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A call to care
Exemplary nurse recognised with the President’s Award for Nurses
When Ms Chong Lai Ling was at school, it was numbers, not nursing, that fascinated her. But when she learnt about nursing and helping the sick from a school friend, the young accountancy student decided to switch her field of study to nursing. Ms Chong, who describes nursing as a calling, is today a Senior Nurse Manager at Singapore General Hospital (SGH) and a winner of the President’s Award for Nurses this year. “Nursing starts with the desire to care. When you have that, any difficulty can be managed,” said Ms Chong, who made news in 2007 when she opened her home to a leukaemia patient from China to help him save on rent. Caring for others, she added, cuts across all barriers. “We have a nurse from India who was nominated for SGH’s Service Quality award by an elderly Singaporean patient who spoke only Chinese dialect. Race, language and nationality – they are not barriers when you show that you care,” she said.
Not surprisingly, before this year’s prestigious national award, Ms Chong had received numerous accolades, including the public service PS21 award, the EXSA Star award, Healthcare Humanity Award and the Singapore Health Service Quality Star Award.
PHOTOS: allen tan
BY Sheralyn Tay
Trained in oncology (the study of cancers), Ms Chong manages the haematology and nuclear medicine ward, and ambulatory service at Haematology Centre at SGH. Her work doesn’t stop when her shift ends. She participates in numerous workgroups and support groups that aim to improve treatments and quality of life for patients. Among the many hats she wears are as leader of SGH’s Haematology Support Group, and Chairperson of SGH Community Partner-
Ms Chong Lai Ling (right) believes the key to good patient care is to pass on good nursing knowledge through formal and informal teaching, as well as discussions with her nurses.
Singapore Health wins international awards
ship Nursing Council, which organises fundraising activities and community outreach programmes. It’s not just patients who receive her care and concern. She’s also a well-loved mentor to her nurses, whom she coaches in various projects, including research. Some of these projects have garnered awards both locally and internationally. Ms Chong said that she loves it when her nurses excel. She takes time to understand her nurses, and to find out their strengths and weaknesses. During orientation, new nurses under her care go through a ward-based programme that she has developed, which Ms Chong Lai Ling, winner of the pres- helps them undertigious President’s stand how to care Award for Nurses. for haematology patients with blood-related diseases. Her door, she said, is always open to her staff and she has been a mentor to many nurse leaders and nurses. “Besides formal group teaching, I enjoy one-to-one discussions with my nurses. These are usually about the soft skills – how they handled certain situations, and how they could have done things better,” Ms Chong said. “Teaching is about the future, to pass on knowledge and experience to others. By doing so, nursing knowledge can continue, which is key to good patient care.”
In focus
Leading publishing competitions recognise Singapore Health for its editorial excellence Singapore Health continues to stand tall among the giants of publishing after winning two prestigious international awards for editorial excellence. We were awarded Silver for Best Overall Editorial at the 2011 Magnum Opus Awards and an Award of Excellence at APEX Awards for Publication Excellence 2011. Currently in our 12th issue, Singapore Health is partially funded by the SGH Integrated
Fund and SingHealth Foundation and aims to advance the health literacy of Singaporeans. Last year, Singapore Health received a Gold for Best Editorial – New Publication at the 2010 Magnum Opus Awards. Judged by professors of the famous Missouri School of Journalism in Columbia, US and leading publishing professionals, the Magnum Opus Awards competition drew 560 entries this year. Like Magnum Opus, the APEX Awards recognise excellence in graphic design, editorial content and the ability to achieve overall communications excellence. APEX is sponsored by Writing That Works, a US-based monthly subscription newsletter for business writers, editors and communicators. The winning Jan/Feb 2011 issue of Singapore Health.
Can you guess what this is? See page 26 for the answer.
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News
PHOTOs: 101teamwork
Post-surgical risks found to be no higher in keyhole surgery for older colorectal cancer patients, compared to open surgery
Keyhole surgery involves the use of devices and instruments, which are inserted through tiny incisions and controlled remotely to perform the operation. The use of robots advances keyhole procedures, as the combination of robotics, special miniature instruments and computer-enhanced technology complements the surgeon’s skills.
BY ruth Loh
Laparascopic or keyhole colorectal surgery can benefit elderly patients with no increased risk of post-operative complications, compared to conventional open surgery, as shown in a study by Singapore General Hospital (SGH). And if patients are fit enough to
undergo surgery, then the keyhole procedure – performed through tiny incisions with the aid of tiny cameras that magnify the surgical area on a viewing screen – should be offered to them as an option, the study said. Dr Tan Wah Siew, Associate Consultant, Department of Colorectal Surgery, SGH, said: “What we discovered is that age is no barrier at all. Our study found that patients who underwent laparoscopic surgery had better outcomes in terms of
Helpline for mums KKH’s new hotline gives mothers peace of mind BY Jacqueline Chia
What do you do if your child has a high fever in the middle of the night? How do you know if the pain you’re experiencing is the start of contractions and you should head for the hospital immediately? The answer is easy: Dial the Ask-ANurse Service at KK Woman’s and Children’s Hospital. Qualified nurses manning the phones can provide immediate and proper health advice on obstetric, gynaecological and paediatric care. The service, which operates daily from 8am to 12am, Mondays to Sundays (including public holidays), gets an average of 1,300 calls every month, of which about 800 come in after office hours. One fulltime nurse is on duty during office hours, and two locum nurses after that. Senior Staff Nurse Cheng Poh Sim, one of the nurses manning the line, said call-
ers are particularly anxious at night when most clinics are closed. The call volume is higher at night, on weekends and public holidays. Calls typically last 3.5 minutes. “Many people call because they are not sure what to do. For example, they may not know whether they need to come to the Accident and Emergency (A&E) department, or if it’s something their primary healthcare provider can handle,” she said. Top queries regarding babies centre around fever management, breastfeeding and weaning. They include whether to take a baby with a high fever to the A&E, whether a breastfed baby who is crying is still hungry, and when to start the infant on solids. Mothers-to-be and new mothers call to seek advice on pregnancy matters including whether they are experiencing the first signs of labour, whether bleeding during the first trimester means a miscarriage, and about post-natal wound care. Call 1900-KK-Nurse per minute.
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faster recovery, a shorter hospital stay and less pain.” The aim of the study, she said, was to prove that elderly patients with colorectal cancer can undergo laparoscopic surgery without a higher risk of complications and should be offered the benefit of having it. Researchers also wanted to find out if older patients face more complications from the longer time under anaesthesia. Keyhole surgery takes slightly longer than conventional surgery as it is technically more intricate. Dr Tan said: “Our numbers showed that elderly patients who went through this surgery didn’t come out with a higher complication rate than those who had open surgery.”
Our study found that patients who underwent laparoscopic surgery had better outcomes in terms of faster recovery, a shorter hospital stay and less pain. Dr Tan Wah Siew, Associate Consultant, Department of Colorectal Surgery, Singapore General Hospital
More than 700 patients aged 70 to 95, who had both open and keyhole colorectal surgery between 2005 and 2008, were studied retrospectively. Although it was not a randomised study, the sheer number of patients involved in the study “made
The study took second place in the Best Oral Paper Award (Clinical), at the SGH 19th Annual Scientific Meeting held in April. Dr Tan led the team of doctors, mainly from SGH’s Department of Colorectal Surgery, as well as Yong Loo Lin School of Medicine, National University of Singapore.
Dr Tan Wah Siew says keyhole surgery is technically more difficult and challenging than conventional surgery.
PHOTO: alecia neo
Study busts colon surgery myths
the results more likely to be accurate,” Dr Tan said. Typically, depending on complexity, conventional open surgery can take from half an hour to slightly over four hours, while keyhole surgery usually requires one to six hours, she added. “But we found older patients were not compromised by this. (General anaesthetic-related) complications are mainly post-op. It seemed there might be a higher risk related to keyhole surgery, but we discovered there wasn’t. The rate of complications was similar, not higher,” she said. Apart from a shorter convalescence, patients also needed less morphine for pain, so morphine-induced side effects, such as nausea, vomiting, constipation, and problems urinating, were reduced. Dr Tan describes keyhole surgery as “technically more difficult and challenging than conventional open surgery”, but said there are sufficient trained and experienced surgeons in SGH to be able to offer this procedure to any patient who wants it and is suitable for it. Not all patients are the same. “You can have a 90-year-old who is fit and another who is bed-bound and frail. But some patients should be offered it,” she said. “The most important thing is safety. If this cannot be assured, we won’t do it or insist on it, and put the patient’s life in danger. For example, if a tumour is too advanced, we may revert to performing open surgery.” Keyhole surgery has been practised for 15 years and has become established in the last five. The use of robots in more recent years has advanced keyhole surgery, as the combination of robotics, special miniature instruments and computer-enhanced technology has improved the surgeon’s skills.
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Fire at SGH? Don’t panic. Lifesaving measures are in place. Here’s a look behind the scenes at the hospital’s recent fire drill A fire breaks out at an operating theatre where a spine surgery is under way. A nurse rushes out to trigger the fire alarm while another grabs the nearest fire extinguisher to put out the fire. Another reports the incident to the hospital’s fire safety officer who, with the emergency response team, heads to the operating theatre within a minute or two to take charge of the situation . During this time, the anaesthetist takes control of the logistical procedures, assessing the patient’s condition to see how best to proceed. The fire isn’t contained and a decision is made to stop the operation. After stitching up the incision, turning off the oxygen supply and providing air to the patient through a manual pump, the anaesthetist orders the operating theatre (OT) nurse to shut down the medical gas supply, which includes oxygen. This is important to contain the spread of the fire. A clear plastic surgical dressing is quickly applied and the patient is evacuated to a nearby ward.
The OTs are well equipped with fire extinguishers and hoses, as well as torches to light the way should the electricity be cut. There are also clear rules governing the use of equipment that can easily start a fire. For instance, when using alcoholbased solutions, doctors must remember to wait for the liquid to dry before using surgical instruments that can create a spark. Gauze, cotton wool and the drape sheet covering the patient – these are materials that are easily combustible, especially in oxygen-rich theatres. Even with all these safeguards in place, said Ms Goh, there are “many ways a fire can start at OTs”. Although no fire incident has been reported in the past 13 years, all the OTs were involved and underwent mock procedures, which included plastic surgery, spine surgery, heart surgery as well as transplants.
When magnetic resonance imaging is used in operations, a precautionary sign will be displayed outside the room. This is because the huge magnetic field in the room will cause the metal fire extinguishers and anything else made of metal, such as body implants, pacemakers and steel-framed spectacles, to fly around. The magnetic field can also cause information stored in the magnetic strips of credit cards to be erased, making the cards useless. Only special fire extinguishers can be used in these rooms by trained personnel.
After all patients were taken off oxygen ventilators and given air that was pumped manually, the anaesthetist in charge gave the order to turn off the oxygen feed. Two oxygen panels (shown here) provide oxygen to the operating theatres.
The “patient”, being evacuated through a designated fire exit to a safe area, was undergoing spine surgery when fire broke out. Surgeons* quickly closed his wound and placed a surgical dressing over the incision, before he was transferred to a trolley and wheeled out. As the oxygen supply was turned off, a nurse* continued to provide him with air through a manual pump, while another held his intravenous drip (not shown).
Each person involved in the OT must know his role and how to react in the event of a fire. Ms Goh Meh Meh, Assistant Director of Nursing, Operating Theatres, Singapore general hospital
Luckily, all these did not happen but were part of a regular fire exercise, conducted recently at Singapore General Hospital’s (SGH) 25 major OTs on the second level of Block 3. According to Ms Goh Meh Meh, Assistant Director of Nursing, Operating Theatres, SGH, a large-scale fire drill involving many departments and staff is organised every year at the OTs, and fire-safety-in-service training, involving mainly nurses, is conducted every six months. “Over time, people may forget or new staff come on board, so we need to remind or train them in the protocol involved. Each person involved in the OT must know what his role is and how to react in the event of a fire at the operating theatre,” said Ms Goh, who was overall in charge of the drill.
“We were glad to get the support of surgeons, anaesthetists, perfusionists, radiographers, technicians, our nurses and ancillary staff. We were able to put up various scenarios to challenge ourselves, such as transferring a ‘patient’ from the heart-lung machine to a portable device, and evacuating ‘patients’ midway through their procedures from the new complex hybrid theatres,” said Ms Goh.
Surgeons, nurses, anaesthetists and other surgery staff* evacuated their “patients” to their designated evacuation holding area. The nurse in charge* of each operating room took a roll call to ensure everyone was accounted for. During this exercise, no one went missing. *Staff participating in the fire drill were not dressed in proper surgical attire as they needed to get ready quickly for scheduled procedures after the drill. The operating theatres were opened for only emergency operations during the drill, which began at 7.15am and ended just before 9am.
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News > Continued from page 1
Tumour size matters less
With liver cancer, the aggressiveness of the tumour – not merely the size – plays a larger role in determining whether a patient is at risk of having a recurrence.
SingHealth Residency, who did the research under Prof Chow’s supervision when he was a student at Duke-NUS Graduate Medical School. “While it has always been known that other factors such as the age of the patient, his relative general health, the functioning capacity of the remaining liver and the aggressiveness of the tumour played a part (in determining how well the patient would do and whether the cancer would recur), which factor was more important, and to what extent, were still being debated,” said Dr Lim. This study demonstrated that one crucial feature to look out for is microvascu-
lar invasion, which means the cancer has already begun to invade the small blood vessels. To determine if the tumour cells have penetrated the small blood vessels, a pathologist has to examine the whole tumour, as microvascular invasion cannot be seen on a scan or detected through a core biopsy. The study also highlighted a certain pattern in the recurrence rates of the cancer. Patients with the aggressive form of the cancer, where microvascular invasion was inherent in the tumour, have a higher risk of getting another tumour in the liver within two years of the surgery. From the study, “we now know that
post-surgery, some patients will inherently do better than others. Those with higher chances of recurrence will need additional treatment. It is definitely something we need to look at in the future, based on data provided by this study,” said Prof Chow, Dr Lim’s mentor in the study. The findings have changed the way Prof Chow follows up on his patients. “In the past, after resection, patients come back every six months for an ultrasound and blood test in order to catch any new tumours. But looking at the data on early recurrence in patients with microvascular invasion, I have changed that – I will schedule followup and surveillance every three months for the first two years for these patients.” By doing this, the cancer can be detected early and some form of treatment can be offered before it’s too late. “Patients who show no symptoms when their cancer or cancer recurrence is detected stand the best chance of early treatment and good survival,” added Dr Lim. Prof Chow and Dr Lim encourage regular screening for liver cancer patients, as well as those most at risk of getting the disease such as hepatitis B carriers. “Asia has a high incidence of hepatitis B, unlike the West. Liver cancer is therefore a very important cancer here. If you are a hepatitis B (or C carrier), we recommend you go for screening every six months. If you don’t know your hepatitis status, it is time to have it checked,” said Prof Chow. *Mr Foo isn’t a real person, but could be any one of the hundreds of people (both men and women) who are diagnosed with the disease every year. Liver cancer was the fourth most common cancer among men from 2005 to 2009, according to Singapore Cancer Registry statistics. During this period, liver cancer was the third highest cause of cancer deaths among men, and fifth among women, although it didn’t come in among the most common cancers. **Fortunately, for patients like Mr Foo, new effective therapies are emerging. Treatment can include selective internal radiation using a chemical element known as yttrium-90 to reduce the size of the tumours, followed by radio-frequency ablation – a minimally invasive procedure that uses radio-frequency energy to burn tumours.
A study of sizeable proportions Dr Lim Kheng Choon (far right) worked closely with Prof Pierce Chow on this groundbreaking study.
size matters very little. But when there is microvascular invasion, then those with a larger tumour or more tumours did not do so well,” said Dr Lim, who like most in his cohort, held a first degree in a non-related field. Dr Lim studied mechanical engineering and spent seven years in the air force as an engineer before entering Duke-NUS, which took in its first batch of students in 2007 to turn them into doctorscientists. This is the first study to have
What is it?
It is the most common infection of the liver in the Asia-Pacific including Singapore Asia holds more than half the world’s hepatitis B burden It is caused by the hepatitis B virus
How is it spread?
By direct contact with the blood or body fluids of an infected person, such as from mother to child during childbirth, through unprotected sex and sharing of needles
What is its link to liver cancer?
Hepatitis B is the most common cause of liver cancer worldwide Those who are hepatitis B carriers are 100 times more likely to develop liver cancer than non-carriers More men tend to develop liver cancer than women Depending on the stage that liver cancer is diagnosed, and if left untreated, the average life expectancy is about three to eight months Individuals who don’t have hepatitis B can get liver cancer from a hepatitis C infection, cirrhosis arising from chronic alcohol consumption or a fatty liver
How can hepatitis B be prevented?
Have a three-dose vaccination if you are not naturally immune to the virus Have protected sex and avoid multiple partners Avoid the sharing of needles, razors and other sharp implements
Don’t all children get vaccinated against it?
PHOTOS: ALVINN LIM
Published in the highly respected international publication, Annals of Surgery, in July this year, the study was authored by Dr Lim Kheng Choon, the top student of the pioneer batch of Duke-NUS Graduate Medical School graduates. With Prof Chow as his mentor, Dr Lim worked on the study during his research year at Duke-NUS Graduate Medical School. He built up a database of more than 500 patients from SGH, and detailed analysis found that patients with microvascular invasion fared far worse, surviving an average of three years after surgery compared with almost eight years in those without microvascular invasion. “We also noted than in the absence of microvascular invasion,
Hepatitis B – what you need to know
compared size and number of tumours against microvascular invasion and shown, in a very robust manner, the greater importance of the latter. It has also opened up new possibilities. “In future, maybe we might be able to identify a biomedical marker for microvascular invasion, now that we know what to look for. That way we can identify patients with microvascular invasion pre-surgically,” said Prof Chow.
Hepatitis B vaccination has been a part of a national childhood immunisation programme since 1985 Those born before 1985 were not vaccinated for hepatitis B, but they can check if they have the virus by having a blood test at a hospital, government polyclinic or with a general practitioner. The test costs between $30 and $40 at neighbourhood clinics
What’s next after blood test results?
If found to be hepatitis B-positive, a half-yearly screening for liver cancer is recommended If the patient has no history of blood transfusion or doesn’t belong to any high-risk groups, but is tested positive, family members should be informed and tested If the test is negative for hepatitis B, vaccination is recommended
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Reaching out Camp organised by medical students offers fun and support for kids of cancer patients BY TAN MAY PING
During his father’s four-year battle with stomach cancer, Vinodhan Kumaran acted on his fears by avoiding his family and problems at home, staying out late with friends and neglecting his schoolwork. When his father died in 2009, Vinodhan, then 11, couldn’t even turn to his mother for comfort as she was suffering from depression. If not for Camp Simba – an annual camp for children with cancerstricken parents – his life could have spiralled out of control. A hospice nurse who recognised the worrying signs in him, urged him to attend the camp. For Vinodhan, Camp Simba was a life-changing experience. He opened up, had fun and learnt to overcome his problems.
The children learnt to have confidence, compassion and courage, which can help them through difficult times. We emphasised teamwork to help them bond and make friends. Mr Joshua Chua, 29, a first-year postgraduate student at Duke-NUS and Head Facilitator
“Before the camp, I didn’t feel like talking to anyone, but the camp facilitators were very kind and taught me to be more disciplined. I enjoyed the games and made many friends,” said the Secondary 1 student, who returned to Camp Simba again this year – his third participation. He was roped in as a leader to help with the younger children. His mother, Madam N Punnitha, 49, said Vinodhan was a changed boy after attending the camp and was instrumental in bringing the family together again. “He became more mature and started to share his feelings with me and his older brother.” She said although it took her a year to get over her husband’s death and that she just wanted to stay home, Vinodhan would insist on taking her out to the movies or window shopping. She hopes more children will attend the camp. “It’s the best thing that’s happened to my son, and I benefited from it too,” she said. About 50 children, aged seven to 12 years old, attended this year’s three-day camp at Sentosa during the June holidays. With main sponsor SingHealth, the camp was jointly organised by medical students from Duke-NUS Graduate Medical School and the National University of Singapore’s Yong Loo Lin School of Medicine. Some student volunteers acted as facilitators, engaging the
Vinodhan in play goggles at Camp Simba. When his father passed away, the boy’s life spiralled out of control. Camp Simba was a lifechanging experience for him.
The children enjoyed the games and bonded with others who went through similar experiences.
children in games, crafts and skits, and creating opportunities for them to interact and make friends. About half of the children had attended the camp before, while others came through Hospice Care Association, KK Women’s and Children’s Hospital and the National Cancer Centre Singapore. Mr Joshua Chua, 29, a first-year postgraduate student at Duke-NUS and Head Facilitator, said: “They learnt to have con-
fidence, compassion and courage, which can help them through difficult times. We emphasised teamwork to help them bond and make friends, so they can support each other.” It was an eye-opener for the medical students too. “We came away with a deeper understanding of the social aspects in families with life-changing medical situations,” he said. First-time participants like Nur Shadrina Hashim, 11, who was initially sceptical and did not want to attend the camp, settled in quickly and had fun. Her mother, Madam Nur Hayati Abu Bakar, 49, a breast cancer patient, said: “She went in reluctantly, but when it was over, she didn’t want to leave. Now she can’t wait for next year’s camp!”
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12 News-Heart to Heart Bursaries V6 path.indd 12
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Tell us
Reminders sent even though bills were settled promptly I have been paying my medical bills regularly, but continue to receive reminders from Singapore General Hospital (SGH) about bill payments. It is very stressful to get those reminders and I have brought this to the attention of your billing staff previously. If I have paid my bills, I should not be receiving the reminders. Can someone in SGH ensure we do not receive any more of such reminders?
A statement of account for each month’s bills is generated automatically at the end of the month, and mailed to patients. Only patients with current outstanding bills will receive the statements. New bills or payments settled after the reminder is generated will not be reflected in the statement. So patients who have made payment after that date may still receive the reminder. As the mailing process takes at least one to two
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 a Cadi T560 Ear and Forehead Thermometer worth $96.
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Singapore General Hospital Kennieth Ong Is there a course to teach first-time parents-to-be on how to take care of a newborn baby? What should expectant mothers avoid? July 9 at 6.40pm via iPhone · Like · Comment 6 people like this
Singapore General Hospital Kennieth, you might like to join our Women & Kids at SGH facebook page for more information. July 10 at 6.58pm
working days, please ignore the request for payment if you have already settled your bill. Patients can also get in touch with the contact person at the telephone number listed on the statement if they need clarification for their bills. Singapore General Hospital’s A&E, specialist clinics and wards receive more than 100,000 patient visits each month. The high volume requires us to automate our processes to ensure efficiency.
Cancer diagnosis after having “harmless” flu symptoms A letter from Ms June Long to Tell Us (Jul/ Aug issue) reminded me of my husband’s condition. He had a persistent cough in March this year, which didn’t go away even after taking antibiotics prescribed by a neighbourhood GP. Polyclinic doctors he saw next advised immediate admission to hospital because an x-ray found water in his lungs. He was warded for a day and discharged. But still, his condition didn’t improve, so he returned for more tests. On June 24, following a variety of tests, he was diagnosed with Stage 4 lung cancer. We were shocked by the quick development of the disease within a short space of three months, and want to highlight to patients, doctors and healthcare professionals that “harmless” symptoms such as cough should not be taken lightly. My husband will start treatment soon. What I can hope for now is that we have the strength to fight this battle and take each day at a time. - Mrs Lee This letter wins a Beiersdorf hamper worth $100.
Soo Kum Hon I submitted a request for a medical report on May 30 this year, then received a letter saying the turnaround time is two to four weeks. Today is July 7 and it has been six weeks with no updates. Each time I call the Medical Record Office, the person who’s in charge tells me it is not ready. The client is waiting for this report to get her application reviewed. I’m not sure if the hospital has the patient’s interests at heart by delaying the process. Hope to hear from someone about this. July 7 at 7.18am · Like · Comment 3 people like this Singapore General Hospital Hi Kum Hon, sorry for the experience. We would like to seek more information from you. Please check your Private Message. Delays in prompt processing may be the result of: 1. The patient being warded or his upcoming clinic appointments. 2. Reports requested from several clinical departments. 3. The doctor being away on leave. July 7 at 8.27pm
Suggestion on parking rates As regular visitors to SGH, we highly commend your efforts to alleviate the problem of too few carpark lots. We parked at the new multistorey carpark, and found that we didn’t have to wait long for the free shuttle bus. It was also a pleasant ride. We are pleased with the reduced parking rate too, but noticed that the amount deducted for payment wasn’t indicated as with many other carpark systems.
Tributes I would like to commend Ms Wong San See, Senior Staff Nurse, SGH, for good service to my grandma when she stayed in Ward 63 recently. Both my dad and I noticed how attentive, courteous and respectful she was to everyone. My dad, who is not easy to please, wants to convey his gratitude and admiration to Ms Wong. He said he has “not met someone like her for a long time”. Thank you, Ms Wong! - Mr A Loo
I have been a trial patient since 2008, and Ms Florence Ang, Assistant Manager, Clinical Trials, NHCS, has been assisting me all this while. She will accompany me each time to do my blood test and consultation, and end the session with a warm interview. I’m totally touched by her assistance. Recently, after a tooth extraction, I immediately contacted NHCS to address some medication concerns. Shortly after, I was exhilarated to receive a call from Ms Ang. She advised me not to worry and to stop the medication for a week. She also said she would pass me the acknowledgement letter from the doctor. - Sing LM
I want to thank the family of a kidney donor for their kindness, benevolence and this gift of life. I will strive to be worthy of the donation by continuing the meaningful work in medical research ethics which I have done for the past 10 years. - A grateful recipient
We would like to suggest that the payment be indicated, so we can tell if the system has deducted the correct amount from our cashcard. Our hope is that the free shuttle service will continue to be provided, and the parking fee stays at the same reduced rate on a long-term basis. – Amy and William
Thank you for pointing out the fault. It has been rectified by Wilson Parking, which manages the multistorey carpark. The payment screen now shows the amount deducted as payment, as with all carparks on SGH Campus.
Sep⁄ oct 2011
Fitness Wake up to a brand new you!
p16-17 Vision
Young people get glaucoma too!
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Erasing the past
Laser basics
Think again before getting a tattoo because even the most advanced methods can’t erase the pigments in one completely. By JR Wu
The laser is calibrated to wavelengths of colour expressed in nanometres (nm) or a billionth of a metre. Some widely used laser wavelengths:
Depp broke up with then-girlfriend actress Winona Ryder. What once read “Winona Forever” on his bicep was stripped of the “na” and his tattoo now reads “Wino Forever”. When the relationship goes bust, what happens to that impulsive idea to flaunt her name on your bicep or his name on your ankle? Hands down, the method of choice to get a tattoo removed is laser technology. It targets the tattoo pigment. It is non-invasive. It beats the don’t-try-thisat-home, do-it-yourself ways of sanding or chemically burning the skin. But even with advanced technology, getting rid of the ink isn’t easy.
Nowadays, we can lighten your tattoo without incurring a scar. Professor Colin Song, Senior Consultant and Head, Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital
“A laser in the wrong hands when you crank up the power… can burn the patient and cause horrific scarring,” said Professor Colin Song, Senior Consultant and Head, Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital (SGH). “It’s got to be in the hands of the people who are trained to use these lasers.”
Prof Song has dealt with young patients coming to him after they’ve tried cruder home remedies, such as attempting to sand off their tattoo with salt or using acid to erase the ink, leaving the patient’s arm looking like an unpeeled potato. In such cases, he said, the treatment is for a burn rather than removing a tattoo. “In the old days, you used to swop a tattoo for a scar. Nowadays, we can lighten your tattoo without incurring a scar, provided you use the laser technology judiciously of course,” said Prof Song. Simply put, a very short pulsed light laser is calibrated to a certain wavelength on the colour spectrum that complements the tattoo colour being targeted. The laser light is absorbed by the tattoo, the tattoo pigment fragments under the laser’s effect, and the immune system’s natural processes remove the fragments from the skin.
Removal is painful How completely a tattoo can be removed depends on the tattoo – its colour, age, size and location – and the number of treatments the patient undergoes. The patient’s own skin condition and health matter too. Asians tend to produce more melanin, which is responsible for skin colour, so that means the silhouette of a tattoo which has been removed could stand out more than if it was done on a lighter-skinned individual.
532nm
emits a green light that is best absorbed by red and orange targets
Tattoo removal has come a long way from home remedies like salt scrubs and acid peels that cause excessive scarring.
694nm and 755nm
emit a red light that is best absorbed by green and dark targets
1,064nm is nearly infrared. It works PHOTO: photolibrary
As an example of tattoo removal, it is one of the simplest. In the early 1990s, American actor Johnny
Colourful tattoos mean a more painstaking removal process, since each colour area will need a different laser calibration. Also, the laser needs to penetrate the skin only as deep as the tattoo pigmentation goes. If the laser beam is too weak, the tattoo colour won’t fragment and the ink won’t disappear. If it is too powerful, it can burn or damage surrounding, healthy tissue. And it hurts. It can feel like needle pricks, a bad sunburn or a rubber band being snapped against the skin.
There is also the fact that patients can never erase the past completely. “No matter how good your laser technology is, there will always be a silhouette of the tattoo,” Prof Song said. Romance gone wrong aside, other reasons for getting a tattoo removed in multiethnic Singapore include religion, parental objection and, sometimes, for the sake of a job.
PHOTOs: Colin Song
No complete solution
Left: It can take many treatments with laser technology, one of the most advanced methods, to remove a tattoo. Right: Lasers target the tattoo pigment, breaking up the colour particles into pieces tiny enough for the body’s natural processes to clear out.
best at targeting black and dark blue tattoos. This laser is referred to as the Q-switch Nd:YAG, and is preferred because it is not easily absorbed by melanin
The commercial proliferation of laser technology in tattoo removals means less effective, cruder methods of the past should no longer be options. These include excising the tattoo (followed by skin grafts if the area cut out is large), dermabrasion or cryosurgery, where the tattooed area is frozen and then peeled off. Tattoo artists don’t need a licence to do their work, a laser practitioner does. Prof Song estimated that 60-70 per cent of the patients who come to him to remove a tattoo don’t finish their treatment with him. It takes multiple laser treatments that can last months to remove one tattoo. Removing a small tattoo may cost just a few hundred dollars, but larger ones covering major body areas could run into thousands of dollars. It isn’t wrong to switch doctors in the middle of treatments, as long as patients stick with trained laser practitioners, Prof Song said. “There are more people in the fray. Medical practitioners who can access a laser machine will try and use it to offer this service. Once you have a laser, anyone is game.”
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Fitness
The wake-up workout This 10-minute morning workout will kick-start your day and benefit you in more ways than you can imagine. By Jacqueline Chia Do you wake up in the morning, bleary eyed and tired? Do you sleep on the train or bus to work? Do you have headaches, or neck and shoulder pains? If so, you may be a perfect candidate for this 10-minute workout – a short routine with long-range benefits. Specially designed by Senior Physiotherapist, Mr Darek Lam, and Sports Trainer, Ms Sharon Khoo, from Changi Sports Medicine Centre, it is meant for office workers aged 35 and below. But with a few modifications, anyone can do it. Mr Lam said many office workers tend to hunch over their desks all day and claim to have no time (or energy) to exercise. “This hunched posture restricts breathing, strains chest muscles and under-utilises back muscles which hold the body in a correct posture. Continual bad posture can increase your risk of
health problems as well as cause headaches, neck pain and even numbing sensations down the hands.” He said that studies show bad posture to be directly linked to stress, so those under stress are more inclined to slouch. A 10-minute workout, although short, will help improve your posture and breathing, and reduce your risk of chronic diseases, including heart problems. The benefits will spill over into your other work and life activities. Ms Khoo said the American College of Sports Medicine recommends 30 minutes of exercise each day for health and fitness, and the 10-minute routine can be repeated at intervals during the day to make up the 30 minutes. “The best thing is that it can be done anywhere, anytime. You only need a small
Senior Physiotherapist Darek Lam says a short 10minute workout can have far-reaching benefits.
space, even a hotel room when you are travelling, and there is no equipment involved,” she said. The power-packed routine includes the stretching, cardio, flexibility, muscle -toning and strength-building exercises of a regular workout. One exercise – the Pectoral Stretch where you pull your shoulders back and stretch your chest muscles – relieves tension caused by poor sitting posture, and encourages you to sit up straight while doing computer work. The workout begins with one minute of light skipping or jumping jacks, a cardio exercise that gets the heart rate up. This can be done slowly at first to warm up, but building speed towards the end of the minute. It is followed by two minutes of stretching to build flexibility in the limbs, and then a series of muscle-toning and strength-building exercises before finishing off with cool -down stretches.
Strong bones, supple joints Although your bones are resilient when you are young, the wear and tear shows up with age. If you want lifelong bone and joint health, start looking after them now. Get Regular exercise: Swimming and quadriceps (for leg muscles at the front of the thighs) weight-bearing and strength-training exercises are excellent for healthy bones and joints as you age. Low impact exercises such as taiji can improve flexibility, balance and
Beautiful Inside Out
Introducing SingHealth’s women’s health book Fifty specialists from across the SingHealth Group – Singapore’s largest healthcare group – came together to contribute health advice and their expertise on medical issues. The 264-page volume, with 16 information-packed chapters, covers top-totoe health concerns of the modern Asian woman in her 20s, 30s, 40s and beyond.
Beautiful Inside Out is designed as every woman’s personal guide to health and wellness Beautiful Inside Out is available at Kinokuniya, Prologue, Page One, Times bookstores, MPH bookstores, Dufry and selected NTUC FairPrice stores and Guardian pharmacies, at a retail price of $24.90 Special for SingHealth patients and visitors: Now $19.90, 20 per cent off the retail price of $24.90 when purchased at SGH and KKH pharmacies
coordination. Wear shoes that enhance the natural walking or running motion, to protect your ankles, knees and hips from impact. Watch Your Diet and Weight: Maintain a healthy weight so that you don’t put stress on your knee and hip joints, which increases your risk of osteoarthritis. Eat more oily fish as the omega-3 in them can help prevent inflammation of the joints. Beat Bone Loss: A high calcium intake, especially in childhood and adolescence, protects your bones for life. But it’s never too late: getting enough calcium as you age can reduce bone loss. You need sunlight to produce vitamin D, which can be found in oily fish, egg yolks, liver and fortified margarine. Alcohol interferes with the production
of vitamin D in the body, while caffeine, cola and salt rob your body of calcium. Tackle Aches and Pains: Back pain is typically due to muscle strain, and wear and tear in the joints. Age-related back pain can lead to chronic back pain. Shoulder and neck strain can be caused by bad posture at your desk, so ensure you have good lumbar support and keep the computer screen at eye level. Stretch your back and neck every 30-45 minutes. This article was adapted from Beautiful Inside Out .
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Jumping Jacks
(left) For warm-up and cardio Stand with two legs together and your arms by your side. Jump, spreading your legs and arms. Do for one minute, warming up slowly, before building up speed to get your heart rate up.
Brisk Walking or Marching on the Spot (right) For seniors, walk or march briskly on the spot for one minute instead of doing jumping jacks.
8
Front Planks
Seniors: If you cannot hold this position, try an easier version by doing it on an incline. For example, prop your arms on a sofa and raise yourself up from the knees, not toes. Otherwise, eliminate this exercise from your workout altogether.
7
Doing The Wake-up Workout
For strengthening trunk muscles Lying flat, face downwards on a mat, lift your body up using your toes and elbows. Keep your body as straight as possible. Hold for 20 seconds and return to the original position. Do one to three times.
Shoulder Retraction
For strengthening shoulder blade muscles Push your arms against your body while you tighten and move your shoulder blades inwards. Then relax your shoulders and arms. Do two sets of 20.
2
with Ms Sharon Khoo, Sports Trainer, Changi Sports Medicine Centre
There are eight exercises in all. Seniors can replace jumping jacks with brisk walking or marching and modify some of the other exercises depending on their endurance levels. Start warming up in bed with deep breathing exercises and trunk twists. Inhale deeply and expand your lungs as much as you can. Exhale slowly and repeat. For trunk twists, turn your hips and left leg to the right while pulling your upper body back towards the left. You should feel the stretch around the core muscles. Repeat on the other side. You can have a light snack like a glass of juice or a slice of toast before the workout, but if you have a heavy breakfast, wait two hours before exercising.
Exercise PHOTOs: Tan Wei te & Alecia Neo
To improve posture Sit upright in a comfortable chair and lift both hands up as if you are surrendering. Then bring your elbows back as much as you can and feel the stretch in the pectoral muscles in your chest. Do two and hold each for 20 seconds.
3
4
If you have a preexisting medical condition, please check with your doctor before starting these exercises.
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Pectoral Stretch
Quadricep Stretch
For flexibility Hold on to something stable such as a sturdy chair. Stand on one leg and hold the other leg up with your hand. You should feel a gentle stretch at the front of your thigh. Try to bring your heel up to your buttocks. Stretch each leg twice and hold each stretch for 20 seconds.
Hamstring Stretch
For flexibility Sit at the edge of a chair. Stretch one leg and bend your body forwards from the hips, but keep your back straight. You should feel a gentle stretch at the back of your thigh. Stretch each leg twice and hold each stretch for 20 seconds.
Calf Raises
For strengthening calf muscles Start by holding onto something stable such as the back of a sturdy chair. With your feet pointing forwards, keep your knees straight and raise your heels off the floor. Lower your heels and repeat. Start with three sets of 10, then work your way to 15.
5
Wall Squats
For strengthening muscles in the thigh and buttocks Starting position: Lean against the wall with your feet pointing forwards and shoulders straight, touching the wall. Slide down the wall till your thighs are parallel to the floor. Keep your back against the wall and ensure your knees are not past your toes when you lower your body. Revert to the starting position. Do three sets of 10. Seniors: Just do the first two steps.
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Vision
Don’t turn a blind eye to glaucoma Glaucoma is not just a disease of the elderly. The young can get it too. But early diagnosis and treatment can prevent blindness. By Vivien Chan
what the doctor found shocked him. “He found that my optic nerve was sparse and my cornea thin,” said sales manager Mike Tan. After an eye test, he was told he had glaucoma, an incurable disease which can result in progressive loss of vision and is one of the leading causes of blindness worldwide. “I felt normal. There were no symptoms or pain in my eye,” Mr Tan said. He was just 35 years old when he was diagnosed with glaucoma, and his only previous encounter with the disease was when a friend lost half his vision, at 18. Today, his condition is under control with six-monthly checkups, and eye drops every night before sleeping. Other than this, life hasn’t changed much for this father of an eight-year-old. He holds a regular job and enjoys sports such as running, tennis, weightlifting and scuba diving. “I’m just thankful I was diagnosed early.”
The misconception Mr Tan’s case highlights the misconception that only the elderly get glaucoma. Dr Ho Ching Lin, Head and Senior Consultant, Glaucoma Service (Clinical), Singapore National Eye Centre (SNEC), who specialises in childhood and adult glaucoma care, said that three out of 10 of her patients may be under the age of 35, although generally, less than 0.5 per cent of people in this age group get glaucoma.
The hard truths Glaucoma occurs when fluid pressure inside the eye slowly increases and damages the optic nerve, which carries visual information from the eye to the brain. Younger patients with glaucoma are more likely to become blind within their lifetime.
PHOTOs: SNEC
It was meant to be a happy trip – to get Lasik surgery so that he could give up contact lenses forever. But
Once a patient develops glaucoma, there is progressive optic nerve damage, leading to gradual loss of the visual field. The patient will experience this as a “tunnelling” of vision or constriction of the field of vision.
Dr Ho Ching Lin said that possibly only 0.5 per cent of the general population who are below 35 years old will get glaucoma.
Many adults only discover they have glaucoma after routine health or eye checks. The disease progresses slowly and painlessly. Sometimes sufferers get pain and redness in their eyes, headaches and nausea. They may also have blurred vision or see coloured rings around lights. Those who come in with some vision loss may have had it for years. Dr Ho said that acute symptoms such as halos, headaches or blurred vision, caused by a rapid rise in eye pressure, can mean the patient has early stage glaucoma, or that there is a rapid deterioration in longstanding glaucoma. Glaucoma is irreversible but medication or surgery can slow down or halt the loss of vision, if it is treated early. Regular screenings are especially important for those with a family history of the disease (see box).
Risk of going blind Age is another risk factor. In Singapore, about
three per cent of people over 50 years old, and 10 per cent over 70 are at risk. Other risk factors include existing conditions such as diabetes, high blood pressure, short- and long-sightedness. Dr Ho said younger patients with glaucoma are more likely to become blind within their lifetime than older patients. “This is because even if the disease progresses at the same rate, a younger patient with the disease starting early in life will live long enough to run out of optic nerve fibres compared to an older patient afflicted with the disease late in life with fewer more years to live. “Acute glaucoma can leave a patient blind within days, while chronic types, without treatment, may take years. While effective treatment cannot reverse any visual loss, it can slow down or halt the progression to blindness. If diagnosed early enough and if appropriate treatment is started and maintained, blindness can be prevented.”
Treating the young Different treatments and surgical modalities have different efficacies with regard to the various types of glaucoma and age groups. “I have many patients who were operated on in their first year of life. They now have normal vision and lead a normal life. Others have become blind because of severe refractory disease, coexisting conditions such as retinal abnormalities, late diagnoses or
failing to comply with treatment and followup.” Medication is the first line of treatment for older children and young adults. However, for very young children, surgery is often more effective than medication. Dr Ho recalled a case which occurred seven years ago and involved a monthold baby boy. His parents were “stunned by (an ophthalmologist’s) diagnosis” that their baby had glaucoma and was likely to go blind. Dr Ho performed surgery on the child successfully, and today, the little boy’s condition is under control. He has normal vision in both eyes but needs half-yearly followups to monitor any rise in eye pressure or progression of the disease.
It’s all in the family Glaucoma runs in the family, so everyone should get screened regularly. An absence of family history does not mean it is not present, as it could have gone undiagnosed. If you have glaucoma, your parents, siblings and children have a higher risk of getting it If you have a parent with glaucoma, you have a two to three times higher risk of getting it If you have a sibling with glaucoma, you have a three to five times higher risk of getting it If you have glaucoma, inform relatives and encourage them to go for screening
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Spotlight
Ace of hearts
in 1990. It has since chalked up successes and matched international standards, with 90 per cent of patients surviving the first year and 60 per cent living past the 10-year mark. Every year, the NHCS gets about 25 to 30 patients for heart transplants. Three to six will most likely get transplants. Various factors come into play in assessing the suitability of the recipient. Among these are blood type, body weight and medical urgency. Patients wait an average of six months for a heart transplant. The shortage of donor hearts prompted Dr Sivathasan in 2001 to introduce the use of ventricular assist devices or mechanical heart devices to keep patients alive while waiting for transplants. A total of 42 mechanical heart device implants have been carried out since 2001. In the past two years, 10 patients, including one foreigner, with end-stage heart failure, were implanted with the HeartMate II, a heart-pumping device for patients waiting for a transplant.
PHOTOS: alecia neo
Heart surgeon wins top award for transplant work
Pictured above is the HeartMate II, a mechanical heart device to keep patients alive while they wait for a transplant. This particular device can be implanted in small-sized adults.
Dr C Sivathasan, Co-Director, Heart and Lung Transplant Programme, National Heart Centre Singapore
BY Tan May Ping
Not many people can claim to be experts in matters of the heart, the way heart transplant surgeon, Dr C Sivathasan, can. For the Co-Director, Heart and Lung Transplant Programme, together with the team at National Heart Centre Singapore (NHCS), has given many patients on the brink of death a new lease of life through transplant surgery. He has been involved in almost all the 53 heart transplants and 10 lung transplants at NHCS over the years. These include the first heart transplant in Singapore in 1990 and the first lung transplant in 2000. He was also involved in Asia’s first heart-liver transplant in 2009. In addition, he pioneered the use of mechanical heart devices here, and established protocols to manage ICU (intensive care unit) patients, laying a strong foundation for the current level of care and safety that are comparable to international standards. For his contributions towards the development of cardiothoracic surgery for close to 30 years, Dr Sivathasan was awarded the prestigious National Outstanding Clinician Award in July. Part of the 2011 National Medical Excellence Awards given out by the Ministry of Health, the award recognises individuals in public or private healthcare establishments who have made exceptional contributions to clinical work that advances the safety and quality of patient care, and who have supported and facilitated research.
I represent the whole team at NHCS, so really, getting this award represents the entire team getting it.
Dr C Sivathasan introduced mechanical heart devices (such as the HeartMate II pictured above) that take over the function of failing hearts of patients waiting for a transplant.
“It’s a great honour and I appreciate it,” he said, adding quickly that “I represent the whole team at NHCS, so really, getting this award represents the entire team getting it.” A family of surgeons Sri Lankan-born Dr Sivathasan decided to become a heart surgeon in the late ’70s, after being inspired by two pioneering American cardiac surgeons and their work with artificial hearts. Hailing from a family of doctors, he came to Singapore in 1983 after postgraduate studies in England, and helped set up the heart transplant programme
HeartMate II – an improvement on a previous version – weighs less than 500g and can be implanted in small-sized patients. The previous version could only be used in larger patients. It has been used worldwide for the past six years. “Its success and the shortage of donor hearts, may mean long-term use for patients with irreversible heart failure,” said Dr Sivathasan. “We could widen the pool of patients, so that even those who are eligible for heart transplants, could benefit from it.” Dr Sivathasan’s other firsts include the start of the robotic-assisted minimally invasive cardiothoracic surgery in 2005, which allows faster post-operation recovery. In 1990, he also set up the first vascular laboratory, using ultrasound to identify blockages in patients’ blood vessels, and training technicians and others who were keen to learn. A successful transplant brings untold joy to the recipient, but there is the other side as well. “You feel satisfied, but also sad, because somebody else had to lose a life for the transplant to be possible.” Having witnessed the pain and struggles of heart patients and their families, he advises people in general to live healthy lives – keep to a sensible diet, exercise regularly and don’t smoke. “The problem is everybody thinks ‘It’s not going to happen to me’,” said Dr Sivathasan, “until it happens to them.”
Award for outstanding research
Associate Professor Tan Eng King was recognised for his groundbreaking work with Parkinson’s disease.
Another healthcare professional from the SingHealth cluster was honoured at this year’s National Medical Excellence Awards. Associate Professor Tan Eng King, Senior Consultant, Department of Neurology and Director, Research, National Neuroscience Institute (NNI), won the National Outstanding Clinician Scientist Award. He was given the award for his work in the field of Parkinson’s disease and movement disorders. His research led to the discovery of genetic risk factors unique to Asians, and his clinical observations have helped in the care of patients with movement disorders such as essential tremor. Assoc Prof Tan was also responsible for setting up the fully integrated Movement Disorders Programme at NNI. Explaining the significance of identifying the genetic risk factors for Parkinson’s disease unique to Asians, he said: “It allows us to monitor healthy individuals through clinical examination and tests, enabling us to pick up cases early.” A National Medical Research Council Clinician Scientist and Associate Professor with Duke-NUS Graduate Medical School, he is the only Singaporean to be elected into the prestigious American Neurological Association. On winning the award, he said: “It gives me the opportunity to raise awareness and acknowledge the enormous amount of hard work contributed by my team members, the many mentors who have helped me along this journey, and the tremendous support given to me by leaders at NNI, SGH, DukeNUS and SingHealth. The success of our programme has always been a team effort.”
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Spotlight
Multiple joy, multiple risks A multiple pregnancy comes with additional risks for both mother and babies BY JR Wu
They are called multiple births – twins, triplets, quadruplets and so on – and they are on the rise in a medically advanced, prosperous country like Singapore. Couples who enjoy the active lifestyle the Lion City offers are planning for kids later in life. But starting a family later means the woman is likely to be older, and conception, probably harder. Often, many turn to fertility drugs or assisted reproductive technology, such as in vitro fertilisation (IVF), which often leads to multiple-birth pregnancies. But a multiple-birth pregnancy – as opposed to a single-birth one – carries with it serious risks. “Chances are the mothers would have successful pregnancies and go home with healthy babies,” said Dr Tan Wei Ching, Consultant, Department of Obstetrics and Gynaecology, Singapore General Hospital (SGH).
{
1988
was the year the first IVF triplets were born in Singapore
1.16
Dr Tan Wei Ching says that women who are pregnant with multiple foetuses need to know the risks they are facing.
“But they must also be aware of the risks and be prepared for the worst – the worst being premature, sick babies who require prolonged hospital stays.” Dr Tan, who has practised in Singapore for nearly 15 years, estimated that 80 per cent of the multiple-birth pregnancies she sees end up with no problems for the mother or her newborns.
1989
was the year the first surviving IVF quadruplets were born in Singapore
But the risk of complications goes up dramatically with the number of foetuses in one pregnancy. The risk of cerebral palsy, for example, is three times higher for triplets, but rises to 10 times for quadruplets, Dr Tan said. Older mothers are also at risk of having babies with Down’s Syndrome. In Singapore, women older than 35 years of age are considered to be at higher risk of having a baby with Down’s Syndrome. Other risks in a multiple birth pregnancy include miscarriage; foetal growth restriction as foetuses fight for food and room in the womb; preterm labour; and prematurity of the newborn. The woman pregnant with multiple foetuses will also be more prone to preeclampsia, or hypertension, due to the larger placenta needed to support more than one foetus, as well as gestational diabetes. Identical twins usually share one placenta, the flat organ attached to the inside of the uterus and connected to the foetus by the umbilical cord. Nonidentical foetuses often have their own. The placenta links the blood supply
1997
was the year the first IVF quintuplets were born in Singapore
of the embryo to the blood supply of the mother, allowing the exchange of oxygen, nutrients, and waste products. The larger placenta and higher hormone levels can cause severe morning sickness, which can lead to the mother and her foetuses becoming malnourished. Potential parents must be aware of their options when risks arise. Having bed rest or taking vitamins or hormones can help reduce the risk of preeclampsia or preterm labour. When a multiple foetal pregnancy starts to become too much of a health risk for the mother and/or the foetuses, the family may be offered the option of reducing the number of foetuses in the womb. Known as multifoetal pregnancy reduction, the ultrasound-guided procedure can reduce the number of foetuses to lower the risks that a larger number of foetuses present to the mother and the pregnancy. “It doesn’t eliminate the risk of your pregnancy as compared to any other single (foetal) pregnancy, but you no longer have the risks associated with a multiple (foetal) pregnancy,” said Dr
1998 was the year the first IVF sextuplets were born in Singapore
}
is Singapore’s total fertility rate – the average number of children a woman would bear in her lifetime
2.1
is the replacement rate of a developed country like Singapore
24
weeks is the earliest a foetus can attempt to survive outside the womb
35
years of age is the threshold for a woman to have her first child before she is considered of advanced maternal age
37-40
weeks is when a foetus reaches full term, ready to be delivered
500
grams is the minimum weight for any newborn to survive
$3,000
is the maximum the government will co-fund an assisted reproductive technology cycle. The grants are based on certain criteria, including a maximum of three cycles per patient
IVF triplets (from left) Kaylyn, Ashton and Nicole were delivered by Caesarean section at 30 weeks, and stayed in the intensive care unit for another six to eight weeks before going home.
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Viewpoint
Limiting success Capping the number of embryos that can be transferred in IVF may be a step in the right direction BY JR Wu
I recently discovered that Singapore will adopt a mandatory two-embryo transfer policy starting on Oct 24, and that some experts think a mandatory single-embryo transfer policy will not be too long behind. I’m a mother of two kids who are 14 months apart and both were conceived naturally. I’ve only heard of in vitro fertilisation or IVF from friends trying to get pregnant, and only through this assignment did I become aware of the acronym ART – assisted reproductive techniques or technology. I’ve also lived in Singapore for less than a year. So there, you have my bias, or rather, non-bias. When I found out about the risks of carrying twins or triplets, it seemed like a no-brainer that this kind of pregnancy decreases your chance of having a healthy baby and couples should make decisions to prevent such a possibility. Right? But when a gynaecologist was explaining the option of a multifoetal reduction procedure (MFRP), my reaction (before rational reason reasserted itself) was disbelief. It is the kind of knee-jerk emotional reflex you feel when you are confronted with sticky ethical issues like euthanasia, capital punishment or abortion. MFRP refers to downsizing of the foetuses – whether it is from three to two, or two to one – when the pregnancy poses a health risk for the mother and/or foetuses. Another reproductive specialist showed me a different way of looking at the consequences of multiple births. He said everyone goes home happy in many cases, but you only have to see one case of premature twins with developmental problems
– and possibly, costly and lengthy treatments – to get jolted back to reality. The reason I am discussing embryo transfers is because they are a critical part of IVF, which has been on the rise here since Singapore’s first IVF babies were born in the 1980s. The more embryos you transfer into the womb, the better the chances of one of them developing into a full-term baby. But implanting more than one embryo means you’re likely to carry twins or triplets. Take a look at the statistics: 10-15 per cent of couples will struggle with infertility. When a woman is 35 years old, she has a 15 per cent chance of conceiving every month. That percentage plummets to 5 per cent when she reaches 40. A woman who is 35 years old will have a 43 per cent success rate of getting pregnant with IVF; if she is over 40, her success rate drops closer to single digits.
Reducing the number of foetuses lowers the risks of a complicated pregnancy significantly.
You only have to see one case of premature twins with developmental problems – and possibly, costly and lengthy treatments – to get jolted back to reality.
In Singapore, more and more women are putting off starting a family till later. Not surprising, Singapore is grappling with one of the lowest birth rates anywhere, even though it is one of the most developed economies in the world. The government offers subsidies for IVF procedures under certain conditions, such as limiting embryo transfers to three in an IVF cycle. This limit will be tightened to two after Oct 24, with some exceptions, even if a couple does not use government subsidies. IVF conception accounts for only a fraction of births worldwide, but it is a big reason why multiple births (and with them the delivery of premature babies) have swelled. Multiple-embryo transfers were necessary when the technology was new. But as IVF success rates have risen to around 40 per cent for women in their early 30s, limiting embryo transfers to reduce the risks associated with multiple births has policy traction. Singapore isn’t unique. Turkey introduced limits on embryo transfers last year. Sweden is pretty much down to
single-embryo transfers unless there are exceptional circumstances, while the US and Canada have no state regulation per se, but guidelines encouraging limited embryo transfers. The broader consequences of multiple births are serious. A study published earlier this year in The Journal of Pediatrics was provocatively titled “The Epidemic of Multiple Gestations and Neonatal Intensive Care Unit (NICU) Use: The Cost of Irresponsibility”. It found that had there been a policy of mandatory single-embryo transfer, the Royal Victoria Hospital in Ontario, Canada, would have saved 3,082 patient days and 270 patient ventilator days in NICU over a two-year period. With NICU costing roughly US$1,000 a day, US$40 million would have been saved annually countrywide, the study concluded. Quantified another way, the study extrapolated that 30 to 40 deaths, 34 to 46 severe intracranial haemorrhages and 13 to 19 retinal surgeries would have been prevented annually throughout Canada. The point, after all this talk of things
like MFRP and NICU, is that limiting embryo transfers is about raising the quality of life at the soonest possible moment. Every pregnancy carries risks, with some higher than others. Despite the success-failure probabilities and the rationality for avoiding a risk, you can’t argue with the irrational responses when you talk to someone who is expecting. I’ll give you two examples. Ms Katrina Ng and her husband tried for two years to conceive naturally. They went through the heartache of failed intrauterine insemination, before succeeding with IVF at Singapore General Hospital. They weren’t expecting triplets, but Ms Ng recalls thinking after seeing the ultrasound: “It’s already there. We just have to carry on.” Her three babies were born prematurely, spent the first six to eight weeks of their lives in incubators, and went through post-natal development therapy. Ironically, two years later, when Ms Ng conceived naturally and found out she was pregnant with her fourth child, she wasn’t sure if the family could cope after the “chaos” of raising the triplets. But her parents counselled her: “If you have this baby naturally, why don’t you just keep him?” Of course, she did. Remember me? Our second child was unwittingly conceived when I was going through a round of live virus vaccinations for measles, mumps and rubella. My husband and I found a lot of information warning about potential birth defects if a foetus was affected by live virus vaccination, but no concrete evidence was there to quantify what actually happens (you can’t ethically test this very well). Despite knowing the risks, we went ahead with the pregnancy. Arthur is four now and he’s just fine. We’ve never looked back. Ms JR Wu is a freelance writer based in Singapore. She worked as a full-time financial journalist for many years before taking up duties as a stay-athome parent to Molly and Arthur, after she and her husband swopped roles and relocated from Beijing last year.
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SEp⁄ OCT 2011
singapore h e alth
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People
Getting high on bugs
I chose to specialise in tropical medicine because… Parasites and worms don’t scare me. I’m used to them as I grew up in a kampung (village in Malay) in Medan, Indonesia, where we were surrounded by insects, chickens and other animals. Also, I’m fascinated by a person’s whole body and not just one part. An infectious disease specialist like me is interested in every aspect of the person. Anything can cause a fever and that is where I like to jump in to figure out the cause. Tropical medicine was a term coined by the British when their soldiers travelled to the tropics and developed prolonged fevers of unknown origins.
PHOTO: alecia neo
Dr Limin Wijaya, Consultant, Department of Infectious Disease, Singapore General Hospital, runs the hospital’s Travel Clinic. As a specialist in tropical medicine, she tells Veena Bharwani why parasites and strange fevers get her heart pumping
Growing up in a kampung, Dr Limin Wijaya doesn’t fear bugs and other animals.
but in sick people like the man whose underlying lung problem suppressed his immune system, the bacteria caused him to be very sick. When I’m not working, … I love to travel and climb mountains. Basically, I love anything that releases endorphins (a chemical that gives people a sense of well-being). The highest mountain I’ve climbed is Mount Kinabalu. I love climbing as it makes me feel like I’ve achieved a new high. But I have a more relaxed side to me too. I like to go to the beach from time to time, just sitting on a bench and staring at the sea. Very few people know that… I don’t shy away from trying things I’ve not eaten before, although I’m well aware of the possibility of contracting parasites from certain foods. I travel a lot and I’m never squeamish about trying new cuisines. I know the risks, but you only live once and what’s the point of travelling if you don’t experience different cuisines and cultures? I’m a risk taker.
I was called on a case where… The patient, in his 80s, was very sick in the intensive care unit and had a persistent and unexplained fever. I was called on a case where the microbiology lab found a worm in the phlegm (sputum) sample that they took. There are ways to treat such cases, but unfortunately, it was too late for this patient as his immune system was already so weak. He passed away shortly after. This very tiny worm is known as strongyloides, and it usually enters the body by penetrating the bowel walls, eventually going to the lungs and carrying with it bacteria. It remains in the body for many years, so we don’t know how and where the patient caught it. This parasite doesn’t cause problems in healthy people,
I am happy to… Just do my clinical job well. Sometimes, we get too bogged down with administrative work, and patient care suffers. What I would like to do is spend more time with my patients and build a relationship with them. I want to talk to them and counsel them when they need it most. That is what medicine is all about.
Mapping breasts Ms Anne Wong, Principal Radiographer at SGH, considers herself a homebody who loves her family, her walks and her dog. But behind that gentle persona is a woman who cares passionately about her work
ished school and were looking for work in the 1960s, Ms Anne Wong had little understanding of the job she was about to embark on. But, said Ms Wong, she “soon fell in love with radiography”. Nearly 40 years later, Ms Wong remains deeply passionate and committed to her work in radiography – the use of various tools to look inside the human body. “The best part of this job is when we are able to detect occult breast cancer at its earliest stage, before the patient or her clinician can feel it,” she said. An occult cancer is not detectable by clinical methods alone. Now Principal Radiographer at Singapore General Hospital, Ms Wong learnt her craft at the Singapore School of Radiography in 1965, after which she worked in various hospitals in Singapore “to gain wide experience in various imaging specialties” before going to London for six years. She moved to Denmark next, staying for half a year, before returning to
Singapore to work in private practice. In 1994, she joined the team of pioneer medical specialists studying mammography and its effectiveness in detecting early breast cancer under the Singapore Breast Cancer Screening Project. Over more than three years, 28,000 women participated in the project. Describing herself as a simple, down-to-earth person “who enjoys life and nature”, the mother of two specialises in breast imaging, such as mammography and breast sonographs, where images of breast tissues are created using ultrasound waves. She
Regular checkups that include mammograms, help detect early changes in breasts, said Ms Anne Wong.
PHOTO: ELLEN LIM
Professional career counselling was virtually unheard of at the time, and job opportunities were scarce. Like many people who had fin-
also assists radiologists in breast interventional radiology procedures, including removing tissue for examination, or locating the exact areas where lumps occur, in preparation for treatment. Her biggest motivation, she said, comes from seeing patients happy after their mammograms. “For me, being successful in a profession is not necessarily about rank and money. A successful mammographer needs to build rapport with her patients, put them at ease and encourage them as they undergo an uncomfortable procedure,” she said. “The radiographer must be committed to acquiring these skills. Also, communication – not just talking – with the patient is important.” Ms Wong feels angry when she sees patients suffering from an advanced stage of breast cancer. The disease could have been detected earlier but wasn’t, because the patient – out of ignorance or fear of undergoing a mammogram – didn’t have or never had such a procedure. Of the top 10 cancers affecting women in Singapore, breast cancer is No. 1, and early detection can prevent the disease from becoming too late or hard to treat. “Regular checkups, including mammograms, help detect early changes in their breasts,” Ms Wong said. “Women should take greater responsibility for their own health, for the sake of their families and themselves. Never leave your health in the hands of others.”
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singapore health
sep⁄ oct 2011
FYI
Interrupted sleep “harms memory” Interrupting a good night’s sleep may affect memory, a study by Stanford University in the US has found, suggesting that disrupted sleep could explain memory problems linked to Alzheimer’s and sleep apnoea. The researchers found that mice which woke up multiple times from their sleep had trouble recognising old objects and
event Calendar
Singapore Health issue 12 contest 1. What is the name of the new drug that is an alternative to warfarin? 2. Which story did you enjoy reading most in this issue of Singapore Health? Closing date: Oct 14, 2011 forming new memories, while those that experienced uninterrupted sleep were able to identify old objects, which allowed them to be curious about new ones. Regardless of the total amount of sleep or sleep intensity, “a minimal unit of sleep is crucial for memory consolidation”, the researchers said.
“Super antibody” to fight flu The first antibody which can fight all types of the influenza A virus has been discovered, researchers claim. It is hoped that the development will lead to a “universal vaccine”. Currently, a new jab has to be made for each winter as viruses change. Virologists described the finding as a “good step forward”.
Alcohol may help anxious people cope in the short term, but over time, this strategy can backfire. According to a study in the Archives of General Psychiatry, selfmedication with alcohol or drugs can increase the risks of alcoholism and other substance-abuse problems, without addressing the underlying anxiety. Source: CNN
Scientists from the UK’s National Institute for Medical Research and their colleagues in Switzerland isolated an antibody – called FI6 – which targeted a protein called haemagglutinin, found on the surface of all influenza A viruses.
When lab mice were given FI6, the antibody was “fully protective” against lethal doses of the H1N1 virus. Mice injected with the antibody, up to two days after being given a lethal dose of the virus, recovered and survived. This is only the antibody, however, and not the vaccine. Source: BBC
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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), Nicole Lim (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.
This conference provides a platform for clinicians in Singapore and the region to share their expertise in the advances of wound care management. Time Full day Venue Mandarin Orchard Hotel Price $350
Sep 11 (Sun)
Send in your answers and stand to win a Betadine Gift Pack worth $35.50.
Warriors of wellness
An event which offers exercise-testing as well as advice on exercising and osteoporosis for office workers and seniors. Time 10am-7pm Venue HDB Hub Price Free
Source: BBC
Alcohol may not help anxiety
The Yin and Yang in wound healing
Beat liver cancer Include your name, age, gender, address and telephone number. Winners will be notified via phone or email. Incomplete or multiple entries will not be considered. Email: editor@sgh.com.sg Post: The Editor, Singapore Health, Singapore General Hospital, Communications Department, Outram Road, Singapore 169608 Winners of Contest 11 These winners will each receive a twomonth supply of Viartril-S 500mg 90s worth over $130. 1. 2. 3. 4. 5.
Afandi bin Ishak Chng Mah Li Chow Kum Wah Goh Tok Khin Kalaivani Supramaniam
Sep 1-3 (Thu-Sat)
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Prizes must be claimed by Nov 2, 2011.
Sep 17 (Sat)
A fun-filled programme with games for all ages, lucky draws and goodie bags. Time 1-5pm Venue IMM Building, Garden Plaza, Level 3 Price Free
Maternal depression – a play
Sep 30 (Fri)
A public awareness play on maternal depression. Time 6pm Venue KKH Auditorium, Level 1 Price Free Contact www.kkh.com.sg For more information and other listings, please visit www.singhealth. com.sg/events or the respective institution websites.
Answer to In focus (Page 3):
An eye-catching display The photo on page 3 (right) is an image of a highly myopic eye. The elongated eyeball can cause overstretching at the outermost corner of the eye and thinning of the retina. The hole in the centre of the retina allows fluid to pass through and can cause retinal detachment. Treatment involves surgery (the only option) to remove a thin membrane around the hole and allow it to close. Postsurgery, the patient must be kept in a face-down position for about two weeks. This image is one of several on display at the Eyes That Tell Stories mobile exhibition by the Singapore Eye
Research Institute (SERI), which is holding the event at selected community centres, universities, schools and other public institutions around the island. The star attractions of the exhibition, however, were not images of diseased eyes, but artistic renditions of the eyes of 14 prominent Singaporeans, including former Minister Mentor Lee Kuan Yew; Chairman of the National Kidney Foundation, Gerard Ee; Olympic silver medalist Tan Howe Liang and Mediacorp artistes and personalities.
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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
9月
与新加坡保健服务
10月 2011
集团的双月刊
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干眼症
关注咳嗽问题
战胜疼痛
肿瘤大小并非最重要 研究结果揭示可能导致肝癌复发的重要因素，因而可能会改变今后对患者的跟进后续治疗方式
图：ALVINN LIM
描或是针吸活组织检查得以发现。 该项研究还凸显了癌症复发率的特 定形态。对患有侵略性癌症的病患来说， 如果微血管入侵已固有的存在于肿瘤中， 在手术后的 2 年内，肝脏内再次长出肿 瘤的风险会更高。 “我们现在知道，一些病患在手术后 康复情况天生比别人更好。对于那些面 临较高复发几率的病患来说，额外的治 疗是否会有帮助？基于本研究提供的 数据，这无疑是我们今后需要关注的方 向，”林医生的研究导师周教授表示。 该研究结果改变了周教授对其病 患 进 行 跟 进 后 续 的 方 式 。“ 过 去 ， 在 切除手术后，病患每6个月就会回医 院进行超声波和血液检查，以查看 是否有新的肿瘤。但是从这项研究 看到有微血管入侵情况的病患提早 复发的相关数据后，我改变了对病患 杜克-国大医学研究生院首届毕业生林竞存医生 ( 左 ) 与他的科研导师周嘉豪教授讨论研究结果 进行跟进后续的方式。现在，我在 他们手术后的前两年内每3个月进行 “体积 因素在某种程度上是确实的。 一次后续检查和监视。” 原文 Thava Rani 如果肿瘤较大且数量不止一个，就意味 着肿瘤是在较后期时发现的，”新加坡 中央医院普通外科高级顾问周嘉豪教授 成功地切除肝脏肿瘤令符先生* 及他的家 表示。 人喜不自禁。但仅仅一年后，他的体内 “有些病患的肿瘤虽然很小，但在显 被发现又有两个肿瘤，还比先前的更大。 微镜下，我们看到有特征显示，它是生 然而更令人担心的是它们处在靠近主血 物学里一种极具侵略性的肿瘤。” 管的位置，这意味着肿瘤可能无法通过 这项重大发现研究是林竞存医生在周 手术予以切除。 教授的督导下完成。当时林医生是杜克由于第一个肿瘤较小，曾认为自己有 国大医学研究生院的学生。目前林医生 很高的存活率，但符先生现在却觉得自 是新加坡保健服务集团放射科实习计划 己所剩的时日已不多了。他或许还可以 下的实习医生。 再活 8 个月，而不是一般典型患有小肿 “众所周知，其他因素诸如病患的年 瘤的病患可再活至少5年。 龄、总体健康状况、剩余的肝脏运作 能力以及肿瘤的侵略性等，在确定病患 大小和数量与侵略性的对比 的状况以及癌症是否会复发方面，起着 符先生之前的乐观并非完全没有依据。 一定的作用，但哪个因素在何种程度上 假设癌症还没扩散到其他器官的情况下， 更为重要，这仍然还受争议，”林医生 通过这方式，可及早发现癌症，在 人们通常会认为，如果肿瘤越小及数量 表示。 为时已晚之前及早提供某种形式的治 越少，手术后的存活几率就越高。 这项研究证明，需要关注的一个关键 疗。“若病患在诊断出癌症或癌症复发 但是近期一项研究表明，其他因素， 因素是微血管入侵，这意味着癌症已开 情况时没出现任何明显症状，就是处于 特别是自然侵略性的肿瘤，在确定患者 始入侵小血管。为了确定肿瘤细胞是否 及早接受治疗的最佳机会，存活率也是 手术后癌症复发以及存活的几率方面起 已渗入小血管，病理学家必须对整个肿 最高的，”林医生补充道。 着更重要的作用。 瘤进行检查；因微血管入侵无法通过扫 > 文转 page 28
对患有侵略性癌症的 病患来说，如果癌症 已开始入侵小血管， 在手术后的2年内，肝 脏内再次长出肿瘤的 风险会更高。
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求诊的人少， 候诊的时间长
预防中风 的新武器 突破性的抗凝血疗法为心房颤动 患者提供更多的预防中风选择 原文 Thava Rani
超过半个世纪后，随着一种新的抗凝 血/血液稀释药物达比加群（dabigatran） 的问世，预防心房颤动患者中风已变得 更加方便、更加安全。 一个全球大规模的试验结果显示，达 比加群可能比自50年代以来一直在使用 的华法林（warfarin）更加有效地预防心 房颤动患者中风。 试验还发现，达比加群也比华法林更 加安全且更容易使用。 “与华法林相比之下，达比加群降 低中风和颅内出血更为显著。担心颅 内出血是防止人们使用华法林的原因之 一，”新加坡国家心脏中心心内科高级顾 问医生兼临床试验主任陈如杉副教授说。 陈副教授是此试验的指导委员会成 员兼新加坡协调员，他形容试验结果 为“意义非常重大。” 此试验是迄今规模最大的心房颤动公 开试验，涉及44个国家的1万8千多名参 与者，其中包括来自新加坡的65人。约 15% 的参与者来自亚洲。参与者都是心 房纤维性颤动即心跳不规则的患者，且 具备一项或多项风险特征，如高龄、心 脏衰竭、曾经中风或有心脏病、糖尿 病或高血压的病史等。他们被随机分配 使用 110 毫克华法林或达比加群、或者 150毫克达比加群进行治疗。 试验结束后，美国食品和药物管理局 在去年年底批准使用达比加群。这是过 去 50年来获得美国当局批准的第一种口 服抗凝血剂。至今，该药已在70多个国 家获得批准。新加坡卫生科学局于今年 3 月批准使用该药物，目前可在新加坡 国家心脏中心和其它医院获得。 这试验的联和首席研究员之一、美 国Lankenau医学研究所副所长迈克尔 伊兹科维兹教授（ Michael Ezekowitz ） 说：“人们告诉我，这是过去20年来最 重要的一次临床试验。试验的结果远远 > 文转 page 28
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新脉动
SEp⁄ OCT 2011
新闻
常见但致命
> 文接 page 27
预防中风的新武器 超出了预期。这个药物为心房颤动患者 带来新的选择，令人欣喜。”
试验结果显示，110毫克达比加群的 剂量最起码如华法林能预防中风，而 150 毫克的剂量显然地更胜一筹。与最 理想的华法林疗法相比，后者能够减少 额外 35%中风和血流堵塞的风险。相比 华法林，达比加群的两种剂量能减少约 60% 至 70% 的颅内出血，这是一个严重 潜在的并发症。不同的是，达比加群并 不需要任何的监测、剂量调整或饮食限 制，因它具有的药物与食物相互作用微 不足道，因此更容易使用。
图：ALVINN LIM
试验结果
这项试验的新加坡协调员陈如杉副教授 ( 右 ) 与联和首席研究员之一迈克尔伊兹科维兹教授说试验 的结果远远超出了预期并为心房颤动患者带来新的选择。
华法林对比达比加群 由于每个人对华法林会有不同的反应， 所以使用该药物的患者需要经常监测 其凝血作用。当患者开始使用华法 林后，他们每周必须复诊，然后保 持每月或每两个月一次的测试。这 是因为种种原因会使抗凝血作用功 效产生波动，包括与其它药物或 食物的相互作用。当波动幅度超 出治疗范围，病人就需要恢复每周监测。 达比加群可预计的反应较强，使其 更方便地使用。“使用达比加群不需要
与华法林对比，使用 达比加群的患者不需 要进行频繁监测也没 有饮食限制。
进行密切监测，不用担心潜在的药物或 食物相互作用。但使用华法林时，你需 要关注抗生素等药物在体内代谢的状况。 饮食方面则更加费神，因为某些蔬菜中 含有大量的维生素K，这可能需要增加 剂量，因为低剂量可能无效。”陈副教 授说。 “如果你给100名患者服用150毫克的 达比加群，然后抽取他们的血液样本， 你会发现，所有样本中的药物含量几乎 相同，只有小范围的差异。但是，如果 你给100名患者使用5毫克的华法林，它
心房颤动既心跳不规律是最常见 的心律紊乱症。其发病率会随着 年龄的增长而不断地增加。心房 颤动患者更容易中风，是正常心 律者的五倍。这种疾病既是心脏 的两个上心室不稳定的跳动，导 致血液的泵送效率降低，并造成 血液在心室中凝结成血栓。 如果血栓进入血液循环中， 它可能固定于某段血管分支，从 而阻断血液的流向。在大脑中， 它使大脑的血液供应中断并导致 中风。心房颤动引起的中风往往 比其它类型的中风更为严重，更 加致命。
的含量在血液中会因药物与食品和药物 与药物之间的相互作用，以及基因因素 而显现不规律的差异。我相信达比加群 将给患者和他们的看护者带来更简单和 更好的治疗，尤其是对那些华法林控制 不稳定的病患。”
成本考虑 使用达比加群的一个缺点是其价格比华 法林要高。然而，其高价或许可以抵消 华法林使用者需要进行频繁监测的相关 费用。
> 文接 page 27
肿瘤大小并非最重要
B型肝炎须知
周教授和林医生鼓励肝癌病患， B型 如果你不知道自己的肝炎状况，那么是 肝炎病毒携带者以及很有可能患上此类 时候进行一下检查了，” 周教授表示。 疾病的人进行定期筛查。 “与西方不同，亚洲的B型肝炎发病率 *符先生不是现实中的人，但可能是众多男女任何一个每 年被诊断出患上肝癌的人。根据新加坡癌症注册局的统 很高。因此肝癌是这个地区的一大癌症。 计数据显示，在2005至2009年里，肝癌是男性当中第四 如果你是B型肝炎（或C型肝炎）病毒携 个最常见癌症。在这时期内，肝癌是男性第三大癌症死 因，女性则是第五大癌症死因（虽然肝癌并非是女性最 带者，我们建议你每6个月进行一次筛查。 常见癌症之一）。
什么是B型肝炎？ 它是由B型肝炎病毒引起的 包括新加坡，是亚太地区最常见的肝 感染情况 亚洲B型肝炎患者占全球B型肝炎患者 总数的一半以上
B型肝炎如何传播？
分析病患数据 该研究报告于2011年7月刊登在外科 学权威期刊《外科学纪事》上，作 者是杜克-国大医学研究生院首批获 得医学博士学位毕业生中的优等生 林竞存医生。 他在杜克-国大医学研究生院的 研究学年期间开展了这项研究，并 由新加坡中央医院普通外科高级顾 问周嘉豪教授担任导师。林医生对 于新加坡中央医院 500名以上的肝癌 病患建立了数据库，而后详细分析 发现，发生微血管入侵的病患的康 复情况要糟得多，手术后的平均寿 命仅约 3 年，而没有发生微血管入侵 的病患能在手术后存活8年左右。 “我们还注意到，在没有发生 微血管入侵的情况下，肿瘤大小一
般并不重要。但当出现微血管入侵 时，患有较大或是较多肿瘤的病患 的情况在手术后并不太好，”林医 生表示。 和大部分研究生同学一样，林医 生拥有非相关领域的第一学历。他 在就读杜克-国大医学研究生院之前 学的是机械工程，并在空军部队担 任了 7 年的工程师。杜克-国大医学 研究生院于 2007 年招收了首批导向 医生科学家方向的学生。 这是首项将肿瘤大小和数量与微 血管入侵进行比较的研究，并强而 有力地显示出后者更加重要。 研究结果也揭示了新的可能 性。“未来我们或许能够发现微血 管入侵的生物学标志，因为我们知 道要寻找什么。这样的话，我们可 以在手术前就能识别出发生微血管 入侵的病患，”周教授表示。
是通过与受感染的人有血液或体液的 直接接触，如分娩过程中从母体传给 婴儿、不安全的性行为以及共用针具
B型肝炎与肝癌有何联系？ B型肝炎是导致全球肝癌最常见的原因 B 型肝炎病毒携带者比非携带者患上 肝癌的可能性还要高出100倍以上 男性患上肝癌的可能性比女性高 根据肝癌诊断阶段，如果不及时治 疗，平均寿命约3至8个月 非 B 型肝炎患者也可能出于其他原因 而患上肝癌，比如C型肝炎感染、能 导致肝硬化的慢性酗酒以及脂肪肝
如何预防B型肝炎？ 如果你对病毒没有先天的免疫力，就 要接种三剂量的疫苗 进行安全性行为并避免拥有多个性伴侣 避免共用针具、刮胡刀和其他尖锐工具
所有的儿童不是都接受B型肝炎疫苗 接种了吗？ 自1985年以来， B型肝炎疫苗接种一 直是全国儿童免疫计划的一部分 1985 年前出生的成人并没有接受过 B 型肝炎疫苗接种，但是他们可以从 医院、政府诊疗所和大部分家庭医生 处，通过验血来检查他们是否携带 B 型肝炎病毒。社区诊所的检查费用 为30-40元之间
在验血结果出来后该做什么？ 如果 B 型肝炎测试结果为阳性，建议 每6个月进行一次肝癌筛查 如果病患没有输血历史或不属于高危 人群，但检查结果为阳性，则应通知 家庭成员并进行测试 如果 B 型肝炎测试结果为阴性，则进 行B型肝炎疫苗接种
sep⁄ oct 2011
新脉动
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新闻 泪液分泌产生变化可以是由年龄、 荷尔蒙变化、眼皮卫生甚至环境因素所 引起的。童医生说：“环境因素不只是 指我们的周围环境，还有我们的生活方 式。一个人睡眠的长短和饮食习惯也都 有所影响。” 干眼症的典型症状包括眼睛泛红或 发痒和眼皮沉重。有些人甚至会视力模 糊。他说：“视力模糊的病人常眨眼 睛，视力的确会变得清晰一些，但很快 地又变得模糊不清。”
沙漠眼
干涩和疲劳的眼睛会令人感到很 不舒服，甚至感觉虚弱。看看你 是否有这种风险
三年前，公司经理陈女士开始发现自己 的眼睛越来越疲劳和干涩。长时间工作 后，双眼尤其难受。 她说：“有时候这感觉就像我的眼 睛里有一粒挥之不去的沙子。” 今年初，60岁的陈女士终于决定到 新加坡全国眼科中心求医时，才知道这 是干眼症。 陈女士超过80%的时间都在用电 脑，是一个典型的干眼症患者。 新加坡全国眼科中心顾问及杜克— 国大医学研究生院兼任副教授童学天医 生说：“干眼症很普遍，10%到30%的 人都会受到影响，而上班族最容易出现 这种症状。这是因为他们一整天都在使 用电脑。很多人也许没有发现，其实我 们长时间盯着电脑屏幕时，我们眨眼睛 的频率比较少。” 他说：“此外，上班族长时间坐在 冷气办公室，而且经常备受压力，这些
图：wong wei liang
原文 Dawn Ng
童医生警告说，干眼症如果不加以治疗，眼球表 面就会发炎。
都对眼睛有影响。” 除了上班族，在肮脏多尘的环境工 作的工人、年长者和不注重眼皮卫生的 人都容易出现干眼症。“在年轻人当 中，做过激光手术或常戴隐形眼镜的人 比较容易出现干眼症。” 在新加坡，干眼症属于常见疾病。 当一个人的泪液分泌不足，无法保持眼 睛湿润时，就会出现干眼症。 童医生说：“如果你有干眼症， 那就表示你的泪液分泌异常或过量 挥发。” “有时候，问题出在你的泪液的质 和量。多数的干眼症会造成眼球表面发 炎，导致损伤。”
干眼症测试方式 1 把标准视力检查表放在面前。 2 往后退直到你只能看清表上最下面一 行字母。 3 滴一滴眼药水。 4 如果最下面一行字母变得清晰（即 使只是几秒钟），那么你很可能有 干眼症。
预防措施 上班族可以稍微调整一下他们的工作环 境。“如果可以的话，尽量把电脑屏幕 的位置调到最低，那么你就不须要往上 看。” 童医生说这个简单的方法可以降 低眼睛天然润滑剂的挥发率，因为这使 一个人的眼睛露出来的面积降至最低。 其他建议包括使用电脑时常滴眼药 水，以及感到压力时小休片刻。 童医生说：“当你感到压力时，你 眨眼睛的频率会比较少。增加眨眼睛的 频率或减少眨眼睛的间隔时间是很重要 的，因为泪液会在眨眼的间隔时间挥发 掉，导致你的眼睛干涩。” 至于不在室内办工或经常在外跑动的 上班族，童医生建议使用保湿眼镜，其 镜框后有一层薄绵，可以保护眼睛和保 持眼睛湿润。
适应干眼症 虽然干眼症无法治愈，但改变生活习惯
我什么时候应该看医生？
如果你怀疑自己有干眼症，可 以先尝试使用药房售卖的眼药 水。但如果几天后没有好转， 就应该看医生。
如果你有潜在系统性疾病如类 风湿性关节炎、结缔组织病或 甲状腺疾病，以及觉得自己有 干眼症，就应该看眼科医生， 做进一步检查。
如维持健康饮食，对舒缓症状有很大助 益。 童医生补充说：“如果你出现干眼 症，经常使用眼药水有助于舒缓不适。 你也不须担心自己会用眼药水成瘾，或 者出现更严重的症状如失明。”
保健：健康
关注咳嗽问题
勤于洗手也有 助于预防细菌 的传播。
咳嗽久久不愈可能不是流感 原文 Jessica Jaganathan
持续咳嗽超过一个星期就可能不只是轻 微感染。这可能是受到一种称为支原体 （mycoplasma）的细菌感染。支原体 是其中一种可独立生存的最小微生物。 这种常见疾病比其他类型的肺炎较 为轻微，有时被称为“游走型肺炎”。 任何人都有可能染上这种疾病，尤其 常见于年龄介于5岁至20岁的年轻人 身上。 目前，我们无法确切统计罹患这种 肺炎的人数，但估计10%至15%的肺炎 患者属于支原体肺炎。 新加坡中央医院呼吸与重症科顾问 王丹浩医生说：“支原体感染导致咳嗽 持续好几个星期。它可能引发头痛、发 烧和不适，而且病人可能会感到喉咙 疼痛。” 有些症状和呼吸道感染如普通感冒 的症状相似。然而，与普通感冒不同的
是，病人很少会打喷嚏或流鼻涕，而且 复原时间比较长。 王医生说：“支原体感染也可能会 引起皮疹。” 细菌会在体内化脓长达三个星期。 各种症状会持续数天至数周不等。持续 咳嗽的病人如果不寻求治疗，就需要几 个星期的时间才能康复。 王医生说，在这个阶段，病菌可以 人传人的形式轻易传播，特别是在人多 的地方。事实上，即使一个人在急性感 染后，他体内的支原体在几个星期内还 是会传染给别人。 在人多的场所（如学校和日间护理 中心）居住或工作的人罹患支原体肺炎 的风险最高。 王医生说，预防病毒入侵的最好方 法是远离那些咳嗽的人。 她说，在温带国家，支原体感染常 见于夏末和秋天，但新加坡没有这种所 谓的季节性感染。 就像流感一样，人们对支原体的
免疫力会在几年后减弱。王医生补充 道，“支原体感染反复发生是绝对有可 能的。” 不过，受这种病毒感染的病人无须 担心医疗费昂贵的问题，因为有几种有 效的口服治疗法都比较便宜。 由于支原体肺炎的症状比其他类型的 肺炎来得轻微，所以只要得到充分的休 息、摄取足够的水分和高蛋白质食物， 许多人即使没有服用抗生素也能痊愈。 如果症状较为严重，医生会开抗生 素。但是，服用这些抗生素却有一定的 风险。王医生说，虽然抗生素本身不会 降低人体的抵抗力，但如果经常服用， 自然存在于人体内的细菌就会对抗生 素产生抵抗作用，使日后的感染更难以 治愈。 新加坡是一个人口稠密的国家，你 几乎无法防范，不受细菌感染。如果你 发现自己发烧、咳嗽或呼吸困难，就必 须看医生。这些症状出现的原因有很 多，重要的是趁情况尚未恶化，尽快进 行肺炎检查。
支原体肺炎误区 我会在拥挤的列车里被传染 支原体会通过人与人之间的密切和 长时间接触传播，这就是它常见于 学校和兄弟姐妹之间的原因。
现在不是流感季节。我不会受 到感染 在新加坡这样的热带国家，支原体 感染一年到头都有可能出现。
幼童最容易受到感染 任何人都有可能受到感染，特别是 5岁至20岁的人。
我打了预防针。我不会受支原 体感染 预防针不是对抗支原体感染的疫 苗。目前，最有效的防范措施是保 持良好的卫生习惯，以及在咳嗽或 打喷嚏时掩住嘴巴。
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新脉动
sep⁄ oct 2011
人物介绍
无怨无悔
这份工作最好和最坏的部分是 什么？ 我这工作最好的部分就是告诉病人他们 没有得癌症。最坏的部分就是告诉病人 他们患癌。看到病人接受治疗后痊愈， 而在接下来的二、三十年没有复发；看 到年轻的病人从刚被告知患癌时大受打 击到若干年后携家带眷来复诊，这些都 让我十分振奋，也给我莫大的满足感。
他从小的志愿就是当一名医生。将近40年后的今天，黄兆 英医生说，他“毫无遗憾”。他仍对治疗乳癌患者以及培 训新晋医生充满热忱
我原本来自马来西亚，但在新加坡大学 念书，这是国立大学当年的名称。毕 业后，我在各个政府医院服务，直到 1988 年加入新加坡中央医院。我创设了 新加坡第一个乳房专科团队。 1989 年， 我们开设了乳房诊所，每逢星期五为综 合诊所转介过来的病人看诊。虽然现在 其他医院也设有乳房部门，不过，经过 这些年的努力，我们的诊所仍是本地首 要的转介中心。 我也设立了本地医院的第一个乳房 辅导服务。高级临床护理导师萨拉瓦蒂 在1992年被派往国外接受培训，回来之
保健：健康
战胜疼痛 学习应付长期疼痛能协助慢性病 患者过得更快乐 原文 Keith G Emuang
38年来，李女士日夜忍受持续性的下背
痛。这是她16岁时在家中发生意外后所 造成的。有时，她甚至痛得坐立难安。 2006 年，当她向新加坡中央医院专 科医生求医时，因之前所尝试过的治 疗法都不曾奏效，让她感到沮丧和 失意。 这名 56 岁的家庭主妇说：“我 痛得无法久坐，坐下去后又得经过一 番挣扎才能站起来。我甚至连睡觉都 成问题。更糟的是，我当时是个 售货员，经常得堆放沉重的 货物。” 她被转介到新加 坡中央医院疼痛中心， 由那里的一组医疗团 队教导她如何应付长 期疼痛。一年后的李 女士犹如重获新生。
你为什么选择乳房专科？ 我会选择这个专科是因为这是所有顾 问医生选择他们的专科后，唯一剩下的 一个专科！不过，也有其他一些事件影 响了我的决定。其中一个是一名正在等 待 O 水准成绩的 16 岁马来少女。她被诊 断出患上了末期乳癌，而且还有溃烂的 癌症伤口。为了改善她的生存质量，我 为她做了乳房切除术，但这只是姑息治 疗。 3 个月后，她去世了。这是发生在
她说：“疼痛中心改变了我的人 生。”虽然她的疼痛无法根治，但她已 学会如何应付疼痛，过着正常的生活。 “现在，当疼痛来袭时，我知道该做 怎样的伸展运动，以及如何分散注意力。 如今我睡得更香，还经常散步和游泳， 也重新找回看电影的乐趣。” 教导病人应付长期性疼痛，在美国及 澳洲等国家地区已是既定的治疗法。但 在新加坡，这种治疗法仍相当新颖。新 加坡中央医院麻醉科顾问兼疼痛中心主 任陈建宪医生说，这种治疗法刚在五年 前开始盛行。 陈医生说：“没有任何一种方法能有 效地应付疼痛。我们中心的计划可以取 得良好的治疗效果是因为它 关注患者的身心健康。” 他还指出：“到疼 痛中心求诊的患者通
你怎么告诉病人他们患病的消息？ 我必须了解被转介到我的诊所的病人所 感受到的忧虑。她们乳房上的那个肿块 会不会是个恶性肿瘤？面对可能要失去 乳房、化疗的副作用以及治疗费等，她 们会变得更害怕、更焦虑。所以我必须 很有耐心地让病人放心，并一一地向她 们解释病情。我需要让她们了解这并不 是世界末日。接受治疗后，她们大多数 可以痊愈。在跟病人解释病情及治疗方 法时，我也必须对她们坦白，并直视她 自1988年，乳房专科外科医生黄兆英就在新加坡 们，时刻和她们保持目光接触。幸好有 中央医院服务。 萨拉瓦蒂女士在旁帮忙安抚病人并给她 们精神上的支持。 1982年的事。当时，我是亚历山大医院 的年轻注册医生。也是差不多那个时候， 你对女性有什么建议？ 我为一个在银行工作的妙龄少女进行乳 从20几岁开始就应该自行进行乳房自检。 癌治疗。她接受了乳房切除术以及化疗。 到了 40 岁，就应该每年进行乳房X光造 她的未婚夫离开了她，而癌症也在两年 影检查。过了 50岁则应该每年进行 2次。 后复发。她把她患癌的心路历程告诉了 如果怀疑乳房有肿块，应该到邻近的诊 一个本地的杂志。 所或综合诊疗所接受进一步检查。 图：101teamwork
你的事业有哪一些高峰点？
后就一直和我共事。她主要负责乳癌病 人的情绪及心理需要而我和我的团队则 负责她们的医疗需要。 这些年来，普通外科部门也培训了许 多医生和护士。目前有超过10个曾经在 新加坡中央医院接受培训的乳房外科医 生在其他政府医院服务。也有好几个是 很成功的私人专科医生。许多在这里接 受培训的护士也在其他医疗机构有很好 的表现。
常是那些不需要或不想要动手术的病患。 他们有的是不适合动手术的老年人，或 是动过手术，却仍饱受长期疼痛折磨的 患者。他们经常申诉背部和颈部疼痛。” 经新加坡中央医院专科医生或家庭医 生转诊到疼痛中心的病人必须先填妥一 份问卷，协助疼痛专家评估他们的疼痛 指数，以及他们在日常作息和生活方式 中如何受到影响。治疗方法可包括打止 痛针以及其他介入性疗程。患者也可和 李女士一样，参与一项九天的认知行为 治疗计划。 新加坡中央医院精神科部门的高级心 理治疗师兼疼痛中心的成员之一陈碧玉 说：“我们通过教导患者认知和应对技 巧，协助减低他们的焦虑感。” 她补充道：“当患者在感觉疼痛时 学习冷静，他们的生活素质就跟着提高。 教导患者放轻松、脱敏以及其他技巧控 制他们的疼痛，能让他们抱有积极的心 态。不论是日常家务事、运动或是社交 李女士下背剧烈疼痛， 活动，他们的应对能力也会更好。” 导致她无法安枕入眠。 陈碧玉强调：“这项计划是应付疼 痛，不是根治疼痛。” 单单学习以上的应对技巧是不够的。 患者也必须设定实际的、可达到的目标。 这样一来，他们才不会因为无法达到目 标，或目标太难或太久才能实现而感到 心灰意冷。 陈碧玉说，重要的是，患者应抱着 锲而不舍得精神，持续地定期练习放轻 松、减低压力以及增强体格。 图：101teamwork
现年60岁的黄兆英医生是新加坡中央医 院，普通外科部门的高级顾问兼门诊外 科中心主任。黄医生敬业乐业地献身于 医疗服务，激励了许多医生和护士。他 与大家分享过去36年的点滴，其中也包 括当了26年外科医生的经验。
消除疼痛 简单的放松运动能帮助疼痛患者减 少他们的负面情绪，让他们的心情 更好。
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渐进性肌肉放松法 患者学习如何在紧张情绪来袭时 放轻松。患者先缓慢地深呼吸，然 后回想让他感到愉快或平静的画面， 使自己放松下来。
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脱敏运动 患者学习通过接触逐渐可怕的 情形，克服自己的紧张情绪，并减 低他在这类情况发生时的负面反应。 新加坡中央医院精神科部门的高级 心理治疗师陈碧玉说：“熟练此技 巧的病人能在任何时刻、任何地点 做这些运动。”
患者也必须学习将疼痛的感觉告诉家 人，以得到他们的支持。新加坡中央医 院的临床护理导师兼疼痛中心的计划协 调员陈春燕说：“疼痛也会影响患者的 情绪，而无法应付疼痛的患者也会感到 郁闷。让家庭成员了解患者的疼痛是重 要的，因为大家都必须为应付疼痛出一 份力。”
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