01-07-08 News-Dot Prog+Robotics Apnea V4 WF pathR3.indd 1 18/2/12 12:30 AM

Early preterm: 27 weeks or less*

Eyelidsmaybefusedat23-25weeks Eyesmayopenbutdonotfocus Hasimmaturegastrointestinal

system Hasweakmuscletoneandcannot

controlpostureandmovement Maybeabletosuck,butsuckingmay

notsynchronisewithswallowing

Developing preterm infant: 28-32 weeks*

Quiet,deepsleepincreasesaround30weeks

Eyeopeningincreasesindimlight Muscletoneisweak,butdevelops

slowlyoverthisgestationalperiod Legmovementsincreasewithhips

andlegsstarttoflex Middleearandtransmissionsection

ofauditorysystemiscomplete

Growing preterm infant: 33-36 weeks*

Maybearousedforfeeding Canturnheadfromsidetoside Hassmootherandmorecontrolled

movements Coordinationforsucking,swallowing

andbreathingmatures Usuallyabletonipple-feed

Older preterm infant: 37 weeks or more*

Hasperiodsofalertnessforsocialisationandlongerattentionspans

Demonstratesawiderangeofmovements

Seesbestatadistanceof20-25cm Sightisstillimmature Canidentifysounds

A preemie’s challenge

Infantsbornprematurelyfacemanychallengesfromtheenvironmentaroundthem,andareespeciallyaversetonoiseandlight.

Babiesaresaidtobeprematurewhentheyarebornbefore37weeksofpregnancy.Thosebornat32weeksorless,orweighinglessthan1.5kg,areusuallyplacedinneonatalinten-sivecare.“Ababyborn10to12weeksbeforetermfacesfardifferentchal-lengesfromababydeliveredonetotwoweeksearly,”saidDrImeldaEreno,StaffRegistrar,DepartmentofNeonatalandDevelopmentalMedicine,SingaporeGeneralHospital.

“Whentheyaredeliveredatlessthan28weeks,theysleepmostofthetime,sowetrynottohandlethemunlessnecessary.Mostcantolerateslowandgentlehandlingwhentheyarebetween28and32weeks.Andafter32weeks,pattingandstrokingmaybetolerated,”sheadded.

Shh! Quiet please, we need our sleep

02 SINGApoREHEALTH MAR⁄ ApR2012

News

Project helps reduce noise levels in neonatal intensive care to help preemies develop better

were “educated” on the special needs of preemies. To remind staff and visitors to keep noise levels low, a visual alarm was installed. It lights up and stays on for 30 seconds when people speak too loudly.

One of the biggest difficulties, how-ever, was bringing about a change in

habit among the staff. “NICU is a very stressful environment. The focus

is on providing care for the preemies, and

urgent communica-tion is often neces-sary. In the past, we called out loudly to quickly get some-

thing done, but we now have to remem-

ber to work and move quietly, which can be an

additional stress on busy people,” said Dr Ereno.

Many things in the ward also cannot be changed. “The project got us to think about how to get around them,” said Dr Ereno.

Four to five alarms, attached to each incubator and other equipment to moni-tor the preemies’ breathing, heartbeat, temperature and the like round the clock, alert doctors and nurses if something is amiss. They can’t be turned off and their volume has already been set to the lowest possible. Still, the sound is too loud. “To make sure an alarm doesn’t sound for too long, we make sure we attend to the baby as soon as possible,” she said.

Further changes can be made if a renovation is planned for the ward, and the hospital is able to take into consider-ation the standards set by the American Academy of Paediatrics, a professional association of paediatricians in the US, on how quiet the intensive care ward should be. “Many overseas hospitals have been trying to get the noise levels down, but no centre has been able to get them down to the recommended levels,” said Dr Ereno, who presented a poster of their findings at an international conference in December last year.

It has been known for some time now that prolonged and excessive noise can impair the development of premature infants or preemies. Yet, the neonatal intensive care unit (NICU), where 75 to 80 per cent of infants warded are preemies, is one of the noisi-est places in any hospital.

At Singapore General Hospital (SGH), Dr Imelda Ereno, Staff Registrar, Depart-ment of Neonatal and Developmental Medicine, and her colleagues decided to do something about making the neonatal intensive care ward less noisy. They man-aged to lower the noise level in the ward by 23 per cent.

“The project is part of our continual efforts to improve developmental care for premature infants. The organs of pree-mies, like the brain, hearing and visual centres, are still developing, and prema-ture exposure to a noisy envi-ronment can have conse-quences,” said Dr Ereno.

Noise agitates pree-mies, disrupts their sleep and makes them cry. It can also lead to other damaging effects later, such as hearing loss, attention deficit disor-der and other behavioural problems, as well as issues with social interaction.

“In the past few years, advances in neonatal care have led to more and more

BY Thava Ranipreemies surviving, but there has also been a higher inci-dence of these minor disabilities in pree-mies in NICU,” said Dr Ereno.

“The best environ-ment for premature infants to develop is inside the womb. If the preemie cannot be inside the womb, we try to ensure the outside environment is as close to that of the womb as possible.”

Noise controlThe group set about looking at the areas that made noise in the intensive care ward and how loud the noise was, then making changes where possible. The SGH team included Ms Tay Yih Yann, Nurse Clinician; Mr David Lam, Senior Manager, Biological Safety; Dr Masitah Ibrahim, Associate Consultant, Depart-ment of Neonatal and Developmen-tal Medicine and Dr Subramanian

Krishnakumar, Epidemiolo-gist. Associate Professor Yeo Cheo Lian and Senior Con-sultant Dr Selina Ho offered support, while SingHealth Foundation funding helped pay for new equipment and other changes.

Some of the modifica-tions were easy to make. Metal bins and water tap valves were replaced and supply drawers moved away from the infants’ cribs. Par-

ents and staff new to the ward

Very early preterm infants should have undisturbed rest, with lights and noise muted. To reduce the infant’s exposure to light, a cover is put over the incubator, said Dr Imelda Ereno, seen here checking on a preemie.

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*Selectedage-appropriatedevelopmentalguidelinesfromDepartmentofNeonatalandDevelopmentalMedicine,SGH

Equipment to monitor the preemies’ vital signs can have four to five alarms attached to alert doctors and nurses if something is amiss.

Mar⁄ apr 2012 singapore health 03

Can you guess what this is?See page 24 for the answer.

News

Eating less rich foods may not lead to a smaller waistline. Instead, replacing one meal in a low-calorie meal plan with a weight-loss shake or bar may be more effective than merely following a low-calorie diet alone, a study by a group of Singapore General Hospital (SGH) dietitians found.

People who are overweight or obese are put on a weight-management pro-gramme that includes a low-calorie diet, or such a diet combined with a meal replacement.

“But the effectiveness of meal replace-ments has not been studied in depth, so we wanted to find out just how useful they are,” said Ms Meina Armanda, a member of the team that included Ms Tan Ai Shan and Mr Tan Lee Boo, all from the Department of Dietetics.

Cutting calories A low-calorie diet works on the principle that if a person consumes fewer calories than he uses up, he will lose weight. The team looked at several studies done to evaluate the effectiveness of a partial meal replacement diet against the stan-dard low-calorie one.

“The results showed that (the people who followed) partial meal replacements had a greater overall weight loss com-pared with those who relied on a reduced-calorie diet alone,” said Ms Armanda. They found that people on the partial meal replacement plan lost a significant 2.7kg, and 1.6kg more than those on the reduced-calorie diet after three and six months respectively.

There were limitations to the review as not all the trials that the group studied were done in a controlled environment, but the results were promising enough

Shake off the kilosStudy suggests that replacing one meal with a weight-loss shake or bar may be more effective than relying solely on a low-calorie diet

BY SheralYn TaYfor the team to consider further study. “Going further, we can try to isolate the variables and factors,” she said.

Replacing a meal Meal replacement shakes or bars are nutritionally balanced products that people trying to lose weight can take in place of some meals. In a diet programme monitored closely by a dietitian, taking appropriate meal replacement products can be useful, said Ms Armanda. “Instead of skipping meals, meal replacements can help people lose weight as they are nutritionally balanced, convenient and easily accessible.”

A diet that includes a partial meal replacement can also help people comply with their diet by reducing hunger pangs and the effects of the so-called yo-yo diet syndrome, which happens when the body responds to an excessively low-calorie intake during a “crash diet” by adjusting the rate at which it burns calories to sup-port the body’s various daily functions. That slower rate of metabolism continues even when the person returns to normal eating, which can lead to weight gain.

“The yo-yo effect happens because crash dieting prompts the body to store fat at a faster rate once a person starts eating normally. This is the body’s pro-tective instinct trying to store reserves for future periods of deprivation,” Ms Armanda said.

Instead of going on a crash diet after binge eating, people should try to lose weight by making sustainable changes to their lifestyles and eating habits, she said.

The SGH team’s study won the first prize in the Best Oral (Allied Health Evi-dence-Based Medicine) category at last year’s SGH Annual Scientific Meeting, a conference showcasing the research and studies undertaken by doctors and other healthcare staff at SGH Campus, includ-ing Duke-NUS Graduate Medical School.

In focus

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From left: Mr Tan Lee Boo, Ms Tan Ai Shan and Ms Meina Armanda were part of a team that studied the effectiveness of using meal replacements in weight-loss diets.

after the birth of her second child, Mdm ellen ang* began putting on weight. Five years later, at the age of 34, she also experiences knee pain and has difficulty breathing as the 70kg that she weighs has been putting pressure on her petite 1.54m frame.

With two young children to look after, she has no time to exercise. Desperate to lose weight and regain her health, she sought help from a dietitian.

as Mdm ang’s body mass index (BMi) is 29.5 kg/m², well above the recommended average of 18.5-22.9 kg/m², Ms tan ai shan, Dietitian, singapore general hospital, recommended that she go on a diet plan which would reduce her weight by 1-2kg a month. Ms tan set Mdm ang’s daily calorie consumption at 1,200 kcal, 500 less than the estimated 1,700 kcal/day that she would ordinarily require.

Counting calories

An example of a 1,200kcal meal plan for Mdm Ang

*not a real person

The food pyramid illustrates the recommended portions of food.

Breakfast2 slices wholemeal bread1 teaspoon margarine300ml low-fat milk

Lunch1/2 bowl rice1 palm-sized stewed chicken (no skin) 1/2 cup stir-fried mixed vegetables1 medium apple(or replace with a weight-loss shake and 1 orange)

Afternoon Snack125g low-fat fruit yogurt (or 250g low-fat fruit yogurt if a meal replacement is taken)

Dinner3/4 bowl rice1 palm-sized steamed white pomfret 1/2 cup stir-fried chye sim1 slice papaya

04 News-CNY Clean Up V3 WF pathR2.indd 4 17/2/12 12:31 AM

04 News-CNY Clean Up V3 WF pathR2.indd 5 17/2/12 1:24 AM

Select your language

Scan your identity card OR key in your local NRIC/FIN number

For all visitors: Enter your name and mobile phone number

Non-ward visitors: After registration, scan your identity card at the gantry to enter

Ward visitors: Enter the patient’s surname, ward, room and bed number

Non-ward visitors: Enter the patient’s full name and identity card number

Ward visitors: When the patient already has the maximum number of people visiting him, you will be registered and placed on a waiting list. An SMS notification will be sent when a slot becomes available

Select your visitor type: Ward visitors Non-ward visitors

• Visitor accompanying Outpatient •Visitor accompanying Day Surgery/Day Procedure Patient

06 singaporehealth Mar⁄ apr2012

An easier way to visit SGHNews

Visitors to Singapore General Hos-pital’s (SGH) wards can now avoid the queue at registration coun-ters by using self-registration kiosks at the hospital, or by registering online on the day of the visit.

Registration is quick and easy, with only a few short steps. SGH allows patients to have only four visitors at any one time, and children who are vulnerable to infec-tion are discouraged from visiting.

People accompanying patients to cer-tain clinics or day procedures on the upper floors will also need to register. Visitors can still register at the usual registration counters found at Blocks 4, 5, 6 and 7.

No registration is required for patients and visitors to the outpatient clinics on Level 1.

The launch of new self-registration kiosks promises to ease the queues for people visiting their families

Register online

registeronlineatwww.sgh.com.sgonthedayofvisitbyenteringpatientandvisitor’spersonalparticulars

Visitorsmustcarryvalididentificationforscanningatthegantrytoentertheward

Identification that can be used for registration:

identitycard

Drivinglicence

seniorcitizencard

studenteZ-linkcard

No identificationVisitorscanapproachregistrationcounterstaffifthey

Don’thaveidentificationdocuments

haveforgottentheiridentificationdetails

Cannotrememberthepatient’sdetails

Where to registeratself-registrationkiosks

locatedneartheliftlobbiesofBlocks4,5,6and7

atregistrationcountersatBlocks4,5,6and7

Insert your identity card

Visiting hoursMondays to Sundays:

12-2pm

5-8.30pm

Frequent visitorspeoplewhoexpecttovisitfrequently

duringthepatient’sstaycanregistertheirparticularsbyfillingaformavailableatvariousplaces,includingvisitorregistrationandinformationcounters

thesevisitorswon’tneedtoregisterateachvisit,butwillstillneedtocarryvalididentificationforscanningatthegantrytoentertheward

MAR/APR 2012 singAPoRe heAlth 07

News> Continued from page 1

On target

benefits are numerous – travel time is now minimal and his waiting time has been considerably reduced. He can also get an appointment easily and the timing is more flexible, as the clinic is also open at night.

“At SGH, if I missed my appointment, I sometimes had to wait for three weeks,” said Mr Chua, who runs his own confine-ment nanny business. “The hospital is so busy. At times, I would be there for half a day, waiting to see the doctor, do tests and collect medicine. Then, I’d have to return on another day for the results.”

Now, all tests (except for x-rays) are done at his neighbourhood clinic. His medicines, which are still subsidised, are couriered from SGH to his home for a small fee.

The only thing he is unhappy with is not being able to use his Medisave account to pay his clinic bills, unlike at the hospital. “This is a real concern. I hope this issue can be looked into.”

from these diseases and GPs are seen as a vital link in their care.

Personalised careA big plus for Mr Chua is the person-alised care and longer consultation time (15 to 30 minutes), during which he can ask questions and Dr Kwan can explain his condition thoroughly to him. “These days, hospitals are overwhelmed. Doc-tors in the hospitals have less time. Here, I can ask him to visit on days when I am not as busy, so I can spend more time with him,” said Dr Kwan.

Personal attention is important to patients with chronic diseases, as they must understand their disease in order to manage it and make lifestyle changes. Mr Chua, for instance, only realised the seriousness of not complying with treat-ment after Dr Kwan found out he was taking only half his prescribed medi-cation. She suspected something was wrong while studying his health indica-tors, which were unsatisfactory.

“I was stubborn. I wanted to be less dependent on drugs and thought I could save money,” said Mr Chua. “But Dr Kwan explained the risks of doing so, and asked me if I wanted to go for kidney dialysis. Of course, I didn’t want to, so I started taking my medication properly again.”

Initially skeptical about whether a GP could handle his problem, Mr Chua now sees Dr Kwan as his family physician. “She’s friendly and approachable. I feel comfortable and open with her, and she encourages and motivates me. She advises me on diet and followup programmes. As my family doctor, she can be consulted if I have a flu or another illness. This is a one-stop, all-in-one service.”

Dr Kwan joined the DOT programme because she believed it would be very good for patients. She started by taking on 40 DOT patients in her busy clinic.

“For me, it’s community service. GPs are a privileged group and, since I’m quite established in my own practice, I wanted to give back to society in my own little way,” said Dr Kwan, a mother of three. “Seeing my patients stay healthy and out of the hospital gives me satisfaction.”

She pointed out that a considerable amount of paperwork is involved to make the DOT programme work. A large amount of it has now been transferred out of the GPs’ clinics to SingHealth.

Participating in the DOT programme is community service to me. I wanted to give back to society in my own little way. Seeing my patients stay healthy and out of the hospital gives me satisfaction. Dr grace kwan, family Doctor at bishan grace clinic

Mr Alex Chua (right) is happy to be able to have his medical followups done with Dr Grace Kwan as part of a pilot programme under SingHealth’s Delivery on Target (DOT) programme.

SingHealth’s team of Right-Siting Officers (RSOs) from the Chronic Disease Management Office consti-tute the nerve centre of the DOT programme.

Spearheading the programme, the team has managed to reduce paperwork – the major bugbear of GPs on the programme – by a con-siderable amount.

To streamline operations and ensure a smooth workflow for the clinics, RSOs, many of whom are retired nurses, have taken over the job of reminding patients about their appointments and following up on laboratory test results.

They also help keep a close watch on the progress of DOT patients to ensure they achieve the recommended targets and that their conditions remain under control.

The DOT programme’s prog-ress has not gone unnoticed. Recently, overseas medical insti-tutions have expressed interest in the programme and are keen to find out more.

In addition, patients are made respon-sible for holding their own records. “I’m happy that much of it has been taken off our hands. Also, when patients hold their own records, it makes them more aware of their own illnesses and more compli-ant with treatment. This is because they can see the results for themselves – the evidence is staring them in the face – so they are more willing to listen,” said Dr Kwan.

What’s next? The question remains: Is the DOT pro-gramme sustainable beyond the pilot project? Dr Kwan said: “If the govern-ment funds a subsidy or co-payment, it would encourage more GPs to join the programme.” She also backs suggestions for Medisave to be used for payments, and a cashcard-style payment linked to Medisave, which will help patients and reduce paperwork.

“If the government comes in, it will raise the standard of GP practice in Sin-gapore. People will have more confidence in coming to us for primary care, leaving hospital care for those who really need it. At the moment, hospitals are over-whelmed because of the subsidised cost, and also because people don’t know if GPs are able to treat chronic diseases,” she said.

With the overcrowding in hospitals, anticipated increase in patients with chronic diseases and the shortage of doctors and allied staff in public health-care, she sees a need for GPs to pitch in and help.

The DOT programmeLaunched in 2005 with two GPs and seven patients, the Singhealth DOT Pro-gramme has more than 100 GPs and 1,000 patients today. The current two-year pilot programme, which Mr Chua and others are on, is to test the feasibil-ity of the scheme.

Under it, patients with illnesses, such as diabetes, hypertension, asthma and hyperlipidaemia (high cholesterol and lipids), are referred by the hospital to GPs around Singapore. SingHealth matches their needs and directs them to clinics near their homes.

The aim is for GPs to keep these patients’ conditions stable and prevent them from needing hospitalisation. If, at any point, the patient’s condition dete-riorates, he will be referred back to the hospital’s specialist for management.

The programme is in line with the government’s plan to transform primary care so chronic diseases are prevented and managed in the community. As Singapore ages, more people are expected to suffer

The nerve centre

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I was stubborn. I wanted to be less dependent on drugs and thought I could save money. But Dr Kwan explained the risks of doing so, and asked me if I wanted to go for kidney dialysis. Of course, I didn’t want to, so I started taking my medication properly again.mr alex chua, a patient of Dr grace kwan

Mouth

Nose

Throat

08 singapore health Mar⁄ apr 2012

News> Continued from page 1

Dreaming of a good night’s sleep

such as at the base of the tongue. For Mr Lee, the CPAP device was

too uncomfortable to use. He also went through two earlier operations to open up his nasal passages and widen the area behind the palate. However, he was reluc-tant to consider a third, more invasive operation, as he was wary of undergoing a procedure which involves cutting the jaw or chin bone in order to pull the tongue forward.

The base of the tongue is a difficult area to reach by conventional surgery and, unless a large incision is made, the surgeon’s view and access are blocked by the jaw and a large part of the tongue. Hence, this usually requires the jaw to be split open.

New robot-assisted surgical option Luckily, for Mr Lee, a new minimally inva-sive technique using a robot-assisted sur-gical system for throat cancers became available late last year for treating sleep apnoea patients.

Robot-assisted surgery doesn’t require large incisions, or even incisions in some cases, to be made in procedures involv-ing hard-to-reach areas. But it still allows surgeons to perform intricate procedures with a high degree of accuracy. This is because the surgeon performs the opera-tion by manipulating surgical instru-ments mounted on robotic arms which have a range of movements wider than

Severe sleep apnoea, if not treated, is linked to hypertension, heart attack, stroke and early death. Dr Toh Song Tar, ConSulTanT, DeparT-menT of oTolaryngology (ear, noSe anD ThroaT Surgery) anD Sleep DiSorDerS uniT, Singapore general hoSpiTal

the human hands’. A 3-D high-definition camera also gives the surgeon a clear view of parts of the body not easily seen except when the surgical area is cut wide open, as in conventional surgery.

In the new procedure to treat sleep apnoea, the surgical instruments are inserted through the mouth to perform the operation, so no external incision is made. The robotic system’s camera enhances the surgeon’s view and the flexibility of the surgical instruments allows an unprecedented range of motion even in a surgical field so deep in.

“The (robot-assisted) system allows us to perform this procedure safely, allow-ing us to reach the most crucial part of the tongue base,” said Dr Tay Hin Ngan, Consultant, Department of Otolaryngol-ogy (Ear, Nose and Throat Surgery), SGH.

In November last year, Drs Toh and Tay performed the operation – the region’s first transoral robotic surgery for obstructive sleep apnoea – on Mr Lee. So far, the technique has been used on three other sleep apnoea and three throat cancer patients.

“There are those who chose not to address tongue base obstruction because they do not want bone surgery, but they

apnoea in itself is not a fatal con-dition because, when the brain senses the lack of oxygen, it wakes the patient from sleep and he begins breath-ing regularly again.

Obstruction of regular breathing can occur at dif-ferent parts of the nose-throat area – the nose, the palate (the roof of the mouth) or the base of the tongue. Mr Lee, like most patients with severe sleep apnoea, had obstruction in all three areas.

The airways close or get blocked for many reasons. In Asians, the typi-cally smaller skeletal framework and structures in the throat play an impor-tant part in causing the sleep disorder. Children can get the disorder if they have overly large adenoids or tonsils, while the airways of adults often narrow as they put on weight or age.

Depending on where the obstructions are, the patient may be asked to make lifestyle changes such as losing weight or quitting smoking, or may have to use a mask-like device called Continuous Posi-tive Airway Pressure (CPAP) to keep the airways open during sleep.

Patients can also have surgery to remove tissues in the nose or tonsils if the obstruction occurs in those areas, but a more invasive procedure is necessary if the problem lies further down the throat,

Snoring About 15 per cent of Singapore’s

population has obstructive sleep apnoea

this compares with 15 to 20 per cent for asians in general and about 25 per cent in Koreans. While the smaller body skeletal structure among asians tends to be the cause of the disorder, obesity is the main cause for Caucasians.

Affects more men than women patients tend to be males in their 30s

or 40s, and the incidence tends to rise in women after menopause.

Not all snorers suffer from sleep apnoea, but patients with sleep apnoea all snore

soft, rhythmic snoring is usually harmless. But if the snoring becomes loud and changes in intensity, it may be indicative of obstructive sleep apnoea.

Severity gauge the apnoea-hypopnea index (ahi)

measures the number of complete airway blockages (apnoea) and partial obstructions (hypopnea) that occur every hour during sleep. an ahi of 5-15 is considered mild, 15-30 is moderate, and a value greater than 30 is deemed severe.

Blood oxygen levels ideally, blood should have at least 95

per cent oxygen. a little dip below that mark is still acceptable, but anything less than 90 per cent is not healthy.

Cure rates When the ahi is less than five,

patients are considered cured. in very severe cases, surgery that reduces ahi to less than 20 is deemed successful.

To help snoring and mild obstructive sleep apnoea

reduce weight avoid alcohol or medication that aids

sleep as these relax the muscles at the back of the throat and cause obstruction

sleep on one side or on the stomach, instead of facing up, to prevent the tongue and soft palate from collapsing against the back of the throat

Getting uninterrupted sleep

can now have this option of a less invasive, safer method of surgery,” said Dr Tay, who regularly performs robot-assisted surgery on the thyroid, and head and neck tumours.

Robot-assisted surgery involving small incisions has several advantages over con-ventional open surgery for patients, such as a shorter time under anaesthesia, which reduces risk in any procedure especially for older people; less bleeding because of the smaller incisions; and often a shorter hos-pital stay and recovery period. However, the costs can be substantially higher.

For Mr Lee, it has made the difference from having airway blockages 46 times an hour to just eight. “I feel much better and fresher, and my mind is able to focus better,” said Mr Lee.

Clear a blocked nose with medication recommended by a doctor or pharmacist

Use dental appliances that reposition the lower jaw and tongue during sleep

For moderate to severe sleep apnoea Use a Cpap device to keep the

airways open during sleep Undergo surgery to enlarge the

back of the throat

While a person with obstructive sleep apnoea sleeps (left), the tissue at

the back of the throat collapses and blocks the flow of air.

During normal breathing (below), the throat is clear and open, allowing air to flow freely to and from the lungs.

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09 SolaxADVERT V3 WF path.indd 9 17/2/12 1:28 AM

How some patients

view treatment

targets“I never thought to

ask the doctor for my precise cholesterol levels as I was told

everything was alright.”

“This kind of things (treatment targets)

can fluctuate.”

“The LDL level should be kept

within 60 or what! I can’t remember the

exact figure.”

Lifestyle change vital after heart attack

Only a handful of patients with coro-nary heart disease (CHD) successfully change their lifestyles for the better. In fact, many revert to their old habits six to nine months after a heart attack or bypass surgery.

This was one of the findings of a study led by Dr Tan Ngiap Chuan, Senior Consultant and Director of SingHealth’s Pasir Ris Polyclinic.

The team found that many CHD patients were unaware of what they needed to do to improve their health and reduce their risk of another heart attack by achieving treatment targets for their blood pressure, LDL cholesterol and dia-betic control.

Some did not know what their target good cholesterol and blood pressure levels should be, or how to control their diabetes. Others continued with poor diets, a lack of exercise and unhealthy lifestyles. Several ate at hawker centres six times a week and said it was hard to change their eating habits. A small number also continued to smoke.

A big killer The study was conducted amid concerns about the deaths of CHD patients in the last few years compared to 10 years ago. An earlier study by Tan Tock Seng Hos-pital showed that 70 per cent of CHD patients did not meet the target choles-terol levels and ran a high risk of get-ting a second heart attack.

“We wanted to look at the factors that prevented our patients from reach-ing their targets, and develop better treat-to-target practices for both our doctors and patients,” Dr Tan said.

The study involved 44 patients and 18 primary care physicians. During focus group sessions, patients discussed their awareness of the disease and life-style choices, while physicians, in sepa-rate focus groups, discussed treatment protocols.

The information correlated with results from a survey of more than 300 patients on their lifestyles, expectations of care and awareness of their disease. The final results of both studies were pre-sented at this year’s Asia Pacific Regional Conference of the World Organisation of Family Physicians (WONCA), held in the Philippines.

The team found that the problem was due to many factors, including commu-

BY JacqueLIne chIa

them the opportunity to seek informa-tion on measures that they can take to achieve such targets.”

The team has now rolled out new measures to close the communication gap and improve awareness. Treatment targets are printed on CHD patients’ appointment cards for easy reference and posters have been put up in high-traffic areas in the polyclinic to serve as further reminders. Nurses also draw patients’ attention to their treatment targets, and patients have their blood pressure checked before consultation to increase their consultation time with the doctor.

These efforts have paid off. The level of quality care – as more patients achieve their treatment targets – has since improved.

10 singapore health Mar⁄ apr 2012

News

Heart patients can reduce their risk of getting a second heart attackp

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Patients with coronary heart disease should be aware of treatment targets so they can work with their doctors to achieve them, said Dr Tan Ngiap Chuan (above) of Pasir Ris Polyclinic.

“Medicine is to safeguard you. Sometimes, I pamper myself when eating, but

I know I’ve got some medicine as backup. I think

that’s the balance.”

Patients should aim for the following targets

Blood pressure < 130/80 mmhg

lDl-C (cholesterol) < 2.6 mmol/l

type 2 diabetes mellitus < 7%

hba1c

nication lapses between physicians and patients. Dr Tan said: “Primary care phy-sicians are often too preoccupied with the clinical assessment of the cardiac status to exclude the risk of a second heart attack. There was little discussion on mutually agreed goals or treatment targets during consultation.”

He said the checks doctors perform on CHD patients are correct and necessary. “What is missing is simply mentioning

“I do exercise. I walk to the market every

morning.”

“My doctor told me ‘your blood pressure is good’. That’s all. I don’t know what’s good and

what’s not.”

the treatment targets. We know the risk of having a heart attack again will be reduced signifi-cantly if patients manage these factors well.”

He said it is important to give patients information on their treatment targets. “Even if they are elderly and have dif-ficulty remembering the target levels, repeating the numbers to them gives

The new registration card has treatment targets printed on it as an additional reminder to patients.

High blood pressure (BP) is called the ‘silent killer’ because there are often no symptoms.

Even though you feel well, you could have had it for years without knowing.

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susceptible to heart attacksand heart failure.

It’s smarter to monitoryour blood pressurebefore you fall sick.

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12 singapore health Mar⁄ apr 2012

Tell us

was cut out and, today, I’m well and my mood is uplifted.

I thank God for being alive. I’m also very grateful to Dr Yong Tze Tein for her care, and visiting me daily despite her hectic schedule; the general surgeon Dr Grace Tan Hwei Ching; and the anaes-thetists Drs Chong Shin Yuet and See Hooi Geok for attending to me. I would not hesitate to recommend SGH to my friends.- Ms Dorothy Ng Siew Gek

In 2002, I had surgery to remove a cyst in my womb. In 2010, I was diagnosed with fibroids and what looked like another cyst in my womb. But my gynaecologist decid-ed to delay surgery as she wasn’t sure if the growth was a cyst or scarring from the previous procedure.

Then, last year, an ultrasound scan in-dicated a larger growth and surgery was strongly advised. I grappled with fear and anxiety, but decided to go ahead eventu-ally. It was a blessing in disguise!

Though no cyst was found, the surgeon discovered that my intestinal wall was clogged with adhesions from my previous procedures. About 10cm of my intestines

i would like to thank and commend sgh Medical social Worker Ms tang Chyi Yueh for her care and concern in dealing with my grandmother’s case. Ms tang did her utmost to facilitate our application to admit our grandmother to a nursing home, and also advised us on seeking financial help. although she was offered a place at ling Kwang home, my 99-year-old grandmother recovered and family circumstances allowed us to keep her at home.- Ms NL Soon

When my dad forgot to bring his polyclinic referral letter, Maslina Wahab, patient service associate, national Dental Centre of singapore, explained things in a very clear and detailed manner and provided alternatives. My father proceeded with his treatment the same day.- A grateful relative of a patient

Dr priscilla lu, Dental officer, national Dental Centre of singapore, made my mother comfortable by placing a rolled-up blanket as a cushion for her back, knowing that she had recently undergone an operation on her back. My mother is very happy. thank you. - A patient’s son

Tributes

Singapore General Hospital

Sindry Dhayzione of my friends is suffering from acne and various skin problems from an early age. this became systemic amyloidosis.like · Unlike · Monday at 11.08pm

3 people like this

Singapore General Hospital hi sindry, we do not discuss a patient’s condition in a public domain. We can only advise you on processes and procedures. We recommend your friend see his/her family physician for a referral.

Yesterday at 2.01pm · like · Unlike

Ibu Nur N Aniqis there any support group for parents whose child is born with a congenital health issue? i hope sgh can seriously consider having one, especially if the child has to go for any form of rehab programmes. it can be strenuous mentally, physically and financially for a parent. it is not only the child who needs help, but his parents too...like · Unlike · Jan 10 at 4.09pm

8 people like this

Singapore General Hospital @ibu nur, we have a list of support groups in sgh here: www.sgh.com.sg/patient-services/support-groups/pages/subpage.aspx. however, if you could send us a private message on what kind of support group you are looking for, we could help you better. alternatively, you may contact Ms Melody from Club rainbow (6377-1789) to find out more. Jan 11 at 6.57pm · like · Unlike

Facebook us!

When our uncle passed away in hospital recently, we weren’t able to claim his body immediately as we were told his death had been referred to the coroner.

Why couldn’t the doctor certify the death since he was under treatment at the hospital?

We are sorry for your loss and the delay in claiming the body. When doctors are unable to

determine the actual cause of death, they have to refer the case to the state coroner, who will decide if a post-mortem is neces-sary to determine the cause of death. An open casket is still possible after a post-mortem as it does not disfigure the body.

Relatives of the deceased can pay their last respects in the ward before the body is transferred to the Mortuary@HSA, which is situated at Health Sciences Au-thority, Level 1, Block 9, SGH.

A police officer will inform the family if a post-mortem is required, while staff at Mortuary@HSA will provide informa-tion relating to the expected time for the registration of death and claiming pro-cedures, including arrangements for the hearse to arrive at the mortuary.

For the registration of death, the iden-tity cards or passports of the deceased and the family member handling the pro-cedures must be produced.

A Certificate of Registration of Death, together with a Permit to Bury/Cremate Body, is then issued for relatives to claim the body at the mortuary.

results may occur. A false positive wrongly indicates the presence of a disease, while a false negative wrongly suggests the absence of a disease that is actually present.

An inappropriate over-reaction to a false positive test may lead to expensive, and pos-sibly invasive, over-investigation. A medical consultation with a doctor enables him to properly assess the patient before ordering appropriate tests and he can also interpret the results later. The doctor can then give appropriate advice to the patient.

I want to do a blood test, but I don’t want to see a doctor. Can SGH just issue me a request form?

Only doctors can order labora-tory tests and, in SGH, only tests ordered by a doctor can be per-

formed. Laboratory tests are complex tools in patient management, and have to be used and interpreted in light of each patient’s condition, including his medical and family history. False positive and false negative

No consultation, no blood test

When cause of death is unclear

A blessing in disguise

letters must include your full name, address and phone number. Singapore Health reserves the right to edit letters and not all letters will be published. Write to editor@sgh.com.sg or The Editor, Singapore Health, Singapore General Hospital, Communications Department, Outram Road, Singapore 169608, or talk to us on Facebook.

AND WIN A PRIZE FOR BEST LETTER

The winner will receive two pieces of Backjoy (worth $129.80) to relieve back pain and improve posture.

My father always has to go to the phar-macy at SGH Block 4 to buy Seretide 25/125mcg Evohaler 120D, and it often takes us about an hour to queue for the medication. Then, there is another half an hour’s wait at NCCS’ pharmacy for other medication. This travelling could be avoided if we could buy all medication at NCCS’ pharmacy.

We regret the inconvenience caused. Unfortunately, NCCS does not carry Seretide

Buy medicines at one location25/125mcg Evohaler 120D. Our pharmacy focuses on oncology drugs and Seretide is used for the regular treatment of asthma.

Our Pharmacy and Therapeutic Com-mittee regularly reviews drugs in NCCS’ list of medicines. Should we observe an increase in the demand for any drug avail-able at NCCS, our pharmacists will submit a request for it to be included in the list of medicines.

We would, however, advise that you discuss the matter with the doctor during your father’s next appointment at NCCS.

This letter wins an iCare 200 Blood Glucose Monitoring System worth $58 and Sun Chlorella A tablets (150 tablets) worth $33.

Lowering the risk of sudden car-diac death in young adults is a key research area which Dr Reginald Liew, Consultant, Department of Cardiology, National Heart Centre Singapore (NHCS) is working on.

“One reason people die suddenly is because of heart rhythm problems. But there are treatments available to prevent this, such as inserting an implantable car-dioverter defibrillator in high-risk cases or performing catheter ablation procedures in others,” he said.

Specialising in heart rhythm disorders (cardiac electrophysiology and pacing), he not only treats patients with irregular/ abnormal heartbeats (arrhythmias), but also researches the condition to better understand it, and improve diagnosis and treatment.

Reaching out through researchAs Deputy Director of NHCS’ Research and Development Unit, Dr Liew and his team have been focusing on the use of stem cell technology to develop a human heart cell model of inherited heart rhythm diseases. This will allow them to study the electrical properties of heart muscle cells from these patients, outside the body and in the labo-ratory, to better understand the diseases

Stalking a silent killer Sudden cardiac deaths take lives unnecessarily. Here’s one doctor who is doing his best to stop them in their tracks

Also an assistant professor at Duke-NUS Graduate Medical School, Dr Liew mentors students and organises the struc-ture of the cardiovascular course for first-year students.

“I was fortunate enough to have had many great mentors during the course of my training. I believe it’s important for young doctors to have role models to look up to,” he said.

His mentoring style is not just to teach facts but also discuss ideas and prin-ciples, and encourage students to think and apply what they know to situations. “The best way to prepare someone to be a junior doctor is to make him think for himself,” he said.

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Apart from clinical work, Dr Reginald Liew (centre with tie) also mentors students. He is seen here with students and researchers at NHCS’ R&D lab.

and improve diagnosis and treatment. “There’s always a lot more to do in this

field. Once you find out something new, there are five more questions you want to ask, so it’s never-ending,” he said.

Why Singapore? It was Singapore’s growth in research that drew him here from Britain, where he was raised and trained in medicine and cardiology. “The research scene in Singapore has taken off in a big way, so I was very interested in using my research background to work here and see if I could contribute to the research output,” said Dr Liew, who is married with two young children.

He first developed a passion for research as an undergraduate medical student at Cambridge University, where a lot of emphasis was placed on understand-ing basic principles of health and disease, and much of the third year was dedicated to formal research.

Before joining NHCS three years ago, he worked at St Bartholomew’s Hospital in London, where he trained in cardiac electrophysiology and was also knee-deep in research. One project which stands out, among the many he did there, is a small prospective trial which showed that using fewer cardiac catheters than standard ones in ablation procedures was more cost-effective and efficient. The results of this study may have a significant impact

on current practices in cardiac electro-physiology.

Dr Liew also undertook a formal period of research in the UK to perform a PhD study on how plant oestrogens (as in soya products) act on the heart. “I discovered novel actions, which may explain some of their beneficial effects, and why Asian populations that consume large amounts of soy appear to have less heart disease.”

His role as mentorHe chose to specialise in cardiology as he found it to be “true physiology in action”. He said: “Cardiology is an exciting specialty. You can treat patients quickly and see them improve over a short space of time.”

People

The “health minister” is home!Ms A Abrojibanu, Oral Health Therapist, National Dental Centre of Singapore (NDC), is often mistaken for a nurse or dentist at work. But, at home, her role is clear

Why I chose this job...I grew up with a strong passion to help and heal people. My dad wanted me to be a doctor but, because I’m a bit queasy about blood, I knew I’d be a therapist of some kind. Being an oral health therapist (OHT) is really the best place for me. It’s an area where I can also educate patients and make a difference. I get satisfaction from seeing them get better and, when they thank me, I feel so appreciated. If I weren’t an OHT, I’d probably be an occu-pational therapist or a physiotherapist – I’d still be in healthcare. I’ve never con-sidered any other career and I don’t get influenced by others. I listen to my heart and, if I feel that it’s right, I’ll go ahead.

My job…I work in the Periodontic Unit, Depart-ment of Restorative Dentistry at NDC. My job is to support the gum specialists by

By Serene Foocarrying out non-surgical treatments such as scaling and root planing (deep clean-ing), which they prescribe for patients with gum disease.

For those coming off their braces, I clean up and take impressions of their teeth so retainers can be made. I educate patients about gum diseases, tooth decay and the importance of regular followups. Busy or cost-conscious people may skip these checkups and allow gum disease to go undetected, as it is painless until the last stage. It’s sad to see young people – some in their 20s – with dentures because of dental neglect. Once a week, I go to the Health Promotion Board to supervise OHT trainees.

Challenging cases… Oral health therapists play a big role in maintaining the oral health of nose cancer patients. Radiation therapy affects their head, neck and oral regions. Some-times, when working on teeth with pal-ettes “exposed” after surgery, my heart will pound from anxiety, but I get over it

by focusing on the teeth and the job on hand. I also teach them how to care for their mouths, which are usually very dry.

Making a difference…Currently, I have a diploma in dental therapy and dental hygiene, but I hope to specialise in caring for patients with special needs. I know this can be a chal-lenging area, but I want to do it because I know I can make a difference there. We may not be able to do fillings for these patients, but we can, at least, maintain their oral hygiene and educate their caregivers.

When the scrubs come off…Every day, when I go home after work, I share my work tales with my husband and mother-in-law. Talking about them usually helps me de-stress. On being the “health minister” in the family…I may not be a doctor, but they certainly treat me like one at home and refer to me as the “health minister”. I have five sib-lings and, as I’m the only one in health-care, if anyone has an ache or pain, I will surely get a call. In fact, they call me for advice on anything related to health as they know I have studied something about diseases.

Educating patients on gum care is part of Ms Abrojibanu’s role at NDC.

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MAR⁄ APR 2012 sINgAPORE HEALTH 13

26x36cm_fullpagead.indd 1 11/30/2010 4:56:11 PM

15 Health+Asthma V4 WF path.indd 14 17/2/12 1:38 AM

Asthma Control Test If you have asthma and are older than the age of 12, take the Asthma Con-trol Test questionnaire below to check if your treatment plan is keeping the disease under control. Be sure to review your results with your doctor or nurse.

Circle your responses, then add up the total score. For instance, the score for the first question is three if your response is “some of the time”, and five if it is “none of the time”.

QUESTION 1 During the past four weeks, how often did your asthma

prevent you from getting as much done at work, school or home?

1. All the time 2. Most of the time 3. Some of the time 4. A little of the time 5. None of the time

QUESTION 2 During the past four weeks, how often have you had shortness of breath? 1. More than once a day 2. Once a day 3. Three to six times a week 4. Once or twice a week 5. Not at all

QUESTION 3 During the past four weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning? 1. Four or more times a week 2. Two to three nights a week 3. Once a week 4. Once or twice 5. Not at all

QUESTION 4 During the past four weeks, how often have you used your rescue inhaler or nebuliser medication (such as salbutamol)? 1. Three or more times a day 2. Once or twice a day 3. Two to three times a week 4. Once a week or less 5. Not at all

QUESTION 5 How would you rate your asthma control during the past four weeks? 1. Not controlled 2. Poorly controlled 3. Somewhat controlled 4. Well controlled 5. Completely controlled

Breath of life

MAr/APr 2012 SINgAPOre heAlTh 15

People with severe asthma can turn their health around with medication and proper treatment. By Angeline Neo

When his asthma flared up, he would be inhaling hard, trying to squeeze as much air as possible into his lungs. He heard wheezing sounds from his chest which felt tight, and he had coughing fits after every few laboured, phlegmy breaths. If his medi-cation – always close at hand – didn’t let him breathe easier, he would have to seek emergency treatment.

“It felt like my airways were blocked and I was breathing in very little air,” said Mr Tan Chay Hua, who has suffered from asthma since his youth.

Because his family was poor, he didn’t pay much attention to his condition, dis-missing it as a cold or cough. The disease – a chronic inflammation of the bronchial tubes or airways of the lungs – wasn’t diag-nosed and treated properly, and it became progressively worse. Just a couple of years ago, Mr Tan’s asthma was so severe that he was getting an attack which required emergency treatment at the hospital a couple of times a week.

Gaining control Now in his early 70s, Mr Tan has his asthma under control and severe attacks have become rare – a turnaround in his health that he credits to Dr Mariko Koh, Consultant, Department of Respiratory Medicine and Critical Care, Singapore General Hospital.

“Dr Koh gave me the confidence to live without my nebuliser,” said Mr Tan, refer-ring to the inhaling device that he uses to relieve the symptoms of asthma quickly. At the time, he was over-reliant on his reliever medication, using it more often than he should.

Under Dr Koh’s care, Mr Tan began to regularly use controller medications instead. Controller or anti-inflamma-tory medications, when used daily, are the most effective and impor-tant treatment for asthma as they prevent attacks by

WellnessThe right exercises for osteoporosis patients

p16-17 Wellnesshope for patients with heart problems

p18

making the airways less sensitive to irritants in the environment. They also help to reduce swell-ing in the airways and decrease the produc-tion of phlegm.

Through asthma counselling, Mr Tan also began to understand his condition, how to get his asthmatic symptoms under control, what causes an attack, how to avoid it and what to do when it strikes.

Asthma, said Dr Koh, is a common dis-ease that affects about 5 per cent of adults and 20 per cent of children in Singapore. While asthma cannot be cured, its symp-toms can be controlled with the proper use of medication and environmental control.

Because the airways of people with asthma are “hyper-reactive”, they react easily to anything from cold weather and exercise to dust mites, pollen, tobacco, and stress, she said. “That’s why asthma waxes and wanes. There are good and bad days, depending on what can trigger an attack,” Dr Koh said.

When the person is exposed to some-thing that triggers an attack, the airways narrow, their lining becomes inflamed, mucus or phlegm is produced and the patient must be given something to help him breathe.

Asthma patients have to use an inhaler containing a reliever medication, like sal-butamol, to quickly open up their airways and allow them to breathe easily. If the attack is severe, the reliever medication alone may not be effective and patients will need to take a tablet kept on standby, usually prednisolone.

Dr Mariko Koh (far right) and Ms Karen Tan (centre), Senior Asthma Coordinator, helped Mr Tan Chay Hua (right) control his asthma.

“It is important to recognise a severe attack of asthma and seek early medical attention,” said Dr Koh.

If left till too late, patients may end up on life-support machines to help them breathe. And if they can’t breathe, they won’t have enough oxygen going to the brain and vital organs, and that can lead to a vegetative state or even death.

“Generally, around 80 per cent of asth-matics have mild to moderate asthma. It can be controlled with the use of daily controller medications and they lead normal lives. They can go to school and work, and even exercise or participate in competitive sports without any prob-lems,” said Dr Koh, noting that footballer David Beckham and Olympic gold medal-list and swimmer Mark Spitz (who won seven gold medals at the 1972 Munich Olympic Games) are among the many famous people who have asthma.

“Like Mr Tan, if you have symptoms suggestive of asthma, seek early medical

help, use your medication as advised by your doctor and go for regu-

lar followup. Asthma can be controlled and asthmat-

ics can lead normal, fulfilling lives.”

ASTHMATIC AIrwAy DUrINg ATTACK

Wall inflamed and thickened

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NOrMAl AIrwAy

Relaxed, smooth muscles

TOTAl SCOre OF 25 – Congratulations! You have total control of your asthma. SCOre OF 20-24 – On target. Your asthma may be well, but not totally, controlled. SCOre OF leSS ThAN 20 – Off target. Your asthma may not be controlled.

16 singapore health Mar⁄ apr 2012

Wellness

High on exerciseBanish fragile and brittle bones by working out regularly. By Clarence Chen

Only old women can get osteoporosis

False osteoporosis can affect anyone, even young men. Young adults account for about 20 per cent of osteoporosis cases seen. osteoporosis can be the result of other conditions, including anorexia, an overactive thyroid and overconsumption of medication, such as steroids.

a condition known as hypogonadism, when the body doesn’t produce enough testosterone, is known to be the cause of about 50 per cent of osteoporosis in men. testosterone is the hormone that plays a key role in masculine growth and development during puberty.

Young men also get it

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Information provided by Dr Manju Chandran, Consultant and Director, Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital.

It may seem strange – and even dangerous – to be told that exer-cise is good for osteoporosis, a condition marked by bones which are fragile, brittle and prone to fracture. But that was exactly what the doctor ordered for Ms Mary Gnanapragasam when she was found to have osteoporo-sis when she was in her 50s.

“I was very worried when I was first diagnosed with osteoporosis. I didn’t want to fall and get fractures, and then have to walk with a stick or need someone to look after me. I wanted to remain indepen-dent,” said Ms Mary.

Now in her 70s, Ms Mary is completely sold on the benefits of exercise, and can be found at Singapore General Hospital’s (SGH) LIFE Centre gym on most days, going through the six or seven exercise routines prescribed for her by the cen-tre’s physiotherapists.

Osteoporosis is a bone disease which occurs when the body fails to form enough new bone, or when too much old bone is reabsorbed by the body, or both, leading to the bones becoming fragile and brittle.

“Although osteoporosis is often consid-ered an old woman’s disease, it can affect younger men as well as women,” said Dr Manju Chandran, Consultant and Direc-tor, Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, SGH.

Older women lose bone very quickly during menopause when their bodies stop producing estrogen – a bone-protective

balance or posture is more likely to fall, and this can lead to bone fracture, said Ms Ng.

She and other physiotherapists at LIFE Centre are present when the patients are exercising, and work with one to four patients during the training sessions. They make sure the patients are doing their exercises correctly, and check regu-larly that they are not having difficulty or feeling discomfort. Then, there are patients like Ms Mary who may need to move up the ladder to do more strenuous or different exercises.

Patients are also regularly monitored by the centre’s doctors, nurses and physio-therapists, and their progress is reported back to their physician. “The patient’s doctor must be happy with the progress he’s making,” said Ms Ng, adding that patients go through two rounds of pro-grammes for each referral, either new or repeat, after which they are discharged.

“We’re not a regular gym after all, but a gym within a hospital, and patients shouldn’t be here forever,” she said.

hormone. In younger people, the condi-tion can be the result of other causes such as an overactive thyroid, excessive con-sumption of steroids, eating disorders and vitamin D deficiency, she said.

was referred for physiotherapy services at LIFE Centre, where a team of doctors, spe-cialist nurses, dietitians, physiotherapists and other medical professionals teach patients suffering from diabetes, obesity and other lifestyle-related conditions how to live healthily through exercise and diet.

Osteoporosis patients are given a treatment that includes drugs to stimu-late bone growth, exercise therapy and a calcium-rich diet. “Diet and exercise are important complementary elements of their treatment,” said Ms Ng Deng Peng Senior Physiotherapist, SGH.

At the centre, Ms Mary was first assessed to find out the state of her health and the areas of concern before an exer-cise regime was put together for her. “It’s not enough to exercise, they have to be the correct ones that address the needs of the patient,” said Ms Ng.

These exercises include resistance, balance, posture and strength training as well as weight-bearing exercises to stim-ulate bone growth. A person with poor

Single leg Stand: To improve balance and coordination; progress by maintaining position – effectively on a smaller base of support – for a longer time or on uneven ground. An alternative is the tandem stand, with one foot in front of the other.

It’s not enough to exercise, they have to be the correct ones that address the needs of the patient. Ms Ng DeNg PeNg, seNior PHysioTHerAPisT, siNgAPore geNerAl HosPiTAl

extreme dieting can cause osteoporosis in young people

TrueBone tissue is constantly growing and replacing itself, with bone formation greater than bone loss in a person’s growing years. Bone mass peaks when a person is in his 20s or early 30s, after which bone cells break faster than they are replaced.

it is important to build up a good peak bone mass because the more a person has, the longer it takes for bone density to decrease during ageing, which causes bones to become thin, weak and prone to breaking.

any condition, such as extreme dieting, being severely underweight or being on long-term steroids for asthma, can interfere with the formation of peak bone mass and, in turn, lead to osteoporosis.

Ms Mary had little warning that she was suffering from osteoporosis, except for feelings of ache and pain in the body. Indeed, the disease is often detected at a late stage, usually when the person seeks treatment for fracture. But Ms Mary was lucky – her condition was diagnosed at an early stage during a medical review fol-lowing the removal of her reproductive organs for a large growth.

She was seen at the osteoporosis clinic by an osteoporosis specialist. In addition to treatment prescription, she p

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Distributes and provides supplies to healthcare professionals

Why collagen is important?In the composition of cartilage we fi nd 67% of collagen versus 1% of glucosamine.Glucosamine is an aminosaccharide contrary to collagen which is a molecularcomplex containing amino acids. Glucosamine is found in interesting quantities only in the liquid of the synovial membrane. Collagen is also found in the synovialmembrane but in larger quantities because the protein structure is more abundant inthe body.

Glucosamine acts more like a lubricantin the joints while collagen helps the tendons, ligaments, cartilage, muscles, membranes and synovial liquid (lubrifi -cation).

Our tendons... Our body’s rubber bandsBy observing the diagram of the human body on this page, we can easily recognize all the space that our muscles, ligaments and tendons occupy. The tendon is composed of thick, white fi bres of collagen that are held tightly against one another. These fi bres are made up in large part by collagen.

Our ligaments act like a connection between the bones. Our tendons act like ties to our internal structure for our muscles and our bones. The tendons and the ligaments of our body act like rubber bands of different sizes.

Since our tendons are used to bind our musculature to our bones, and to maintain elasticity and suppleness, our tendons necessitate a large amount of collagen, particularly after an injury or from aging.

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16-17 Health+ExerciseForOsteoporosis V2 WF path R3.indd 17 17/2/12 11:35 PM

18 singapore health Mar⁄ apr 2012

Wellness

Hello mate!the new, improved heartMate ii left ventricular assist device is a lifeline for patients waiting for a heart transplant. By Jacqueline Chia

Financial adviser Mr Senthil Nathan, 35, was living precari-ously with heart problems until the HeartMate II left ventricular assist device stabilised his condition and became a lifeline before his heart transplant.

In 2005, he had what appeared to be the flu bug, but the cough persisted and he had difficulty breathing and sleeping. He also gained weight despite losing his appetite.

His condition worsened and, one eve-ning, he struggled to the clinic for help. “The doctor took one look at me and knew something was wrong. He did an ultra-sound which showed my clearly enlarged heart. He said I needed to go to the hospi-tal immediately.”

There, doctors informed him that a viral infection could have attacked his heart, causing it to enlarge and result in heart failure. “I was utterly shocked because I’d never had any heart prob-lems before. The doctors said my heart was pumping at only 10 per cent of its full strength.”

In 2009, he was referred to National Heart Centre Singapore (NHCS), where he was evaluated and put on the heart trans-plant waiting list. “I couldn’t eat, sleep or walk. It took me 10 minutes to walk 3m and I was so breathless that, when I slept, I had to be in a sitting position.”

As a bridge-to-transplant, HeartMate II was implanted in him by NHCS doctors.

The device helps the heart pump blood to the rest of the body. Placed just below the diaphragm in the abdomen, it is attached to the left ventricle and the aorta – the main artery that carries oxygenated blood from the left ventricle to the entire body. An external wearable system that includes a small controller and two batter-ies is attached by an external cable, which the patient wears all the time and charges every day. Since May 2009, 19 patients have been implanted with it.

“I walked around with 5kg of batter-ies all the time. Every night, I plugged myself into a machine that kept my heart beating. But none of it mattered as HeartMate II allowed me to work again and I was much stronger than I’d been in years,” said Mr Nathan.

The transplant must waitInsurance adviser Mdm Jessie Tan-Neu-bronner, 46, developed heart failure in 2006 following an adverse reaction to chemotherapy for breast cancer.

Her doctors said she needed a heart transplant to survive, but did not think it was advisable to have the operation until she was in remission. In the interim, her heart condition was so bad, she was

practically bedridden and needed a device to help it function.

Her doctors put her in touch with NHCS where, after a series of

assessments, she was implanted with the HeartMate II left ventricular assist device in 2009. Since then, things have gone well – she’s regained normalcy and gone back to part-time work.

HeartMate II allows more patients to stay alive while waiting for a suit-able heart. Currently, about 15 patients are supported on left ventricular assist devices, while five patients are on the active waiting list for heart transplants, with a waiting time of about a year.

Strong hopes for a young heartThe youngest recipient of a mechanical heart-assist device in Asia is 14-year-old Choong Wei Tzen. He had a rude shock in February 2010 when, upon being admit-ted to a children’s hospital for acute appendicitis, it was discovered that he had an enlarged and weak heart.

In August 2011, he was admitted with severe heart failure and was transferred to NHCS for further treatment. There, he was put on a temporary life support system known as the Extra Corporeal Membrane Oxygenator (ECMO) before receiving the HeartMate II device five days later.

Since getting the device, he has regained his appetite and feels better. “I’m feeling very good. Before this, my appetite was poor but, now, I can eat better. I was breathless before, but not anymore,” said Wei Tzen, who has returned to school.

His mother Mdm Jacqueline Liau said: “He’s happier, healthier and more positive. Before the operation, especially when he was reaching the heart failure stage, he was very weak and knew it. Every time we visited him in hospital, he would keep a tight hold of his father’s and my hands.”

His surgeon Dr Tan Teing Ee, Senior Consultant, Department of Cardiotho-racic Surgery, NHCS, said: “HeartMate II gives most patients a very good quality of life. Most are able to go back to their normal activities after it is implanted in them. Before surgery, quite a number of them cannot even walk a few steps with-out becoming short of breath.”

Mdm Jessie Tan-Neubronner,

Insurance Adviser, 46She carries the external system in her bag, which looks ordinary save for the white cable, which

links the system in her bag to the device through a small opening

in her body.

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in the last decade, national heart Centre singapore (nhCs) has implanted over 50 mechanical heart devices in patients. ten of these patients went on to receive successful heart transplants.

Dr David sim, Consultant, Department of Cardiology and Co-Director of the heart Failure programme, nhCs, said people with weak hearts generally have them functioning at below 50 per cent. prior to this programme, about 30 per cent of patients died while waiting for a transplant, due to the lack of suitable donors.

heartMate ii, the latest mecha-nical heart device, was introduced in singapore in 2009. Compared to older devices, it has a much smaller pump that is fully implantable in the patient’s body. it was designed to significantly improve survival and quality of life, and provide several years of circulatory support to patients with advanced heart failure.

it is also more durable and can potentially be used for chronic long-term support for patients with irreversible heart failure. the first recipient in May 2009 was a 30-year-old female patient and she is still doing well today.

HeartMate II gives patients with heart failure a new lease of life while they await a heart transplant.

Mr Senthil Nathan, Financial Adviser, 35

Choong Wei Tzen, 14

Flu-like symptoms led to a viral infection that caused his heart

to be enlarged. His condition worsened and doctors finally implanted Heartmate II in him. It kept him fit and healthy till

his heart transplant in 2011 allowed him to travel

freely without it.

Doctors found that he had an enlarged heart when he was

admitted to KKH for appendicitis in February 2011. He had

HeartMate II implanted and has to carry a bag –

with batteries that need to be recharged

every day.

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About HeartMate II

18 Health+HeartMateII V4 WF path.indd 19 17/2/12 1:59 AM

20 singapore health Mar⁄ apr 2012

Spotlight

Let’s hear it for the winners!

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More than 2,700 healthcare professionals in Singapore – doctors, nurses, allied health professionals and ancillary staff – were honoured at the Singapore

Health Quality Service Awards 2012. From public and private healthcare organisations and community hospitals, they received Silver, Gold, Star

and Superstar awards. We feature five winners from SingHealth here

Caring is a family traditionIt was her parents – both doctors – who inspired her to become a nurse and care for the sick.

“They provided medi-cal services to the poor and needy in rural China, saving many lives in the process. When I was young,

my father taught me not to envy the rich, but think

of the poor and remember how lucky I was. From then

on, I made up my mind to help people,” she said.

Mdm Liang came to Singapore in the early ’90s as a trainee nurse

in the haematology ward of Singapore General Hospital. She remembers her kind colleagues teaching her patiently and helping her overcome the language bar-rier. “My friends also let me explore and enjoy Singapore culture and made me feel at home.”

She returned to work in Singapore because of its well-developed healthcare system and advanced medical technology, as well as the good working relationships she enjoyed here.

For the past 15 years, she has been looking after patients with heart disease at the Department of Cardiothoracic Sur-gery of National Heart Centre Singapore. Her role is to educate patients on how to prevent falls, maintain hygiene standards and assess their pain. If they need an operation, she explains the preoperation instructions and handles their discharge orders. She also teaches junior nurses, and is involved in nursing research and quality audits.

Her aim is to provide the best nursing care for her patients, and she feels happy and fulfilled when she sees them recov-ering. Currently pursuing an advanced diploma to upgrade her skills, she said: “This course energises me and fills me with ideas on how to do even better in the future.”

While honoured to receive the award, she wants to share it with her team. “Nurs-ing is about teamwork. We won’t do well without support from each other. So, the credit should go not just to me, but to the whole team.”

Mr Tay Kai Ming, Podiatrist, Singapore General HospitalSILVER AWARD

Madam Zabaria Yusoff, Senior Patient Services Assistant, Singapore National Eye Centre (SNEC) SILVER AWARD

Tending tired solesRepeated foot injury from too much com-petitive running in his school days, and his subsequent recovery, got Mr Tay inter-ested in podiatry.

He remains grateful to the podiatrist who helped him not only recover, but continue running and enjoying sports. “I was inspired by her level of profes-sionalism throughout the rehabilitation

process, and I hope to achieve the same level one day.”

The pain of his pre-vious foot injuries has taught him to be more sympathetic towards

his patients. “It helps me treat them better and

with lots of personal care,” said Mr Tay, who speaks Eng-

lish, Mandarin and Hokkien. His job involves helping

people with problems that affect their lower limbs. This includes assess-

ing gait and alignment, and advising on proper footwear. Correcting biomechani-cal abnormality relieves their symptoms and gets them ready for rehabilitation. Many patients have complications from diabetes, so he also does foot screening and manages diabetic foot wounds.

He finds it satisfying to help patients recover. He sees his “ultimate challenge” as convincing women to avoid non-sup-portive footwear as these are the common causes of foot problems.

The award came as a pleasant surprise to him. He said: “I’m grateful for the com-pliments. It’s always nice to be appreci-ated. I’ll continue to work hard to provide my patients with the best care.”

A friendly face at the frontline Although hospital counters are always busy, Mdm Yusoff has a ready smile for everyone no matter how hectic it gets.

She knows it can be harrow-ing for patients, so she ensures the registration, payment and appointment scheduling are done as smoothly as possible. “I’m concerned about people, especially those who need help. And since patients are worried, it’s my job to make them feel happy,” she said.

Inspired by her mum’s kind-heartedness, she chose this pro-fession because it gives her a chance to interact and help people. “I enjoy helping them and learning something new from them.”

One interaction she remembers clearly was when a patient’s daughter was trying desperately to fix an earlier appointment with a specialist for her father, who had discomfort in his eye. Mdm Yusoff man-aged to squeeze him in the next day, when doctors found his condition seri-ous enough to operate immediately. “His daughter’s gratitude serves as my inspira-tion to go the extra mile for patients.”

She does not think she did any better than her peers at SNEC to receive the award. “We all work hard to achieve ser-vice standards. This award is an impor-tant recognition, not just for me but all clinic clerks for the important work we do at SNEC.”

Madam Liang Ming, Senior Staff Nurse, National Heart Centre SingaporeGOLD AWARD

It doesn’t feel like work Dr Arjandas’ day starts very early with morning rounds and can finish – especially when there are emergencies – extremely late. But it never feels like work to him.

This is so because he is doing what he is really passionate about – working with chil-dren with bone and joint problems.

The study and management of bone con-ditions have always fascinated him. “Bones have this ability to heal completely and go back to their original state, unlike many other tissues and muscles in the body.”

At the hospital, he sees all kinds of bone fractures and deformities, some for the first time, but these challenges only make his work more interesting.

What makes his day is to see a sick child recover against all odds, and walk out of hospi-tal strong again. He thinks patients who are positive do better. “Perhaps, that’s why children, who are inherently happy and positive, heal better.”

A believer in the importance of play for children, Dr Arjandas also has a special interest in playground safety, and has conducted several studies to assess the severity and factors

What is gum disease?Periodontal disease, or gum disease, is a chronic bacterial infection of the gums and bone supporting the teeth, affecting one or more teeth. A milder form – gin-givitis – can be reversed by professional dental scaling, followed by regular brush-ing and flossing. But if left untreated, it can progress to periodontitis, where the gums, bone and connective tissue are damaged, causing tooth loss.

What causes it? The main cause is bacterial plaque which hardens and forms tartar over time. As the plaque grows, the body’s immune system fights the bacteria. The toxins mix with the enzymes to break down and destroy the bone and connec-tive tissue holding the teeth in place. If unchecked, the teeth may eventually become loose and have to be removed. Gum disease can range from mild to severe and can affect people of any age.

What can predispose you to it? Smoking can increase the risk of getting it and lessen the success of some treatments. Uncontrolled diabetes also increases the

SingHealth Women’s Forum 2012 – Fabulous From 40!Dr Tan Wah Ching, Consultant, National Dental Centre of Singapore (NDC), will give a talk at the forum on gum health. Dr Tan is from NDC’s Periodontic Unit, Department of Restorative Dentistry, and is also a clinical lecturer at the National University of Singapore. There will also be talks on diet, eye care, diabetes, perimenopause and menopause, as well as ovarian cancer.

Date: April 28, 2012, SaturdayTime: 10-11.30am (Special Interactive Sessions), 1-5pm (Forum)Venue: Sheraton Towers HotelContact: For more information, call 6377-8511, email marcom@singhealth.com.sg or visit www.singhealth.com.sg/FabulousFrom40

risk of infection. Hormonal changes in women’s bodies can make the gums more sensitive. Certain oral medication, treat-ments for cancer and AIDs, plus general susceptibility can all contribute towards increasing the risk.

What are its symptoms? They include swollen, puffy and tender gums which bleed when brushed, a receding gum line, abscesses, teeth that are shaky or drifting out of position, persistent bad breath and a dull ache in the gums or teeth. Some people have no symptoms or pain.

How is it treated? Treatments vary but are aimed at con-trolling the gum infection and restoring good oral health. Non-surgical treatments include scaling and root planing. Scaling involves scraping away tartar from above and below the gum line. In root planing, tough tartar and bacteria deposits along the root surfaces are removed with spe-cial instruments while the patient is on local anaesthetic.

Gum surgery serves to remove resid-ual tartar in deep unresolved periodontal

pockets. The aims are to control disease progression and make the area easier to clean at home. In patients with more advanced disease, gum surgery may be needed. The periodontist may sometimes suggest bone or tissue grafts to encourage new growth of bone or tissue to replace the damaged areas.

How do you prevent gum disease?Brush your teeth with a toothbrush and fluoride toothpaste twice a day or after every meal to minimise plaque buildup. Use interdental aids like an interdental brush or floss daily. Visit the dentist twice a year for checkups and professional cleaning. Don’t use tobacco products. If you smoke, quit.

Can gum disease affect other parts of the body? It is possible but, so far, research has been inconclusive. However, studies are ongoing to see if there is a link between gum disease and increased risks of heart attack, stroke or delivering preterm/low-weight babies, and whether diabetics with gum disease have greater difficulty controlling their blood sugar levels.

Dr Tan Wah Ching, Consultant, National Dental Centre of Singapore (NDC) answers questions about periodontal disease

Are your gums in the pink of health?

We pass this way but onceShe is described as a kind person who always sees the good, not bad, in others. Ms Quek attributed her good nature to her philosophy of life and her role models – her mother and grandmother.

“My philosophy is to live life to the fullest each day as life is unpredictable. We are all just passing through this world. When we are happy and treat others with

Ms Lilian Quek Lee Hua, Senior Staff Nurse, Marine Parade Polyclinic SILVER AWARD

MAR⁄ APR 2012 SINgAPoRe HeAlTH 21

Madam Liang Ming, Senior Staff Nurse, National Heart Centre SingaporeGOLD AWARD

causing playground injuries. “Play enhances a child’s physical and mental development, but caregivers must be mindful that some precautions are necessary to avert potential injuries,” he said.

Dr Arjandas interned under his mentor Professor E H Lee, a pioneer of paediatric orthopaedic surgery in Singapore. His spe-cial areas of interest include foot deformi-ties, developmental dysplasia of the hips, cerebral palsy, limb deformities and paedi-atric fractures.

A winner of two Excellence Service Awards (EXSA) Star accolades and one EXSA Gold award before this, he said: “Doctors don’t work with the intention of winning awards. But I am honoured to receive it and grateful for the recognition.”

Dr Arjandas Mahadev, Head and Senior Consultant, Department of Orthopaedic Surgery, KK Women’s and Children’s Hospital STAR AWARD

respect and kindness, they will be happy too.”

She is grateful to her role models for inculcat-

ing the kind streak in her. “My mother and grandmother would offer students from our hometown in Malaysia, who came here to study, free board and lodging, until they found a place to stay.”

Her personality traits were the rea-

sons why relatives and friends advised her to

go into either teaching or nursing. After choosing

nursing, she has never looked back. Her workday is hectic but

she has a ready smile for everyone. “Even if the environment becomes stress-ful, I keep my spirits high by counting my blessings,” she said.

She feels happy when patients, espe-cially those she has counselled, improve and adopt healthier lifestyles. “A change in lifestyle can translate into fewer hos-pital admissions and a lower financial burden on families.”

A winner of multiple awards, Ms Quek said: “I am thankful to my supportive bosses, colleagues and patients. With or without this award, it is my duty to deliver the best to my patients and be a respon-sible nurse serving the community. I hope to continue to do this every day.”

The experience in Bright Vision Hospital has been unex-pected because it led me to a brand new learning journey, and also inspiring as it got me thinking a lot about relation-ships and familial ties.

Venerable Kuan Yan, with the direction of the late Master Yen Pei, developed Bright Vision Hospital (BVH) into the largest community hospital providing the broad-est range of inpatient care, which covers rehabilitative, palliative and chronic sick care as well as a nursing home.

Today, BVH takes in patients referred by the restructured hospitals regardless of their religious affiliation and ability to pay. What an admirable achievement and important contribution to the community. The depth and breadth of human ability is great when we are guided by dedication, commitment and spiritual strength.

It has been my privilege to be sec-onded to BVH for this past year and a half, and to be part of the new chapter in the hospital’s life journey as part of the

decreases over time and where one lives from week to week and is unable to plan for the future. The dissonance is painful. We share the same small physical space, but live in different dimensions.

Doing betterI recently watched for the third time the movie Invictus, when, once again, I could barely fathom Nelson Mandela’s strength in transcending the experience of 27 years in prison to lead South Africa to its first multiracial elections.

For the rest of us mere ordinary mor-tals, his query to the Captain of the Spring-boks, who led the underperforming team to victory in the 1995 Rugby World Cup, is perhaps more achievable: “How do we exceed our expectations of ourselves?”

As I pen down these somewhat ram-bling thoughts, I am hoping we can all do a little more, a little better, with a bit more grace and kindness for the people around us with whom we share a space.

22 singapore health Mar⁄ apr 2012

Viewpoint

Do a little more, a little better

BY Choo Shiu Ling

Ms Choo Shiu Ling is Director, CEO’s Office, Bright Vision Hospital.

Bright Vision Hospital has come a long way to become the largest community hospital providing the broadest range of inpatient care.

SingHealth family. Changing expecta-tions of our patients, staff and broader community are a source of encourage-ment for the hospital to do even better and meet changing needs.

The gift of givingFor our patients and caregivers, BVH has been a reliable sanctuary for continuing medical care after their long journey in an acute hospital.

Given the socio-demographic profile of our patients, they often arrive at BVH both financially and emotionally drained. For the few months our patients are with us, the BVH team has the time and unique opportunity to truly create a recuperative environment and, perhaps, even provide moments of joy and happiness, beyond medical care.

Developing a dedicated and broad volunteer network has been critical, and engaging our volunteers such that we help them find personally fulfilling roles engag-ing with our patients is fundamental.

I have often wondered at the source of a person’s charitable instincts. I remem-ber being completely floored when I learnt that one of our kitchen staff from Myanmar, who earns a mere few hundred

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A member of Bright Vision Hospital’s senior management shares her observations and thoughts about working at the community hospital, which is now part of SingHealth Group

It is a daunting thing to get out of our comfort zone and accept new ideas, let alone a new vision.

dollars a month, is a regular donor of tubs of ice cream and sweet buns to our termi-nal palliative patients.

It made me think about what it takes to climb the hurdle of self-interest or self-preservation to genuinely spare a thought for another person before ourselves.

Thinking beyond the currentIt is a daunting thing to get out of our comfort zone and accept new ideas, let alone a new vision. As stated by Einstein: “Insanity is doing the same thing, over and over again, but expecting different results.” Enough said.

Perhaps, the most challenging and also the most rewarding effort for the BVH team has been to create viable oppor-tunities to meet new needs.

These include the opportunity for staff to do better and display their abili-ties in new areas, the chance to serve their colleagues and patients better, the opportunity for the hospital to provide better and new services, the chance for patients to better express their needs and receive the help they require and the opportunity for volunteers to fruitfully engage with patients.

Unresolved dissonanceAmong our patients, there are those who have made mistakes in life which family members and/or friends have not been able to forgive and reconcile with. Hence, they are presented to us at BVH alone, with little or no support, or with extremely aggravated familial ties. I sup-pose my mind then rationalises that there is some form of a reason, without judg-ing the circumstance, why a person ends up alone and lonelier than anyone needs to be.

However, the greatest challenge has been to frequently encounter patients who come from intact families or have supportive social relationships, but yet exist at the margins of society. The space in society which they occupy is very tough. Many exist in households where the entire income is less than $1,500 a month, where the family supports one person in a hospital and school-going chil-dren, where one’s standard of living likely

A sanctuary of care

Bright Vision hospital (BVh) is the larg-est of six community hospitals in sin-gapore providing treatment to patients who are not critically ill, but still require hospital care.

Community hospitals are run by vol-untary welfare organisations with some government funding. Following a request by singapore Buddhist welfare ser-vices to the Ministry of health for more professional medical services for BVh, senior singapore general hospital doctors are helping to provide clini-cal leadership and ensure continued improvements in the clinical expertise of the hospital’s medical team. the team is supported by visiting consultants from a range of specialties, including geriatrics, rehabilitation medicine, psychiatry and palliative care. the doctors work closely with nurses, therapists, social workers and pharmacists to ensure the patients receive the best possible care in a com-munity hospital.

Bright Vision offers inpatient and out-patient rehabilitation to help patients regain independence in their daily activities, as well as inpatient palliative care, continued specialised inpatient sub-acute care to prepare patients for discharge and inpatient long-term care for the elderly and chronically ill.

the management of Bright Vision is led by Chief executive officer Chua puay hian and Ms Choo shiu ling, who were seconded from singhealth group.

23 Money Matters-MedisaveFunds V4 pathR2.indd 23 17/2/12 1:01 AM

Public Forum: What Irritable Bowel Syndrome is All AboutTime 2-4pmVenue National Dental Centre Auditorium, Level 8Price $5 per person Registration Call Sonia at 6321-3922 for pre-registration.

Public Forum: Surviving a Cardiac ArrestTime 2-4pmVenue SGH Block 6, Level 9, Deck on 9Price Free. No registration required.Contact 6321-3590

Public Forum: Colorectal Cancer Awareness Time 1-5pmVenue HDB Hub AuditoriumPrice $5 per personContact 6321-4671 (SGH Colorectal Surgery Department) or 6421-5804 (Singapore Cancer Society)

SingHealth Women’s Forum 2012 – Fabulous From 40!Time 10-11.30am (Special Interactive Sessions), 1-5pm (Forum)Venue Sheraton Towers HotelContact 6377-8511 or visit www.singhealth.com.sg/FabulousFrom40

eVenT CalendaR

For more information and other listings, please visit www.singhealth.com.sg/events or the respective institution websites.

24 SINGAPore HeALTH MAr⁄ APr 2012

FYI

All rights reserved. Copyright by SGH (registra-tion no: 198703907Z). opinions expressed in Singapore Health are solely those of the writ-ers and are not necessarily endorsed by SGH, SingHealth Group and/or SPH Magazines Pte Ltd (registration no: 196900476M) and their related companies. They are not responsible or liable in any way for the contents of any of the adver-tisements, articles, photographs or illustrations contained in this publication. editorial enqui-ries should be directed to the editor, Singapore Health, 7 Hospital Drive, #02-09 Block B, Singa-pore 169611. Tel:+65 6222 3322, email: editor@sgh.com.sg. Unsolicited material will not be re-turned unless accompanied by a self-addressed envelope and sufficient return postage. While every reasonable care will be taken by the editor, no responsibility is assumed for the return of un-solicited material. ALL INForMATIoN CorreCT AT TIMe oF PrINTING. MICA (P) 076/06/2011. Printed in Singapore by Singapore Press Holdings Limited (registration no: 198402868e).

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Editorial TeamAngela Ng (SGH), Lim Mui Khi (SGH), Tina Nambiar (SingHealth), Ann Peters (SingHealth), Deborah Moh (SGH), Wendy Seah (SGH)

Singapore Health is partially funded by SGH Integrated Fund and SingHealth Foundation to advance the health literacy of Singaporeans.

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Co-funded

For advertising enquiries, please call 6319-3022 or email jrani@sph.com.sg

Mar 17 (Sat)

Answer to In focus (PAge 3):

Eat chocolate to prevent stroke and heart attack 1. What programme allows patients

with chronic diseases to be referred to their family doctors?

2. What is your favourite story in this issue of Singapore Health?

Closing date: Mar 14, 2012

Singapore Health issue 15 contest

Include your name, age, gender, address and telephone number. Winners will be notified via phone or email. Incomplete or multiple entries will not be considered.

email: editor@sgh.com.sg Post: The editor, Singapore Health, Singapore General Hospital, Communications Department, outram road, Singapore 169608

Winners of Contest 14They will each receive eight sample packs of Viartril-S worth more than $80.

Send in your answers and stand a chance to win a Blood Pressure Monitor from Bosch + Sohn, Germany (model: boso medicus control) worth $135.

Prizes must be claimed by May 6, 2012.

1. Beti Nuryanti2. Freddy Chew3. Chua Cheng Wee4. Leon Poh Chong Mei5. Pearlin Poh Bo Xuan

Mar 17 (Sat)

This is a photo of HeartMate II – a mechanical heart device which can be implanted in the human body. It keeps patients with heart failure alive while they wait for a transplant. It has a much smaller pump than older devices, which helps the heart pump blood around the body. Patients carry with them a small external support system in a bag, with batteries that need to be charged every day. For stories on patients living with HeartMate II, see page 18.

Mar 31 (Sat)

Eating a lot of chocolate could reduce the risk of coronary heart disease and

stroke by about a third, researchers at the University of Cambridge

discovered in a study done on data collected from 114,009 patients.

Although evidence suggested that chocolate was able to lower blood pressure – thus reducing

the risk of heart disease and stroke – researchers were

quick to warn that excessive consumption could result in

weight gain and diabetes.

Source: BBC

A new study by researchers in Spain found that people who were

physically fit had better odds of recovery if they suffered a stroke.

Physically active people responded much better to clot-busting drugs, had less brain damage and were

more likely to recover their motor skills than patients who had led a

more sedentary lifestyle before they suffered a stroke.

“Physical activity seems to prepare the brain to face stroke in a better and more efficient way,” said study author Dr Ana Clara Ricciardi

Ciocchini, a stroke researcher at Hospital Universitari Germans Trias

i Pujol in Barcelona.Patients with the highest level

of activity were more likely to have blood flow restored within two hours of receiving tPA – a

medication that dissolves blood clots and reopens arteries.

Fitness helps stroke recovery

Source: HealthDay News

Apr 28 (Sat)

Blood PressureNormal blood pressure

=120/80Pre-hypertension

>120/80 <139/89 Hypertension

> 140/90

CholesterolTotal cholesterol

< 200 mg/dLHDL (“good” cholesterol)

> 50 mg/dL (women) > 40 mg/dL (men)

Optimal LDL

<100 Triglycerides

<150 mg/dL

Waist sizeRisks of cardiovascular disease, diabetes, metabolic problems, high blood pressure and abnormal cholesterol increase if your

waist size is

Women

>35 inchesMen

>40 inchesSource: Webmd

Healthy numbers

6. Seto Ah Soo7. Tai May Yen8. Tan Poh Lay9. Vivian Wong10. Irene Yam Ching Wah

鼻

喉

口

page 28

随心所欲 的生活

当气道关闭或阻塞时，血液中的氧气含量可能会下降，有时还会降至危险水平。但睡眠呼吸暂停本身并不会致命，因为当脑部感觉到缺氧时，它会使患者从睡眠中稍微唤醒再使其开始规则呼吸。

呼吸受阻可能发生在鼻喉区的不同部位上 — 鼻、上腭（口腔顶部）或舌根部。像大多数重度睡眠呼吸暂停患者一样，李家顺所有三个部位都发生梗阻。

气道受阻或关闭有很多原因。一般对亚洲人来说，喉部的骨骼框架和结构较小是导致呼吸障碍的重要原因。儿童可能会因扁桃腺肥大而导致此病，成人的气道则常常因体重增加或年龄增大而变得狭窄。

医疗方法需根据梗阻出现的部位，患者可能需要调整生活方式，例如减轻体重、戒烟或使用称为连续气道正压通气（continuous positive airway pressure，简称CPAP）的面罩样装置来保持睡眠时段气道开放。如果梗阻发生在鼻或扁桃体内，患者也可动手术切除鼻内的阻塞性组织或扁桃体，但如果问题出现在喉咙更深处，例如舌根部，患者则需要更入侵性的疗法，针对下颌骨的手术。

对李家顺来说，CPAP装置使用起来非常不适。他之前还动过两次手术，以打开鼻道并拓宽上腭后部分。但涉及切除颌骨或下巴骨以将主舌肌前移的手术让他却步。

新选择：机器人辅助手术对李家顺来说可幸的是，新加坡中央医院在去年年底推出了一项采用机器人辅

新加坡中央医院

与新加坡保健服务

集团的双月刊

3月

20124月

> 文转 page 26

借助一种新的机器人辅助外科手术切除喉咙后部的阻塞性组织，阻塞性睡眠呼吸暂停综合症患者可以一夜安眠

李家顺先生又开始在睡眠中做梦了。也许这并不是一件大事，但能够做梦意味着又能正常睡觉了。这五年多来，他很少能够睡个安稳觉或深睡到做梦。他的睡眠频繁地受到干扰，以至于不论每晚睡多少个小时，隔天早上醒来时仍觉得疲惫不堪。

现年45岁的李家顺患有阻塞性睡眠呼吸暂停症，患者的上呼吸道在睡眠当中重复受阻，导致在夜间频繁地醒来。但通过一种称为经口腔机器人辅助手术

（transoral robotic surgery，简称TORS）解决了喉咙深部的梗阻问题从而帮助他缓解病症。

“尽管我打鼾，家人也注意到我一直看起来很疲倦，但我并不知道自己患有这种病症。我从未重视这些症状，直到开始出现严重头痛和眩晕时才去看医生，”李家顺说。

打鼾是一种常见症状睡眠呼吸暂停最常见的症状为大声打鼾，但由于睡眠经常在夜间受到干扰，患者

就会在日间时出现疲劳、嗜睡、健忘、易怒（脾气暴躁）和工作时无法集中注意力等症状。一些患者在清晨醒来时会有喉咙痛或头痛等不太明显的症状。

“随着病情加重，患者在夜间常常因气道关闭而停止呼吸、影响睡眠，”新加坡中央医院耳鼻喉外科及睡眠障碍组顾问医生卓颂达说。

卓颂达医生（左）和郑歆彦医生（中）使用鼻镜为患有阻塞性睡眠呼吸暂停的李家顺做检验。

原文 Thava Rani

过去的十多年来，患有慢性疾病的商人蔡家裔先生必须定期到新加坡中央医院看专科医生。但现在他可以往住家附近的家庭医生诊所就诊，同时还能获得相同的津贴。

患有肾病的蔡家裔对这个安排赞赏有加。这不仅更为方便，治疗妥当，同时费用也保持不变。

诸多优势这项方案是从新加坡保健服务集团（简称新保集团）共同护理计划（Delivering on Target，简称DOT）下延伸的，而蔡家裔是参与该项目的其中一名慢性疾病患者。按照方案的安排，在病情稳定后，患者可从新加坡中央医院的专科门诊转介至社区的家庭医生。

现年54岁的蔡家裔目前在距离住处仅一步之遥的碧山Grace诊所向关伟慈医生寻诊。这样的安排好处不胜枚举，不但大大缩短行程和等待时间，而且方便预约，就诊时间也灵活，因为诊所也会在夜间开诊。

“在新加坡中央医院，如果错过了预约日期，下个空档有时需等上三周，” 经营陪月保姆生意的蔡家裔说。“医院太忙了。我有时需要在那里呆上半天；等着看医生、做检查、取药。然后还得择日回医院索取检验结果。”

现在除了X光之外，所有的检查都能在邻里诊所进行。而且还继续享有药物津贴的他只需支付一小笔的快递费，新加坡中央医院便会把药物送至家中。

唯一不满的是他不能像以往在医院就诊时使用保健储蓄（Medisave）来支付门诊账单。“这是一个实际问题，希望能够得到关注。”

量身定制个性化医疗护理对蔡家裔来说，参与这项初步方案的

DOT共同 护理计划转由家庭医生照顾慢性疾病患者以减轻医院负担的初步方案

> 文转 page 26

一夜安眠的梦想

原文 SeRene FOO

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page 31

未使用的药物不可退款

page 29

消除疼痛

（左）阻塞性睡眠呼吸暂停患者睡眠时，喉咙后部的组织塌陷并阻

断空气流动

（下）在正常呼吸过程中，喉咙通畅并开放，使空气自由流入及流出肺部

page 29

饮食与癌症

新闻> 文接 page 25

一夜安眠的梦想> 文接 page 25

DOT共同护理计划

助手术系统治疗喉癌的新型微创技术，也能用来治疗阻塞性睡眠呼吸暂停症。

在舌根处动传统手术会受到下颌与舌头的阻挡，活动范围有限，入侵性高。机器人辅助手术无需大切口，利用内窥镜的角度和犹如蛇一般活动自如的机器臂，让医生绕过障碍施手术。三维高清摄像机清晰的画面也增加了手术的精准性 。

“机器人辅助系统给了我们在舌根，口咽和下咽前所未有的内视和施术能力，

26 新脉动 MAR⁄ APR 2012

好处在于个性化跟进及较长的就诊时间 （15至30分钟）。会诊时，他可以提出问题，而关医生也会仔细地向他解释病情。关医生解释：“目前，医院总是人满为患，医生的时间也有限。这里，我可以安排在非繁忙的时段就诊，这一来我便有更多时间与患者互动。”

个性化跟进对慢性病患者来说非常重要，因为患者必须了解自己的病情从而控制疾病并相应地改变生活方式。例如，从蔡家裔不理想的健康指标上，关医生发现他没有遵从叮嘱服用正确的药量，她便加以解释，直到蔡家裔意识到其严重性。

“过去我比较顽固。我想减轻对药物的依赖，并认为这样可以省钱，”蔡家裔说。“但关医生解释这样做的风险，并问我是否想进行肾透析。我当然不想，所以我便开始乖乖地服药。”

蔡家裔起初怀疑家庭医生是否能够处理他的问题，但他现已改观了。“关医生很友好并且平易近人。我感觉很舒服，还能对她推心置腹。她鼓励并劝导我，还提供有关饮食和后续管理的建议。作为家庭医生，如果我患上了流感或其他疾病，我也会咨询她，是个周全完善的一站式服务。”

回馈社会关医生认为DOT计划对患者来说是利多于弊非常有益，因此她也加入了该方案。在应付她日常繁忙的诊所的同时也接纳了40名DOT患者并为他们看诊。

新保集团的DOT计划在2005年推出。至今有100余名家庭医生和超过1,000名患者参与。

“对我来说，这是社区服务。家庭医生是有特权的群体，由于我行医经验已达成熟稳定，我想尽自己的绵薄之力回馈社会，”育有三名孩子的关医生说。“我最大的满足感是看到我的病人保持健康也不须再入院治疗。”

她指出，DOT项目涉及大量的文书工作。这工作现已从家庭医生的诊所转移

到新保集团。此外，患者将负责保管自己的记录。“我很高兴我们脱离了大量的文书工作。况且让患者保管自己的记录也能让他们更加了解自己的状况，并能更好地配合治疗，因为他们可以看到自己的成果。把事实摆在面前，他们会更愿意听从，”关医生说。

技能提升当关医生参加此项目时，她唯一担心

的是能否胜任管理慢性病患者的诊治工作，因为她通常会将此类患者转介到专科医生处。但DOT医生必须上四堂医学延续教育课程，帮助她提升医学知识并增强了她的信心。

她发现经由不同医学学会所主办的心脏学、呼吸疾病等主题课程既密集又累人，可是对她的工作却非常有帮助。“虽然每年必须放弃25个周末，但医学延续教育是非常重要的。你会学到很多东西，不仅能提高技能，而且还会增强治疗慢性病患者的信心。事实上，我进一步多上一些课程，从而增进本身的技能，”她说。

接下来会怎样？问 题 仍 然 存 在 ： 初 步 方 案 之 后 ，

D O T 计 划 是 否 可 持 续 发 展 ？ 关 医 生说 ：“ 如 果 政 府 出 资 补 贴 或 共 同 支付，这会鼓励更多家庭医生参与此项目。”她也支持使用保健储蓄及与保健储蓄相联的现金卡支付账单的建议，这将帮助并减少患者所有的文书工作。

“如果政府参与此方案，它也会提高新加坡家庭医生的行医标准。人们将对我国的基层医疗更有信心，从而将医院留给真正需要它的人。目前，医院拥挤不堪是因为医院的费用可获得津贴，而且人们也不确定家庭医生能否治疗慢性疾病，”她说。

由于医院里的患者太多，慢性病患者有增加的趋势，再加上公共医疗中的医生和专职人员短缺，她认为此时我国更需要家庭医生的参与和帮助。

有助于打鼾和轻度阻塞性睡眠呼吸暂停

减轻体重 避免使用酒精或药物以助睡

眠，因为它们会放松喉咙后部的肌肉并导致阻塞

侧睡或俯睡而不是仰睡，这样可以防止舌和软腭塌陷、阻塞喉咙后部

使用医生或药剂师推荐的药物消除鼻塞

睡眠时使用矫正下颌及舌的牙科配备

对于中至重度呼吸暂停 使用连续气道正压通气装置

保持睡眠时气道开放 进行手术开放鼻道或扩大喉

咙后部

实现不间断睡眠

睡眠呼吸暂停确实会间接导致死亡。如果未经治疗，重度睡眠呼吸暂停还与高血压、心脏病发作、卒中和早逝有关。患者更容易因休息不足导致的疲劳发生工业或道路交通事故。新加坡中央医院耳鼻喉外科及睡眠障碍组顾问医生卓颂达

增加了病患者的选择，”常用机器人辅助甲状腺和头颈肿瘤手术的耳鼻喉外科顾问医生郑歆彦说。

于2011年11月，卓医生和郑医生已为李家顺进行了该手术，这是本区域第一宗为阻塞性睡眠呼吸暂停症治疗的经口腔机器人辅助手术。迄今为止，这项技术已用于另三例睡眠呼吸暂停症患者及三例喉癌患者。至少还有另外两例睡眠呼吸暂停症患者正等待使用这种新技术进行手术。

“由于不想进行骨骼手术，所以有的患者选择不处理舌根部阻塞，但他们现在可以选择这种创伤性更小、更安全的手术方法，”郑医生说。

对患者而言，微创机器人辅助手术较传统开放性手术有多处优点，例如麻醉时间缩短（麻醉时间长附带风险，尤其是对老年人）；由于切口更小，出血减少；住院时间和恢复期常常缩短。但费用可能相当可观。

对 李 家 顺 而 言 ， 该 微 创 手 术 使 他的 气 道 阻 塞 从 一 小 时 4 6 次 缩 减 为 仅8次。“毫无疑问，我感觉好多了。我变得清醒多了，而且思维更加能够集中，”李家顺说。

大约15%的新加坡人患有阻塞性睡 眠呼吸暂停症 总体来说亚洲人有15-20%患病，韩

国人则高达25%。对亚洲人而言，身体骨骼结构较小往往是罹患此症的原因；对白种人来说，病因多为肥胖。

影响男性多于女性 患者以30多岁或40多岁的男性居

多，女性则是绝经后发病率较高。

并非所有打鼾者都患有睡眠呼吸暂 停，但睡眠呼吸暂停患者都打鼾 柔和、有节律的打鼾通常无害，但

如果打鼾声越来越大且强度发生变化，则可能是患阻塞性睡眠呼吸暂停症的征兆。

血氧气水平 血液中的氧气含量至少达到95%才视

为理想。略低于该指数仍可接受，但再低于90%则不健康。

严重度衡量 呼吸暂停-低通气指数（a p n o e a -

hypopnea index，简称AHI）测量睡眠时段每小时发生的气道完全阻塞（呼吸暂停）及部分阻塞（呼吸不足）次数。AHI为5-15视为轻度，15-30为中度，超过30视为重度。

治愈率 当AHI低于5时，患者视为治愈。在

十分严重的病例中，将AHI降低至小于20的手术视为成功。

打鼾

在新保集团DOT共同护理计划的安排下，蔡家裔（右）在住处的邻近向关伟慈医生寻诊。他对这样的安排感到很满意。

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MAR⁄ APR 2012 新脉动 27

保健

原文 Thava Rani

足够还是过剩？适量摄取维生素和矿物质才是保健的关键

维生素A，C和E是可帮助预防癌症的抗氧化物。但摄取过量的维生素C，可造成腹泻，或更糟的是可引起肾结石。同样的，摄取过量维生素A可以危害身体健康，包括肝脏损坏。

这是因为人体吸收某些维生素，如A和E及矿物质的速度较慢。如果所进食的维生素和矿物质比每日建议量还多，这些物质将渐渐累积在肝脏和脂肪组织，提高中毒的威胁。

维生素C是属于水溶性的维生素，当体内有过多的维生素C时，它会随尿液排出体外。新加坡中央医院药剂师张家兴表示：“即使如此，一个健康的普通人如果长期服用过量的维生素仍可以危害身体健康。”

维生素和矿物质分别在身体的正常成长和运作方面扮演不同功能。

张家兴说，水果和蔬菜中的维生素C是美容的基本元素，也有促进伤口愈合的作用。无法摄取足够维生素C可能会导致牙龈流血和容易有淤血的现象。

维 生 素 C 和 E 的 来 源 包 括 果 仁 、 油类、绿叶和根类蔬菜，可帮助提升身体的自然抗氧化物，以及清除多余可加速老化和致癌的自由基（化学名称为游离基）。钙和磷是维持骨骼健康的要素， 而铁则是红血球形成及运作的要素。

维生素和矿物质可是天然存在于我们的日常食物中。因此，吃具有各类新鲜肉类、谷类和蔬菜的均衡饮食应该能提供生体所需的维生素和矿物质。不过工作时间长和外卖餐的方便，意味着越来越多人每天所吸收的维生素和矿物质并没有达到每日建议量的标准。

增强身体的免疫力，存于酶内。它也是抗氧化物。

美国推荐饮食量：8mg（男），18mg（女）食物来源：

红肉如牛肉，蚝，虾， 金枪鱼，小扁豆，

四季豆，腰果过量服用：

轻微过量会造成便秘。 过度服用会导致胃粘膜 溃疡，和增加多个器官

损坏的风险。过量服用症状：

呕吐和腹泻

铁

有助于皮肤保健，和保护视网膜和粘膜

美国推荐饮食量：700mcg (男)， 900mcg (女)食物来源：

黄色和橙色蔬菜 如红萝卜、南瓜、

菠菜、番薯和鱼肝油过量服用：

引致皮肤干燥 和骨头脆弱

过量服用症状：疲倦，食欲不振， 呕吐，关节疼痛， 嘴唇和皮肤干裂，

头发脱落和皮肤呈黄色。

维生素A

维持心脏健康和肌肉收缩及神经传递。 健康骨骼的基础。

美国推荐饮食量：1,000mg食物来源：

奶制品，如牛奶，乳酪和酸乳酪，蔬菜如花椰

菜和包心菜过量服用：

会影响肾脏功能和减低吸收其他矿物质的能力。

过量服用症状：恶心，呕吐，

食欲不振和频尿。

钙

促进胶原形成。 胶原是细胞之间的连结物，连结皮肤下的血管、骨头、肌腱和

韧带。它也是 抗氧化物。

美国推荐饮食量：90mg (男)，75mg (女)

食物来源：水果如橙，葡萄柚和草莓，蔬菜如花椰菜

和番茄过量服用：

可能会累积在肾脏，造成肾结石，和造成另一重要矿物质如铜的流失。

过量服用症状：腹泻，肚子抽痛，恶心

维生素C

新加坡中央医院药剂师张家兴主张通过均衡饮食，来摄取足够日常所需的维生素。

强化免疫系统， 影响体内酶活动。 也是抗氧化物。

美国推荐饮食量：11mg (男)，8mg (女)

食物来源：红肉如牛肉，蚝，奶，

烘豆，鹰嘴豆过量服用：

会导致缺铜过量服用症状：

恶心、呕吐

锌

张家兴说：“我很好奇有多少人，在面对繁忙工作日程的同时能达到卫生科学局所推荐每天摄取各两份的新鲜水果和蔬菜量。”

在这样的情况下，服食综合维生素可确保摄取足够的营养。综合维生素含有足够的维生素以预防和补充营养的不足，但它并不提供日常所需的建议量。例如，它的钙质量并没有达到美国当局建议成年人每天需摄取的1000mg钙元素。

不过，很多人都开始服食维生素和矿物质的片剂或胶囊，因为他们相信大量的营养素可防止老化，避免疾病和促进精神和身体的机能。

虽然摄取量可能还低于最高摄取量的限度，但长时间过量的摄取维生素和矿物质会导致身体出现状况。

和所有好的事物一样，适量才是维持强健体魄的关键。

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郭照 在接受捐献的心脏瓣膜移植后能够不气喘地跑上一段楼梯。

28 新脉动 Mar⁄ apr 2012

焦点

不论何时走进安静的房间，规律的滴嗒声总是伴随着他，就连他的妻子和儿子都对他胸口发出的奇怪声音感到困惑。

郭照 说：“我之前没有意识到滴嗒声是来自我年轻时植入的心脏机械 瓣膜。”

现年44岁的郭照 因患有先天性心脏瓣膜缺失，13岁时进行了心脏机 械瓣膜移植手术。为了确保瓣膜周围不会形成血液凝块，他开始服用血液稀释药物。

郭 照 说 ： “ 虽 然 感 觉 很 好 ， 但 我必须坚持服药并定期监测血液粘稠度。随着年龄的增长，我并没有遵照指示坚持服药，母亲去世后我就完全停止了服药。”

三年后，郭照 因牙痛再次到医院就诊。“在检查时，医生问我是否一直遵照医生的指示服用药物。当他得知我并没有这么做时，他立即将我转诊到新加坡国家心脏中心，”郭照 说。

新加坡国家心脏中心马上要他入院观察。由于没有定期服药，他脑中风的风险十分高。

郭照 说：“那天下午我还有一场足球比赛，我试图说服医生让我去，但他告诉我猝死的风险实在太高了。”

心脏瓣膜性疾病新加坡约有1万名罹患先天性心脏瓣膜缺失或异常的成人患者，郭照 是其 中之一。除了先天性缺陷外，心脏瓣 膜也会因年龄增加或其他心脏性疾病而受损。

心脏瓣膜病变时会出现两种情况。新加坡国家心脏中心心内科顾问医生陈培德说：“一种是瓣膜关闭出现问题，导致血液返流或血液渗漏；另一种则是瓣膜开放问题。”

四个心脏瓣膜控制血液从心脏至身体其他各个部位的流向，任何功能障碍都可能导致伤残甚至死亡。心脏瓣膜异常的患者通常会在做爬楼梯等日常活动时感到虚弱无力和呼吸急促。

陈医生说：“认为自己可能患有心脏瓣膜性疾病的人应找医生对病情进行评估，即使病情较轻微尚无需手术，他们也应采取预防措施以避免不必要的 伤害。”

“例如，因为他们有晕厥的风险，他们应在有人陪同时进行锻炼并确保不做过于剧烈的运动。”

如果对心脏瓣膜疾病的诊断或治疗为时太晚，心脏可能会严重受损和过度虚弱，即使进行瓣膜置换手术也不 奏效。

漏水的水龙头需要更换零件更换受损的瓣膜是晚期患者的唯一选择。药物治疗仅能缓解症状，不能修复瓣膜受损、磨损或撕裂。对于患有先天性瓣膜缺失的人而言，手术最终是唯一的选择。

“不幸的是，心脏瓣膜问题是机械性问题。比如水龙头漏水，除了更换 漏水部件外没有其他修理办法，”陈医生说。

目前可移植的心脏瓣膜有两类：机械瓣膜或取自人或动物的瓣膜。

“虽然机械瓣膜十分可靠且耐用，但其缺点是需要患者终生服用华法林等血液稀释药物，”新加坡国家心脏中心心胸外科高级顾问医生林勇方说。除了

服用药物外，患者还需要定期监测血液粘稠度以确保适量服用药物。

另一选择是移植取自动物或他人捐献的生物瓣膜。

林医生说：“对不适宜服用华法林药物的患者来说，生物瓣膜是最理想的选择，例如育龄女性、生活方式十分活跃的人或服用华法林会导致生命危险的人。虽然生物瓣膜功效十分好，但使用的时间并不耐久。” 捐献的心脏瓣膜通常可使用上15年，才出现磨损和撕裂症状。

郭照 被转诊到新加坡国家心脏中心后，医生决定为他进行生物瓣膜置换手术（亦称同种移植），这也是针对郭照 病情的标准治疗法。手术康复后，郭照 感觉像一个全新的人。他说：“我现在感觉好多了，能够充分享受运动的快乐。手术前，每踢球10到15分钟就得停下来休息，但现在我能持续整个半场球赛。”此外，他每周还与朋友骑45至50公里的单车。2008年以前，像郭照 一样的患者必须选择从国外进口的捐献心脏瓣膜，因为本地没有收集和贮存捐献的人类心脏瓣膜的组织库。而这些瓣膜得来不易，价格不菲（约1万新元）同时也需要等待及运输时间。

为确保这里的患者能够及时获得并负担得起人类心脏瓣膜，新加坡国家心脏中心成立了全国心血管移植片存库。

根据《医学（治疗、教育和研究）法令》规定，心脏瓣膜捐献基于选择，死于心脏病发作的人也可以捐献心脏 瓣膜。

亦担任全国心血管移植片存库医药总监的林医生说：“表示愿意捐献心脏瓣膜的人将接受筛查和评估，从而确保他们的瓣膜可以进行捐献。例如，我们会评估他们的生活方式，确保他们不属于高危类别或携带肝炎等病毒。“

“我们还要通过检查确保他们的瓣膜没有任何感染、没有癌症迹象以及没

随心所欲的生活新的心脏瓣膜使患者重焕新生

原文 Claire Yeo

虽然通过开心手术置换瓣膜仍然是晚期瓣膜功能不全患者的首选治疗，但由于健康状况或高龄不适宜进行开心手术的患者现在可获得一种被称为经导管主动脉瓣置换术的新型微创方案。

新加坡国家心脏中心的医生于 2009年2月在亚洲首次成功实施这一治疗方案，通过腹股沟或胸部动脉的小切口将预先安装了组织瓣膜的球囊导管或安装在自膨式支架框架内的瓣膜引导至患病的心脏瓣膜，然后通过扩张球囊或使支架框架对着旧瓣膜自行膨胀，在旧瓣膜上放入经导管心脏瓣膜。

新 加 坡 国 家 心 脏 中 心 心 内 科顾问医生及经导管主动脉瓣置换术团队成员詹尊林医生说：“目前，经导管主动脉瓣置换术主要用于不适宜进行手术或手术风险比较大的患者。研究证明，这一治疗方法有助于降低死亡风险并提高这些患者的存活率。”

除开心手术之外的选择

四个心脏瓣膜控制血液从心脏至身体其他各个部位的流向，心脏的每一次搏动都只有两个瓣膜开放（右图，上/下）。

四个心脏瓣膜

图：

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neo 詹尊林医生表示，对不适

宜进行手术的患者而言，经导管主动脉瓣置换术提高了他们的存活率。

有可能影响瓣膜的其他疾病，”林医生补充说。

林医生说：“与其他类型的移植相比，找到匹配的心脏瓣膜相对来说比较容易。心脏瓣膜移植没有排斥的风险，不需要服用免疫抑制剂，而且供体与受体不需要进行血型匹配。”迄今为止，已有近30人向全国心血管移植片存库捐献了瓣膜，有近20名患者从中受益，几乎一半为儿童。

林医生说：“同种移植对儿童最为理想，他们3岁时就可接受移植。由于华法林可能会影响妊娠，育龄女性也适合此类移植。”

目前仍然需要从海外运输瓣膜来满足本地需求，但全国心血管移植片存库希望减少这数量。

“郭照 是一个幸运的受益人，但我们需要更多人自愿捐献这生命之礼物。我们也需要让大众知道我们拥有一个为本地患者的全国心血管移植片存库，”林医生说。

郭照 现在终于能够全身心地投入生活，虽然有时夜里还会在恐惧中惊醒。他说：“我惊醒是因为我听不到以前机械瓣膜的滴嗒声，一瞬间，我担心我的心脏停止了跳动。但是，这个新瓣膜给予了我更加美好的生活，我已经成为了一个正常人！”

他 补 充 道 ： “ 我 很 想 鼓 励 人 们 捐 献瓣膜，因为并非每一个人都像我这么幸运。”

主动脉

肺动脉瓣 主动脉瓣

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三尖瓣

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正常心脏瓣膜的运作

Mar⁄ apr 2012 新脉动 29

焦点

四年前的某个深夜，他的脚突然感到剧烈的疼痛，以至严重到无法行走。

向 来 身 体 健 康 的 邱 耀 庭 先 生说：“感觉就像有一把刀在我的右膝盖一样。”随后，这名88岁的调琴师被新加坡中央医院的医生诊断出患上类风湿性关节炎。

根据邱耀庭的主治医生，新加坡中央医院风湿病与免疫科部门的顾问医生熊嘉俊指出，类风湿性关节炎是一种关节慢性炎症性疾病，有时也会影响皮肤、眼睛、肺部和其他器官。

他说：“类风湿性关节炎是最普遍的自身免疫性风湿病，总人口的1％，约4万5千人，会受到这疾病的影响。当中女性占四份之三，但疾病会影响所有的种族，而且往往被发现在介于20至45岁之间。”

自身免疫性疾病是指人体免疫系统攻击自身体内组织，造成损害而引发疾病。导致类风湿性关节炎的原因至今仍无法确认，但某些人似乎较容易患

消除疼痛类风湿性关节炎未必会缠上你一辈子

上此疾病。它会导致关节僵硬、疼痛、肿胀，有时还会损坏器官。它的严重性因患者而异，有些患者因症状还轻微，所以不会意识到自己已经患病。他们可能会感到持续疲劳或关节稍微有一点 僵硬。

饮食与癌症我弟弟患有鼻癌，妹妹患有胃癌。不知道是不是因为我们的饮食习惯而造成的？我们年轻的时候吃很多罐头食品配白饭。请问我要怎样预防癌症？您患癌的风险是受遗传因素、环境，以及生活方式等几个因素所造成的。

只要吃得健康、经常运动，以及保持良好的体重，高达40%的癌症病例是可以避免的，而约20%可以通过多吃蔬菜和水果来预防。

美国癌症协会建议以下的防癌措施: 吃全麦食品以及每天吃至少五份水

果和蔬菜。 少吃红肉和动物脂肪。 少喝酒。 每星期数天运动30分钟。

保持健康的体重。 避免吃腌制食品和熏烤肉类如火腿

和香肠。

对于正在接受化疗和放射治疗的人，该吃些什么才算是良好的饮食？除了烧烤食物，还应该避免吃些什么？良好的饮食应该是均衡的，并且包含适量的蔬菜和肉类。避免吃太甜、太咸或太油腻的食物。

首选的烹饪方法是蒸、煮、炒，比油炸、烧烤或烘烤更好。

动物蛋白经过油炸、烧烤或烘烤等高温处理后会产生致癌物杂环胺。我们应该避免吃这些食物。如果想吃的话，适量就好。新加坡国立癌症中心药剂师程玉瑛

前列腺问题前列腺有问题有那些征兆和症状？我应该从几岁开始关注这个问题？前列腺是位于膀胱及尿道（把尿液输送出体外的管道）之间的器官。前列腺会随着年龄的增长而肿大，阻碍尿液流动。您可能会发现：

排尿启动变慢，要等比较久才可以排尿

专家说

原文 Thava Rani

尿流变细 排 尿 后 ， 感 觉 仍 有 尿 液 潴 留 在 膀

胱内 排尿后滴沥 排尿不久后又想上厕所 尿频 有控制排尿的困难

前 列 腺 肿 大 是 老 化 过 程 的 自 然 现象。它通常出现在50岁以上的男性身上。严重时，它可能会引起肾衰竭。要正确诊断病情严重与否，请向您的医生咨询。

我每次复诊医生都会为我进行前列腺活检。医生是不是担心我患上前列腺癌？因为尿频，我晚上不敢喝水。应该怎么办？前列腺活检是检查是否患上前列腺癌的程序。你的前列腺特异性抗原水平可能有过高或逐渐升高的现象，表示患癌的几率比较高。另一个原因是，过去的活检结果可能出现令人担心的症状，但是

医生仍无法断定是否是癌症。在晚上尿频（夜尿）可能是因

为前列腺肿大或膀胱衰老造成的。你可以通过药物控制情况。有些医生会建议不要在睡前喝水，以减少夜里上厕所的次数。不过，必须记得在24小时内喝足够的水。樟宜综合医院泌尿科顾问医生吴国杰

健康交流站 我们的专家为您解答饮食与癌症的关系和有关前列腺肿大的一些征兆和症状

熊医生说：“及早诊断出类风湿性关节炎非常重要。”延误治疗可导致器官和关节永久性的损坏。研究也显示，及时治疗能让患者提高保持关节和器官健康的机会。

为了准确诊断出类风湿性关节炎，医生会凭验血及X光报告做评定。除了服用适当的药物，患者也可能需要接受风湿科临床护理导师、物理治疗师及职能治疗师的后续护理。若不治疗，类风湿性关节炎可能导致关节畸形。

熊嘉俊医生（左）向邱耀庭先生和太太解释类风湿性关节炎所导致的炎症为何会使关节疼痛。

为了管理患者的病情，保持每三至四个月一次的会诊记录是很重要的。在新加坡中央医院，患者是被鼓励通过记事本或使用医院推出的智能手机网络应用程序来记录每天的病情。

熊医生说：“这不仅能让病人掌握自己的病情，同时也给我们提供客观的资料。这样一来，我们便能更了解病患的病情，从而作出更好的临床 判断。”

图：

ale

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确定津贴如何确定受雇者享有的津贴？受雇者享有的津贴将视收入而定。医院的系统将从中央公积金局的系统中提取受雇者的收入信息并自动计算其能享有的津贴水平。

从中央公积金局提取哪些收入信息？对于受薪雇员患者，该信息将依据雇 员在过去12个月间获得的平均月收入（花红可纳入计算，但不包括最后一次的薪水）。向中央公积金局自愿供款不会影响收入信息。

对于自雇患者，该信息将依据新加坡国内税务局在过去两个评估年内由自雇患者最后交易所得净值得出的月收入，或依据自雇患者向中央公积金局上报的过去两年内的收入来评估。

如 何 确 定 失 业 或 无 收 入 患 者 享 有 的 津贴？家庭主妇、儿童、退休和失业人士等无收入患者将获得全额津贴（B2级病房65%，C级病房80%），除非他们所居住的房产年值超过11,000元。如果是这样，他们则分别享有B2级病房50%和C级病房65%的津贴。

如何对儿童进行住院支付能力调查？对于21岁以下的儿童，将根据其出生证、身份证或其父母身份证中所述的住宅年值进行评估。

30 新脉动 Mar⁄ apr 2012

焦点

住院支付能力调查确保在选择同等级津贴病房时，低收入患者比高收入患者获得的津贴较多

构里实施。这使低收入患者享有更多的政府医疗津贴。

住院支付能力调查仅适用于B2（包括B2+）级和C级病房。日间手术、急诊、专科门诊和综合诊疗所等服务都不列入住院支付能力调查的范围。

有了政府津贴，B2级和C级病房的设施得到了改善与提升。之前选择a级或B1级病房的患者也能够选择B2级或C级病房，这潜在地让低收入患者受到了排挤。与前者相比，低收入患者负担不起a级或B1级病房或私人医院，别无他选，只能求医于享有高政府额津贴的B2级或C级病房。

自由选择病房级别鉴于住院支付能力调查，患者可保留选择病房级别的自由。任何患者 — 不论收入 — 都可选择入住C级或B2级病房。差

黄女士是一名月入3,850元的行政管理人员。当她入住一家公共医院时，她选择了享有住院津贴的B2级病房。鉴于住院支付能力调查，她仅能享有60%的住院津贴，而不是B2级病房65%的全额津贴 — 因为黄女士的月入在3,801 – 3,950元的收入阶层。

黄 女 士 是 健 保 双 全 保 险 （ M e d i -Shield）的投保人，可是对于健保双全不予赔付的医疗费，她必须从保健储蓄户头（Medi Save）或现金以支付比预期更多的款项。

仅适用于B2级和C级病房的住院支付能力调查住院支付能力调查旨在确保让最有需要的国人从有限的资源获益。自2000年起，该调查在政府资助的养老院开始实施，至2001年起于其他中长期护理机

别在于获得的政府津贴金额会有所不同。尽管所有入住C级和B2级病房的患者

都可获得政府津贴，在与低收入患者相比之下，高收入患者能获得的津贴较少。不过，他们仍然可以选择享有比B1级病房更高津贴的B2级病房。

新加坡永久居民也得接受入住B2级和C级病房的支付能力调查。他们能获得的住院津贴将比同等收入水平的新加坡公民少10%。自2008年1月1日起，外国公民不再享有住院津贴，所以住院支付能力调查对他们没有任何的影响。

住院支付能力调查不会影响出院后的后续复诊。如果患者在B2级或C级病房住院后需要在专科门诊进行后续治疗，他将继续享有津贴。

信息摘自www.moneysense.gov.sg网站上的

《健康保险指南及了解健康保险》。

同意从新加坡中央公积金局或新加坡国内税务局检索您的个人信息

如果我入院时丧失意识或没有能力表示同意，怎么办？医院工作人员将对您做些跟进以获取您的同意。同时，院方将基于您所选病房级别享有最低的津贴估算您的医疗费。在获得您的同意后，院方才会使用从中央公积金局检索到的信息来结 清 您 的 住院费用。

任何患者不会因负担不起医疗费而得不到所需的治疗。在实施住院支付能力调查时会有一定的灵活性，而且要求重新评估的个案将会按个别情况获得考虑。如果需要更多帮助，您可以与医务社工探讨医疗基金（MediFund）或

其他形式的财政援助。

住院支付能力 调查后的援助

患者在接受住院支付能力调查后仍可重新选择病房级别， 差别在于获得的政府津贴金额会不同。

我为何需要同意让个人的收入信息从新加坡中央公积金局检索？只有经过您的同意，系统才能更准确地估算您的医疗费。如果您不愿意，您医疗费的估算将基于C级病房享有的65%的最低津贴（或B2级病房享有的50%的最低津贴），而不是基于C级和B2级病房享有的80%和65%的全额津贴。

我的家人能否代表我表示同意？不能，家人是不允许代表患者表示同意。需要经患者本人的同意，系统才能从中央公积金局检索到他的信息。这是为了保护个人隐私。

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