rObOTiCS SurgEry imPrOvES fibrOid rEmOval PrOCEdurE

SEP
OCT
2013
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and SingHealth ACADEMIC
HEALTHCARE CLUSTER
MCI (P) 069/06/2013
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Bronze
COntent Marketing
Awards 2013
07
Cancer-stricken dad gets a new lease of
life after son donated part of liver to him
AWARD OF
EXCELLENCE
APEX Awards 2013
09
Stroke patients get vital, real-time help
from specialists via video conferencing
12
New clinics for specialised and coordinated care are part of SGH’s makeover
21
robotics Surgery 机器人辅助手术
改进子宫肌瘤
improves fibroid
切除程序
removal procedure
P27
Photo: ALVINN LIM
P3
Find out which cardiac test is suitable
for you
29
患上饮食失调症的人，可能对糖和奶油
等日常食物产生恐惧感
02
singapore health
SEP – OCT 2013
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SEP – OCT 2013
singapore health
Robotics surgery pushes
limits in fibroid removal
Keyhole surgery is not often an option when a fibroid is very large,
but robotics surgery can help a surgeon to perform the procedure safely
By Desmond Ng
stalk (see diagram on page 4), so we were
able to perform keyhole robotic-assisted
surgery,” said Dr Peter Barton-Smith,
Senior Consultant, Depar tment of
Obstetrics and Gynaecology, SGH.
Usually, surgeons will not use minimally invasive or keyhole laparoscopic
surgery if the patient has too many
fibroids or if the growths are too large. In
such cases, open surgery is typically the
only surgical option. Conventional laparoscopic surgery generally limits cases
to patients who have about three to
five fibroids, each less than 5-6cm long,
said Dr Barton-Smith.
Another way for surgeons to decide
on the type of procedure to perform is
the size of the uterus. When the fibroids
have caused the womb to enlarge to the
equivalent size of a 16-week pregnancy,
that is usually around the limit for conventional keyhole surgery, said Dr Barton-Smith. “With robotics, we can push
that limit to a 20-week pregnancy, but
WITH robotics, we can
push that limit to a
20-week pregnancy, but
after that, usually
open surgery is the
only option.
Dr Peter Barton-Smith, Senior Consultant, Department of Obstetrics and Gynaecology, Singapore General Hospital ,
on the difference Robotics surgery can
make. Surgeons are unlikely to use conventional keyhole surgery if the fibroids
have caused the womb to enlarge to A
size equivalent TO a 16-week pregnancy.
03
Common
and mostly
harmless
Fibroids are common and can
grow to very large sizes. But
they are rarely cancerous.
About one in five women
will develop fibroids, usually in
her 30s or 40s. “But less than
one in 1,000 patients will have
a form of cancer inside the
fibroids,” said Dr Peter Barton-Smith, Senior Consultant,
Department of Obstetrics and
Gynaecology, SGH.
Fibroids do not cause trouble for most women because
they stay relatively small. But
some of these benign tumours
can grow very large. “The largest I’ve ever removed weighed
9kg,” said Dr Barton-Smith.
When the fibroids grow very
large, they may start pressing
on the other organs, such as
the kidneys.
In such situations, the
woman might star t experiencing heavy bleeding during
menstruation, discomfort in
the abdomen, pain in the lower
back, and frequent urination.
Some women can also end up
having problems conceiving.
I n S i n g a p o r e , D r B a rton-Smith said, “the added
problem is that women appear
to not only have fibroids but
also endometriosis (a condition
in which womb lining grows
outside the uterus) at the same
time, which makes it more complicated. A lot of Asian women
have both problems at the
same time, which is new to me.”
> Continued on page 4
( 华文版本请翻阅至27页 )
Dr Peter BartonSmith sits at a
control console, a
few feet away from
the operating table.
He uses controls
at the console to
manipulate tiny
surgical instruments
and a high-definition
3D camera, inserted
through small
incisions in the
body, to perform the
procedure.
PhotoS: ALVINN LIM
L
inda N g’ s f ib r o i d s we ig h e d
nearly half a kilogram when they
were removed via surgery in May.
The largest of the four benign growths
removed from her abdomen measured
14.5cm in length. But except for an
expanding waistline, Ms Ng, 54, had few
other symptoms. “I just thought I was
putting on weight,” said the training and
projects manager.
Uterine fibroids are a common condition among women of child-bearing
age. These usually harmless smooth
tumours, that grow in the muscle layer
of the womb, often develop when women
are in their 30s or 40s. When the fibroids
grow too large, however, they can cause
heavy periods, abdominal discomfort,
back pain, frequent urination, and fertility problems.
Ms Ng, a mother of two, found out
she had fibroids during a regular gynaecological examination earlier this year.
When her doctor advised her to have the
fibroids removed, she opted to undergo a
new minimally invasive robotics surgical
procedure offered by Singapore General
Hospital (SGH).
The relatively large size of Ms Ng’s
fibroids would normally limit her surgical
choices to an open procedure – the conventional method where a large incision
is made for the surgeon to perform surgery through. But the main fibroid, which
was a pedunculated fibroid, was “on a
NEWS
04
NEWS
singapore health
SEP – OCT 2013
> Continued from page 3
Robotics surgery pushes limits in fibroid removal
Belly
button
Spine
Uterus
Ms Linda Ng’s pedunculated fibroid was so large that it
extended to above the level of her navel and was equivalent
to the size of a 20-week pregnant uterus. Below, inside the
uterus, is another circular dark blob of fibroid, with a much
smaller one just to the right of it. The fibroids and the uterus
fill most of this MRI view of her abdominal cavity.
Flexible robotic arms
During surgery, Dr Barton-Smith made
five tiny incisions in Ms Ng’s
abdomen to allow for the
insertion of a high-definition 3D camera, and
tiny but highly precise
and flexible surgical
instruments. Sitting
at a console a distance away, he was
able to look inside
her abdomen and
perform surgery.
“ I t ’s l i ke b e i n g
inside the patient,” he
said of the camera’s ability. The highly flexible joints
of the robot’s surgical arms,
meanwhile, translated his hand movements into small, precise movements
inside the body to cut the surface of the
uterus and then to “shell the fibroids out,
much like shelling peas,” he said.
The incision in the uterus was then
stitched closed. Using a device known as
a morcellator, a hollow tube with a circular blade at one end, he finally pulled
the fibroids out of Ms Ng’s abdomen. The
morcellator was used to cut the fibroid
into long strips, allowing the otherwise huge mass of tissue to be removed
through the small incisions.
With robotic-assisted surgery, said
Dr Barton-Smith, “patients experience less pain, less blood loss,
a shorter hospital stay, and
a quicker return to normal
activity – in two to three
weeks after surgery,
compared with the
usual six weeks for
people who undergo
open surgery.”
Ms Ng’s surgery
took about three and
a half hours. After two
days in hospital, she
was discharged.
Patients who undergo
open surgery for the procedure normally go home after three
to five days.
Ms Ng said: “The marvellous part was
that there was no pain post-surgery. It
felt like having gastric.”
Pedunculated fibroid
Fallopian (uterine)
tube
Intracavitary
fibroid
Uterus
Ovary
Submucosal
fibroid
Subserosal fibroid
Intramural
fibroid
Cervix
Vagina
More on Fibroids
In addition to the very large pedunculated
fibroid, Ms Linda Ng had three other
smaller fibroids, known as submucosal
and intracavitary fibroids. According
to Dr Peter Barton-Smith, these types
of fibroids can be removed by surgery
through the cervix if they are small
enough. Larger ones, and the other types
of fibroids, often have to be removed by
surgery through the abdomen.
ILLUSTRATION: HEYMANS THO
Pedunculated
fibroid
after that, usually open surgery is the
only option,” he said.
“This limit can be pushed because the
computer-enhanced technology allows
the surgeon a greater range of movement
to deal with larger masses, that are very
difficult to achieve with conventional
straight laparoscopic instruments,” he
added.
SEP – OCT 2013
singapore health
NEWS
05
Depression can be a cause
or effect of dementia
By Satish Cheney
W
hen Mr Lim, a retiree, forgot
how to use the T V remote
control and what he had for
lunch, his family thought, “Oh, he’s getting old.” But soon, his memory started
getting hazier. He forgot his grandchildren’s names, and later his children’s,
although he could recollect childhood
memories.
Then he began losing his way when
driving, forgetting his way home; before
long, he was asking his reflection in the
mirror, “Who are you?” Meanwhile, his
worsening dementia was accompanied
by bouts of depression.
This connection between depression
and dementia is something researchers
have been looking at for some time now. Is
there a link between the two? If so, which
comes first? These questions are becoming more urgent, because dementia cases
are on the rise both globally and locally.
It’s all in your head
Professor Ranga Krishnan, Dean of DukeNUS Graduate Medical School, explained
that there is a vascular link between
depression and dementia, and that either
condition can occur first.
He said that in the last two decades,
there have been about 200 studies on
this subject. Retrospective investigations showed that many people who
had depression later developed dementia. “It’s the same illness showing up as
dementia in one person and depression
in another. Quite commonly, you see
depression first and then dementia.” He
explained that silent strokes, multiple
low-intensity strokes which people hardly
notice, damage nerves in the front of the
brain and cause vascular depression.
More extensive damage leads to vascular
dementia. “When there is less damage,
you get depression; more damage, you
get dementia,” Prof Ranga said.
He added that depression is vascular because psychiatric conditions are
medical and involve the brain. “So, it’s
true when they say, ‘It’s all in your head!’
All medical illnesses can lead to depression because of chemical changes in
the brain. What is different is who treats
them – psychiatrists, neurologists or general practitioners.”
There are many causes of depression.
Vascular damage in the brain is one of
them. Other causes, including stress,
nutrition and possible genetic factors,
also involve the brain. Other types of
damage to the brain, such as frontotemporal dementia, can also lead to both
depression and dementia.
Depression often manifests as sadness without reason, losing interest even
in food, withdrawing, not going out, a
change in sleep patterns, self-blame, a
negative outlook, and feeling helpless,
hopeless, worthless and suicidal.
Dementia manifests as a loss of
short-term memory, although long-term
memory remains intact. “It is akin to
peeling an onion, with the outer layers
(representing recent memory) coming
off first.
The bigger the onion, the longer it
would take someone to peel it right to
the core (long-term memory).”
Causes and prevention
Prof Ranga said that old age significantly
increases one’s risk of getting dementia –
especially after 60. Unlike other illnesses,
the earlier the symptoms appear, the
more severe the illness and the swifter its
progression to severe memory loss.
Those who have suffered silent strokes
are also at high risk of dementia. Globally,
genetics are blamed for these strokes. But
in Asia, where it has affected people in
their 40s and 50s with no genetic predisposition to it, possible causes have been
linked to high blood pressure and a highsalt Asian diet, as well as diabetes, smoking and high cholesterol.
Prof Ranga said that there is no cure
for dementia, but medication can slow
down memory loss. That is why it is important for elders to see a doctor when
early signs appear. It is also important
for teens who are depressed to overcome it, live healthily and keep a positive outlook on life, to prevent strokes
and dementia in middle age.
People without dementia-prone
genes can reduce their risk of silent
strokes by adopting a healthy, low-salt
diet (the same diet advice for a healthy
heart), coupled with exercise and a positive mental attitude. “This is important
because what affects the mind can affect
the body,” he said.
Prof Ranga also stressed the importance of building reserves of strength to
ward off the illness for as long as possible, even if it is already in the body.
“Our bodies have reserves to handle
mental and physical problems. With low
reserves, dementia can be unmasked
after surger y, especially in elderly
patients. High reserves, built by studying,
using the brain or being actively engaged
in life, won’t change the disease, but can
reduce the chance of silent strokes.”
But he said there are no long-term
studies on this yet. “We can only presume.”
Photo: Zaphs Zhang
PhotoS: GETTY iMAGES
There is a vascular link between both conditions, and either can occur first
When an older
relative is
depressed or
getting forgetful
Don’t presume it is just
old age. People tend to
withdraw and slow down
in old age, but if you
immediately dismiss it as
“old age”, you miss noticing an actual problem.
Don’t immediately attribute it to other medical
problems such as diabetes or a weak heart, as
this will prevent you from
seeking treatment for the
real problem, which is
dementia.
Don’t miss getting a doctor’s evaluation. Although
dementia cannot be
cured, medication can
make the elder feel better,
look better, and stay
better for much longer.
According to Prof Ranga Krishnan,
it is also important for teens who
are depressed to overcome it,
live healthily and keep a positive
outlook on life, to prevent strokes
and dementia in middle age.
NEWS
06
singapore health
SEP – OCT 2013
ILLUSTRATION: courtesy of HeartWare International, Inc.
New heart pump
improves patient’s
quality of life
Singapore’s first patient with latest lightweight device
enjoys new lease of life as she waits for a heart donor
The pouch,
containing the
heart pump’s
controller, can be
carried in a few
different ways.
Illustration
showing a
HVAD pump in
a patient’s body.
Photo: JASPER YU
The lifeline
Post-operation, Mdm Helen Tan (above, with her husband and grandchildren) is enjoying a new lease of life.
M
adam Helen Tan, 58, was in a
dilemma this year. Should she
take a long-haul flight to New
Zealand or a shorter holiday in China?
Given her medical condition, the longer
trip would prove more challenging.
You see, Mdm Tan is the first patient in
Singapore to have the latest heart pump
implanted in her chest. A special battery-powered pouch keeps her mechanical heart going, and she has to carry
it around along with its two batteries,
which last six hours each. “The doctors
said I’ll have to carry more batteries
with me if I want to go to New Zealand,
as there are no charging points on the
plane,” she said.
Her heart pump is connected to a
controller in the pouch, through a cable
that exits her body near the abdomen, so
she always has to carry the pouch with
her. “I have to wrap the whole pouch
in plastic before I take a shower. When
I sleep, I have to make sure the batteries are connected to the power points.”
Before and after the implant
Mdm Tan found that her quality of life
improved dramatically after receiving
the third generation heart pump known
as a HeartWare Ventricular Assist Device
(HVAD) last year. Made of titanium composite materials, it is smaller (the size
of a golf ball) and lighter than the previous two versions. Before the implant,
she would get breathless from doing
simple household chores, or even talking.
“Sometimes I’d wake up in the middle
of the night, feeling that my heart had
stopped beating. I’d also break into a cold
sweat even in air-conditioned rooms,”
said Mdm Tan.
She had been diagnosed as having
dilated cardiomyopathy (see below).
“The doctors told me my heart was operating at only about 20 per cent capacity,
and this had affected my lungs as well.
“Without the pump, I’d have had
only about a year to live,” said the grandmother, who now cycles to and from the
market several times a week.
Although it has given her a new lease
of life, the HVAD is not meant to be a longterm solution. Mdm Tan is on the waiting list for a heart transplant. She said:
“There were times before the implant
when I wanted to give up, but now that
I have my grandchildren, there are even
more reasons to stick around.”
Photo: courtesy of National Heart Centre Singapore
By AJ Leow
Th e h ear t pump im planted into Mdm Tan’s
chest is a comparatively
smaller, lighter device
that can be fitted right
next to the heart, said
Associate Professor Lim
Chong Hee, Senior Consultant, Department of
Cardiothoracic Surgery
and Director, Heart and
Lung Transplant Pro gramme, National Heart
The National Heart Centre Singapore
medical team involved in Singapore’s
first third-generation heart pump
surgery (clockwise from top left):
Dr C Sivathasan, Co-Director, Heart
and Lung Transplant Programme; Dr
David Sim, Co-Director, Heart Failure
Programme; Associate Professor Lim
Chong Hee, Director, Heart and Lung
Transplant Programme; Mdm Helen
Tan, patient.
Centre Singapore (NHCS).
He led the surgical team
that carried out Mdm
Tan’s four-hour surgery.
“This removes the
need for the creation of
a pocket space near the
abdominal area as in the
case of the older model of
heart pumps,” he added.
Second-generation
pumps are still very much
in use. “Prices for both
types of pumps are about
the same, but we decided
to bring in the HVAD as
the results are comparable to HeartMate II and
to give patients more
options. It can potentially be used to support
the right side of the heart
too,” said Prof Lim.
NHCS per forms an
average of three heart
transplants yearly. To
help bridge the gap due
to the limited donor pool,
it set up the Mechanical
Heart Device Programme
in 2001 to provide patient s with advanced
heart failure a means to
prolong and improve their
quality of life while waiting for a suitable donor. To
date, NHCS has performed
70 me chanic al hear t
device implantations.
What is dilated cardiomyopathy?
Dilated cardiomyopathy is a disease of the heart muscle
in which the left ventricle becomes enlarged and cannot
pump blood efficiently to the body.
The condition can cause cardiac failure, but a patient
may have it for many years before symptoms surface.
Most patients’ quality of life is not affected, especially
in the earlier stages. Symptoms include shortness of
breath, fatigue, fluid retention in the legs, lightheadedness or fainting, as well as sensations of having rapid,
fluttering or pounding heartbeats.
SEP – OCT 2013
singapore health
NEWS
07
Son gives dad a liver and a new life
One young pilot opted for the best course of treatment for his cancer-stricken dad by donating part of his liver to him
By DESMOND NG
Mr Edwin Poh (left) who donated
part of his liver to his dad, Mr
David Poh (right), took two
months to recover from surgery
and was given the green light
to resume his flying duties in
December last year.
T
h e o n e thought that raced
through his mind as he was
wheeled into the operating theatre
at the Singapore General Hospital (SGH)
in September last year was: I might not
survive.
Mr Edwin Poh, then 32, was young,
healthy and had no medical problems.
But he was going to have a part of his
liver cut out and transplanted into his
father, Mr David Poh, who was suffering
from liver cancer.
Doctors had told him that the procedure was a relatively low risk one, and
that his liver would regenerate to 90 per
cent of its original size after the operation. Yet, he could not stop thoughts of
the worst-case scenario from flooding his
mind.
Said the younger Mr Poh: “I thought
I might die. I had written letters to my
family. I was prepared for the worst.”
PhotoS: aLVINN LIM
From hepatitis B to liver cancer
Mr David Poh was diagnosed with hepatitis B during a routine blood test about 30
years ago.
Hepatitis B is an infectious inflammatory illness of the liver, which can lead
to cirrhosis, a hardening of the liver, and
liver cancer.
When his father was diagnosed with
hepatocellular carcinoma (liver cancer)
in December 2011, the younger Mr Poh
knew that he wanted to do the right thing
and give part of his liver to his father. “If
anyone was to help him, it should be me.”
His older sister was married with two
children, while his other sister was too
young. “The size of the donor’s liver had
to be big enough,” Mr Poh said.
A pilot for seven years, Mr Poh had to
consider if he would be able to resume
flying – his life-long dream – after the
procedure. “I was very gung ho about the
After the liver donation, Mr David
Poh is now able to play a light game
of squash and badminton.
I have a new lease
of life now, and I
have better stamina
Mr DAvid Poh, 65, on his transplant
New transplant
clinic offers
convenience
transplant initially, and it took some time
to get my father to agree to it. Later, as I
was going through the tests, I started to
think about the risks and costs. It was
then that I began to worry if I could still
fly after that,” he said.
“But at the end of the day, the question was not just – ‘could I not go through
with it?’ – but also, ‘could I continue to
live with myself if I did not?’”
His company was supportive, assuring him that he would have a job if he was
medically fit to fly after the operation.
His decision to donate a part of his
liver was also bolstered by the knowledge
that a fellow pilot, who went through the
same procedure eight years earlier, was
still flying.
Mr Poh stopped work for about two
months to recover from the surgery, and
received the green light from an aeromedical doctor to resume his flying duties
in December last year.
Accepting the “gift” of life
The elder Mr Poh, who is semi-retired,
said he found the strength to accept his
illness – stage 2 liver cancer – in prayer.
However, he wasn’t prepared to accept
his son’s sacrifice at first.
“My family was not prepared to let
me go. They begged me to go for a trans-
plant,” said the 65-year-old. His wife, 62,
works in the healthcare industry.
The older Mr Poh said the tumour in
his liver was about 4.6cm long, but was
inoperable as it was located too close to
the main arteries.
Before the transplant, he had undergone other treatments, including a
minimally invasive medical procedure
called transarterial chemo-embolization, or TACE, which managed to shrink
his tumour down to 60 per cent of its
original size. He also went through two
rounds of chemotherapy, but with little
progress.
Mr Poh was then told that he needed
to have a transplant, but the wait for a
deceased donor would take about a year.
After much pleading from his family,
he decided to accept his son’s gift
of life.
“I know that he (my son) is a good boy.
I didn’t want to put him in any jeopardy,
especially his career. I was worried he
might not be able to fly again. I prepared
myself and prayed and left it to God. I had
confidence in the doctors and that the
operation would work,” he said.
The older Mr Poh said he is now able
to play a light game of squash and badminton. He added: “I have a new lease of
life now, and I have better stamina.”
Following a transplant,
patients have to see several
healthcare professionals
for follow-up care. When
the new Transplant Centre
opens later this year at SGH,
these patients only need to
make a single appointment
to see them.
“Transplantation is a
highly complex field of
medicine that requires different healthcare professionals coming together as
a team to provide a collaborative and patient-centric
approach to care planning
and provision,” said Dr Terence Kee, Senior Consultant, Department of Renal
Medicine, SGH. Dr Kee is
also Programme Director,
Renal Transplantation, SGH.
The centre will house
a multi-disciplinary team
involved in various aspects
of transplantation. Dedicated to caring for patients
who have undergone or
are undergoing tr ans plants, the Centre has clinics, counselling rooms, a
phlebotomy cubicle and
procedure unit. Among its
many services are pre- and
post-transplant education
by transplant coordinators,
donor and recipient assessment, post-transplant follow-up care, transplant
pharmacist clinics, and
intravenous drug infusions.
08
NEWS
singapore health
SEP – OCT 2013
Their efforts to ease bottlenecks and simplify procedures were
lauded at the International Convention on Quality Control Circles
Photo: GETTY iMAGES
SGH staff raise the bar
for quality healthcare
By Teo Kuan Yee
C
ustomer satisfaction is key to the
long-term success of any organisation. At Singapore General Hospital
(SGH), the term “customers” refers not
only to patients but also to staff, as many
of them work in teams that depend on
one another to carry out vital tasks.
To this end, teams from SGH implemented a variety of changes that untangled complex work routines, making
patients’ times at the hospital more
pleasant in turn.
Their efforts were recognised at
last year’s International Convention on
Quality Control Circles (ICQCC) in Kuala
Lumpur, Malaysia. We present three of
the winning projects here.
Better arrangement of ward items saves time
The team
Ms Doris Lim Wei Feng, Ms Kamsiah
Jaafar, Mr Muhammad Fuad Bakari,
Ms Chan Shi Ming, Mr Mazlan Omar
The problem
Nursing students, house officers
and other staff who work on rotation often faced difficulties in finding items in the ward preparation
rooms of the departments they are
posted to. Although staff undergo
an orientation at each department
they are posted to, they need time
to learn the layout of each preparation
room because of the different storage
arrangements at each location.
The solution
The team devised a standard arrangement for five frequently used items,
including 10ml syringes, normal saline
and gauze, in the preparation rooms.
These were placed together for easy
retrieval when preparing for a common
procedure like blood-taking.
Items were categorised and labels were
colour-coded for easy identification.
Retrieving the five commonly used
items took an average of 47.6seconds, versus 97.5seconds before the
changes. The changes seem small,
but the seconds saved added up to
63,254.5 hours a year.
Flexibility eases
workload
The team
From the Department of Internal
Medicine: Ms Stephanie Teo, Associate Professor Chow Wan Cheng,
Ms Vanessa Ng, Mr Geoffrey Gui,
Ms Linda Lim, Mr Desmond Lee
The problem
The previous system of allocating
patients to teams of doctors often
added to the doctors’ already
heavy workload.
The solution
The team spent weeks speaking to
doctors, nurses and administrative
staff to identify gaps in the system.
They then made use of information
technology to automate and standardise the process of allocating
doctors to patients. The old system
of simply assigning patients to
the next available team in a fixed
sequence was changed to take into
account each team’s workload.
“Porters”
speed up ward
admission
The people
From the Department of Emergency Medicine: Ms Norizan
Jaafar, Ms Norhashimah Hasim,
Ms Teo Kai Yunn, Ms Joanne Jong
Yen-Yen
The problem
Patients at the A&E department
often face prolonged waits before
being sent to the wards. This can
compromise their safety, and interrupt the nurses at work if they have
to leave their clinical areas to take
such patients to the wards.
The solution
Teams comprising two nurses and
two patient-care assistants are
rostered to work as porter teams
during peak admission times.
When a bed is ready, the team on
duty (wearing orange tags) takes
charge and sends the patient to
the ward. The same team also prepares the patient’s case record.
SEP – OCT 2013
singapore health
Tele-Stroke to the rescue
With a neurologist always on standby for consultation by video conferencing,
stroke patients have a fighting chance of a good recovery
By Denyse Yeo
09
How it works
NNI’s stroke neurologists are rostered as acute stroke consultants
on call and are responsible for
Tele-Stroke consultations 24 hours
a day, 365 days a year.
When a patient arrives at the
hospital’s emergency department, triage nurses identify if
he has had a stroke. If so, he
is immediately reviewed by an
emergency department physician, who notes his medical
history and verifies the time of
the onset of the stroke.
He is sent for a brain scan.
The radiologist studies the
scan to see if he has had an
ischaemic stroke or a haemorrhagic stroke.
The Tele-Stroke service is activated.
The NNI stroke neurologist
remotely examines the patient,
assesses the CT scan and gives
a treatment recommendation.
With Tele-Stroke, Dr Singh can
provide vital diagnosis and
treatment for stroke patients
via video conferencing.
Mr Low Yiang Chua (right)
witnessed how Tele-Stroke
saved his dad, Mr Low Choong
Heong.
bleeding, which occurs in less than 10 per
cent of cases.”
Another patient rescued
A separate case saw a 50-year-old man
with a history of hypertension diagnosed
with an acute ischaemic stroke in CGH’s
A&E department. The Tele-Stroke service
was activated. The neurologist assessed
him and found him suitable for r-tPA,
so the emergency doctor administered
the drug.
Hundreds of Stroke
patients admitted to
peripheral hospitals
have had immediate
access to stroke
specialists from NNI,
Around the clock.
Dr Rajinder Singh, Consultant,
Department of Neurology,
National Neuroscience Institute,
on the benefits of Tele-stroke
Within several hours, the patient
became less drowsy and regained
strength on his right side. The next day,
he could talk and obey commands, and
after rehabilitation, was well enough to
be discharged.
Dr Singh said: “Such cases show that
without this service, acute stroke patients
Photo: ALVINN LIM
A leading cause of death and disability
In Singapore, stroke is the fourth leading
cause of death and the leading cause
of chronic severe disability. It is caused
either by bleeding in the brain (haemorrhagic stroke) or a blood clot (acute
ischaemic stroke) that deprives a certain
part of the brain of oxygen and nutrients.
The latter can be treated with a
clot-busting drug called recombinant-tissue plasminogen activator (r-tPA), which
is best prescribed by neurologists
because of its potential complications.
This treatment is effective in treating
strokes caused by blood clots, because
it breaks down the clots, explained Dr
Rajinder Singh, Consultant, Department
of Neurology, NNI. “Compared to patients
who were not given r-tPA, those who were
given it within three hours of the onset of
the stroke, were 30 per cent more likely
to be back to their original state, or have
just minimal symptoms which do not
affect their day-to-day activities, at three
months. The main side effect is that of
Photo: WINSTON CHUANG
A
t first glance, you cannot tell
that 83-year-old Mr Low Choong
Heong suffered a stroke that left
him comatose barely two years ago.
Today, the spry retiree goes for walks,
does calisthenics and meets up with
friends for coffee.
In 2011, he was at a coffee shop
when he had a stroke. His left side suddenly became weak, and he foamed at
the mouth. His friends immediately
called an ambulance, which took him to
Changi General Hospital (CGH), recalled
his eldest son, businessman Mr Low Yiang
Chua, 59.
“When I saw him, he was already
comatose,” said the younger Mr Low. “But
within two or three hours, the doctors
gave him an injection that saved his life.
He woke up on the third day and was
discharged within a week. He improved
steadily over the next three months, and
is now independent and able to do everything by himself, just like before.”
His father was saved by the National
Neuroscience Institute’s (NNI) Tele-Stroke
service, currently provided to two hospitals – CGH and Khoo Teck Puat Hospital
– round the clock, seven days a week. The
service allows doctors in the hospital’s
emergency department to get an NNI
neurologist to remotely examine stroke
patients in real time via video conferencing. This way, the patients get the attention of a specialist for vital diagnosis and
treatment within the crucial three-hour
window. This will reduce their likelihoods
of a poor outcome.
NEWS
admitted to CGH or KTPH may not have
the opportunity to be assessed by neurologists rapidly. Hence, they may not
receive r-tPA. It is this lack of round-theclock, on-site neurology service at these
hospitals that prompted NNI to use TeleStroke to provide round-the-clock service and cover this gap in service.”
Although there were teething problems at the start, partly due to a sub-optimal Internet connection, the system is
working smoothly today and issues have
been resolved, said Dr Singh.
The system has seen tremendous
benefits. “Hundreds of stroke patients
admitted to peripheral hospitals have
had immediate access to stroke special-
ists from NNI around the clock. This has
helped them get the best treatment and
outcomes for their strokes in a cost-effective and efficient way,” he said.
Tele-Stroke numbers up
To date, NNI has handled 582 cases – 25 to
30 patients a month – since the Tele-Stroke
service started in August 2011. The number
is likely to increase due to greater public
awareness and an ageing population.
“Right now, there are no definitive
plans to extend the service, but the
potential to add more ‘spokes’, or peripheral hospitals with no in-house neurologists, to the network is always there,”
said Dr Singh.
10
NEWS
singapore health
SEP – OCT 2013
In pursuit
of better
patient care
Study:
Dietar y composition and
weight outcomes in postmetabolic bariatric surgery
patients
Ms Teo Soo Lay, Department of
Dietetics, SGH
The trends in percentage of excess
weight loss and diet composition
of post-metabolic bariatric surgery
patients. Bariatric surgery is one of
the most effective ways of manag-
Among other results, the study found
that at three and six months post-surgery, the caloric intakes averaged 670
kcal/day and 861 kcal/day respectively. At
three months, protein, carbohydrate and
Oral Presentation - Young Investigator’s Award (Allied Health)
Lead investigator:
To Investigate:
Category:
Poster Presentation - Best Poster Award
(Nursing) - WINNER
Lead investigator:
How it was carried out:
This retrospective study analysed the
diets of 54 patients who underwent
surgery between September 2008 and
2011, first at pre-surgery, then at three,
six and 12 months after surgery. The 18
men and 36 women had a mean age of
50 years. They had an average caloric
intake of 1,814 kcal/day, with protein,
carbohydrate and fat contributing 17, 52
and 31 per cent respectively.
Category:
Study:
Incidence and predic tors of
new-onset constipation during hospitalisation in patients with stroke
versus orthopaedic conditions
ing obesity. After surgery, a higher protein, moderate fat and lower carbohydrate diet is usually recommended.
Conclusion:
Photo: GettyImages
At this year’s Singapore General Hospital (SGH) Annual
Scientific Meeting, 350 studies were presented in 14 categories.
Winning an award rewards an author’s efforts, and sharing the
findings improves patient care
fat compositions contributed 26, 44 and
30 per cent respectively. At six months,
protein, carbohydrate and fat contributed 20, 49 and 31 per cent respectively.
At 12 months, the average caloric
intake was 1,088 kcal/day, comprising 21
per cent protein, 49 per cent carbohydrate and 30 per cent fat.
Compared to the baseline, the
patients’ diet composition at 12 months
did not differ except for protein. At three,
six and 12 months, the respective percentage of excess weight loss was 27,
40 and 46 per cent. No correlation was
found between excess weight loss and
the composition of the patients’ diets.
Patients mostly reverted to a diet with
similar compositions of protein, carbohydrate and fat as at pre-surgery, despite
the weight loss they experienced.
Ms Lim Su Fee, Nursing Division, SGH
TO Investigate:
New-onset constipation among stroke
and orthopaedic patients, and the predictors associated with constipation.
Constipation is a common complaint for
patients warded for acute stroke. It can
cause discomfort and affect patients’
physical and psychological well-being.
Study:
The use of an innovative cueing
device to improve gait and reduce
fear of falling in patients with
Parkinson’s disease
How it was carried out:
Category:
This prospective cohort study looked
at 55 patients warded for stroke, and
55 patients warded for orthopaedic-related problems. Demographics, other
medical complaints, mobility gain, fluid
intake, and medication use were among
the factors evaluated as predictors for
constipation.
Oral Presentation – Outstanding Allied
Health Research Award
Lead investigator:
Ms Dawn Tan, Department of Physiotherapy, SGH
TO Investigate:
Many of the stroke and orthopaedic
patients developed constipation during
their hospital stay, with seven of the
stroke patients (39 per cent) and four
(27 per cent) of the orthopaedic patients
developing the complaint on day two.
The early occurrence of constipation
on the second day of admission calls for
early preventive measures such as promoting mobility and reducing the length
of hospital stays. Selective use of shortterm prophylactic laxatives could be considered in high-risk patients.
Photo: GettyImages
Conclusion:
The feasibility of the locally developed
Parkinson’s Mobility Aid and its effects
on gait and fear of falling in Parkinson’s
disease patients.
Parkinson’s disease is a degenerative
disorder of the central nervous system.
It affects movement and balance, making
patients prone to losing their balance or
falling.
The Parkinson’s Mobility Aid allows
users to select visual, auditory or tactile
cues to improve their gaits or to overcome freezing episodes.
How it was carried out:
Twenty Parkinson’s disease patients,
including 15 men with an average age
of 67.5 years, participated in this randomised controlled study.
The control group received standard
physiotherapy twice a week for a month.
The intervention group received a similar
type and intensity of treatment but were
also trained in the use of the Parkinson’s
Mobility Aid.
All the participants were assessed at
the start or the baseline, and at one and
two months after, for various things such
as gait speed, freezing severity, and fear
of falling.
Conclusion:
Neither group of patients displayed significant changes in gait speed, freezing,
and fear of falling, relative to baseline.
The group taught to use the aid
demonstrated greater, but non-significant, improvement in gait after one
month, compared to the control group.
Gait training using the mobility aid
appears to be somewhat useful and safe
for people with Parkinson’s disease.
Because of the study’s small sample
size, the investigators suggested that
large sample sizes and higher training
intensity be studied in order to better
test the aid’s effectiveness.
11
Academia opens
at SGH Campus
The first of its kind in the region, SingHealth’s
new diagnostic, research and education
hub is set to improve patient care and
advance medicine in Singapore
President Tony Tan
Keng Yam officiated
at the opening of
Academia, which
houses SGH’s
Department of
Pathology and
SingHealth’s research,
education and
training facilities.
By Jamie Ee
P
atients in Singapore can expect
better healthcare with the opening of Academia – SingHealth’s new
diagnostic, research and education hub
on the SGH Campus. The $360 million
13-storey twin-tower building is the new
home of SGH’s Department of Pathology
as well as the Group’s research and education facilities.
Located near Duke-NUS Graduate
Medical School and leading medical institutions, the 807,293 sq ft building has
laboratories, conference facilities, offices
and a “mini hospital” under one roof.
Initially conceived as a home for SGH’s
Pathology Department, it evolved during
construction into a hub and incubator for
biomedical breakthoughs and innovations in medical care.
President Tony Tan Keng Yam, who
officiated at Academia’s opening, said:
“The co-location of the Pathology Department with SingHealth’s education and
research functions will enhance the interconnectivity among pathologists, clinician scientists, academics and healthcare
professionals and result in more sharing
of ideas, as well as the acceleration of
research efforts that will translate into
clinically useful applications for better
patient care.”
SGH’s Pathology Department, which
handled more than 12 million laboratory
investigations last year, now has a 50 per
cent increased capacity for diagnostic services. Equipped with the latest technology,
it will offer enhanced test accuracy and
reliability, and improved turnaround times.
Research and training facilities
There is also plenty of scope for advanced research here. The SingHealth Tissue
Repository (STR), Singapore’s largest
tissue repository, is based at Academia.
STR offers core tissue research and bio-
banking services to help researchers
identify new biomarkers, treatment targets, and drugs.
Another occupant, the SingHealth
Translational Immunology and Inflammation Centre, is set to advance research led
by SingHealth and Duke-NUS. Potential
clinical collaborations it has identified
include paediatric allergies and immunological disorders, transplantation immunology, and stem cell and immunotherapy for cancers and other diseases.
With 80,729 sq ft dedicated to healthcare training and education, Academia is
the world’s largest and most comprehensive training facility offering varied platforms, from procedural and team-based
skills to computer and environment simulation under one roof.
The wet and dry skills laboratories
and mini hospital come complete with
simulated wards, an intensive care unit,
and a fully functional operating theatre.
Doctors, nurses and allied health staff
can hone their skills by carrying out procedures in controlled yet realistic settings that are wired for live streaming
– procedures can be beamed to seminar
rooms for teaching purposes.
Professor Ivy Ng, Group Chief Executive Officer, SingHealth, said: “One enduring passion that unites us, all through the
generations, has been the burning desire
to improve the lives of our patients. Academia has been purpose-built for this.
“Our relentless pursuit of academic
medicine will stay focused and driven
by that same burning passion that characterised the generations who served
on this campus. We want to improve the
lives of our patients through better care
for better outcomes. The work in Academia must be dedicated to this one purpose and keep patients at the heart of all
we do.”
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NEWS
singapore health
SEP – OCT 2013
SGH undergoes makeover
S
ingapore General Hospital (SGH)
is undergoing a major facelift. After
months of construction, new clinics
have opened, while some existing facilities have been expanded or improved.
After the remaining renovation and
building work is done, the hospital and the
rest of SGH Campus will be transformed
into a vibrant academic medical centre.
On July 1, the Centre for Digestive
and Liver Diseases opened its doors to
patients suffering from complex digestive and liver disorders, such as liver and
intestinal cancer, chronic hepatitis, liver
failure, and chronic inflammatory disorders of the intestines.
The centre integrates the former C, D
and E outpatient clinics to offer patients
specialised and coordinated care in one
facility. Patients will be able to consult
their doctors at the centre, as well as
undergo endoscopic and other tests,
dietetic and drug management services,
as the clinic pulls together a multitude of
healthcare professionals providing differ-
ent but complementary expertise. With
the new premises, patients will no longer
have to go to different places within
SGH’s sprawling compound for different
services.
Such integrated medical services
are also offered at the new Autoimmunity and Rheumatology Centre, the only
regional hub providing a one-stop service dedicated to complex rheumatology
and autoimmune disorders. The centre,
which opened in May this year, also provides physiotherapy and occupational
therapy services, as well as drug management and patient education.
The Diabetes Centre, on the other
hand, has been relocated to the basement of Block 1 from the ground floor
of the same building. The new facility
is much larger than the old one. These
centres address the growing demand for
care in various medical disciplines.
And it isn’t just clinics that are being
made over. Two of the hospital’s larger
pharmacies have been made even bigger.
Photo: ZAPHS ZHANG
New clinics for specialised and coordinated care have opened after recent
renovations, and wards are next to get a facelift
The one serving the Specialist Outpatient
Clinics now has a medication management service room for pharmacists to
advise patients about the medicines they
are taking, while the pharmacy at Block 4
is roomier.
The next phase of the makeover will
be sprucing up the wards. To make sure
that bed space is not lost during renovation, patients will be moved to three
levels of “transit” wards at Block 6.
Specialist nurses
are part of a multidisciplinary team
looking after patients
at the new one-stop
centres, like the
one dedicated to
digestive and liver
diseases.
These three floors used to be the
offices of the hospital’s more than 1,000
doctors, who have been given space at
Academia, a new 13-storey twin-tower
building that houses SGH’s pathology
services as well as SingHealth research
laboratories and education and training
facilities.
Work on the wards has begun, and
is expected to be completed within the
next few years.
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SEP – OCT 2013
singapore health
UP CLOSE
13
P nk
Breast Cancer Awareness Month
Alert
Breast cancer is the most
common cause of cancer death
in women, accounting for
18%
By Denyse Yeo
Symptoms
of cancer deaths.
See your doctor immediately if you
experience any of these symptoms:
A painless
lump in
your breast
Breast cancer accounts
for more than
The disease is the most
common cancer in Singaporean
women, with about
of all cancers in women.
women diagnosed every year.
20% 1,600
250,000
Persistent
rash around
the nipple
Nearly
Bleeding
or unusual
discharge from
the nipple
Retracted
nipple
Swollen,
thickened,
dimpled or
puckered skin
on the breast
Early
Detection
Breast lumps are a common
occurrence in women. Only
one out of every 10 lumps
is due to cancer, which means
that 90 per cent of all breast
lumps are benign.
women have been screened by BreastScreen
Singapore in the last 10 years.
Women who
have a family
history
of breast
cancer may be
at increased
risk. If your
mother
and/or sister
developed breast
cancer before
menopause, talk
to your doctor
or a breast
specialist.
+
40
Lower
Your
Risk
The risk of breast
cancer increases
with age. Most
women who are
diagnosed with
breast cancer
are aged 40
and above. Late
menopause, having
fewer children or
none at all, being
on hormone
replacement therapy
and weight gain are
other risk factors.
Sources: KK Women’s and Children’s Hospital, Ministry of Health, singhealth.com.sg, www.healthxchange.com.sg, hpb.gov.sg, nccs.com.sg
get tested National breast cancer screening programme
BreastScreen Singapore (BSS) is available at SingHealth (Tel:
6536-6000), Radiologic Clinic (Tel: 6533-2721) and National
Healthcare Group Diagnostics (Tel: 6275-6443/ 6-ASK-NHGD)
14
people
singapore health
SEP – OCT 2013
Taking nursing up a notch
Advanced Practice Nurse Ms Patsy Chiang works on some tasks done by junior doctors
By Sol E Solomon
Photo: alecia Neo
A
s a young girl, hospitalised for
gastritis in 1985, Ms Patsy Chiang
was so deeply inspired by the
nurses who took care of her that she
decided that she would join their ranks.
She started off as a staff nurse, but
rose through the ranks to become an
Advanced Practice Nurse (APN) at the
National Heart Centre Singapore (NHCS)
in 2004.
Unlike regular nurses, APNs are qualified to assess patients and make certain clinical judgments, taking up some
of the tasks done by junior doctors.
During her daily rounds, she physically examines patients, looks at their
X-rays and charts, pens her diagnoses,
and updates their daily care plans.
In the wards, she orders tests like
ECGs (electrocardiographies) and X-rays,
interprets laboratory results to prescribe
treatments and non-pharmacological
therapies, and escalates complicated
cases to the doctors.
Advanced Practice Nurse, Ms Patsy Chiang with two patients, Mr Victor Jonathan
Garnell (left) and Mr Albert Pang Cheong Kong, who are under her care.
At the NHCS’ Anti- coagulation
Clinic, she advises patients about managing medication such as warfarin, a
blood-thinning drug that prevents blood
clots in heart patients at risk of stroke.
A patient’s dosage of warfarin has to be
carefully managed in response to his or
her condition, lifestyle and diet.
It’s clear that being an APN requires
a great deal of training and experience.
A candidate must have a bachelor’s or
master’s degree, and a certificate in a
particular speciality.
Ms Chiang – part of Singapore’s first
cohort of 15 nurses who enrolled in the
one-and-a-half-year APN course in 2003 –
specialises in providing critical care.
One module, Cardiovascular System
Assessment, gave her the knowledge to
identify abnormalities of the heart and
circulatory system, and that has helped
save a life.
Once, listening to the lungs of a
patient in hospital who had just received
a pacemaker implant, she could not hear
anything from one lung. “I alerted a consultant, who ordered tests which showed
signs of lung collapse, but it was unclear
and could only be detected by a very
senior radiologist.”
A CT scan confirmed her suspicion
that there was air in the patient’s lung.
A chest tube was inserted to release
the air. If the problem had gone unnoticed, the patient could have collapsed at
home after discharge.
Despite her qualifications and experience, she still sometimes faces resistance
from patients. “They may initially ask
why they aren’t being seen by a doctor
but an APN,” she said.
Once past this hurdle, however, most
patients warm up to her. Some, upon
learning that another patient at NHCS is
not under her care, will ask, “Why aren’t
we seeing Sister Patsy?” And that is testimony enough for her.
SEP – OCT 2013
Two of a kind?
Photo: alecia Neo
Brothers and oncologists, Dr Wong Fuh Yong and Dr Wang
Fuqiang are also colleagues in the same department
Dr Wong Fuh Yong (left) and his brother Dr Wang Fuqiang work in the same field, and
recently collaborated on a research project for the first time.
By Jamie Ee
M
eet Dr Wong Fuh Yong, 38, Consultant, and his brother Dr Wang
Fuqiang, 29, Registrar, from the
Department of Radiation Oncology at the
National Cancer Centre Singapore (NCCS).
Did you notice that they have different
surnames? Their parents registered the
elder sibling’s surname as Wong because
that is how it is pronounced in dialect, and
the younger one’s as Wang because that is
how it is pronounced in Mandarin.
This difference has led to some amusement at work. Dr Wong said: “One of my
colleagues was quite taken aback when
he found out, a year later, that Fuqiang is
my brother. He said it was lucky that he
hadn’t said anything bad about him!”
Their family resemblance and other
similarities have not gone unnoticed,
though. Dr Wang said: “Some patients
who hadn’t seen me before have said
that I look familiar.
“Once, a patient saw me and told
his family that I was his consultant. But
I hadn’t seen any patients yet, so I told
him that he was probably referring to my
brother.”
Same work, different interests
So, did one brother influence the other?
And are they two of a kind?
Not really. Dr Wong, who is married and has a seven-year-old daughter,
describes himself as having eclectic pursuits. He enjoys reading, photography,
and travelling. His bachelor brother professes to be more athletic, and enjoys
running, swimming, and hitting the
gym. “But deep down, we are probably more similar than we care to admit,
even though this may not show up in the
things we do,” said Dr Wong.
Their paths have indeed been similar.
Both graduated from The Chinese High
School and Hwa Chong Junior College.
Both studied medicine at the National
singapore health
University of Singapore, specialising in
radiation oncology – a speciality that
focuses on using radiation therapy to
treat cancer. Both were (and still are)
motivated by compassion and an interest
in science and technology.
Dr Wong, who joined NCCS in 2003,
did not actively draw his brother into his
sphere of work. “I hardly talked to him
about cancer care, so I was surprised that
he took up radiation oncology,” he said.
But Dr Wang, who joined NCCS in 2010,
said that he was indeed influenced by his
brother. “After graduation, I was trying to
figure out my interests. Since my brother
was in radiation oncology, I thought, why
not give it a try and see what it is like?”
Their being brothers does not have
any impact on their professional roles
and relationship, though. Their paths
usually cross at department meetings
or in small group teaching sessions
conducted by Dr Wong, who treats his
brother like any other doctor under his
tutelage while on the job.
They do not always share a similar
work schedule as Dr Wang has not yet
chosen a sub-speciality. They did, however, recently collaborate on a research
project for the first time. They were part
of a five-member team studying the outcome of breast conservation therapy in
people
15
Once, a patient saw
me and told his
family that I was
his consultant. But
I hadn’t seen any
patients yet, so I
told him that he was
probably referring
to my brother.
Dr Wang Fuqiang on the confusion
that arises from his brother, Dr Wong
Fuh Yong, being in the same department
breast cancer patients in Southeast Asia
who had not yet had surgery.
They have a middle brother, a
pharmacist, who works in another
hospital. Their father works in finance
and their mother is a housewife. When the
family meets, conversation is varied and
does not centre on medicine. “At home,
we don’t usually talk about our work,”
said Dr Wong.
Money
16
singapore health
SEP – OCT 2013
Community help for
the chronically sick
Rising medical costs can be worrying, especially for those grappling with long-term illness.
The Community Health Assist Scheme can help pay for treatment
Who Qualifies for CHAS?
To be eligible for the subsidies under the Community Health Assist Scheme or CHAS, you must be
Singaporean, aged 40 and above or disabled, and
meet the following criteria:
●Have a per capita household monthly income
of $1,500 or less; OR
●The annual value of your home is $13,000 and
below for households with no income.
By Stella Thng
M
dm Cecilia Tan*, 60, is a retired
beautician. Her husband, an
accounts clerk, draws a monthly
salary of about $2,700. Their only daughter is an administrative assistant who
earns $1,700 a month. Their combined
household income is $4,400 and they
live modestly in a three-room flat.
But five years ago, Mdm Tan was
diagnosed with kidney failure and the
family of three had to curb their spending to pay for her daily medication.
Thankfully, patients like Mdm Tan
can now apply for the Community
Health Assist Scheme (CHAS), a programme spearheaded by the Ministry
of Health (MOH) programme that helps
provide Singaporeans with accessible
and affordable medical and dental care.
Patients who qualify for the scheme
receive subsidies for outpatient medical
treatment for chronic and/or acute conditions from general practitioners (GPs)
registered under the scheme. They also
receive selected dental services at participating dental clinics near their homes.
How do
I apply
for CHAS?
CHAS members also enjoy subsidised
referrals to specialist outpatient clinics.
The eligibility criteria were changed
on Jan 15, 2012, to allow more Singaporeans to benefit from the programme. For
example, the qualifying age was lowered
from 65 to 40 years old and the income
criteria was raised from $800 to $1,500
per capita monthly household income.
CHAS also works in conjunction
with the Government’s Chronic Disease
Management Programme. Patients
covered by the programme will receive
CHAS subsidies for their chronic disease
treatments that range from $200 to $480
per year.
Patients can then use their Medisave to pay for the balance of the cost of
the treatment, up to a limit of $400 per
Medisave account per year. For example,
if the total bill is $1,000 and the CHAS
subsidy covers $350, the remaining $650
can be paid using $400 from Medisave
and $250 in cash.
Disability is measured by an inability to do any of
the six activities of daily living without assistance –
washing/bathing, using the toilet, getting in and out
of a wheelchair, feeding, dressing, and/or mobility.
All family members (related by blood, marriage
and/or legal adoption) living at the same address as
the main applicant, as reflected on their NRICs, must
include their details on the same application form
as the main applicant. Their income will be included
when calculating the household’s per capita
monthly income.
To calculate
per capita
household
monthly
income
=
Total gross
monthly
household
income
Number of
members
in the family
*Story based on a real-life example.
Get a CHAS application
form at any restructured
hospital, polyclinic, Community Centre or Club, or
Community Development
Council, or download it
from chas.sg. Submit the
completed form with clear
copies of NRICs (front and
back) of the main applicant
and all family members,
and/or clear copies of birth
certificates of family members below 15 years old who
do not have NRICs.
A Functional Assessment
Report will be mailed to you
if you meet the income criteria. Take the report with
you and go for a disability
assessment by any Singapore Medical Council-registered doctor or GP who
is on the preferred list of
medical practitioners. After
you have been assessed on
the six activities of daily
living, mail the completed
Functional Assessment
Report back to the Agency
for Integrated Care (AIC)
at PO Box 680 Bukit Merah
Central Post Office,
Singapore 911536.
If your application
is successful, you will
receive either a blue or
orange Health Assist card,
depending on your per
capita household monthly
income level. All eligible
family members within
your household (i.e. have
the same address as you on
their NRICs) will be issued
an individual Health Assist
card each. The cards are
valid for two years.
SEP – OCT 2013
How to deal with excessive
burping and belching?
I have a problem with burping and
belching. I try to eat five small meals a
day, but I still belch very often. Sometimes, I wake up at night because of
the gas build-up, and belch for some
time before I can go back to sleep.
What is wrong with me?
When one eats, one also swallows air.
When too much air has been swallowed,
the body needs to expel or belch it out.
Eating slowly, not smoking and drinking less carbonated drinks and beer can
reduce the incidence of belching.
Excessive belching or burping can be
due to indigestion (non-ulcer dyspepsia). It can also be caused by an undiagnosed problem within the digestive
system, which then should be appropriately identified and if necessary, treated
by a doctor.
Indigestion happens to almost everyone at some time, and it usually resolves
itself after a short while. It commonly
occurs after a heavy or greasy meal, or
after eating food that doesn’t agree with
the person.
Simple measures, symptomatic
therapy or lifestyle changes can alleviate some symptoms of indigestion. Your
family physician can refer you for specialist assessment if an undiagnosed problem is suspected or if more meticulous
investigations are required.
Dr Ong Wai Choung, Senior Consultant, Department of
Gastroenterology and Hepatology, Singapore General
Hospital
17
Our experts answer all your questions about health
Coping with
periodic eczema
Choosing
the right
shoes for
toddlers
Photo: getty images
Health Xchange
singapore health
When should my baby start to wear shoes? How do I choose the right shoes
for my child?
Babies start walking when they are
about one year old. They can start
wearing shoes when they are able to
walk competently outdoors. At home,
they can walk barefoot, especially at
the stage where they are just learning
to walk by holding on to furniture. Be
sure to keep the floor clear of clutter
and sharp objects.
Walking barefoot at home helps
babies develop their tactile functions,
as well as their sense of balance and
coordination. Tickling babies’ soles will
also make them stretch and curl their
toes, working the intrinsic muscles
of their feet.
Any cure for astigmatism?
My young nephew has had astigmatism since he was five or six years old.
We understand from the doctor that
it is due to his irregular corneal curvature. Is there any chance of a full recovery? How do we protect his eyes from
deteriorating further?
It is unlikely that the astigmatism will
disappear, unless it is very mild. Astigmatism can change as a child grows, as the
When choosing footwear for babies,
go for soft shoes with flexible soles for
toddlers who have just started walking. Shoes should fit snugly – neither
too tight nor too loose. If the child’s
feet often slide forward and you can
see a space at the back of the shoe, the
shoes are not a good fit. At the same
time, the shoes shouldn’t be too tight;
they should have room for the child’s
toes to wriggle freely.
Generally, children’s feet grow
about two baby shoe sizes a year for
the first four years.
Ms Marabelle Heng, Senior Podiatrist, Department
of Podiatry, Singapore General Hospital
I have had eczema since I was young.
One patch on a toe never completely
goes away even though it improves
when I use the prescribed cream. The
eczema on my fingers and toes flares
up on and off. Over the last few years, I
have periodically had eczema on other
parts of my body. How do I prevent or
reduce it? Recurrence of eczema is common. To
reduce recurrences, you need to prevent
dryness and relieve itching. This can be
done by removing or avoiding aggravating factors, such as:
Rapid changes in temperature,
strenuous exercise and hot weather
Rough, scratchy, tight and woollen
clothing
Frequent use of soaps, bubble
baths and hot water, and cleansing
procedures that tend to remove
natural oil from skin
Emotional upsets
Wear light, smooth, soft, non-binding clothing. Do not increase the skin’s
dryness by having prolonged or frequent
hot baths or showers. Use mild soaps or
emulsifying ointment as soap. Bathe or
shower with lukewarm water.
When necessary, sponge gently under
the arms, in the groin and in other areas
where cleansing is imperative. At other
times, cleanse the entire skin with a nongreasy lotion. Avoid sudden changes of
temperature, for instance, going into an
air-conditioned room from the hot outdoors. Try not to rub or scratch. When
the itching is severe, try to relieve it by
dabbing or applying cloths soaked in
cold water.
corneal curvature can change with time.
You can protect his eyes by ensuring he
wears his glasses, if recommended by
the ophthalmologist, to prevent development of “lazy eye” or amblyopia.
Healthy eye habits such as reducing
close-range work, and taking part in outdoor activities, can prevent him from
developing myopia.
Dr Zena Lim, Consultant, Paediatric Ophthalmology
& Adult Strabismus Service, Singapore National
Eye Centre
Dr Shah Mitesh, Family Physician, Consultant,
SingHealth Polyclinics – Geylang
These articles are from www.healthxchange.com.sg,
Singapore’s first interactive health and lifestyle portal.
Topics for discussion in
September-October 2013:
Autoimmune disorders, corneal
transplants, heart and renal issues
18
Opinion
singapore health
SEP – OCT 2013
illustration: heymans tho
Accepting
the inevitable
When the end is near,
acceptance brings peace
Life is like a piece of
string, smooth until
it gets knotted. These
knots grow bigger if
you leave them alone,
or smaller if
Untangled.
died, she wrote a beautiful letter to each
of her children, detailing how much she
loved them. It was her gift to them. Whenever they missed her, they could read her
letters and be comforted by the thought
that she was still with them in spirit.
There are tools that can help patients
accept their conditions. Meditation offers
opportunities for deep self-reflection.
Experiential exercises can bring them
through real-world situations, and therapy (individual or group) is a powerful
process for reframing their thoughts.
By Dr Gilbert Fan
P
eople are not progr amme d
to suffer, so most terminally ill
patients fear suffering. They worry
about pain, not being able to sleep or eat,
how they will look after surgery or treatment, and their waning interest in life.
They are concerned about who will
take care of them and the financial cost
of prolonged treatment. They also worry
about their spouses becoming single parents and taking care of the children and
in-laws.
Some, even after living with the illness
for years, cannot get past the fact that
they have cancer – but counselling by
medical social workers can help.
Coming to terms with the truth
The first premise that is introduced
during counselling is that life is imperfect. If patients can accept this, they will
accept that obstacles in life – cancer or
other life-changing issues – can occur.
Life is like a piece of string, smooth
until it gets knotted. These knots grow
bigger if you leave them alone, or smaller
if untangled. Sometimes there are issues
that cannot be resolved, no matter how
hard you try.
The second premise is that some
things cannot be changed. If they can
accept that life is imperfect and that not
all things can be changed, they can better
accept their condition.
People who are better able to accept
their conditions tend to have supportive
families, religion, or a positive outlook
on life. Studies show that the more supportive the family, the better the patient
copes. And staunch believers tend to be
more accepting than those with no faith.
A positive outlook can come from religion or life experiences. People who have
faced losses or setbacks tend to adapt,
and become more resilient and positive.
Those who are often sick or have a family
history of cancer are often not too surprised if they are diagnosed with cancer.
Acceptance is harder for those who were
once in good health.
John*, a successful CEO, was fit and
careful with his food. He found out he
had advanced cancer in his 40s and died
when he was 50. He found it difficult to
accept his illness and was angry with
himself. In his anger, he hurt his family
with unkind words and actions, but in
time, through counselling, came to terms
with his illness. He saw that by hurting
his loved ones, he would be perpetuating
this cycle of anger even after his death.
Leaving a legacy
When patients find that they have fulfilled their purpose and that there is
nothing more they can do to make a big
difference, they let go more easily.
It helps if they can identify this purpose. One way is by leaving behind
a legacy, which can be as simple as a
memento for their loved ones.
Mary*, a young mother with three
young children, was diagnosed with
advanced cancer in her 30s. Before she
Psychotherapist Dr Gilbert
Fan, 54, has been a medical
social worker and psychotherapist for 28 years. He is
Head of the Department of
Psychosocial Oncology and
Co-Chair of Patient Support
at the National Cancer Centre
Singapore. He is also an
Adjunct Senior Lecturer at the
Alice Lee Centre for Nursing
Studies, Yong Loo Lin School of
Medicine, National University
of Singapore.
Seeing the whole picture
Many cancer patients go through emotional roller coasters, seeing only their
diagnosis, a bad prognosis or an unsuccessful treatment. They don’t see the
whole picture because it is so eventbased. It’s just like marriage: Focus only
on the quarrels with your spouse and
you will feel that your relationship is an
unhappy one. But if you look at the big
picture, your marriage is actually not so
bad as there have been good times.
This reframing process works the
same way for cancer patients. Individual setbacks can be sad or disappointing, but seeing the big picture helps. An
example is thinking, “I’m a cancer survivor who has managed to live an additional 10 years.”
The truth is that most terminally ill
patients cannot accept death until the
very end, because they have been conditioned to put up a fight. But when things
do not improve despite the struggles,
and they know they are dying, they begin
to accept their condition for what it is.
It is at this point that they will be able
to let go and finally be at peace with
themselves.
*Names have been changed.
SEP – OCT 2013
Why must I pay the
foreigner’s rate for day
surgery?
Why was I asked to pay the foreigner’s
rate when I underwent day surgery
recently? I am married to a Singaporean
and hold a Long-Term Visit Pass – Plus,
and I understand that holders of this
pass are eligible for healthcare benefits.
April 2012, qualified forSGH Since
eign spouses of Singapore
citizens are given a longer
Type of ward class/ service
at restructured hospitals
period of residency under the Long-Term
Visit Pass – Plus scheme. They are also
eligible for healthcare subsidies for
inpatient services at restructured hospitals, set at a level close to that for permanent residents.
The levels of inpatient subsidy depend
on the choice of ward class and are similar to the corresponding subsidy levels
for permanent resident patients. LongTerm Visit Pass – Plus holders, however,
are not eligible for subsidies for day surgery, specialist outpatient clinics and
polyclinics services.
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
[email protected] or The Editor, Singapore Health,
Singapore General Hospital, Communications
Department, Outram Road, Singapore 169608, or
talk to us on Facebook.
The winner will receive a bottle of Ultra Hemoshield
(120 capsules) and Ultra Organic Green Barley (100
capsules). The products, worth $112.85 in total, are
sponsored by United Pharma.
Maximum subsidy levels
Singapore
citizens
Permanent
residents
Long-Term Visit
Pass – Plus Holders
Class A
0%
0%
0%
Class B1
20%
10%
10%
Class B2+
50%
30%
30%
Class B2
65%
45%
45%
Class C
80%
60%
60%
Day surgery
50%
45%No subsidy
Specialist outpatient clinic 50%
30%No subsidy
A&E
19
about your health
experience and win a
prize for best letter
Emergency department fees are the same for
all patients
Table adapted from Immigration & Checkpoints Authority of Singapore website
My unexpected admittance to the
I was warded in SGH for 10 days
National Heart Centre Singapore has earlier this year for second degree
given me many good memories of the burns on my arms and legs, followattentive care and empathy I received ing a car accident. Dr Mohamed
Zulfikar Rasheed, Associate Consulfrom the nurses and staff .
Throughout my stay at Ward 44, Staff tant, Department of Plastic ReconNurse Ibanez Ariescena Incierto and struction and Aesthetic Surgery, left
Senior Staff Nurse Natasha Choo Shan a deep impression on me. He gave me
Shan were extremely accommodating, a detailed explanation of my surgerfriendly and kind. My recuperation is ies and was also very warm and thornot only due to them but all the other ough when checking on me. Thank you,
nurses and doctors in the ward. Thank Dr Zul! I also wish to thank the Ward
you very much for your wonderful care. 43 staff, especially Staff Nurse Tan Li
I was also impressed by the prompt Khoon, Principal Enrolled Nurse Winnie
updates my family and I received. You Ong, and Healthcare Assistant Goh Poh
really are angels and unsung heroines. Chin. I consider them – who are so committed to their work – my friends!
Keep up the good work!
– Mr KH Toh
– Mr Gan
tributes
says
your say
singapore health
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synovial membrane. Collagen is also found in the synovial
membrane but in larger quantities because the protein
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Glucosamine acts more like a lubricant in the joints while
collagen helps the tendons, ligaments, cartilage, muscles,
membranes and synovial liquid (lubrification).
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20
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FYI
singapore health
SEP – OCT 2013
event Calendar
▲
SGH Alzheimer’s and
Dementia Day
Date Sep 14, Saturday
Time 10am–12pm
Venue Singapore General Hospital, Block 6
Level 9 (Deck on 9)
REGISTRATION Call 6576-7658 during office
hours (8.30am–5.30pm) to register by 6
September.
Price Free
Find out, from SGH neurologists, geriatric
experts and psychologists, the common
symptoms of dementia, behavioural problems of dementia patients, treatments,
and how caregivers can learn to cope with
their patients.
daily servings of
Vegetables
and Fruits
▲
Live 3
years
Longer
People who eat at least five servings of fruit and
vegetables a day lived, on average, three years
longer than those who do not, stated a study
published in the American Journal of Clinical
Nutrition. The study was based on data collected
from more than 71,000 Swedes, aged 45 to 83, who
were tracked over a period of 13 years.
Eating more than five servings of fruits and
vegetables daily, however, did not result in an even
longer lifespan, the researchers said.
Date Sep 21, Saturday
Time 2–4pm
Venue Academia, 20 College Road, Level 1
REGISTRATION Call 6326-5151 or 6576-7658
during office hours (9.30am–5.30pm) to
register.
Price $5
Source: reuters.com
Acting out dreams
linked to dementia
If a man acts out his dreams in his sleep,
there is a high likelihood that he is
developing dementia with Lewy bodies,
which is the second most common form of
dementia in the elderly. This sleep behaviour
disorder is caused by the loss of normal muscle
paralysis during rapid eye movement sleep.
Mayo Clinic researchers in Minnesota and Florida
found that patients with this sleep behaviour
disorder were five times more likely to have
dementia with Lewy bodies than if they had symptoms such
as fluctuating cognition or hallucinations.
Repeat anterior
cruciate ligament injury
likely after surgery
29.5%
of athletes had a second
ACL injury within two years
of returning to sports
Broaden your understanding of psoriasis,
a common chronic skin disorder, and learn
how to manage it at this bilingual public
forum organised by SGH’s Department of
Dermatology.
Source: Mayo Clinic
20.5%
suffered an injury to the
opposite knee
9%
re-injured the
same knee
▲
Air pollution ups
risk of burst appendix
The risk of suffering a burst appendix rises on smoggy
days, a new study suggests. Dr Gil Kaplan of the
University of Calgary found that the risk rose by up
to 22 per cent with every 16 parts-per-billion rise of
ozone (a component of smog) in the air, during the
three to seven days before an appendicitis incident.
Ozone is one of the five pollutants measured for
Pollutant Standards Index or PSI.
The anterior cruciate ligament (ACL) is one of four major
ligaments in the knee, and is crucial for stabilising the knee
during turning. ACL injuries are common among athletes. After
undergoing reconstructive surgery for such injuries, athletes
are six times more likely to suffer a similar injury within two
years than their peers who have never had such an injury. The
finding is from a study by Associate Professor Mark Paterno of
Cincinnati Children’s Hospital Medical Center.
Source: consumer.healthday.com
Source: consumer.healthday.com
1. What are uterine fibroids?
2. Which story in this issue did you
find the most informative?
Closing date: October 3, 2013
Send in your answers and stand
to win a bottle of Spirulina 100%
Extra 10% Deep Ocean Water (750
tablets) worth $69.
Include your name, age, gender, address and telephone number.
Winners will be notified via phone or e-mail. Incomplete or
multiple entries will not be considered.
E-mail [email protected] Post The Editor, Singapore Health,
Singapore General Hospital, Communications Department,
#13-01 Surbana One, Blk 168, Jalan Bukit Merah, Singapore 150168
Winners of Contest 23: Each will receive a bottle of Ultra
Selenium Dietary Supplement (60 Veggie Capsules) worth $68.50.
Prizes must be claimed by October 3, 2013.
1. Chim Wai Chong 2. Jed Leong 3. K Muthukumar
4. Teo Hock Wah 5. Vanipriya Balasubramanian
An Approach to Common
Urological Diseases
Date Oct 12, Saturday
Time 9am–5pm (Mandarin session 9.30–
11am; English session 12–1.30pm; Malay
session 2.30–4pm)
Venue Health Promotion Board Auditorium
REGISTRATION Call 6326-5151 or 6576-7658
during office hours (9.30am–5.30pm) to
register.
Price $8 per session
Learn from SGH’s urologists how to
manage common urological conditions,
including incontinence, prostate diseases,
urinary stone diseases and men’s health.
▲
contest
Managing Psoriasis
Have you run out of excuses?
Managing menstrual pain
or bleeding; Getting back
to life and work
Date Oct 5, Saturday
Time 10am–1pm with post-presentation
lunchtime refreshments
Venue To be confirmed
Visit www.singhealth.com.sg/events or the
websites of respective institutions for any
changes, more information, and other listings.
Sep–Oct 2013
singapore health
21
Put your
heart to
the test
The National Heart Centre Singapore offers
an array of cardiac examinations ‒ from the
basic to the nuclear. By Sol E Solomon
photos: alecia neo
YOUR GUIDE TO BETTER LIVING
Electrocardiogram (ECG)
This is the first test used to check if someone
has heart disease. An ECG records a heart’s
electrical activity, and an abnormal result may
be an early sign of an abnormal heart rhythm,
heart blockage, damage or changes to the heart
muscle, or enlarged heart chambers.
When it is done
Before surgery.
If the patient has chest pain or an abnormal
heart beat.
If the patient has a history of heart problems.
illustrations: heymans tho
H
eart disease is the second most
common cause of death and hospitalisation in Singapore. Between
1994 and 2012, specialist outpatient
visits for cardiology and cardiothoracic
surgery across Singapore’s public institutions rose from 74,000 to 271,000. At the
National Heart Centre Singapore (NHCS)
alone, outpatient visits almost tripled,
from 42,000 to 113,000.
Singapore’s ageing population
means that demand for these services
will grow even more ‒ the number of
people aged 65 years and above is
expected to triple to 900,000 by 2030.
The recent spate of sudden cardiac
deaths among young people indicates
that even more caution is needed.
There are many tests to diagnose heart
problems, and a patient’s symptoms and
family medical history will be considered
before a doctor orders them. However,
there are cases when heart conditions do
not produce specific symptoms or signs
that are detectable by current tests, said
Dr Ewe See Hooi, Consultant, Department
of Cardiology, NHCS.
She describes four common tests:
Procedure
Electrodes are placed on the chest, arms and
legs. The ECG machine detects the electrical
impulses which cause the heart to contract
and relax, and transforms them into waves that
are displayed on a monitor or graph. The test
detects heart rate, damage to the heart, and the
size and position of the heart’s chambers.
Pros and cons
An ECG presents no risks, but some heart conditions may go undetected as they never produce
any specific ECG changes.
> Continued on page 22
22
singapore health
Sep–Oct 2013
> Continued from page 21
Put your heart
to the test
Stress Echocardiogram
This test adds on to the stress test by including an imaging test precodure called echocardiography. Images of
the heart are taken while the patient is performing the
stress test or while lying down immediately after reaching peak exercise level. It captures images of the heart
at its peak heart rate.
When it is done
When the patient has chest pain.
If the patient has had a previous heart attack, angioplasty or bypass surgery.
If there is narrowing of the vessels supplying blood to
the heart muscle.
If there is an abnormal heart rhythm during exercise.
As a screening test before starting an exercise programme or going for surgery.
To assess symptoms and blood pressure response in
patients with heart valve diseases.
Procedure
It uses ultrasound to study how the heart contracts and
pumps blood while under stress. It also measures the
size and function of the heart’s chambers, the motion of
the heart valves, and the way blood is flowing.
There are two kinds of stress tests. The pharmacological stress echocardiogram is for patients who are
unable to exercise. The exercise stress echocardiogram
is for those who can carry out treadmill exercises.
Pros and cons
A stress echocardiogram can identify the site of narrowed blood vessels, and the extent of reduced blood
flow to the heart. There is a small possibility of the
patient experiencing chest pain, irregular heartbeat,
blood pressure changes, or a heart attack during the
test. The doctor will take necessary precautions.
Exercise Stress Test
If the ECG detects abnormalities, this is the next step
‒ assessing how the heart responds to an increased
workload during exercise. While the patient exercises
on the treadmill, his heart’s electrical activity, heart
rate and heart rhythm, as well as his blood pressure
are continuously monitored.
When it is done
If the patient has chest pain.
If the patient has had a previous heart attack,
angioplasty or bypass surgery.
If the patient has an abnormal heart rhythm,
or to monitor his heart rate and heart rhythm
during exercise.
As a screening test before starting an exercise
programme or going for surgery.
Procedure
Sticky electrodes are placed on a patient’s chest, and
a blood pressure cuff around his arm. This is to take
his blood pressure and an ECG of his heart at rest. The
patient starts walking on the treadmill, and the speed
and gradient are increased every three minutes for
about 20 minutes.
At the end of the test, the patient rests on a bed
while his blood pressure and ECG are monitored.
Pros and cons
It can detect abnormal heart rhythms during
exercise, and reduced blood supply to the heart due
to blockages in the arteries. It does not reveal the
extent of the reduced blood supply, or the specific
area in the heart that is not receiving enough blood.
It may not detect arterial wall thickening, as this
condition does not always lead to a reduction of
blood flow to the heart.
The test is not suitable for patients who are
unable to perform treadmill exercises.
Nuclear Cardiology Test
In this test, images taken with a gamma camera can
reveal which part of the heart is not getting supplied
with enough blood and oxygen. It can also reveal the
size of the affected area and the severity of the blockage.
When it is done
In more complex cases, such as when a patient has
multiple blockages, or when a patient experiences
chest pain after a previous surgery or angioplasty.
Procedure
It involves the injection of a radioactive tracer into the
body, and use of a special gamma camera to track the
tracer’s path. Radiographic images are then taken over
a period of 15 to 20 minutes. The whole procedure takes
two to three hours.
Pros and cons
It can reveal exactly where the heart is not getting
enough blood and oxygen. But parts of the body near
the heart, like the diaphragm or breast tissue, may produce some alterations that confuse the test results.
The test does expose the patient to some radiation,
but only within safe levels.
Sep–Oct 2013
singapore health
23
Lactose
-intoler
ant suf
ferers
need no
t
g
dairy pr ive up
oducts
Find ou
t how t
o
enjoy c plan your di
et
heese a
nd milk so that you c
a
. By Ng
Hui Hui n still
D
Get your
calcium from
these foods
Soymilk
Oranges
Pinto beans
Lettuce
Dark green
vegetables
(broccoli,
spinach)
Fish (sardines,
salmon, tuna)
Nuts and seeds
o you suffer from diarrhoea, vomiting or abdominal
cramps after eating cheese or drinking milk? If you do, you
may be lactose intolerant.
Lactose intolerance, the inability to digest milk sugar or
lactose in dairy products because of an enzyme shortage in the
small intestine, is common among Asians. When unprocessed
lactose enters the colon, it interacts with normal intestinal bacteria and causes symptoms such as abdominal cramps, bloating,
gas, diarrhoea, nausea and vomiting.
Fortunately, there is no need to give up dairy products completely. The key is moderation. Most lactose intolerant individuals can still consume some dairy products without having symptoms, as long as they eat or drink only small amounts.
If you suspect that you might be lactose intolerant, simply
limit the amount of milk products in your diet. If the symptoms
disappear, you are probably lactose intolerant. A doctor can also
use blood tests and a hydrogen breath test to diagnose lactose
intolerance.
There is no treatment currently available to improve the
body’s ability to process lactose, but the symptoms can be controlled by choosing a diet that limits the consumption of lactose.
One should consult a dietitian before avoiding lactose-containing foods, however, as doing so may lead to certain dietary
deficiencies. Dairy products contain important nutrients and are
rich in calcium. If you are avoiding dairy products, you need to
make sure you get enough calcium from other foods to meet your
body’s requirements.
Lactose intolerance may be hereditary, or it may develop as
one ages as a result of bowel injury or gastrointestinal disorders.
Use over-the-counter
lactase (the enzyme
that breaks down lactose)
tablets or drops to help
digest dairy products.
Choose smaller servings
of dairy products.
Drink milk with other
foods to slow the
digestive process and help
reduce symptoms of lactose
intolerance.
Experiment with
different dairy
products as they contain
2
3
4
Ingredients (serves 4)
800g
chicken meat, skin removed
and cut into pieces
Marinade
1
teaspoon (tsp) chilli powder
1
tsp cumin powder
2
tsp garam masala
25g
garlic, ground
1
thumb-size piece of ginger,
ground
25ml lemon juice
1
tsp margarine
1
tsp oil
½
tsp salt
4
tablespoon (tbsp) low fat
yogurt, whisked
Method
Diet Tips
1
Tandoori chicken
different amounts of
lactose. Yogurt may be
tolerated better as the
bacteria in cultured milk
products naturally produce
lactase (see recipe).
Check nutrition labels
for milk and lactose
as they are often added
to cereal, instant soups,
salad dressings, non-dairy
creamers, processed
meats, and baking mixes.
Lactose is also used in some
medications.
5
1 Mix the marinade ingredients
together.
2 Make shallow cuts on the chicken
with a sharp knife.
3Rub chicken with marinade and set
aside for 30 minutes.
4Preheat oven at 180ºC.
5Grease baking tray with a little oil.
6Place chicken on baking tray and
put small dollops of margarine on
each piece of chicken.
7 Bake chicken for about 25 minutes,
or until done.
8Remove from oven and serve hot.
The recipe in this article was adapted from
Where is the Fat? Cookbook, published by
Dietetics and Nutrition Services, SGH.
24
Laundromat
for surgical instruments
Two little-known units at the Singapore General Hospital perform
the vital task of cleaning and sterilising medical instruments and
utensils. By Desmond Ng
Decontamination
Instruments from the
various departments
and operating theatres
are transported by a
porter to the TSSU via
a “dirty lift”.
These instruments
are scanned and
checked for defective
or missing items. Every
instrument has to be
accounted for.
PhotoS: VERON WONG
Instruments are
Within the team of 62 at the TSSU, the eldest is Ms Khoo Chai Yan (right), 72, while
Mr Muhammad Ariff Ahmad, 24, is the youngest. Ms Goh Meh Meh (middle), Assistant
Director of Nursing, is overall in charge.
K
eeping surgical instruments clean
and sterile is top priority at any
hospital as it can mean the difference between life and death.
At the Singapore General Hospital
(SGH), this duty is carried out by the little-known Theatre Sterile Supplies Unit
(TSSU) and Central Sterile Supplies
Department (CSSD).
The TSSU serves the operating theatres, procedural rooms, and more specialised departments like the diagnostic
radiology department, delivery suites,
cardiovascular laboratory and emergency department. It also supplies sterilised instruments to the National Cancer
Centre Singapore, the National Heart
Centre Singapore, and the National
Dental Centre of Singapore.
“We turn around instrument sets to
make them sterile and safe for use in the
operating theatres,” said Ms Goh Meh
Meh, Assistant Director of Nursing, SGH.
The TSSU is like a giant laundromat
for surgical instruments. It usually takes
about five hours to decontaminate and
process a set of instruments, from entry
to sterile storage. The same process can
take up to six and a half hours in the evenings, when procedures have ended and
instruments return for cleaning.
Like the TSSU, the Central Sterile Supplies Department (CSSD) also collects
and disinfects reusable items, said Ms Ng
Suat San, Manager, CSSD. The difference
is that the items the CSSD handles include
those meant for the wards and the clinics.
They also include utensils for operating
theatres, dressing packs, and cleansing
sets. Just as at the TSSU, the utensils
are decontaminated, washed, sorted,
packed, and sterilised at the CSSD. The
entire process takes about four hours.
The inventories and processes at both
units are carefully tracked and monitored by customised IT systems.
Operating
round-the-clock,
the TSSU Processes
25,000 to 28,000
sterile units
a month.
usually given a
preliminary wash to
get rid of residual
tissue and blood
before they are
transported to the
TSSU.
After an inventory
check, these
instruments are
ready for washing.
Sterile storage
The TSSU inventory
contains some 2,950
sets of instruments,
3,500 different types
of instruments, and
tens of thousands
of individual
instruments.
SEP – OCT 2013
Washing
Instruments are
placed on trays on an
air-glide system to be
washed in machines.
Washing takes place
in a controlled
environment and at a
specific temperature.
Instruments are 99.99
per cent disinfected
and dried at 90 deg C.
Most instruments then
have to be lubricated.
A final rinse is given
using de-ionised water
that has been purified
by reverse osmosis, to
maintain the shelf life
of the instruments.
The washing cycle
takes about 50
minutes.
Some medical devices
are water- and heatsensitive, and these
are cleaned manually.
singapore health
Assembly
Washed instruments are
unloaded and placed in
trolleys, in zones colourcoded by department, to
ensure that they do not
get mixed up.
Nurses and technical
staff pack the
instruments at their
workstations, with
pictures and videos
to guide them in the
assembly of more
complicated instruments
such as power drills.
Some instruments,
such as scissors, need
to be sharpened or
demagnetised. Some
instrument sets, such
as those used for
laparoscopy, need to be
oiled to ensure they are
in top working order.
Instruments that need to
be repaired will be sent
out to vendors.
The barcoded tag that
accompanies each
instrument or instrument
set contains that
instrument's or set's
production history data,
as it passes through
the TSSU to the user
departments.
Instruments are assembled
and packed in instrument
containers, or doublewrapped with sterilisation
paper or linen paper.
Together, the TSSU and
CSSD use 818,000 sheets of
sterilisation paper a year.
Loading and sterilisation
Assembled sets are
Packed instruments
are cooled in a storage
area after sterilisation.
The instrument sets
are placed in colourcoded stations. The
sets will be collected
and delivered to
operating theatres by
porters as needed.
The sets are placed in
covered carts, which
are transported via
a “clean lift” to the
various departments.
placed on loading
carts to allow for
maximum contact with
the sterilising agents.
The sterilisation
process takes another
50 minutes. Steam, dry
heat, and hydrogen
peroxide plasma
sterilants are used to
kill germs.
Biological tests are
done twice daily to
ensure that all germs
are killed.
25
26
singapore health
SEP – OCT 2013
Pearls of wisdom
Painful wisdom teeth can be avoided with proper care. By Satish Cheney
M
ention wisdom tooth surgery and people usually wince. Many avoid seeing a dentist until the
pain in their teeth becomes unbearable, but such
delays can lead to complications.
Dr Shermin Lee, Consultant, Department of Oral
and Maxillofacial Surgery, National Dental Centre Singapore (NDCS), said: “I’ve seen patients who needed to
be hospitalised because they procrastinated. An infection can develop, potentially compromising a patient’s
airway and ability to swallow. People often wait till the
last minute because they are afraid and unaware of
problems an infected wisdom tooth can cause if not
attended to.”
When wisdom teeth become impacted
Wisdom teeth are also known as the third (rearmost)
molars. We typically have four – two each in the upper
and lower jaws, one on either side. They are associated
with wisdom because they usually erupt between the
later growing ages of 16 and 21.
Some studies suggest that wisdom teeth could once
have been useful, when human jawbones were bigger
and could accommodate their fully erupted size. But
over the centuries, with a diet of softer, processed food,
our jawbones gradually shrank – providing less space for
teeth to grow. This has led to most wisdom teeth, especially those in the lower jaw, being impacted.
An impacted wisdom tooth does not grow in the
right direction, said Dr Lee. “It could be partially or
fully impacted, either with soft tissue or by parts of the
jawbone. An X-ray will show how deeply the tooth is
impacted, and the decay associated with it or the tooth
besides it.”
Impacted wisdom teeth can lead to a slew of problems, including gum infection, tooth decay, and occasionally, the formation of dental cysts. When a dental
cyst develops and enlarges, it can cause pain in the jawbone and surrounding area, and at times even weaken
the jawbone, causing a pathological fracture.
Going under the knife
Oral surgeons (dentists with speciality training in Oral &
Maxillofacial Surgery, equipped with the skills and experience to remove impacted wisdom teeth) will consider
all possible factors before recommending the removal
of impacted wisdom teeth.
Surgery usually involves cutting the gums to expose
the impacted tooth and the bone, dividing the impacted
tooth, and then stitching up the gums. NDCS carried out
over 4,500 cases of wisdom tooth removal in 2012.
Impacted wisdom teeth, accompanied by pain and
other symptoms, occur mostly in young patients. But
elderly patients with problematic wisdom teeth may
sometimes need surgery as well. “Older patients may
have pre-existing conditions like diabetes or hypertension, which need to be taken into consideration when
managing their surgical and post-operative care. Also,
they may have a slightly longer downtime to heal, compared to younger people,” said Dr Lee.
Dentists are often asked whether all four wisdom
teeth, even unproblematic ones, should be removed
while the patient is young to pre-empt future problems.
Dr Lee said: “This is a grey area which is debatable even
among experts from the UK and the US. Treatment
should be tailored to the individual.”
Get checked before pregnancy or radiotherapy
Pregnant patients with wisdom tooth problems are
treated only if their teeth cause problems during pregnancy. Doctors will give serious consideration to any
medication, such as painkillers or antibiotics, before
prescribing them to pregnant or breastfeeding mothers.
Dr Lee advises women planning for pregnancy to
have regular dental check-ups, to avoid undergoing
complicated dental procedures during pregnancy as far
as possible.
She also said that patients diagnosed with head and
neck cancers, who need radiotherapy, should preferably
have dental screenings weeks before starting treatment, to avoid post-radiotherapy dental surgery. Dental
extractions and surgery after radiotherapy can give rise
to unfavourable healing or even osteoradionecrosis
(bone infection).
Fact or fiction?
Dr Lee throws light on some frequently
asked questions about wisdom teeth.
Do all adults have four wisdom teeth?
Not everyone has four. Some have fewer.
Do only young people have problems
with wisdom teeth?
No, and some people never develop problems
with their wisdom teeth, even through old age.
Are wisdom teeth completely useless?
If a wisdom tooth erupts ideally into the jaw
arch, has an opposing tooth and can be used
when chewing , it serves a purpose and does
not need to be removed. In some cases, a
wisdom tooth can be used as a substitute for
a lost tooth, but this is usually applicable only
to young patients.
Is it best to remove all one’s wisdom
teeth in a single procedure?
There are no hard and fast rules. Various
options and patients’ preferences will need
to be discussed. It depends on whether
the patient is going to the procedure done
under local anaesthesia, sedation or general
anaesthesia. This also depends on a patient’s
comfort level and whether they prefer to
be awake or asleep during the procedure.
If the patient will be undergoing general
anaesthesia, we usually advise removing all
the wisdom teeth during that procedure.
Are the procedures always painful?
If you have regular check-ups, or visit a
dentist immediately upon feeling slight
discomfort around your wisdom tooth, any
problems can be addressed before infection
sets in or decay occurs. Adequate pain relief
medication will be available to support
patients during the post-operation phase.
An X-ray showing
that all four
wisdom teeth are
impacted. X-rays
can also reveal
whether the teeth
next to impacted
wisdom teeth are
affected.
2013 年9 – 10月刊
新加坡中央医院与新加坡保健服务集团的双月刊
机器人辅助手术
突破肌瘤切除限制
常见且
基本无害
图： alvinn lim
通常需经开腹式手术切除巨大肌瘤，现在也能通过锁孔手术安全地进行
彼得巴顿史密斯医生坐在远离手术台的控制台前，通过一个三维高清摄像头和精度高的微巧手术器械进行手术。
原文 Desmond Ng
医生说。“使用机器人技术，我们能
将限制放宽到相当于怀孕20周大小，
但如果还是超出界限，也只能选择开
腹手术了，”他补充道。
“由于机器人辅助科技给外科医生更
大的操作范围，所以限制也被放宽，
比传统直式腹腔镜设备更能处理大块
肌瘤，” 巴顿史密斯医生说。
可弯曲机器人臂实现精确操作
在手术中，巴顿史密斯医生在她腹部
做了5个微小切口，插入一个三维高
清摄像头和一个既灵活又精度高的微
巧手术器械，然后坐在远离手术台的
控制台前，透视黄瑞兰腹腔内的情况
并进行手术。
“感觉（自己）犹如手术器械一样只
身在体内动手术，”巴顿史密斯医生
说。真多亏了这台机器人高度灵活的
手术臂，让他更能掌控轻柔且精细地
操作，切开子宫表面，再像“剥豌豆
一样轻而易举地把肌瘤从子宫剥离出
来，”他说。
接着，他将子宫切口缝合，再采
用一种称为组织粉碎器的工具（一端
具有环形刀片的中空管）将原本巨大
的肌瘤切成长条状，然后从腹腔狭小
的切口中取出。
“使用机器人辅助手术，患者所承受
的痛苦会减轻，失血量减少，住院时
间缩短，患者也能更快地恢复正常活
动，约术后2至3周，而进行常规开腹
”
手术的患者则需要6周，巴顿史密斯
医生说。
黄瑞兰的手术耗时3个半小时。留
院2天。进行开腹手术治疗（称为子
宫肌瘤切除术）的患者，通常需要住
院3至5天才能回家。
“其惊人之处在于术后无疼痛。感
觉就像胃部不适。有不适感但不疼
痛，”黄瑞兰说。
子宫肌瘤不但常见而且可以
长得很大。但是，它们很少
癌变。
大约每5位女性中就有一
位患有子宫肌瘤，通常发生
在30或40多岁时。“但是发
生肌瘤癌变的几率很低，每
1000名患者中不到1名会发生
肌瘤癌变，”新加坡中央医
院妇产科高级顾问医生彼得
巴顿史密斯说。
对于大部分女性而言，子
宫肌瘤不会带来什么麻烦，
因为它们通常保持较小的状
态。但是一些良性肿瘤可以
长得非常大。“我曾切除过
重达9公斤的肌瘤呢，” 巴
顿史密斯医生说。
当肌瘤长得非常大时，它
们可能开始压迫其他器官，
比如肾脏。发生此情况时，
患者就会开始出现月经大量
出血，腹部不适，腰背疼痛，
以及尿频症状。部分女性也
可能出现不孕。
“在新加坡，女性常常不仅
患有子宫肌瘤，还同时伴有
子宫内膜异位，这使得情况
更加复杂，”他说。很多亚
洲女性同时患有这两种疾病，
这对来自英国的巴顿史密斯
医生来说是前所未见的。
带蒂肌瘤
腔内肌瘤
输卵管
子宫
卵巢
黏膜下肌瘤
浆膜下肌瘤
肌壁间肌瘤
子宫颈
阴道
子宫肌瘤类型
除了非常巨大的带蒂肌瘤外，黄瑞兰还有其他三个较
小的肌瘤，称为黏膜下及腔内肌瘤。据彼得巴顿史密斯
（ Peter Barton-Smith） 医生说，这类肌瘤，如果瘤体
够小的话，可以经子宫颈进行手术切除。瘤体更大的和
其他类型的肌瘤通常都不得不经腹部进行手术切除。
图： HEYMANS THO
黄
瑞兰女士在五月份做了子宫
肌瘤切除术。切除的良性
肿瘤共有4粒，总重量约半
公斤，最大的瘤体直径14.5厘米。现
年54岁的黄瑞兰，除了腰围增粗外，
几乎没有其他症状。
“我还以为是自己长胖了呢，”这位
培训和项目经理说。
子宫肌瘤是育龄期妇女最常见的疾
病，开始发病的年龄通常是30或40多
岁的女性。肌瘤生长于子宫肌层，一
般无害而且表面光滑。肌瘤长得越大
就会导致月经量更多、腹部不适、背
痛、尿频及生殖功能障碍。
今年初，已有两个孩子的黄瑞兰在
常规妇检中发现自己患有子宫肌瘤，
而且体积还不小。医生建议她将肌瘤
切除。
“她最大的瘤体是带蒂肌瘤（见图
解），所以我们选择为她进行微创性
的机器人辅助手术，”新加坡中央医
院妇产科高级顾问医生彼得巴顿史密
斯（Peter Barton-Smith）说。
一般上，如果患者肌瘤数目太多或
者最大瘤体太大，外科医生是不会选
择微创性或微创腹腔镜手术，而是开
腹手术。巴顿史密斯医生说，传统
的腹腔镜手术一般适合限于有3到5个
肌瘤，每个瘤体直径小于5-6厘米的
患者。
另一种决定手术方式的方法就是依
据子宫的大小。当子宫逐渐增大至相
当于怀孕16周大小时，就是达到传统
腹腔镜手术条件的限制，巴顿史密斯
27
新闻
28
新闻
2013 年9 – 10月刊
您的牙龈健康吗？
新加坡国立牙科中心顾问医生陈华情回答关于牙周病的疑问
牙龈病，也称为牙周病，是指在牙龈
上和支撑牙齿的骨质中发生的慢性细
菌性感染，会影响一颗或波及多颗牙
齿。牙龈炎是较轻型的牙龈病。按时
刷牙，使用牙线，并配合专业洁牙护
理，牙龈炎是可以治愈的。但如果
牙龈炎未经治疗，则可发展成为牙周
炎。此时牙龈、骨质和结缔组织都会
受损，引起脱牙。
牙周病的起因是什么？
引起牙周病的主要原因是菌斑。菌斑
会随时间而变硬并形成牙结石。在菌
斑变大的同时，机体的免疫系统也在
与细菌斗争。细菌产生的毒素和酶一
起作用，导致固定牙齿的骨质和结缔
组织受损。如果任其发展，牙齿最
终会松动，不得不拔除。牙周病的
病情轻重不一，可以影响任何年龄的
人群。
牙周病的易患因素有哪些？
吸烟会增加患牙周病的机率，并降低
某些治疗的效果。不受控制的糖尿病
会增加感染的危险。女性体内的激素
变化也会使得牙龈更为敏感。可能诱
发牙周病的其他因素包括某些口腔用
药、某些癌症和艾滋病的治疗方式以
及个人体质等。
牙周病有哪些症状？
牙周病的症状有牙龈肿胀、疼痛、刷
牙时出血、龈线退缩、脓肿、牙齿松
动、移位、持续口臭及牙龈和牙齿
钝痛。也有些人没有任何症状或疼
痛感。
牙周病如何治疗？
牙周病的治疗方式各不相同，但目标
都是控制牙龈感染及恢复良好的口腔
环境。非手术疗法包括洁牙加根面
平整。洁牙是刮除龈线上下方的牙结
石。根面平整是在局部麻醉下采用专
门器械沿着牙根表面清除坚硬的牙结
石和细菌沉积物。
牙龈手术的目的是清除深部牙周
袋内的残余牙结石。其目的是避免疾
图：getty images
什么是牙龈病？
病恶化并使日常牙齿清洁变得更为容
易。牙周病病程较长的病人，应选择
牙龈手术。牙周病专科牙医有时会建
议病人做骨移植或组织移植，促进骨
或组织的重新生长，以达到修复病变
部位的目的。
如何预防牙周病？
使用含氟的牙膏刷牙，每天两次或每
餐后进行，可减少牙菌斑的积聚。每
天使用牙间清洁工具如牙间刷或牙线
做清洁。每年看牙医两次，进行例行
检查和专业洁牙。拒绝烟草。
牙周病会影响身体其他部位吗？
牙周病可能会影响身体其他部位，然
而目前科学研究对此还没有定论。相
关研究涉及探讨牙周病与心脏病发
作、中风或早产儿/低体重儿的出生之
间是否存在联系，以及探讨患有牙周
病的糖尿病人是否更难以控制其血糖
水平。
2013 年9 – 10月刊
新闻
29
食物恐惧
利用烘焙和共同用餐方式克服饮食失调症
原文 Jamie Ee
新
加坡中央医院职能治疗师郑
素玫每星期都开办烘焙课。
她不仅仅是传授糕点食谱，
也利用这个方式来帮助患上饮食失调
症的学员们，克服他们对糖和奶油等
日常食物的恐惧感。
在课堂上，学员们得直接接触他们
平时讨厌的食物。这有助于他们逐渐
抛却对食物的反感，更重要的是，解
除他们的饮食禁忌，重拾正常规律的
饮食习惯。
“饮食失调症患者与食物之间存
着一种‘错乱’的关系，”郑素玫
说。“每当看到食物时，他们不是在
哭喊、呼吸紧凑就是大发脾气。曾经
就有一名患者一看到食物便变得如坐
针毡，经常多次逃离现场，试图使自
己冷静下来克服恐惧，还不惜撕扯自
己的手指甲。”
这些人正是因为太在意自己的体重
和身材，才惹上食物恐惧症的。他们
认为高热量食物如奶油和糖
会使他们发胖，所以对它
们退避三尺。结果把自
己搞得瘦弱、营养不
良，还不时出现代谢或
荷尔蒙问题。
“饮食失调是一种
心理疾病。这种疾病没
有主要原因，一般被
视为一种诸多因
素的综合症，
包括遗传学、
家族类型、个
性类型以及媒
体影响等，”
新加坡中央医院康跃中心饮食失调治
疗计划主任、精神科高级顾问医生李
慧媛说，“对意志薄弱的人来说，只
要他们承受不了压力或他人的议论就
会很容易引起饮食失调。”
这种失调症会往往使人过于关注
食物和饮食，过分在意自己的身形和
体重，以至严重地影响他们的日常生
活，如工作和交际等。厌食症和暴食
症就是其中的两种。前者是进食量微
乎其微，后者则是无节制进食，然后
采取催呕或服用泻药来控制体重。
李医生和郑素玫是专治饮食失调症
的多学科医疗团队的成员。其他团队
成员则为患者提供营养、医疗和心理
方面的协助。
在那两小时的烘焙课上，郑素玫
与大家一起称重、计量食材和揉面
团。“对饮食失调症患者来说，这些
都是很难独自完成的工作。”
课堂结束后，学员们会分享他们
患上饮食失调症的人，
可能对糖和奶油等日常
食物产生恐惧感。
每个人都可从餐桌上选择各式各样的
肉类和蔬菜。
饮食失调症患者也会时常挑食剩
饭。为转移他们的注意力，在就餐过
程中，郑素玫会和他们谈论时事、最
新电影和书籍。“简言之，我会将整
个午餐体验正常化，好让他们能够
再次与别人舒服地一起用餐，”她
表示。
四到六个星期后，疗程结束。医
生会再三叮咛他们继续定时进餐、吃
多元化的食物和避免缺餐。李医生
说：“我们还会帮他们做些调整，好
让他们回到学校或工作岗位后，把注
意力转移到其他事情，而不是饮食和
体重问题上。”
然而，康复是一条很漫长的路，复
发率也“相当高”。她还指出，有三
四成的患者在结束治疗后的一年内又
重返恶习。她表示，及早治疗是康复
的关键，因此“承认问题”并寻求帮
助对患者来说是至关重要的。
的体验和感受。“当有些说奶油或糖
用得太多时，我就会提醒他们，说他
们不是只做一个人的份量，”郑素玫
表示。
她还补充说，“为亲朋好友准备一
顿或共享一餐，对我们大多数人来说
是再自然不过的事。但这种常态却反
而对他们造成极大的困扰。”
加上，中餐没有如西餐那样有固定
的份量。饮食失调症患者无法决定进
餐量，也因此无法与别人一起用餐。
所以，郑素玫偶尔会带他们
到典型亚洲家庭式的
场所共进晚餐，体验
所谓的群体餐，让
职能治疗师郑素玫
每星期都开办烘焙
课，帮助患上饮食
失调症的学员们。
征兆的蛛丝马迹
体重已明显急剧下降仍感觉
肥胖或超重
过度在意体重、食物、热
量、脂肪克数和节食；或极
度顾虑体重和体型
抗拒某种食物或某个类别的
所有食物
对增加体重或变胖感到无限
恐惧和焦虑
图：Alecia neo
否认饥饿
年轻人
和女性
饮食失调症
日益普遍，新加坡
中央医院康跃中心
每年平均接到
120
个新病例
大约
90%
的饮食失调
症病人是
女性
暴食症多见于
20岁到
30多岁
左右的年轻人
厌食症多见于
10多岁到
20多岁
左右的青少年
饮食程式化，例如有特定的
进食顺序、重复排列盘子上
的食物或将食物切成小块
为缺餐或逃避与食物有关的
情况找借口
远离朋友和社交活动
月经周期紊乱
有过度或严格的运动计划
30
新闻
2013 年9 – 10月刊
重获心生，喜获千金
幸运患者得到心脏瓣膜捐赠也晋升为人父
受惠包括林惠综。这当中，几乎一半
是18岁以下的患者。林惠综获得匿名
捐赠者的心脏瓣膜组织。
与其他器官移植不同的是，心血
管同种移植不会造成器官排斥等副作
用，所以也不必长期服用药物。
图：Alvinn Lim
缺乏捐赠者
林惠综先生于2011年3月做了心脏瓣膜移植手术后仅仅几个月便与妻子生下了女儿。
原文 Tan May Ping
做
了心脏瓣膜移植手术不久，
太太便顺利地怀孕，这对林
惠综先生来说是个奇迹。
在 2011年 3月 ， 他 进 行 了 移 植 手
术，以修复已损坏的心脏瓣膜。如果
不动手术，受损的瓣膜会导致血液流
返心脏。到那时，林惠综将会面临心
力衰竭的危险。
手术成功无疑是件值得庆祝的事，
然而宝宝的诞生更令人雀跃万分。怀
里抱着女儿，年仅33岁，已婚三年的
年轻牧师林惠综说：“我没料到手术
后那么快就有孩子的。我相信这是移
植手术促成的惊喜。”
目前，他不仅享受着初为人父的
喜悦，身体也逐步好转。曾经容易气
喘、疲劳和胸部紧张等状况，现在全
都消失了。完成手术三个月后才获准
做运动，让这名自行车发烧友积极地
回到正常生活的轨道上。
其实，林惠综对心脏病一点都
不陌生，因为他一出生就患有法洛四
联症（tetralogy of fallot）。这是一种
先天性心脏缺陷，而心脏穿孔是缺陷
之一。
林惠综八岁时曾修补过穿孔的心
脏。之后，身体恢复良好，状况也保
持稳定。直到2011年，他那衰坏的肺
动脉瓣引起了严重的心脏血液回流问
题。这次，他必须接受心脏瓣膜移植
来修复漏洞。
瓣膜和组织存库
全 国 心 血 管 移 植 片 存 库 （ National
Cardiovascular Homograft Bank，简称
NCHB）是个负责采集、筛选和存放捐
赠的人体心血管组织（同种移植片）
的机构。采集的人体组织有心脏瓣
膜、血管组织和气管等。
自2008年成立以来，已有45名患者
获得合格鉴定
全国心血管移植片存库 (简称NCHB) 于2012年2月被美国组织库协会
（American Association of Tissue Banks）鉴定为合格存库，成为北
美以外第一个被该协会鉴定合格的组织存库。
所有NCHB工作人员也都通过了该协会举办的考试，成为了专业
认证的组织存库人员。
新加坡国家心脏中心心胸外科的高级顾问兼NCHB项目总监林崇
熹医生说：“每当采集逝者的心脏和血管组织时，我们总要面对组
织可能被细菌感染的风险。所以要保留高素质的组织就必须确立一
套标准。”
林惠综并没有等太久，但情况并非都
是如此。事实上，等候名单上平均有6
到8名患者正等着受捐，然而心血管同
种移植片供不应求，使患者必须等上
至少3个月才能做移植手术。
由于有些人普遍认为捐赠器官会造
成遗容受损，因此捐赠者难求。“这
完全是个误解。采集的工作是由训练
有素的外科医生以最尊重逝者的方式
来执行的，”新加坡国家心脏中心心
胸外科高级顾问兼NCHB项目总监林崇
熹医生说。
他表示，人体心脏瓣膜往往是移植
给法洛四联症或瓣膜感染患者的。倘
若是人造瓣膜，他们不只必须终身服
用血液稀释剂，还要面对较高的中风
风险。如果移植的是动物组织瓣膜，
生命延长期也仅是8到10年。然而人体
心脏瓣膜，有研究显示，可延长生命
15到20年。
林惠综对那名捐赠者心存无限
感激。他说：“他的无私延续了我的
生命。”
他有意认捐自己的遗体，也会鼓励
身边的人这么做。现在，他非常期待
与女儿培养紧密的亲子关系，并计划
与她分享这身经历。
“我期待在她成长过程中，教会她
享受运动的乐趣。”
全国心血管移植片存库工作人员将
同种移植片存放进金属柱里然后浸
没于零下180℃的液氮中。
募集捐赠者
全国心血管移植片存库(简称
NCHB) 高级临床协调员石修风有
一份充满挑战性的工作，那就是
找寻捐赠者。
她说：“由于很多人在生前都
不愿与家人讨论自己的身后事，
家人不知道逝者的心愿，所以在
面临决择时困难重重。”
石修风继续说，当确定合适的
捐赠者时，她会先向其家人询问
这名可能是捐赠者的个性或他平
时待人处事的态度，像他是否与
人为善、慷慨大方，喜欢乐于助
人等。约有三分之一的家人都会
同意捐赠。
在获得家人的允许以及NCHB
医疗总监的批准后，以下是工作
人员处理所捐赠的心脏组织的
步骤：
1 从 逝 世 者 体 内 取 出 附 有 主
动脉瓣和肺动脉瓣的部分
心脏。
2 在实验室里把主动脉瓣和肺动
脉瓣分离。
3 用抗生素培育这些瓣膜，并做
细菌污染检测。
4 用 低 温 保 存 剂 把 瓣 膜 包 起
来 ， 存 放 进 零 下 180℃ 的 液
氮中。
5 直到实验结果通过才将隔离容
器里的瓣膜移到临床容器里，
为移植手术做准备。同种移植
片可存放长达五年。
NCHB也 会 不 时 举 办 宣 传 活
动，向学生讲解以提高他们对器
官捐献的意识。石修风说：“我
们希望他们可以从中得到启发，
长大后能够认捐自己的器官或细
胞组织。”
如何成为捐赠者
捐赠者 必须是18岁以上。
根据医药（治疗、教育及
研究）法令（ Medical Therapy
Education Research Act， 简 称
MTERA）的规定，捐赠者可以指
定他要认捐的身体组织及部位。
诸如人体心脏瓣膜、血管组
织 和 气 管 等 组 织 均 在 MTERA
范围之内。人们可以选择死后
捐出身体组织以供移植或研究
用途。
如果个人没有认捐器官组织，
他的家人可以选择在他去世
后，通过MTERA捐赠逝者的器
官组织。
有关网站 www.liveon.sg
2013 年9 – 10月刊
新闻
31
意见箱
乐龄人士牙科保健辅助津贴
我想要检查牙齿。但我发现自资
的病人与受辅助的病人付费有差
异。我应该怎么获取辅助津贴的
资格？哪一家医疗所会受理？
新加坡国立牙科中心答复： 若要
获取一般检查与治疗的辅助费用津
贴，您除了可以到任何一间综合牙科
诊所安排申请之外，也可以到那些有
参与卫生部社保援助计划的家庭牙科
诊所办理。
若您父亲进行例检时发现有口腔问
题，该计划里的牙医会把他推介给合
适的专科牙医，做进一步治疗。
在新加坡国立牙科中心，凡是年龄
在40岁以上，同时又是从社保援助计
划推介过来接受专科护理的病人，一
律都会小保留辅助收费资格。
目前，全国已有超过200间家庭牙
科诊所加入这项社保援助计划计划。
欲知详情，请上网：chas.sg/index
patients.aspx.
为什么我需要另付检查费？
我到一家综合诊疗所的牙科门
诊去洗牙和牙石清理。付费时才
发现门诊还另收检查费。我已支
付服务费了，为什么还要支付检
查费？
新加坡保健服务集团综合诊疗所
答复： 如果患者超过一年没到综合
诊疗所的牙科门诊处就诊，牙医必须
先为患者从新进行一次口腔检查，确
认其整体口腔状况，再为他进行疗
程。这是为了确保疗法得以在患者
口中安全地进行。因此，需要另付检
查费。
解读。但被回拒了。为什么我得
要为一份报告去见医生呢？
新加坡保健服务集团综合诊疗所
答复： 为了对您的健康状况进行更
好的评估，医生有义务审阅您
的实验报告。这样一
来，医生就可以
根据您的实验结果
和医疗状况，为您
开药方、提供建议
或制定一套适合您进
一步的治疗方案。
不邮寄试验结果
试验两星期后收到通知，要我去
见医生检视报告。我要求他们把
实验报告邮寄给我，以便我自己
若有任何关于入院手续、账
单及程序等疑问，可电邮至
[email protected]，我们会在
这个栏目里解答您的问题。
专家解答
黄斑病变
心传导阻滞是一种心脏病吗？
我被诊断患上一级心传导阻滞（first-degree heart block）。我的
家庭医生叫我不用特别在意，因为这个疾病不必治疗，所以也没
给我任何跟进病情的建议。请问心传导阻滞是一种心脏病吗？它
会不会随着年龄增长而恶化，增加患上心房颤动（心律不齐）、
心脏病突发或中风的风险？我是否应该做些监测管理，例如每年
做一次心电图检？还有，病情有痊愈的可能吗？
一级心传导阻滞通常不会引发任何
其他症状。它是因为某些像β受
体阻断剂（beta blockers）的
药物或生理因素所引起的，
像受过特训的运动员，他们
的心律较会偏慢所以可能有
患上一级心传导阻滞的倾
向。要是你的情况是因这两
者而起，你可停止服药和做
相关的运动。但如果病情没有
恶化到非常严重的程度，像晕厥
之类的症状，那就不必治疗。
人的心脏传导系统（犹如电力
供应，负责控制调节心跳节奏和脉
冲）会随着年龄增长逐渐退化。对
痴呆症的诱因是什么？
有什么征兆？
痴呆症是否会遗传？脑震荡会导
致痴呆吗？痴呆症患者是否会
有类似精神失常的行为，例如对
着镜子自言自语、不与任何人说
话，或者不让别人阻挡他们想要
做的事？
家族遗传是痴呆症的其中一种因素。
对早期发病患者（30到50岁之间）来
说，它的影响力是相当高的，但对65
岁以上的来说，导致痴呆症的综合因
素比遗传还来得更多，像混合性痴呆
症和能引发血管性痴呆症的糖尿病、
高血压、中风和高胆固醇或高脂血症
等。另外，头部如果频频受创或震荡
也会提高诱发痴呆症的风险。
有些痴呆症患者人格上会发生
剧烈的转变，有些则是情绪或行为表
现异常，包括易怒或易激动、妄想、
幻听或幻视和神志恍惚等等。由于他
们平时看起来与常人无异，所以他们
的记忆能力或功能能力常被家人朋友
忽略。
不过，以上症状
也可能是其他疾
病或精神状况的
征兆。依您描述的
症状，最好是寻求
专业医疗的评估。
新加坡中央医院老年医
学科顾问医生萧俊才
于60岁以上的年长者来说，心脏传
导阻滞可能就是心传导系统功能减
慢的早期迹象，要是情况恶化，患
者就得安装心脏起搏器。
至于是否需要做心电图检，那就
要看情况而定，因为这通常是一些
病症像高血压、心脏瓣膜病和甲状
腺功等，造成心律不齐或心房颤动
的情况下才会提议的。除非，一级
心传导阻滞恶化导致心房和心室收
缩不协调或心房逐渐扩大（这是非
常罕见的情况。），不然就没有必
要每年进行一次心电图检查。
新加坡国家心脏中心心内科顾问医生何
佳恩
保护我们的眼角膜
我们应该如何防止眼角膜受损？
眼角膜移植会引起哪些风险？
眼角膜移植的首要风险是排斥反应，
其次是在移植后的头几个阶段，眼角
膜可能会受到感染，眼压也可能会日
渐提升。如果要避免眼角膜遭到外
伤，运动时可佩戴护目镜。
目前没有任何证据可以证实饮食
可以保护眼角膜，然而具有抗炎作
用的亚麻籽油能够稳定眼球表面进
而稳定泪膜层，尤其在强风环境
里。另一方面，抗氧化剂也可以
保持眼睛健康。
新加坡全国眼科中心角膜及眼表疾病
科顾问医生兼任副教授Jodhbir Mehta
我今年46岁，双眼近视度约900
，右眼患有与年龄相关的黄斑变
性病。由于状况稳定所以没在服
药。但是，我开始感觉中央视觉
有个模糊的斑点，在强光底下斑
点会扩大，使用电子表格时也会
看到弯曲波浪线。
往后的日子里，我的视力是
否还可以得到改善还是会继续恶
化？我该怎么做？另外，在吃滚
烫或辛辣食物时，双眼会有刺痛
感，为什么会出现这种情况？
高度近视者在四十岁左右会发生黄斑
变性病，多数是因为视网膜中心的“
黄斑”区萎缩变薄而引起的。由于眼
球在这年纪已不再发育，所以状况一
般都能保持稳定。
然而，如果新生血管（血管也偶尔
会生长在这区域）出现出血或结疤的
状况，中央视力和近视力就会进一步
被削弱。若要控制这个问题，您应该
定期每年一次做瞳孔放大检查。
热辣食物会让眼睛产生刺痛感，主
要的原因是因为连接泪腺的自主神经
受到了刺激。这是一种正常的反射作
用。不过，如果您流泪时眼睛感到疼
痛的话，那可能是干眼症或眼睑皮脂
腺发炎（睑板腺炎）所引起的。
要舒解状况，您可以定期使用人工
泪液以及清洗眼睑，尤其是眼睑边缘
部位（睑板腺的位置）。如果您有任
何疑问，请务必就医。
新加坡全国眼科中心白内障和综合眼科服务
顾问医生韩竹燕
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