Singapore Health Sep/Oct by Singapore General Hospital

sep oct

2014 a Bimonthly Publication of Singapore General Hospital and SingHealth ACADEMIC HEALTHCARE CLUSTER MCI (P) 173/05/2014 www.sgh.com.sg | www.singhealth.com.sg

Best Overall Editorial

Bronze

COntent Marketing Awards 2013

AWARD OF EXCELLENCE

APEX Awards 2014

More children are seeing the dentist before turning two

Drinking coffee cuts the risk of dying from some liver diseases

New injection method for overactive parathyroid glands

With the right posture, equipment and attire, cyclists can enjoy the sport better

能快速恢复甲状旁腺功能的新疗法 P27

An expectant mother’s moods can affect her baby’s development

居家护理让病患省却了往返医院的奔波，也减轻了医院的负担

singapore health

SEP– OCT 2014 Publisher

Co-funded

Content Advisor

Tan-Huang Shuo Mei

Group Director, Communications & Service Quality, SingHealth & SGH Editorial Team

Angela Ng (SGH) Lim Mui Khi (SGH) Carol Wee (SingHealth) Ann Peters (SingHealth) Deborah Moh (SGH) Singapore Health is partially funded by SGH Integrated Fund, SingHealth Foundation, Tote Board and Singapore Turf Club to advance the health literacy of Singaporeans.

Read Singapore Health online at www.sgh.com.sg/singaporehealth

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Group Editor-in-chief

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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 reserved. Copyright by SGH (registration no: 198703907Z). Opinions expressed in Singapore Health are solely those of the writers and are not necessarily endorsed by SGH, SingHealth Group and/or SPH Magazines Pte Ltd (registration no: 196900476M) and their related companies. They are not responsible or liable in any way for the contents of any of the advertisements, articles, photographs or illustrations contained in this publication. Editorial enquiries should be directed to the Editor, Singapore Health, 168 Jalan Bukit Merah, #13-01 Surbana One, Singapore 150168. 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) 173/05/2014. Printed in Singapore by Singapore Press Holdings Limited (registration no: 198402868E).

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Cut, mince and jab A new technique that injects finely minced parathyroid gland tissue into the arm of a kidney failure patient works better than implanting a bit of the gland By Thava Rani

urgery to remove overactive parathyroid glands in patients with kidney failure was often followed up immediately with a small bit of the gland being implanted into the arm muscle. This was done to restore the glands’ function, which could take nearly nine months to recover. But a team of surgeons from the Singapore General Hospital (SGH) and the National Cancer Centre Singapore (NCCS) recently found through a retrospective study of 132 patients that injecting a solution containing finely minced gland tissue into the upper arm got the parathyroid function up and running again more quickly. The glands’ function was restored in just two months, the study found. “This new injection method promotes faster recovery and can be performed in nearly half the time that the conventional method requires,“ said Dr Jeremy Ng, Consultant, General Surgery, SGH. Unlike the previous method of cutting up muscle to implant the gland, the injec-

(From left) Dr Gopal Iyer, Dr Jeremy Ng and Associate Professor Lina Choong, were involved in the study on the new injection method which promotes quicker recovery.

Small but important

thyroid gland

parathyroid glands The tiny parathyroid glands, found behind the thyroid, can grow many times their normal size in some advanced stage renal disease patients.

tion does not leave any scars, and there is less risk of bleeding or infection. “If the gland becomes overactive again, surgeons can get to the injection site more easily, without having to cut through muscle again,” said Dr Gopal Iyer, Senior Consultant, Department of Surgical Oncology, NCCS. The study involved 132 patients who underwent surgery to remove their parathyroid glands between February 2005 and February 2012. The patients’ parathyroid function was restored by either implantation or injection. The study was published in Surgery, a renowned international journal, in

January this year. The injection method, which carries a lower risk of complications, has become the standard procedure for this condition at SGH. About 130 patients have undergone the procedure. The tiny parathyroid glands that sit near the thyroid glands in the neck serve the very important function of maintaining the right balance of calcium and phosphate levels in the blood. When this balance goes out of whack, as is common among those suffering from poor kidney function, medication or even surgery is needed to treat the condition. “Patients with poor kidney function have a problem with phosphate because

Implantation or injection?

What is How long How long before scarring? risks Done it takes parathyroid function is restored

Injection

Solution of finely minced gland injected into fat under the skin

Implantation

Gland pieces implanted 30min 9 months 4-5cm into arm muscle

18min

2 months

None

Bleeding, infection

Sometimes too small to be detected even by ultrasound, parathyroid glands

• Are small pea-sized glands, usually four, located just behind the butterfly-shaped thyroid glands in the neck • Can grow 20-30 times their normal size when stimulated to keep producing a hormone that deals with phosphate and calcium imbalance

The glands’ Balancing act

• Parathyroid hormone is released to control levels of calcium (too low) and phosphate (too high) in the body; magnesium too • Causes kidneys to excrete excess phosphate in urine • Causes release of calcium from bones, calcium to be absorbed, and stops kidneys from getting rid of calcium in urine

Calcium and phosphate are important in • Building and repairing bones and teeth • Helping nerves to function • Making muscles contract • Helping blood to clot

When there is Too much phosphate

• Kidneys are not able to remove excess phosphate in urine effectively when prompted by hormone • Parathyroid glands keep releasing hormone to try and lower high phosphate level • Continued discharge of hormone causes side effects: more calcium is released from bones, resulting in slow loss of support function; released calcium clogs blood vessels • Patients may experience bone and joint pains, fractures and/ or cardiovascular problems

> Continued on page 4 ( 华文版本请翻阅至27页 )

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sep– oct 2014

> Continued from page 3

Cut, mince and jab

with people suffering from end-stage renal failure, the signals cannot be heard and the kidneys cannot get rid of phosphate easily, leading to phosphate levels staying at elevated levels, she said. When this occurs for a long time, bone and cardiovascular diseases can occur. Not everyone with kidney failure will

Measuring kidney deterioration

Kidney disease usually worsens slowly over a period of years. There are five stages of kidney deterioration, each requiring different tests and treatments, said Associate Professor Lina Choong, Senior Consultant and Director of Dialysis, Department of Renal Medicine, SGH.

develop overactive parathyroid glands; an estimated one-third of kidney failure patients develop the condition eventually. While the overactive glands can be controlled through medication and diet, about 5 per cent to 15 per cent of patients will need to turn to surgery as a last resort to address the problem.

The stages are defined based on the glomerular filtration rate (GFR), the best measure of kidney function. The GFR is calculated using the results of a blood test along with the patient’s age, race and gender. The higher the GFR, the better the kidney’s function.

Stage I

Stage II

Stage III

Stage IV

Stage V (end-stage)

GFR > 90

GFR 60 – 89

GFR 30 – 59

GFR 15 – 29

GFR < 15

PhotoS: alvinn lim

all food has some phosphate in it,” said Associate Professor Lina Choong, Senior Consultant and Director of Dialysis, Department of Renal Medicine, SGH. For people with kidneys that function normally, this excess phosphate is excreted through the urine, and balance is regained quickly. But when the kidney is not functioning normally, as

Dr Jeremy Ng (foreground) uses an ultrasound scan to check Mr Ho Peng Fun’s parathyroid glands. Mr Ho underwent surgery to have his parathyroid glands removed and the gland function restored by the injection method. The 65-year-old had bone pain, a common symptom of overactive glands in kidney failure patients.

(dialysis or kidney transplant needed)

GFR 100 90 80 70 60 50 40 30 20 10

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Show me your teeth The call to take very young children for dental check-ups seems to be getting heard

rect dental habits and dietary practices set up a negative environment for baby teeth, even before the first tooth erupts. After evaluation, dentists will formulate a plan with parents to lower this risk. This is a cost-effective strategy for parents and dentists to prevent problems with.

Consequently, the age recommendation was reduced to two years. But even with this lowering of the age recommendation, many children were still coming in with dental cavities. Decay was spreading rampantly. “We needed a change in strategy to get ahead of this disease,” said Dr Chng. The first dental visit According to AAPD, the first dental visit is now recommended at the time when the first tooth erupts; no later than age one. This is so that before children develop decay (as many children did by age two previously), parents will be able to avoid the risk factors and keep their children’s teeth decay-free. Paediatric dentists at NDCS have long adopted and supported this recommendation, setting up the first dedicated infant oral health programme five years ago. However, inertia against bringing children by age one was only more recently overcome – the result of public education by the PDU. Other outreach platforms include its Facebook page, media interviews, and publication in newspapers and magazines. The key element of a first visit is dental risk assessement. Incor-

Photo: jasper yu

aediatric dentists at the National Dental Centre Singapore (NDCS) are happy because more infants and very young children are coming in for their first visit. Last year, the NDCS’ Paediatric Dentistry Unit (PDU) saw a 50 per cent increase in parents taking their children there for their first dental visit before their second birthday. “This trend is very encouraging,” said Dr Tabitha Chng, Senior Registrar, PDU. “First Dental Visit By Age One” is a proactive measure parents are taking to maintain their children’s dental health. Currently, the dental health of children in Singapore is on the decline: the number treated for Severe Early Childhood Caries (SECC) before the age of six doubled from about 500 in 2000 to 1,000 in 2011 and 2012. The American Academy of Paediatric Dentistry (AAPD) revised its recommendations in the 1990s with regards to the timing of a child’s first dental visit. Historically, many parents used to take their children to the dentist after the age of three. However, many had succumbed to SECC by then.

According to Dr Tabitha Chng, last year, the Paediatric Dentistry Unit saw a 50 per cent increase in parents taking their children there for their first dental visit before their second birthday.

The ABCs of the first dental visit Assessment

Preventing future dental problems is the goal of an early first visit. Parent-child dental risk assessments include a detailed interview with parents, an oral examination for child and caregiver (e.g. parent), and discussions on the management of dental injuries, dental habits (e.g. thumb sucking) and choosing the right tools for the child’s current needs (e.g. toothpaste).

Be honest

Parents should not feel embarrassed to share their own dental struggles or concerns with their child. Paediatric dentists are there to guide them.

Comfort

The number of children treated for Severe Early Childhood Caries before the age of six doubled from about 500 in 2000 to 1,000 in 2011 and 2012.

The child’s comfort is important. Pick appointment times when the child is well-rested (e.g. avoid nap times or feeding times). During the examination, the paediatric dentist will be able to guide the parent to position the child in a comfortable position that is safe and secure.

Paediatric dentists at work Dr Chng is part of a diverse team of paediatric dentists at NDCS. She obtained her Masters of Science in Paediatric Dentistry from the University of Toronto, Canada, and is doubly board-certified in the United States and Canada. As a paediatric dentist, Dr Chng has one main goal – to equip parents and children with the right dental practices and attitudes, so that children grow into adults with good dental attitudes. An understanding of child psychology, patience, and most importantly sincerity, is needed when treating children, she said. “They are the best lie detectors and can tell when you’re not sincere. Trust needs to be earned.”

It warms my heart to see parents take ownership of their child’s dental health and commit to cultivating good dental habits. It gives me a lot of satisfaction to see a child’s dental health improve, and the smiles on a child and his parents’ faces when I tell them that their efforts have paid off. Dr Tabitha Chng, Senior Registrar, PDU, NDCS

Dr Chng is proud of the progress her patients and their parents are making. She said: “It warms my heart to see parents take ownership of their child’s dental health and commit to cultivating good dental habits. It gives me a lot of satisfaction to see a child’s dental health improve, and the smiles on a child and his parents’ faces when I tell them that their efforts have paid off. These remind me of why I chose to be a paediatric dentist.”

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East-West drug mix has benefits, dangers Doctors worried about the herbal medicines their patients take with the Western medical drugs they prescribe are turning to a traditional medicine information service for help By Sol E Solomon

and experience, and less in the way of documented trials. “So it’s hard to draw a conclusion about whether a herb works, or whether a result is due to something else,” said Ms Lim. To address this shortcoming, Ms Lim and a group of like-minded SGH colleagues set up a traditional medicine information service in October 2011 to provide doctors, pharmacists and other health care professionals with evidence-based information about traditional and alternative medicines.

Because we believe that traditional medicines do have their benefits, we want patients to benefit from both traditional medicine and Western medicine (within safety limits). Ms Lim Ching Hui, Senior Principal Pharmacist, SGH

The others in her team are Dr Linn Yeh Ching, Senior Consultant, Department of Haematology, SGH; Mr Ricky Ang Seng Kok, Principal Pharmacist, Department of Oncology Pharmacy, National

Photo: Alvinn Lim

any patients regularly take traditional or herbal medicines without realising that such remedies can have harmful effects or interact with the conventional Western drugs prescribed by their doctors. Yet, the use of such medicines is on the rise. While doctors and other medical professionals can and should play a role in ensuring that folk or complementary remedies are used safely, high-quality evidence about the efficacy, effects and other pharmaceutical information of these products must also be readily available, said Ms Lim Ching Hui, Senior Principal Pharmacist, Singapore General Hospital (SGH). “There is a gap in current medical practice,” said Ms Lim. “We know through our daily contact with patients that many of them take complementary and alternative medicines, but the reality is that many don’t or won’t tell their doctors they are using such products. Doctors, on the other hand, may not know how to advise their patients because they don’t know enough about these products.” Much of the distrust that Western medical professionals have about traditional medicines stems from the differences in practice. Cold, hard evidence following years – sometimes decades – of documented clinical observations and tests is the cornerstone of conventional Western medical practice. With traditional and herbal medicines, however, the proof is in centuries’ worth of practice

(From left) Dr Linn Yeh Ching, Mr Ricky Ang Seng Kok, Ms Lim Ching Hui, and Ms Fung Foon Yin are members of the team that set up a traditional medicine information service to help health care professionals with queries about herbs and traditional medicines.

Cancer Centre Singapore; Ms Shyamala Out of 15 cases for which no risk Narayanaswamy, Pharmacy Practice was indicated, eight (53 per cent) of the Manager, SGH; and Ms Fung Foon Yin, health care professionals allowed the use Traditional Medicine Resource Executive, of the product in question. The remaining Pharmacy Department, SGH. Ms Fung 47 per cent took a cautious stance and answers queries and does the literature discouraged their use, said Ms Lim, who searches. was the lead investigator of the survey. Funded by the Ministry of Health, the Ms Lim added that those who gave the service covers all traditional remedies go-ahead to their patients did so because including traditional Chinese, Ayurvedic they continued monitoring their patients’ and Malay/Indonesian Jamu medicines, conditions, or the drug had already been as well as health supplements. used for a while by the patient with no “Because we believe that traditional reported problems. medicines do have their benefits, we The queries came from pharmacists want patients to benefit from both tra- (77 per cent) and doctors (20 per cent). ditional medicine and Western medicine Not surprisingly, safety issues predomi(within safety limits),” said Ms Lim. For nated, such as concerns with drug interinstance, ginger, a traditional herbal cure actions (56 per cent) and adverse reacfor nausea and vomiting, can help allevi- tions (22 per cent). The findings were ate the side effects that a patient under- summarised in a poster and presented at going chemotherapy may get. Acupunc- last year’s SGH Annual Scientific Meeting, ture can also help with such symptoms, Annual Singapore Pharmacy Congress said Ms Lim, noting that patients have (where it was the 2nd runner-up in the stopped treatment when the side effects Competitive Poster category), and other of chemotherapy became too severe to overseas conferences. bear. “Reducing the side effects of the Ms Lim said that her team is working chemotherapy helped them to continue on another project to build up a datawith their treatment,” she said. base of treatments on cancer, diabetes The traditional medicine information and hypertension with Thong Chai Medservice receives two to three queries a ical Institution. The effects – both posiweek. Ms Fung trawls through medical tive and negative – of using both Westreference books, medical journals, case ern and traditional Chinese treatments reports, and Chinese medical databases for cancer, diabetes or hypertension will to find the information needed. The pro- be studied carefully and documented. cess can take anywhere from one to two “Hopefully, we will be able to develop a hours to several days. database of findings to share with both The team analysed the 216 queries Western and traditional Chinese docthe service received between October tors,” said Ms Lim. 2011 and April 2013, and found that 77 per If the group is able to secure a grant cent related to the safety of traditional or for the project, the study will begin at herbal medical products. Published infor- the end of this year. The team is also mation was available for 82 per cent of looking to set up a database on warfathese queries. And of these, 115 enquirers rin, a common blood-thinning drug, and provided feedback about whether they its interactions. When that is completed, encouraged or discouraged the use of the they will continue and set up databases of product in question. other medications.

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Good brew Drinking at least two cups of coffee a day lowers the risk of dying from some types of liver cirrhosis

Study recruited older Chinese living in Singapore

By Desmond Ng

he jury may still be out on whether coffee is good or bad for health. But a new study has given the beverage a thumbs-up – at least for the benefits it has for some liver diseases. The study by Singapore General Hospital (SGH) and Duke-NUS Graduate Medical School doctors found that drinking at least two cups of coffee a day lowered the risk of dying from non-viral hepatitis-related cirrhosis among Chinese in Singapore by 66 per cent. Cirrhosis is scarring of the liver and can be due to viral hepatitis B or C, or non-viral causes such as heavy drinking, autoimmune disease and fatty liver disease. According to Dr George Goh, Consultant, Department of Gastroenterology and Hepatology, SGH, the benefits of coffee reported in earlier international studies on several aspects of liver disease have been inconsistent. But the SGH-Duke-NUS study was able to show for the first time “that it is the non-viral hepatitis cirrhosis group, rather than the viral hepatitis group, that benefits from drinking coffee,” Dr Goh said. “Coffee did not affect mortality from viral hepatitis-related cirrhosis, but drinking two or more cups of coffee per day reduced mortality from non-viral hepatitis-related cirrhosis by 66 per cent.” Coffee has more than a thousand compounds, and it is difficult to identify the actual active component that reduces the risk of dying from cirrhosis, said Dr Goh, one of the investigators of the study. “From our data, we know that it is not caffeine, which is one of the more prominent compounds that come to mind when talking about coffee. We postulate that several of its other compounds such as polyphenols, melanoidins, cafestol and kahweol have antioxidant and anti-inflammatory properties that are beneficial for the liver.” The study found that other caffeine-containing beverages like green tea and black tea had no significant effects on cirrhosis mortality. Drinking fruit juices or soft drinks also didn’t affect the risk of dying from cirrhosis. Another finding of the study, unsurprisingly, was that respondents who drank at least 20g of ethanol (alcohol) every day had a greater risk of dying from cirrhosis than non-drinkers. The study was based on data from an earlier research study cohort by Associate Professor Koh Woon Puay of Duke-NUS Graduate Medical School. Together with Associate Professor Chow Wan Cheng, Senior Consultant,

The data of 63,275 ethnic Chinese living in Singapore were used for the Coffee reduces risk of mortality from nonviral hepatitis-related cirrhosis among Chinese in Singapore study to find out if drinking coffee, alcohol, black tea, green tea and soft drinks affected the risk of dying from cirrhosis. The subjects, between 45 and 74 years of age, were surveyed for an earlier study, and had provided information on their diets, lifestyle choices, and medical histories during in-person interviews conducted between 1993 and 1998. They were followed for an average of nearly 15 years, during which 14,928 or 24 per cent died at the average age of 67. Of this number, 114 died of liver cirrhosis.

Chronic hepatitis B and nonalcoholic fatty liver disease

form the majority of the chronic liver diseases seen at SGH clinics

2.9%

or about 1 in 35 adults in Singapore are hepatitis B carriers

360,000,000 people worldwide have chronic hepatitis B infections; a significant proportion of them are in Asia

3rd

4th

16th

Liver cancer occurs more often in men than women and is the 3rd highest cause of male cancer mortality in Singapore

Liver cancer accounts for 7.5 per cent of all cancer incidences – the 4th highest – among Singapore residents

Liver cirrhosis, which can lead to the development of liver cancer, is the 16th leading cause of death in Singapore

Up to

12%

of chronic hepatitis B patients develop cirrhosis annually

2 billion people worldwide have been infected with the hepatitis B virus

*Figures from World Health Organization, Ministry of Health

Department of Gastroenterology and Hepatology, SGH, the investigators then collaborated by identifying the cases and conducting the analysis together, said Prof Koh. The finding from their study, said Prof Koh, “resolves the seemingly conflicting results on the effect of coffee in Western and Asian-based studies of death from liver cirrhosis. Our finding suggests that while the benefit of coffee may be less apparent in the Asian population where chronic viral hepatitis B predominates currently, this may change as the incidence of non-viral hepatitis-related cirrhosis is expected to increase in these regions, accompanying the increasing affluence and westernised lifestyles of their younger populations.” Coffee is widely consumed globally and is universally accepted as a lifestyle choice, rather than a “pharmacological drug”, said Dr Goh. Hence, it has worldwide appeal in its use as a therapeutic option in liver disease, particularly in chronic liver diseases such as non-alcoholic fatty liver disease where treatment options are limited. “However, there remains a lot more research that is required before we can confidently ‘prescribe’ coffee as a treatment option,” he said. The study was published in February in Hepatology, the international publication for original, peer-reviewed articles concerning all aspects of liver structure, function and disease, and was presented orally in the Outstanding Clinical Research Award category of the SGH 20th Annual Scientific Meeting.

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Singapore National Eye Centre (SNEC)

Professor Wong Tien Yin is the new Medical Director of the Singapore National Eye Centre.

On Aug 1, 2014, Professor Donald Tan, Medical Director of SNEC since 2008, passed the leadership baton to Professor Wong Tien Yin. Prof Wong will also take on the concurrent role of Academic Chair, SingHealth Duke-NUS Ophthalmology Academic Clinical Program. During his six years at the helm, Prof Tan steered SNEC to global leadership in ophthalmology. His work has led to major innovations in corneal and stem cell transplantation, refractive surgery and myopia treatments in the international arena. Prof Tan will remain a tenured Professor in Ophthalmology and senior faculty member of

SNEC and will continue his research at Singapore Eye Research Institute (SERI). Prof Wong has a strong track r e co r d in r e s ear ch wit h many research breakthroughs, published papers, and patents for eye imaging software and related technolog y. His local and international awards include t h e Singap ore Translational Research Investigator Award, the National Clinical Scientist Award, the President’s Science Award and the 2013 Eisenhower Fellowship Award. As Medical Director of SNEC, Prof Wong will continue to elevate the Centre’s service and reputation in the field of ophthalmology. He also ser ves as Group Director, Research, SingHealth.

Changes at the helm

Three SingHealth institutions recently had leadership changes By celine lim

Professor Terrance Chua is the new Medical Director of the National Heart Centre Singapore.

Associate Professor Poon Choy Yoke is the new Director of the National Dental Centre Singapore.

National Dental Centre Singapore (NDCS)

Associate Professor Kwa Chong Teck has been succeeded by Associate Professor Poon Choy Yoke as Director of NDCS. Prof Poon has also been appointed Academic Chair of the newly-established SingHealth DukeNUS Oral Health Academic Clinical Program. Under Prof Kwa, NDCS developed into a specialist oral health care centre, offering multi-disciplinar y care to patients with dento-facial and cleft deformities, facial pain and sleep disorders, or in need of complex oral rehabilitation. NDCS is Asia’s first Joint Commission International-accredited oral health care institution, and the Centre collaborates with international universities and educational institutes to further dental education and research. Prof Kwa was appointed Senior Advisor of NDCS on Aug 1, 2014. Prof Poon, formerly Direc tor, Department of Oral & Maxillofacial Surgery, has played a key role in pushing the frontiers of dental research and education at NDCS. In her new role as Director of NDCS, Prof Poon will continue to provide leadership and vision to strengthen NDCS’ reputation for excellence in clinical services, education and research.

CMY

National Heart Centre Singapore (NHCS)

Professor Koh Tian Hai, Medical Director of NHCS, has been succeeded by Professor Terrance Chua, who has also taken on the position of Academic Chair, SingHealth Duke-NUS Cardiovascular Academic Clinical Program. Prof Koh led NHCS to become a global leader in cardiovascular care, research and training. From a speciality centre with 650 staff members, NHCS’ staff strength has more than doubled, with expanded services including operating theatres and a short-stay unit in a new 12-storey building. Under Prof Koh, NHCS also pioneered complex cardiac therapies, boosted medical fellowship training, and has become a place where

research flourishes. Prof Koh has been appointed to the SingHealth Board of Advisors and is now Senior Advisor of NHCS. Prof Chua, a cardiologist with an interest in imaging, is Adjunct Professor with Duke-NUS Graduate Medical School and Clinical Associate Professor with the Yong Loo Lin School of Medicine at the National University of Singapore. He is dedicated to patient care and committed to teaching and research, with a particular research interest in imaging and heart disease. He received the National Outstanding Clinician Award in 2013. In his new role, Prof Chua will continue to advance NHCS’ standing as a national specialist centre for cardiovascular treatment.

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Residents, staff help pick hospitals’ new logo The new logo represents collaboration between the patient, the community and the health care professional towards better health

engkang Health has launched its CEO of Sengkang Health, said: “The new logo, vision and mission state- logo represents collaboration between ments, keeping in mind the the patient, the community and the health people it will serve when Sengkang care professional towards better health. General and Community Hospitals open The right hand symbolises us reaching out in 2018. towards healthier futures and the northThe logo, launched in July, was devel- east community we will be serving.” oped with input from staff and residents He said the organisation’s vision, from Sengkang and Punggol. They were “Healthy Living. Fulfilling Life”, and mission, asked to pick one of five designs. The “Better Health Together”, will be achieved majority picked the design that Sengkang through “holistic, informed and reassuring Health ultimately chose. care in partnership with the community”. One resident described the design as To bring the message home, Sengkang touching. “It looks as if three staff mem- Health is engaging the community early. bers are standing with their hands wide It will be holding a sporting challenge open to welcome patients.” Another, who to encourage families to stay healthy chose the same design, said: “It looks together during the September holidays. like people holding hands in partnership, cooperating as a community, helping For more details on the September event, each other heal and living a healthy life.” Millennia Kids Challenge 2014, refer to the Professor Christopher Cheng, Pro-Tem event calendar on page 20.

Sengkang Health’s logo, launched in July, was developed with input from staff and residents from Sengkang and Punggol.

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Celebrating passion By Jessica Leow and Chua Hwee Leng

Here, take the hot seat!

Dr Hwang Siew Wai, Clinic Director, SingHealth Polyclinics Bukit Merah Outstanding Clinician Award Dr Hwang Siew Wai is quite used to the hot seat – the clinician’s chair – and he believes in giving medical students a taste of it, early. His “hot seat” sessions involve getting them – postgraduates from Yong Loo Lin School of Medicine and DukeNUS who are assigned to SingHealth Polyclinics - Bukit Merah – to lead consultations while he keeps a watching brief. “We allow them to play the role of the doctor. They really enjoy it, because for the first time, they feel like they are being real doctors.” While they get vital hands-on experience from this, Dr Hwang said that he learns much from experiences too. In fact, it was his own experience as a patient that inspired him to become a doctor.

When I was five, I was hospitalised with dengue haemorrhagic fever. The doctors and nurses were very good, and that inspired me to want to help others.

even before they see a doctor, they can go for screening,” said Dr Hwang. As a result of the success of this, the initiative was spread and improved upon across the other SingHealth Polyclinics. Dr Hwang said patients may be unaware they have complications from diabetes as the symptoms are silent. “Diabetes can affect the nerves, and once this happens patients may not feel any pain or sensation.” The foot test screens for nerve damage and patients also learn about proper foot care to reduce the risk of infection. The eye test detects changes in the eyes, such as small bleeds, so the doctor can refer patients to a specialist. Dr Hwang was also behind a clinic project to increase the number of patients with chronic lung infections being vaccinated against influenza. At Bukit Merah Polyclinic, the numbers increased from 10 per cent to 50 per cent over six months in 2013. “Convincing patients to have the injection, which protects them against pneumonia and death from infection, is more challenging than getting them to do the diabetes tests. Checking the eyes and feet is easy, but patients don’t want a jab because it’s painful,” he said. “These projects help us to look after patients even better. And if they’re successful here, we can share them with other polyclinics.”

Photo: Jasper Yu

Dedication and strength of purpose underpin the passion of these four health care professionals, winners of the 2014 SingHealth GCEO Excellence Award

Loving the challenge

Mdm Maliga Riaki Chinniah, Senior Staff Nurse, Cardiothoracic Surgery Intensive Care Unit, National Heart Centre Singapore Outstanding Nurse Award As a young girl, one of eight siblings, she applied to become a nurse to lighten her parents’ financial load. After 40 years on the job, Mdm Maliga Riaki Chinniah, now a Senior Staff Nurse (Clinical), has no regrets and would do it all over again.

“When I was five, I was hospitalised with dengue haemorrhagic fever,” he said. “The doctors and nurses were very good, and that inspired me to want to help others. As a doctor now, I have the rare opportunity to really make a difference in peoples’ lives.” This latest award joins a long list that Dr Hwang already has. And it is not his first award for excellence. As head of Bukit Merah Polyclinic since 2008, Dr Hwang has spearheaded many initiatives which have since been adopted by other polyclinics. Among them are increasing the rates of diabetic foot screening and diabetic retinal photography done for patients with diabetes. “At the registration counter, via a computer alert system, we identify diabetic patients who need these tests. So,

Photo: Alvinn lim

Dr Hwang Siew Wai, Clinic Director, SingHealth Polyclinics - Bukit Merah

Working at the Cardiothoracic Surgery Intensive Care Unit, National Heart Centre Singapore (NHCS), she said nursing suits her personality. She is naturally composed, caring, alert, a fervent time manager, and constantly looks for better ways of doing things. Over the years, her work has not only given her a lot of satisfaction but also won her an array of awards, including this year’s Outstanding Nurse Award. An Intensive Care Unit (ICU) nurse since 1985 – first in Tan Tock Seng Hospital, then Singapore General Hospital and now NHCS – her confidence is apparent, but this has not always been the case. “When I first started, I was nervous when I encountered sudden changes in a patient’s condition without doctors around. Now, having been in the ICU for so long, issues like blood pressure falling have become everyday issues that we can manage with confidence,” she said. Mdm Maliga was part of the team who cared for Singapore’s first heart transplant patient in 1990, and for many others since then. During the course of her work, she also takes time to find out if the patients’ families are facing any difficulties, and when needed, refers them to a medical social worker. In fact, Mdm Maliga has been so engrossed in her job that she has not taken a single day of medical leave in the 23 years after her last maternity leave. This was despite wearing many hats – nurse, mother, housekeeper, children’s tutor and volunteer, just to name a few. A mother of three, Mdm Maliga managed without domestic help when her children were younger – by doing the night shift for many years and strictly managing her time during the day. She even volunteered in the hospital’s outreach efforts then, and is doing more of that, since her children are now grown up.

sep– oct 2014

Mdm Koay Saw Lan runs a huge kitchen. The Senior Manager of Singapore General Hospital’s (SGH) Department of Food Services oversees a dedicated catering team that prepares meals for some 1,300 patients each day. It isn’t just the sheer number of meals. For a large hospital with patients suffering from many different serious medical conditions, the kitchen needs to concoct vast permutations of meals: carbohydrate control for diabetics, low cholesterol and low salt for cardiac patients, soft food for stroke patients with difficulty swallowing, nourishing confinement dishes for new mothers, and halal meals for Muslims are some of the special-requirement “cuisines” that are prepared alongside more regular fare. The logistics of preparing over a thousand meals three times a day can be a nightmare. But the many changes that Mdm Koay made over the years have led to a smooth running kitchen. Hot meals are served hot, while desserts are refreshingly cool – and on time. Above all, the meals are also healthy, nutritious and appetising. “When I first joined the public health sector more than 30 years ago, dietitians had to be involved in the operational aspects of food preparation. And because soft foods weren’t readily available like they are now, we had to show kitchen staff how to puree and strain food for patients on soft diets, for instance,” said Mdm Koay, a trained dieti-

Keeping it real

Associate Professor Deidre Anne De Silva, Senior Consultant, Department of Neurology, Singapore General Hospital Outstanding Clinician Researcher Award Clinical research can be isolating and detached from reality. But for Associate Professor Deidre Anne De Silva, Senior Consultant, Department of Neurology (SGH Campus), National Neuroscience Institute, having regular patient contact through clinic and other consultations helps make her efforts to improve treatments and care relevant. “I get to know the issues that they, as well as our health care system, face. I can then identify the problems on the ground, and this makes the research real,” said Prof De Silva. Without that ongoing contact with patients, research work can become “just science”, said Prof De Silva. Her unwavering dedication to making a difference in patients’ lives helped Prof De Silva clinch a SingHealth GCEO Excellence Award 2014 in the Outstanding Clinician Researcher category. Often, as a researcher, she is plug-

tian who previously headed SGH’s Dietetics and Nutrition Services Department. Under Mdm Koay, professional cooks and kitchen staff were brought in, while technology was introduced to automate mundane kitchen operations like meal ordering. “It was a huge challenge to make these changes in the 1990s, but we persevered and saw the automation project to fruition,” she said. To make sure her dietitians reach their full potential, she encourages them to advance professionally. They underwent further education and training under programmes like the Ministry of Health’s Health Manpower Development Plan. They undertook research and participated in scientific meetings, as well as patient seminars to teach participants about eating the right foods to enhance recovery.

at SGH. They give expert advice on diet to patients with gastrointestinal, eating and renal disorders, and serious burns. Among the many changes Mdm Koay has made to improve patients’ comfort is the introduction of an Asian menu to add variety to hospital meals. “When you are in bed with nothing much to do, you look forward to your meals,” she said, adding that there is no reason for patients to miss their chicken rice and nasi goreng. Patients can look forward to their meals by checking the colourful pictorial menus on the hospital’s in-house TV channel.

It was another first in Singapore hospitals when she and her team of dietitians and chefs launched a special snack alternative for patients on therapeutic diets, instead of just biscuits, for afternoon tea. The energetic Mdm Koay may have been lauded this year, but she isn’t resting on her laurels. Next on her plate is the design and set-up of the kitchens for the planned SingHealth community hospital and Sengkang Health, the new general hospital for residents in the northeast of Singapore.

When you are in (a hospital) bed with nothing much to do, you look forward to your meals. Mdm Koay Saw Lan, Senior Manager, Department of Food Services, SGH

Indeed, Mdm Koay has played a critical part in changing the general perception of dietitians. They are no longer seen as people who merely offer advice on weight loss, but as key partners with other health care professionals in offering patients multi-disciplinary care

ging away in her own “little cave” and not always sure if she’s on the right path. Receiving the award, she said, is “a nice boost to the research work that my team and I are doing, and an affirmation that we are on the right track.” She works with other researchers, notably fellow neurologist, Associate Professor Chang Hui Meng, stroke research

coordinators and research fellows whom she mentors. Research is no bed of roses, said Prof De Silva. Behind every paper published or grant received are the many long hours and failures that a researcher goes through. Still, the disappointment of not getting a grant is a small thing when compared to the reality of sick patients.

Photo: Jasper Yu

Mdm Koay Saw Lan, Senior Manager, Department of Food Services, Singapore General Hospital Outstanding Ancillary Staff Award

people

Photo: zaphs zhang

creating great meals

singapore health

“At the end of my career, I hope to say that my research has added to the evolution of stroke care,’’ said the neurologist, who describes herself as a 100 per cent clinician. “It will take many steps to get there, but if I had contributed in some way, that would be good.” It was patient contact that first got Prof De Silva interested in stroke neurology. While on ward rounds as a first-year registrar, she observed that young Indian patients outnumbered Chinese patients. “I asked my mentor, Associate Professor Wong Meng Cheong (the former Head of the Department of Neurology) if Indian stroke patients were generally younger than Chinese patients, expecting him to provide me with the answer.” Instead, Assoc Prof Wong told her to “go and find out”, she said. Her curiosity was piqued, and with guidance and support from her teacher, she delved into the subject, subsequently co-publishing a paper with her mentor on the findings. Stroke neurology is more than an area of medical interest for Prof De Silva. As President of the Singapore National Stroke Association, she is always pushing for greater public awareness of the disease and greater support for stroke survivors and their caregivers.

singapore health

sepâ&#x20AC;&#x201C; oct 2014

sep– oct 2014

singapore health

Money

An extra helping hand

Mrs Jenny Thang can hold a day job knowing that her husband, a stroke patient, is well cared for at home

ooking at Ms Jamiati Tolan’s petite figure, you may not think the 28-year-old Indonesian domestic helper has the strength to move bedridden Mr Robert Thang from his bed to a wheelchair. Mr Thang, 62, weighs 68kg. But with proper caregiving techniques picked up from nurses at Ang Mo Kio Community Hospital, Ms Tolan – or Jamie to her employers – has been able to do it expertly without injuring herself over the last four years. “Even I have difficulty moving him, but Jamie is able to do it, as she has the skills. She has really been a great help,” said Mrs Jenny Thang. “Not only does she look after my husband, she helps to watch over my eldest daughter who has special needs. She also takes care of the cooking and household chores.” Thanks to the government’s Foreign Domestic Worker Grant which provides a monthly payout of $120, the Thangs have been able to defray part of the cost of hiring Ms Tolan. The grant gives Mrs Thang, 58, peace of mind and allows her to continue working even after her husband’s illness to support her family of five. She is an administrative assistant. To qualify for the grant, the foreign domestic worker in question needs to be trained. Ms Tolan attended the Effective Caregiving For Foreign Domestic Workers course at Hua Mei Training Academy, which is under the Tsao Foundation. The Thang family tapped on a training fee subsidy – the $200 Caregivers Training Grant – to help pay for Ms Tolan’s training.

Programme of Integrated Comprehensive Care (EPICC) centre in Tiong Bahru, using transport provided by the centre. It was there that she picked up physiotherapy techniques and other caregiving tips from other caregivers. “Everybody in the family is very good to me. Madam gives me a lot of freedom. When Sir gets frustrated and scolds me, I can go for a jog. Someday, I may want to work in a nursing home,” Ms Tolan said. The family sees her as a godsend. “Jamie basically took over my role in the family, allowing me to play my part as the breadwinner. In fact, she is just like a daughter to me,” said Mrs Thang, who has three children aged 25 to 35. Her 26-yearold son recently started work as a finance executive while her youngest son is a fulltime polytechnic student.

With Ms Jamiati Tolan (left) taking care of stroke patient Robert Thang at home, his wife, Mrs Jenny Thang (right), can continue to work as an administrative assistant to support their family of five.

The Foreign domestic worker grant

...is a monthly grant of $120 given to families who need a foreign domestic worker to care for their loved ones who have at least moderate disability. To apply for the grant:

You need to be a family member staying with your loved one at the same address shown on both your NRICs.

2 She has really been a great help. Not only does she look after my husband, she helps to watch over my eldest daughter who has special needs. She also takes care of the cooking and household chores. Mrs Jenny Thang

Mr Thang, who had been a cook in a five-star hotel, spent three months at the Ang Mo Kio Community Hospital following his initial stroke treatment. Ms Tolan then came into the picture and began looking after him at home. She now accompanies him thrice a week to the Hua Mei Elder-centred

This article is adapted from An Extra Caregiving Hand in Nextstep (Issue 8), the Agency for Integrated Care’s quarterly newsletter. Visit silverpages.sg for more information on longterm care and caregiving.

You must be a Singaporean. Your loved one being cared for must also be a Singaporean if he is below the age of 65. If he is above 65, he can be a Singaporean or Permanent Resident.

The person being cared for must have at least moderate disability, requiring permanent assistance in at least three activities necessary for daily living. These include dressing, eating, taking a bath or shower, toileting, moving from bed to wheelchair, and moving about on a level floor without help.

The foreign domestic worker will need to attend caregiver training courses.

Your monthly household income per person must not exceed $2,600. For households without income, the annual value of the property must be less than $13,000. Visit silverpages.sg/fdwg/ for more information on the eligibility criteria and how to apply for the grant.

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singapore health

sep– oct 2014

Health Xchange

Early cataracts?

Our experts answer all your questions about health

Recently, I went for an eye examination to check if I qualify for LASIK, but was told that I have early cataracts. What causes cataracts in people under 45 years old and how do I prevent them from getting worse? Cataracts usually affect people above 60, but it is not uncommon to see younger sufferers too. Cataracts may develop earlier in patients on steroid medication. People with diabetes, or

those who smoke or have had prolonged exposure to UV light, may be predisposed to its earlier onset. Possible causes include constant rubbing of the eyes due to allergies and previous eye trauma. Other patients may be born with a congenital form of cataract. Staying healthy, having a balanced diet, not smoking and reducing UV light exposure may delay the worsening of cataracts. Wearing glasses for short- and long-sightedness is still the most trusted way to correct your vision for now. Having LASIK when you already have a cataract is a waste of resources as cataract surgery can be refractive in nature nowadays. Eventually, you should consider cataract surgery when your corrected eyesight is no longer adequate for daily functioning. Dr Daphne Han, Consultant, Cataract & Comprehensive Ophthalmology Service, Singapore National Eye Centre

Getting plastic surgery overseas

I am thinking of getting plastic surgery done overseas. What should I consider and how do I pick a good surgeon? The same considerations apply when looking for a plastic surgeon either locally or overseas. You should: Check that the surgeon is certified by the relevant regulatory/government bodies in his country of practice. In Singapore, all plastic surgeons need to be accredited by the Ministry of Health, and a list of plastic surgeons can be found on the Singapore Association of Plastic Surgeons’ website (plasticsurgery.org.sg). Find out from reliable sources like your primary care doctor and/or existing patients of the surgeon

in mind about the procedure and/or the surgeon. Check that the surgeon has facilities that are fully equipped for the procedure, as well as for any emergency. Find out about the surgeon’s follow-up care procedure as good surgical care does not end with surgery. Note that follow-up visits with an overseas surgeon can be inconvenient and costly, especially if complications arise and revisionary care is needed. Meet the surgeon at least once or twice in person before committing to the procedure so he can address any queries and concerns about the procedure. It is important to have good communication and rapport with the surgeon of your choice. Dr Leo Kah Woon, Consultant, Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital

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

Please visit our website listed above to see the topics for discussion in Sep-Oct 2014.

SEP– OCT 2014

singapore health

upclose

wo r l d s i g h t day

The prevalence of myopia in Singapore is one of the highest in the world.

50% of children are myopic by age 12.

Common eye problems (KIDS) Blurred vision Squinting

eye Care

Spectacles or contact lenses that help to refocus light rays onto the retina are the most common ways of correcting myopia. Surgical procedures like LASIK can correct or improve myopia in adults. LASIK is generally only performed on adults after their myopia has fully stabilised. Clinical trials have shown that lowdose atropine is effective in slowing myopia progression.

NOT lose sight

o f

e y e

c a r e a

of people aged 60 and above have some form of cataract

With childhood myopia on the rise, this “myopic generation” will face more eye problems in their adult and twilight years

Cloudy vision Eye pain

eye care

Surgical procedures can slow or halt the progression of agerelated macular degeneration.

Presbyopia or lao hua can be corrected with special spectacle lenses called bifocals.

TEXT BY NG Hui HUI

Eye infections Blurred vision

eye care

Eye infections can be treated with antibiotic eyedrops and ointment. Laser treatment is used to seal or remove leaking blood vessels in those diagnosed with diabetic retinopathy.

60% of all eye infection cases are associated with contaminated contact lenses

e v e n

Common eye problems (elderly)

80%

Common eye problems (ADULTS)

60%

of patients who have had diabetes for 15 years or more have some blood vessel damage in their eyes

Age-related macular degeneration is a major cause of blindness in those over

50 years old

Sources: Ministry of Health, Health Promotion Board, Singapore National Eye Centre, National University of Singapore

your say

singapore health

SEP– OCT 2014

Can I donate blood at SGH? I donated blood for the first time about a year ago when the Health Sciences Authority (HSA) held a mobile blood drive at our office building. That was also the last time, even though I received many reminders to donate again. The places for blood donation are inconvenient for me to travel to. Can I donate blood at the Singapore General Hospital (SGH) as I accompany my elderly mother there for treatment quite frequently? Ms May Tan

you are next at SGH and want to donate blood, you can SGH When go to the blood bank at HSA on Outram Road. The HSA’s other

says

blood banks are at Woodlands Civic Centre and Dhoby Ghaut MRT station. You can also check donorweb.org/singapore-bloodmobiles for a schedule of HSA’s mobile blood drive locations. More information about donating blood can be found on the HSA website at www.hsa.gov.sg/ publish/hsaportal/en/health_services/blood_donation.html. This letter wins a bottle of Heritage® American Ginseng (60 capsules). The product, worth $92.40, is sponsored by HST Medical, Singapore.

tributes

Ms Roslina Rahim, Senior Enrolled Nurse, was excellent when I visited a clinic at the National Neuroscience Institute. She was patient, friendly and efficient. I had been referred to the wrong specialist by my general practitioner’s clinic. However, Ms Rahim helped to arrange another appointment at the correct one, even trying to get an appointment for me on that very day. I could see that it was a busy morning at the

clinic, but she stayed calm and cheerful throughout. I truly appreciate the help she gave me. - N Yong My elderly sister was born with Down’s Syndrome and has been bedridden for several years because of various other illnesses. She was admitted to Singapore General Hospital (SGH) earlier this year and was diagnosed with several other

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Financial help for the elderly sick My friend’s mother became bedridden after suffering a stroke. She needs to be tube-fed and is on diapers. Milk feeds and adult diapers are expensive. Is there a financial scheme to help them pay for these items? Seniors’ Mobility and AIC The Enabling Fund (SMF) has

says

a category of subsidised consumables for frail seniors to help defray the costs of medical consumables such as diapers, milk feeds, catheters, nasal tubing and wound dressings. If she is currently receiving home care services or enrolled in the Singapore Programme for Integrated Care for the Elderly (SPICE), she can approach a nurse or centre man-

conditions. We were told that one of these was life-threatening and she was given early treatment. She has since been discharged and is on the mend. I was very worried about the bill and her condition, and am very grateful that government subsidies took care of a substantial portion of the bill. I would also like to thank SGH, especially Associate Professor Tan Ban Hock, Senior Consultant and Head, Department of Infectious Diseases, and Dr Lim Chin Siah, Associate Consultant, Department of Emergency Medicine. - Mr HC Low On my recent visit to SGH’s Clinic H to have my surgical wound dressed, I was attended to by Mr Solzhavalavan Govindasamy, Principal Enrolled Nurse, SGH. He was very friendly, helpful and professional. I really appreciate his help. - Ms Siti ZS My second child was delivered at KK Women’s and Children’s Hospital (KKH) on Feb 27, 2013. A few days after I was discharged from the hospital, Ms Sharon Lee, Nurse Clinician, Lactation Consultant, gave me her mobile number and said I could call her anytime if I had issues with breastfeeding. I suffered a blocked duct due to breastfeeding once and called her. She promptly made an appointment for me and advised me on what to do. She even called me at the end of the day to ensure I was all right. Recently,

ager to apply. The eligibility criteria include: Age 60 and above Must be a Singapore citizen Requires a high level of care Monthly household income per person is $1,800 and less Not receiving any other subsidy for similar consumables Other than consumables, SMF also provides subsidies for assistive devices to help the elderly move around their homes. It also provides subsidies for transport between home and Ministry of Health-funded day rehabilitation centres, dialysis centres or dementia day care centres. For more information about SMF and how to apply for assistance, visit silverpages.sg/SMF.

my sister also had a blocked duct and an infection. I suggested she call Ms Lee. Even though my sister is not a KKH patient, Ms Lee was very willing to give her advice. It’s very inspiring to have nurses like Ms Lee who is ever willing to help patients, and encourage and motivate them to breastfeed. My sincere compliments to her. - Ms Seema D My husband and I would like to commend Ms Jennifer Shim Poh Shwan, Dietitian, Department of Dietetics, SGH, for her professionalism and patience. She took much time to explain clearly the dietary plan she drew up for my husband. We certainly look forward to our next appointment with her. - Ms SQ Lai I would like to thank Dr Jack Tan, Ms Lim Zhiyu, Ms Kelly Cheong, Ms Joey Wong, Ms Christine Ramos, Ms Asmah Ibrahim, Ms Noraini, Ms Nurhidayu Hatbar, Dr Gayathri, Ms Devi Nadarajan from the National Heart Centre Singapore (NHCS). The team is very professional and knowledgeable in their areas of work. They are courteous, attentive and go all the way to meet a patient’s needs. Thank you Dr Soon Jia Lin, Consultant, Department of Cardiothoracic Surgery, NHCS for your caring, attention and advice during my husband’s recovery in ICU. Keep up the good work. Thank you. - A grateful patient

SCIENCE 科学

a b o u t yo u r h e a lth experience and win a prize for best letter

NATURE

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.

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sepâ&#x20AC;&#x201C; oct 2014

singapore health

FYI

singapore health

SEP– OCT 2014

▲

Cynicism

event Calendar

Date Sep 6, Saturday Time 8am-12pm Venue: Sengkang Sports & Recreation Centre Registration Log on to sengkanghealth.com.sg

linked to dementia

for more information or to register

Celebrate active and healthy living with Sengkang Health. Sign up for the Parent and Child Obstacle Course or participate in the 5km Community Cycling event to receive a goodie bag. Check out the health screening and physiotherapy booths at the event too.

▲

Being cynical or distrustful increases one’s risk of developing dementia, according to a study by Dr AnnaMalia Tolppanen of the University of Eastern Finland. Tests for dementia and a questionnaire to assess cynicism levels were given to 1,449 people (average age 71). After adjusting for factors that could affect dementia risk such as hypertension, the study found that individuals with high levels of cynical distrust were three times more likely to develop dementia than those with low levels.

to preserve transplant

Source: BBC News

Source: Cornell University

contest

1. How long does it take for parathyroid function to be restored using the new injection technique? 2. Which story in this issue did you find the most informative? Closing date: Oct 1, 2014

Send in your answers and stand to win a Kyäni SunriseTM 30-pack, worth $83.75, sponsored by Kyäni Singapore Pte. Ltd.

Hospital, Women’s Tower, Level 1, Auditorium, Conference, Seminar and Patient Education Rooms Fees $5 to $8 per person for workshops. Plays are free of charge Registration Call 6394-5038 to register An interactive play and six workshops promote positive communication between different members of the family, and provide parenting tips and strategies to build children’s resilience. Conducted in English.

▲

A technique that supercools rat livers was able to preserve the organs for days before transplants, a team of US researchers have found. The technique combines chilling the organ and pumping nutrients and oxygen through its blood vessels. Further experiments will be needed to see if the technology can be scaled up from preserving a 10g rat liver to a 1.5kg human liver. If the technique works on human organs, it has the potential to transform organ donation.

Call it a “scenic walk” Think of your next run as a well-deserved break, and you will eat less afterwards. Think of it as exercise or a workout, and you will eat more after to reward yourself, according to two studies by Cornell University’s Food and Brand Lab. In the first study, 56 adults were led on a 2km walk and were either told it was for exercise or a scenic walk. Those who believed they had been exercising ate 35 per cent more chocolate pudding after the walk than those who believed they had been on a scenic walk. In the second study, 46 adults were given mid-afternoon snacks after a similar walk. Those who thought they had been on an exercise walk ate 206 more calories of M&M’s – 124 per cent more than those who had been told they were on a scenic walk.

Love out Loud: Enabling Families through Communication Date Nov 9, Sunday Time 9am-12.30pm Venue KK Women’s and Children’s

Source: Medical News Today

Supercooling

Millennia Kids Challenge 2014

Run For Hope 2014

Date Nov 16, Sunday Time 7am Venue The Promontory @ Marina Bay Fees $55 (adult); $32 (5-18 years old). Early

registrants will enjoy discounts

Registration Closes on Oct 26, Sunday. Log on

to runforhope.sg for more information or to sign up

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 29: Each will receive a bottle of Spirulina 100% Extra 10% Deep Ocean Water (750 tablets) worth $59, sponsored by IMI Lifestyle Products Pte. Ltd., and a Buddie the Badger plush toy. Prizes must be claimed by Oct 1, 2014. 1. Abdul Razak Haja Mohideen 2. Aw Hui Yee 3. Valerie Chong Lih Wen 4. Ong Kim Siong 5. Yoon Tai Yaw

An annual run organised by Four Seasons Hotel Singapore, Regent Singapore and the National Cancer Centre Singapore to raise awareness and support for cancer research, Run For Hope maintains its tradition as a non-competitive leisure run. Be part of the 15,000 who are running together for a worthy cause.

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

sep– oct 2014

singapore health

YOUR GUIDE TO BETTER LIVING

Sit right for

a great ride With the right posture, equipment and attire, avid cyclists can enjoy their sport more comfortably and successfully. By Sol E Solomon

ere’s the bad news: long-distance cycling can be bad for sex. But the good news is that correct posture or a change of saddle can quickly reverse the erectile dysfunction that can occur when cyclists ride their bicycles for too long, use the wrong saddle, have the wrong posture or wear overly tight bike shorts. Before erectile dysfunction actually occurs – and it can last as long as a week – a cyclist might feel pain, tingling

or numbness in the groin and penis as pressure is concentrated on that part of the body, said Ms Liang Zhiqi, Senior Physiotherapist, Singapore General Hospital (SGH). “But not many cyclists talk openly about such symptoms, so they might not know there is a problem till something more serious like dysfunction happens,” she said. A serious cyclist, said Ms Liang, should see a sports medicine specialist for an assessment of his level of fitness

and general health condition, and have his bicycle checked out. Getting the basic s right is impor tant for someone who intends to train seriously for the sport as it involves many hours of intense riding.

Get your posture right, work out any problem in position or cycling technique. That way, you might see a huge improvement in your performance without additional hard work, pain or risk of injury.

photos: jasper yu

Ms Liang Zhiqi, Senior Physiotherapist, SGH

According to Ms Liang Zhiqi, Senior Physiotherapist, a serious cyclist should see a sports medicine specialist for an assessment of his level of fitness and general health condition, and have his bicycle checked out.

At SGH, for instance, its physiotherapists can help people who have suffered musculoskeletal injuries sustained from cycling. Patients are taught to prevent injuries that might occur from overtraining or improper training, and how to reach their individual peak performance as quickly and safely as possible. Consultation by the cycling service’s physiotherapists costs between $100 and $150 for each session, and is by appointment only. Patients need a referral from a Singaporeregistered doctor. The patient first undergoes an interview followed by a physical

Riding after dark

Some cyclists prefer to ride or train at night. It can be as enjoyable as day cycling, but they need to exercise greater caution. For night riding, it is mandatory to have a lamp at the front of the bicycle that emits white light and another at the rear to emit flickering red light. Wear light-coloured clothes, especially with reflective panels, for high visibility. Reflective anklets, tape and stickers made of cloth or plastic that can be attached to bikes, helmets and riders are highly recommended. Be alert and ride defensively. Watch out for joggers, pedestrians and other vehicles, and make sure they are aware of your presence. Be wary of approaching vehicles as their headlights can dazzle.

Source: Singapore Sports Council’s Safe Cycling Guide

> Continued on page 22

singapore health

sep– oct 2014

> Continued from page 21

Sit right for a great ride

examination by a physiotherapist. With a better understanding of the patient's condition, the physiotherapist can then tailor adjustments and exercises based on detailed assessments both on and off his bicycle. Many cyclists are not aware that the way they position themselves on a bicycle is just as important as building up stamina and strength. The exercises they are taught help build posture awareness, control and endurance, develop flexibility and strength for power and endurance, and give them postural control for stability. Mirrors are used to show multi-angle views of the cyclists on a bicycle. Most of Ms Liang’s patients are men in their 40s returning to the sport after their children have grown up, or new cyclists. “Filled with enthusiasm, they are suddenly training a lot longer, faster and harder,” she said. She also sees many recreational cyclists who might spend five to six days a week cycling, easily doing 300km in that time, but who don’t spend time – enough or at all – stretch-

ing or streng thening their backs. Merely cycling to improve endurance without working on flexibility in areas like the spine, hip and knees can lead to injury. Likewise, weekend warriors (so-called because they sit in the office all day during the week but go all out and push themselves over the weekend) risk injuring themselves if they don’t build up an exercise regime. They may begin to suffer from overuse injuries in the form of neck and back pain, and tingling numbness in the hands. A problem may start with a sensation of mild discomfort which gets more and more uncomfortable. Eventually, the problem persists even when not cycling. Although it is common for a cyclist to get aches and pains in the beginning as the body adjusts and accommodates to the bike, if such pains persist after a few weeks, he should seek medical help, said Ms Liang. Triathlon bikes are among the most uncomfortable because they are designed to be aerodynamic, said Ms Liang, an avid cyclist herself.

GET it RIGHt! Ms Liang Zhiqi, Senior Physiotherapist, Singapore General Hospital, explains the correct posture to adopt when cycling.

Lower back: Do not overarch or slouch. This avoids excessive strain on the lower back and excessive pressure on the perineum region (the area that is in contact with the saddle).

Trunk: Head is held at shoulder height, not below the shoulders. The neck is not overly arched and the chin is tucked in slightly. The shoulders are relaxed, and the upper back is held in a strong stable position.

Arms: Elbow is relaxed or slightly bent, not fully straightened, to help absorb the impact when the bicycle rolls over bumps on the road. This prevents excessive impact on the shoulders and neck.

Pedalling: Keep centre of kneecap pointing forward (towards the middle toe). Avoid turning the knee inward (towards the bicycle toptube) or outwards (away from bicycle). This will prevent excessive strain on the knee joint.

As these bicycles are all about speed and performance, they are designed for the cyclist to assume a very low and crouched position in order to cut wind drag. Not surprisingly, this position requires the cyclist to have tight muscle control, good posture, strength and endurance. Some bicycle shops can fit a bike to a person’s body measurements with the aim of getting the cyclist into the best aerodynamic position, she said. But they don’t necessarily check posture, riding technique or whether the cyclist is strong or flexible enough to hold that position over a long time.

Train smar t, Ms Liang tells cyclists. “Get your posture right, work out any problem in position or cycling technique. That way, you might see a huge improvement in your performance without additional hard work, pain or risk of injury.” Doing some weight or power stretching exercises and posture work will also improve a cyclist’s performance on a bicycle, she added. This is because the more comfortable and more stable one is on a bicycle, the more efficiently the energy that he produces will go into pushing the bike forward.

sep– oct 2014

Easy listening

photos: Darren chang

Hearing aids now come with many advanced features that stream sounds as near to normal hearing as possible. By Thava Rani

According to Mr Gopal Krishna, one of the biggest challenges faced by hearing aid wearers is their inability to tune in to a desired sound and tune out the rest of the noise.

n “invisible” hearing aid placed inside the ear canal, worn 24 hours a day, and which requires maintenance only every few months. A surgically implanted hearing aid system with no external components and whose batteries need replacing only every few years. Science fiction? Not at all. These hightech hearing aids do exist, although they may only be available elsewhere. But with significant advances in technology in the last five years, many hearing devices sold in Singapore now have improved capabilities and features that can be adjusted to their wearers’ needs, said Mr Gopal Krishna, Senior Manager, ENT Centre, Singapore General Hospital (SGH). “Gone are the days of big, bulky hearing aids. Now they are getting not only smaller but also trendier in terms of

colour and design. The computer chip circuitry has also become more sophisticated. This means better processing speed and a lot more natural and clearer sound quality,” Mr Gopal said. All hearing aids have a microphone, an amplifier and a receiver. The very basic analogue models work much like mini loudspeakers by merely making sounds louder. But digital devices come with features that let wearers do more – from manual volume control in the more basic models to enhancements that stream sounds as near to normal hearing as possible in the very high end models. “One of the biggest challenges faced by wearers is their inability to tune in to a desired sound and tune out the rest of the noise – the louder the ambient noise, the more difficult it is to pick out a single voice,” said Mr Gopal. “It’s not likely we’ll be able to overcome this fully, but some of the newer models have as many as 48 channels which can help filter out much of the background noise and enhance speech understanding,” he added. These high-tech hearing aids have adjustment controls to personalise preferences. Some devices have directional microphones, an enhancement that lets a user listen to only sounds from the front, for instance. Then there is Bluetooth, a wireless technology standard for exchanging data over short distances from fixed and mobile devices; it is expanding the world of the hearing impaired. With Bluetooth streaming, a device can wirelessly

connect to mobile phones, tablets, MP3 players and even television. FM-compatible hearing aids are particularly useful in noisy classrooms or lecture theatres. The speaker wears a transmitter and the signals are wirelessly picked up by the wearer’s device. Hearing aids are sold singly. But hearing impairment often affects both ears, so wearers need to buy two hearing aids. Basic devices tend to work independently, much like listening to two different programmes at the same time. But with the more sophisticated devices, two pieces of equipment can be synchronised to work together to improve listening comfort.

Gone are the days of big, bulky hearing aids. Now they are getting not only smaller but also trendier in terms of colour and design. Mr Gopal Krishna, Senior Manager, ENT Centre, SGH

Advances in technology help not only wearers, but also health care professionals in getting newly-diagnosed users adjusted to their devices. One of the bigger recent breakthroughs is data-logging. This feature keeps track of usage history, environment variations and user preferences. “Now, I’m able to understand a patient’s lifestyle by looking at how he has been using the device, and I can then make adjustments to suit his needs,” said Mr Gopal.

Sudden hearing loss in people in their 20s and 30s may be due to trauma or viral infections.

singapore health

One downside of sophisticated hearing aids is the frequency of battery replacement. Their hightech features are energy guzzlers. Luckily, rechargeable batteries address this issue. The list of advancements to improve the quality of life of the hearing impaired is growing. Features to subdue the noise of rattling plates or even keyboard typing – technology seems to have taken care of it all. With technology advancing so rapidly, earrings or spectacles that double up as hearing aids may not be so far-fetched after all.

With technological advances, many hearing devices have improved capabilities and features.

Not only the old lose their hearing The elderly: Hearing loss is an expected part of growing old, especially after reaching 60 years of age. Hearing impairment gets progressively worse over time, and if not addressed, it can lead to social isolation, depression or miscommunication for the elderly. Adults: Sudden hearing loss in people in their 20s and 30s may be due to trauma or viral infections. But if the loss is gradual, it is likely to have started at birth, with the individual only realising that he is suffering from impairment later in life. Young adults/teenagers: One in six young people are at risk of losing their hearing simply from listening to loud music on their por table players, an SGH-Temasek Polytechnic study found. The study did not take into account other sources of loud music (e.g. television, rock concerts, etc), so more young people may actually be at risk. Infants/babies: Genetics is the biggest cause of hearing loss in newborns. Contributing factors include complications during pregnancy or birth, such as low birth weight or exposure to certain medications/infections while in the womb.

singapore health

SEP– OCT 2014

Watch your step

Older people are more susceptible to falls and should actively reduce their risk of a tumble. By Lediati Tan

Injuries from falls Ms Nor Diana said that it is important to seek medical attention after a fall. Injuries vary from mild abrasions and fractures to severe injuries that cause death. Those with superficial abrasions can be seen as outpatients in polyclinics or by a general practitioner. More serious injuries such as a fracture may require total bed rest, hospitalisation or surgery. Falls can cause pain, discomfort, reduced mobility and inability to carry out daily tasks for long periods. More

The elderly can reduce their risk of falls if they and caregivers are more aware of the dangers.

photo: vernon wong

The elderly can reduce their risk of falls if they and caregivers are more aware of the dangers, said Ms Nor Diana. Making improvements such as removing clutter, installing better lighting in the home, not rushing for the bus, and paying attention to uneven ground can help. SHP holds regular free classes on reducing the risk of falls where participants can also learn simple exercises to strengthen their muscles. Get more information on the classes by enquiring at the polyclinics, or look under Education and Training at SHP’s website at polyclinic.singhealth.com.sg.

According to Senior Staff Nurse Nor Diana Togeman (left), the elderly can exercise regularly to maintain muscle strength and improve joint mobility and balance to reduce their risk of falls.

Reduce the Risk of Falls

photo: Blue Jean Images/Corbis

alls in those aged 65 and above must not be taken lightly. Injuries in older people may be more serious than in the young. Ms Nor Diana Togeman, Senior Staff Nurse, SingHealth Polyclinics (SHP) - Geylang, said research shows that once people fall, they are more susceptible to recurrent falls. She said falls can happen to anyone, anywhere. “The elderly tend to fall at home or in the community while going about their daily activities.” Causes include clutter, slippery floors and loose cords in the home. Elderly people with mobility issues due to muscle weakness, or poor balance or coordination are at risk. Also vulnerable are those with chronic medical conditions like cataracts, arthritis, Parkinson’s disease or osteoporosis that affect vision, muscle strength and reflexes. Other risk factors include lack of exercise, poor diet, alcohol, and medicines such as sedatives that can cause unsteadiness or affect balance, vision and alertness. Adding to the problem are poor lighting, poorly designed steps and stairways, and chairs and beds of unsuitable height.

serious falls may cause social and psychological problems. For instance, longterm hospitalisation may be a financial burden and also make patients lose social contact. They may also feel frustrated, and lose self-esteem and confidence from not being able to carry out their daily activities independently. A severe fall may make them fearful of another fall, or distressed or embarrassed about their injuries, especially if they need a walking aid.

Personal care: • Check your eyesight regularly. • Exercise regularly to maintain muscle strength and improve joint mobility and balance. Take walks or do simple exercises such as extending your knee, as well as heel and toe raises to strengthen muscles. Speak to your doctor before starting any exercise. • Ask your doctor to review your medication as some can cause drowsiness or dizziness. • Reduce alcohol intake, stop smoking and eat a balanced diet to reduce your risk of falls and osteoporosis. At home: • Store commonly used items within easy reach, at chest or waist level. • Don’t stand on stools or chairs to reach high shelves. • Use a night light. If you wear glasses or use a walking aid, place them next to you when you go to bed. • Don’t get up too quickly when sitting or lying down.

• Put non-slip mats on the toilet or bathroom floors. Remove loose rugs or mats that tend to slide. • Install hand rails or grab bars in the toilet and bathroom. • Be extra cautious in high-risk areas such as the toilet and kitchen. • Remove excess clutter from the floor, and tidy up cords and wires. Outdoors: • Pay attention to your environment. Look out for uneven steps, especially in dimly lit areas. • Concentrate on walking. Don’t use your mobile phone or be distracted while walking. • Don’t rush. Walk slowly and carefully, especially when the floor is wet. • Wear flat shoes with rubber or non-skid soles; check the soles for wear and tear and change them regularly. • Talk to a doctor or physiotherapist if you think you need a walking aid so they can recommend an appropriate one for you.

Source: Changi General Hospital’s Your Guide To Falls Prevention

sep– oct 2014

singapore health

Ask the doctor Dr Ng Chung Wai, Family Physician and Chairperson (Infection Control & Infectious Diseases Workgroup), SingHealth Polyclinics, answers questions about immunity.

Q A

photos: vernon wong

Does being exposed to a few germs build up children’s immunity? While getting an actual infection may make a child immune to subsequent infections by the same germ, this is not always the case. For example, a child can get diphtheria more than once. The infections may result in complications that cause permanent damage, so it is safer to be protected by the diphtheria vaccine than by getting diphtheria.

Parents can play an important role in reducing the risk of infections in their children. For instance, they can teach older children good habits such as hand-washing, and cough etiquette (e.g. coughing or sneezing into a tissue).

That bug at school

Parents can boost their children’s immunity by ensuring they get all the recommended childhood vaccinations. By Desmond Ng

any parents notice that once taught good habits such as handtheir children start attending washing, and cough etiquette (e.g. daycare or nursery school, coughing or sneezing into a tissue).” they begin to fall sick. Why is this so? Studies show that attending daycare centres increases the risk of common colds and ear infections in children between three and five, said Dr Ng Chung Wai, Family Going to school and Physician and Chairperson (Infec- childcare exposes a tion Control & Infec tious Diseases Workgroup), SingHealth child to large Polyclinics (SHP). “Going to school numbers of other and childcare exposes a child to large children, which in numbers of other children, which in turn, increases the likelihood of expo- turn, increases the sure to germs,” he said. likelihood of Infections include the common exposure to germs. cold as well as HFMD, sinusitis, infectious diarrhoea, chickenpox Dr Ng Chung Wai, Family Physician and Chairperson (Infection Control & Inand influenza. While the common fectious Diseases Workgroup), SHP cold tends to be mild, influenza can lead to severe complications such as pneumonia, encephalitis (brain infection), myocarditis (heart muscle But it is not always easy for workinfection) and even death, said Dr Ng. ing parents to make alternative arrHe said that parents can play an angements. Thankfully, hygiene important role in reducing the risk of standards in some centres are good. infections. “If a child is unwell, stay- Temperatures are checked twice a ing home will reduce the chance of day and children with fever are spreading germs. This may mean turned away. that working parents need to make Dr Ng said parents can boost their alternative arrangements like having children’s immunity by ensuring they a grandparent or child-sitter look get all the recommended vaccinaafter the child. Older children can be tions. “Childhood vaccines* not only

ensure that children develop antibodies which protect them against these infections, but also reduce the likelihood of the infections occurring in the population, further reducing the possibility of a child catching the infection from another child. This is what we call ʻherd immunity’.” *The schedule of recommended childhood vaccinations can be found at the Health Promotion Board’s website: hpb.gov.sg/HOPPortal/ health-article/630

Can making the environment and children super clean actually make them more susceptible to germs? This is the Hygiene Hypothesis which postulates that an “overly-clean environment” and the lack of exposure to germs predisposes a child to developing allergic diseases such as hay fever and asthma, not so much a susceptibility to germs. There are several major issues with the hypothesis. For example, studies suggest that improving hygiene is not necessarily linked to an increase in asthma in children. So the answer is: “No, making the environment and children superclean does not make them more susceptible to germs.”

Q A

Are there differences in the levels of immunity at different ages and why? The immune system is not yet mature in a very young child, so those under one year old are more susceptible to infections. Some infections, such as blood infections by the pneumococcus bacteria, particularly affect children aged below two. An immature immune system also may not respond adequately to a vaccine, which works by stimulating the immune system to produce antibodies. For this reason, vaccines should not be administered before the recommended age. They are ineffective if given to a child earlier than the recommended age.

Q A According to Dr Ng Chung Wai, studies show that attending daycare centres increases the risk of common colds and ear infections in children between three and five.

Is there any way to prevent illnesses such as the common cold and measles? Vaccines can prevent childhood diseases such as mumps, measles, German measles, diphtheria, chickenpox and pneumococcus infections. Unfortunately there are no vaccines for some infections such as the common cold. They are caused by germs which mutate so rapidly that we are unable to prepare vaccines in time.

singapore health

sep– oct 2014

Mind your moods A mother’s moods while pregnant can affect her baby’s development. By Chua Hwee Leng

hen a pregnant woman is severely stressed, anxious or depressed, she is not the only one suffering. Her unborn child is affected too. According to the preliminary findings of a landmark local study, such babies have less developed limbic systems in their brains (networks linked to things such as memor y, stress regulation, emotional reactions and decision-making). The more depressed a mother is, the more her baby is affected. He may be shorter at birth, and as he develops, he may be more distracted, and have poorer memory. Researchers studied the mental and emotional states of 1,200 mothers and scanned their babies’ brains at a week old as well as later in life. The study is a sub-study of the Growing Up in Singapore Towards Healthy Outcomes (GUSTO) study, and a joint effort of KK Women’s and Children’s Hospital (KKH), the National University Health System, and the Singapore Institute for Clinical Sciences, the Agency for Science, Technology and Research. Explaining how babies might be affected in the womb, Dr Helen Chen, Head and Senior Consultant, Department of Psychological Medicine, KKH, said that while an unborn baby may not sense his mother’s distress, stress hormones can cross the placenta and influence the baby’s structural brain development. “The baby is then primed to live in a state of high stress, and there are studies which suggest that infants of anxious mums are more temperamental or difficult to settle.” Doctors here find the study results impactful, as they now have local data to use in their practice, where previously they relied on research in other populations. “As clinicians, these findings help us educate women about the need for intervention if they suffer from depression

Studies suggest that infants of anxious mums are more temperamental or difficult to settle.

or anxiety during pregnancy, as there can be a real impact on their babies.” Dr Chen said early intervention and treatment are extremely important. “I have seen women who have aborted a much wanted and planned pregnancy because they couldn’t cope with the antenatal depression and anxiety.”

Societal pressures on working women demand that they continue to perform. But pregnancy is, in itself, demanding psychologically and physically, so this is a time of vulnerability. Dr Helen Chen, Head and Senior Consultant, Department of Psychological medicine, kkh

Although some studies indicate that babies are more impacted if the mother is depressed in the last trimester than in earlier ones, doctors here are more concerned about the duration of the emotional disturbance. “If a mother is depressed or anxious persistently and for a long time, rather than transiently, it will probably impact her baby more, as physiological changes associated with her mental state can have a prolonged effect on foetal growth.” If the depression continues after delivery, most of these mothers have difficulty caring for their babies, who in turn are hard to settle, awake frequently and have feeding difficulties. Understanding needed “The most worrying cases are women with unplanned pregnancies who struggle to cope. Some reject their babies or give up caring for them. Some severely anxious ones have irrational fears of not being able to care for their babies, or of dropping them, because they are so distressed. These women need special intervention to address the mother-infant bonding problem, apart from treatment for their depression and anxiety.” Dr Chen advises mothers to be mindful of their emotional state and if they have distressing symptoms, to speak to their obstetrician or general practitioner who can refer them for psychological intervention. This does not just involve pregnancy-safe medication alone. There is also therapy and supportive counselling.

During pregnancy, a mother should let go of guilt, and focus on keeping well for her child and building a strong family unit.

If mothers are carrying guilt about their moods affecting their babies’ development, they should let go of the guilt and focus on what they can do to help now, Dr Chen said. “And that is keeping well for her child, and building a strong family unit. Fathers definitely have a big role in this too!” Many women are uncomfortable about seeking psychological help, but KKH’s Women’s Mental Wellness Service has counsellors and case managers who work with psychiatrists and psychologists to offer help at both outpatient clinics and inpatient wards. The hospital’s Department of Psychological Medicine is also raising awareness of the importance of a healthy family system to ensure the psychological and emotional well-being of women and their children. Dr Chen sees the need for society to be more understanding towards pregnant women. She said although there is

currently no local data, clinical observations suggest that women in high-pressure jobs with long hours and tight timelines face more challenges, and may be more vulnerable. “Societal pressures on working women demand that they continue to perform. But pregnancy is, in itself, demanding psychologically and physically, so this is a time of vulnerability. “I hope that through more public education, our community can understand the need to address maternal mental health issues, and that employers, supervisors and colleagues will be supportive of pregnant women. We need them to nurture well the next generation, on whom we will also depend on collectively as a nation!” For more details on a related event, Love Out Loud: Enabling Families Through Communication, refer to the event calendar on page 20.

2014 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

新闻

注射碎片，加快康复效率新的注射方式能更有效地解决其中一种肾衰竭的并发症原文 Thava Rani

为

Photo: alvinn lim

了让甲状旁腺恢复功能，肾衰竭病人在切除过度活跃的甲状旁腺后，经常得马上将一小部分的甲状旁腺重新植入手臂肌肉里。整个恢复过程需要将近九个月的时间。不过，新加坡中央医院和新加坡国立癌症中心的一支外科医生团队，从一项针对132名病人回顾性的研究中发现，将细细剁碎的腺体组织与溶液混合注射在上臂，短短的两个月内甲状旁腺功能便恢复了。 “比传统治疗程序，新的注射方式既快捷又能缩短复原期，”新加坡中央医院普外科顾问医生吴颂辉说。据他补充，新的注射方式无需像之前的方法需切开肌肉植入腺体，这不只降低了出血或受感染风险，也不会在上臂留下任何疤痕。 “此外，要是甲状旁腺再次变得过度活跃，外科医生将能够更容易地处理注射部位，无需重新切开肌肉，”新加坡国立癌症中心肿瘤外科高级顾问医生 Gopal Iyer说。参与研究的132名病人分别在2005 年2月至2012年2月期间，接受了甲状旁腺移除手术，然后通过植入或注射方式，恢复甲状旁腺功能。

(左起) Gopal Iyer医生，吴颂辉医生和钟慧玲副教授有份参于一项有关快速恢复甲状旁腺的功能新疗法的研究。

体积小、功能大体积很小，连超声波有时也难以检测出来 • 通常有四个，每个小如豌豆，位于颈部的蝴蝶状甲状腺后 • 当受到刺激时，可从正常大小增大20-30 倍，以不断产生荷尔蒙去处理磷酸盐和钙质的平衡失调

甲状腺

甲状旁腺

对于一些末期肾功能衰竭病人，他们甲状腺后面的微小甲状旁腺可增长到比正常的大几倍。

研究结果于今年1月被刊登在国际知名期刊《外科》上。这种能够减低并发症风险的注射方式现已成为新加坡中央医院在治疗这类病症的标准程序。至今，已有约130名病人接受了注射疗程。位于颈部甲状腺 ( t hy r o i d )附近的甲状旁腺(parathyroid)，体积虽然很小，但肩负的却是非常重要的功能；为血液中的钙质和磷取得最佳平衡。若失去这个平衡，病人就得需要服药或接受手术治疗，这是常见于肾功能衰竭的病人身上。 “由于所有食物都含有一些磷酸盐，因此肾功能衰竭的病人都需要面对处理磷酸盐的问题，”新加坡中央医院肾科高级顾问医生钟慧玲副教授说。

她说，肾功能正常的人在排尿时会把多余的磷酸盐排出，快速地恢复血液成分的平衡。然而，当肾功能失常时，比如末期肾功能衰竭病人所面对的情况，人体将无法处理平衡失调的信号，肾脏也难以简单地去除多余的磷酸盐，导致磷酸盐含量持续保持在过高的水平。如果这种情况持续很久，很可能会导致骨骼和心血管疾病。不是每个肾衰竭病人都会出现甲状旁腺过度活跃的问题。据估计，有大约三分之一的肾功能衰竭病人最终将有可能出现这种情况。虽然病人可通过药物和饮食控制过度活跃的腺体，不过大约百分之五至十五的病人最后在无计可施之下，都需要接受手术以解决问题。

植入和注射治疗方式的对比

技术上说明程序时间恢复甲状旁腺功能

植入或注射所需的时间

风险部位的疤痕

以往的植入方式

把一部分的腺体植入手臂肌肉内

30分钟

9个月

4-5厘米

出血或受感染

新的注射方式

在皮下脂肪层注射含有细细剁碎的腺体组织的溶液

18分钟

2个月

没有

平衡功能 • 释放甲状旁腺荷尔蒙，控制人体内过低的钙质水平和过高的磷酸盐（和镁）水平 • 促使肾脏通过排尿排出多余的磷酸盐 • 促使骨骼吸收和释放钙质，阻止肾脏通过排尿排出钙质

钙质和磷酸盐对以下功能是不可或缺的成分 • 建造与修补骨骼和牙齿 • 促进神经功能 • 使肌肉收缩 • 促进血液凝固

当磷酸盐水平过高 • 当荷尔蒙产生时，肾脏无法通过排尿，有效地去除多余的磷酸盐 • 甲状旁腺不断释放荷尔蒙，以尝试降低过高的磷酸盐水平 • 持续释放的荷尔蒙会造成副作用：骨骼释放更多的钙质，导致骨骼慢慢失去支撑的功能；被释放的钙质堵塞血管 • 病人可能会经历骨痛和关节疼痛或骨折，以及心血管问题

新闻

2014 年9– 10月刊

防患乳癌意识月

提高警觉预防乳癌原文 Denyse Yeo

乳癌是最主要导致女性死亡的癌症，占癌症死亡率的

18% 20% 1,600

症状如果您出现任何以下症状，请立即去看医生：

在新加坡女性之中，乳癌是最常见的癌症。每年，大约有

乳癌占女性癌症的

感觉乳房里有无痛的肿块

乳头周围出现持久性的皮疹

名女性被诊断患上乳癌。

250,000 在过去十年内（2002-2012），将近

乳头出血或流出异常分泌物

乳头内陷

及早检查

女性乳房肿块并不罕见，但在每10个肿块之中，只有一个是因为癌症而形成的。这意味着 90%的乳房肿块都是良性的。

资料来源：卫生部和保健促进局

名女性已接受过新加坡乳房检验计划（BreastScreen Singapore）的检查。

乳房皮肤肿胀、增厚、凹陷或起皱

降低患病风险

拥有乳癌家族病史的女性可能面对较高的风险。如果您的母亲和/或姐妹在更年期前患上乳癌，您应该与您的医生或乳腺专科医生详谈。

+ 40

1 女性患上乳癌的风险会随着年龄增加。大部分被诊断患上乳癌的女性都年届40 岁及以上。其他的致病因素包括较迟出现更年期、完全没有生育或儿女不多、正在接受荷尔蒙替代疗法和体重增加。

维持健康的生活方式。定时运动，保持健康的体重。多一点进食水果、蔬菜和全麦食品，少一点进食肥腻的食物。减少喝酒，马上戒烟。

在每次月经来潮后的第三至第五天，自我检查乳房，养成习惯。

定期接受乳房X 光检验。如果您的年龄介于40-49岁，您应该每年接受一次乳房X光检验，直到50岁为止。50岁后，您应该每隔两年接受一次检验。

接受检验您可以在以下机构参与全国性的新加坡乳房检验计划：新加坡保健服务集团（电话: 6536-6000）、Radiologic Clinic（电话: 6533-2721）和国立健保集团诊断服务（电话: 6275-6443/ 6-ASK-NHGD）

2014 年9– 10月刊

健康

居家护理让病患省却了往返医院的奔波，也减轻了医院的负担文杨萌

近

职总乐龄合作社家务助理黄金春为八旬病患冲凉和按摩身体，让卧床不起的病患获得片刻舒坦。

图：联合早报何炳耀摄

几年来，居家护理（home care）已成为本地医疗界的热门话题。他们上门提供治疗的模式既让病患省却了往返医院的奔波，也减轻了医院的负担。居家护理领域依工作性质有所区别。业者中，有的专注提供居家医疗（home medical）和居家护理（home nursing），有的专提供居家看护或家务助理（home help）。同时提供医疗和非医疗服务的业者不多。一般上，家务助理负责为病患冲凉、按摩、喂药、量体温血压，工作也包括煮饭和陪同病患去医院。这份工作看起来不难，但一点也不简单。除了耐心，还得心细和不怕脏。所以虽然市场上有需求，但要找到合适的人选并不容易。本地提供居家护理的志愿福利团体大约有15家，私人公司3 0多家。志愿福利团体照顾的年长者多来自低收入家庭，他们多由医院或社区服务机构转介，本地人可获得高达80%卫生部津贴。属于中高收入者则可私人家务助理业者。在津贴之前的收费约每小时$20，但实际收费还须视业者和具体服务而定。低收入家庭即便是获得高额津贴，也未必能负担家务助理每天上门，因此会要求家务助理每周探访一至三次，这也就意味着老人家一个星期也就冲凉几次。那些需要长期服务的，可选择配套，比如50个小时的配套，以每小时$18来算是$900。

卫生部津贴家庭人均月入 0–$700 $701–$1100 $1101–$1600 $1601–$1800 $1801–$2600 >$2601

居家护理服务 80% 75% 60% 50% 30% 0

居家复健服务 $97 $91 $73 $61 $36 0

*适用于新加坡公民，永久居民津贴较少

资料来源：卫生部

居家护理服务和收费服务名称

服务内容

费用（津贴前）

居家医疗

医疗团队定期上门提供治疗

每次$130–$200

居家护理

护士上门清洗伤口和拆除伤口缝线、换食管和尿管、打针、包装药物等

每次$80以上

居家复健

专业物理或职能治疗师上门提供复健服务

每次$100–$150

家务助理

陪伴病患、做些简单运动、冲凉、准备餐食和陪同病患看病等

每小时$2.70–$30，视具体内容和业者而定

看护者喘息护理

家务助理上门提供数小时照顾

每小时约$20

看护者训练

教导看护者（亲人或女佣）每年可获培训津贴在家照顾年长病患

最高$200

部分资料来源： “新加坡乐银页”(Singapore Silver Pages)，silverpages.sg

卫生部3C强化居家护理服务卫生部新财政年的重点计划之一，是从3C下手强化居家护理服务。第一个C是强化能（capacity）。比如，卫生部鼓励医院提供更多医疗延续服务（t r an s i t io nal c ar e programmes），安排医疗人员短期上门照料病患，减少病患再次住院概率。另外，卫生部也会资助更多团体提供长期的居家护理服务。目前每年有 5 4 0 0人接受居家医护服务，1100人接受家务助理服务，到了 2020年，这两个群体估计会分别增加至一万人和7500人。第二个C是提高服务的多元性和完整性（comprehensiveness），比如两家医院去年推出短期看护者服

务（Interim Caregiver Service），在病患出院两周内安排专人每天上门提供长达12小时看护服务，今年底所有重组医院和社区医院都将提供这一服务。另外，规模还在初期阶段的居家复健（home rehabilitation）也将获得卫生部津贴（见表）。卫生部也将调整对居家护理业者的资助方式。目前，卫生部主要是以每小时或每次服务给予资助，今后则计划以“人头计算”（capitated funding），根据业者为年长者设计的一整个护理配套来拨款。业者对此普遍表示欢迎。触爱的萧树耀说，这意味着业者长期财务资助有了保障。曹氏的黄卫众医生

说，这解决了一些业者为了获得更多资助而盲目增加年长者探访次数的问题。但他认为，卫生部在衡量各居家护理计划时应采用更全面的标准，比如看护者压力、病患疼痛是否减轻等。第三个 C 是协助看护者（c a r e g i v e r），卫生部打算通过试点推出周末喘息看护（r e s p i t e care），让需要在周末出外办事或休息的看护者暂时将年长者交给日间托管中心。卫生部将在今年第三季度成立看护者一站式热线中心。看护者只需拨打一个号码，便有专人回答有关转介护理服务和申请津贴等问题。

居家护理须八面玲珑居家护理的护理人员必须有“八面玲珑、左右逢源”的本领。曹氏基金属下华美中心医药总监黄卫众医生解释，在医院里，医生直接开药、吩咐病患去做检查，最多问问在家里由谁照顾，但一旦到了病患家，尤其是那些家徒四壁的病患，医护人员也才发现，原来病患不是不肯吃药或不肯好起来，而是有种种的障碍摆在他们面前。他说： “你给糖尿病人开胰岛素，但他家里连冰箱都没有，怎么存放胰岛素？一些病患的问题不是生病本身，而是生活孤立无助，这个生命的问题比他的健康还重要，他一个人一整天坐在椅子上，他觉得生命已无意义，还要健康来干吗？” 从事居家护理13年，黄卫众医生除了看病，还得亲自抹地、洗脏被单和清理满屋的臭虫，但同时，满足感也无可比拟，因为他可以走进病患的生活，帮助一些原本已放弃自己的病患重新振作、健康起来。他强调，从事居家护理需要的技能远大于专业技术，最需要知道社区里有什么资源、如何处理情绪问题、如何和病患家属合作。 “这都需要八面玲珑、左右逢源的技巧，就连该不该把病患转介给专科医生都要仔细想过，因为这名病患可能连门都出不了，出门要安排什么交通，是不是真的有必要，还有没有更好的办法？” 因此，各机构越来越重视员工的培训，比如职总乐龄的家务助理在物理治疗师的教导下，学习基本的物理治疗技巧，当物理治疗师不在时，家务助理也能帮老人家做简单伸展动作。负责职总乐龄居家服务的助理总经理冯时韵说，家务助理还学习如何辨认失智症及适合失智症患者做的游戏。随着训练和技能的完善，这些助理还可能朝管理方面发展。触爱四年前推出看护者热线，护理协调员除了给看护者推介服务，还能给他们建议，减少看护者压力，省去他们四处敲门求助的烦恼。

原文首次刊登于早报星期天2014年3月30日

焦点

2014 年9– 10月刊

及时注射疫苗

汤医生说： “受感染的母亲通过生产过程将病毒传染给孩子，是孩童感染B型或C型肝炎最常见的方式。其他传播方式包括跟受感染、同住的家庭成员有亲密接触，或被沾有受感染的血液的器具或物品割伤，如通过纹身、在耳朵或身体其他部位打洞、针灸、共用使用注射针等。在较为罕见的情况，被感染者咬也能造成被咬的人受感染。”

保护孩子免受肝炎病毒感染并非难事原文 Thava Rani

您

是否知道，几乎所有受B型肝炎病毒感染的婴儿与孩童都不会出现迹象或症状？也就是说，他们有可能会在不知情的情况下将病毒传染给其他孩童。然而，许多人仍对肝炎一知半解，并不知道这种疾病的种类与个别的传播方式。

应当心蚶和针卫生条件差，是传染A型肝炎的主要原因。此病毒存在于受感染者的粪便中。病患在出现症状前的两三周前传染性极高，所以家属如果接触不干净的食物或液体，此病毒便很容易传播。食用生的或没有完全煮熟的蚶也是

感染肝炎的常见方式，不过，此方式在孩童中较少见。竹脚妇幼医院儿科传染病高级顾问医生兼部门主任汤国正说： “贝类食物是肝炎的病因之一。在较落后国家里，人们常将粪便倒入河流与沟渠中，粪便进而流入贝类繁殖的海里。” 另一方面，B型肝炎的传播方式跟人体免疫缺陷病毒（HIV）的传播方式是相同的，既是通过受感染的血液或其他体液如精液或阴道分泌液等。然而，B型肝炎的传染可能性比人体免疫缺陷病毒的传染可能性高出50至100倍。同样的，C型肝炎也是通过与受感染的血液直接接触而传播的，但较少通过其他体液传播。

注射疫苗！

保护您的孩子若要预防孩子感染A型肝炎，最好的方法就是确保他们严格遵守卫生习惯，如在家里经常洗手。当您到卫生水平较低的国家时，饮食方面最好多加小心。汤医生警告说： “没有煮滚、煮熟或去皮的食物就别吃。在饮料方面也必须小心，尤其是冰冻饮料。用来制作饮料的水也许是干净卫生的，但冰块可能已受污染。” 确保孩子们免受感染的最佳保障是对B型肝炎有免疫。如果有家庭成员是带菌者，那您就得在住家内采取额外预防措施。包括确保他们无法取得尖利

新加坡所有婴儿在全国性计划下都接受B型肝炎疫苗注射疫苗共有3剂，分别在刚出

世时、一个月大时及5至6个月大时注射。

的物品如使用过的针或剃须刀，和避免与伤口有直接接触。孩子们也不应吃接触过他人口的任何食物。母乳喂养是安全的。那些会接触到C型肝炎感染者的孩童，也应在住家内采取类似预防措施。通过疫苗注射能有效预防A型和B 型肝炎，然而目前C型肝炎并没有预防疫苗。自1985年起，B型肝炎疫苗注射是全国儿童免疫计划的其中一项疫苗注射，有效度高达95%。汤医生说： “注射疫苗不但对接受注射的孩童有利，也有助于降低他们在社区中将病毒传染给他人的风险，尤其是对那些不能接受疫苗注射的人。更大的利益是，注射疫苗能提供 ‘增强’保护，这远比直接保护来得有效。通过注射疫苗，我们能根除此疾病，而并非只是控制它。” “注射疫苗能直接降低B型肝炎长期感染的风险，进而降低患上肝硬化和肝癌的长期风险。” 目前，为孩童注射A型肝炎疫苗并非常规，只有当孩童需要到此疾病较为普遍的国家时才需要接受疫苗注射。

3 一般上不需要重复注射疫苗

某些孩童不宜接受注射对前一剂疫苗产生危及生命的过敏反应的孩童。对任何疫苗成分（如酵母）有已知过敏反应的孩童。

首两剂疫苗提供迅速保护作

用，第3剂疫苗则让保护期限尽可能延长。

在许多孩童当中，疫苗的保护期相信可长达至少25年，而在一些孩童当中则是终身的。孩童在成年后若有染病风险，如跟受感染的人接触过、需要接受输血或进行高风险性性交，则应再次接受检测与注射。

肝炎须知肝炎指的是肝脏发炎，而肝脏发炎可能是由病毒感染造成，或因接触到有毒物质、酒精或药物而引起的。虽然A型、B型及C型这三种肝炎很相似，但是导致个别肝炎的病毒却是不同的。

B型或C型肝炎

能通过沾留在针头或刀片上的受感染的血液传播。A型肝炎则很容易通过食用未经烹煮或没有完全煮熟的贝类或不卫生的食物，如已剥了皮的香蕉而传播。

A型肝炎

B型肝炎

C型肝炎

由什么造成

A型肝炎病毒（HAV）

B型肝炎病毒（HBV）

C型肝炎病毒（HCV）

症状

疲劳、食欲不振、发烧、恶心、呕吐、腹部疼痛、体重下降、关节疼痛、眼球与皮肤发黄（黄疸病）、尿液呈深色、粪便呈灰白色

孩童

小于6岁，一般上不会出现明显症状，感染黄疸病的人数只有约10%

年龄较大的孩童

出现更为严重的症状，感染黄疸病的人数超过70%

并发症

在没有并发症的情况下，康复过程一般历时数周

绝大多数的感染病例是毫无症状的

90%的孩童可能成为慢性B型肝炎带菌者。在这些孩童当中，其肝炎恶化成慢性肝硬化，可能导致肝脏衰竭，甚至是肝癌的人数可高达三分之一

恶化成慢性肝硬化或肝癌的人数约为15% 至20%，尽管这个恶化过程在孩童中可能历时数十年

2014 年9– 10月刊

新闻

专家解答

烟霾使哮喘病加剧最近的烟霾使我的哮喘病病情恶化，经常发作。我该怎么做？在哮喘病发作时，患者的呼吸道会收窄，导致呼吸困难。如果没有适当地控制病情，让呼吸道受到环境的触发因素所刺激，病情很容易就会发作。要减少哮喘病发作，就必须控制好病情。因此，患者可能需要服用适量的控制性药物。哮喘病的吸入性药物可被分为两大种类：控制性药物：治疗肺炎，同时降低肺部对于触发因素，如烟霾这种环境污染物的敏感度，从而减轻敏感反应。缓解性药物：在哮喘病发作时，舒缓并扩张已收缩的气管。在阴霾笼罩时，病情一般受到控制的哮喘病患者可能会觉得病情转坏，并需要服用控制性药物。至于已在服药的患者，则可能需要医生调整药物剂量。所有的哮喘病患者都应该有一份列明指示的哮喘病控制行动计划：识别早期症状，以便采取适当的措施，预防发作程度恶化；发作时需要采取的步骤；以及如何辨别发作程度是否严重到需要紧急救护治疗。

无论病情是否已受到良好的控制，所有哮喘病患者都应该随身携带一个吸入器，预防哮喘病随时发作。新加坡保健服务集团综合诊疗所家庭内科顾问医生黄忠伟

我患上抑郁症了吗？我经常感到情绪低落，对任何东西都不感兴趣。这是不是抑郁症的征兆？月经来潮之前感到忧郁消沉是正常的吗？月经来潮的前两周，有些妇女可能会感到情绪低落是因为黄体酮（一种会导致情绪消沉的荷尔蒙）一直在体内不断地增加所引起，又或者因为月经而必须避免进行某些活动，例如游泳/ 水上运动、穿紧身或浅色衣服，甚至性行为，而感到沮丧。至于抑郁症，它主要的症状是情绪低落和意志消沉，或对任何东西失去兴趣和无法透过任何事物感到欢愉。其他症状还包括：失眠（尤其是在凌晨醒来）食欲不振和消瘦（或爆食和发胖）

无法集中精神或健忘失去正能量或动力、无精打采（或容易激动和焦躁不安）意志消极、过度内疚、绝望感，以及有自杀倾向。但如果以上症状连续出现超过两周，并引起重大的痛苦或影响个人的日常生活能力时，那可能就是抑郁症了。竹脚妇幼医院心理医学科主管及高级顾问医生陳瑜

近视可以治疗吗？我其中一名孩子患有近视。请问有什么方法治疗吗？如何预防近视度继续加深？另外，我也开始限制小儿子使用电脑和电子产品的时间。我是否过度反应了？

眼镜或隐形眼镜和使用阿托品滴眼剂（Atropine Eye Drop）。眼镜和隐形眼镜的治疗效果因人而异，一般成功率从零至30%不等。如果选用隐形眼镜来治疗，家长必须加倍小心护理，以确保孩子的眼睛不会受到感染和威胁到视力健康。阿托品滴眼剂是一种能够减缓近视恶化的有效药剂，控制效率可达50% 至80%。不过，不同浓度的滴眼剂可能会造成瞳孔放大和近距离视力模糊。副作用较轻的较低浓度滴眼剂去年上市，给使用者更多样化的选择。如果你希望知道自己的孩子是否适合接受以上治疗，请咨询你的医生。新加坡全国眼科中心及竹脚妇幼医院幼儿眼科与斜视治疗组高级顾问医生谢玮玲

遗传和环境因素会导致近视。如果你有近视，你孩子患上近视的几率会更高。此外，我们目前的生活模式也过份偏重于室内工作和近距离聚精会神。为了减轻以上因素，保健促进局推行了一个计划，支持孩子多到户外活动，避免长时间留在室内。你也应该限制孩子玩电脑游戏和看电视的时间，并让他多到户外玩耍。如果近视持续加深，我们可以通过其他方法来控制它，例如配戴特制

Wide circulation that reaches over 200,000 readers Available at strategic locations Contains authoritative health care news and information Singapore Health is the official publication of Singapore General Hospital and SingHealth

Published bimonthly in a handy Group, the largest health care group in Singapore. tabloid size, the newspaper aims to raise the health literacy level of Singaporeans. Singapore Health is available at Singapore General Hospital, KK Women’s and Children’s Hospital, Changi General Hospital, national speciality centres, and polyclinics under the SingHealth umbrella. It is also available at high-traffic points within the CBD area. Singapore Health ensures your message gets across to your target audience. For advertising enquiries, e-mail Lin Mi’er at mierlin@sph.com.sg

2014 年9– 10月刊

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