Singapore Health Mar/Apr 2012

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News

Shh! Quiet please, we need our sleep Project helps reduce noise levels in neonatal intensive care to help preemies develop better

BY Thava Rani

It has been known for some time now that prolonged and excessive noise can impair the development of premature infants or preemies.

Yet, the neonatal intensive care unit (NICU), where 75 to 80 per cent of infants warded are preemies, is one of the noisiest places in any hospital.

At Singapore General Hospital (SGH), Dr Imelda Ereno, Staff Registrar, Department of Neonatal and Developmental Medicine, and her colleagues decided to do something about making the neonatal intensive care ward less noisy. They managed to lower the noise level in the ward by 23 per cent.

“The project is part of our continual efforts to improve developmental care for premature infants. The organs of preemies, like the brain, hearing and visual centres, are still developing, and premature exposure to a noisy environment can have consequences,” said Dr Ereno.

Noise agitates preemies, disrupts their sleep and makes them cry. It can also lead to other damaging effects later, such as hearing loss, attention deficit disorder and other behavioural problems, as well as issues with social interaction.

“In the past few years, advances in neonatal care have led to more and more

preemies surviving, but there has also been a higher incidence of these minor disabilities in preemies in NICU,” said Dr Ereno.

“The best environment for premature infants to develop is inside the womb. If the preemie cannot be inside the womb, we try to ensure the outside environment is as close to that of the womb as possible.”

Noise control The group set about looking at the areas that made noise in the intensive care ward and how loud the noise was, then making changes where possible. The SGH team included Ms Tay Yih Yann, Nurse Clinician; Mr David Lam, Senior Manager, Biological Safety; Dr Masitah Ibrahim, Associate Consultant, Department of Neonatal and Developmental Medicine and Dr Subramanian Krishnakumar, Epidemiologist. Associate Professor Yeo Cheo Lian and Senior Consultant Dr Selina Ho offered support, while SingHealth Foundation funding helped pay for new equipment and other changes.

Some of the modifications were easy to make.

Metal bins and water tap valves were replaced and supply drawers moved away from the infants’ cribs. Parents and staff new to the ward

were “educated” on the special needs of preemies. To remind staff and visitors to keep noise levels low, a visual alarm was installed. It lights up and stays on for 30 seconds when people speak too loudly.

One of the biggest difficulties, however, was bringing about a change in habit among the staff.

“NICU is a very stressful environment. The focus is on providing care for the preemies, and urgent communication is often necessary. In the past, we called out loudly to quickly get something done, but we now have to remember to work and move quietly, which can be an additional stress on busy people,” said Dr Ereno.

Many things in the ward also cannot be changed. “The project got us to think about how to get around them,” said Dr Ereno.

Four to five alarms, attached to each incubator and other equipment to monitor the preemies’ breathing, heartbeat, temperature and the like round the clock, alert doctors and nurses if something is amiss. They can’t be turned off and their volume has already been set to the lowest possible. Still, the sound is too loud. “To make sure an alarm doesn’t sound for too long, we make sure we attend to the baby as soon as possible,” she said.

Further changes can be made if a renovation is planned for the ward, and the hospital is able to take into consideration the standards set by the American Academy of Paediatrics, a professional association of paediatricians in the US, on how quiet the intensive care ward should be. “Many overseas hospitals have been trying to get the noise levels down, but no centre has been able to get them down to the recommended levels,” said Dr Ereno, who presented a poster of their findings at an international conference in December last year.

A preemie’s challenge Infants born prematurely face many challenges from the environment around them, and are especially averse to noise and light.

Babies are said to be premature when they are born before 37 weeks of pregnancy. Those born at 32 weeks or less, or weighing less than 1.5 kg, are usually placed in neonatal intensive care. “A baby born 10 to 12 weeks before term faces far different challenges from a baby delivered one to two weeks early,” said Dr Imelda Ereno, Staff Registrar, Department of Neonatal and Developmental Medicine, Singapore General Hospital.

“When they are delivered at less than 28 weeks, they sleep most of the time, so we try not to handle them unless necessary. Most can tolerate slow and gentle handling when they are between 28 and 32 weeks. And after 32 weeks, patting and stroking may be tolerated,” she added.

Early preterm: 27 weeks or less* Eyelids may be fused at 23-25 weeks Eyes may open but do not focus Has immature gastrointestinal system Has weak muscle tone and cannot control posture and movement May be able to suck, but sucking may not synchronise with swallowing

Developing preterm infant: 28-32 weeks* Quiet, deep sleep increases around 30 weeks Eye opening increases in dim light Muscle tone is weak, but develops slowly over this gestational period Leg movements increase with hips and legs start to flex Middle ear and transmission section of auditory system is complete

Growing preterm infant: 33-36 weeks* May be aroused for feeding Can turn head from side to side Has smoother and more controlled movements Coordination for sucking, swallowing and breathing matures Usually able to nipple-feed

Equipment to monitor the preemies’ vital signs can have four to five alarms attached to alert doctors and nurses if something is amiss.

PHOTO: Vee chin

Older preterm infant: 37 weeks or more*

Very early preterm infants should have undisturbed rest, with lights and noise muted.

To reduce the infant’s exposure to light, a cover is put over the incubator, said Dr Imelda Ereno, seen here checking on a preemie.

Has periods of alertness for socialisation and longer attention spans Demonstrates a wide range of movements Sees best at a distance of 20-25cm Sight is still immature Can identify sounds *Selected age-appropriate developmental guidelines from Department of Neonatal and Developmental Medicine, SGH

Mar⁄ Apr 2012

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News

Shake off the kilos

Counting calories

PHOTO: Vernon WONG

Study suggests that replacing one meal with a weightloss shake or bar may be more effective than relying solely on a low-calorie diet

From left: Mr Tan Lee Boo, Ms Tan Ai Shan and Ms Meina Armanda were part of a team that studied the effectiveness of using meal replacements in weight-loss diets.

BY Sheralyn Tay

Eating less rich foods may not lead to a smaller waistline.

Instead, replacing one meal in a lowcalorie meal plan with a weight-loss shake or bar may be more effective than merely following a low-calorie diet alone, a study by a group of Singapore General Hospital (SGH) dietitians found.

People who are overweight or obese are put on a weight-management programme that includes a low-calorie diet, or such a diet combined with a meal replacement.

“But the effectiveness of meal replacements has not been studied in depth, so we wanted to find out just how useful they are,” said Ms Meina Armanda, a member of the team that included Ms Tan Ai Shan and Mr Tan Lee Boo, all from the Department of Dietetics.

Cutting calories A low-calorie diet works on the principle that if a person consumes fewer calories than he uses up, he will lose weight. The team looked at several studies done to evaluate the effectiveness of a partial meal replacement diet against the standard low-calorie one.

“The results showed that (the people who followed) partial meal replacements had a greater overall weight loss compared with those who relied on a reducedcalorie diet alone,” said Ms Armanda.

They found that people on the partial meal replacement plan lost a significant 2.7kg, and 1.6kg more than those on the reduced-calorie diet after three and six months respectively.

There were limitations to the review as not all the trials that the group studied were done in a controlled environment, but the results were promising enough

for the team to consider further study.

“Going further, we can try to isolate the variables and factors,” she said.

Replacing a meal Meal replacement shakes or bars are nutritionally balanced products that people trying to lose weight can take in place of some meals. In a diet programme monitored closely by a dietitian, taking appropriate meal replacement products can be useful, said Ms Armanda. “Instead of skipping meals, meal replacements can help people lose weight as they are nutritionally balanced, convenient and easily accessible.”

A diet that includes a partial meal replacement can also help people comply with their diet by reducing hunger pangs and the effects of the so-called yo-yo diet syndrome, which happens when the body responds to an excessively low-calorie intake during a “crash diet” by adjusting the rate at which it burns calories to support the body’s various daily functions.

That slower rate of metabolism continues even when the person returns to normal eating, which can lead to weight gain.

“The yo-yo effect happens because crash dieting prompts the body to store fat at a faster rate once a person starts eating normally. This is the body’s protective instinct trying to store reserves for future periods of deprivation,” Ms Armanda said.

Instead of going on a crash diet after binge eating, people should try to lose weight by making sustainable changes to their lifestyles and eating habits, she said.

The SGH team’s study won the first prize in the Best Oral (Allied Health Evidence-Based Medicine) category at last year’s SGH Annual Scientific Meeting, a conference showcasing the research and studies undertaken by doctors and other healthcare staff at SGH Campus, including Duke-NUS Graduate Medical School.

After the birth of her second child, Mdm Ellen Ang* began putting on weight. Five years later, at the age of 34, she also experiences knee pain and has difficulty breathing as the 70kg that she weighs has been putting pressure on The food pyramid illustrates the recommended portions of food. her petite 1.54m frame.

With two young children An example of a 1,200kcal meal plan to look after, she has no for Mdm Ang time to exercise. Desperate to lose weight and regain her Afternoon Snack Breakfast health, she sought help from 125g low-fat 2 slices wholemeal a dietitian. fruit yogurt bread As Mdm Ang’s body (Or 250g low-fat 1 teaspoon margarine mass index (BMI) is 29.5 fruit yogurt if a 300ml low-fat milk kg/m², well above the meal replacement recommended average is taken) Lunch of 18.5-22.9 kg/m², Ms 1/2 bowl rice Tan Ai Shan, Dietitian, Dinner 1 palm-sized stewed Singapore General Hospital, 3/4 bowl rice chicken (no skin) recommended that she 1 palm-sized 1/2 cup stir-fried go on a diet plan which steamed white mixed vegetables would reduce her weight pomfret 1 medium apple by 1-2kg a month. Ms Tan 1/2 cup stir-fried (Or replace with a set Mdm Ang’s daily calorie chye sim weight-loss shake and consumption at 1,200 kcal, 1 slice papaya 1 orange) 500 less than the estimated 1,700 kcal/day that she *Not a real person would ordinarily require.

In focus

Can you guess what this is?

See page 24 for the answer.

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MAR⁄ APR 2012

News

An easier way to visit SGH The launch of new self-registration kiosks promises to ease the queues for people visiting their families Visitors to Singapore General Hospital’s (SGH) wards can now avoid the queue at registration counters by using self-registration kiosks at

Register online

the hospital, or by registering online on the day of the visit.

Registration is quick and easy, with only a few short steps. SGH allows patients to have only four visitors at any one time, and children who are vulnerable to infection are discouraged from visiting.

People accompanying patients to certain clinics or day procedures on the upper floors will also need to register. Visitors can still register at the usual registration counters found at Blocks 4, 5, 6 and 7.

No registration is required for patients and visitors to the outpatient clinics on Level 1.

Select your language

Register online at www.sgh.com.sg on the day of visit by entering patient and visitor’s personal particulars Visitors must carry valid identification for scanning at the gantry to enter the ward

Select your visitor type: Ward visitors Non-ward visitors

Visitor accompanying

Outpatient

Visitor accompanying Day Surgery/Day Procedure Patient

• •

Scan your identity card OR key in your local NRIC/FIN number

Where to register

No identification Visitors can approach registration counter staff if they Don’t have identification documents

At self-registration kiosks located near the lift lobbies of Blocks 4, 5, 6 and 7

Ward visitors: Enter the patient’s surname, ward, room and bed number

At registration counters at Blocks 4, 5, 6 and 7

Non-ward visitors: Enter the patient’s full name and identity card number

Have forgotten their identification details Cannot remember the patient’s details

For all visitors: Enter your name and mobile phone number

Visiting hours Mondays to Sundays: 12-2pm 5-8.30pm

Insert your identity card

Identification that can be used for registration: Identity card Driving licence Senior citizen card Student EZ-Link card

Non-ward visitors: After registration, scan your identity card at the gantry to enter

Ward visitors: When the patient already has the maximum number of people visiting him, you will be registered and placed on a waiting list.

An SMS notification will be sent when a slot becomes available

Frequent visitors People who expect to visit frequently during the patient’s stay can register their particulars by filling a form available at various places, including visitor registration and information counters These visitors won’t need to register at each visit, but will still need to carry valid identification for scanning at the gantry to enter the ward

MAR/APR 2012

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News > Continued from page 1

On target

Participating in the DOT programme is community service to me. I wanted to give back to society in my own little way. Seeing my patients stay healthy and out of the hospital gives me satisfaction.

Dr grace kwan, family doctor at bishan grace clinic

The DOT programme Launched in 2005 with two GPs and seven patients, the Singhealth DOT Programme has more than 100 GPs and 1,000 patients today. The current twoyear pilot programme, which Mr Chua and others are on, is to test the feasibility of the scheme.

Under it, patients with illnesses, such as diabetes, hypertension, asthma and hyperlipidaemia (high cholesterol and lipids), are referred by the hospital to GPs around Singapore. SingHealth matches their needs and directs them to clinics near their homes.

The aim is for GPs to keep these patients’ conditions stable and prevent them from needing hospitalisation. If, at any point, the patient’s condition deteriorates, he will be referred back to the hospital’s specialist for management.

The programme is in line with the government’s plan to transform primary care so chronic diseases are prevented and managed in the community. As Singapore ages, more people are expected to suffer

In addition, patients are made responsible for holding their own records. “I’m happy that much of it has been taken off our hands. Also, when patients hold their own records, it makes them more aware of their own illnesses and more compliant with treatment. This is because they can see the results for themselves – the evidence is staring them in the face – so they are more willing to listen,” said Dr Kwan.

PHOTO: ALVINN LIM

benefits are numerous – travel time is now minimal and his waiting time has been considerably reduced. He can also get an appointment easily and the timing is more flexible, as the clinic is also open at night.

“At SGH, if I missed my appointment, I sometimes had to wait for three weeks,” said Mr Chua, who runs his own confinement nanny business. “The hospital is so busy. At times, I would be there for half a day, waiting to see the doctor, do tests and collect medicine. Then, I’d have to return on another day for the results.”

Now, all tests (except for x-rays) are done at his neighbourhood clinic. His medicines, which are still subsidised, are couriered from SGH to his home for a small fee.

The only thing he is unhappy with is not being able to use his Medisave account to pay his clinic bills, unlike at the hospital. “This is a real concern. I hope this issue can be looked into.”

Mr Alex Chua (right) is happy to be able to have his medical followups done with Dr Grace Kwan as part of a pilot programme under SingHealth’s Delivery on Target (DOT) programme.

from these diseases and GPs are seen as a vital link in their care.

Personalised care A big plus for Mr Chua is the personalised care and longer consultation time (15 to 30 minutes), during which he can ask questions and Dr Kwan can explain his condition thoroughly to him. “These days, hospitals are overwhelmed. Doctors in the hospitals have less time. Here, I can ask him to visit on days when I am not as busy, so I can spend more time with him,” said Dr Kwan.

Personal attention is important to patients with chronic diseases, as they must understand their disease in order to manage it and make lifestyle changes.

Mr Chua, for instance, only realised the seriousness of not complying with treatment after Dr Kwan found out he was taking only half his prescribed medication. She suspected something was wrong while studying his health indicators, which were unsatisfactory.

“I was stubborn. I wanted to be less dependent on drugs and thought I could save money,” said Mr Chua. “But Dr Kwan explained the risks of doing so, and asked me if I wanted to go for kidney dialysis. Of course, I didn’t want to, so I started taking my medication properly again.”

Initially skeptical about whether a GP could handle his problem, Mr Chua now sees Dr Kwan as his family physician.

“She’s friendly and approachable. I feel comfortable and open with her, and she encourages and motivates me. She advises me on diet and followup programmes. As my family doctor, she can be consulted if I have a flu or another illness. This is a one-stop, all-in-one service.”

Dr Kwan joined the DOT programme because she believed it would be very good for patients. She started by taking on 40 DOT patients in her busy clinic.

“For me, it’s community service. GPs are a privileged group and, since I’m quite established in my own practice, I wanted to give back to society in my own little way,” said Dr Kwan, a mother of three. “Seeing my patients stay healthy and out of the hospital gives me satisfaction.”

She pointed out that a considerable amount of paperwork is involved to make the DOT programme work. A large amount of it has now been transferred out of the GPs’ clinics to SingHealth.

I was stubborn. I wanted to be less dependent on drugs and thought I could save money. But Dr Kwan explained the risks of doing so, and asked me if I wanted to go for kidney dialysis. Of course, I didn’t want to, so I started taking my medication properly again.

Mr Alex Chua, a patient of Dr grace kwan

What’s next?

The question remains: Is the DOT programme sustainable beyond the pilot project? Dr Kwan said: “If the government funds a subsidy or co-payment, it would encourage more GPs to join the programme.” She also backs suggestions for Medisave to be used for payments, and a cashcard-style payment linked to Medisave, which will help patients and reduce paperwork.

“If the government comes in, it will raise the standard of GP practice in Singapore. People will have more confidence in coming to us for primary care, leaving hospital care for those who really need it. At the moment, hospitals are overwhelmed because of the subsidised cost, and also because people don’t know if GPs are able to treat chronic diseases,” she said.

With the overcrowding in hospitals, anticipated increase in patients with chronic diseases and the shortage of doctors and allied staff in public healthcare, she sees a need for GPs to pitch in and help.

The nerve centre SingHealth’s team of Right-Siting Officers (RSOs) from the Chronic Disease Management Office constitute the nerve centre of the DOT programme.

Spearheading the programme, the team has managed to reduce paperwork – the major bugbear of GPs on the programme – by a considerable amount.

To streamline operations and ensure a smooth workflow for the clinics, RSOs, many of whom are retired nurses, have taken over the job of reminding patients about their appointments and following up on laboratory test results.

They also help keep a close watch on the progress of DOT patients to ensure they achieve the recommended targets and that their conditions remain under control.

The DOT programme’s progress has not gone unnoticed.

Recently, overseas medical institutions have expressed interest in the programme and are keen to find out more.

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News > Continued from page 1

Nose

Dreaming of a good night’s sleep Mouth

Severe sleep apnoea, if not treated, is linked to hypertension, heart attack, stroke and early death.

Dr Toh Song Tar, Consultant, Department of Otolaryngology (Ear, Nose and Throat Surgery) and Sleep Disorders Unit, Singapore General Hospital

During normal breathing (below), the throat is clear and open, allowing air to flow freely to and from the lungs.

PHOTOS: VERNON WONG

apnoea in itself is not a fatal condition because, when the brain senses the lack of oxygen, it wakes the patient from sleep and he begins breathing regularly again.

Obstruction of regular breathing can occur at different parts of the nosethroat area – the nose, Throat the palate (the roof of the mouth) or the base of the tongue. Mr Lee, like most patients with severe sleep apnoea, had obstruction in all three areas.

The airways close or get blocked for many reasons. In Asians, the typically smaller skeletal framework and structures in the throat play an important part in causing the sleep disorder.

Children can get the disorder if they have overly large adenoids or tonsils, while the airways of adults often narrow as they put on weight or age.

Depending on where the obstructions are, the patient may be asked to make lifestyle changes such as losing weight or quitting smoking, or may have to use a mask-like device called Continuous Positive Airway Pressure (CPAP) to keep the airways open during sleep.

Patients can also have surgery to remove tissues in the nose or tonsils if the obstruction occurs in those areas, but a more invasive procedure is necessary if the problem lies further down the throat,

While a person with obstructive sleep apnoea sleeps (left), the tissue at the back of the throat collapses and blocks the flow of air.

such as at the base of the tongue.

For Mr Lee, the CPAP device was too uncomfortable to use. He also went through two earlier operations to open up his nasal passages and widen the area behind the palate. However, he was reluctant to consider a third, more invasive operation, as he was wary of undergoing a procedure which involves cutting the jaw or chin bone in order to pull the tongue forward.

The base of the tongue is a difficult area to reach by conventional surgery and, unless a large incision is made, the surgeon’s view and access are blocked by the jaw and a large part of the tongue.

Hence, this usually requires the jaw to be split open.

New robot-assisted surgical option Luckily, for Mr Lee, a new minimally invasive technique using a robot-assisted surgical system for throat cancers became available late last year for treating sleep apnoea patients.

Robot-assisted surgery doesn’t require large incisions, or even incisions in some cases, to be made in procedures involving hard-to-reach areas. But it still allows surgeons to perform intricate procedures with a high degree of accuracy. This is because the surgeon performs the operation by manipulating surgical instruments mounted on robotic arms which have a range of movements wider than

Snoring the human hands’. A 3-D high-definition camera also gives the surgeon a clear view of parts of the body not easily seen except when the surgical area is cut wide open, as in conventional surgery.

In the new procedure to treat sleep apnoea, the surgical instruments are inserted through the mouth to perform the operation, so no external incision is made.

The robotic system’s camera enhances the surgeon’s view and the flexibility of the surgical instruments allows an unprecedented range of motion even in a surgical field so deep in.

“The (robot-assisted) system allows us to perform this procedure safely, allowing us to reach the most crucial part of the tongue base,” said Dr Tay Hin Ngan, Consultant, Department of Otolaryngology (Ear, Nose and Throat Surgery), SGH. In November last year, Drs Toh and Tay performed the operation – the region’s first transoral robotic surgery for obstructive sleep apnoea – on Mr Lee. So far, the technique has been used on three other sleep apnoea and three throat cancer patients.

“There are those who chose not to address tongue base obstruction because they do not want bone surgery, but they

Getting uninterrupted sleep To help snoring and mild obstructive sleep apnoea Reduce weight Avoid alcohol or medication that aids sleep as these relax the muscles at the back of the throat and cause obstruction Sleep on one side or on the stomach, instead of facing up, to prevent the tongue and soft palate from collapsing against the back of the throat

can now have this option of a less invasive, safer method of surgery,” said Dr Tay, who regularly performs robot-assisted surgery on the thyroid, and head and neck tumours.

Robot-assisted surgery involving small incisions has several advantages over conventional open surgery for patients, such as a shorter time under anaesthesia, which reduces risk in any procedure especially for older people; less bleeding because of the smaller incisions; and often a shorter hospital stay and recovery period. However, the costs can be substantially higher.

For Mr Lee, it has made the difference from having airway blockages 46 times an hour to just eight. “I feel much better and fresher, and my mind is able to focus better,” said Mr Lee.

Clear a blocked nose with medication recommended by a doctor or pharmacist Use dental appliances that reposition the lower jaw and tongue during sleep For moderate to severe sleep apnoea Use a CPAP device to keep the airways open during sleep Undergo surgery to enlarge the back of the throat

About 15 per cent of Singapore’s population has obstructive sleep apnoea This compares with 15 to 20 per cent for Asians in general and about 25 per cent in Koreans. While the smaller body skeletal structure among Asians tends to be the cause of the disorder, obesity is the main cause for Caucasians.

Affects more men than women Patients tend to be males in their 30s or 40s, and the incidence tends to rise in women after menopause.

Not all snorers suffer from sleep apnoea, but patients with sleep apnoea all snore Soft, rhythmic snoring is usually harmless. But if the snoring becomes loud and changes in intensity, it may be indicative of obstructive sleep apnoea.

Severity gauge The apnoea-hypopnea index (AHI) measures the number of complete airway blockages (apnoea) and partial obstructions (hypopnea) that occur every hour during sleep. An AHI of 5-15 is considered mild, 15-30 is moderate, and a value greater than 30 is deemed severe.

Blood oxygen levels Ideally, blood should have at least 95 per cent oxygen. A little dip below that mark is still acceptable, but anything less than 90 per cent is not healthy.

Cure rates When the AHI is less than five, patients are considered cured. In very severe cases, surgery that reduces AHI to less than 20 is deemed successful.

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News

Lifestyle change vital after heart attack

them the opportunity to seek information on measures that they can take to achieve such targets.”

The team has now rolled out new measures to close the communication gap and improve awareness. Treatment targets are printed on CHD patients’ appointment cards for easy reference and posters have been put up in hightraffic areas in the polyclinic to serve as further reminders. Nurses also draw patients’ attention to their treatment targets, and patients have their blood pressure checked before consultation to increase their consultation time with the doctor.

These efforts have paid off. The level of quality care – as more patients achieve their treatment targets – has since improved.

Heart patients can reduce their risk of getting a second heart attack

BY Jacqueline Chia

A big killer The study was conducted amid concerns about the deaths of CHD patients in the last few years compared to 10 years ago.

An earlier study by Tan Tock Seng Hospital showed that 70 per cent of CHD patients did not meet the target cholesterol levels and ran a high risk of getting a second heart attack.

“We wanted to look at the factors that prevented our patients from reaching their targets, and develop better treat-to-target practices for both our doctors and patients,” Dr Tan said.

The study involved 44 patients and 18 primary care physicians. During focus group sessions, patients discussed their awareness of the disease and lifestyle choices, while physicians, in separate focus groups, discussed treatment protocols.

The information correlated with results from a survey of more than 300 patients on their lifestyles, expectations of care and awareness of their disease.

The final results of both studies were presented at this year’s Asia Pacific Regional Conference of the World Organisation of Family Physicians (WONCA), held in the Philippines.

The team found that the problem was due to many factors, including commu-

Patients should aim for the following targets Blood pressure < 130/80 mmHg LDL-C (cholesterol) < 2.6 mmol/L Type 2 diabetes mellitus < 7%

PHOTO: VERNON WONG

Only a handful of patients with coronary heart disease (CHD) successfully change their lifestyles for the better.

In fact, many revert to their old habits six to nine months after a heart attack or bypass surgery.

This was one of the findings of a study led by Dr Tan Ngiap Chuan, Senior Consultant and Director of SingHealth’s Pasir Ris Polyclinic.

The team found that many CHD patients were unaware of what they needed to do to improve their health and reduce their risk of another heart attack by achieving treatment targets for their blood pressure, LDL cholesterol and diabetic control.

Some did not know what their target good cholesterol and blood pressure levels should be, or how to control their diabetes. Others continued with poor diets, a lack of exercise and unhealthy lifestyles. Several ate at hawker centres six times a week and said it was hard to change their eating habits. A small number also continued to smoke.

HbA1c

Patients with coronary heart disease should be aware of treatment targets so they can work with their doctors to achieve them, said Dr Tan Ngiap Chuan (above) of Pasir Ris Polyclinic.

nication lapses between physicians and patients. Dr Tan said: “Primary care physicians are often too preoccupied with the clinical assessment of the cardiac status to exclude the risk of a second heart attack. There was little discussion on mutually agreed goals or treatment targets during consultation.”

He said the checks doctors perform on CHD patients are correct and necessary.

“What is missing is simply mentioning

How some patients view treatment targets

the treatment targets. We know the risk of having a heart attack again will be reduced significantly if patients manage these factors well.”

He said it is important to give patients information on their treatment targets. “Even if they are elderly and have difficulty remembering the target levels, repeating the numbers to them gives

“This kind of things (treatment targets) can fluctuate.”

“The LDL level should be kept within 60 or what! I can’t remember the exact figure.”

The new registration card has treatment targets printed on it as an additional reminder to patients.

“I do exercise.

I walk to the market every morning.”

“I never thought to ask the doctor for my precise cholesterol levels as I was told everything was alright.”

“Medicine is to safeguard you. Sometimes, I pamper myself when eating, but I know I’ve got some medicine as backup. I think that’s the balance.”

“My doctor told me ‘your blood pressure is good’. That’s all. I don’t know what’s good and what’s not.”

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Tell us

A blessing in disguise In 2002, I had surgery to remove a cyst in my womb. In 2010, I was diagnosed with fibroids and what looked like another cyst in my womb. But my gynaecologist decided to delay surgery as she wasn’t sure if the growth was a cyst or scarring from the previous procedure.

Then, last year, an ultrasound scan indicated a larger growth and surgery was strongly advised. I grappled with fear and anxiety, but decided to go ahead eventually. It was a blessing in disguise!

Though no cyst was found, the surgeon discovered that my intestinal wall was clogged with adhesions from my previous procedures. About 10cm of my intestines

was cut out and, today, I’m well and my mood is uplifted.

I thank God for being alive. I’m also very grateful to Dr Yong Tze Tein for her care, and visiting me daily despite her hectic schedule; the general surgeon Dr Grace Tan Hwei Ching; and the anaesthetists Drs Chong Shin Yuet and See Hooi Geok for attending to me. I would not hesitate to recommend SGH to my friends.

- Ms Dorothy Ng Siew Gek

This letter wins an iCare 200 Blood Glucose Monitoring System worth $58 and Sun Chlorella A tablets (150 tablets) worth $33.

AND WIN A PRIZE FOR BEST LETTER Letters must include your full name, address and phone number. Singapore Health reserves the right to edit letters and not all letters will be published. Write to editor@sgh.com.sg or The Editor, Singapore Health, Singapore General Hospital, Communications Department, Outram Road, Singapore 169608, or talk to us on Facebook.

The winner will receive two pieces of Backjoy (worth $129.80) to relieve back pain and improve posture.

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Singapore General Hospital Sindry Dhayzi One of my friends is suffering from acne and various skin problems from an early age. This became systemic amyloidosis.

Like · Unlike · Monday at 11.08pm 3 people like this

Singapore General Hospital Hi Sindry, we do not discuss a patient’s condition in a public domain. We can only advise you on processes and procedures. We recommend your friend see his/her family physician for a referral.

Yesterday at 2.01pm · Like · Unlike

Ibu Nur N Aniq Is there any support group for parents whose child is born with a congenital health issue? I hope SGH can seriously consider having one, especially if the child has to go for any form of rehab programmes. It can be strenuous mentally, physically and financially for a parent. It is not only the child who needs help, but his parents too...

Like · Unlike · Jan 10 at 4.09pm 8 people like this Singapore General Hospital @Ibu Nur, we have a list of support groups in SGH here: www.sgh.com.sg/Patient-Services/ Support-Groups/Pages/Subpage.aspx. However, if you could send us a private message on what kind of support group you are looking for, we could help you better. Alternatively, you may contact Ms Melody from Club Rainbow (6377-1789) to find out more. Jan 11 at 6.57pm · Like · Unlike

When cause of death is unclear When our uncle passed away in hospital recently, we weren’t able to claim his body immediately as we were told his death had been referred to the coroner.

Why couldn’t the doctor certify the death since he was under treatment at the hospital?

We are sorry for your loss and the delay in claiming the body.

When doctors are unable to determine the actual cause of death, they have to refer the case to the state coroner, who will decide if a post-mortem is necessary to determine the cause of death. An open casket is still possible after a postmortem as it does not disfigure the body.

Relatives of the deceased can pay their last respects in the ward before the body is transferred to the Mortuary@HSA, which is situated at Health Sciences Authority, Level 1, Block 9, SGH. A police officer will inform the family if a post-mortem is required, while staff at Mortuary@HSA will provide information relating to the expected time for the registration of death and claiming procedures, including arrangements for the hearse to arrive at the mortuary.

For the registration of death, the identity cards or passports of the deceased and the family member handling the procedures must be produced.

A Certificate of Registration of Death, together with a Permit to Bury/Cremate Body, is then issued for relatives to claim the body at the mortuary.

Tributes I would like to thank and commend SGH Medical Social Worker Ms Tang Chyi Yueh for her care and concern in dealing with my grandmother’s case. Ms Tang did her utmost to facilitate our application to admit our grandmother to a nursing home, and also advised us on seeking financial help. Although she was offered a place at Ling Kwang Home, my 99-year-old grandmother recovered and family circumstances allowed us to keep her at home.

- Ms NL Soon

When my dad forgot to bring his polyclinic referral letter, Maslina Wahab, Patient Service Associate, National Dental Centre of Singapore, explained things in a very clear and detailed manner and provided alternatives.

My father proceeded with his treatment the same day.

- A grateful relative of a patient

Dr Priscilla Lu, Dental Officer, National Dental Centre of Singapore, made my mother comfortable by placing a rolledup blanket as a cushion for her back, knowing that she had recently undergone an operation on her back. My mother is very happy. Thank you.

- A patient’s son

No consultation, no blood test I want to do a blood test, but I don’t want to see a doctor. Can SGH just issue me a request form?

Only doctors can order laboratory tests and, in SGH, only tests ordered by a doctor can be performed. Laboratory tests are complex tools in patient management, and have to be used and interpreted in light of each patient’s condition, including his medical and family history. False positive and false negative

results may occur. A false positive wrongly indicates the presence of a disease, while a false negative wrongly suggests the absence of a disease that is actually present.

An inappropriate over-reaction to a false positive test may lead to expensive, and possibly invasive, over-investigation. A medical consultation with a doctor enables him to properly assess the patient before ordering appropriate tests and he can also interpret the results later. The doctor can then give appropriate advice to the patient.

Buy medicines at one location My father always has to go to the pharmacy at SGH Block 4 to buy Seretide 25/125mcg Evohaler 120D, and it often takes us about an hour to queue for the medication. Then, there is another half an hour’s wait at NCCS’ pharmacy for other medication. This travelling could be avoided if we could buy all medication at NCCS’ pharmacy.

We regret the inconvenience caused. Unfortunately, NCCS does not carry Seretide

25/125mcg Evohaler 120D. Our pharmacy focuses on oncology drugs and Seretide is used for the regular treatment of asthma.

Our Pharmacy and Therapeutic Committee regularly reviews drugs in NCCS’ list of medicines. Should we observe an increase in the demand for any drug available at NCCS, our pharmacists will submit a request for it to be included in the list of medicines.

We would, however, advise that you discuss the matter with the doctor during your father’s next appointment at NCCS.

MAR⁄ APR 2012

singapore health

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People

Stalking a silent killer Sudden cardiac deaths take lives unnecessarily. Here’s one doctor who is doing his best to stop them in their tracks

Lowering the risk of sudden cardiac death in young adults is a key research area which Dr Reginald Liew, Consultant, Department of Cardiology, National Heart Centre Singapore (NHCS) is working on.

Why Singapore?

It was Singapore’s growth in research that drew him here from Britain, where he was raised and trained in medicine and cardiology. “The research scene in Singapore has taken off in a big way, so I was very interested in using my research background to work here and see if I could contribute to the research output,” said Dr Liew, who is married with two young children.

He first developed a passion for research as an undergraduate medical student at Cambridge University, where a lot of emphasis was placed on understanding basic principles of health and disease, and much of the third year was dedicated to formal research.

Before joining NHCS three years ago, he worked at St Bartholomew’s Hospital in London, where he trained in cardiac electrophysiology and was also knee-deep in research. One project which stands out, among the many he did there, is a small prospective trial which showed that using fewer cardiac catheters than standard ones in ablation procedures was more cost-effective and efficient. The results of this study may have a significant impact

“One reason people die suddenly is because of heart rhythm problems. But there are treatments available to prevent this, such as inserting an implantable cardioverter defibrillator in high-risk cases or performing catheter ablation procedures in others,” he said.

Specialising in heart rhythm disorders (cardiac electrophysiology and pacing), he not only treats patients with irregular/ abnormal heartbeats (arrhythmias), but also researches the condition to better understand it, and improve diagnosis and treatment.

PHOTO: ALECIA NEO

and improve diagnosis and treatment.

“There’s always a lot more to do in this field. Once you find out something new, there are five more questions you want to ask, so it’s never-ending,” he said.

By Jamie Ee

Apart from clinical work, Dr Reginald Liew (centre with tie) also mentors students. He is seen here with students and researchers at NHCS’ R&D lab.

His role as mentor He chose to specialise in cardiology as he found it to be “true physiology in action”.

He said: “Cardiology is an exciting specialty.

You can treat patients quickly and see them improve over a short space of time.”

Also an assistant professor at DukeNUS Graduate Medical School, Dr Liew mentors students and organises the structure of the cardiovascular course for firstyear students.

“I was fortunate enough to have had many great mentors during the course of my training. I believe it’s important for young doctors to have role models to look up to,” he said.

His mentoring style is not just to teach facts but also discuss ideas and principles, and encourage students to think and apply what they know to situations.

“The best way to prepare someone to be a junior doctor is to make him think for himself,” he said.

The “health minister” is home!

by focusing on the teeth and the job on hand. I also teach them how to care for their mouths, which are usually very dry.

Reaching out through research As Deputy Director of NHCS’ Research and Development Unit, Dr Liew and his team have been focusing on the use of stem cell technology to develop a human heart cell model of inherited heart rhythm diseases.

This will allow them to study the electrical properties of heart muscle cells from these patients, outside the body and in the laboratory, to better understand the diseases

on current practices in cardiac electrophysiology.

Dr Liew also undertook a formal period of research in the UK to perform a PhD study on how plant oestrogens (as in soya products) act on the heart. “I discovered novel actions, which may explain some of their beneficial effects, and why Asian populations that consume large amounts of soy appear to have less heart disease.”

Ms A Abrojibanu, Oral Health Therapist, National Dental Centre of Singapore (NDC), is often mistaken for a nurse or dentist at work. But, at home, her role is clear

carrying out non-surgical treatments such as scaling and root planing (deep cleaning), which they prescribe for patients with gum disease.

For those coming off their braces, I clean up and take impressions of their teeth so retainers can be made. I educate patients about gum diseases, tooth decay and the importance of regular followups.

Busy or cost-conscious people may skip these checkups and allow gum disease to go undetected, as it is painless until the last stage. It’s sad to see young people – some in their 20s – with dentures because of dental neglect. Once a week, I go to the Health Promotion Board to supervise OHT trainees.

Why I chose this job...

I grew up with a strong passion to help and heal people. My dad wanted me to be a doctor but, because I’m a bit queasy about blood, I knew I’d be a therapist of some kind. Being an oral health therapist (OHT) is really the best place for me. It’s an area where I can also educate patients and make a difference. I get satisfaction from seeing them get better and, when they thank me, I feel so appreciated. If I weren’t an OHT, I’d probably be an occupational therapist or a physiotherapist – I’d still be in healthcare. I’ve never considered any other career and I don’t get influenced by others. I listen to my heart and, if I feel that it’s right, I’ll go ahead.

My job…

I work in the Periodontic Unit, Department of Restorative Dentistry at NDC. My job is to support the gum specialists by

PHOTO: ALVINN LIM

By Serene Foo

Educating patients on gum care is part of Ms Abrojibanu’s role at NDC.

Challenging cases…

Oral health therapists play a big role in maintaining the oral health of nose cancer patients. Radiation therapy affects their head, neck and oral regions. Sometimes, when working on teeth with palettes “exposed” after surgery, my heart will pound from anxiety, but I get over it

Making a difference…

Currently, I have a diploma in dental therapy and dental hygiene, but I hope to specialise in caring for patients with special needs. I know this can be a challenging area, but I want to do it because I know I can make a difference there. We may not be able to do fillings for these patients, but we can, at least, maintain their oral hygiene and educate their caregivers.

When the scrubs come off…

Every day, when I go home after work, I share my work tales with my husband and mother-in-law. Talking about them usually helps me de-stress.

On being the “health minister” in the family…

I may not be a doctor, but they certainly treat me like one at home and refer to me as the “health minister”. I have five siblings and, as I’m the only one in healthcare, if anyone has an ache or pain, I will surely get a call. In fact, they call me for advice on anything related to health as they know I have studied something about diseases.

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15 Health+Asthma V4 WF path.indd 14

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17/2/12 1:38 AM

Mar/Apr 2012

Wellness The right exercises for osteoporosis patients

p16-17 Wellness Hope for patients with heart problems

Asthma Control Test

People with severe asthma can turn their health around with medication and proper treatment. By Angeline Neo Relaxed, smooth muscles

Gaining control Now in his early 70s, Mr Tan has his asthma under control and severe attacks have become rare – a turnaround in his health that he credits to Dr Mariko Koh, Consultant, Department of Respiratory Medicine and Critical Care, Singapore General Hospital.

“Dr Koh gave me the confidence to live without my nebuliser,” said Mr Tan, referring to the inhaling device that he uses to relieve the symptoms of asthma quickly.

At the time, he was over-reliant on his reliever medication, using it more often than he should.

Under Dr Koh’s care, Mr Tan began to regularly use controller medications instead. Controller or anti-inflammatory medications, when used daily, are the most effective and important treatment for asthma as they prevent attacks by

Dr Mariko Koh (far right) and Ms Karen Tan (centre), Senior Asthma Coordinator, helped Mr Tan Chay Hua (right) control his asthma.

making the airways less sensitive to irritants in the environment. They also help to reduce swelling in the airways and Wall inflamed and thickened decrease the production of phlegm.

Through asthma counselling, Mr Tan also began to understand his condition, how to get Normal airway his asthmatic symptoms under control, what causes an attack, how to avoid it and what to do when it strikes.

Asthma, said Dr Koh, is a common disease that affects about 5 per cent of adults and 20 per cent of children in Singapore.

While asthma cannot be cured, its sympAsthmatic airway during attack toms can be controlled with the proper use of medication and environmental control.

“It is important to recognise a severe Because the airways of people with attack of asthma and seek early medical asthma are “hyper-reactive”, they react attention,” said Dr Koh. easily to anything from cold weather and If left till too late, patients may end exercise to dust mites, pollen, tobacco, up on life-support machines to help them and stress, she said. “That’s why asthma breathe. And if they can’t breathe, they waxes and wanes. There are good and bad won’t have enough oxygen going to the days, depending on what can trigger an brain and vital organs, and that can lead attack,” Dr Koh said. to a vegetative state or even death.

When the person is exposed to some“Generally, around 80 per cent of asththing that triggers an attack, the airways matics have mild to moderate asthma. It narrow, their lining becomes inflamed, can be controlled with the use of daily mucus or phlegm is produced and the controller medications and they lead patient must be given something to help normal lives. They can go to school and him breathe. work, and even exercise or participate Asthma patients have to use an inhaler in competitive sports without any probcontaining a reliever medication, like sallems,” said Dr Koh, noting that footballer butamol, to quickly open up their airways David Beckham and Olympic gold medaland allow them to breathe easily. If the list and swimmer Mark Spitz (who won attack is severe, the reliever medication seven gold medals at the 1972 Munich alone may not be effective and patients Olympic Games) are among the many will need to take a tablet kept on standby, famous people who have asthma. usually prednisolone.

“Like Mr Tan, if you have symptoms suggestive of asthma, seek early medical help, use your medication as advised by your doctor and go for regular followup. Asthma can be controlled and asthmatics can lead normal, fulfilling lives.”

Photo: Allen Tan

sounds from his chest which felt tight, and he had coughing fits after every few laboured, phlegmy breaths. If his medication – always close at hand – didn’t let him breathe easier, he would have to seek emergency treatment.

“It felt like my airways were blocked and I was breathing in very little air,” said Mr Tan Chay Hua, who has suffered from asthma since his youth.

Because his family was poor, he didn’t pay much attention to his condition, dismissing it as a cold or cough. The disease – a chronic inflammation of the bronchial tubes or airways of the lungs – wasn’t diagnosed and treated properly, and it became progressively worse. Just a couple of years ago, Mr Tan’s asthma was so severe that he was getting an attack which required emergency treatment at the hospital a couple of times a week.

15

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Breath of life When his asthma flared up, he would be inhaling hard, trying to squeeze as much air as possible into his lungs. He heard wheezing

singapore he alth

If you have asthma and are older than the age of 12, take the Asthma Control Test questionnaire below to check if your treatment plan is keeping the disease under control. Be sure to review your results with your doctor or nurse.

Circle your responses, then add up the total score. For instance, the score for the first question is three if your response is “some of the time”, and five if it is “none of the time”.

QUESTION 1 During the past four weeks, how often did your asthma prevent you from getting as much done at work, school or home?

1. All the time 2. Most of the time 3. Some of the time 4. A little of the time 5. None of the time

QUESTION 2 During the past four weeks, how often have you had shortness of breath?

1. More than once a day 2. Once a day 3. Three to six times a week 4. Once or twice a week 5. Not at all

QUESTION 3 During the past four weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?

1. Four or more times a week 2. Two to three nights a week 3. Once a week 4. Once or twice 5. Not at all

QUESTION 4 During the past four weeks, how often have you used your rescue inhaler or nebuliser medication (such as salbutamol)?

1. Three or more times a day 2. Once or twice a day 3. Two to three times a week 4. Once a week or less 5. Not at all

QUESTION 5 How would you rate your asthma control during the past four weeks?

1. Not controlled 2. Poorly controlled 3. Somewhat controlled 4. Well controlled 5. Completely controlled TOTAL SCORE OF 25 – Congratulations! You have total control of your asthma.

SCORE OF 20-24 – On target. Your asthma may be well, but not totally, controlled.

SCORE OF LESS THAN 20 – Off target. Your asthma may not be controlled.

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singapore he alth

Mar⁄ Apr 2012

Wellness

High on exercise Banish fragile and brittle bones by working out regularly.

By Clarence Chen It may seem strange – and even dangerous – to be told that exercise is good for osteoporosis, a

hormone. In younger people, the condition can be the result of other causes such as an overactive thyroid, excessive consumption of steroids, eating disorders and vitamin D deficiency, she said.

condition marked by bones which are fragile, brittle and prone to fracture.

But that was exactly what the doctor ordered for Ms Mary Gnanapragasam when she was found to have osteoporosis when she was in her 50s.

“I was very worried when I was first diagnosed with osteoporosis. I didn’t want to fall and get fractures, and then have to walk with a stick or need someone to look after me. I wanted to remain independent,” said Ms Mary.

Now in her 70s, Ms Mary is completely sold on the benefits of exercise, and can be found at Singapore General Hospital’s (SGH) LIFE Centre gym on most days, going through the six or seven exercise routines prescribed for her by the centre’s physiotherapists.

Osteoporosis is a bone disease which occurs when the body fails to form enough new bone, or when too much old bone is reabsorbed by the body, or both, leading to the bones becoming fragile and brittle.

“Although osteoporosis is often considered an old woman’s disease, it can affect younger men as well as women,” said Dr Manju Chandran, Consultant and Director, Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, SGH. Older women lose bone very quickly during menopause when their bodies stop producing estrogen – a bone-protective

It’s not enough to exercise, they have to be the correct ones that address the needs of the patient.

Ms Mary had little warning that she was suffering from osteoporosis, except for feelings of ache and pain in the body.

Indeed, the disease is often detected at a late stage, usually when the person seeks treatment for fracture. But Ms Mary was lucky – her condition was diagnosed at an early stage during a medical review following the removal of her reproductive organs for a large growth.

She was seen at the osteoporosis clinic by an osteoporosis specialist. In addition to treatment prescription, she

Young men also get it Extreme dieting can cause osteoporosis in young people

Only old women can get osteoporosis

False

True

Osteoporosis can affect anyone, even young men. Young adults account for about 20 per cent of osteoporosis cases seen. Osteoporosis can be the result of other conditions, including anorexia, an overactive thyroid and overconsumption of medication, such as steroids.

A condition known as hypogonadism, when the body doesn’t produce enough testosterone, is known to be the cause of about 50 per cent of osteoporosis in men. Testosterone is the hormone that plays a key role in masculine growth and development during puberty.

PHOTO: Ellen Lim

Bone tissue is constantly growing and replacing itself, with bone formation greater than bone loss in a person’s growing years. Bone mass peaks when a person is in his 20s or early 30s, after which bone cells break faster than they are replaced.

It is important to build up a good peak bone mass because the more a person has, the longer it takes for bone density to decrease during ageing, which causes bones to become thin, weak and prone to breaking.

Any condition, such as extreme dieting, being severely underweight or being on long-term steroids for asthma, can interfere with the formation of peak bone mass and, in turn, lead to osteoporosis.

Information provided by Dr Manju Chandran, Consultant and Director, Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital.

PHOTOs: veron wong

Ms Ng Deng Peng, Senior Physiotherapist, Singapore general hospital

was referred for physiotherapy services at LIFE Centre, where a team of doctors, specialist nurses, dietitians, physiotherapists and other medical professionals teach patients suffering from diabetes, obesity and other lifestyle-related conditions how to live healthily through exercise and diet.

Osteoporosis patients are given a treatment that includes drugs to stimulate bone growth, exercise therapy and a calcium-rich diet. “Diet and exercise are important complementary elements of their treatment,” said Ms Ng Deng Peng Senior Physiotherapist, SGH. At the centre, Ms Mary was first assessed to find out the state of her health and the areas of concern before an exercise regime was put together for her. “It’s not enough to exercise, they have to be the correct ones that address the needs of the patient,” said Ms Ng. These exercises include resistance, balance, posture and strength training as well as weight-bearing exercises to stimulate bone growth. A person with poor

Single leg stand: To improve balance and coordination; progress by maintaining position – effectively on a smaller base of support – for a longer time or on uneven ground. An alternative is the tandem stand, with one foot in front of the other.

balance or posture is more likely to fall, and this can lead to bone fracture, said Ms Ng. She and other physiotherapists at LIFE Centre are present when the patients are exercising, and work with one to four patients during the training sessions.

They make sure the patients are doing their exercises correctly, and check regularly that they are not having difficulty or feeling discomfort. Then, there are patients like Ms Mary who may need to move up the ladder to do more strenuous or different exercises.

Patients are also regularly monitored by the centre’s doctors, nurses and physiotherapists, and their progress is reported back to their physician. “The patient’s doctor must be happy with the progress he’s making,” said Ms Ng, adding that patients go through two rounds of programmes for each referral, either new or repeat, after which they are discharged.

“We’re not a regular gym after all, but a gym within a hospital, and patients shouldn’t be here forever,” she said.

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

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

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

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

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

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Mar⁄ Apr 2012

Wellness

The new, improved HeartMate II left ventricular assist device is a lifeline for patients waiting for a heart transplant. By Jacqueline Chia Financial adviser Mr Senthil Nathan, 35, was living precariously with heart problems until

The transplant must wait Insurance adviser Mdm Jessie Tan-Neubronner, 46, developed heart failure in 2006 following an adverse reaction to chemotherapy for breast cancer.

Her doctors said she needed a heart transplant to survive, but did not think it was advisable to have the operation until she was in remission. In the interim, her heart condition was so bad, she was

practically bedridden and needed a device to help it function.

Her doctors put her in touch with NHCS where, after a series of assessments, she was implanted with the HeartMate II left ventricular assist device in 2009. Since then, things have gone well – she’s regained normalcy and gone back to part-time work.

HeartMate II allows more patients to stay alive while waiting for a suitable heart. Currently, about 15 patients are supported on left ventricular assist devices, while five patients are on the active waiting list for heart transplants, with a waiting time of about a year.

Strong hopes for a young heart The youngest recipient of a mechanical heart-assist device in Asia is 14-year-old Choong Wei Tzen. He had a rude shock in February 2010 when, upon being admitted to a children’s hospital for acute appendicitis, it was discovered that he had an enlarged and weak heart.

In August 2011, he was admitted with severe heart failure and was transferred to NHCS for further treatment. There, he was put on a temporary life support system known as the Extra Corporeal Membrane Oxygenator (ECMO) before receiving the HeartMate II device five days later.

PHOTOs: Alvinn Lim

the HeartMate II left ventricular assist device stabilised his condition and became a lifeline before his heart transplant.

In 2005, he had what appeared to be the flu bug, but the cough persisted and he had difficulty breathing and sleeping.

He also gained weight despite losing his appetite.

His condition worsened and, one evening, he struggled to the clinic for help.

“The doctor took one look at me and knew something was wrong. He did an ultrasound which showed my clearly enlarged heart. He said I needed to go to the hospital immediately.”

There, doctors informed him that a viral infection could have attacked his heart, causing it to enlarge and result in heart failure. “I was utterly shocked because I’d never had any heart problems before. The doctors said my heart was pumping at only 10 per cent of its full strength.”

In 2009, he was referred to National Heart Centre Singapore (NHCS), where he was evaluated and put on the heart transplant waiting list. “I couldn’t eat, sleep or walk. It took me 10 minutes to walk 3m and I was so breathless that, when I slept, I had to be in a sitting position.”

As a bridge-to-transplant, HeartMate II was implanted in him by NHCS doctors.

The device helps the heart pump blood to the rest of the body. Placed just below the diaphragm in the abdomen, it is attached to the left ventricle and the aorta – the main artery that carries oxygenated blood from the left ventricle to the entire body. An external wearable system that includes a small controller and two batteries is attached by an external cable, which the patient wears all the time and charges every day. Since May 2009, 19 patients have been implanted with it.

“I walked around with 5kg of batteries all the time. Every night, I plugged myself into a machine that kept my heart beating. But none of it mattered as HeartMate II allowed me to work again and I was much stronger than I’d been in years,” said Mr Nathan.

HeartMate II gives patients with heart failure a new lease of life while they await a heart transplant.

PHOTO: alecia neo

Hello mate!

Mdm Jessie Tan-Neubronner, Insurance Adviser, 46 She carries the external system in her bag, which looks ordinary save for the white cable, which links the system in her bag to the device through a small opening in her body.

Mr Senthil Nathan, Financial Adviser, 35 Flu-like symptoms led to a viral infection that caused his heart to be enlarged. His condition worsened and doctors finally implanted Heartmate II in him.

It kept him fit and healthy till his heart transplant in 2011 allowed him to travel freely without it.

Choong Wei Tzen, 14 Doctors found that he had an enlarged heart when he was admitted to KKH for appendicitis in February 2011. He had HeartMate II implanted and has to carry a bag – with batteries that need to be recharged every day.

Since getting the device, he has regained his appetite and feels better. “I’m feeling very good. Before this, my appetite was poor but, now, I can eat better. I was breathless before, but not anymore,” said Wei Tzen, who has returned to school.

His mother Mdm Jacqueline Liau said: “He’s happier, healthier and more positive.

Before the operation, especially when he was reaching the heart failure stage, he was very weak and knew it. Every time we visited him in hospital, he would keep a tight hold of his father’s and my hands.”

His surgeon Dr Tan Teing Ee, Senior Consultant, Department of Cardiothoracic Surgery, NHCS, said: “HeartMate II gives most patients a very good quality of life. Most are able to go back to their normal activities after it is implanted in them. Before surgery, quite a number of them cannot even walk a few steps without becoming short of breath.”

About HeartMate II In the last decade, National Heart Centre Singapore (NHCS) has implanted over 50 mechanical heart devices in patients. Ten of these patients went on to receive successful heart transplants.

Dr David Sim, Consultant, Department of Cardiology and Co-Director of the Heart Failure Programme, NHCS, said people with weak hearts generally have them functioning at below 50 per cent.

Prior to this programme, about 30 per cent of patients died while waiting for a transplant, due to the lack of suitable donors.

HeartMate II, the latest mechanical heart device, was introduced in Singapore in 2009. Compared to older devices, it has a much smaller pump that is fully implantable in the patient’s body. It was designed to significantly improve survival and quality of life, and provide several years of circulatory support to patients with advanced heart failure.

It is also more durable and can potentially be used for chronic long-term support for patients with irreversible heart failure. The first recipient in May 2009 was a 30-yearold female patient and she is still doing well today.

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MAR⁄ APR 2012

Spotlight

Let’s hear it for the winners!

More than 2,700 healthcare professionals in Singapore – doctors, nurses, allied health professionals and ancillary staff – were honoured at the Singapore Health Quality Service Awards 2012. From public and private healthcare organisations and community hospitals, they received Silver, Gold, Star and Superstar awards. We feature five winners from SingHealth here

Madam Liang Ming, Senior Staff Nurse, National Heart Centre Singapore GOLD AWARD

Caring is a family tradition

Madam Zabaria Yusoff, Senior Patient Services Assistant, Singapore National Eye Centre (SNEC) SILVER AWARD

Although hospital counters are always busy, Mdm Yusoff has a ready smile for everyone no matter how hectic it gets.

She knows it can be harrowing for patients, so she ensures the registration, payment and appointment scheduling are done as smoothly as possible.

“I’m concerned about people, especially those who need help. And since patients are worried, it’s my job to make them feel happy,” she said.

Inspired by her mum’s kindheartedness, she chose this profession because it gives her a chance to interact and help people. “I enjoy helping them and learning something new from them.”

One interaction she remembers clearly was when a patient’s daughter was trying desperately to fix an earlier appointment with a specialist for her father, who had discomfort in his eye. Mdm Yusoff managed to squeeze him in the next day, when doctors found his condition serious enough to operate immediately. “His daughter’s gratitude serves as my inspiration to go the extra mile for patients.”

She does not think she did any better than her peers at SNEC to receive the award. “We all work hard to achieve service standards. This award is an important recognition, not just for me but all clinic clerks for the important work we do at SNEC.”

Mr Tay Kai Ming, Podiatrist, Singapore General Hospital SILVER AWARD

Tending tired soles Repeated foot injury from too much competitive running in his school days, and his subsequent recovery, got Mr Tay interested in podiatry.

He remains grateful to the podiatrist who helped him not only recover, but continue running and enjoying sports.

“I was inspired by her level of professionalism throughout the rehabilitation

PHOTOS: ALECIA NEO

A friendly face at the frontline

process, and I hope to achieve the same level one day.”

The pain of his previous foot injuries has taught him to be more sympathetic towards his patients. “It helps me treat them better and with lots of personal care,” said Mr Tay, who speaks English, Mandarin and Hokkien.

His job involves helping people with problems that affect their lower limbs. This includes assessing gait and alignment, and advising on proper footwear. Correcting biomechanical abnormality relieves their symptoms and gets them ready for rehabilitation.

Many patients have complications from diabetes, so he also does foot screening and manages diabetic foot wounds.

He finds it satisfying to help patients recover. He sees his “ultimate challenge” as convincing women to avoid non-supportive footwear as these are the common causes of foot problems.

The award came as a pleasant surprise to him. He said: “I’m grateful for the compliments. It’s always nice to be appreciated. I’ll continue to work hard to provide my patients with the best care.”

It was her parents – both doctors – who inspired her to become a nurse and care for the sick.

“They provided medical services to the poor and needy in rural China, saving many lives in the process. When I was young, my father taught me not to envy the rich, but think of the poor and remember how lucky I was. From then on, I made up my mind to help people,” she said.

Mdm Liang came to Singapore in the early ’90s as a trainee nurse in the haematology ward of Singapore General Hospital. She remembers her kind colleagues teaching her patiently and helping her overcome the language barrier. “My friends also let me explore and enjoy Singapore culture and made me feel at home.”

She returned to work in Singapore because of its well-developed healthcare system and advanced medical technology, as well as the good working relationships she enjoyed here.

For the past 15 years, she has been looking after patients with heart disease at the Department of Cardiothoracic Surgery of National Heart Centre Singapore.

Her role is to educate patients on how to prevent falls, maintain hygiene standards and assess their pain. If they need an operation, she explains the preoperation instructions and handles their discharge orders. She also teaches junior nurses, and is involved in nursing research and quality audits.

Her aim is to provide the best nursing care for her patients, and she feels happy and fulfilled when she sees them recovering. Currently pursuing an advanced diploma to upgrade her skills, she said: “This course energises me and fills me with ideas on how to do even better in the future.”

While honoured to receive the award, she wants to share it with her team. “Nursing is about teamwork. We won’t do well without support from each other. So, the credit should go not just to me, but to the whole team.”

MAR⁄ APR 2012

Ms Lilian Quek Lee Hua, Senior Staff Nurse, Marine Parade Polyclinic SILVER AWARD

We pass this way but once She is described as a kind person who always sees the good, not bad, in others.

Ms Quek attributed her good nature to her philosophy of life and her role models – her mother and grandmother.

“My philosophy is to live life to the fullest each day as life is unpredictable.

We are all just passing through this world.

When we are happy and treat others with

respect and kindness, they will be happy too.”

She is grateful to her role models for inculcating the kind streak in her. “My mother and grandmother would offer students from our hometown in Malaysia, who came here to study, free board and lodging, until they found a place to stay.”

Her personality traits were the reasons why relatives and friends advised her to go into either teaching or nursing. After choosing nursing, she has never looked back. Her workday is hectic but she has a ready smile for everyone.

“Even if the environment becomes stressful, I keep my spirits high by counting my blessings,” she said.

She feels happy when patients, especially those she has counselled, improve and adopt healthier lifestyles. “A change in lifestyle can translate into fewer hospital admissions and a lower financial burden on families.”

A winner of multiple awards, Ms Quek said: “I am thankful to my supportive bosses, colleagues and patients. With or without this award, it is my duty to deliver the best to my patients and be a responsible nurse serving the community. I hope to continue to do this every day.”

Dr Arjandas Mahadev, Head and Senior Consultant, Department of Orthopaedic Surgery, KK Women’s and Children’s Hospital STAR AWARD

It doesn’t feel like work Dr Arjandas’ day starts very early with morning rounds and can finish – especially when there are emergencies – extremely late. But it never feels like work to him.

This is so because he is doing what he is really passionate about – working with children with bone and joint problems.

The study and management of bone conditions have always fascinated him. “Bones have this ability to heal completely and go back to their original state, unlike many other tissues and muscles in the body.”

At the hospital, he sees all kinds of bone fractures and deformities, some for the first time, but these challenges only make his work more interesting.

What makes his day is to see a sick child recover against all odds, and walk out of hospital strong again. He thinks patients who are positive do better. “Perhaps, that’s why children, who are inherently happy and positive, heal better.”

A believer in the importance of play for children, Dr Arjandas also has a special interest in playground safety, and has conducted several studies to assess the severity and factors

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causing playground injuries. “Play enhances a child’s physical and mental development, but caregivers must be mindful that some precautions are necessary to avert potential injuries,” he said.

Dr Arjandas interned under his mentor Professor E H Lee, a pioneer of paediatric orthopaedic surgery in Singapore. His special areas of interest include foot deformities, developmental dysplasia of the hips, cerebral palsy, limb deformities and paediatric fractures.

A winner of two Excellence Service Awards (EXSA) Star accolades and one EXSA Gold award before this, he said: “Doctors don’t work with the intention of winning awards. But I am honoured to receive it and grateful for the recognition.”

Are your gums in the pink of health?

Dr Tan Wah Ching, Consultant, National Dental Centre of Singapore (NDC) answers questions about periodontal disease What is gum disease?

Periodontal disease, or gum disease, is a chronic bacterial infection of the gums and bone supporting the teeth, affecting one or more teeth. A milder form – gingivitis – can be reversed by professional dental scaling, followed by regular brushing and flossing. But if left untreated, it can progress to periodontitis, where the gums, bone and connective tissue are damaged, causing tooth loss.

What causes it?

The main cause is bacterial plaque which hardens and forms tartar over time. As the plaque grows, the body’s immune system fights the bacteria. The toxins mix with the enzymes to break down and destroy the bone and connective tissue holding the teeth in place. If unchecked, the teeth may eventually become loose and have to be removed.

Gum disease can range from mild to severe and can affect people of any age.

What can predispose you to it?

Smoking can increase the risk of getting it and lessen the success of some treatments.

Uncontrolled diabetes also increases the

risk of infection. Hormonal changes in women’s bodies can make the gums more sensitive. Certain oral medication, treatments for cancer and AIDs, plus general susceptibility can all contribute towards increasing the risk.

What are its symptoms?

They include swollen, puffy and tender gums which bleed when brushed, a receding gum line, abscesses, teeth that are shaky or drifting out of position, persistent bad breath and a dull ache in the gums or teeth. Some people have no symptoms or pain.

How is it treated?

Treatments vary but are aimed at controlling the gum infection and restoring good oral health. Non-surgical treatments include scaling and root planing. Scaling involves scraping away tartar from above and below the gum line. In root planing, tough tartar and bacteria deposits along the root surfaces are removed with special instruments while the patient is on local anaesthetic.

Gum surgery serves to remove residual tartar in deep unresolved periodontal

pockets. The aims are to control disease progression and make the area easier to clean at home. In patients with more advanced disease, gum surgery may be needed. The periodontist may sometimes suggest bone or tissue grafts to encourage new growth of bone or tissue to replace the damaged areas.

How do you prevent gum disease?

Brush your teeth with a toothbrush and fluoride toothpaste twice a day or after every meal to minimise plaque buildup.

Use interdental aids like an interdental brush or floss daily. Visit the dentist twice a year for checkups and professional cleaning. Don’t use tobacco products. If you smoke, quit.

Can gum disease affect other parts of the body?

It is possible but, so far, research has been inconclusive. However, studies are ongoing to see if there is a link between gum disease and increased risks of heart attack, stroke or delivering preterm/lowweight babies, and whether diabetics with gum disease have greater difficulty controlling their blood sugar levels.

SingHealth Women’s Forum 2012 – Fabulous From 40!

Dr Tan Wah Ching, Consultant, National Dental Centre of Singapore (NDC), will give a talk at the forum on gum health. Dr Tan is from NDC’s Periodontic Unit, Department of Restorative Dentistry, and is also a clinical lecturer at the National University of Singapore. There will also be talks on diet, eye care, diabetes, perimenopause and menopause, as well as ovarian cancer.

Date: April 28, 2012, Saturday Time: 10-11.30am (Special Interactive Sessions), 1-5pm (Forum) Venue: Sheraton Towers Hotel Contact: For more information, call 6377-8511, email marcom@ singhealth.com.sg or visit www.singhealth.com.sg/ FabulousFrom40

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Viewpoint

Do a little more, a little better A member of Bright Vision Hospital’s senior management shares her observations and thoughts about working at the community hospital, which is now part of SingHealth Group

dollars a month, is a regular donor of tubs of ice cream and sweet buns to our terminal palliative patients.

It made me think about what it takes to climb the hurdle of self-interest or selfpreservation to genuinely spare a thought for another person before ourselves.

photo: wong wei liang

Thinking beyond the current It is a daunting thing to get out of our comfort zone and accept new ideas, let alone a new vision. As stated by Einstein: “Insanity is doing the same thing, over and over again, but expecting different results.” Enough said.

Perhaps, the most challenging and also the most rewarding effort for the BVH team has been to create viable opportunities to meet new needs.

These include the opportunity for staff to do better and display their abilities in new areas, the chance to serve their colleagues and patients better, the opportunity for the hospital to provide better and new services, the chance for patients to better express their needs and receive the help they require and the opportunity for volunteers to fruitfully engage with patients.

Bright Vision Hospital has come a long way to become the largest community hospital providing the broadest range of inpatient care.

BY Choo Shiu Ling

The experience in Bright Vision Hospital has been unexpected because it led me to a brand new learning journey, and also inspiring as it got me thinking a lot about relationships and familial ties.

Venerable Kuan Yan, with the direction of the late Master Yen Pei, developed Bright Vision Hospital (BVH) into the largest community hospital providing the broadest range of inpatient care, which covers rehabilitative, palliative and chronic sick care as well as a nursing home.

Today, BVH takes in patients referred by the restructured hospitals regardless of their religious affiliation and ability to pay. What an admirable achievement and important contribution to the community.

The depth and breadth of human ability is great when we are guided by dedication, commitment and spiritual strength.

It has been my privilege to be seconded to BVH for this past year and a half, and to be part of the new chapter in the hospital’s life journey as part of the

SingHealth family. Changing expectations of our patients, staff and broader community are a source of encouragement for the hospital to do even better and meet changing needs.

The gift of giving For our patients and caregivers, BVH has been a reliable sanctuary for continuing medical care after their long journey in an acute hospital.

Given the socio-demographic profile of our patients, they often arrive at BVH both financially and emotionally drained.

For the few months our patients are with us, the BVH team has the time and unique opportunity to truly create a recuperative environment and, perhaps, even provide moments of joy and happiness, beyond medical care.

Developing a dedicated and broad volunteer network has been critical, and engaging our volunteers such that we help them find personally fulfilling roles engaging with our patients is fundamental.

I have often wondered at the source of a person’s charitable instincts. I remember being completely floored when I learnt that one of our kitchen staff from Myanmar, who earns a mere few hundred

Unresolved dissonance Among our patients, there are those who have made mistakes in life which family members and/or friends have not been able to forgive and reconcile with.

Hence, they are presented to us at BVH alone, with little or no support, or with extremely aggravated familial ties. I suppose my mind then rationalises that there is some form of a reason, without judging the circumstance, why a person ends up alone and lonelier than anyone needs to be.

It is a daunting thing to get out of our comfort zone and accept new ideas, let alone a new vision.

However, the greatest challenge has been to frequently encounter patients who come from intact families or have supportive social relationships, but yet exist at the margins of society. The space in society which they occupy is very tough. Many exist in households where the entire income is less than $1,500 a month, where the family supports one person in a hospital and school-going children, where one’s standard of living likely

A sanctuary of care Bright Vision Hospital (BVH) is the largest of six community hospitals in Singapore providing treatment to patients who are not critically ill, but still require hospital care.

Community hospitals are run by voluntary welfare organisations with some government funding. Following a request

by Singapore Buddhist Welfare Services to the Ministry of Health for more professional medical services for BVH, senior Singapore General Hospital doctors are helping to provide clinical leadership and ensure continued improvements in the clinical expertise of the hospital’s medical team. The team is supported by visiting consultants from a range of specialties, including geriatrics, rehabilitation medicine, psychiatry and palliative care. The doctors work closely with nurses, therapists, social workers and pharmacists to ensure the patients receive the best possible care in a community hospital.

Bright Vision offers inpatient and outpatient rehabilitation to help patients regain independence in their daily activities, as well as inpatient palliative care, continued specialised inpatient sub-acute care to prepare patients for discharge and inpatient long-term care for the elderly and chronically ill.

The management of Bright Vision is led by Chief Executive Officer Chua Puay Hian and Ms Choo Shiu Ling, who were seconded from SingHealth Group.

decreases over time and where one lives from week to week and is unable to plan for the future. The dissonance is painful.

We share the same small physical space, but live in different dimensions.

Doing better I recently watched for the third time the movie Invictus, when, once again, I could barely fathom Nelson Mandela’s strength in transcending the experience of 27 years in prison to lead South Africa to its first multiracial elections.

For the rest of us mere ordinary mortals, his query to the Captain of the Springboks, who led the underperforming team to victory in the 1995 Rugby World Cup, is perhaps more achievable: “How do we exceed our expectations of ourselves?”

As I pen down these somewhat rambling thoughts, I am hoping we can all do a little more, a little better, with a bit more grace and kindness for the people around us with whom we share a space.

Ms Choo Shiu Ling is Director, CEO’s Office, Bright Vision Hospital.

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Mar⁄ Apr 2012

FYI

Eat chocolate

to prevent stroke and heart attack

Eating a lot of chocolate could reduce the risk of coronary heart disease and stroke by about a third, researchers at the University of Cambridge discovered in a study done on data collected from 114,009 patients.

Although evidence suggested that chocolate was able to lower blood pressure ­– thus reducing the risk of heart disease and stroke – researchers were quick to warn that excessive consumption could result in weight gain and diabetes.

event Calendar

Singapore Health issue 15 contest 1. What programme allows patients with chronic diseases to be referred to their family doctors?

2. What is your favourite story in this issue of Singapore Health?

Closing date: Mar 14, 2012 Send in your answers and stand a chance to win a Blood Pressure Monitor from Bosch + Sohn, Germany (model: boso medicus control) worth $135.

Blood Pressure

Normal blood pressure

=120/80

Pre-hypertension

>120/80 <139/89 Hypertension

> 140/90

Cholesterol Total cholesterol

< 200 mg/dL HDL (“good” cholesterol)

> 50 mg/dL (women) > 40 mg/dL (men) Optimal LDL

<100

Triglycerides

<150 mg/dL Waist Size

Risks of cardiovascular disease, diabetes, metabolic problems, high blood pressure and abnormal cholesterol increase if your waist size is

Fitness helps stroke recovery A new study by researchers in Spain found that people who were physically fit had better odds of recovery if they suffered a stroke.

Physically active people responded much better to clot-busting drugs, had less brain damage and were more likely to recover their motor skills than patients who had led a more sedentary lifestyle before they suffered a stroke.

“Physical activity seems to prepare the brain to face stroke in a better and more efficient way,” said study author Dr Ana Clara Ricciardi Ciocchini, a stroke researcher at Hospital Universitari Germans Trias i Pujol in Barcelona.

Patients with the highest level of activity were more likely to have blood flow restored within two hours of receiving tPA – a medication that dissolves blood clots and reopens arteries.

Women

>35 inches Men

>40 inches Source: Webmd

Publisher

Source: HealthDay News

Co-funded

Content Advisor Tan-Huang Shuo Mei Group Director, Communications & Service Quality, SingHealth & SGH Editorial Team Angela Ng (SGH), Lim Mui Khi (SGH), Tina Nambiar (SingHealth), Ann Peters (SingHealth), Deborah Moh (SGH), Wendy Seah (SGH) Singapore Health is partially funded by SGH Integrated Fund and SingHealth Foundation to advance the health literacy of Singaporeans.

Time 2-4pm Venue National Dental Centre Auditorium, Level 8 Price $5 per person Registration Call Sonia at 6321-3922 for pre-registration.

Mar 17 (Sat)

Public Forum: Surviving a Cardiac Arrest

Time 2-4pm Venue SGH Block 6, Level 9, Deck on 9 Price Free. No registration required.

Contact 6321-3590

Public Forum: Colorectal Cancer Awareness

Source: BBC

Healthy numbers

Public Forum: What Irritable Bowel Syndrome is All About

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

Winners of Contest 14 They will each receive eight sample packs of Viartril-S worth more than $80.

1. Beti Nuryanti 6. Seto Ah Soo 2. Freddy Chew 7. Tai May Yen 3. Chua Cheng Wee 8. Tan Poh Lay 4. Leon Poh Chong Mei 9. Vivian Wong 5. Pearlin Poh Bo Xuan 10. Irene Yam Ching Wah

Prizes must be claimed by May 6, 2012.

Mar 31 (Sat)

Time 1-5pm Venue HDB Hub Auditorium Price $5 per person Contact 6321-4671 (SGH Colorectal Surgery Department) or 6421-5804 (Singapore Cancer Society)

Email: editor@sgh.com.sg Post: The Editor, Singapore Health, Singapore General Hospital, Communications Department, Outram Road, Singapore 169608

Mar 17 (Sat)

SingHealth Women’s Forum 2012 – Fabulous From 40!

Apr 28 (Sat)

Time 10-11.30am (Special Interactive Sessions), 1-5pm (Forum) Venue Sheraton Towers Hotel Contact 6377-8511 or visit www. singhealth.com.sg/FabulousFrom40 For more information and other listings, please visit www.singhealth. com.sg/events or the respective institution websites.

Answer to In focus (Page 3): This is a photo of HeartMate II – a mechanical heart device which can be implanted in the human body. It keeps patients with heart failure alive while they wait for a transplant. It has a much smaller pump than older devices, which helps the heart pump blood around the body. Patients carry with them a small external support system in a bag, with batteries that need to be charged every day.

For stories on patients living with HeartMate II, see page 18.

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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, Email: 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) 076/06/2011.

Printed in Singapore by Singapore Press Holdings Limited (registration no: 198402868E).

新加坡中央医院

3月

与新加坡保健服务

4月 2012

集团的双月刊

page 28

随心所欲 的生活

page 29

page 29

消除疼痛

饮食与癌症

page 31

未使用的药物 不可退款

一夜安眠的梦想

图：VERNON WONG

当气道关闭或阻塞时，血液中的氧 气含量可能会下降，有时还会降至危险 水平。但睡眠呼吸暂停本身并不会致命， 因为当脑部感觉到缺氧时，它会使患者 借助一种新的机器人辅助外科手术切除喉咙后部的阻塞性组织，阻塞 从睡眠中稍微唤醒再使其开始规则呼吸。 呼吸受阻可能发生在鼻喉区的不同部 性睡眠呼吸暂停综合症患者可以一夜安眠 位上 — 鼻、上腭（口腔顶部）或舌根 部。像大多数重度睡眠呼吸暂停患者一 样，李家顺所有三个部位都发生梗阻。 气道受阻或关闭有很多原因。一般对 亚洲人来说，喉部的骨骼框架和结构较 小是导致呼吸障碍的重要原因。儿童可 能会因扁桃腺肥大而导致此病，成人的 气道则常常因体重增加或年龄增大而变 得狭窄。 医疗方法需根据梗阻出现的部位，患 者可能需要调整生活方式，例如减轻 体重、戒烟或使用称为连续气道正压通 气（continuous positive airway pressure， 简称 CPAP）的面罩样装置来保持睡眠时 段气道开放。如果梗阻发生在鼻或扁桃 体内，患者也可动手术切除鼻内的阻塞 性组织或扁桃体，但如果问题出现在喉 咙更深处，例如舌根部，患者则需要更 入侵性的疗法，针对下颌骨的手术。 卓颂达医生（左）和郑歆彦医生（中）使用鼻镜为患有阻塞性睡眠呼吸暂停的李家顺做检验。 对李家顺来说， CPAP 装置使用起来 就会在日间时出现疲劳、嗜睡、健忘、 非常不适。他之前还动过两次手术，以 原文 Thava Rani 易怒（脾气暴躁）和工作时无法集中注 打开鼻道并拓宽上腭后部分。但涉及切 意力等症状。一些患者在清晨醒来时会 除颌骨或下巴骨以将主舌肌前移的手术 有喉咙痛或头痛等不太明显的症状。 让他却步。 李家顺先生又开始在睡眠中做梦了。也 “随着病情加重，患者在夜间常常因 许这并不是一件大事，但能够做梦意味 气道关闭而停止呼吸、影响睡眠，”新 新选择：机器人辅助手术 着又能正常睡觉了。这五年多来，他很 加坡中央医院耳鼻喉外科及睡眠障碍组 对李家顺来说可幸的是，新加坡中央医 少能够睡个安稳觉或深睡到做梦。他的 顾问医生卓颂达说。 院在去年年底推出了一项采用机器人辅 睡眠频繁地受到干扰，以至于不论每晚 鼻 睡多少个小时，隔天早上醒来时仍觉得 （左）阻塞性睡眠呼吸暂停患者睡 疲惫不堪。 眠时，喉咙后部的组织塌陷并阻 口 现年45岁的李家顺患有阻塞性睡眠呼 断空气流动 吸暂停症，患者的上呼吸道在睡眠当中 （下）在正常呼吸过程中， 重复受阻，导致在夜间频繁地醒来。但 喉咙通畅并开放，使空气 自由流入及流出肺部 通过一种称为经口腔机器人辅助手术 （transoral robotic surgery，简称 TORS） 解决了喉咙深部的梗阻问题从而帮助他 缓解病症。 “尽管我打鼾，家人也注意到我一直 喉 看起来很疲倦，但我并不知道自己患有 这种病症。我从未重视这些症状，直到 开始出现严重头痛和眩晕时才去看医 生，”李家顺说。

DOT共同 护理计划 转由家庭医生照顾慢性疾病患者 以减轻医院负担的初步方案 原文 Serene Foo

过去的十多年来，患有慢性疾病的商人 蔡家裔先生必须定期到新加坡中央医院 看专科医生。但现在他可以往住家附近 的家庭医生诊所就诊，同时还能获得相 同的津贴。 患有肾病的蔡家裔对这个安排赞赏有 加。这不仅更为方便，治疗妥当，同时 费用也保持不变。

诸多优势 这项方案是从新加坡保健服务集团（简 称新保集团）共同护理计划（Delivering on Target，简称 DOT）下延伸的，而蔡 家裔是参与该项目的其中一名慢性疾病 患者。按照方案的安排，在病情稳定后， 患者可从新加坡中央医院的专科门诊转 介至社区的家庭医生。 现年54岁的蔡家裔目前在距离住处 仅一步之遥的碧山Grace诊所向关伟慈医 生寻诊。这样的安排好处不胜枚举，不 但大大缩短行程和等待时间，而且方便 预约，就诊时间也灵活，因为诊所也会 在夜间开诊。 “在新加坡中央医院，如果错过了预 约日期，下个空档有时需等上三周，” 经营陪月保姆生意的蔡家裔说。“医院 太忙了。我有时需要在那里呆上半天； 等着看医生、做检查、取药。然后还得 择日回医院索取检验结果。” 现在除了 X光之外，所有的检查都能 在邻里诊所进行。而且还继续享有药物 津贴的他只需支付一小笔的快递费，新 加坡中央医院便会把药物送至家中。 唯一不满的是他不能像以往在医院就 诊时使用保健储蓄（ Medisave）来支付 门诊账单。“这是一个实际问题，希望 能够得到关注。”

打鼾是一种常见症状

量身定制个性化医疗护理

睡眠呼吸暂停最常见的症状为大声打鼾， 但由于睡眠经常在夜间受到干扰，患者

对蔡家裔来说，参与这项初步方案的 > 文转 page 26

> 文转 page 26

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DOT共同护理计划

图：ALVINN LIM

在新保集团DOT共同护理计划的安排下，蔡家裔（右）在住处的邻近向关伟慈医生寻诊。他对这 样的安排感到很满意。

好处在于个性化跟进及较长的就诊时间 （ 15 至 30 分钟）。会诊时，他可以提出 问题，而关医生也会仔细地向他解释病 情。关医生解释：“目前，医院总是人 满为患，医生的时间也有限。这里，我 可以安排在非繁忙的时段就诊，这一来 我便有更多时间与患者互动。” 个性化跟进对慢性病患者来说非常 重要，因为患者必须了解自己的病情从 而控制疾病并相应地改变生活方式。例 如，从蔡家裔不理想的健康指标上，关 医生发现他没有遵从叮嘱服用正确的药 量，她便加以解释，直到蔡家裔意识到 其严重性。 “过去我比较顽固。我想减轻对药物 的依赖，并认为这样可以省钱，”蔡家 裔说。“但关医生解释这样做的风险， 并问我是否想进行肾透析。我当然不想， 所以我便开始乖乖地服药。” 蔡家裔起初怀疑家庭医生是否能够处 理他的问题，但他现已改观了。“关医 生很友好并且平易近人。我感觉很舒服， 还能对她推心置腹。她鼓励并劝导我， 还提供有关饮食和后续管理的建议。作 为家庭医生，如果我患上了流感或其他 疾病，我也会咨询她，是个周全完善的 一站式服务。”

增加了病患者的选择，”常用机器人辅 助甲状腺和头颈肿瘤手术的耳鼻喉外科 顾问医生郑歆彦说。 助手术系统治疗喉癌的新型微创技术， 于 2011 年 11 月，卓医生和郑医生已 也能用来治疗阻塞性睡眠呼吸暂停症。 为李家顺进行了该手术，这是本区域第 在舌根处动传统手术会受到下颌与舌 一宗为阻塞性睡眠呼吸暂停症治疗的经 头的阻挡，活动范围有限，入侵性高。机 口腔机器人辅助手术。迄今为止，这项 器人辅助手术无需大切口，利用内窥镜 技术已用于另三例睡眠呼吸暂停症患者 的角度和犹如蛇一般活动自如的机器臂， 及三例喉癌患者。至少还有另外两例睡 让医生绕过障碍施手术。三维高清摄像机 眠呼吸暂停症患者正等待使用这种新技 清晰的画面也增加了手术的精准性 。 术进行手术。 “机器人辅助系统给了我们在舌根， “由于不想进行骨骼手术，所以有的 口咽和下咽前所未有的内视和施术能力， 患者选择不处理舌根部阻塞，但他们现 在可以选择这种创伤性更小、更安全的 手术方法，”郑医生说。 对患者而言，微创机器人辅助手术较 传统开放性手术有多处优点，例如麻醉 时间缩短（麻醉时间长附带风险，尤其 是对老年人）；由于切口更小，出血减 少；住院时间和恢复期常常缩短。但费 用可能相当可观。 对李家顺而言，该微创手术使他 的气道阻塞从一小时46次缩减为仅 8 次。“毫无疑问，我感觉好多了。我 变得清醒多了，而且思维更加能够集 中，”李家顺说。

一夜安眠的梦想

到新保集团。此外，患者将负责保管自 己的记录。“我很高兴我们脱离了大量 的文书工作。况且让患者保管自己的记 录也能让他们更加了解自己的状况，并 能更好地配合治疗，因为他们可以看到 自己的成果。把事实摆在面前，他们会 更愿意听从，”关医生说。

睡眠呼吸暂停确实会间 接导致死亡。如果未经 治疗，重度睡眠呼吸暂 停还与高血压、心脏病 发作、卒中和早逝有关。 患者更容易因休息不足 导致的疲劳发生工业或 道路交通事故。 新加坡中央医院耳鼻喉外科及睡眠障碍组顾问 医生卓颂达

打鼾

技能提升 当关医生参加此项目时，她唯一担心 的是能否胜任管理慢性病患者的诊治工 作，因为她通常会将此类患者转介到专 科医生处。但 DOT 医生必须上四堂医学 延续教育课程，帮助她提升医学知识并 增强了她的信心。 她发现经由不同医学学会所主办的 心脏学、呼吸疾病等主题课程既密集 又累人，可是对她的工作却非常有帮 助。“虽然每年必须放弃25个周末，但 医学延续教育是非常重要的。你会学到 很多东西，不仅能提高技能，而且还会 增强治疗慢性病患者的信心。事实上， 我进一步多上一些课程，从而增进本身 的技能，”她说。

接下来会怎样？

问题仍然存在：初步方案之后， D OT 计 划 是 否 可 持 续 发 展 ？ 关 医 生 说 ：“ 如 果 政 府 出 资 补 贴 或 共 同 支 回馈社会 关医生认为 DOT 计划对患者来说是利多 付，这会鼓励更多家庭医生参与此项 于弊非常有益，因此她也加入了该方案。 目。”她也支持使用保健储蓄及与保健 在应付她日常繁忙的诊所的同时也接纳 储蓄相联的现金卡支付账单的建议，这 将帮助并减少患者所有的文书工作。 了40名DOT患者并为他们看诊。 “如果政府参与此方案，它也会提 新保集团的 DOT 计划在 2005 年推出。 至今有100余名家庭医生和超过1,000名 高新加坡家庭医生的行医标准。人们将 对我国的基层医疗更有信心，从而将医 患者参与。 “对我来说，这是社区服务。家庭医 院留给真正需要它的人。目前，医院拥 生是有特权的群体，由于我行医经验 挤不堪是因为医院的费用可获得津贴， 已达成熟稳定，我想尽自己的绵薄之力 而且人们也不确定家庭医生能否治疗慢 回 馈 社 会 ， ” 育 有 三 名 孩 子 的 关 医 生 性疾病，”她说。 由于医院里的患者太多，慢性病患 说。“我最大的满足感是看到我的病人 者有增加的趋势，再加上公共医疗中的 保持健康也不须再入院治疗。” 她指出， DOT项目涉及大量的文书工 医生和专职人员短缺，她认为此时我国 作。这工作现已从家庭医生的诊所转移 更需要家庭医生的参与和帮助。

大约15%的新加坡人患有阻塞性睡

眠呼吸暂停症 总体来说亚洲人有15-20%患病，韩 国人则高达25%。对亚洲人而言，身 体骨骼结构较小往往是罹患此症的原 因；对白种人来说，病因多为肥胖。 影响男性多于女性 患者以30多岁或40多岁的男性居

多，女性则是绝经后发病率较高。 并非所有打鼾者都患有睡眠呼吸暂

实现不间断睡眠

有助于打鼾和轻度阻塞性睡 眠呼吸暂停 减轻体重 避免使用酒精或药物以助睡 眠，因为它们会放松喉咙后 部的肌肉并导致阻塞 侧睡或俯睡而不是仰睡，这 样可以防止舌和软腭塌陷、 阻塞喉咙后部 使用医生或药剂师推荐的药 物消除鼻塞 睡眠时使用矫正下颌及舌的 牙科配备

停，但睡眠呼吸暂停患者都打鼾 柔和、有节律的打鼾通常无害，但 如果打鼾声越来越大且强度发生变 化，则可能是患阻塞性睡眠呼吸暂 停症的征兆。 血氧气水平

血液中的氧气含量至少达到95%才视 为理想。略低于该指数仍可接受， 但再低于90%则不健康。 严重度衡量

呼吸暂停-低通气指数（apnoeahypopnea index，简称 AHI）测量睡 眠时段每小时发生的气道完全阻塞 （呼吸暂停）及部分阻塞（呼吸不 足）次数。 AHI 为 5 - 15 视为轻度， 15 - 30为中度，超过30视为重度。

对于中至重度呼吸暂停 使用连续气道正压通气装置 保持睡眠时气道开放 进行手术开放鼻道或扩大喉 咙后部

治愈率 当 AHI 低于 5 时，患者视为治愈。在 十分严重的病例中，将 AHI降低至小 于20的手术视为成功。

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保健

足够还是过剩？ 适量摄取维生素和矿物质才是保健的关键 原文 Thava Rani

维生素 A ，C 和 E 是可帮助预防癌症的抗 氧化物。但摄取过量的维生素 C ，可造 成腹泻，或更糟的是可引起肾结石。同 样的，摄取过量维生素 A 可以危害身体 健康，包括肝脏损坏。 这是因为人体吸收某些维生素，如 A和E及矿物质的速度较慢。如果所进食 的维生素和矿物质比每日建议量还多， 这些物质将渐渐累积在肝脏和脂肪组 织，提高中毒的威胁。 维生素C是属于水溶性的维生素，当 体内有过多的维生素 C 时，它会随尿液 排出体外。新加坡中央医院药剂师张家 兴表示：“即使如此，一个健康的普通 人如果长期服用过量的维生素仍可以危 害身体健康。” 维生素和矿物质分别在身体的正常 成长和运作方面扮演不同功能。 张家兴说，水果和蔬菜中的维生素 C 是美容的基本元素，也有促进伤口愈 合的作用。无法摄取足够维生素 C 可能 会导致牙龈流血和容易有淤血的现象。 维生素C和E的来源包括果仁、 油类、绿叶和根类蔬菜，可帮助提升身体 的自然抗氧化物，以及清除多余可加速 老化和致癌的自由基（化学名称为游离 基）。钙和磷是维持骨骼健康的要素， 而铁则是红血球形成及运作的要素。 维生素和矿物质可是天然存在于我 们的日常食物中。因此，吃具有各类新 鲜肉类、谷类和蔬菜的均衡饮食应该能 提供生体所需的维生素和矿物质。不过 工作时间长和外卖餐的方便，意味着越 来越多人每天所吸收的维生素和矿物质 并没有达到每日建议量 的标准。

铁

锌

增强身体的免疫力，存于 酶内。它也是抗氧化物。

强化免疫系统， 影响体内酶活动。 也是抗氧化物。

美国推荐饮食量： 8mg（男）， 18mg（女） 食物来源： 红肉如牛肉，蚝，虾， 金枪鱼，小扁豆， 四季豆，腰果 过量服用： 轻微过量会造成便秘。 过度服用会导致胃粘膜 溃疡，和增加多个器官 损坏的风险。 过量服用症状： 呕吐和腹泻

美国推荐饮食量： 11mg (男)，8mg (女)

食物来源： 红肉如牛肉，蚝，奶， 烘豆，鹰嘴豆 过量服用： 会导致缺铜 过量服用症状： 恶心、呕吐

维生素C 促进胶原形成。 胶原是细胞之间的连 结物，连结皮肤下的 血管、骨头、肌腱和 韧带。它也是 抗氧化物。

维生素A

美国推荐饮食量：

有助于皮肤保健，和 保护视网膜和粘膜

90mg (男)，75mg (女)

食物来源： 水果如橙，葡萄柚和 草莓，蔬菜如花椰菜 和番茄 过量服用： 可能会累积在肾脏，造 成肾结石，和造成另一 重要矿物质如铜的流失。 过量服用症状： 腹泻，肚子抽痛，恶心

美国推荐饮食量： 700mcg (男)， 900mcg (女) 食物来源： 黄色和橙色蔬菜 如红萝卜、南瓜、 菠菜、番薯和鱼肝油 过量服用： 引致皮肤干燥 和骨头脆弱 过量服用症状： 疲倦，食欲不振， 呕吐，关节疼痛， 嘴唇和皮肤干裂， 头发脱落和皮肤呈黄色。

钙 维持心脏健康和肌肉 收缩及神经传递。 健康骨骼的基础。

新加坡中央医院药剂师 张家兴主张通过均衡饮 食，来摄取足够日常所 需的维生素。

美国推荐饮食量：

图：GETTYIMAGES

1,000mg

食物来源： 奶制品，如牛奶，乳酪 和酸乳酪，蔬菜如花椰 菜和包心菜 过量服用： 会影响肾脏功能和减低 吸收其他矿物质的能力。 过量服用症状： 恶心，呕吐， 食欲不振和频尿。

张家兴说：“我很好奇有多少人， 在面对繁忙工作日程的同时能达到卫生 科学局所推荐每天摄取各两份的新鲜水 果和蔬菜量。” 在这样的情况下，服食综合维生素 可确保摄取足够的营养。综合维生素含 有足够的维生素以预防和补充营养的不 足，但它并不提供日常所需的建议量。 例如，它的钙质量并没有达到美国当局 建议成年人每天需摄取的 1000mg 钙元 素。 不过，很多人都开始服食维生素和 矿物质的片剂或胶囊，因为他们相信大 量的营养素可防止老化，避免疾病和促 进精神和身体的机能。 虽然摄取量可能还低于最高摄取量 的限度，但长时间过量的摄取维生素和 矿物质会导致身体出现状况。 和所有好的事物一样，适量才是维 持强健体魄的关键。

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Mar⁄ apr 2012

焦点

随心所欲的生活 新的心脏瓣膜使患者重焕新生

郭照 在接受捐献的心脏瓣膜移植后能够不气 喘地跑上一段楼梯。

四个心脏瓣膜控制血液从心脏至身 体其他各个部位的流向，任何功能障碍 都可能导致伤残甚至死亡。心脏瓣膜异 常的患者通常会在做爬楼梯等日常活动 时感到虚弱无力和呼吸急促。 陈医生说：“认为自己可能患有心 脏瓣膜性疾病的人应找医生对病情进行 评估，即使病情较轻微尚无需手术，他 们也应采取预防措施以避免不必要的 伤害。” “例如，因为他们有晕厥的风险， 他们应在有人陪同时进行锻炼并确保不 做过于剧烈的运动。” 如果对心脏瓣膜疾病的诊断或治疗 为时太晚，心脏可能会严重受损和过 度虚弱，即使进行瓣膜置换手术也不 奏效。

漏水的水龙头需要更换零件 原文 Claire Yeo

不论何时走进安静的房间，规律的滴嗒 声总是伴随着他，就连他的妻子和儿子 都对他胸口发出的奇怪声音感到困惑。 郭照 说：“我之前没有意识到滴 嗒声是来自我年轻时植入的心脏机械 瓣膜。” 现年44岁的郭照 因患有先天性 心脏瓣膜缺失，13岁时进行了心脏机 械瓣膜移植手术。为了确保瓣膜周围不 会形成血液凝块，他开始服用血液稀释 药物。 郭照 说：“虽然感觉很好，但 我必须坚持服药并定期监测血液粘稠 度。随着年龄的增长，我并没有遵照指 示坚持服药，母亲去世后我就完全停止 了服药。” 三年后，郭照 因牙痛再次到医院 就诊。“在检查时，医生问我是否一直 遵照医生的指示服用药物。当他得知我 并没有这么做时，他立即将我转诊到新 加坡国家心脏中心，”郭照 说。 新加坡国家心脏中心马上要他入院 观察。由于没有定期服药，他脑中风的 风险十分高。 郭照 说：“那天下午我还有一场 足球比赛，我试图说服医生让我去，但 他告诉我猝死的风险实在太高了。”

更换受损的瓣膜是晚期患者的唯一选 择。药物治疗仅能缓解症状，不能修复 瓣膜受损、磨损或撕裂。对于患有先天 性瓣膜缺失的人而言，手术最终是唯一 的选择。 “不幸的是，心脏瓣膜问题是机械 性问题。比如水龙头漏水，除了更换 漏水部件外没有其他修理办法，”陈医 生说。 目前可移植的心脏瓣膜有两类：机 械瓣膜或取自人或动物的瓣膜。 “虽然机械瓣膜十分可靠且耐用， 但其缺点是需要患者终生服用华法林等 血液稀释药物，”新加坡国家心脏中心 心胸外科高级顾问医生林勇方说。除了

四个心脏瓣膜

服用药物外，患者还需要定期监测血液 粘稠度以确保适量服用药物。 另一选择是移植取自动物或他人捐 献的生物瓣膜。 林医生说：“对不适宜服用华法林 药物的患者来说，生物瓣膜是最理想的 选择，例如育龄女性、生活方式十分活 跃的人或服用华法林会导致生命危险的 人。虽然生物瓣膜功效十分好，但使用 的时间并不耐久。” 捐献的心脏瓣膜 通常可使用上15年，才出现磨损和撕 裂症状。 郭照 被转诊到新加坡国家心脏中 心后，医生决定为他进行生物瓣膜置换 手术（亦称同种移植），这也是针对郭 照 病情的标准治疗法。 手术康复后，郭照 感觉像一个全新的 人。他说：“我现在感觉好多了，能够 充分享受运动的快乐。手术前，每踢球 10到15分钟就得停下来休息，但现在 我能持续整个半场球赛。”此外，他每 周还与朋友骑45至50公里的单车。 2008年以前，像郭照 一样的患者必 须选择从国外进口的捐献心脏瓣膜，因 为本地没有收集和贮存捐献的人类心脏 瓣膜的组织库。而这些瓣膜得来不易， 价格不菲（约1万新元）同时也需要等 待及运输时间。 为确保这里的患者能够及时获得并 负担得起人类心脏瓣膜，新加坡国家心 脏中心成立了全国心血管移植片存库。 根据《医学（治疗、教育和研究） 法令》规定，心脏瓣膜捐献基于选择， 死于心脏病发作的人也可以捐献心脏 瓣膜。 亦担任全国心血管移植片存库医药 总监的林医生说：“表示愿意捐献心脏 瓣膜的人将接受筛查和评估，从而确保 他们的瓣膜可以进行捐献。例如，我们 会评估他们的生活方式，确保他们不属 于高危类别或携带肝炎等病毒。“ “我们还要通过检查确保他们的瓣 膜没有任何感染、没有癌症迹象以及没

正常心脏瓣膜的运作 主动脉瓣

肺动脉瓣 主动脉

二尖瓣

新加坡约有1万名罹患先天性心脏瓣膜 缺失或异常的成人患者，郭照 是其 中之一。除了先天性缺陷外，心脏瓣 膜也会因年龄增加或其他心脏性疾病而 受损。 心脏瓣膜病变时会出现两种情况。 新加坡国家心脏中心心内科顾问医生陈 培德说：“一种是瓣膜关闭出现问题， 导致血液返流或血液渗漏；另一种则是 瓣膜开放问题。”

三尖瓣

插图：heymans THO

心脏瓣膜性疾病

四个心脏瓣膜控制血液从心脏至身体其他各个部位的流向，心脏的每一次搏动都只有两个瓣膜开 放（右图，上/下）。

除开心手术 之外的选择 虽然通过开心手术置换瓣膜仍然 是晚期瓣膜功能不全患者的首选 治疗，但由于健康状况或高龄不 适宜进行开心手术的患者现在可 获得一种被称为经导管主动脉瓣 置换术的新型微创方案。 新加坡国家心脏中心的医生于 2009年2月在亚洲首次成功实施 这一治疗方案，通过腹股沟或胸 部动脉的小切口将预先安装了组 织瓣膜的球囊导管或安装在自膨 式支架框架内的瓣膜引导至患病 的心脏瓣膜，然后通过扩张球囊 或使支架框架对着旧瓣膜自行膨 胀，在旧瓣膜上放入经导管心脏 瓣膜。 新加坡国家心脏中心心内科 顾问医生及经导管主动脉瓣置换 术团队成员詹尊林医生说：“目 前，经导管主动脉瓣置换术主要 用于不适宜进行手术或手术风险 比较大的患者。研究证明，这一 治疗方法有助于降低死亡风险并 提高这些患者的存活率。”

图：alecia neo

28

詹尊林医生表示，对不适 宜进行手术的患者而言， 经导管主动脉瓣置换术提 高了他们的存活率。

有可能影响瓣膜的其他疾病，”林医生 补充说。 林医生说：“与其他类型的移植相 比，找到匹配的心脏瓣膜相对来说比较 容易。心脏瓣膜移植没有排斥的风险， 不需要服用免疫抑制剂，而且供体与受 体不需要进行血型匹配。” 迄今为止，已有近30人向全国心血管 移植片存库捐献了瓣膜，有近20名患 者从中受益，几乎一半为儿童。 林医生说：“同种移植对儿童最为 理想，他们3岁时就可接受移植。由于 华法林可能会影响妊娠，育龄女性也适 合此类移植。” 目前仍然需要从海外运输瓣膜来满 足本地需求，但全国心血管移植片存库 希望减少这数量。 “郭照 是一个幸运的受益人，但 我们需要更多人自愿捐献这生命之礼 物。我们也需要让大众知道我们拥有一 个为本地患者的全国心血管移植片存 库，”林医生说。 郭照 现在终于能够全身心地投入 生活，虽然有时夜里还会在恐惧中惊 醒。他说：“我惊醒是因为我听不到以 前机械瓣膜的滴嗒声，一瞬间，我担心 我的心脏停止了跳动。但是，这个新瓣 膜给予了我更加美好的生活，我已经成 为了一个正常人！” 他补充道：“我很想鼓励人们捐 献瓣膜，因为并非每一个人都像我这么 幸运。”

Mar⁄ apr 2012

新脉动

29

焦点

消除疼痛

类风湿性关节炎未必会缠上你一辈子

四年前的某个深夜，他的脚突然感到剧 烈的疼痛，以至严重到无法行走。 向来身体健康的邱耀庭先生 说：“感觉就像有一把刀在我的右膝盖 一样。”随后，这名88岁的调琴师被新 加坡中央医院的医生诊断出患上类风湿 性关节炎。 根据邱耀庭的主治医生，新加坡中 央医院风湿病与免疫科部门的顾问医生 熊嘉俊指出，类风湿性关节炎是一种关 节慢性炎症性疾病，有时也会影响皮 肤、眼睛、肺部和其他器官。 他说：“类风湿性关节炎是最普遍 的自身免疫性风湿病，总人口的1％， 约4万5千人，会受到这疾病的影响。当 中女性占四份之三，但疾病会影响所有 的种族，而且往往被发现在介于20至 45岁之间。” 自身免疫性疾病是指人体免疫系统 攻击自身体内组织，造成损害而引发 疾病。导致类风湿性关节炎的原因至 今仍无法确认，但某些人似乎较容易患

上此疾病。它会导致关节僵硬、疼痛、 肿胀，有时还会损坏器官。它的严重性 因患者而异，有些患者因症状还轻微， 所以不会意识到自己已经患病。他们可 能会感到持续疲劳或关节稍微有一点 僵硬。

图：alecia neo

原文 Thava Rani

熊嘉俊医生（左）向邱耀庭先生和太太解释类风湿性关节炎所导致的炎症为何会使关节疼痛。

若不治疗，类风湿性关节炎可能导致关节畸形。

专家说

健康交流站 我们的专家为您解答饮食与癌症的关系和有关前列 腺肿大的一些征兆和症状

饮食与癌症 我弟弟患有鼻癌，妹妹患有胃 癌。不知道是不是因为我们的饮 食习惯而造成的？我们年轻的时 候吃很多罐头食品配白饭。请问 我要怎样预防癌症？ 您患癌的风险是受遗传因素、环境，以 及生活方式等几个因素所造成的。 只要吃得健康、经常运动，以及保 持良好的体重，高达40%的癌症病例是 可以避免的，而约20%可以通过多吃蔬 菜和水果来预防。 美国癌症协会建议以下的防癌措施: 吃全麦食品以及每天吃至少五份水 果和蔬菜。 少吃红肉和动物脂肪。 少喝酒。 每星期数天运动30分钟。

保持健康的体重。 避免吃腌制食品和熏烤肉类如火腿 和香肠。

对于正在接受化疗和放射治疗的 人，该吃些什么才算是良好的饮 食？除了烧烤食物，还应该避 免吃些什么？ 良好的饮食应该是均衡的， 并且包含适量的蔬菜和 肉类。避免吃太甜、太 咸或太油腻的食物。 首选的烹饪方法是 蒸、煮、炒，比油 炸、烧烤或烘烤 更好。

熊医生说：“及早诊断出类风湿性 关节炎非常重要。”延误治疗可导致器 官和关节永久性的损坏。研究也显示， 及时治疗能让患者提高保持关节和器官 健康的机会。 为了准确诊断出类风湿性关节炎， 医生会凭验血及X光报告做评定。除了 服用适当的药物，患者也可能需要接受 风湿科临床护理导师、物理治疗师及职 能治疗师的后续护理。

为了管理患者的病情，保持每三至 四个月一次的会诊记录是很重要的。 在新加坡中央医院，患者是被鼓励通 过记事本或使用医院推出的智能手机 网络应用程序来记录每天的病情。 熊医生说：“这不仅能让病人掌 握自己的病情，同时也给我们提供客 观的资料。这样一来，我们便能更了 解病患的病情，从而作出更好的临床 判断。”

动物蛋白经过油炸、烧烤或烘烤等 高温处理后会产生致癌物杂环胺。我们 应该避免吃这些食物。如果想吃的话， 适量就好。

尿流变细 排尿后，感觉仍有尿液潴留在膀 胱内 排尿后滴沥 排尿不久后又想上厕所 尿频 有控制排尿的困难 前列腺肿大是老化过程的自然现 象。它通常出现在50岁以上的男性身 上。严重时，它可能会引起肾衰竭。要 正确诊断病情严重与否，请向您的医生 咨询。

新加坡国立癌症中心药剂师程玉瑛

前列腺问题 前列腺有问题有那些征兆和症 状？我应该从几岁开始关注这个 问题？ 前列腺是位于膀胱及尿道（把尿液输送 出体外的管道）之间的器官。前列腺会 随着年龄的增长而肿大，阻碍尿液流 动。您可能会发现： 排尿启动变慢，要等比较久才可以 排尿

我每次复诊医生都会为我进行前 列腺活检。医生是不是担心我患 上前列腺癌？因为尿频，我晚上 不敢喝水。应该怎么办？ 前列腺活检是检查是否患上前列腺癌的 程序。你的前列腺特异性抗原水平可能 有过高或逐渐升高的现象，表示患癌的 几率比较高。另一个原因是，过去的活 检结果可能出现令人担心的症状，但是 医生仍无法断定是否是癌症。 在晚上尿频（夜尿）可能是因 为前列腺肿大或膀胱衰老造成 的。你可以通过药物控制情况。 有些医生会建议不要在睡前喝 水，以减少夜里上厕所的次数。 不过，必须记得在24小时内喝 足够的水。 樟宜综合医院泌尿科顾问医生吴国杰

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Mar⁄ Apr 2012

焦点

住院支付能力调查

确定津贴

如何确定受雇者享有的津贴？ 受雇者享有的津贴将视收入而定。医院 的系统将从中央公积金局的系统中提取 受雇者的收入信息并自动计算其能享有 构里实施。这使低收入患者享有更多的 别在于获得的政府津贴金额会有所不同。 的津贴水平。 政府医疗津贴。 尽管所有入住C级和B2级病房的患者 住院支付能力调查仅适用于B2（包 都可获得政府津贴，在与低收入患者相 从中央公积金局提取哪些收入信息？ 括B2+）级和C级病房。日间手术、急 比之下，高收入患者能获得的津贴较少。 对于受薪雇员患者，该信息将依据雇 诊、专科门诊和综合诊疗所等服务都不 不过，他们仍然可以选择享有比B1级病 员在过去12个月间获得的平均月收入 房更高津贴的B2级病房。 （花红可纳入计算，但不包括最后一次 列入住院支付能力调查的范围。 有了政府津贴，B2级和C级病房的设 新加坡永久居民也得接受入住B2级 的薪水）。向中央公积金局自愿供款不 施得到了改善与提升。之前选择A级或 和C级病房的支付能力调查。他们能获 会影响收入信息。 B1级病房的患者也能够选择B2级或C级 得的住院津贴将比同等收入水平的新加 对于自雇患者，该信息将依据新加 病房，这潜在地让低收入患者受到了排 坡公民少10%。自2008年1月1日起， 坡国内税务局在过去两个评估年内由自 挤。与前者相比，低收入患者负担不起 外国公民不再享有住院津贴，所以住院 雇患者最后交易所得净值得出的月收 A级或B1级病房或私人医院，别无他选， 支付能力调查对他们没有任何的影响。 入，或依据自雇患者向中央公积金局上 只能求医于享有高政府额津贴的B2级或 住院支付能力调查不会影响出院后 报的过去两年内的收入来评估。 C级病房。 的后续复诊。如果患者在B2级或C级病 房住院后需要在专科门诊进行后续治疗， 如 何 确 定 失 业 或 无 收 入 患 者 享 有 的 津贴？ 他将继续享有津贴。 自由选择病房级别 鉴于住院支付能力调查，患者可保留选 家庭主妇、儿童、退休和失业人士等 择病房级别的自由。任何患者 — 不论收 信息摘自www.moneysense.gov.sg网站上的 无收入患者将获得全额津贴（B2级病 房65%，C级病房80%），除非他们 入 — 都可选择入住C级或B2级病房。差 《健康保险指南及了解健康保险》。 所居住的房产年值超过11,000元。如 果是这样，他们则分别享有B2级病房 50%和C级病房65%的津贴。

确保在选择同等级津贴病房时，低收入患者比高收入患者获得的津贴较多

黄女士是一名月入3,850元的行政管理 人员。当她入住一家公共医院时，她选 择了享有住院津贴的B2级病房。鉴于住 院支付能力调查，她仅能享有60%的 住院津贴，而不是B2级病房65%的全 额津贴 — 因为黄女士的月入在3,801 – 3,950元的收入阶层。 黄女士是健保双全保险（MediShield）的投保人，可是对于健保双全 不予赔付的医疗费，她必须从保健储蓄 户头（Medi Save）或现金以支付比预 期更多的款项。

仅适用于B2级和C级病房的住院 支付能力调查 住院支付能力调查旨在确保让最有需要 的国人从有限的资源获益。自2000年 起，该调查在政府资助的养老院开始实 施，至2001年起于其他中长期护理机

同意从新加坡中央公积金局或新加 坡国内税务局检索您的个人信息 我为何需要同意让个人的收入信 息从新加坡中央公积金局检索？

如果我入院时丧失意识或没有 能力表示同意，怎么办？

只有经过您的同意，系统才能更准 确地估算您的医疗费。如果您不愿 意，您医疗费的估算将基于C级病 房享有的65%的最低津贴（或B2级 病房享有的50%的最低津贴）， 而不是基于C级和B2级病房享有的 80%和65%的全额津贴。

医院工作人员将对您做些跟进以 获取您的同意。同时，院方将基 于您所选病房级别享有最低的津 贴估算您的医疗费。在获得您的同 意后，院方才会使用从中央公积金 局检索到的信息来 结清您的住 院费用。

如何对儿童进行住院支付能力调查？ 对于21岁以下的儿童，将根据其出生 证、身份证或其父母身份证中所述的住 宅年值进行评估。

我的家人能否代表我表示同意？ 不能，家人是不允许代表患者表示 同意。需要经患者本人的同意，系 统才能从中央公积金局检索到他的 信息。这是为了保护个人隐私。

住院支付能力 调查后的援助 任何患者不会因负担不起医疗费 而得不到所需的治疗。在实施住 院支付能力调查时会有一定的灵 活性，而且要求重新评估的个案 将会按个别情况获得考虑。如果 需要更多帮助，您可以与医务社 工探讨医疗基金（MediFund）或 其他形式的财政援助。 患者在接受住院支付能力调查后仍可重新选择病房级别， 差别在于获得的政府津贴金额会不同。

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