Singapore Health Sep/Oct 2013 by Singapore General Hospital

SEP OCT 2013

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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Cancer-stricken dad gets a new lease of life after son donated part of liver to him

AWARD OF EXCELLENCE

APEX Awards 2013

Stroke patients get vital, real-time help from specialists via video conferencing

New clinics for specialised and coordinated care are part of SGH’s makeover

robotics Surgery 机器人辅助手术改进子宫肌瘤 improves fibroid 切除程序 removal procedure P27

Photo: ALVINN LIM

Find out which cardiac test is suitable for you

患上饮食失调症的人，可能对糖和奶油等日常食物产生恐惧感

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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).

SEP – OCT 2013

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Robotics surgery pushes limits in fibroid removal Keyhole surgery is not often an option when a fibroid is very large, but robotics surgery can help a surgeon to perform the procedure safely

By Desmond Ng

stalk (see diagram on page 4), so we were able to perform keyhole robotic-assisted surgery,” said Dr Peter Barton-Smith, Senior Consultant, Depar tment of Obstetrics and Gynaecology, SGH. Usually, surgeons will not use minimally invasive or keyhole laparoscopic surgery if the patient has too many fibroids or if the growths are too large. In such cases, open surgery is typically the only surgical option. Conventional laparoscopic surgery generally limits cases

to patients who have about three to five fibroids, each less than 5-6cm long, said Dr Barton-Smith. Another way for surgeons to decide on the type of procedure to perform is the size of the uterus. When the fibroids have caused the womb to enlarge to the equivalent size of a 16-week pregnancy, that is usually around the limit for conventional keyhole surgery, said Dr Barton-Smith. “With robotics, we can push that limit to a 20-week pregnancy, but

WITH robotics, we can push that limit to a 20-week pregnancy, but after that, usually open surgery is the only option. Dr Peter Barton-Smith, Senior Consultant, Department of Obstetrics and Gynaecology, Singapore General Hospital , on the difference Robotics surgery can make. Surgeons are unlikely to use conventional keyhole surgery if the fibroids have caused the womb to enlarge to A size equivalent TO a 16-week pregnancy.

Common and mostly harmless Fibroids are common and can grow to very large sizes. But they are rarely cancerous. About one in five women will develop fibroids, usually in her 30s or 40s. “But less than one in 1,000 patients will have a form of cancer inside the fibroids,” said Dr Peter Barton-Smith, Senior Consultant, Department of Obstetrics and Gynaecology, SGH. Fibroids do not cause trouble for most women because they stay relatively small. But some of these benign tumours can grow very large. “The largest I’ve ever removed weighed 9kg,” said Dr Barton-Smith. When the fibroids grow very large, they may start pressing on the other organs, such as the kidneys. In such situations, the woman might star t experiencing heavy bleeding during menstruation, discomfort in the abdomen, pain in the lower back, and frequent urination. Some women can also end up having problems conceiving. I n S i n g a p o r e , D r B a rton-Smith said, “the added problem is that women appear to not only have fibroids but also endometriosis (a condition in which womb lining grows outside the uterus) at the same time, which makes it more complicated. A lot of Asian women have both problems at the same time, which is new to me.”

> Continued on page 4 ( 华文版本请翻阅至27页 )

Dr Peter BartonSmith sits at a control console, a few feet away from the operating table. He uses controls at the console to manipulate tiny surgical instruments and a high-definition 3D camera, inserted through small incisions in the body, to perform the procedure.

PhotoS: ALVINN LIM

inda N g’ s f ib r o i d s we ig h e d nearly half a kilogram when they were removed via surgery in May. The largest of the four benign growths removed from her abdomen measured 14.5cm in length. But except for an expanding waistline, Ms Ng, 54, had few other symptoms. “I just thought I was putting on weight,” said the training and projects manager. Uterine fibroids are a common condition among women of child-bearing age. These usually harmless smooth tumours, that grow in the muscle layer of the womb, often develop when women are in their 30s or 40s. When the fibroids grow too large, however, they can cause heavy periods, abdominal discomfort, back pain, frequent urination, and fertility problems. Ms Ng, a mother of two, found out she had fibroids during a regular gynaecological examination earlier this year. When her doctor advised her to have the fibroids removed, she opted to undergo a new minimally invasive robotics surgical procedure offered by Singapore General Hospital (SGH). The relatively large size of Ms Ng’s fibroids would normally limit her surgical choices to an open procedure – the conventional method where a large incision is made for the surgeon to perform surgery through. But the main fibroid, which was a pedunculated fibroid, was “on a

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SEP – OCT 2013

> Continued from page 3

Robotics surgery pushes limits in fibroid removal

Belly button Spine

Uterus

Ms Linda Ng’s pedunculated fibroid was so large that it extended to above the level of her navel and was equivalent to the size of a 20-week pregnant uterus. Below, inside the uterus, is another circular dark blob of fibroid, with a much smaller one just to the right of it. The fibroids and the uterus fill most of this MRI view of her abdominal cavity.

Flexible robotic arms During surgery, Dr Barton-Smith made five tiny incisions in Ms Ng’s abdomen to allow for the insertion of a high-definition 3D camera, and tiny but highly precise and flexible surgical instruments. Sitting at a console a distance away, he was able to look inside her abdomen and perform surgery. “ I t ’s l i ke b e i n g inside the patient,” he said of the camera’s ability. The highly flexible joints of the robot’s surgical arms, meanwhile, translated his hand movements into small, precise movements inside the body to cut the surface of the uterus and then to “shell the fibroids out,

much like shelling peas,” he said. The incision in the uterus was then stitched closed. Using a device known as a morcellator, a hollow tube with a circular blade at one end, he finally pulled the fibroids out of Ms Ng’s abdomen. The morcellator was used to cut the fibroid into long strips, allowing the otherwise huge mass of tissue to be removed through the small incisions. With robotic-assisted surgery, said Dr Barton-Smith, “patients experience less pain, less blood loss, a shorter hospital stay, and a quicker return to normal activity – in two to three weeks after surgery, compared with the usual six weeks for people who undergo open surgery.” Ms Ng’s surgery took about three and a half hours. After two days in hospital, she was discharged. Patients who undergo open surgery for the procedure normally go home after three to five days. Ms Ng said: “The marvellous part was that there was no pain post-surgery. It felt like having gastric.”

Pedunculated fibroid Fallopian (uterine) tube

Intracavitary fibroid Uterus

Ovary

Submucosal fibroid

Subserosal fibroid

Intramural fibroid Cervix Vagina

More on Fibroids In addition to the very large pedunculated fibroid, Ms Linda Ng had three other smaller fibroids, known as submucosal and intracavitary fibroids. According to Dr Peter Barton-Smith, these types of fibroids can be removed by surgery through the cervix if they are small enough. Larger ones, and the other types of fibroids, often have to be removed by surgery through the abdomen.

ILLUSTRATION: HEYMANS THO

Pedunculated fibroid

after that, usually open surgery is the only option,” he said. “This limit can be pushed because the computer-enhanced technology allows the surgeon a greater range of movement to deal with larger masses, that are very difficult to achieve with conventional straight laparoscopic instruments,” he added.

SEP – OCT 2013

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Depression can be a cause or effect of dementia

By Satish Cheney

hen Mr Lim, a retiree, forgot how to use the T V remote control and what he had for lunch, his family thought, “Oh, he’s getting old.” But soon, his memory started getting hazier. He forgot his grandchildren’s names, and later his children’s, although he could recollect childhood memories. Then he began losing his way when driving, forgetting his way home; before long, he was asking his reflection in the mirror, “Who are you?” Meanwhile, his worsening dementia was accompanied by bouts of depression. This connection between depression and dementia is something researchers have been looking at for some time now. Is there a link between the two? If so, which comes first? These questions are becoming more urgent, because dementia cases are on the rise both globally and locally. It’s all in your head Professor Ranga Krishnan, Dean of DukeNUS Graduate Medical School, explained that there is a vascular link between depression and dementia, and that either condition can occur first. He said that in the last two decades, there have been about 200 studies on this subject. Retrospective investigations showed that many people who had depression later developed dementia. “It’s the same illness showing up as dementia in one person and depression in another. Quite commonly, you see depression first and then dementia.” He explained that silent strokes, multiple

low-intensity strokes which people hardly notice, damage nerves in the front of the brain and cause vascular depression. More extensive damage leads to vascular dementia. “When there is less damage, you get depression; more damage, you get dementia,” Prof Ranga said. He added that depression is vascular because psychiatric conditions are medical and involve the brain. “So, it’s true when they say, ‘It’s all in your head!’ All medical illnesses can lead to depression because of chemical changes in the brain. What is different is who treats them – psychiatrists, neurologists or general practitioners.” There are many causes of depression. Vascular damage in the brain is one of them. Other causes, including stress, nutrition and possible genetic factors, also involve the brain. Other types of damage to the brain, such as frontotemporal dementia, can also lead to both depression and dementia. Depression often manifests as sadness without reason, losing interest even in food, withdrawing, not going out, a change in sleep patterns, self-blame, a negative outlook, and feeling helpless, hopeless, worthless and suicidal. Dementia manifests as a loss of short-term memory, although long-term memory remains intact. “It is akin to peeling an onion, with the outer layers (representing recent memory) coming off first. The bigger the onion, the longer it would take someone to peel it right to the core (long-term memory).”

Causes and prevention Prof Ranga said that old age significantly increases one’s risk of getting dementia – especially after 60. Unlike other illnesses, the earlier the symptoms appear, the more severe the illness and the swifter its progression to severe memory loss. Those who have suffered silent strokes are also at high risk of dementia. Globally, genetics are blamed for these strokes. But in Asia, where it has affected people in their 40s and 50s with no genetic predisposition to it, possible causes have been linked to high blood pressure and a highsalt Asian diet, as well as diabetes, smoking and high cholesterol. Prof Ranga said that there is no cure for dementia, but medication can slow down memory loss. That is why it is important for elders to see a doctor when early signs appear. It is also important for teens who are depressed to overcome it, live healthily and keep a positive outlook on life, to prevent strokes and dementia in middle age. People without dementia-prone genes can reduce their risk of silent strokes by adopting a healthy, low-salt diet (the same diet advice for a healthy heart), coupled with exercise and a positive mental attitude. “This is important because what affects the mind can affect the body,” he said. Prof Ranga also stressed the importance of building reserves of strength to ward off the illness for as long as possible, even if it is already in the body. “Our bodies have reserves to handle mental and physical problems. With low reserves, dementia can be unmasked after surger y, especially in elderly patients. High reserves, built by studying, using the brain or being actively engaged in life, won’t change the disease, but can reduce the chance of silent strokes.” But he said there are no long-term studies on this yet. “We can only presume.”

Photo: Zaphs Zhang

PhotoS: GETTY iMAGES

There is a vascular link between both conditions, and either can occur first

When an older relative is depressed or getting forgetful Don’t presume it is just old age. People tend to withdraw and slow down in old age, but if you immediately dismiss it as “old age”, you miss noticing an actual problem. Don’t immediately attribute it to other medical problems such as diabetes or a weak heart, as this will prevent you from seeking treatment for the real problem, which is dementia. Don’t miss getting a doctor’s evaluation. Although dementia cannot be cured, medication can make the elder feel better, look better, and stay better for much longer.

According to Prof Ranga Krishnan, it is also important for teens who are depressed to overcome it, live healthily and keep a positive outlook on life, to prevent strokes and dementia in middle age.

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SEP – OCT 2013

ILLUSTRATION: courtesy of HeartWare International, Inc.

New heart pump improves patient’s quality of life Singapore’s first patient with latest lightweight device enjoys new lease of life as she waits for a heart donor

The pouch, containing the heart pump’s controller, can be carried in a few different ways. Illustration showing a HVAD pump in a patient’s body.

Photo: JASPER YU

The lifeline

Post-operation, Mdm Helen Tan (above, with her husband and grandchildren) is enjoying a new lease of life.

adam Helen Tan, 58, was in a dilemma this year. Should she take a long-haul flight to New Zealand or a shorter holiday in China? Given her medical condition, the longer trip would prove more challenging. You see, Mdm Tan is the first patient in Singapore to have the latest heart pump implanted in her chest. A special battery-powered pouch keeps her mechanical heart going, and she has to carry it around along with its two batteries, which last six hours each. “The doctors said I’ll have to carry more batteries with me if I want to go to New Zealand, as there are no charging points on the plane,” she said. Her heart pump is connected to a controller in the pouch, through a cable that exits her body near the abdomen, so she always has to carry the pouch with her. “I have to wrap the whole pouch in plastic before I take a shower. When I sleep, I have to make sure the batteries are connected to the power points.” Before and after the implant Mdm Tan found that her quality of life improved dramatically after receiving the third generation heart pump known as a HeartWare Ventricular Assist Device (HVAD) last year. Made of titanium composite materials, it is smaller (the size of a golf ball) and lighter than the previous two versions. Before the implant,

she would get breathless from doing simple household chores, or even talking. “Sometimes I’d wake up in the middle of the night, feeling that my heart had stopped beating. I’d also break into a cold sweat even in air-conditioned rooms,” said Mdm Tan. She had been diagnosed as having dilated cardiomyopathy (see below). “The doctors told me my heart was operating at only about 20 per cent capacity, and this had affected my lungs as well. “Without the pump, I’d have had only about a year to live,” said the grandmother, who now cycles to and from the market several times a week. Although it has given her a new lease of life, the HVAD is not meant to be a longterm solution. Mdm Tan is on the waiting list for a heart transplant. She said: “There were times before the implant when I wanted to give up, but now that I have my grandchildren, there are even more reasons to stick around.”

Photo: courtesy of National Heart Centre Singapore

By AJ Leow

Th e h ear t pump im planted into Mdm Tan’s chest is a comparatively smaller, lighter device that can be fitted right next to the heart, said Associate Professor Lim Chong Hee, Senior Consultant, Department of Cardiothoracic Surgery and Director, Heart and Lung Transplant Pro gramme, National Heart

The National Heart Centre Singapore medical team involved in Singapore’s first third-generation heart pump surgery (clockwise from top left): Dr C Sivathasan, Co-Director, Heart and Lung Transplant Programme; Dr David Sim, Co-Director, Heart Failure Programme; Associate Professor Lim Chong Hee, Director, Heart and Lung Transplant Programme; Mdm Helen Tan, patient.

Centre Singapore (NHCS). He led the surgical team that carried out Mdm Tan’s four-hour surgery. “This removes the need for the creation of a pocket space near the abdominal area as in the case of the older model of heart pumps,” he added. Second-generation pumps are still very much in use. “Prices for both types of pumps are about the same, but we decided to bring in the HVAD as the results are comparable to HeartMate II and to give patients more options. It can potentially be used to support the right side of the heart too,” said Prof Lim. NHCS per forms an average of three heart transplants yearly. To help bridge the gap due to the limited donor pool, it set up the Mechanical Heart Device Programme in 2001 to provide patient s with advanced heart failure a means to prolong and improve their quality of life while waiting for a suitable donor. To date, NHCS has performed 70 me chanic al hear t device implantations.

What is dilated cardiomyopathy? Dilated cardiomyopathy is a disease of the heart muscle in which the left ventricle becomes enlarged and cannot pump blood efficiently to the body. The condition can cause cardiac failure, but a patient may have it for many years before symptoms surface.

Most patients’ quality of life is not affected, especially in the earlier stages. Symptoms include shortness of breath, fatigue, fluid retention in the legs, lightheadedness or fainting, as well as sensations of having rapid, fluttering or pounding heartbeats.

SEP – OCT 2013

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Son gives dad a liver and a new life One young pilot opted for the best course of treatment for his cancer-stricken dad by donating part of his liver to him

By DESMOND NG

Mr Edwin Poh (left) who donated part of his liver to his dad, Mr David Poh (right), took two months to recover from surgery and was given the green light to resume his flying duties in December last year.

h e o n e thought that raced through his mind as he was wheeled into the operating theatre at the Singapore General Hospital (SGH) in September last year was: I might not survive. Mr Edwin Poh, then 32, was young, healthy and had no medical problems. But he was going to have a part of his liver cut out and transplanted into his father, Mr David Poh, who was suffering from liver cancer. Doctors had told him that the procedure was a relatively low risk one, and that his liver would regenerate to 90 per cent of its original size after the operation. Yet, he could not stop thoughts of the worst-case scenario from flooding his mind. Said the younger Mr Poh: “I thought I might die. I had written letters to my family. I was prepared for the worst.”

PhotoS: aLVINN LIM

From hepatitis B to liver cancer Mr David Poh was diagnosed with hepatitis B during a routine blood test about 30 years ago. Hepatitis B is an infectious inflammatory illness of the liver, which can lead to cirrhosis, a hardening of the liver, and liver cancer. When his father was diagnosed with hepatocellular carcinoma (liver cancer) in December 2011, the younger Mr Poh knew that he wanted to do the right thing and give part of his liver to his father. “If anyone was to help him, it should be me.” His older sister was married with two children, while his other sister was too young. “The size of the donor’s liver had to be big enough,” Mr Poh said. A pilot for seven years, Mr Poh had to consider if he would be able to resume flying – his life-long dream – after the procedure. “I was very gung ho about the

After the liver donation, Mr David Poh is now able to play a light game of squash and badminton.

I have a new lease of life now, and I have better stamina Mr DAvid Poh, 65, on his transplant

New transplant clinic offers convenience

transplant initially, and it took some time to get my father to agree to it. Later, as I was going through the tests, I started to think about the risks and costs. It was then that I began to worry if I could still fly after that,” he said. “But at the end of the day, the question was not just – ‘could I not go through with it?’ – but also, ‘could I continue to live with myself if I did not?’” His company was supportive, assuring him that he would have a job if he was medically fit to fly after the operation. His decision to donate a part of his liver was also bolstered by the knowledge that a fellow pilot, who went through the same procedure eight years earlier, was still flying. Mr Poh stopped work for about two months to recover from the surgery, and received the green light from an aeromedical doctor to resume his flying duties in December last year. Accepting the “gift” of life The elder Mr Poh, who is semi-retired, said he found the strength to accept his illness – stage 2 liver cancer – in prayer. However, he wasn’t prepared to accept his son’s sacrifice at first. “My family was not prepared to let me go. They begged me to go for a trans-

plant,” said the 65-year-old. His wife, 62, works in the healthcare industry. The older Mr Poh said the tumour in his liver was about 4.6cm long, but was inoperable as it was located too close to the main arteries. Before the transplant, he had undergone other treatments, including a minimally invasive medical procedure called transarterial chemo-embolization, or TACE, which managed to shrink his tumour down to 60 per cent of its original size. He also went through two rounds of chemotherapy, but with little progress. Mr Poh was then told that he needed to have a transplant, but the wait for a deceased donor would take about a year. After much pleading from his family, he decided to accept his son’s gift of life. “I know that he (my son) is a good boy. I didn’t want to put him in any jeopardy, especially his career. I was worried he might not be able to fly again. I prepared myself and prayed and left it to God. I had confidence in the doctors and that the operation would work,” he said. The older Mr Poh said he is now able to play a light game of squash and badminton. He added: “I have a new lease of life now, and I have better stamina.”

Following a transplant, patients have to see several healthcare professionals for follow-up care. When the new Transplant Centre opens later this year at SGH, these patients only need to make a single appointment to see them. “Transplantation is a highly complex field of medicine that requires different healthcare professionals coming together as a team to provide a collaborative and patient-centric approach to care planning and provision,” said Dr Terence Kee, Senior Consultant, Department of Renal Medicine, SGH. Dr Kee is also Programme Director, Renal Transplantation, SGH. The centre will house a multi-disciplinary team involved in various aspects of transplantation. Dedicated to caring for patients who have undergone or are undergoing tr ans plants, the Centre has clinics, counselling rooms, a phlebotomy cubicle and procedure unit. Among its many services are pre- and post-transplant education by transplant coordinators, donor and recipient assessment, post-transplant follow-up care, transplant pharmacist clinics, and intravenous drug infusions.

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SEP – OCT 2013

Their efforts to ease bottlenecks and simplify procedures were lauded at the International Convention on Quality Control Circles

Photo: GETTY iMAGES

SGH staff raise the bar for quality healthcare By Teo Kuan Yee

ustomer satisfaction is key to the long-term success of any organisation. At Singapore General Hospital (SGH), the term “customers” refers not only to patients but also to staff, as many of them work in teams that depend on one another to carry out vital tasks. To this end, teams from SGH implemented a variety of changes that untangled complex work routines, making patients’ times at the hospital more pleasant in turn. Their efforts were recognised at last year’s International Convention on Quality Control Circles (ICQCC) in Kuala Lumpur, Malaysia. We present three of the winning projects here.

Better arrangement of ward items saves time The team

Ms Doris Lim Wei Feng, Ms Kamsiah Jaafar, Mr Muhammad Fuad Bakari, Ms Chan Shi Ming, Mr Mazlan Omar

The problem

Nursing students, house officers and other staff who work on rotation often faced difficulties in finding items in the ward preparation rooms of the departments they are posted to. Although staff undergo an orientation at each department they are posted to, they need time

to learn the layout of each preparation room because of the different storage arrangements at each location.

The solution

The team devised a standard arrangement for five frequently used items, including 10ml syringes, normal saline and gauze, in the preparation rooms. These were placed together for easy retrieval when preparing for a common procedure like blood-taking. Items were categorised and labels were colour-coded for easy identification.

Retrieving the five commonly used items took an average of 47.6seconds, versus 97.5seconds before the changes. The changes seem small, but the seconds saved added up to 63,254.5 hours a year.

Flexibility eases workload The team

From the Department of Internal Medicine: Ms Stephanie Teo, Associate Professor Chow Wan Cheng, Ms Vanessa Ng, Mr Geoffrey Gui, Ms Linda Lim, Mr Desmond Lee

The problem

The previous system of allocating patients to teams of doctors often added to the doctors’ already heavy workload.

The solution

The team spent weeks speaking to doctors, nurses and administrative staff to identify gaps in the system. They then made use of information technology to automate and standardise the process of allocating doctors to patients. The old system of simply assigning patients to the next available team in a fixed sequence was changed to take into account each team’s workload.

“Porters” speed up ward admission The people

From the Department of Emergency Medicine: Ms Norizan Jaafar, Ms Norhashimah Hasim, Ms Teo Kai Yunn, Ms Joanne Jong Yen-Yen

The problem

Patients at the A&E department often face prolonged waits before being sent to the wards. This can compromise their safety, and interrupt the nurses at work if they have to leave their clinical areas to take such patients to the wards.

The solution

Teams comprising two nurses and two patient-care assistants are rostered to work as porter teams during peak admission times. When a bed is ready, the team on duty (wearing orange tags) takes charge and sends the patient to the ward. The same team also prepares the patient’s case record.

SEP – OCT 2013

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Tele-Stroke to the rescue With a neurologist always on standby for consultation by video conferencing, stroke patients have a fighting chance of a good recovery

By Denyse Yeo

How it works

NNI’s stroke neurologists are rostered as acute stroke consultants on call and are responsible for Tele-Stroke consultations 24 hours a day, 365 days a year. When a patient arrives at the hospital’s emergency department, triage nurses identify if he has had a stroke. If so, he is immediately reviewed by an emergency department physician, who notes his medical history and verifies the time of the onset of the stroke. He is sent for a brain scan. The radiologist studies the scan to see if he has had an ischaemic stroke or a haemorrhagic stroke. The Tele-Stroke service is activated. The NNI stroke neurologist remotely examines the patient, assesses the CT scan and gives a treatment recommendation. With Tele-Stroke, Dr Singh can provide vital diagnosis and treatment for stroke patients via video conferencing. Mr Low Yiang Chua (right) witnessed how Tele-Stroke saved his dad, Mr Low Choong Heong.

bleeding, which occurs in less than 10 per cent of cases.” Another patient rescued A separate case saw a 50-year-old man with a history of hypertension diagnosed with an acute ischaemic stroke in CGH’s A&E department. The Tele-Stroke service was activated. The neurologist assessed him and found him suitable for r-tPA, so the emergency doctor administered the drug.

Hundreds of Stroke patients admitted to peripheral hospitals have had immediate access to stroke specialists from NNI, Around the clock. Dr Rajinder Singh, Consultant, Department of Neurology, National Neuroscience Institute, on the benefits of Tele-stroke

Within several hours, the patient became less drowsy and regained strength on his right side. The next day, he could talk and obey commands, and after rehabilitation, was well enough to be discharged. Dr Singh said: “Such cases show that without this service, acute stroke patients

Photo: ALVINN LIM

A leading cause of death and disability In Singapore, stroke is the fourth leading cause of death and the leading cause of chronic severe disability. It is caused either by bleeding in the brain (haemorrhagic stroke) or a blood clot (acute ischaemic stroke) that deprives a certain part of the brain of oxygen and nutrients. The latter can be treated with a clot-busting drug called recombinant-tissue plasminogen activator (r-tPA), which is best prescribed by neurologists because of its potential complications. This treatment is effective in treating strokes caused by blood clots, because it breaks down the clots, explained Dr Rajinder Singh, Consultant, Department of Neurology, NNI. “Compared to patients who were not given r-tPA, those who were given it within three hours of the onset of the stroke, were 30 per cent more likely to be back to their original state, or have just minimal symptoms which do not affect their day-to-day activities, at three months. The main side effect is that of

Photo: WINSTON CHUANG

t first glance, you cannot tell that 83-year-old Mr Low Choong Heong suffered a stroke that left him comatose barely two years ago. Today, the spry retiree goes for walks, does calisthenics and meets up with friends for coffee. In 2011, he was at a coffee shop when he had a stroke. His left side suddenly became weak, and he foamed at the mouth. His friends immediately called an ambulance, which took him to Changi General Hospital (CGH), recalled his eldest son, businessman Mr Low Yiang Chua, 59. “When I saw him, he was already comatose,” said the younger Mr Low. “But within two or three hours, the doctors gave him an injection that saved his life. He woke up on the third day and was discharged within a week. He improved steadily over the next three months, and is now independent and able to do everything by himself, just like before.” His father was saved by the National Neuroscience Institute’s (NNI) Tele-Stroke service, currently provided to two hospitals – CGH and Khoo Teck Puat Hospital – round the clock, seven days a week. The service allows doctors in the hospital’s emergency department to get an NNI neurologist to remotely examine stroke patients in real time via video conferencing. This way, the patients get the attention of a specialist for vital diagnosis and treatment within the crucial three-hour window. This will reduce their likelihoods of a poor outcome.

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admitted to CGH or KTPH may not have the opportunity to be assessed by neurologists rapidly. Hence, they may not receive r-tPA. It is this lack of round-theclock, on-site neurology service at these hospitals that prompted NNI to use TeleStroke to provide round-the-clock service and cover this gap in service.” Although there were teething problems at the start, partly due to a sub-optimal Internet connection, the system is working smoothly today and issues have been resolved, said Dr Singh. The system has seen tremendous benefits. “Hundreds of stroke patients admitted to peripheral hospitals have had immediate access to stroke special-

ists from NNI around the clock. This has helped them get the best treatment and outcomes for their strokes in a cost-effective and efficient way,” he said. Tele-Stroke numbers up To date, NNI has handled 582 cases – 25 to 30 patients a month – since the Tele-Stroke service started in August 2011. The number is likely to increase due to greater public awareness and an ageing population. “Right now, there are no definitive plans to extend the service, but the potential to add more ‘spokes’, or peripheral hospitals with no in-house neurologists, to the network is always there,” said Dr Singh.

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SEP – OCT 2013

In pursuit of better patient care Study: Dietar y composition and weight outcomes in postmetabolic bariatric surgery patients

Ms Teo Soo Lay, Department of Dietetics, SGH The trends in percentage of excess weight loss and diet composition of post-metabolic bariatric surgery patients. Bariatric surgery is one of the most effective ways of manag-

Among other results, the study found that at three and six months post-surgery, the caloric intakes averaged 670 kcal/day and 861 kcal/day respectively. At three months, protein, carbohydrate and

Oral Presentation - Young Investigator’s Award (Allied Health)

Lead investigator: To Investigate:

Category:

Poster Presentation - Best Poster Award (Nursing) - WINNER

Lead investigator:

How it was carried out:

This retrospective study analysed the diets of 54 patients who underwent surgery between September 2008 and 2011, first at pre-surgery, then at three, six and 12 months after surgery. The 18 men and 36 women had a mean age of 50 years. They had an average caloric intake of 1,814 kcal/day, with protein, carbohydrate and fat contributing 17, 52 and 31 per cent respectively.

Category: Study: Incidence and predic tors of new-onset constipation during hospitalisation in patients with stroke versus orthopaedic conditions

ing obesity. After surgery, a higher protein, moderate fat and lower carbohydrate diet is usually recommended.

Conclusion:

Photo: GettyImages

At this year’s Singapore General Hospital (SGH) Annual Scientific Meeting, 350 studies were presented in 14 categories. Winning an award rewards an author’s efforts, and sharing the findings improves patient care

fat compositions contributed 26, 44 and 30 per cent respectively. At six months, protein, carbohydrate and fat contributed 20, 49 and 31 per cent respectively. At 12 months, the average caloric intake was 1,088 kcal/day, comprising 21 per cent protein, 49 per cent carbohydrate and 30 per cent fat. Compared to the baseline, the patients’ diet composition at 12 months did not differ except for protein. At three, six and 12 months, the respective percentage of excess weight loss was 27, 40 and 46 per cent. No correlation was found between excess weight loss and the composition of the patients’ diets. Patients mostly reverted to a diet with similar compositions of protein, carbohydrate and fat as at pre-surgery, despite the weight loss they experienced.

Ms Lim Su Fee, Nursing Division, SGH

TO Investigate:

New-onset constipation among stroke and orthopaedic patients, and the predictors associated with constipation. Constipation is a common complaint for patients warded for acute stroke. It can cause discomfort and affect patients’ physical and psychological well-being.

Study: The use of an innovative cueing device to improve gait and reduce fear of falling in patients with Parkinson’s disease

How it was carried out:

Category:

This prospective cohort study looked at 55 patients warded for stroke, and 55 patients warded for orthopaedic-related problems. Demographics, other medical complaints, mobility gain, fluid intake, and medication use were among the factors evaluated as predictors for constipation.

Oral Presentation – Outstanding Allied Health Research Award

Lead investigator:

Ms Dawn Tan, Department of Physiotherapy, SGH

TO Investigate:

Many of the stroke and orthopaedic patients developed constipation during their hospital stay, with seven of the stroke patients (39 per cent) and four (27 per cent) of the orthopaedic patients developing the complaint on day two. The early occurrence of constipation on the second day of admission calls for early preventive measures such as promoting mobility and reducing the length of hospital stays. Selective use of shortterm prophylactic laxatives could be considered in high-risk patients.

Photo: GettyImages

Conclusion:

The feasibility of the locally developed Parkinson’s Mobility Aid and its effects on gait and fear of falling in Parkinson’s disease patients. Parkinson’s disease is a degenerative disorder of the central nervous system. It affects movement and balance, making patients prone to losing their balance or falling. The Parkinson’s Mobility Aid allows users to select visual, auditory or tactile cues to improve their gaits or to overcome freezing episodes.

How it was carried out:

Twenty Parkinson’s disease patients,

including 15 men with an average age of 67.5 years, participated in this randomised controlled study. The control group received standard physiotherapy twice a week for a month. The intervention group received a similar type and intensity of treatment but were also trained in the use of the Parkinson’s Mobility Aid. All the participants were assessed at the start or the baseline, and at one and two months after, for various things such as gait speed, freezing severity, and fear of falling.

Conclusion:

Neither group of patients displayed significant changes in gait speed, freezing, and fear of falling, relative to baseline. The group taught to use the aid demonstrated greater, but non-significant, improvement in gait after one month, compared to the control group. Gait training using the mobility aid appears to be somewhat useful and safe for people with Parkinson’s disease. Because of the study’s small sample size, the investigators suggested that large sample sizes and higher training intensity be studied in order to better test the aid’s effectiveness.

Academia opens at SGH Campus The first of its kind in the region, SingHealth’s new diagnostic, research and education hub is set to improve patient care and advance medicine in Singapore

President Tony Tan Keng Yam officiated at the opening of Academia, which houses SGH’s Department of Pathology and SingHealth’s research, education and training facilities.

By Jamie Ee

atients in Singapore can expect better healthcare with the opening of Academia – SingHealth’s new diagnostic, research and education hub on the SGH Campus. The $360 million 13-storey twin-tower building is the new home of SGH’s Department of Pathology as well as the Group’s research and education facilities. Located near Duke-NUS Graduate Medical School and leading medical institutions, the 807,293 sq ft building has laboratories, conference facilities, offices and a “mini hospital” under one roof. Initially conceived as a home for SGH’s Pathology Department, it evolved during construction into a hub and incubator for biomedical breakthoughs and innovations in medical care. President Tony Tan Keng Yam, who officiated at Academia’s opening, said: “The co-location of the Pathology Department with SingHealth’s education and research functions will enhance the interconnectivity among pathologists, clinician scientists, academics and healthcare professionals and result in more sharing of ideas, as well as the acceleration of research efforts that will translate into clinically useful applications for better patient care.” SGH’s Pathology Department, which handled more than 12 million laboratory investigations last year, now has a 50 per cent increased capacity for diagnostic services. Equipped with the latest technology, it will offer enhanced test accuracy and reliability, and improved turnaround times. Research and training facilities There is also plenty of scope for advanced research here. The SingHealth Tissue Repository (STR), Singapore’s largest tissue repository, is based at Academia. STR offers core tissue research and bio-

banking services to help researchers identify new biomarkers, treatment targets, and drugs. Another occupant, the SingHealth Translational Immunology and Inflammation Centre, is set to advance research led by SingHealth and Duke-NUS. Potential clinical collaborations it has identified include paediatric allergies and immunological disorders, transplantation immunology, and stem cell and immunotherapy for cancers and other diseases. With 80,729 sq ft dedicated to healthcare training and education, Academia is the world’s largest and most comprehensive training facility offering varied platforms, from procedural and team-based skills to computer and environment simulation under one roof. The wet and dry skills laboratories and mini hospital come complete with simulated wards, an intensive care unit, and a fully functional operating theatre. Doctors, nurses and allied health staff can hone their skills by carrying out procedures in controlled yet realistic settings that are wired for live streaming – procedures can be beamed to seminar rooms for teaching purposes. Professor Ivy Ng, Group Chief Executive Officer, SingHealth, said: “One enduring passion that unites us, all through the generations, has been the burning desire to improve the lives of our patients. Academia has been purpose-built for this. “Our relentless pursuit of academic medicine will stay focused and driven by that same burning passion that characterised the generations who served on this campus. We want to improve the lives of our patients through better care for better outcomes. The work in Academia must be dedicated to this one purpose and keep patients at the heart of all we do.”

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SEP – OCT 2013

SGH undergoes makeover S

ingapore General Hospital (SGH) is undergoing a major facelift. After months of construction, new clinics have opened, while some existing facilities have been expanded or improved. After the remaining renovation and building work is done, the hospital and the rest of SGH Campus will be transformed into a vibrant academic medical centre. On July 1, the Centre for Digestive and Liver Diseases opened its doors to patients suffering from complex digestive and liver disorders, such as liver and intestinal cancer, chronic hepatitis, liver failure, and chronic inflammatory disorders of the intestines. The centre integrates the former C, D and E outpatient clinics to offer patients specialised and coordinated care in one facility. Patients will be able to consult their doctors at the centre, as well as undergo endoscopic and other tests, dietetic and drug management services, as the clinic pulls together a multitude of healthcare professionals providing differ-

ent but complementary expertise. With the new premises, patients will no longer have to go to different places within SGH’s sprawling compound for different services. Such integrated medical services are also offered at the new Autoimmunity and Rheumatology Centre, the only regional hub providing a one-stop service dedicated to complex rheumatology and autoimmune disorders. The centre, which opened in May this year, also provides physiotherapy and occupational therapy services, as well as drug management and patient education. The Diabetes Centre, on the other hand, has been relocated to the basement of Block 1 from the ground floor of the same building. The new facility is much larger than the old one. These centres address the growing demand for care in various medical disciplines. And it isn’t just clinics that are being made over. Two of the hospital’s larger pharmacies have been made even bigger.

Photo: ZAPHS ZHANG

New clinics for specialised and coordinated care have opened after recent renovations, and wards are next to get a facelift

The one serving the Specialist Outpatient Clinics now has a medication management service room for pharmacists to advise patients about the medicines they are taking, while the pharmacy at Block 4 is roomier. The next phase of the makeover will be sprucing up the wards. To make sure that bed space is not lost during renovation, patients will be moved to three levels of “transit” wards at Block 6.

Specialist nurses are part of a multidisciplinary team looking after patients at the new one-stop centres, like the one dedicated to digestive and liver diseases.

These three floors used to be the offices of the hospital’s more than 1,000 doctors, who have been given space at Academia, a new 13-storey twin-tower building that houses SGH’s pathology services as well as SingHealth research laboratories and education and training facilities. Work on the wards has begun, and is expected to be completed within the next few years.

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SEP – OCT 2013

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UP CLOSE

P nk Breast Cancer Awareness Month

Alert

Breast cancer is the most common cause of cancer death in women, accounting for

18%

By Denyse Yeo

Symptoms

of cancer deaths.

See your doctor immediately if you experience any of these symptoms:

A painless lump in your breast

Breast cancer accounts for more than

The disease is the most common cancer in Singaporean women, with about

of all cancers in women.

women diagnosed every year.

20% 1,600 250,000

Persistent rash around the nipple

Nearly

Bleeding or unusual discharge from the nipple

Retracted nipple

Swollen, thickened, dimpled or puckered skin on the breast

Early Detection

Breast lumps are a common occurrence in women. Only one out of every 10 lumps is due to cancer, which means that 90 per cent of all breast lumps are benign.

women have been screened by BreastScreen Singapore in the last 10 years.

Women who have a family history of breast cancer may be at increased risk. If your mother and/or sister developed breast cancer before menopause, talk to your doctor or a breast specialist.

Lower Your Risk

The risk of breast cancer increases with age. Most women who are diagnosed with breast cancer are aged 40 and above. Late menopause, having fewer children or none at all, being on hormone replacement therapy and weight gain are other risk factors.

Sources: KK Women’s and Children’s Hospital, Ministry of Health, singhealth.com.sg, www.healthxchange.com.sg, hpb.gov.sg, nccs.com.sg

get tested National breast cancer screening programme BreastScreen Singapore (BSS) is available at SingHealth (Tel: 6536-6000), Radiologic Clinic (Tel: 6533-2721) and National Healthcare Group Diagnostics (Tel: 6275-6443/ 6-ASK-NHGD)

people

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SEP – OCT 2013

Taking nursing up a notch Advanced Practice Nurse Ms Patsy Chiang works on some tasks done by junior doctors By Sol E Solomon

Photo: alecia Neo

s a young girl, hospitalised for gastritis in 1985, Ms Patsy Chiang was so deeply inspired by the nurses who took care of her that she decided that she would join their ranks. She started off as a staff nurse, but rose through the ranks to become an Advanced Practice Nurse (APN) at the National Heart Centre Singapore (NHCS) in 2004. Unlike regular nurses, APNs are qualified to assess patients and make certain clinical judgments, taking up some of the tasks done by junior doctors. During her daily rounds, she physically examines patients, looks at their X-rays and charts, pens her diagnoses, and updates their daily care plans. In the wards, she orders tests like ECGs (electrocardiographies) and X-rays, interprets laboratory results to prescribe treatments and non-pharmacological therapies, and escalates complicated cases to the doctors.

Advanced Practice Nurse, Ms Patsy Chiang with two patients, Mr Victor Jonathan Garnell (left) and Mr Albert Pang Cheong Kong, who are under her care.

At the NHCS’ Anti- coagulation Clinic, she advises patients about managing medication such as warfarin, a blood-thinning drug that prevents blood clots in heart patients at risk of stroke. A patient’s dosage of warfarin has to be

carefully managed in response to his or her condition, lifestyle and diet. It’s clear that being an APN requires a great deal of training and experience. A candidate must have a bachelor’s or master’s degree, and a certificate in a

particular speciality. Ms Chiang – part of Singapore’s first cohort of 15 nurses who enrolled in the one-and-a-half-year APN course in 2003 – specialises in providing critical care. One module, Cardiovascular System Assessment, gave her the knowledge to identify abnormalities of the heart and circulatory system, and that has helped save a life. Once, listening to the lungs of a patient in hospital who had just received a pacemaker implant, she could not hear anything from one lung. “I alerted a consultant, who ordered tests which showed signs of lung collapse, but it was unclear and could only be detected by a very senior radiologist.” A CT scan confirmed her suspicion that there was air in the patient’s lung. A chest tube was inserted to release the air. If the problem had gone unnoticed, the patient could have collapsed at home after discharge. Despite her qualifications and experience, she still sometimes faces resistance from patients. “They may initially ask why they aren’t being seen by a doctor but an APN,” she said. Once past this hurdle, however, most patients warm up to her. Some, upon learning that another patient at NHCS is not under her care, will ask, “Why aren’t we seeing Sister Patsy?” And that is testimony enough for her.

SEP – OCT 2013

Two of a kind?

Photo: alecia Neo

Brothers and oncologists, Dr Wong Fuh Yong and Dr Wang Fuqiang are also colleagues in the same department

Dr Wong Fuh Yong (left) and his brother Dr Wang Fuqiang work in the same field, and recently collaborated on a research project for the first time.

By Jamie Ee

eet Dr Wong Fuh Yong, 38, Consultant, and his brother Dr Wang Fuqiang, 29, Registrar, from the Department of Radiation Oncology at the National Cancer Centre Singapore (NCCS). Did you notice that they have different surnames? Their parents registered the elder sibling’s surname as Wong because that is how it is pronounced in dialect, and the younger one’s as Wang because that is how it is pronounced in Mandarin. This difference has led to some amusement at work. Dr Wong said: “One of my colleagues was quite taken aback when he found out, a year later, that Fuqiang is my brother. He said it was lucky that he hadn’t said anything bad about him!” Their family resemblance and other similarities have not gone unnoticed, though. Dr Wang said: “Some patients who hadn’t seen me before have said that I look familiar. “Once, a patient saw me and told

his family that I was his consultant. But I hadn’t seen any patients yet, so I told him that he was probably referring to my brother.” Same work, different interests So, did one brother influence the other? And are they two of a kind? Not really. Dr Wong, who is married and has a seven-year-old daughter, describes himself as having eclectic pursuits. He enjoys reading, photography, and travelling. His bachelor brother professes to be more athletic, and enjoys running, swimming, and hitting the gym. “But deep down, we are probably more similar than we care to admit, even though this may not show up in the things we do,” said Dr Wong. Their paths have indeed been similar. Both graduated from The Chinese High School and Hwa Chong Junior College. Both studied medicine at the National

singapore health

University of Singapore, specialising in radiation oncology – a speciality that focuses on using radiation therapy to treat cancer. Both were (and still are) motivated by compassion and an interest in science and technology. Dr Wong, who joined NCCS in 2003, did not actively draw his brother into his sphere of work. “I hardly talked to him about cancer care, so I was surprised that he took up radiation oncology,” he said. But Dr Wang, who joined NCCS in 2010, said that he was indeed influenced by his brother. “After graduation, I was trying to figure out my interests. Since my brother was in radiation oncology, I thought, why not give it a try and see what it is like?” Their being brothers does not have any impact on their professional roles and relationship, though. Their paths usually cross at department meetings or in small group teaching sessions conducted by Dr Wong, who treats his brother like any other doctor under his tutelage while on the job. They do not always share a similar work schedule as Dr Wang has not yet chosen a sub-speciality. They did, however, recently collaborate on a research project for the first time. They were part of a five-member team studying the outcome of breast conservation therapy in

people

Once, a patient saw me and told his family that I was his consultant. But I hadn’t seen any patients yet, so I told him that he was probably referring to my brother. Dr Wang Fuqiang on the confusion that arises from his brother, Dr Wong Fuh Yong, being in the same department

breast cancer patients in Southeast Asia who had not yet had surgery. They have a middle brother, a pharmacist, who works in another hospital. Their father works in finance and their mother is a housewife. When the family meets, conversation is varied and does not centre on medicine. “At home, we don’t usually talk about our work,” said Dr Wong.

Money

singapore health

SEP – OCT 2013

Community help for the chronically sick Rising medical costs can be worrying, especially for those grappling with long-term illness. The Community Health Assist Scheme can help pay for treatment

Who Qualifies for CHAS? To be eligible for the subsidies under the Community Health Assist Scheme or CHAS, you must be Singaporean, aged 40 and above or disabled, and meet the following criteria: ● Have a per capita household monthly income

of $1,500 or less; OR

● The annual value of your home is $13,000 and

below for households with no income.

By Stella Thng

dm Cecilia Tan*, 60, is a retired beautician. Her husband, an accounts clerk, draws a monthly salary of about $2,700. Their only daughter is an administrative assistant who earns $1,700 a month. Their combined household income is $4,400 and they live modestly in a three-room flat. But five years ago, Mdm Tan was diagnosed with kidney failure and the family of three had to curb their spending to pay for her daily medication. Thankfully, patients like Mdm Tan can now apply for the Community Health Assist Scheme (CHAS), a programme spearheaded by the Ministry of Health (MOH) programme that helps provide Singaporeans with accessible and affordable medical and dental care. Patients who qualify for the scheme receive subsidies for outpatient medical treatment for chronic and/or acute conditions from general practitioners (GPs) registered under the scheme. They also receive selected dental services at participating dental clinics near their homes.

How do I apply for CHAS?

CHAS members also enjoy subsidised referrals to specialist outpatient clinics. The eligibility criteria were changed on Jan 15, 2012, to allow more Singaporeans to benefit from the programme. For example, the qualifying age was lowered from 65 to 40 years old and the income criteria was raised from $800 to $1,500 per capita monthly household income. CHAS also works in conjunction with the Government’s Chronic Disease Management Programme. Patients covered by the programme will receive CHAS subsidies for their chronic disease treatments that range from $200 to $480 per year. Patients can then use their Medisave to pay for the balance of the cost of the treatment, up to a limit of $400 per Medisave account per year. For example, if the total bill is $1,000 and the CHAS subsidy covers $350, the remaining $650 can be paid using $400 from Medisave and $250 in cash.

Disability is measured by an inability to do any of the six activities of daily living without assistance – washing/bathing, using the toilet, getting in and out of a wheelchair, feeding, dressing, and/or mobility. All family members (related by blood, marriage and/or legal adoption) living at the same address as the main applicant, as reflected on their NRICs, must include their details on the same application form as the main applicant. Their income will be included when calculating the household’s per capita monthly income.

To calculate per capita household monthly income

Total gross monthly household income Number of members in the family

*Story based on a real-life example.

Get a CHAS application form at any restructured hospital, polyclinic, Community Centre or Club, or Community Development Council, or download it from chas.sg. Submit the completed form with clear copies of NRICs (front and back) of the main applicant

and all family members, and/or clear copies of birth certificates of family members below 15 years old who do not have NRICs. A Functional Assessment Report will be mailed to you if you meet the income criteria. Take the report with

you and go for a disability assessment by any Singapore Medical Council-registered doctor or GP who is on the preferred list of medical practitioners. After you have been assessed on the six activities of daily living, mail the completed Functional Assessment

Report back to the Agency for Integrated Care (AIC) at PO Box 680 Bukit Merah Central Post Office, Singapore 911536. If your application is successful, you will receive either a blue or orange Health Assist card,

depending on your per capita household monthly income level. All eligible family members within your household (i.e. have the same address as you on their NRICs) will be issued an individual Health Assist card each. The cards are valid for two years.

SEP – OCT 2013

How to deal with excessive burping and belching? I have a problem with burping and belching. I try to eat five small meals a day, but I still belch very often. Sometimes, I wake up at night because of the gas build-up, and belch for some time before I can go back to sleep. What is wrong with me? When one eats, one also swallows air. When too much air has been swallowed, the body needs to expel or belch it out. Eating slowly, not smoking and drinking less carbonated drinks and beer can reduce the incidence of belching. Excessive belching or burping can be due to indigestion (non-ulcer dyspepsia). It can also be caused by an undiagnosed problem within the digestive system, which then should be appropriately identified and if necessary, treated by a doctor. Indigestion happens to almost everyone at some time, and it usually resolves itself after a short while. It commonly occurs after a heavy or greasy meal, or after eating food that doesn’t agree with the person. Simple measures, symptomatic therapy or lifestyle changes can alleviate some symptoms of indigestion. Your family physician can refer you for specialist assessment if an undiagnosed problem is suspected or if more meticulous investigations are required. Dr Ong Wai Choung, Senior Consultant, Department of Gastroenterology and Hepatology, Singapore General Hospital

Our experts answer all your questions about health Coping with periodic eczema

Choosing the right shoes for toddlers Photo: getty images

Health Xchange

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When should my baby start to wear shoes? How do I choose the right shoes for my child? Babies start walking when they are about one year old. They can start wearing shoes when they are able to walk competently outdoors. At home, they can walk barefoot, especially at the stage where they are just learning to walk by holding on to furniture. Be sure to keep the floor clear of clutter and sharp objects. Walking barefoot at home helps babies develop their tactile functions, as well as their sense of balance and coordination. Tickling babies’ soles will also make them stretch and curl their toes, working the intrinsic muscles of their feet.

Any cure for astigmatism?

My young nephew has had astigmatism since he was five or six years old. We understand from the doctor that it is due to his irregular corneal curvature. Is there any chance of a full recovery? How do we protect his eyes from deteriorating further? It is unlikely that the astigmatism will disappear, unless it is very mild. Astigmatism can change as a child grows, as the

When choosing footwear for babies, go for soft shoes with flexible soles for toddlers who have just started walking. Shoes should fit snugly – neither too tight nor too loose. If the child’s feet often slide forward and you can see a space at the back of the shoe, the shoes are not a good fit. At the same time, the shoes shouldn’t be too tight; they should have room for the child’s toes to wriggle freely. Generally, children’s feet grow about two baby shoe sizes a year for the first four years. Ms Marabelle Heng, Senior Podiatrist, Department of Podiatry, Singapore General Hospital

I have had eczema since I was young. One patch on a toe never completely goes away even though it improves when I use the prescribed cream. The eczema on my fingers and toes flares up on and off. Over the last few years, I have periodically had eczema on other parts of my body. How do I prevent or reduce it? Recurrence of eczema is common. To reduce recurrences, you need to prevent dryness and relieve itching. This can be done by removing or avoiding aggravating factors, such as: Rapid changes in temperature, strenuous exercise and hot weather Rough, scratchy, tight and woollen clothing Frequent use of soaps, bubble baths and hot water, and cleansing procedures that tend to remove natural oil from skin Emotional upsets Wear light, smooth, soft, non-binding clothing. Do not increase the skin’s dryness by having prolonged or frequent hot baths or showers. Use mild soaps or emulsifying ointment as soap. Bathe or shower with lukewarm water. When necessary, sponge gently under the arms, in the groin and in other areas where cleansing is imperative. At other times, cleanse the entire skin with a nongreasy lotion. Avoid sudden changes of temperature, for instance, going into an air-conditioned room from the hot outdoors. Try not to rub or scratch. When the itching is severe, try to relieve it by dabbing or applying cloths soaked in cold water.

corneal curvature can change with time. You can protect his eyes by ensuring he wears his glasses, if recommended by the ophthalmologist, to prevent development of “lazy eye” or amblyopia. Healthy eye habits such as reducing close-range work, and taking part in outdoor activities, can prevent him from developing myopia. Dr Zena Lim, Consultant, Paediatric Ophthalmology & Adult Strabismus Service, Singapore National Eye Centre

Dr Shah Mitesh, Family Physician, Consultant, SingHealth Polyclinics – Geylang

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

Topics for discussion in September-October 2013: Autoimmune disorders, corneal transplants, heart and renal issues

Opinion

singapore health

SEP – OCT 2013

illustration: heymans tho

Accepting the inevitable When the end is near, acceptance brings peace

Life is like a piece of string, smooth until it gets knotted. These knots grow bigger if you leave them alone, or smaller if Untangled. died, she wrote a beautiful letter to each of her children, detailing how much she loved them. It was her gift to them. Whenever they missed her, they could read her letters and be comforted by the thought that she was still with them in spirit. There are tools that can help patients accept their conditions. Meditation offers opportunities for deep self-reflection. Experiential exercises can bring them through real-world situations, and therapy (individual or group) is a powerful process for reframing their thoughts.

By Dr Gilbert Fan

eople are not progr amme d to suffer, so most terminally ill patients fear suffering. They worry about pain, not being able to sleep or eat, how they will look after surgery or treatment, and their waning interest in life. They are concerned about who will take care of them and the financial cost of prolonged treatment. They also worry about their spouses becoming single parents and taking care of the children and in-laws. Some, even after living with the illness for years, cannot get past the fact that they have cancer – but counselling by medical social workers can help.

Coming to terms with the truth The first premise that is introduced during counselling is that life is imperfect. If patients can accept this, they will accept that obstacles in life – cancer or other life-changing issues – can occur. Life is like a piece of string, smooth until it gets knotted. These knots grow bigger if you leave them alone, or smaller if untangled. Sometimes there are issues that cannot be resolved, no matter how hard you try. The second premise is that some things cannot be changed. If they can accept that life is imperfect and that not all things can be changed, they can better accept their condition. People who are better able to accept their conditions tend to have supportive families, religion, or a positive outlook

on life. Studies show that the more supportive the family, the better the patient copes. And staunch believers tend to be more accepting than those with no faith. A positive outlook can come from religion or life experiences. People who have faced losses or setbacks tend to adapt, and become more resilient and positive. Those who are often sick or have a family history of cancer are often not too surprised if they are diagnosed with cancer. Acceptance is harder for those who were once in good health. John*, a successful CEO, was fit and careful with his food. He found out he had advanced cancer in his 40s and died when he was 50. He found it difficult to accept his illness and was angry with himself. In his anger, he hurt his family with unkind words and actions, but in time, through counselling, came to terms with his illness. He saw that by hurting his loved ones, he would be perpetuating this cycle of anger even after his death. Leaving a legacy When patients find that they have fulfilled their purpose and that there is nothing more they can do to make a big difference, they let go more easily. It helps if they can identify this purpose. One way is by leaving behind a legacy, which can be as simple as a memento for their loved ones. Mary*, a young mother with three young children, was diagnosed with advanced cancer in her 30s. Before she

Psychotherapist Dr Gilbert Fan, 54, has been a medical social worker and psychotherapist for 28 years. He is Head of the Department of Psychosocial Oncology and Co-Chair of Patient Support at the National Cancer Centre Singapore. He is also an Adjunct Senior Lecturer at the Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore.

Seeing the whole picture Many cancer patients go through emotional roller coasters, seeing only their diagnosis, a bad prognosis or an unsuccessful treatment. They don’t see the whole picture because it is so eventbased. It’s just like marriage: Focus only on the quarrels with your spouse and you will feel that your relationship is an unhappy one. But if you look at the big picture, your marriage is actually not so bad as there have been good times. This reframing process works the same way for cancer patients. Individual setbacks can be sad or disappointing, but seeing the big picture helps. An example is thinking, “I’m a cancer survivor who has managed to live an additional 10 years.” The truth is that most terminally ill patients cannot accept death until the very end, because they have been conditioned to put up a fight. But when things do not improve despite the struggles, and they know they are dying, they begin to accept their condition for what it is. It is at this point that they will be able to let go and finally be at peace with themselves. *Names have been changed.

SEP â&#x20AC;&#x201C; OCT 2013

Why must I pay the foreignerâ&#x20AC;&#x2122;s rate for day surgery?

Why was I asked to pay the foreignerâ&#x20AC;&#x2122;s rate when I underwent day surgery recently? I am married to a Singaporean and hold a Long-Term Visit Pass â&#x20AC;&#x201C; Plus, and I understand that holders of this pass are eligible for healthcare benefits.

April 2012, qualified forSGH Since eign spouses of Singapore citizens are given a longer

Type of ward class/ service at restructured hospitals

period of residency under the Long-Term Visit Pass â&#x20AC;&#x201C; Plus scheme. They are also eligible for healthcare subsidies for inpatient services at restructured hospitals, set at a level close to that for permanent residents. The levels of inpatient subsidy depend on the choice of ward class and are similar to the corresponding subsidy levels for permanent resident patients. LongTerm Visit Pass â&#x20AC;&#x201C; Plus holders, however, are not eligible for subsidies for day surgery, specialist outpatient clinics and polyclinics services.

Letters must include your full name, address and phone number. Singapore Health reserves the right to edit letters and not all letters will be published. Write to editor@sgh.com.sg or The Editor, Singapore Health, Singapore General Hospital, Communications Department, Outram Road, Singapore 169608, or talk to us on Facebook. The winner will receive a bottle of Ultra Hemoshield (120 capsules) and Ultra Organic Green Barley (100 capsules). The products, worth $112.85 in total, are sponsored by United Pharma.

Maximum subsidy levels Singapore citizens

Permanent residents

Long-Term Visit Pass â&#x20AC;&#x201C; Plus Holders

Class A

Class B1

20%

10%

Class B2+

50%

30%

Class B2

65%

45%

Class C

80%

60%

Day surgery

50%

45% No subsidy

Specialist outpatient clinic

50%

30% No subsidy

A&E

about your health experience and win a prize for best letter

Emergency department fees are the same for all patients

Table adapted from Immigration & Checkpoints Authority of Singapore website

My unexpected admittance to the I was warded in SGH for 10 days National Heart Centre Singapore has earlier this year for second degree given me many good memories of the burns on my arms and legs, followattentive care and empathy I received ing a car accident. Dr Mohamed Zulfikar Rasheed, Associate Consulfrom the nurses and staff . Throughout my stay at Ward 44, Staff tant, Department of Plastic ReconNurse Ibanez Ariescena Incierto and struction and Aesthetic Surgery, left Senior Staff Nurse Natasha Choo Shan a deep impression on me. He gave me Shan were extremely accommodating, a detailed explanation of my surgerfriendly and kind. My recuperation is ies and was also very warm and thornot only due to them but all the other ough when checking on me. Thank you, nurses and doctors in the ward. Thank Dr Zul! I also wish to thank the Ward you very much for your wonderful care. 43 staff, especially Staff Nurse Tan Li I was also impressed by the prompt Khoon, Principal Enrolled Nurse Winnie updates my family and I received. You Ong, and Healthcare Assistant Goh Poh really are angels and unsung heroines. Chin. I consider them â&#x20AC;&#x201C; who are so committed to their work â&#x20AC;&#x201C; my friends! Keep up the good work! â&#x20AC;&#x201C; Mr KH Toh â&#x20AC;&#x201C; Mr Gan

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singapore health

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

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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. 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

SEP – OCT 2013

event Calendar

▲

SGH Alzheimer’s and Dementia Day

Date Sep 14, Saturday Time 10am–12pm Venue Singapore General Hospital, Block 6

Level 9 (Deck on 9)

REGISTRATION Call 6576-7658 during office

hours (8.30am–5.30pm) to register by 6 September. Price Free Find out, from SGH neurologists, geriatric experts and psychologists, the common symptoms of dementia, behavioural problems of dementia patients, treatments, and how caregivers can learn to cope with their patients.

daily servings of

Vegetables and Fruits

▲

Live 3 years Longer

People who eat at least five servings of fruit and vegetables a day lived, on average, three years longer than those who do not, stated a study published in the American Journal of Clinical Nutrition. The study was based on data collected from more than 71,000 Swedes, aged 45 to 83, who were tracked over a period of 13 years. Eating more than five servings of fruits and vegetables daily, however, did not result in an even longer lifespan, the researchers said.

Date Sep 21, Saturday Time 2–4pm Venue Academia, 20 College Road, Level 1 REGISTRATION Call 6326-5151 or 6576-7658

during office hours (9.30am–5.30pm) to register. Price $5

Source: reuters.com

Acting out dreams linked to dementia

If a man acts out his dreams in his sleep, there is a high likelihood that he is developing dementia with Lewy bodies, which is the second most common form of dementia in the elderly. This sleep behaviour disorder is caused by the loss of normal muscle paralysis during rapid eye movement sleep. Mayo Clinic researchers in Minnesota and Florida found that patients with this sleep behaviour disorder were five times more likely to have dementia with Lewy bodies than if they had symptoms such as fluctuating cognition or hallucinations.

Repeat anterior cruciate ligament injury likely after surgery

29.5% of athletes had a second ACL injury within two years of returning to sports

Broaden your understanding of psoriasis, a common chronic skin disorder, and learn how to manage it at this bilingual public forum organised by SGH’s Department of Dermatology.

Source: Mayo Clinic

20.5%

suffered an injury to the opposite knee

re-injured the same knee

▲

Air pollution ups risk of burst appendix The risk of suffering a burst appendix rises on smoggy days, a new study suggests. Dr Gil Kaplan of the University of Calgary found that the risk rose by up to 22 per cent with every 16 parts-per-billion rise of ozone (a component of smog) in the air, during the three to seven days before an appendicitis incident. Ozone is one of the five pollutants measured for Pollutant Standards Index or PSI.

The anterior cruciate ligament (ACL) is one of four major ligaments in the knee, and is crucial for stabilising the knee during turning. ACL injuries are common among athletes. After undergoing reconstructive surgery for such injuries, athletes are six times more likely to suffer a similar injury within two years than their peers who have never had such an injury. The finding is from a study by Associate Professor Mark Paterno of Cincinnati Children’s Hospital Medical Center.

Source: consumer.healthday.com

1. What are uterine fibroids? 2. Which story in this issue did you find the most informative? Closing date: October 3, 2013 Send in your answers and stand to win a bottle of Spirulina 100% Extra 10% Deep Ocean Water (750 tablets) worth $69.

Include your name, age, gender, address and telephone number. Winners will be notified via phone or 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 23: Each will receive a bottle of Ultra Selenium Dietary Supplement (60 Veggie Capsules) worth $68.50. Prizes must be claimed by October 3, 2013. 1. Chim Wai Chong 2. Jed Leong 3. K Muthukumar 4. Teo Hock Wah 5. Vanipriya Balasubramanian

An Approach to Common Urological Diseases

Date Oct 12, Saturday Time 9am–5pm (Mandarin session 9.30–

11am; English session 12–1.30pm; Malay session 2.30–4pm) Venue Health Promotion Board Auditorium REGISTRATION Call 6326-5151 or 6576-7658 during office hours (9.30am–5.30pm) to register. Price $8 per session Learn from SGH’s urologists how to manage common urological conditions, including incontinence, prostate diseases, urinary stone diseases and men’s health.

▲

contest

Managing Psoriasis

Have you run out of excuses? Managing menstrual pain or bleeding; Getting back to life and work Date Oct 5, Saturday Time 10am–1pm with post-presentation

lunchtime refreshments Venue To be confirmed

Visit www.singhealth.com.sg/events or the websites of respective institutions for any changes, more information, and other listings.

Sep–Oct 2013

singapore health

Put your heart to the test The National Heart Centre Singapore offers an array of cardiac examinations ‒ from the basic to the nuclear. By Sol E Solomon

photos: alecia neo

YOUR GUIDE TO BETTER LIVING

Electrocardiogram (ECG)

This is the first test used to check if someone has heart disease. An ECG records a heart’s electrical activity, and an abnormal result may be an early sign of an abnormal heart rhythm, heart blockage, damage or changes to the heart muscle, or enlarged heart chambers. When it is done Before surgery. If the patient has chest pain or an abnormal heart beat. If the patient has a history of heart problems.

illustrations: heymans tho

eart disease is the second most common cause of death and hospitalisation in Singapore. Between 1994 and 2012, specialist outpatient visits for cardiology and cardiothoracic surgery across Singapore’s public institutions rose from 74,000 to 271,000. At the National Heart Centre Singapore (NHCS) alone, outpatient visits almost tripled, from 42,000 to 113,000. Singapore’s ageing population means that demand for these services will grow even more ‒ the number of people aged 65 years and above is

expected to triple to 900,000 by 2030. The recent spate of sudden cardiac deaths among young people indicates that even more caution is needed. There are many tests to diagnose heart problems, and a patient’s symptoms and family medical history will be considered before a doctor orders them. However, there are cases when heart conditions do not produce specific symptoms or signs that are detectable by current tests, said Dr Ewe See Hooi, Consultant, Department of Cardiology, NHCS. She describes four common tests:

Procedure Electrodes are placed on the chest, arms and legs. The ECG machine detects the electrical impulses which cause the heart to contract and relax, and transforms them into waves that are displayed on a monitor or graph. The test detects heart rate, damage to the heart, and the size and position of the heart’s chambers. Pros and cons An ECG presents no risks, but some heart conditions may go undetected as they never produce any specific ECG changes. > Continued on page 22

singapore health

Sep–Oct 2013

> Continued from page 21

Put your heart to the test

Stress Echocardiogram

This test adds on to the stress test by including an imaging test precodure called echocardiography. Images of the heart are taken while the patient is performing the stress test or while lying down immediately after reaching peak exercise level. It captures images of the heart at its peak heart rate. When it is done When the patient has chest pain. If the patient has had a previous heart attack, angioplasty or bypass surgery. If there is narrowing of the vessels supplying blood to the heart muscle. If there is an abnormal heart rhythm during exercise. As a screening test before starting an exercise programme or going for surgery. To assess symptoms and blood pressure response in patients with heart valve diseases. Procedure It uses ultrasound to study how the heart contracts and pumps blood while under stress. It also measures the size and function of the heart’s chambers, the motion of the heart valves, and the way blood is flowing. There are two kinds of stress tests. The pharmacological stress echocardiogram is for patients who are unable to exercise. The exercise stress echocardiogram is for those who can carry out treadmill exercises. Pros and cons A stress echocardiogram can identify the site of narrowed blood vessels, and the extent of reduced blood flow to the heart. There is a small possibility of the patient experiencing chest pain, irregular heartbeat, blood pressure changes, or a heart attack during the test. The doctor will take necessary precautions.

Exercise Stress Test

If the ECG detects abnormalities, this is the next step ‒ assessing how the heart responds to an increased workload during exercise. While the patient exercises on the treadmill, his heart’s electrical activity, heart rate and heart rhythm, as well as his blood pressure are continuously monitored. When it is done If the patient has chest pain. If the patient has had a previous heart attack, angioplasty or bypass surgery. If the patient has an abnormal heart rhythm, or to monitor his heart rate and heart rhythm during exercise. As a screening test before starting an exercise programme or going for surgery. Procedure Sticky electrodes are placed on a patient’s chest, and a blood pressure cuff around his arm. This is to take his blood pressure and an ECG of his heart at rest. The patient starts walking on the treadmill, and the speed and gradient are increased every three minutes for about 20 minutes. At the end of the test, the patient rests on a bed while his blood pressure and ECG are monitored. Pros and cons It can detect abnormal heart rhythms during exercise, and reduced blood supply to the heart due to blockages in the arteries. It does not reveal the extent of the reduced blood supply, or the specific area in the heart that is not receiving enough blood. It may not detect arterial wall thickening, as this condition does not always lead to a reduction of blood flow to the heart. The test is not suitable for patients who are unable to perform treadmill exercises.

Nuclear Cardiology Test

In this test, images taken with a gamma camera can reveal which part of the heart is not getting supplied with enough blood and oxygen. It can also reveal the size of the affected area and the severity of the blockage. When it is done In more complex cases, such as when a patient has multiple blockages, or when a patient experiences chest pain after a previous surgery or angioplasty. Procedure It involves the injection of a radioactive tracer into the body, and use of a special gamma camera to track the tracer’s path. Radiographic images are then taken over a period of 15 to 20 minutes. The whole procedure takes two to three hours. Pros and cons It can reveal exactly where the heart is not getting enough blood and oxygen. But parts of the body near the heart, like the diaphragm or breast tissue, may produce some alterations that confuse the test results. The test does expose the patient to some radiation, but only within safe levels.

Sep–Oct 2013

singapore health

Lactose -intoler ant suf ferers

need no t g dairy pr ive up oducts Find ou t how t o enjoy c plan your di et heese a nd milk so that you c a . By Ng Hui Hui n still

Get your calcium from these foods Soymilk Oranges Pinto beans Lettuce Dark green vegetables (broccoli, spinach) Fish (sardines, salmon, tuna) Nuts and seeds

o you suffer from diarrhoea, vomiting or abdominal cramps after eating cheese or drinking milk? If you do, you may be lactose intolerant. Lactose intolerance, the inability to digest milk sugar or lactose in dairy products because of an enzyme shortage in the small intestine, is common among Asians. When unprocessed lactose enters the colon, it interacts with normal intestinal bacteria and causes symptoms such as abdominal cramps, bloating, gas, diarrhoea, nausea and vomiting. Fortunately, there is no need to give up dairy products completely. The key is moderation. Most lactose intolerant individuals can still consume some dairy products without having symptoms, as long as they eat or drink only small amounts. If you suspect that you might be lactose intolerant, simply limit the amount of milk products in your diet. If the symptoms disappear, you are probably lactose intolerant. A doctor can also use blood tests and a hydrogen breath test to diagnose lactose intolerance. There is no treatment currently available to improve the body’s ability to process lactose, but the symptoms can be controlled by choosing a diet that limits the consumption of lactose. One should consult a dietitian before avoiding lactose-containing foods, however, as doing so may lead to certain dietary deficiencies. Dairy products contain important nutrients and are rich in calcium. If you are avoiding dairy products, you need to make sure you get enough calcium from other foods to meet your body’s requirements. Lactose intolerance may be hereditary, or it may develop as one ages as a result of bowel injury or gastrointestinal disorders.

Use over-the-counter lactase (the enzyme that breaks down lactose) tablets or drops to help digest dairy products. Choose smaller servings of dairy products. Drink milk with other foods to slow the digestive process and help reduce symptoms of lactose intolerance. Experiment with different dairy products as they contain

2 3

Ingredients (serves 4) 800g

chicken meat, skin removed and cut into pieces

Marinade 1 teaspoon (tsp) chilli powder 1 tsp cumin powder 2 tsp garam masala 25g garlic, ground 1 thumb-size piece of ginger, ground 25ml lemon juice 1 tsp margarine 1 tsp oil ½ tsp salt 4 tablespoon (tbsp) low fat yogurt, whisked Method

Diet Tips

Tandoori chicken

different amounts of lactose. Yogurt may be tolerated better as the bacteria in cultured milk products naturally produce lactase (see recipe). Check nutrition labels for milk and lactose as they are often added to cereal, instant soups, salad dressings, non-dairy creamers, processed meats, and baking mixes. Lactose is also used in some medications.

1 Mix the marinade ingredients together. 2 Make shallow cuts on the chicken with a sharp knife. 3 Rub chicken with marinade and set aside for 30 minutes. 4 Preheat oven at 180ºC. 5 Grease baking tray with a little oil. 6 Place chicken on baking tray and put small dollops of margarine on each piece of chicken. 7 Bake chicken for about 25 minutes, or until done. 8 Remove from oven and serve hot. The recipe in this article was adapted from Where is the Fat? Cookbook, published by Dietetics and Nutrition Services, SGH.

Laundromat for surgical instruments Two little-known units at the Singapore General Hospital perform the vital task of cleaning and sterilising medical instruments and utensils. By Desmond Ng

Decontamination

Instruments from the

various departments and operating theatres are transported by a porter to the TSSU via a “dirty lift”. These instruments are scanned and checked for defective or missing items. Every instrument has to be accounted for.

PhotoS: VERON WONG

Instruments are

Within the team of 62 at the TSSU, the eldest is Ms Khoo Chai Yan (right), 72, while Mr Muhammad Ariff Ahmad, 24, is the youngest. Ms Goh Meh Meh (middle), Assistant Director of Nursing, is overall in charge.

eeping surgical instruments clean and sterile is top priority at any hospital as it can mean the difference between life and death. At the Singapore General Hospital (SGH), this duty is carried out by the little-known Theatre Sterile Supplies Unit (TSSU) and Central Sterile Supplies Department (CSSD). The TSSU serves the operating theatres, procedural rooms, and more specialised departments like the diagnostic radiology department, delivery suites, cardiovascular laboratory and emergency department. It also supplies sterilised instruments to the National Cancer Centre Singapore, the National Heart Centre Singapore, and the National Dental Centre of Singapore. “We turn around instrument sets to make them sterile and safe for use in the operating theatres,” said Ms Goh Meh Meh, Assistant Director of Nursing, SGH.

The TSSU is like a giant laundromat for surgical instruments. It usually takes about five hours to decontaminate and process a set of instruments, from entry to sterile storage. The same process can take up to six and a half hours in the evenings, when procedures have ended and instruments return for cleaning. Like the TSSU, the Central Sterile Supplies Department (CSSD) also collects and disinfects reusable items, said Ms Ng Suat San, Manager, CSSD. The difference is that the items the CSSD handles include those meant for the wards and the clinics. They also include utensils for operating theatres, dressing packs, and cleansing sets. Just as at the TSSU, the utensils are decontaminated, washed, sorted, packed, and sterilised at the CSSD. The entire process takes about four hours. The inventories and processes at both units are carefully tracked and monitored by customised IT systems.

Operating round-the-clock, the TSSU Processes

25,000 to 28,000 sterile units a month.

usually given a preliminary wash to get rid of residual tissue and blood before they are transported to the TSSU. After an inventory check, these instruments are ready for washing.

Sterile storage

The TSSU inventory contains some 2,950 sets of instruments, 3,500 different types of instruments, and tens of thousands of individual instruments.

SEP â&#x20AC;&#x201C; OCT 2013

Washing

Instruments are

placed on trays on an air-glide system to be washed in machines. Washing takes place in a controlled environment and at a specific temperature. Instruments are 99.99 per cent disinfected and dried at 90 deg C. Most instruments then have to be lubricated.

A final rinse is given

using de-ionised water that has been purified by reverse osmosis, to maintain the shelf life of the instruments. The washing cycle takes about 50 minutes. Some medical devices are water- and heatsensitive, and these are cleaned manually.

singapore health

Assembly

Washed instruments are

unloaded and placed in trolleys, in zones colourcoded by department, to ensure that they do not get mixed up. Nurses and technical staff pack the instruments at their workstations, with pictures and videos to guide them in the assembly of more complicated instruments such as power drills. Some instruments, such as scissors, need to be sharpened or demagnetised. Some instrument sets, such as those used for laparoscopy, need to be oiled to ensure they are in top working order. Instruments that need to be repaired will be sent out to vendors. The barcoded tag that accompanies each instrument or instrument set contains that instrument's or set's production history data, as it passes through the TSSU to the user departments.

Instruments are assembled

and packed in instrument containers, or doublewrapped with sterilisation paper or linen paper. Together, the TSSU and CSSD use 818,000 sheets of sterilisation paper a year.

Loading and sterilisation

Assembled sets are

Packed instruments

are cooled in a storage area after sterilisation. The instrument sets are placed in colourcoded stations. The sets will be collected and delivered to operating theatres by porters as needed. The sets are placed in covered carts, which are transported via a â&#x20AC;&#x153;clean liftâ&#x20AC;? to the various departments.

placed on loading carts to allow for maximum contact with the sterilising agents. The sterilisation process takes another 50 minutes. Steam, dry heat, and hydrogen peroxide plasma sterilants are used to kill germs. Biological tests are done twice daily to ensure that all germs are killed.

singapore health

SEP – OCT 2013

Pearls of wisdom Painful wisdom teeth can be avoided with proper care. By Satish Cheney

ention wisdom tooth surgery and people usually wince. Many avoid seeing a dentist until the pain in their teeth becomes unbearable, but such delays can lead to complications. Dr Shermin Lee, Consultant, Department of Oral and Maxillofacial Surgery, National Dental Centre Singapore (NDCS), said: “I’ve seen patients who needed to be hospitalised because they procrastinated. An infection can develop, potentially compromising a patient’s airway and ability to swallow. People often wait till the last minute because they are afraid and unaware of problems an infected wisdom tooth can cause if not attended to.” When wisdom teeth become impacted Wisdom teeth are also known as the third (rearmost) molars. We typically have four – two each in the upper and lower jaws, one on either side. They are associated with wisdom because they usually erupt between the later growing ages of 16 and 21. Some studies suggest that wisdom teeth could once have been useful, when human jawbones were bigger and could accommodate their fully erupted size. But over the centuries, with a diet of softer, processed food, our jawbones gradually shrank – providing less space for teeth to grow. This has led to most wisdom teeth, especially those in the lower jaw, being impacted. An impacted wisdom tooth does not grow in the right direction, said Dr Lee. “It could be partially or fully impacted, either with soft tissue or by parts of the jawbone. An X-ray will show how deeply the tooth is impacted, and the decay associated with it or the tooth besides it.” Impacted wisdom teeth can lead to a slew of problems, including gum infection, tooth decay, and occasionally, the formation of dental cysts. When a dental cyst develops and enlarges, it can cause pain in the jawbone and surrounding area, and at times even weaken the jawbone, causing a pathological fracture.

Going under the knife Oral surgeons (dentists with speciality training in Oral & Maxillofacial Surgery, equipped with the skills and experience to remove impacted wisdom teeth) will consider all possible factors before recommending the removal of impacted wisdom teeth. Surgery usually involves cutting the gums to expose the impacted tooth and the bone, dividing the impacted tooth, and then stitching up the gums. NDCS carried out over 4,500 cases of wisdom tooth removal in 2012. Impacted wisdom teeth, accompanied by pain and other symptoms, occur mostly in young patients. But elderly patients with problematic wisdom teeth may sometimes need surgery as well. “Older patients may have pre-existing conditions like diabetes or hypertension, which need to be taken into consideration when managing their surgical and post-operative care. Also, they may have a slightly longer downtime to heal, compared to younger people,” said Dr Lee. Dentists are often asked whether all four wisdom teeth, even unproblematic ones, should be removed while the patient is young to pre-empt future problems. Dr Lee said: “This is a grey area which is debatable even among experts from the UK and the US. Treatment should be tailored to the individual.” Get checked before pregnancy or radiotherapy Pregnant patients with wisdom tooth problems are treated only if their teeth cause problems during pregnancy. Doctors will give serious consideration to any medication, such as painkillers or antibiotics, before prescribing them to pregnant or breastfeeding mothers. Dr Lee advises women planning for pregnancy to have regular dental check-ups, to avoid undergoing complicated dental procedures during pregnancy as far as possible. She also said that patients diagnosed with head and neck cancers, who need radiotherapy, should preferably have dental screenings weeks before starting treatment, to avoid post-radiotherapy dental surgery. Dental extractions and surgery after radiotherapy can give rise to unfavourable healing or even osteoradionecrosis (bone infection).

Fact or fiction?

Dr Lee throws light on some frequently asked questions about wisdom teeth.

Do all adults have four wisdom teeth? Not everyone has four. Some have fewer.

Do only young people have problems with wisdom teeth?

No, and some people never develop problems with their wisdom teeth, even through old age.

Are wisdom teeth completely useless?

If a wisdom tooth erupts ideally into the jaw arch, has an opposing tooth and can be used when chewing , it serves a purpose and does not need to be removed. In some cases, a wisdom tooth can be used as a substitute for a lost tooth, but this is usually applicable only to young patients.

Is it best to remove all one’s wisdom teeth in a single procedure?

There are no hard and fast rules. Various options and patients’ preferences will need to be discussed. It depends on whether the patient is going to the procedure done under local anaesthesia, sedation or general anaesthesia. This also depends on a patient’s comfort level and whether they prefer to be awake or asleep during the procedure. If the patient will be undergoing general anaesthesia, we usually advise removing all the wisdom teeth during that procedure.

Are the procedures always painful?

If you have regular check-ups, or visit a dentist immediately upon feeling slight discomfort around your wisdom tooth, any problems can be addressed before infection sets in or decay occurs. Adequate pain relief medication will be available to support patients during the post-operation phase.

An X-ray showing that all four wisdom teeth are impacted. X-rays can also reveal whether the teeth next to impacted wisdom teeth are affected.

2013 年9 – 10月刊

新加坡中央医院与新加坡保健服务集团的双月刊

机器人辅助手术突破肌瘤切除限制

常见且基本无害

图： alvinn lim

通常需经开腹式手术切除巨大肌瘤，现在也能通过锁孔手术安全地进行

彼得巴顿史密斯医生坐在远离手术台的控制台前，通过一个三维高清摄像头和精度高的微巧手术器械进行手术。原文 Desmond Ng

医生说。“使用机器人技术，我们能将限制放宽到相当于怀孕20周大小，但如果还是超出界限，也只能选择开腹手术了，”他补充道。 “由于机器人辅助科技给外科医生更大的操作范围，所以限制也被放宽，比传统直式腹腔镜设备更能处理大块肌瘤，” 巴顿史密斯医生说。

可弯曲机器人臂实现精确操作在手术中，巴顿史密斯医生在她腹部做了5个微小切口，插入一个三维高清摄像头和一个既灵活又精度高的微巧手术器械，然后坐在远离手术台的控制台前，透视黄瑞兰腹腔内的情况并进行手术。 “感觉（自己）犹如手术器械一样只身在体内动手术，”巴顿史密斯医生说。真多亏了这台机器人高度灵活的手术臂，让他更能掌控轻柔且精细地操作，切开子宫表面，再像“剥豌豆一样轻而易举地把肌瘤从子宫剥离出来，”他说。接着，他将子宫切口缝合，再采用一种称为组织粉碎器的工具（一端具有环形刀片的中空管）将原本巨大的肌瘤切成长条状，然后从腹腔狭小的切口中取出。 “使用机器人辅助手术，患者所承受的痛苦会减轻，失血量减少，住院时间缩短，患者也能更快地恢复正常活动，约术后2至3周，而进行常规开腹 ” 手术的患者则需要6周，巴顿史密斯医生说。

黄瑞兰的手术耗时3个半小时。留院2天。进行开腹手术治疗（称为子宫肌瘤切除术）的患者，通常需要住院3至5天才能回家。 “其惊人之处在于术后无疼痛。感觉就像胃部不适。有不适感但不疼痛，”黄瑞兰说。

子宫肌瘤不但常见而且可以长得很大。但是，它们很少癌变。大约每5位女性中就有一位患有子宫肌瘤，通常发生在30或40多岁时。“但是发生肌瘤癌变的几率很低，每 1000名患者中不到1名会发生肌瘤癌变，”新加坡中央医院妇产科高级顾问医生彼得巴顿史密斯说。对于大部分女性而言，子宫肌瘤不会带来什么麻烦，因为它们通常保持较小的状态。但是一些良性肿瘤可以长得非常大。“我曾切除过重达9公斤的肌瘤呢，” 巴顿史密斯医生说。当肌瘤长得非常大时，它们可能开始压迫其他器官，比如肾脏。发生此情况时，患者就会开始出现月经大量出血，腹部不适，腰背疼痛，以及尿频症状。部分女性也可能出现不孕。 “在新加坡，女性常常不仅患有子宫肌瘤，还同时伴有子宫内膜异位，这使得情况更加复杂，”他说。很多亚洲女性同时患有这两种疾病，这对来自英国的巴顿史密斯医生来说是前所未见的。

带蒂肌瘤腔内肌瘤

输卵管

子宫

卵巢

黏膜下肌瘤

浆膜下肌瘤

肌壁间肌瘤子宫颈阴道

子宫肌瘤类型除了非常巨大的带蒂肌瘤外，黄瑞兰还有其他三个较小的肌瘤，称为黏膜下及腔内肌瘤。据彼得巴顿史密斯（ Peter Barton-Smith）医生说，这类肌瘤，如果瘤体够小的话，可以经子宫颈进行手术切除。瘤体更大的和其他类型的肌瘤通常都不得不经腹部进行手术切除。

图： HEYMANS THO

黄

瑞兰女士在五月份做了子宫肌瘤切除术。切除的良性肿瘤共有4粒，总重量约半公斤，最大的瘤体直径14.5厘米。现年54岁的黄瑞兰，除了腰围增粗外，几乎没有其他症状。 “我还以为是自己长胖了呢，”这位培训和项目经理说。子宫肌瘤是育龄期妇女最常见的疾病，开始发病的年龄通常是30或40多岁的女性。肌瘤生长于子宫肌层，一般无害而且表面光滑。肌瘤长得越大就会导致月经量更多、腹部不适、背痛、尿频及生殖功能障碍。今年初，已有两个孩子的黄瑞兰在常规妇检中发现自己患有子宫肌瘤，而且体积还不小。医生建议她将肌瘤切除。 “她最大的瘤体是带蒂肌瘤（见图解），所以我们选择为她进行微创性的机器人辅助手术，”新加坡中央医院妇产科高级顾问医生彼得巴顿史密斯（Peter Barton-Smith）说。一般上，如果患者肌瘤数目太多或者最大瘤体太大，外科医生是不会选择微创性或微创腹腔镜手术，而是开腹手术。巴顿史密斯医生说，传统的腹腔镜手术一般适合限于有3到5个肌瘤，每个瘤体直径小于5-6厘米的患者。另一种决定手术方式的方法就是依据子宫的大小。当子宫逐渐增大至相当于怀孕16周大小时，就是达到传统腹腔镜手术条件的限制，巴顿史密斯

新闻

2013 年9 – 10月刊

您的牙龈健康吗？新加坡国立牙科中心顾问医生陈华情回答关于牙周病的疑问

牙龈病，也称为牙周病，是指在牙龈上和支撑牙齿的骨质中发生的慢性细菌性感染，会影响一颗或波及多颗牙齿。牙龈炎是较轻型的牙龈病。按时刷牙，使用牙线，并配合专业洁牙护理，牙龈炎是可以治愈的。但如果牙龈炎未经治疗，则可发展成为牙周炎。此时牙龈、骨质和结缔组织都会受损，引起脱牙。

牙周病的起因是什么？引起牙周病的主要原因是菌斑。菌斑会随时间而变硬并形成牙结石。在菌斑变大的同时，机体的免疫系统也在与细菌斗争。细菌产生的毒素和酶一起作用，导致固定牙齿的骨质和结缔组织受损。如果任其发展，牙齿最终会松动，不得不拔除。牙周病的病情轻重不一，可以影响任何年龄的人群。

牙周病的易患因素有哪些？吸烟会增加患牙周病的机率，并降低

某些治疗的效果。不受控制的糖尿病会增加感染的危险。女性体内的激素变化也会使得牙龈更为敏感。可能诱发牙周病的其他因素包括某些口腔用药、某些癌症和艾滋病的治疗方式以及个人体质等。

牙周病有哪些症状？牙周病的症状有牙龈肿胀、疼痛、刷牙时出血、龈线退缩、脓肿、牙齿松动、移位、持续口臭及牙龈和牙齿钝痛。也有些人没有任何症状或疼痛感。

牙周病如何治疗？牙周病的治疗方式各不相同，但目标都是控制牙龈感染及恢复良好的口腔环境。非手术疗法包括洁牙加根面平整。洁牙是刮除龈线上下方的牙结石。根面平整是在局部麻醉下采用专门器械沿着牙根表面清除坚硬的牙结石和细菌沉积物。牙龈手术的目的是清除深部牙周袋内的残余牙结石。其目的是避免疾

图：getty images

什么是牙龈病？

病恶化并使日常牙齿清洁变得更为容易。牙周病病程较长的病人，应选择牙龈手术。牙周病专科牙医有时会建议病人做骨移植或组织移植，促进骨或组织的重新生长，以达到修复病变部位的目的。

如何预防牙周病？使用含氟的牙膏刷牙，每天两次或每餐后进行，可减少牙菌斑的积聚。每天使用牙间清洁工具如牙间刷或牙线

做清洁。每年看牙医两次，进行例行检查和专业洁牙。拒绝烟草。

牙周病会影响身体其他部位吗？牙周病可能会影响身体其他部位，然而目前科学研究对此还没有定论。相关研究涉及探讨牙周病与心脏病发作、中风或早产儿/低体重儿的出生之间是否存在联系，以及探讨患有牙周病的糖尿病人是否更难以控制其血糖水平。

2013 年9 – 10月刊

新闻

食物恐惧利用烘焙和共同用餐方式克服饮食失调症原文 Jamie Ee

新

加坡中央医院职能治疗师郑素玫每星期都开办烘焙课。她不仅仅是传授糕点食谱，也利用这个方式来帮助患上饮食失调症的学员们，克服他们对糖和奶油等日常食物的恐惧感。在课堂上，学员们得直接接触他们平时讨厌的食物。这有助于他们逐渐抛却对食物的反感，更重要的是，解除他们的饮食禁忌，重拾正常规律的饮食习惯。 “饮食失调症患者与食物之间存着一种‘错乱’的关系，”郑素玫说。“每当看到食物时，他们不是在哭喊、呼吸紧凑就是大发脾气。曾经就有一名患者一看到食物便变得如坐针毡，经常多次逃离现场，试图使自己冷静下来克服恐惧，还不惜撕扯自己的手指甲。” 这些人正是因为太在意自己的体重和身材，才惹上食物恐惧症的。他们认为高热量食物如奶油和糖会使他们发胖，所以对它们退避三尺。结果把自己搞得瘦弱、营养不良，还不时出现代谢或荷尔蒙问题。 “饮食失调是一种心理疾病。这种疾病没有主要原因，一般被视为一种诸多因素的综合症，包括遗传学、家族类型、个性类型以及媒体影响等，”

新加坡中央医院康跃中心饮食失调治疗计划主任、精神科高级顾问医生李慧媛说，“对意志薄弱的人来说，只要他们承受不了压力或他人的议论就会很容易引起饮食失调。” 这种失调症会往往使人过于关注食物和饮食，过分在意自己的身形和体重，以至严重地影响他们的日常生活，如工作和交际等。厌食症和暴食症就是其中的两种。前者是进食量微乎其微，后者则是无节制进食，然后采取催呕或服用泻药来控制体重。李医生和郑素玫是专治饮食失调症的多学科医疗团队的成员。其他团队成员则为患者提供营养、医疗和心理方面的协助。在那两小时的烘焙课上，郑素玫与大家一起称重、计量食材和揉面团。“对饮食失调症患者来说，这些都是很难独自完成的工作。” 课堂结束后，学员们会分享他们

患上饮食失调症的人，可能对糖和奶油等日常食物产生恐惧感。

每个人都可从餐桌上选择各式各样的肉类和蔬菜。饮食失调症患者也会时常挑食剩饭。为转移他们的注意力，在就餐过程中，郑素玫会和他们谈论时事、最新电影和书籍。“简言之，我会将整个午餐体验正常化，好让他们能够再次与别人舒服地一起用餐，”她表示。四到六个星期后，疗程结束。医生会再三叮咛他们继续定时进餐、吃多元化的食物和避免缺餐。李医生说：“我们还会帮他们做些调整，好让他们回到学校或工作岗位后，把注意力转移到其他事情，而不是饮食和体重问题上。” 然而，康复是一条很漫长的路，复发率也“相当高”。她还指出，有三四成的患者在结束治疗后的一年内又重返恶习。她表示，及早治疗是康复的关键，因此“承认问题”并寻求帮助对患者来说是至关重要的。

的体验和感受。“当有些说奶油或糖用得太多时，我就会提醒他们，说他们不是只做一个人的份量，”郑素玫表示。她还补充说，“为亲朋好友准备一顿或共享一餐，对我们大多数人来说是再自然不过的事。但这种常态却反而对他们造成极大的困扰。” 加上，中餐没有如西餐那样有固定的份量。饮食失调症患者无法决定进餐量，也因此无法与别人一起用餐。所以，郑素玫偶尔会带他们到典型亚洲家庭式的场所共进晚餐，体验所谓的群体餐，让

职能治疗师郑素玫每星期都开办烘焙课，帮助患上饮食失调症的学员们。

征兆的蛛丝马迹体重已明显急剧下降仍感觉肥胖或超重过度在意体重、食物、热量、脂肪克数和节食；或极度顾虑体重和体型抗拒某种食物或某个类别的所有食物对增加体重或变胖感到无限恐惧和焦虑图：Alecia neo

否认饥饿

年轻人和女性

饮食失调症日益普遍，新加坡中央医院康跃中心每年平均接到

120

个新病例

大约

90%

的饮食失调症病人是女性

暴食症多见于

20岁到 30多岁

左右的年轻人

厌食症多见于

10多岁到 20多岁左右的青少年

饮食程式化，例如有特定的进食顺序、重复排列盘子上的食物或将食物切成小块为缺餐或逃避与食物有关的情况找借口远离朋友和社交活动月经周期紊乱有过度或严格的运动计划

新闻

2013 年9 – 10月刊

重获心生，喜获千金幸运患者得到心脏瓣膜捐赠也晋升为人父

受惠包括林惠综。这当中，几乎一半是18岁以下的患者。林惠综获得匿名捐赠者的心脏瓣膜组织。与其他器官移植不同的是，心血管同种移植不会造成器官排斥等副作用，所以也不必长期服用药物。

图：Alvinn Lim

缺乏捐赠者

林惠综先生于2011年3月做了心脏瓣膜移植手术后仅仅几个月便与妻子生下了女儿。

原文 Tan May Ping

做

了心脏瓣膜移植手术不久，太太便顺利地怀孕，这对林惠综先生来说是个奇迹。在 2011年 3月，他进行了移植手术，以修复已损坏的心脏瓣膜。如果不动手术，受损的瓣膜会导致血液流返心脏。到那时，林惠综将会面临心力衰竭的危险。手术成功无疑是件值得庆祝的事，然而宝宝的诞生更令人雀跃万分。怀里抱着女儿，年仅33岁，已婚三年的年轻牧师林惠综说：“我没料到手术后那么快就有孩子的。我相信这是移植手术促成的惊喜。” 目前，他不仅享受着初为人父的喜悦，身体也逐步好转。曾经容易气喘、疲劳和胸部紧张等状况，现在全都消失了。完成手术三个月后才获准做运动，让这名自行车发烧友积极地回到正常生活的轨道上。

其实，林惠综对心脏病一点都不陌生，因为他一出生就患有法洛四联症（tetralogy of fallot）。这是一种先天性心脏缺陷，而心脏穿孔是缺陷之一。林惠综八岁时曾修补过穿孔的心脏。之后，身体恢复良好，状况也保持稳定。直到2011年，他那衰坏的肺动脉瓣引起了严重的心脏血液回流问题。这次，他必须接受心脏瓣膜移植来修复漏洞。

瓣膜和组织存库全国心血管移植片存库（ National Cardiovascular Homograft Bank，简称 NCHB）是个负责采集、筛选和存放捐赠的人体心血管组织（同种移植片）的机构。采集的人体组织有心脏瓣膜、血管组织和气管等。自2008年成立以来，已有45名患者

获得合格鉴定全国心血管移植片存库 (简称NCHB) 于2012年2月被美国组织库协会（American Association of Tissue Banks）鉴定为合格存库，成为北美以外第一个被该协会鉴定合格的组织存库。所有NCHB工作人员也都通过了该协会举办的考试，成为了专业认证的组织存库人员。新加坡国家心脏中心心胸外科的高级顾问兼NCHB项目总监林崇熹医生说：“每当采集逝者的心脏和血管组织时，我们总要面对组织可能被细菌感染的风险。所以要保留高素质的组织就必须确立一套标准。”

林惠综并没有等太久，但情况并非都是如此。事实上，等候名单上平均有6 到8名患者正等着受捐，然而心血管同种移植片供不应求，使患者必须等上至少3个月才能做移植手术。由于有些人普遍认为捐赠器官会造成遗容受损，因此捐赠者难求。“这完全是个误解。采集的工作是由训练有素的外科医生以最尊重逝者的方式来执行的，”新加坡国家心脏中心心胸外科高级顾问兼NCHB项目总监林崇熹医生说。他表示，人体心脏瓣膜往往是移植给法洛四联症或瓣膜感染患者的。倘若是人造瓣膜，他们不只必须终身服用血液稀释剂，还要面对较高的中风风险。如果移植的是动物组织瓣膜，生命延长期也仅是8到10年。然而人体心脏瓣膜，有研究显示，可延长生命 15到20年。林惠综对那名捐赠者心存无限感激。他说：“他的无私延续了我的生命。” 他有意认捐自己的遗体，也会鼓励身边的人这么做。现在，他非常期待与女儿培养紧密的亲子关系，并计划与她分享这身经历。 “我期待在她成长过程中，教会她享受运动的乐趣。”

全国心血管移植片存库工作人员将同种移植片存放进金属柱里然后浸没于零下180℃的液氮中。

募集捐赠者全国心血管移植片存库(简称 NCHB) 高级临床协调员石修风有一份充满挑战性的工作，那就是找寻捐赠者。她说：“由于很多人在生前都不愿与家人讨论自己的身后事，家人不知道逝者的心愿，所以在面临决择时困难重重。” 石修风继续说，当确定合适的捐赠者时，她会先向其家人询问这名可能是捐赠者的个性或他平时待人处事的态度，像他是否与人为善、慷慨大方，喜欢乐于助人等。约有三分之一的家人都会同意捐赠。在获得家人的允许以及NCHB 医疗总监的批准后，以下是工作人员处理所捐赠的心脏组织的步骤： 1 从逝世者体内取出附有主动脉瓣和肺动脉瓣的部分心脏。 2 在实验室里把主动脉瓣和肺动脉瓣分离。 3 用抗生素培育这些瓣膜，并做细菌污染检测。 4 用低温保存剂把瓣膜包起来，存放进零下 180℃ 的液氮中。 5 直到实验结果通过才将隔离容器里的瓣膜移到临床容器里，为移植手术做准备。同种移植片可存放长达五年。 NCHB也会不时举办宣传活动，向学生讲解以提高他们对器官捐献的意识。石修风说：“我们希望他们可以从中得到启发，长大后能够认捐自己的器官或细胞组织。”

如何成为捐赠者捐赠者必须是18岁以上。根据医药（治疗、教育及

研究）法令（ Medical Therapy Education Research Act，简称 MTERA）的规定，捐赠者可以指定他要认捐的身体组织及部位。诸如人体心脏瓣膜、血管组织和气管等组织均在 MTERA 范围之内。人们可以选择死后捐出身体组织以供移植或研究用途。如果个人没有认捐器官组织，他的家人可以选择在他去世后，通过MTERA捐赠逝者的器官组织。有关网站 www.liveon.sg

2013 年9 – 10月刊

新闻

意见箱

乐龄人士牙科保健辅助津贴我想要检查牙齿。但我发现自资的病人与受辅助的病人付费有差异。我应该怎么获取辅助津贴的资格？哪一家医疗所会受理？新加坡国立牙科中心答复：若要获取一般检查与治疗的辅助费用津贴，您除了可以到任何一间综合牙科

诊所安排申请之外，也可以到那些有参与卫生部社保援助计划的家庭牙科诊所办理。若您父亲进行例检时发现有口腔问题，该计划里的牙医会把他推介给合适的专科牙医，做进一步治疗。在新加坡国立牙科中心，凡是年龄在40岁以上，同时又是从社保援助计划推介过来接受专科护理的病人，一律都会小保留辅助收费资格。目前，全国已有超过200间家庭牙科诊所加入这项社保援助计划计划。欲知详情，请上网：chas.sg/index patients.aspx.

为什么我需要另付检查费？我到一家综合诊疗所的牙科门

诊去洗牙和牙石清理。付费时才发现门诊还另收检查费。我已支付服务费了，为什么还要支付检查费？新加坡保健服务集团综合诊疗所答复：如果患者超过一年没到综合诊疗所的牙科门诊处就诊，牙医必须先为患者从新进行一次口腔检查，确认其整体口腔状况，再为他进行疗程。这是为了确保疗法得以在患者口中安全地进行。因此，需要另付检查费。

解读。但被回拒了。为什么我得要为一份报告去见医生呢？新加坡保健服务集团综合诊疗所答复：为了对您的健康状况进行更好的评估，医生有义务审阅您的实验报告。这样一来，医生就可以根据您的实验结果和医疗状况，为您开药方、提供建议或制定一套适合您进一步的治疗方案。

不邮寄试验结果试验两星期后收到通知，要我去见医生检视报告。我要求他们把实验报告邮寄给我，以便我自己

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。

专家解答

黄斑病变

心传导阻滞是一种心脏病吗？我被诊断患上一级心传导阻滞（first-degree heart block）。我的家庭医生叫我不用特别在意，因为这个疾病不必治疗，所以也没给我任何跟进病情的建议。请问心传导阻滞是一种心脏病吗？它会不会随着年龄增长而恶化，增加患上心房颤动（心律不齐）、心脏病突发或中风的风险？我是否应该做些监测管理，例如每年做一次心电图检？还有，病情有痊愈的可能吗？一级心传导阻滞通常不会引发任何其他症状。它是因为某些像β受体阻断剂（beta blockers）的药物或生理因素所引起的，像受过特训的运动员，他们的心律较会偏慢所以可能有患上一级心传导阻滞的倾向。要是你的情况是因这两者而起，你可停止服药和做相关的运动。但如果病情没有恶化到非常严重的程度，像晕厥之类的症状，那就不必治疗。人的心脏传导系统（犹如电力供应，负责控制调节心跳节奏和脉冲）会随着年龄增长逐渐退化。对

痴呆症的诱因是什么？有什么征兆？

痴呆症是否会遗传？脑震荡会导致痴呆吗？痴呆症患者是否会有类似精神失常的行为，例如对着镜子自言自语、不与任何人说话，或者不让别人阻挡他们想要做的事？家族遗传是痴呆症的其中一种因素。对早期发病患者（30到50岁之间）来说，它的影响力是相当高的，但对65 岁以上的来说，导致痴呆症的综合因素比遗传还来得更多，像混合性痴呆症和能引发血管性痴呆症的糖尿病、高血压、中风和高胆固醇或高脂血症等。另外，头部如果频频受创或震荡

也会提高诱发痴呆症的风险。有些痴呆症患者人格上会发生剧烈的转变，有些则是情绪或行为表现异常，包括易怒或易激动、妄想、幻听或幻视和神志恍惚等等。由于他们平时看起来与常人无异，所以他们的记忆能力或功能能力常被家人朋友忽略。不过，以上症状也可能是其他疾病或精神状况的征兆。依您描述的症状，最好是寻求专业医疗的评估。新加坡中央医院老年医学科顾问医生萧俊才

于60岁以上的年长者来说，心脏传导阻滞可能就是心传导系统功能减慢的早期迹象，要是情况恶化，患者就得安装心脏起搏器。至于是否需要做心电图检，那就要看情况而定，因为这通常是一些病症像高血压、心脏瓣膜病和甲状腺功等，造成心律不齐或心房颤动的情况下才会提议的。除非，一级心传导阻滞恶化导致心房和心室收缩不协调或心房逐渐扩大（这是非常罕见的情况。），不然就没有必要每年进行一次心电图检查。新加坡国家心脏中心心内科顾问医生何佳恩

保护我们的眼角膜我们应该如何防止眼角膜受损？眼角膜移植会引起哪些风险？眼角膜移植的首要风险是排斥反应，其次是在移植后的头几个阶段，眼角膜可能会受到感染，眼压也可能会日渐提升。如果要避免眼角膜遭到外伤，运动时可佩戴护目镜。目前没有任何证据可以证实饮食可以保护眼角膜，然而具有抗炎作用的亚麻籽油能够稳定眼球表面进而稳定泪膜层，尤其在强风环境里。另一方面，抗氧化剂也可以保持眼睛健康。新加坡全国眼科中心角膜及眼表疾病科顾问医生兼任副教授Jodhbir Mehta

我今年46岁，双眼近视度约900 ，右眼患有与年龄相关的黄斑变性病。由于状况稳定所以没在服药。但是，我开始感觉中央视觉有个模糊的斑点，在强光底下斑点会扩大，使用电子表格时也会看到弯曲波浪线。往后的日子里，我的视力是否还可以得到改善还是会继续恶化？我该怎么做？另外，在吃滚烫或辛辣食物时，双眼会有刺痛感，为什么会出现这种情况？高度近视者在四十岁左右会发生黄斑变性病，多数是因为视网膜中心的“ 黄斑”区萎缩变薄而引起的。由于眼球在这年纪已不再发育，所以状况一般都能保持稳定。然而，如果新生血管（血管也偶尔会生长在这区域）出现出血或结疤的状况，中央视力和近视力就会进一步被削弱。若要控制这个问题，您应该定期每年一次做瞳孔放大检查。热辣食物会让眼睛产生刺痛感，主要的原因是因为连接泪腺的自主神经受到了刺激。这是一种正常的反射作用。不过，如果您流泪时眼睛感到疼痛的话，那可能是干眼症或眼睑皮脂腺发炎（睑板腺炎）所引起的。要舒解状况，您可以定期使用人工泪液以及清洗眼睑，尤其是眼睑边缘部位（睑板腺的位置）。如果您有任何疑问，请务必就医。新加坡全国眼科中心白内障和综合眼科服务顾问医生韩竹燕

2013 年9 – 10月刊

Dermatologist Formulated

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