GP Buzz (July - Sep 2015) by Tan Tock Seng Hospital

A PUBLICATION FOR

PRIMARY CARE PHYSICIANS

MCI (P) 118/03/2015

july-september 2015

I Feel Pulsating In My Tummy! Managing Common Side Effects Of

Chemotherapy

The Electrifying Truth Behind A Racing Heart healthy recipe

Preventing Dementia with Health Supplements:

Do They Work? Scan the QR code using your iPhone or smart phone to view GP BUZZ on the TTSH website or visit www.ttsh.com.sg/gp/.

Hearty Tuna and Walnut Patties

contents

editor’s note

The GP BUZZ editorial team: Ms Jessie Tay Ms Evelyn Tan Ms Mellissa Chew

The Body’s Powerhouse

08 in every issue

ADVISORY PANEL: Associate Professor Thomas Lew Associate Professor Chia Sing Joo Associate Professor Chin Jing Jih Adjunct Assistant Professor Chong Yew Lam Dr Tan Kok Leong Dr Pauline Yong Ms Susan Niam Mr Yong Keng Kwang

030 editor’s note 040 in the news 060 UPDATES ON CHAS/CRISP 240 fitness

GP Buzz is a magazine by Tan Tock Seng Hospital, designed by

310 healthy recipe

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 08 The Electrifying Truth Behind A Racing Heart

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.

11 I Feel Pulsating In My Tummy!

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.

16 Managing Common Side Effects Of Chemotherapy

21 Preventing Dementia With Health Supplements: Do They Work?

pproximately the size of a clenched fist, the heart is a small but formidable powerhouse of the

human body.

The heart pumps blood, which supplies nutrients and oxygen to the body through the blood vessels of the circulatory system. Beating 100,000 times a day, pumping five or six quarts of blood every minute, the heart carries fresh oxygen from the lungs and nutrients to the body’s tissues, and also takes the body’s waste products away from the tissues, thus sustaining life and promoting the wellbeing of every area of the body. In this issue of GP BUZZ, we commemorate World Heart Day in September, with a series of heart and vascular health articles. The cover story examines palpitations – a common cardiac symptom. The article introduces various devices that can be used in identifying the cause of the palpitations, so that the physician can prescribe definitive therapy to the patient. Next, we examine Abdominal Aortic Aneurysms (AAA) and treatment via minimally invasive endovascular techniques. In the Fitness segment, our Physiotherapist highlights how sedentary behaviour at work and

at home can increase cardiovascular risk. We will also feature a series of ‘desk-xercises’ to help you sit less, stand up and move more, more often. This is followed by a hearty, healthy recipe designed by the Nutrition and Dietetics Department of Tan Tock Seng Hospital (TTSH). In addition, we take a closer look at cancer, the number one killer disease in Singapore, with an informational article on managing the common side effects of chemotherapy – an important cancer treatment method. With Singapore’s ageing population, the incidence of dementia is projected to increase over the years. Dr Noorhazlina Binte Ali from the Cognition and Memory Disorders Service in the Department of Geriatric Medicine, examines the health benefits of supplements in the prevention of dementia in our feature article. We are also pleased to share that SOC-discharged patients can now enjoy access to subsidised medication through their General Practitioners (GPs) under TTSH's Community Right Siting Programme (CRiSP). Find out more in this issue of GP BUZZ. Happy reading! The GP BUZZ Editorial Team

Reference: How Heart Works, http://www.webmd.com/heart-disease/guide/how-heart-works.

july - september 2015 02

in the news

“I Have Washed My Hands!”

Volunteer Hand Hygiene Ambassadors and our student volunteers raising awareness about good hand hygiene among visitors. Launch of the hand hygiene campaign on 5 May with the 7-step hand washing technique.

TSH launched the "I Have Washed My Hands" Hand Hygiene campaign on 5 May 2015, in conjunction with World Hand Hygiene Day.

Winners of the 12th Healthcare Humanity Awards.

12th Healthcare Humanity Awards

eld in April 2015, the prize presentation ceremony for the 12th Healthcare Humanity Awards (HHA) saw 62 winners, with six individuals receiving Honourable Mention awards. Guest-of-Honour and Courage Fund Patron Dr Tony Tan Keng Yam, President of the Republic of Singapore graced and presented the awards together with Mr Gan

Kim Yong, Minister of the Ministry of Health. The HHA is a lasting legacy of the Courage Awards, originally presented in 2003 to the healthcare heroes and heroines of the SARS outbreak. In 2004, Courage Awards was replaced by the HHA, which honours exemplary healthcare professionals who go beyond the

call of duty to help others. The Honourable Mention Awards recognise outstanding individuals for their selfless commitment to humanitarian efforts in uplifting the lives of others. This year, 14 healthcare professionals from Tan Tock Seng Hospital were recognised by HHA.

Launched by Ms Denise Phua, Mayor of the Central Singapore District, the six-week long effort sees over 400 TTSH volunteers making rounds at the hospital to remind hospital staff, patients and visitors on the

importance of hand hygiene in preventing the spread of infection. This campaign led by TTSH volunteers is initiated by Tan Tock Seng Hospital (TTSH)'s Infection Control Unit and CareConnect Volunteer Committee, made up of members from patient volunteers, healthcare professionals and community representative groups.

CME Schedule July – September 2015 General Medicine Update 2015 CME points

2 CME Points*

Family Practitioner Symposium Haematology Sharing 2015 CME points

2 CME Points*

DATE

15 August 2015

DATE

22 August 2015

TIME

1.00pm – 4.00pm

TIME

1.00pm – 4.30pm

VENUE REGISTRATION DETAILS

Seminar Room 1 & 2, Tan Tock Seng Hospital, Level 3 6357 7893 Email: debra_lee@ttsh.com.sg

VENUE REGISTRATION DETAILS

Theatrette, Tan Tock Seng Hospital, Level 1 6357 3159 E-register at: http://goo.gl/forms/AVbJgafRVW

* Subject to the approval of Singapore Medical Council. For an updated listing of CME and event schedule, please visit www.ttsh.com.sg/gp/. Information is correct at the time of publishing.

Updates on CHAS / CRiSP

TTSH CRiSP GP PARTNERS TO GET MEDICATION SUPPORT FOR SOC DISCHARGED PATIENTS General Practitioners (GPs) enrolled in TTSH's Community Right Siting Programme (CRiSP) as partners will be able to access the hospital’s medication support for managing Specialist Outpatient Clinic (SOC) discharged patients.

TSH SOC discharged patients will continue to have access to medication support similar to TTSH through their General Practitioners (GPs) who enrolled in the hospital’s right siting programme, CRiSP. CRiSP GP partners now have the option to tap on TTSH drug delivery systems for a list of agreed conditions*. If the drugs for these conditions are not available at their clinic, CRiSP GP partners would be able to receive medication support for the hospital’s right-sited patients according to the patient’s TTSH financial class. Through this system, CRiSP GP partners can assure patients that healthcare costs will not increase when they continue their follow-up care in the GP clinic, once their condition has stabilised. CRiSP GPs can fax a prescription (prescription pad to be provided by TTSH) to TTSH's pharmacy and inform patients to collect the medication at their clinic. The TTSH pharmacy will get the medication ready and deliver it to the GP clinic. This reduces the hassle for GPs to establish a procurement system for drugs that are not commonly prescribed. Our GP partners could then focus on the quality of care rendered.

“The Community Right-Siting Programme will enable us to accelerate right-siting to our GP partners, with ease of mind for our patients who are concerned with medication costs; and the assurance of shared care with TTSH specialists.” - A/Prof Thomas Lew, Chairman of Medical Board, Tan Tock Seng Hospital

This access is only offered to GPs who have enrolled in the hospital’s right siting programme (CRiSP); and patients who are discharged to these GP partners under this programme. *As of July 2015, CRiSP covers the following chronic conditions: 1. Diabetes 2. Hypertension 3. Lipid Disorders 4. Stroke 5. Asthma

6. Osteoarthritis 7. Benign Prostatic Hyperplasia 8. Parkinson’s Disease 9. Hypothyroidism

Support Us in Adding Years of Healthy Life Currently, CRiSP is implemented in the following regions:

Ang Mo Kio Yio Chu Kang Yishun Woodlands

Serangoon Seng Kang Hougang

About CRiSP TTSH CRiSP is a partnership between TTSH and GP partners where stable chronic patients from Specialist Outpatient Clinics are being appropriately reviewed at primary care environments. CRiSP was launched in April 2015 enabling TTSH, NHG Pharmacy and NHG Diagnostic to collaborate closely with GPs to provide continual care to our right sited patients. Right-siting is enabled through a wide network of supporting GPs receiving discharges; and patient incentives that provide more convenient access to care and easing the burden of out-of-pocket expenditures. At present, CRiSP has right sited more than 50 patients a month to CRiSP GPs. Referrals to GPs are made by patient’s attending specialists based on clinical criteria for stable discharges; and Right Siting Officers to conduct assessment for financial suitability. Right Siting Officers will shift the care of our SOC patients to the community and maintain a general oversight and support to GP partners. CRiSP is committed to promote the message of “one patient, one family physician” so that patients would follow-up with GPs more regularly, and to improve accessibility of care by enlisting the participation of more GP partners in this programme. For GPs interested in TTSH CRiSP and/or signing up for this programme, you may wish to email your personal particulars to the Primary Care Partners Office.

Bishan Bendemeer

Jurong East Toa Payoh

If your clinic is located in any of these locations and you would like to find out more about CRiSP, please contact the following representatives from the Primary Care Partners Office (PCPO): Evelyn Tan (Ms) Senior Account Manager Email: Evelyn_SM_Tan@ttsh.com.sg Jayne Tong (Ms) Account Manager Email: Jayne_LM_Tong@ttsh.com.sg

cover story

The Electrifying Truth behind

a Racing Heart

Palpitations are a common cardiac symptom, but elucidating the cause is notoriously challenging. Most episodes are sporadic and short-lived, making it difficult to obtain a heart rhythm recording during such occurrences. Without a symptom-heart rhythm correlation, physicians will not be able to prescribe definitive therapy. With the advent of technology, devices are now available to assist physicians in being able to make that formerly elusive diagnosis.

ost individuals have experienced palpitations at some point in their lifetime. The sensation of palpitations varies from person to person. Patients may report rapid and/or strong heart beats that may be regular or irregular, and associated with skipped or missed beats. Identifying the cause of the palpitations is never easy and at times, despite multiple investigations, the cause is still unknown. The crux of the approach to palpitations is to obtain a symptom-heart rhythm correlation. To this end, several devices have proven useful, and will be discussed in this article.

12-Lead Electrocardiography (ECG) ECG presents the simplest method of capturing and analysing a patient's heart rhythm. It provides a snapshot of the heart's surface electrical activity when the 12 electrodes are attached to the patient. If no significant arrhythmia is identified on the ECG whilst the patient experiences palpitations, one can conclude that the palpitations are not secondary to malignant heart rhythms. However, the challenge lies in performing ECG on a patient during palpitations. Most patients experience short-lived, self-limiting palpitations, and by the time they reach the clinic or emergency department, the palpitations would have resolved.

Ambulatory ECG Monitors Compared to standard 12-lead ECG machines, ambulatory ECG monitors are more useful for recording heart rhythms during symptoms. There are a myriad of such devices available, but the most common one being employed in restructured hospitals, is the 24-hour Holter monitor.

The 12 ECG leads are secured over the patient's chest/torso and connected to a portable monitor. The patient is allowed to leave the hospital or clinic with the monitor, but needs to return 24 hours later for leads removal and data analysis. The main drawback of the Holter monitor is its limited recording period of 24 hours. Therefore, it is only suitable for patients with frequent symptoms, especially those who experience daily palpitations. Patients' activities are also restricted by the monitor and leads. Some individuals may develop rashes as a result of prolonged skin exposure to the ECG electrodes.

Implantable Loop Recorders (ILR) To circumvent the limited recording period of external monitors, ILRs may be implanted in the left chest, next to the

cover story

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Conclusion

Figure 1. The latest implantable loop recorder is even smaller than a large paper clip.

sternum, with recording capabilities of two to three years. These days, ILR has been miniaturised to a mere 4.5cm by 0.6cm by 0.4cm, allowing implantation via an "injector" system under local anaesthesia (See Figure 1). The ILR provides continuous monitoring of the heart rhythm and records arrhythmias based on pre-programmed parameters. Patients can also manually instruct the ILR to record the heart rhythm during palpitations using a handheld activator. Data recorded on the ILR is downloaded and analysed during regular clinic reviews or remotely via transmitters from a patient’s home.

The tools all serve to provide a recording of the heart rhythm during symptoms, but they should not replace proper history-taking. A thorough history of the nature and frequency of the palpitations provides vital clues to the underlying etiology. The choice of investigative modality will then depend on the features elicited.

Cardiac Electrophysiology Study Under appropriate circumstances, patients with palpitations may be recommended to undergo a cardiac electrophysiology study. This entails the introduction of catheters via the femoral vein into the heart, to study the intracardiac electrical signals in order to elucidate the pathophysiology of the palpitations. If abnormal foci of electrical activity are detected, radiofrequency ablation of these foci may be performed in the same setting, providing a possible cure to the palpitations.

Adjunct Assistant Professor Chia Pow-Li Adj. Assistant Prof. Chia Pow-Li is a Consultant from the Cardiology Department and Director of the Coronary Care Unit at Tan Tock Seng Hospital. He obtained his basic medical degree and Masters of Medicine (Internal Medicine) from the National University of Singapore. He is a Member of the Royal College of Physicians (Edinburgh) and a Fellow of the Academy of Medicine (Singapore). He completed a one year fellowship at St Vincent's Hospital, Sydney in cardiac electrophysiology and pacing in 2011.

I feel pulsating in my tummy! – New Frontiers in Minimally Invasive Treatment for Abdominal Aortic Aneurysms

r Lee (not his real name), a 68-year-old Chinese man, was referred to Tan Tock Seng Hospital (TTSH) after his general practitioner (GP) felt a pulsating mass in his abdomen. A Computerised Tomography (CT) scan revealed a large Abdominal Aortic Aneurysm (AAA).

refused to undergo treatment for his AAA, as his neighbour had open surgical repair of AAA 8 years ago and stayed in the hospital for 12 days, spending a significant time in the intensive care unit. His daughter echoed the same thought, and felt that his ‘heart was too weak for him to undergo major surgery’.

He has severe ischaemic heart disease after a myocardial infarction which left him with impaired ejection fraction of 20%. He

I reassured him that advances in technology have resulted in widespread application of minimally invasive treatment for AAA and 11

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explained that his neighbourâ&#x20AC;&#x2122;s traditional surgery for AAA involved a laparotomy, cross-clamping of the aorta, and a prosthetic graft replacement of the aneurysmal portion, resulting in his prolonged stay at the hospital and significant morbidity and mortality. The minimally invasive treatment of AAAs, using endovascular techniques grew in popularity during the 1990s. Today, a majority of AAAs are treated using the EndoVascular Aneurysm Repair (EVAR) method. EVAR is carried out with two small incisions in the groin, where several stent grafts are passed into the aneurysmal aorta and deployed for reinforcement while under fluoroscopic x-ray guidance. This creates a new path for blood to flow through, thus excluding blood flow from the aneurysm. Randomised controlled trials have shown a reduction in operative mortality by more than half in patients undergoing EVAR, as compared to traditional open surgery.

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A few complex EVAR options are illustrated below.

How do AAAs present? AAAs are primarily a condition of the elderly, affecting those above 55 years old, with a predilection for males. The main risk factors are hypertension and cigarette smoking. Most patients have their AAAs discovered incidentally on imaging for an unrelated symptom, or because they feel a pulsatile mass in their abdomen. Unfortunately, some patients present with a ruptured AAA or symptomatic AAA (AAA in the presence of abdominal and back pain is a sign of impending rupture), and require emergent surgery. The mortality from ruptured AAAs are 80%, and the treatment for this is often open surgery via laparotomy, as the patient is usually too unstable for EVAR.

A) Fenestrated EVAR

Figure 1. Angiogram before EVAR.

Fenestrated EVARs are custom-made devices tailored to the patientâ&#x20AC;&#x2122;s anatomy, and manufactured to fit individual patients should they have complex aneurysms that cannot be treated with conventional EVAR. These patients usually have juxtarenal aneurysms or thoracoabdominal aneurysms which extend very closely to or involve the renal and visceral vessels. These EVAR devices have small fenestrations (holes) to accommodate the renal arteries, superior mesenteric arteries and coeliac arteries. Traditionally, these patients require an open surgical repair of their aneurysm, which carries a higher risk. Unfortunately, in the past, some patients unfit for open surgical repair had to accept the risk of rupture and mortality as the aneurysm grew.

This highlights the importance of early detection and elective repair to reduce the mortality and morbidity associated with a ruptured AAA. Treatment is offered to patients when their AAAs grow to more than 5.5cm.

B) Branch Graft EVAR

Figure 2. Conventional EVAR stent graft.

Up to 30% of AAAs are associated with concomitant iliac aneurysms. The traditional approach to iliac aneurysms was to sacrifice the internal iliac arteries, in order to achieve total exclusion of the common iliac artery aneurysm. However, this can be associated with catastrophic bowel ischaemia, buttock necrosis, and pelvic ischaemia, causing buttock claudication.

Figure 3. EVAR post deployment.

aneurysms, we use the Iliac Bifurcation Device (IBD) to maintain patency of the internal iliac artery and pelvic circulation, while repairing the aneurysm effectively. This device comes with a side branch which is deployed in conjunction with a main EVAR stent

With fenestrated EVAR, we have been able to offer a treatment option for such patients previously deemed inoperable.

When is EVAR suitable? 80% of AAAs are infra-renal (below the kidney blood vessels) and are suitable for conventional EVAR. However, 20% of AAAs may not be suitable for the standard off-theshelf EVAR devices and will require customisation and complex endovascular treatment.

Figure 5. Fenestrated EVAR post-deployment. Arrows indicate where additional stents have been inserted into the fenestrations to maintain patency of the renal and superior mesenteric arteries.

Figure 4. Fenestrated EVAR stent graft with 3 fenestrations (holes) for the renal arteries and superior mesenteric artery (red arrows) and scallop (larger incomplete hole) for the coeliac artery (blue arrow).

As part of our armamentarium in TTSH to treat such complex

Figure 6. AAA (blue arrow) with left iliac artery aneurysm (red arrow).

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graft. Another smaller stent graft is then placed into the side branch to channel blood into the internal iliac artery to preserve it.

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The latest innovative treatment for AAA is called Endovascular Aneurysm Sealing (EVAS). This technique involves the use of two stent grafts inserted into the aorta with specially attached endobags, which are then inflated with a liquid polymer that subsequently hardens to occupy the entire aneurysm cavity. This acts to anchor the stent graft and seals the entire aneurysm. This new technique reduces the risk of treatment failure associated with traditional EVAR devices such as persistent blood flow in the aneurysm after EVAR, which is known as endoleak. Endoleaks can occur in a few ways. It can occur as a result of migration of the EVAR

Figure 7. EVAR with left IBD (red arrow) stent graft.

Figure 11. CT of EVAS post-deployment with visible endobags (arrows).

stent graft or because blood is able to squeeze past the EVAR stent graft to continue to fill the aneurysm. Endoleaks can also happen when blood enters the aneurysm directly through small vessels feeding into the aneurysm. The EVAS device addresses all these clinical challenges and provides another option for treatment of AAAs.

With the advent of new closure devices, EVAR can now be performed with two 1 to 2 cm stab incisions in the groin rather than conventional 6 to 8 cm surgical incisions. Figure 9. Angiogram before EVAS.

Figure 8. EVAR and IBD post deployment (iliac aneurysm repaired).

C) Novel Devices

Figure 12. Conventional EVAR incision.

Figure 10. EVAS post-deployment.

old, especially males with a history of hypertension and/or cigarette smokers, an abdominal examination may be able to elicit a pulsatile mass characteristic of AAA.

Up to 50% of EVAR performed by TTSH are now percutaneous. The advantages include shorter operative time, less post-operative pain, lower risk of infection, lesser blood loss and smaller scars.

Should you suspect that a patient has AAA or clinical examination proves inconclusive for AAA, we can arrange for a simple ultrasound scan for further investigation. If a patient’s AAA has reached the size criteria for treatment, a CT scan will be arranged in preparation for EVAR planning. Should a small AAA be detected, the patient will then be placed on an ultrasound surveillance programme with scanning intervals ranging from 6 months to 1 year, and intervention offered only when the size criteria for treatment is met.

The story continues …

Percutaneous EVAR

There are several EVAR devices available in the market and each has its own strengths and limitations. A device’s suitability for its patient depends on individual considerations. Thus, a variety of EVAR devices is currently employed at TTSH.

This has allowed us to perform EVAR for patients under local anaesthesia, if their underlying co-morbidities deem them at too high a risk for general anaesthesia.

Figure 13. Percutaneous EVAR incision.

Mr Lee subsequently underwent percutaneous EVAR. With minimal pain experienced after the surgery, he was able to ambulate independently on the first day after his surgery and was discharged from hospital on the second day. A month later, during his scheduled review, Mr Lee’s daughter remarked that she can hardly even see the scars from the operation. Primary care physicians are indispensable partners in healthcare for our population and play an important role in managing the chronic conditions of patients. For patients above the age of 55 years

Multidisciplinary Team in TTSH All EVARs in TTSH are performed by vascular surgeons in collaboration with the interventional radiologists along with a team of anaesthetists, radiographers, nurses and operating theatre support staff. Patients undergo stringent pre-operative assessment and are referred to other

specialties such as Cardiology, should they require further pre-operative optimisation. This is especially important as most AAA patients have other cardiovascular co-morbidities, and a multidisciplinary approach towards aneurysm surgery ensures that every patient receives high quality, safe and individualised care.

Adjunct Assistant Professor Glenn Tan Adj. Assistant Prof. Glenn Tan is the Head of the Vascular Diagnostic Laboratory and Consultant in the Department of General Surgery in Tan Tock Seng Hospital. He is active in undergraduate and postgraduate medical education. He is Lead for Surgery at the Lee Kong Chian School of Medicine and Core Clinical Faculty Member in the NHG-AHPL General Surgery Residency Programme and NHG Transitional Year Residency Programme. He has undergone subspecialty training in Vascular and Endovascular Surgery in Glasgow, United Kingdom and Melbourne, Australia. His areas of interest include aortic surgery, particularly in complex endovascular aneurysm repair, endovenous therapy for varicose veins and surgery for lower limb salvage in peripheral vascular disease.

References: 1. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomiSed controlled trial. The EVAR trial participants. Lancet 2004; 364: 843–48. 2. A multicenter, randomised, controlled trial of totally percutaneous access versus open femoral exposure for endovascular aortic aneurysm repair (the PEVAR trial). Peter R. Nelson, Zvonimir Kracjer, Nikhil Kansal, Vikram Rao, Christian Bianchi, Homayoun Hashemi, Paul Jones and J. Michael Bacharach. J Vasc Surg 2014;59:1181-94. 3. Fenestrated and Branched Stent Grafts. Joseph J. Ricotta and Gustavo S. Oderich. Perspect Vasc Surg Endovasc Ther 2008 20: 174-187.

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Managing common side effects of

medication to overcome this side effect, and if needed, additional medications can be prescribed for subsequent cycles. Conversely, anti-emetics might be stopped or doses reduced if the patient reacts well to the chemotherapy.

Chemotherapy The number of available systemic anti-cancer treatments has increased considerably over the past few decades, ranging from conventional cytotoxic chemotherapy agents, to targeted anticancer drugs, hormonal treatments and immunotherapy. While considerable hype surrounds the newer classes of agents, conventional cytotoxic chemotherapy still plays an important role in the treatment of most cancer types. Individuals undergoing chemotherapy are faced with some common side effects. While chemotherapy is an important tool in the treatment of cancer, support from caregivers and physicians can help individuals cope with the side effects. In this article, we take a closer look at some of the side effects that come with chemotherapy.

Anticipatory nausea and vomiting are typically related to anxiety. Individuals often experience nausea and some vomiting on the scheduled date of chemotherapy, upon arrival at the hospital or in the treatment room. This is typically triggered by sensory stimuli such as sounds, sights, and smells within the hospital.

Gastric Discomforts Nausea and vomiting remains the most feared side effect amongst individuals undergoing chemotherapy. While a majority of patients experience different degrees of nausea, the incidence of actual vomiting has decreased considerably, with the use of newer anti-emetic drugs. These have significantly improved a patientâ&#x20AC;&#x2122;s tolerance to chemotherapy.

Meditation, relaxation techniques and having a relative or close friend accompany individuals for chemotherapy often helps. Anti-anxiety medication may be prescribed if the nausea and vomiting is significant. Such medication is typically taken before a patient comes for their treatment.

Chemotherapy related nausea and vomiting are commonly classified into the following subtypes: acute, chronic and anticipatory.

Individuals may experience loss of appetite caused by the cancer itself, or by the treatments administered.

Individuals with acute side effects of nausea and vomiting usually see its effects within one day of receiving chemotherapy, while individuals with chronic nausea and vomiting will experience it for a few days, and occasionally, up to a week or longer.

Nutritional supplements such as milk or dairy products may be needed to help the patient overcome the effects of cancer treatment and achieve adequate nutrition and hydration. Family members and caregivers can play a part to make meals more enjoyable by having regular family meals, and cooking varied foods with better nutritional values and tastes.

Physicians typically use a combination of anti-nausea

Loss of appetite

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Oral ULCERS Chemotherapy often causes the thinning of the oral mucosae and decreased saliva production. Painful mouth ulcers can develop, which affect the patient’s ability to eat or drink. Patients are advised to take frequent sips of fluids throughout the day to keep the mouth lubricated. Toothbrushes with soft bristles and non-alcoholic mouthwash can help improve good oral hygiene and reduce pain caused by the ulcers. Eating soft foods such as porridge, soups and stews instead of hard, fried and oily foods helps. Avoid snacking on

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hard solid food, drinking hot beverages or consuming spicy food as these can trigger and aggravate existing ulcers.

Chemotherapy affects the bone marrow’s ability to produce red blood cells, white blood cells and platelets. The degree and duration of this bone marrow suppression depends on the type and combination of chemotherapy used. Regular blood tests are needed to monitor the level of blood components. Physicians might opt to adjust doses of chemotherapy administered, defer chemotherapy or to switch treatments if needed. At times, individuals might be admitted for transfusions.

In the treatment of oral ulcers, oral gels and topical analgesics may be prescribed. In severe cases, a temporary feeding tube might be inserted through the nose to allow the patient to achieve adequate hydration and nutrition.

Bowel Discomforts Individuals undergoing chemotherapy treatment may experience diarrhoea or constipation, depending on the prescribed chemotherapy agents, prior surgical procedures or changes in the dietary habits. For chemotherapy agents that are more likely to cause diarrhoea, physicians may preemptively prescribe antidiarrhoea agents and oral antibiotics. Individuals are advised to take these medications as instructed, and to seek medical help if diarrhoea persists. Chemotherapy denudes the intestine lining and impairs the ability to absorb nutrients. As such, taking multiple small meals and avoiding high fibre and high fat diet food may help manage diarrhoea and abdominal pains. Individuals with low lactose tolerance are recommended to avoid milk and dairy products, and to drink plenty of fluids to stay hydrated. Admissions for intravenous hydration and nutrition, with a period of bowel rest might be needed for severe bouts of diarrhoea.

Bone Marrow Suppression

Medications such as opioid analgesics for pain and anti-nausea drugs that are used to combat nausea and vomiting often causes constipation in individuals dealing with cancer. When faced with this side effect, physicians will routinely prescribe laxatives. Individuals are advised to seek medical help if they experience severe constipation. Rectal enemas and manual rectal evacuation might be needed in serious cases. Individuals are advised to drink plenty of fluids and include adequate fibre in their diet.

Fatigue Chemotherapy is known to cause fatigue in individuals dealing with cancer. Individuals often experience a degree of tiredness after every chemotherapy treatment. As they

progress through the treatment cycles, the baseline level of fatigue may increase. Individuals are advised to avoid strenuous activities during chemotherapy. Light regular exercises and adequate rest are encouraged while caregiver support with the daily routines may help.

Most individuals who experience bone marrow suppression may encounter red blood cell deficiency also known as anaemia. Anaemia can aggravate fatigue and affect a person’s day-to-day functions, resulting in breathlessness (typically on exertion), giddiness and occasional fainting. Individuals are not required to limit their meat intake during treatment. Iron supplements and

erythropoiesis stimulating agents might be prescribed by physicians to increase red blood cell production and if severe, individuals will undergo transfusions. Patients may also experience low platelets which affects a person’s clotting function. When experiencing low platelet count, nose or gum bleeding risk increases and individuals are easily bruised and may experience prolonged bleeding from simple cuts. Individuals are advised to avoid heavy manual work, contact sports or vigorous exercises following chemotherapy. One of the most feared and potential complications of chemotherapy is known as febrile neutropenia. Individuals with febrile neutropenia have a severe deficit of neutrophils in the blood stream, to fight infections. Mild infections in a patient with neutropenia can become serious and life threatening in a matter of hours. Individuals are advised to return to their hospitals or respective oncologists should they experience fever after chemotherapy. Should their neutrophil count fall below a certain threshold, admission for intravenous antibiotics might be warranted. Neutrophil stimulating factors are commonly administered to individuals following chemotherapy to reduce the

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likelihood of such occurrences. Post chemotherapy, individuals are advised to avoid crowded places and to stay away from close contacts who are unwell.

Hair Loss The loss of hair during chemotherapy can be distressing for most individuals. However, the degree of hair loss varies from each regimen and differs between individuals. Hair loss typically starts after a few treatments and not immediately. Hair loss is usually not limited to the scalp, areas such as the axillae, eyebrows and pubic region can also be affected. Individuals are recommended to avoid harsh shampoos, vigorous combing, use of curlers and perms. As treatment commences, patients may also choose wigs or hair prostheses that closely match their

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hair texture and color. Support groups are useful and often conduct meetings and sessions to help cancer individuals cope with issues of treatment-related physical changes to their body. In summary, the occurrence and severity of the different side effects mentioned above varies from patient to patient, and treatment regimen to treatment regimen. When faced with any side effects or changes in daily living, individuals are advised to alert the attending physician for further preventive medication to be prescribed. The doses of the chemotherapy can be adjusted or in situations of poor treatment tolerance, regimens might need to be changed. Our nurse educators, pharmacists, and dietitians are available to

help patients through this difficult period of their cancer treatment. In Tan Tock Seng Hospital, our various support groups meet on a regular basis, to provide respite for individuals dealing with cancer and support for individuals to face cancer survivorship with strength and confidence.

Dr Yeo Wee Lee Dr Yeo Wee Lee is a Consultant of the Medical Oncology Department at Tan Tock Seng Hospital and the Johns Hopkins Singapore International Medical Centre. He graduated from the National University of Singapore and went on to receive his specialist training in medical oncology at the National University Hospital. He spent a year pursuing lung cancer research at Harvard Medical School. His sub-specialty interests are in head and neck, thoracic and gastrointestinal malignancies.

Preventing Dementia with Health Supplements: Do They Work? It may be a common scenario in the primary care setting, and even in specialist clinics, for physicians to come across elderly patients seeking a professional opinion on the benefits of health supplements. For those concerned with memory difficulties, they would typically ask questions such as, “Can these supplements prevent me from getting dementia?” or “Can these supplements improve my memory?”. What advice would be appropriate: to encourage the consumption of these supplements, or not?

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ncidence of dementia in Singapore is projected to increase over the years. According to the Dementia Asia-Pacific Report (2010), about 53,000 Singaporeans are estimated to be suffering from dementia in 2020. This figure is estimated to rise to 187,000 by 2050. The population in Singapore is ageing, and at risk of suffering from dementia as it grows older. Hence, it is understandable that the elderly are taking an active role in preventing dementia. Some of the more common health supplements brought to physicians’ clinics by elderly patients, or prescribed by physicians, include Ginkgo Biloba and Omega-3 fatty acids.

Can these supplements prevent dementia? Ginkgo Biloba is a herbal product frequently prescribed by physicians for patients with memory issues. Its proposed mechanism is its antioxidant effect, and an in-vitro study reported that it may also possess an antiamyloid aggregation effect. Hence, various studies have been done to assess the effectiveness of Ginkgo Biloba in the prevention of dementia. To date, there are no consistent results to show its effectiveness in preventing dementia. A large randomised controlled study done in the United States (i.e. Ginkgo Evaluation of Memory (GEM) Study) reported that Ginkgo Biloba has not been effective in preventing or delaying the onset of dementia in those above 75 years old. Due to the lack of evidence to support its effectiveness in dementia prevention, physicians will need to exercise their clinical judgment and discuss their recommendation with their patients prior to prescribing Ginkgo Biloba solely for memory complaints.

Omega-3 fatty acids can be found in fish (salmon, sardines), fish oil, chia seeds, walnuts and soy foods. Fatty acids promote cell membrane stability, fluidity and maintain synaptic connectivity. One of the postulated mechanisms of the Alzheimer’s disease pathogenesis is fatty acid oxidation by free radicals that leads to the damage of cell membranes. Omega-3 fatty acids have been reported to yield anti-inflammatory, antiarrhythmic, antiaggregant and antiatherogenic effects, thus supporting its beneficial effects on both cardiovascular and cerebrovascular function. Multiple studies have been done to examine the role of Omega-3 fatty acid supplements in the primary prevention of dementia. To date, results have been inconsistent, and a Cochrane Review published in 2012 reported no benefits of Omega-3 fatty acid supplementation in the prevention of dementia in cognitively healthy individuals. Nevertheless, Omega-3 fatty acid supplementation has been found to be beneficial in those with cardiovascular disease, and its prescription may benefit certain groups of individuals.

Would other health supplements such as vitamin B12, vitamin E and folate be a helpful in reducing the incidence of dementia? Vitamin B12 and folate play an important role in lowering homocysteine levels. Elevated homocysteine levels have been associated with strokes, cardiovascular events (heart attacks) and Alzheimer’s disease. Though the evidence is lacking for the use of vitamin B12 and folate supplements in primary prevention of dementia, patients who have B12 or folate deficiency should have their vitamin

levels repleted to reduce complications of deficiency states such as anaemia and neurological sequelae. Vitamin E has an antioxidant effect, and studies have been done in the past to evaluate its effectiveness in dementia prevention since oxidative stress may have contributed to the pathogenesis of Alzheimer’s disease. Similarly, there are no consistent results to suggest that vitamin E supplementation can prevent dementia. There are many other health supplements that are readily available over the counter, at various pharmacies. These supplements do not require a physician’s prescription. However, as physicians, we may need to offer appropriate advice to our patients who may be taking various health supplements for a multitude of reasons, by highlighting that these supplements may interact with prescribed medications and render them less effective. The benefits of these health supplements will need to be weighed against their side effects, the burden of polypharmacy, and the lack of evidence in dementia prevention.

Dr Noorhazlina Binte Ali Dr Noorhazlina Binte Ali is a Consultant of the Cognition and Memory Disorders Service, Department of Geriatric Medicine at Tan Tock Seng Hospital. She obtained her basic medical degree and Masters of Medicine (Internal Medicine) from the National University of Singapore. She is a Member of the Royal College of Physicians, UK. Her interest is in advance care planning, end-of-life care, advanced dementia, and caregiver education.

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Fitness

Too Much

Sitting, Too Little Exercise The importance of physical activity in managing cardiovascular disease

recommended for patients with heart disease. However, this is no longer advocated.

Physical activity is defined as any bodily movement produced by skeletal muscles that requires energy. According to the World Health Organisation, physical inactivity has been identified as the fourth leading risk factor for global mortality, causing an estimated 3.2 million deaths worldwide. Physical activity is a modifiable risk factor for cardiovascular disease. There is strong evidence to show that moderate to vigorously intense physical activities plays a key role in preventing cardiovascular disease by targeting risk factors such as type 2 diabetes, hypertension and obesity.

In recent studies, strong evidence has shown the importance of engaging in regular exercise to attenuate or reverse the disease process in patients with cardiovascular disease; for example, slowing down the progression of coronary artery disease. The recent physical activity and health recommendations from the American College of Sports Medicine and the American Heart Association continue to stress the importance of participating in at least 30 minutes of moderateintensity physical activity or 20 minutes of vigorous-intensity physical activity for at least 5 days a week, accumulating a minimum of 150 minutes a week. This is applied in addition to the light activities of daily living such as standing, walking slowly and lifting objects.

The benefits of physical activity also extend to patients with existing cardiovascular disease. In the past, rest and reduced activity have been

The Sitting Disease With advances made in the modern world, the need to be active is significantly reduced. People can now spend the majority of their waking day in a chair watching television, working at a desk, ordering and receiving items in the comfort of their homes such as take-out and online shopping etc.. There are many forms of locomotion that rid the need for walking. A study by the Singapore Heart Foundation in 2010 revealed that only 19% of adults aged 18 to 69 years exercise regularly and more than half of Singapore residents do not exercise during their leisure time. Although the human body is made to be in frequent motion, people can sit for many hours at a time, day after day. Sedentary behaviour has been the new focus for research in physical activity and health. This phrase ‘sedentary behaviour’, originates with the Latin word “sedere” which means “to sit”. Sedentary behaviour is defined by their posture (sitting or reclining) and their low energy expenditure – typically at least three times lower than moderate-intensity activities such as brisk walking. Recent studies have shown that time spent in sitting have an independent impact on increasing cardiovascular risk factors namely obesity, lipids and type 2 diabetes. One of the most striking findings in these studies is that these negative

effects of prolonged sitting also apply to those who fulfil the criteria of 30 minutes of physical activity daily but spend the majority of their day sitting. This highlights that physical activity does not cancel out the ill effects of too much sitting during the day. These effects are further magnified in people who do not exercise and remain sedentary for most of their day. The highest mortality risk is seen with people who are obese.

So how much sitting, is ‘too much’? According to a US survey, at least half, and up to two thirds of an adult’s waking hours are spent sedentary which range from 6-10 hours a day. Prolonged sitting has an impact on mortality and life expectancy. Too much sitting impairs the body’s ability to deposit fat from the blood stream into the body. In addition, it is observed that too much sitting during the day impairs the functioning of the body’s good cholesterol, known as high-density lipoprotein (HDL) which is responsible for cleaning up plaque that sticks to arteries. In a nutshell, the more you sit, the higher the risk of increasing your systolic blood pressure, waist circumference, blood glucose and triglycerides even if you adhere to the recommendation of 30 minutes of moderate-intensity physical activity a day. All studies are indicating that moving more during the day, in addition to getting the daily 30 minutes of moderate activity on a

daily basis, is necessary to lower one’s risk of cardiovascular disease and other causes of mortality.

The Remedy: Stand up, sit less, move more, more often Now that we know that sitting increases cardiovascular disease risk factors and reduces length of life, how can we turn things around? This is especially important for people who are in occupations which involve prolonged sitting. For example: office workers, transport drivers and those who have to sit due to musculoskeletal disorders like osteoarthritis which can be a barrier to participation in moderately intense activity as well. The key here is breaking up sedentary time with light activities such as standing and normal paced walking. Studies have shown that insulin action improves with more standing time and stepping time. The effects of light activity compared to moderate activity is shown in another study. Sitting interrupted by a short 2-minute bout of walking showed similar, significant reductions in post-meal glucose and insulin. These short breaks suggest that light activity plays a beneficial role in reducing the adverse effects of prolonged sitting, compared to having no interruptions at all. The importance of regular moderately vigorous exercise should continue to be emphasised in the prevention and treatment of

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cardiovascular disease. At this stage, everyone is encouraged to create opportunities to limit your sitting time at home, at work and during transportation and break-up long periods of sitting through frequent transitions from sitting to standing to walking as much as possible throughout the day. The key to minimising cardiovascular disease is: ‘stand up, sit less, move more, more often’.

Fitness

The following information may be useful in offering you practical suggestions in reducing sitting time throughout the day, as well as through a 5-minute desk workout. If you are above the age of 40, or have any existing medical conditions, or recently been inactive or concerned about your health, it is advisable for you to consult a doctor before starting on any moderate-vigorous intensity physical activity. Not all exercise programmes are suitable for everyone, and some programmes may result in injury. Activities should be carried out at a pace that is comfortable for the user. Users should discontinue participation in any exercise activity that causes pain or discomfort. In such event, please seek medical consultation immediately.

Fact sheet of how sitting is bad • People with sitting jobs have twice the risk of cardiovascular disease compared to those with standing jobs

5 Minute Desk-xercise! Equipment needed: Desk, Chair, Stopwatch Optional: Ankle weights Complete 10 reps of each exercise, repeating as many cycles as possible to complete 5 minutes.

Arms 1

• Standing one to two feet from a sturdy desk, lean forward until palms are flush against the desk, with arms straight and parallel to the ground.

• Fat burning drops drastically to 1 calorie per min the moment we sit • Every 2 hours spent just sitting reduces blood flow, raises blood glucose and drops good cholesterol by 20% • Watching television for 6 hours a day takes away 5 years off your life • Walking burns 3-5 times more calories that sitting does. Take every opportunity to walk around the office

Desk Push-ups

• Bend the elbows to bring the body towards the desk, hold for 3 seconds, and then push. • Move back to the starting position.

Triceps Dips Against Desk • Using a sturdy desk, with the feet planted on the floor a step or two away from the desk or chair, straighten up the arms to lift up the body. • Bend the arms to reach a 90-degree angle so that the body dips down, hold, and re-straighten the arms.

• Interrupt sitting whenever you can

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Fitness

TRUNK 1

legs

Seated Sit-ups

• Sit all the way to the edge of the chair, lean back towards the backrest. • With arms crossed in front of the chest, come up to an upright sitting position. 2

Controlled Squats

Modification: Single Knee Lift

Double Knee Lift • Sit back all the way in a chair, arms supported on the arm rest. Keep your back straight.

• Start standing with feet together (with the desk chair pushed out of the way). Bend the knees slightly so the thighs are almost parallel to the ground, as if sitting in a chair. • Keep the arms straight up or towards the computer screen. Hold for 10 seconds and release.

Heel Raises

• Bring one or both knees up towards the chest without pressing too hard on the arm rest.

• Standing with feet shoulderwidth apart, press up onto the toes.

• Repeat (alternating legs if raising them separately).

• Hold for 3 seconds at the top, then lower back down.

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healthy recipe

Hearty Tuna and Walnut Patties

legs 1

Seated Leg Raise • Keeping your back straight and while seated, straighten one or both legs and hold in place for 5 or more seconds. • Lower the leg(s) back to the ground without letting the feet touch the floor. • Repeat (alternating legs if raising them separately). Add ankle weights as a progression.

(Serves 4)

Eat your way to a healthier heart with these hearty tuna and walnut patties. Tuna is a rich source of omega 3 while walnuts are a good source of polyunsaturated fat, which are shown to reduce blood triglyceride level. Rich in soluble fibre, rolled oats also help to reduce cholesterol absorption. As egg yolk is a source of dietary cholesterol, you may consider replacing whole eggs with egg whites.

Methods

Modification: Single Leg Raise

1. Beat egg whites with lemon juice in a bowl; stir in sliced cheese, oats and black pepper to make a paste. 2. Add tuna flakes and shallots to the paste and mix gently. 3. Shape mix into 4 large patties. 4. Add 1 tsp canola oil in a frying pan; fry each patty until golden brown on both sides, for about 3 minutes per side. Remove cooked patties and put it aside. 5. Repeat step 4 with the remaining patties. 6. Serve tuna patties with salad or rice on the side.

Ingredients Canned tuna flakes 2 cans X 150g in water (drained) Egg whites 3 eggs Walnuts (chopped) 30g Shallots (chopped) 2 Red capsicum (chopped) ½ Rolled oats 85g Lemon juice 1 tbsp Low fat cheese (sliced thinly) 1 slice Black pepper ½ tsp Canola oil 4 tsp

Nutrition Analysis Calories 293kcal Carbohydrates 14g Protein 27g Total fat 13g Saturated fat 2.7g Cholesterol 40mg Fibre 2.5g Sodium 117mg Omega 3 299mg

Ms Jaclyn Chow Ms Jaclyn Chow is a Senior Physiotherapist with Tan Tock Seng Hospital. She was awarded the Bachelor in Health Science (Physiotherapy) from Trinity College Dublin in 2013. Ms Chow has a special interest in Cardiac and Pulmonary Rehabilitation and has been working in both the inpatient and outpatient settings.

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