Singapore Health Jan/Feb 2013 by Singapore General Hospital

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JAN⁄ FEB 2013

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Checkmate Some hospital patients sometimes find it difficult to stay positive, especially when there is nothing for them to do except lie in bed and hope for time to pass sooner. That was the case for Mr Aw Chee Seng, 51, who had been staying in Singapore General Hospital’s (SGH’s) orthopaedic ward for over two weeks as doctors treated a viral infection in his leg. Imagine his surprise when a group of students showed up in his ward one Saturday afternoon and offered to entertain him with games and other activities. “I was really worried about my condition, after being warded here for so long,” said Mr Aw. “But when the girls came to play chess with me, I became a lot more cheerful and temporarily forgot about my condition.” The programme was the brainchild of a group of five first-year Raffles Junior College students who had been friends since they were in Raffles Girls School. They came up with the idea after deciding to do something meaningful for

elderly patients. Said Ms Li Yichan, 18: “We do volunteer work every year, mostly at school or organised by our friends. This is the first time we are doing our own service project.” Volunteers at SGH typically entertain patients with art-and-craft activities, but the girls wanted to do something that would allow them to interact more actively with the patients. They decided to play board or card games with the patients, so as to have more interaction and communication with them. Card and board games can exercise and stimulate the brain, and help elderly patients stay mentally alert. So, every Saturday afternoon for three months, the girls went prepared with card games, chess, as well as some coloured cards and folding paper for patients who were more interested in arts and craft. Depending on how much time they had, the students might visit two or three different wards. Chinese chess turned out to be a big favourite. Chinese chess enthusiast Ms Sun Xuemeng, 19, was called on to play against a few opponents. Her friend, Ms Wei Lian Qiong, 19, said: “I noticed that it’s mostly ‘uncles’ who like Chinese

Chinese chess was a big favourite among many patients, especially the older men. The student volunteers hoped such games would allow them to interact and communicate better with patients, and keep them mentally alert.

chess. We will do some research and find out from our grandmas what games interest elderly women.” Mr Michael Mok, who was visiting his mother at the hospital, approved of the girls’ work. “It’s great because it keeps the patients occupied. Otherwise, it’s very boring here as there is no TV.” Ms Li said the experience helped her and her friends improve their ability to communicate with older folks. It also

taught them to be more patient. “Most importantly, we realised we can make a difference,” she said. The 12-week programme lasted till the end of December.

How can I help? If you want to volunteer and help entertain patients at SGH, please contact Ms Mumtaj Ibrahim at Mumtaj.ibrahim@sgh.com.sg

In focus

The girls from Raffles Junior College prepared thank-you cards and folded paper cranes for patients to give to their doctors and nurses.

PHOTO: DARREN CHANG

BY DREW PAN

PHOTOS: ALVINN LIM

Raffles Junior College volunteers entertain patients with games

Can you guess what this is? See page 26 for the answer.

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Pregnant women must beware of the flu

Flu etiquette for everyone Here are simple steps to prevent spreading the flu to others, including pregnant women, when you are ill. They are recommended by Ms Mandy Govender, Deputy Director, Communicable Disease Education, Adult Health Division, the Health Promotion Board

Expectant mothers are more prone to the flu and, if not treated early, they can develop complications which may harm them and their unborn baby BY Usha Das

Wash your hands with soap and water, or use hand sanitisers before and after meals before handling food after using the toilet after blowing your nose after touching shared surfaces like tabletops, doorknobs and handrails

Nobody likes being sick with influenza but, for pregnant women, getting the flu can be especially worrisome.

Get the flu vaccination once a year if you are an expectant mother or have low immunity

PHOTO: Morven koh

Flu is caused by various strains of the influenza virus, and pregnancy reduces a woman’s resistance to them. “Pregnant mothers are more prone to infections, and have a higher chance of getting complications,” said Dr Lim May Li, Head, Peripartum Unit, and Consultant, Maternal Fetal Medicine, KK Women’s and Children’s Hospital. Pregnant women with pre-existing illnesses, such as diabetes, asthma or heart disease, can be even more susceptible to flu complications. New mothers face similar risks, especially two weeks after delivery, as their bodies need more time to recover their pre-pregnancy resistance. Flu in pregnancy can carry serious risks, such as foetal malformation if the illness strikes during the early stages of pregnancy. Flu may also seriously impair the growth of the foetus in the second and third trimesters of pregnancy. “It’s not the influenza infection, but the fever associated with the infection that is thought to contribute to the slightly higher risk of birth defects,” said Dr Lim. A fever of more than 38.5 deg C could potentially be dangerous to both mother and child. Also, during advanced pregnancy, a mother’s growing womb presses against her lungs, which strains her ability to breathe. Catching a flu at this time may

Catching a flu during pregnancy may carry serious risks for the foetus, so expectant mothers should see a medical professional for help rather than self-medicate.

add to the strain and cause further breathing difficulties. Pneumonia is the most common complication that may arise from flu. The flu virus can also spread to other parts of the body – the heart, brain or spinal cord – and cause critical illnesses such as myocarditis (inflammation of the heart muscle or myocardium), encephalitis (inflammation of the brain) and meningitis (inflammation of brain membranes). In extreme cases, flu may even result in death of the mother and baby. But that’s a worst-case scenario. In general, women can stay active during pregnancy, but should take special care if they catch the flu.

the flu and the common cold They may appear similar, but the symptoms are actually quite different

The Flu

The common cold

Cough, runny nose, fever and sore throat

Can be serious with high fever, vomiting, abdominal pain and diarrhoea

Cough and runny nose

Symptoms are less severe

Takes longer to resolve than the common cold

Severe exhaustion

Symptoms subside within 48 hours

Tiredness

Early detection is important. There is a smaller chance of complications if the pregnant woman is treated within 48 hours of a flu infection. She should consult her general practitioner (GP) as soon as possible and never self-medicate. This is because her flu-like symptoms may be symptoms of other infections that may require different treatment. Dr Lim cautions against self-medication. “You won’t know what you’re dealing with, so it’s best to get help from a medical professional. But if you have a fever while waiting for a doctor’s appointment, it’s okay to take paracetamol,” she said. Flu in pregnancy is usually treated with a drug called oseltamivir, which is taken orally. The mother-to-be should drink plenty of fluids such as juices and water, and avoid any strenuous activity during the recovery period to give her body a chance to recuperate. Preventing the flu Expectant mothers and women who plan to get pregnant are advised to get flu vaccinations, which are readily available at most polyclinics and GP clinics. “The only proven means of preventing or minimising the risk of getting the flu is vaccination. The vaccine is generally safe in pregnancy and breastfeeding,” said Dr Lim. Although studies show there are some risks to the flu vaccines such as anaphylaxis (allergic reaction), the risks are very small. The benefit to be gained from the vaccination far outweighs the risks. The vaccine injects various flu strains

Stay at home if you are unwell. Avoid the workplace, hospitals visits and crowded places to stop spreading germs to others Use tissues or wear a mask if you have flu-like symptoms, and keep your mask on until you have recovered to cover your mouth and nose when you cough or sneeze. This prevents the release of respiratory droplets into the air, protecting others close to you and dispose of used tissues in a covered dustbin. Wash your hands afterwards

into the body. The immune system produces antibodies to fight the infection, which are passed on to the baby during pregnancy. Newborn babies are not vaccinated until they are six months old, so these and other antibodies inherited from their mothers are crucial in combating infections in their first few months of life outside the womb. Dr Lim said: “Flu vaccinations should be done yearly, as viruses can mutate and scientists are always trying to identify the more prevalent viruses, to incorporate them in the next season’s vaccine.” Although vaccinations help, Dr Lim said people should be socially responsible and not spread the flu to others by wearing face masks and minimising contact with others when they are ill.

Jan⁄ Feb 2013

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Lose weight and get paid for it A 12-month trial, the first of its kind in Asia, aims to find out how cash rewards will encourage people to maintain healthy behaviour BY Lediati Tan

Activity/Goals

For those seeking to shed a few pounds, here’s an offer they may find hard to refuse: Lose weight and win cash in return. The catch, though, is that they must participate in a 12-month programme that examines the impact of economic incentives on influencing weight loss. There’s another catch: Individuals must pay $399 to participate. The study is being conducted by the Duke-NUS Graduate Medical School Singapore and the Lifestyle Improvement and Fitness Enhancement (LIFE) Centre at Singapore General Hospital (SGH). The study started in October last year and is expected to end in March 2015. Associate Professor Eric Finkelstein, Deputy Director of Health Services and Systems Research Program at Duke-NUS, and one of the study’s lead researchers, said the fee is meant to deter people who are not serious about losing weight. He said: “We want to get people who

Participants will learn customised exercises at supervised gym sessions.

are really committed and who otherwise might have joined a weight-loss programme. We didn’t want to charge the full fee, because this is a trial and people are giving us their time to do the surveys.” Prof Finkelstein, an economist by training, had previously evaluated some fairly expensive government-run weightloss programmes in the US. He said: “I used to say over and over, ‘I bet you, instead of running these programmes, the government could just pay

Monthly weight-loss target: Lose 1kg or more, or if BMI falls below 23.5

$20/month

$200/month

Step target per month: Registering 10,000 steps on pedometer on at least 20 days. (1st month: Target 8,000 steps for at least 20 days)

$20/month

$200/month

Month 4: $100 Month 8: $200

Month 4: $1,000 Month 8: $2,000

*Participants of the incentive programme can choose between receiving a guaranteed payment for meeting targets and a lottery payment, where they have a one-in-10 chance of winning more money. Visit hssr.duke-nus.edu.sg/projects/trio to find out more about the trial. You can also contact Ms Patsy Lam or Ms Karyn Sailstad at 6516-4237 or e-mail trio@nus.edu.sg for more details.

PHOTOs: vernon wong

For the purpose of the Duke-NUS study, each participant will be given a pedometer – a counting device that records the number of steps taken by an individual. The participants must wear the pedometer while they are awake. They must take 8,000 steps a day during the first month of the study. This will be increased to 10,000 steps a day for the rest of the programme. The study is not meant to achieve a great deal of weight loss. It aims, instead, to instil lifestyle changes and encourage participants to keep losing weight after the programme.

The study team comprises (from left) Ms Karyn Sailstad, Associate Professor Eric Finkelstein, Dr Tham Kwang Wei and Ms Patsy Lam. Ms Sailstad and Ms Lam are the coordinators for the trial.

Lottery payment*

Significant weight-loss target: Weight loss of between 5% and 8% of baseline weight or if BMI falls below 23.5

Instilling healthy habits over 4 months The Singapore General Hospital’s (SGH’s) Obesity Management Unit runs a four-month obesity-management programme comprising consultations with a physician and a clinical coordinator at the SGH Lifestyle Improvement and Fitness Enhancement Centre. It includes individual and group sessions with dietitians, who will also take participants to the supermarket to learn about healthier food choices. The programme includes four supervised gym sessions, each tailored to individual needs.

Guaranteed payment

people the money and it would generate at least as much weight loss.’ “We tested that eventually and we showed that my guess is basically correct. We showed that incentives alone generated about the same short-term weight loss as other programmes. In each case, though, the weight loss wasn’t sustained.” Prof Finkelstein later spoke to Dr Tham Kwang Wei, Senior Consultant at SGH’s Department of Endocrinology, and Programme Director of the hospital’s Obesity Management Unit. Dr Tham runs a series of weight-loss programmes at her unit. Though successful, the programmes suffer from a very high dropout rate of up to 60 per cent. So, Prof Finkelstein’s study has two main goals. Firstly, it wants to reduce the dropout rate from SGH’s weight-loss programmes and keep people on the programmes for a longer time. Secondly, it aims to use monetary incentives to encourage people to maintain their weight loss over a longer period. Prof Finklestein said: “It’s really about how we can use carrots and sticks, or subsidies and punitive taxes, to encourage people to maintain healthy behaviour. “We’re trying to figure out where incentives can be used and where they are cost-effective, and how we can more broadly tie these things together in what might look like an incentive-based healthcare design.” Similar studies have been done in the US, but the Singapore study is the first of its kind in Asia. Prof Finkelstein added that previous studies lasted only four months or less, and were not combined with evidence-based, weight-loss programmes like Dr Tham’s. The study is expected to cost up to $171,000. The NUS Initiative to Improve Health in Asia (NIHA) will provide $130,000 in funding, and the remainder would be subsidised by Duke-NUS.

How to join the study To participate in the study, individuals must be healthy adults between 21 and 65 years old, and their body mass index must be between 25 and 40. Participants must pay $399. The sum comprises $234 for the LIFE Centre’s four-month obesity-management programme, and a $165 enrolment fee for the incentive scheme. Not every participant will join the incentive programme, as some will be allocated to a control group. The sub-total of $165 will be refunded to participants who are not allocated to the incentive scheme. Those assigned to the control group will have access to only the four-month obesity-management programme, while those in the running for cash rewards will join not just the programme, but also an eight-month incentive programme. Participants of the incentive programme will get cash rewards based on how well they meet their exercise and weight-loss goals (see table above). All participants must attend sessions regularly during a 12-month period to monitor their progress.

Control group won’t lose out Participants in the control group will receive a fairness payment equal to the average amount paid to participants in the incentive programme, less $165, in the eighth month of the study. The payment is not based on the amount of weight they lose, and is meant to reward them for completing the study.

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Robot helps replace human knee A new high-tech procedure enables faster and more accurate knee-replacement surgery causes of knee pain

BY Desmond Ng

Sedentary lifestyle Regular movement is essential for healthy joints and physical activity circulates joint fluid and strengthens cartilage and bones. Light exercise like walking has been shown to protect against osteoarthritis. However, a lack of exercise or even too much exercise can speed up the onset of the condition.

RETIREE Rokiah Amat, 62, never thought she would see the day when she would be operated on by a robot. But in May last year, she

High-impact sports

PHOTOS: winston Chuang

became the first person in Singapore to have a knee replaced by a robot at the Singapore General Hospital (SGH). More importantly, Mdm Rokiah received an extremely well-fitting and durable knee, thanks to the new surgical technique known as the Robodoc Surgical System. “This new technique allows us to perform surgery with a precision unmatched by any technique humanly possible,” said Dr Chin Pak Lin, Consultant, Department of Orthopaedic Surgery, SGH. “Based on projected 3-D images, a surgeon can plan the operation and be assured of getting the predicted good results every time. This may help to reduce intra-operative and post-operative complications,” he added. The Robodoc allows the surgeon to first plan the procedure on a computer workstation using 3-D data from a computer tomography (CT) scan of the patient. The surgeon is able to plan the best location and orientation of the implant, and perform “virtual surgery”, trying out different implant sizes and models to predict the outcome before the actual operation. The surgical blueprint is then loaded onto the Robodoc machine, which mills the bone surfaces to the exact fit and position of the implant based on the preoperative plan. Fit and position are the most important factors in determining the success of a knee replacement. An implant that is slightly off position can malfunction because the weight of gravity is unevenly distributed, raising the risk of reconstructive surgery later. The robot, a gift from South Korea, cuts bone to an accuracy of 0.02mm – finer than a strand of hair. Because of this precision, the knee implant also lasts

Mdm Rokiah Amat with Dr Chin Pak Lin. Mdm Rokiah recovered quickly from the Robodoc procedure on her left knee and visited Johor Baru two months after the operation.

longer. A typical implant, when fitted well, can last 15 to 20 years. Mdm Rokiah, whose right knee was treated in the conventional way in 2004, said she recovered sooner from the latest procedure on her left knee and added that there was less pain. She even made a trip to Johor Baru two months after surgery. In Mdm Rokiah’s earlier operation, which was also performed at SGH, a surgeon prepared the surfaces of the bone for the implant using hand tools such as mallets and broaches. Mdm Rokiah learnt that she had osteoarthritis – a degenerative joint disease – when she was 52, which led to a knee replacement two years later. She said: “I couldn’t walk for long before I went for the first surgery. I would feel a lot of pain in my knee after walking a few hundred metres.” As a subsidised patient, she paid about $4,000 for the Robodoc procedure. That is about the same amount she paid for conventional surgery. Two knee-replacement operations later, Mdm Rokiah enjoys her

Fit and position are the most important factors that determine the success of a knee replacement. The pictures on the left and in the middle show the parts of the knee joint that will be milled to take in a knee implant (right).

newfound mobility. She takes her three grandchildren to school four times a day, does her housework and goes to the market nearby with relative ease. So far, SGH is the only hospital in this region, outside of South Korea and Japan, to offer this procedure. Of the more than 1,500 knee-replacement operations performed at SGH in the past year, about 20 were done using the Robodoc procedure. The median age of the patients was about 60 years old.

Knee pain not just a problem of old age Many people think osteoarthritis of the knee is part and parcel of ageing, but it is actually a disease that can cause disability. Osteoarthritis refers to the gradual deterioration of cartilage in the knee, usually a result of carrying heavy loads over a long time. As the cartilage wears out, the rest of the knee also degenerates. The pain may discourage the person from using his knee. His knee muscles and ligaments may then weaken, making it increasingly hard to walk, squat and climb the stairs.

Athletes are more likely to develop osteoarthritis than non-athletes. Athletes who participate in high-impact sports – for example, soccer, long-distance running, competitive weight-lifting and wrestling – have a higher risk of developing knee and hip osteoarthritis.

Early treatment options In its early stages, knee osteoarthritis can be treated with non-surgical measures, such as:

Lifestyle modification Lose weight Switch from running to swimming or cycling Minimise activities such as climbing the stairs

Exercise and physiotherapy Do exercises that increase range of motion and flexibility, and which strengthen leg muscles Physical therapy is often effective for reducing pain and improving knee function

Supportive devices Use supportive devices, such as a cane Wear energy-absorbing shoes, or don a brace or knee sleeve

Medication Anti-inflammatory medication can reduce swelling in the knee joint Pain relievers are usually prescribed as the first line of treatment Dr Darren Tay, Consultant, Department of Orthopaedic Surgery, Singapore General Hospital

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News > Continued from page 1

Reborn with two new organs

Complex process Removing and preparing an organ for transplant is a delicate procedure, due to the need to prevent damage to nearby organs that can be used for other patients. The pancreas is especially hard to remove as it has multiple blood vessels and arteries. Its two arteries are joined into one, and the donor’s blood vessels are used to make the operation more straightforward, said Dr Tiong Ho Yee, Director, Kidney Surgery and Transplantation, National University Hospital.

More organ donors needed

How are type 1 and type 2 diabetes different? Type 1 diabetes

Type 2 diabetes

Who gets it

Usually develops in young people

The most common type of diabetes in Singapore, and usually develops in people who are 40 and above, and who are overweight

What causes it

Insulin-producing cells in the body are destroyed, and the body produces practically no insulin

Insulin is produced, but in smaller than normal or insufficient amounts

How it is treated

Can be controlled only with insulin replacement in the form of daily insulin injections, together with proper diet and exercise

Can be controlled with medication, proper diet and exercise but, in advanced cases, daily insulin injections are needed

are stabilised. His total hospital stay was just about four weeks.” As with other transplant patients, Mr Huang will be on medication for the rest of his life to prevent his body from rejecting the grafted organs. Mr Huang recalled his surprise when he was told that a donor had been found. He was asleep when the call came and his first thought was that “I must be dreaming”. He added: “I called my family and they told me to be brave and go for the operation.” Mr Huang, who has two sisters, said he could now live like a normal person. “I have to thank the donor and his family for giving me a new life,” he said.

What made the operation possible In April 2011, the Ministry of Health set aside $2.7 million for a national five-year pilot programme for pancreas transplants. Mr Shawn Huang’s simultaneous pancreas-andkidney transplant is estimated to cost $80,000 to $100,000. It will be partly funded by the programme. Four pancreas transplants are expected to be performed a year by Singapore General Hospital and National University Hospital, or 20 cases over the next five years.

PHOTO: GETTY IMAGES

to “improve their survival and quality of life”, said Dr Lee, who noted that patients who received a pancreas-andkidney transplant lived 10 years longer than those who underwent just a renal transplant. Double-transplant operations are not new. As many as 30,000 of such operations have been carried out in other countries since 1966. Still, simultaneous pancreas-and-kidney transplants won’t have an impact on a large number of people in any country, said Associate Professor Krishnakumar Madhavan, who heads National University Hospital’s (NUH) hepatobiliary and pancreatic surgery division. “But for this small number of people, the impact is tremendous, because they will suddenly be freed from a routine of dialysis, insulin injections and looking after their blood sugar levels,” said Prof Krishnakumar, who led the surgeons from both NUH and SGH. Mr Huang’s type 1 diabetes destroys his body’s ability to produce insulin (see box). However, a month after his surgery in October, he no longer needs insulin injections as his new pancreas began functioning immediately after it was implanted, as did his new kidney. Both organs came from the same donor, which significantly lowers the risk of his body rejecting them. Dr Lee said: “We had immediate graft functions for both the pancreas and kidney. This was expected. The donor was near perfect. There was urine production at the time we finished the operation. “Mr Huang’s blood sugar normalised very quickly, even before he was taken back to the intensive care unit. And he was able to start eating four days after the operation. His wounds have healed well and he’ll be on regular reviews on a weekly basis until his medication levels

Mr Shawn Huang’s case highlights a pressing problem in Singapore: the constant need for more life-saving organs. “We continue to suffer from a shortage of organ donors,” said Professor A Vathsala, Head and Senior Consultant, Division of Nephrology, National University Hospital (NUH). “For more patients to benefit from pancreas-kidney, kidney, heart or liver transplants, we need more people to say yes to organ donation.” In the US and Europe, as many as 40 out of every million people donate their organs. In Singapore, the donation rate is 6.5 out of every million. More than 500 patients are waiting for an organ as of September last year, despite the introduction of the Human Organ Transplant Act (HOTA) in 1987, which allows kidneys, hearts, livers and corneas to be removed from Singaporeans and permanent residents who have died. HOTA is complemented by the Medical (Therapy, Education and Research) Act, or MTERA, which allows people who aren’t included under HOTA to donate their organs. MTERA also covers cases where people want to pledge organs that are not governed by HOTA, such as the pancreas. Of the people waiting for an organ, 465 are on the National Kidney Transplant waiting list, said the National Organ Transplant Unit (NOTU). Another 14 are waiting for hearts, 24 for livers, 25 for corneas and one for lungs. As of last September, about 2,500 organ transplants have been carried out successfully since the introduction of HOTA, said NOTU. Those who choose to remain under HOTA have a chance to help others. They will also have higher priority for a deceased donor organ if they need a transplant in the future, according to the Ministry of Health’s website. Please call the organ donor registry at 6321-4390 or go to www.moh.gov.sg for more information.

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More than $1 million saved

PHOTOS: Darren CHANG

A SingHealth bulk-buying initiative helps voluntary welfare organisations save money and focus on caring for patients

Freed from managing the purchase of essential items, staff at Peacehaven can spend more time with residents like Mr Tay Lee Hong, 70, who is on temporary tube feeding.

BY Karen Tee

Every day in Singapore, large amounts of essentials, such as milk feeds and diapers, are used by nursing homes, hospices and community hospitals. A small drop in the prices would mean huge savings for these organisations. With this in mind, SingHealth’s Group Procurement Office (GPO) teamed up with the Agency for Integrated Care (AIC) to help 30 such organisations save money. The project began in 2009. After 2½ years, total savings have amounted to more than $1 million. The Salvation Army Peacehaven Nursing Home is one organisation benefiting from the project. The home currently gets its milk feeds, diapers, wet wipes, dressing sets, catheterisation sets and surgical masks through bulk buying. The project has been so successful that Peacehaven hopes to also buy linen sheets, uniforms, wheelchairs and hospital beds, said Mdm Low Mui Lang, Executive Director of Peacehaven. With milk feeds alone, the home saves 30 per cent of the cost. Every month it uses 7,000 units of tinned and liquid milk. Tinned milk curbs wastage because nurses can measure exact amounts for residents who cannot finish a packet by themselves. “Liquid milk comes in 250ml singleserve packets, but some residents are prescribed smaller amounts by dietitians. What’s left in the packet has to be thrown away as we can’t feed the leftovers to others or store it for the next feed,” said Mdm Low.

“The savings allow the home to control rising costs and reduce its deficit, while leveraging on the scheme to buy products it cannot otherwise afford,” she said. Cost savings One such item is wet wipes, which would have blown the home’s budget by three times if Peacehaven bought it on its own. Previously, nurses used cotton rolls for incontinent residents, as it was more economical. “With the cost now more

manageable, I have started to slowly introduce wet wipes to wards which require a higher level of care,” said Mdm Low. Dressing wounds has also become easier. Instead of picking up gauze and swabs individually, nurses now have conveniently grouped dressing sets which are easier to store and retrieve. One big advantage is that the home gets expert buying help. Previously, procuring a single item was a tedious process that often took two months. They had to get quotations from at least three sellers and evaluate samples before deciding which to buy. “Not all nursing home staff are experts at procurement. Charitable organisations like us have limited manpower, and would prefer that our staff spend more time with the residents,” said Mdm Low. In addition, nurses no longer need to track stocks in wards and submit individual forms to Mr Spencer Mak, Peacehaven’s Operations Supervisor, who tracks total stocks and gets replenishments from the vendors. He said: “I no longer have to collect orders from individual nurses and now have time to handle responsibilities such as facility maintenance and transport.” Nurses, too, freed from managing purchases, have more time for residents. Ms Jeena Thomas, Senior Registered Nurse, said: “I am happy that we have more time with them, and they are happier that we’re around for longer.”

Bulk buying

How bulk buying started It was clear to everyone that some form of bulk buying would save costs for Singapore’s smaller healthcare establishments. So, SingHealth’s Group Procurement Office (GPO) worked with the Agency for Integrated Care (AIC) to set up the bulk-buying pilot programme in 2009. Under the programme, the GPO bulk-buys milk feeds, diapers and other essentials for 30 local nursing homes, hospices and community hospitals. Six months into the project, the homes already saw savings of about 10 per cent on milk feeds and diapers, compared to the 5 per cent they had initially projected. After 2½ years, the savings amounted to more than $1 million. The GPO buys drugs, supplies, equipment and IT services for healthcare institutions. Since beginning operations, it has saved more than $200 million for the SingHealth Group (including drugs for the National Healthcare Group and government bodies), which has helped contain healthcare costs. Mr Tan Jack Thian, Group Chief Procurement Officer, SingHealth Group, said: “By consolidating individual purchases from the charitable organisations into bulk purchases, we gain volume discounts that help them contain rising operating costs.”

What SingHealth’s Group Procurement Office buys yearly for 30 organisations Milk feeds

550,000 tins

Dressing sets

52,000 sets

Wet wipes

100,000 packets

Catheterisation sets

2,500 sets

Diapers

4.2 million pieces

Mr Spencer Mak, Peacehaven’s Operations Supervisor, finds it easier to collect orders and keep track of stocks through the GPO joint-buying scheme, allowing him to spend more time on his other responsibilities.

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SGH takes steps to boost service From its shuttle bus service to directional signs, a range of services at the hospital has been improved in response to feedback from patients and visitors It used to be a long and frustrating wait for the shuttle bus that ferries patients and visitors from Outram Road to Singapore General Hospital (SGH) and national centres on campus. But that’s no longer the case since two enterprising Singapore General Hospital (SGH) staff came up with a simple idea to improve the free shuttle service. “After the opening of the North East Line, the bus stop outside that station (on Eu Tong Sen Street) became the first stop for the shuttle buses leaving the campus,” said Mr Matthew Wee, Assistant Team Leader, Department of Transportation, SGH. Previously, the first stop for buses leaving SGH Campus was the bus stop opposite the East West Line station on Outram Road. Passengers boarding the bus at the North East Line stop often quickly filled up the seats, meaning that those waiting at the East West Line stop would have no chance to board. The problem was solved when the staff managing the shuttle bus service, Mr Quek Bak Siang, Senior Operations Executive, and Mr Ong Ming Hui, Operations Assistant, General Services Department, came up with the idea to have some services skip the North East Line stop during peak periods, allowing an empty bus to pick up passengers at the next stop. Feedback makes a difference The change to the shuttle service was just one of the many service improvements undertaken by SGH staff in response to feedback from patients and visitors. Many are simple but make a huge difference to the many patients and visitors to SGH and its sister institutions on SGH Campus. For instance, visitors who don’t speak English – the main language of communication at the hospital – can easily find someone who does by checking the badge that visitor-registration-counter staff wear. It shows prominently a phrase in the language that the customer relations officer is proficient in, be it Chinese, Tamil or Malay. At the Accident and Emergency (A&E) department, patients asked to have an x-ray after their initial examination will be guided by bright blue floor stickers of footprints that line the passage way from the triage room to the x-ray area, while visitors entering SGH at Block 4 won’t be able to miss the huge numbers that mark the different blocks. These numbers are lit up at night for greater visibility. A more efficient queue system has also been implemented at the pharmacies. Patients who are collecting three or fewer items are given a separate queue number to cut their waiting time.

The improvements:

Patients always have procedures they are about to undergo explained to them, but they may not always understand or remember them. Hence, at the Preadmission Testing office, large wall illustrations explain to patients the pre-admission procedure, which includes financial counselling and the tests that they will undergo. Similarly, at A&E, illustrations on the walls in different sections of the department help allay patients’ anxiety by explaining what they can expect to go through. After consultation and tests at A&E, they may be admitted for further investigation, referred to a specialist at an outpatient clinic or discharged. All these make for a less confusing experience at the hospital, said staff at the various departments. Patients don’t always understand or remember the directions given to help them find the x-ray area from the A&E’s triage room, But it’s hard to miss the floor stickers showing them the way.

To spread out the passenger load, some shuttle bus services will stop only at a designated MRT station during peak periods.

Large wall illustrations explain to patients scheduled for surgery what they can expect to go through during pre-admission testing.

Patients who are collecting three or fewer items at the pharmacies are given separate queue numbers to cut waiting time.

To provide better assistance to patients and visitors, customer relations officers wear badges indicating the languages they speak.

Bright blue footprint-shaped stickers on the floor at the Accident and Emergency department guide patients from the triage room to the x-ray area.

To help visitors find their way around SGH Campus, large and highly visible numbers are displayed on each hospital block. D

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Jan/Feb 2013

Infant care Mother’s milk helps premature babies pull through

p16 Children’s health Spanking your child can cause long-term emotional harm

an outward sign of something psychological. The child has an immense urge to pull out his hair and is not at ease until he does it. Then, he feels tremendous relief and release of tension.” Because the child often pulls his hair in private, parents are usually shocked when told of the diagnosis. They may also find it difficult to accept that the child has what is essentially an underlying psychological disorder. But the young patient needs plenty of support and understanding from his parents, said Dr Lee. Many of them have difficulty coping with stressful school examinations or strained family relationships, he added.

Trichotillomania patients may display other obsessive-compulsive behaviours like compulsive nail-biting or the repeated picking of skin. The constant hair-pulling can lead to permanent hair loss especially if the behaviour is left unchecked and continues for a long time. The child often gets trapped in a destructive circle. “They pluck their hair and get bald spots. They then get made fun

What causes hair loss

Normal hair grows in cycles and goes through three stages: stage 1

stage 2

stage 3

anagen

catagen

telogen

The growing phase

The transitional phase when hair starts to break down

The resting phase

Photo: VErnon wong

In the absence of other symptoms, hair loss is uncommon in children, said Dr Lee Haur Yueh.

A coping mechanism

of or bullied. They become more isolated and stressed. To find relief, they pluck out even more of their hair. It’s stressful for both child and parent,” said Dr Lee. At its extreme, people who suffer from this obsessive behaviour may eat the pulled hair. Experts don’t yet fully understand what causes this condition and, while unusual, this disorder known as trichophagia can lead to physical problems like abdominal pain, vomiting and bleeding. In more severe cases, ingested hair form indigestible “hairballs” which, if left untreated, may perforate the intestine. Surgery may be required to remove the “hairballs”. After the dermatologist diagnoses the problem as an obsessive disorder, the patient is usually referred to a psychiatrist. Recognising that hair-pulling is an illness is often enough for people suffering the mild form of the disorder to overcome it. But for those who suffer the more serious form, the psychiatrist may prescribe behavioural therapy such as relaxation or habit-reversal training.

Once patients have gained a heightened awareness of their condition, they are taught “competing responses” that they can use whenever they feel the urge to pull their hair out. For example, they are taught to keep their hands occupied so as to avoid touching their hair. “For some people, trichotillomania is mild and can be quelled with awareness and concentration. For others, the urge may be so intense that it makes thinking or doing something else feel almost impossible,” said Dr Lee.

Hair loss in adults Androgenetic alopecia This condition, also known as androgenic alopecia, is the most common cause of hair loss in men and women. It involves the male hormone androgen. The female variation is known as femalepattern baldness. It results in diffuse thinning all over the scalp. The condition usually affects women later in life than men and may be genetic, although the exact cause of this pattern of hair loss is unknown.

Alopecia areata Thought to be an autoimmune condition, alopecia areata occurs when your body attacks its own hair follicles. It’s often characterised by circular bald patches as hair falls out in clumps. The good news is that the hair usually grows back in three to six months, even without treatment. The condition seems to run in families. The exact cause is yet to be determined.

Scalp diseases and others

Treating hair loss See your doctor if you’re losing more hair than normal. Meanwhile, avoid brushing your hair. Use a wide-toothed comb instead. Avoid chemical treatments for your hair to reduce chemical damage, and try to keep your hair short. Depending on the cause of hair loss, your doctor will decide on the appropriate treatment.

Photo: Getty images

Balding can be caused by a number of physical ailments, but what happens when hair loss is self-inflicted? By Usha Ranee Chandradas

his mother took him to see a doctor and was shocked when she was told that he had been pulling his hair out. The boy, it seemed, had been doing it in secret, but he couldn’t say why he did it. He just needed to, he said. Apart from this unusual habit, there was nothing wrong with him. According to Dr Lee Haur Yueh, Consultant, Department of Dermatology, Singapore General Hospital (SGH), pulling his hair out was not a harmless habit that the boy would eventually grow out of. It is a condition known as trichotillomania that affects mostly young teenagers struggling to come to terms with the physical, emotional and other changes that adolescence brings. A harrowing and rare psychological disorder, trichotillomania compels victims to pluck hair from their bodies – usually from the scalp, but also from eyebrows, eyelashes or even the pubic area. “It is usually a manifestation of an obsessive compulsive disorder, but can also be associated with depression and anxiety,” said Dr Lee, who has treated patients as young as 10. “Parents may think this is a mere habit and scold the child. They need to understand that the hair-pulling may be

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Hair today, gone tomorrow For some time now, the child had looked unkempt. His hair was straggly and there were small bald patches on his head. Worried,

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Fungal and bacterial infections, and hormone changes such as those experienced after pregnancy, can cause hair loss. It can also be due to curling or braiding hair too tightly, drugs, anaemia or thyroid disease. It is difficult to say how much hair loss per day is normal, as it varies from person to person. However, some studies indicate that losing up to 100-150 strands of hair a day is normal.

The above information was adapted from Beautiful Inside Out – The SingHealth Guide to Women’s Health.

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Jan⁄ Feb 2013

Infant care

Breast milk is best for preemies A mother’s milk contains a high concentration of nutrients that helps premature babies pull through their critical stage of growth. By Sim Ee Waun

w Ho

Photo: getty images

Photos: wong wei liang

Dr Varsha Shah (fourth from right), lactation nurses, midwives and other nurses of SGH’s neonatal ward help support mothers to breast-feed their newborn babies.

The birth of a baby can be one of life’s most joyful moments, but it can also be stressful if the baby arrives earlier than expected. A premature baby – or preemie, for short – has to be placed in an incubator in a neonatal intensive care unit for at least a few weeks. Its organs will not be fully developed yet and its condition will be initially unstable. So, when doctors advise new mothers to breast-feed their preemies, they are often met with disbelief. Doctors and nurses at Singapore General Hospital (SGH) hope to convince mothers that breast-feeding is the best gift for their premature babies. Dr Varsha Shah, Senior Consultant, Department of Neonatal and Developmental Medicine, SGH, called breast milk “liquid gold”,

because of its amazing concentration of protective substances. “Colostrum is the milk a mother produces right after delivery and, compared to other kinds of milk, it has the highest concentration of antibodies needed to fight the complications that may arise from premature birth,” she said. Mother’s milk is also highly effective in protecting a baby from infections such as meningitis and necrotising enterocolitis, a serious intestinal infection. “By consuming mother’s milk, a baby effectively receives his first immunisation, because all the antibodies a mother has in her body will be passed on to him through her breast milk. No man-made vaccine can replicate that,” said Dr Varsha. “Mother’s milk is specially designed

28 34 32 37 to

weeks old: to help a premature infant through those first difficult weeks. It is richer in proteins and has slightly different fats from later breast milk.” Pre-term mothers make colostrum for a longer time than full-term mothers, so it is important to express as much of the milk as possible. Dr Varsha said it is essential for pre-term mums to express their milk within six hours of giving birth. To ensure that milk production does not dwindle away due to a lack of breastfeeding, pre-term mothers should express their milk regularly – around eight times a day – as though they were breast-feeding a full-term child, Dr Varsha said.

Intravenous fluids and nutrition, plus tube feeding

weeks old:

Tube feeding plus feeding by breast or bottle

SGH, KKH to become baby-friendly hospitals Nurseries at Singapore General Hospital (SGH) are almost empty. This isn’t because fewer babies are delivered, but a result of the efforts by a team of doctors and nurses to promote total breast-feeding. New mothers are encouraged to have their newborn babies in their rooms to start the bonding process as soon as possible, as this helps to trigger the production of breast milk, which can begin as soon as within half an hour of delivery.

Dr Varsha Shah, Senior Consultant, Department of Neonatal and Developmental Medicine, SGH, said: “Every newborn baby has the ability to find his mother’s breast on his own and to decide when to take his first feed, provided he has skin-to-skin contact with his mother’s breasts.” Breast milk helps protect a baby from infection and allergic reactions. For the new mother, breast-feeding stimulates contraction of the uterus, reduces the chances of haemorrhage and helps

prevent painful breast engorgement. At SGH, mothers are discouraged from using formula milk. Babies are not given any food but mother’s milk. Nurses in the maternity wards are trained to help mums practise correct breast-feeding techniques. After a mother and her baby are discharged, the nurses and lactation specialists will call the mother regularly to check that she is breast-feeding well. Similar efforts are being made at KK Women’s and Children’s Hospital (KKH),

which has set up breast-feeding rooms on different levels of its outpatient areas for mothers to breast-feed their babies conveniently. Through their efforts, KKH and SGH aim to receive accreditation in 2013 by the Baby-Friendly Hospital Initiative, a programme sponsored by the World Health Organisation and the United Nations Children’s Fund. More mothers breast-feed at babyfriendly hospitals and child health at these hospitals has also improved.

Intravenous fluids plus intravenous nutrition

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weeks old or younger:

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Jan⁄ Feb 2013

Common misconceptions about breast-feeding

Strong support helps pre-term mum pull through

Not enough milk

A mum may feel guilty if she thinks she is not producThe sight of tubes stuck to her tiny ing enough milk. baby brought on a flood of tears. Born Stress can affect very prematurely at 27 weeks, baby milk production. h it ft), 41, w Vincent Lim weighed just 1.165 kg. A full-term baby’s ah See (le g N rn n o a b T Mdm who was Vincent, “When I saw my baby in the incustomach is very , y b a b . r s e k h ee ly at 27 w bator, my tears started pouring down,” small, so it won’t premature said 41-year-old Mdm Tan Ngah See. actually need a Baby Vincent was delivered via caesarlot of milk. Mums should ean section after Mdm Tan was rushed to hospital following relax and bond with their sudden contractions. For the first five days after birth, he was babies, and their milk in an unstable condition as he fought an infection. will flow naturally. They Luckily, Mdm Tan received a lot of support from her should also drink lots of husband and family. With the encouragement of the nurses, fluids before and after she started to express milk two days after birth. At first, she breast-feeding.

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could produce only 20ml to 30ml a day, but that was more than enough for Vincent. While in confinement, Mdm Tan watched Vincent in his cot at the Singapore General Hospital every night via a computer as she expressed her milk. Her husband took the milk to the hospital every morning before work, and every evening after work. After several weeks in hospital, Vincent grew to just over 2.4kg and was in a stable condition. Mdm Tan believes her milk made a difference to his growth and development.

Milk must flow the moment the baby is born Not true. Milk starts to be produced in greater quantities a few days after giving birth.

Mums must avoid certain foods if she breast-feeds Not strictly true. Generally, a breast-feeding mother should maintain a balanced diet rich in iron, protein and calcium. But her energy needs will be greater, about 400 to 500 calories a day more than normal.

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Common obstacles to breast-feeding No place to express milk A mum may not have a private place to express milk in her office. If a nursing room is not available, she may lock herself in a meeting room. She can use a scarf to cover herself and express milk in a hygienic environment.

Finding time to breast-feed A working mum can breastfeed her baby when she is at home. She should aim to provide at least

one feed of expressed breast milk each day. She should express milk at four- to six-hour intervals and store the milk in sterile bottles, with the date and time clearly labelled. The milk should be put in a fridge and taken home in a cooler box. Sore nipples Mums can use a nipple shield while breast-feeding to avoid this problem. If her nipples turn swollen, a mum should see a lactation consultant.

Tips for breast-feeding Latching on Getting into a proper and comfortable position, especially in the early weeks, is important in allowing your newborn baby to feed efficiently. Mdm Ho Ai Lian, Senior Midwife, Singapore General Hospital, offers some tips: Use pillows to support your back and arms, and on your lap, so they help you sit and breast-feed more comfortably.

Position your baby close to you with its hips flexed, so it doesn’t have to turn its head to reach your breast. Its mouth and nose should be facing your nipple. Support your breast so it is not pressing on your baby's chin. Leaning over your baby can cause backaches, neck and shoulder strain or sore nipples.

Mdm Ho demonstrates three common breast-feeding positions:

After

weeks old:

Cradle hold

Best for full-term babies who were delivered naturally. Mothers who had a caesarean section may find this position uncomfortable as it puts a lot of pressure on their abdomens. Commonly used for all newborn babies.

Usually by breast or bottle. No more tube feeding

38 weeks old:

A preemie reaches full term when it is about 38 weeks old. As an “ex-preemie”, it will still be relatively weak. Compared to full-term babies, it will still take a longer time to feed. When breastfeeding an “ex-preemie”, parents must watch out for problems with sucking, swallowing and breathing. As most preemies are not as adept at this sequence of actions, parents need to let them take breaks, so they can swallow the milk and catch their breath. If a baby starts getting blue around the mouth, it may be choking.

Cross cradle hold

Useful in the early weeks of breast-feeding, or for small babies or one with trouble latching on to its mother’s breast. If nursing from the right breast, use your left hand and arm to hold your baby, whose tummy and chest should be facing your breast directly. It’s also good for mums with big breasts or flat or short nipples.

Football hold

Tuck your baby under your arm like a football or handbag, with its nose level with your nipple and feet pointing towards your back. Works well for a mum who had a caesarean section as it avoids having her baby rest on her tummy. Good for mums with big breasts or flat nipples, or with twins. This method also works if a baby is small or has trouble latching on.

Preemies have relatively weaker neck muscles, so their heads need to be supported during breastfeeding. A mum should place her hands behind her baby’s neck, with her index finger and thumb lightly over her baby’s ears. Gastro oesophageal reflux affects up to half of premature babies, causing them to spit up whatever they have ingested. Putting the baby on its tummy or side can help. Mums can also feed their babies more frequently, and with smaller amounts of milk each time.

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Jan⁄ Feb 2013

Children’s health Discipline your child without spanking

Don’t slap that kid

Ms Lynn Soh, Head and Senior Psychologist (Psychology Service), KK Women’s and Children’s Hospital, said parents are often surprised by the effectiveness of alternative methods of discipline. These are some steps parents can take:

If you think shoving, slapping or hitting a child will not leave a lasting psychological mark on him, think again. A study published in the journal Pediatrics suggests that children subjected to such punishments risk having mental health problems as adults. According to the Canadian researchers, these can show up as mood and anxiety disorders or substance abuse. They analysed data from thousands of American adults in one of the first studies to look at the long-term effects of physical punishment on children, even if the punishment was not major maltreatment or physical abuse. The study defined “harsh physical punishment” as pushing, grabbing, shoving, slapping or hitting by elders. It suggests that even if there is no major maltreatment or physical abuse, these punishments can psychologically affect a child in adulthood. The study found that 2 to 7 per cent of mental problems, including depression, bulimia, personality disorders and intellectual disabilities, were linked to such punishments in childhood. The findings are consistent with those of other studies on the effects of

Picture cards that help kids communicate A These “Bear” cards can help a child communicate his feelings to his parents. The child picks out cards which reflect his feelings, for example, happy, sad, fearful and so on. B These “Strength” cards depict positive things that a child can do. They help him identify positive behaviour and build self-awareness. The child can also use the cards to acknowledge a feeling which his parents can label for him. This helps him recognise emotions and, if an emotion is identified as negative, he may be less likely to act that out.

physical punishment on children, said Ms Lynn Soh, Head and Senior Psychologist (Psychology Service), KK Women’s and Children’s Hospital (KKH). Commenting on the study, she said as long as discipline involves hitting, slapping or smacking a child, it may increase the likelihood of negatively impacting his mental health as an adult. “The message sent to children through corporal punishment is one of aggression. It includes repeatedly telling a child that he is worthless, useless, unloved or unwanted, and threatening to use physical or psychological violence on him. This message of aggression, more than the actual physical punishment, has an important effect on a child’s psychological health later in life.” She said physical punishment usually occurs with psychological aggression. If this continues, over time the child internalises a message of violence, and may grow up believing that physical aggression is okay in certain social situations. “It’s ironic to use physical punishment to teach a child not to be aggressive. It reduces his understanding of the rules and values being taught.” A child may learn to fear punishment, rather than understand why he should follow rules, and so grow up with less ability to stop himself from misbehaving. Some children may interpret spanking as a sign that

Photos: Morven koh

A new study has shown that the adverse effects of physical punishment on children follow them into adulthood. By Desmond Ng

Ms Lynn Soh, Head and Senior Psychologist (Psychology Service), KKH.

their parents do not love them, and this could lead to a strained relationship with their parents. A child who is physically punished, without being told why, may develop poor self-esteem and this can make it difficult for him to adjust socially in school. “Poor self-esteem and low selfconfidence can increase the likelihood of poor academic performance. The child may have difficulty concentrating, and this can reduce his potential to excel academically,” said Ms Soh. In a worst-case scenario, a child may even contemplate suicide. Parents are responsible for taking care of their children’s material needs, and be role models who facilitate the healthy physical,

Set rules and explain them to your children This creates structure and provides a sense of safety, as your children will not fear being punished for reasons they did not know in advance. BE patient as your children test the limits of your rules Your children will not be willing to accept your measures at first, and their behaviour may initially worsen. Stay firm and press on with punishment when rules are broken If your children break the rules, they must face the consequences. For younger children, the punishment can take the form of timeouts, for example. Both parents must uphold the rules and mete out punishment consistently This will discourage children from turning to the more lenient parent to avoid punishment. Use rewards to reinforce positive behaviour Negotiate the form of rewards and consequences with older children and teenagers, to encourage them to take responsibility for their actions.

mental, emotional and social growth of their kids. Given the adverse effects of physical punishment, it is important to look for alternatives, said Ms Soh. “There are many non-violent ways to discipline or punish a child instead of hitting, smacking or spanking him.”

Culture shouldn’t be an excuse

Some countries and cultures, more than others, have a low tolerance for physical punishment because of an observed link between anxiety and stress, and the propensity for violence. One of them is Sweden. “If you grow up in Sweden, where there is no acceptance of physical abuse, hitting a child will have a big impact on him. But in other countries where physical punishment is more normal, the adjustment for the child won’t be as great,” said Ms Lynn Soh, Head and Senior Psychologist (Psychology Service), KK Women’s and Children’s Hospital. In Singapore, some parents admit to smacking and slapping their kids on the spur of the moment, or when they are stressed. But after being taught positive parenting methods, these parents often realise how

harmful physical punishment can be, said Ms Soh. “It’s really about being mindful of how frequently and severely children are dealt physical punishment. It’s important to strike a balance between punishment and providing positive experiences that acknowledge a child’s strengths.” Parents are encouraged to take care of themselves before they can take care of their kids. Ms Soh said: “They must take care of their mental health and seek professional help if necessary. If we don’t take care of ourselves, it’s very hard to ensure that we can provide for our children’s well-being.” Timing is also important. “When we are angry, sad or worried, we are not in the right state of mind to discipline our children,” said Ms Soh.

jan⁄ Feb 2013

singapore he alth

Viewpoint

With IVF, less may be more “Congratulations!” I beamed happily at Kim. It was the 1990s and Kim, married and childless for 10 years, had undergone an in-vitro fertilisation (IVF) cycle. Moments later, however, my enthusiasm wavered as I did the ultrasound scan. On the screen before me was, not one, not two but, three little foetal hearts. I was an obstetrics and gynaecology trainee at the time and was uncertain about what I should do next, so I called the consultant in charge to convey the news. To the layman, having multiple pregnancies is a novelty. One usually pictures cute little babies in a row and jokes about “buying one and getting two free”. To an IVF clinician, however, it is a mixed bag. As much as we want our patients to get pregnant, multiple pregnancies bring a host of potential complications, spanning almost everything covered in our obstetrics textbook. Everything is exaggerated in a multiple pregnancy: a higher risk of miscarriage, morning sickness, anaemia, high blood pressure, diabetes and so on. But the major concern is having the babies delivered way before term, weighing a mere few hundred grams, needing intensive care unit (ICU) support just to breathe and being at risk of cerebral palsy. Twins have four times, and triplets up to 10 times, the risk of cerebral palsy compared to a singleton pregnancy. There is also the social and economic cost of looking after two or more babies at once. Most of us struggle coping with just one. Imagine having three! Over the past two decades, the number of twins and triplets born in Singapore has spiked. But in October 2011, the Ministry of Health mandated that a maximum of two embryos, instead of three, can be implanted in a woman through IVF at any one time. Yet, despite knowing the risks involved, why do doctors put in so many embryos in the first place? At first, the goal of IVF was to achieve a pregnancy. Just having a positive urine pregnancy test was a reason to celebrate. When we replace more embryos, we increase the possibility that one of them will be implanted. At the same time, however, this increases the risk that more than one will be implanted. This strategy was chosen because we could not predict which embryo

would eventually be implanted. So, to increase the chance of a pregnancy, we put in more embryos. It made sense in those days. Often, even after three embryos were transferred, we would end up with only one foetus. But as IVF became more advanced and embryo quality improved, we became a victim of our own success – more embryos were successfully implanted and multiple pregnancy rates began to soar. In natural pregnancies, only one in 70 births results in twins. In IVF, however, one in four does. The burgeoning multiple pregnancies came with heavy medical and financial burdens. And the problems did not end after the delivery, as the complications from prematurity can be lifelong. Expectations also began to change. Higher standards meant that we measured IVF success with live birth rates, as opposed to celebrating when a positive pregnancy test popped up. A healthy baby is what couples expect now. It no longer seems like it’s too much to ask. Kim’s ordeal Kim appeared to be doing well until she was in the 26th week – or the sixth month – of pregnancy, when her water bag broke. Soon after, she delivered the first of her triplets. Because the baby was delivered so early, it did not survive. The umbilical cord was cut but the placenta was left in situ. There was a very high risk that the other two foetuses might be delivered soon, but we wanted to see if we could keep them in the womb for a bit longer. The next few weeks were heartrending for Kim and us, her doctors. We

In IVF, up to two embryos are replaced back into the uterus to raise the chance of successful implants.

Twins have four times, and triplets up to 10 times, the risk of cerebral palsy compared to a singleton pregnancy. There is also the social and economic cost of looking after two or more babies at once.

were worried about possible infections that could be life-threatening, as well as the threat of premature delivery. We treated her aggressively with antibiotics and she was sent to the labour ward repeatedly for close monitoring. In those days, complete bed rest was prescribed. (This is no longer the practice as it carries the potentially lethal risk of blood-clot formation, without evidence of benefits.) Amazingly, Kim’s pregnancy lasted another six weeks, one of the rare few that did. At 32 weeks, Kim went into labour. She delivered safely and, afterwards, faithfully went to the neonatal ICU to see the little girls every day, going through the emotional roller coaster that comes with taking care of such vulnerable babies. Thankfully, after one long month, she went home with two healthy daughters. Today, Kim comes with her girls when we hold our annual IVF Babies’ Party. I admire her tenacity, but seeing her also reminds me of the physical, emotional, medical and financial burdens of multiple pregnancies in IVF. She had a happy outcome. But for many others, things may not turn out to be so rosy. Time to do something It is time for something to be done to reduce the rate of multiple pregnancies through IVF. One may think the simple solution is to just put in fewer embryos. But this means a lower chance of pregnancy, which may not be acceptable to a childless couple. For the IVF centres, the pressure to maintain a good pregnancy rate is also high. It is little wonder then that adopting the strategy of putting in fewer embryos has been slower than expected, especially in countries where many IVF cycles are paid for by the patients.

So, it is in countries like those in Scandinavia, where IVF is regulated and funded by the government, that this strategy has been highly successful and widely implemented. It has been found that if only one embryo is transferred, while the excess is frozen and put in one at a time in another cycle in younger women, the cumulative pregnancy rate is comparable to that of a single transfer of multiple embryos. The pregnancy rate for the initial cycle might fall by a few percentage points, but the multiple pregnancy rate would fall significantly. The initial cost appears higher because one needs to freeze the excess embryos and come back for subsequent transfers. But it also means fewer premature and vulnerable babies. A recent study in Quebec, Canada, found that after the legislation of such elective single-embryo transfers, the pregnancy rate fell from 42 to 32 per cent, sparking another debate about the cost effectiveness of this strategy. What they overlooked was this – the multiple pregnancy rates fell from 25.6 per cent to 3.7 per cent. If we recall what IVF is supposed to be about – getting a healthy baby – then, clearly, the way forward is to limit it to only one-embryo transfers, especially in younger patients. After that, it is just a matter of how fast we want to follow through.

photo: Tan Wei te

BY Yong Tze Tein

Photos: getty images

IVF can often result in multiple pregnancies with higher risk of complications. It may be time to rethink the procedure

This is an abridged version of an article that was first published in The Straits Times Blogs. Dr Yong Tze Tein, Senior Consultant, Department of Obstetrics and Gynaecology, Singapore General Hospital (SGH), is an accredited IVF specialist. She has special interests in sub-fertility, menopause, adolescence and female sexual dysfunction. She is an educational supervisor for medical students and house officers and is also Clinical Quality Chairman, Department of Obstetrics and Gynaecology, SGH.

singapore he alth

Jan⁄ Feb 2013

Viewpoint

A sweet report for the Kitchen God

illustration: heymans tho

With careful planning, diabetics can enjoy sweet festive desserts and still give the Kitchen God something good to report

BY Goh Su-Yen

“Doctor! I’ve sneaked in two pineapple tarts!” whispered the sprightly octogenarian, as he poked his silver-haired head past the door of my consultation room. “Here, for you,” Mr L continued in his conspiratorial tone. “My daughter makes so many, but she won’t let me have any. You’ll tell her later that my diabetes is good, otherwise she won’t let me eat any this year. OK, ah? Promise you’ll give me a good report!” Now I know how the Kitchen God must feel!

It is believed that every year, on the 23rd day of the 12th lunar month, just before the Chinese New Year, the Kitchen God, whose name is Zao Jun, returns to heaven to report the activities of every household over the past year. As the Jade Emperor would reward or punish a family based on the Kitchen God’s report, families would often smear the lips of Zao Jun’s paper effigy with honey or nian gao (a dessert made from glutinous rice) to sweeten his words or to keep his lips stuck together. But unlike the Kitchen God, the test we doctors use to evaluate diabetes cannot be bribed with snacks. The HbA1c test gives an overall picture of a patient’s blood glucose level over the past two to

three months. It is determined by measuring the percentage of glycated haemoglobin in the blood. When a patient’s diabetes is out of control, the test will find too much glucose in his bloodstream. This extra glucose “links up” (the medical term is “glycates”) with haemoglobin, the oxygen-carrying molecules found in our red blood cells. The greater the level of excess glucose, the more haemoglobin gets glycated. The amount of A1c in the blood reflects the effectiveness of blood sugar control over the past 120 days, the usual lifespan of a red blood cell. An A1c reading of 6.5 per cent to 7 per cent reflects good diabetes control, while a reading of more than 9 per cent indicates poor control. In the latter case, the diabetes treatment plan must be reviewed. Mr L’s HbA1c was 7.2 per cent. That was pretty good, given that he was already 82 years old. He was diagnosed with diabetes just a few months earlier, and we wanted to avoid triggering hypoglycaemia (low blood sugar) events. So, we didn’t put Mr L on a very tight diabetes control plan. I explained the test result to Mr L only to get a groan of dismay. “You mean the test shows my result from the past 120 days? That means I can’t hide. Even what I ate during Christmas would be counted,” he said sadly. By now, his ever-vigilant daughter had joined us in the room. She said: “Anyway, he shouldn’t eat any bak kwa (barbecued pork) or pineapple tarts right?” Well, the answer is yes and no. Patients like Mr L used to be told that all sugary foods were off limits. Today, we believe patients can substitute small amounts of sugar with food containing carbohydrates and still be able to keep their diabetes under control. Also, while the type of carbohydrate that patients consume can affect the rate at which their blood glucose levels rise, it’s the total amount of carbohydrates they eat that has a greater effect.

It will help, too, if patients actively monitor their blood sugar levels with a glucometer. Still, none of this means that Mr L could gorge on all the starch and sugar he wanted. Many Chinese New Year goodies contain a large amount of carbohydrates and sugar, even in very small servings. One slice of bak kwa contains as much as 230 calories. One pineapple tart contains about 30g of carbohydrates and 70 to 80 calories. And let’s be frank: No one ever stops at just one slice of bak kwa or one pineapple tart! Working with a dietitian, I planned some meals and food choices for Mr L. His daughter, who would be doing most of the festive cooking, helped to decide which sugar substitutes to use, along with the spices and flavourings she could include to reduce the amount of salt.

As the Jade Emperor would reward or punish a family based on the Kitchen God’s report, families would smear the lips of Zao Jun’s paper effigy with honey to sweeten his words. But unlike the Kitchen God, the test doctors use to evaluate diabetes cannot be bribed with snacks.

After calculating the amount of carbohydrates in a bowl of his favourite orh nee, a Teochew dessert made from yam and pumpkin paste, Mr L said: “I think I’ll reserve that for my 85th birthday, in three years’ time!” He had a point. Saving sweets for a special occasion is a healthy way to enjoy a treat, and a great motivation for patients to focus on nutrient-dense foods such as vegetables, beans, whole grains, fruits, non-fat dairy, fish and lean meat. Most of us are familiar with the concept of “informed consent”. When patients are scheduled for an operation, doctors have to explain the procedure, the risks and its benefits. Perhaps it’s time to consider getting “informed consumption”. That’s something for the Kitchen God to think about as he enjoys his annual portion of nian gao.

This article was first published in The Straits Times’ Mind Your Body section on Feb 1, 2011. Dr Goh Su-Yen is Director, Diabetes Clinical Services, and Consultant, Department of Endocrinology, Singapore General Hospital.

JAN⁄ FEB 2013

singapore h ealth

Spotlight

Recipe for a happy mind Your mind is the window to your body and soul, so make sure it receives proper nourishment

Your brain is a powerful thing. Your mental state not only controls your consciousness, but also determines how your body functions. Stress, grief and depression can have a negative effect on your mental health. Studies have shown that serious mental illnesses can lower life expectancy by 10 to 15 years. Here are 10 ingredients that can boost your mental wellness for a healthier you.

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Interact with others. Talk to another person for at least 10 minutes daily. Talking to people stimulates the brain. A study in the US found that talking to another person for just 10 minutes a day improves memory scores. Also, the more you interact with others, the faster your brain will work.

Get at least eight hours of sleep a day. You are more alert and less prone to stress after a good night’s rest. Getting enough sleep can also improve your memory.

PHOTO: GETTy IMAGES

Avoid alcohol, cigarettes and drugs. They are not the solutions to problems. If you have emotional problems, seek support from family and friends, or get professional help. Alcohol, cigarettes and drugs provide only temporary relief from stress and unhappiness.

Do something for others. This is the best remedy when you’re feeling down. Helping a friend or family member, or doing community work helps you to take the focus away from yourself. In turn, you will feel more positive and less helpless.

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Eat a healthy diet. Foods rich in omega-3 fatty acids, such as salmon, tuna and mackerel, cut the risk of dementia and mental decline. Good nutrition is a natural defence against stress. Begin your day with a nutritious breakfast, preferably of wholegrain cereals and fruits, and take balanced meals throughout the day.

Keep yourself active. At least 30 minutes of exercise, three times a week, is ideal. Exercising keeps you physically strong, and reduces or prevents stress. Go for a walk or unwind with yoga. It is better to do moderate exercise regularly than to have a heavy workout occasionally.

Pick up a new skill or hobby. Learning to play a musical instrument, acquiring computer skills, starting a new hobby or learning to cook a new dish can help keep your brain active and healthy.

Get a mental workout. Scrabble or mahjong anyone? Engaging in mind-boggling games involves a combination of memory, decision-making and strategising, which keeps the brain active and prevents dementia. In addition, playing in a group will boost interaction.

Learn to manage stress. Shift your mindset and make a list. Make a list of goals and check them off when they are completed. This will help you tackle things one at a time. Seeing problems as opportunities or focusing on the positive can also help to reduce stress. Stress cannot be avoided, but you can learn to manage it.

Laughter is the best medicine. Laugh yourself silly and have fun whenever you can. Laughing can help to keep the doctor away because humour activates the brain’s reward and pleasure centres, generating emotions and relaxing the mind. This article was adapted from the Agency for Integrated Care publication NEXTSTEP. For more information, go to www.aic.sg

singapore he alth

Jan⁄ Feb 2013

Spotlight

Wet palms? No sweat, a solution exists

illustration: heymans tho

Sweaty palms may not pose a danger to health, but wet hands make social interaction awkward. A surgical procedure can help with severe cases

The average person produces 200ml to 250ml of sweat a day, depending on temperature, humidity and activity. During intense activity, the body can produce more than three litres of sweat.

BY Sol E Solomon

She has had sweaty palms since her school days. Whenever she felt anxious, her palms would drip with sweat. When she began driving lessons, perspiration from her sweaty hands made the steering wheel so wet and slippery that Ms Tan Quee Eng decided she had to do something about the problem. “I couldn’t get a firm grip on the wheel, which made it very dangerous to drive,” said Ms Tan, Nurse Clinician, Singapore General Hospital (SGH). “I was

autonomic nervous system, which controls body functions like breathing and sweating. It is not quite clear what causes these nerves to become overactive. It’s also not clear how common the condition is, although it’s likely that less than 5 per cent of the population suffer from it. In some families, all the members suffer from the condition, suggesting that it can be passed on. Sympathectomy carries some risks and can be performed on most people. But as hyperhidrosis is not a life-threatening condition, “I recommend it only when the sweating is very severe and when it affects the patient’s work or lifestyle”, said Prof Mack. An electrician whose hands are always wet runs the risk of causing electric short circuits qualifies as a candidate for this surgery, as is the piano student who may have to give up a music career if he is unable to perform properly because his hands keep slipping off the keyboard.

A small incision is made under the armpit to allow the insertion of an endoscope into the chest in a sympathectomy, said Associate Professor Peter Mack (below).

also always embarrassed, because I was worried people wouldn’t like it if I shook hands with them.” Ms Tan approached the SGH surgeon that she was working with at the time for help. She had heard that Associate Professor Peter Mack, Senior Consultant, Department of General Surgery, could perform a surgical procedure known as sympathectomy to permanently stop the heavy perspiration in the palms. A minimally invasive or keyhole procedure done under general anaesthesia, sympathectomy involves destroying the nerves that cause the excessive sweating.

Anyone who wants surgical treatment has to be very clear that we’re treating a social inconvenience and not a health issue.

PHOTOs: Alvinn lim

associate professor peter mack, senior consultant, department of general surgery, singapore general hospital

Ms Tan Quee Eng sought help when she found that she couldn’t keep a firm grip on the steering wheel while driving.

According to Prof Mack, sweaty palms – or palmar hyperhidrosis – are caused by overactive nerves in the

To stop heavy sweating in the hands, the nerves that regulate the sweat glands of the palms and armpits are destroyed. These nerves are bead-like structures within the sympathetic nerve chain that runs parallel to the thoracic spine, just below the neck.

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singapore he alth

JAN⁄ FEB 2013

People

Making big strides by starting very small A specialist in keyhole surgery, Dr Tan Yeh Hong is often at the forefront of new surgical techniques organ, touched me deeply. Giving an organ has no benefit for the donor,” said Dr Tan. The courage of donors and other patients spurs him to look for better procedures and treatment. Dr Tan is the author of several scientific articles, many of which were published in international peer review journals like the Journal of Urology, Journal of Endourology and British Journal of Urology International.

By Audrina Gan

His wife thinks he’s married to his job, and he unabashedly declares that he enjoys work, enjoys working and enjoys seeing patients.

Breaking new ground He is often at the forefront of new procedures in Singapore. When the age limit of organ donors was lifted, Dr Tan participated in a groundbreaking case where a renal-failure patient was transplanted with two kidneys from an elderly deceased donor. Allowing older people to donate their kidneys will help many patients with renal failure receive new organs faster. Dr Tan specialises in laparascopic endoscopic single site or keyhole surgery. He was one of the first surgeons in Singapore to perform a single port procedure.

PHOTO: ALVINN LIM

Indeed, a 12-hour work day is routine for Dr Tan Yeh Hong, Senior Consultant, Department of Urology, Singapore General Hospital (SGH). Besides his clinical work, he still manages to find time to do research and teach. For Dr Tan, being a surgeon isn’t just a job. It’s a vocation that allows him to participate in life-changing moments that inspire and invigorate him. One procedure is etched in his memory. He was part of a team that made local history when they performed a transplant involving a 75-year-old woman donating a kidney to her seriously ill 46year-old daughter. The mother became Singapore’s oldest living donor. “The love and sacrifice of donors like the mother, who unreservedly gave up an

Dr Tan specialises in keyhole surgery and was one of the first surgeons in Singapore to perform a single port procedure.

Rebuilding the courage to speak Ms Deirdre Tay, Senior Speech Therapist, Singapore General Hospital (SGH), helps patients overcome their swallowing or speaking difficulties by giving them tasks to spur confidence

Speech therapists see… patients with a variety of communication difficulties such as fluency, stuttering and articulation. They have difficulty swallowing or speaking because of muscle weakness, a result of traumatic brain injury, stroke or dementia. The symptoms may be mild for some, but they can still affect the patients’ jobs as teachers, lecturers or singers. Half of my time… is spent on clinical work, and another 35 per cent is spent teaching staff about communication disorders. I’m also involved in a project to develop a test for assessing language difficulties in people who suffered a stroke. The language and norms of the existing test (developed in the West) are not quite relevant here, especially as many of our patients speak Mandarin. I recently went on a study trip to the US… as part of a team to observe how our US counterparts care for people with traumatic brain injury. We visited a hospital that was rated the country’s best in rehab.

We aren’t too far behind in terms of our cognitive treatment and processes at SGH, but the American hospital focused heavily on the entire care process. It took a holistic approach towards nursing and patients requiring allied health services. Everyone worked together to come up with a complete care plan. For example, a nurse knew exactly what the speech therapist and physiotherapist were doing. The caregiver, family and friends were also involved in the care plan. One of my most memorable cases… happened when I was very young. The patient, a 19-year-old, was disorientated after a traffic accident. It was the first time I handled a case where brain injury caused so many behavioural problems. He didn’t know where he was, and couldn’t remember his name and birthday. The occupational therapist and I wrote down details he needed to remember, and we repeated this every day for two weeks. One morning, when I went to see him, I was pleasantly surprised to find that he recognised me. I had not expected such a fast recovery. What keeps me going… is knowing that I can help my patients communicate better. At times, we think

we do very little to help our patients with their speech, language or cognitive disabilities. But, sometimes, just being there for a patient and his family is enough. I remember two recent patients, both in their mid-40s. They were devastated as they went from being high-flying professionals to not being able to speak

properly after suffering a stroke. It’s not that they couldn’t speak, but that they didn’t have the confidence to do so. I tried to assure them and gave them small tasks to rebuild their confidence. I hope to… improve my skills as a clinical mentor as I teach at SGH and the National University of Singapore. I like to… travel as I get to meet different people and cultures. I love food and travelling helps to satisfy my taste buds. I travel at least twice a year.

PHOTO: DARREN CHANG

By Audrina Gan

The operation involves making a tiny cut in the navel to facilitate the removal of a kidney tumour. “Traditional operations involve making big incisions. In contrast, belly button and laparoscopic operations leave hardly any scars and also allow patients to recover faster,” said Dr Tan, who also serves as Director, Endourology (kidney stone disease) and Laparoscopy Service/Minimally Invasive Surgery, Urology Centre, SGH. Dr Tan’s daily schedule starts at 7am. He sees 70 to 90 patients a day, attends meetings and performs morning and evening ward rounds, clinical sessions or surgery. He even teaches at various medical schools. For Dr Tan, his greatest joy is “watching my five-year-old daughter grow up”. He doesn’t play table-tennis as much now as he prefers to spend time with his daughter. Neither does he travel as much for leisure. “Most of my travelling has been work-related. I just went to Istanbul and China last year for medical conferences. I hope to visit South America one day,” the history buff said.

Ms Deirdre Tay is keen to mentor others who treat communication disorders. She shows how a fibre optic endoscope is used to examine patients with swallowing difficulties.

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singapore he alth

Jan⁄ Feb 2013

FYI

Too much sugar may harm the brain People who are 70 and older, and who eat food high in carbohydrates, have nearly four times the risk of developing mild cognitive impairment, Mayo Clinic researchers have found. The danger also rises with a diet heavy in sugar. Meanwhile, those who consume a lot of protein and fat relative to carbohydrates are less likely to suffer cognitive impairment. The research highlights the importance of a well-rounded diet, said lead researcher Dr Rosebud Roberts. “A high carbohydrate intake could be bad because carbohydrates affect your glucose and insulin metabolism. Sugar fuels the brain, so moderate intake is good, but high levels of sugar may prevent the brain from using it, similar to what we see with type 2 diabetes.”

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

PHOTO: getty images

Publisher

Women live, on average, 4½ years longer than men, according to United Nations world data. In Singapore, women can expect to live four years more than men. According to Dr Kaysar Mamun, Senior Consultant and Head, Department of Geriatric Medicine, Singapore General Hospital, there a number of possible reasons: Women suffer from less oxidative stress, which generates free radicals that can lead to cell damage. The female hormone oestrogen also raises good cholesterol levels while lowering bad cholesterol levels. This reduces women’s risk of stroke and heart disease. Women have two X chromosomes, unlike men who have only one. The X chromosome contains molecules that regulate the body’s immune system, meaning women tend to fight infections better than men. Social expectations tend to make men engage in risky behaviour that may lead to higher stress and mortality. Men also tend to have unhealthy diets, favouring red meat over vegetables and dietary fibre. Source: Health Xchange

Source: BBC

1. How much must each person pay to participate in the weight-loss trial conducted by the Duke-NUS Graduate Medical School and SGH’s LIFE Centre? 2. Which story in this issue did you find the most informative?

Send in your answers and stand to win a bottle of VitaHealth L-Glutathione Skin Plus – Advanced Skin Nourishing and Whitening supplement (60 tablets) worth $72.

Why women live longer than men

Scientists have developed an experimental breath test that can accurately tell if a person has bowel cancer. The test looked for exhaled chemicals linked to tumour activity, and was able to identify a majority of patients with the disease at an overall accuracy of 76 per cent, reported the British Journal of Surgery. The technology relies on the idea that the biology of tumours can produce specific “volatile organic compounds” that are unlikely in a healthy person. Bigger studies with more patients are now needed to fine-tune the test. One scientist said it was unlikely that a fully functioning and reliable breath test will be available soon for the public.

Singapore Health issue 20 contest

Closing date: Feb 1, 2013

Source: Mayo Clinic

Breath test may detect bowel cancer

event Calendar

Co-funded

E-mail: editor@sgh.com.sg Post: The Editor, Singapore Health, Singapore General Hospital, Communications Department, Outram Road, Singapore 169608 Winners of Contest 19 Each will receive a bottle of Spirulina 100% Extra 10% Deep Ocean Water (750 tablets) worth $69. 1. Lee Ah Choy 2. Nurhani Idris 3. Pua En 4. Johnny Seto Chee Choon 5. Kelly Soo Lai Mui Prizes must be claimed by Feb 1, 2013.

Answer to In focus (Page 3): This is a fibre optic endoscope used by speech therapists to examine patients with swallowing difficulties. The difficulties are a result of muscle weakness caused by traumatic brain injury, stroke or dementia. The symptoms may be mild for some, but they can still affect patients who work as teachers, lecturers or singers. Speech therapists use a variety of tests to assess language difficulties and develop therapies to help patients regain their confidence to speak.

Singapore Rehabilitation Conference

Venue Singapore Expo Convention and Exhibition Centre Registration Please contact Ms Gwendolyn Goh at 6403-2176 or e-mail gwendolyn.goh@singex.com.sg for more information.

Held in conjunction with the annual trade exhibition, RehabTech Asia 2013, the second Singapore Rehabilitation Conference brings together international experts who will present the latest in rehabilitation technology and physical medicine through lectures, scientific presentations, discussions and workshops. The theme of the conference is Rehabilitation Technology and Innovation for Everyone. July 18-23 (Thu-Tue)

19th Asian Congress of Surgery and 1st SingHealth Surgical Congress

Venue The Academia, Singapore General Hospital Campus Registration Please log on to www.acs2013.org to view submission guidelines. Participants are invited to submit oral, poster and/or video abstracts to programme-acs@ globewerks.com by April 30. Submitted abstracts stand to win a SingHealth Surgical Congress Educational Grant Award worth $1,000. Themed Training for the Future, the congress stresses the importance of training future surgeons to meet the challenges of the changing world, along with the advances in technology, innovation and surgical techniques, and changes in the socioeconomic and healthcare demands of our nation. All the events, including discussions and workshops, will be held at SingHealth’s newly built centre for research and education, The Academia. Its comprehensive programme will cover diverse aspects of surgery, such as trauma and critical care, oncology, vascular surgery, as well as surgical training and education. Visit www.singhealth.com.sg/events or the websites of respective institutions for more information and other listings.

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All rights reserved. Copyright by SGH (registration no: 198703907Z). Opinions expressed in Singapore Health are solely those of the writers and are not necessarily endorsed by SGH, SingHealth Group and/or SPH Magazines Pte Ltd (registration no: 196900476M) and their related companies. They are not responsible or liable in any way for the contents of any of the advertisements, articles, photographs or illustrations contained in this publication. Editorial enquiries should be directed to the Editor, Singapore Health, 7 Hospital Drive, #02-09 Block B, Singapore 169611. Tel:+65 6222 3322, E-mail: editor@ sgh.com.sg. Unsolicited material will not be returned unless accompanied by a self-addressed envelope and sufficient return postage. While every reasonable care will be taken by the Editor, no responsibility is assumed for the return of unsolicited material. ALL INFORMATION CORRECT AT TIME OF PRINTING. MICA (P) 070/06/2012. Printed in Singapore by Singapore Press Holdings Limited (registration no: 198402868E).

新加坡中央医院

1月

与新加坡保健服务

2月 2013

集团的双月刊

page 29

甜蜜的痛苦

page 30

page 31

新式微创手术改善血液反流

打消新加坡医疗制度的大误解

专家解答医药问题

胰脏和肾脏双器官同移植让糖尿病病人重获新生

电脑游戏能探测早期痴呆症虚似仿真软件使医生更有效地诊断出痴呆症，让病人及早就医

国大医院和新加坡中央医院移植手术团队为青年同时移植胰脏和肾脏，让他从此免受第一型糖尿病之苦

图： 101TEAMWORK

李医生表示，如今有了这个新的手术选择，第一型糖尿病患者有机会“提高他们的存活率和改善生活素质。”他也透露，比起那些只接受肾脏移植的病人，接受肾脏和胰脏双器官同移植的病人至少还能活多十年。其实，双器官移植手术并不新颖。自 1966 年以来，世界各国已进行过多达 3万宗的双器官移植手术。国大医院肝脏和胰腺移植兼外科主任马哈万（Krishnakumar Madhavan）副教授表示，尽管如此，只有少数病人能够从肾脏和胰脏双器官同移植手术中受益。带领国大医院和新加坡中央医院外科医生团队，并联手进行移植手术的马哈替黄乐文（前排坐）进行移植手术的主要成员包括（右起）国大医院肾脏内科与移植主任瓦萨拉万副教授说：“双器官移植手术为病人教授、国大医院肝脏和胰腺移植与外科主任马哈万副教授、新加坡中央医院胰腺移植主任李存文所带来的影响是极大的，因为他们不再医生、国大医院肾脏外科与移植主任张和义医生和国大医院器官移植中心临床移植助理主任考尔（Manjit Kaur）。需要洗肾、注射胰岛素和监察血糖水平，解除了一切日常生活的束缚。” 常常出现在年纪较轻的人身上，他们当移植手术后，黄乐文的新胰脏和肾脏原文 Desmond Ng 中有少数人可能会患上肾衰竭，一旦病便立即开始运作，再也不需注射胰岛素发，能活超过五年的患者平均只有38%。和洗肾。由于这两个器官来自同一名捐庆幸的是，经过一番努力不懈地推动献者，因此身体遭到排斥的风险也显著去年十月， 29 岁的黄乐文成为了本地下，新加坡医学界终于在去年，首度接较低。李医生说：“捐献者的身体状况史无前例肾脏和胰脏双器官同移植的受纳和认可肾脏和胰脏双器官同移植手术相当理想。与我们的预期一样，当我们益者。黄乐文在14岁那年就被诊断患有的益处，让其成为第一型糖尿病的标准即刻完成移植手术时，新的肾脏已经开第一型糖尿病；一种因胰脏机能失常而外科手术疗程。此举也得到本地政府的始排出尿液。” > 文转 page 28 引起的疾病。资助。胰岛素是调节体内血糖水平的激素，黄乐文的胰脏却分泌不足的胰岛素，导致这15年来，他一直都得接受胰岛素注射，来保持正常的血糖水平。在欧美国家，每百万人之中就有多达问医生瓦萨拉（A. Vathsala）教授说。可是随着肾脏开始衰竭，他的病情 40人愿意捐献自己的器官。可是，在也跟着恶化。于是，去年8月，他加入了全国器官移植组表示，在等候移植肾脏移植等候名单。本地，每百万人之中却只有6.5人愿意器官的病人之中，有465人在全国肾捐献。黄乐文的复原前景似乎并不乐观。新脏移植等候名单上。此外，14人正在 “我们一直都缺乏捐献者，这仍是等侯适合移植的心脏，24人正在等候加坡中央医院胰腺移植主任兼外科顾问新加坡所面对的重大问题。如果我们肝脏，25人正在等候眼角膜和1人正医生李存文透露说：“肾衰竭患者一般希望更多病人能够通过胰脏肾脏双器在等候肺部。自1987年开始执行人体需要等候八至九年，才会等到适合移植的肾脏。” 官、肾脏、心脏或肝脏移植手术受益，器官移植法令以来，截至去年九月，我们需要更多人自愿捐献自己的器本地总共成功完成了约2,500宗器官移 “然而，同时患上第一型糖尿病和肾官，”国大医院肾脏内科主任及高级顾植手术。衰竭的患者一般无法存活那么久。” 第一型糖尿病，又称青少年糖尿病，

原文 Ng Hui Hui

曾经，已退休的廖先生每天可花上三个小时左右来上网和玩电脑游戏，最近却渐渐开始有点健忘了。在医生的建议下，他做了一连串由心理学家所主导的记忆测试，结果花了他将近两个小时才完成测试，包括视觉空间能力、执行功能（完成一项工作的能力）、语言能力和大脑处理信息速度。他前后接受了至少三次的记忆测试。“被问及的题目如‘ 97 减 8 等于多少？’或在图表上连接字母数字等，让我感觉自己像个傻瓜似的，”现年 80岁的廖先生说。 “我有时或许会有点健忘，譬如忘记自己把手机放在哪儿，但这并非完全丧失记忆。简单的数学题，我还是会做的，”廖先生说。

通过玩游戏来测试记忆力后来，廖先生被推荐了一款三维软件。这款软件是专为中风和早期痴呆症病人诊断大脑功能而研发的。软件是由国立脑神经医学院和综合保健信息系统公司联合开发。它可模拟现实生活中的行为活动，例如在超市里购买食品或挑选早餐食材等。当病患执行模拟任务时，软件就会开始追踪和收集与患者举动相关的数据，并在 45分钟之

图：DARREN CHANG

本地需要更多器官捐献者

纳根兰医生正在着手研究如何让这套三维诊断软件更易于操作使用。 > 文转 page 28

新脉动

JAN⁄ FEB 2013

新闻

四种最常见的痴呆症

> 文接 page 27

内出示诊断结果。这比传统测试所需的时间削减了高达80%。廖先生很快就上手了，也玩得很开心。“我基本上是在玩电脑游戏，这远比与医生一对一的问卷调查有趣且快得多了。”

诊断工具自2010年以来，国立脑神经医学院神经科顾问医生纳根兰（ Nagaendran Kandiah ）一直在专心地研发这款软件。他说：“作为诊断工具，它比传统测试所需要的人力来得少，诊出的结果也快，进而缩短病人的等候时间，让他们能够及早就医。” 据了解，痴呆症主要分为三个阶段，即轻度、中度和重度。一般来说，病情从一个阶段发展到另一个阶段需要三至四年的时间。尽管痴呆症目前尚无法治愈，但如果能够提早治疗，可延缓病情恶化长达八年之久。纳根兰医生说，廖先生所患的是轻

度认知功能障碍，即轻度痴呆症之前的阶段。然而，这款软件目前只能适用于视力良好和懂得使用电脑的病人。纳根兰医生预计，将来会有越来越多的年长者懂得使用电脑。与此同时，他的团队正在着手研究如何让软件更易于操作使用，另外也计划开发触屏和多语言版本。他进一步说：“我们还打算将此推广为一种可让患者在家里自行测试，并由家庭医生监测的诊断工具。” 廖先生喜爱玩犹如一个互动的电脑游戏的三维软件，例如在超市里选购生活用品。

1（阿尔茨海默氏症或早老性痴呆病 Alzheimer’s disease）

占所有痴呆症病例约70% 发病群/年龄层多为65岁或以上的人士脑部扫描会显示大脑的记忆中心萎缩症状包括短期记忆丧失、判断或推理变化以及丧失熟悉任务的执行能力

Parkinson’s 3 帕金森病性痴呆症（ Disease with dementia）占所有痴呆症病例约5%至10%。

帕金森病患者当中就有约30%至 80%会发展成痴呆症执行（工作）功能和空间功能可能会受到影响

血管性痴呆症（Vascular dementia， Fronto temporal 2 即中风导致的痴呆症） 4 额颞叶痴呆症（ dementia）占所有痴呆症病例约25%至30% 发病群/年龄层为40岁以下的病人，一般与中风有关记性尚可，所以许多病人不会寻求治疗可以通过预防中风发作来控制病情

占所有早期性痴呆症病例的20%

发病群/年龄层多为50多岁的人士主要影响语言能力和行为，病人可能会有行为冲动的表现，但记忆力和定向能力仍完好

压力可能促成早期性痴呆症

图：DARREN CHANG

电脑游戏能探测早期痴呆症

虽然痴呆症常见于 65 岁或以上人士，但据国立脑神经医学院脑神经科顾问医生纳根兰称，该学院最年轻的患者仅48岁。这名病人患的是早期性痴呆症，这种病症多见于 40 岁至 65 岁之间的人士。 “年轻的病人在经济活动上有着活跃的表现，因此他们的病情将会给

社会带来更大的冲击，真是令人担忧啊！”纳根兰医生说。据他所言，早期性痴呆症的发病原因尚未明确，压力可能是间接的因素。 “当人们感受到压力时，饮食习惯往往会受到影响，运动量会减少，也会引起其他健康问题，例如可导致中风的糖尿病和高胆固醇，进而促成痴呆症。” 图：DARREN CHANG

> 文接 page 27

胰脏和肾脏双器官同移植让糖尿病病人重获新生

“在我们把黄乐文送入重症监护病房前，他的血糖水平已快速地回复正常。手术后的第四天，便能正常进食，伤口也愈合得很好。黄乐文留医四周左右，之后每周都必须回来复诊直到他用药情况稳定下来为止。” 就像其他接受移植手术的病人一样，为了预防移植器官遭到他的免疫系统的排斥，黄乐文必需终生服用抗排斥药物。黄乐文说，当接获医院的通知说已找到捐献者时，他仍在睡觉。听了消息后，他感到非常意外，心想“我一定是在做梦。”他还说：“我打电话给我的家人，他们要我勇敢一点，接受手术。” 黄乐文表示，他现在终于可以过正常人的生活了。他说：“我必须感谢捐献者和他的家人，他们让我重获新生。”

复杂的手术过程在取出和准备用于移植的器官时，医生必需小心谨慎的进行，以预防附近的器官受损。胰脏尤其难取出，因它拥有众多血管和动脉。

第一型和第二型糖尿病的差别第一型糖尿病

第二型糖尿病

患者特征

通常发生在年轻身上

新加坡最常见的糖尿病类型，通常发生在 40岁及以上和体重超重的人士身上

病因

体内产生胰岛素的细胞被摧毁，导致几乎无法产生胰岛素

体内能够产生胰岛素，但产量不足或比正常低

治疗方式

每天注射胰岛素是唯一的控制方式，还有加上正确的饮食和运动习惯

可以通过服药，加上正确的饮食和运动习惯来控制，但如果病情加剧，则需要每天注射胰岛素

移植手术能以实现在2011年4月，卫生部拨款 270 万元，设立为期五年的胰脏移植试点计划。肾脏和胰脏双器官同移植手术的医药费总额介于 8 万元至 10 万元之间，部分费用将由试点计划资助。预计新加坡中央医院和国大医院每年将联手进行四宗胰脏移植手术，或在未来五年内进行总共二十宗胰脏移植手术。

Jan⁄ Feb 2013

新脉动

保健：健康

甜蜜的痛苦

春节常见的零食（如肉干、凤梨酥和蛋糕）粘在牙齿上，唾液很难将其清除。

在华人春节前夕，新加坡国立牙科中心洁牙和美白牙齿的人数骤增。但节日过后，患者未经预约便基于各种原因前来就诊如牙齿填充物松脱、牙痛、牙齿过敏、牙齿崩裂或断裂。这些问题多数都是在节日期间吃了又粘又甜的食物、喝大量的碳酸饮料、啃咬硬糖和坚果以及用牙齿嗑瓜子壳有关。不过，让肚子放肆吃几天就能造成那么大的伤害吗？ “几天的暴饮暴食对牙齿的影响会令人咂舌，”新加坡国立牙科中心口腔修复科资深顾问医生沈宝珠说。

饮食与牙损害沈医生解释说，传统零食，如肉干、年糕（糯米糕）、凤梨酥、鸡蛋卷、甜品、巧克力和蛋糕都含有可发酵的碳水化合物，潜藏在牙菌斑中的细菌会将坚果、瓜子和甜品会损害牙釉质。

意见箱就诊预约反复推迟我原本的复诊日期是3月15日以进行六个月评估。但我在3月 1日收到通知书，告知我的医生要出席国外会议，所以我的预约推迟到3月30日。可是在3月 10日，我又收到另一封通知书，再次把预约日期改为4月10日。为什么我的预约日期会反复变更？新加坡中央医院答复：预约反复变更给您带来不便，我们深表歉意。有时侯，当医生生病、不能工作、必须出席会议、请假或辞职时，我们通常需要提前几个月来重新安排所有的预约日期。

这些食物的代谢化为酸类物质使牙齿中的矿物质逸出，引起龋齿、牙病或损害牙齿。在正餐之间，频繁地吃零食是华人春节的习俗，这会使口腔的酸度保持在较高水平，矿物质也会不断地逸出。事实上，这样对牙齿的损害反而还比一次性大量进食或少吃多餐还要大。 “粘性食物，例如年糕、凤梨酥、巧克力和太妃糖会在牙齿表面上紧密粘合，唾液更难将其清除。唾液能将口腔内的酸碱度（pH）保持平衡，并减缓矿物质从牙里流失并促进牙齿修复。但要恢复正常的酸碱度需要有足够的时间，”沈医生说。许多家庭通常会准备一些富含高糖份和酸性物质的饮料和橙汁（橙色代表财富），这些都是对牙齿非常不利的饮品。 “饮用这些饮料常常会降低口腔内的酸碱度，也会导致矿物质从牙齿流失。这些饮料也会侵蚀牙齿的外层釉质，从而暴露更敏感、更柔软

在医生辞职的情况下，被指派给病人的新医生可能会要求推迟出诊日期，以便有时间评估病例。如果某次预约已经推迟了两次，医生会收到通知，并竭尽所能尽快对病人作出评估。如果实在不行，他可能会要求另一位医生为病人看病，或者额外安排一次临床问诊。如果在不得以的情况下必须更改预约日期（通常是预约日期的七天内），医院会打电话与病人联系，并安排新的就诊日期。其他的情况下，医院会通过信函通知病人预约变更事宜。新加坡中央医院在预约日之前的一个星期左右，会向病人发送手机简讯，以作提醒。如果您需要更改预约时间，请至少提前三天拨打预约电话热线 6321-4377。这将有助于我们安排其他

的内层牙质层。事实上，长时间啜饮软饮料比在10分钟内喝完更容易引起龋齿，”沈医生说。另一个令人担心的问题是牙釉质崩裂。“当我们咀嚼高糖份的粘性硬质食物（如糖果、坚果和瓜子）时，牙齿会施加更大的咀嚼力，以至牙釉质结构出现微小的裂缝，”沈医生说。良好的口腔卫生、减少吃零食的频率、少吃高糖份的食物和饮料能预防牙损害和牙龈病。唾液是人体里天然基本防御物质可调节口腔内的酸碱度。稳定的唾液流量和喝足够的水能助于提升唾液的防御力。 “唾液也是口腔和咽部健康的重要关键。它不仅能湿润口腔，帮助吞咽、消化、发音和味觉、防止酸性牙菌斑的滋生，还含有抗菌酵酶可帮助消化。唾液含有矿物质和其他成分，能促进并补充牙齿的矿物质。良好的唾液流量也有助于清除口腔中的食物残渣。不过，吸烟、饮酒和消遣性毒品可能会影响唾液的分泌量和质量，” 沈医生说。充足饮水也很重要。沈医生说，缺水会降低唾液流量和酸碱度，长期缺水则会促进侵蚀和损害牙齿。在吸收咖啡因或酒精时也应该多喝水，以恢复体液的平衡。无糖口香糖和人造甜味剂对牙齿健康有益。咀嚼口香糖20分钟便可达到正常口腔酸碱水平。甜味剂也不会把口腔细菌转化为酸性物质。所以一

病人在您原先的预约时段内就诊。如果因为预约变更导致病人没有足够的药物支撑到下次预约的日期，病人可以提出药物处方补充的要求。备好药物后，诊所工作人员会打电话通知病人前来领取。

图：gettyimages

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吃零食的建议限制含糖的酸性食物的摄取。少食高糖份的果汁、咖啡、茶及碳酸饮料。避免长时间啜饮酸性或含糖饮料。用吸管饮用，尽量减少饮料与牙齿的接触时间。坚持严格的口腔卫生习惯。喝足够的水，避免脱水，脱水会减少唾液流量并降低口腔的酸碱水平。要留有足够的时间让口腔的酸碱水平恢复正常。可用一片酸碱试纸检测唾液的酸碱水平，酸碱试纸能很容易地从牙医处获得。健康的唾液酸碱值为7.4的轻微碱性。

年之计在于春，不仅房屋庭院要大扫除，同时也要保持口腔清洁卫生。 “为了避免春节时突然牙痛，这期间牙医也难寻，我们强烈地建议人们应该在节日前去看牙医，以确保牙齿的良好状况。牙医也能检查出任何已出现的牙齿裂缝或填充物渗漏，并减低可能会使用崩裂的牙齿饮食的风险。你也可以要求牙医做一次简单的唾液功能检测，评估唾液流量、唾液酸度以及唾液酸的产量，”沈医生说。

用。巴士服务的实际频率，取决于当时的交通状况、天气等多个因素。如果这些因素造成了出乎意料之外的延误，并给您带来了任何不便，敬请谅解。

巴士服务的时间跟网站上公布的不符你们短程巴士实际的服务时间跟短程巴士站前和网站上公布的班次频率有所出入。为什么？竹脚妇幼医院答复：我们的短程巴士服务营运时间是星期一至星期五每15分钟一趟，星期六则是每半小时一趟。然而，在我们网站上和短程巴士站前所公布的时间间隔是估计时间，仅供参考

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。

新脉动

Jan⁄ Feb 2013

焦点

做最重要的事不能冒险做开心手术的患者现在可以接受一种新式微创手术治疗

不过，现在有一种被称为MitraClip的新式微创手术，为像林女士这样的患者带来新的希望。 2011年 4月，林女士成为亚洲首位接受 MitraClip 治疗的患者，该手术由杨医生担当。 “手术后我没有一丝疼痛的感觉。以前，我总是感到疲倦和呼吸困难。现在，我感觉有劲多了，可以做家务，也能和朋友一起逛街了，”林女士说。自首例以来，新加坡国家心脏中心已有25位患者成功进行该手术。随着新加坡人口老化，新加坡国家心脏中心预计每年将会为 50 位这群患者进行手术。据估计， 75岁以上的老年人当中，约 12 %会罹患中重度二尖瓣反流。如果延迟治疗，重度患者中约有三分之一的人存活时间很难超过6年。

原文 Thava Rani

林玛格丽特女士是一位退休小贩，既不抽烟也不喝酒。然而，这两年以来，她在卧房内走动时都会感到呼吸困难、身体疲劳。事实上，她总是疲惫不堪，甚至无法与朋友相约聚会。现年 68 岁的林女士患上了一种被称为二尖瓣反流的严重心脏病（ mitra regurgitation），这种病只能通过手术进行治疗。更雪上加霜的是，她还患有慢性肺病，心脏功能也非常衰弱，所以传统手术的危险性是非常高的。过去，像林女士这样的患者几乎没有其他治疗的选择。“他们只能通过药物来控制症状，并自求多福，”新加坡国家心脏中心心内科顾问医生杨孔健说。

新加坡国家心脏中心的多学科团队与亚洲首例接受MitraClip手术的患者合影，从左至右：杨孔健医生（手握MitraClip器械）、蔡耀龙副教授、新加坡国家心脏中心医务总监辜天海副教授、陈之平副教授和首例MitraClip手术患者林玛格丽特女士（中间）。

分弥补或应对反流，症状就会出现。 “你可以将其看作一艘小船。所有的船只都会漏水。只有当漏水变得严重时，小船才会难以应付，这时我们就需要采取行动，”杨医生解释道。

什么是二尖瓣反流？当二尖瓣（分隔左侧心脏上下腔的瓣膜）关闭不够紧时就会发生二尖瓣反流。这会引起血液从左心室（左侧心脏的下腔）渗漏并反向流入左心房（左侧心脏的上腔），而正常情况下，血液是从左心室流向身体的其他部位。结果导致心脏不得不更加费力地将血液泵至全身，患者会感到呼吸困难、疲乏，不能做以前可以轻松做到的事情，例如运动或搬运重物。病情轻微的患者通常不会出现此类症状，因为他们的心脏仍然有能力应对这种状况。不过，如果患者的心脏无法充

植入Mitraclip 的过程首例微创手术于2003年在委内瑞拉进行手术实施时，通过一条微创通路将一个覆盖有特氟隆纤维的钴铬合金夹子（4毫米宽）置入心脏夹子与一根导管相连，通过腿静脉上一个1厘米宽的切口插入体内然后，导管经过引导进入心脏，在心脏内，夹子将两片瓣膜封合起来，从而减轻渗漏为确保夹子的放置准确无误，该手术在超声波引导下进行整个手术平均耗时3小时，需要一个多学科人员组成的团队通力合作。

据估计，75岁以上的老年人当中，约12%会罹患中重度二尖瓣反流。如果延迟治疗，重度患者中约有三分之一的人存活时间很难超过6年。

年轻患者患二尖瓣反流的原因可能是某种形式的瓣膜变性。不过，像林女士这样的老年患者，最常见的原因是功能性的，也就是说瓣膜本身没有问题，而可能是由于心脏病或病毒损伤削弱了心脏的功能。杨医生将其比作一扇完好无损的门，不过门框或周围的墙壁上有裂缝。“随着时间的流逝，发生渗漏的瓣膜可能引起心力衰竭、心率不齐或肺部压力增加。”

治疗选择一线疗法是药物治疗，虽不能解决根本问题，但有助于心脏更有效率地泵血，同时降低发生并发症（比如心率不齐）的危险。同时医生还建议患者保持健康的生活方式，因为定期的适度锻炼（比如快走或慢跑）有助于患者了解病情是否恶化。一旦出现症状，通过手术修复瓣膜为首选治疗方案。但是，修复手术并不适合所有患者，因为对患有其他潜在疾病的患者来说，传统手术非常危险或者说风险实在太高了。

优势

(A) MitraClip 和导管经腹股沟处的一个小切口进入插图：heymans THO

传统开心手术和MitraClip手术都是通过纠正病因改善二尖瓣反流的症状。不过，MitraClip手术还有额外的优势：手术时心脏能正常跳动，从而毋须使用体外循环机减少对输血的需要患者恢复快速，间而缩短住院时间降低伤口感染和其他并发症的危险

体内，然后经过股静脉、通过房间隔（分隔左右心房的一层组织壁）进入左心房。

(B) 将器械对准渗漏处，然后将打开的夹子送入左心室。

Jan⁄ feb 2013

新脉动

财经

打消新加坡医疗制度的大误解

医疗与保健费用是许多国人关注的课题之一。我们将说明几项有关医疗保健的误解，让您更深入了解政府设立的各层保健安全网。误解#1

我不愿留院治疗因为我支付不了庞大的住院费用。

国人在政府医院B2/C等级的病房留院求医的费用都会得到高达八成的津贴。在津贴后， B2/C等级病房的平均留院费是$1,768 (2010)。多数国人年龄到56至60岁时，在保健储蓄里的资金往往超出在这笔医药费。您也可使用健保双全计划或至亲的保健储蓄来支付其余的费用。政府医院不会因病人付不起医药费而将他们拒于门外。如果您有经济上的困难，可选择入住较便宜的 C级病房，同时也能得到高达80%的政府津贴。

除了根据自己的经济能力选择入住负担得起的病房之外，您也可选择较低廉但同样有效的治疗，或向政府医院的医疗社工询问有关保健基金之类的资金援助计划。

病人资料：七十岁女士状况：髋部骨折住院天数：8天（C等级病房）病房与治疗费 $4,080 手术费 $3,800 植入体费用 $1,920 总帐单（津贴前） $9,800 总帐单（津贴后）健保双全计划支付数额用保健储蓄支付数额以现金支付

$2,820 $1,456 $1,364 $0

新加坡国家心脏中心心内科顾问医生詹尊林

隐形眼镜和您的眼睛我佩戴隐形眼镜已经 20年了。 2年前，我开始感到轻微抽搐和不适，于是就改用日抛型隐形眼

误解 #3

无论是哪个收入基层的国人都能选择入住B2/C等级病房。支付能力调查的目的是让医院了解哪些病人需要更多的资助。如果您选择不通过收入测试，您还是能分别在B2与C 等级病房得到 50%和65% 的住院津贴。

佩戴隐形眼镜没有产生任何问题，也要定期给验光师检查眼睛。

爬楼梯时气喘如牛

胆固醇水平低是会减少患心脏病的风险，但并不代表毫无风险。您爬楼梯时感到气喘吁吁，是有必要找出原因的。出现这种情况有很多因素，并不一定是心脏病。没什么测试能准确预测像您这样的低风险病人突发心脏病的可能性。尤其是当您没有任何风险因素，如高血压，糖尿病或高胆固醇。除了血压测试，您可以进行血液检查，测试您是否患有糖尿病和高胆固醇就足够了。

健保双全计划和乐龄健保计划是两项不同的保健计划。健保双全计划能帮您应付在B2/ C级病房长期住院或动手术的费用。乐龄健保计划则是帮您支付与老年有关的疾病所带来的医疗费用。

请到以下网站查询更多有关详情：卫生部网站提供保健储蓄，健保双全计划，和基层医疗合作计划的资料。www.moh.gov.sg 公积金局网站提供保健储蓄，健保双全计，和综合健保双全计划的资料。 www.cpf.gov.sg 护联中心网站提供疗养院费用的经济支援讯息。www.aic.sg 保健促进局网站提供使用保健储蓄支付慢性病的治疗费用的资料。 www.hpb.gov.sg

医院设定了支付能力调查如何使用健保双全计划（MediShield ）（ means testing）后，和保健储蓄（Medisave）减轻医药费我就不能选择入住 B2/C等级的病房。负担（85百分位数）

专家解答如果我的胆固醇水平低，是否意味着我不会患上心脏病？我有些超重，而每周有两三个晚上会以散步当作运动。但是最近我发现自己在爬楼梯时气喘吁吁。我是否应该为此担忧，并能做些什么测试呢？

误解 #2

我已拥有健保双全计划，不需要乐龄健保计划。

新加坡全国眼科中心角膜部高级顾问医生林俐

中风镜。最近，我在使用日抛型隐形眼镜时，只配戴半天就感觉到眼中有沙粒。请问我可以用眼药水吗？我该如何保护眼睛健康? 如果您因佩戴隐形眼镜而感到不适，最重要的是找您的验光师检查眼睛。如果您佩戴隐形眼镜已经有好几年，您可能患上由隐形眼镜所引发的一种称作巨乳头性结膜炎的慢性过敏性眼疾。佩戴日抛型隐形眼镜有助缓解这个问题，因为镜片没有蛋白质堆积。不过，日抛型镜片不一定会完全缓解这个情况，而您也可能会在戴隐形眼镜时持续感到不适。如果情况持续，应停止使用隐形眼镜一段时间（例如6个星期）让眼睛复原。我们的眼睛有天然的眼泪机制，因此没有必要使用眼药水。重要的是即使

我弟弟的血压是140/110，可是他没有接受药物治疗。他今年 34岁，而且总是承受着极大的压力。他是否有中风的风险? 您的弟弟患有高血压。一般上，高血压指的是血压相等于或超过140/90毫米汞柱。高血压是提高中风风险的因素。事实上，一个人患有高血压，却没有接受治疗，他中风的风险将高出四倍。健康的生活习惯和药物可将高血压病患中风的几率减低三成。健康的生活习惯包括定期运动、保持标准体重、减少压力、少喝酒以及多吃蔬菜和水果。国立脑神经医学院神经内科高级顾问医生李思豪

耳鸣过去四年里，我一直承受着耳鸣带给我的困扰，但核磁共振扫描却无显示出异常肿块。有时，耳鸣的声音很大，尤其是

在临睡前或宁静的地方。耳鸣是否能够治愈？造成耳鸣的原因是什么？随着年龄增长，我是否会损失听力？耳鸣通常很难根除，尤其是长期性的。这是由于听觉传导通路的某处受到过度刺激所引起的。而这种刺激也可以是一些简单的原因所造成的，如耳垢阻塞或耳朵感染。然而，许多患者的耳朵里未曾找出明显的物体。你的医生已通过核磁共振扫描为你排除了一些严重的原因。即使不太可能根治耳鸣，也不至于会对你造成严重的影响。尽量不要将注意力集中于你目前的状况。避免呆在非常安静的环境里。在寂静的夜晚，尝试听一些轻柔、舒缓的背景音乐。虽然它不一定会发展至听力损伤，但许多老年人都会因年龄增大而经历听力退化。新加坡中央医院耳鼻喉科医生

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