Singapore Health Mar/Apr 2014 by Singapore General Hospital

MAR APR

2014

a Bimonthly Publication of Singapore General Hospital and SingHealth ACADEMIC HEALTHCARE CLUSTER MCI (P) 069/06/2013 www.sgh.com.sg | www.singhealth.com.sg

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New tennis elbow treatment is an alternative to surgery

APEX Awards 2013

potential cure for a Dangerous Heart condition

Patients with fractures get osteoporosis checks

New parents can ring for nanny services by retired midwives and nurses

新研发能减低心律疾病病发风险

Help children build resilience to cope better with life’s challenges

Photo: GETTY IMAGES

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除了年幼孩童，成人和青少年也可能感染手足口症

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Preciosa Reynoso Ramos For editorial enquiries, please e-mail editor@sgh.com.sg For advertising enquiries, please call 6319-3022 or e-mail jrani@sph.com.sg All rights reser ved. 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. MCI (P) 069/06/2013. Printed in Singapore by Singapore Press Holdings Limited (registration no: 198402868E).

MAR– APR 2014

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A cure in a petri dish

NHCS researchers have discovered a potential cure for a heart rhythm condition that can cause the sudden death of young and otherwise healthy people By Celine Lim

Killer on the loose LQTS is usually inherited and can affect young victims. A check with the family revealed that Mr Wong’s father too had died of sudden cardiac death some years back. Victims develop sudden, uncontrollable and chaotic heart rhythms during exercise, when feeling strong emotions, or for no apparent reason. It is a known cause of collapse and sudden death in young athletes running marathons. If not corrected within a couple of minutes, these erratic heart rhythms can cause death. Associate Professor Philip Wong, Director, Research and Development Unit (RDU), National Heart Centre Singapore (NHCS), said, “These dangerous heart rhythms can occur at any time and there need not be any specific trigger. Prolonged QT is a well-known cause of sudden cardiac death.” The QT interval on an ECG indicates the time the heart takes to recharge before beginning its next contraction. In LQTS, the QT interval is prolonged as the electrical system controlling the heart’s rhythms takes longer to recharge. The delay may result in dangerous heart rhythms. In Singapore, about 1 in 5,000 people have LQTS, said Prof Wong. “The incidence for LQTS is not as high as that of diabetes, which is one in five for those above the age of 50. But the difference is that diabetes is a chronic disease and doesn’t kill people suddenly, unlike LQTS which may affect the young in the prime of their lives,” he added.

Photo: WONG WEILIANG

r Ted Wong* was in the pink of health and an all-round athlete who regularly ran marathons. So, when the 27-year-old lawyer suddenly slumped over at his desk one morning, his colleagues thought he was simply fooling around. When he failed to respond to their nudges and calls after several minutes, they realised that he had stopped breathing. A colleague called for an ambulance while another started emergency cardiopulmonary resuscitation on him. When paramedics arrived, they tried to revive him. An electrocardiogram (ECG) done at the emergency department showed the presence of Long QT Syndrome (LQTS) – a disorder of the electrical activity that controls the heartbeat, and a known cause of sudden cardiac deaths in young, otherwise healthy people. Despite aggressive intervention by the medical team, Mr Wong unfortunately passed away.

The team from National Heart Centre Singapore’s Research and Development Unit discovered that a compound known as ALLN could correct heart cells’ prolonged QT after a year of rigorous testing on a cellular model developed in a petri dish. Team members included (from left) Prof Philip Wong, Dr Ashish Mehta and Dr Winston Shim.

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research to identify a drug compound that could reverse the effects of this mutation. “The drug compound allows the faulty proteins to bypass the cell’s ‘quality control check’, which then results in an increase in the inflow and outflow of potassium and corrects the effects of LQTS 2,” said Dr Mehta. The breakthrough occurred when the team used stem cells from a young patient with LQTS to mimic the disease in a petri dish. In two to three weeks, they generated human-induced pluripotent stem cells. They spent six weeks maturing the cells, then reprogrammed them into beating heart cells (real heart cells beating in a petri dish). ECG readings of these cells mirrored the patient’s heart condition, giving researchers a cellular model with which to understand how LQTS 2 develops in the human body.

These dangerous heart rhythms can occur at any time and there need not be any specific trigger. Prolonged QT is a well-known cause of sudden cardiac death. Associate Professor Philip Wong, Director, RDU, NHCS

Do you have LQTS?

Since LQTS has no signs or symptoms, many people are unaware they have it. See a doctor if: A parent, sibling or child has been diagnosed with LQTS. The condition may be inherited. You suddenly faint during physical exertion or when you experience intense emotions. You have seizures. A continually erratic heartbeat deprives the brain of oxygen – this condition is what causes seizures.

The 10-member team from NHCS’ RDU was working on Long QT Syndrome 2 (LQTS 2), one of 13 types of LQTS, when they made the discovery. All 13 types of LQTS look the same on ECG readings. Types 1, 2 and 3 are the most common. LQTS 2 is caused by mutation in the hERG (human ether-a-go-gorelated gene), which affects the electrical system that controls heartbeats. Dr Ashish Mehta, Senior Research Scientist, RDU, NHCS, who led the study, said the team used existing stem cell

The team then tested various drugs on the cellular model. Doing this in the petri dish allowed them to test without any risk to the patient, and to continuously monitor how the cells were reacting to the drugs. After a year of rigorous testing, they saw on ECG readings that a compound known as ALLN could correct the heart cells’ prolonged QT. The research findings earned the team a best poster prize in 2013 at the

Normal QT Interval

Some people with LQTS experience symptoms such as palpitations, fainting spells or seizures, but many do not, and remain unaware they have the condition. Even if LQTS is diagnosed – often through ECG results during a routine check-up – there is currently no known cure for it. The only way to prevent deaths in LQTS patients is for them to get an automated implantable cardioverter defibrillator implanted in their bodies. The device monitors heart rhythms, and when it detects a dangerous one, delivers electrical shocks to reset the heart rate. However, this does not cure or correct the underlying cause of the condition. The science behind the breakthrough In September 2013, researchers at NHCS made a breakthrough – a world first. They discovered a potential cure for the condition, in a petri dish.

Prolonged QT Interval

The QT interval on an electrocardiogram indicates the time the heart takes to recharge before beginning the next contraction. In patients with Long QT Syndrome, the QT interval is prolonged as the electrical system controlling the heart’s rhythms takes longer to recharge. > Continued on page 4 ( 华文版本请翻阅至27页 )

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MAR– APR 2014

> Continued from page 3

A cure in a petri dish

prestigious European Society of Cardiology Congress – a large international cardiology meeting with about 30,000 participants.

Photo: Getty Images

Clinical trials ahead The team’s task now is to test for toxicity and safety in similar conditions before finding partners to bring these drugs to clinical trials. Conventional drug testing can be a long and laborious process; it can take about 15 years to progress from a discovery to a commercially available drug. The breakthrough is expected to quicken the quest for a cure. Prof Wong said, “Using this platform we can potentially halve the time required for drug testing by doing away with multiple drug screenings. We were able to focus our search for drugs that only affect the hERG mechanism instead of testing multiple drugs. Previously, we used computer simulations, but now we can show what happens during drug testing on actual live cells that mimic the disease. Results can be seen right there in the petri dish.” There are other advantages. Dr Winston Shim, Scientific Director, RDU, NHCS, said that making such drugs commercially available will involve partnering with pharmaceutical companies,

Treating Long QT Syndrome

Patients of Long QT Syndrome develop sudden, uncontrollable and chaotic heart rhythms during exercise, when feeling strong emotions, or for no apparent reason.

drug discovery incubators and others, to test the compounds. The likelihood of these partnerships forming is high, as the team’s research in proving the efficacy of the drug has lowered the risks of testing, which can be very expensive. “With our current knowledge of the drug and LQTS 2 manifestation, we were able to cherry-pick drugs likely to be out on the market for testing. Selecting

Digital Healthcare Enabling Digital Healthcare

these drugs means we know where to look for side effects,” said Dr Shim. Prof Wong explained that people with LQTS 2 will have to be on the drug for life, to manage the effects of the disease and reduce the risk of sudden cardiac death. *The patient’s description is based on the typical profile of a patient with Long QT Syndrome.

Studies have shown that if left untreated, more than 50 per cent of people with inherited Long QT Syndrome (LQTS) die within 10 years. To manage LQTS, patients are advised to avoid competitive sports. Treatment includes the following: Medication: Drugs like beta blockers slow the heart rate by blunting the heart’s reaction to adrenaline in times of stress, fear or exertion, making dangerous rhythms in a patient with LQTS less likely. Medical procedure: An Implantable Cardioverter Defibrillator (ICD) is implanted under the skin of the patient’s chest, where it continuously monitors his heartbeat. It will deliver electrical shocks to restore a normal heart rhythm when necessary.

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MAR– APR 2014

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New ultrasound treatment for tennis elbow

PhotoS: ALVINN LIM

SGH unveils minimally invasive treatment involving ultrasound energy for treating tennis elbow – the first such service in the Asia-Pacific

Administrator Elaine Chew (right, with Dr Joyce Koh) went through the Singapore General Hospital’s new percutaneous ultrasonic tenotomy procedure for tendinitis of her left elbow in 2011, and for her right one in 2012. By DESMOND NG

t’s called tennis elbow. But it isn’t just the elbow that is affected, nor is it only caused by playing tennis. Tennis elbow, or tendinitis, is a painful condition that occurs when the tendon – the structure that joins the muscle to the bone, allowing the joint to move – in the elbow (or any other part of the body) is overworked, usually by repeated motions in the wrist and arm. So it is a problem for people who repeatedly strain their elbows, like administrators who use a computer mouse or carry heavy files, housewives and chefs. It is also likely to be a problem for someone who is middle-aged rather than the young or the very old. When tendinitis is diagnosed, treatment can include rest and anti-inflammatory medications in the initial stages, physical therapy such as hot and/or cold compresses and exercises, steroid and anaesthetic injections, or blood products, as well as surgery when the disease is advanced. First such procedure in Asia-Pacific Recently, a new and quicker treatment has become available at the Singapore General Hospital (SGH): it is a non-invasive day-surgery treatment that results in faster recovery, and is the first such procedure available in the Asia-Pacific region. “The SGH sees about 20 to 30 patients with tennis elbow every month, and we understand how frustrating it can be for

patients when their conditions do not improve after non-surgical therapies,” said Dr Joyce Koh, Senior Consultant, Department of Orthopaedic Surgery, SGH. “The procedure provides patients who are hesitant or fearful of surgery with another treatment option, as it is performed in an outpatient clinic setting.” Known as a percutaneous ultrasonic tenotomy, the procedure is performed under local anaesthesia and involves using ultrasound and a toothpick-sized probe to treat the damaged tendon tissue. Using ultrasound imaging, the location of

No sutures or stitches are needed for the new procedure for tennis elbow, and only a sterile adhesive bandage is used to cover the wound.

the damaged tendon tissue is identified and the probe is inserted through the skin into the area. Ultrasonic energy then cuts, breaks up and removes the damaged tissue, sparing the surrounding healthy tendon tissue. No sutures or stitches are needed when the procedure is completed, and only a sterile adhesive bandage is used to cover the wound. The patient is discharged on the same day. Patients who undergo the procedure typically take about a week to heal from the wound, although Dr Koh advises staying off stressful activities for at least six weeks for internal tissues to heal and to build up. With more conventional forms of surgery, patients may need two weeks to recuperate before the surgical stitches are removed, and several more weeks before they can return to work. Most conventional surgeries are also done under general anaesthesia, with its related risks and complications. Alternative to surgery “This procedure is really for people who have ‘maxed out’ on every other treatment. We wouldn’t recommend it for someone who’s experienced just three months of symptoms, for instance,” said Dr Koh, adding that 75 per cent of the people who go through the procedure are likely to have undergone other forms of invasive treatments without success. Typically, about 10-20 per cent of patients with tennis elbow go through surgery eventually. The procedure takes less than 20 minutes to perform, and this includes getting the patient and equipment ready. The “energy” time – the actual time spent cutting out the abnormal tissue – lasts only about half a minute, she said. The technology used is similar to that for eye cataract surgery where ultrasonic energy is focused into a very small area, is very strong, and does not cause much damage to surrounding, healthy tissue. Previously, cataract surgery was complex, performed under general anaesthesia, and often required the patient to stay in hospital for a week to recover. “(Percutaneous ultrasonic tenotomy) uses the same technology for musculoskeletal problems, and that’s why it’s so exciting!” Dr Koh said. The SGH introduced the minimally invasive procedure in August 2012 after a joint trial between the hospital and the Mayo Clinic of the US to test its efficacy and safety. The Mayo Clinic’s Professor Bernard Morrey came to Singapore to perform the procedure on the first seven patients in June 2011, with another 13

Hey, it’s not arthritis!

Tendinitis and arthritis have subtle differences. It’s not arthritis when one feels: Pain over the bump where the

tendon inserts into the bone

Pain when opening a heavy

door, but not when opening a tight bottle cap Weakness in one’s grip, because the pain inhibits the action of the muscle Pain that is sharp and acute, sometimes bad enough to disturb a patient in his sleep

The new non-invasive procedure involves using ultrasound and a toothpick-sized probe to remove damaged tendon tissue.

done by SGH doctors in November of the same year. After the trial, another 20 patients underwent the procedure. In the US, 9,000 people have gone through the procedure for tendinitis of various parts of the body, including the most commonly affected elbow and heel. Dr Koh, who was the principal investigator of the local study, said that the trial found that all patients took to the procedure very well without any device or procedural complication recorded. Wounds healed without complication within a week, and none of the participants had complaints. The findings of the study were presented at the Singapore Orthopaedic Association Annual Scientific Meeting in October 2013, and internationally at the European Federation of National Associations of Orthopedics and Traumatology and the Canadian Orthopedic Association annual meetings.

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MAR– APR 2014

Breaking the fragility fracture cycle

Collaboration among different clinical departments helped SGH win an international award for identifying and treating osteoporosis among the elderly By Satish Cheney

till a scan is done. We want to remind people that osteoporosis is a chronic disease. It doesn’t stop. You have to be on medication long-term. And we want health-care professionals to think of osteoporosis as a potential underlying cause first when they see a patient with a fragility facture and take appropriate steps,” she said.

PhotoS: Zaphs Zhang

steoporosis of ten doesn’t get the attention it deserves – both from patients and doctors alike. The condition and its underlying causes can get submerged under other seemingly more serious problems that the elderly suffer from. A fracture sustained as a result of fragile bone health will get treated, but the underlying cause – osteoporosis – may be overlooked and forgotten. And osteoporotic fractures can be serious. “We know that a person who has had an osteoporotic fracture is at risk of a subsequent fracture,” said Dr Manju Chandran, Senior Consultant, Department of Endocrinology, Singapore General Hospital (SGH). “A fracture begets a fracture. And we know that treating the first can go a long way towards preventing a second. Treatment lowers the risk of having another fracture by about 50 per cent.” Osteoporotic fractures among old people – a group particularly at risk of osteoporosis – also “carry significant mortality”, Dr Chandran added. For instance, 20 per cent of old people who suffer a hip fracture die within a year of sustaining the injury. To make sure that osteoporosis patients are not ignored, Dr Chandran canvassed colleagues from various departments to actively identify and enrol patients who had suffered a fragility fracture – often people over 50 who had had a fall from a standing height or less – into a Health Ministry-led and funded initiative, the Osteoporosis

Retired teacher, Mdm Phuah Liew Hong (right), joined the OPTIMAL programme at the Singapore General Hospital early last year. Mdm Phuah said she felt steadier on her feet and had better balance after undergoing an exercise regimen, a component of the programme. Dr Manju Chandran (left) canvassed colleagues from various departments to actively identify and enrol patients who had suffered a fragility fracture into OPTIMAL.

A fracture begets a fracture. And we know that treating the first can go a long way towards preventing a second. Treatment lowers the risk of having another fracture by about 50 per cent. Dr Manju Chandran, Senior Consultant, Department of Endocrinology, SGH

Patient Targeted and Integrated Management for Active Living (OPTIMAL) for public hospitals and polyclinics. SGH recruited a significantly large number of patients – 1,152 – for follow-up assessment and treatment. Dr Chandran and her colleagues tracked these patients closely, and their efforts to ensure that the patients complied with osteoporotic medication and treatment won Dr Chandran the Young Investigator Award at the prestigious IOF-ECCEO conference in 2013.

“Compliance is notoriously poor, and more than 50 per cent of osteoporosis patients drop out after one year of treatment. But after two years, we had 73 per cent compliance. What we have shown is that the close follow-up by our case manager helped our patients stick to their appointments and medications,” said Dr Chandran, who is also the Director of SGH’s Osteoporosis and Bone Metabolism Unit. “Osteoporosis is a silent disease. Some patients don’t even know they have a small fracture

The OPTIMAL programme is for patients above the age of 50 who have been identified with fragility fractures. It aims to prevent more fractures and to treat osteoporosis quickly if it is identified as the underlying cause of the initial fracture. Patients in the programme are taught to eat the right foods to build up bone mass, given appropriate medication and counselling, and put on an exercise regime.

building big bones for old age People today have generally become more inactive, and their lifestyles are more sedentary when compared with a period even as recent as the 1960s, said Dr Manju Chandran, Senior Consultant, Department of Endocrinology, Singapore General Hospital. That may also be the reason for the rise in the number of people diagnosed with osteoporosis. But the risk of developing the degenerative disease can be lowered by making lifestyle changes, among others things. “We can’t change our genetics, but we can change our habits,” said Dr Chandran. Bones are living tissue, developing and strengthening from the moment

of birth until young adulthood when peak bone mass is reached. At that point, bones are at their most dense and strongest. After that, the body starts to lose bone mass faster than it can make new tissue. If significantly more bone mass is lost

versus new bone tissue formed, the bone becomes osteoporotic. Osteoporotic bone (below, left) is more porous, with larger holes in its honeycomb structure, and is more fragile and more likely to break than normal, healthy bone (below, right).

Taking calcium-rich foods like milk and soya products as a way of growing strong bones when young can be a protection against osteoporosis developing later. Exercising regularly and maintaining a healthy weight, and not smoking or over-indulging in alcohol are other ways of lowering the risk of developing the condition. It is also important to know what might cause the degenerative disease so that preventive steps can be taken. For instance, asthma sufferers who are on long-term steroids should have their bone density checked regularly to catch the disease early, as the use of steroids has been associated with secondary osteoporosis.

MAR– APR 2014

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The midwife is here! Once home with a newborn, many new parents are prone to panic. But help is near. Just ring for it

PhotoS: JASPER YU

Mdm Fok found herself making lists of questions to ask Ms Oh, on breastfeeding, bathing her baby and more. Her husband also found the sessions useful. “We found the service very good and useful. There were a lot of things we thought that we knew (about taking care of a baby) but then we found a better way,” he said, citing the example of burping a baby after his feed. He learnt from Ms Oh that the most effective way is to rest the baby’s head on one’s forearm and stroke the baby’s back to burp him properly. Ms Oh also guided the couple on how to bathe Nathan and clean his umbilical cord. The family signed up for an extra three sessions to learn more.

Ms Dorothy Oh looks on as Daddy Steven Teo attempts to burp baby Nathan.

By Desmond Ng

HEN Mdm Jane Fok, a 31-yearold teacher, was pregnant, she searched for a part-time midwife who could help her after her baby was born. But such services were few and far between. New mothers typically hire a confinement lady, who usually lives with the family during the confinement. But Mdm Fok preferred her privacy. “I didn’t want a confinement lady staying with us, as I wanted to do things my way,” said Mdm Fok. “Also, I don’t really take confinement food.” She added that her mother, who lives a few blocks away, could cook for her. By a stroke of luck, she came across the exact service she was looking for while watching TV.

Retired midwives and nurses for hire The Postnatal Home Care Service (PHCS) offers part-time, non-live-in confinement nanny services by retired midwives and nurses. Apart from looking after mother and baby, these professionals also teach the baby’s father how to do the same. The ser vice was set up in 2007 by the Healthcare Services Employees Union, the Southeast Community Development Council and SingHealth’s Silver Connection. It quickly filled a gap in the market and provided a way for retired professionals, if they wished, to return to the workforce and contribute to society. Services focusing on the mother include guidance on breastfeeding, the review and care of perineal wounds, and

advice on diet. Services focusing on the baby include guiding new parents on how to bathe their newborn, sterilise milk bottles, and care for the umbilical cord. Help comes in blocks of three sessions of one and a half to two hours each and costs $205 in total. Mums have the option of extending the service at $67 per session. Most midwives and nurses will leave their phone numbers with the new mums in case they have more questions or require more sessions. These retired midwives and nurses are registered with the Singapore Nursing Board (SNB) and are paid directly by the parents. She signed on immediately Mdm Fok, who is married to fellow teacher, Mr Steven Teo, was keen on using the service. After the couple brought their baby boy, Nathan, home from the hospital, Mdm Fok looked forward to the visits from her midwife, 71-year-old Ms Dorothy Oh, who was trained as a midwife at KK Women’s and Children’s Hospital (KKH) from 1961 to 1964. Ms Oh had also worked in maternal and child health clinics and polyclinics till her retirement in 2005. “I felt very comfortable having Dorothy around because she is a trained nurse with clinical knowledge, unlike a confinement nanny,” said Mdm Fok. On the first day of the sessions, Ms Oh explained the theory of baby care, before showing the parents how and what to do. In subsequent sessions, she supervised and guided the parents as they cared for their baby themselves.

For the love of babies Ms Oh joined the PHCS Programme in 2008 and has since helped with more than 100 babies. She chose to continue working after her retirement because of her love for babies. “I like babies and am very happy with this arrangement,” she said. Ms Sng Miuh Tin, Assistant Manager, Silver Connection, SingHealth, said that the programme has been well received. Since 2007, when it started, 690 cases (at press time) have been assigned to the midwives/nurses. Twenty midwives are currently registered with the programme. “The midwives take on a more clinical approach, compared to a confinement lady who cooks for the mother and stays with the family for a month,” said Ms Sng.

Mummy Jane Fok gives baby Nathan a bath with help from Ms Dorothy Oh (with glasses).

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new parents’ Top 3 concerns Here is some advice from retired midwife Ms Dorothy Oh

Not enough breast milk

Breastfeeding issues usually occur during the first three days when there is not enough milk, and the baby is too sleepy to feed. New mothers tend to get worried when their baby is not feeding. I encourage them to stay positive, drink more fluids, and teach them how to help the baby latch on and feed.

New mothers are exhausted

New mothers are tired after delivery, so when the baby sleeps, they should rest too. During the night, it is advisable to take turns with the husband and others, to look after the newborn.

Bathing the newborn

It is advisable to bathe the baby in the morning when it is cooler. The baby will tend to sleep better after that too. Do not bathe the baby immediately after a feed because he may vomit. Wait at least 30 minutes after a feed. While bathing, hold the baby’s arm and support his neck. Water should be lukewarm, between 36 to 38ºC. Bathe the baby with mild soap from head to toe. Contact Information For more information about PHCS, contact Silver Connection at 6377-8539 or email them at silverconnection@singhealth.com.sg. Patients who deliver at KKH can book the service through the ward nurses.

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MAR– APR 2014

Malnutrition affects cancer treatment of the old

Elderly cancer patients at risk of malnutrition should be offered holistic and not standard treatment By Stella Thng

Preventing malnutrition in the old

Checking nutritional status Dr Tira Tan, Registrar, Department of Medical Oncology, National Cancer Centre Singapore (NCCS), said that nutritional status is associated with how well the elderly cope with cancer treatment. The malnourished tend to suffer more from the side effects of chemotherapy such as nausea, vomiting, diarrhoea, mouth ulcers and loss of energy.

Malnourished patients suffer more toxicity, complications and side effects FROM chemotherapy. Dr Tira Tan, Registrar, Department of Medical Oncology, NCCS

Dr Tan said that although 60 per cent of cancer patients in Singapore are over 65 years old, there is very little clinical trial evidence available on their treatment. This is because elderly patients are not usually enrolled in trials due to their age and frailty. “We need more evidence and data to guide us on how to treat them,” she added.

While caring for her late grandfather, Dr Tira Tan found herself coping better when she was better informed. She has some advice for those who look after the elderly sick.

Photo: Zaphs Zhang

r Lee Ah Seng*, 80, lives alone in a one-room HDB flat. He receives public assistance and collects tin cans to supplement his income. He usually eats out, but occasionally misses a meal or two when he forgets to watch the time or runs out of money. Mr Lee is a lifelong smoker. He has a chronic cough which in recent months has become blood-streaked and more persistent. In need of stronger cough medication, he saw a doctor at his local polyclinic who recognised signs of advanced lung cancer. This was confirmed with imaging and a biopsy. Because of his age, doctors have to consider various things when working out a treatment plan. Is cancer treatment going to benefit him? Will it do him more good than harm? Will he suffer from toxicity? Another impor tant fac tor that doctors have to consider when treating the elderly ill is their risk of malnourishment, and how that could affect them after cancer treatment.

Dr Tira Tan says that cancer patients who are malnourished suffer more from the side effects of treatments like chemotherapy.

In her study, Dr Tan analysed data collected by her mentor, Dr Ravindran Kanesvaran, Associate Consultant, Department of Medical Oncology, NCCS, who spearheaded the first (and so far, only) geriatric oncology clinical research programme in Singapore at NCCS. He interviewed 249 Asian cancer patients aged 70 to 94 years old between 2007 and 2010. They were suffering from a range of cancers, from gastrointestinal to lymphoma, and were interviewed before receiving cancer treatment at NCCS. Dr Tan said the data showed that three quarters of them were at a moderate to high risk of malnutrition. Her study identified the following risk factors associated with malnutrition: When patients’ cancer is at an

advanced stage: “Cancer cells produce hormones that can affect a patient’s oral intake and appetite. They lose weight and muscle mass.” When they cope poorly with day-today activities: “The Eastern Cooperative Oncology Group (ECOG) index is used to grade how independent a patient is in going about daily activities, such as getting out of bed, using the toilet and running errands. A patient who needs help is more likely to suffer from malnutrition.”

When patients suffer from anaemia:

“Anaemia is common in those who suffer from chronic diseases. It can be secondary to the cancer itself, blood loss or the body’s impaired ability to make red blood cells. Anaemia causes symptoms such as lethargy, shortness of breath and heart problems. If severe, blood transfusions may be necessary, and treatment for cancer delayed.” When patients suffer from depression: “When a patient’s mood is low, he often has a poor appetite and is also less willing to seek out food.”

Palliative chemotherapy Dr Tan is already finding the information useful when treating patients. Those with all four risk factors may benefit from simple interventions such as help with meals in the community, dental assessment or a referral to a medical social worker. “Those who eat well and are healthier tolerate treatment better, have a better quality of life and a better survival outcome. Malnourished patients suffer more toxicity, complications and side effects from chemotherapy. By identifying those who may not benefit from chemotherapy, we can intervene early to treat them in other ways, like

Don’t assume that the old lose their appetite as they age “Many people assume it is common and all right for this to happen, but it is not always normal. Find out the causes and be aware of the risk factors commonly associated with malnutrition. Highlight any to the patient’s doctors so that they can intervene earlier and help the patient.” It is possible to be overweight yet malnourished “The elderly patients who took part in our study weighed between 21kg and 81.3kg. Malnutrition occurs when people don’t get the right nutrients in the right quantity. It’s possible for someone to be overweight, or even obese, yet suffer from malnutrition, as he could be eating inappropriate or unhealthy food.”

working with a dietitian to improve their oral intake, prescribing supplements, and making them more comfortable,” she said. Dr Tan said there is a need for more information on how to treat elderly cancer patients. “Globally, the population is ageing and we’re treating patients who are older and older. We need more such data and other studies to help us treat them more effectively.” She hopes that her study, which won a prestigious award from the American Society of Clinical Oncology Merit Awards in 2013, will raise greater awareness in patients and their caregivers of the risks of malnutrition. The geriatric oncology team at NCCS is working towards forming a dedicated multi-disciplinary team of physiotherapists, nutritionists, occupational therapists, oncologists and geriatricians to treat elderly cancer patients. *The patient’s description is based on a typical patient profile from study.

MARâ&#x20AC;&#x201C; APR 2014

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MAr– Apr 2014

New heart centre now open The new building is age-friendly and ready to take on an expected increase in heart patients in the future

he new National Heart Centre Singapore (NHCS) is opening its doors to patients on March 10. The new building is located at 5 Hospital Drive, opposite Singapore General Hospital’s (SGH) Block 4. A pedestrian underpass is currently being built to link it to Block 4 and the SGH campus. With a gross floor area of 48,000 sq m, the new building is twice the size of the previous one, with 38 specialist outpatient clinic rooms, six cardiac catheterisation labs, and three major operating theatres. The increased space and amenities will help it cope with an expected increase in patient load. Currently, NHCS sees more than 100,000 outpatients yearly, with about one in three over 65 years old. Singapore’s ageing population will contribute to the growth in overall

demand for cardiology services in the coming years, with the number of people aged 65 and above expected to triple to 900,000 by 2030. Designed with patients, visitors and staff in mind, the building has a host of features that make it a safe, accessible and comfortable environment for everyone. These include: Age-friendly signage, lighting, colours and amenities. A One Queue One Bill system to make the outpatient experience simpler and faster. A new short stay unit for patients undergoing day procedures or surgeries, such as coronary angiography and coronary angioplasty. The inpatient wards – Wards 44 and 56, and the Cardiothoracic Surgery Intensive Care

map: SGH

By Desmond Ng

Unit (CTICU) – will remain at SGH. A patient-centric layout, with key clinical services conveniently sited at levels 4 and 5. Planned as a digital heart hospital, the new building makes use of technology to improve processes and care. One and a half floors are dedicated to cardiovascular research. The building received the Building

and Construction Authority Green Mark Platinum Award 2012 for its energy efficient and eco-friendly features. These include extensive natural ventilation in the concourse area, an efficient air-conditioning plant and regenerative lifts that generate energy when moving. These features cut energy use by 30 per cent and carbon emissions by 3,000 tonnes annually, saving an estimated $1.3 million each year.

MAR– APR 2014

singapore health

NEWS

A bag for all things

A bag large enough for a laptop and fastened with a security tie to keep valuables safe while patients undergo surgery has won a Singapore Health Quality Service Award By Desmond Ng

AT THE CENTRE...

The previous process of collecting and listing patients’ possessions, and signing for them, took a long time. Ms Irene Goh Seok Tin, Nurse Clinician, SDA Centre, SGH

The eight-member team, who called themselves the Super United Rangers, comprised nurses from the SDA Centre and wards, admissions office staff and porters. Together, they brainstormed and identified the key problems. They found that the standard hospitalissued bag used to hold patients’ valuables was too small, so some needed several bags to hold all their belongings. Securing so many bags was difficult, and there was the danger of a bag or two coming loose. “It’s common for patients to bring their laptops, iPads, mobile phones and even large, expensive designer handbags. It was hard to fit these items into the bags,” said Ms Goh. The time taken to collect and itemise each patient’s belongings took an average of 13 minutes. The SDA Centre reg-

PhotoS: VERNON WONG

espite reminders, many patients scheduled for surgery at the Singapore General Hospital (SGH) continue to bring their valuables with them. If no one accompanies them, this puts the responsibility of keeping their possessions safe on the hospital staff. The task is tedious and thankless, and can also lead to delays in surgery. At SGH’s Same Day Admission (SDA) Centre, a group of nurses decided to do something about this problem. The efforts of the team, which included staff from other departments, didn’t just lead to a more efficient way of accepting and keeping patients’ possessions – it also won them prizes. “The previous process of collecting and listing patients’ possessions, and signing for them, took a long time,” said Ms Irene Goh Seok Tin, Nurse Clinician, SDA Centre, SGH. “So we decided to look at what we could do. The new process takes less time, is simpler for both staff and patients and makes our nurses happy.”

Before surgery, patients drop their belongings into a custom-made bag. It is fastened securely with a cable tie. The nurse and the patient no longer need to go through the tedious process of checking each item kept with the hospital. The new plastic bag is larger, made of a stronger material and secured with a plastic cable tie, complete with a unique serial number (inset) for easy reference.

isters about 11,000 patients a year, or an average of 50 a day, of whom 20 will typically bring their belongings, said Ms Thurgathavi Vellasamy, Nurse Clinician, SDA Centre, and a team member. Previously, an SDA nurse delivered belongings in the afternoon to various wards after surgeries ended and the patients were sent to the wards, located in different blocks in SGH. Sometimes, a patient whose surgery ended early might not want to wait till the afternoon and would ask for his things to be delivered promptly. Then, a nurse would have to drop what she was doing to make the delivery. The team considered many options, eventually settling on a custom-made plastic bag that is larger and made of a stronger material. Now, patients just need to put all their things into one bag. Tightened with a drawstring, the bag is further secured with a cable tie that comes with a serial number. There is no need to check and list each item. Ms Goh said: “Now, patients just drop their

things into the bag and nurses don’t have to itemise each piece of property – they just need to tie it up and have the patient sign on a form with the serial number included (to acknowledge that their things have been safely placed in the bag).” Collecting items from patients now takes about three minutes, while distribution time is zero, as the hospital’s porters and not the SDA nurses deliver the bags every day at two scheduled times – 11am for patients who undergo early surgeries, and 4pm for the later ones. This leaves the nurses free to do their work – calling patients scheduled for the next day’s surgeries, educating and counselling patients, and making other preparations, said Ms Goh. At the same time, surgeries are no longer held back by the previously lengthy process of documenting patients’ possessions. Their solution won the Super United Rangers two awards: a gold award at the Team Excellence IQC, and the Singapore Health Quality Service Award 2014.

Patients can be admitted to the Singapore General Hospital’s (SGH) Same Day Admission (SDA) Centre a couple of hours before their scheduled surgeries, instead of the day before. This saves them time, ward and other charges. Patients scheduled for procedures under SGH’s general surgery, gynaecology, colorectal, dental, neurosurgery, ENT, orthopaedic, hand and plastic surgery departments may be admitted on the day of surgery if they are deemed well enough. They would have gone through various pre-surgery tests about a week before, at SGH’s Pre-Admission Testing Centre. Patients with chronic illnesses like diabetes must be in stable condition, or will be admitted a day before surgery. Patients scheduled for some complex procedures are ineligible for same-day admission because of pre-surgery preparations. The SDA Centre admits about 80 per cent of the patients who go through surgery at SGH. A nurse from the SDA Centre calls patients a day before to explain various aspects of the surgery. Patients arrive two hours before their surgeries to register and take care of surgery-related paperwork. Their vital signs are checked to determine that their conditions have not changed since the pre-admission test done about a week before. Nurses explain to patients again what happens before and after surgery, and how they might feel after surgery. After changing into operation gowns, patients wait to be taken to the operating room. Their families and friends wait at the SDA Centre for updates from nurses. When surgery is completed and a patient is sent to the ward, his relatives and friends will be told his ward location and contact number.

MAR– APR 2014

It’s about living, not dying To some, palliative care is an unglamorous field of medicine. To her, it is full of meaning By Denyse Yeo

I never use the phrases ‘letting go’ or ‘giving up’. People are stronger than we give them credit for. Dr Alethea Yee, Senior Consultant and Head, Department of Palliative Medicine, NCCS, on how the human spirit is resilient and adaptive, and Patients constantly adjust their goals as reality sinks in

At that time, there were few palliative care doctors in Singapore. But Dr Yee was fortunate to be mentored by the HCA Home Hospice’s Medical Director then, Dr Rosalie Jean Shaw. An Australian, Dr Shaw was involved in developing Singapore’s hospice movement, and is hailed as a pioneer of palliative care both here and in the region. “Dr Shaw taught me that there was a lot to learn from patients, and that this is both art and science. She encouraged me to take my postgraduate exams in Internal Medicine and find a formal pro-

Photo: Jasper Yu

n encounter with a dying patient at Dover Park Hospice 16 years ago changed the life of Dr Alethea Yee, Senior Consultant and Head, Department of Palliative Medicine, National Cancer Centre Singapore (NCCS). A young medical officer then, she met the patient who had motor neurone disease, a rare degenerative illness that damages the nervous system, resulting in paralysis, loss of speech and being dependent on a machine to breathe. “I got to know him not just as a doctor but as a friend, as he spoke to me about his life, his joys and his suffering. While treating him, I discovered that suffering is transformative both for patient and doctor.” She said that having someone listen to him helped him feel affirmed as a person. “He wasn’t ignored, because you do get invisible in that situation. I learnt how people can be resilient and courageous in the midst of tremendous suffering, and carry on living with respect and dignity.” It was at that point that she realised palliative care had a lot to teach her about life. “Because of him, I chose to go into palliative care. It resonated with me at the deepest level and reaffirmed the reasons why I became a doctor. Although tough and challenging, it is meaningful because in the midst of a sad situation, you can discover joy and hope.”

To Dr Alethea Yee, if hope is communicated well to patients, it helps them and their families refocus their efforts on more achievable goals and find some meaning in their remaining time.

gramme in which to train in palliative care.” However, no such formal training existed in Singapore then. So Dr Yee went overseas for her postgraduate medical examinations and sub-speciality training in palliative medicine. Many patients, few doctors In 2006, she returned to Singapore and joined NCCS to help run its Palliative Medicine department. Today, with more than 25 doctors, nurses and support staff, it is one of the largest palliative medicine departments in Singapore and has its work cut out for it. With an ageing population, the number of patients with cancer and chronic illnesses who need palliative care has increased dramatically. What makes the situation even more challenging is that it has been regarded as an unglamorous and depressing field of medicine, with few doctors choosing to specialise in it. Still, Dr Yee, who is also Director of Education at the Lien Centre for Palliative Care, Duke-NUS, remains optimistic about the future. “The situation is much better now than 10 or 20 years ago, and new cohorts of young doctors are open to the concept, but more can be done to encourage doctors to specialise in it. The medical curriculum started some years back to include this speciality. Mentoring can also show young doctors that this is a job with meaning.” Message of hope Dr Yee does, however, admit that it can get emotionally draining. “Dying is often a sad affair, and we feel their sadness.” She also believes that it is important to bring the message of hope in palliative care to patients. “There’s always hope. It

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all depends on what’s being hoped for. People tend to associate hope with cure. But there are many other goals to hope for if cure is not possible.” To her, if hope is communicated well to patients, it helps them and their families refocus their efforts on more achievable goals and find some meaning in their remaining time. “I never use the phrases ‘letting go’ or ‘giving up’. People are stronger than we give them credit for. The human spirit is amazingly resilient and adaptive. Patients constantly adjust their goals as reality sinks in.” She said that palliative care is about how patients can live well in spite of their life-limiting illnesses. “It’s not about alleviating all suffering because that’s not possible, but making it more bearable. It is about living, not dying.” Dr Yee added that a supportive team is important. Her department recently started a pilot project to help manage burnout among staff. It is a monthly focus group session led by an external psychiatrist to share and make sense of difficult situations. If successful, Dr Yee will share the initiative with other departments in NCCS. Her other support system is her family. “I have a very supportive husband and three lively kids. When they hug and kiss me, I am reminded of life and its joys. That’s my coping strategy.”

people

singapore health

MAR– APR 2014

Saying it with music

What cannot be expressed in words can be communicated, ever so gently, with music

he works in a hospital but unlike a nurse or doctor, she has no stethoscope or thermometer on her. Her tools include shakers, lollipop drums, bells, guitars, a ukulele, and a q-chord – a synthesiser-like instrument that can create sounds from a wide range of instruments and rhythms. Ms Ashley Spears is a Music Therapist at KK Women’s and Children’s Hospital (KKH). Her job is to use music to soothe and help patients in the healing process. Unlike what some people think, she does not sing to entertain, but since she has a good voice, it is hard not to

enjoy the music. Armed with a college degree in music therapy from the US, Ms Spears handles children and adult patients referred to her by doctors for help. Attending health professionals such as social workers can also refer patients to her, but referrals must be approved by a doctor. The power of music Doctors generally refer distressed and anxious patients to Ms Spears in the hope that songs and self-expression can help them redirect their focus from their illness or fears to more positive feelings.

Photo: Winston Chuang

By Sol E Solomon

As a Music Therapist at KK Women’s and Children’s Hospital, Ms Ashley Spears’ job is to use music to soothe and help patients in the healing process.

This will help them regain control of their situations, which they tend to lose when illness strikes. “Music cannot cure, but research shows that it helps,” said Ms Spears. She is aware that patients in hospital face an unfamiliar environment and a lot of unknowns. “They don’t even decide what time they get to eat, so there’s this loss of control. But music can help them cope better with their difficulties.” One of her most heart-rending cases involved singing to a dying baby girl to help her parents say goodbye. Her parents sang with Ms Spears, and by doing that, although heartbroken, they found the strength to be with and support their terminally ill child as she neared her end. Another case was when she used music to lift the spirits of a frequently hospitalised teenage girl who often found herself isolated. Music lifted the girl’s mood so much that when she sang her favourite song, Justin Bieber’s Baby, the therapeutic process led her to create her own lyrics to the chorus, and she sang, “Make my platelets come back, oh!” “It was her way of saying that she understood why she was in hospital. And being able to share this put her back in control of her treatment, because she could sing about it,” she said. Why music is therapy Ms Spears starts therapy by asking patients about their favourite songs, interests, and if they have ever played an instrument. If she does not know their favourite song, she will find something similar to use during the first session, and learn it for the next. She said that music therapy is a triangular relationship between therapist, patient and the music, which helps with communication, especially when some things might be hard to say directly.

Most of her patients are children, but she also works with women hospitalised with cancer. She also facilitates the hospital’s breast cancer support group choir, which is made up of women who are either currently undergoing treatment, have recently completed their treatment, or are in remission. “The focus of this group is not therapy, but on supporting each other through living with cancer, by singing together as a choir,” she said. Culture buff Ms Spears grew up listening to pop music. She took piano and voice lessons, sang in choirs, joined vocal competitions and did musicals, the last one being Grease in college. She loves musical theatre, but realises it offers little security. So, while researching which college to attend, she and her mother came across a music therapy undergraduate course at the liberal arts college, Queens University of Charlotte in the US. She decided to do that. After graduation, her other love – exploring the world and cultures – took hold. She spent a year in Germany and moved to Singapore three and a half years ago when the opportunity at KKH came up. She said it was her colleague, Ms Melanie Kwan, Senior Music Therapist, KKH, who started the music therapy programme in the hospital, and worked hard for a grant which let Ms Spears come over. Since being here, she has learnt Malay, Mandarin and Hokkien songs, as well as some K-pop which many of her patients enjoy. She said, “K-pop’s catchy and I kind of caught on to that. There are also some really good songs in Malay that are sentimental, similar to the style of Mariah Carey or Celine Dion. Those are really fun to belt out.” On Mandarin and Hokkien songs, she said, “My pronunciation may not be great but the patients love it because it sounds familiar to them.”

MAR– APR 2014

singapore health

Money

The price of addiction

Anyone grappling with an addiction, whether it is gambling, drugs, alcohol or the Internet, can find help at the National Addictions Management Service By Stella Thng

hundred and fifty thousand dollars. That was the total gambling debt that Mdm Karen Chan*, 65, racked up over a two-year period by frequenting floating casinos with her ex-colleagues. Mdm Chan started gambling after she retired. With time on her hands, and with no real interests or friends outside of work, she had found life boring and meaningless. After winning several thousand dollars during her first few visits, Mdm Chan felt a sense of accomplishment and control over her life again. Then, she started losing. Before long, she had exhausted her savings and maxed out her credit cards. Soon, winning or losing became unimportant. She was addicted to the rush she got from gambling, and was spending a great deal of time in casinos. She was well and truly an addict. Fortunately, Mdm Chan had a caring daughter who persuaded her to seek help from the National Addictions Management Service (NAMS), which was set up by the Institute of Mental Health (IMH).

From April 2011 to March 2012, the two helplines that NAMS runs, received 23,000 calls for help. Of those who eventually sought treatment for addictions, 356 were for gambling, 520 for drugs and 418 for alcohol.

NAMS has helped pathological gambling addicts – as well as those addicted to drugs, alcohol, the Internet, and other behaviours – to improve their conditions with treatment. It also runs a dedicated outpatient clinic for adolescents, private and subsidised patients, and an inpatient ward for patients who need detoxification and rehabilitation. With treatment, Mdm Chan began to understand that her gambling addiction was a result of the deep loneliness and isolation that overwhelmed her as she adjusted to life after retirement. In group counselling sessions, Mdm Chan learnt how to overcome temp-

tation, and to recognise the triggers of her addictive behaviour. For example, she learnt to say “no” tactfully to friends who invited her to floating casinos, to call a friend for support when the going got tough, and to avoid places where she would be tempted to gamble. With help from NAMS, Mdm Chan has not gambled for two years now. She leads a more fulfilling life and enjoys better relationships with her family members. Mdm Chan is just one of many people who have sought help from NAMS to curb their gambling and other addictions. From April 2011 to March 2012, the two helplines that NAMS runs – the National Problem Gambling Helpline and the All Addictions Helpline 6-RECOVER – received 23,000 calls for help. Of those who eventually sought treatment at NAMS, 356 were for gambling, 520 for drugs, and 418 for alcohol. According to the NAMS website, after three months of treatment, 76 per cent of those who sought help for gambling addiction saw improvement, while 68 per cent of patients with alcohol addiction said they had quit or reduced their drinking. According to IMH, among patients successfully reassessed at six and 12 months, these initial observed benefits were sustained for up to a year, as noted during the one-year observation period.

According to the NAMS website, after three months of treatment, 76 per cent of those who sought help for gambling addiction saw improvement, while 68 per cent of patients with alcohol addiction said they had quit or reduced their drinking.

NAMS uses an integrated, multi-disciplinary approach that combines medical and psychosocial therapy. A psychiatrist first assesses the patient for psychiatric conditions such as depression or suicidal or anxiety tendencies, and other addictive disorders. He then draws up a treatment plan, or refers the patient to a psychologist if necessary. A counsellor provides psychosocial therapy during individual counselling sessions, using various approaches like motivational interviewing, cognitive behavioural therapy, and active case management. Patients and their families are encouraged to attend NAMS’ evening group counselling programmes, which consist of psycho-educational and support groups. Two phases of treatment take place over 21 days – detoxification (one week) and rehabilitation (two weeks). Patients with gambling addictions undergo only the rehabilitation phase. Patients can also opt for acupuncture treatment at $200 for 10 sessions, which reduces the severity of withdrawal symptoms, pain, cravings, and symptoms of comorbid disorders such as mood disorder and anxiety. *The patient’s name has been changed to protect her privacy.

Treatment rates at NAMS

Like other health-care institutions, the National Addictions Management Service (NAMS) offers a range of rates for private and subsidised patients who are citizens, subsidised patients who are permanent residents, and nonresidents. Adolescents pay a separate set of rates. For instance, subsidised patients pay $31 for their first consultation, which can be with a registrar, associate consultant, consultant or senior consultant. Private patients pay between $75 (to see a registrar or associate consultant) and $105 (for a senior consultant). First-visit rates for non-residents range from $97.50 to $136.50. Subsidised counselling fees range from $6 to $21. Full fees range from $14 to $65. These do not include the costs of medication, laboratory tests or other investigations. For a full list of charges, go to www.nams.sg/patient-information/Pages/Charges.aspx. Medisave and MediShield cannot be used to pay for outpatient services, but can be used for inpatient bills from NAMS. Medifund, the government endowment fund for needy Singaporeans who cannot afford even subsidised medical expenses, is available to eligible Singapore citizens. All applications must be approved by the Medifund Committee. People with difficulty paying their medical bills can approach a medical social worker for help. To get help, call NAMS’ All Addictions Helpline 6-RECOVER (6-7326837), or the National Problem Gambling Helpline 1800-6-668-668, or visit nams.sg.

singapore health

MAR– APR 2014

Health Xchange Side effects of medication for hypertension I have been monitoring my blood pressure and it has hovered between 135140/80. I have reduced my sugar and salt intake for 11 months, but am wondering if I need to start taking medication. If so, what are the side effects and will they affect renal function? When you measure your blood pressure (BP) at home, it should be done after sitting down for at least five minutes, and not soon after drinking coffee. Home BP readings should, on average, be below 135/85 mmHg, so it does sound like you have hypertension. However, please verify this with your doctor. Hypertension is a silent disease without symptoms, which can slowly damage internal organs such as your heart and kidneys. If you are concerned about kidney disease, you should consider starting medication for this. Medication will not cause kidney damage. Treatment is likely to be lifelong, but it is important to reduce long-term complications, such as worsening kidney function, heart attacks or heart failure, and stroke, through optimal blood pressure control.

There are several classes of medication for hypertension, each with different side effects. Most people tolerate medication well without side effects, especially if a low dose is used. See a doctor to discuss which medication is suitable for you. In addition to reducing salt intake, try to stay active. The Health Promotion Board recommends about 30 minutes of moderate intensity exercise five days a week. Any increase in physical exercise can help control your blood pressure. Dr Andrew Ang, Family Physician, Geylang Polyclinic

Our experts answer all your questions about health

Does spicy food worsen acid reflux?

I was diagnosed with acid reflux recently. My problem is not serious but I understand that severe cases can lead to hoarseness in the voice. Is this true? Will eating spicy hot food aggravate my condition? Acid reflux, or gastroesophageal reflux disease, occurs when acid and digestive juices travel upwards from the stomach into the esophagus, and sometimes into the throat, burning the lining of the throat and voice box. In mild cases, the throat becomes sore and hoarse and phlegm develops. In more severe cases, the throat swells and becomes ulcerated, and polyps may form. The muscles around the throat may also tighten. Some foods may increase the level of acidity in the stomach or loosen the lower esophageal valve. The valve

Worried about ovarian cysts

What are the chances of ovarian cysts recurring after removal? What percentage of these cysts tends to be cancerous? Ovarian cysts are relatively common among women. Treatment may depend on factors such as the size of the cysts, the patient’s age, her menopausal status, and specific medical conditions and risks. Most ovarian cysts are benign or functional cysts. The risk of small cysts (less than 5cm long) on a single ovary in a premenopausal woman being cancerous are

prevents acid and stomach contents from travelling backwards. Food that is spicy, sour, or greasy, like char kway teow and laksa, are culprits, as are caffeine and tobacco. Overeating can worsen or bring on acid reflux. After a heavy meal, the stomach becomes distended and the lower esophageal valve gets stretched. People who suffer from acid reflux should not go to bed immediately after eating. Ideally, they should stop eating three hours before going to bed. Some ways to ease the symptoms of acid reflux include elevating the head of the bed so that the body is raised from the waist up, maintaining a healthy weight and lifestyle, and not wearing tight clothing. Department of Otolaryngology, Singapore General Hospital

usually low. Half of functional cysts disappear upon follow-up ultrasound scans, done once every four months. Larger cysts may need closer follow-up until they are gone. Consult your doctor if any earlier cysts removed have borderline or malignant potential. If so, then there is a possibility of further surgery, or even chemotherapy, for patients at higher risk. Dr Francis Chin, Senior Consultant, Department of Radiation Oncology, National Cancer Centre Singapore

Stopping diabetes medication completely If a diabetic normalises his blood sugar levels over time, is it possible for him to stop medication completely? It depends on how long the patient has had diabetes and how much medication he is on. The longer he has had the condition, the less his body is able to produce enough insulin (the hormone that controls the blood sugar level), and the less likely he can manage his blood sugar level without medication. The more medication he needs to keep his sugar level within the “normal” range, the less likely he can stop taking medication. Most Type 2 diabetics are overweight. Too much body fat causes resistance to the action of insulin. If the patient can maintain a healthy weight, there may be a chance that medication may be stopped. For Asians, the ideal body weight is when the Body Mass Index (BMI) is between 18.5 and 23. BMI is calculated by dividing the weight, in kilograms, by the square of the height in metres. Some elderly patients who have lost weight because of smaller appetites may sometimes be able to control their blood sugar without medication. Most patients on oral diabetic medication will need to take it for life. Diabetes is a lifelong condition but it can be controlled with diet, exercise and medication. If your control is good, ask your doctor if your medication can be reduced; you will need to continue monitoring your sugar level in case it creeps up again. If it does go up again, it probably means that you should not stop taking medication. Dr Ian Phoon, Family Physician, Pasir Ris Polyclinic

These articles are from www.healthxchange.com.sg, Singapore’s first interactive health and lifestyle portal.

Topics for discussion in March-April 2014: Second-hand smoke and children, will writing and foot problems

MAR– APR 2014

singapore health

Opinion

Having second thoughts...

PHOTO: Getty Images

When faced with the prospect of major knee surgery, Mdm Eng sought a second opinion, and was glad she did

By Mdm Eng*

started having problems with my left knee in 2006. For no apparent reason, it would make a clicking noise before giving way, causing me to fall over. The first time it happened, I was in class. When I stood up to talk to a pupil, I heard that “click” and before I could catch myself, I had fallen. The students were shocked. I was very embarrassed. A few weeks later, I was walking to class when I fell over in the school field and got mud all over myself. At home, there were times when I would hear the “click” and lose my balance. I managed to steady myself each time. At first, I put my falls down to clumsiness. But by 2007, I was falling as often as several times a day so I went to see an orthopedic surgeon. Two doctors, two diagnoses After an X-ray, the doctor said my kneecap was worn out and had to be replaced with a plastic one in a procedure that would require me to be under general anaesthesia. He said I should have the operation as soon as possible, adding, “What if you fell down while crossing the road one day?” He gave the diagnosis very matter-offactly, and he gave me an appointment for the operation in a month’s time. I felt like crying. Although I would only have to pay 20 per cent of the ward charges because I was under the old (civil service) pension scheme, I did not want to have the operation as I was worried about the pain and the recovery time. I would have to walk with a cane for a

while after the operation. I did not want to be perceived as an elderly woman with limited mobility either. Friends who had gone through the same procedure told me that the artificial knee would last for only about 10 years. I could not help wondering if the doctor’s diagnosis was right, and if there were alternatives. I felt confused and overwhelmed, and decided to get another opinion. Through a friend, I went to see an orthopedic surgeon at another hospital.

I was really glad I sought a second opinion. It was not an easy decision to make, and it would have been even harder if i had had a life-threatening condition. The second doctor recommended keyhole surgery to fix my kneecap, which he said was out of alignment, probably because of a fall in the past. I would not have to remove my kneecap; I just had to have it pushed back into place. And because only a small incision would be made, the

recovery period would be very short. I was so relieved to hear that I would not need a major operation. The doctor gave me confidence and I felt comfortable with his suggestion, so I decided to go for keyhole surgery. The operation went smoothly. I felt only slight pain when I was transferred from the stretcher onto the bed. I stayed in hospital overnight for observation. The bandages were removed the next day. A physiotherapist taught me how to walk without straining the knee, and I did not have to use a walking aid. By the time I returned home the next day, I was able to walk without pain. My son was surprised at how mobile I was. I did the exercises the physiotherapist taught me for a month, and recovered fully. I even travelled to China with my sisters a month after the surgery. We walked a lot and climbed a long flight of steps up a mountain. Today, I have no problems with my knee or with walking long distances. I

exercise regularly, and brisk-walk 4km twice a week. The removal of a kneecap is a major surgical procedure that one should go through only if it is absolutely necessary. A second – or even a third – opinion is a good idea before opting for a major procedure, as it will have a big impact on your life, such as a lot of pain or even immobility. It is important to find a doctor in whom one has trust and confidence. I was really glad I sought a second opinion. It was not an easy decision to make, and it would have been even harder if I had had a life-threatening condition. If anyone is facing the same dilemma, all I can say is this: Talk to your family members, seek help from professionals, and think long and hard about it before making your decision.

*Mdm Eng is a 65-year-old retired civil servant.

singapore health

MAR– APR 2014

Gadgets for the old and handicapped? I found your article, The Gadget Man, in Singapore Health (November/December 2013) very instructive. I am wondering if your researchers are working on other gadgets that would help the old and handicapped. Do you have any gadgets that can relieve the overpowering bad breath that is a symptom of trench mouth, or anything that can help deodorise diaper smells? If there are any, please let me know where I can purchase them. K Soma

you for your letter and suggestions. We are glad you found the SH Thank article instructive. Our department is constantly working on new devices

says which we hope will be useful to patients. We collaborate closely with our academic partners who provide the technical know-how and expertise to bring our suggestions to fruition. Unfortunately, we have no devices specific to the functions you enquired after, nor do we know of any currently on the market. However, as we are always exploring new ideas, we will certainly discuss your suggestions. This letter wins a value pack of Heritage® Cordyceps CS-4. The product, worth $94, is sponsored by Heritage® by HST Medical, Singapore.

Registration of caregiver done repeatedly

be accompanied by a different caregiver each time. The caregiver, who may be a family member or a domestic helper, accompanies the patient for the duration of his stay in hospital and is not considered to be one of the four visitors that each patient is allowed to have. The SGH provides caregivers with two sessions of training, where qualified trainers teach them how to assist the patient with bathing, feeding, changing positions in bed, and transferring between the bed and chair. The training is free but registration is necessary. You can get more details from the nurse manager of the ward.

I suffer from a serious renal condition, and am admitted to the Singapore General Hospital (SGH) frequently. Why do I have to register my caregiver at each admission? Her details should be in your computer system, so you can register her by default and spare us from having to do it at every admission. require the patient’s careSGH We giver to be registered at each

says

admission as the patient may

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I would like to offer a special word of thanks to Professor Fong Kok Yong, Chairman, Medical Board, Singapore General Hospital (SGH), and Ms Christine Chua Chew Thoe, Principal Enrolled Nurse, Autoimmunity and Rheumatology Centre (ARC). Both of them have been attending to my medical needs for more than a decade, and I’m embarrassed to admit that I have not written a word of thanks to them over the years. They represent the pinnacle of excellence in patient care and service. The rest of the ARC team – from registration to payment – are just as fabulous. Thank you for your wonderful care, SGH and ARC team! - Mr Leon I would like to thank the surgeons who have been attending to me at the Department of Hand Surgery, SGH. I am particularly grateful to Dr Chong Chew Wei, Registrar, who has been overseeing my recovery. She has been very careful, reminding me repeatedly to keep my wound dry. She has been very thorough in reviewing my progress. I am now on the way to recovery. - Mr P Lek We had a very lovely experience recently. The driver of an SGH shuttle bus took the trouble to carry an elderly, wheelchair-bound man on and off the bus as he was having a lot of difficulty moving. Not only was this driver compassionate and helpful, he was also very cheerful. We had the honour of having him as our driver! We didn’t get his name, but he drove bus PL 4858 K. - Mr E Upatissa We are very grateful to Ms Yasotha Devi Devathas, Patient Service Associate, Department of Occupational Therapy, SGH, for helping us buy pressure stockings, which my mother needs for her varicose vein problem. Although my mother’s doctor had given her a letter stating that she requires lifelong stocking therapy, she was unable to buy the stockings because she had been discharged and was no longer being seen at SGH for her varicose vein problem. My mum urgently needed to replace her worn stockings as she was due to travel shortly. We were worried about the health risks if she did not wear pressure stockings during a long flight. Ms Devi took the time to understand our problem and with her help,

we managed to buy two pairs the same day. The following week, Ms Devi followed up with the head of the relevant department, who had not been at work as we were at SGH on a Saturday. Shortly after, we received an appointment card to facilitate our future stocking purchases. By listening to patients, understanding their needs and going out of her way to help them, Ms Devi exemplifies the SGH motto. My mum and I hope SGH will recognise her dedication and professionalism. Thank you again, Ms Devi! - Mr P Sim I have always been afraid of needles. In the past, I would complain if staff or nurses who were carrying out a procedure were not responsive, and did not show any care towards patients like myself. I was impressed, however, by the good and polite service of the radiographer, Ms Tan Siok Bin, and two of her colleagues from the Department of Neuroradiology, National Neuroscience Institute (NNI). They were very attentive. I have never received such good care before. Overall, I am delighted and happy. I am assured that choosing NNI was the right choice for me. - Ms Siti Syahida Our family wishes to say a big thank you to everyone who cared for our mother during her stay at the National Heart Centre Singapore (NHCS). No words can truly express how grateful our family is to you all. First, a big thank you to Associate Professor Kenny Sin, Head and Senior Consultant, Department of Cardiothoracic Surgery, NHCS, for carrying out a difficult operation and giving my mother a new lease of life. A big thank you also to Dr Philip Pang, Registrar, from the same department, for going the extra mile to provide updates about my mum’s condition and the medical team for their support and encouragement. All the nurses, especially Nurse Clinician Tan Sin Yain, were wonderful. We could not have made it without the wonderful physiotherapists, Ms Lim Xue Ling and Ms Nadiah Bte Mohamed Rahim, who helped us right from the beginning, and Ms Chloe Kong and Mr Nai Thye Heng, who helped my mum stand after being in bed for so long. Thank you too to Senior Staff Nurses Huang Na and Zhang Xiaoxia for helping to cut my mother’s hair. We are very grateful. - The family of Mdm Lim

about your health experience 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.

Ask for your no sugar added Nonya Kaya and Jams at: Singapore General Hospital, Changi General Hospital, Alexandra Hospital, Khoo Teck Puat Hospital, Raffles Hospital, NHG Polyclinics & Jurong Medical Centre. For Enquiries: (65) 8181 2995

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The winner will receive a bottle of Ultra Selenium (60 capsules). The product, worth $68.50, is sponsored by United Pharma Pte. Ltd.

MARâ&#x20AC;&#x201C; APR 2014

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FYI

singapore health

Mar– Apr 2014

2.45pm–5.30pm (in Mandarin) Venue SGH Block 6 Level 9, Deck on 9 FEE $5 per person REGISTRATION Call 6576-7658 or email name and contact details to public.forum@sgh.com.sg Dr Tan Kian Hian, Director of SGH’s Pain Management Centre, and other specialists will talk about the 10 most common pain conditions and their treatment options, including acupuncture.

beat anxiety

Source: American Psychological Association

An apple a day for those

over 50

University of Oxford researchers said apples give a similar boost to cardiovascular health as medicines, such as statins, with none of the side effects. The researchers based their study on mathematical models, calculating that if adults over 50 either ate an apple a day or were given a statin drug as a preventive measure, the medication would save 9,400 lives anually while the apples could save 8,500 a year. an apple a day saves

Mobile phone use Frequent use of mobile phones by university students is tied to poorer academic performance and increased anxiety and unhappiness, according

frequent user

academic performance life satisfaction

Source: Medical News Today

1. Name one symptom of Long QT Syndrome. 2. Which story in this issue did you find the most informative? Closing date: April 2, 2014 Send in your answers and stand to win a bottle of Spirulina 100% Extra 10% Deep Ocean Water (750 tablets) worth $69, sponsored by IMI Lifestyle Products Pte. Ltd.

gnrsdu@sgh.com.sg The SGH’s Sleep Disorders Unit, a multidisciplinary team of doctors and surgeons, will talk about insomnia, sleep apnoea and other common sleep disorders, and their prevention, management and treatment.

a statin drug saves

9,400 lives

Baby Weaning Workshop Date March 22, Saturday Time 10am-12pm (pre-

registration at 9.45am) Venue KK Women’s and Children’s Hospital Training Centre, Conference Room 2, Women’s Tower, Level 1 Fee $10 per person (KKJC member); $15 per person (non-KKJC member) REGISTRATION Closes on March 7, Friday. For more information, call 6394-1268 (Monday–Friday, 9am–5.30pm) or log on to kkh.com.sg. This two-hour workshop is for parents who are weaning their babies aged six months and older. The hospital’s nutritionist will speak about baby nutrition and weaning.

The researchers concluded that drugs as well as healthier living can make a real difference in preventing heart disease and stroke. They added that no one already taking statins should stop, although they should, by all means, eat more apples. Source: BMJ (formerly the British Medical Journal)

contest

Not All Who Sleep Are Rested Date March 15, Saturday Time 10am–12pm Venue SGH Block 6 Level 9, Deck on 9 Fee $5 per person Registration Call 6326-6621 or email

▲

to a study in the journal, Computers in Human Behavior. Researchers from Kent State University in Ohio surveyed more than 500 students about their mobile phone use, and compared their responses with their grades, and results of clinical tests they took for anxiety and life satisfaction. They found that the higher the mobile phone use, the poorer the grades. Higher mobile phone use was also linked to higher levels of anxiety.

8,500 lives

sgmyeloma@gmail.com Haematologists from SGH and NUH are among the speakers at this forum about stem cell transplants and other myelomarelated topics.

▲

linked to poorer grades

Auditorium

FEE $5 per person REGISTRATION Call 9779-1581 or email

▲

It may sound counter-intuitive, but people perform better during anxiety inducing activities such as public speaking and math tests when they tell themselves to get excited rather than to relax, according to a study published by the American Psychological Association. In one experiment at Harvard University, 140 participants were told to say “I am excited” or “I am calm” before giving a speech in front of a panel of judges. Those who said they were excited gave longer, more persuasive and competent speeches and were more relaxed than those who said they were calm.

4th National Myeloma Patient Forum

DATE March 8, Saturday TIME 9am–2pm VENUE NUH Main Building, Dental Centre

Source: Journal of the Academy of Nutrition and Dietetics

Get excited to

Top 10 Pains! 十大疼痛! Date March 1, Saturday Time 12pm–3pm (in English),

▲

photo: GETTY IMAGES

event Calendar

▲

Social norms influence food choices

Is obesity a socially transmitted disease? UK researchers analysed 15 experimental studies that examined whether knowing what other people ate influenced a person’s food intake or choices. The results, published in the Journal of the Academy of Nutrition and Dietetics, showed that informing participants of other people’s low- or high-calorie food choices significantly increased the likelihood of the participants making similar choices. Lead investigator Eric Robinson, University of Liverpool, said that it “may be a way of reinforcing identity to a social group… (and that) the findings of the present review may have implications for the development of more effective public health campaigns to promote ‘healthy eating’.”

Taking Charge of Your Healthcare Costs

Date March 26, Wednesday Time 7.30pm–9pm Venue NTUC Auditorium, 1 Marina

Boulevard, NTUC Centre, Level 7

Include your name, age, gender, address and telephone number. Winners will be notified via phone or e-mail. Incomplete or multiple entries will not be considered. E-mail editor@sgh.com.sg Post The Editor, Singapore Health, Singapore General Hospital, Communications Department, #13-01 Surbana One, Blk 168, Jalan Bukit Merah, Singapore 150168 Winners of Contest 26: Each will receive a Kyäni SunriseTM 30-pack, worth $83.75, sponsored by Kyäni Singapore Pte. Ltd. Prizes must be claimed by April 2, 2014. 1. Chin Poh Seng 2. Goh Yee Ping 3. Catherine Lim 4. Benjamin Tan 5. Gary Tan

REGISTRATION Call 1800-227-1188

(Monday–Friday, 9am–5.30pm) or log on to www.cpf.gov.sg/events. Get the latest updates on the 3Ms (Medisave, MediShield and Medifund), ElderShield, and private Integrated Shield plans. This event is suitable for those who want to know more about healthcare financing in Singapore. Visit www.singhealth.com.sg/events or the websites of respective institutions for any changes, more information, and other listings.

Mar– Apr 2014

singapore health

YOUR GUIDE TO BETTER LIVING

Help your child

build resilience

Resilient children cope better with the stresses and challenges of daily life. By Lediati Tan but became unwilling to talk. She closed herself off and was always in a sad state,” she said. Her son complained of recurrent stomach aches, chest pains and headaches, and was admitted to hospital four times that year. Doctors found nothing medically wrong with him and suspected that his complaints stemmed from psychological issues. The two children were referred to mental health professionals at KK Women’s and Children’s Hospital (KKH),

and since then, Mdm Tan has noticed improvements in their behaviour. Her daughter is now more willing to talk and her son’s complaints have stopped. He has also become more caring and attentive to his sisters – a marked change from previously, when he wanted to hog all the attention. Mdm Tan hopes that her children will emerge from this time of grief more resilient, and better able to cope with future challenges in life. “This is a process and we don’t know when it will be over. We just have to keep going,” she said.

Resilience is the ability to bounce back, cope with crises and challenges... Resilient children bend but don’t break. Dr Lois Teo, Senior Psychologist, Psychology Service, KKH

Building confidence in children can help them deal with, and rise above life's challenges.

Mental health issues According to Ms Rebecca Lo, Educational Psychologist, Child and Adolescent Mental Wellness Service, Department of Psychological Medicine, KKH, emotional and mental health problems such as anxiety, depression, phobias, post-traumatic stress disorder, attention deficit hyperactivity disorder (ADHD) and eating disorders are common issues faced by schoolgoing children nowadays. She said that if parents respond negatively to their

child’s concerns and there is no timely specialised intervention, a child’s mental well-being can worsen. Dr Lois Teo, Senior Psychologist, Psychology Service, KKH, said that stress need not be due to traumatic, dramatic or catastrophic events such as divorce, death, disability or natural disasters. It can be caused by the prolonged accumulation of minor everyday stressors such as conflicts between siblings, friends or parents, being teased or bullied, and academic pressure. Ms Estelle Lim, Senior Medical Social Worker, Child and Adolescent Mental Wellness Service, Department of Psychological Medicine, KKH, said, “While children experience common psychosocial difficulties daily, support from resources like parents, school counsellors and teachers can help reduce the risk of a child developing a mental health issue.” Building resilience in kids One way to enhance children’s well-being is to help them build resilience. “Resilience is the ability to bounce back, cope with crises and challenges, and have the strength to recover and turn the stresses of life into opportunities. Resilient children bend but don’t break,” said Dr Teo. It is more than just coping. Resilient people are more prepared to seek new experiences and opportunities, and take reasonable risks to achieve their goals. She said: “Resilience is not a trait that people have or don’t have. It involves behaviours, thoughts and actions that can be learnt and developed in anyone.” However, Dr Teo said that there is no magic formula for building resilience

Resilient children have…

photo: getty images

oping with the death of a loved one is a difficult process. When her husband died suddenly of liver cirrhosis, Mdm Mary Tan (not her real name) and her three children aged five to nine struggled to come to terms with it. Soon, it became clear that her son, now 10, and the older of her two daughters, now 8, were unable to cope. Three months after her husband’s death, Mdm Tan, an administrative assistant, noticed that her elder daughter was very withdrawn. “She used to be lively,

> Continued on page 22

Strong feelings of self-esteem and self-efficacy, which is a person’s belief in his ability to succeed in a particular situation Developed systematic problem-solving skills, especially within the social context The ability to identify and describe their feelings to an interested adult Parents who clearly and consistently demonstrate warmth, care and support, and teach them positive skills and attitudes

Source: Dr Lois Teo, Senior Psychologist, Psychology Service, KKH

singapore health

Mar– Apr 2014

> Continued from page 21

Help your child build resilience

How to tell if a child is not coping? There are some signs which show that a child is not coping, said Dr Vicknesan Jeyan Marimuttu, Associate Consultant, Child and Adolescent Mental Wellness Service, Department of Psychological Medicine, KKH. These include becoming more irritable and grumpy, complaining of tummy aches, headaches and nausea when there is no underlying medical reason, withdrawing from family and friends, loss of appetite, and having difficulty sleeping. If parents are worried and their child is unwilling to talk, they should share their concerns with their child in a loving and non-judgmental way. “Tell him what you have noticed and why you are worried, and encourage him to share what he is going through. An answer may not be immediately forthcoming if he senses that he may be judged or scolded. Young people often need space and time to share their worries,” said Dr Marimuttu.

How parents can help their children handle challenges

ParentS should be empathetic, putting themselves in their children’s shoes and seeing the world through their eyes. Empathy is not agreeing with everything they do, but understanding their point of view.

Help children recognise that mistakes are experiences and opportunities to learn from.

Identify, develop and emphasise a child’s strengths to boost his competence and confidence.

Communicate effectively and listen actively. It is not just about how parents speak to children, but also about actively listening to them, and understanding and validating what they are attempting to convey. Respond in ways that avoid power struggles, such as by not interrupting them or putting them down.

9 photo: getty images

in children, as they develop at different rates and react differently to different situations. Supportive relationships in and outside the family can help, and parents can play a crucial role in this.

Teach children to make their own decisions, as this will strengthen their sense of ownership, confidence and control.

Discipline in a way that promotes self-discipline and selfworth. Ensure that parenting methods are consistent yet not rigid, and where Be flexible. Help children to see Accept them for who they are, possible, implement logical and natuthat there are many alternative and help them set realistic expec- ral consequences rather than punitive ways to solve problems if one method tations and goals. or arbitrary measures. Positive feeddoes not seem to work. back and encouragement are often the Give them a chance to con- most helpful forms of discipline. Give them undivided attentribute. Help children develop tion. Children feel loved when responsibility, compassion and a they know their parents enjoy being social conscience by allowing them with them, and this is important in to contribute by taking on chores at Source: Dr Lois Teo, Senior Psychologist, Psychology building their self-esteem. home or by doing charity. Service, KKH

Mar– Apr 2014

Dry, rough and scaly As people age, skin becomes thinner and its protective barrier can become damaged. If the condition is left untreated, intense itching, eczema and other dry skin-related conditions may develop

photo: getty images

t’s not easy being old. Among the many ailments that can affect people as they age is dry skin. The skin can feel rough and scaly at first, and if left untreated, this can lead to more serious problems such as intense itching, eczema, and other skin disorders. “Dry skin affects up to 50 per cent of elderly people,” said Dr Lee Haur Yeh, Consultant, Department of Dermatology, Singapore General Hospital, adding that intense itching, known as pruritus, and eczema are common among the old. The skin undergoes many changes with age. The epidermis, or the uppermost layer of the skin, becomes thinner, and its protective lipid (oil) barrier also becomes damaged, Dr Lee said. These changes weaken the skin’s function as a protective barrier. More moisture is lost from the skin, compounding the problem of dry skin. At the same time, the skin’s sebaceous glands – microscopic glands that secrete sebum, an oily substance – shrink, slowing down sebum production. Sebum helps to lubricate the skin and hair, and prevents loss of moisture. Initially, the skin feels dry and scaly, especially on the lower limbs and the body. If this is not treated, the dryness will worsen over time and the areas affected may become itchy, red and inflamed. Excessive scratching or rubbing will damage and disrupt the skin's barrier function further, leading to a vicious circle of itching and inflammation. Using harsh soaps, antiseptics or other topical medications may further aggravate the itch or extend the rash to other parts of the body. “This itchy, inflamed, dry and scaly rash, a result of dryness and repeated itch-scratch cycles, is known as asteatotic eczema, a form of eczema associated with dry skin,” said Dr Lee. “Skin that is inflamed, or develops eczema, is more prone to damage by irritants or allergens.” It’s not just physiological changes that contribute to dry skin. One’s environment and personal habits are also factors. Dry and cold weather, spending long periods

in an air-conditioned environment, frequent overseas travel or residence, prolonged baths, hot showers, or the use of harsh cleansers or soaps can strip skin further of its moisture. “There are many simple steps that can be taken to prevent dry skin and eczema. For a start, changes to the external environment can be made and external triggers removed,” said Dr Lee. For instance, people with dry skin should consider spending less time in dry, air-conditioned environments. If they have to spend many hours in such an environment, they might want to consider using humidifiers in conjunction with the air-conditioning. They should shower using lukewarm or cool water, rather than very hot water, and not take longer than five to 10 minutes each day. The type of soap used is also important. Harsh soaps strip away the natural moisturisers found in skin, drying and irritating the skin further. A mild moisturising soap, soap substitute or bath oil is better, and should ideally be unscented. Perfumed and scented toiletries can irritate the skin, said Dr Lee. Moisturisers or emollients help to improve and retain moisture within the skin. There are various types of moisturisers, and most preparations imitate

Different moisturisers work in different ways to combat dry skin. Some prevent loss of moisture by building up an oil barrier, some draw in moisture, while others work by replacing deficient lipids in the skin.

singapore health

the lipid component of the skin and help trap water within the skin. Different moisturisers work in different ways to combat dry skin. Some prevent loss of moisture by building up an oil barrier, some draw in moisture, while others aim to replace the deficient lipids in the skin. Regardless of their purpose, moisturisers should be applied to the skin quickly after a shower or bath to help trap moisture within the skin. Making changes to one’s external environment and using moisturisers are usually enough to help improve dry skin or eczema. But for some, additional treatment is necessary. Doctors may prescribe steroid creams of appropriate potency to calm severe redness or inflammation and itching. These are usually used for short periods until the itching goes away. Antihistamines may be useful in reducing itching, particularly at night. They also aid sleep, which can be disrupted by a persistent itch, said Dr Lee. “Although dryness of skin and eczema are common among the elderly, simple daily modifications, the frequent use of moisturisers, and appropriate medical therapy can help in eliminating the symptoms,” he added.

singapore health

MAr– Apr 2014

Running the PIE from end to end

For those planning to run their first marathon, it is crucial to train beforehand, keep your focus on race day and condition the body post-race. By Thava Rani

novice can build up stamina and speed to run his first marathon by following a six-month training programme. While that may not seem like a very long time, gearing up for the race can be rather like “taking an exam”, said Mr Trevor Lee, Physiotherapist, Singapore General Hospital (SGH). The 35-year-old, considered to be something of a marathon veteran, has been running an average of two to three marathons every year for about eight years now. Yet, he still adheres strictly to a “timetable” before each and every race, and a “lesson plan” that guides his daily activities. Mr Lee also joins “group studies” to run with like-minded friends. They not only motivate him to do better, but also help him understand his own progress and how to improve. On race day, he stays focused and “manages his time”. For instance, even if he feels that he can run faster, he sticks to his goals and maintains his pace to sustain him till the end of the race.

possibility of injuring a body that isn’t yet fully grown. For a healthy young adult running 42.195km – the official distance for a marathon, and about the length of the PIE – for the first time, the first phase of training involves getting the body used to the idea of running. “Start by running twice a week and gradually increase the frequency. This will help your body adapt to the muscle soreness, as well as the aches and pains,” he said.

photos: darren chang

Getting started Almost anyone can train to run a marathon, but older people should have a full medical check-up for underlying health conditions like a heart problem or hypertension before embarking on such a rigorous training programme, said Mr Lee. Young people should also wait till they are at least 18 years old before they begin running such long distances, because of the

The next phase of training is for improving endurance. Most people build up their stamina by slowly increasing the distance run from about 20km a week to 40km to 55km a week. A gradual increase of about 2km per week is about right for most first-time runners. Also, contrary to popular belief, it is not necessary to run the full distance before the actual race. “The accumulative distance over the week is what counts. The maximum for any one training run should be 30km to 35km because that’s when the body starts reacting differently. So it’s good to get there once in a while to understand what it feels like,” said Mr Lee. In the last phase, other types of activities are added into the training programme, such as lifting weights or swimming in between runs. Yoga classes can be beneficial too as the movements help stretch and loosen the muscles, keeping the body supple and flexible. The crucial weeks The week before and the week after the race are both important periods in marathon training. After running increasingly long distances during the months of training, it’s time to ease off and relax a little in the last one week before the race. “We

Mr Trevor Lee has been running two to three marathons every year for about eight years now.

don’t want to overwork the muscles, but neither do we want to lose the conditioning. So you should aim to run about 10km in that last week,” said Mr Lee. Loading up on carbohydrates is also an important consideration in running a marathon. As Asians already have a high-carbohydrate diet, “just a little more than the usual amount” should do the trick, Mr Lee said. While loading up on carbohydrates will not lead to higher speeds, it will help a runner avoid hitting “the wall”. That is when the body reaches its tipping point and the runner feels sudden fatigue and energy loss, and cramps set in. “Once you get cramps, it’s very difficult to continue running. It drains you physically and mentally. Sometimes it can take about 30 minutes to recover. At other times, you may find yourself walking all the way to the end,” said Mr Lee. Reaching the end is indeed a celebratory moment but the game plan is not over. Doing simple stretching exercises post-marathon is a must, as is eating a carbohydrate- and protein-rich meal within an hour after the run. After a couple of days, a massage to help stretch the muscles and get rid of stiffness is something that some runners like to have to help their bodies recover. “Personally, I prefer the pool. I don’t swim. I just do some gentle stretching in the water,” said Mr Lee. When the soreness eventually fades away, a light short jog will help keep the body conditioned until the next “exam”.

What to eat and drink, and what to wear are other important considerations in the race to Race day tips the finish line:

Hydration

Avoid diuretic beverages like coffee or milk as they can promote urination. Avoid drinking water. Pick isotonic drinks instead to help replace the water, electrolytes, and energy lost. Grab a drink at every station (there’s usually one ever y 1.5km to 2km). Take small sips while continuing to run.

Food

Eat a reasonably substantial meal about one to two hours before the race begins. Bananas or energy gels are usually provided along the way. If eating, take small bites and munch. Don’t stop running.

photo: GETTY IMAGES

Attire

Try out different clothes, shoes and socks before the actual run to find the most comfortable ones. Synthetic, high-performance wicking materials are best because they help draw perspiration away from the skin, keeping the body cool.

Before you run... and after Warming up

Do warm-up exercises that get the heart rate going and the muscles more flexible before the run. Do eight to 10 sets of each exercise except for Exercise 1.

CAN HELP SUPPORT CARTILAGE, PROMOTE JOINT HEALTH AND MAINTAIN JOINT FLEXIBILITY & MOBILITY

Blood vessel

Exercise 1 for quads Place the hands behind the back with the palms facing out. Jog in place for about one minute, lifting each leg to try to touch the palms with the heel.

Exercise 2 for hamstrings and quads Take a big step forward and bend the front knee until the other knee almost touches the ground. Repeat with the other leg, alternating a few times. These are known as walking lunges.

Exercise 3 for hamstrings and calves Stand with the feet slightly apart. Place one heel forward and bend the body towards th e leg while stretching the hands forward. Curl the toes of the front leg towards the body. Repeat with the other leg.

Cooling down

Do cooling down stretches after the run to help the muscles to relax. Do eight to 10 sets of each exercise.

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Exercise 4 for calves Stand with the feet slightly apart. Place one foot forward and bend the body towards that leg. Repeat with the other leg.

Exercise 5 for quads Sit on the ground with both legs outstretched. Bend one knee, tucking the foot behind the buttocks. Try to stretch the two legs apart as far as possible. Repeat with the other leg.

Exercise 6 for hamstrings Sit on the ground with the knees bent and soles facing each other. Stretch one leg out and reach for the toes. Repeat with the other leg.

By observing the diagram of the human body on this page, we can easily recognize all the space that our muscles, ligaments and tendons occupy. The tendon is composed of thick, white fibres of collagen that are held tightly against one another. These fibres are made up in large part by collagen. Our ligaments act like a connection between the bones. Our tendons act like ties to our internal structure for our muscles and our bones. The tendons and the ligaments of our body act like rubber bands of different sizes. Since our tendons are used to bind our musculature to our bones, and to maintain elasticity and suppleness, our tendons necessitate a large amount of collagen, particularly after an injury or from aging.

Why collagen is important? In the composition of cartilage we find 67% of collagen versus 1% of glucosamine. Glucosamine is an aminosaccharide contrary to collagen which is a molecular complex containing amino acids. Glucosamine is found in interesting quantities only in the liquid of the synovial membrane. Collagen is also found in the synovial membrane but in larger quantities because the protein structure is more abundant in the body.

Injuries

Prevent abrasions or chafing by applying silicone cream, petroleum jelly or other barrier creams before the run. If necessary, the cream can be reapplied during the run. Prevent straining the calf, hamstrings or thigh muscles by conditioning the body as much as possible. Train frequently and intensively in the months before a run.

Pace

Run at a slower pace than during training. Once a comfortable rhythm is reached, maintain it even if it’s a slow jog. Stopping or walking will make it much harder to start running again.

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

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singapore health

MAr– Apr 2014

Nothing to fear, but… Flashes and floaters are harmless, but may warn of more serious issues. By Sol E Solomon

dm Marilyn Tan*, 60, had nothing wrong with her vision except that she was slightly short-sighted. But when she started seeing spots that persisted after three weeks, she got a little worried and made an appointment to see a specialist. At the Singapore National Eye Centre (SNEC), Dr Loh Boon Kwang, Consultant, Vitreo-Retinal Service, Cataract and Comprehensive Service, found that the vitreous humour – a jelly-like liquid in her eye – had degenerated. Dr Loh said that the condition, known as vitreous degeneration, is fairly common, and causes flashes and floaters – moving spots and light streaks in one’s field of vision. They are not usually a cause for worry, but can sometimes be indicative of a more serious condition. Follow-up consultations confirmed that Mdm Tan was well and she was discharged, but Dr Loh advised her to watch for any signs of a retinal detachment. This is because flashes and floaters can

indicate a more serious eye condition if the jelly-like liquid pulls more against the inside of the wall of the eyeball, where the retina (the eye’s light-sensing inner layer) is located. This can cause breaks or holes in the retina and detach it. This happened to Mdm Cassandra Lee*, 40. Also short-sighted to begin with, she had blurred vision in her left eye for a week before consulting Dr Loh. Examinations revealed that she had suffered a retinal detachment, which could lead to a partial or complete loss of vision. She had to undergo scleral buckling surgery, where the doctor puts a synthetic plastic belt-like device around the outside of the eyeball, to push the eyewall against the detached retina. The operation was successful and Mdm Lee’s retina was re-attached. Nothing serious, but… Dr Loh said flashes and floaters are part of ageing, so it is common for people aged 60 and above to have them – but

Cornea Lens

CMY

Optic nerve (Carnial Nerve II)

younger people can get them too. “Generally, the effects of flashes and floaters are the same in the initial phase for those in their 20s and 60s. It just means that the onset of vitreous degeneration can occur at different ages – the progression is about the same,” he said. Over time, as the jelly-like liquid in the eye degenerates, the vitreous humour becomes smaller and forms tiny clumps of gel, casting shadows on the retina which appear as floaters. They are seen as small spots even when the eyes are closed, and are more obvious in bright sunlight or when looking at a white background. Flashes – an illusion of flashing lights or lightning streaks – occur when the jelly-like liquid pulls on the retina, sending a signal to the brain, and making the person perceive a light flash. Flashes may appear on and off for several weeks or months. The symptoms decrease after a few months, so many patients get used to it. “But they know they are not cured of the flashes or floaters,” said Dr Loh. Risk of retinal tears Serious conditions such as a retinal tear or renal detachment can arise, if there is a sudden increase in flashes and floaters, and risk factors are present. These risk factors include ageing, short-sightedness of over 600 degrees, previous internal eye surgery, and a family history of retinal detachment, which may make structures in a person’s eyes more prone to retinal tearing, said Dr Loh. Diabetics are also at risk of retinal detachment and diabetic retinopathy, where blood vessels in the retina

Vitreous chamber

You have flashes OR floaters if you see the following in your field of vision Flashes Arcs of light Flashes of light Lightning streaks

Floaters Flying specks of varying shapes and sizes Small clouds moving while you look at a blank wall Squiggly lines Cobwebs

Central retinal blood vessels

Floaters

Over time, as the vitreous humour or jelly-like liquid in the eye degenerates, it becomes smaller and forms tiny clumps of gel, casting shadows on the retina which appear as floaters in a person's field of vision.

photo: getty images

Flashes – an illusion of flashing lights or lightning streaks – occur when the vitreous humour, or the jelly-like liquid in the eye, pulls on the retina, sending a signal to the brain and making the person perceive a light flash.

weaken and bleed. When blood seeps into the jelly of the eye, it causes floaters. Global studies show that one in 10,000 people in the general population suffers from retinal detachment. Also, one out of 10 patients with an acute increase in flashes and floaters, seen in the emergency setting, runs the risk of having a retinal tear or detachment, said Dr Loh. Warning signs of a retinal tear or detachment include: An acute onset of flashes and/or floaters, which develops suddenly within a few days or weeks. Floaters appearing in the hundreds and thousands. Blurred vision, or a curtain effect where the person sees shadows within his visual field. There is currently no cure for flashes and floaters, and those who experience a sudden increase in them, or those most at risk of a torn retina, should seek medical attention early. *Names of patients have been changed to protect their privacy.

2014 年3 – 4月刊

新加坡中央医院与新加坡保健服务集团的双月刊

培养皿中的解药

根据研究显示，如果不及时治疗，超过一半遗传了 LQTS 的患者会在 1 0 年内死亡。为控制 LQTS 病情，医生会建议患者避免参加竞争性的运动。 LQTS 的治疗方式包括：

原文 Celine Lim

药物治疗：在感到压力、恐惧或劳累时，乙型受体阻断剂（ beta blockers ）等药物能够利用肾上腺素去减弱心脏的反应，减缓心律，使 LQTS 患者不会那么容易出现危险性的心律。

黄

先生*， 27 岁，擅长各种运动，还是一名马拉松赛常客。身体向来健壮的他某天却突然晕倒在办公桌上，身边的同事们还以为他在开玩笑。大家尝试唤醒他，却始终毫无反应，过了数分钟大家才惊觉他已没有气息。一名同事马上召唤救护车，另一人则开始实施紧急心肺复苏术，进行抢救。救护人员赶到现场后继续抢救工作，但仍然没有醒来的迹象。最后，在急诊室做了心电图检之后才发现， QT波（心率活动）有过长的现象，也就是说黄先生患有QT间期延长综合症（Long QT Syndrome, 简称LQTS）。经过再三抢救，黄先生最终还是不幸离开了人世。

多数的LQTS是遗传性的。经过查证，黄先生的父亲在数年前，同样地也是死于心脏性猝死。患者在运动或经历强烈情绪波动时，或在原因不明的情况下，心律都可能突然产生失控、混乱。如果当下无法将情况稳定下来，紊乱的心律是足以造成死亡。这就是导致年轻马拉松健儿突然倒下猝死的原因之一。

LQTS 是一种心律失常；能导致晕厥、猝死的综合症。它没有特别征兆，也没有完全根治的方法。新加坡国家心脏中心研发组主任王恩厚副教授

新加坡国家心脏中心研发组主任王恩厚副教授说： “QT间期延长综合症经常是造成心脏性猝死的原因。其患病率虽然不高，但这种心律异常可在毫无前兆的情况之下，一触即发。” QT 间期是指心脏从开始搏动到下一次搏动，所需要的充电时间。当QT 间期延长，心脏便需要更长的时间恢复搏动，而这个延迟可导致危险性心律失常。

治疗LQTS

身强体壮的年轻人也能因心律疾病而猝死。新加坡国家心脏中心研究人员成功研发帮助减低病发风险

令人措手不及

新闻

图： WONG WEILIANG

医疗程序：在患者的胸部皮肤下装置植入型自动心脏复律除颤器（implantable cardioverter defibrillator），以持续监测他的心跳。在有需要时，除颤器会传出电震，恢复正常的心律。

新加坡国家心脏中心研究团队利用一名LQTS患者的干细胞，试图在培养皿里模拟疾病。经过一年的测试后，他们发现了一种被称为ALLN的化合物可以纠正心脏细胞的QT间期延长问题。研究团队包括王恩厚副教授（左起），阿希什梅塔（Ashish Mehta）博士和沈时宜博士。

细胞对药物的反应。经过一年的严格测试后，他们从心电图发现了一种被称为ALLN的化合物可以纠正心脏细胞的QT间期延长问题。这项研究成果也让团队在 2013 年赢得了欧洲心脏病学会国际学术大会最佳新研究大奖。

未来的临床试验据王教授指出，在新加坡，每 5,000人当中，就有1人患有LQTS。其实很多人并不知道自己患有此病因为LQTS没有特别征兆。就算被证实患上LQTS（通常从定期心电图检测结果解析），也没有完全根治的方法。目前唯一能够预防 LQTS 患者猝死的方法，就是在他们体内植入一个自动型心脏复律除颤器。这个装置能够监测心律。当侦测到危险性节律时，装置就会传出电震，调整心律。不过，这也不尽然是个治标的方法。

突破背后的科学理论

在 2013 年 9 月，新加坡国家心脏中心研究人员从培养皿中找到了 LQTS 的解药。这 10 人研发组对 13 种 LQTS 基因表型之一的 LQTS 二型（ LQTS 2 ）进行研究，并从中获得首个全球革命性的发现。 LQTS 总共有 1 3 个基因表型，以一、二和三型最为典型，而 LQTS 2是因为hERG基因（与情绪有关的基因）突变而造成心律失常。这项研究是由新加坡国家心脏中心研发组高级研究科学家阿希什梅塔（ Ashish Mehta ）博士率领。他解释说为了识别可以扭转突变的药物化合物，小组利用了现有的干细胞进行研究。梅塔博士说：“这种药物化

合物可使有问题的蛋白质避开细胞的 ‘质量控制检查’系统，使得钾的流入和流出增加，从而纠正 LQTS 2的异常表现。” 为了了解 LQTS 2 如何在人体内运作，团队利用一名年轻LQTS患者的干细胞，试图在培养皿里模拟疾病。团队用了两至三个星期的时间培植人类诱导多能干细胞，再花六个星期去培养成熟的细胞，然后把它们程序化，让心脏细胞模型在培养皿中跳动。这些细胞的心电图则反映出患者的心脏病状况。之后，团队开始在细胞模型上测试各种药物。这样一来，不但不会对患者构成任何风险，而且能够持续监察

您有可能患LQTS吗？由于 LQTS 无征兆或症状，所以许多患者都不会意识到自己患有此病。如果您有任何以下特征，请尽快看医生：您的父母、兄弟姐妹或孩子曾被诊断患有LQTS 在消耗体力或经历强烈的情绪波动时，曾经突然晕倒曾经因持续性心脏跳动紊乱，导致大脑缺氧，造成癫痫发作

这项发现在寻求良方的道路上指日可待。不过，团队首先必须在类似条件下对药物进行严谨的毒性和安全性测试，再寻找患者试用这些药物。王教授说：“以前，我们利用电脑模拟效果，现在却可以利用真实的活细胞，在培养皿里模仿疾病环境和测试药物。这不但让我们减少繁多的测试步骤，集中寻找会影响 hERG 机制的药物，也缩短测试时间，效果一目了然。” 除了缩短测试时间，这种研发方式还有其他优势。新加坡国家心脏中心研发组科研主任沈时宜博士说，在生产药物并推出市场之前，还需要与制药公司、药物开发公司和其他机构合作再进行一轮药物测试。由于团队的研究已证明药物疗效，降低了测试成本与风险，所以找合作伙伴的成功机率相当高。 “凭我们目前对药物和LQTS 2的表现的认知，我们可以从市面上的药物精心挑选，进行测试。当然，这也意味我们了解各可能出现的副作用，” 沈博士说。王教授解释说，LQTS 2患者将必须终身服药，以管理疾病以及减低心脏性猝死的风险。 *患者描述以QT间期延长综合征（LQTS）典型特征为基础。

财经

2014 年3 – 4月刊

医药保险买了就保险？原文郭书真

私人医药保险计划难选择财务上有能力者应该考虑私人综合健保双全（Integrated Shield Plan）。但是，怎么选是一个问题，因为市面上的私人医药保险计划太多，根据卫生部网站的资料，五家保险公司提供的计划不下20个。要根据什么标准来挑选，令人伤脑筋。例如，为应付私人医院开支的计划就有六个（其中一个已经不再接受新的申请）。保费最昂贵的却不见得是最好的，这给消费者增加了选择的难度。

图：蔡婉婷 / ZaoBao

医

药保险一直以来都被认为是财务规划的重要环节，所以不时会提醒身边的朋友应有足够的医药保险保障。尤其是随着年纪大了，身体机能开始出现各种状况，患病的概率增高，更需要拥有足够的财务保障以应付日益昂贵的医药开支，单靠健保双全（MediShield）是不足够的。李显龙总理去年 8月在国庆群众大会上宣布，终身健保双全（MediShield Life）将取代有20多年历史的健保双全，预计在2015年推出。现在只知道终身健保双全将强制全民加入，详细内容目前还不清楚，许多现有计划下的限制预料会撤销。健保双全作为最基本的医药保险，是一个多数人负担得起的计划。以一个51岁的人为例，保费是每年345元，但是，它的保障是有限的，每日、每年，以及终身的索偿额都设限，而且顶限相当低，例如每年的索偿额不得超过7万元，主要是为B2和C级的津贴病房而设计，不适合收入较高者。

保险公司的保费难保不会调高，也可能随时修改计划的涵盖范围。如果人们对现有的医药保单不满而更换保险公司，可能令自己陷入不利的处境。因为随着年龄增加，保险公司提供保障的意愿会降低，并将一些病症排除在涵盖范围之外。

以51岁为例，Prudential PruShield Plan A Premier 的保费最便宜，介于 955元到977元，而 Aviva MyShield Plan 1最昂贵，介于 1130元到 1205元。虽然两个配套的共同承担部分（coinsurance）都是10％，但是后者却有每年2万5500元的顶限。从另一个角度看，前者的每年索偿顶限是56万6900元，而后者则是65万元。到底哪一个配套比较“划算”，一目并不能了然。再加上个别公司有本

身的条款，这些附属细则都需要仔细研究，增加了选择上的困难。这又带出了另一个问题。索偿顶限固然重要，可是到底有多重要？保险公司可以把每年索偿顶限设在100万元，但有没有病人真的会一年索偿100 万元？还是超高的顶限只为了让保单看起来更吸引人？

新近产妇也可选传统华人月内补身的食物。这些餐食不仅要确保健康，也要忠于不同种族、宗教饮食忌讳，还有合乎病人的口味。例如，一些病人因医疗关系只能进食低脂肪、低胆固醇，低盐，低蛋白或是低糖等饮食配方。如果您对我们的餐食有任何意见或想改善您的餐食，您可向病房里执勤护士接洽，要求与我们的饮食学家进行磋商。更多详情，可上网到sgh.com.sg/ patient-services/admission/ hospitalcuisine/pages/ hospital-cuisine.aspx查询。

手术被重复推迟

不能让保险公司任意调整保费或范围现在看似最适合的计划， 30年后不

见得依然如此。按现行保费，对 81 岁的人来说，NTUC Income Enhanced IncomeShield Preferred plan 最便宜。不过当51岁的你真的到了81岁时，情况可能又有变化—不要说30年后，就连明年或后年的保费也难保不会比现在高，保险公司也可能随时修改计划的涵盖范围。最近有人反映他的医药保险保费在近一年里涨了一倍，一家四口的保费超过5000元，让他开始怀疑这些保险计划是否还有意义。也难怪他有这样的想法。因为即使接下来30年的保费不变，他支付给保险公司的保费也要多达15万元，而这笔钱是“一去不复返”的。这15万元是假设保费维持不变，可事实是，医药保险的保费随着年龄增长上调—50 岁的保费和80岁的保费相差整三倍，因此30年下来，他实际支付的保费绝对不止30万元。虽然说这是一个自由市场，保险公司可以自由调整保费与涵盖范围，但是如果我们鼓励人们正视医药保险、在财务上为自己的医药费负责，那么有关部门也有必要正视问题，让医药保单在设计上更浅白易懂，方便人们做有意义的比较。与此同时，也不能让保险公司任意调整保费或涵盖范围。医药保险跟汽车保险不同，车主如果对现有的车险保单不满意，可以在下一年更换保险公司，不会有损失；但是如果人们对现有的医药保单不满而更换保险公司，却可能令自己陷入不利的处境。因为随着年龄增加，保险公司提供保障的意愿会降低，并将一些病症排除在涵盖范围之外。原文首次刊登于联合早报2014年1月19日。

意见箱

无调味料的餐食最近在我住院期间，我对医院提供的膳食非常失望。尽管我再三要求在我餐食里加点酱油或盐，但总是不能如愿以偿。为什么院方不能应允那么简单的要求呢？新加坡中央医院答复：为了力求符合病人的医疗需要与营养要求，医院所提供的餐食都是经由我们的饮食学家精心策划制定的。我们有中华料理，素食，印度或回教，与西式等各种烹饪供病人选择。

我母亲做了膝关节置换术后，经医生评估，确定她的身体状况适合再接受膝关节置换术，以治疗另一个膝盖。她的二次手术原本被安排在一个月后，可是不知怎么的手术日期却连续被推迟了两次。为什么？新加坡中央医院答复：导致手术推迟的原因各有不同，例如外科重症监护病房床位短缺、执行该手术的科医生突然病倒等。在情非得已的情况下，我们也会将非紧急或选择性的手术推迟，将手术室让给急需手术的重症病人。

不过，请放心。无论何时，我们所做的每个决定都是以病人的健康和安全为优先考量。所以在推迟手术之前，我们都会仔细评估病人的情况，确定手术延期不会危及到他的病情才会做出明确的决定。若有任何关于入院手续、账单及程序等疑问，可电邮至editor@sgh.com.sg，我们会在这个栏目里解答您的问题。

2014 年3 – 4月刊

新闻

家长们也可能受感染除了年幼孩童，成人和青少年也可能感染手足口症

手足口症须知原文 Thava Rani

手

足口症疫情每年都有增加的趋势。在 2013 年，每周平均有超过 600宗新病例。如此惊人的数据让家长们在保障年幼儿女的安全方面，变得格外警惕。他们不时检查孩子的手和口，也留意托儿中心的新增病例。然而，在照顾孩子的同时，家长们可能没发觉自己也需要受保护。他们不应误以为成人不会患上手足口症。事实上，在本地手足口症的病例当中，每十名患者就有一人是成人或 15 岁以上的青少年。多数情况下，家长都是因为儿女患手足口症而导致自己也受到感染。

手足口症的发病过程在成人和孩童之间并无差别，成人患者所可能产生的并发症与孩童是一样的。新加坡保健服务集团欧南园综合诊疗所顾问兼传染病和感染控制委员会主席黄忠伟医生

我应该如何保护自己免受感染？发性疫情在托儿中心、幼儿园及学校也偶有发生。此轻微疾病容易在孩童之间通过口水、黏液或其他体液传染。它是由属于肠道病毒群的病毒所引发的，如肠道病毒 71 型和柯萨奇病毒。肠道病毒 71 型的毒性较强，是导致脑部与神经系统并发症的病毒，本地多数手足口症死亡病例都是由此病毒造成的。新加坡当前的疫情则是由毒性较弱的柯萨奇病毒引发的。

成人抵抗力较强吗？只要接触到受感染者的鼻涕、口水、粪便或体液，任何人患上手足口症的风险都会提高。随着年岁增长，成人的身体一般上都会形成免疫力，因此较不易受此病毒感染。然而，那些有能减弱免疫系统的潜在病因的成人则有较高的风险。目前并没有预防手足口症的疫苗。黄医生说： “手足口症的发病过程在成人和孩童之间并无差别，成人手足口症患者所可能产生的并发症与孩童是一样的。” 手足口症最常出现的并发症是脱水，这是因为口腔溃疡有时会严重到足以影响液

常见症状

避免接触受感染的人的鼻涕、口水、粪便或体液不要共用餐具

体的摄入。持续不断的呕吐也能造成脱水。其他较为严重但也较罕见的并发症包括脑部、肺部及心脏感染，这些通常是由肠道病毒71型所引起的。

手足口症如何治疗手足口症并无特定治疗方法，但患者能服用某些药物来退烧并减缓疼痛。在家休养并饮用大量液体有助于身体康复。如果口腔溃疡造成进食困难，患者也能改吃粥或类似较容易下咽的软食。黄医生也说：“我们也应留意其他症状，因为如果出现较为严重的情况或并发症，患者可能需要住院。” 截断感染链是非常关键的。您可以采取以下措施防止自己将手足口症传染给他人：避免到公众场合去；避免与家人有亲密接触；将个人物品（如毛巾、衣物及餐具）与他人的分开；等到水泡完全干了才回去上班。

将玩具、书本、餐具、毛巾及衣物分开储存避免亲密接触（如拥抱和亲吻）将患有手足口症的人所使用过的玩具和物品清洗干净并进行消毒

如果我感染手足口症，我应该怎么做？此疾病具病程自限性，也就是说它一般会在五至七天内消退。在这期间，您应该确保自己得到足够的休息，并饮用足够的液体。如果口腔溃疡造成疼痛，您可选择较软的食物。

我应该留意什么并发症？气短困倦与迷失方向之感剧烈头疼颈项僵硬感呕吐没有胃口昏厥如果出现以上这些症状应该马上就医。

图：getty images

成人的症状与小孩的症状相似。新加坡保健服务集团欧南园综合诊疗所顾问医生兼传染病和感染控制委员会主席黄忠伟说：“孩童和成人患有手足口症的症状是相似的。皮疹通常为红疙瘩和水泡，出现在手掌和／或脚底。在一些情况中，皮疹可能只是红斑点或没有起泡的疙瘩，也可能出现在臀部、膝盖或手肘。” 其他症状包括发烧、喉咙痛、食欲不振，以及喉咙、嘴巴及舌头上长溃疡。患者也会有整体上的不适感。手足口症在新加坡属于流行性疾病，即全年候都可能发生。然而，突

经常洗手并注意一般卫生措施

如果口腔溃疡造成进食困, 手足口症患者也能改吃粥或类似较容易下咽的软食。

手足口症症状包括发烧、喉咙痛、食欲不振，以及喉咙、嘴巴及舌头上长溃疡。

新闻

2014 年3 – 4月刊

骨痛热症

公共卫生

第一号敌人骨痛热症疫情在去年大规模爆发，全年累计病例共有22,196起，共有7人不治。感染人数比2012年4,632起多出近五倍，也突破了历年来的最高纪录—2005年的14,209人。在2013年6月16日至22日的一周内，新增病例更创新高，达到 842宗。根据卫生部的数据显示，今年的骨痛热症新病例逐渐下降，1月第5个星期的每周新病例有240起，是过去12 个月来最低。同时，国家环境局网站显示疫情黑区比去年高峰期出现十多个红色警戒区少了许多。骨痛热症疫情虽有缓解迹象，但它仍未结束。骨痛热症的病毒是由伊蚊携带及传播的。由于伊蚊主要在住家里繁殖，所以公众必须共同采取行动，阻止骨痛热症持续蔓延。以下资料让我们更深入了解目前的骨痛热症疫情和预防感染的方法：

在2013年，新加坡经历了有史以来最严重的骨痛热症疫情

常见症状突然发烧两至七天严重头痛，尤其是在眼球后部关节和肌肉疼痛皮疹恶心和呕吐食欲不振鼻孔或牙龈出血因轻微的碰撞和冲撞导致瘀伤

根据数字显示，潜伏已久的第一型（Den-1）病毒已重新出现，并导致目前超过50％的感染个案。

避免感染骨痛热症

应付骨痛热症如果您怀疑自己患上了骨痛热症，您应该去看医生。大部分患者只要遵循以下行为，都会在两个星期内痊愈：

人受感染

获得充分的休息饮用大量液体，尤其是等渗饮料服用扑热息痛（paracetamol）退热。避免服用阿斯匹林，因为它的薄血作用可能会加重骨痛热症的症状。

人死亡

当传染病迅速扩散，让许多人受到感染时，疫情就发生了。

保护自己

22,196 7

您知道吗？

使用含有避蚊胺或柠檬和桉树油的驱蚊剂

在清晨和晚上，穿上长袖衬衫、长裤、袜子和鞋子

在没有使用花盆、容器和竹竿晒衣服时，除去积水和盖好竹竿插座

信息来源：

dengue.gov.sg

有关信息以截稿时为准。

骨痛热症的类型骨痛热症

骨痛溢血热症

骨痛休克综合征

轻微的骨痛热症一般会在无需治疗的情况下慢慢痊愈，大部分人在两周内就会康复。在进行第一次验血的两至三个星期后，患者必须再次接受验血，以确定是否带有骨痛热症病毒。

骨痛溢血热症是一种严重的骨痛热症，症状包括鼻孔和牙龈或皮肤下严重出血，并可能导致死亡。如果您的症状恶化到这个程度，您应该立即入院。

骨痛休克综合征是最严重的骨痛热症类型，症状为大量出血和休克（血压极低），足以致命。患者必需住院，接受重症监护治疗。

原文 JAMIE EE

2014 年3 – 4月刊

新闻

一起对抗癌症新加坡国立癌症中心，拥有丰富经验与专业知识的医疗团队，吸引了本地与海内外棘手癌症患者慕名前来求医

新

加坡国立癌症中心的棘手癌症病人来自本地及世界各地。 M先生就是其中之一。 M 先生 40岁，来自马来西亚丰盛港，育有2名孩子，是家中的唯一经济支柱。几个月前，他发现左边的腹股沟部有个小肿块。但由于生活忙碌，肿块没引起疼痛，加上又是在敏感部位，不好意思去求医，所以没把它放在心上。过后，他在当地看了泌尿科医生，接受了切除肿块的手术。但当他得知肿块是癌性又有可能没有完全被切除时，一切宛如晴天霹雳。正值壮年期的他一直过着烟酒不沾、作息规律的健康生活。他怎么也没想到，甚至还认为癌症只会发生在较年长的人身上，会沦落在他身上。 M先生患的是罕见的腹股沟软组织肿瘤。软组织癌症，或肉瘤，是一种罕见的肿瘤，可以发生在身体上有肌肉和骨头的任何部位。他的主治医生把他转介到新加坡国立癌症中心接受治疗。 M 先生也同意这门介绍因为该中心拥有医治棘手病例的良好声誉。在新加坡国立癌症中心，我们每年接获近 200 起病例，每起都有其独

特的挑战性。然而没有一种疗法可以治疗所有的病人。这也是我们的困难所在。每周，我们会在肿瘤会议里通过从显微镜、磁共振成像（ MRI ）和电脑断层扫描（CT scan）所观察到细胞展现，详细地讨论每个病例，然后拟定最佳的治疗方案。这个聚集了肿瘤内外科医生、放射肿瘤学家、放射学家、病理学家，还有医学院院生的会议，除了讨论治疗方案之外也可以作为学术论坛，提供参考，教育下一代的医生和专家。癌症是一种复杂的疾病。单靠一名医生的力量是不够的，因为他每天得处理繁重的诊治工作，没有多余时间和精力去阅读大量的科学文献，以及与世界各地最尖端的肿瘤研究并进，所以才需要组织团队，一起研究、讨论，对症下药。以 M先生的例子，经过一番讨论后，医生决定让他再次接受一项更大的手术，将剩余的肿瘤细胞除去，并进行肌肉移植来修复坏死部分，然后再进行电疗和化疗。

双赢局面

M 先生成功地完成整个治疗也对成效感到非常满意。之后，医生也给了他

图：Cheng Puay Koon

原文陈国俊医生

海内外棘手癌症患者都是因为无法在自己国家得到完善的治疗与护理，才会前来新加坡。因为这里拥有丰富经验与专业知识的医疗团队可以帮助他们。

一份详细的医疗报告，好让他回国后能接受后续护理。对 M先生来说，最让他留下深刻印象的，不是医院的外观设计或先进器材，而是我们那充满热心的医护人员，包括敬业乐业的护士们，每天为他进行放射治疗的放射科技师，以及负责协调和管理他的医药护理的专科医生。很多时候，象 M先生一样的患者，都是因为无法在自己国家得到完善的治疗与护理，才会前来新加坡国立癌症中心求医。身为一名医者，为了履行人道使命，我们都会尽最大的努力去帮助他们。

另外，这些外国病人所缴付的全额费用也能让新加坡国人继续享受负担得起的医疗服务。这是一个双赢局面，因为这不仅能以实行最佳医疗方法来保持我们的技术水平，我们的病人也能从中得到高素质的医疗服务。在对抗癌症里，团队的每一个人都有重要的角色。

陈国俊医生是新加坡国立癌症中心的放射肿瘤学家，专治儿科疾病、软组织肉瘤和妇科癌症。

专家解答

如何处理眼睛分泌物？高血压患者适合什么样的日常饮食？心肌缺血（一种高血压的并发症）患者在饮食方面应该要注意些什么？药物、饮食、维生素或营养补助品如钙片或葡糖胺对于控制心肌缺血的病情有帮助吗？在日常饮食里，高血压者可以多吃些高纤维、低脂肪食品的食物，如脱脂牛奶、瘦肉、蔬果、糙米/糙米粉和全麦面包，以及避免吃高盐、高脂肪或胆固醇的食物，如：酱汁、高汤、炸薯条、炸薯片、快熟面和腌制肉如腊肠、火腿和培根等。烹调手法也应该尽量采用清蒸、烧烤和烘烤。心肌缺血，是由于胆固醇积聚在血管壁上，导致血管变窄，血液难以顺畅地抵达心脏，进而减少心脏血氧供应。心肌缺血只能预防和避免发生更严重的症状，它不会完全

痊愈。另外，现今也没有证据显示营养补助品如维生素、葡糖胺和钙片对降低心脏病发作的风险有任何帮助。饮食方面，心肌缺血患者可以遵从以上所列出的健康守则。医生也可能会让你开始服用稀血药例如阿斯匹林来减低血液凝固的风险。患者不只必须终生接受治疗，也必须自律，监控任何可能导致心脏病发作的风险因素，包括戒烟、维持血压水平在 130/80mmHg以下和服用斯达汀药物（statin）降低胆固醇水平。如果患者有糖尿病症，就要控制血糖水平。新加坡保健服务集团白沙综合诊疗所家庭医生潘光恩

我五月大的女儿左眼会不断渗出微黄色的分泌物，右眼则没有这样的问题。她没有承受任何痛楚，眼部范围也没有肿胀。我带她去看了两名医生，一名说那是因为眼睛感染所致，另一名却说成因是泪腺阻塞。哪一种说法是正确的呢? 你女儿的眼睛问题，如果没有疼痛或肿胀的迹象，那她左眼的分泌物应该不是因感染而起的。在每三个新生儿之中，大概就有一人会出现泪腺阻塞的情况。由于婴儿的泪腺开端被一片小型薄膜阻挡着，所以才会造成泪腺阻塞。随着婴儿成长，泪腺通常会自然打开。一般来说，当婴儿到了 10 至 12 个月大时，薄膜就会开启，其中，大约 95 %的婴儿会在一岁之前自然康复。在等侯问题自行解决的时候，请记得保持婴儿眼部清洁。你也可以按摩位于眼头图：getty images

控制高血压问题

附近的泪囊，帮助改善情况。如果流泪的现象持续，家长可考虑通过外科手术来打开泪腺管，改善婴儿泪水引流的情况。万一问题持续，建议你向你的儿科医生或眼科医生求助。

如何祛除宝宝的胎记

我五月大的女儿颈背有一片红印，据医生所说，那是胎记。虽然医生向我保证大约 90 % 的红印会随着时间而淡化，但我想知道有没有什么方法可以完全祛除它？你女儿颈背上的红印很可能是因为皮层的毛细血管聚集所引致的。这种情况被称为先天性血管畸形，或送子鸟叼痕（stork bite），常见于大约 25 - 50 % 的新生儿身上。一般情况无需治疗。如果孩子到了三岁，红印依然存在，家长可考虑采用激光手术来祛除红印，改善孩子的外表。新加坡中央医院新生儿及孩童发育科高级顾问医生杨秋莲副教授

CMY

2014

3 4

年 – 月刊 FA_TheShoeCo_ad_345x260mm.pdf

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