A PUBLICATION FOR
PRIMARY CARE PHYSICIANS
MICA (P) 242/03/2012
DECEMBER 2012-FEBRUARY 2013
Unblocking Your Sleep Get
Right
Tackling Sports Injuries
Heart
How to
tothe
Satisfy
Your Partner
Scan the QR code using your iPhone or smart phone to view GP BUZZ on the TTSH website or visit http://www.ttsh.com.sg/gp/.
Sculpt Your Core
contents
editor’s note
Man Your Health
15 in every issue 030 editor’s note 040 in the news
The GP BUZZ editorial team: Jessie Tay Lee Wei Kit Celine Ong
260 fitness 310 healthy recipes
ADVISORY PANEL: Associate Professor Thomas Lew Associate Professor Chia Sing Joo Associate Professor Chin Jing Jih Dr Chong Yew Lam Dr Tan Kok Leong Joe Hau
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in this issue 06 Man, Watch Your Colon!
GP Buzz is a quarterly magazine by Tan Tock Seng Hospital, designed by
11 Get Right to the Heart 15 Unblocking Your Sleep
We value your feedback on how we can enhance the content of GP Buzz. Please send in your comments and queries to gp@ttsh.com.sg.
18 How to Satisfy Your Partner
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22 Tackling Sports Injuries
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At 64 years of age, Mr Ang stands at a height of 1.65 metres and weighs over 80kg. His BMI shows that he’s obese. With high total blood cholesterol, Mr Ang has to be on medication to control his cholesterol level and he routinely visits the local hospital every six months for a blood cholesterol test.
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r Ang is just one example of one in eight Singaporean men* with a BMI of more than or equal to 30kg/m2 or categorised as obese. This places him in the high risk group of developing heart disease and diabetes. High total blood cholesterol also affects over 18% of the local male population. In fact, the results of the 2010 National Health Survey by Health Promotion Board have shown that there are more men with major noncommunicable diseases and health risk factors (e.g. diabetes, hypertension, obesity, cigarette smoking, alcohol drinking) than women. As primary healthcare practitioners, you are placed in a unique position to care and lead these male patients to better health. Hence, we have developed a Men’s Health edition of GP BUZZ, following Women’s Health in the last issue.
Raising the red alert is easy but without knowledge and steps to improve on health, all efforts will come to nought.
In this edition, you will find health essentials for all men, starting from the cover story on colorectal cancer, the most common cancer in men. A feature on the latest advances, techniques and drugs for cardiovascular diseases, the second top killer of men is also included. Together with other spotlights on common men’s health conditions like sleep apnoea, tips on satisfying your partner sexually, ways to stay injury-free in sports; this Men’s Health issue of GP BUZZ promises to be a power-packed edition. That’s not all. We bring you core exercises for body-sculpting and strength-building in the fitness section. To boot, we have a protein packed steak dish specially developed by TTSH’s Food & Beverage and Nutrition & Dietetics Departments. Have an enriching read! The GP Buzz Editorial Team
* Singapore residents and permanent residents aged 18 to 69 years of age.
DECEMBER 2012-FEBRUARY 2013
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in the news
Clinicians Honoured at the National Medical Excellence Award (NMEA) 2012
in the news
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he National Medical Excellence Award (NMEA) 2012 initiated by the Ministry of Health, honours the best talents in Singapore’s medicine. It recognises the exceptional contributions of distinguished individuals and teams not only in medicine and also in clinical research, clinical quality, education, training and mentorship. This year, two clinicians from Tan Tock Seng Hospital (TTSH) were honoured amongst the 10 medical professionals who received their awards from Mr Gan Kim Yong, Minister for Health and Guest-of-Honour at the ceremony held on 28 August 2012 at the Hilton Hotel, Singapore.
New One-stop Multidisciplinary Facility for Musculoskeletal Conditions
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an Tock Seng Hospital officially launched a multidisciplinary centre for treatment of musculoskeletal conditions on 17 September 2012, laying the foundation for a musculoskeletal centre of excellence for patient-centric care, training, education and research.
Adjunct Associate Professor Tai Hwei Yee, Deputy Chief Quality Officer, NHG and Senior Consultant, Department of Anaesthesiology, Intensive Care & Pain Medicine of TTSH, was awarded the National Outstanding Clinical Quality Activist Award 2012. Adj. A/Prof Tai was recognised for her contributions in advancing clinical quality and patient safety in Singapore and in introducing innovative clinical quality improvement programmes that have led to an increased quality, sustained safety and standards in patient care.
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Associate Professor Lim Tock Han, Assistant CEO (Education & Research) of NHG and Senior Consultant, Department of Ophthalmology of TTSH, was awarded the National Outstanding Clinician Educator Award 2012. A/Prof Lim’s passion and his immense contributions towards the creation of an encouraging learning environment for clinicians as well as his continuous efforts in nurturing the current generation of clinicians were acknowledged through this award.
Occupying more than 3,000 square metres of floor area, this new facility within the Medical Centre Block comprises 56 consultation and treatment rooms; diagnostic imaging rooms including on-site bone mineral densitometry, musculoskeletal ultrasound and nailfold capillaroscopy services; a hand procedure suite, a day facility and pharmacy. Our specialists in Orthopaedic and Hand Surgery, Rheumatology, Allergy and Immunology (RAI) now share this new facility, giving our patients better access to interdisciplinary management of various musculoskeletal conditions. Patients now move seamlessly among imaging, consultation, procedure and treatment areas. A Hand Procedure Suite offers same day local anaesthetic procedures. Occupational therapists and podiatrists provide joint consultation with our hand and ankle/foot surgeons respectively. A dedicated 8-hour day facility is available for patients who require outpatient intravenous
infusions including biologics for inflammatory arthritis. A pharmacy is also housed within the facility for seamless and holistic patient care. The Musculoskeletal Centre will eventually integrate with the existing Pain Management and Sports Medicine and Surgery services, as well as Allied Health services which include Occupational Therapy and Physiotherapy.
Working as a team: (Second from left) Adj. Asst. Prof Ganesan Naidu Rajamoney, Orthopaedic Surgery, Head of Department, Consultant and Dr Bernard Thong, Rheumatology, Clinical Immunology & Allergy, Head of Department, Senior Consultant with members of their team.
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cover story
cover story
Man, watch your colon! Colorectal Cancer is most prevalent in men. Regular screening for this disease allows for early diagnosis and effective treatment. Colorectal Cancer patients need not fret as an individualised treatment process and a multidisciplinary team are at hand to help men (and women) combat this condition.
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olorectal Cancer is the cancer with the highest incidence in Singapore. The incidence of Colorectal Cancer in Singapore for both females and males has steadily increased over the past 20 years. The average lifetime risk of a Singaporean is 1:55. This risk increases with age and rises sharply from the age of 50 years onwards. In men, Colorectal Cancer was the most common cancer with 4,456 cases from 2006 to 2010. This condition affects one in every 20 men as compared to one in every 30 women.* Therefore, in an effort to increase survival rates, population screening programmes such as the National Colorectal Cancer Screening Programme organised by Health Promotion Board for early diagnosis and treatment have been developed.
Colorectal Cancer Screening Our local Colorectal Cancer screening guidelines divide the population into three categories based on the risk of the Cancer: average, moderate and high risk.
1. Average Risk Screening for average risk individuals should begin at 50 years old. This includes an annual digital rectal examination, either a yearly fecal occult blood testing and a flexible sigmoidoscopy every five years. Alternatively,
a total colonic examination can be done using colonoscopy or a double contrast enema once every five to ten years.
2. Moderate Risk Those at moderate risk include asymptomatic individuals with a first degree relative diagnosed with Colorectal Cancer who is less than 45 years old; or two first or second degree relatives from the same side of the family with Colorectal Cancer diagnosed at any age. It is recommended that they should have a colonoscopy at a three-yearly interval from age 45 or 10 years younger than the age of the earliest diagnosis of colorectal cancer in the family.
3. High Risk High-risk individuals are those with a hereditary or genetic predisposition, such as familial adenomatous polypsis. These people should be screened yearly after diagnosis. After identification of Colorectal Cancer, a thorough evaluation is required to rule out synchronous cancers and significant polyps. An assessment to rule out advanced or metastatic disease is also needed. For colon cancers, a CT scan of the abdomen and pelvis together with a chest X-ray is usually done. For rectal cancer, besides the above, endorectal ultrasound or MRI pelvis is done to assess the depth of tumor penetrations through
* Singapore Cancer Registry Interim Report, 2006 to 2010, Ministry of Health.
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cover story
cover story
the rectal wall and for assessment of the locoregional lymph nodes. Carcinoembryonic Antigen (CEA) is routinely used for advanced and metastatic diseases and may be a predictor for poor outcome.
Surgical Therapy – The Main Treatment For colorectal cancer, surgery is the mainstay of curative treatment. The goal of surgical therapy is to do a complete resection of the primary lesion, all the primary feeding vessels, the adjacent organs if local invasion is present and the regional lymph nodes.
There is an increasing trend towards minimally invasive surgery, such as Standard Laparoscopic or Single Incision Laparoscopic (SIL) colectomies. Studies have shown many post-operative benefits such as a reduction in post-operative pain, a reduced incidence of post-operative ileus and decreased length of hospitalisation stay. In experienced hands, all oncological principles are maintained. The operation time is also comparable to open surgery and with meticulous specimen handling and extraction techniques, port site metastasis are not more common than incisional metastasis in open colonic surgeries. In Tan Tock Seng Hospital (TTSH), an increasing number of patients have undergone minimally invasive surgery with positive results.
• Individualised Treatment for Each Patient
Dr Tay Guan Sze explaining the colonoscopy process to a patient.
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decrease the risk of recurrence and optimise oncological outcomes.
• Minimally Invasive Surgery
For rectal carcinoma, deciding on the optimal treatment plan is a complex and a highly individualised process. Stage one rectal cancer can be treated definitely with surgery alone. However, patients with stage two and three cancers are treated with neoadjuvant chemotherapy and radiotherapy prior to surgery to
Surgical options in rectal carcinoma also vary depending on the type and location of the primary tumour. Options of transanal excision (for low tumour) and transanal endoscopic mircosurgery (for higher tumour) are available for carcinoma in situ and T1N0 rectal carcinoma, although studies have shown higher recurrence rate even with clear margins. Radical surgery for rectal cancer should be performed for larger tumours. Sphincter preserving low anterior resection can be performed safely when cancers are located more than one centimetre from the upper portion of the anorectal ring. Otherwise, an abdominoperinal resection is preferred. Post-operative chemotherapy for colorectal carcinoma is usually recommended to improve survival rates for tumours which are stage two and above.
• Multidisciplinary Team Management In TTSH, our patients diagnosed with Colorectal Carcinoma are seen by a multidisciplinary team consisting of surgeons (colorectal surgeons, hepatobiliary surgeons, thoracic surgeons), a medical oncologist, a radio oncologist and a radiologist. They are also assessed by a dietitian, a stoma nurse and a physiotherapist.
In men, Colorectal Cancer was the most common cancer with 4,456 cases from 2006 to 2010. Our specialised colorectal nurses will also give regular telephone consultations with our post-operation patients to ensure their well-being. As an increasing number of people are diagnosed with Colorectal Carcinoma, a specialised team of specialists should be dedicated in looking after them to ensure the best outcome possible.
Therefore, to stem the spread of this condition, do encourage your patients, especially male patients, to undergo the screening tests regularly. Men out there, remember to watch your colon!
Dr Tay Guan Sze Dr Tay Guan Sze is the Head and Consultant of the Colorectal Surgery Unit, General Surgery Department in Tan Tock Seng Hospital. He completed his fellowship training in surgery for inflammatory bowel disease and recurrent rectal tumour in Leeds General Infirmary, UK. His specialty interests are in complex colorectal tumour including recurrent rectal tumour.
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cover story
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A Patient's Journey
Early Detection Saved His Life! At 57 years of age, Mr Boo Ai Kuan enjoys an easy and comfortable life. With two adult children and a grandchild, he is a face of bliss and contentment. Nobody would have guessed that he was once a stage three Colorectal Cancer patient two years ago. A carpenter by profession, Mr Boo loves indulging on food, especially meaty delights. With nary any exercise apart from physical activities at work, Mr Boo’s health spiralled downhill. In 2010, Mr Boo found blood in his stool (hematochezia) and he went on to seek help from his General Practitioner who found piles developing in his rectum. Medication was prescribed and Mr Boo’s condition improved, but his hematochezia came back soon after. Mr Boo was then referred to Ang Mo Kio Community Hospital for detailed checks into his condition where Dr Tay Guan Sze, Consultant from the Department of General Surgery in Tan Tock Seng Hospital, was also practising in. As Mr Boo’s specialist, Dr Tay performed a colonoscopy on Mr Boo and found a 1.5 cm lump in his colon which was confirmed to be malignant. The colorectal cancer was in its third stage but there were no obvious symptoms
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or pains apart from the hematochezia that Mr Boo experienced. The subsequent treatments were administered swiftly, starting with a surgery to remove the cancerous lump in Tan Tock Seng Hospital in December 2010 by Dr Tay. Mr Boo recovered quickly from the surgery without much pain. The subsequent chemotheraphy sessions in Johns Hopkins Singapore International Medical Centre (JHSIMC) however proved to be physically draining for Mr Boo. Fortunately, Mr Boo’s body reacted well to the treatment and he was given a clean bill of health eight months later. Now, Mr Boo visits JHSIMC and Dr Tay annually for his health reviews. He still indulges in food but goes for healthier dishes with more greens, less oil and salt. Looking back on his experience two years ago, he constantly shares the importance of early detection especially for higher risk groups. In fact, as soon as he was diagnosed with cancer, he urged all the members of his immediate family to undergo colonoscopy since his family belongs to the moderate risk group and also because Mr Boo knew how it had saved his own life.
Get Right to the Heart
As the second top killer after cancer in Singapore, ischaemic heart diseases are not to be taken lightly and must be treated immediately. With medical advancements, there are now new ways of treating these diseases for better outcomes and faster recovery for the patient. 11
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ardiovascular Diseases including coronary heart diseases, cerebrovascular diseases (stroke), hypertension, heart failure claimed an estimated 17.1 million lives globally, making it the leading cause of death. In Singapore, ischaemic heart disease was the second killer at 18.7% after cancer (28.5%) in 20101. The incidence of Acute Myocardial Infarction (AMI) or what is commonly known as heart attacks in men is about twice that amongst women in 20092.
These statistics are consistent with the local health perspective where there are more men vis-à-vis women afflicted with high total blood cholesterol, hypertension or overweight, all risk factors of coronary heart disease and cerebrovascular disease. With enhancements medically and technologically, we now see more treatment options for cardiovascular diseases which allow for better healing and improved quality of life for both males and females. This article provides a lowdown of the new techniques and medications available in the treatment of Acute Myocardial Infarction (AMI) or Acute Coronary Syndrome (ACS), terms
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used to define any group of clinical symptoms compatible with acute myocardial ischemia.
1. New Approach Radial Artery
The traditional arterial access to angiogram and percutaneous coronary intervention or angioplasty was via the femoral arteries. There is an increasing trend in switching to the radial artery as the preferred access route due to the following advantages: • Improved patient safety and comfort, early ambulation, reduced length of stay, cost and need to stop anti-coagulation before the angiogram. • With the lower complication rates, it means better patient outcomes and faster recovery. Currently, Tan Tock Seng Hospital uses the radial artery approach in about 80% of all cases.
2. New Technology
a) Drug Eluting Balloons The drug (Paclitaxel) is mounted on a balloon and delivered to the vessel wall directly. This technique is developed to overcome the problems with drug eluting stents of late and very late stent thrombosis which include
delayed healing, local inflammation and impaired endothelial function resulting in prolonged dual antiplatelet therapy. The main advantages include: • Homogenous drug transfer to the entire vessel wall. • Absence of polymer could decrease chronic inflammation and the trigger for late thrombosis. • Absence of a stent allows the artery’s original anatomy to remain intact, notably in cases of bifurcation or small vessels, thereby diminishing abnormal flow patterns. • With local drug delivery, overdependence on anti-platelet therapy could be curtailed which means a shorter duration of therapy and thereby lowering bleeding risk. This technique is mainly used in treating in-stent restenosis, small vessel disease and bifurcating lesions.
b) Bioabsorbable Coronary Stents The stent platform is made of bioabsorbable Poly-Llactic Acid (PLLA) and has a polymer coating that contains and controls the release of the drug everolimus. This
stops cells from reproducing by decreasing blood supply to the cells. All components of the bioabsorbable stents except for two radio-opaque markers are expected to be fully absorbed into the human body within two to three years. The main advantages include: a) Reduced or abolished late stent thrombosis due to the ‘disappearance’ of the stent. b) Improved lesion imaging with computed tomography or magnetic resonance. c) Facilitation of repeat treatments (surgical or percutaneous) to the same site. d) Restoration of natural vasomotion of the artery. e) Freedom from side-branch obstruction by struts and from strut fracture-induced restenosis.
f) Potential pediatric role because they allow vessel growth and do not need eventual surgical removal.
c) Dual Therapy Stents Stents that leverage a partitioned effect, combining an abluminal (facing the vessel wall) sirolimus drug elution for the control of neointimal proliferation and prevent restenosis; and an endothelial progenitor cell (EPC) capture technology that promotes the accelerated natural healing of the vessel wall after stenting for the prevention of thrombosis. The main aim and advantage of this technique is to achieve good clinical outcomes, promote healing and reduce dependence on long-term dual anti-platelet therapy.
3. New Drugs
New Anti-platelet Drugs Prasugrel (Effient®) and Ticagrelor (BRILINTA®) are the two newly launched anti-platelets. Both are direct-acting P2Y12 receptor antagonist similar to Clopidogrel (Plavix®).
In Singapore, ischaemic heart disease was the second killer at 18.7% after cancer (28.5%) in 2010.
Singapore Health Facts, Ministry of Health. Information Paper on Acute Myocardial Infarction in Singapore. September 2011. Health Promotion Board.
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Both are more potent antiplatelet agents compared to clopidogrel and proved to be more effective in reducing the risk of death from cardiovascular causes like myocardial infarction or stroke and rates of stent thrombosis. However, this better outcome came at a cost of higher bleeding rates for both drugs.
What Can I Do to Make a Difference?
Prasugrel increases bleeding risk, clustering particularly in the elderly and those with previous stroke or transient ischemic attack. Therefore, there is an exclusion criteria in its usage. It is contraindicated in those with active pathological bleeding, those going for urgent coronary artery bypass surgery, above 75 years old, history of TIA/Stroke and cautionary use in those who weigh less than 60kg.
This is what you, as a General Practitioner can do for your patient.
Ticagrelor significantly decreases the rates of vascular death, myocardial infarction or stroke without the risk of increased overall major bleeding events compared with clopidogrel. However, there is an increase in rates of PLATO-defined minor and non-CABG major bleeding. There also seems to be added advantage of lower mortality after CABG. It is also important to note that with double anti-platelet agent, the bleeding risk is doubled compared to single agent alone.
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1. Time is Muscle!! Every minute counts in Acute ST elevation myocardial infarction. The faster the patient gets revascularisation, the better his outcome and the more myocardium is saved.
• Once you make a diagnosis in definite, clear-cut cases, an urgent call for an ambulance should be made immediately.
• The diagnosis should be made
clear to the ambulance crew and advise them to put a call out to the hospital to activate the primary angioplasty team. This will help reduce the door to balloon time and help the patient receive the early intervention for his occluded artery.
• Aspirin 300 mg should be loaded and Clopidogrel 600 mg if available.
2. Better Management of Patients with Chronic Disease and Aggressive Risk Factor We should try and adhere to the guidelines in managing chronic diseases and risk factors. This is especially important for secondary prevention as it can make a real difference.
Sometimes, the usage of more expensive drugs maybe required to bring the levels down within range. We should then try and convince the patients that they are investing in their health and long-term well-being.
Dr Jason Loh Dr Jason Loh is a Consultant in the Cardiology Department of Tan Tock Seng Hospital. He graduated from the Medical Faculty of the National University of Singapore in 1999 and completed his specialist training in cardiology in Tan Tock Seng Hospital in 2009. He was subsequently awarded a HMDP scholarship to Imperial College, London for a one-year fellowship in Interventional Cardiology and Cardiac Computer Tomography. His main area of specialty is in Interventional Cardiology, Nuclear Cardiology, Cardiac Computer Tomography and Cardiac Rehab.
UNBLOCKING YOUR SLEEP Is snoring keeping you or your partner awake at night? You might just be suffering from Obstructive Sleep Apnoea. Find out how this can have more serious consequences than just disrupting your sleep.
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oes your spouse complain that you snore loudly at night? Do you constantly feel sleepy during the day? Do you need to pass urine in the middle of the night? If you’ve said yes to all these questions, you may want to check with a sleep physician as you could be suffering from Obstructive Sleep Apnoea (OSA), a potentially dangerous sleep disorder that often goes undetected. According to the World Association of Sleep Medicine, an estimated 45 per cent of the world’s population suffer from some form of sleep disorder. Long-term sleep deprivation leads to detrimental effects on one’s alertness, mood, performance and functioning at work. On average, a person requires six to eight hours of sleep on a regular basis to maintain a healthy body and mind. However, those with disorders such as OSA experience poor quality sleep
and no amount of time in bed will enable him or her to recharge and repair.
What Is Osa? OSA is a potentially serious sleep disorder in which breathing repeatedly stops and starts during sleep, with each interruption lasting for 10 seconds or more. This can occur during all stages of sleep although it is more prevalent in the REM (Rapid Eye Movement) stage of sleep. During sleep, especially during the REM stage, the muscles of the upper airway relax, narrowing the airway, and thus obstructs the flow of oxygen. The brain detects the decrease in oxygen levels and sends a signal for the upper airway to reopen, and allow air to flow normally through the air passageway again. This can happen many times during sleep, resulting in sleep fragmentation and poor quality of sleep.
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APNOEA-HYPOPNOEA INDEX (AHI) A 2011 report by Channel NewsAsia estimated that over 15 per cent of the population in Singapore could possibly be affected by this condition. Dr Chong Yaw Khian, ENT Consultant, Snoring and Sleep Disorder Cilnic at Tan Tock Seng Hospital (TTSH) thinks this figure could be even higher at around 20 per cent. He has been running TTSH’s sleep clinic for the past three years and has observed a steady increase in the number of people coming to him for snoring and sleep apnoea problems. “A few years ago, we used to just open the sleep clinic once a week, but because of the overwhelming demand, we now run two dedicated Sleep Disorder clinics in a week,” he says. On average, the TTSH Sleep Disorder Clinic sees over 100 people every month, and around 60 per cent of the patients are male.
Who Suffers From It? Dr Chong attributes this spike in sleep clinic patients to an increasing awareness of sleep disorders as well as the rise of obesity in Singapore. “People with high BMI (Body Mass Index) tend to have fat accumulated around the neck, resulting in more blockage in the upper air passageway,” he explains. However, there are other factors that can contribute to OSA such as
TTSH SLEEP DISORDER CLINIC The Department of Otorhinolaryngology (Ear, Nose and Throat) at TTSH has a sleep clinic that provides holistic solutions for patients with obstructive sleep apnoea problems. A multidisciplinary team — including the ENT surgeon, respiratory physician, dietitians, physiotherapists, bariatric surgeons and prosthodontis — is consulted.
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a bulky and excessively long soft palate, large tongue and large tonsils. Alcohol intake, jet lag and old age can also cause OSA. “It’s very easy to tell who an OSA patient is,” says Dr Chong. “If you walk past the TTSH Sleep Disorder Clinic, you’ll see the patients fast asleep in the waiting room.” According to him, this level of fatigue caused by OSA has direct repercussions on one’s relationships, performance at work and even virility. “Besides being extremely irritable and having poor memory and concentration, people with OSA have a 2.5 times more risk of getting high blood pressure, heart rhythm abnormalities, heart disease and stroke. At the same time, the health of patients with both OSA and diabetes is put at risk further because OSA is likely to make them more insulin-resistant.” This is why it is important to get help if one is suffering from the symptoms of OSA. “The interesting thing is that most of our patients are brought to our sleep clinic by their spouses. Most OSA patients are not aware their breathing is being obstructed when they sleep, or that they are disturbing their sleep partners with their loud snoring,” says Dr Chong. He adds that he has met patients who came to the sleep clinic thinking they had OSA but it was just a simple case of sleep deprivation. “I usually ask about a patient’s sleep patterns. If I see the patient is getting less than six hours of sleep each day, then the solution is simple — just get more sleep. However, OSA is entirely different. These patients are sleeping a lot but they are not able to rest well because of sleep fragmentation.”
How Is It Diagnosed? According to Dr Chong, a visit to TTSH’s sleep disorder clinic would typically involve a full patient historytaking as well as a comprehensive examination of the upper airway, which includes a flexible fibre optic
AHI SCORE 5-15 15-30 More than 30
LEVEL Mild Moderate Severe
endoscopic exam. The patient’s BMI and blood pressure reading would also be taken. The gold standard of diagnosis, however, is the polysomnography or sleep study. For this, the patient will sleep overnight in the hospital while a technician measures the patient’s biophysical changes during sleep and determine the extent of the sleep apnoea. For OSA patients who are obese, weight-loss programmes are necessary so Dr Chong works with a multidisciplinary team of nutritionists, physiotherapists and surgeons in TTSH to come up with customised programmes for such patients. The first line of treatment recommended for OSA is a non-invasive treatment called CPAP (Continuous Positive Airway Pressure), a kind of respiratory ventilation machine that applies gentle positive pressure on one’s upper airway to relieve the obstruction — through a mask. “The CPAP is very effective but takes some getting used to and some patients get put off with the claustrophobic feeling of wearing the mask or the noise made by the machine,” he adds. However, in some cases where the patient is unable to tolerate CPAP due to lifestyle reasons, surgery is offered. There is a spectrum of surgical procedures available to help widen the upper airway. One is UPPP (Uvulopapatophayrngoplasty) which shortens and stiffens the soft palate thereby increasing the airway space behind the palate. Another common procedure is coblation chanelling of the tongue which aims to increase the airway space behind the tongue base. Whatever the treatment option, Dr Chong recommends that patients go for a follow-up sleep study after the treatment. “Even if the snoring appears to have stopped, it doesn’t mean that OSA has gone away.
There still could be breathing blockages that do not show up through snoring,” he cautions. Dr Chong advises patients who may be in denial about their OSA condition to be aware of the importance of good quality sleep. “Sleep is a transient, reversible disengagement from the environment that allows the body to repair and regenerate. If you do not rest properly with at least 20 per cent of your sleep being in the REM stage, your well-being will be severely affected.”
OTHER SLEEP DISORDERS INSOMNIA Difficulty in falling and/or staying asleep. SLEEPWALKING Getting up and doing things (not necessarily walking) in deep sleep and having no recollection of actions after that. NARCOLEPSY A neurological disorder that causes someone to sleep suddenly and involuntarily in the daytime. Most sleep disorders can be managed with a combination of effective sleep medication and behavioural modification. However, treatment depends on the root causes of the sleep disorder. This is why sleep clinics are usually staffed with health professionals from multiple disciplines (e.g. neurologists, psychiatrists, psychologists, respiratory physicians and otolaryngologists) to deal with the wide range of issues that contribute towards sleep disorders. Republished with permission from lifewise, national healthcare group
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How to Satisfy Your Partner
GP BUZZ speaks to Associate Professor Chia Sing Joo, Senior Consultant, Department of Urology of Tan Tock Seng Hospital to find how to create the ‘sexual highs’ for a more fulfilling and satisfying relationship.
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“…usually men would satisfy themselves first before thinking of their partner. As a result, there is a lot of unhappiness between sexes.”
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en and women in Singapore want to have more and better sex, according to Pfizer’s The Ideal Sex in Asia Survey conducted in 2011. The study showed that men want an average of 3.5 times more sex over a four-week period, while women want 1.8 times more sex in the same period. In another global sexual well-being survey by Durex last year, Singaporeans are ranked second lowest for sexual pleasure satisfaction at 58%, ahead of Japan which scored 34%. “Satisfaction can be subjective and objective at the same time. It can be a mental, sexual and physical state or even all of the above,” quipped A/Prof Chia Sing Joo, Senior Consultant, Department of Urology of Tan Tock Seng Hospital. “In my experiences in sexual counselling, usually men would satisfy themselves first before thinking of their partner. As a result, there is a lot of unhappiness between sexes.” So, how can man enjoy better sex and satisfy both themselves and their partners?
Four Tips to a Sexier Relationship To improve sexual experience, A/Prof Chia coined a simple formula to guide males in their sexual encounters with their female counterparts:
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B2 + T + P B2 refers to both the Brain and Better quality of life or Blood flow. T refers to Time. P refers Passion or Penis. B2 (Brain, Better quality of life) + T (Time) + P (Passion)
Brain – The Most Potent Sex Organ The human brain can be the most lethal sex organ. It drives the sexual urges of both the male and female and stimulates sexual reactions, like erection and ejaculation in man. At the same time, the brain aids in the creation of a pleasant sexual process. It begins with knowledge of your own organs, their functions, the woman’s anatomy and sex itself. The brain tells you to listen to your partner, to watch her body language and to interpret or react to the signs. It helps you stay alert, be sensitive to her needs, find the erogenous zones that stimulates her for a more intimate session.
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Better Quality of Life or Blood Flow – Body Fitness
sexually,” explained A/Prof Chia. “Women need to feel loved and men have to earn their trust.”
Good health and good sex are interlinked. With better body fitness, sexual performances can then be sustained. Good physics also gives your sex drive an extra boost, and helps in the foreplay and bodily functions (e.g. erection and ejaculation) for a more satisfying experience. So, remember to exercise regularly and maintain a balanced and nutritional diet. On the other hand, if your lifestyle is not healthy or if you are suffering from medical conditions like cardiology issues, your sex life and sex drive may be affected. In a survey conducted in Singapore, it is found that 52.9% of the 859 male respondents are suffering from some degree of erectile dysfunction*. “Erectile dysfunction and premature ejaculation are a few of the common problems in males that cause the failure to satisfy. Many a times, the men also lacks the knowledge and skills in sex,” shared A/Prof Chia. “With good sex knowledge and skills, you can still compensate for the deficiency but do remember to seek professional help or advice early to eliminate these problems.”
Passion or Penis – Think Sensually A/Prof Chia added that a satisfying sex experience begins even before it is actually done. “It is important to nurture a loving environment and relationship with your partner so that you will desire for each other.”
“If you have a normal sized penis (usually four to six inches), with proper skills, passion and physics, you should be able to enjoy a good sex life.” Time – Be Patient and Go Slow Some men fail to recognise that women are different and generally slower to warm up. The survey by Pifzer showed that the two most common factors for an ideal sexual
experience for men and women are foreplay and emotional connection. “Singaporean men don’t foreplay and as a result, women are often not satisfied both emotionally and
Cultivating the Environment for Sex The environment for sex also helps to set the mood right to make sex fun, exciting and even interesting. For one, come to an agreement with your partner that domestic and work stresses and issues will not be brought to bed. Trivial as it sounds, engaging in quick sex and rushing off to nurse your hunger pangs can be a major turn-off. “Couples should avoid having sex on an empty stomach, when you are overly full and when you are tired,” advised A/Prof Chia. Understanding for Improved Relationship Appreciate that good sex is mutual and spontaneous but do not let your passion go on an overdrive.
“Sex with your partner should not be a routine or boring but it is mutual. You need to understand that woman is not a passive aspect of the sexual relationship but an active part of the process. They want to be appreciated too”. So, do not be afraid to ask for feedback and recognise that this is not personal or a report card of your performance. A/Prof Chia shared a tip to end on a positive high, “A simple hug or cuddle can do the trick to make the woman feel loved.” Work the Ps “You cannot satisfy your partner with no penis or with penis without erection. Actually size does matter to a lot of woman. She will be unhappy with a small penis or a very big penis,” said A/Prof Chia. “If you have a normal sized penis (usually four to six inches), with proper skills, passion and physics, you should be able to enjoy a good sex life.”
If you cannot recall all the details above, fret not. A/Prof Chia summarised the golden rules to a satisfying sexual in three simple points:
Golden Rule #1 Fitness Stay healthy. Exercise regularly and maintain a balanced diet.
Golden Rule #2 Be Sensitive To Your Partner Stay alert. Listen, feel and watch your partner. Interpret and react to her needs.
Golden Rule #3 Understand Sex and the Anatomy of You and Your Partner Be patient and go slow. Think sensually and develop good skills (e.g. engage in foreplay).
Associate Professor Chia Sing Joo A/Prof Chia Sing Joo is the Senior Consultant in the Department of Urology and Chairman of the Division of Surgery in Tan Tock Seng Hospital. He obtained his medical degree at the National University of Singapore and completed his post-graduate surgical diplomas at the Royal College of Surgeons of Edinburgh, UK. He is also a fellow of the Academy of Medicine, Singapore (Urology). His sub-specialty includes Uro-Oncology, Sexual Dysfunction and Sub-fertility. A/Prof Chia is also the author of the book, “Ask Prof Chia” – Male Urological Problems – The essential guide for Every Man & Couple.
* J K Tan, D J C Png, L C H Liew, M K Li, M L Wong. Prevalence of Prostatitis-Like Symptoms in Singapore: A Population-Based Study. Singapore Med J 2002 Vol 43(4) : 189-193.
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Tackling
Sports Injuries Early diagnosis and treatment of sports injuries are important so that patients do not suffer the consequence of leaving these injuries untreated later in life. With a structured set of principles to treat sports injuries and a multidisciplinary management of these injuries, we can be assured that proper care and management will be rendered to achieve an injury-free and fitter body.
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O The end point of treating the injury is not just fitness for daily activity, but attaining a level which commensurates with the demand for sports, often through a conditioning programme by an exercise physiologist and sports trainer.
ver the years, Tan Tock Seng Hospital (TTSH) has seen an increase in the number of patients with sports-related injuries which is an irony since most patients visit the clinic with the intention of improving their health and fitness levels. The growth is probably due to increased participation in sports, the growing range of new sports available in Singapore, as well as a growing awareness of sports medicine as a medical discipline. Though there is a wide array of injuries, there are some common principles of treating sports injuries:
Principle 1 Treatment of Sports Injuries Goes Beyond Anatomical Diagnosis Runners Beware! We often see runners in the clinic for running injuries, which are predominantly a result of overuse or overexertion. Common problems include plantar fasciitis, shin splints and anterior knee pain (patellofemoral pain syndrome). While they are often attributed to over enthusiastic training, there are also underlying biomechanical issues affecting the
runners and contributing to the injury which need to be corrected. Overpronation (flat footedness), tightness of the calf muscles may contribute to plantar fasciitis as can running shoes with insufficient arch support. The alignment of the knee can sometimes be affected by weakness of the core and hip muscles while running in turn contributes to anterior knee pain. Medial tibial stress syndrome, attributed to excessive traction of the origin of the tibialis posterior muscle may be related to excessive eccentric activity of the muscle in an over-pronating foot. From the sports medicine perspective, a complete diagnosis and management include looking out for these biomechanical problems and correcting them in order to prevent recurrence upon return to running.
Principle 2 Look for the Underlying Technical Error in Sports Movement Some of sports are inherently technical in nature and technical errors are often responsible for overuse injuries.
Golfers’ Injuries Golf is a typical example in which the inherently stereotypical movement and the steep learning curve result in repetitive loading of areas such as the spine, elbows, shoulder and wrists. Counter-intuitively, the forces involved in a golf swing are very high. In golf, axial loading of the lumbar spine comes up to eight times the body weight versus two times in running, hence explaining why lower back pain is a common golf-related injury. Often, poor technique, and the overloading of the joints and tendons result in niggling and recurrent injuries which afflict many golfers. Perhaps the combination of repetitively loading from poor technique is best seen in Figure 1 depicting stress fractures of the ribs in a novice golfer learning to use his driver. For instance, addressing the golf ball with a hunch often restricts trunk rotation, which results in compensatory over-rotation of the shoulder, thus leading to rotator cuff impingement.
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Another common error is a lateral sway of the body towards the target (the correct but counter-intuitive movement is to keep the axis of rotation still to generate more
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centrifugal force). The compensation is often to employ the strength in the arms to generate more swing speed and the additional tightening of the grip often results in tennis or golfers elbow. Hence, complete diagnosis and treatment in a recurrent golf injury often entails analysis of the golf swing and correcting the errors through strengthening and stretches to improve the range of movement as well as drills to help the body get use to the correct movements to facilitate the swing (e.g. learning to isolate hip rotation from upper trunk rotation).
Figure 1 – Stress fractures of the ribs in a novice golfer.
Triathlon Pains A triathlete chants the mantra ‘Pain is weakness leaving the body’ as a motivational tool in a particularly long bike ride (six hours into it) to combat the lower back pain. It seemed like a more extreme form of the ‘no pain no gain’ mantra and he had tried various forms of treatment only to have the backache hit him every time at the 50km mark, regardless of the amount of strength or flexibility training. Fortunately, the problem was eventually resolved by looking at
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the set up of the bike. Apparently, the frame of the second hand bike was too small resulting in a curled up position while riding. The importance of correct equipment fit cannot be more important.
Principle 3 Diagnose the Underlying Factors Particular to the Patient The treatment of sports injuries often require a multidisciplinary approach. Sports sciences and medical disciplines deal with the individual’s condition with an emphasis on early anatomical diagnosis and intensive rehabilitation to prepare one’s fitness for return to sports; beyond that of healing the injured structure. There is also an emphasis on looking for and correcting the root cause in order to prevent recurrence. Patients are surprised that the end point in treating a sports injury is not a painless body but also a body that is moving correctly, with the correct strength and flexibility or even the correct nutritional support to sustain the stress of training and competing.
Multidisciplinary Management Management of any sports injuries often entails a team made up of not only doctors, surgeons, physiotherapists, podiatrists and dieticians. It is important to maintain fitness even during the period of recovery. The end point of treating the injury is not just fitness for daily activity, but attaining a level which commensurates to the demand for sports, often through a conditioning programme by an exercise physiologist and sports trainer. Early Diagnose and Treatment Soccer would be the archetypal sport in which the injuries are predominantly traumatic. While there have been evidence-based initiatives that are aimed at reducing traumatic injuries, it is just as important to pick up undiagnosed musculoskeletal injuries early and treat these before they become chronic. Often patients who have recurrent injuries would ignore them so that they can continue with the game. If those patients knew what it might like in their thirties or forties when they are plagued by unilateral osteoarthritis, they would have sought treatment for
anterior cruciate ligament injuries in their teen or earlier during their adulthood.
recognise relevant symptoms (‘good pain’ versus ‘bad pain’ in the patient’s parlance).
These injuries can sometimes be picked up through musculoskeletal screening for those playing regularly in team sports. Public education also helps as patients can then
Implicit in this model of diagnosis and management of sports injuries is the need for a multidisciplinary team to provide a solution of ‘best fit’ for the sportsman.
Dr Jason Chia Dr Jason Chia is the Head and Consultant of the Sports Medicine & Surgery Clinic of Tan Tock Seng Hsopital. He graduated from the National University of Singapore and obtained his Masters of Sports Medicine from Australia in 2002. He is involved in sports injury management, fitness testing and exercise prescription, weight management, and extracorporeal shockwave therapy as well as gait analysis. He has also written and published a handbook for exercise prescription for general practitioners. Dr Chia’s areas of clinical research include ESWT (extracorporeal shockwave therapy) as well as biomechanical research.
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fitness
T
he general impression is that core strengthening means abdominal strengthening. This is not wrong but it is not entirely correct.
What is a Core?
Sculpt Your
CORE
Core means the centre and the most important part of our body, which is the trunk. We cannot have good arm and leg strength if we don’t have a stable trunk. Core includes the abdominals, back, hips and pelvic girdle. All muscles around these areas need to be strong and working in harmony in order for us to have a strong and functional core. A strong core provides a good base for your limb movements during daily activities such as walking, climbing a flight of stairs or carrying a heavy load. It also helps to improve posture and enhances trunk stability so that risk of injuries and postural related musculoskeletal pain can be reduced. For athletes, a stronger core can boost performance, no matter what sport it is. It can enhance your kicking strength, swimming or running speed as your core produce stability for your limbs to generate the extra power.
Core Strengthening Exercises Core strengthening exercises such as sit-ups is a good way to strengthen and tone up the muscle. However, it does not give 26
you a ‘six-pack’. Losing abdominal fat, which covers up the muscle, is crucial for having a ‘six-pack’! This needs to be done with aerobic exercise, such as running, swimming or cycling at moderate intensity three to five times per week for at least 30 minutes each time and with diet modification. There are many types of core strengthening exercises — choosing the correct one to do and progressing appropriately is important for the exercise to be effective and to minimise the risk of injury. Exercises shown on the next few pages are more advanced and it can target at multiple core components at one time.
Points to Note During The Exercises 1. Draw-in or tighten your lower abdominal muscle to activate the deeper layer of your core muscle (called transverse abdominus) to prevent back injuries. 2. Do not hold your breath, feel any pain or struggle too much to maintain the posture. Try the easiest set of exercises first and move on to the next level if you can manage. If you cannot maintain the proper form of the movement in the next level, you may not be ready to progress yet. 3. Please consult your doctor or physiotherapist before starting these exercises, if you have any back or joint problems, injuries or other health concerns. 27
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CORE BODY EXERCISES Front Plank
Side Plank
(2) Moderate: Do the same thing – use your ankle to support instead of your knee. Make sure that your body is in a straight line.
(3) Challenge: (1) Easy: Lie on the side. Lift up your buttock so that body is supported on your elbow and knee. Keep your trunk and hip straight. Perform 10 times with 10-second hold on each side.
Bring your top leg up and down for 10 repetitions while maintaining the form.
(1) Easy: Prop up your elbows in a push-up position. (2) Moderate: Lift up one leg backwards while
(3) Challenge: Do the same exercise on the
Maintain your trunk and thigh in line by keeping your buttocks down. Stay in this position for 10 seconds and repeat 10 times.
gym ball. Begin with gym ball against the wall and slowly move it away.
maintaining the plank. Repeat on the other leg. Take note not to arch the lower back.
Balance on the ball
Mermaid
(2a) Moderate: Maintaining lower back in neutral position, slowly bring the ball over the head and back. Repeat two sets of 10.
(1) Easy: Lie on the gym ball with hands holding a small ball in front. Thigh and trunk should be in a straight line with your knee bending at 90 degrees. (1) Easy: Begin in a kneeling position with your arm elevated in front at a 90-degree angle.
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(2) Moderate: While maintaining your trunk and hip in a straight line, slowly lean backwards until you feel tension over your abdominal and thigh muscles. Hold for 10 seconds and return to original position. Perform 10 repetitions.
(3) Challenge: To increase the difficulty, lean backwards to your limit and twist your body to the left at an angle of 45 degrees. Hold for five seconds and come back to original position. Repeat five times for each side.
(2b) After that, bring the ball to the right at 45 degrees and then to the left. Repeat two sets of 10.
(3) Challenge: In the same position, straighten one leg while keeping buttocks straight. Hold for 10 seconds and repeat on the other leg. Perform five times on each leg.
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healthy recipes
Beef Sirloin with Cranberry Sauce
CORE BODY EXERCISES Bridging
Methods: Beef Sirloin: (1a) Easy: Lie on your back with your knee bent.
(1b) Lift up your buttocks and hold for 10 seconds. Perform three sets of 10.
Serving Portion: 1
1. Season the beef sirloin with salt, pepper, mashed garlic and rosemary. 2. Heat up the pan, add oil and pan-fry the sirloin until it is medium done. Set it aside.
Ingredients: Beef Sirloin:
Asparagus:
Beef Sirloin
1. Heat up the pan and lightly coat the pan with oil, then add in the asparagus and sauté.
Rosemary
1 pinch
Salt
1 pinch
Pepper
1 pinch
Cranberry Sauce:
120gm
Mashed Garlic
½ tsp
1. Heat up a small pot and add in the cranberry, bay leaf, rosemary and onion. Season with salt and pepper, and sauté.
Oil
½ tsp
Asparagus
15gm
2. Mix the chicken gravy mix in water and add into the pan. Let it cook until gravy thickens.
Cranberry Sauce:
3. Strain the gravy.
Bay Leaf
1gm
Rosemary
5gm
Onion
5gm
Water
100ml
Serve the steak and asparagus with the hot cranberry sauce.
20gm
Chicken Gravy Mix (Powder)
Nutritional Information Calories (kcal) 278 Carbohydrate (g) 21 Protein (g) 26 Total fat (g) 10
Cranberry (dried)
Saturated fat (g) 3 Cholesterol (mg) 60 Dietary fibre (g) 1.4 Sodium (mg) 366
5gm
Salt
1 pinch
Pepper
1 pinch
Kiwi Milk Shake (2a) Moderate: In the same pose, straighten one leg to 45 degrees. (2b) Lift up the buttocks using the other leg. Hold for 10 seconds and perform two sets of 10 on each leg. Challenge: If the above are too easy, lift up your hands in front and do the same exercise.
Ms Janius Tsui Ms Janius Tsui is the Senior Physiotherapist in the Physiotherapy Department of Tan Tock Seng Hospital. She completed her Masters in Musculoskeletal and Sport Physiotherapy at the University of South Australia in 2010. Ms Tsui works closely with patients suffering from musculoskeletal and sport injuries. She has a special interest in the shoulder joint and lower back.
Nutritional Information Calories (kcal) Carbohydrate (g) Protein (g) Total fat (g) Saturated fat (g) Cholesterol (mg) Dietary fibre (g) Sodium (mg)
173 27 8 4 1.7 6 2.7 48
Serving Portion: 1 Ingredients: Kiwi Low Fat Milk Honey
170gm 150ml 1 tsp
Methods: 1. Wash and peel each kiwi and cut into four pieces. 2. Put the kiwi in the blender, then add in the milk and honey. 3. Blend until the kiwi is pureed. 4. Pour into a glass and serve chilled.
Recipes were designed by the Hospitality & General Services and Nutrition & Dietetics Departments of Tan Tock Seng Hospital. Photo Courtesy of Mr Henry Lim, Photographer, TTSH.
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MultiDisciplinary Specialist Care TTSH PEARL’s suite of clinics and services is guided by the four pillars of care through Evidence Care, Destination Care, Team Care and Personalised Care. We remain committed to delivering a higher level of patient care as we value our patients most.
Clinic B1B – Orthopaedic Surgery – Rheumatology, Allergy and Immunology
Clinic 2B – Gastroenterology and Hepatology Our sub-specialties include: • General Gastroenterology • Hepatology (Liver) Service • Inflammatory Bowel Disease • Gastrointestinal Endoscopy • Pancreato-Biliary Diseases • Upper Gastrointestinal Motility • Nutrition
– General Surgery Our sub-specialties include: • General Surgery • Colorectal Service • Bariatric and Weight Management Services • Upper Gastrointestinal Service • Head and Neck Surgical Services • Endocrine Service • Liver, Pancreas and Biliary Services
• Vascular Service • Veins Service • Thoracic Service • Plastics, Reconstructive and Aesthetics Services
– Urology Our sub-specialties include: • General Urology • Andrology and Men’s Health • Adrenal Surgery • Continence and Voiding Dysfunction • Endo-Urology and Stone Surgery • Female Urology • Minimally Invasive Surgery and Laparoscopic Surgery • Neuro-Urology • Prostate Surgery • Reconstructive Urology • Robotic Surgery • Subfertility and Sexual Dysfunction • Urologic Cancer Surgery
– Endoscopy Services • Colonoscopy • Flexible Cystoscopy • Gastroscopy
Clinic 4B – Diabetes and Endocrine – General Medicine – Haematology – Infectious Disease – Pain Management – Psychological Medicine – Renal Medicine – Respiratory and Critical Care Medicine Clinic B1B Orthopaedic Surgery Tel: (65) 6889 4055
Email: ClinicB1B@ttsh.com.sg
Rheumatology, Allergy and Immunology Tel: (65) 6889 4027 Email: ClinicB1B@ttsh.com.sg
Clinic 2B
Tel: (65) 1800-PEARL-00
(65) 1800-73275-00
Email: Clinic2B@ttsh.com.sg
Clinic 4B
Tel: (65) 1800-PEARL-00
(65) 1800-73275-00
Email: Clinic4B@ttsh.com.sg