editor@sgh.com.sg

Cute animal photos can make you a better worker

How to stay healthy before a marathon Marathon runners train long and hard.

Here are some tips for them to avoid injuries just before their big race.

New research shows that looking at images of cute animals may actually improve your work performance.

Tests show that pictures of cute animals “not only improve fine motor skills, but also increase perceptual carefulness”, according to researchers at Hiroshima University.

Such images could be used “to induce careful behavioural tendencies in specific situations, such as driving and office work”, they said.

Professor Hiroshi Nittono, who led the study, said: “The feeling that something is adorable can prompt a person to want to be closer to and know more about the object.

That, perhaps, creates the effect of increased concentration.”

The study, entitled The Power of Kawaii (kawaii means “cute” in Japanese), was published in the online version of American journal PLOS ONE.

The day before a marathon, eat extra calories, especially high-carbohydrate foods such as bread, cereal, rice, pasta or potatoes.

Drink fluids at least four hours before exercise.

Most marathoners find that they perform better if they eat carbohydrates during the race. Sports drinks, bars and gels are good options.

To avoid runners’ diarrhoea, stay away from sweeteners at least a day before running. These are found in foods such as sugar-free candies and ice cream. Three to six hours before running, avoid or limit intake of caffeine and high-fat foods.

Within two hours after the marathon, eat foods that contain protein, such as peanut butter or string cheese.

Winners of Contest 18 Each will receive a bottle of Ultra B-Power (120 capsules) worth $42.80.

1. Ho Kok Guan 2. Kee Su Keyau 3. Lakhani Girish Ramchand 4. Lee Meng Sun 5. Shi Xinmei Prizes must be claimed by Dec 7, 2012.

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Time 10am-12pm (registration starts at 9.30am) Venue Lecture Theatre, SGH Block 6, Level 9 Registration Call 6326-5859 for more information and to register. On-site registration at event will be subject to availability.

Price $5 per person (cash payment only on actual day). Free for children below seven years old.

Nov 17 (Sat)

Public forum: One Generation Caring for Another: For Caregivers of the Elderly

Time 10.30am-12.30pm (registration starts at 10am) Venue School of Nursing Auditorium, Block A (opposite carpark E on SGH Campus) Registration Register by Nov 6 for an Elderly Care Gift. Seats are limited, so please register early. Registration will close on Nov 14. Call 6326-5859 for more information to register. On-site registration will be subject to availability.

Price Free Each attendee will get a goodie bag containing pamphlets and samples sponsored by BW Generation.

COURSE: CPR and AED Course for the Public

Time 8.30am-12.30pm or 1.30pm-5.30pm Venue SingHealth Polyclinics Prime Training Centre, Jade Room, Connection One (Tower 3), #07-07, 168 Jalan Bukit Merah Registration For more details, email syafiqah.sazalli@singhealth.com.sg.

Price $128.40 (including GST) Learn to respond to cardiac emergencies using cardiopulmonary resuscitation (CPR) and the Automatic External Defibrillator (AED). The course teaches the basics of CPR and how to use the AED. Participants will learn the theory and practice of emergency resuscitation. A certificate, valid for two years, will be issued to those who pass the theory and practical tests.

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Dec 18 (Tue)

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新加坡中央医院

11月

与新加坡保健服务

12月 2012

集团的双月刊

page 29

男性也有生理钟

page 30

page 31

page 31

患心脏病 的风险

情感遗嘱 能避免争议

已逝病人屡接 短信提醒

药剂师与服用华法 林的病人风雨同舟

抗凝血治疗诊所成立于 1986 年，旨 在促进使用华法林疗法的病人的安全 性。当时，诊所的医护人员全以血液病 专科医生为主。但随着越来越多病人开 始服用华法林，诊所在2011年增添了一 批药剂师，协助状况稳定的病人进行复 诊，让专科医生有更多时间专注于病况 复杂的病人或新病例上。诊所医护团队 人员增多了，对病人来说，也能有更长 的就诊时间和得到更多关注。 新加坡中央医院的药剂师林承翰 说，抗凝血病人每年需要看主治医生一 次，而在下个诊期到来之前，他们得经 常去看诊所里的药剂师，具体频度取决 于病人自己的状况，可以是每两周一 次，或是每三个月一次。除了评估病人 的验血结果之外，药剂师还会询问病人 的生活和饮食习惯是否有显著变化。举 例来说，锻炼能促进身体对华法林的代 谢，这就可能需要更高剂量的华法林。 “在药剂师的问诊中，若有必要， 我们会调整病人华法林的剂量，也确定 他们有充足的药物。我们还查看是否有 出现副作用，或是否有出血或血栓的症 状，”林承翰说道。

图：ALVINN LIM

新加坡中央医院抗凝血治疗诊所的药剂师，协助照料服用华法林的 病人。华法林是一种可预防中风的药物，但服用起来必须小心谨慎

在新加坡中央医院抗凝血治疗诊所，药剂师林承翰（左）不只监测叶亚进的情况，也详细解释正 确服用华法林的方法。

原文 Teh Joo Lin

原本是非常普通的一天，可是叶亚进先 生的手臂却骤然出现肿胀，几小时内呈 黑色，状况严重到必须马上入院治疗。 由于患有心律不齐，叶亚进需要定 时服用华法林来预防中风。华法林是 一种抗凝血剂，能使血液变得较为稀 薄，防止血块形成。服用这种药物的 病人必须多加注意自己的饮食和生活 习惯，以避免这种强效药与某些食品 或药物发生相互作用时可能出现的严 重副作用。 在最糟的情况下，华法林会令病人 的血液变得太稀薄，乃至出现严重出 血。叶亚进的状况就是如此产生的。 但值得庆幸的是，自从他大约七年前

开始接受新加坡中央医院抗凝血治疗 诊所的照料后，这“血淋淋”的插曲 就再也没有发生过。

近年来，抗凝血治疗诊所 就诊的病人数字有增无 减。自 2001 年，被转介 到该诊所的病人人数已经 达到500名左右。

更多的关注，更长的就诊时间 据叶亚进称，抗凝血治疗诊所所提供的 照料服务，协助他对华法林及其安全事 项有着更好的了解。自从药剂师的加 入，协助两名分身乏术的主治医生，他 也得到了更多关注。目前，诊所有25名 药剂师。 “我宁可去见药剂师，因为他们比 较有时间向我详细解释正确用药的方 法，”现年56岁的叶亚进解释道。 “他们就诊时会问很多问题，例如 我是否有锻炼身体、是否吸烟、是否有 便血等等。他们也提高了我对华法林的 使用意识。现在我知道了，倘若出现任 何出血症状，就必须要去看医生。”

向病人开展关于华法林的教育，像它 如何发挥作用、如何与某些食品和药物相 互作用，以及提防具有威胁性的信号，比 如尿液和大便颜色变黑，可能指示体内出 血，这是就诊中的一个重要部分。

研究：住院率降低 该诊所近期发表的一项研究证实了药剂 师加入治疗过程后，病人的总体护理素 质得到提升。研究结果发现，因华法林 相关并发症而导致住院的病人，已从 2001年约9%降到了2011年的2%以下。 > 文转 page 28

新发现推进了 脑肿瘤疗法 本地医生的一项研究，意味着脑 肿瘤患者将得到更好的治疗 原文 Thava Rani

本地一支研究团队做了一项具有里程 碑意义的研究，发现目前有一种癌 症化疗药物可能可以抑制具侵袭性的 脑肿瘤，既多形性胶质细胞瘤（ GBM, Gliobastoma Multiforme 的缩写）。 于今年 5 月在国际领先刊物《癌症研 究》上发表，研究发现癌细胞中的帕金 蛋白含量越高，患者的存活期就越长。 这也确认了帕金基因所产生的蛋白质， 又称帕金蛋白，有如同肿瘤抑制的功能。 由于帕金森病（运动障碍疾病）的 关系，医生们对帕金蛋白早已有所认识。 如果将来研究揭露它对治疗脑肿瘤的功 效，那么不必从零开始研发新药，也能 很快地找到治疗药物。 所以研究团队希望在这第二阶段的 研究里，找出各种与帕金蛋白异常调节 有关的生化途径。如果一切顺利，新发 现将开启更多药物来治疗脑肿瘤的可能 性，更为患者带来新希望。 “目前还言之过早呢，”国立脑神经 医学院脑神经外科顾问医生洪明智教授 提醒道，也是新加坡科技研究局旗下新 加坡临床科学研究院的高级首席研究员。

里程碑式的发现 与洪教授一同协力合作获得此发现的是 国立脑神经医学院科学家邓淑伶博士， 以及国大杨潞龄医学院生理学系林嘉隆 副教授。 洪教授说：“帕金基因可以阻止细 胞不断迅速或不受控制地生长防止癌症 （肿瘤）恶化。可是我们发现，帕金基 因突变可能会扰乱或出现功能异常导致 胶质瘤（一种脑肿瘤）。” 帕金蛋白并非肿瘤唯一抑制物，可是 它丰富完善的研究资料在医学和研究界 里是数一数二的，尤其在运动障碍疾病 方面。当新加坡研究团队从医学文献中 获悉帕金基因可能与癌症有关时，便决 定去探讨是否与那既普遍又高度恶性的 胶质瘤有任何的关联。 > 文转 page 28

28

新脉动

NOV⁄ DEC 2012

新闻 > 文接 page 27

新发现推进了脑肿瘤疗法

即使成功地切 除胶质瘤，也不 能保证化疗能起 作用，因为不同 患者对治疗的效应 不同。 “我们虽然可以将 显而易见的部分切除， 但始终不能避免可能造成 复发的微小肿瘤播种，”洪教 授说。 洪教授说，每一次的复发会造 成治疗效果每况愈下。更不幸的 是，患者丧失的功能就会加剧。总 的来说，仅有 60% 至 80% 的多形性 胶质细胞瘤患者可存活超过一年。

谁会患上GBM?

图： VEE CHIN

他们在实验室里证实了帕金蛋白可以 调节癌细胞的生长，然后进一步将国际 患者年龄通常介于40岁至 患者数据库里的胶质瘤患者的存活状况 60岁。病状在儿童中罕见。 与基因表达资料做对比。终于让他们成 功地证实帕金蛋白水平越低，患者的存 没有任何特定种族群体中 活率相对地更低。 发病。 “这可说是守得云开见月明！当我们 看到患者存活数据与实验数据相符时， 本地并无性别关联性，但一 就知道我们已上了轨道，” 洪教授说。 些欧洲研究提示，男性 目前，为了更清楚涉及的生化途径， 出现病状的风险略高。 团队希望能找出帕金蛋白如何扰乱引发 肿瘤的发展过程。 “途径范围一旦被缩小，我们就可以 从一些成药中，寻找合适的药物再对 症下药。我们希望能够在未来的五到十 年内在临床试验上验证我们的理论。” 研究进展顺利将带来的希望 洪教授说。 如果新研究取得了成果，治疗方案将可 以有更多的选择。如果该研究团队成功 治疗方案 地找到与帕金蛋白有关的分子途径，现有 尽快切除胶质瘤是最理想的方法。随着 的化疗药物便可能被用来针对这种病症。 神经外科技术发展，即使肿瘤靠近脑部 其实这类针对性治疗并不新颖，而且 最关键的部位，也能在患者清醒状态下 已应用在乳腺癌和肺癌等其他癌症。 安全进行手术。手术后，患者会需要接 “不是每种疗法都适合每一个人。等 受几周的电疗和化疗。这是目前 GBM 治 找到另一种合适的疗法时，患者的状况 疗的国际标准。 可能已经变差了，治疗效果肯定不会好。 当让阻碍还是存在的。例如，如果胶 但现在如果我们能确定每名患者帕金 质瘤从原本的位置扩散到脑部的另一半， 蛋白表达的特征，就有可能为患者量身 洪明智教授与研究团员证实了帕金蛋白可以调 即使是肿瘤的主要部分，也难以将它完 定制化疗方案，大大提高其存活率，” 节癌细胞的生长，他们的发现与国际患者数据 全切除。这就是非常具有挑战性的地方。 洪教授说。 相符。

不是简单的头痛 头痛通常会对药物作出响应，但脑肿瘤 可能显示出下列特征: 取决于肿瘤在脑部的位置 ，症状有所不 同，但可能包括…… 头痛 恶心或呕吐 视力模糊 无食欲 肢体无力 情绪变化 思考和学习能力的变化 新的痉挛 讲话困难 症状通常…… 在开始发病时是渐进性的，例如，手 臂的渐进性无力 顽固，即症状持续，不会消失 头痛通常是…… 特别严重的 持续的 模式与你一般的头痛不同 在清晨特别严重 伴有视力问题或恶心

> 文接 page 27

药剂师与服用华法林的 病人风雨同舟

对于有心房颤动等病状的病人来说， 华法林是一种“灵丹妙药”。心房颤 动造成心律不齐，从而导致心脏上部 腔室形成血栓。当一个血栓松脱后， 它会进入血流，并沿着血流，嵌入通 图：MORVEN KOH

与此同时，研究也还发现病人的 国际标准化比值（ INR, international normalised ratio 的缩写）标准范围之 内的读数，从 46.6% 上升到了 65.9% 。 INR值是测量凝血时间的一项标准试验。 无法把 INR 值维持在标准范围之内是 有危险性的，新加坡中央医院的高级药 剂师，也是此研究的首席调查员龚铭泽 先生说。当 INR 值超出范围时，出血的 风险将会提高；如果低于范围，则会提 高血栓形成的风险。 近年来，抗凝血治疗诊所就诊的病人 数字有增无减。自2001年，被转介到该 诊所的病人人数已经增加了一倍，达到 500名左右，占新加坡中央医院1,500名 接受华法林疗法约三分之一的病人。 没有到诊所就诊的华法林病人，则 继续由各自的医生（分别来自心脏科和 神经科等各个学科的医生）负责照料。 在这期间，抗凝血治疗诊所的药剂 师已经开始着手以进一步改善华法林疗 法为目标的研究项目。 例如：与其他种族群体相比，为何 印族同胞病人更倾向于超出标准范围。 还有研究斋戒如何影响回教徒病人的凝 血能力。 “研究成果能帮助我们更好地管理 回教徒病人，尤其在斋月期间。如果我

华法林如何发挥作用

药剂师龚铭泽（右）和林承翰合力协助减轻诊 所的医生的工作量。

们知道斋戒会提高 INR 值，我们就可以 事先为他们调整剂量，”研究团队成员 之一的林承翰说。 诊所的目标是要把INR值还处于治疗 时间的范围（TTR, time in therapeutic range 的缩写）提高到70%或以上，也 就是说，华法林病人的血液能够在至 少70%的治疗时间中，维持适当的“稀 释”度。 龚铭泽说：“我们希望把TTR提升到 70%或 80%，这样，华法林就能不落后 于各种新药。如果我们能将这个指标再 升到80%，有可能就意味着华法林比新 药还要好。” 不过最终关键还是病人的安全。“病 人的安全性和满意度并减少不必要的住 院次数才是最重要的，”龚铭泽说。

密切监测 服用华法林的病人必 须做定期验血，以确 定血液是否能在设定的时间标准范 围内凝结，测量指标是国际标准化 比值（INR, international normalised ratio的缩写）。 一般人的INR值为1，但大多数接 受华法林处方的病人必须把INR保持

向脑部或脑内的狭窄血管处，导致中 风。其他血液病况包括血栓凝结在下 肢的深静脉血栓以及凝结在肺部的肺 栓塞。 华法林可以通过减缓血液的凝结 能力来缓和这些病状。但此药物也必 须小心使用。

在2至3之间。这意味着，他们必须服 用足够华法林的剂量，使血液凝结的 时间比一般人慢两到三倍。 确保病人维持在INR标准的范围内 是一项挑战。INR值过高，不只会增 加病人出血的风险，还会有可能在严 重胃出血或颅内出血（脑部出血）这 类病例中造成死亡。但如果INR值过 低，则会提高中风的风险。

的生活作息和饮食习惯发生了改变， 便会扩大或抵消药效，导致病人的血 很多因素都可干扰华法林的药效。象 液变得过“稠”或过“稀”。 富含维生素 K 的花椰菜和绿茶等，可 如果绿茶并非病人常规饮食中的 以中和华法林的药效。维生素 K 是肝 一部分，喝绿茶就可能致使他的INR值 脏用来制造人体中凝血的蛋白质。 在第二天从2降到1。但如果绿茶已经 这并不代表病人必须停止食用花 是病人常规饮食中的一部分，那么， 椰菜或其他富含维生素 K 的蔬菜或食 喝 茶 就 不 应 该 影 响 到 INR 值 。 因 此 ， 物。他们每个星期还是得需要继续保 服用华法林的病人必须定期监视其状 持一贯维生素 K 的摄入量；如果病人 况，在必要时改变他们的剂量。

注意饮食

Nov⁄ Dec 2012

新脉动

29

新闻

男性也会受到 生理钟左右

全新眼科手术 带来完美视力

手术可使患者获得完美视力，且排斥率 不超过1%

一项本地研究发现丈夫年龄越大越会增加妻子流产的危险

对于年满40岁想要 孩子的男性而言， 生理钟对其来说已 经很紧迫了。

全新手术可使患者获得完美视力，且排斥率不 超过1%。

原文 Jamie Ee

说到生孩子，时间未必总利于男方。 “越来越多的研究证明，男性也有 生理钟，可在40岁左右开始影响他们的 生殖能力，”竹脚妇幼医院妇产科顾问 医生陈添财说。最近由他在新加坡所领 导的一项研究显示，丈夫年龄越大越会 增加妻子流产的危险。 该研究持续 16 周，监测了 139 名先 兆流产（妊娠早期出现阴道出血）的女 性。结果发现，与年龄介于30至40岁的 男性相比，超过40岁的男性会使流产的 危险性增加8倍。 而与年龄介于20至30岁的男性相 比，年龄介于30至40岁的男性会使流产 的危险性增加约4倍。 “流产风险较高与年龄较大的男性 精液质量降低有关，”陈医生表示。 “我们已经发现胎儿流失的危险 性因男性年龄超过40岁而增加，因此我 们可以推断，生理钟不仅在准妈妈体内

有助于逆转生理钟的措施

1

定期锻炼有助于保持较高的睾丸酮水 平，改善精子质量并降低勃起功能障 碍的危险。

2 3

保持健康体重和摄入富含抗氧化剂 如维生素A、C和E的健康膳食。 减少毒素暴露，如戒烟和避 免染上性病。

起作用，在准爸爸体内也一样，”陈医 生说。 由竹脚妇幼医院和杜克 - 国大医学 研究生院联合开展的这项研究进一步证 实，男性的年龄不仅影响生育力，而且 还会影响妊娠和婴儿的健康。 “尽管女性年龄对生育影响的研究 众所周知，但有关男性年龄对生育影响 的研究还很少，”陈医生说。他也是杜 克-国大医学研究生院的助理教授。 女性的生理学分界点很明确地限定 在35岁。而对于男性，该分界点可能在 40岁左右，陈医生说。 “对于超过 40 岁的男性，我们更担 心的是男性基因可能发生变化，这会使 其后代易于出现先天性障碍，甚至导致 流产，”他说道。 跟女性一样，随着年龄增加，男性 也会出现身体和生殖系统的变化，从而 影响生育力和后代的健康。 “男性虽然不会停止产生精子，但 随着年龄增加，产生和输送精子的结构 会发生衰退。譬如，精液产生变慢且生 殖管道变窄，”竹脚妇幼医院生育医学 科顾问医生刘世瑰说。 男性性功能也会发生衰 退。随着年龄增加， 男性的睾丸酮水平 降低，性欲减退， 并且更容易发生诸 如勃起等性功能障 碍，刘医生说。

陈添财医生（右）和刘世 瑰医生（左）建议年龄40岁 及以上的男性如果想要孩子 就不应该再拖延了。

图：vee chin

随着年龄增加，男性的精子质量会退化，引起精子DNA损伤并增加女性流产的几率。

“勃起障碍与供血障碍密切相关。 随着年龄增加，如果患上糖尿病或高胆 固醇，则容易出现血管问题。如果此 类问题影响到阴茎，则会导致勃起障 碍，”他补充道。 年龄较大的男性精液质量也会变 差。因为精液产生速度降低，暴露于感 染和吸烟等因素产生的毒素的风险也会 较高。这会损伤精子的基因，刘医生 说。如果四成以上的精液基因受损，那 么流产的几率就会升高。 研究还证明，对于年龄较大的男 性，其后代出现遗传问题，如自闭症和 侏儒症的危险性也会增加。 除了老化过程，男性的生活方式也 会影响到精液中的精子计数值和质量。 研究已经发现很多因素都会降低精液 中的精子计数值和质量，例如压力、吸 烟、饮酒、在高温环境下工作等，陈医 生说。 他还强调说，男性生育力在全球范 围内都在降低，新加坡的男性也不例 外。“正常情况下，1毫升的精液标 本中应该有1千5百万以上的精子。但 是，我们看到的一些标本中可能只有一 个精子。” 当前的趋势是男女婚育年龄推迟， 这样就对年龄较大的准父亲不利的吗？ 刘医生不那么认为。他说，只要男 性继续生成精子并能完成正常性交，就 仍有可能生育孩子。女性能育就能弥补 男性生育潜能降低的不利影响。宫内人 工授精（IUI）和体外受精（IVF）生殖技 术也可用于帮助受孕困难的夫妇。 不过，随着男性年龄增加，发生生 育问题的危险性也相对增加，因此医 生建议那些想当父亲的男性要及早做 计划。 陈医生说：“年龄 40 岁及以上的男 性如果想要孩子就不应该再拖延了。”

原文 Thava Rani

在过去10年，卓荻钊先生曾进行过两次 左眼角膜移植手术，现在他担心右眼也 需要同样的手术。 “那时不仅缝合需要 20 针，复原期 也达6个月，” 现年59岁，已半退休的 卓荻钊说。 不过，他已不必再担心了。通过新 加坡全国眼科中心展开的一项改良角膜 移植术，他模糊的视力只持续短短几 天。“手术后的第四天，我的视力已恢 复到不需要旁人的协助也能够自己外出 的程度了，”他说。 该手术名为后弹力层内皮角膜成 形术（Descemets Membrane Endothelial Keratoplasty，简称 DMEK），是最新改 良的微创角膜移植术。目前手术所需 移植的那层纤薄角膜细胞的厚度只有 0.01毫米，是新加坡全国眼科中心以往 在常用手术中的0.1毫米再薄上10倍。 角膜是眼睛外侧的透明保护层，对 因老化或疾病而引起角膜混浊患者，角 膜移植是最有效的治疗方式。 使用 DMEK技术，患者本身的角膜基 本上保持完好无损，因此手术后效果不 会立竿见影，患者也可能在几周内便能 恢复100%的视力。 新加坡全国眼科中心医药总监陈长 慧教授说：“今后将是 DMEK 的时代。 手术后，患者也可获得完美视力，而排 斥率不超过1%。” 这种新颖无缝合技术起源于欧洲， 陈教授于 2010年 9月首次在亚洲采用该 技术。此后，通过该技术，他已在新加 坡全国眼科中心完成了 11 例角膜移植 术。每例手术费可高达 5,900 新元，但 如果扣除医药津贴，费用是介于1,5001,700新元之间。 唯一不利的地方是这项改良手术极 为复杂。因为移植的角膜极为纤薄，在 触碰时易产生皱褶，所以可能在将其展 开时损坏角膜细胞。 为克服这个难题，陈教授与新加坡眼 科研究院团队成功地找到了一种既安全 又容易进行的新DMEK手术插入装置的方 法，目前该装置正在申请专利当中。 新加坡每年大约会进行 350 例角膜 移植术，其中约四成是属于角膜老化的 患者。随着人口老化，预计这数字将会 增加。

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Nov⁄ Dec 2012

保健

专家解答

帮助中风患者 克服困难

谷蛋白和糖尿病

对家中做出一些改变可减少中风患者对其看护人的依赖 造。张妙珍说：“家具可以重新摆设， 使小房间更宽敞、舒适，尤其是对坐轮 椅的患者。有些公寓的浴室非常狭小， 不能容纳洗澡椅或患者和其看护者两 人，但可以在其他房间或空间进行改 造，例如，患者可选择在厨房淋浴。” 住处的一些基本改造包括，在卫生 间和浴室里安装扶手杆和防滑垫，以防 止患者滑倒或摔倒。那些不能够站立的 患者应该使用洗澡椅。卫生间里也可 安装斜坡道，方便轮椅或座便椅移动 自如。能见度非常重要，所以光线要充 足。在卧室里安装小夜灯也是一种安全 措施，使患者在夜晚时不用摸黑也能 行动。 尽管有许多设施和装置能助于患者穿 衣、吃饭以及烹饪等的日常活动。可是 对于行动不便却力求独立的中风患者来 说，不能一如既往地进行 曾经得心应手的事情， 始终会带给他们一些挫 败感。

穿衣

洗澡 湿滑的浴室通常是最容易发生摔伤的 地方。如果设有扶手杆和洗澡椅就能 让行动不便或缺乏灵活性的人士更安 全地使用。比起一般平滑的钢铁扶手 杆，波纹扶手杆也较为安全，因为即 使扶手杆湿了也能抓牢。

要一名仅能活动 一只手的中风患 者扣上衬衫的纽扣 是件非常费力的事。要是 使 用个像缝针穿线器的钮扣钩， 便能轻松又快速地将扣子扣 好。其他辅助装置如穿衣辅助 杆（一个末端带有钩子，能让 中风患者轻易地拉上裤子、袜 子或袖子的长杆)和鞋拔都能够 帮助有穿衣困难的人。

中风后，患者的手或胳膊可能无法 活动自如，像吃饭这样简单的事情 可能一下子会变得非常困难。定制 餐具如改装盘子、饭碗和杯子都有 助于克服这些困难。使用凸边盘能 避免患者在盛舀食物 时外溅。经改造 的汤匙能辅助 患者的手腕 动作，让患 者轻而一举 地从盘子中 舀取食物送入 口中。

面筋是从大麦、小麦和黑麦等谷类制成 的食品含有的一种谷蛋白质。面筋本身 不含任何碳水化合物，而是素食中的面 粉（并非面筋）含有碳水化合物。 目前没有任何证据证明谷蛋白会 导致第2型糖尿病患者的血糖控制 恶化。相对的，也没有研究显示无谷 蛋白的饮食能改善第2型糖尿病患者的 血糖控制。 第1型糖尿病患者主要是在童年和 青春期确诊，患者有可能患上称为乳糜 泻的肠道相关疾病。患有乳糜泻的患者 对谷蛋白非常敏感，一旦服食可造成腹 泻。这类患者需服食无谷蛋白的饮食。 新加坡中央医院内分泌科顾问医生苏华逸

患心脏病的风险 图：justin loh & Alvinn lim

对中风患者来说，扣个钮扣、系上鞋带 或手握汤匙可能都是些非常困难的动 作。而根据中风的严重程度，患者有可 能是局部胳膊、腿或身体其他部位丧失 活动能力或全身瘫痪。 那些日常动作如起身、坐、走路、 吃饭、穿衣服以及上卫生间等，原是 一般的本能反应，忽然间也得花上一 段时间或需要他人的协助下，才能完 成的事情。 新加坡中央医院职能治疗师张妙珍 表示，对家中进行基本的改造，能让情 况已稳定，并返回家中休养的患者，更 容易且安全地移动。 在患者返回家之前，张妙珍通常都 会先往其住家进行评估，并对可能或必 须改进的地方提出建议。她说：“我会 观察居住环境和周围情况，了解哪些可 能会阻碍患者行走安全，哪里可能会绊 倒他。环境周遭应该尽可能保持整洁有 序。” 即使是非常小的房间也可以进行改

吃饭

面筋是否富含碳水化合物？对糖 尿病患者是否有害？我经常在素 食里吃的人造肉替代品是不是用 面筋来做的？

我今年38岁。最近感觉胸口疼 痛，双手麻痹。血液检查和心电 图的结果都显示一切正常。这可 能是因为压力而造成的，因此拒 绝了血管造影。我应该做进一步 的检查吗？

橡胶柄餐 具更容易握紧 且能够防滑， 而弯角汤匙对手 腕或手部移动受 限的人来说更 易使用。

烹饪

梳洗

心脏病，特别是冠状动脉疾病，虽然在 年轻人中较少见，但仍然可能发生。而 且，随着现代生活方式的影响，年轻人 患上心脏疾病有上升的趋势。 只要胸口疼痛超过数分钟以上就要 认真看待，尤其是有家族心脏病史或有 其它引起冠状动脉疾病的危险因素，如 高血压、糖尿病、抽烟、高胆固醇或甚 至是年事渐高。 您可能需要进一步确诊是否患上冠 状动脉疾病，因为疼痛停止后所做的血 液检查和心电图虽然结果正常，但也有 可能因此而忽略了这个可能性。最好是 找个心脏专科医生就诊。视检查结果而 定，你未必需要再进一步作检测。检测 方法有很多种，各有优劣利弊。 血管造影非常准确，但侵入性较 高，令人望而生畏。视情况而定，还有 其他侵入性较低的测试如跑步机的压力 测试、核素心肌灌注或负荷超声心动图 和心脏冠状动脉CT扫描。 您可以咨询心脏病专家最合适的测 试。 新加坡国家心脏中心心脏病科顾问医生陈 培德

长柄的弯梳更容 易使用，这样一 来胳膊行动不便 的患者不用抬高 胳膊也能在后脑 勺梳头。

使用和处理如菜刀等利器 时，患者的安全是至关重 要的。如左（图），如这 款特殊的砧板，,它的底部 装有强力的吸盘，不只能紧紧 地固定在桌面防滑，也能单手轻松调 节钳子夹紧各式各样的食物。既降低 受伤的风险也让那些只能靠单手活动 的使用者更放心地烹饪。

Nov⁄ Dec 2012

新脉动

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财经

有遗嘱就有办法

“这两类遗嘱的区别是在于各自不同 的目的。一类是反映情感愿望的，另一 类则是实现物质的，”陈先生说。 不过，他宁可把两者都视为遗嘱， 而不是区分它们。这是因为‘情感’遗 嘱能让逝世者的家属、甚至法院知道 逝世者生前内心深处的想法、未吐露的 方式向公众推行‘情感’遗嘱的概念， 愿望以及懊悔，是为法院提供至关重要 即‘有生之年’，力图提倡人们给予临 的信息。譬如，逝世者指明某资产对他 终者更好地照料还有没有忌讳地谈论死 来说非常重要，并不希望这资产在自己 亡课题。‘情感’遗嘱是该基金会一系 出现任何状况时被变卖或处理掉，诸如 列积极对待生命的其中一种方式。 此类。 陈先生说，在遗嘱里包含我们 情感遗嘱的价值 的‘情感愿望’、精神状态、生活价 李宝华说，写一份‘情感’遗嘱能帮助 值观、待人处世态度以及感情十分重 我们正视自己、坦然地面对死亡并思 要。“这些都是经过深思熟虑后表达出 考如何诚恳地与亲人分享一些重要东 来的情感，也表示立遗嘱人已经慎重考 西。它也提醒我们不要拖延表达我们 虑了其财产的分配方式。” 的感激、歉意、宽恕和爱。对某些人 至亲或亲戚要是感到有任何不满都 而言，这样深思熟虑的抒发行为足 以让我们将之铭记于心，改变我 们的人生态度并积极地看待活着 的意义。 在 用 意 和 目 的 上 ，‘ 情 感’遗嘱与情书类似，李先 一份遗嘱要有效力且在法 生说。 律上可以执行，它就必 原文 Celene Ting ‘情感’遗嘱采用了日常对话方式 须准确地包括立遗嘱人 和语言而非法律用语，简单地通过记 全部关切和意愿。模棱 “ 最 终 ， 我 想 是 时 候 给 你 说 些 以 前 没 忆、生活教训与价值观细腻地抒写来体 两可的遗嘱可能引 有 说 过 的 事 情 了 。 那 事 不 宜 迟 ， 开 始 现个人情感和对他人的祝愿，特别是对 发争议并有被宣布 吧……” 深爱的人。例如“我对你未来的祝愿 为无效的风险。 给亲人留下一份‘情感’遗嘱或许 是……”或“不知道我以前是否告诉 能够为他们解答这一生中未曾试着回答 过你，但我……很抱歉”等。这些都 为避免争议，请考虑下述方面： 的问题。 能帮助人们依环境随意地传递未曾表 立遗嘱人必须神志清晰。立遗嘱 “酝酿一份‘情感’遗嘱能抚平临终 达的感情。 人可能患有身体疾病或身体虚 者的心灵，因为它代表了维系子孙的一 根 据 新 加 坡 律 师 公 会 （ T h e Law 弱，但他在立遗嘱时必须神志清 道桥梁，”连氏基金会首席执行长李宝 Society of Singapore）会员Simon Tan先 醒。建议请医生证明在签署遗 华先生说。 生所说，‘情感’遗嘱不须要与传统遗 嘱时，立遗嘱人在神志上没有问 “ 活 着 的 人 因 获 得 意 义 深 远 的 ‘ 遗 嘱区别开来，一般传统遗嘱是死后财产 题，且他的判断力还足以判断他 产’而感到充实、然后随之成长并从逝 的分配方式。 正在给予的是何物。 去亲人的悲伤中得到解脱，从而更能节 遗嘱里也可以包含临终者的心里话、 立遗嘱人必须身份明确。应在遗 哀顺变。” 感情和意愿。他说，如果一份文件只有 嘱中写明立遗嘱人的姓名和身份 因此于 2011 年 10 月，作为一项大义 个人对他人的情感表达，却没有死后财 证号码。 运动的一部分，连氏基金会以鼓励的 产分配说明，则不能将此作为法律文件。

为亲人留下一份遗嘱对他们而言可能受益匪浅

避免争议

不能争辩逝世者不是在神志清晰的状态 下做出的决定，这也降低法院做出可能 有悖立遗嘱人意愿的判决风险。 如果当事人给律师的指令具体明了， 那么法院就没有充分的理由或审判权裁 定此人是否存有对他人立遗嘱的了解。 不然在没有铁证如山的医学证据证明， 那么法院就会实施判决。 遗嘱中的情感意愿通常示意法院立 遗嘱人本身清楚地知道他在做什么，而 毋须法院去解读他的意愿。因此，写份 易于理解的‘情感’遗嘱不仅是解决临 终问题的一种方式，也是可以让家人免 于诉讼的纷扰。 毕竟，在失去亲人后他们最不愿面 对的就是不满的亲戚发起的诉讼风波。 从 www.lienfoundation.org/news 下载情感遗嘱 小册子。

应 该 指 定 一 位 执 行 人 和 / 或 受 托 人。执行人将办理丧葬事宜、支 付费用、确定要分配的财产，并 指定一名律师授予遗嘱认证书， 以赋予他在遗嘱规定下分配财产 的权力。若涉及到子女或未成年 人，则应该指定一名受托人。若 财产不能立即分配，那么在执行 人保全了财产并准备好将来分配 后，受托人开始履行其职责。 必须指定受益人。否则，就不是 一份遗嘱。不过，如果某人只是 想表达情感，而不想在去世后分 配其财产，那么可以通过信件的 方式办理，其格式不必与有效力 且可执行的遗嘱一致。 遗嘱必须在有两位证人在场的情 况下签署。 *上述资讯由新加坡律师公会会员 Simon Tan先生提供。

意见箱 验血没有病假单 如果我到医院只为验血，院方是 否能给我一张病假单？ 竹脚妇幼医院答复： 医生一般会在 就诊时先对病情进行评估，再决定患者 是否须要请病假休息。而验血则是由护 士来执行，所以院方只能出示一张时 间记录单据，为您的缺勤或缺课提供 证明。

为什么挂号需要病 人在场? 当我在综合诊疗所为我既年迈又 行动不便的父母挂号时，挂号室 服务人员告诉我说，父母本人

必须在场才能挂号。我理解核实 病人身份的必要性，但这还不如 就诊时确认身份来得更重要。况 且，挂号时仅核实姓名，那病人 何必亲身在场才能挂号呢？ 新加坡保健服务集团综合诊疗所 答复： 对于我们给您与您的父母造成 的不便感到抱歉。病人的安全对我们 而言至关重要。因此在每一个服务站 我们都要核实其信息，例如姓名 和居民证号码，以确保 为每名患者提供的医疗 服务正确无误。由于挂 号室是我们与病人接触 的第一站，所以在见到 医护人员之前，确保病 人 信 息 的 准 确 性 是 非 常 重 要的。

对短信提醒百思 不解 我的父亲几个月前就去世了。为 何新加坡中央医院还不断发送简 讯提醒我们他的就诊预约呢？ 新加坡中央医院答复：对您父亲过 世的噩耗，我们深表遗憾并请节哀顺 变。如果病人在新 加坡中央医院去 世，我们的资 料系统会 自动记

录病人的死亡信息。如果病人在家里、 疗养院或临终关怀机构去世，则需要病 人的家属通知医院以便更新资料。 家属可以通过邮寄或电子邮件发送 死亡证明书的副本给医院。如果没有死 亡证明书，家属也可以发送其他证明文 件，比如警察局或临终关怀机构的报 告。家人还可以给医院写信或发送电子 邮件至medicalreport@sgh.com.sg，并 说明与病人的亲属关系。 在未收到通知之前，医院的资料系 统没有病人去世的记录，所以其家人还 会收到有关预约的简讯或其他提醒。敬 请谅解。 若有任何关于入院手续、账单及程序等疑问，可 电邮至 editor@sgh.com.sg，我们会在这个栏目解 答您的问题。

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