A PUBLICATION FOR
PRIMARY CARE PHYSICIANS
MCI (P) 088/03/2014
JULY-SEPTEMBER 2014
PHYSICAL ACTIVITY FOR
THE HEART Scan the QR code using your iPhone or smart phone to view GPBUZZ on the TTSH website or visit www.ttsh.com.sg/gp/.
Community Right-Siting Programme (CRiSP) ROBOT-ASSISTED THORACIC SURGERY
Chronic DiseaseS: Can We Help Our Patients Live Better?
contents
editor’s note
Celebrating The GP BUZZ editorial team: Jessie Tay Celine Ong
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ADVISORY PANEL: Emeritus Professor Feng Pao Hsii Associate Professor Thomas Lew Associate Professor Chia Sing Joo Associate Professor Chin Jing Jih Adjunct Assistant Professor Chong Yew Lam Dr Tan Kok Leong Mr Joe Hau
in every issue 030 editor’s note 040 in the news 250 fitness 300 healthy recipe
GP Buzz is a magazine by Tan Tock Seng Hospital, designed by
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.
in this issue
© All rights reserved. No part of this publication may be reproduced, stored in a database, retrieval system or transmitted in any form by any means without prior consent from the publisher. Although the publisher and author have exercised reasonable care in compiling and checking that the information is accurate at the time of publication, we shall not be held responsible in any manner whatsoever for any errors, omissions, inaccuracies, misprint and/or for any liability that results from the use (or misuse) of the information contained in this publication.
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07 A Journey Of The People’s Hospital 11 Community Right-Siting Programme (CRiSP)
All information and materials found in this publication are for purposes of information only and are not meant to substitute any advice provided by your own physician or other medical professionals. You should not use the information and materials found in this publication for the purpose of diagnosis or treatment of a health condition or disease or for the prescription of any medication. If you have or suspect that you have a medical problem, you should promptly consult your own physician and medical advisers.
14 Thyroid Nodules Sorting The Wheat From The Chaff 17 Robot-Assisted Thoracic Surgery
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20 Fundus Photograph Interpretation For Primary Eye Care Professionals 23 Chronic Diseases: Can We Help Our Patients Live Better?
170 YEARS IN HEALTHCARE
J
uly 2014 marks an important milestone in Tan Tock Seng Hospital (TTSH)’s history. 170 years ago, TTSH became the first Chinese Pauper’s Hospital to care for the ‘diseased of all nations’. Today, its legacy as a people’s hospital continues to be rooted in our vision, mission and values. This is a shared achievement with our General Practitioners (GP) partners and patients who have witnessed the transformation of the hospital amidst changes and challenges.
care setting. GP BUZZ walks you through the diagnostic process and treatment options for prompt investigation and management of your patients. In another article, GP BUZZ explores the mechanics of robot-assisted thoracic surgery and its benefits in the treatment of early stage lung cancer. The manual by National Healthcare Group Eye Institute (NHGEI), titled ‘Fundus Photograph Interpretation for Primary Eye Care Practitioners', is officially launched in this magazine with a feature article.
In this issue of GP BUZZ, we take you through memory lane, with reviews of TTSH’s key achievements in a special commemorative segment. In conjunction with our hospital’s 170th birthday, we would also like to seek your generous contribution of TTSH heritage memorabilia.
GP BUZZ also brings you the Chronic Disease Self-Management Programme (CDSMP) and explains how better communication skills and structured self-management techniques can help chronic disease patients enhance their quality of life and self-efficacy.
TTSH’s Community Right-Siting Programme (CRiSP) and the newly launched Pioneer Generation Package by the Ministry of Health are two initiatives that provide more affordable healthcare to the community. GP BUZZ brings you the updates on CRiSP and the Pioneer Generation Package, and review how they benefit our patients.
In conjunction with World Heart Day on 29 September 2014, GP BUZZ is pleased to share how physical readiness can be determined and physical activities can be prescribed to pump up your heart for a healthier you. To end on a sweet note, we present a heart-healthy recipe developed by TTSH in the Healthy Recipe section of GP BUZZ.
In this edition, we cast the spotlight on thyroid nodules, which are commonly detected in the primary
Enjoy! The GP BUZZ Editorial Team
JULY - SEPTEMBER 2014
02
03
in the news
in the news
CRYOABLATION
- NEW PROCEDURE
IN KIDNEY CANCER TREATMENT
T
an Tock Seng Hospital (TTSH) rolled out a new procedure that destroys tumours on the kidney, known as Cryoablation.
A refurbished ward in Tan Tock Seng Hospital.
‘WARD OF THE FUTURE’ WON EXCELLENCE IN PUBLIC SERVICE AWARD, BEST PRACTICE AWARD 2014
T
an Tock Seng Hospital (TTSH)’s ward revamp project - the ‘Ward of the Future’ (WOF) bagged the Excellence in Public Service Award, Best Practice Award for Organisation Development. This award aims to recognise organisations that demonstrate the use of organisational development principles, including taking a systems view, understanding of behavioural processes and emphasising on humanistic behaviour, in coming up with quality solutions to achieve success.
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n 14 May 2014, 12 healthcare professionals from Tan Tock Seng Hospital (TTSH) received the annual Healthcare Humanity Awards (HHA) from Dr Tony Tan Keng Yam, President of Singapore and Mr Gan Kim Yong, Minister of Health, at the ceremony in Biopolis. This year, a record number of 76 healthcare workers were honoured from across 26 public hospitals, polyclinics, nursing homes and related organisations. The HHA is a lasting legacy of the Courage Awards, originally presented in 2003 to the healthcare heroes and heroines of the SARS outbreak. It was replaced by the HHA the following year.
This new procedure is conducted by inserting a probe into the tumour and rapidly cooling the probe to minus zero temperature. The temperature of the frozen water in the cancer cells is later raised, causing the tumour to expand rapidly and thus destroying them completely. The procedure is conducted using a Computed Tomography (CT) scan and it lowers the risks made to the other organs around the kidney. Cryoablation is not intended to replace conventional surgery, but it presents itself as an option for patients who cannot undergo surgery, especially elderly patients. To date, TTSH has administered this new technique on six patients, aged 60 to 80 years old.
HHA recipients from Tan Tock Seng Hospital with members of the management team.
BREATHE EASY WITH THE HOME VENTILATION PROGRAMME
TTSH WOF was lauded for its success at strategically leveraging on infrastructure to enable work redesign and transform care delivery. Besides structural improvements in the TTSH wards, work processes were reviewed to enhance care delivery as well as to increase patient and staff satisfaction. The refurbished wards now include cubicle-based work stations and a decentralised supplies cabinet. This new layout helps to reduce unnecessary foot traffic within wards, which in turn helps nurses to make better use of time for patient care. Other new ward features include anti-slip floors, ensuite toilets, Acute Care areas and the End of Life room, to meet the different needs of patients.
12 TTSH HEALTHCARE PROFESSIONALS CONFERRED THE HEALTHCARE HUMANITY AWARDS 2014
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s part of the National Healthcare Group’s Regional Health System (RHS) initiatives, Tan Tock Seng Hospital (TTSH) has seen about 80 patients on its Home Ventilation Respiratory Support Service (HVRSS). HVRSS aims to help patients with respiratory ventilation problems enjoy a
better quality of life at home. Under this programme, caregivers are also trained to use the respiratory machine and manage the condition of their loved ones. HVRSS has also helped to cut down extended stays in the hospital and hence free up more resources in the wards.
A probe used in Cryoablation.
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in the news
special
NOTICE
New GP
REFERRAL
Appointment Hotline
NEW!
Dear Doctors, To serve you better, we have implemented a new non-subsidised appointment hotline, 6359 6500.
GP Appointment Hotline Tel: 6359 6500 (24-hours)
Patients’ Appointment Hotlines Non-subsidised Appointments Tel: 6357 8000 Subsidised Appointments Tel: 6357 7000
This new 24-hour GP appointment hotline will replace the old mobile number, 9666 6698, which will be terminated after October 2014. 6359 6500 is designated for our GPs and hence not for dissemination to patients. The two appointment hotlines, 6357 8000 (non-subsidised appointments) and 6357 7000 (subsidised appointments) will still be available for our patients to make their personal appointments.
Fax: 6357 7001 / 7011 Email: contact@ttsh.com.sg 8.00am - 6.00pm (Mon - Fri) 8.00am - 12.30pm (Sat) For further queries on the new hotline, please contact the Primary Care Partners Office.
MAKE A PATIENT
Melvin Ng (Mr) DID: 6357 3176 Evelyn Tan (Ms) DID: 6357 8206 GP@ttsh.com.sg
CME Schedule July – September 2014 General Medicine Update 2014 CME POINTS
2 CME Points (Pending SMC’s approval)
DATE
02 August 2014
TIME
1.00pm – 4.00pm
VENUE REGISTRATION DETAILS
Theatrette, Tan Tock Seng Hospital, Level 1 Ms Debra Lee Email: debra_lee@ttsh.com.sg
Multi-disciplinary Management of a Common Disorder on Thyroid Disease CME POINTS
1 CME Point
DATE
23 August 2014
TIME
12.30pm – 3.30pm
VENUE REGISTRATION DETAILS
Seminar Room 1 & 2, Tan Tock Seng Hospital, Level 3 Ms Chai Jye Yi Tel: 6357 7891 Email: jye_yi_chai@ttsh.com.sg
* Subject to the approval of Singapore Medical Council (SMC). For an updated listing of CME and event schedule, please visit http://www.ttsh.com.sg/gp/. Information is correct at the time of publishing.
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The People’s Hospital Tan Tock Seng Hospital (TTSH)’s heritage takes us back 170 years when it was built as a hospital for the poor in the Chinese community. Today, TTSH remains committed to its legacy of compassion, philanthropy and care and its duty as a people’s hospital. In the past, the hospital witnessed the transformation of healthcare and braved multiple challenges and tough times (e.g. SARS in 2003, H1N1 in 2009). We would not have come this far without the support from GP partners and patients. In this issue, we take a ride down memory lane, in review of TTSH’s historical milestones and its growth over the years, in service to the community.
1844
Pearl’s Hill
Tan Tock Seng, a businessman, philanthropist and the first Asian Justice of Peace, donated Spanish $7,000 to build the first hospital for the sick and poor on Pearl’s Hill on 25 July.
1858
The first female ward was set up.
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1910
special
TTSH welcomed its pioneer batch of graduate doctors.
1976 1985
TTSH’s cardiac surgeons performed Singapore’s first coronary by-pass operation.
TTSH set up the first night clinic in Singapore.
1937
TTSH became a restructured hospital on 1 April.
TTSH became the first local hospital to provide Magnetic Resonance Imaging (MRI) to patients.
Tuberculosis Control Unit
TTSH was designated as the centre for Tuberculosis (TB) treatment. Dr Benjamin Chew administered the first penicillin injection to his colleague to treat a lung infection.
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TTSH was designated as the hospital for the treatment of SARS patients on 22 March. The Singapore Government conferred The Public Service Star Award to Dr Lim Suet Wun, then CEO of the National Healthcare Group (NHG) and TTSH, Dr Leo Yee Sin, Clinical Director of Communicable Disease Centre and A. Prof Philip Choo, Chairman, Medical Board of TTSH for their outstanding contributions in the SARS battle.
TTSH opened the first Geriatric Unit in Singapore.
TTSH succeeded in using Vitamin B1 for the treatment of beri-beri.
1945
1989 1992 1995 2000
Middleton Hospital, which treated infectious diseases like cholera and typhoid, became TTSH’s Communicable Disease Centre.
2003
The new TTSH located at Jalan Tan Tock Seng was officially opened by then Deputy Prime Minister BG (NS) Lee Hsien Loong on 1 April.
2008
special
TTSH went beyond acute care and into community care, with the set up of the Division of Integrative and Community Care that encompassed the Geriatric Medicine, Continuing and Community Care, and Palliative Medicine departments.
2010 2011
NHG and UK’s Imperial College London cemented their collaboration for the 3rd Medical School and named TTSH the main clinical hospital.
The opening of the Centre for Advanced Rehabilitation Therapeutics (CART), a first in Singapore to combine innovative robotics and virtual reality technologies with regular rehabilitation therapy.
2007
TTSH first rolled out radio frequency identification (RFID) technology to track patients and locate them within the facility. Subsequently, system improvements allowed the monitoring of the individual’s body temperature and detected serious infections without disturbing patients from rest. We were the first hospital to enhance patient safety by using RFID technology to track surgical instruments.
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special
2013
The Health City Novena Masterplan, a 17-hectare integrated healthcare development project, was officially launched to cater to Singapore’s future healthcare needs. From acute to intermediate and long-term care, the Health City will offer the full spectrum of holistic care experiences for the residents in the central region of Singapore.
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Community Right-Siting Programme (CRiSP)
Here’s to the next century in healthcare and many more to come.
Stay r tuned rifotage e re mo shco ming new r way! u o y
GP BUZZ spoke to Adjunct Assistant Professor Chong Yew Lam, Programme Champion of the Community Right-Siting Programme (CRiSP) on this new care initiative by Tan Tock Seng Hospital (TTSH) in the October – December 2013 issue of the magazine. Here are the updates on the programme and upcoming government initiatives to address the rising healthcare burden of the ageing Singapore population.
C
RiSP is a partnership between TTSH and our primary care partners, where stable chronic patients from TTSH Specialist Outpatient Clinics (SOCs) are being appropriately reviewed and cared for at the primary care environment. CRiSP aims to integrate TTSH’s existing rightsiting programmes such as Asthma Decant Programme and Heart Failure Programme with other medical conditions such as benign prostatic hyperplasia, anxiety, depressive disorder and osteoarthritis knee. 11
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Update on CRiSP Pilot Since the launch of CRiSP, 22 General Practitioner (GP) clinics including the two Family Medicine Clinics, have participated in the CRiSP pilot. TTSH CRiSP works with participating GP partners through a shared-care model, where right-sited patients returning to TTSH SOCs for specialist intervention can be assured of faster SOC subsidised appointments. With Community Health Assist Scheme (CHAS) accredited GP clinics, patients right-sited from TTSH to GPs under CRiSP are also eligible for subsidised SOC appointments beyond the eligible period without going through the polyclinic route again. Between April 2013 to March 2014, under CRiSP, 106 patients were identified and right-sited to the
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community. These patients were found to be in stable condition and had optimised medications, thus making them suitable candidates for right-siting.
What’s Next? In the coming year, CRiSP GP partners will be augmented with National Healthcare Group Diagnostic support which provides right-sited patients access to selected subsidised radiology and
laboratory investigations. GP partners can also access the National Electronic Health Record (NEHR) for clinical notes to manage the health outcomes of their patients in the most efficient way possible. Moving forward, CRiSP is committed to benefit another 300 patients this year and to improve accessibility of care by enlisting the participation of more GP partners in this programme.
Portable Pioneer Generation Package# From 1 September 2014, about 450,000 seniors will benefit from extra subsidies under the new Pioneer Generation Package: a. MediShield Life – more subsidies for the Pioneer Generation, so that they enjoy the enhanced benefits of MediShield Life but pay less premiums than they do for MediShield today. b. Outpatient Treatment – extra subsidies for the Pioneer Generation at SOCs, polyclinics and GP clinics under CHAS, on top of other subsidies that all citizens already enjoy. c. Medisave – annual top-ups to the Medisave accounts of the Pioneer Generation.
Refer to the table below for further information on CHAS subsidies for the Pioneer Generation, vis-à-vis the Blue and Orange subsidy tiers.
Special CHAS Subsidies for the Pioneer Generation Eligibility Criteria
CHAS Blue
CHAS Orange
CHAS for Pioneer Generation
Household monthly income per person
$1,100 and below
$1,101 to $1,800
Not applicable
Annual Value (AV) of residence (only for households with no income)
$13,000 and below
$13,001 to $21,000
$18.50 per visit
Not applicable
$28.50 per visit
Simple2
$80 per visit, capped at $320 per year
$50 per visit, capped at $200 per year
$90 per visit, capped at $360 per year
Complex2
$120 per visit, capped at $480 per year
$75 per visit, capped at $300 per year
$135 per visit, capped at $540 per year
$11 to $256.50 per procedure (dependent on procedure)
$65.50 to $170.50 per procedure (for crowning, denture and root canal treatments only)
$21 to $266.50 per procedure (dependent on procedure)
CHAS Subsidies Common illnesses (e.g. cough and cold)
Chronic conditions under CDMP1
Selected dental services
Health screening under Health Promotion Board (HPB)’s ISP3
Screening test: Free with HPB’s invitation letter; and Doctor’s consultation: $18.50 per visit (up to 2 times per year)
Screening tests: Free with HPB’s invitation letter; and Doctor’s consultation: $28.50 per visit (up to 2 times per year)
1 These are diabetes, hypertension, lipid disorders, stroke, asthma, chronic obstructive pulmonary disease (copd), major depression, schizophrenia, dementia, bipolar disorder, osteoarthritis, benign prostatic hyperplasia, anxiety, parkinson’s disease, and nephritis/nephrosis. 2 “Simple” refers to visits for a single chronic condition. “Complex” refers to visits for multiple chronic conditions, or a single chronic condition with complication(s). 3 This includes screening for hypertension, diabetes, lipid disorders, colorectal cancer and cervical cancer. # Information adapted from MOH website.
TTSH will continue to explore better ways for shared care of our patients and support our primary care partners. To be part of CRiSP or to find out more, please email TTSH Primary Care Partners Office (PCPO) at GP@ttsh.com.sg. PCPO is the main facilitator for TTSH CRiSP. Let’s work together to add years of healthy life for our patients.
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How do thyroid nodules present? Thyroid nodule cases are frequently referred to the Head and Neck Surgery clinic, under the General Surgery Department in Tan Tock Seng Hospital (TTSH). It is estimated that up to 60% of the population may harbour thyroid nodules. While a majority of nodules are small, asymptomatic and never noticed; others may present as a lump in the anterior neck as a first symptom. While painless, the patient may be alarmed by an increasing growth or onset of compressive symptoms such as difficulty in swallowing. Rapid growth of the nodule may cause pain in some cases.
Thyroid Nodules:
Sorting The Wheat From The Chaff Thyroid nodules are a common problem in the primary care setting. Even though the incidence of malignancy remains low at around 10%, nodules are still a cause of anxiety for patients, especially in cases that are symptomatic or enlarging. Timely referral to the specialist surgical clinic enables the nodules to be investigated and treated promptly.
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Young and educated patients are among those concerned about the risk of malignancy. Given the prevalence, many patients are also aware of family or friends who have had similar problems or have undergone previous surgery.
Since an examination is insufficient to differentiate solid from cystic nodules as well as to screen for other non-palpable nodules or lymph nodes, an ultrasound is recommended. The ultrasound is accurate in picking up features that immediately raise the suspicion of malignancy. This can then be followed by an ultrasound-guided fine-needle biopsy of the nodule(s). Such targeted biopsy increases the yield of cytology by up to 75%.
For patients with large cystic nodules, complete aspiration via ultrasound guidance provides immediate relief and assurance. When thyroid malignancy is suspected, further imaging of the neck for invasion or metastasis using Computed Tomography (CT) scan or Magnetic Resonance Imaging (MRI) may be obtained within a short notice. Nowadays, a radionuclide thyroid scan has very limited utility.
In our practice at TTSH’s General Surgery Department, a one-stop service is provided such that all these investigations are performed within the clinic upon initial consultation. This serves to greatly allay the patient’s fears and anxieties as the cytology result is often available the next day.
Which treatment is suitable for the patient? When the thyroid cytology report is available, patients are counselled based on the National Cancer Institute (Bethesda classification) recommendations. A benign result brings reassurance and relief.
Making the right diagnosis After an adequate examination, the workup for thyroid nodules should include an ultrasound and fine-needle biopsy. Blood tests to determine the thyroid function may be done to screen for concomitant hyper- or hypothyroidism.
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The patient may then opt for a conservative approach with regular follow-ups and surveillance ultrasound with the referring primary care physician. A cytology result that is malignant or suspicious would warrant total thyroidectomy, often performed with nodal dissection. The remaining categories of cytology require further discussions with the patient. Surgery may eventually be necessary to ascertain the histology accurately. Some patients with large, benign nodules may still opt for surgery
because of fear of a falsenegative result, persisting symptoms or for cosmetic reasons. Traditional open surgery with a cosmetic-centric and minimalscar approach is the standard recommendation. For patients keen to avoid a neck scar, endoscopic and robotic thyroidectomy are available. Both surgical approaches allow the thyroid to be resected via incisions that are sited away from the neck such as in the chest and axilla.
GP Forum:
ROBOT-ASSISTED THORACIC SURGERY Dr. Ho Wai Thong, Thomas Dr. Thomas Ho is the Head and Consultant of the Head and Neck Surgical Service under the Department of General Surgery at Tan Tock Seng Hospital, Singapore. Dr Ho has completed a Surgical Oncology Fellowship in Canada. His areas of interest include treatment of head and neck, colorectal and advanced pelvic cancers.
Date: 23 August 2014 (Saturday)
Multi-Disciplinary Management Of A Common Disorder On Thyroid Disease
Venue: Tan Tock Seng Hospital, Seminar Room 1 & 2, Level 3 Time: 12.30pm – 3.30pm
Programme Outline Time
Topic
Speaker
12.30pm – 1.30pm
Registration and Lunch
1.30pm – 1.50pm
Thyrotoxicosis and Graves' Disease
Dr Rinkoo Dalan Consultant, Endocrinology
1.50pm – 2.10pm
Hypothyroidism: When to Start Treatment
Dr Kon Yin Chian, Winston Senior Consultant, Endocrinology
2.10pm – 2.30pm
Thyroid Masses and Neck Lumps: When are They Worrying?
Dr Tan Choon Chieh Consultant, General Surgery (Head and Neck Surgery)
2.30pm – 2.50pm
Thyroidectomy: A Comprehensive and Cosmetic Approach
Dr Ho Wai Thong, Thomas Chief of Service and Consultant, General Surgery (Head and Neck Surgery)
2.50pm – 3.10pm
Minimally Invasive Approaches: RFA, Endoscopic and Robotic
Adjunct Assistant Professor Uei Pua Consultant, Diagnostic Radiology
3.10pm – 3.30pm
Tea Break
3.30pm
End of Forum
One CME point will be awarded for your participation. To register for the Forum and for more information, please contact Ms Chai Jye Yi at 6357 7891 or email her at jye_yi_chai@ttsh.com.sg.
Surgery is the treatment of choice in early-stage lung cancer and has traditionally been performed through a large cut on the side of the chest. This results in increased pain and a longer hospital stay for patients. Robot-assisted thoracic surgery is a minimal-access approach that allows surgeons to perform operations remotely, using robotic arms inserted through several small incisions. With this technology available at Tan Tock Seng Hospital, our patients are able to experience less pain and a shorter hospital stay.
L
ung cancer is a leading cause of death from cancer in Singapore. The treatment of lung cancer depends on a number of factors, such as the extent of the cancer (stage) and the patient’s overall health. Surgery is one of the treatment options available to patients and traditionally involves the use of a large cut on the side of the chest. This increases postoperative discomfort and patient requires a longer hospital stay to recover from the surgery. Over the years, video-assisted thoracic surgery (VATS), a minimalaccess approach that allows
surgeons to perform lung cancer surgery through three to four small incisions was introduced. However, VATS demands skills that are very different from the hand motions used in traditional open surgery, and hence requires longer training times to master such procedures.
HOW DOES ROBOTIC SURGERY WORK?
Robot-assisted thoracic surgery is an extension of VATS and this technology is able to replicate the surgeon’s hand movements precisely. Consequently, the training time required to master the movements using the robot is much shorter, resulting in its widespread acceptance in the USA and Europe.
The robot provides enhanced vision and control and is made up of several components, which includes an ergonomically-designed console, four interactive robotic arms and a three-dimensional (3D), highdefinition vision system. The four interactive robot arms are introduced into the patient’s chest
The surgical robot was originally developed by the US military, to allow complex surgery to be performed on a wounded soldier by a surgeon on a console at a hospital, removed from the battlefield.
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using small incisions, while the surgeon sits at the console and uses finger, eye and foot controls to manipulate the arms of the robot.
ROBOT-ASSISTED SURGERY FOR LUNG CANCER In robotic lung cancer surgery, surgeons operate through small incisions in the chest to remove the cancer and a certain amount of surrounding healthy tissue from the affected lobe of the lung. The right lung consists of three lobes while the left lung is made up of two. At Tan Tock Seng Hospital (TTSH), several different types of lung cancer operations are performed, depending on the size and the location of the tumour.
1. Robot-Assisted Wedge Resection
With this procedure, the surgeon removes a small wedge-shaped portion of the lung, which includes the cancer and some healthy tissue surrounding the tumour.
2. Robot-Assisted Sub-Lobar Resection
With this procedure, the surgeon removes a segment of the lobe containing the cancer, with some normal surrounding lung tissue.
3. Robot-Assisted Lobectomy With this procedure, the surgeon removes the entire lobe containing the cancer, for example, the left upper lobe.
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'Robot' used in thoracic surgery for the treatment of early-stage lung cancer.
Regardless of the type of procedure performed, surgical removal of the lymph nodes surrounding the lung is also performed using the robot. This allows the surgeon to determine if the cancer has progressed beyond the lungs.
ADVANTAGES OF ROBOTASSISTED LUNG CANCER SURGERY Robot-assisted lung cancer surgery is performed through a series of small incisions, which results in faster recovery and significantly less post-operative discomfort and scarring, as compared to traditional open lung cancer surgery that requires a large incision. Since the introduction of robotic lung cancer surgery at TTSH in 2012, we have seen an improvement in our patients’ post-operative recovery as well as reduced hospital stays (three to four days).
The other advantage of using robotic surgery in lung cancer includes the surgical robot’s high definition, 3D camera, which provides a superior view of the tissues being operated on. The robot is also able to translate the surgeon’s hand, wrist and finger movements into real-time movements of the surgical instruments inside the patient. This allows for exceptional precision, which is ideal for resecting lung tissues and removing lymph nodes within the chest.
WORKING AS A TEAM IN ROBOT-ASSISTED LUNG CANCER SURGERY At TTSH, we offer a team-based approach to robot-assisted thoracic surgery. Surgeons are accompanied by a team of trained nurses and supporting healthcare staff to ensure that every patient receives the highest quality and personalised care.
Dr. Dokev Basheer Ahmed Aneez Ahmed Dr. Aneez Ahmed is the Chief and Senior Consultant of Thoracic Surgery Service in the Department of General Surgery of Tan Tock Seng Hospital, Singapore. He obtained a Level III Certificate Specialist training in Robotic Thoracic Surgery from European Association of Cardiothoracic Surgery (EACTS). He is a board member of the regional ASEAN VATS Study Group and is also a member of the editorial review board of the SMJ (Singapore Medical Journal). He has undergone further training in Germany, Europe and United States in his specialised area of service in laser application in thoracic and robotic surgeries.
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Fundus Photograph Interpretation For Primary Eye Care Professionals
I
Fundus photography has an edge over the direct ophthalmoscope as the latter needs a greater skill to perform and allows only a limited view of the fundus at a time. In addition, with direct ophthalmoscopy, there is no means of keeping a record, other than manual drawing. On the other hand, fundus photography offers means of capturing wider-view digital images of the fundus. With newer technology, fundus images can be captured without dilating the pupils, thus eliminating the need for assessing the suitability of dilating the pupils and the risks associated with pupil dilation such as acute angle-closure glaucoma.
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Anterior segment photograph showing a brunescent (brown) cataract in the right eye.
Image source: Fundus Photograph Interpretation for Primary Eye Care Practitioners - a publication by the NHG Eye Institute @ TTSH.
n recent years, greater emphasis has been placed on the early detection of diseases at the primary healthcare level. Eye diseases such as diabetic retinopathy, age-related macular degeneration and glaucoma are the leading causes of blindness in Singapore and worldwide. These conditions can be detected with fundus photography – the perennial conservative tool for ophthalmic diagnosis.
Fundus photograph of the same eye is dark and rather brown.
Anterior segment photograph showing the same eye after cataract surgery and intraocular lens implantation.
Fundus photograph of this eye shows a ‘paler’ optic disc and a retina that is more orange in tone.
While the fundus camera can be operated by technicians, the interpretation of images acquired require some knowledge, skills and experience. The doctors in National Healthcare Group (NHG) Eye Institute, together with a senior optometrist, have compiled a user-friendly guidebook on the interpretation of fundus photography for use by primary care professionals. This is believed to be first of its kind locally. One of the challenges in the interpretation of fundus photography is the wide variety of normal fundi seen in our local population. The appearance of fundus may be affected by age, race, degree of myopia and other factors. We have compiled a wide range of normal fundi and provided guidelines on subtle changes to watch out for in diseases such as glaucoma, macular pucker and diabetic maculopathy. Other highlights of the book include advice on choice of fundus camera, practical tips on its use and possible artifacts. Case studies of real-life scenarios in optometric practice are included as well.
Fundus photographs of a 20 year old – there are shiny reflective areas around the macula and along the blood vessels.
Presently, there is a national effort to provide centralised online reporting of fundus images by trained personnel and optometrists. It is hoped that with this book, more primary eye care professionals will perform fundus photography as part of the eye disease detection and join the fight for blindness prevention.
Dr. Lim Boon Ang Dr. Lim Boon Ang is a Senior Consultant at the National Healthcare Group Eye Institute @ Tan Tock Seng Hospital. She received her cataract and glaucoma training at the Sydney Eye Hospital/Save Sight Institute in Australia. She is a champion for patient education and training of primary eye care professionals including general practitioners and optometrists.
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Learning to cope with chronic disease conditions can be a frustrating process for afflicted patients. Tan Tock Seng Hospital’s Chronic Disease Self-Management Programme (CDSMP) imparts patients with strategies to help them play a more active role in managing their chronic disease and to enhance their quality of life.
Chronic DiseaseS:
Can We Help Our Patients Live Better?
C
hronic diseases like cardiovascular disease and cancers constitute the bulk of morbidity and mortality in Singapore. Ischaemic heart disease, stroke and cancers are among the top five causes of death* in Singapore. Hyperlipidemia, hypertension and diabetes are
among the top four conditions for polyclinic visits**. Chronic diseases are often longdrawn and treatments are not simply just medications, but involve learning to cope with difficult emotions, symptoms and improving communication with others.
Communication Skills for Better Engagement and Self-Management Are your patients ignorant of their own health conditions? Are your diabetic patients not complying with prescriptions, despite reminders and explanations? Good communication is key in building good doctor-patient relationships and it lays the vital foundation for patient engagement and compliance. Good partnerships between doctors and patients facilitate shared decision-making. Empowering our patients with communication skills that enable them to be active and take charge of their health is an important strategy for healthy and happy outcomes. Communication is a two-way process that requires asking, listening, repeating and clarifying by the doctor and patient. Medications not working, medication side-effects, tiredness, anxiety and frustrations are
23
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Fitness
presented frequently in clinic consults. Patients can be more active in their chronic disease management through better communication.
In setting any goal, we need to ask ourselves what we really want to do and the emphasis here is on ‘what I want’, not what someone else wants.
To do so, they can make the consultation more meaningful by preparing a list of questions before the appointment date and prioritising their concerns on that list. During consultation, patients should use the list of prepared questions, listen and seek clarifications regarding symptoms, diagnosis, laboratory results and medications.
The next step involves working out the specifics of ‘how, where and when’ to do it. A self-rating measure of confidence is added on to evaluate the potential success of such a plan. When the plan is carried out, review the outcomes and seek solutions for difficulties or failures. With successive practices, we learn to make better action plans and become more confident in achieving our goals. We can achieve better outcomes in health and disease as well as in other areas of life where we desire to make changes.
Towards the end of the consult, patients can also learn to repeat what the doctor has explained and even make notes. By repeating what has been said, patients show understanding and this heightens engagement. Doctors work under pressure, so imparting better communication techniques to patients promotes patient selfmanagement and avoids misunderstandings and conflicts.
Goal Setting Through Action Planning Wanting good health is everyone’s goal. Public health policies strongly support preventive health. Healthcare providers, Health Promotion Board and the media have been successful in raising awareness of cardiovascular disease, cancers, degenerative disease and their risk factors. However, helping people to make behavioural changes in lifestyle habits and to effectively manage their diseases still remain a daunting task. Besides better communication, learning to set goals through action planning is another important strategy for active self-management.
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Chronic Disease Self-Management Programme (CDSMP) Tan Tock Seng Hospital (TTSH)’s Chronic Disease Self-Management Programme (CDSMP) is a stepped programme developed by Stanford University that teaches active self-management to enhance the quality of life and self-efficacy. Studies report better symptoms and emotions, greater activity, medication usage, better communication with healthcare providers and reduced utilisation of healthcare services. Key concepts include goal setting, action planning, problem solving, and the use of self-management tools. Through a series of feedback, brainstorming, discussions and lectures, individuals become empowered in helping themselves and others manage chronic diseases.
CDSMP consists of weekly sessions of about 2½ hours conducted over six weeks. Patients can be referred by family doctors or they can refer themselves to attend the programme. Each workshop is led by two trained facilitators and is conducted at TTSH. Ministry of Health - Health Statistics *2011, **2013
For registration and enquiries on Chronic Disease SelfManagement Programme (CDSMP), contact us at 6359 6439 or email to chep@ttsh.com.sg. Details on CDSMP can also be found on www.ttsh.com.sg/CDSMP. Email us at chep@ttsh.com.sg to receive our quarterly newsletter. For operational matters and collaborations, please contact Lynn Lee at 6359 6398 or email to lynn_lee@ttsh.com.sg.
Dr. Teoh Mei Lin Dr. Teoh Mei Lin is the Associate Consultant of the Department of Continuing and Community Care in Tan Tock Seng Hospital, Singapore, where she oversees community education on active ageing, chronic disease and behaviour modification. She graduated with MBBS from the National University of Singapore and further advanced her training in Family Medicine. She subsequently achieved the Master of Medicine and the Fellowship of College of Family Physicians. Her clinical experience and interests include health promotion, multi-disciplinary management of complex care patients and behavioural modification to achieve active and healthy living. Dr Teoh is a certified Master Trainer in Stanford University’s Chronic Disease SelfManagement Programme.
PHYSICAL ACTIVITY
FOR THE HEART
Regular physical activity is crucial in preventing and managing lifestyle-related diseases and heart disease. An ideal physical programme should include both aerobic, resistance and lifestyle-related activities to improve endurance and strength training. Physical activity prescription should be tailored according to age, physical fitness and gradual progression for sedentary adults.
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Health Promotion Board Physical Activity Readiness Questionnaire PAR-Q
fITNESS
A
ccording to the Ministry of Health, one third of Singaporean deaths in 2011 and 2012 were due to heart-related conditions. 10% of total hospital admissions in these two years were linked to heart disease and 40% of polyclinics’ attendances were due to risk factors of heart disease (e.g. hyperlipidemia, hypertension and diabetes mellitus). These statistics demonstrate the rising healthcare burden of heart disease in Singapore. The heart is the engine of the human body; it ensures consistent and continuous delivery of oxygen and nutrients to our body tissues. Optimum heart function is essential to ensure health and vitality. This can be optimised through regular and sufficient doses of physical activity. Today, there is an increasing trend of reduced physical activity due to mechanisation. Living a sedentary lifestyle has been associated with increased risks of chronic diseases, cancers, obesity, accelerated functional deterioration and lower life expectancy. Strong evidence has supported the risk of developing both heart disease and early death from occupations that are less active. The 2010 National Health Survey demonstrated that 39.1% did not meet physical activity guidelines for healthy living. Therefore, physical inactivity is an avoidable risk factor for heart disease.
Types of Physical Activity Although increasing activity levels have obvious benefits, getting people to participate can be challenging. There are many barriers – on the personal level through external factors and other environmental factors that affect
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adherence to regular physical activity. In addition, there is lack of understanding on the types and dosage of physical activity in reaping real health benefits. It is usual to assume that any form of physical activity is considered sufficient for health promotion. Physical activity is defined as any body movement produced by muscle contractions that result in the burning of calories. In contrast, exercise is a purposeful physical activity programme to ensure gains or maintenance in physical function and fitness (e.g. running, walking, dancing, swimming). Exercise programmes can be divided into aerobic and resistance physical activities. Aerobic exercises help in improving endurance and fitness, while resistance exercises help in
loading and strengthening both bones and muscles strength. In order to maximise benefits from incidental physical activity, a new modality which is ‘lifestyle physical activity’ was formulated to acknowledge the role of these activities. Local guidelines of physical activity have an inclusive model for various types of physical activity to improve adherence to regular physical activity.
Benefits of Physical Activity Regular exercise can reduce overall risk of developing heart disease by 50%, possibly through reduction of hardening, narrowing and decreasing the risks of acute blood clot formation in the blood vessels of the heart. Franklin and McCullough 2009 (Table 1) suggested that it could be contributed by improved dilation, compliance or a combination of factors on the blood vessels.
Table 1
Anti-atherosclerotic (Reduce stiffness of blood vessels)
Anti-thrombotic (Reduce acute blood clot formation)
Anti-ischaemic (Reduce risk of insufficient blood flow)
Anti-arrhythmic (Reduce irregularity of heart rate)
Regular exercise is associated with many health benefits. Increasing physical activity is safe for most people. However, some individuals should check with their doctor before they become more physically active. Completion of this questionnaire is a first step when planning to increase the amount of physical activity in your life. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly. If you have honestly answered ‘NO’ to all questions you can be reasonably sure that you are at low risk to participate in this HPB exercise programme or event. If you have answered ‘YES’ to any of the questions below, you are required to be evaluated by your doctor whether you can participate in this HPB exercise programme or event. Please ask your doctor to complete the Medical Recommendations/ Advisory Form. Please read each question carefully and answer to your best knowledge by circling on the form: 1. Has anyone in your immediate family (mother, father, sister or brother) had a heart attack or died suddenly of a heart related disorder before age 55 (men) or 65 (women)?
Yes
No
2. Has your doctor informed you that you have any of these conditions? (check all that apply) Heart condition or disease (also includes any type of heart surgery) Stroke
Yes
No
3. Has your doctor informed you that you have any of these conditions? (check all that apply) Lung disease (e.g. chronic obstructive pulmonary disease/COPD or asthma) Diabetes
Yes
No
4. In the past 1 year, have you had chest pain: when you engage in physical activity when at rest
Yes
No
5. Do you ever experience dizziness or even lose consciousness?
Yes
6. Do you have any bone, joint or muscle problem (e.g. back, knee, hip, shoulder or ankle) that could be made worse by participating in exercise?
Yes
7. Are you taking medication for high blood pressure?
Yes
8. Are you currently pregnant? (Female participants to note: If you are currently pregnant, please speak with your doctor about an appropriate exercise programme)
Yes
No
Yes
No
No
No No
Improve cholesterol profile
Stickiness of blood
Demand of heart
Constrictive activity of blood vessels
Improve control of high blood pressure
Blood clotting factors
Blood flow to heart
Relaxation
9. Do you know of any reason why participating in this HPB exercise programme or any other physical activity might be harmful to your health?
Fat tissue mass
Thickness of blood
Blood vessel compliance
Heart rate regulation
If you have answered YES to one or more questions: Talk with your doctor in person before you proceed with this HPB exercise programme. Tell your doctor about the PAR-Q and which questions you have answered YES. Provide your doctor with the Medical Recommendations/Advisory Form with page 1 completed.
Inflammation
Breaking down of blood clot
Factors opening up blood vessels
Uptake of glucose
Production of new cells for lining of blood vessels
Screening and Readiness for Physical Activity Before prescribing exercise, it is important to screen for red flags for risks of participation in physical activity. Physical activity readiness questionnaire (PAR-Q) is a readily accessible tool to address risks. Further assessment may be required for any “yes” to the questionnaire as well as supervision of exercise intensity and progression. After assessing risks, physical activity prescription is made through the Frequency, Intensity, Type and Time (FITT) principle.
“I have read, understood and completed this questionnaire to the best of my knowledge. I accept full responsibility for the answers given and agree to indemnify HPB (its directors, employees, agents and servants) from any loss, injury or claims that may be made against HPB as a result of my participation in this exercise programme”. Name of participant:
NRIC/FIN/Passport no.:
Email address:
Tel No:
Yes
No
Signature: Date: Name and signature of parent or guardian (for participants below the age of 21 years): Relationship to participant: Name and signature of witness: Note: This completed questionnaire is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes at any point of time such that you would answer YES to any of the nine questions. The HPB PAR-Q and Medical Recommendations/Advisory Forms are adapted from the American College of Sports Medicine and the Canadian Society for Exercise Physiology guidelines. Adapted versions reviewed and approved by the HPB National Physical Activity Consensus Group and HPB Legal Representative. HPB-PAR-Q
Excerpted from Health Promotion Board
fITNESS
Fitness
A sample of a simulated physical activity prescription can be shown in Table 3 below. Table 3: 3 X 3 Physical Activity Strategies
Leisure-time Physical Activity (Exercise, Recreation and Sports)
Domain Type
Work/Home
Active Transport (Commuting)
Lifestyle: Intermittent light or moderate intensity activity
• Doing household chores • Walking in the house during advertisement breaks
• Taking a 10-minute walk to the market • Going for a stroll • Standing in the MRT
• Playing miniature golf • Walking the dog
Aerobics: Moderate or vigorous intensity of at least 10 minutes at a time
• Scrubbing the floor • Washing the car
• Taking a 15-minute brisk walk to and from the MRT (4-5km/hr) • Climbing the overhead bridge • Walking with 2kg of groceries
• Doing low impact aerobics • Doing Zumba • Swimming
Strength
• Lifting or moving heavy objects
• Carrying groceries • Taking the stairs
• Lifting hand weights • Doing Qigong TaiChi
Excerpted from Health Promotion Board
Table 4
Male Age
Km/hr
Min/km
Min/2km
Min/3km
20-29
6.5-7.5
8:00-9:00
16:00-18:00
24:00-27:00
30-49
6.0-7.0
8:30-10:00
17:00-20:00
25:30-30:00
49-59
5.0-6.5
9:00-12:00
18:00-24:00
27:00-36:00
60-69
3.5-6.0
10:00-17:00
20:00-34:00
30:00-51:00
Age
Km/hr
Min/km
Min/2km
Min/3km
20-29
5.5-7.0
8:30-11:00
17:00-22:00
25:30-33:00
30-49
4.5-6.5
9:00-13:30
18:00-27:00
27:00-40:30
49-59
3.5-6.0
10:00-17:00
20:00-34:00
30:00-51:00
60-69
2.5-4.5
13:30-24:00
27:00-48:00
40:30-72:00
References • Franklin, BA and Mc Collough PA (2009) Cardiorespiratory fitness: an independent and additive marker of risk stratification and health outcomes. Mayo Clinic proceedings 84(9): 776-779. • Green, D.J., O’Driscoll, G., Joyner, M.J., Cable, N.T. (2008) Exercise and cardiovascular risk reduction: time to update the rationale for exercise? Journal of Applied Physiology 105(2): 766-768. • Sloan et al (2011) National physical activity guidelines: professional guide. Health Promotion Board 1-26.
Female
Physical Activity Prescription Physical activity prescription is based on FITT principle. A sample of a complete simulated physical activity prescription should include both aerobic, resistance and lifestyle-related activities (Table 2). Ideal frequency of physical activity should be at least five times a week at moderate intensity level for aerobic-based activity for 30 minutes. Resistancebased exercises should be done at least two to three times a week in a few sets of 10, for major muscle groups.
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Table 2: FITT Principle
Frequency
5 times a week
Intensity
Moderate: Noticeable increase in breathing rate but still able to carry on a conversation but does not have enough breath to sing.
2-3 times a week
Every day Light: Minimal increase in breathing rate and carry on a conversation comfortably.
(Based on individual effort level by level of shortness of breath) Type
Aerobics (e.g. walking, running, dancing, cycling, swimming)
Resistance (e.g. resistant bands, weights)
Lifestyle
Time
30 minutes
2 to 3 sets of 10 repetitions for 8-10 major muscle groups
• Work • Transport • Leisure
Excerpted from Health Promotion Board
Walking is a great form of exercise through everyday physical activity. It is readily accessible, does not require equipment and has low health risks. Walking intensity can be gradually built up, according to the physical capacity of each individual. Walking is beneficial for all ages to increase mobility and strength, while reducing the risks of disability and chronic diseases. Table 4 provides a set of recommended walking speeds for males and females of different age groups. Walk at a comfortable pace for a few minutes to warm up before progressing to the ideal speed suitable for your age; maintain the speed for 30 minutes before cooling down to a slower speed. For sedentary adults or individuals with joint pains and injuries, it would be preferable to start at a slower pace in short bouts of 10 minutes before progressing to an ideal duration of 30 minutes.
Ms Cindy Soh Cindy Soh is a Principal Physiotherapist at Tan Tock Seng Hospital, Singapore. She obtained her Bachelor of Physiotherapy degree in Australia and a Masters in Preventive Cardiology in UK. She is also an American College of Sports Medicine Certified Clinical Exercise Specialist.
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healthy recipe
Healthy eating is an effective strategy to lower the risk of cardiovascular diseases. Eating more fruits and vegetables, increasing whole grain (e.g. oats) intake, substituting trans or saturated fats with monounsaturated and polyunsaturated fats, choosing low-fat protein sources (e.g. egg white) and reducing sodium intake are some ways of maintaining a heart-healthy diet. The Chocolate Muffins with Walnuts recipe developed by Tan Tock Seng Hospital shows that heart-healthy food can be delicious too.
Chocolate Muffins with Walnuts Serving size: 12 Ingredients
Steps 1. Preheat the oven to 350 degrees. 2. Line a 12-cup muffin pan with foil cupcake liners or spray the muffin pan with non-stick cooking spray. Set aside.
1¾ cup 3 eggs ¾ cup ½ cup 1 tsp ½ cup ½ tsp 1½ tsp 1½ tsp ¼ tsp ½ cup ½ cup ½ cup
3. In a blender or food processor, mix all the ingredients together except for the chopped walnuts. Blend the mixture until the oats are ground and the mixture is smooth.
Nutritional Value
Oats Egg whites Unsweetened cocoa Unsweetened apple sauce Vanilla extract Plain, non-fat greek yogurt (or regular plain low-fat yogurt) Cream of tartar Baking powder Baking soda Salt Hot water Sugar Walnuts (chopped)
Amount Per Serving
Weight (g)
75
4. Place the mixture in a bowl and gently stir in the walnuts (set half aside). Scoop the mixture into the prepared muffin pans.
Calories (kcal)
133
Energy (kJ)
556
Carbohydrate (g)
21
5. Place the muffins pans in the oven for 10 minutes. Remove muffins from the oven (but do not switch the oven off), and distribute the other half of the walnuts on top of each muffin.
Sugar (g)
10
Protein (g)
6
Fat (g)
5
6. Bake for another 10 to 13 minutes before serving.
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Sodium (mg)
287
Multi-Disciplinary 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 • Hand Procedure Suite
– Rheumatology, Allergy and Immunology
• Intravenous Infusion Day Facility
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 • Colonoscopy • Flexible Cystoscopy • Gastroscopy
Clinic 4B
Clinic B1B Orthopaedic Surgery Tel: (65) 6889 4055 Email: ClinicB1B@ttsh.com.sg
– Diabetes and Endocrinology – General Medicine – Haematology – Psychological Medicine – Renal Medicine – Respiratory and Critical Care Medicine – Travellers' Health and Vaccination Clinic (THVC)
Rheumatology, Allergy and Immunology Tel: (65) 6889 4027 Email: ClinicB1B@ttsh.com.sg
CLINIC 6B
Email: Clinic2B@ttsh.com.sg
Clinic 2B Tel: (65) 1800-PEARL-00
(65) 1800-73275-00
- Complementary Integrative Medicine • Acupuncture • Cupping • Dietary Advice • Pain-relief Physiotherapy
- Dental
Our specialist services include: • Braces • Root Canal Treatment • Wisdom Tooth Surgery • Dental Implants
Clinic 4B Tel: (65) 1800-PEARL-00
(65) 1800-73275-00 Email: Clinic4B@ttsh.com.sg
CLINIC 6B Complementary Integrative Medicine Tel: (65) 6889 4628 Email: Clinic6B@ttsh.com.sg Dental Tel: (65) 6889 4627 Email: Clinic6B@ttsh.com.sg
Years of Care